The puerperium (Question-Answers)

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    Pyrexia in puerperium

    What is puerperium ?

      It is a period after child birth (6-8 weeks) during which the mother gradually returns to the non pregnant state.

    What is involution of uterus ?

      It is the process in which the postpartum uterus which is about 21b and 8-10 inches long, returns to it’s original state which is approximately 3 inches and 2 ounces.

    What is autolysis ?

      The fibres of uterine muscle get dissolved by their own proteolytic enzymes and end products are absorbed by the blood.

    How do you assess involution clinically ?

      By measuring the distance between pubic symphysis and fundus of the uterus after emptying the bowel and bladder.Decrease is approximately 1 cm each day.By 12-14th day fundus is felt just above the symphysis pubis.

    What is subinvolution ?

      Delay in the involution of uterus is called sub involution.

    What are the causes of subinvolution ?

      Multiple pregnanc
      Hydramnios
      Anaemia
      Multiparity
      Failure of breast feeding
      Infection
      Fibroids
      Retained products of conception

    What is lochia ?

      A mixture of blood & mucous or decidua which is discharged vaginally during pueperium.

    What is the normal pattern of lochia ?

      for first five days—It is moderate, red in colour which gradually becomes brown.Between 5-10 days–There is excess of mucus and it is less reddish brown ( lochia serosaAfter 10th day onwards– It is scanty, colour varies from brown-yellow–white which is called lochia alba.

    What is indicated by cessation of lochia in early puerperium ?

      Infection in genital tract.

    Red , profuse lochia indicates what ?

      It indicates that there are some retained products inside the uterine cavity.

    How do you treat retained products ?

      By investigating for routine haemogram , doing an usg, giving ergometrine , antibiotics , blood transfusion if required and by removing the products with the help of suction evacuation.

    What is colostrum ?

      It is a clear fluid secreted from the breast after 12 weeks which is baby’s staple diet for first few days.

    How the milk formation is stimulated ?

      Due to removal of the inhibition from lactogenic hormones which is due to high levels of progesterone and oestrogen during pregnancy.

    How the lactation is established ?

      Mammary gland’s response to the stimulation by baby’s ability to suck and desire of the mother starts milk secretion.

    What are the causes of retention of urine after delivery ?

      Fear due to perineal stitching ( episiotomy ) or obstetric trauma . Prolonged labour can cause brusing of the bladder base

    What should be done for retention of urine ?

      She should be encouraged for the spontaneous emptying. She should be told to get out of the bed.Use commode , if it fails then catheterise. Mild urinary antiseptic like potassium citrate can be given for few days

    What is indicated by persistent hypertension ?

      Means it is residual hypertension , not toxaemia.

    Tell me something about taking general care during pueperium ?

      See the uterine involution
      Amount , colour of lochia and odour
      Febrile or afebrile
      Examination of breasts–hygiene after each feed and proper support.
      Examination of bladder and history of passing urine and it’s quantity.
      Laxative to treat constipation
      Care of episiotomy wound.
      Regular change of aseptic vulval pads.
      Record of BP, pulse and temperature.

    How do youencourage drainage of lochia ?

      By fowler’s position; lying on abdomen for 1-2 hours daily and early ambulation

    What drugs and diet you suggest for early recovery ?

      Oral iron therapy, vitamins, high protein diet, lot of fluids ( which they restrict in villages ), adequate rest and sleep during night.

    When should she start the post natal exercises ?

      Within 24 hrs of normal delivery.But should never overfatigue her.It prevents pulmonary embolism and restores the tone of rectii abdominis., internal and external obliques , levator ani etc.In case of C-section also, deep breathing , passive and active leg movements are advised as soon as possible

    Can a woman conceive during lactational amenorrhoea ?

      Yes

    Pyrexia in puerperium

    What is puerperal pyrexia ?

      A febrile condition of urogenital tract or extragenital infection within 21 days of the child birth in which temperature of 100.4degree F or more , sustained for a period of 24 hrs is called pueperal pyrexia.

    What are the sequeale of pyrexia ?

      Chronic pelvic disease , sterility , chronic cervicitis, urinary symptoms.

    What investigations you will carry out for pyrexia ?

      Routine haemogram or CBC
      ESR
      High vaginal swab
      Microscopic urine examination and culture and sensitivty
      Blood culture
      USG

    What measures are to be taken to prevent pyrexia ?

      During pregnancy–hygiene is to be maintained.
      Improvement of general health and prevention of anemia.
      During labour–aseptic technique while conducting labour.Gloves and instruments should be properly autoclaved.Labour room should be aseptic.
      During puerperium–Episiotomy care , breast care and proper diet and rest.

    What are the causes of pyrexia ?

      Infection of urogenital tract
      Anemia is a predisposing factor.
      Breast engorgement and infection
      Superficial and deep thrombophlebitis of leg veins
      Intercurrent infections such as viral fever, malaria , typhoid etc.

