Dr.

Megalaseran

Normal Puerperium
Definition
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 hours y Early- up to 7 days y Remote- up to 6 weeks


 Monitoring of involution process  Satisfactory establishment of lactation  For examination of newborn  Management of Normal puerperium  Treatment of Minor Ailments  Detection of risk at earlier stage & its management  Treatment of anaemia  Health & nutrition education  Postnatal 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. decrease markedly in size

 Total number of muscle cells does not decrease, individual cells  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 contracted  Multiparas : 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

y Uterine infection y Breast infection y Urinary infection y Thrombophlebitis y Other incidental infections

Puerperal Sepsis
y Definition y Risk Factors for Puerperal Sepsis y Diagnosis y Management y Complication

Definition
y Infection of genital tract : Delivery-42 days after

delivery y 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

y Anaemia y Malnutrition y DM y Prolonged labor y Obstructed labor y Prolonged PPROM y Frequent vaginal examinations

Contd .
y Operative delivery y Un-repaired tears y PPH y Poor hygiene y Poor aseptic technique for delivery y Manipulations high in the birth canal y Retained bits of placenta or membranes y Pre-existing STDs

Diagnosis
y Endometritis y Subinvolution y Pelvic cellulites y Salpingitis & peritonitis y Pelvic thrombophlebitis y Septicaemia

Management
Preventive y Good antenatal care y Proper intra-natal care y Post natal care Curative y General care y Antibiotics for infection y Local care of various wounds

Complication
y Septicaemia y Septic shock y DIC y Pulmonary embolization y Distant spread of infection y Kidney failure y Death

Contd .
Late complications: y Menstrual problems y Chronic pelvic pain y Chronic PID y Secondary 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 -lactalbumin, -lactoglobulin and casein y - 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 Feeding
Immunological 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 Feeding Contraception

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 Feeding
Breast 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

y Mastitis y 2.5-3% in the USA y 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 Feeding
Treatment
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 delivery Tub bathing after uncomplicated delivery is allowed

Chapter. 17 Puerperium

Bladder function Hospital Care

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

Hospital Care
Tx 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 y constipation

y Hemorrhoids
y

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

y Abdominal wall relaxation Remains soft and poorly toned for many weeks y 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 g : nonimmunized women - within 72 hours of the birth of a D-positive infant Rubella vaccination Diphtheria-tetanus toxoid booster infection Measles 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. y the gluteal m. are affected. Foot dropSpontaneous recovery usually y 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
y Transient y Self limiting y Antidepressants & psychological counseling

Wound Infection
Perineum
(episiotomy or laceration) y 3-4 days postpartum y rare

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

Wound Infection
Perineum
Risk Factors:
y y y

Abdominal incision
y Risk factors: y Diabetes y Hypertension y Obesity y Corticosteroid treatment y Immunosuppression y Anemia y Prolonged labor y Prolonged rupture of membranes y Prolonged operating time y Abdominal twin delivery y Excessive blood loss

Infected lochia Fecal contamination Poor hygiene

Postpartum Thyroiditis (PPT)

y y

Transient destructive lymphocytic thyroiditis occuring within the 1st year after delivery Autoimmune disorder
1.

2.

Thyrotoxicosis y 1-4 months postpartum; self-limited y Increased release (stored hormone) Hypothyroidism y 4-8 months postpartum

Postpartum Thyroiditis (PPT)

y ~4% develop transient thyrotoxicosis
y 66-90% return to normal y 33% progress to hypothyroid
y

10-3% develop permanent thyroid dysfunction

Risk Factors y Positive antithyroid antibody testing y History of PPT y Family or personal history of thyroid or autoimmune disorders

Postpartum Thyroiditis (PPT)

Clinical Presentation
y y y y y y

Fatigue Palpitations Eat intolerance Tremulousness Nervousness Emotion liability

*mild & nonspecific (may go undiagnosed)

Hypothyroid Phase: y Fatigue y Dry skin y Coarse hair y Cold intolerance y Depression y Memory & concentration impairment

Postpartum Thyroiditis (PPT)

Exam findings
y Tachycardia y Mild exopthalmos y Painless goiter

Treatment
Thyrotoxicosis
y No treatment (mild) y Beta-blocker

Lab testing
y TSH L thyrotoxicosis y TSH K hypothyroid

Hypothyroid
y No treatment (mild) y Thyroxine (T4)

Postpartum Graves Disease

y Autoimmune disorder y Diffuse hyperplasia of the thyroid gland
y Response to antibodies to the thyroid TSH receptors

y Increased thyroid hormone production and release y Les common than PPT y Accounts for 15% of postpartum thyrotoxicosis

Postpartum Blues
y Transient disorder
y Lasts hours to weeks

y Bouts of crying and sadness

Postpartum Depression
y More prolonged affective disorder
y Weeks to months

y S&S of depression

Postpartum Psychosis
y First postpartum year y Group of severe and varied disorders

(psychotic symptoms)

Etiology
y Unknown y Theory: multifactorial y Stress
y Responsibilities of child rearing

y Sudden decrease in endorphins of labor, estrogen and

progesterone y Low free serum tryptophan (related to depression) y Postpartum thyroid dysfunction (psychiatric disorders)

