Obstetrics Simplified - Diaa
It is the 6-8 weeks following delivery during which the anatomical and
physiological changes of pregnancy regress.
- Temperature: normal but,
- A reactionary rise may occur after difficult labour. It does
not exceed 38oC and drops within 24 hours.
- A slight rise may occur at the 3rd day due to engorgement of
- Pulse: normal but may rise if there is haemorrhage or infection.
- After pains: Painful uterine contractions occur in early puerperium
increasing with suckling due to oxytocin release. If intolerable use
- Colostrum is secreted in the first 3 days.
- With the establishment of milk secretion at the 3rd to 4th day,
the breasts become engorged, larger, painful, tender while suckling
relieves the discomfort.
- Suckling stimulates prolactin secretion, which causes milk production
and oxytocin release, which stimulates milk ejection.
- Urine: Diuresis by the 2nd - 4th day, lasting for 3-4 days.
- Retention of urine may occur due to:
- Atony of the bladder.
- Laxity of the abdomen.
- Reflex inhibition if the perineum is sutured.
- Compression of the urethra by vulval oedema or haematoma
- Bowel: Tendency to constipation due to;
- Atony of the intestine.
- Laxity of abdomen and perineum.
- Loss of fluids.
- Loss of weight: due to
- Evacuation of the uterine contents.
- More fluid loss in urine and sweat.
- Increased coagulability of the blood continues during the first
two weeks in spite of significant decrease in a number of coagulation
- Haemoglobin concentration: tends to fall in the first 2-3 days.
- Menstruation: is regained by the 6th - 8th weeks after delivery
but in lactating women a variable period of amenorrhoea may be present.
- The uterus is involuted as follow:
- Structure: i) Autolysis of the excess muscle fibres. ii) The
blood vessels are obliterated by thrombosis and become degenerated
while its remnants are transformed into elastic tissues iii) The
decidua, except the basal layer, is separated.
- Weight: After delivery the uterine weight is 1000 gm . By the
end of 6 weeks it is 50 gm.
- Size: After delivery the length of the uterus is 20 cm and felt
at the level of umbilicus. After one week it is midway between umbilicus
and symphysis pubis. After 2 weeks it is at the level of symphysis.
By the end of the 6th week it is 7.5 cm long.
- Uterine ligaments: are involuted and subinvolution predisposes
to prolapse and retroversion.
- It is the genital tract discharge in the first 15 days of peurperium.
- It is alkaline and composed of blood, decidual fragments, cervical
mucus, vaginal transudate and bacteria.
- Lochia rubra (red): consists mainly of blood and decidua.
It lasts for 5 days.
- Lochia serosa (pale): due to relative decrease in RBCs and
predominance of leukocytes. It lasts for 5 days.
- Lochia alba (white): consists mainly of leukocytes and mucus.
It lasts for 5 days.
- Persistence of red lochia means subinvolution.
- Offensive lochia means infection.
- In severe infection with septicaemia, lochia is scanty and not
- Cervix: is closed by the end of the first week.
- Vagina: Vaginal rugae appear in the 3rd week.
- Vulva: Its gaping disappears by the end of puerperium.
- Perineum: regains its tone by the end of puerperium while persistence
of its laxity predisposes to prolapse.
Management of the Puerperium
Rest and exercises
- Rest in bed for 2 days is advised after uncomplicated vaginal delivery
and for a longer few days in complicated or operative delivery.
- Semisitting position encourage drainage of lochia with 2 hours in
prone position daily to encourage anteversion of the uterus.
- Movement in and outside the bed and breathing exercises are advised
during this period to minimise the risk of deep venous thrombosis (DVT).
- Pelvic floor exercise is started in the 3rd day if there is no perineal
wound by alternating contraction and relaxation of the pelvic floor
muscles. Abdominal exercises are done later on. These exercises have
the following advantages:
- Diminish respiratory and vascular complications.
- Minimise future prolapse and stress incontinence.
- Give a better cosmetic appearance later on.
- The vulva and perineum are washed with antiseptic lotion from before
backwards after each micturition and defecation and a sterile vulval
pad is applied.
- If there is perineal stitches add local antibiotic.
Rich in proteins, vitamins, minerals and fluids.
Care of the bowel
Constipation is prevented by plenty of green vegetables and fruits, sufficient
fluids and local glycerine suppositories if needed.
Care of the bladder
Patient is encouraged to micturate frequently. If there is retention a
catheter is applied under aseptic conditions.
Care of the breasts
- Wash the nipple and areola with warm water and soap before each
- Breast disorders in the puerperium: see later.
- Mother: Pulse, temperature, breasts, lochia and involution of the
- Foetus: jaundice and umbilical stump.
