CHANGES DURING PUERPERIUM PUERPERIUM CHANGES IN URINARY TRACT

1. REPRODUCTIVE TRACT INVOLUTION :  The time following the delivery during which pregnancy - induced  Normal pregnancy-induced glomerular hyperfiltration persists during the
BIRTH CANAL maternal anatomical and physiological changes return to the non- puerperium but returned to their pre-pregnant state by 2 weeks
 Vagina rarely regain their nulliparous dimensions. It's epithelium is in pregnant state.  Dilated ureters and renal pelvis retrun to their prepregant state by 2 to 8
hypoestrogenic  Duration is considered to be 4-6 weeks weeks postpartum
 state and does not begin to proliferate until 4-6 weeks LOCHIA  Symptomatic urinary tract infection is a concern.
 Rugae reapear by 3rd week but less prominent than before  Vaginal disharge which contains erythrocytes,shredded decidua,
 Hymen is represented by small tags of tissue which scar and they form epithelial cells and Bacteria BLADDER
Myrtiform caruncles.  Duration of lochial discharge ranges form 24-36 weeks a) The bladder has an increase capacity and relative insensitivity to
 Lacerations and Episiotomy repairs are fully healed by 1-2 weeks after intravesicular pressure
delivery b) Over distension, incomplete emptying and excessive residual urine
UTERUS are frequent
 Uterus muscles contract and retract Compression of uterine c) Diuresis observed during 2nd to 5th day
vessels Decrease in uterine blood flow Prevents bleeding Causes of Urinary Retention:
 Note: Palpate the uterus after placental delivery to check for 1. Edema and congestion of vulva,urethra, trigone
contraction! 2. Edema and reflex spasm of the urethral sphincter
 LOCATION OF UTERUS 3. Bladder atony , UTI
 After placental expulsion- fundus can be palpated slightly below CHANGES IN ABDOMINAL WALL
the umbilicus PLACENTAL SITE INVOLUTION  Abdominal wall is soft and flaccid as a result of ruptured elastic
 Within 2 weeks- Uterus becomes a pelvic organ  AN EXFOLIATION process consists of both extension and downgrowth fibers in the skin and prolonged distension by the pregnant uterus.
 Within 4-6 weeks - uterus regains its pre-pregnant state of endometrium from margins of placental site.  Abdomen may become flabby/pendulous.
 WEIGHT OF THE UTERUS  BLOOD VESSELS UNDERGO THROMBOSIS and hyalinization,  Exercise is important to return tone.
 Immediately Postpartum- 1000g sloughing off of infarcted and necrotic tissues followed by reparative  After caesarian delivery, a 6-week interval to allow fascia to heal and
 After 1 week- 500g process. abdominal soreness to diminish is reasonable. They can exercise after 3
 End of 2nd week- 300g  COMPLETE EXTRUSION of placental site takes up to 6 weeks. months.
 End of 4th weeek-100g  Striae gravidarum: silver streaks for those with severe distension
CERVIX Clinical Aspect:  Diactasis recti: separation of rectus musle from midline of linea alba
 After delivery, opening of cervix is 2 cm. (POINT TO SLIT)  Uterine subinvolution  Macrosomic and twin pregnancy will cause the abdomen to wrinkle.
 The opening narrows, cervix thickens and endocervical canal re-forms  an arrest/retardation of the involution of uterus.
DECIDUA AND ENDOMETRIAL REGENERATION  Causes: BLOOD AND BLOOD VOLUME CHANGES
 Separation of placenta and membranes involves the spongy layer, the 1. Retention of placental fragment Hematological and Coagulation changes
decidua basalis is not Sloughed. 2. Pelvic infection (Chlamydia Trachomatis)  Marked leukocytosis and thrombocytosis may occur during and after
 Within 2-3 days after delivery , the remaining decidua is differentiated 3. Clot formation at the thrombosed placental site labor.
into 2 layers:  Bimanual Examination  The white blood cell count sometimes reached 30,0000/microliter .
