9. Normal puerperium. Immediate care for the mother. Flashcards
what is puerperium ?
the period of about six weeks after childbirth during which the mother’s reproductive organs return to their original non-pregnant condition.
what are the stages of puerperium ?
there are three stages :
acute/ immediate - first 24 hours
subacute/ early - unto a week
and remote - unto 6 weeks
in puerperium what are the major organs and their morphology we look out for ?
uterus
vagina
cervix
clinical involution of the uterus
following delivery, the uterus becomes firm and retract with alternate hardening and softening
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after delivery the uterus measures 20cm vertically and 10 cm , anteroposteriorly
7.5cm3 thickness
and weight about 1000g
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normal involution takes 6 weeks
One hour after delivery the fundus of the uterus lies At the umbilicus
or 13.5 cm above symphysis pubis for the first 24 hours following delivery then steady decrease in 1.25cm in the next 24 hours.
day 14 should not become palpable
endometrium starts regeneration on day 7 - It occurs from the epithelium of the uterine gland mouths and interglandular stromal cells. Regeneration of the epithelium is completed by 10th day and the entire endometrium is restored by the day 16, except at the placental site where it takes about 6 weeks.
the uterine by the end of 6 weeks should be 60 g
and uterine involution is usually complete by 6-8 weeks
what is the involution of vagina ?
Broad ligaments and round ligaments require considerable time.
6–10 weeks to involute
mucosa remains delicate for the first few weeks and submucous venous congestion persists even longer.
Rugae partially reappear at 3rd week but never to the same degree as in prepregnant state.
assessment of vaginal discharge
characteristic changes of the vaginal discharge after delivery ?
vaginal discharge of first night - offensive fishy smell
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lochia - vaginal discharge after giving birth
lochi rubra = 1-4 days ,
discharge of blood , fetal membranes , decidual remnants , meconium , vernix caseoa , lanugo
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lochi serosa = 5-9 days
yellowish or pink or pale brownish
more leukocytes than rbc,
mucus from cervix , wound exudates ,
micro-organisms
decidua
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lochi alba = 10-15 days
lots of decidual
cells ,
leukocytes , mucus ,
cholestrin crystals , fatty epithelial cells , microorganisms
because of the vaginal discharge women are advised to wear what ?
pampers
normal duration of lochis may extend up to 3 weeks
women who deliver vaginally should also do what type of excersies
kegel exercises
if there is a malodour in the vaginal discharge what does this suggest ?
infection such as ecoli
what is the clinical significance if the discharge is scant or absent?
infection
lochiostasis where the lochia is retained in the uterus and result in lochiometra - distension of the uterus pushing it out of shape
following premature labor
what is the clinical significance if there is excessive lochia?
indicate infection
or hydramnios
what is the clinical significance if red colour in lochia persist
sub involution at placenta sight - inadequate closure and sloughing of spiral arteries
or
retained products of conception
these two lead to secondary PPH (other causes uterine infection
divisions for the immediate care for mother after delivery
Secondary PPH/bleeding
RESPIRATORY FUNCTION
Cardiovascular function
haematological study
BOWEL function - constipation
Lactation
Psychiatric disorders
temperature
urinary tract
weight loss
menstruation
ovulation
rest and early ambulation
diet - lactating - high calorie and protein and fat
immunisation anti-d- gamma globulin
maternal infant bonding
postnatal exercises
to prevent infection - hygiene of bladder , vulva , care of epistomy wound
what are the changes to the urinary tract and how is it clinically important ?
pronounced diuresis 2,3rd day,
over distension of bladder
incomplete emptying leading to
urinary stasis in the ureters and bladder (observed even up to 12 weeks postpartum.)
Glomerular filtration
Dilated ureters and renal pelvis return to normal size within 8 weeks
== all leading to high risk of urinary infections
to asses there is no urinary tract infection clean catch of mis stream urine need to be collected and cultured without the presence of lochia
====== causes are — (1) unaccustomed position (2) pain from the perineal injuries. An increase in progesterone level, which inhibits the bladder muscle and leads to urinary retention.
If the patient still fails to pass urine,
physically moving around
analgesia
catheterization also indicated in case of incomplete emptying of the bladder evidenced by the presence of residual urine of more than 60 mL.
what are the cardiovascular changes ? and clinical significance ?
immediate reduction in blood volume after birth
consequently rise in CO according through out 1st week
blood pressure rises in first 48 hours
all return to normal in two weeks
clinical significance
post partum eclampsia
give nifedipine
review after 2 weeks
when does menstruation resume ?
if not breast fed resumes in 12 weeks
when does ovulation resume ?
non lactating mother - as early as 4 weeks
lactating - 10 weeks
exclusive breastfeeding - 98 percent contraception up to 6 months
how does lactation provide contraceptive and amenorrhea ?