At the end of the 6th week postpartum, but earlier in complicated pregnancy
- Detection or follow up of complications of pregnancy or labour.
- To be sure of involution of the genital tract.
- Choice of the method of contraception.
- Vaginal bleeding or discharge.
- Breast disorders.
- Urinary or gastrointestinal symptoms.
For pulse, temperature, blood pressure, breasts.
- to ensure involution of the uterus (not felt abdominally).
- for detection of abdominal wall tone.
- Vulva and perineum: for healing of the wound if present, gaping
of the introitus, bleeding or discharge, stress incontinence and tone
of the pelvic floor.
- Vagina: for prolapse or vaginitis.
- Cervix: for ectopy, lacerations or cervicits.
- Uterus: for size, position, tenderness, consistency and mobility.
- Adnexae: for salpingitis, parametritis or adnexael swellings.
- Gynaecological Problems May Be Present:
- Perineal tear: If not well repaired within 24 hours of delivery
the tissues become oedematous, infected and friable that stitches will
cut through the tissues, so repair is delayed 3-6 months.
- Vesico-vaginal fistula: A Foley’s catheter is applied for 14 days
during which antibiotics are given. The fistula may heal or become smaller
and needs an operation after 3-6 months.
- Prolapse or stress incontinence: Conservative treatment as Kegel
exercise and vaginal cones is advised, if not responding surgical treatment
is carried out after 3-6 months.
- Cervical ectopy: Many of these are due to hormonal effect and usually
regress spontaneously within 3 months. If persists and is symptomatizing
it is cauterised.
- Retroversion of the uterus: If it was present before pregnancy or
not associated with symptoms as subinvolution it needs no treatment.
Otherwise, manual correction is done and Hodge Pessary is applied for
- Subinvolution of the uterus: The uterus did not regress to its pre-pregnancy
size by the end of the puerperium. This may be due to:
- Retained placental fragments.
- Retroversion causing congestion
- Antepartum overdistension e.g. multiple pregnancy.
- Non-lactating women.
- Bad general condition.
- Ergot preparations.
- Uterine curettage: to remove retained fragments if there is considerable
It is a rise of temperature reaching 38oC or more and lasting for 24
hours or more during the first 3 weeks of puerperium.
- Puerperal infection (sepsis).
- Urinary tract infection.
- Breast infection.
- Respiratory infection.
- Intercurrent febrile illness.
- Complicated pelvic tumours as infected ovarian cyst or red degeneration
Any case of puerperal pyrexia should be considered puerperal infection
(sepsis) until proved otherwise.
It is a genital tract infection resulted from bacterial invasion during
or after labour.
Mode of Infection
Endogenous origin: It may be present in the genital
tract as anaerobic streptococci which are normal non-pathogenic commensals
that become pathogenic in presence of devitalised tissues.
It may be outside the genital tract as in the gastrointestinal tract,
perineum or in a distant part as tonsils where it is transmitted by blood
Exogenous origin: from infected attendants, dust, instruments...etc.
- Bad general condition: as anaemia, diabetes and debilitating diseases.
- Large number of bacteria: introduced into the genital tract due
to improper asepsis.
- Intrapartum factors:
- Premature rupture of membranes.
- Prolonged labour.
- Instrumental delivery.
- Marked blood loss.
- Retained fragments.
Pathology and Clinical Picture
Localised or Putrid
Generalised or Septic
Type of infection
is low as anaerobic streptococci.
Virulent organism as haemolytic streptococci.
Resistance of the patient
Subinvoluted and soft.
Offensive retained necrotic parts.
Empty but lined with purulent membrane.
is excessive and offensive.
Scanty and not offensive.
Well defined zone of leukocytes next to the endometrium preventing
spread of infection.
Absent or deficient leucocytic zone favouring spread of infection.
4 days after delivery there is fever, tachycardia, rigors and
1-2 days after delivery with more severe manifestations.
- The wound edges are red, oedematous and extruding greenish or yellowish
- There is mild fever with local pain and tenderness.
- Extension to the secondary sites occurs usually in the 2nd week
of puerperium and rarely before that .
- Extension occurs by direct, lymphatic or vascular spread.
- Predisposing factors for secondary extension:
- Virulent organisms.
- Low resistance of the patient.
- Delayed effective treatment of the primary infection.
Parametritis and pelvic cellulitis
Manifestations develop about the 10th day in the form of:
- mild fever and tachycardia,
- pain and tenderness in both iliac fossae,
- firm, tender mass felt by P/V in one adnexa or both pushing the
uterus to the opposite side or restricting its mobility.
- if parametric abscess is formed the mass becomes fluctuating and
the fever is hectic.
- Fever, rigors and vomiting.
