DR A.O. OGUNLAJA

SENIOR LECTURER/CONSULTANT OBSTETRICIAN GYNAECOLOGIST

OUTLINE Introduction

Physiological Changes

Uterine involution

Lochia

Genital tract changes

The breast and lactation

Other systems

• Puerperal disorders

INTRODUCTION Puerperium is a six week period following

completion of third stage of labour, when

considerable adjustments occur before return to

the pre-pregnant state.

It is a period of considerable psychological

vulnerability.

PHYSIOLOGICAL CHANGES

The physiological changes includes;

1. Uterine involution

2. Lochia

3. Genital tract changes

4. The breast and lactation

5. Resumption of menses

6. Other systems

Uterine Involution This is the process by which the postpartum

uterus, weighing about 1000grams(1kg) returns

to its pre-pregnancy state of less than 100grams.

Immediately after delivery, the uterine fundus lies

at about the umbilicus, in some cases it may be

about four(4)cm below the umbilicus or even

12cm above the symphysis pubis.

When there is coexisting fibroid the uterine

fundus may lie above the umbilicus.

Uterine Involution

Uterine involution is achieved by a process of

autolysis.

Autolysis is the enzymatic digestion of cytoplasm

of muscle cells including digestion of blood clots,

some blood vessels and other fibroelastic tissues.

This virtually has no effect on the number of

muscle cells, and the excess protein produced

from autolysis is absorbed into the bloodstream

and excreted in the urine.

Causes Of Delayed Involution

Uterine infection

Retained products of conception like placenta tissue, fetal membrane and occasionally blood clots

Uterine Fibroids

NOTE:

A delay in involution in the absence of any other signs or symptoms e.g. bleeding or delay in lochia resolution is of no clinical significance.

LOCHIA Lochia is a blood-stained uterine discharge that

is comprised of blood and necrotic decidua. Only

the superficial layer of decidua becomes necrotic

and is sloughed off.

The lochia consists of erythrocytes, shreds of

decidua, epithelial cells, leucocytes and bacteria

which invade the uterine cavity from the vaginal

commensals.

Types Of Lochia

1. Lochia Rubra

2. Lochia Serosa

3. Lochia Alba

1.Lochia rubra; is seen for the first 3-4 days after

delivery. it is red in colour. Persistent rubra

suggests delay in involution.

2.Lochia serosa; is seen for about 5-9 days after

delivery. It is pale in colour compared to rubra

3.Lochia alba; is seen about the 10th day after

delivery. It is yellowish white in colour.

GENITAL TRACT CHANGES Cervix;

the cervix is flaccid and hypertrophied after delivery with the internal and external os open. With these changes, the cervix shrinks down rapidly and the internal os and external os gradually reduce in size; the internal os becomes closed on finger examination towards the second week of the puerperium although the external os may remain open for quite a variable period beyond the end of puerperium.

GENITAL TRACT CHANGES Vagina;

The vagina is usually dilated and stretched out

with flattening and smoothening of the vaginal

wall. Within a few days after delivery, it shrinks

down to its normal capacity with return of some

of the rugae.

The fourchette and introitus return to their pre-

pregnancy state gradually.

The Breast And Lactation

Recall anatomic & physiologic changes of breast in pregnancy

Proliferation of ducts & alveoli. Increased lobules by hyperplasia & later hypertrophy.

After delivery, marked increased size of alveolar cells & secretory organelles, ultimately distension of the alveoli by milk

Colostrum is secreted (higher Immunoglobulin & White Blood Cells, lower fat & lactose)

Concentration of fat & lactose increase rapidly first two weeks Postpartum.

RESUMPTION OF MENSES

Amenorrhea

Duration & frequency of breast feeding important factors

In non-breast feeding mothers, 1st postpartum menses

occurs approx 55 – 60days (range 20 – 120days).

Frequency of ovulation increases the farther from delivery

1st menses occurs

(84% of cycles ovulatory after 60 DPP versus 52% when

less than 60days)

Wider variation in return of menses in breast feeding women

NB – Elevated prolactin inhibits ovarian response to FSH

Suckling increases normal pulsatile release of FSH & LH, by

interfering with hypothalamic GnRH.

MANAGEMENT OF NORMAL PUERPERIUM Early discharge

Perineal Care( sitz bath, perineal hygiene, Analgesics)

Breast Care

Good nutrition

Health Education

Immunization

Resumption of coitus

Social support

Contraception and family planning Counselling

Follow-up Visit

PUERPERAL DISORDERS Perineal complications

Bladder dysfunction

Bowel dysfunction

Secondary postpartum haemorrhage

Obstetric palsy( foot drop)

Symphysis pubis diastesis

Puerperal pyrexia

Sheehan’s syndrome

Psychiatric disorders

Perineal complications Perineal discomfort is the single major problem for

mothers, and about 80% complain of pain in the first 3 days after delivery, with a quarter continuing to suffer discomfort at day 10.

Discomfort is greatest in women who sustain spontaneous tears or have an episiotomy, but especially following instrumental delivery.

Infections of the perineum are generally uncommon considering the risk of bacterial contamination during delivery.

