PATOLOGICAL CONDITION IN PUERPERIUM STAGE

1. Puerperium Definition
Puerperium is defined as the time from the delivery of the placenta through the first
few weeks after the delivery. This period is usually considered to be 6 week 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.
2. Involution of The Reproductive Tract
a. Uterus
The pregnant term uterus (not including baby, placenta, fluids, etc) weights
approximately 1000 g. In the 6 weeks following delivery, the uterus recedes to a
weight of 50-100 g.[1]
After postpartum, the fundus of the contracted uterus is palpable at or near the level of
the maternal umbilicus. Thereafter, most of the reduction in size and weight occur in
the first 2 week, until the uterus has shrunk enough to return to the true pelvis. The
total number of the myocytes does not decrease appreciably-rather, their size decrease
markedly.[1,2]
The decidua is not sloughed. Within 2 or 3 days after delivery, the remaining
decidua become differentiated into two layers. The superficial layer becomes necrotic
and is sloughed in the lochia. The basal layer adjacent to the myometrium remains
intact and the is the source of new endometrium. The endometrial lining rapidly
regenerates, so that by the sevent day endometrial glands are already evident. By the
16th day, the endometrium is restored throughout the uterus.
Right after delivery, a large amount of blood flows from the uterus until the
contraction phase occurs. Thereafter, the volume of vaginal discharge (lochia) rapidly
decrease. The duration of this discharge, know as lochia rubra which cointains
erythrocytes, shredded decidua, epithelial cells, and bacteria, is for the first few days
after delivery. The red discharge progressively changes to brownish red and within 3
to 4 days, lochia progressively more watery consistency (lochia serosa). Over a period
of weeks, the discharge continues to decrease in amount and color and eventually
changes to yellow-white color (lochia alba). The period of time the lochia can last
varies, although it averages approximately 5 weeks.[1,2]
b. Cervix
 The cervix also begins to rapidly revert to a nonpregnant state, but it never
returns to the nullipatous states. By the end of the first week, the external os narrows,
the cervix thickens, and the endocervivalcanal reforms such that a finger cannot be
easily introduced.[1,2]
c. Vagina
The vagina also regresses but it does not completely return to its prepregnant
size. Resolution of the increased vascularity and edema occur by 3 weeks, and the
rugae of the vagina begin to reappear in women who are not breastfeeding but less
prominent than before. At this time, the vaginal epithelium appears atrophic on smear.
Vagina epithelium begins to proliferate by 4 to 6 weeks, usually coincidental with
resumed ovarian esterogen production. [1,2]
d. Perineum and Abdoiminal Wall
The perineum has been stretched and traumatized, and sometimes torn or cut,
during the process of labor and delivery. The swollen and engorged vulva rapidly
resolves within 1-2 weeks. Most of the muscle tone is regained by 6 weeks, with more
improvement over the following few months. [1,2]
The abdominal wall remains soft and poorly toned for several weeks. The recovery is
aided by exercise. These may be started anytime following vaginal delivery and as
soon as abdominal soreness diminishes after cesarean delivery. The abdominal wall
usually resumes its prepregnancy appearance. [1,2]
e. Ovaries
The resumption of normal function by the ovaries is highly variable and is
greatly influenced by breast feeding the infant. The woman who breastfeeds her infant
has a longer period of amenorrhea and anovulation than the mother who chooses to
bottle-feed. The mother who does not breastfeed may ovulate as early as 27 days after
delivery. Most women have menstrual period by 12 weeks; the mean time to first
menses is 7-9 weeks. The delay in the return to normal ovarian function in the
lactating mother is caused by the suppression of ovulation due to the elevation in
prolactin.[1]
f. Breasts
The changes to the breast that prepare the body for breastfeeding occur
throughout pregnancy. Each mature mammary gland or breast is composed of 15 to
25 lobes. If delivery ensues, lactation can be established as early as 16 weeks
gestation. Lactogenesis is initially triggered by the delivery of the placenta, which
 results in falling levels of estrogen and progesterone, with the continued presence of
prolactin. If the mother is not breastfeeding, the prolactin level decrease and return to
normal within 2-3 weeks.
The colostrum is a deep lemon-yellow liquid that is initially released by the
breast during the first 2-4 days after delivery. Compared with mature milk, colostrum
is rich in immunological components (IgA) and contains more minerals and amino
acids. It also has more protein, much of which is globulin, but less sugar and fat. The
colostrum which the baby receives in the first few days postpartum, is already present
in the breast, and suckling by the newborn triggers its release. Secretion persist for 5
days to 2 weeks, with gradual conversion to mature milk by 4 to 6 weeks.. The
process, which begins as an endocrine process, switches to an autocrine process; the
removal of milk from the breast stimulates more milk production.
