Puerperal Complications

Dr. Benny Hasan.dr.SpOG (K)

Divisi Uroginekologi – Rekonstruksi

Departemen Obstetri – Ginekologi
FKUP/RS. Hasan Sadikin
THE WORD PUERPERIUM
is derived from Latin—puer, child + parus,
bringing forth.

Currently, it defines the time following delivery

during which pregnancy-induced
maternal anatomical and physiological changes
return to the non pregnant state.

Its duration is understandably inexact, but is

considered to be between 4 and 6 weeks
LACTATION DISODERS / COMPLICATIONS
Why Breastfeed?
Literature is replete with scientific evidence on the benefit of
the most natural process of a mother- breast feeding her
baby

Exclusive breast feeding in the first six months of life can cut
down under-five child mortality by
13-15%

There could not be more compelling reasons for

breastfeeding the baby.
Advantages to the
mother
 Involution of uterus and haemorrhage
 Postnatal amenorrhoea
 Decreaserisk of breast and ovarian
malignancy
 Decreased
risk of hip fracture after
menopause
How is milk produced?

Preparation of breast for milk

production
Production of milk
Let down Reflex
How Soon?
 At The Earliest
In the healthy neonate suckling
reflex is at its peak- 30 to 40 mins
after birth
Early feeds stimulate production of
prolactin and increases the mean
duration of breast feeding
 Latching – The Right
Technique
 Latching on is the creation of a
tight seal around nipple and most
of the areola through baby‘s
mouth.
 Ideally,
baby’s lower lip should be
covering more of the areola than
the upper lip and nipple should
not hurt after few min
Frequency And Length Of Breast
Feeding
 Exclusive breast feeding for 6 months
 Onan average 650 to 850 ml milk is
produced per day.
2 to 3 hourly or 8 feeds per day or
feed on demand
 Durationtime is 25 to 30 min- both
breasts should be fed each time
Care Of Mother
Calorie intake- 300 to 500 extra calories
( 2200 to 3000 kcal per day)
Balance diet and no weight reduction
Fluid intake : 22% from well balanced
diet; increase fluid intake is essential but
excessive consumption can result in
reduction of production of
milk( Dusdiekor in 1994)
Iron and Calcium Supplementation
Contra Indications For Breast
Feeding
Maternal:
 Acute febrile conditions and critically ill patients
 Breast abscess
 HIV +ve mother
 Open cases of pulmonary TB
 Anti thyroid drugs
 Anti cancer drugs
 Hepatitis A
 Following radio pharmaceuticals
SUPPRESSION

 Estrogen
 Bromocriptin
 Cabgolin
 Thiazide
 Pyridoxine
 OCP
 Testosterone
Lactation Complaints

 Insufficient
Milk Syndrome
 Retracted nipples
 Sore nipples
 Breast engorgement
 Mastitis
 Breast abscess
 Choice of contraception
 Problem of working women
 RETRACTED NIPPLE

 Antenatal examination and

counseling for cleaning of nipples
and their aversion is important
 20 cc syringe may also be used
for correcting retraction
 Nipple shield
 Use of breast pump
SORE NIPPLE

 Commonest
 Cause improper latching
 Symptoms: pain
 Signs:
nipple is red, cracked,
bruised, blistered and tender
 Treatment: linolin/ emolient cream;
air drying and applying own milk,
nipple shield for time being, EBM
ENGORGEMENT
 Swollen breast due to increased
milk production
 Maybe early or late
 Early engorgement resolves with baby
sucking
 Painful, swollen, warm, hard or rigid breasts
needs treatment
 Treatment: gentle massages, warm
compresses, milk expression, breast support,
oxytocics, NSAID
Mastitis And Breast Abscess
 Pain, fullness, fever with or without chills, swollen,
red, tender breasts
 Treatment: broad spectrum antibiotics,
anti-inflammatory drugs, breast support, feeding to
continue,
 Untreated or under-treated neglected cases may lead
to antibioma / abscess formation
Mastitis And Breast Abscess
(cont.)
 Breast Abscess
 High fever with chills
 Localized,
swollen, red, warm, tender,
indurated mass with fluctuation
 Treatment
is I&D and supportive therapy
same as mastitis
 Breastfeeding to be resumed as early as
possible
Milk Expression

