Normal & Abnormal

Puerperium
 Objectives
• Normal Puerperium
– Reproductive organs
– Systemic change

• Abnormal Puerperium
– Postpartum Hemorrhage
– Puerperal fever and sepsis
– Septic Pelvic Thrombophlebitis
– Endocrine Disorders
– Psychiatric Disorders
– Uterine Subinvolution
 Normal
Puerperium
 Normal Puerperium
Definition
Period following delivery of baby & placenta
to about 6 weeks post partum

By 6 weeks after delivery, most of the changes

of pregnancy resolved and the body has
regained the non-pregnant state.
 A- Reproductive organs
1) Abdominal wall
Remains soft and poorly toned for many weeks.
The return to a prepregnant state depends greatly on exercise.

2) Perineum
Swelling & engorgement are completely gone within 1-2 weeks
The muscle tone may return to normal, depending on the
extent of injury.
Cont. (Reproductive organs)

3) Uterus
- 1000g 100 – 200 g ( Uterine involution )
- The endometrial lining rapidly regenerates (16 days)
- After delivery at the level of the umbilicus
- After 2 weeks midway b\w umbilicus & symphysis
- After 4 weeks the uterus become pelvic organ
Cont. (Reproductive organs)
4) Cervix
- Loses its elasticity & regain firmness
- Closed by the end of the 2nd week

5) Vagina
- By 3 weeks increased vascularity and edema
- At the end of puerperium Shrinks to a nonpregnant state
- by 6-10 weeks The vaginal epithelium appears atrophic
on smear and the normal epitheliaum will be restored
Cont. (Reproductive organs)
6) Ovaries
- Ovulate as early as 27 days after delivery (not breastfeed).
- The suppression of ovulation is due to the elevation in
prolactin
- Menstruation returns by 6-8 weeks in women who do not
nurse
 Cont. (Reproductive organs)
7) Breasts
- Lactogenesis is initially triggered by the delivery of the
placenta drop of placenta H ( esp. estrogen ) &↑prolactin
- In non nursing women The prolactin levels decrease and
return to normal within 2-3 weeks

Colostrum secreted for 2 days contain protein , fat , minerals , IgA and IgG
After 3-6 days replaced by milk (protein , lactose , water and fat )
 Physiology of lactation

The physiological basis of lactation is divided into

four phases:
1. Preparation of breasts (mammogenesis).

2. Synthesis and secretion from the breast alveoli

(lactogenesis).
3. Ejection of milk (galactokinesis).

4. Maintenance of lactation (galactopoiesis).

 There are 2 stages of lactogenesis :

Stage 1:
 Occurs by mid pregnancy.
Mammary gland becomes competent to secrete milk.

Lactose, total protein, and immunoglobulin

concentrations increase within the secreted glandular
fluid, whereas sodium and chloride concentrations
decrease.

High circulating levels of progesterone and estrogen

hold the secretion of milk in check.
 Stages of lactogenesis contd…

Stage 2 (day 2 or 3 to day 8 after birth):

 Occurs around the time of delivery.

Onset of copious milk secretion.

Blood flow, oxygen, and glucose uptake increase, and citrate

concentration increases sharply.

Progesterone plays a key role.

Removal of the placenta is necessary for the initiation of

milk secretion; however, the placenta does not inhibit
established lactationcontrol.
 Physiology of lactation contd…

Galactokinesis
Discharge of milk from the mammary glands
depends not only on the suction exerted by the
baby during suckling but also on the contractile
mechanism which expresses the milk from the
alveoli into the ducts.
How Does Lactation Happen?
Hypothalamus

PIF Paraventricular
nucleus

Anterior Posterior
pituitary pituitary

Prolactin Oxytocin

Milk Milk
production ejection
 Oxytocin

• Moves milk from

lobules to sinuses,
so baby can eat
• Inhibited by stress,
pain, anxiety
• Triggered by sound,
smell, sight of infant

Let Down: Ejection, not suction,

moves milk to the areola.
 Milk Transfer
• Infant grasps most
of the areola in his
mouth
• Tongue “milks”
milk to the back of
the mouth prior to
swallowing.