3. Routine postpartum care
For 2 hours after delivery, blood pressure and pulse should be taken every 15 minutes,
or more frequently if indicated. Temperature is assessed every 4 hour for the first 8 hours
and the at least every 8 hours subsequently. The amount of vaginal bleeding is
monitored, and the fundus palpated to ensure that it is well contracted. If relaxation is
detected, the uterus should be massaged through the abdominal wall until it remains
contracted. Blood may accumulate within the uterus without external bleeding. This may
be detected early by uterine enlargment during fundal palpation in the first postdelivery
hours. Because the likelihood of significant hemorrhage is greatest immediately
postpartum, even in normal births, the uterus is closely monitored for at least 1 hour after
delivery.[2]
Nursing
Health workers have to persuade mother to breast feed her baby, because the benefits
of breast feeding are long-term for both mother and infant. Women who breast feed have
a lower risk of breast and reproductive cancer, and their children have increased adult
intelligence independent of a wide range of possible cofounding factors. Breast feeding
is associated with decreased postpartum weight retention. Rates of sudden-infant-death
syndrome are significantly lower among breast-fed infants. For all these reasons, the
American Academy of Pediatrics (2012) supports the World Health Organization (2011)
recommendations of exclusive breast feeding for up to 6 months, with avoidance of
exposure to cow milk proteins.[2]
 Adepted from the World Health Organization, 1989. [2]
The nipples require little attention other than cleanliness and attention to skin fissures.
Fissured nipples render nursing painrul, and they may have a deleterious influence on
milk production. These cracks also provide a portal of entry for pyogenic bacteria.
Because dried milk is likely to accumulate and irritate the nipples, washing the areola
with water and mild soap is helpful before and after nursing. When the nipples are
irritated or fissured, it may be necessary to use topical lanolin and a nipple shield for 24
hours or longer. If fissuring is severe, the infant should not be permitted to nurse on the
affected side. Instead, the breast should be emptied regularly with a pump until the
lessions are healed. [2]
Nursing is contraindicated in women who take street drugs or do not control their
alcohol use; have an infant with galactosemia; have human immunodeficiency virus
(HIV) infection; have active, untreated tuberculosis; take certain medications; or are
undergoing breast cancer treatment. Breast feeding has been recognized for some time as
mode of HIV transmission and is proscribe in developed countries in which adequate
nutrition is otherwise available. Other viral infections do not contraindicate breast
feeding. For example, with maternal cytomegalovirus infection, both virus and
antibodies are present in breast milk. And although hepatitis B virus is excreted in milk,
breast feeding is not contraindicated if hepatitis B immune globulin is given to the
newborns of affeccted mothers. Maternal hepatitis C infection is not a contraindication
because breast feeding has not been shown to transmit infection. Women with active
herpes simplex virus may sukle theis infants if there are no breast lession and if
particular care is directed to hand washing before nursing.[2]
Sexual Intercourse
Sexual intercouse may resume when bright red bleeding ceases, the vagina and vulva
are healed, and the woman is physically comfortable and emotionally ready. Physical
readiness usually takes about 3 weeks. Birth control is important to protect against
pregnancy because the first ovulation is very unpredictable.[1,2]
Vaginal Delivery
After vaginal delivery, most women experience swelling of the perineum. This is
intensified if the woman has had an episiotomy or a laceration. Routine care of this area
includes ice applied to the perineum 24 hous after delivery and then switch to warm
baths to reduce swelling and pain relief. Paracetamol and NSAIDs medication are helpful
for reduce the pain as well.[1]
Hemorrhoids are another postpartum issue likely to affect women who have vaginal
deliveries. Symptomatic relief is the best treatment during this immediate postpartum
period because hemorrhoids often resolve as the perineum recovers. There is no
substitute for a high-fiber diet and plenty of fluids in preventing constipation, but
lactulose may be useful as a temporary measure.[1]
Cesarean Delivery
Women who have had a cesarean delivery are often slower to begin ambulating,
eating, and avoiding; however, encourage them to quickly resume these and other normal
activities. The main pain has gone by the end of the first week, but for two months the
woman can have days when the scar is sore, or gets jabbing pain, especially when she
has done too much. Paracetamol is usually enough, potentially supplemented by
NSAIDs. Codeine has a theoretical risk in breast feeding.[1]
Beside pain, the normal tiredness of the puerperium is exaggerated in women who
have had a CS. In the first month especially, they may have days of getting exaggerated
in women who have had a CS. In the first month especially, they may have days of
getting exhausted by normal tasks. If this happens, do the blood test to see the Hb
value.[1]
4. Patology condition in puerperium
a. Hemorrhage
b. Anemia
c. Psychiatric disorder
d. Uterine Infection
Postpartum uterine infection or puerperal sepsis has been called variously
endometritis, endomyometritis,and endoparametritis. Because infection involves not
only the decidua but also the myometrium and parametrial tissue.
