Puerperium

Franzblau N, Witt K. Normal and Abnormal Puerperium. Emedicine available at www.emedicine.com/med/topic3240.htm; accessed 13 December 2005.

Puerperium

The time from the delivery of the placenta through the first few weeks after the delivery

Usually considered to be 6 weeks Body returns to the nonpregnant state

Uterus

Immediately after the delivery, the uterus can be palpated at or near the umbilicus

Most of the reduction in size and weight occurs in the first 2 weeks

2 weeks postpartum, the uterus should be located in the true pelvis

Lochia

Vaginal discharge, lasts about 5 weeks 15% of women have lochia at 6 weeks

postpartum

Lochia rubra Red Duration is variable

Lochia serosa Brownish red, more watery consistency Continues to decrease in amount

Lochia alba Yellow

Cervix, Vagina, Perineum

Tissues revert to a nonpregnant state but never return to the nulliparous state

Abdominal Wall

Remains soft and poorly toned for many weeks Return to a prepregnant state depends greatly on

exercise

Ovulation

Breastfeeding Longer period of amenorrhea and

anovulation Highly variable

50-75% return to periods within 36 weeks

Not breastfeeding As early as 27 days after delivery Most have a menstrual period by 12 weeks

Breasts

Changes to the breast that prepare for breastfeeding occur throughout pregnancy

Lactation can occur by 16 weeks’ gestation

Colostrum 1st 2-4 days after delivery High in protein and immune factors

Milk matures over the first week* Contains all the nutrients necessary

*Continues to change thoughout the period of breastfedeing to meet the changing demands of the baby

Breastfeeding

“Breastfeeding is neither easy nor automatic.”

Should be initiated ASAP after delivery Feed baby every 2-3 hrs to stimulate milk

production Production should be established by 36-96 hrs

Considerations

Vaginal Birth Swelling and pain in the perineum

Episiotomy? Laceration? Hemorrhoids

Often resolve as the perineum recovers

Cesarean Delivery Pain from the abdominal incision Slower to begin ambulating, eating, and voiding

Sexual Intercourse

May resume when… Red bleeding ceases Vagina and vulva are healed Physically comfortable Emotionally ready

*Physical readiness usually takes ~3 weeks

Concerns - Puerperal Period

Hemorrhage

Postpartum Hemorrhage

Excessive blood loss during or after the 3rd stage of labor Average blood loss is 500 mL

Early postpartum hemorrhage 1st 24 hrs after delivery

Late postpartum hemorrhage 1-2 weeks after delivery (most common) May occur up to 6 weeks postpartum

Postpartum Hemorrhage

Incidence Vaginal birth: 3.9% Cesarean: 6.4%

Delayed postpartum hemorrhage: 1-2%

Mortality 5% of maternal deaths

Postpartum Hemorrhage

May result from: Uterine atony Lower genital tract lacerations Retained products of conception Uterine rupture Uterine inversion Placenta accreta

adherence of the chorionic villi to the myometrium Coagulopathy Hematoma

Most common

Uterine Atony

Lack of closure of the spiral arteries and venous sinuses

Risk factors: Overdistension of the uterus secondary to multiple

gestations Polyhydramnios Macrosomia Rapid or prolonged labor Grand multiparity Oxytocin administration Intra-amniotic infection

Lower genital tract lacerations Result of obstetrical trauma

More common with operative vaginal deliveries Forceps Vacuum extraction

Other predisposing factors: Macrosomia Precipitous delivery Episiotomy

Infection

Endometritis

Ascending polymicrobial infection Usually normal vaginal flora or enteric bacteria

Primary cause of postpartum infection 1-3% vaginal births 5-15% scheduled C-sections 30-35% C-section after extended period of labor

May receive prophylactic antibiotics

<2% develop life-threatening complications

Endometritis

Risk factors: C-section Young age Low SES Prolonged labor Prolonged rupture of

membranes

Multiple vaginal exams Placement of

intrauterine catheter Preexisting infection Twin delivery Manual removal of the

placenta

Endometritis

Clinical presentation Fever Chills Lower abdominal pain Malodorous lochia Increased vaginal

bleeding Anorexia Malaise

Exam findings Fever Tachycardia Fundal tenderness

Treatment Antibiotics

Urinary Tract Infection

Bacterial inflammation of the bladder or urethra

3-34% of patients Symptomatic infection in ~2%

Urinary Tract Infection

Risk factors C-section Forceps delivery Vacuum delivery Tocolysis Induction of labor Maternal renal disease

Preeclampsia Eclampsia Epidural anesthesia Bladder catheterization Length of hospital stay Previous UTI during

pregnancy

Urinary Tract Infection

Clinical Presentation Urinary

frequency/urgency Dysuria Hematuria Suprapubic or lower

abdominal pain

OR… No symptoms at all

Exam Findings Stable vitals Afebrile Suprapubic tenderness

Treatment antibiotics

Mastitis

Inflammation of the mammary gland Milk stasis & cracked nipples contribute to the

influx of skin flora

2.5-3% in the USA Neglected, resistant or recurrent infections can

lead to the development of an abscess (5-11%)

