Puerperium By Prof. dr. A. El-Sharef puerperium Puerperium : Is period during which the reproductive...

PuerperiumPuerperiumBy Prof. dr. A. El-SharefBy Prof. dr. A. El-Sharef

DIRECT CAUSES OF MATERNAL DEATH

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HAEMORRHAGE

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UNSAFEABORTION

RUPTURE UTERUS

OBSTRUCTEDLABOUR

PUERPERALSEPSIS

OTHERS

puerperiumpuerperium Puerperium : Is period during Puerperium : Is period during

which the reproductive organs and which the reproductive organs and all the system of the body returns all the system of the body returns to their normal condition following to their normal condition following the delivery of the placenta andthe delivery of the placenta and

o Ends approximately 6 weeks laterEnds approximately 6 weeks later..

puerperiumpuerperium

When the endocrine influences When the endocrine influences of the placenta removed the of the placenta removed the physiological changes of physiological changes of pregnancy is reversedpregnancy is reversed

PuerperiumPuerperium

Maternal physiology is well prepared for Maternal physiology is well prepared for hemorrhage:hemorrhage:

increase in blood volumeincrease in blood volume . .

hypercoagulable state. hypercoagulable state.

the “tourniquet” effect of uterinethe “tourniquet” effect of uterine contractionscontractions..

MECHANISM OF HAEMOSTASIS MECHANISM OF HAEMOSTASIS AFTER DELEVERYAFTER DELEVERY

• Uterine contraction & retractionUterine contraction & retraction

• Platelet aggregation Platelet aggregation clot formation clot formation

The Principal ChangesThe Principal Changes

1)1) Uterine Involution Uterine Involution ::

The principal The principal changeschanges

Uterine involution Uterine involution ::

1.1. Uterine involution :Uterine involution :

After the delivery of baby the uterus After the delivery of baby the uterus (myomaterial muscle )is well contracted & (myomaterial muscle )is well contracted & retracted and become at the level of the retracted and become at the level of the umbilicus , and after 10 – 14 days the umbilicus , and after 10 – 14 days the uterus well become as pelvic organ.uterus well become as pelvic organ.

Breast feeding leading to release of Breast feeding leading to release of oxytocin from the hypothalamus & oxytocin from the hypothalamus & posterior pituitary aiding the posterior pituitary aiding the process of involution & more process of involution & more contraction & retraction of the contraction & retraction of the myomaterial muscle of the uterus myomaterial muscle of the uterus and decrease the incidence of post and decrease the incidence of post partum hemorrhagepartum hemorrhage

Uterine involution Uterine involution ::

Uterine involutionUterine involution

At the time of the delivery At the time of the delivery uterine weight about ( 1 uterine weight about ( 1 Kg) then after few weeks Kg) then after few weeks become 50 -60 gm and become 50 -60 gm and shrinks at the process of shrinks at the process of autolysis .autolysis .


Sub-involution of the uterus this Sub-involution of the uterus this occur when the uterus is not occur when the uterus is not completely contracted & completely contracted & retracted which well leads to retracted which well leads to post partum hemorrhage and post partum hemorrhage and this mostly due to :this mostly due to :

I.I. Full bladderFull bladder


II.II. Retained products of Retained products of placentaplacenta


III.III. Infection at the Infection at the uterusuterus


Para-vaginal Para-vaginal haematomahaematoma

2 - endometrium2 - endometrium The deciduas castes off as result of ischemia and

lost as lochial flow . The lochia consists of blood , leucocytes , shreds of

deciduas and organisms . The lochia is initially dusky red but this color fades after the first week and the flow usually clears completely within 4 weeks of delivery .

The new endometrial will grow from the basal areas of the deciduas but this will influenced by breast feeding.

3- cervix3- cervix

Cervix is very flaccid and curtain –like Cervix is very flaccid and curtain –like after delivery but within a few days is after delivery but within a few days is returning to the original form and returning to the original form and consistency . consistency .