Latch: The baby’s tongue moves

milk from areola to nipple.
 Negative feedback

• Milk in lobules contains

whey protein called
Feedback Inhibitor of
Lactation (FIL)
• If milk is not removed,
and lumen is full,
production will decrease
• Goal: 10-12 feeds in 24
hours, until baby is done.

Moving Milk:
Demand drives supply.
Evidence-based early care

Let
Latch
Down
Breastfeeding
Success

Moving
Milk

Start out right: establish

normal physiology
 Physiology of lactation contd…

Galactopoiesis
Prolactin appears to be the single most important
galactopoietic hormone.

Continuous suckling is essential for removal of milk

from glands, also release prolactin.

Secretion is the continuous process unless

suppressed by congestion or emotional
disturbances.
 B- Systemic changes
1) Cardiovascular system
• Cardiac output ↑(immediately after delivery) → slowly
declines→ reach normal 2-6 weeks.
• Blood volume returns to nonpregnant levels by the 10th day
of puerperium

2) Hematologic changes :
• Hemoglobin & hematocrit ↑ after delivery
• Coagulation factors remain elevated in early puerperium
8-12 weeks return to non pregnant level
 Manifestations

In First 24 hours:
PBL F
• Pain uterine contraction
• Breast colostrum
• Lochia
• Fever not exceed 38 C
 LOCHIA
it originate from
Lochia:- “vaginal
body of uterus,
discharge along
cervix and vaginal.
with decidua, clots
it is fishy odor.
and membrane
Reaction is
after delivery of
alkaline first and
placenta during
tends to acidic at
puerperium.”
end.

-Lochia discharge continues for 2 to 6 weeks

after delivery .
- Monitor for signs of infection “foul smelling “
 endometritis
 Stages
Traits Lochia rubra Lochia serosa Lochia alba
Colour Red Yellow or pale Pale white
brown
Composition Mainly RBC, Mainly mucus and Mucus, serous
leucocytes, serum, few RBC exudates, epithelial
decidua, mucus. and leucocytes. cell, leucocytes.
Duration 1-4 days 5-9 days 10-15 days.

Abnormality with lochia:-

1. persistent lochia rubra:- causes secondary PPH due to retained placental
tissue and membrane.
2. Offensive lochia:- puerperal sepsis due to E.coli.
3. Scanty serous lochia:- severe streptococcal infection.
4. Suppression of lochia:- obstruction at internal os by clots
Abnormal
Puerperium
 Abnormal Puerperium
A-Postpartum Hemorrhage (PPH)
B-Puerperal fever and sepsis
-Endometritis - Mastitis
-Wound Infections - UTIs
C-Septic Pelvic Thrombophlebitis
D-Endocrine Disorders
-Postpartum thyroiditis - PP Graves disease
-Sheehan syndrome - Lymphocytic hypophysitis
E-Psychiatric Disorders
-Postpartum blues - Postpartum depression (PPD)
-Postpartum psychosis
F- UTERINE SUBINVOLUTION
 Sequence of events in abnormal
puerperium
• At 2nd OR 3rd day Endometritis

• At 4th day Mastitis OR Wound infection

• At 7th day Thrombophlebitis

 Puerperal fever

A temperature rise above 38°C on any of the

first 10 days after delivery .

Differential diagnosis:
1. Endometritis
2. Wound or chest Infections
3. Mastitis
4. UTIs
5. Thrombophlebitis
6. Any general cause of fever
 1) Endometritis

Endometritis is the primary cause of postpartum

infection.
The causative agents are usually normal vaginal
flora or enteric bacteria.
Cont. (Endometritis)
Risk factors 4Ps 3Ms 1C
1. Cesarean delivery
2. Prolonged labor
3. Preexisting infection of the lower genital tract
4. Placement of an intrauterine catheter
5. Prolonged rupture of membranes
6. Multiple vaginal examinations
7. Multiple pregnancy (Twin delivery)
8. Manual removal of placenta
Cont. (Endometritis)
Diagnosis (After excluding other causes)
A. History of fever, chills, lower abdominal p
malodorous lochia, increased vaginal bleeding, anorexia,
and malaise.

B. Physical Examination showing a fever of

38°C, tachycardia, and fundal tenderness.

