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Phase 4 of Parturition

Abdessalam Ewais

on 15 April 2013

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Transcript of Puerperium

Puerperium E_Z > refers to the 6 week period following completion of the third stage of labour , when considerable adjustments occur before return to the pre-pregnant state. Physiological Changes that occur during puerperium: Routine Postpartum care Stage 4 of Labour Cervix Uterus Vagina Placenta Abdominal Wall ovaries Cervical opening contracts slowly for a few days after delivery.

The cervix reverts back to the non-pregnant state, but never to the nulliparous state.

By the end of the 1st week difficult to pass more than one finger.

By the end of the 2nd week the internal os is closed.

External os can remain open permanently (parous cervix)
Cervix The vagina is edematous and has poor tone following vaginal delivery. It remains stretched and smooth in the first few days after delivery.

By the end of 3rd week Rugae begin to appear but never return back to its nulliparous state.

4-6 weeks after delivery its regains its tone and returns to its original size Vagina Placenta complete extrusion of the placental site takes up to 6 weeks.

When defective, late puerperal haemorrhage may follow.

Immediately after delivery the placenta is about the size of the palm of the hand. By the end of the 2nd week, it is 3-4 cm in diameter. Abdominal Wall As a result of rupture of the elastic fibers of
the skin and prolonged distension caused
by the enlarged pregnant uterus,
the abdominal wall remains soft and
flabby for a while. Returns to normal but requires several weeks (aided by exercise).

Usually resumes its pre-pregnancy state except for silvery striae. The immediate postpartum period most often occurs in the hospital setting, where the majority of women remain for approximately 2 days after a vaginal delivery and 3-5 days after a cesarean delivery. During this time they make sure the mother is stable, not losing any blood and shows no signs of infection, and you should cover her with adequate dose of Anti-D if she needs it.
Abdessalam Ewais
Hala Odeibat
Nur Izzah
Batool Hamadneh
Maron Shehadi
Rahmah Nasir
Sami Shehadi Puerperium By: Local physiological General physiological
changes including: changes including:
Abdominal wall Weight
Bowel habit
CVS - It is the process by which the postpartum uterus, weighing about 1Kg , returns almost to its pre- pregnant state of less than 100g
Uterine involution: Autolysis of excess muscle fibers(no effect on the number of the muscle cells)
Accelerated by the release of oxytocin in women who are breastfeeding.
Obliteration & thrombosis of blood vessels
Degeneration & transformation into elastic tissue
Separation of the decidua
Supervised by:
Dr. Laila Al-Zaghal The uterus slowly returns to its non-pregnant state, although the overall uterine size remains larger than prior to gestation.
The process is accelerated in breastfeeding women by the effect of oxytocin.
* Causes of delayed involution (subinvolution) include:
full bladder
loaded rectum
uterine infection
retained products of conception
broad ligament hematoma
Ovarian cyst Endometrium: The endometrial lining rapidly regenerates:

7th day: Endometrial glands are evident.

16th day: endometrium is restored (except at placental site.)

The placental site undergoes a series of changes after delivery:

Hemostasis: caused by arterial smooth muscle contraction and myometrium compression on the vessels ("physiologic ligatures”).

The size of the placental bed decreases by half, and the changes in the placental bed result in the quantity and quality of the lochia that is experienced. Uterine ligaments
ligaments involution and predisposes the uterus to prolapse and retroversion.

Uterine vessels
Caliber of extrauterine vessels decrease to equal size of prepregnant state after delivery.
Lochia A vaginal discharge that flows from the uterus after delivery to about 3-5 weeks postpartum.

Large amount of red blood initially flows from the uterus as the contraction phase rapidly occurs.

Lochia is composed of blood stained uterine discharge that is composed of cervical mucous, vaginal transudate and products of necrosis.
Lochia clots whereas normal menstrual flow does not.

Lochia flow is slightly heavier after breast-feeding.

Lochia with a foul-smell or a green-tinge may indicate infection. perineum The perineum The perineum regains its tone by the end of puerperium.

