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Obstetrics Simplified - Diaa M. EI-Mowafi

The Puerperium
Puerperal sepsis

NORMAL PUERPERIUM

Definition

It is the 6-8 weeks following delivery during which the anatomical and physiological changes of pregnancy regress.

Physiological changes

General changes

  • 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 the breasts.
  • 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 analgesics.
  • Breasts:
    • 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.
      • Recumbancy.
      • 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.
    • Anorexia.
    • Loss of fluids.
  • Loss of weight: due to
    • Evacuation of the uterine contents.
    • More fluid loss in urine and sweat.
  • Blood:
    • Increased coagulability of the blood continues during the first two weeks in spite of significant decrease in a number of coagulation factors.
    • 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.

Local changes

  • 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.
  • Lochia:
    • 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 offensive.
  • 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.

Local asepsis

  • 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.

Diet

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 feed.
  • Breast disorders in the puerperium: see later.

Observations

  • Mother: Pulse, temperature, breasts, lochia and involution of the uterus.
  • Foetus: jaundice and umbilical stump.

POST-NATAL EXAMINATION

Time

At the end of the 6th week postpartum, but earlier in complicated pregnancy or delivery.

Aims

  • 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.

History

Ask about:

  • Vaginal bleeding or discharge.
  • Breast disorders.
  • Urinary or gastrointestinal symptoms.

General examination

For pulse, temperature, blood pressure,  breasts.

Abdominal examination

  • to ensure involution of the uterus (not felt abdominally).
  • for detection of abdominal wall tone.

Local examination

  • 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 4-6 weeks.
  • 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.
    • Infection.
    • Retroversion causing congestion
    • Myomas.  
    • Antepartum overdistension e.g. multiple pregnancy.
    • Non-lactating women.
    • Bad general condition.

Treatment

  • Ergot preparations.
  • Antibiotics.
  • Uterine curettage: to remove retained fragments if there is considerable bleeding.

PUERPERAL PYREXIA

Definition

It is a rise of temperature reaching 38oC or more and lasting for 24 hours or more during the first 3 weeks of puerperium.

Causes

  • Puerperal infection (sepsis).
  • Urinary tract infection.
  • Breast infection.
  • Respiratory infection.
  • Intercurrent febrile illness.
  • Complicated pelvic tumours as infected ovarian cyst or red degeneration of myoma.

Any case of puerperal pyrexia should be considered puerperal infection (sepsis) until proved otherwise.

PUERPERAL SEPSIS

Definition

It is a genital tract infection resulted from bacterial invasion during or after labour.

Causative Organisms

  • Aerobic
    • Gram+
      • Haemolytic streptococcus group A (severe cases).
      • Non-haemolytic streptococci.
      • Staphylococcus aureus.
      • Gonococci.
    • Gram-
      • E.coli.
      • Proteus.
      • Pseudomonas.
      • Klebsiella.
  • Anaerobic
    • Gram+
      • Anaerobic streptococci (the commonest).
    • Gram-
      • Cl. Welchii.
      • Bacteroids.

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 stream.

Exogenous origin: from infected attendants, dust, instruments...etc.

Predisposing Factors

  • 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.
    • Lacerations.
    • Marked blood loss.
    • Retained fragments.

Pathology and Clinical Picture

Primary sites

Uterus:

  Localised or Putrid Generalised or Septic
Type of infection is mild. is severe.
Organism virulence is low as anaerobic streptococci. Virulent organism as haemolytic streptococci.
Resistance of the patient is good is low.
Uterus Subinvoluted and soft. Well involuted.
Uterine cavity Offensive retained necrotic parts. Empty but lined with purulent membrane.
Lochia is excessive and offensive. Scanty and not offensive.
Microscopically Well defined zone of leukocytes next to the endometrium preventing spread of infection. Absent or deficient leucocytic zone favouring spread of infection.
Clinical picture 4 days after delivery there is fever, tachycardia, rigors and malaise. 1-2 days after delivery with more severe manifestations.

Infected lacerations:

  • The wound edges are red, oedematous and extruding greenish or yellowish offensive pus.
  • There is mild fever with local pain and tenderness.

Secondary sites

  • 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.

Salpingo-ophritis

Manifestations:

  • 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.

Peritonitis

  • 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 neglected.
    • 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.

Thrombophlebitis

  • 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.

Septicaemia

  • 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

History

  • 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.

General examination

  • Temperature, pulse, blood pressure, level of consciousness.
  • Skin eruption or jaundice (Cl. welchii infection).
  • Tonsils.
  • Breasts, chest and heart.
  • Lower limbs for signs of thrombophlebitis.

Abdominal examination:

  • Loin tenderness
  • Abdominal rigidity and tenderness.
  • Uterine size, tenderness and abdominal masses related to the uterus.

Local examination:

  • 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.

Investigations

  • Swab and culture: from the cervix and upper vagina for aerobic and anaerobic cultures.
  • 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

  • Antenatal:
    • Proper diet, vitamins and minerals.
    • Anaemia and diabetes should be treated.
    • Local or distant infection should be treated.
    • Avoid sexual intercourse late in pregnancy.
  • Intranatal:
    • Strict aseptic and antiseptic measures for the patient, attendants and instruments.
    • 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 delivery.
  • Postnatal:
    • 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

General treatment

  • 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:
    • Analgesics,
    • antipyretics and cold fomentations.
  •  Observations: pulse, temperature, blood pressure, vaginal bleeding, lochia, manifestations of DVT.

Antibiotic therapy

  • 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.
  • Thrombophlebitis:
    • Antibiotics.
    • Anticoagulant therapy (see DIC).
    • Immobilisation and elastic stocking.

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