Puerperium

Definition

Normal puerperium

1. The time from the delivery of the placenta through the first few weeks after the delivery
2. 6 weeks in duration. 
3. By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery resolves and the body reverts to the non pregnant state.

The puerperium has been referred to as the “ fourth trimester” of pregnancy, encompassing the period between the delivery and complete physiologic involution and psychological adjustment. 

Abnormal Puerperium

• Puerperal Pyrexia
• postnatal psychosis and depression

Puerperal Pyrexia

Definition

P pyrexia is defined as temperature of 38oC ( 100.4oF) or higher on any two occasions persisting after the first 24 hrs of delivery, and within 10 days postpartum taken by mouth by a standard technique.

Cause of P. Pyrexia

1. P. Sepsis- Genital tract infection
2. UTI
3. Breast Complications
4. Wound Infections
5. Thrombophlebitis and DVT
6. Respiratory infections

Puerperal Sepsis

Definition

An infection of the genital tract which occurs as a complication of delivery is termed as P sepsis.

Vaginal flora

1. L bacillus ( 60-70%)
2. Yeast like fungus- Candida albicans ( 25%)
3. Staph albus or aureus
4. Strepto β haemolyticus
5. E coli and bacteroids
6. Cl welchii-rare

These organisms remain dormant and are harmless during normal delivery conducted in aseptic conditions. 

Predisposing factors to P Sepsis

1. Conditions lowering the resistance 
2. Malnutrition & anaemia
3. PROM
4. Chronic debilitating diseases
5. Repeated PV examination after rupture membrane
6. Traumatic manipulative & operative delivery
7. Haemorrhage 
8. RPOC- retained product of conception
9. Placenta previa

Organism responsible for P sepsis

• Aerobic- Staph, Ecoli, Klebsiella, Pseudomonas, Non-haemolyticus Strepto, 

• Anaerobic- Anaerobic streptococcus, Bacteroids, Cl welchii and tetani

Pathology and the primary site of infection

Uterus

Endomyometritis- is the most common and usually mildest form of genital infection.

4 Classical signs:

• Pyrexia 37.8-38o C
• Pulse 100-120
• Fundal height- not decreasing
• Lochia red &offensive smell

Clinical examination & Daily Charting

Investigations

1. High vaginal smear and endocervical swab for C/S
2. MSU for R/M/E & C/S
3. Blood for Hb,TC, DC & C/S
4. Blood for MP
5. Widal Test
6. X-ray chest

Treatment 

1.Adequate fluids, rest and movement of bowel- Milk of magnesia

2.Correction of anaemia

3.Antibiotics- Broad spectrum

        I/V Ampicillin 500mg  6 hrly

        I/V Metronidazole 500 mg  8 hrly

        I/V Gentamycin  3-5 mg/kg body wt in divide dose

                                    OR

        I/V Ceftriaxone / Cefotaxim 1 gm 12 hrly

                    Change according to C/S             

Urinary tract infection

• Incidence is 1-5%
• Organisms- E coli, klebsiella, Proteus, Staph aureus
• Causes- Frequent catheter, stasis of urine due to lack of bladder tone & less desire to pass urine, Asymptomatic bacteriuria becomes symptomatic, 
• Present- Fever with chills & rigor, burning micturition, frequency, nausea, vomiting, acute pain in the loins radiating to groin.
• Investigation- Urine for R/M/E and C/S
• Treatment -Antibiotics

Causes of retention urine in puerperium

1.Bruising and oedema of the bladder neck

2.Reflex from the perineal injury

3.Unaccustomed position

4.Haematoma

Treatment

• General measures
• Indwelling catheter for 48 hrs- It helps in regaining the normal bladder tone and the sensation of fullness.
• Antibiotics

