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
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 Multiple vaginal exams
Young age Placement of
Low SES intrauterine catheter
Prolonged labor Preexisting infection
Prolonged rupture of Twin delivery
membranes Manual removal of the
placenta
Endometritis

Clinical presentation Exam findings

Fever Fever
Chills Tachycardia
Lower abdominal pain Fundal tenderness
Malodorous lochia
Increased vaginal Treatment
bleeding Antibiotics
Anorexia
Malaise
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 Preeclampsia
Forceps delivery Eclampsia
Vacuum delivery Epidural anesthesia
Tocolysis Bladder catheterization
Induction of labor Length of hospital stay
Maternal renal disease Previous UTI during
pregnancy
Urinary Tract Infection

Clinical Presentation Exam Findings

Urinary Stable vitals
frequency/urgency Afebrile
Dysuria Suprapubic tenderness
Hematuria

Suprapubic or lower
Treatment
abdominal pain
antibiotics
OR
No symptoms at all
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 Moist heat
stasis
Chills Massage
Myalgias Fluids
Warmth, swelling and breast Rest
tenderness Proper positioning of the
infant during nursing
Exam Findings Nursing or manual
expression of milk
Area of the breast that is
warm, red, and tender
Analgesics

Antibiotics
Wound Infection

Perineum Abdominal incision

(episiotomy or laceration) (C-section)
3-4 days postpartum Postoperative day 4

rare 3-15%

prophylactic antibiotics
2%
Wound Infection

Perineum Abdominal incision

Risk Factors: Risk factors:
Infected lochia Diabetes
Fecal contamination Hypertension
Poor hygiene Obesity
Corticosteroid treatment
Immunosuppression
Anemia
Prolonged labor
Prolonged rupture of
membranes
Prolonged operating time
Abdominal twin delivery
Excessive blood loss
Wound Infection

Clinical Presentation Diagnosis

Erythema
Perineal Infection:
Pain
Induration
Malodorous discharge
Warmth
Vulvar edema
Tenderness
Purulent drainage
With or without fever
Abdominal Infection
Persistent fever

(despite antibiotics)
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 Hypothyroid Phase:
Fatigue
Palpitations
Dry skin
Eat intolerance
Coarse hair
Tremulousness
Cold intolerance
Nervousness
Depression
Emotion liability
Memory &

*mild & nonspecific concentration

(may go undiagnosed) impairment
Postpartum Thyroiditis (PPT)

Exam findings Treatment

Tachycardia
Thyrotoxicosis
Mild exopthalmos No treatment (mild)
Painless goiter Beta-blocker

Hypothyroid
Lab testing No treatment (mild)
TSH thyrotoxicosis Thyroxine (T4)
TSH hypothyroid
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 Economic problems
Feeling unloved by Poor relationship with
mate husband or boyfriend
<20 years Being part of a family
Unmarried with 6 or more siblings
Medical indigence Limited parental
support
Low self-esteem
Past or present
Dissatisfaction with
evidence of emotional
extent of education
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 Mood lability
Crying Headache
Anxiety Confusion
Irritation Forgetfullness
Restlessness 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 Incapacity for familial love
Lethargy Feelings of inadequacy
Loss of libido Ambivalence or negative
Diminished appetite feelings towards the infant
Pessimism 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