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Puerperium

Definition

Normal puerperium
  1. The time from the delivery of the placenta through the first few weeks after the delivery
  2. 6 weeks in duration. 
  3. By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery resolves and the body reverts to the non pregnant state.

The puerperium has been referred to as the “ fourth trimester” of pregnancy, encompassing the period between the delivery and complete physiologic involution and psychological adjustment. 

Abnormal Puerperium

  • Puerperal Pyrexia
  • postnatal psychosis and depression

Puerperal Pyrexia

Definition

P pyrexia is defined as temperature of 38oC ( 100.4oF) or higher on any two occasions persisting after the first 24 hrs of delivery, and within 10 days postpartum taken by mouth by a standard technique.

Cause of P. Pyrexia
  1. P. Sepsis- Genital tract infection
  2. UTI
  3. Breast Complications
  4. Wound Infections
  5. Thrombophlebitis and DVT
  6. Respiratory infections

Puerperal Sepsis

Definition

An infection of the genital tract which occurs as a complication of delivery is termed as P sepsis.

Vaginal flora
  1. L bacillus ( 60-70%)
  2. Yeast like fungus- Candida albicans ( 25%)
  3. Staph albus or aureus
  4. Strepto β haemolyticus
  5. E coli and bacteroids
  6. Cl welchii-rare


These organisms remain dormant and are harmless during normal delivery conducted in aseptic conditions. 

Predisposing factors to P Sepsis


  1. Conditions lowering the resistance 
  2. Malnutrition & anaemia
  3. PROM
  4. Chronic debilitating diseases
  5. Repeated PV examination after rupture membrane
  6. Traumatic manipulative & operative delivery
  7. Haemorrhage 
  8. RPOC- retained product of conception
  9. Placenta previa




Organism responsible for P sepsis
  • Aerobic- Staph, Ecoli, Klebsiella, Pseudomonas, Non-haemolyticus Strepto, 

  • Anaerobic- Anaerobic streptococcus, Bacteroids, Cl welchii and tetani

Pathology and the primary site of infection

Uterus

Endomyometritis- is the most common and usually mildest form of genital infection.

4 Classical signs:
  • Pyrexia 37.8-38o C
  • Pulse 100-120
  • Fundal height- not decreasing
  • Lochia red &offensive smell


Clinical examination & Daily Charting

Investigations

  1. High vaginal smear and endocervical swab for C/S
  2. MSU for R/M/E & C/S
  3. Blood for Hb,TC, DC & C/S
  4. Blood for MP
  5. Widal Test
  6. X-ray chest


Treatment 

1.Adequate fluids, rest and movement of bowel- Milk of magnesia
2.Correction of anaemia
3.Antibiotics- Broad spectrum
        I/V Ampicillin 500mg  6 hrly
        I/V Metronidazole 500 mg  8 hrly
        I/V Gentamycin  3-5 mg/kg body wt in divide dose
                                    OR
        I/V Ceftriaxone / Cefotaxim 1 gm 12 hrly
                    Change according to C/S             

Urinary tract infection
  • Incidence is 1-5%
  • Organisms- E coli, klebsiella, Proteus, Staph aureus
  • Causes- Frequent catheter, stasis of urine due to lack of bladder tone & less desire to pass urine, Asymptomatic bacteriuria becomes symptomatic, 
  • Present- Fever with chills & rigor, burning micturition, frequency, nausea, vomiting, acute pain in the loins radiating to groin.
  • Investigation- Urine for R/M/E and C/S
  • Treatment -Antibiotics

Causes of retention urine in puerperium

1.Bruising and oedema of the bladder neck
2.Reflex from the perineal injury
3.Unaccustomed position
4.Haematoma

Treatment
  • General measures
  • Indwelling catheter for 48 hrs- It helps in regaining the normal bladder tone and the sensation of fullness.
  • Antibiotics

Breast Complications

Common breast complications are

1.Breast engorgement
2.Cracked & retracted nipples
3.Mastitis and breast abscess
4.Failing lactation