 superficial layer- becomes necrotic and sloughed in lochia  Uterus is larger and softer than normal for the particular peiod of  Fluctuation in hemoglobin and haematocrit
 basal layer- adjacent to myometrium ,remains intact and the source perperium  Coagulation Factors are elevated for variable periods.
of new endometrium  Treatment  Hypercoagubility appears to be greater and is reflected by the
Clinical Aspects  Methylergonovine(methergine) 0.2 mg orally every 3-4 hours for likelihood of deep vein thrombosis and pulmonary embolism
 After pains- intermittent crampy abdominal pain felt after delivery due to 24-48 hrs.  Encourage patient to ambulate!!!
uterine contactions Late Postpartum Hemorrhage Pregancy induced Hypervolemia
 Decrease in intensity and milder by 3rd day.  Secondary postpartum hemorrhage is bleeding 24 hrs to 12 weeks after  1 wk after delivery, blood volume return to nearly the nonpregnant state.
 Factors which worsen them: delivery.  Cardiac output usually remains elevated for 24-48 hrs postpartum and
1. Increase in parity  Such bleeding most often is the result of abnormal involution of placental declines to nonpregnant values by 10 days
2. Newborn suckles (oxytocin release) site.  Heart rate and blood pressure follow this pattern too.
3. Infection  Placental polyp was formed when retained products undergo necrosis  Systemic Vascular resistance remains in the lower range, characteristic
with fibrin deposition.
of pregnancy, for 2 days postpartum and then increase to normal .
 POSTPARTUM DIURESIS A. CARE FOR THE MOTHER 8. IMMUNIZATIONS
 Is the reversal of increase in extracellular sodium and water retention HOSPITAL CARE  Anti-D immune globulin 300 ug given within 72 hours of birth of a D-
associated with pregnancy.  For 2 hours after delivery,blood pressure and pulse are taken Q15 min positive infant.
 Clinical Aspect:  Temperature Q4hrs for the first 8 hrs and then Q8H subsequently  Rubella vaccine and Measles (MMR)
 Weight loss: Pospartum diuresis results in rapid weight loss of 2-3 kg  Amount of vaginal bleeding is monitored and the fundus is palpated.  Diptheria-Tetanus-toxoid Booster (DTaP)
 This add to 5-6 kg loss due to delivery and blood loss  Uterus is monitored is closely monitored for at least 1 hour after delivery. B. TIME OF DISCHARGE
 6 months postpartum -return of prepregnant weight  2 hrs after uncomplicated vaginal delivery, a woman is allowed to eat.  Up to 48 hrs following uncomplicated vaginal delivery
 Factors of weight loss:  Postpartum women may experience hot flashes especially at night  Up to 96 hrs following uncomplicated cesarian delivery
1. Weight gain during pregnancy  Dramatic hypoestrogenism may trigger headache.  Pelvic and IE examination must be done to acertain that there is no
2. Primiparity 4. BLADDER gauze is retained in the vaginal canal
3. Early return to work  Advise patients on self care, breastfeeding, breast care,sexual activities,
4. Smoking  When oxytocin is infused, rapid bladder filling is common.
immunizations and planned parenthood.
1. AMBULATION  Decreased bladder sensation and capability to empty were due to:
 Considerations:
 Progressive ambulation: Dangle first, then stand up and walk within 12- 1. Anesthesia
 Uncomplicated Cs- 72 hrs after delivery
24 hrs. 2. Episiotomy
3. Laceration  Normal delivery
 Advantages of early ambulation:  Multipara- after 1-2 days
 Less bladder complications 4. Hematoma
If woman has not voided within 4 hours of delivery, it is likely that she  Nullipara- after 2-3 days
 Less incidence of thromboembolic disease C. HOME CARE
cannot.
 Hastens drainage of lochia
COITUS
 Hastens uterine involution
 After 2 weeks , coitus maybe resumed based on desire and comfort.
 Improves circulation of the lower extremities 5. PAIN, MOOD AND COGNITION  Based on both parties.
 Reduce inidence of puerperal venous thrombosis and pulmonary  It is important to screen postpartum women for depression.  Following delivery and breastfeeding, there is a hypoestrogenic state
embolism  POSTPARTUM BLUES that leads to vaginal atrophy and dryness.
