PUERPERIUM

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:

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

Clinical Exam findings

presentation
Fever
Fever
Chills Tachycardia
Lower abdominal Fundal
pain tenderness
Malodorous lochia
Increased vaginal
bleeding Treatment
Anorexia
Antibiotics
Malaise
Urinary Tract Infection

Bacterial inflammation of the bladder or urethra

3-34% of patients
Symptomatic infection in ~2%
Urinary Tract Infection

Risk factors
Preeclampsia
C-section
Eclampsia
Forceps delivery Epidural
Vacuum delivery anesthesia
Tocolysis Bladder
catheterization
Induction of Length of hospital
labor stay
Maternal renal Previous UTI during
disease pregnancy
Urinary Tract Infection

Clinical Exam Findings

Presentation
Stable vitals
Urinary
frequency/urgency Afebrile
Dysuria Suprapubic
Hematuria tenderness
Suprapubic or lower
abdominal pain
Treatment
OR
antibiotics
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
Massage
Chills
Fluids
Myalgias
Rest
Warmth, swelling Proper positioning of
and breast the infant during
tenderness nursing
Nursing or manual
expression of milk
Exam Findings
Analgesics
Area of the breast
that is warm, red,
and tender Antibiotics
Wound Infection

Perineum Abdominal
(episiotomy or incision
laceration) (C-section)
3-4 days Postoperative
postpartum day 4
3-15%
rare
prophylactic
antibiotics
2%
Wound Infection

Perineum Abdominal incision

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

Clinical Diagnosis
Presentation
Erythema
Perineal Infection:
Pain
Induration
Malodorous Warmth
discharge
Vulvar edema
Tenderness
Purulent
Abdominal Infection drainage
Persistent fever With or without
(despite antibiotics) fever
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 Hypothyroid Phase:
Fatigue
Fatigue
Palpitations
Eat intolerance Dry skin
Tremulousness Coarse hair
Nervousness Cold intolerance
Emotion liability Depression
Memory &
*mild & nonspecific concentration
(may go undiagnosed) impairment
Postpartum Thyroiditis
(PPT)
Exam findings Treatment
Tachycardia
Mild Thyrotoxicosis
exopthalmos No treatment (mild)
Beta-blocker
Painless goiter
Hypothyroid
Lab testing No treatment (mild)

TSH i thyrotoxicosis Thyroxine (T4)

TSH h 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 Economic problems
Poor relationship with
husband or boyfriend
Being part of a family
Undesired with 6 or more siblings
pregnancy Limited parental
support
Feeling unloved by
mate Past or present
evidence of emotional
<20 years problems
Unmarried
Medical indigence
Low self-esteem
Dissatisfaction with
extent of education
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 Mood lability

Sadness Headache
Crying Confusion
Anxiety Forgetfullness
Irritation Insomnia
Restlessness
Postpartum Blues

Often resolves by postpartum day 10

No pharmacotherapy is indicated

Treatment
Provide support and education
Postpartum Depression
(PPD)
Signs and Incapacity for familial
symptoms love
Insomnia Feelings of inadequacy
Lethargy Ambivalence or
Loss of libido negative feelings
towards the infant
Diminished
appetite Inability to cope
Pessimism
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