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

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

Usually considered to be 6 weeksBody returns to the nonpregnant state

UterusImmediately after the delivery, the uterus can be palpated at or near the umbilicusMost 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

LochiaVaginal discharge, lasts about 5 weeks15% of women have lochia at 6 weeks postpartum

Lochia rubraRedDuration is variableLochia serosaBrownish red, more watery consistencyContinues to decrease in amountLochia albaYellow

Cervix, Vagina, PerineumTissues revert to a nonpregnant state but never return to the nulliparous state

Abdominal WallRemains soft and poorly toned for many weeksReturn to a prepregnant state depends greatly on exercise

OvulationBreastfeedingLonger period of amenorrhea and anovulationHighly variable50-75% return to periods within 36 weeks

Not breastfeedingAs early as 27 days after deliveryMost have a menstrual period by 12 weeks

BreastsChanges to the breast that prepare for breastfeeding occur throughout pregnancyLactation can occur by 16 weeks gestation

Colostrum1st 2-4 days after deliveryHigh in protein and immune factorsMilk 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

BreastfeedingBreastfeeding is neither easy nor automatic.

Should be initiated ASAP after deliveryFeed baby every 2-3 hrs to stimulate milk productionProduction should be established by 36-96 hrs

ConsiderationsVaginal Birth Swelling and pain in the perineumEpisiotomy? Laceration?HemorrhoidsOften resolve as the perineum recovers

Cesarean DeliveryPain from the abdominal incisionSlower to begin ambulating, eating, and voiding

Sexual IntercourseMay resume whenRed bleeding ceasesVagina and vulva are healedPhysically comfortableEmotionally ready

*Physical readiness usually takes ~3 weeks

Concerns - Puerperal Period

Hemorrhage

Postpartum HemorrhageExcessive blood loss during or after the 3rd stage of laborAverage blood loss is 500 mL

Early postpartum hemorrhage1st 24 hrs after deliveryLate postpartum hemorrhage1-2 weeks after delivery (most common)May occur up to 6 weeks postpartum

Postpartum HemorrhageIncidenceVaginal birth: 3.9%Cesarean: 6.4%

Delayed postpartum hemorrhage: 1-2%

Mortality5% of maternal deaths

Postpartum HemorrhageMay result from:Uterine atonyLower genital tract lacerationsRetained products of conceptionUterine ruptureUterine inversionPlacenta accretaadherence of the chorionic villi to the myometriumCoagulopathyHematomaMost common

Uterine AtonyLack of closure of the spiral arteries and venous sinuses

Risk factors:Overdistension of the uterus secondary to multiple gestationsPolyhydramniosMacrosomiaRapid or prolonged laborGrand multiparityOxytocin administrationIntra-amniotic infection

Lower genital tract lacerationsResult of obstetrical traumaMore common with operative vaginal deliveriesForcepsVacuum extraction

Other predisposing factors:MacrosomiaPrecipitous deliveryEpisiotomy

Infection

EndometritisAscending polymicrobial infectionUsually normal vaginal flora or enteric bacteria

Primary cause of postpartum infection1-3% vaginal births5-15% scheduled C-sections30-35% C-section after extended period of laborMay receive prophylactic antibiotics

EndometritisRisk factors:C-sectionYoung ageLow SESProlonged laborProlonged rupture of membranes

Multiple vaginal examsPlacement of intrauterine catheterPreexisting infectionTwin deliveryManual removal of the placenta

EndometritisClinical presentationFeverChillsLower abdominal painMalodorous lochiaIncreased vaginal bleedingAnorexiaMalaise

Exam findingsFeverTachycardiaFundal tenderness

TreatmentAntibiotics

Urinary Tract InfectionBacterial inflammation of the bladder or urethra

3-34% of patientsSymptomatic infection in ~2%

Urinary Tract InfectionRisk factorsC-sectionForceps deliveryVacuum deliveryTocolysisInduction of laborMaternal renal disease

PreeclampsiaEclampsiaEpidural anesthesiaBladder catheterizationLength of hospital stayPrevious UTI during pregnancy

Urinary Tract InfectionClinical PresentationUrinary frequency/urgencyDysuriaHematuriaSuprapubic or lower abdominal painORNo symptoms at allExam FindingsStable vitalsAfebrile Suprapubic tenderness

Treatmentantibiotics

MastitisInflammation of the mammary glandMilk stasis & cracked nipples contribute to the influx of skin flora

2.5-3% in the USANeglected, resistant or recurrent infections can lead to the development of an abscess (5-11%)

MastitisClinical PresentationFeverChillsMyalgiasWarmth, swelling and breast tenderness