2. PERINEAL CARE  Transient depressive mood fairly common for mother after delivery DIET
 Clean vulva from anterior to posterior, vulva to anus  Mild and self-limited to 2 to 3 days and may lasts up to 10 days  2500 kilocalories/day
 A cool pack (ice bag) is applied to perineum if there is laceration  Factors:  Give balanced diet
 Severe perineal, vaginal or rectal pain always warrants careful inspection  Emotional letdown  Increase milk and calcium supplementation
and palpation  Disomfort of early puerperium  Increase calories by 300 and protein for lactating women
 Severe discomfort usually indicates a problem such as a hematoma within  Fatigue from lack of sleep
 Iron supplementation for 3 months or more
the first day or so and infection after 3rd day or 4th day.  Stresses during labor
 Beginning 24 hrs after delivery, warm sitz bath(moist heat) can be uised to  Anxiety over the ability to provide
D. FOLLOW UP CARE
reduce discomfort  Body image concerns
 By the end of 3rd week, episiotomy incision is normally healed and nearly 6. OVULATION  ACOG recommend a postpartum visit between 4-6 weeks.
asymptomatic  Return as early as 4 weeks  To assess complications of episiorraphy and education for
3. GASTROINTESTINAL TRACT  Delayed resumption of ovulation with breastfeeding contraception
 Ovulation can occur without bleeding  To identify abnormalities associated with puerperium
 Atony in GIT is due to prolonged labor
 Lactating Women  Presents option for contraception.
 Constipation is common due to:
1. Inactivity  Extend upto 6 months if they are exclusively breasfeeding  Pap smear should be done in 6 months.
2. Decreased intraabdominal pressure  Nonlactating women (Returns after 4 weeks)  Mothers should be taught self-breast examination
3. some patients were hesitant to defecate because of pain in the  Normal delivery and puerperium can resume most activities
episiotomy site HORMONAL CONTRACEPTION FOR BREASTFEEDING
 Hemorrhoidal veins are often congested at term and thrombosis is MOTHERS (source)
common and maybe promoted by second-stage pushing. 7. MENSTRUATION • Progestin only Oral contraceptive: start 2 -3 weeks pospartum
 Bleeding can be anovulatory • Depot Medroxyprogesterone acetate: 6 weeks postpartum
 Lactating women • Hormonal Implants: Inserted 6 weeks pospartum
 1st period returns 2nd month to 18 month after delivery depending on • Levonorgestrel intrauterine system: 6 weeks postpartum
how she breastfeeds • Combined estrogen-progestin contraceptives
 Nonlacatating women (within 7 weeks)
 A. BREAST INFECTION PUERPERAL INFECTIONS D. UTERINE TRACT INFECTIONS
1. BREAST ENGORGEMENT TRIAD CAUSES OF MATERNAL DEATH  Most common serious complication of the puerperium
 About 15% of women who do not breastfeed develop postpartum fever PREECLAMPSIA  Metritis with pelvic cellulitis
 from breast engorgement OBSTETRICAL HEMORRHAGE  Previously called:
 Brief temperature elevation INFECTIONS  Endometritis
 Fever of 39°C  General term to describe a bacterial infection following childbirth  Endomyometritis
 BILATERAL  Genital tracts is the most common affected site  Endoparametritis
 Breasts are firm, tender & nodular upon palpation (whole breast affected)  Puerperal Fever - presence of fever at any point between birth and 10  Route of delivery: single most significant risk factor for the development
 TREATMENT days postpartum of metritis with CS delivery having a higher incidence of postpartum
 Support (breast binder/sports bra)  A temperature of 38 C or higher uterine infection
 Cold compress/Ice pack  Consider potential sources: 4 W’s  Risk factors for infection following CS
 Analgesic  1st day: WIND (lungs – atelectasis) 1. Prolonged labor
