NORMAL AND ABNORMAL PUERPERIUM [Autosaved] (1) (1) (2) (2).pptx

EDUCATIVE

1. NORMAL AND ABNORMAL PUERPERIUM

2. Learning objectives: The learner will be able to; Manage a mother during puerperium Manage a woman during normal puerperium Define puerperal pyrexia Describe management of puerperal pyrexia Manage breast complications during puerperium

3. Normal Puerperium Content; Definitions, normal physiological and emotional changes, targeted postpartum care, physiology of lactation, infant feeding methods, minor complications of puerperium, primary postpartum hemorrhage, breast complications , depression, sepsis, pyrexia, deep venous thrombosis, EMTCT

4. INTRODUCTION Definition : Puerperium is the period following childbirth during which the body tissues, especially the pelvic organs revert back approximately to the prepregnant state both anatomically and physiologically. The retrogressive changes are mostly confined to the reproductive organs with the exception of the mammary glands which in fact show features of activity. Involution is the process whereby the genital organs revert back approximately to the state as they were before pregnancy.

5. The woman is termed as a puerpera . Duration: Puerperium begins as soon as the placenta is expelled and lasts for approximately 6 weeks when the uterus becomes regressed almost to the nonpregnant size. The period is arbitrarily divided into — immediate – within 24 hours, (b) early – up to 7 days and (c) remote – up to 6 weeks. Similar changes occur following abortion but takes a shorter period for the involution to complete.

6. Fourth trimester is the time from delivery until complete physiolgical involution and psychological adjustment

7. INVOLUTION OF THE UTERUS Immediately following delivery, the uterus becomes firm and retract with alternate hardening and softening. The uterus measures about 20 × 12 × 7.5 cm 3 (length, breadth and thickness) and weighs about 1,000 g . At the end of 6 weeks, its measurement is almost similar to that of the nonpregnant state and weighs about 60 g. The decrease in size of the uterus and cervix has been shown with serial MRI

8. Changes occur in the following components: (1) Muscles, (2) Blood vessels (3) Endometrium. Muscles : There is marked hypertrophy and hyperplasia of muscle fibers during pregnancy and the individual muscle fiber enlarges to the extent of 10 times in length and 5 times in breadth. During puerperium, the number of muscle fibers is not decreased, but there is substantial reduction of the myometrial cell size.

9. Blood vessels : The changes of the blood vessels are pronounced at the placental site. The arteries are constricted by contraction of its wall and thickening of the intima followed by thrombosis New blood vessels grow inside the thrombi

10. Endometrium : Following delivery, the major part of the decidua is cast off with the expulsion of the placenta and the membranes, more at the placental site. The endometrium left behind varies in thickness from 2 mm to 5 mm. The superficial part containing the degenerated decidua, blood cells and bits of fetal membranes becomes necrotic and is cast off in the lochia. Regeneration starts by 7th day. It occurs from the epithelium of the uterine gland mouths and interglandular stromal cells. Regeneration of the epithelium is completed by 10th day and the entire endometrium is restored by the day 16,except at the placental site where it takes about 6 weeks.

11. Clinical assessment of involution The rate of involution of the uterus can be assessed clinically by noting the height of the fundus of the uterus in relation to the symphysis pubis. The measurement should be taken carefully at a fixed time every day, preferably by the same observer. Bladder must be emptied beforehand and preferably the bowel too, as the full bladder and the loaded bowel may raise the level of the fundus of the uterus. The uterus is to be centralized and with a measuring tape, the fundal height is measured above the symphysis pubis. Following delivery, the fundus lies about 13.5 cm above the symphysis pubis.

12. During the first 24 hours, the level remains constant; thereafter, there is a steady decrease in height by 1.25 cm in 24 hours, so that by the end of 2nd week the uterus becomes a pelvic organ . The rate of involution thereafter slows down until by 6 weeks, the uterus becomes almost normal in size. The involution may be affected adversely and is called subinvolution . Sometimes, the involution may be continued in women who are lactating so that the uterus may be smaller in size — superinvolution . The uterus, however, returns to normal size if the lactation is withheld.

13. Cervix : The cervix contracts slowly; the external os admits two fingers for a few days but by the end of 1 st week, narrows down to admit the tip of a finger only. The contour of the cervix takes a longer time to regain (6 weeks) and the external os never reverts back to the nulliparous state .

14. INVOLUTION OF OTHER PELVIC STRUCTURES Vagina : The distensible vagina, noticed soon after birth takes a long time (6–10 weeks) to involute. It regains its tone but never to the virginal state. The mucosa remains delicate for the first few weeks and submucous venous congestion persists even longer. It is the reason to withhold surgery on puerperal vagina. Rugae partially reappear at 3rd week but never to the same degree as in prepregnant state. Introitus remains permanently larger than the virginal state. Hymen is lacerated and is represented by nodular tags — the carunculae myrtiformes.

15. Broad ligaments and round ligaments require considerable time to recover from the stretching and laxation. Pelvic floor and pelvic fascia take a long time to involute from the stretching effect during parturition

16. LOCHIA Definition : It is the vaginal discharge for the first fortnight during puerperium. The discharge originates from the uterine body, cervix and vagina. Features; Odor and reaction: It has got a peculiar offensive fishy smell. Its reaction is alkaline, tending to become acid toward the end. Color: Depending upon the variation of the color of the discharge, it is named as: (1) lochia rubra (red) 1–4 days, (2) lochia serosa (5–9 days) — the color is yellowish or pink or pale brownish, (3) lochia alba — (pale white) — 10–15 days. Composition : Lochia rubra consists of blood, shreds of fetal membranes and decidua, vernix caseosa, lanugo and meconium

17. Lochia serosa consists of less RBC but more leukocytes, wound exudate, mucus from the cervix and microorganisms (anaerobic streptococci and staphylococci). The presence of bacteria is not pathognomonic unless associated with clinical signs of sepsis. Lochia alba contains plenty of decidual cells, leukocytes, mucus, cholesterin crystals, fatty and granular epithelial cells and microorganisms. Amount: The average amount of discharge for the first 5–6 days is estimated to be 250 mL.

18. Normal duration: The normal duration may extend up to 3 weeks. The red lochia may persist for longer duration especially in women who get up from the bed for the first time in later period. The discharge may be scanty, especially following premature labors or may be excessive in twin delivery or hydramnios. puerperal state. The vulval pads are to be inspected daily to get information of: Odor: If malodorous—indicates infection. Retained plug or cotton piece inside the vagina should be kept in mind.

