9. Normal puerperium. Immediate care for the mother.

Question 1

what is puerperium ?

Answer 1

the period of about six weeks after childbirth during which the mother’s reproductive organs return to their original non-pregnant condition.

Question 2

what are the stages of puerperium ?

Answer 2

there are three stages :

acute/ immediate - first 24 hours

subacute/ early - unto a week

and remote - unto 6 weeks

Question 3

in puerperium what are the major organs and their morphology we look out for ?

Answer 3

uterus
vagina
cervix

Question 4

clinical involution of the uterus

Answer 4

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

Question 5

what is the involution of vagina ?

Answer 5

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

Question 6

characteristic changes of the vaginal discharge after delivery ?

Answer 6

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

Question 7

because of the vaginal discharge women are advised to wear what ?

Answer 7

pampers

normal duration of lochis may extend up to 3 weeks

Question 8

women who deliver vaginally should also do what type of excersies

Answer 8

kegel exercises

Question 9

if there is a malodour in the vaginal discharge what does this suggest ?

Answer 9

infection such as ecoli

Question 10

what is the clinical significance if the discharge is scant or absent?

Answer 10

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

Question 11

what is the clinical significance if there is excessive lochia?

Answer 11

indicate infection

or hydramnios

Question 12

what is the clinical significance if red colour in lochia persist

Answer 12

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

Question 13

divisions for the immediate care for mother after delivery

Answer 13

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

Question 14

what are the changes to the urinary tract and how is it clinically important ?

Answer 14

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

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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.

Question 15

what are the cardiovascular changes ? and clinical significance ?

Answer 15

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

Question 16

when does menstruation resume ?

Answer 16

if not breast fed resumes in 12 weeks

Question 17

when does ovulation resume ?

Answer 17

non lactating mother - as early as 4 weeks

lactating - 10 weeks

exclusive breastfeeding - 98 percent contraception up to 6 months

Question 18

how does lactation provide contraceptive and amenorrhea ?

Answer 18

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

Question 19

what are the temp changes?

Answer 19

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

Question 20

what is a complication in acute phase after delivery

Answer 20

POSTPARTAL BLEEDING

Question 21

what are the subacute diseases in puerperium ?

Answer 21

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

Question 22

why breast feeding should be recommenced as care for the mother ?

Answer 22

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

====

first few days is colostrum - high in protein immunological - igaA, G.M , lactoferrin , complements
lower carbohydrate, fat and potassium than the breast milk

======

after 3-4 days replaced by mature breast milk - high in fat then carbs and low in protein

Question 23

what are the two mechanisms important in lactation ?

Answer 23

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.

Question 24

how does post partum affect repsiratory changes ?

Answer 24

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

Question 25

there can be perineal complication because?

Answer 25

discomfort infected episiotomy

Question 26

what are the bowl complications?

Answer 26

constipatin - can be due to progesterone decreasing the bowel movements fecal incontinece due to 3rd -4th degree tear

Question 27

haematological changes and their clinical significance

Answer 27

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

Question 28

what are the psychiatric disorders ?

Answer 28

depression due to hormonal changes

Question 29

puerperium of cervix regained in ?

Answer 29

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

Question 30

describe closure of epstiotomy wound ?

Answer 30

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

Question 31

describe the care for epstiotomy wound and vulva ??

Answer 31

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

Question 32

if loch alba is beyond 3 weeks ?

Answer 32

lochia alba beyond 3 weeks suggests local genital lesion

Question 33

management of sub involution ?

Answer 33

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.

Question 34

urinarY traCt infeCtion: It is one of the common causes of puerperal pyrexia, what is the cause ?

Answer 34

effect of frequent catheterization, either during labor or in early puerperium to relieve retention of urine, (b) stasis of urine

Question 35

organism reposnisble for urinary tract infection

Answer 35

E. coli, Klebsiella, Proteus and S. aureus

Question 36

what is puerperal pyrexia ?

Answer 36

A rise of temperature reaching 38°C | on two separate occasions 24 hours apart within first 10 days following delivery

Question 37

what are the leading cause of puerperal pyrexia?

Answer 37

puerperal sepsis - infection of the genital tract occurring as a complication of delivery urinary tract infections - cysts pyelonephritis mastitis or breast abcess

Question 38

what causes puerperal sepsis?

Answer 38

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 ====== antepartum - PROM ,

Question 39

what are the sites where the bacteria colonise to get an infection ?

Answer 39

damaged cervicovaginal mucous membrane open wound where the decidua cleaves when the placenta detaches blood clot at placental site - excellent site for bacteria growth

Question 40

what are the microorganism which causes puerperal sepsis ?

Answer 40

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

Question 41

what are the clinical features of puerperal infection ?

Answer 41

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

Question 42

what are the complications of puerperal sepsis ?

Answer 42

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

Question 43

what are the outcomes of septic pelvic thrombophlebitis ?

Answer 43

complete resolution or suppuration

Question 44

what are the clinical features of the complication of puerperal sepsis ?

Answer 44

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 ======== 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

Question 45

what is the diagnosis and treatment of puerperal pyrexia ?

Answer 45

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 ==== 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 ```