The cervical channel become closed to The cervical channel become closed to a finger during the second week of a finger during the second week of PuerperiumPuerperium . .

4- Vagina4- Vagina The vagina almost , always shows evidence of parity . The vagina almost , always shows evidence of parity .

In the first few days of puerperium , the vaginal walls In the first few days of puerperium , the vaginal walls are smooth , soft and edematous .are smooth , soft and edematous .

The distention which has resulted from labor remains The distention which has resulted from labor remains for a few days but the return to the normal capacity for a few days but the return to the normal capacity quit quick .quit quick .

the episiotomies or vaginal and perennial tears the episiotomies or vaginal and perennial tears healed well provide adequate suturing has been healed well provide adequate suturing has been undertaken .undertaken .

Healing may be impaired in the presents of infection Healing may be impaired in the presents of infection or haematoma but even if this happens, healing by or haematoma but even if this happens, healing by granulation is usually occurs.granulation is usually occurs.

5- 5- Other Other systemssystems

During the first few days the bladder and urethra During the first few days the bladder and urethra may show evidence minor trauma sustained at may show evidence minor trauma sustained at delivery but don't usually remains in evidence for delivery but don't usually remains in evidence for long .long .

The physiological hydroureter & hydronephrosis The physiological hydroureter & hydronephrosis will disappears within 6 weeks . will disappears within 6 weeks .

there is usually a diuresis during first day of the there is usually a diuresis during first day of the puerperium and there is fall in plasma volume.puerperium and there is fall in plasma volume.

5- 5- Other systemsOther systems The blThe blood loss at delivery has been normal ood loss at delivery has been normal

and should be no anemia and hemoglobin and should be no anemia and hemoglobin concentration will rise.concentration will rise.

The levels of blood clotting factors and The levels of blood clotting factors and platelet count rise after delivery .platelet count rise after delivery .

The inhibition of systemic fibrinolytic The inhibition of systemic fibrinolytic activity which occurs during pregnancy is activity which occurs during pregnancy is reversed within 30 min. of placental reversed within 30 min. of placental delivery . delivery .

Active mangement 0f 3Active mangement 0f 3rdrd stage of labourestage of laboure

Oxytocics - Oxytocics - Routine use in third stage Routine use in third stage blood loss blood loss by by 30-40% 30-40% 10 Units Oxytocin IV bolus10 Units Oxytocin IV bolus Syntometrine 1 Amp IV at the delivery of the anterior Syntometrine 1 Amp IV at the delivery of the anterior

shoulder.shoulder. Ergometrine 1 Amp IV at the delivery of the anterior Ergometrine 1 Amp IV at the delivery of the anterior

shoulder.shoulder. Carboprost ( better than Ergometrine) 0.125 – 0.25 Mg Carboprost ( better than Ergometrine) 0.125 – 0.25 Mg

IM IM

Early cord clampingEarly cord clamping

Active mangement 0f 3Active mangement 0f 3rdrd stage of labourestage of laboure

Inspection of placenta & Inspection of placenta & lower genital tractlower genital tract

Management of normal Management of normal puerperiumpuerperium


The majority of mothers are perfectly The majority of mothers are perfectly well during the puerperium and well during the puerperium and should be encouraged to establish should be encouraged to establish normal activities. normal activities.

Immediately following the delivery of Immediately following the delivery of the placenta observation of :the placenta observation of :


1.1. Vital signs (P,BP,Temp,R.R)Vital signs (P,BP,Temp,R.R)

+ contraction of the uterus (uterin involution) + contraction of the uterus (uterin involution) + Lochia (amount; colure ,and odder) + Lochia (amount; colure ,and odder)

=Every 5 min. for ½ hours , then every ½ =Every 5 min. for ½ hours , then every ½ hourly for 2 hours, then transfer the hourly for 2 hours, then transfer the mother to the postnatal ward and mother to the postnatal ward and observation every 2 hours for 6 hourly; observation every 2 hours for 6 hourly; then 6 hourly till discharge.then 6 hourly till discharge.