Predisposising factors
The route of delivery is the single most singnificant risk factor for the
development of uterine infection. [2]
Metritis following vaginal delivery is relatively infrequent, compared with
cesarean delivery. Women at high risk for infection because of membrane rupture,
prolonged labor, and multiple cervical examination have a 5-6 percent frequency of
metritits after vaginal delivery. If there is intrapartum chorioamnionitis, the risk of
persistent uterine infection increases to 13 percent. Finally, in one study, manual
removal of the placenta, increased the puerperal metritis rate threefold.[2]
In cesarean delivery, single-dose perioperative antimicrobial prophylaxis is
recommended for all women before undergoing operation. It has done to decrease the
incidence and severity of postcesarean delivery infection. Such practices decrease the
puerperal pelvic infection risk by 65 to 75 percent. Important risk factors for infection
following surgery included prolonged labor, membrane rupture, multiple cervical
examination, and internal fetal monitoring. Women with all these factors who were
not given perioperative prophylaxis had a 90 percent serious postcesarean delivery
pelvic infection rate. [2]
It is generally accepted that pelvic infection is more frequent in women of
lower socioeconomic status. Anemia or poor nutrition predispose to infection.
Bacterial colonization of the lower genital tract with certain microorganism-for
example, group B streptococcus, Chlamydia trachomati, Mycoplasma hominis,
Ureaplasma urealyticum, and Gardnerella vaginalis-has been associated with an
increased postpartum infection risk. Other factors associated with an increased
infection risk include general anesthesia, cesarean delivery for multifetal gestation,
young maternal age and nulliparity, prolonged labor induction, obesity, and
meconium-stained amniotic fluid.[2]
Etiology
The most common organisms are divided into 4 groups: aerobic gram-negative
bacilli, anaerobic gram-negative bacilli, aerobic streptococci, and anaerobic gram-
positive cocci. Specifically, Escherichia coli, Klebsiella pneumoniae, and Proteus
species are the most frequently identified organisms.
If metritis occuring on postpartum day 1 or 2 can be caused by group A streptococci.
Metritis that develops more than 7 days after delivery can caused by Chlamydia
trachomatis. Metritis following cesarean delivery is most frequently caused by
anaerobic gram-negative bacilli.[1]

History
A patient may report any of the following symptoms: fever, chills, lower
abdominal pain, malodorous lochia, increased vaginal bleeding, anorexia, and
malaise.[1]
Examination
Physical examination is important and should include vital sign, an
examination of the respiratory system, breast, abdomen, perineum and lower
extremities. Patient with metritis typically has a fever of 38˚C, tachycardia, and fundal
tenderness. Some patients may develop mucopurulent vaginal discharge, whereas
others have scant and odoless discharge.[1]
 Differential Diagnosis
Urinary tract infection; acute pyelonephritis; lower genital tract infection;
wound infection; atelectasis; pneumonia; thrombophlebitis; mastitis; appendicitis;
DVT.[1]
Laboratory tests
In blood laboratory test can be found leukocytosis may range from 15,000 to
30,000 cell/µL. Blood cultures, urine culture, and urinalysis should be performed. [1]
Treatment
If nonsevere metritis develops following vaginal delivary, then treatment with
an oral anti-microbial agent is usually sufficient. For moderate to severe infections,
however, intravenous therapy with a broad-spectrume antimicrobial regimen is
indicated.[2]
For infections following vaginal delivery, as many as 90 percent of women
respond to regimens such as ampicillin plus gentamicin. [2]

Table Antimicrobial Regimens for Intravenous Treatment of Pelvic Infection Following Cesarean
Delivery[2]
e. Urinary tract infections
f. Mastitis
Etiology
Milk stasis and cracked nipples, which contribute to the influx of the skin
flora, are the underlying factors associated with the development of mastitis. Masititis
is associated with primiparity, incomplete emptying of the breast, and improper
nursing technique. The most common causative organism, isolated in approximately
half of all cases, is Staphylococcus aureus. Other common pathogens include
Staphylococcus epidermidis, Streptococcus viridans, and E coli.[1]
Incidence
 In the United States, the incidence of postpartum mastitis is 2.5-3%. Mastitis
typically develops during the first 3 months postpartum, with the highest incidence in
the first few weeks after delivery.[2]
History
Fever, chills, myalgias, erythema, warmth, swelling, and breast tenderness
characterize this disease.[1]
Examination
Focus examination on vital signs, review of systems, and a complete
examination to look for other source of infection. Typical findings include an area of
the breast that is warm, red, and tender. When the exam reveals a tender, hard,
possibly fluctuant mass with overlying erythema, a breast abscess should be
considered.[1]
Investigation
No laboratory test are required. Expressed milk can be sent for analysis, but
the accuracy and reliability of these results are controversial and aid little in the
diagnosis and treatment of mastitis.[1]
Treatment
Milk stasis sets the stage for the development of mastitis, which can be treated
with moist heat, massage, fluids, reast, proper positioning of the infant during nursing,
nursing or manual expression of milk, and analgetics.[1]
Flucloxacillin is the drug of choice. Erythromycin, clindamycin, and
vancomycin may be used for infections that are resistant to penicillin. Resolution
usually occurs 48 hours after the onset of antimicrobial therapy. An abscess usually
needs surgery.[1]
g. Wound infection
h. Venous thrombo-embolism
i. Pre-eclampsia/ eclampsia/ hypertension
j. Endocrine disorders