- Lower abdominal pain, tenderness and rigidity.
- Tender lateral vaginal fornices with marked pain on moving the cervix
from side to side.
- Localised (pelvic) peritonitis:
- Fever, tachycardia and vomiting.
- Lower abdominal pain, tenderness and rigidity.
- If pelvic abscess is formed a tender fluctuating bogginess of
the Douglas pouch is felt by P/V. Rectal symptoms as tenesmus and
diarrhoea may develop.
- Generalised peritonitis:
- usually occurs after caesarean section, unrecognised uterine
rupture, intestinal injury or if localised peritonitis had been
- The classic signs of pain, tenderness and rigidity may be absent
due to previous distension of the abdomen by pregnancy but;
- The patient is clearly ill, toxic and dehydrated.
- There is high fever, rapid pulse, vomiting and absent intestinal
sounds due to paralytic ileus.
- Extension of infection to the pelvic veins leads to high fever,
rapid pulse and deep seated pelvic pain.
- If extension progresses to the femoral vein, pain and tenderness
extends to the leg which becomes swollen, oedematous and hot.
- High fever with severe tachycardia up to 140/min, rigors, severe
headache, jaundice due to haemolysis in cl. welchii infection, hypotension
and loss of consciousness.
- In virulent organisms manifestations may develop within 48-72 hours
of delivery .
- Local abdominal and pelvic manifestations may be undetected.
Diagnosis of the Cause of Puerperal Pyrexia
- Pre-existing infection before labour as chest or urinary tract infection.
- Symptoms of infection else where as cough, dysuria, breast pain
or sore throat.
- Complicated labour as PROM, instrumental or prolonged delivery.
- The onset of manifestations in relation to labour.
- Temperature, pulse, blood pressure, level of consciousness.
- Skin eruption or jaundice (Cl. welchii infection).
- Breasts, chest and heart.
- Lower limbs for signs of thrombophlebitis.
- Loin tenderness
- Abdominal rigidity and tenderness.
- Uterine size, tenderness and abdominal masses related to the uterus.
- The perineum for infected episiotomy or lacerations.
- Lochia for amount, colour and odour.
- Bimanual examination for:
- Uterine size, consistency, tenderness, position and mobility.
- Cervix: closed or opened, contents felt through it or lacerations.
- Adnexae: mass.
- Douglas pouch: bogginess.
- Speculum examination: to visualise the cervix and vagina.
- Swab and culture: from the cervix and upper vagina for aerobic and
- Blood culture: taken at peak of temperature in case of septicaemia.
- Blood picture: haemoglobin and leukocytes.
- Urine analysis and culture: midstream or catheter specimen.
Prevention of Puerperal Sepsis
- Proper diet, vitamins and minerals.
- Anaemia and diabetes should be treated.
- Local or distant infection should be treated.
- Avoid sexual intercourse late in pregnancy.
- Strict aseptic and antiseptic measures for the patient, attendants
- Minimise vaginal examinations.
- Avoid bleeding and excessive blood loss should be replaced.
- Lacerations should be properly sutured immediately.
- Prophylactic antibiotics in PROM and prolonged or instrumental
- Maintenance of aseptic precautions.
- Care of the perineal or abdominal wounds.
- Minimise visitors and keep whom are infected away.
- Early isolation of cases of puerperal sepsis.
Treatment of Puerperal Sepsis
- Isolation in a separate room or fever hospital.
- Diet: light diet rich in vitamins and minerals with plenty of fluids.
- Supportive treatment: restoration of fluid and electrolyte balance,
correction of anaemia and tonics.
- Symptomatic treatment:
- antipyretics and cold fomentations.
- Observations: pulse, temperature, blood pressure, vaginal
bleeding, lochia, manifestations of DVT.
- Broad spectrum antibiotic (ampicillin or cephalosporin) + gentamycin
+ metronidazole or
- Clindamycin + gentamycin.
One of these regimen is started till the result of culture and sensitivity.
Antitoxin serum is given in Cl. welchii infection.
Promotion of drainage
- Fowler’s or semisitting position.
- Removal of stitches if there is purulent discharge from a wound.
- Ergot preparations: help drainage of lochia.
- Incision and drainage of the abscess:
- In pelvic abscess: posterior colpotomy + drain.
- In parametric abscess: incision + drain at the pointing point
(usually above the inguinal ligament).
- Manual removal of retained parts: if felt during P/V examination.
Treatment of complicated cases
- General peritonitis:
- No oral feeding.
- Ryle tube and suction.
- Intravenous fluids.
- Parenteral antibiotics.
- Anticoagulant therapy (see DIC).
- Immobilisation and elastic stocking.
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Edited by Aldo Campana,