2 ) -2 ) - Breast examination+lawer limb Breast examination+lawer limb examination for the detection of signs examination for the detection of signs of DVT every day. of DVT every day.

3 ) -3 ) - The mother should be encouraged The mother should be encouraged to pass urine.to pass urine.


4 ) -4 ) - Early mobilization. Early mobilization.

5 ) -5 ) - Management of episiotomy ;and perennial Management of episiotomy ;and perennial tears.tears.

6 ) -6 ) -In normal delivery the mother can go home In normal delivery the mother can go home 48 hours after delivery ;and 10 days in C.S. 48 hours after delivery ;and 10 days in C.S.

7 ) -7 ) - Diet regime. Diet regime.

8 ) -8 ) - postnatal visit. postnatal visit.

9 ) -9 ) - Advising for contraception and spacing of Advising for contraception and spacing of pregnancy.pregnancy.

breast feedingbreast feeding

LactationLactation Lactation : In those mothers who breast Lactation : In those mothers who breast

feed , lactation is the most dominant feed , lactation is the most dominant physiological event of puerperium .physiological event of puerperium .

• The primary function of breast feeding to The primary function of breast feeding to continuing of nutrition for newborn .continuing of nutrition for newborn .

• The secondary function :The secondary function : protection agonist infant infection .protection agonist infant infection . Inhibition of ovarian activity .Inhibition of ovarian activity . Encouragement of uterine involutionEncouragement of uterine involution . .

Physiology of lactationPhysiology of lactation

The major part of breast development The major part of breast development occurs at puberty before the first occurs at puberty before the first pregnancy . pregnancy .

SoSo , only requires minimal hormonal , only requires minimal hormonal stimulation for production of milk stimulation for production of milk

The skin of the areola is relatively The skin of the areola is relatively insensitive to tactile stimuli during insensitive to tactile stimuli during pregnancy but , much more sensitive pregnancy but , much more sensitive immediately after delivery .immediately after delivery .

Breast changesBreast changes

Milk productionMilk production

Two similar independent mechanisms for Two similar independent mechanisms for successful lactation :successful lactation :

1.1. Prolactin release from A .p Prolactin release from A .p mammary glandular tissue mammary glandular tissue stimulation of milk secretion .stimulation of milk secretion .

Prolactin is long chain of polypeptide it Prolactin is long chain of polypeptide it has only physiological role that its action has only physiological role that its action on lactating breast . on lactating breast .


Prolactin level during lactation depending Prolactin level during lactation depending on the suckling ( strength , frequency and on the suckling ( strength , frequency and duration ) duration )

Prl. release from A.p Prl. release from A.p reaching peak blood level at 30 -45 min. reaching peak blood level at 30 -45 min. after suckling and returns to the basal after suckling and returns to the basal level after 2 hour after suckling .level after 2 hour after suckling .

Adequate emptying of milk – secretary Adequate emptying of milk – secretary glands.glands.

Milk productionMilk production Basal prl. Is highest in the immediate puerperium but :Basal prl. Is highest in the immediate puerperium but : In breast feeding decline slowly as suckling In breast feeding decline slowly as suckling

declines in later lactation revert to non pregnant declines in later lactation revert to non pregnant levels immediately after weaning ( 54 weeks).levels immediately after weaning ( 54 weeks).

In bottle feeding reverted to non In bottle feeding reverted to non

pregnant levels immediately after delivery ( 10 weeks ).pregnant levels immediately after delivery ( 10 weeks ). so prl. appears essential for lactation due to : so prl. appears essential for lactation due to :

bromocriptin or dopamine agonist which is selectively bromocriptin or dopamine agonist which is selectively inhibits prl. secretion and decrease milk secretion . inhibits prl. secretion and decrease milk secretion .

so prl. appears essential for so prl. appears essential for lactation due to : bromocriptin lactation due to : bromocriptin or dopamine agonist which is or dopamine agonist which is selectively inhibits prl. selectively inhibits prl. secretion and decrease milk secretion and decrease milk secretion . secretion .