Exam FindingsArea of the breast that is warm, red, and tender

TreatmentMoist heatMassageFluidsRestProper positioning of the infant during nursingNursing or manual expression of milkAnalgesics

Antibiotics stasis

Wound InfectionPerineum (episiotomy or laceration)3-4 days postpartumrare

Abdominal incision (C-section)Postoperative day 43-15% prophylactic antibiotics2%

Wound InfectionPerineum Risk Factors:Infected lochiaFecal contaminationPoor hygiene

Abdominal incision Risk factors:DiabetesHypertensionObesityCorticosteroid treatmentImmunosuppressionAnemiaProlonged laborProlonged rupture of membranesProlonged operating timeAbdominal twin deliveryExcessive blood loss

Wound InfectionClinical Presentation

Perineal Infection:PainMalodorous dischargeVulvar edema

Abdominal InfectionPersistent fever(despite antibiotics)DiagnosisErythemaIndurationWarmthTendernessPurulent drainageWith or without fever

Endocrine Disorders

Postpartum Thyroiditis (PPT)Transient destructive lymphocytic thyroiditis occuring within the 1st year after deliveryAutoimmune disorder

Thyrotoxicosis1-4 months postpartum; self-limitedIncreased release (stored hormone)Hypothyroidism4-8 months postpartum

Postpartum Thyroiditis (PPT)~4% develop transient thyrotoxicosis66-90% return to normal33% progress to hypothyroid10-3% develop permanent thyroid dysfunction

Risk FactorsPositive antithyroid antibody testingHistory of PPTFamily or personal history of thyroid or autoimmune disorders

Postpartum Thyroiditis (PPT)Clinical PresentationFatiguePalpitationsEat intoleranceTremulousnessNervousnessEmotion liability

*mild & nonspecific (may go undiagnosed)

Hypothyroid Phase:FatigueDry skinCoarse hairCold intoleranceDepressionMemory & concentration impairment

Postpartum Thyroiditis (PPT)Exam findingsTachycardiaMild exopthalmosPainless goiter

Lab testingTSH i thyrotoxicosis TSH h hypothyroidTreatment

ThyrotoxicosisNo treatment (mild)Beta-blocker

HypothyroidNo treatment (mild)Thyroxine (T4)

Postpartum Graves DiseaseAutoimmune disorderDiffuse hyperplasia of the thyroid glandResponse to antibodies to the thyroid TSH receptorsIncreased thyroid hormone production and release

Les common than PPTAccounts for 15% of postpartum thyrotoxicosis

Psychiatric Disorders

Postpartum BluesTransient disorderLasts hours to weeksBouts of crying and sadness

Postpartum Depression More prolonged affective disorderWeeks to monthsS&S of depression

Postpartum PsychosisFirst postpartum yearGroup of severe and varied disorders (psychotic symptoms)

EtiologyUnknownTheory: multifactorial

Stress Responsibilities of child rearingSudden decrease in endorphins of labor, estrogen and progesteroneLow free serum tryptophan (related to depression)Postpartum thyroid dysfunction (psychiatric disorders)

Risk factorsUndesired pregnancyFeeling unloved by mate

Incidence50-70% develop postpartum blues10-15% of new mothers develop PPD0.14-0.26% develop postpartum psychosis

History of depression30% chance of develping PPDHistory of PPD or postpartum psychosis50% chance of recurrence

Postpartum BluesMild, transient, self-limitingCommonly in the first 2 weeks

Signs and symptomsSadnessCryingAnxietyIrritationRestlessness

Mood labilityHeadacheConfusionForgetfullnessInsomnia

Postpartum BluesOften resolves by postpartum day 10No pharmacotherapy is indicated

TreatmentProvide support and education

Postpartum Depression (PPD)Signs and symptomsInsomnia LethargyLoss of libidoDiminished appetitePessimism

Incapacity for familial loveFeelings of inadequacyAmbivalence or negative feelings towards the infantInability to cope

Postpartum Depression (PPD)Consult a psychiatrist ifComorbid drug abuseLack of interest in the infantExcessive concern for the infants healthSuicidal or homicidal ideationsHallucinationsPsychotic behaviorOverall impairment of function

Postpartum Depression (PPD)Lasts 3-6 months25% are still affected at 1 yearAffects patients ADLs

TreatmentSupportive care and reassurance (healthcare professionals and family)Pharmacological treatment for depressionElectroconvulsive therapy

Postpartum PsychosisSigns and symptomsAcute psychosisSchizophreniaManic depression

Postpartum PsychosisTreatmentTherapy should be targeted to the patients specific symptomsPsychiatristHospitalization

*Generally lasts only 2-3 months