Puerperium

Nazila Karamy –MDGenecology and Obstetric Specialist

www.doctorkaramy.ir

Puerperium

The time 6 w from the delivery tht

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 Not depend on the root of delivery (c/s,nvd)

Ovulation

Breastfeeding Longer period of amenorrhea and

anovulationNot breastfeeding As early as 1 month after delivery Most have a menstrual period by 3 months Suggest birth control &R/O PREGNANCY in

doubtful cases

Sexual Intercourse

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

*Physical readiness usually takes ~3 weeks

Postpartum Period

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

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

Postpartum Hemorrhage

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

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)BF NOT SUGGESTED

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 Blue

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

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

Danger

Postpartum Psychosis

Treatment Therapy should be targeted to the patient’s

specific symptoms Psychiatrist Hospitalization

*Generally lasts only 2-3 months

Breastfeeding Breastfeeding is the best feeding method for most

infants Contraindications include galactosemia of neonate,

breast cancer,maternal hepatitis C,breast abcess,post partum psychosis, HIV infection, chemical dependency(immune suppressive medication), and use of certain medications

Structured behavior counseling and breastfeeding-education programs may increase breastfeeding success