2 ) – milk ejection reflex ( milk lead down ) mediated 2 ) – milk ejection reflex ( milk lead down ) mediated by release of oxytocin from hypothalamus and by release of oxytocin from hypothalamus and ( p.p ):( p.p ):

causing contraction of myoepithelial cells around causing contraction of myoepithelial cells around the milk –secretary .the milk –secretary .

dilatation of main ducts .dilatation of main ducts .SoSo , Expelling milk from glands . , Expelling milk from glands . oxytocin released in response to : suckling , and oxytocin released in response to : suckling , and

sensory input like mother seeing or hearing their sensory input like mother seeing or hearing their baby crying baby crying ..


Highest levels of oxytocin occurring before Highest levels of oxytocin occurring before suckling in response to the baby cry .suckling in response to the baby cry .

Milk ejection reflex may be inhibited by emotional Milk ejection reflex may be inhibited by emotional stress and maternal anxiety and leads to failure of stress and maternal anxiety and leads to failure of lactation .lactation .

SoSo , the key of both mechanisms activated by , the key of both mechanisms activated by suckling and mediated through neuro-suckling and mediated through neuro-endocrianological pathways .endocrianological pathways .

Breast feeding & fertilityBreast feeding & fertility

The key event in lactating amenorrhea The key event in lactating amenorrhea is suckling induce changes in the is suckling induce changes in the hypothalamic sensitivity to the feed hypothalamic sensitivity to the feed back effects of ovarian hormones .back effects of ovarian hormones .

During lactation hypothalamus more During lactation hypothalamus more sensitive to the negative feedback and sensitive to the negative feedback and less sensitive to the positive feedback less sensitive to the positive feedback ..


In bottle feeding :In bottle feeding :Prl. Returns to level of non pregnant

ovarian follicular development ( E2 > 10 micro – gm ).

And ovulation occur ( P4 >1 mg ) menstruation by 14 weeks post _ delivery .


In breast feeding :In breast feeding :• During first week of suckling ( 60 min./ day ) , the ovarian During first week of suckling ( 60 min./ day ) , the ovarian

activity is inhibited and menstruation is suppressed .activity is inhibited and menstruation is suppressed .• At 32 weeks suckling has fallen to 25 min/ day the ovarian At 32 weeks suckling has fallen to 25 min/ day the ovarian

follicular activity returns to the normal ( anovulatory follicular activity returns to the normal ( anovulatory cycles )cycles )

• At 52 weeks normal ovulatory cycles occurs .At 52 weeks normal ovulatory cycles occurs .• Breast feeding has important contraceptive effect but not Breast feeding has important contraceptive effect but not

absolutely reliable especially after menstruation absolutely reliable especially after menstruation returns ,and ( 1-10%) of women will conceive during returns ,and ( 1-10%) of women will conceive during lactation lactation ..

Complication during breast Complication during breast feedingfeeding

1)1) cracked nipple .cracked nipple .2)2) Breast engorgementBreast engorgement . .

3.3. Acute mastitisAcute mastitis

4.4. Breast abscess drain and Breast abscess drain and with systemic antibioticwith systemic antibiotic

Composition of breast Composition of breast milk milk

Comparison to Cow's Comparison to Cow's milk :milk :