Episiotomy (an incision in the perineal body at the time of delivery) or tear area leaves a scar which might be tender.

Perineal discomfort occurs in 80% of women in the first 3 days postpartum especially following instrumental delivery

** Best managed by:

local cooling

topical anesthesia

The Ovaries The resumption of normal ovarian function is highly variable and is influenced by breastfeeding.

Women who breastfeed have a longer period of amenorrhea and anovulation than the women who choose to bottle-feed.

The mother who does not breastfeed may ovulate as early as 27 days after delivery. Most women have a menstrual period by 12 weeks.

Brestfeeding & prolactin

Urinary retention is relatively common especially in the first 24 hour after instrumental delivery. It may be due to edema of the bladder neck as a result of stretching or bruising or due to the pain of perineal sutures or due to regional anaesthesia(epidural/spinal)

There is diuresis during the first five days after delivery and urinary nitrogen is much raised.

Diuresis is the body’s mechanism of getting rid of the excess fluid retained during pregnancy.

The high nitrogen excretion is a direct result of the autolytic process of the uterus.

Hyper-coagulable state of pregnancy continues in first 2 weeks despite significant decrease in coagulation factors.

This may increase the incidence of DVT and PE.

Hemoglobin concentration falls in the first 2-3 days.most women who are symptomatic should be transfused if their HB<8g/dl

It is regained by 6 to 8 weeks postpartum in non-lactating women, ovulation may not occur for several months .
Uterine evacuation & normal blood loss : 5-6 kg.
Further decrease through diuresis: 2-3 kg.  

Factors of Weight loss:
Weight gain during pregnancy
Early return to work (outside the home)

Factors not related to weight loss
may be due to :
1. An interruption in the normal diet.
2. Dehydration during labour.
3. Fear of evacuation due to pain from sutured perineum, prolapsed hemorrhoids or anal fissure .

Progesterone continues to inhibit smooth muscle motility.
Hemorrhoids are common. Leukocytosis and thrombocytosis occur during and after labor.

One week after delivery, blood volume return nearly to non pregnant level. are referred to as uterine contractions which continue following delivery. Occasionally severe enough to require an analgesic, usually become mild by the 3rd postpartum day.

Primiparas: puerperal uterus tends to remain tonically contracted
Multiparas : contracts vigorously at interval ==>→ after pain
Infant suckles ==> →oxytocin release ==> →Ut. contraction ==>→ after pain The CVS Immediately following delivery, there is marked increase in peripheral vascular resistance due to the removal of the low-pressure uteroplacental circulatory shunt .

The cardiac output and plasma volume gradually return to normal during the first two weeks of puerperium. Temperature

significant puerperal pyrexia is defined as a Tem.>=38˚C on any two of the first 10 days pospartum, exclusive of the first 24 hours.
A reactionary increase may occur following difficult delivery, but it does not exceed 38.0˚C and drops within 24 hours.
A slight rise may occur in the 3rd day due to breast engorgement.

Tends to be slower, about 60-70 per minute, probably because the woman is resting after the exertion of labor.
Rises only in the presence of hemorrhage or infection.
Transient tachycardia associated with thrombosis. General Physiological Changes After Pains Blood & Fluid Changes Blood changes Urine Constipation Weight loss Breast anatomy A ducts
B lobules
C dilated section of duct to hold milk
D nipple
E fat
F pectoralis major muscle
G chest wall/rib cage
A normal duct cells
B basement membrane
C lumen (center of duct) Contraindications
Take street drugs (like drug abuse, amphetamines and others).
Do not control alcohol use
Have an infant with galactosemia
Have HIV infection
Have active, untreated tuberculosis
Take certain medications
Are undergoing breast cancer treatment       
Cytomegalovirus and hepatitis B virus are excreted in milk
Women with active herpes simplex virus
Immunological Consequences of Breast Feeding

Predominant immunoglobulin in milk is secretory IgA.
Contains both T & B lymphocytes.