19. Clinical importance: The character of the lochial discharge gives useful information about the abnormal puerperal state. The vulval pads are to be inspected daily to get information of: Odor: If malodorous—indicates infection. Retained plug or cotton piece inside the vagina should be kept in mind. Amount: Scanty or absent — signifies infection or lochiometra . If excessive — indicates infection. Color: Persistence of red color beyond the normal limit signifies subinvolution or retained bits of conceptus. Duration: Duration of the lochia alba beyond 3 weeks suggests local genital lesion.

20. GENERAL PHYSIOLOGICAL CHANGES Pulse : For a few hours after normal delivery, the pulse rate is likely to be raised, which settles down to normal during the second day. However, the pulse rate often rises with after-pain or excitement. Temperature : The temperature should not be above 37.2°C (99°F) within the first 24 hours. There may be slight reactionary rise following delivery by 0.5°F but comes down to normal within 12 hours. On the 3rd day, there may be slight rise of temperature due to breast engorgement which should not last for more than 24 hours. However,genitourinary tract infection should be excluded if there is rise of temperature.

21. Urinary tract: The bladder mucosa becomes edematous and hyperemic and often shows evidences of submucous extravasation of blood. The bladder capacity is increased. The common urinary problems are: overdistention, incomplete emptying and presence of residual urine. Urinary stasis is seen in more than 50% of women. The risk of urinary tract infection is, therefore, high. Dilated ureters and renal pelvis return to normal size within 8 weeks. There is pronounced diuresis on the 2 nd or 3rd day of the puerperium. Only “clean catch” sample of urine should be collected and sent for examination and contamination with lochia should be avoided.

22. Gastrointestinal tract : Increased thirst in early puerperium is due to loss of fluid during labor, in lochia, diuresis and perspiration. Constipation is a common problem for the following reasons: delayed gastrointestinal motility, mild ileus following delivery, together with perineal discomfort. Some women may have the problem of anal incontinence

23. Weight loss : In addition to the weight loss (5–6 kg) as a consequence of the expulsion of the fetus, placentae, liquor and blood loss, a further loss of about 2 kg (4.4 lb ) occurs during puerperium chiefly caused by diuresis. This weight loss may continue up to 6 months of delivery Urinary tract and renal function : In relation to changes in pregnancy persistence of urinary stasis in the ureters and bladder is observed even up to 12 weeks postpartum.

24. Fluid loss of at least 2 liters during the 1st week and an additional 1.5 liters during the next 5 weeks. The amount of loss depends on the amount retained during pregnancy, dehydration during labor and blood loss during delivery. The loss of salt and water are larger in women with preeclampsia and eclampsia. Slight decrease of blood volume due to blood loss and dehydration. Blood volume returns to nonpregnant level by the 2nd week Cardiac output rises soon after delivery to about 80% above the prelabor value but slowly returns to normal within 1 week

25. Leukocytosis to the extent of 25,000/mm3 occurs following delivery probably in response to stress of labor. Platelet count decreases soon after the separation of the placenta but secondary elevation occurs, with increase in platelet adhesiveness between 4 and 10 days.

26. Ovarian function (menstruation and ovulation): The onset of the first menstrual period following delivery is very variable and depends on lactation. If woman does not breastfeed her baby, menstruation returns by 12th week following delivery in 80% of cases. The meantime for onset of first menstruation is 7 – 9 weeks. In nonlactating mothers, ovulation may occur as early as 4 weeks and in lactating mothers about 10 weeks after delivery. Duration of anovulation depends upon the frequency (>8/24 hours), intensity and duration of breastfeeding.

27. The physiological basis of anovulation and amenorrhea is due to elevated levels of serum prolactin associated with suckling Women who is exclusively breastfeeding, the contraceptive protection is about 98% up to 6 months of postpartum. Thus, lactation provides a natural method of contraception However, ovulation may precede the first menstrual period in about one-third and it is possible for the patient to become pregnant before she menstruates following her confinement. Nonlactating mother should use contraceptive measures in 3rd postpartum week and the lactating mother in 3rd postpartum month.

28. Thyroid function : Thyroid volume regresses gradually to prepregnant state by 12 weeks’ time. Thyroid functions return to normal by 4 weeks postpartum. Women on thyroid medications should get their thyroid function checked to readjust the drugs.

29. LACTATION For the first 2 days following delivery, no further anatomic changes in the breasts occur. The secretion from the breasts called colostrum , which starts during pregnancy becomes more abundant during the period. Composition : It is deep yellow serous fluid, alkaline in reaction. It has got a higher specific gravity; a high protein, vitamin A, sodium and chloride content but has got lower carbohydrate, fat and potassium than the breast milk. Colostrum and milk contains immunologic components such as immune globulin A (IgA), complements, macrophages, lymphocytes, lactoferrin and other enzymes

30. Microscopically: It contains fat globules, colostrum corpuscles and acinar epithelial cells. The colostrum corpuscles are large polynuclear leukocytes, oval or round in shape containing numerous fat globules.

31. Advantages : The antibodies (IgA, IgG, IgM) and humoral factors (lactoferrin) provides immunogical defense to the new born baby It has laxative action on the baby because of large fat globules. Ready and portable Production of oxytocin helps in uterine contraction Breastmilk is highly nutritious e.g colostrum May reduce disease risk Prevention of menstruation Economical [ saves time and money]

32. PHYSIOLOGY OF LACTATION The physiological basis of lactation is divided into four phases: (a) Preparation of breasts (mammogenesis). (b) Synthesis and secretion from the breast alveoli (lactogenesis). (c) Ejection of milk (galactokinesis). (d) Maintenance of lactation (galactopoiesis)

33. Mammogenesis : Pregnancy is associatedwith remarkable growth of both ductal and lobuloalveolar systems. An intact nerve supply is not essential for the growth of mammary glands during pregnancy. Lactogenesis : The alveolar cells are the principal sites for production of milk. Though some secretory activity is evident (colostrum) during pregnancy and accelerated following delivery, milk secretion actually starts on 3rd or 4th postpartum day. Around this time,the breasts become engorged, tense, tender and feel warm. Inspite of a high prolactin level during pregnancy, milk secretion is kept in abeyance. Probably, steroids — estrogen and progesterone circulating during pregnancy make the breast tissues unresponsive to prolactin.

34. When the estrogen and progesterone are withdrawn following delivery, prolactin begins its milk secretory activity in previously fully developed mammary glands Prolactin, insulin, growth hormone and glucocorticoids are the important hormones this stage. The secretory activity is also enhanced directly or indirectly by growth hormone , thyroxine and insulin . For milk secretion to occur, nursing effort is not essential.