H . M H . M C. MC. M

Energy ( Kcl / 1000ml )Energy ( Kcl / 1000ml ) 7575 6666

Protein ( g /100 ml)Protein ( g /100 ml) 1.11.1 3.53.5

Fat ( g / 1000 ml )Fat ( g / 1000 ml ) 4.54.5 3.73.7

Lactose ( g / 1000ml)Lactose ( g / 1000ml) 6.86.8 4.74.7

Sodium (mcq / L )Sodium (mcq / L ) 77 2222

contra- indication to breast feedingcontra- indication to breast feeding

I.I. Maternal : Maternal : A.A. general disease :general disease :o H .I .V ( + ve )H .I .V ( + ve )o Active pulmonary T.B .Active pulmonary T.B .o Heart failure .Heart failure .o Chronic nephritis .Chronic nephritis .B.B. local : breast abscess and cracked nipples .local : breast abscess and cracked nipples .2)2) newborn : sever prematurely and newborn : sever prematurely and

malformation interfere with suckling as cleft –malformation interfere with suckling as cleft –palate .palate .

Drugs and breast feedingDrugs and breast feeding

Some drugs depress milk secretion like :Some drugs depress milk secretion like : AtropinesAtropines Estrogens Estrogens Bromocriptines Bromocriptines drugs produce sedation like :drugs produce sedation like :Opiates , phenobarbiton , diazepam , chlorohydrate , Opiates , phenobarbiton , diazepam , chlorohydrate ,

bromides and large amount of alcohol .bromides and large amount of alcohol . Iodides , thioracil , and radioactive iodine can Iodides , thioracil , and radioactive iodine can

damage thyroids function. damage thyroids function. BUTBUT (carbimazol is (carbimazol is safe )safe ) . .

Breast feeding is contraindicated ifBreast feeding is contraindicated if Mother is under treatment of :Mother is under treatment of :1)1) Alkylating agents .Alkylating agents .2)2) 250 H cholecateiferol .250 H cholecateiferol .3)3) Metronidazol .Metronidazol .4)4) Lithium .Lithium .5)5) Ergotamins .Ergotamins .6)6) Antithyriod .Antithyriod .7)7) Cytotoxin drugs . Cytotoxin drugs .

Complication of Complication of puerperiumpuerperium

Complication of puerpruimComplication of puerpruim

Serious , and sometimes fatal Serious , and sometimes fatal complication arise during complication arise during puerprium , the most serious puerprium , the most serious complication are :complication are :

1)1) thrombus – embolism ( D. V . T thrombus – embolism ( D. V . T and pulmonary embolismand pulmonary embolism . .

Complication of Complication of puerpruimpuerpruim

Deep veins thrombosis Deep veins thrombosis and pulmonary embolism and pulmonary embolism is now one of main causes is now one of main causes of maternal death and the of maternal death and the majority of deaths occur majority of deaths occur during the puerpuimduring the puerpuim . .

Acute DVT present in the superficial femoral vein (arrow). The Acute DVT present in the superficial femoral vein (arrow). The vein is dilated in the transverse view relative to the adjacent vein is dilated in the transverse view relative to the adjacent

superficial femoral artery, which contains Doppler flow. No flow is superficial femoral artery, which contains Doppler flow. No flow is

present in the vein.present in the vein.


2)2) Infection .Infection .

3)3) post partum post partum hemorrhage primary hemorrhage primary & secondary& secondary

PPHPPH

. . . the most common and severe type of obstetric hemorrhage, is an enigma even to the present day obstetrician as it is sudden, often unpredicted, assessed subjectively and can be catastrophic. The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period.

PPH CausesPPH Causes

ccUterine atony in 70% of cases .-Retained Placenta-Trauma to birth channel.-Coagulation disorders -Uterine inversion


4)4)Injury to the Injury to the birth canalbirth canal . .

UTERINE INVERSIONUTERINE INVERSION

Mostly iatrogenic due Mostly iatrogenic due to mismanagement of to mismanagement of 33rdrd stage - strong stage - strong traction on the cord traction on the cord with a relaxed uterus / with a relaxed uterus / adherent placentaadherent placenta..

Hypertensive disease.Hypertensive disease.Commonest cause of maternalCommonest cause of maternal

mortality & morbiditymortality & morbidity

about 15-20% of maternal about 15-20% of maternal deaths.deaths.