high release of prolactin inhibit the release of gonadotropin - FSH -hypoestrogenic state and therefore no menstruation
prolactin suppress LH = an ovulation
exclusively breast feed - contraception for 6 months post partum
Nonlactating mother should use contraceptive measures in 3rd postpartum week and the lactating mother in 3rd postpartum month
what are the temp changes?
should not be above 37.2°C (99°F) within the first 24 hours
3rd day, there may be slight rise of temperature due to breast engorgement which should not last for more than 24 hours
what is a complication in acute phase after delivery
POSTPARTAL BLEEDING
what are the subacute diseases in puerperium ?
increased risk of DVT- particularly women with c cessation
Anticogaulants may be prescribed or physical activity
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postpartum infections = puerperal pyrexia
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urinary tract infections
urinary incontinence
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postpartum depression
or postraumatic stress disorder
due to all hormonal changes
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puerperal mastitis
why breast feeding should be recommenced as care for the mother ?
gives passive immunity - igA
breast feeding accelerates the involution of the uterus - because suckling and contact with the mother and child releases oxytocin - thereby causing increased uterine contractions
breast feeding has also shown to reduce breast cancer in women
weight reduction
essential amino acids delivered from the mothers milk
source of omega 3 fatty acid - which is important for brain development
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first few days is colostrum - high in protein immunological - igaA, G.M , lactoferrin , complements
lower carbohydrate, fat and potassium than the breast milk
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after 3-4 days replaced by mature breast milk - high in fat then carbs and low in protein
what are the two mechanisms important in lactation ?
milk secretion actually starts on
3rd or 4th postpartum day even though prolactin is high during pregnancy
it is only when there is drop in placental hormones esp oestrogen and progesterone prolactin from anterior pituitary gland (lh , fsh) becomes effective in lactogeneisis
Prolactin, glucocorticoids are the important hormones. Including growth hormone, thyroxine and insulin.
second suckling - release oxytocin from posterior pituitary gland - oxytocin causes contraction of the myoepithelial cells cells in the alveoli of milk ducts milk is forced down into the ampulla of the lactiferous ducts, where from it can be expressed by the mother or sucked out by the baby.
Presence of the infant or infant’s cry can induce this without suckling.
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Galactopoiesis:
maintenance
Prolactin single most important galactopoietic hormone.
ALSO equally important For maintenance is effective and continuous (>8/24 hours) is essential.
Distension of the alveoli by retained milk is due to failure of suckling. This causes decrease in milk secretion by the alveolar epithelium.
how does post partum affect repsiratory changes ?
there is immediate reduction in intrabdominal pressure
and the chest wall compliance returns to normal with the with the relief of diaphragmatic pressure
they all return to normal after 1-3 weeks postpartum - mother can feel dyspnea
there can be perineal complication because?
discomfort infected episiotomy
what are the bowl complications?
constipatin - can be due to progesterone decreasing the bowel movements
fecal incontinece due to 3rd -4th degree tear
haematological changes and their clinical significance
RBC volume and hematocrit values returns to normal by 8 weeks postpartum
leukocytosis
increase in plates and adhesiveness between them -4-10 days postpartum- esp c section
fibrinogen high till 2 weeks postpartum
= hypercoaguble state = 48 hrs postpartum
and
fibirnolytic activity enhanced first 4 days postpartum = protective
high risk for thromboembolism
in first week
what are the psychiatric disorders ?
depression due to hormonal changes
puerperium of cervix regained in ?
the external os admits two fingers for a few days but by the end of 1st week, narrows down to admit the tip of a finger only
6 weeks = for contour to be regained
External os never reverts back to nulliparas
describe closure of epstiotomy wound ?
begin by epithelial suture at the 5mm abve the apex ( the highest point of the epstiotmy) to take in any cotracted arteries
and continuous non locking sutures is put n first
then the dead space between the perineal muscles closed by intereputed suture - so there is no hematoma
if this is done propery then the perineal skin and is lying close to each ther and this is then zeaed again by continues subcuticular catgut suture
describe the care for epstiotomy wound and vulva ??
Shortly after delivery, the vulva and buttocks are washed with soap water down over the anus and a sterile pad is applied
perineal wound should be dressed with spirit and antiseptic powder after each act of micturition and defecation or at least twice a day.
sitz baths,
ice pack
pain relief medications - ibuprofen
if loch alba is beyond 3 weeks ?
lochia alba beyond 3 weeks suggests local genital lesion
management of sub involution ?
Mere size of the uterus is not important , provided there is absence of features, such as excessive lochia or irregular bleeding or sepsis, the size of the uterus can be safely ignored.
Appropriate therapy is to be instituted only when subinvolution is found to be a mere sign of some local pathology:
(1) Antibiotics in endometritis,
(2) dilation and currtegae for retained products,
(3) Pessary in prolapse or retroversion.
