Puerperium

Dr. Megalaseran

Normal PuerperiumDefinition The time from the delivery of the placenta through the first 6

subsequent weeks after the delivery during which, most of the changes of pregnancy, labor, and delivery have resolved and the body reverts to the nonpregnant state normal pregnancy involution occurs.

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

First 24 hoursEarly- up to 7 daysRemote- up to 6 weeks

Monitoring of involution processSatisfactory establishment of lactationFor examination of newborn Management of Normal puerperiumTreatment of Minor AilmentsDetection of risk at earlier stage & its

managementTreatment of anaemiaHealth & nutrition educationPostnatal Exercise Postnatal follow Up

Involution of uterine corpus

Fundus of contracted uterus lies slightly below umbilicus immediately after placental expulsion. Body consists of myometrium covered by serosa and lined by basal decidua. Anterior and posterior walls are in close approximation.

Total number of muscle cells does not decrease, individual cells decrease markedly in size

With in 2 wks descend into a cavity of true pelvis, by about 4 wks regain previous nonpregnant size

Weight of uterus       : immediately postpartum, 1000g        - 1 week later : 500g         - at the end of 2nd week : 300g,  - soon thereafter 100g or less  

Changes in the uterine vessels

After delivery the caliber of extrauterine vessels decrease to equal or closely approximate that of the size of prepregnant state

 Blood vessels within puerperal uterus are obliterated by hyaline changes reabsorbed and replaced by smaller vessels .

Cut section :

- Pregnant : hyperemic – Reddish purple

- Puerperal uterus: Ischemic.

Endometrial regeneration: Endometrial regeneration is rapid, except at the placental site.

The decidua becomes differentiated into two layers. Superficial layer becomes necrotic and sloughed in lochia. The basal adjacent to myometrium becomes the source of new endometrium. Entire endometrium is restored during the 3rd week

Placental site involution: Immediately after delivery, palm size 3-4cm in diameter. Complete extrusion of placental site takes up to 6 weeks

Cervix and lower uterine segment

Cervical opening contracts slowly and for a few days, immediately after labor ( ≒ 2fingers ). By the end of the 1st wk narrows further. As the opening narrows the cervix thickens and canal reforms.

Bilateral depression at the site of lacerations remain as permanent changes that characterize the parous cervix

Cervical epithelium also undergoes considerable remodelling.  

Afterpains 

Primiparas: puerperal uterus tends to remain tonically contractedMultiparas : contracts vigorously at interval → afterpain Infant suckles →oxytocin release →Ut. contraction → afterpain Occasionally severe enough to require an analgesic usually become mild by the 3rd postpartum day

Lochia     Early in the puerperium, sloughing of decidual tissue  → vaginal

discharge of variable quantity lochia rubra : Red, first few days after delivery blood in lochia  lochia serosa :, after 3 or 4 days, Brownish red, more watery in

consistency, becomes progressively pale in color, continues to decrease in amount.

lochia alba    : after 10th day white or yellowish-white color,     lasts for approximately 2weeks after delivery

Sub involution 

An arrest or retardation of involution , the process by which the puerperal uterus is normally restored to its original proportions

Cause : retention of placental fragments, pelvic infection

Accompanied by prolongation of lochial discharge & irregular or excessive uterine bleeding and sometimes by profuse hemorrhage

Bimanual examination    : uterus is larger & softer than normal for the particular period of puerperium

dilated renal pelvis & ureters       : return to prepregnant state 2-8 weeks after delivery 

Puerperal diuresis      physiological reversal of pregnancy-induced increase in extracellular water       : regularly occurs between 2nd and 5th day

Puerperal bladder create optimal condition for development of UTI : increased capacity & relative insensitivity to intravesical fluid pressure       → overdistention, incomplete emptying, excessive residual urine  

Vagina and vaginal outlet gradually diminishes in size but rarely returns to nulliparous dimensions

Rugae : reappear by the 3rd week

hymen: represented by several small tags of tissue, which during cicatrization

are converted into the myrtiform caruncles

Relaxation of vaginal outlet     ← extensive laceration or overstretching of perineum during delivery

