Puerperium

Definition

Normal puerperium

1. The time from the delivery of the placenta through the first few weeks after the delivery
2. 6 weeks in duration. 
3. By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery resolves and the body reverts to the non pregnant state.

The puerperium has been referred to as the “ fourth trimester” of pregnancy, encompassing the period between the delivery and complete physiologic involution and psychological adjustment. 

Abnormal Puerperium

• Puerperal Pyrexia
• postnatal psychosis and depression

Puerperal Pyrexia

Definition

P pyrexia is defined as temperature of 38oC ( 100.4oF) or higher on any two occasions persisting after the first 24 hrs of delivery, and within 10 days postpartum taken by mouth by a standard technique.

Cause of P. Pyrexia

1. P. Sepsis- Genital tract infection
2. UTI
3. Breast Complications
4. Wound Infections
5. Thrombophlebitis and DVT
6. Respiratory infections

Puerperal Sepsis

Definition

An infection of the genital tract which occurs as a complication of delivery is termed as P sepsis.

Vaginal flora

1. L bacillus ( 60-70%)
2. Yeast like fungus- Candida albicans ( 25%)
3. Staph albus or aureus
4. Strepto β haemolyticus
5. E coli and bacteroids
6. Cl welchii-rare

These organisms remain dormant and are harmless during normal delivery conducted in aseptic conditions. 

Predisposing factors to P Sepsis

1. Conditions lowering the resistance 
2. Malnutrition & anaemia
3. PROM
4. Chronic debilitating diseases
5. Repeated PV examination after rupture membrane
6. Traumatic manipulative & operative delivery
7. Haemorrhage 
8. RPOC- retained product of conception
9. Placenta previa

Organism responsible for P sepsis

• Aerobic- Staph, Ecoli, Klebsiella, Pseudomonas, Non-haemolyticus Strepto, 

• Anaerobic- Anaerobic streptococcus, Bacteroids, Cl welchii and tetani

Pathology and the primary site of infection

Uterus

Endomyometritis- is the most common and usually mildest form of genital infection.

4 Classical signs:

• Pyrexia 37.8-38o C
• Pulse 100-120
• Fundal height- not decreasing
• Lochia red &offensive smell

Clinical examination & Daily Charting

Investigations

1. High vaginal smear and endocervical swab for C/S
2. MSU for R/M/E & C/S
3. Blood for Hb,TC, DC & C/S
4. Blood for MP
5. Widal Test
6. X-ray chest

Treatment 

1.Adequate fluids, rest and movement of bowel- Milk of magnesia

2.Correction of anaemia

3.Antibiotics- Broad spectrum

        I/V Ampicillin 500mg  6 hrly

        I/V Metronidazole 500 mg  8 hrly

        I/V Gentamycin  3-5 mg/kg body wt in divide dose

                                    OR

        I/V Ceftriaxone / Cefotaxim 1 gm 12 hrly

                    Change according to C/S             

Urinary tract infection

• Incidence is 1-5%
• Organisms- E coli, klebsiella, Proteus, Staph aureus
• Causes- Frequent catheter, stasis of urine due to lack of bladder tone & less desire to pass urine, Asymptomatic bacteriuria becomes symptomatic, 
• Present- Fever with chills & rigor, burning micturition, frequency, nausea, vomiting, acute pain in the loins radiating to groin.
• Investigation- Urine for R/M/E and C/S
• Treatment -Antibiotics

Causes of retention urine in puerperium

1.Bruising and oedema of the bladder neck

2.Reflex from the perineal injury

3.Unaccustomed position

4.Haematoma

Treatment

• General measures
• Indwelling catheter for 48 hrs- It helps in regaining the normal bladder tone and the sensation of fullness.
• Antibiotics

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