Mastitis

Clinical Presentation Fever Chills Myalgias Warmth, swelling and

breast tenderness

Exam Findings Area of the breast that is

warm, red, and tender

Treatment Moist heat Massage Fluids Rest Proper positioning of the

infant during nursing Nursing or manual

expression of milk Analgesics

Antibiotics

stasis

Wound Infection

Perineum (episiotomy or laceration) 3-4 days postpartum rare

Abdominal incision (C-section) Postoperative day 4 3-15% prophylactic antibiotics

2%

Wound Infection

Perineum Risk Factors:

Infected lochia Fecal contamination Poor hygiene

Abdominal incision Risk factors:

Diabetes Hypertension Obesity Corticosteroid treatment Immunosuppression Anemia Prolonged labor Prolonged rupture of

membranes Prolonged operating time Abdominal twin delivery Excessive blood loss

Wound Infection

Clinical Presentation

Perineal Infection: Pain Malodorous discharge Vulvar edema

Abdominal Infection Persistent fever

(despite antibiotics)

Diagnosis Erythema Induration Warmth Tenderness Purulent drainage With or without fever

Endocrine Disorders

Postpartum Thyroiditis (PPT)

Transient destructive lymphocytic thyroiditis occuring within the 1st year after delivery

Autoimmune disorder

1. Thyrotoxicosis 1-4 months postpartum; self-limited Increased release (stored hormone)

2. Hypothyroidism 4-8 months postpartum

Postpartum Thyroiditis (PPT)

~4% develop transient thyrotoxicosis 66-90% return to normal 33% progress to hypothyroid

10-3% develop permanent thyroid dysfunction

Risk Factors Positive antithyroid antibody testing History of PPT Family or personal history of thyroid or autoimmune

disorders

Postpartum Thyroiditis (PPT)

Clinical Presentation Fatigue Palpitations Eat intolerance Tremulousness Nervousness Emotion liability

*mild & nonspecific (may go undiagnosed)

Hypothyroid Phase: Fatigue Dry skin Coarse hair Cold intolerance Depression Memory &

concentration impairment

Postpartum Thyroiditis (PPT)

Exam findings Tachycardia Mild exopthalmos Painless goiter

Lab testing TSH thyrotoxicosis TSH hypothyroid

Treatment

Thyrotoxicosis No treatment (mild) Beta-blocker

Hypothyroid No treatment (mild) Thyroxine (T4)

Postpartum Graves Disease

Autoimmune disorder Diffuse hyperplasia of the thyroid gland

Response to antibodies to the thyroid TSH receptors Increased thyroid hormone production and release

Les common than PPT Accounts for 15% of postpartum thyrotoxicosis

Psychiatric Disorders

Postpartum Blues Transient disorder

Lasts hours to weeks Bouts of crying and sadness

Postpartum Depression More prolonged affective disorder

Weeks to months S&S of depression

Postpartum Psychosis First postpartum year Group of severe and varied disorders

(psychotic symptoms)

Etiology

Unknown Theory: multifactorial

Stress Responsibilities of child rearing

Sudden decrease in endorphins of labor, estrogen and progesterone

Low free serum tryptophan (related to depression) Postpartum thyroid dysfunction (psychiatric

disorders)

Risk factors

Undesired pregnancy Feeling unloved by

mate <20 years Unmarried Medical indigence Low self-esteem Dissatisfaction with

extent of education

Economic problems Poor relationship with

husband or boyfriend Being part of a family

with 6 or more siblings Limited parental

support Past or present

evidence of emotional problems

Incidence

50-70% develop postpartum blues 10-15% of new mothers develop PPD 0.14-0.26% develop postpartum psychosis

History of depression 30% chance of develping PPD

History of PPD or postpartum psychosis 50% chance of recurrence

Postpartum Blues

Mild, transient, self-limiting Commonly in the first 2 weeks

Signs and symptoms Sadness Crying Anxiety Irritation Restlessness

Mood lability Headache Confusion Forgetfullness Insomnia

Postpartum Blues

Often resolves by postpartum day 10 No pharmacotherapy is indicated

Treatment Provide support and education

Postpartum Depression (PPD)Signs and symptoms Insomnia Lethargy Loss of libido Diminished appetite Pessimism

Incapacity for familial love Feelings of inadequacy Ambivalence or negative

feelings towards the infant Inability to cope

Postpartum Depression (PPD)Consult a psychiatrist if… Comorbid drug abuse Lack of interest in the infant Excessive concern for the infant’s health Suicidal or homicidal ideations Hallucinations Psychotic behavior Overall impairment of function

Postpartum Depression (PPD) Lasts 3-6 months

25% are still affected at 1 year Affects patient’s ADLs

Treatment Supportive care and reassurance (healthcare

professionals and family) Pharmacological treatment for depression Electroconvulsive therapy

Postpartum Psychosis

Signs and symptoms Acute psychosis

Schizophrenia Manic depression

Postpartum Psychosis

Treatment Therapy should be targeted to the patient’s

specific symptoms Psychiatrist Hospitalization

*Generally lasts only 2-3 months