2. BACTERIAL MASTITIS  2nd - 3rd day: WATER (urinary tract) 2. PROM >6 hours cause colonization of the lower uterine with
 Fever appears on the 3rd or 4th week postpartum (where trauma  4th - 5th day: WOUND/WOMB (cellulitis/endometritis)Uterine pathogenic bacteria
 happened) infections 3. Multiple cervical examination nwould introduce the entry of
 UNILATERAL  5th day: WALKING (DVT, thrombophlebitis) bacteria >6 IE
B. RESPIRATORY INFECTIONS 4. Internal fetal monitoring
 S. aureus,MRSA is the most common isolated organism in breast
1. ATELECTASIS 5. Intrapartum Chorioamnionitis
infections
 Most common  Bacterial Contamination Inoculation and colonization of uterine
 Pathogenenesis:
 Secondary to nipple trauma (due to inappropriate attachment when  Caused by hypoventilation due to generalized anaesthesia leading to segment Favourable anaerobic bacterial condition polymicrobial
alveolar collapse proliferation with tissue invasion metritis
breastfeeding) → abrasions or cuts in the nipples provide site of
 Thick secretions and diminished cough reflex that eventually lead to  CLINICAL COURSE
entry for the bacteria inside the parenchyma → cellulitis
airway obstruction 1. Fever (38-39 C) – most important criterion for the diagnosis of
 Treatment:
 Best prevented by routine coughing and deep breathing every 4 hours postpartum metritis. It’s proportional to the extent of infection.
 Dicloxacillin 500mg 4x/d x 10-14 days 2. Chills
 Erythromycin (for penicillin sensitive women) 3. Increase in Pulse Rate
2. PNEUMUNIA
 Vancomycin (penicillinase resistant antibiotic) 4. Abdominal pain & parametrial tenderness
Signs and symptoms 5. Foul smelling discharge
C. URINARY INFECTIONS
 Engorgement 6. Increased vaginal bleeding
  Bacterial inflammation of the bladder and urethra
Chills and fever (predominant symptom) 7. Leucocytosis – 15,000 to 30,000/uL
 Tachycardia  Common in post CS delivery due to bladder catheterization
 Myalgia  Dysuria and urinary frequency – less valuable symptom of UTI GOLD STANDARD:
postpartum
 Breasts are hard and reddened  Clindamycin (900mg) + Gentamicin (1.5mg/kg) Q8H IV
 Typical S/Sx
 localized only to specific parts  Perioperative Prophylaxis: Single-dose Ampicillin/ 1st-gen Cephalosporin
• bacteriuria
E. THROMBOPHLEBITIS
• pyuria (pus in the urine)
• costovertebral angle tenderness  Superficial or deep venous thrombosis of the legs caused by venous
3. BREAST ABSCESS • Spiking temperature diagnosis stasis.
Causes Treatment • Diagnosis : Urinalysis – clean-catch or catheterized  Signs and symptoms
 Engorged breast  Analgesics • Treatment: Broad spectrum antibiotics  Brief temperature elevations
 Cracked Nipple  Antibiotics  Tenderness in the calf area
 Mastitis  Incision and Drainage  Diagnosis: Femoral triangle area tenderness
 Treatment
 Early ambulation OR Wear compression stockings
UTERINE TRACT INFECTION TREATMENT

INFECTION INVOLVING PERINEUM, VAGINA AND CERVIX PATHOGENESIS

 F. COMPLICATIONS OF PELVIC INFECTIONS PUERPERAL INFECTIONS 8. SEPTIC PELVIC THROMBOPHLEBITIS
 0% of women have good response to antibiotic therapy  Clinical Presentation
 10% will have fatal and life-threatening complications  Asymptomatic
 Chills
G. ABDOMINAL INCISIONAL INFECTIONS
 Fever Spikes – ENIGMATIC FEVER
1. WOUND INFECTIONS
 Flank and lower abdominal pain
 Refers to the skin incision infection
 Tender rope-sausage shape abdominal mass
 Most common cause of antimicrobial failure in women treated for metritis
–most diagnostic PE finding but rarely found
 Most common cause of persistent fever in women treated with metritis
 Pulmonary embolism –only in 2.5%
Incisional Abscess
 Diagnosis : Pelvic CT or MRI
 Fever on the 4th post-operative day,erythematous, drains pus