Breast Complications

Common breast complications are

1.Breast engorgement

2.Cracked & retracted nipples

3.Mastitis and breast abscess

4.Failing lactation

Breast engorgement

• Due to exaggerated normal venous & lymphatic engorgement preceding lactation, preventing escape of milk from lacteal systm.
• Manifest after the milk secretion- 3rd -4th PPD
• S/S- Pain, feeling of tenseness and heaviness in both breast, malaise, ↑tempt
• Treatment-Support breast with binder & brassiere, ice bag, express milk or frequent breast feeding, analgesic
• Prevention- Manual expression of the remaining milk & frequent breast feedings

Cracked Nipple

• Due to a) loss of surface epithelium, causing a raw area b) fissure at the tip or base of nipple
• Caused by 1)unhygiene –crust over the nipple 2) retracted nipple 3) vigorous suckling
• Asymptomatic usually but if infection, it is painful due to mastitis
• Treatment-keep nipple clean & dry, nipple shield during each feed, rest if worst and feed by expression, antibiotics ( oral & applicant)  and analgesic
• Prevention-Local cleanliness during pregn and puerperium

Retracted nipple

• Primigravida
• If left uncorrected may predispose to cracked nipple- difficulty in breast feeding
• Manual lifting of the retracted nipple during pregnancy is advisable.
• After delivery, use of nipple shield is advisable.

Acute Mastitis

Mode of infection

2 different types of mastitis

• Infection follows a cracked nipple to involve the breast parenchymal tissues leading to cellulites.
• Infection gains access through the lactiferous duct leading to development of primary mammary adenitis
• Responsible organism is Staph aureus- infection comes from nasopharynx of the baby.

Clinical feature

• Symptom- Generalised malaise, headache, fever with chills
• Severe pain and tender, swelling in 1 quadrant of the breast.
• Sign- Wedge shaped swelling on the breast with the apex at the nipple
•  Over lying skin is hot, flushed, tense and tender

Treatment

• Antibiotics- Cloxacillin, Cefalosporin
• Analgesic 
• Antenatal-Wash the nipple periodically to keep the patency of the duct opening.
•  Breast feeding on the affected is suspended
• Manual expression & prevention of engorgement of breast.

Breast Abscess

• Swinging tempt
• Reddened breast
• Marked tenderness with fluctuation.

Treatment

• Antibiotics
• Incision and drainage

Wound infection

• Wound can be that of a CS or an episiotomy wound
• Infection in the wound usually develops around the 5th to 6th POD
• Take Swab from the wound and send for C/S 
• Treat with antibiotics and daily dressing
• Followed by secondary suture,

Chest infections

• Usually following general anaesthesia in CS
• Take x-ray chest and sputum for C/S
• Treatment is with physiotherapy, warm saline gurgle, steam inhalation and antibiotics

Deep Vein Thrombosis (DVT)

• Usually occurs at around 7-10th PPD
• Begins in the deep veins of the calf or soles of the feet and extend upwards
• Often symptomless
• Sharp dorsiflexion of the foot elicit pain in the calf-Homan’s sign
• Slight rise of tempt & pulse.
• These early S/S may be missed and detected only when pulmonary embolism has developed or when the generalised oedema of the leg has set.
• Exercise in early puerperium is beneficial.
• The foot end of the bed is elevated to increase the venous flow from the leg.
• Antibiotics to prevent infection
• Anticoagulant to prevent clot formation-Heparin.
• After being afebrile the pt is encouraged to walk about with the affected leg supported by elastic bandage.

Post Partum Blues, Depression and Psychosis


Post partum Blues

• Occurs in around 50% of the women
• Around 4th to 5th PPD
• Usually self limiting though in rare circumstances progresses to postnatal depression.
• Cure by support of medical practitioner is all that is required

Post natal depression

• Onset at around 4th week PP 
• Lasting for around 6 months
• Family H/O mental disorder is usually present.
• C/F are that of sleep disturbance, depression, social withdrawal, lack of worthiness of being a mother, suicidal thoughts, concern that she may harm her child
• Management- Social support, refd to psychiatrist

Puerperal Psychosis

• Occurs in 0.2% of the mothers
• Onset is earlier than the postnatal depression
• The chance that a mother may harm her baby is very high.
• Serious condition the requires an expert psychiatric evaluation and treatment