Methergine, often prescribed to enhance the involution process, is of little value in prophylaxis.
urinarY traCt infeCtion: It is one of the common causes of puerperal pyrexia, what is the cause ?
effect of frequent catheterization, either during labor or in early puerperium to relieve retention of urine,
(b) stasis of urine
organism reposnisble for urinary tract infection
E. coli, Klebsiella, Proteus and S. aureus
what is puerperal pyrexia ?
A rise of temperature reaching 38°C
on two separate occasions 24 hours apart within first 10 days following delivery
what are the leading cause of puerperal pyrexia?
puerperal sepsis - infection of the genital tract occurring as a complication of delivery
urinary tract infections - cysts pyelonephritis
mastitis or breast abcess
what causes puerperal sepsis?
due to
endometritis , endomyometritis and endoparametritis = pelvic cellulitis if all affected
due to
intrapartum -
repeated vaginal examination ,
dehydration and ketoacidosis during labour
traumatic vaginal delivery ,
hemorrhage ,
retained placenta , tissue or membrane
prolonged labour
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antepartum - PROM ,
what are the sites where the bacteria colonise to get an infection ?
damaged cervicovaginal mucous membrane
open wound where the decidua cleaves when the placenta detaches
blood clot at placental site - excellent site for bacteria growth
what are the microorganism which causes puerperal sepsis ?
aerobic :
* group a , beta hemolytic strep
- staphylococcus aureus
- ecoli
klebsiella
pseudomonas
proteus
chlamydia
anaerobic :
*ANEROBIC STREPTOCCCUS (MOST PREDOMINANT) bacteroides (fragilis)
clostridia ,
mobiluncus , peptococcus
mixture of aerobic and aerobic usually causes the puerperal sepsis
what are the clinical features of puerperal infection ?
if local
rise of temp
malaise
iflammatory signs of local wound - pain
uterine
mild rise in temp rise in pulse offensive smelling , copious discharge sub involuted uterus and tender
severe - acute onset with rise of temp and chills
rapid pulse
dysuria , dyspareunia
scanty and odourless loch (group a beta haemolytic strep)
sub involuted uterus , tender
what are the complications of puerperal sepsis ?
pelvic cellulitis - lymphatic or hematogenous route
peritonits - usually c section - dehiscence and incision wound
or spread of infection from the tubules
lymphatic
RARELY generalised peritonitis
salpingitis -
interstitial most common - lymphatic spread
or perisalpingitis
pelvic abcess following pelvic peritonitis
SEPTIC PELVIC THROMBOPHLEBITIS - ovarian vein , uterine vein , pelvic vein
= commonly anaerobic
septic shock
streptococci - streptococcal tocix shock syndrome
or
aerobic strep
necrotising fasciitis - rare but fatal - muscle and fascia involved
diabetets , hypertension are risk factors
cause group a beta hemolytic strep
what are the outcomes of septic pelvic thrombophlebitis ?
complete resolution or suppuration
what are the clinical features of the complication of puerperal sepsis ?
parametritis or pelvic cellulitis - tissue inflammation adjacent to uterus esp broad lig
usually 7-10th day of puerperium
constant pelvic pain
vaginal examination
UNILATERAL ,hard tender mass pushing the uterus to one site
rectal examination confirm the indurationesp extending along uterosacral lig
rise in temp
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pelvic peritonitis - high temp
high pulse
abdominal pain and tenderness ,
muscle guarding may be absent unlesss generalised
vaginal examination - tender fornix with movement of cervix
if pus reach the pouch of douglas - swinging temp , diarrhea ,, bulging fluctuant mass through posterioir fornix
what is the diagnosis and treatment of puerperal pyrexia ?
high vaginal and endocervical swabs for culture
clean catch midstream of urine and culture
blood - cup and leukocytosis
blood culture is fever associated with CHILLS AND RIGOR - septicaemia
pelvic ultrasound
CT or MRI
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prophylaxis
prophylactic antibiotic at time of c section
aseptic working conditions atleast 1 week after delivery
reduce any vaginal examination
treatmnet
isolate the patient
empiric - gentamicin and clindamycin , metronidazole iv empiric
if severe sepsis - piperacillin tazobactum,
or
carbapenem pls clindamycin
MRSA 0 vancomycin and teicoplanin
septic pelvic thrombophlebitis - iv heparin
pelvic abcess - drainage under ultrasound guidance
perineal wound - drainage of pus
SITZ BATH cleavage of wound
dressing with antiseptic ointment or powder
wound dehiscence through eptisotomy or c section = scrubbing wound nice daily
debridement
closing wound with secondary suture
laparotomy last case when unresponsive peritonitis ,
necrotising fasciitis - rehydration , wound scrubbing , debridement his dose broad spectrum antibiotics
septic shock - rehydration high dose antibiotics cardiopulmonary support hemodilaysis