    What is reactionary temperature ?

      Rise in temperature upto 100 degre F within 24 hrs of delivery.It is due to autolysis of uterine muscle and can be due to maternal exhaustion also.

    What is the commonest site of infection ?

      Placental site.

    What are the organisms who cause infection ?

      Usualy aerobic haemolytic streptococcus group A, C G and if there are retained products , then anaerobes cause infection

    What are the sources of infection ?

      Organisms present in the vagina before the onset of labour
      Organisms reaching the placenta from mother’s body(endogenous source )
      Exogenous source–organisms reaching the cavity from outside.This is the most common cause especially in villages where delivery is conducted by Dais or Midwives
      Infective focci may be nurse , attendant , mother. It comes from hands , fingers , bed sheets , gloves , blankets , dust , bed pans , toilets etc.

    What are the predisposing factors for infection ?

      Prolonged labour
      Repeated per vaginum examinations
      Difficult delivery like forceps and ventouse application
      Anaemia ,
      Diabetic mother ,
      chronic heart and lung diseases ,
      Premature rupture of membranes(PROM) etc.

    What is severe and acute infection ?

      High grade fever 102-103 degree F, within 48 hrs , with chills and rigors , tachycardia, pale look , lower abdominal pain which is persistent, some rigidity and guarding of the abdominal muscles , extremely tender uterus , malodourous and scanty lochia.

    How will you manage such case ?

      Adequate antibiotics
      IV fluids
      Blood transfusion
      Antipyretics
      Good nursing care like cold sponging
      Antiinflammatory drugs
      Proper sleep and rest
      Investigations like USG, culture of lochia , CBC, urine culture and sensitivity are to be done regularly till fever subsides.

    What are the complications if not treated ?

      Bilateral salpingo-oophoritis , endometritis , parametritis , peritonitis , septicemia and death.
      What are the characteristics of mild infection ?
      Gradual onset of fever
      Lower abdominal discomfort
      Offensive lochia which is excessive & reddish brown in colour.

    How will you treat gaped episiotomy wound ?

      Remove the suture and clean the wound with Hydrogen peroxide , eusol and betadine. One can resuture the wound under the cover of antibiotic umbrella with non absorbable suture material like silk or prolene. Vicryl can also be used depending upon the timing, gaping and amount of infection and granulation tissue.

    What are the causes of urinary tract infection ?

      Retention overflow , prolonged labour , frequent catheterisation, bruising and trauma of the bladder base due to the pressure of presenting part or forcep’s delivery & failure to keep the bladder empty during third stage of labour.

    What are the signs of cystitis ?

      Dull pain in lower abdomen, dysuria , frequency , rigor , tempr 100-101degree F .

    What can be done for the prevention ?

      All ladies should be given mild alkaline antiseptic containing potassium citrate during first pueperal week.

    When do you see breast engorgement during puerperium ?

      It is seen usually on 4th or 5th day after delivery .

    What is the treatment of engorgement ?

      Hot fomentation , use of breat pumps and expression of milk.

    What are the predisposing factors for breast infection ?

      Breast engorgement , cracked nipples & anaemia.

    What organisms cause breast infection ?

      Usually staph pyogens cause breast infection

    What are the signs and symptoms of mastitis ?

      Pain and tenderness in the breast , malaise , headache , rigors with tempr 101-103 degree F , tachycardia , angry look of the affected breast , pitting on pressure of the skin of breast and fluctuation if there is pus formation.

    What investigations are to be done if it is mastitis ?

      Culture of the nipple swab and milk from the affected breast.

    What is the treatment of mastitis ?

      Antibiotics , hot fomentation, antiinflammatory drugs , stopping of the feeding from affected breast.If abscess is formed then drainage under antibiotic cover.

    What are the characteristics of superficial thrombophlebitis ?

      Involves one or both legs
      Severe pain
      Mild fever upto 100 degree F
      What is the treatment ?
      Usually self limiting.
      Firm crepe bandage
      Glycerine ichthyol dressings
      Pain killers
      Early ambulation.

    What are the signs of deep vein thrombosis ?

      Pain and tenderness in the affected calf muscles on touch , higher swinging temperature.Its complication is pulmonary embolism and sometimes death.

    What is Homan’s sign ?

      Pain in the calf muscle while dorsiflexing the foot and keeping the knee in extended position.

    What organism causes deep vein thrombosis ?

      Anaerobic streptococcii.

    What is the treatment of deep vein thrombosis ?

      Investigations like doppler ultrasound and coagulation profile are carried out
      Antibiotics , low molecular weight heparin, thrombolytic agents within 48 hrs and removal of clot with umbrellacan be done.

    How do you prevent deep vein thrombosis ?

      By early ambulation and leg movements.
      Not only in normal delivery but in C- section also early ambulation and early breast feeding with active leg movements with deep breathing exercise is advised.


    References

    • Dr B N Tiwary 1977 Viva in Obstetrics

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