Changes in pelvic supports during parturition       : predispose to uterine prolapse & urinary stress incontinence          → operative correction is usually postponed until childbearing is ended

Peritoneum and Abdominal wall

Broad & round ligaments      : much more lax than nonpregnant      : require considerable time to recover from stretching & loosening

Abdominal wall     : return to normal → requires several weeks (aided by exercise)    : usually resumes its prepregnancy state except for silvery striae

Blood and Fluid Changes

leukocytosis and thrombocytosis occur during and after labor

    : by 1 week after delivery, blood volume return nearly to

nonpregnant level

 Cardiac output remains elevated for at least 48 hours

postpartum

      (due to increased stroke volume from venous return)

Causes of Puerperal fever

Uterine infectionBreast infectionUrinary infectionThrombophlebitisOther incidental infections

Puerperal Sepsis DefinitionRisk Factors for Puerperal SepsisDiagnosisManagement Complication

Definition

Infection of genital tract : Delivery-42 days after delivery

Two or > features to be present pelvic pain, fever 38.50 C, vaginal D/S, smell of

D/S, sub-involution

Risk Factors for Puerperal Sepsis

AnaemiaMalnutritionDMProlonged laborObstructed labor Prolonged PPROMFrequent vaginal examinations

Contd….Operative deliveryUn-repaired tearsPPHPoor hygienePoor aseptic technique for deliveryManipulations high in the birth canalRetained bits of placenta or membranesPre-existing STDs

DiagnosisEndometritisSubinvolutionPelvic cellulitesSalpingitis & peritonitisPelvic thrombophlebitisSepticaemia

Management

PreventiveGood antenatal careProper intra-natal carePost natal careCurativeGeneral careAntibiotics for infectionLocal care of various wounds

ComplicationSepticaemiaSeptic shockDICPulmonary embolizationDistant spread of infectionKidney failureDeath

Contd….Late complications:Menstrual problemsChronic pelvic painChronic PIDSecondary infertility

Breast Feeding

Lactation Colostrum

the deep lemon-yellow colored liquid secreted initially by the breasts        - expressed from the nipples by the second postpartum day        - contains more minerals and protein - globulin less sugar and fat        - Abs esp. IgA              - persists for about 5days - gradual conversion to mature milk during the ensue 4weeks

Milk   - 600mL/day .High in protein and immunoglobulins    - major proteins -including α-lactalbumin, β-lactoglobulin and casein

 - interleukin -6, epidermal growth factor  Contains all the nutrients necessary

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

Endocrinology of lactation  Progesterone, estrogen, placental lactogen, prolactin, cortisol, insulin

      : appear to act in concert to stimulate the growth & development of           milk-secreting apparatus of mammary glands

Prolactin is essential for lactation       Although plasma prolactin falls after delivery, suckling triggers a rise

Milk ejection or letting down reflex       : initiated especially by suckling       → stimulates neurohypophysis to liberate oxytocin       → contraction of myoepithelial cells in the alveoli & small milk ducts       → milk expression from lactating breast     

Breast FeedingImmunological Consequences of Breast Feeding

Predominant immunoglobulin in milk is secretory IgA       : contains secretory IgA antibodies against E. coli → breast-fed infants are less prone to enteric infections

Contains both T & B lymphocytes

Nursing

Even though the milk supply at first appears insufficient, it become adequate if suckling is continued

Nursing accelerates uterine involution : repeated stimulation of nipples release oxytocin → contracts uterine muscle 

Breast Feeding

Lactation Inhibition

Milk leakages, engorgement, & breast pain peak at 3 to 5 days postpartum    → support with well-fitting brassiere or breast binder, ice packs oral analgesics  

Inhibitors Bromocriptine

bromocriptine has been associated with strokes, myocardial infarction, seizures, and psychiatric disturbances in puerperal women 

Breast FeedingContraception

Not needed in the first 3 weeks postpartum

Progestin only contraceptives      : mini-pills, depot medroxyprogesterone, levonorgestrel implant      : do not affect the quality & increase the volume of milk very slightly          → contraceptives of choice for breast feeding women

