Normal and Abnormal Puerperium

1
Normal and Abnormal Puerperium

• Liu Wei
• Department of Ob Gy
• Ren Ji hospital

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Normal Puerperium

• Definition
• The time from the delivery of the placenta
  through the first few weeks after the delivery.
• 6 weeks in duration.
• By 6 weeks after delivery, most of the changes of
  pregnancy, labor, and delivery have resolved and
  the body has reverted to the nonpregnant state.

3
Normal Puerperium

• The relevant anatomy and physiology in the
  puerperium
• Reproductive organs
• Uterus
• 1000g ? 50-100g
• The endometrial lining rapidly regenerates (16
  days)
• The placental site undergoes a series of changes
  in the postpartum period

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Normal Puerperium

• Cervix
• it never returns to the nulliparous state.
• the external os is closed to the extent that a
  finger could not be easily introduced.
• Vagina
• shrinks to a nonpregnant state
• resolution of the increased vascularity and edema
  occurs by 3 weeks
• the vaginal epithelium appears atrophic on smear.
  This is restored by weeks 6-10.

5
Normal Puerperium

• Perineum
• swelling and engorgement are completely gone
  within 1-2 weeks
• the muscle tone may or may not return to normal,
  depending on the extent of injury.
• Ovaries
• ovulate as early as 27 days after delivery (not
  breastfeed ) 12 weeks (most) 7-9 weeks (mean).
• the suppression of ovulation due to the elevation
  in prolactin

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Normal Puerperium

• Breasts
• Lactation can occur by 16 weeks' gestation.
• Lactogenesis is initially triggered by the
  delivery of the placenta (E?P?and prolactin).
• the prolactin levels decrease and return to
  normal within 2-3 weeks (not breastfeeding)
• The colostrum??(the first 2-4 days)
• The milk continues to change throughout the
  period of breastfeeding to meet the changing
  demands of the baby.

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Normal Puerperium

• Systemic change
• Cardiovascular system
• Blood volume returns to nonpregnant levels by the
  tenth days of puerperium
• Cardiac output ?(immediately after delivery) ?
  slowly declines? reach late pregnancy levels 2
  days postpartum? normal 2-6 weeks.
• Hematologic changes
• Hemoglobin concentration?on the first postpartum
  days
• Several clotting factors (fibrinogen) ?on the
  first days

8
Normal Puerperium

• Manifestation
• Fever (24 hours)
• Pain (uterine contraction)
• Sweat
• Lochia ??
• a large amount of red blood initially flows from
  the uterus as the contraction phase rapidly
  occurs. (5 weeks)
• lochia rubra lochia serosa (brownish red, with a
  more watery consistency) lochia alba (yellow)

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Normal Puerperium

• Management
• 2 hours after delivery
• Bleeding
• Uterine contraction
• HR and Bp and R and T
• 1 weeks after delivery
• Bleeding

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Normal Puerperium

• Emiction and defecate
• Lochia
• Episiotomy and Laceration
• Breast

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Puerperal Infection

• Puerperal Infection
• any bacterial infection of the genital tract
  after delivery. Incidence 6. The most important
  cause of maternal death.
• Puerperal Morbidity
• temperature 38.0? or highter, the temperature to
  occur on any 2 of the first 10days postpartum,
  exclusive of the first 24 hours, and to be taken
  by mouth by a standard technique at least four
  times daily.

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Puerperal Infection

• Risk factors
• PROM
• Anemia
• Hemorrhage
• EP and CS
• Placenta retain

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Puerperal Infection

• Common pathogens
• Aerobes
• Group A, B, and D streptococci??????
• Gram-negative bacteria Escherichia coli????,
  Klebsiella?????
• Staphylococcus aureus????

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Puerperal Infection

• Anaerobes
• Petococcus species????
• Petostreptococcus species?????
• Bacteroides fragilis group?????
• Clostridium species??????
• Other
• Chlamydia trachomatis?????
• Mycoplasma species???

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Puerperal Infection

• Manifestation
• Acute vulvitis vaginitis and cervicitis
• Uterine infection
• Adnexal infections
• Septic pelvic thrombophlebitis ??????
• Sapremia ???

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Puerperal Infection

• Diagnosis
• History
• Physical examination and PV
• Lab finding
• Differential diagnosis

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Puerperal Infection

• Treatment
• Nutrition anemia prevention
• Antimicrobial treatment
• broad-spectrum, high dose, long time
• Drainage
• Treatment of thrombophlebitis

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Late Postpartum Hemorrhage

• Definition
• Uterine bleeding by 24 hours after delivery.
• Etiology
• Placenta or membrane or decidua retain
• Abnormal redintegration
• Infection
• Problems of incision

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END