Breast engorgement
  • Due to exaggerated normal venous & lymphatic engorgement preceding lactation, preventing escape of milk from lacteal systm.
  • Manifest after the milk secretion- 3rd -4th PPD
  • S/S- Pain, feeling of tenseness and heaviness in both breast, malaise, ↑tempt
  • Treatment-Support breast with binder & brassiere, ice bag, express milk or frequent breast feeding, analgesic
  • Prevention- Manual expression of the remaining milk & frequent breast feedings

Cracked Nipple
  • Due to a) loss of surface epithelium, causing a raw area b) fissure at the tip or base of nipple
  • Caused by 1)unhygiene –crust over the nipple 2) retracted nipple 3) vigorous suckling
  • Asymptomatic usually but if infection, it is painful due to mastitis
  • Treatment-keep nipple clean & dry, nipple shield during each feed, rest if worst and feed by expression, antibiotics ( oral & applicant)  and analgesic
  • Prevention-Local cleanliness during pregn and puerperium

Retracted nipple
  • Primigravida
  • If left uncorrected may predispose to cracked nipple- difficulty in breast feeding
  • Manual lifting of the retracted nipple during pregnancy is advisable.
  • After delivery, use of nipple shield is advisable.

Acute Mastitis

Mode of infection


2 different types of mastitis

  • Infection follows a cracked nipple to involve the breast parenchymal tissues leading to cellulites.
  • Infection gains access through the lactiferous duct leading to development of primary mammary adenitis
  • Responsible organism is Staph aureus- infection comes from nasopharynx of the baby.

Clinical feature
  • Symptom- Generalised malaise, headache, fever with chills
  • Severe pain and tender, swelling in 1 quadrant of the breast.
  • Sign- Wedge shaped swelling on the breast with the apex at the nipple
  •  Over lying skin is hot, flushed, tense and tender

Treatment

  • Antibiotics- Cloxacillin, Cefalosporin
  • Analgesic 
  • Antenatal-Wash the nipple periodically to keep the patency of the duct opening.
  •  Breast feeding on the affected is suspended
  • Manual expression & prevention of engorgement of breast.

Breast Abscess
  • Swinging tempt
  • Reddened breast
  • Marked tenderness with fluctuation.

Treatment
  • Antibiotics
  • Incision and drainage

Wound infection
  • Wound can be that of a CS or an episiotomy wound
  • Infection in the wound usually develops around the 5th to 6th POD
  • Take Swab from the wound and send for C/S 
  • Treat with antibiotics and daily dressing
  • Followed by secondary suture,

Chest infections
  • Usually following general anaesthesia in CS
  • Take x-ray chest and sputum for C/S
  • Treatment is with physiotherapy, warm saline gurgle, steam inhalation and antibiotics

Deep Vein Thrombosis (DVT)
  • Usually occurs at around 7-10th PPD
  • Begins in the deep veins of the calf or soles of the feet and extend upwards
  • Often symptomless
  • Sharp dorsiflexion of the foot elicit pain in the calf-Homan’s sign
  • Slight rise of tempt & pulse.
  • These early S/S may be missed and detected only when pulmonary embolism has developed or when the generalised oedema of the leg has set.
  • Exercise in early puerperium is beneficial.
  • The foot end of the bed is elevated to increase the venous flow from the leg.
  • Antibiotics to prevent infection
  • Anticoagulant to prevent clot formation-Heparin.
  • After being afebrile the pt is encouraged to walk about with the affected leg supported by elastic bandage.



Post Partum Blues, Depression and Psychosis


Post partum Blues



  • Occurs in around 50% of the women
  • Around 4th to 5th PPD
  • Usually self limiting though in rare circumstances progresses to postnatal depression.
  • Cure by support of medical practitioner is all that is required



Post natal depression


  • Onset at around 4th week PP 
  • Lasting for around 6 months
  • Family H/O mental disorder is usually present.
  • C/F are that of sleep disturbance, depression, social withdrawal, lack of worthiness of being a mother, suicidal thoughts, concern that she may harm her child
  • Management- Social support, refd to psychiatrist



Puerperal Psychosis


  • Occurs in 0.2% of the mothers
  • Onset is earlier than the postnatal depression
  • The chance that a mother may harm her baby is very high.
  • Serious condition the requires an expert psychiatric evaluation and treatment