Puerperium Flashcards
What are the genital tract changes that occur after delivery?
Takes 4 - 6 weeks to return back to normal
- involution of the uterus & placenta
- uterus returns to non-gravid size by 8 weeks
- immediately after delivery uterus is at or below umbilicus
If placenta is retained -> sub involution
What is after pain?
Labour like pain secondary to involution -> becomes mild by day 3
- occurs more with breastfeeding -> secondary to oxytocin release
What are the types of lochia?
1- Lochia rubra -> erythrocytes, bacteria, decidua, epithelial cells
2- Lochia serosa-> pale after 3 - 4 days
3- Lochia Alba -> less fluid more leucocytes (yellow) -> white after 10th day
Continues till 24 - 36 days postpartum
What are the causes of maternal morbidity during puerperium?
- puerperal infections & sepsis
- secondary postpartum hemorrhage
- venous thromboembolic disorders
What is puerperal fever?
38 C or 100.4 F or higher
- 80% of ladies develop fever in first 24 hours
-> 70% after CS
-> 20% pelvic infection
Spiking fever > 39C due to group A streptococcal infections
WhatWhat are the causes of postpartum fever?
1- breast engorgement
2- atelectasis (complication of anesthesia post CS)
3- pelvic infections
4- urinary tract infections
5- abdominal incisions & perineal lacerations
What are the types of uterine infections?
- endometritis
- endomyometritis
- endoparametritis
Occurs after delivery
What are the risk factors for uterine infections?
Maternal
- DM
- obesity
- HIV infections
Intrapartum
- prolonged labour
- rupture membranes
- multiple vaginal exams
- retained products of conception
Procedure
- manual removal of placenta
- operative vaginal delivery
- cervical cerclage
- C section
How do uterine infections present?
- fever
- headache
- malaise
- lower abdominal pain & uterine tenderness
- offensive lochia
- secondary PPH
What are the pathogens that cause uterine infections?
Gram +ive
- group A B D streptococci
- staph aureus
Gram - ive
- E. coli
- Klebsiella
- Proteus
Mycoplasma, Chlamydia trachomatis, Niesseria gonorrhea
Anaerobic (with C section)
- bacteroids
- Pepto cocci
- Pepto streptococci
What investigations are done in suspected uterine infection?
1- CBC: anemia, leukocytosis 15 000 - 30 000, low PLT
2- Renal function tests: urea & electrolyte
3- High vaginal swab
4- blood culture if there are systemic features
5- Coagulation profile: DIC
6- Pelvic ultrasound: retained products or abscess
How are uterine infections treated?
AFTER C SECTION -> clindamycin + gentamicin
AFTER VAGINAL -> oral treatment if mild
-> if moderate or severe: IV Ampicillin + gentamicin
What are the complications of metritis?
1- pelvic abscess
2- peritonitis
3- parametritis
4- septic pelvic thrombophlebitis
How can incidence of wound infection be reduced?
1- prophylactic antibiotics 2g 1st generation cephalosporin before skin incision
2- skin cleaning before operation with chlorhexidine
What are the risk factors for wound infections?
- immunosuppression
- hematoma formation
- diabetes
- obesity
- hypertension
- anemia
What is the presentation of wound infection?
- fever on the 4th day usually
- wound erythematous
- drains pus
How are wound infections managed?
1- antimicrobial therapy
2- surgical drainage
3- debridement of devitalized tissue
4- wound dressing twice daily till clear
5- secondary wound closure
What is mastitis & what are its causes?
Infection of breast parenchyma -> 3rd or 4th week
Due to
- Staph aureus esp MRSA
- cracks at nipple & breast engorgement
What is the presentation & treatment of mastitis?
Fever, pain, swelling, & painful breast feeding
Treat with -> Dicloxacillinb 500mg 4 times a day for 10 days
-> for MRSA: vancomycin
When is breastfeeding contraindicated?
1- maternal HIV or active TB
2- breast cancer treatment
3- infant galactosemia
4- women taking street drugs & uncontrolled alcohol use
What are the risk factors for urinary retention post partum?
1- primiparity
2- operative vaginal delivery
3- perineal lacerations
4- epidural analgesia
5- prolonged labour
How is bladder dysfunction diagnosed postpartum?
1- enlarged bladder is felt suprapubically
2- if lady doesn’t void for 4 hours after delivery -> urine is emptied and left for 24hrs by urinary catheter
3- voiding trial done again -> residual volume > 200ml (failed)
What vaccinations should be taken during puerperium?
- rubella
- varicella
- COVID 19
When can a lady return to coitus & what are the problems she might face?
By 2nd month postpartum, most by 4 months
Problems
- Pain -> due to episiotomies & lacerations
- Dryness -> due to hypoestrogenic state
- Dyspareunia -> after C section
