Puerperium

Question 1

When does puerperium begin?

Answer 1

§ Begins after the delivery of the placenta and lasts until the reproductive organs have returned to their pre-pregnant state
§ About 6 weeks

Question 2

What happens to the genital tract in puerperium?

Answer 2

§ 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

Question 3

What are the constituents of lochia? What does it look like?

Answer 3

§ 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

Question 4

What happens to the breasts in puerperium?

Answer 4

Become engorged between 2nd and 4th days

Question 5

What is recorded in the puerperal record?

Answer 5

Question 6

What are the major causes of morbidity in puerperium?

Answer 6

Major causes of morbidity:
* Secondary postpartum haemorrhage
* Venous thromboembolism
* Puerpural pyrexia

Question 7

What is Secondary PPH?

Answer 7

§ Any excessive bleeding occurring between 24 hours and 6 weeks postnatally
§ Causes:
* Retained products
* Endometritis
* Genital tract tears
* Rare: gestational trophoblastic disease, AV malformation

Question 8

Ix for persistent lochia

Answer 8

Question 9

Risk of venous thromboembolism in puerperium

Answer 9

Question 10

Signs of venous thromboembolism

Answer 10

§ 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

Question 11

What is puerperal pyrexia?

Answer 11

§ 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

Question 12

Predisposing factors of puerperal pyrexia

Answer 12

§ 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

Question 13

Predisposing factors of uterine infection (endometritis)

Answer 13

Predisposing factors:
l Caesarean section
l Intrapartum chorioamnionitis
l Prolonged labour
l Multiple pelvic examinations
l Internal fetal monitoring

Question 14

Sx of uterine infection (endometritis)

Answer 14

§ Fever
§ Foul, profuse and bloody discharge
§ Subinvolution of uterus
§ Tender bulky uterus on abdominal examination

Question 15

What do perineal wound infection include?

Answer 15

• Includes infection of episiotomy wounds and repaired lacerations
• Perineum becomes painful
• May cause breakdown of wound

Question 16

Non-genital causes of puerperial fever

Answer 16

§ Breasts (mastitis, breast abscess)
§ Urinary tract
§ Respiratory
§ Skin wound
§ Venous thromboembolism

Question 17

Breast causes of engorgement

Answer 17

§ ~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

Question 18

Cause of breast mastitis

Answer 18

§ 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)

Question 19

How common is UTI in puerperium? Why are they at risk of UTI? What are the Sx? What are common causative pathogen?

Answer 19

Question 20

What are respiratory complications in puerperium?

Answer 20

§ Usually seen within first 24 hours after delivery

§ Almost invariably in women delivered by CS

§ Complications due to atelectesis, aspiration, and/or bacterial pneumonia

Question 21

What is the risk of wound infection after CS? What can be done for wound infection in CS? What are the risk factors?

Answer 21

Incidence following CS in ~6%
Prophylactic antibiotics
Risk factors:
* Obesity
* Diabetes
* Poor haemostasis at surgery with subsequent haematoma

Question 22

Ix for puerperal fever

Answer 22

§ Aimed at identifying the most likely source of infection
§ CBP, blood cultures, MSU, swabs from cervix and vagina, wound swabs, CXR

Question 23

Management of puerperal fever

Answer 23

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

Question 24

Surgical management of puerperal fever

Answer 24

• Suction evacuation if associated RPOG
• Drainage of vulvovaginal haematoma
• Drainage of breast abscess

Question 25

How to manage postnatal pain?

Answer 25

• After-pains due to uterine contraction
• Perineal pain
• Paracetamol and NSAIDs are effective

Question 26

Bladder problems in postnatal problems

Answer 26

• 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

Question 27

Bowel problems in puerperium

Answer 27

• Constipation may continue
• Pain and fear of wound disruption can exacerbate the problem
• Increase intake of fibre and fluids
• Sometimes may require stool softeners

Question 28

Symphysis pubis discomfort

Answer 28

• 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

Question 29

Mental health problems in puerperium

Answer 29

§ 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

Question 30

Screening for PND

Answer 30

Question 31

What are postpartum blues?

Answer 31

Question 32

Postpartum depression

Answer 32

§ Mild to moderate depression may respond to counselling
§ Severe depression requires anti-depressants and psychotherapy
§ May need psychologist, social worker input

Question 33

Hx taking for puerperal fever

Answer 33

• 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?

Question 34

How will you manage the patient?

Answer 34

‘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.’