35. Galactokinesis : Oxytocin is the major galactokinetic hormone. Discharge of milk from the mammary glands depends not only on the suction exerted by the baby during suckling but also on the contractile mechanism which expresses the milk from the alveoli into the ducts.

36. During suckling, a Conditioned reflex is set-up: The ascending tackle impulses from the nipple and areola pass via thoracic sensory (4, 5 and 6) aff erent neural arc to the paraventricular and supraoptic nuclei of the hypothalamus to synthesize and transport oxytocin to the posterior pituitary Oxytocin is liberated from the posterior pituitary, produces contraction of the myoepithelial cells of the alveoli and the ducts containing the milk. This is the “ milk ejection ” or “ milk let down ” reflex whereby the milk is forced down into the ampulla of the lactiferous ducts, where from it can be expressed by the mother or sucked out by the baby.

37. Presence of the infant or infant’s cry can induce let down without suckling. A sensation of rise of pressure in the breasts by milk experienced by the mother at the beginning of sucking is called “ draught ”. This can also be produced by injection of oxytocin.

38. The milk ejection reflex is inhibited by factors such as pain, anxiety, breast engorgemen or Adverse psychic condition (depression). The ejection reflex may be deficient for several days following initiation of milk secretion and results in breast engorgement

39. Galactopoiesis : Prolactin appears to be the single most important galactopoietic hormone. For maintenance of effective and continuous lactation, frequency of suckling (>8/24 hours) is essential. Distension of the alveoli by retained milk is due to failure of suckling. This causes decrease in milk secretion by the alveolar epithelium. Ductal and alveolar distension due to failure of milk transfer (suckling) is a cause of lactation failure. Milk pressure reduces the rate of production and hence periodic breastfeeding is necessary

40. MilK Production : A healthy mother will produce about 500–800 mL of milk a day to feed her infant. This requires about 700 Kcal/day for the mother, which must be made up from diet or from her body store. For this purpose a store of about 5 kg of fat during pregnancy is essential to make up any nutritional deficit during lactation

41. Stimulation of Lactation Mother is motivated as regard the benefits of breastfeeding since the early pregnancy. Following delivery important steps are: to put the baby to the breast at 2–3 hours interval from the 1st day, plenty of fluids to drink and (iii) to avoid breast engorgement. Early (½ – 1 hour) and exclusive breastfeeding in correct position (see p. 521) is encouraged

42. Inadequate milk Production (lactation failure): It may be due to infrequent suckling or due to endogenous suppression of prolactin (ergot preparation, pyridoxin, diuretics or retained placental bits). Pain, anxiety and insecurity may be the hidden reasons. Unrestricted feeding at short interval (2–3 hours) is helpful.

43. Drugs To Improve milk Production (Galactagogues') Metoclopramide (10 mg thrice daily) increases milk volume (60–100%) by increasing prolactin levels. Sulpiride (dopamine antagonist), Domperidone has also been found effective by increasing prolactin levels. Intranasal oxytocin contracts myoepithelial cells and causes milk let down

44. Lactation Suppression It may be needed for women who cannot breastfeed for personal or medical reasons. Lactation is suppressed when the baby is born dead or dies in the neonatal period or if breastfeeding is contraindicated. Methods commonly used are: ( i ) to stop breastfeeding, (ii) to avoid pumping or milk expression, (iii) to wear breast support, (iv) ice packs to prevent engorgement, (v) analgesics (aspirin) to relieve pain and (vi) a tight compression bandage is applied for 2–3 days. The natural inhibition of prolactin secretion will result in breast involution

45. Medical methods of suppression with estrogen, androgen or bromocriptine is not advised. The side effects of bromocriptine are: hypotension, rebound secretion, seizures, myocardial infarction and puerperal stroke Breast milk for premature infant is beneficial by many ways (psychological, nutritional and immunological). Metabolic disturbances like azotemia, hyperaminoacidemia and metabolic acidosis are less with breast milk compared to formula. It gives immunological protection to the premature infant. Methods for collection (manual expression or electric pumps), and milk preservation.

46. MANAGEMENT OF NORMAL PUERPERIUM Purposes: To restore the health of the mother. To prevent infection. To take care of the breasts, including promotion of breastfeeding. To motivate the mother for contraception

47. Immediate attention : Immediately following delivery, the patient should be closely observed a outlined in the management of the fourth stage of labor She may be given a drink of her choice or something to eat, if she is hungry. Emotional support is essential. Usually the first feeling of mother is the sense of happiness and relief, with the birth of a healthy baby. The woman needs emotional support when she suffers from postpartum blues or stress due to newborn’s prematurity, illness, congenital malformation or death

48. Rest a ambulation Early ambulation is encouraged. Advantages are: provides a sense of well-being, bladder complications and constipation are less, facilitates uterine drainage and hastens involution of the uterus and (4) lessens puerperal venous thrombosis and embolism. Following an uncomplicated delivery, climbing stairs, lifting objects, daily household work and cooking may be resumed.

49. Hospital stay : Most women are discharged fit and healthy after 2 days of spontaneous vaginal delivery with proper education and instructions. Early discharge may be done in a few selected women. Some need prolonged hospitalization due to morbidities (infections of urinary tract, or the perineal wound, pain, or breastfeeding problems)

50. Diet : The patient should be on normal diet of her choice. If the patient is lactating, high calories, adequate protein, fat, plenty of fluids, minerals and vitamins are to be given. However, in nonlactating mothers, a diet is enough as in nonpregnant woman. Bladder Care : The patient is encouraged to pass urine following delivery as soon as convenient. At times, the patient fails to pass urine and the causes are — (1) unaccustomed position and (2) reflex pain from the perineal injuries. This is common after a difficult labor or a forceps delivery.

51. If the patient still fails to pass urine, catheterization should be done It is also indicated in case of incomplete emptying of the bladder evidenced by the presence of residual urine of more than 60 mL Continuous drainage is kept until the bladder tone is regained The underlying principle of the bladder care is to ensure adequate drainage of urine so that infection and cystitis are avoided

52. Bowel care: The problem of constipation is much less because of early ambulation A diet containing sufficient roughage and fluids is enough to move the bowel. If necessary, mild laxative such as isabgol husk two teaspoons may be given at bed time.

53. Adequate sleep Care of the vulva and episiotomy wound The perineal wound should be dressed with spirit and antiseptic powder after each act of micturition and defecation or at least twice a day. The nurse should use sterilized gloves during dressing. Cold (ice) sitz baths relieve pain by reducing edema and inflammation. It causes vasoconstriction.