This complaint alongside with the discharge of lochia can affect resumption of coitus

Bladder function Voiding difficulty and over-distension of the bladder

are common after childbirth, especially if regional

anaesthesia ( epidural/spinal) has been used.

Over-stretching of the detrussor muscle can dampen

bladder sensation and make the bladder

hypocontractile, particularly with fibrous replacement

of the smooth muscle.

Bowel function Constipation is a common problem in the

puerperium. This may be due to an interruption in

the normal diet and possible dehydration during

labour.

Advice on adequate fluid intake and increase in fibre

intake may be all that is necessary.

Secondary postpartum hemorrhage Secondary postpartum hemorrhage(PPH) is defined

as fresh bleeding from the genital tract between 24 hours and 6 weeks after delivery.

The most common time for secondary PPH is between days 7 and 14, and the cause is most commonly attributed to retained placental tissue.

The management of heavy bleeding includes an intravenous infusion and antibiotics in cases of infection, cross-match of blood, syntocinon, an examination under anaesthesia and evacuation of the uterus.

Obstetric palsy Obstetric palsy or traumatic neuritis, is a condition in

which one or both lower limbs may develop signs of

a motor and/or sensory neuropathy following

delivery.

Presenting features include sciatic pain, foot-drop,

parasthesia, hypoaesthesia and muscle wasting.

The mechanism of injury is unknown and it was

previously attributed to compression or stretching of

lumbrosacral trunk as it crosses the sacroiliac joint

during the descent of the fetal head.

Obstetric palsy It is now believed that herniation of the lumbrosacral

discs ( L4 or L5) can occur, particularly in the

exaggerated lithotomy position and during

instrumental delivery.

An orthopeadic surgeon and physiotherapist opinion

should be sought and management includes bed

rest with a firm broad beneath the matress,

analgesia and physiotherapy.

Symphysis pubis diasthesis Separation of the symphysis pubis can occur

spontaneously in least 1 in 800 vaginal deliveries.

Deliberate surgical separation of the pubis in labour (symphysiotomy) is rarely in extreme cases of shoulder dystocia.

It is important to note that this seperation may occur spontaneously in some cases of difficult vaginal deliveries.

Treatment includes bed rest, anti-inflammatory agents, physiotherapy and pelvic corset to provide support and stability.

Thromboembolism The majority of death in puerperium and are more

common after caesarean section.

It is worthy to note that there is a hypercoagulable

state in pregnancy and peurperium.

If deep vein thrombosis or pulmonary embolism is

suspected, full anticoagulant therapy should be

commenced, and a lower limb compression

ultrasound and/or lung scan should be carried out

within 24-48 hours.

Puerperal pyrexia Significant puerperal pyrexia is defined as a

temperature of 38 centigrade or higher on any two

of the first 10 days postpartum, exclusive of the first

24 hours (measured orally by a standard technique)

A mildly elevated temperature is not uncommon in

the first 24 hours, but any pyrexia associated with

tachycardia merits investigation.

In about 80% of women who develop a temperature

in the first 24 hours following vaginal delivery, no

obvious evidence of infection can be identified.

Puerperal pyrexia Common sites associated with puerperal pyrexia

include chest, throat, breasts, urinary tracts, pelvic

organs, ceasarean section or perineal wounds.

Causes; Malaria, puerperal sepsis, mastitis, Urinary

Tract Infection, chest infection, wound infection.

Puerperal sepsis Puerperal sepsis is infection of the genital tract.

It is usually due to poly microbial organism. It

involves contaminants from the bowel that colonize

the perineum and genital tract.

The frequently identified is group B streptococcus

The risk factors include; chorioamnionitis, prolonged

rupture of membrane, instrumental delivery.

Organisms commonly associated with pueperal sepsis Aerobes Anaerobes

Gram positive

1. Beta-hemolytic

streptococcus

2. Staphylococcus

epidermidis

Gram negative

1.Escherichia coli

2.Heamophilus influenza

3.Klebsiella pneumonia

4.Pseudomonas aeruginosa

1.Peptococcus sp

2. Peptostreptococcus sp

3.Bacteroides species- B

fragilis, B. bivius, B. disiens

Miscellaneous

1. Mycoplasma hominis

2. Chylamdia trachomatis

Mastitis Inflammation of the mammary gland

Milk stasis & cracked nipples contribute to the influx of skin flora

• Clinical Presentation; • Fever, chills, myalgias, warmth, swelling and breast

tenderness • Exam Findings; • Area of the breast that is warm, red, and tender • Treatment; • moist heat,massage,fluids,rest,Proper positioning of

the infant during nursing,Nursing or manual expression of milk,analgesics,antibiotics

Sheehan’s syndrome COMPONENTS OF SHEEHAN’S SYNDROME

Absence of lactation

amenorrhea

Loss of axillary & pubic hair

Genital & breasts atrophy

Super-involution of the uterus

Infertility

Hypothyroidism

Adreno-cortical insufficiency

Psychological Disorders in Puerperium

Puerperium Blues Transient disorder

Lasts hours to weeks Bouts of crying and sadness

Puerperium Depression More prolonged affective disorder

Weeks to months Symptoms and signs of depression

Puerperium Psychosis First postpartum year Group of severe and varied disorders (psychotic symptoms)

Thank You For Listening