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 Brownish red, more watery consistency Continues to decrease in amount Yellow

Lochia serosa

Lochia alba

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
Contains all the nutrients necessary

Milk matures over the first week*

*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 Most common Lower genital tract lacerations Retained products of conception Uterine rupture Uterine inversion Placenta accreta

adherence of the chorionic villi to the myometrium

Coagulopathy Hematoma

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

Exam findings

Fever Chills Lower abdominal pain Malodorous lochia Increased vaginal bleeding Anorexia Malaise

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

Treatment

Fever Chills Myalgias Warmth, swelling and breast tenderness

Exam Findings

Area of the breast that is warm, red, and tender

Moist heat stasis Massage Fluids Rest Proper positioning of the infant during nursing Nursing or manual expression of milk Analgesics
Antibiotics

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:

Abdominal incision

Risk factors:

Infected lochia Fecal contamination Poor hygiene

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.

2.

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

Treatment
Thyrotoxicosis

Tachycardia Mild exopthalmos Painless goiter

No treatment (mild) Beta-blocker

Lab testing

Hypothyroid

TSH i thyrotoxicosis TSH h 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 More prolonged affective disorder

Postpartum Depression

Weeks to months

S&S of depression
First postpartum year Group of severe and varied disorders (psychotic symptoms)

Postpartum Psychosis

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 50% chance of recurrence

History of PPD or postpartum psychosis

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 infants 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 patients 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 patients specific symptoms Psychiatrist Hospitalization

*Generally lasts only 2-3 months