54. Breast Care: The nipple should be washed with sterile water before each feeding. It should be cleaned and kept dry after the feeding is over. Nipple soreness is avoided by frequent short feedings rather than the prolonged feeding, keeping the nipples clear and dry. Candida infection may be another cause Nipple confusion is a situation where the infant accepts the artificial nipple but refuses the mother’s nipple. This is avoided by making the mother’s nipple more protractile and not offering any supplemental fluids to the infant.

55. Mother-to-child bonding/ rooming is: starts from first few moments after birth. This is manifested by bonding, kissing, cuddling and gazing at the infant This not only establishes the mother-child relationship but the mother is conversant with the art of baby care so that she can take full care of the baby while at home. Baby friendly hospital initiative promotes parent-infant bonding, baby rooming with the mother and breastfeeding.

56. Asepsis and antisceptics must be maintained especially during the 1st week of puerperium. Liberal use of local antiseptics, aseptic measures during perineal wound dressing, use of clean bed linen and clothings are positive steps. Clean surroundings and limited number of visitors could be of help in reducing nosocomial infection

57. immunization ( i ) Administration of anti–D–gamma globulin to unimmunized Rh-negative mother bearing Rh-positive baby; (ii) Women who are susceptible to rubella can be vaccinated safely with live attenuated rubella virus. Mandatory postponement of pregnancy for at least 2 months following vaccination can be easily achieved. (iii) The booster dose of tetanus toxoid, HepB,Tdap , should be given at the time of discharge, if it is not given during pregnancy. All are safe during breastfeeding

58. Management of ailments: After pain — It is infrequent, spasmodic pain felt in the lower abdomen after delivery for a variable period of 2–4 days. The treatment includes massaging the uterus with expulsion of the clot followed by administration of analgesics (Ibuprofen) and antispasmodics. Pain on the perineum: Never forget to examine the perineum when analgesic is given to relieve pain. Early detection of vulvo -vaginal hematoma can thus be made. Sitz baths (hot or cold) can give additional pain relief.

59. Correction of anemia: Majority of the women in the tropics remain in an anemic state following delivery. Supplementary iron therapy (ferrous sulfate 200 mg) is to be given daily for a minimum period of 4–6 weeks. Hypertension is to be treated until it comes to a normal limit. Physician should be consulted if proteinuria persists

60. A progress chart is to be maintained noting the following points: pulse, respiration and temperature recording 6 hourly or at least twice a day, (2) measurement of the height of the uterus above the symphysis pubis once a day in a fixed time with prior evacuation of the bladder and preferably the bowel too, (3) character of the lochia and (4) urination and bowel movement

61. Postpartum excises: Advantages to minimize the risk of puerperal venous thrombosis by promoting arterial circulation and preventing venous stasis, to prevent backache and to prevent genital prolapse and stress incontinence of urine.

62. Procedure:ProCedure : Initially, she is taught breathing exercise and leg movements lying in bed. Gradually, she is instructed to tone up the abdominal and perineal muscles and to correct the postural defects. These can be taught well by a trained physiotherapist. The exercise should be continued for at least 3 months.

63. The common exercises prescribed Kegel’s exercise to tone up the pelvic floor muscles: The process is to be repeated as often as possible each day. (b) To tone up the abdominal muscles: The patient is to lie in dorsal position with the knees bent and the feet flat on the bed. The abdominal muscles are contracted and relaxed alternately and the process is to be repeated several times a day

64. (c) To tone up the back muscles: The patient is to lie on her face with the arms by her side. The head and the shoulders are slowly moved up and down. The procedure is to be repeated 3–4 times a day and gradually increased each day.

65. Physical activity should be resumed without delay. Sexual activity may be resumed (after 6 weeks) when the perineum is comfortable and bleeding has stopped. A thorough check-up of the mother and the baby is mandatory prior to discharge of the patient from the hospital. Discharge certificate should have all the important informations regarding mother and baby Advice includes: (1) Measures to improve her general health. Continuance of supplementary iron therapy (2) postnatal exercises, (3) procedures for a gradual return to day-to-day activities,

66. (4) breastfeeding and care of the newborn, (5) avoidance of intercourse for a reasonable period of 4–6 weeks until lacerations or episiotomy wound are well healed, (6) family planning advice and guidance— Nonlactating women should practice some form of contraceptive measures after 3 weeks and the lactating women should start 3 months after delivery and (7) To have postnatal check up after 6 weeks.

67. The method of contraception will depend upon breastfeeding status , state of health and number of children Natural methods cannot be used until menstrual cycles are regular Exclusive breastfeeding provides 98% contraceptive protection for 6 months. Barrier methods may be used. Steroidal contraceptions — combined preparations are suitable for nonlactating women and should be started 3 weeks after.

68. In lactating women it is avoided due to its suppressive effects. Progestin only pill may be a better choice for them Insertion of IUD immediately following delivery is currently done Sterilization (puerperal) is suitable for those who have completed their families.

69. ABNORMAL PUERPERIUM 1. Puerperal Pyrexia Definition: A rise of temperature reaching 100.4°F (38°C) or more (measured orally) on two separate occasions at 24 hours apart (excluding first 24 hours) within first 10 days following delivery is called puerperal pyrexia. In some countries, postabortal fever is also included.

70. Causes of Puerperal Pyrexia Puerperal sepsis UTIs e.g cystitis, pyelonephritis Mastitis and other breast infection Wound infection, c/s or episiotomy Pulmonary infections like atelectasis, pneumonia Septic pelvic thrombophlebitis A recrudescence of malaria or pulmonary TB Others e.g pharyngitis, GE

71. Puerperal Sepsis or Puerperal Infection Definition: An infection of the genital tract which occurs as a complication of delivery is termed puerperal sepsis . Puerperal pyrexia is considered to be due to genital tract infection unless proved otherwise. There has been marked decline in puerperal sepsis during the past few years due to: Improved obstetric care, (2) availability of wider range of antibiotics.

72. Puerperal sepsis is commonly due to; endometritis, (ii) Endomyometritis, or (iii) endoparametritis or a combination of all these when it is called pelvic cellulitis

73. Vaginal flora in late pregnancy and at the onset of labor consists of the following organisms: Doderlein’s bacillus (60–70%), (2) Yeast-like fungus with increased prevalence of Candida albicans (25%), (3) Staphylococcus albus or aureus, (4) Streptococcus—anaerobic common; beta-hemolytic rare, (5) Vaginal Escherichia coli and Bacteroides group, (6) Clostridium welchii on occasion. These organisms remain dormant and are harmless during normal delivery conducted in aseptic condition.

