Obstetrics 13

• Urinary tract - Bladder wall becomes edematous and hyperemic  and often shows evidence of submucous extravasation of blood.
• Stagnation of  urine along with a devitalized bladder wall contribute to UTI in puerperium. 

GIT - slight intestinal paresis leads to constipation.

Blood values - Decrease in blood volume; RBC and hematocrit values returns to normal by the end of first week, Platelet count decreases soon after the separation of the placenta, Fibrinogen level remains high upto the second week of puerperium. 

Involution  of uterus is stimulated by vasospasm. [IOM 00]

• Following delivery, the fundus lies about 13.5 cm  above the symphysis pubis. 
• During first 24 hours, the level remains constant. 
• Thereafter, there is a steady decrease in height by 1.25 cm in a day so that by the end of second week the uterus becomes pelvic organ. 
• The rate of involution thereafter slows down until 6 weeks, the uterus becomes almost normal in size.

In a woman in the 10th postpartum day, the uterus is felt just above symphysis pubis. [IOM 05]

6 weeks

• Lochia is the discharge from the uterus of blood, mucus, and tissue during the puerperal period. [AI 97] 
• Lochia rubra - for first 6 days, blood tinged 
• Lochia serosa - next 3-4 days,  brown 
• Lochia alba - after loachia serosa, white

• Early - blood loss of >500ml during first 24 hours after delivery. 
• Late - blood loss after 24 hours has passed.

• 4Ts:
• 1. Tone - Uterine atony (50%) - most common cause [UP 98,IOM 09] 
• 2. Trauma - Genital lacerations (20%) 
• 3. Tissue - Retained placenta (10%) 
• 4. Thrombin - DIC
• Other rare causes - Uterine inversion

• 1. Overworked uterus – Rapid labor, Prolonged labor, 
• 2. Infected uterus – Chorioamnionitis 
• 3. Relaxed uterus -  MgSO4, Beta-adrenergic agonists (Ritodrine, Terbutaline), Halothane 
• 4. Overdistended uterus – Multiple pregnancy, Polyhydraminos, Macrosomia

Doughy soft uterus above the umbilicus

• Bimanual uterine massage should be done before any medications are used. 

Uterotonics – Oxytocin, Methergine, PGF2α

A) Mifepristone

Mifeprostone is an anti-progesterone, used in early pregnancy to induce abortion.

• Is done if the uterus doesnot contract after C/S
• - It helps to preserve the uterus sometimes if otherwise needs to be removed.  

• - Accessory lobe (common),
• - Placenta accreta

Uterine atony

• - Generalized oozing of blood
• – Bleeding even from sites of  suture needle prick  
• - Petechiae
• – Contracted uterus

• Inverted uterus – normally it should be palpable  upto the umbilicus.
• BEEFY BLEEDING MASS IS seen – the beefy color is of  the endometrium seen that is inverted.

• Management  is to elevate the uterus  and replace the uterus in its anatomic position and give IV oxytocins to contract.
• It should be done before cervix closes because after cervix closes, it is almost impossible to  replace the uterus back.

Sheehan syndrome  is  hypopituitarism  caused by ischemic necrosis due to blood loss and hypovolemic shock during and after childbirth.

• Hypertrophy and hyperplasia of lactotrophs during pregnancy results in the enlargement of the anterior pituitary, without a corresponding increase in blood supply.
• Secondly, the anterior pituitary is supplied by a low pressure portal venous system.
• These vulnerabilities, when affected by major hemorrhage or hypotension during the peripartum period, can result in ischaemia of the affected pituitary regions leading to necrosis.
• The posterior pituitary is usually not affected due to its direct arterial supply.

Failure of lactation due to lack of  prolactin hormone

• Maintainence regimen of:
• - Thyroxin,
• - Adrenal cortical hormones [AI 95]
• - and possibly gonadotropin

• Ligation of uterine arteries or
• TAH(Total Abdominal Hysterectomy)

• Day 0  - Wind (Atelectasis)
• Day 1-2 - Water (UTI) 
• Day 2—3 - Womb (endometritis) 
• Day 4-5 - Wound (Wound infection) 
• Day 5-6 - Walk (Septic pelvic thrombophlebitis)

Atelectasis

• - Atelectasis is more common on general anesthesia use.
• - Management is pulmonary exercise.

UTI with pyelonephritis.

• Multiple vaginal examination and multiple catheterization due to prolonged labor is the cause of UTI.
• Management is with IV antibiotics.

• Endometritis 

Septic thrombophlebitis

• – There is picket fence type of fever.  
• - Managemennt   is IV  heparin -  for 7-10 days 

• Infectious mastitis develops on day 7-21 because of Lactational Nipple trauma.
• Most common organism for infection is Staphylococcus aureus. [UP 97]
• The immediate source of organism that cause mastitis is almost always the infants nose and throat.
• Fissures, abrasions or cracks predispose to infections.

• The drug of choice for mastitis is Flucloxacillin.
• If patient is allergic, use erythromycin. 
• Breast feeding should be continued even with infected breasts. 
• Breast should be incised and drained if the infection does not resolve within 48 hours. [UP 94]

Infectious mastitis.

• Congestive mastitis or Breast engorgement.
• Some breast engorgement is found in almost every women.
• Encourage emptying the breast either by feeding or by breast pump.

Oxytocin

• It is much easier to suck the milk from the  bottle – so once  it finds that it is easier from the bottle,  the baby forgets the  breast.
• So, you should  exclusively breast feed and not bottle feed at least for 6 weeks.

Endometritis