 Heparin Challenge Test – confirmatory test; before imaging studies
 Preceded by uterine infection (metritis)
 Treatment: Antimicrobial - Imipenem
 Offending organism same as the amniotic fluid at CS delivery
 Treatment: H. INFECTION IN PERINEUM, VAGINA AND CERVIX
 Antimicrobial 1. EPISIOTOMY BREAKDOWN OR DEHISCENCE AND PARAMETRIAL
 Surgical drainage (for massive infections) EXTENSION : more common in 4th degree lacerations
 Debridement of devitalized tissue 5. NECROTIZING FASCIITIS Predisposing Factors Common Signs and Symptoms
 Wound care 2-3x daily with the added use of topical Lidocaine  Rare but fatal 1. INFECTION 1. pain/ purulent discharge
2. WOUND DEHISCENCE  Involve abdominal incision, episiotomy & perineal laceration 2. coagulation disorder 3. fever
 Fascial dehiscence at 5th day post-operative  Tissue necrosis is significant 3. cigarette smoking 4. dysuria + urinary retention
 Polymicrobial 4. human papilloma virus 5. edematous vulva with exudate
 Serosanguinous discharge
 Clinical findings will vary, it is difficult to differentiate from superficial Treatment Early Repair
 Requires secondary closure of incision in the operating room perineal infection to the deep fascial, one must have a high index of 1. Drain  Intravenous antimicrobial therapy
suspicion and surgical exploration can be life-saving 2. Remove sutures  Remove sutures and open wound
3. PERITONITIS
Treatment: 3. Debridement of all Wound care: (2-3x a day)
 Cause: inadvertent bowel injury at cesarean delivery rupture of  Early diagnosis infected tissueS  Debridement of all necrotic tissue
parametrial and adnexal abscess
 Antibiotics – Clindamycin + B lactam 4. Antibiotics IV – broad  Scrub wound with betadine 2x daily
 Signs and Symptoms: spectrum  Sitz bath several times daily for comfort
 Surgical debridement
 abdominal rigidity – less prominent
6. PARAMETRIAL PHLEGMON SECOND REPAIR
 severe pain
 an area of indurations (feels hard) in the broad ligament due to spread of  Episiotomy wound free of infection and exudate
 adynamic ileus- frequently the first symptom
severe uterine infection  Covered by pink granulation tissue
 marked bowel distension  Unilateral (more often at the RIGHT)  Good tissue mobility
 Treatment  Complication: uterine dehiscence  Identification and mobilization of sphincter ani muscles
 If infection begins in uterus and extends into the peritoneum-  Symptom: Persistent fever >72 hours 2. TOXIC SHOCK SYNDROME
antimicrobial treatment alone
 Treatment  Acute febrile illness: multisystem organ derangement caused by S.
 If due to uterine incisional necrosis or from bowel perforation-
 Antibiotics aureus produces an exotoxin called Toxic Shock Syndrome Toxin
surgical intervention
 Surgery  1 (TSST1) - causing profound endothelial injury.
4. OVARIAN ABSCESS  Hysterectomy most appropriate with uterine dehiscence Signs and Symptoms: Complications:
 Caused by bacterial invasion tear in the ovarian capsule • Fever • Renal failure
 Abscess usually unilateral 7. PELVIC ABSCESS • Headache • Hepatic failure
 Seen 1-2 weeks after delivery  After a phlegmon suppurates – forms a fluctuant mass in the broad • Mental confusion (alarming sign) • DIC
 Treatment ligament above inguinal ligament • Diffuse macular erythematous • Circulatory collapse
 antimicrobial- if not severe  Treatment rash- desquamation upon
 surgical exploration - if rupture occurs  If dissects anteriorly –treat with CT guided drainage recovery Management:
 If rectovaginal septum – surgical drainage by colpotomy incision • Subcutaneous edema • Supportive
 COLPOTOMY – TREATMENT OF CHOICE • Nausea, vomiting • Antimicrobial therapy
• Watery diarrhea • Extensive Wound Debridement
• Marked hemoconcentration • Possible Hysterectomy – if stable