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
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

Exam Findings

Urinary
frequency/urgency
Dysuria
Hematuria
Suprapubic or lower
abdominal pain
OR
No symptoms at all

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

Antibiotics

Wound Infection
Perineum

Abdominal incision

(episiotomy or laceration)
3-4 days postpartum
rare

(C-section)
Postoperative day 4
3-15%
prophylactic antibiotics

2%

Wound Infection
Perineum

Abdominal incision

Risk Factors:

Infected lochia
Fecal contamination
Poor hygiene

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

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

Tachycardia
Mild exopthalmos
Painless goiter

Lab testing

TSH thyrotoxicosis
TSH hypothyroid

Treatment
Thyrotoxicosis

No treatment (mild)
Beta-blocker

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

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
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 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