Hypertensive disease.Hypertensive disease. EclampsiaEclampsia O.5 per 1000 maternities.O.5 per 1000 maternities. Maternal mortality around 1.8%.Maternal mortality around 1.8%. 35% has major complication. 35% has major complication. 44% occurs postpartum , 38% ante 44% occurs postpartum , 38% ante

partum 18% intra partum.partum 18% intra partum.


5)5) Urinary complication .Urinary complication .

6)6) Breast infectionBreast infection

Puerperal infectionPuerperal infection

Puerperal pyrexia : which may be due to infection Puerperal pyrexia : which may be due to infection in: in:

respiratory tract infection .respiratory tract infection . pelvic organs( Site of placenta =Endometritis).pelvic organs( Site of placenta =Endometritis). U. T . I .U. T . I . surgical wounds .surgical wounds . breast infection & abscessbreast infection & abscess . . thrombo phlebitis .thrombo phlebitis .

Puerperal pelvic Puerperal pelvic infectioninfection

Before the introduction of antibiotic , it was the Before the introduction of antibiotic , it was the most important cause of maternal death .most important cause of maternal death .

now rarely results on maternal death and now rarely results on maternal death and although it can still present as acute life – although it can still present as acute life – threatening illness , it more frequently occurs as threatening illness , it more frequently occurs as low – grade infection which causes both immediate low – grade infection which causes both immediate and long – term morbidity .and long – term morbidity .

It is important that pelvic infection are diagnosed It is important that pelvic infection are diagnosed and treated as early as possibleand treated as early as possible . .


Pathology :Pathology : At delivery , the normal protective barrier

agonist infection are temporarily broken down.


this gives an opportunity for potential pathogens to ascending infection to the decidua and placenta site .

spread infection to myomatium , parametrium

Fallopian tubes , ovaries ,& peritoneum.


If virulent infection , the organism reach If virulent infection , the organism reach the peripheral circulation and the patient the peripheral circulation and the patient develops sings of septicemia and end toxic develops sings of septicemia and end toxic shock .shock .

it is more common for the infection to it is more common for the infection to remain localized in the pelvis , and if remain localized in the pelvis , and if treatment is not immediate and effective , treatment is not immediate and effective , there is danger of chronic pelvic infection there is danger of chronic pelvic infection with tubal blockage . with tubal blockage .


Predisposing factors :Predisposing factors : prolonged P. R . M. a protacted labour with multiple vaginal

examination . retained products of conception in the

uterus . blood clots in the uterus . prolonged labour .


Organisms :Organisms : Gram ( + ) : Gram ( + ) : B – hemolytic streptococci is the most virulentB – hemolytic streptococci is the most virulent Other streptococci & staphylococci may cause Other streptococci & staphylococci may cause

acute clinical picture .acute clinical picture . Gram ( Gram ( -- ): more common to find coliform such ): more common to find coliform such

as E . Coli or bacteroides fragilis .as E . Coli or bacteroides fragilis . clostridii .clostridii .


Chlamydia : more recently , there has Chlamydia : more recently , there has been interest as a cause of pelvic been interest as a cause of pelvic infection .infection .

anaerobic infection .anaerobic infection . difficult to culture .difficult to culture . it can cause chronic problems of it can cause chronic problems of

vaginal discharge , adhesion and tubal vaginal discharge , adhesion and tubal blockageblockage . .


Clinical features :Clinical features : Puerperal pyrexia associated with : Puerperal pyrexia associated with : Offensive lochia.Offensive lochia. lower abdominal discomfort . lower abdominal discomfort . In abdominal or bimanual examination :In abdominal or bimanual examination : Uterine tenderness aggravated by moving cervix .Uterine tenderness aggravated by moving cervix . Swelling beside the uterus or in the pouch of Douglas.Swelling beside the uterus or in the pouch of Douglas. Evidence of peritonitis , septicemia and bacteraemic Evidence of peritonitis , septicemia and bacteraemic

shock , at this stage :shock , at this stage : patient acutely ill , restless ,dyspnoeic with high swinging patient acutely ill , restless ,dyspnoeic with high swinging

Temp. tachycardia , dehydration and have rigors . Temp. tachycardia , dehydration and have rigors .