C. Laboratory tests CBC, ESR , CRP , blood

cultures , urinalysis and microscopic culture of discharge .
ROLE of F (Endometritis)

First Exclude
Foul smelling lochia
oFFensive vaginal bleeding
Fever > 38 ᴼC
Fundal tenderness
Cont. (Endometritis)

Treatment
IV antibiotics (Gentamicin & clindamycin have
a cure rate of approximately 90%)
Parenteral antibiotics are usually stopped once
the patient is afebrile for 24-48 hours,
tolerating a regular diet, and ambulating
without difficulty
 2) Wound Infection
Include infections of the perineum developing
at the site of an episiotomy or laceration, as
well as abdominal incision after a cesarean
birth.
Diagnosis based on presence of erythema,
induration, warmth, tenderness, and purulent
drainage from the incision site (expolortion),
with or without fever.
Cont. (Wound Infection)
Perineal infections are rare appears on the
third or fourth postpartum day.
• Risk factors include infected lochia, fecal
contamination of the wound, and poor hygiene.

Abdominal wound infections

S aureus, is isolated in 25% of these infections.
Treatment :
Abscesses must be drained, and broad-spectrum
antibiotics may be initiated.
 3) Mastitis
- It is an inflammation of the mammary gland
(parenchyma) .
- Develops during the first 3 months.
- Milk stasis and cracked nipples, which
contribute to the influx of skin flora, are the
underlying factors associated with the
development of mastitis.
- The most common causative organism is
S.aureus
• Risk factors primiparity, incomplete emptying
of the breast, and improper nursing technique.
Cont. (Mastitis)

Diagnosis
A. History of fever, chills, and malaise.
B. Physical Examination
- Should Focus on looking for other sources of infection.
- Typical findings include an area of the breast that is
swollen, warm, red, and tender.
- When the exam reveals a tender, hard, possibly fluctuant
mass with overlying erythema, an abscess should be
considered.
Cont. (Mastitis)
Treatment
• Milk stasis can be treated with moist heat,
massage, fluids, rest, proper positioning of the infant
during lactation, manual expression of milk, and
analgesics.
• Penicillinase-resistant penicillins and
cephalosporins, such as dicloxacillin or cephalexin,
are the drugs of choice.
• Erythromycin, clindamycin, and vancomycin may be
used for patients who are resistant to penicillin.
• Resolution usually occurs 48 hours after the onset of
antimicrobial therapy.
 4) UTIs
- The most common pathogen is E coli. In pregnancy
- Risk factors Cesarean delivery, forceps delivery, vacum
delivery, induction of labor, maternal renal disease,
preeclampsia, eclampsia, epidural anesthesia, bladder
catheterization, length of hospital stay, and previous UTI
during pregnancy.
Diagnosis
History (frequency, urgency, dysuria, hematuria)
Physical examination (febrile patient, Suprapubic tender
Laboratory tests (urinalysis, urine culture and CBC)
Treatment
Empirical culture selective (3-7 Days)
 E) Psychiatric Disorders
1- Postpartum blues - 50-70%
• Mild, self limited, arises during the first 2 weeks PP
• TTT: Support & education

2- Postpartum depression (PPD) - 10-15%.

• More prolonged (3-6 months)
• TTT: Supportive care and reassurance, SSRI

3- Postpartum psychosis- 0.14-0.26%.

• Generally lasts only 2-3 months. Need psychiatrist.
• Better prognosis than nonpuerperal psychosis.
 F) Uterine Subinvolution
It is a transient autoimmune destructive
lymphocytic thyroiditis.
Causes: Endometritis, retained placental
fragments, pelvic infection and uterine fibroids
Signs and Symptoms
1) Prolonged lochial flow.
2) Profuse vaginal bleeding.
3) Large, flabby uterus.
Cont. (Uterine Subinvolution )
Treatment:
1- Administration of oxytocic medication to
improve uterine muscle tone, includes:
(a) Methergine - a drug of choice (PO)
(b) Pitocin.
(c) Ergotrate.
2- Dilation and curettage (D&C) to remove any
placental fragments.
3- Antimicrobial therapy for endometritis