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during postpartum:
1. Uterine Involution
2. Return of Menstruation
3. Vagina
4. Cardiovascular System
Normal Puerperium
Definition
* lochia
=lochia ruba: bloody discharge in the first few
days after delivery.
=lochia serosa: the discharge becomes pale in
color after 3 – 4 days.
=lochia alba: uterine discharge assumes a
white or yellow-white color by
the 10th day postpartum.
NB:
foul-smelling lochia suggests endometritis.
(2) Return of menstruation
* non-nursing mothers:
menstruation returns by 6 – 8 weeks.
* nursing mothers:
may develop lactating amenorrhea.
NB:
In all women , although ovulation may not occur
for several months ,particularly in nursing mothers
contraceptive use should be advised during the
puerperium to avoid an undesired pregnancy.
(3) Vagina
* the supportive tissues of the pelvic floor
gradually returns its former tone.
* women who deliver vaginally should be
taught & encouraged to perform Kegel excercises
Correct Wrong
* Complications
1. Fissured Nipples:
= nipples may become fissured and nursing
become painful and difficult.
= breast fissures are a portal of entry for
bacteria, so they should be managed aggressively
by lanolin breast cream.
= further breast feeding should be stopped , milk
can be expressed manually until the nipples
heal and breastfeeding can be resumed.
2. Mastitis :
= uncommon complication usually develops
after 2 – 4 weeks.
= symptoms & signs
low grade fever , chills , indurated ,red and painful
segment of the breast.
= caused by Staphylococcus aureus bacteria
from the infant’s oral pharynx.
= mother should start antibiotics immediately,
such as dicloxacillin for 7-10 days.
Puerperal Disorders:
1. Puerperal Pyrexia.
2. 2ry Postpartum Hemorrhage.
3. Thromboembolism.
4. Perineal Complications.
5. Bladder Dysfunction.
6. Bowel Dysfunction.
Puerperal Pyrexia
Definition:
a temperature of 38C or > lasts for 2 days
or > in the first 10 days postpartum,
exclusive of the first 24h.
(puerperal sepsis)
4. UTI.
5. chest infection.
6. CS delivery, wound infection & fasciites.
7. meningitis.
Genital Tract Infection
( Puerperal Sepsis)
Incidence: 3%
7% of all direct maternal deaths , excluding deaths
after abortion.
Etiology:
Puerperal infection is usually poly microbial
involves contaminants from the bowel
that colonize the perineum and
lower genital tract.
The most frequently identified organisms are :
* Group B Streptococcus.
* Mycoplasma species.
* others:
=Gram +ve
-beta-hemolytic streptococcus gr.A,B,D
-staphylococcus aureus.
-staphylococcus faecalis.
=Gram –ve
-E coli
-Hemophilus influenzae.
-gardenella vaginalis.
=Anaerobes
as; Bactroides fragilis.
=Miscellaneous
as; Chlamydia trachomatis
Predisposing Factors:
1. instrumental delivery.
2. internal fetal monitoring.
3. multiple vaginal examinations.
4. prolonged ROM and chorioamnonitis.
5. cervical cerclage.
6. Non obstetric :
.. Obesity.
.. DM.
.. HIV.
Factors that determine
the clinical course & severity of the infection:
3. prophylactic antibiotics
especially in emergency CS.
a single intra operative dose of cephalosporin+
metronidazole.
Treatment
A. Mild and Moderate infections :
broad spectrum antibiotic as:
cephalosporin + metronidazole.
in the first 48h ,antibiotic should be given IV.
B. Severe infections :
septic/endotoxic shock
appropriate antibiotics should be aggressively
given ,any delay could be fatal.
Complications
1. Pelvic abscess
salpingo- ophoritis and pelvic peritonitis . This
could progress to a generalized peritonitis and
the development of pelvic absess.
2. Pelvic Peritonitis
metritis and parametitis.
3. Septic Thrombophlebitis
spread to distant sites via lymphatics to
the iliac vessels or directly via the ovarian
vessels.
Necrotizing Fasciitis
* treatment
..antibiotics.
..drainage if pus collected by removal of
any skin sutures.
..if spontaneous opening of repaired tears
or episiotomy ,in presence of infection,
should be irrigated twice daily & healing
is allowed by secondary intention.
(4) Bladder Dysfunction
* Causes
• after epidural anesthesia the bladder may
take 8 – 12h to regain normal sensation.
* Important
stress incontinence is a rare problem in the
puerperium ,thus any urine incontinence
should be investigated to exclude obstetric
fistulae.
(5) Bowel Dysfunction
Superficial thrombophlebitis
3 to 4th day after delivery
Assessment
Tenderness >> Localized heat
Swelling >> Redness
No or low fever
Intervention
Elevate leg >> Bed rest
Local moist heat >> Analgesia
Little risk of pulmonary embolism
Thromboembolic
Disorders
Deep vein thrombosis
10 to 20 days after delivery
Assessment
Swelling
Pain
Erythema
Heat
Pedal edema
Low to high fever
Positive Homan’s
Chills
Thromboembolic
Disorders
Deep vein thrombosis
Intervention
Bed rest >> Elevate leg
Analgesia >> Antibiotics
Anticoagulant therapy
IV heparin