Estrogen-progestin contraceptives     : reduce the quantity & quality of breast milk : puerperal women have predisposition to venous thrombosis           → increased by combination contraceptive pills               ⇒ low dose pills are preferred if used in lactating women   

Breast Feeding Contraindications

take street drugs

do not control alcohol use

have an infant with galactosemia

have HIV infection

have active, untreated tuberculosis

take certain medications

are undergoing breast cancer treatment         (ACOG, 2000)

Cytomegalovirus and hepatitis B virus are excreted in milk

Women with active herpes simplex virus

Breast Feeding Contraindications

take street drugs

do not control alcohol use

have an infant with galactosemia

have HIV infection

have active, untreated tuberculosis

take certain medications

are undergoing breast cancer treatment         (ACOG, 2000)

Cytomegalovirus and hepatitis B virus are excreted in milk

Women with active herpes simplex virus

Breast FeedingBreast fever

For the first 24 hours after development of lacteal secretion, : breasts to become distended, firm, & nodular        ← exaggeration of normal venous & lymphatic engorgement of the breast             (not the result of overdistention of lacteal system with milk)

Puerperal fever from breast engorgement is common           : 37.8~39 , seldom persists for longer than 4~16 hours ℃          : other causes (especially infection) of fever must be excluded

Treatment           : binder or brassiere, ice bag, analgesics, pumping or manual expression     

  Mastitis 2.5-3% in the USA

Neglected, resistant or recurrent infections can lead to the development of an abscess (5-11%)

Parenchymatous infection of mammary glands seldom appear before the end of the 1st week postpartum not until the

3rd or 4th week. unilateral, breast becomes hard, reddened and painful  Signs : chills (1st), rigor, fever, tachycardia Etiology

Staphylococcus aureus (most common)  ※ breast abscess : caused by group B streptococcus - almost always from nursing infant's nose & throat   → the organism enters the breast through the nipple at the site of a fissure or abrasion      

Breast FeedingTreatment

swab and cultured  antimicrovial therapy

       : penicillin or cephalosporin       : MRSA →vancomycin       - continued for about 7-10days

Continue breast feeding      : early Tx & continued lactation is successful in avoiding abscess formation

Breast abscess surgical drainage (essential) & general anesthesia

Hospital Care

Attention immediately after labor

for the first hour after delivery    - BP & PR : should be taken every 15 minutes

monitor amount of vaginal bleeding

Fundus should be palpated to ensure that it is well contracted     if relaxation detected, uterus should be massaged through abdominal wall until it remains contracted

Early ambulation

Advantages less frequent bladder complications & constipation reduced frequency of puerperal venous thrombosis & pulmonary embolism

Care of the Vulva

Should be instructed to cleanse vulva from anterior to posterior (vulva→anus) Ice bag applied to perineum Warm sitz bath

: beginning about 24 hours after deliveryTub bathing after uncomplicated delivery is allowed  

Hospital Care Bladder function

Oxytocin : commonly infused after placental delivery sudden withdrawal of antidiuretic effect of oxytocin      → rapid bladder filling

both bldder sensation and its capability to empty      → diminished by anesthesia (esp. conduction analgesia), by episiotomy, laceration or hematomas → Urinary retention with bladder overdistention          : common complication of the early puerperium

woman who has not voided within 4 hours after delivery       → indwelling catheter → prevent overdistension        

Chapter. 17 PuerperiumChapter. 17 Puerperium

Hospital CareTx of bladder overdistention

indwelling of catheter for at least 24 hours empty the bladder completely prevent prompt recurrence allow recovery of normal bladder tone & sensation 

after catheter remove, if the woman cannot void after 4hours     → should be catheterized and urine vol. measured

≥200 cc of urine        : catheter should be left in place and the bladder drained for another day

≤200cc of urine 　 : remove the catheter & recheck the bladder.