Risk factors
y Undesired pregnancy y Feeling unloved by mate y <20 years y Unmarried y Medical indigence y Low self-esteem y Dissatisfaction with y Economic problems y Poor relationship with

extent of education

husband or boyfriend y Being part of a family with 6 or more siblings y Limited parental support y Past or present evidence of emotional problems

Incidence
y 50-70% develop postpartum blues y 10-15% of new mothers develop PPD y 0.14-0.26% develop postpartum psychosis

History of depression
y 30% chance of develping PPD

History of PPD or postpartum psychosis

y 50% chance of recurrence

Postpartum Blues
y Mild, transient, self-limiting y Commonly in the first 2 weeks

Signs and symptoms y Sadness y Crying y Anxiety y Irritation y Restlessness

y y y y y

Mood lability Headache Confusion Forgetfullness Insomnia

Postpartum Blues
y Often resolves by postpartum day 10 y No pharmacotherapy is indicated

Treatment y Provide support and education

Postpartum Depression (PPD)

Signs and symptoms
y Insomnia y Lethargy y Loss of libido y Diminished appetite y Pessimism y Incapacity for familial love y Feelings of inadequacy y Ambivalence or negative

feelings towards the infant y Inability to cope

Postpartum Depression (PPD)

Consult a psychiatrist if y Comorbid drug abuse y Lack of interest in the infant y Excessive concern for the infant s health y Suicidal or homicidal ideations y Hallucinations y Psychotic behavior y Overall impairment of function

Postpartum Depression (PPD)

y Lasts 3-6 months y 25% are still affected at 1 year y Affects patient s ADLs

Treatment y Supportive care and reassurance (healthcare professionals and family) y Pharmacological treatment for depression y Electroconvulsive therapy

Postpartum Psychosis
Signs and symptoms y Acute psychosis
y Schizophrenia y Manic depression

Postpartum Psychosis
Treatment y Therapy should be targeted to the patient s specific symptoms y Psychiatrist y Hospitalization *Generally lasts only 2-3 months

Puerperal Infection
Risk factors 1. PROM 2. Anemia 3. Hemorrhage 4. EP and CS 5. Placenta retain
y

Puerperal Infection
y Puerperal Infection

any bacterial infection of the genital tract after delivery. Incidence: 6%. The most important cause of maternal death. y 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 pathogens 1. Aerobes  Group A, B, and D streptococci  Gram-negative bacteria: Escherichia coli , Klebsiella  Staphylococcus aureus
y

Puerperal Infection
2.     3.  

Anaerobes Petococcus species Petostreptococcus species Bacteroides fragilis group Clostridium species Other Chlamydia trachomatis Mycoplasma species

Puerperal Infection
y
    

Manifestation Acute vulvitis vaginitis and cervicitis Uterine infection Adnexal infections Septic pelvic thrombophlebitis Sapremia

Puerperal Infection
y
   

Diagnosis History Physical examination and PV Lab finding Differential diagnosis

Puerperal Infection
y
1. 2. 3. 4.

Treatment Nutrition: anemia prevention Antimicrobial treatment broad-spectrum, high dose, long time Drainage Treatment of thrombophlebitis

Late Postpartum Hemorrhage

y Definition

Uterine bleeding by 24 hours after delivery. y Etiology  Placenta or membrane or decidua retain  Abnormal redintegration  Infection  Problems 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 Hemorrhage
Incidence y Vaginal birth: 3.9% y Cesarean: 6.4%
y Delayed postpartum hemorrhage: 1-2%

Mortality y 5% of maternal deaths

Postpartum Hemorrhage
May result from: y Uterine atony y Lower genital tract lacerations y Retained products of conception y Uterine rupture y Uterine inversion y Placenta accreta
y Coagulopathy y Hematoma
Most common

y adherence of the chorionic villi to the myometrium

Uterine Atony
y Lack of closure of the spiral arteries and venous

sinuses

Risk factors:
y y y y y y y

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

y Result of obstetrical trauma y More common with operative vaginal deliveries
y y

Forceps Vacuum extraction

Other predisposing factors:

y Macrosomia y Precipitous delivery y Episiotomy

Endometritis
y Ascending polymicrobial infection y Usually normal vaginal flora or enteric bacteria y Primary cause of postpartum infection y 1-3% vaginal births y 5-15% scheduled C-sections y 30-35% C-section after extended period of labor
y

May receive prophylactic antibiotics

y <2% develop life-threatening complications

Endometritis
Risk factors:
y C-section y Young age y Low SES y Prolonged labor y Prolonged rupture of y Multiple vaginal exams y Placement of

membranes

intrauterine catheter y Preexisting infection y Twin delivery y Manual removal of the placenta

Endometritis
Clinical presentation
y Fever y Chills y Lower abdominal pain y Malodorous lochia y Increased vaginal

Exam findings
y Fever y Tachycardia y Fundal tenderness

bleeding y Anorexia y Malaise

Treatment
y Antibiotics

Urinary Tract Infection

y Bacterial inflammation of the bladder or urethra y 3-34% of patients y Symptomatic infection in ~2%

Urinary Tract Infection

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

pregnancy

Urinary Tract Infection

Clinical Presentation
y Urinary

Exam Findings
y Stable vitals y Afebrile y Suprapubic tenderness

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

Treatment
y antibiotics