Even though the milk supply at first appears insufficient, it become adequate if suckling is continued.
Nursing accelerates uterine involution: repeated stimulation of nipples release oxytocin contracts uterine muscle.    Mastitis
Parenchymatous infection of mammary glands.
usually presents in the third to fourth postpartum week
Can occur due :
1. infective process
2.blocked duct obstruct the flow of milk and distend the alveoli
Unilateral, breast becomes hard, reddened and painful, edematous.
Symptoms:  flu-like symptoms and pyrexia
Signs : chills (1st), rigor, fever, tachycardia.
1.Staphylococcus aureus (most common) 
2.Breast abscess : caused by group B streptococcus   
Most comomon sources of infection :
1- baby’s nose or throat 2-infected umbilical cord    
Breast fever

For the first 24 hours after development of lacteal secretion breasts become distended, firm, & nodular.
 Exaggeration of normal venous & lymphatic

Engorgement of the breast
Puerperal fever from breast engorgement is common 37.8~39, seldom persists for longer than 4~16 hours
**other causes (especially infection) of fever must be excluded
Breast Feeding Breast Feeding Endocrinology of lactation
 Progesterone, estrogen, placental lactogen, prolactin, cortisol, insulin: Appear to act in concert to stimulate the growth & development of milk-secreting apparatus of mammary glands.

Prolactin: is essential for lactation although plasma prolactin falls after delivery, suckling triggers a rise
Milk ejection or letting down reflex:
Initiated especially by suckling
stimulates neurohypophysis to liberate oxytocin
contraction of myoepithelial cells in the alveoli & small milk ducts
milk expression from lactating breast      Management Isolation the mother and baby
Ceasing breastfeeding from affect breast
Expression of milk either manually or by electric pump
Microbiological culture and sensitivity of a sample of milk
Flucloxacillin can be commenced while awaiting sensitivity result .

Breast abscess : Surgical drainage (essential) & general anesthesia Problems during the Puerperium Psychological problems Etiology Baby Blues Postpartum Psychosis Post partum Depression PPD The specific etiology of these disorders is unknown.

The current view is based on a multifactorial model.

Psychologically, these disorders are thought to result from the stress of the peripartum period and the responsibilities of child rearing.

Other authorities ascribe the symptoms to the sudden fall in estrogen and progesterone levels that occur after delivery.

Postpartum thyroid dysfunction has also been correlated with postpartum psychiatric disorders. Incidence Approximately 50-70% of women who have given birth develop symptoms of postpartum blues.

PPD occurs in 10-15% of new mothers.

The incidence of postpartum or puerperal psychosis is 0.14-0.26%. 80% of women may experience ‘post-natal blue‘ in the first 2 weeks after delivery .
Fatigue, short temperedness , difficulty sleeping ,depressed mood and tearfulness are common
Usually mild and resolve spontaneousaly . Postpartum pyrexia

Inadequate sleep

Delayed healing of the episiotomy or caesarean section wound

Delay in establishing breast feeding

Decline in sympathy, congratulations and attention of friends and family

No pharmacotherapy is indicated.

Providing support and education has been shown to have a positive effect. Factors that prolong the baby blues are: Baby blues merge with serious depression
It’s a specific form of depression that is related solely to pregnancy and childbirth
PPD generally lasts for 3-6 months, with 25% of patients still affected at 1 year.
PPD greatly affects the patient's ability to complete activities associated with daily living.
Factors aggravate depression are: Background predisposition due to previous history or family history.

A conflict in the responsibilities of looking after a new baby.

Hormone changes acting on predisposition to depression.

Anxiety and guilt.

Residual pain .

Sleeplessness . Rare condition

It’s potentially life-threatening to both the mother and the baby

It is recurrent (about 20%) but chances are decreased by a 2-year or more gap between pregnancies. Symptoms Rejection of the baby.



Agitation. Management: Admit the mother and baby to a special ward in the psychiatric unit.

Ensure 24 hour supervision.

Give appropriate psychotherapy drugs (some use electroconvulsive therapy).
This may persist after the birth and affects approximately a quarter of women.

50% of these women suffered backache before pregnancy.