 Manual or hand expression

 Via pump: hand held pumps, mechanical, cylindrical,
battery operated and semi operated pumps
 Mechanical, cylindrical pump is safe and easy to use
and can be sterilized, cost effective
 Suction generated by battery operated pump can be
regulated to suit the user
 EBM stays in good condition in room temp for 8 hrs;
refrigerator 24 hrs or in the freezer at -20 degree
cent for 3 months.
 DevelopmentofMastitis

Im p r o p e r F ir s t S u p p le m " L a zy F e e d
b re a k i n N u rs i n g e n ta l F e er"
g o fs u c E x p e ri e n c e edings
ti o n

Poor Strong A b ru I n te r
Positioning o Sucking ptW e valb
fInfant Infant anin etw e
g en
n u rs i n g t o o
long

Nipple Trauma Pain Impaired Engorgement

Let down

Cracked Stasis
of
nipples milk
Entry for Bacteria Plugged ducts
Mastitis
Treatment, No Treatment
Problem will resolve Breast Abscess
TREATMENT OF
MASTITIS
 Rest
Appropriate Antibiotics-- Usually Cephalosporins

 Hot and / or Cold Packs

 Don’t Stop Br east F eedin g beca u se:

 If the milk contains the bacteria, it also contains
the antibiotic
 Sudden cessation of lactation will cause severe
engorgement which will only complicate the
situation
 Breastfeeding stimulates circulation and moves
the bacteria containing milk out of the breast
 MASTITIS
Meticulous
handwashing

Frequent feedings
and massage
Preventive Measures distended area to
help emptying

Rotate position of
baby on the breast
Deep vein thrombosis

Introduction

Pregnancy And The Puerperium Are Wellestablished Risk

Factors For Venous Thromboembolism (Vte)

 Incidence Of VTE Ranging From 4 To 50 Times Higher In

Pregnant Versus Nonpregnant Women

 It An Absolute Incidence Rate Of 1 In 500 To 2000

Pregnancies (0.025 To 0.10 Percent)

 More Common Postpartum Than Antepartum

 DVT Is Far More Common In The Left Than The Right Leg
PATHOGENESIS AND RISK FACTORS

VIRCHOW'S TRIAD :
venous stasis, endothelial injury, and a hypercoagulable
state Stasis :
pregnancy-associated changes in venous capacitance
and compression of large veins by the gravid uterus
Endothelial injury:

 Delivery is associated with vascular injury and

changes at the uteroplacental surface

 Forceps, vacuum extraction, or surgical delivery can

exaggerate vascular intimal injury
Hypercoagulability:
 associated with progressive increases in several
coagulation factors, such as factors I, II, VII, VIII, IX,
and X, along with a decrease in protein S

 A progressive increase in resistance to activated

protein C

 Activity of the fibrinolytic inhibitors is increased

during pregnancy
 Risk Factors Included Cesarean Section,
Premature Delivery, Or History Of Cardiac
Disease. Multiple Births

 The risk of deep vein thrombosis (DVT) is

approximately twice as high after cesarean delivery
than vaginal birth

 In addition, DVT is far more common in the left

than the right leg

 increased venous stasis in the left leg related to

compression of the left iliac vein by the right iliac
artery, coupled with compression of the inferior vena
cava by the gravid uterus itself
 THROMBOEMBOLIC
DISEASE
 Predisposing Factors
 Slowing of blood in the legs
 Tra um a to the veins

Signs and Symptoms

 Sudden onset of pain
 Tenderness of the calf
 Redness and a n increase in skin temperature
 Positive Homan’s Sign
 T reat m ent

  Heparin --it does not cross into breast milk

  Antidote: protamine sulfate
 Teach patient to report any unusual bleeding,
or petchiae, bleeding gums, hematuria,
epistaxis, etc.