Hospital Care

Bowel function   early ambulation and early feeding    → constipation ↓Hemorrhoids

Often resolve as the perineum recovers

Subsequent discomfort during the first few days after vaginal delivery

uncomfortable by afterpains, episiotomy & lacerations, breast engorgement    → codeine, aspirin, acetaminophen

Episiotomy & lacerations     - early application of an ice bag     - local analgesic spray      - healed and nearly asymptomatic by the 3rd weeks

Mild depression

Some degree of depression a few days after delivery is fairly common

: Postpartum blues (= transient depression)

Cause

The emotional letdown that follows the excitement and fears that most women experience during pregnancy and delivery

The discomforts of the early puerperium

Fatigue from loss of sleep during labor and postpartum in most hospital settings

Anxiety over her capabilities for caring for her infant after leaving the hospital

Fears that she has become less attractive

self-limited & usually remits after 2~3 days

Councelling

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

Exercise to restore abdominal wall tone       : any time after vaginal delivery, as soon as abdominal soreness diminishes after cesarean delivery

Diet No dietary restrictions for women who have been delivered vaginally    2 hours after normal vaginal delivery, (if, no Cx)

lactating women : should be increased in calories and protein

not breast feeding : dietary requirement as for a nonpregnant woman     

Care at Home

Return of menstruation and ovulation 

If not nursing

: usually return within 6-8 weeks

Lactating woman       

    : first period may occur 2nd~18th months after delivery 

Ovulation

- as early as 36-42 days(5-6 wks) after delivery

      - delayed resumption of ovulation with breast feeding

           but early ovulation is not precluded by persistent lactation

            → pregnancy can occur with lactation   

Hospital Care

Immunizations     Anti D-immune globulin 300 μg

: nonimmunized women    - within 72 hours of the birth of a D-positive infant

Rubella vaccination   Diphtheria-tetanus toxoid booster infectionMeasles immunization

Time of discharge      if, no complication (at vaginal delivery)           hospitalization period ≤ 48 hours 

Care at Home

Coitus Median interval between delivery and intercourse

: 5 weeks (1~12 weeks)

Best rule is one of common sense after 2 weeks, coitus may be resumed based on the pt's desire & comfort

* breast feeding : cause a prolonged period of suppressed estrogen

production with a resulting vaginal atrophy and dryness

Care at Home

Follow-up care Normal delivery and puerperium

: women can resume most activities (bathing, driving, household functions) by the time of discharge

Follow-up examination during 3rd postpartum wk has proven quite satisfactory

    - identify any abnormalities of later puerperium    - initiate contraceptive practice   

Care at Home

Thromboembolic disease

in recent year : decreased identified during the antepartum period

Pelvic venous thrombosis

during the puerperium a thrombus may transiently form in any of the dilated pelvic veins without associated thrombophlebitis – not incite clinical signs or symptoms

The massive and fetal pulm. emboli that develop without warning in the puerperium

: symptomatic puerperal pelvic thrombosis is most commonly associated with uterine infection    

Care at Home Obstetrical paralysis 

Pressure on branches of lumbosacral plexus during labor      : complaints of intense neuralgia or cramplike pains extending down one or both legs as soon as the fetal head begins to descend the pelvis          

Involved external popliteal n. femoral n. obturator n, sciatic n. the gluteal m. are affected. Foot dropSpontaneous recovery usually Physiotherapy is helpful

Separation of the symphysis pubis or one of the sacroiliac synchondroses during labor may be followed by pain and marked interference with locomotion.

Puerperal Psychosis

TransientSelf limitingAntidepressants & psychological counseling

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 treatment ImmunosuppressionAnemiaProlonged laborProlonged rupture of

membranesProlonged operating

timeAbdominal twin deliveryExcessive blood loss

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 normal33% progress to hypothyroid

10-3% 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

thyrotoxicosisTSH hypothyroid

Treatment

ThyrotoxicosisNo treatment (mild)Beta-blocker

HypothyroidNo treatment (mild)Thyroxine (T4)

Postpartum Graves DiseaseAutoimmune disorderDiffuse hyperplasia of the thyroid gland

Response to antibodies to the thyroid TSH receptors

Increased thyroid hormone production and release

Les common than PPTAccounts for 15% of postpartum

thyrotoxicosis

Postpartum BluesTransient disorder

Lasts hours to weeksBouts of crying and sadness

Postpartum Depression More prolonged affective disorder

Weeks to monthsS&S of depression

Postpartum PsychosisFirst postpartum yearGroup of severe and varied disorders

(psychotic symptoms)