Pain may be considerable and last for several months. May be difficult in first 24 hours and may require catheterization.

Around 1 in 10 women have urinary incontinence and this usually takes the form of stress incontinence.

For most women this has resolved after a few weeks.

Pelvic floor exercises may help with this. Micturation Backache Puerperal pyrexia Puerperal pyrexia is

>> a temperature of 38C or higher on any two of the first 10 days postpartum, exclusive of the first 24h measured orally by a standard technique
Predisposing factors to Puerperal Sepsis Puerperal Sepsis Definition:
An infection of the genital tract which occurs as a complication of delivery is termed as P sepsis.

L bacillus ( 60-70%)
Yeast like fungus- Candida albicans ( 25%)
Staph aureus
Strepto B haemolyticus
E coli and bacteroids
Cl welchii-rare

These organisms remain dormant and are harmless during normal delivery conducted in a septic conditions. Vaginal flora Conditions lowering the resistance 
Malnutrition & anemia
Chronic debilitating diseases
Repeated PV examination after rupture membrane
Traumatic manipulative & operative delivery
RPOC- retained product of conception
Placenta previa Investigations Management Diagnosis History Physical Complications Investigations Management Diagnosis History Physical Complications Infections Endometritis UTI Mastitis The common infections of the puerperium are:

Endometritis (Infection of the Genital Tract)

Urinary Tract Infection

Breast Infections

Wound infection It is an ascending infection which involves the placental bed.
Unlike pelvic inflammatory disease (PID) it spreads directly through the uterus to the parametrial tissues
The commonest organisms are E.coli and streptococcus faecalis
Epidemiology Endometritis complicates 1-3% of all vaginal deliveries and 5-15% of scheduled cesarean deliveries.

The incidence of endometritis in patients who undergo cesarean delivery after an extended period of labor is 30-35% and falls to 15-20% if the patient receives prophylactic antibiotics.

Following 48-72 hours of intravenous antibiotic therapy, 90% of women recover.

Fewer than 2% of patients develop life-threatening complications such as septic shock, pelvic abscess, or septic pelvic thrombophlebitis. Puerperal pyrexia-temperature above 38.0 C twice.

Offensive discharge.
Low abdominal pain.
Passage of clots and a return of red lochia.
Systemic symptoms associated with the pyrexia.
4 Classical signs:

Pyrexia 37.8-38.0 C.

Pulse 100-120.

Fundal height- not decreasing.

Lochia red & offensive smell Hb-may be reduced.
White cell count-raised with neutrophilia.
High vaginal or endocervical swab may grow the organisms. Admit to hospital.
Evacuation of retained products of conception under antibiotics cover . (broad-spectrum antibiotics should be used to cover the bacteraemia and subsequently for 5 days) Acute: Parametritis Salpingitis Broad ligament abscess Peritonitis Septic thromboembolism Long term:
Menstrual irregularities
and pelvic pain These are common in the puerperium because of:
Bladder stasis. Oedema of the bladder base. Diminished bladder sensation. Catheterization in labour.
The commonest organisms are E.coli and proteus spp.

Frequency of micturition
Loin pain if pyelonephritis supersedes
Systemic symptoms such as pyrexia and tachycardia
May be asymptomatic and recognized on routine mid-stream urine (MSU) sample
(This should be performed on all patients who have been catheterized in labour) Raised temperature
Tender suprapubically or in the renal angle MSU

White cell count

Nitrites and leucocytes on dipstick Bed rest
High fluid, light solid diet
Broad-spectrum antibiotics until the results of culture and sensitivity are known, then be specific Pyelonephritis
Exacerbation of the baby blues Inflammation of the mammary gland.
Milk stasis and cracked nipples causes the influx of skin flora.
Risk factors include primipara , incomplete emptying and improper technique.
Most common organism is s.aureus, others include s.saprophyticus, s.epidermidis, s.viridans and e.coli. Highest incidence is in the first few weeks after delivery.