 Complication
  Pulmonary Emboli
Causes and Predisposing
Factors:

Lacerations of perineum are the result of

overstreching or too rapid streching of the
tissues, especially if they are poorly extensile
and rigid.

Perineal injuries are more common in

primigravida than multigravida.
Causes and Predisposing
Factors:
Obstetric injuries:
Malpresentations such as breech
Contracted pelvic outlet
spontaneous labour
operative vaginal deliveries( forceps or vaccum)
Macrosomic babies
.
Causes and Predisposing
Factors:

 Non-obstetric injuries: rape, molestation, fall,

accidental injuries like RTA, bull horn injuries etc.
Degrees of Perineal tear:
First degree- limited to vaginal mucosa
and skin of the introitus.
Second degree- extends to the fascia
and muscles of the perineal body.
Third degree- trauma involves the anal
sphincter.

Fourth degree - extends into the rectal

lumen, through the rectal mucosa.
Degrees of Perineal tear:
 First degree- limited to vaginal mucosa and skin of
the introitus.
 Second degree- extends to the fascia and muscles of
the
perineal body.
 Third degree- trauma involves the anal sphincter.
 Fourth degree - extends into the rectal lumen,
through
the rectal mucosa.

A rare type of tear is central tear of the perineum when the

head penetrates first through the posterior vaginal wall,
then through the perineal body and appears through the
skin of the perineum. It usually occurs in patients with
Symptomatology:
Immediate:
Bleeding Traumatic PPH - hemorrhagic

shock.
Perineal Pain

Perineal hematoma

Urinary retention due to painful perineum

Urinary incontinence

Anorectal dysfunctions like fecal

Symptomatology:
 Delayed:
1. Infected perineum- perineal abscess

2. Uterovaginal prolapse

3. Urinary incontinence (stress and urinary

fistula)
4. Fecal incontinence ( rectovaginal fistula)

5. Dyspareunia

6. Feeling of slack vagina during coitus

 Bleeding
 Prevention
:
 Timely episiotomy should be given in all primigravida,
vacuum and forceps delivery, breech delivery and breech
extraction done after IPV, rigid
perineum in multigravida or previous cases with history of
perineal tears.

 Proper support of perineum at the time of crowning and expulsion

of head.
Repair

Lacerations should be repaired immediately if possible, and

certainly within 24 hours of delivery.
Complications if left
untreated:

 Infection
 Hemorrhagic Shock
 Cosmetic disadvantage
 3rd and 4 t h degree tears if left untreated may lead to fecal
incontinence.
Chronic perineal
laceration
In most cases of Chronic perineal
laceration with long standing disruption
of anal sphincter complex, classical
symptoms are progressive loss of control
of gas and faeces from anus.
Chronic perineal
laceration
If the puborectalis muscle is left intact and is well
innervated and functional, it can provide sufficient
muscular contraction to permit control of faeces
when the patient is constipated and when the stool
is of normal consistency.
 Such patients quickly learn this and remain
in a constipated state to decrease their
symptoms.
Why is an episiotomy only performedwith clear
indication?

Third and fourth degree lacerations and anal

incontinence of stool or flatus are more common
with an episiotomy than with a spontaneous
laceration
What muscles are affected by seconddegree
lacerations?

Bulbocavernous and ischiocavernous

Laterally Superficial transverse perineal
muscle.
The prevalence of clinically recognized anal
sphincter lacerations varies widely and has been
reported to occur in 0.6% to 20.0% of vaginal
deliveries, with higher rates documented after
operative vaginal delivery.
The Perineal Skin May Be Intact With An Underlying
Muscle Tear Not Visible. Risk Factors For Both Occult
And Clinically Recognized Anal Sphincter Disruption
Include :
Midline Episiotomy,
Operative Vaginal Delivery (Both Forceps And Vacuum),
Persistent Occiputo- Posterior Head Position,
Prolonged Second Stage Of Labor (>2 Hours),
Delivery Of Macrosomic Infants.