74. Predisposing Factors of Puerperal Sepsis The pathogenicity of the vaginal flora may be influenced by certain factors: The cervicovaginal mucous membrane is damaged even in normal delivery, (2) The uterine surface too, especially the placental site, is converted into an open wound by the cleavage of the decidua which takes place during the third stage of labor, and (3) The blood clots present at the placental site are excellent media for the growth of the bacteria.

75. Antepartum risk factors: (1) Malnutrition and anemia, (2) Preterm labor, (3) Premature rupture of the membranes, (4) Immunocompromised (HIV), (5) Prolonged rupture of membrane more than 18 hours, (6) Diabetes. Intrapartum risk factors: (1) Repeated vaginal examinations, (2) Dehydration and ketoacidosis during labor, (3) Traumatic vaginal delivery, (4) Hemorrhage—antepartum or postpartum, (5) Retained bits of placental tissue or membranes, (6) Prolonged labor, (7) Obstructed labor, (8) Cesarean delivery.

76. Due to the factors mentioned above, the organisms gain foothold either in the traumatized tissues of the uterovaginal canal or in the raw decidua left behind or in the blood clots, especially at the placental site.

77. Microorganisms responsible for puerperal sepsis and the major pathology Aerobic —Group A beta-hemolytic Streptococcus (GAS)—Toxic shock syndrome, necrotizing fasciitis in episiotomy or cesarean section wound. Group B beta-hemolytic Streptococcus (GBS) is a significant cause of neonatal deaths due to septicemia, respiratory disease and meningitis. Maternal risks are also high. Methicillin-resistant S. aureus (MRSA) causes severe infection. Others—Staphylococcus pyogenes, S. aureus, E. coli, Klebsiella, Pseudomonas, Proteus, Chlamydia

78. Anaerobic —Streptococcus, Peptococcus , Bacteroides (fragilis, bivius ), Fusobacteria, Mobiluncus and Clostridia Most of the infections in the genital tract are polymicrobial with a mixture of aerobic and anaerobic organisms.

79. Pathology The primary sites of infection are: (1) perineum, (2) vagina, (3) cervix, (4) uterus. The infection is either localized to the site or spreads to distant sites. The lacerations on the perineum, vagina and the cervix are often infected by the organisms due to the presence of blood clots or dead space. The wounds become inflamed and there is associated seropurulent discharge. There may be disruption of the wound if repaired before control of infection. Diabetes, obesity, immunocompromised state (HIV) are the other high risk factors for wound infection.

80. Pathogenesis Endometrium (placental implantation site), cervical lacerated wound, vaginal wound or perineal lacerated wound are the favorable sites for bacterial growth and multiplication. The devitalized tissue, blood clots, foreign body (retained cotton swabs), and surgical trauma favor polymicrobial growth, proliferation and spread of infection. This ultimately leads to metritis, parametritis and/or cellulitis.

81. Endomyometritis —The incidence varies from 1–3% following vaginal delivery and about 10% following cesarean delivery. It is commonly polymicrobial (Group A or B Streptococci, Clostridia). The decidua especially over the placental site is primarily affected. The risk factors for endometritis are, retained products of conception, cesarean section, chorioamnionitis, prolonged rupture of membranes, preterm labor and repeated vaginal examinations in labor.

82. The necrosed decidua sloughs off. The discharge is offensive. A zone of leukocytic barrier prevents the infection to the deeper myometrium. Severe infection is rare nowadays

83. Spread of Infection Pelvic cellulitis (parametritis) is due to spread of infection to the pelvic cellular tissues by direct or by lymphatic or hematogenous routes. The infection causes exudation and formation of an indurated mass usually confined to one side of the uterus. [Parametrial abscess] Peritonitis is common following infection (metritis) after cesarean delivery. There may be necrosis of uterine incision wound and dehiscence. Patient presents with bowel distension and a dynamic ileus

84. Salpingitis may be interstitial (due to lymphatic spread) or perisalpingitis (following pelvic peritonitis). Endosalpingitis (tubal mucosa) is uncommon. Pelvic abscess following pelvic peritonitis may be due to spread of infection—(a) directly through the tubes, (b) lymphatic spread, or (c) bursting of parametrial abscess. Rarely, there may be generalized peritonitis.

85. Septic pelvic thrombophlebitis —may involve the ovarian veins, uterine veins, pelvic veins and rarely, the inferior vena cava. The infected thrombus may undergo complete resolution or suppuration Septicemia and septic shock —may be due to hemolytic Streptococci (Streptococcal toxic shock syndrome) or anaerobic Streptococci. Septicemia may cause lung abscess, meningitis, pericarditis, endocarditis or multiorgan failure. Death occurs in about 30% of cases

86. Clinical Features There are feature of: Local infection Uterine infection Spreading infection

87. Local infection (Wound infection): (1) There is slight rise of temperature, Local infection generalized malaise or headache, (2) The local wound becomes red and swollen, (3) Pus may form which leads to disruption of the wound. When severe (acute), there is high rise of temperature with chills and rigor. Uterine infection ; Mild—(1) There is rise in temperature (>100.4°F) and pulse rate (>90), (2) Lochial discharge becomes offensive and copious, (3) The uterus is subinvoluted and tender.

88. Severe—(1) The onset is acute with high rise of temperature, often with chills and rigor, (2) Pulse rate is rapid, out of proportion to temperature, (3) Often there is breathlessness, coughs, abdominal pain and dysuria, (4) Lochia may be scanty and odorless, (5) Uterus may be subinvoluted , tender and softer. There may be associated wound infection (perineum, vagina or the cervix)

89. Spreading infection (extrauterine spread) Evident by presence of pelvic tenderness (pelvic peritonitis), tenderness on the fornix (parametritis), bulging fluctuant mass in the pouch of Douglas (pelvic abscess). Parametritis —The onset is usually about 7–10th day of puerperium. (1) Constant pelvic pain, (2) Tenderness on either side of the hypogastrium, (3) Vaginal examination reveals a unilateral tender indurated mass pushing the uterus to the contralateral side, (4) Rectal examination confirms the induration especially extending along the uterosacral ligament. It takes a few weeks to resolute completely. If, however, suppuration occurs, the features are: (a) steady rise of spiky temperature with chills and rigor, (b) intense pain, (c) gradual deterioration of the general condition, ( (d) leukocytosis.

90. Pelvic peritonitis —(1) Pyrexia with increase in pulse rate, (2) Lower abdominal pain and tenderness, muscle guard may be absent, (3) Vaginal examination reveals tenderness on the fornix and with the movement of the cervix,(4) Collection of pus in the pouch of Douglas is evidenced by swinging temperature, diarrhea and a bulging fluctuant mass felt through the posterior fornix. General peritonitis —(1) High fever with a rapid pulse, (2) Vomiting, (3) Generalized abdominal pain, (4) Patient looks very ill and dehydrated, (5) Abdomen is tender and distended. Rebound tenderness is often present.