Neglected , recurrent infections lead to the development of breast abscess which needs parenteral antibiotics and surgical drainage.
Diagnosis is mainly clinical : based on fever, chills, erythema, warmth, swelling and breast tenderness .
Breast Abscess
If a tender hard mass develops with high fever suspect the diagnosis of breast abscess.
Treatment includes :rest , massage , moist heat , fluids , analgesics and antibiotics.
Antibiotics include penicillinase-resistant penicillins and cephalosporines like dicloxacellin and cephalexin.
It includes Infections in the perineum at the site of episiotomy or lacerations and infections of the abdominal incision of a c-section.
Diagnosis is clinical based on erythema , induration ,pain , warmth ,tenderness and purulent discharge with fever
Perineal infections become apparent in the third or fourth day postpartum.

Risk factors include : infected lochia , fecal contamination of the wound , and poor hygiene.

Polymicrobial arising from the vaginal flora.

Always check for abscesses and hematoma.

Usually develop in the fourth postop. day and often preceded by endometritis.

Usually caused by vaginal flora but in 25% S.aureus is isolated , and in cases resistant to penicillin genital mycoplasma is isolated.

Risk factors include : DM, HT, obesity, corticosteroids ,prolonged labor , prolonged rupture of membrane , chorioamnionitis
The risk of abdominal wound infections can be decreased by the use of prophylactic antibiotic.
May be complicated by wound dehiscence and more seriously by necrotizing fasciitis

Work up : the diagnosis is clinical , but serial CBC , differential and CRP may helpful.
Treatment is based on symptomatic relief with NSAID , local anesthetics , and if there is an abscess to be drained plus the use of broad spectrum antibiotics..
In abdominal wound infection we also have to inspect the fascia to be sure that it is intact Wound infections Endocrine Disorders Postpartum thyroditis Postpartum Grave’s disease Lymphocytic hypophysitis Postpartum thyroid dysfunction can occur in 5-10% of women any time in the first postpartum year.

Primary thyroid disorder like postpartum thyroiditis or postpartum graves disease.

secondary (hypothalamic-pituitary axis disorder) like Sheehan syndrome or postpartum lymphocytic hypophysitis. Transient destructive lymphocytic thyroiditis occurring in the first year postpartum.
Silent or painless thyroiditis.
Most likely autoimmune in etiology .
Has two phases : an initial phase of thyrotoxicosis caused by destruction of the gland and release of the thyroid hormone.
Then a second phase of hypothyroidism.
Risk factors include: positive antithyroid antibody test , and a family r a personal history of thyroid or autoimmune diseases.
Clinically : patients present with painless goiter in addition to symptoms of thyrotoxicosis (fatigue , palpitation heat intolerance , nervousness) or symptoms of hypothyroidism (cold intolerance , dry skin , depression) These symptoms are mild and nonspecific and may be associated with the normal postpartum period.
Work up : TSH , thyroid stimulating antibodies (for graves disease) , radioactive iodine uptake (which can differentiate it from graves) Treatment: usually no treatment is needed since it is a mild transient disorder except if the symptoms are sever.
For thyrotoxicosis :propranolol is enough , no role for propylthiouracil .
For hypothyroidism :replacement therapy with T4 is enough.
Long term sequale is permanent hypothyroidism. Less common than PPT.
Similar to Grave’s disease in other settings.
Autoimmune antibodies against TSH receptors leading to excess production of thyroid hormones .
Needs treatment, like any other grave’s disease. Rare autoimmune disorder leading to pituitary enlargement and hypopituitarism.
Clinically : headache , visual field defects , difficult lactating , and amenorrhea.
Proper diagnosis is essential to avoid unnecessary surgery, since it is a self-limiting disorder.
Treatment of the acute phase includes hormone replacement Sheehan Syndrome During pregnancy the ant. Pituitary enlarges because of an increase in the size and the number of prolactin secreting cells.

Patients who develop severe hemorrhage during the peripartum period will suffer from ischemic necrosis of the gland.

Pan hypopituitarism : problem in lactation , amenorrhea , cortisol and thyroid deficiency symptoms.

Treatment is by hormonal replacement.
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