1. Abnormal puerperium

2. The most serious complications that may arise during the puerperium are:
D V T
Infections
Secondary post partum hemorrhage
Urinary complications
Complications of breast feeding
Mental disorders

3. Infections (puerperal pyrexia)
1.Respiratory infection
It commonly occur due to the use of general anesthesia but as now epidural anesthesia becom more common the incidence of resp. infection is less.
It occur more commonly in patients with chronic bronchitis or who smoke.
The patient presented with fever ,cough ,on examination there are rhonchi.
If there is sever bronco spasm the possibility of Mendelson’s syndrome
The diagnosis of respiratory infection is confirmed by X-ray & seputum culture.

4. Treatment is by physiotherapy ,broad spectrum antibiotic which may be changed according to the result of culture.
In some cases intensive therapy & madical consultation is required.
2. Pelvic infection
It can present as an acute life threatening illness or more frequently occur as a low grade infection which causes both immediate & long term morbidity.
Pathology
At delivery the normal protective barrier against infection are temporarily broken & potential pathogens may pass from the lower genital tract to the normally sterile environment of the uterus & spread to the myometrium, parametrium ,fallopian tubes , peritoneum & to the circulation.

5. The most virulent organism that cause post partum pelvic infection is β- hemolytic strept. ,staphylococci. ,E coli , Bacterial fragilis ,Clostridia & also Chlamydia could cause chronic pelvic infection.
Predisposing factors
Prolong rupture of membrane
Prolong labor
Multiple vaginal examination
If there is retained product of conception
Surgical interference
Clinical presentation
During early stage of illness there is
Puerperal pyrexia
Offensive lochia
Lower abdominal discomfort

6. O/E:
with bimanual examination the uterus is tender specially on moving the cervix or there may be collection of pus (abscess formation )lateral to the uterus or in the pouch of Douglas.
If the infection spread to the circulation the patient will be presented with features of septicaemia (looks tiered , dyspnoeic , feverish , tachycardia , hypotension & other signs of septic shock )
Diagnosis
History
Examination
Investigation
A. different swabs taken from upper vagina, cervical.

7. canal & from urethra.
B. Blood culture if there is features of septicaemia.
C. U/S
Treatment
The 1st line in treatment is the appropriate antibiotic & the best is to combine cephalosporin with metronidazol which cover the most +ve & –ve organism .
In acute illness these are given I.V & the treatment continue for 48 hours till response occur then oral rout is used for at least 10 days ,if result of culture & sensitivity is available then the treatment is changed to the most appropriate one.
Surgical intervention is indicated when:

8. 2.Urinary tract infection
There is a retained product of conception which should be evacuated after 24 hours of antibiotic treatment. Evacuation is don under G.A.
If there is failure to response to antibiotic treatment either due to pelvic collection of pus or other diagnosis such as appendicitis. In these conditions laparatomy is indicated either to drain the pus or for management of other conditions .
2.Urinary tract infection
These are common during puerperium spatially if there is history of UTI or catheterization to relieve urinary retention
Infection may be in the form of cystitis or less commonly pyelonephritis.

9. Cystitis presented as frequency , urgency & dysurea, the urine is offensive & cloudy or there is heamaturea.
Pyelonephritis presented as pyrexia ,shivering tenderness & pain at the renal angle , nausea & vomiting
The diagnosis of UTI is confirmed by culturing a sample of midstream urine, U/S
The treatment is with broad spectrums antibiotic which then changed according to the result of culture & sensitivity , with increase fluid intake .
If the patient had vomiting then parentral antibiotic & I.V fluid are given .The treatment should last for 10 – 14 days

10. 4.Wound infection
If the patient had Caesarean section ,the wound may be infected & presented as puerperal pyrexia.
The wound become tender , red indurated surrounding area & pus collection
The management is by taking swab from the wound for culture & sensitivity & start broad spectrum antibiotic with frequent changing of dressing & after clearance of infection ,secondary suturing may be required if there is a large cavity.

11. 5.Breast abscess 6.Thrombophlebitis
It usually develop after 2 weeks from delivery . There is a red ,painful, fluctuant swelling in the breast & the patient is feverish.
The milk should be expressed from the affected breast & the abscess should be drained under GA with the use of antibiotic & analgesic drugs
6.Thrombophlebitis
Alsoca be presented as puerperal pyrexia therefore the legs should be inspected

12. Secondary post partum haemorrhage
It is the vaginal bleeding that occur after 24 hours following delivery till 6 weeks of puerperium
Causes:
Retained product of conceptions
Infection
Clotting defect
Chorio carcinoma
Presentation either as changing in the colour of lochial discharge to a fresh red blood , or as heavy bleeding with clots. There may be cramping abdominal pain & if the bleeding is heavy the patient is pale & may develop signs of shock.

13. The uterus may be subinvoluted & on vaginal examination a retained placental tissue may be at the cervical canal.
Management
The patient should be admitted to hospital.
If the bleeding is slight : 0.5 mg ergometrin given IM or IV with gentle massage of the fundus with removal of blood clot or placental tissue from the vagina
Then U/S should be don to exclude retained placental tissue ,which if present should be removed surgically.
Infection also may cause secondary PPH & if there is evidence of infection then antibiotic should be given
If bleeding is heavy: the treatment is
IV fluid & preparation of blood

14. When the patient condition is stabilized examination under GA should be don with surgical evacuation of the uterine cavity
Initially the uterine cavity should be explored by fingers then evacuation don by sponge holding forceps but we should be very careful because it is easy to perforate the soft puerperal uterus.

15. Urinary complications
Infections
Urinary retention
Urinary incontinence
This is common after delivery ,spatially if there is bruising or oedema around the bladder base or there is painful episiotomy or after epidural anaesthesia when the sensory stimuli from the bladder is temporarily interrupted. the bladder can hold a litre of urine & as it become more distended , retention with overflow may develop with the passage of cc of urine

16. Urinary fistula may be caused by
The treatment is to leave an indwelling catheter for 48 hours & then the catheter is removed & a close check for the voided urine is don & if retention re -occur then re -catheterization for further 24 hours is don.
Incontinence of urine
Stress incontinence may be a complication of childe birth but usually it resolve with physiotherapy & improving tone of pelvic floor.
If continuous incontinence is present , it must be established if this is urethral or through a fistula.
Urinary fistula may be caused by
direct injury with obstetric forceps or other instrument ,when the leak of urine will be immediate .

17. If the fetal head was pressed on the bladder for too long period during obstructed second stage of labour , necrosis of bladder tissue & subsequent sloughing with fistula formation will occur & incontinence will develop at about 8-12 days
A ureter may be damaged at a complicated Caesarean section & incontinence will develop after similar interval.
The management is by continuous bladder drainage that very small fistula may close spontaneously or if not then surgical repair is required