91. Thrombophlebitis —(1) The clinical features of pelvic thrombophlebitis are similar to those of uterine infection or parametritis, (2) There may be swinging temperature continued for a longer period with chills and rigor, (3) The features of pyemia are present according to the organs involved. It runs a protracted course. These cases are fortunately rare with the advent of wider range of antibiotics.

92. Septicemia —(1) There is high rise of temperature usually associated with rigor. Pulse rate is usually rapid even after the temperature settles down to normal, (2) Blood culture is positive, (3) Symptoms and signs of metastatic infection in the lungs, meninges or joints may appear

93. Investigations for Puerperal Sepsis History : Antenatal, intranatal and postnatal history of any high risk factor for infection like anemia, prolonged rupture of membranes or prolonged labor are to be taken. Clinical examination includes thorough general, physical and systemic examinations. Investigations ; Vaginal and endocervical swabs, CBC,U/S, CT scan and MRI as confirmatory, UECs in case of renal failure

94. Treatment General care: ( i ) Isolation of the patient is preferred especially when hemolytic Streptococcus is obtained on culture, (ii) Adequate fluid and calorie are maintained by intravenous infusion, (iii) Anemia is corrected by oral iron or if needed by blood transfusion, (iv) An indwelling catheter is used to relieve any urine retention due to pelvic abscess, (v) Progressive vitals chart

95. Antibiotics: Ideal antibiotic regimen should depend on the culture and sensitivity report. Pending the report, gentamicin (2 mg/kg IV loading dose, followed by 1.5 mg/kg IV every 8 hours) and clindamycin (900 mg IV every 8 hours) should be started. Metronidazole 0.5 g IV is given TDS to control the anaerobic group. The treatment is continued until the infection is controlled for at least 7–10 days. In severe sepsis. A combination of either piperacillin-tazobactam or carbapenem plus clindamycin has broadest range of antimicrobial coverage. Women with MRSA infection should be treated with vancomycin or teicoplanin

96. Cases with septic pelvic thrombophlebitis are treated with IV heparin for 7–10 days Surgical treatment; The stitches of the perineal wound may have to be removed to facilitate drainage of pus and relieve pain. The wound is to be cleaned with sitz bath several times a day and is dressed with an antiseptic ointment or powder RPCOs with a diameter of 3 cm or less may be disregarded and left alone. Otherwise surgical evacuation after antibiotic coverage for 24 hours should be done to avoid the risk of septicemia.

97. Pelvic abscess should be drained by colpotomy under ultrasound guidance. Dehiscence of episiotomy or abdominal wound following cesarean section is managed by scrubbing the wound twice daily, debridement of all necrotic tissue and then closing the wound with secondary suture Hysterectomy is indicated in cases with rupture or perforation, having multiple abscesses, gangrenous uterus or gas gangrene infection. Ruptured tubo -ovarian abscess should be removed

98. Wound scrubbing, debridement of all necrotic tissues in case of necrotizing fasciitis , a rare but fatal complication of wound infection (abdominal, perineal, vaginal), involving muscle and fascia

99. Indications of intensive care unit management (1) Hypotension, (2) Oliguria, (3) Raised serum creatinine, (4) Raised serum lactate (≥4 mmol/L), (5) Thrombocytopenia, (6) ARDS, (7) Hypothermia.

100. 2.SubinvolutIon When the involution is impaired or retarded, it is called subinvolution . The uterus is the most common organ affected in subinvolution. As it is the most accessible organ to be measured per abdomen, the uterine involution is considered clinically as an index to assess subinvolution.

101. Causes : Predisposing factors are— Grand multiparity, (2) Overdistension of uterus as in twins and hydramnios, (3) Maternal ill-health, (4) Cesarean section, (5) Prolapse of the uterus, (6) Retroversion after the uterus becomes pelvic organ, (7) Uterine fibroid.

102. Aggravating factors are: Retained products of conception, (2) Uterine sepsis (endometritis).

103. Symptoms: The condition may be asymptomatic. The predominant symptoms are: Abnormal lochial discharge, either excessive or prolonged, (2) irregular or at times excessive uterine bleeding, (3) irregular cramp-like pain in cases of retained products or rise of temperature in sepsis. (4) The uterine height is greater than the normal for the particular day of puerperium. (5) Presence of features responsible for subinvolution may be evident.

104. Management Mere size of the uterus is not important and provided there is absence of features,such as excessive lochia or irregular bleeding or sepsis, the size of the uterus can be safely ignored Appropriate therapy is to be instituted only when subinvolution is found to be a mere sign of some local pathology: Antibiotics in infections like endometritis, (2) Exploration of the uterus in retained products, (3) Pessary in prolapse or retroversion. Methergine, so often prescribed to enhance the involution process, is of little value in prophylaxis.

105. 3. Breast Complications The common breast complications in puerperium are: (1) breast engorgement, (2) cracked and retracted nipple leading to difficulty in breastfeeding, (3) mastitis and breast abscess, (4) lactation failure. Breast engorgement and infection are responsible for puerperal pyrexia.

106. Breast Engorgement Cause : Breast engorgement is due to exaggerated normal venous and lymphatic engorgement of the breasts which precedes lactation. This in turn prevents escape of milk from the lacteal system. The primiparous patient and the patient with inelastic breasts are likely to be involved. Engorgement is an indication that the baby is not in step with the stage of lactation.

107. Onset : It usually manifests after the milk secretion starts (third or fourth day postpartum). Symptoms include—(a) Considerable pain and feeling of tenseness or heaviness in both the breasts (b) Generalized malaise or even transient rise of temperature and (c) Painful breastfeeding. Prevention includes —( i ) To avoid prelacteal feeds, (ii) To initiate breastfeeding early and unrestricted, (iii) exclusive breastfeeding on demand, (iv) Feeding in correct position, (v) Correct latch on

108. Treatment : (1) To support the breasts with a binder or brassiere, (2) Frequent suckling, (3) Manual expression of any remaining milk after each feed, (4) To administer analgesics for pain, (5) The baby should be put to the breast regularly at frequent intervals, (6) In a severe case, gentle use of a breast pump may be helpful. This will reduce the tension in the breast without causing excess milk production.

