Puerperium Flashcards
When does puerperium begin?
§ Begins after the delivery of the placenta and lasts until the reproductive organs have returned to their pre-pregnant state
§ About 6 weeks
What happens to the genital tract in puerperium?
§ Uterus: undergo rapid involution; returns to pelvis by 2 weeks
§ Cervix: cervical os gradually closes after delivery; barely more than 1cm dilated by 2 weeks
What are the constituents of lochia? What does it look like?
§ Constitues of sloughed-off necrotic decidual layer mixed with blood
§ Initially red, then paler, and finally becomes a yellowish white discharge
§ Flow may last for 3-6 weeks
What happens to the breasts in puerperium?
Become engorged between 2nd and 4th days
What is recorded in the puerperal record?
What are the major causes of morbidity in puerperium?
Major causes of morbidity:
* Secondary postpartum haemorrhage
* Venous thromboembolism
* Puerpural pyrexia
What is Secondary PPH?
§ Any excessive bleeding occurring between 24 hours and 6 weeks postnatally
§ Causes:
* Retained products
* Endometritis
* Genital tract tears
* Rare: gestational trophoblastic disease, AV malformation
Ix for persistent lochia
Risk of venous thromboembolism in puerperium
Signs of venous thromboembolism
§ Low grade fever
§ Symptoms and signs of deep vein thrombosis and pulmonary embolism
§ Requires high level of suspicion
§ Treatment should be commenced while diagnostic tests are awaited
What is puerperal pyrexia?
§ Presence of fever in a mother 38°C in the first 14 days after giving birth
§ Most common cause of maternal mortality before the introduction of antibiotics
§ Genital causes vs non-genital causes
Predisposing factors of puerperal pyrexia
§ Antepartum:
l Anaemia
l Duration of membrane rupture
§ Intrapartum:
l Duration of labour
l Bacterial contamination during vaginal examination l Instrumentation
l Trauma, e.g. episiotomy, tears, C/S
l Haematoma
Predisposing factors of uterine infection (endometritis)
Predisposing factors:
l Caesarean section
l Intrapartum chorioamnionitis
l Prolonged labour
l Multiple pelvic examinations
l Internal fetal monitoring
Sx of uterine infection (endometritis)
§ Fever
§ Foul, profuse and bloody discharge
§ Subinvolution of uterus
§ Tender bulky uterus on abdominal examination
What do perineal wound infection include?
- Includes infection of episiotomy wounds and repaired lacerations
- Perineum becomes painful
- May cause breakdown of wound
Non-genital causes of puerperial fever
§ Breasts (mastitis, breast abscess)
§ Urinary tract
§ Respiratory
§ Skin wound
§ Venous thromboembolism
Breast causes of engorgement
§ ~15% develop fever from breast engorgement; may be high as 39°C
§ Associated with painful and hard breasts
§ Antibiotics may be required in presence of
infection
§ Breast-feeding should be continued
Cause of breast mastitis
§ Results from obstruction of milk drainage from one section of the breast
§ Swollen, red and painful area on breast, tachycardia, pyrexia
§ Resolves with relieving the obstruction by continuing to breast-feed
§ May get infected (S. aureus)
How common is UTI in puerperium? Why are they at risk of UTI? What are the Sx? What are common causative pathogen?
What are respiratory complications in puerperium?
§ Usually seen within first 24 hours after delivery
§ Almost invariably in women delivered by CS
§ Complications due to atelectesis, aspiration, and/or bacterial pneumonia
What is the risk of wound infection after CS? What can be done for wound infection in CS? What are the risk factors?
Incidence following CS in ~6%
Prophylactic antibiotics
Risk factors:
* Obesity
* Diabetes
* Poor haemostasis at surgery with subsequent haematoma
Ix for puerperal fever
§ Aimed at identifying the most likely source of infection
§ CBP, blood cultures, MSU, swabs from cervix and vagina, wound swabs, CXR
Management of puerperal fever
Supportive:
- Analgesics and anti-pyretics
- Wound care in case of wound infection
- Ice packs for pain from perineum or mastitis
§ Antibiotics
§ Surgical
- Drainage if abscess
Surgical management of puerperal fever
- Suction evacuation if associated RPOG
- Drainage of vulvovaginal haematoma
- Drainage of breast abscess
How to manage postnatal pain?
- After-pains due to uterine contraction
- Perineal pain
- Paracetamol and NSAIDs are effective
Bladder problems in postnatal problems
- Urinary retention: following instrumental delivery or extensive tears, pain and oedema can cause voiding difficulties and retention Pain relief and reassurance
- Catheterization may be required
Bowel problems in puerperium
- Constipation may continue
- Pain and fear of wound disruption can exacerbate the problem
- Increase intake of fibre and fluids
- Sometimes may require stool softeners
Symphysis pubis discomfort
- Severe pubic and groin pain exacerbated by
- weight bearing
- Usually resolve by 6-8 weeks
- Rest, belt, weight-bearing assistance, analgesics
Use hand to gently press on PS = if there is pain, it could be symphysis pubic discomfort
Mental health problems in puerperium
§ Over 10% of women are depressed in the postnatal period
§ Link between difficulties in mother-infant relationship and poor social support
§ One of the leading cause of maternal death
– Result of suicide, substance abuse
Screening for PND
What are postpartum blues?
Postpartum depression
§ Mild to moderate depression may respond to counselling
§ Severe depression requires anti-depressants and psychotherapy
§ May need psychologist, social worker input
Hx taking for puerperal fever
- SOCRATES (wound? abdomen? below belly-button?)
- Which day post-op?
- What happen in the operation?
- Any problems in the antepartum period?
- When did the fever start? Any throat pain, runny nose, cough, dyspnea? Any chest pain?
- Any breast engorgement? Any erythema? Is breastfeeding okay?
- Any problems with child care? Anyone helping with child care?
- Any problem with urination? (frequency, urgency, nocturia)
- Any problem with defecation? Any flatulence?
- Appetite?
- Any back pain?
- Any leg pain?
- How’s the lochia? How many pads do you have to change? What colour?
- Any dizziness?
- Did hospital say you need iron supplementation?
- Any palpitation?
- How’s sleep?
How will you manage the patient?
‘I will help you measure BP, take your temperature, auscultate your heart, lungs, look at your wound, examine your uterus.
I will take some samples of your vaginal discharge, legs to see if there is swelling, any breast engorgement.’