EtiologyUnknownTheory: 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 factorsUndesired

pregnancyFeeling unloved by

mate<20 yearsUnmarriedMedical indigenceLow self-esteemDissatisfaction with

extent of education

Economic problemsPoor relationship with

husband or boyfriendBeing part of a family

with 6 or more siblings

Limited parental support

Past or present evidence of emotional problems

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

History of depression30% chance of develping PPD

History 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 love

Feelings of inadequacyAmbivalence or

negative feelings towards the infant

Inability to cope

Postpartum Depression (PPD)Consult a psychiatrist if…Comorbid drug abuseLack of interest in the infantExcessive concern for the infant’s healthSuicidal or homicidal ideationsHallucinationsPsychotic behaviorOverall impairment of function

Postpartum Depression (PPD)Lasts 3-6 months

25% are still affected at 1 yearAffects patient’s ADLs

TreatmentSupportive care and reassurance (healthcare

professionals and family)Pharmacological treatment for depressionElectroconvulsive therapy

Postpartum PsychosisSigns and symptomsAcute psychosis

SchizophreniaManic depression

Postpartum PsychosisTreatmentTherapy should be targeted to the patient’s

specific symptomsPsychiatristHospitalization

*Generally lasts only 2-3 months

Puerperal Infection Risk factors1. PROM2. Anemia3. Hemorrhage4. EP and CS5. Placenta retain

Puerperal InfectionPuerperal Infectionany bacterial infection of the genital tract

after delivery. Incidence: 6%. The most important cause of maternal death.

Puerperal Morbidity temperature 38.0℃ or highter, the

temperature to occur on any 2 of the first 10days postpartum, exclusive of the first 24 hours, and to be taken by mouth by a standard technique at least four times daily.

Puerperal Infection Common pathogens1. Aerobes Group A, B, and D streptococci 溶血性

链球菌 Gram-negative bacteria: Escherichia

coli 大肠杆菌 , Klebsiella 克雷伯氏菌 Staphylococcus aureus 葡萄球菌

Puerperal Infection2. Anaerobes Petococcus species Petostreptococcus species Bacteroides fragilis group Clostridium species3. Other Chlamydia trachomatis Mycoplasma species

Puerperal Infection Manifestation Acute vulvitis vaginitis and cervicitis Uterine infection Adnexal infections Septic pelvic thrombophlebitis 血栓性

静脉炎 Sapremia 败血症

Puerperal Infection Diagnosis History Physical examination and PV Lab finding Differential diagnosis

Puerperal Infection Treatment1. Nutrition: anemia prevention2. Antimicrobial treatment broad-spectrum, high dose, long

time 3. Drainage4. Treatment of thrombophlebitis

Late Postpartum HemorrhageDefinition Uterine bleeding by 24 hours after

delivery.EtiologyPlacenta or membrane or decidua

retainAbnormal redintegrationInfectionProblems of incision

Late postpartum hemorrhage Serious uterine hemorrhage occasionally develops 1-2 weeks after delivery

Cause abnormal involution of placental site (most often) retention of a portion of the placenta

          → usually undergo necrosis with deposition of fibrin           → form a placental polyp

Treatment intravenous oxytocin, ergonovine, methylergonovine, prostaglandins

curettage

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 accreta

adherence of the chorionic villi to the myometriumCoagulopathyHematoma

Most 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 trauma

More common with operative vaginal deliveries Forceps Vacuum extraction

Other predisposing factors:MacrosomiaPrecipitous deliveryEpisiotomy

EndometritisAscending polymicrobial infection

Usually 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

labor May receive prophylactic antibiotics

<2% develop life-threatening complications

EndometritisRisk factors:C-sectionYoung ageLow SESProlonged laborProlonged rupture of

membranes

Multiple vaginal exams

Placement of intrauterine catheter

Preexisting 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 pain

OR…No symptoms at all

Exam FindingsStable vitalsAfebrile Suprapubic

tenderness

Treatmentantibiotics