109. Cracked Nipple The nipple may become painful due to; Loss of surface epithelium with the formation of a raw area on the nipple, or (2) Due to a fissure situated either at the tip or the base of the nipple. These two conditions frequently coexist and are referred to as cracked nipple . It is caused by—(a) unclean hygiene resulting in formation of a crust over the nipple, (b) retracted nipple, and (c) trauma from baby’s mouth due to incorrect attachment to the breast, (d) infection with Candida albicans and S. aureus is often present. The condition may remain asymptomatic but becomes painful when the infant sucks

110. When infected, the infection may spread to the deeper tissue producing mastitis. Prophylaxis includes local cleanliness during pregnancy and in the puerperium before and after each breastfeeding to prevent crust formation over the nipple.

111. Treatment : Correct attachment (latch on) will provide immediate relief from pain and rapid healing. Fresh human milk and saliva have got healing properties. Purified lanolin with the mother’s milk is applied three or four times a day to hasten healing. When it is severe, mother should use a breast pump Miconazole lotion is applied over the nipple as well as in the baby’s mouth if there is oral thrush

112. If it fails to heal up, rest is given to the affected nipple using a breast pump while the nipples heal. Nipple shields (thin latex) can be used. Biopsy in case of persistence of a nipple ulcer, in spite of therapy mentioned to exclude malignancy

113. Retracted and Flat nipple A nipple that is turned inward It is commonly met in primigravidae. It is usually acquired. Babies are able to attach to the breast correctly and are able to suck adequately. Let the baby explore the breast, skin to skin Help mother make nipples stand out more by trying different positions and also massaging the base of the nipple

114. In difficult cases, and when the baby cannot suckle effectively manual expression of milk by use of a breast pump or a syringe can initiate lactation Gradually breast tissue becomes soft and more protractile, so that feeding is possible

115. Acute Mastitis Incidence: 2–5% in lactating and less than 1% in non-lactating women. The common organisms involved are S. aureus, Staphylococcus epidermidis and Streptococci viridans . Risk factors are; poor nursing, maternal fatigue and cracked nipple .

116. Mode of Infection 1) Infection that involves the breast parenchymal tissues leading to cellulitis. The lacteal system remains unaffected. (2) Infection gains access through the lactiferous duct leading to development of primary mammary adenitis. The source of organisms is the infant’s nose and throat.

117. Onset : In superficial cellulitis, the onset is acute during first 2–4 weeks postpartum. However, acute mastitis may occur even several weeks after the delivery. Clinical features : (a) Generalized malaise and headache, nausea, vomiting, (b) Fever (102°F or more) with chills, (c) Severe pain and tender swelling in one quadrant of the breast. (d) Presence of toxic features, (e) Presence of a swelling on the breast. The overlying skin is red, hot and flushed and feels tense and tender.

118. Diagnosis : Microscopic examination of breast milk, showing leucocytes more than 106 /mL and bacterial count more than 103/mL, supports the diagnosis of mastitis. Complications : Breast abscess Prophylaxis : Thorough hand washing before each feed, Cleaning the nipples before and after each feed, and Keeping them dry, reduce the nosocomial infection rates.

119. Management — Breast support, (b) Plenty of oral fluids, (c) Breastfeeding is continued with good attachment. Nursing is initiated on the uninfected side first to establish let down, (d) The infected side is emptied manually with each feed, (e) Antibiotics, Dicloxacillin p.o 500mg qid is a drug of choice till the sensitivity report available. Alternatively erythromycin for pts. allergic to penicillin. Dose to be continued for 7days

120. (f) Analgesics (ibuprofen) are given for pain, (g) Milk flow is maintained by breastfeeding the infant. This prevents proliferation of Staphylococcus in the stagnant milk. The ingested Staphylococcus will be digested without any harm.

121. Breast Abscess Features (1) Flushed breasts not responding to antibiotics promptly, (2) Brawny edema of the overlying skin, (3) Marked tenderness with fluctuation, (4) Swinging temperature.

122. If an abscess is formed, it is to be drained under general anesthesia by a deep radial incision extending from near the areolar margin to prevent injury of the lactiferous ducts. Incision perpendicular to the lactiferous ducts The cavity is loosely packed with gauze which should be replaced after 24 hours by a smaller pack. The procedure is continued till it heals up.

123. The abscess can also be drained by serial percutaneous needle aspiration under ultrasound guidance. Surgical drainage is commonly done. Breastfeeding is continued in the uninvolved side. The infected breast is mechanically pumped every 2 hours and with every let down. Once cellulitis has resolved, breastfeeding from the involved side may be resumed. Antibiotics to be continued depending upon the culture report of pus.

124. Breast Pain May be due to engorgement, infection (C. albicans), nipple trauma, mastitis or occasionally with latching on or let down reflex Management: Appropriate nursing technique, positioning and breast care can reduce pain significantly when it is due to nipple trauma, engorgement or mastitis. Use of miconazole oral lotion or gel into both the nipples and into infant’s mouth thrice daily for 2 weeks is helpful.

125. The causes are: (1) Infrequent suckling, (2) Depression or anxiety state in the puerperium, (3) Reluctance or apprehension to nursing, (4) Ill development of the nipples, (5) Painful breast lesion, (6) Endogenous suppression of prolactin (retained placental bits), (7) Prolactin inhibition (ergot preparations, diuretics, pyridoxine) Treatment; Antentally ; counsel the mother on breast care, care for breast anormallies like rectracted nipple

126. Puerperium; fluids intake, teach on regular nursing of the baby, treat painful lessions /sores, Metoclopramide 10mg TDS, intranasal oxytocin and sulpiride (selective dopamine antagonist) have been found to increase milk production

127. 4. Puerperal Venous Thrombosis Thrombosis of the leg veins and pelvic veins is one of the common and important complications in puerperium especially in the Western countries. The prevalence is, however, low in Asian and African countries Causes; ( i ) Vascular stasis, (ii) Hypercoagulability of blood (pregnancy), and (iii) Vascular endothelial trauma

128. Venous thromboembolic diseases include: Deep vein thrombosis (iliofemoral) Thrombophlebitis (superficial and deep veins) Pulmonary embolus

129. Pathophysiology (1) In a normal pregnancy there is rise in concentration of coagulation factors I, II, VII, VIII, IX, X, XII. Plasma fibrinolytic inhibitors are produced by the placenta and the level of protein S is markedly decreased. (2) Alteration in blood constituents—increased number of young platelets and their adhesiveness. (3) Venous stasis (4) Thrombophilias [inherited and acquired]

130. Risk Factors Previous VTE, Thrombophilia; Heart disease, SLE, Surgical procedures (LSCS); age >35 years, Obesity (BMI >35), Parity ≥3,

131. Immobility, Dehydration, Hyperemesis, Multiple pregnancy.

132. Deep Vein Thrombosis Diagnosis Symptoms include pain in the calf muscles, edema legs and rise in skin temperature. On examination asymmetric leg edema (difference in circumference between the affected and the normal leg more than 2 cm) is significant A positive Homan’s sign—pain in the calf on dorsiflexion of the foot may be present.

