The puerperium and
A 24-year-old G1P1 woman underwent a forceps delivery via vagina 2
days ago for prolonged second stage. she had leakage of fluid per vagina 2
days before the onset of labor. She required oxytocin and an internal
uterine pressure catheter during labor. Her baby weighed 4.1kg. The past
medical and surgical histories were unremarkable. She denies a cough or
dysuria. On examination, the temperature is 102℉, HR 80/min, BP 120/70,
and RR12/min. The breasts are nontender. The lungs are clear to
auscultation. There is no costovertebral angle tenderness. The abdomen
reveals that the skin incision is without erythema. The uterine fundus is
firm, at the level of the umbilicus, and somewhat tender. No lower
extremity cords are palpated.
What is the most likely diagnosis?
What is the most likely etiology of the condition?
What is the best therapy for the condition?
The definition of puerperium
The immediate puerperium
The early puerperium
The remote puerperium
Anatomic &physiologic changes during
Immediate puerperium: 1 kg,
20-week pregnancy size( at
the level of the umbilicus)
Early puerperium: 12-week
size (palpable at the
Remote puerperium: 100g
Placental implantation site
Following delivery of the placenta, there is immediate
contraction of the placental site to a size less than half the
diameter of the original placenta.
Endometrial regeneration except at the placental site is
completed by the end of the third week postpartum.
The placental site regeneration is usually complete until 6
Changes of Cervix
Clinical Symptoms of puerperium
• Lochia rubra
• Lochia serosa
• Lochia alba
Complications of puerperium
Late postpartum hemorrhage
subinvolution: this term describes an arrest or retardation of
involution. It is accompanied by prolongation of lochial
discharge and irregular or excessive uterine bleeding.
how to consider a puerperal fever
• “Milk fever” (Lasts < 24 hours)
• Drug reaction
• Pulmonary Atelectasis (48 hours)
• Mastitis (2-3 weeks post partum)
Evaluate for pulmonary etiology:
Evaluate for pyelenephritis:
costovertebral angle tenderness? Dysuria? Pyuria?
Evaluate for wound infection:
Is the wound indurated, erythemotous? Is there
Evaluate for breast engorgement:
Are breasts engorged, tender, red?
Evaluate for endometritis:
Is the uterus tender? Foul-smelling lochia?
• Endomyometritis: fever, pain, foul lochia,
• pelvic peritonitis
• pelvic thrombophlebitis
• DIC, septic shock
• Multiple exams during labor
• long labor
Treat with Gentamycin/Clindomycin (Gold
Standard), extended spectrum penicillin or