Diagnosis : Made by :Diagnosis : Made by : clinical grounds . And confirmed by clinical grounds . And confirmed by

culturing : culturing : high vaginal swabs , cervical canal high vaginal swabs , cervical canal

swab urethral swab , and blood swab urethral swab , and blood culture for aerobic and anaerobic culture for aerobic and anaerobic should be takenshould be taken


Treatment : after taking swabs for C.S :Treatment : after taking swabs for C.S : the initial choice : combined broad spectrum the initial choice : combined broad spectrum

antibiotics ( one of cephalosporins = cephradin 1 antibiotics ( one of cephalosporins = cephradin 1 gm / 6 hourly ) + gm / 6 hourly ) +

metronidazole 500 mg / 6 hourly and this to metronidazole 500 mg / 6 hourly and this to provides a wide rang of activity agonist Gram (+) provides a wide rang of activity agonist Gram (+) and Gram ( -) organisms .and Gram ( -) organisms .

The treatment in I .V line for (24- 36 hours) and The treatment in I .V line for (24- 36 hours) and till response has been achievedtill response has been achieved . .


When the symptoms are less acute change When the symptoms are less acute change to the oral route and treatment should to the oral route and treatment should continued for at least 10 days .continued for at least 10 days .

If there is no improvement we should If there is no improvement we should change antibiotic according to the culture change antibiotic according to the culture and sensitivity.and sensitivity.

If there is retained placental tissue within If there is retained placental tissue within uterine cavity, this should be removed uterine cavity, this should be removed under G.A.under G.A.

If there is pelvic abscess should be If there is pelvic abscess should be drainagedrainage . .

Urinary complicationUrinary complication

The commonest urinary complication The commonest urinary complication in puerperuim is : in puerperuim is :

Urinary injures .Urinary injures . Infection .Infection . Urinary retention .Urinary retention .Urinary incontinence .Urinary incontinence .

Urinary retentionUrinary retention This is common complication following delivery This is common complication following delivery

especially if there is bruising and edema around especially if there is bruising and edema around the bladder base or if there is painful episiotomy the bladder base or if there is painful episiotomy wound .wound .

sensory stimuli from the bladder are temporarily sensory stimuli from the bladder are temporarily interrupted and the bladder can be over distended interrupted and the bladder can be over distended with out discomfort to the patient .with out discomfort to the patient .

this may prevent uterine involution and lead to this may prevent uterine involution and lead to post –partum hemorrhagepost –partum hemorrhage . .

Urinary complicationUrinary complication Incontinence of urine : this is an infrequent symptom Incontinence of urine : this is an infrequent symptom

following childbirth .following childbirth . If incontinuance present it must be established if this If incontinuance present it must be established if this

urethral or through a fistula urethral or through a fistula ,,soso this need carefully this need carefully examination .examination .

Urinary fistula are uncommon in modern obstetric Urinary fistula are uncommon in modern obstetric practice and may be practice and may be due todue to : :

instrumental delivery .instrumental delivery . neglected obstructed second stage of labour .neglected obstructed second stage of labour . damaged bladder or ureter as a complication of C .Sdamaged bladder or ureter as a complication of C .S . .

Puerperal mental Puerperal mental disordersdisorders

the puerpruimthe puerpruim is frequently associated is frequently associated with feeling anxiety and depression and with feeling anxiety and depression and acute psychiatric disordersacute psychiatric disorders . .

THIS IS THE END OF THE LECTUR .

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Puerperium By Prof. dr. A. El-Sharef puerperium Puerperium : Is period during which the reproductive...

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