133. Investigations Doppler ultrasound to detect the changes in the velocity of blood flow in the femoral vein by noting the alteration of the characteristic “whoosh” sound which is audible from a patent’s vein Venography; injecting nonionic water soluble radiopaque dye to note the filling defect in the venous lumen is a reliable method, if carefully interpreted. Venogram is restricted in pregnancy due to the risk of radiation and contrast allergy MRI

134. Pelvic Thrombophlebitis It originates in the thrombosed veins at the placental site by organisms such as anaerobic Streptococci or Bacteroides (fragilis). When localized in the pelvis, it is called pelvic thrombophlebitis There is no specific clinical feature of pelvic thrombophlebitis, but it should be suspected in cases where the pyrexia continues for more than a week in spite of antibiotic therapy. It can spread[extrapelvic spread] e.g to lungs,kidney

135. Prophylaxis and Management of VTE Preventive Measures; Prevention of trauma, sepsis, anemia in pregnancy and labor. Dehydration during delivery should be avoided. Use of elastic compression stocking [TED stockings] and intermittent pneumatic compression devices during surgery. Leg exercises, early ambulation are encouraged following operative delivery.

136. Thromboprophylaxis depends on the specific risk factor and the category; A low risk woman has no personal or family history of VTE. Such a woman needs no thromboprophylaxis, early mobilization and adequate hydration to be maintained. A high risk woman needs low-molecular-weight heparin (LMWH) prophylaxis throughout pregnancy and postpartum for 6 wks Intermediate risk women with three or more risk factors are considered for antenatal prophylaxis with LMWH up to 7 days of puerperium.

137. Management Bed rest with legs elevated Analgesics for pain Appropriate antibiotics Anticoagulants— Heparin 15,000 units are administered intravenously, followed by 10,000 units 4–6 hourly for 4–6 injections when the blood coagulation is likely to be depressed to the therapeutic level. Heparin is continued for at least 7–10 days or even longer if thrombosis is severe The anticoagulant (warfarin, LMWH or unfractionated heparin) is safe for breastfeeding

138. As soon as the pain subsides, gentle movement is allowed on bed by the end of first week. High quality elastic stockings are fitted on the affected leg before mobilization. Surgical ; Inferior vena cava filters are used for patients with recurrent pulmonary embolism or where anticoagulant therapy is contraindicated Venous thrombectomy is needed for massive iliofemoral vein thrombosis or for massive pulmonary embolus

139. Pulmonary Embolism Pulmonary embolism is the leading cause of maternal deaths in many centers especially in the developed countries after the sharp decline of maternal mortality due to hemorrhage, hypertension and sepsis. It occurs without any previous clinical manifestations of deep vein thrombosis. The clinical features depend on the size of the embolus and on the preceding health status of the patient. The classical symptoms of massive pulmonary embolism are sudden collapse with acute chest pain and air hunger.

140. Death usually occurs within short time from shock and vagal inhibition Signs and symptoms of pulmonary embolism are: tachypnea (>20 breaths/min), dyspnea, pleuritic chest pain, cough, tachycardia (>100 bpm), hemoptysis and rise in temperature more than 37°C.

141. Diagnosis X-ray of the chest shows diminished vascular marking in areas of infarction, elevation of the dome of the diaphragm and often pleural effusion. It is useful to rule out pneumonia, pulmonary infiltrates and atelectasis ECG, Tachycardia, right axis shift, nonspecific ST change, right bundle branch block. ABGs, SPO2 <95% Doppler ultrasound can identify a DVT

142. Lung scans (Ventilation/Perfusion scan or V/Q scan) V/Q scanning is the method of choice for patients with suspected PE and with normal chest radiograph. High probability V/Q scan suggests PE. Pulmonary angiography is accurate to the diagnosis but has got high risks of complications

143. Prophylaxis and Management (1) Resuscitation—cardiac massage, oxygen therapy (2) IV heparin bolus dose of 5,000 IU and. Heparin remains the mainstay of therapy for VTE. Therapeutic doses of LMWH [enoxaparin 1 mg/kg subcutaneous (SC) twice daily] may be used for about 5-10 days (3) Morphine 15 mg (IV) are started for chest pain (4) IV fluid support is continued and blood pressure is maintained, if needed by dopamine or adrenalin

144. (5) Surgical treatment (embolectomy, placement of inferior caval filter or ligation of inferior vena cava and ovarian veins) is done following pulmonary angiography due to recurrent attacks of pulmonary embolism

145. Obstetric Palsies (Postpartum traumatic neuritis) Commonest is foot drop . It is usually unilateral and appears shortly after delivery or during first day postpartum or so. It is thought to be due to stretching of the lumbosacral trunk by the prolapsed intervertebral disk between L 5 and S 1 . Backward rotation of the sacrum during labor may also be a contributing factor. Direct pressure either by the fetal head or by forceps blade on the lumbosacral cord or sacral plexus as a causative factor is no longer tenable

146. The condition is usually mild and may pass unnoticed unless there is disability. Neurological examination reveals lower motor neuron type of lesion with flaccidity and wasting of the muscles in areas supplied by the femoral nerve or lumbosacral plexus. Sensory loss is often present

147. Management of the damaged lumbosacral nerve roots is the same as that of the prolapsed intervertebral disk in consultation with an orthopedist

148. Puerperal Emergencies There are many acute complications that may occur during the puerperium The majority of the alarming complications, however, arise immediately following delivery, except pulmonary embolism Immediate Complications—(1) Postpartum hemorrhage, (2) Shock—hypovolemic, endotoxic or idiopathic,(3) Postpartum eclampsia, (4) Pulmonary embolism—liquor amnii or air, (5) Inversion.

149. Early (within one week)—(1) Acute retention of urine, (2) Urinary tract infection, (3) Puerperal sepsis, (4) Breast engorgement, (5) Mastitis and breast abscess, (6) Pulmonary infection (atelectasis), (7) Anuria following abruptio placentae, mismatched blood transfusion or eclampsia. Delayed—(1) Secondary postpartum hemorrhage, (2) Thromboembolic manifestation—pulmonary embolism, thrombophlebitis, (3) Psychosis, (4) Postpartum cardiomyopathy, (5) Postpartum hemolytic uremic syndrome

150. Read and Make notes on: Psychiatric disorders during puerperium Psychological response to perinatal death and how it is managed

151. THE END