Puerperium

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Puerperium
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• Dr. Geetha Balsarkar,
• Associate Professor and Unit incharge,
• Nowrosjee Wadia Maternity Hospital,
• Seth G.S. Medical college, Parel , Mumbai
• Joint Asst. Secretary to the Editor,
• Journal of Obstetrics and Gynecology of India,
• Secretary, AMWI, Mumbai branch

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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

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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

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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

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Cervix, Vagina, Perineum

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

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Abdominal Wall

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

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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

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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

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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

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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

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Sexual Intercourse

• May resume when
• Red bleeding ceases
• Vagina and vulva are healed
• Physically comfortable
• Emotionally ready
• Physical readiness usually takes 3 weeks

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Concerns - Puerperal Period
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Hemorrhage
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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

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Postpartum Hemorrhage

• Incidence
• Vaginal birth 3.9
• Cesarean 6.4
• Delayed postpartum hemorrhage 1-2
• Mortality
• 5 of maternal deaths

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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
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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

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Lower genital tract lacerations

• Result of obstetrical trauma
• More common with operative vaginal deliveries
• Forceps
• Vacuum extraction
• Other predisposing factors
• Macrosomia
• Precipitous delivery
• Episiotomy

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Infection
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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
• lt2 develop life-threatening complications

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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

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Endometritis

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

• Exam findings
• Fever
• Tachycardia
• Fundal tenderness
• Treatment
• Antibiotics

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Urinary Tract Infection

• Bacterial inflammation of the bladder or urethra
• 3-34 of patients
• Symptomatic infection in 2

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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

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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

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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)

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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
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Wound Infection

• Perineum
• (episiotomy or laceration)
• 3-4 days postpartum
• rare

• Abdominal incision
• (C-section)
• Postoperative day 4
• 3-15
• prophylactic antibiotics
• - 2

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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

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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

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Endocrine Disorders
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Postpartum Thyroiditis (PPT)

• Transient destructive lymphocytic thyroiditis
  occuring within the 1st year after delivery
• Autoimmune disorder
• Thyrotoxicosis
• 1-4 months postpartum self-limited
• Increased release (stored hormone)
• Hypothyroidism
• 4-8 months postpartum

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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

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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

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Postpartum Thyroiditis (PPT)

• Exam findings
• Tachycardia
• Mild exopthalmos
• Painless goiter
• Lab testing
• TSH i thyrotoxicosis
• TSH h hypothyroid

• Treatment
• Thyrotoxicosis
• No treatment (mild)
• Beta-blocker
• Hypothyroid
• No treatment (mild)
• Thyroxine (T4)

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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
• Less common than PPT
• Accounts for 15 of postpartum thyrotoxicosis

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Psychiatric Disorders
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• Postpartum Blues
• Transient disorder
• Lasts hours to weeks
• Bouts of crying and sadness
• Postpartum Depression
• More prolonged affective disorder
• Weeks to months
• SS of depression
• Postpartum Psychosis
• First postpartum year
• Group of severe and varied disorders
• (psychotic symptoms)

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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)

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Risk factors

• Undesired pregnancy
• Feeling unloved by mate
• lt20 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

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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

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Postpartum Blues

• Mood lability
• Headache
• Confusion
• Forgetfullness
• Insomnia

• Mild, transient, self-limiting
• Commonly in the first 2 weeks
• Signs and symptoms
• Sadness
• Crying
• Anxiety
• Irritation
• Restlessness

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Postpartum Blues

• Often resolves by postpartum day 10
• No pharmacotherapy is indicated
• Treatment
• Provide support and education

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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

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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

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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

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Postpartum Psychosis

• Signs and symptoms
• Acute psychosis
• Schizophrenia
• Manic depression

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Postpartum Psychosis

• Treatment
• Therapy should be targeted to the patients
  specific symptoms
• Psychiatrist
• Hospitalization
• Generally lasts only 2-3 months