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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

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puerperium

Puerperium

Franzblau N, Witt K. Normal and Abnormal Puerperium. Emedicine available at www.emedicine.com/med/topic3240.htm; accessed 13 December 2005.

puerperium1
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
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
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
Cervix, Vagina, Perineum
  • Tissues revert to a nonpregnant state but never return to the nulliparous state
abdominal wall
Abdominal Wall
  • Remains soft and poorly toned for many weeks
    • Return to a prepregnant state depends greatly on exercise
ovulation
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
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

“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
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
Sexual Intercourse

May resume when…

  • Red bleeding ceases
  • Vagina and vulva are healed
  • Physically comfortable
  • Emotionally ready

*Physical readiness usually takes ~3 weeks

postpartum 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 hemorrhage1
Postpartum Hemorrhage

Incidence

  • Vaginal birth: 3.9%
  • Cesarean: 6.4%
  • Delayed postpartum hemorrhage: 1-2%

Mortality

  • 5% of maternal deaths
postpartum hemorrhage2
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

uterine atony
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
Lower genital tract lacerations
  • Result of obstetrical trauma
    • More common with operative vaginal deliveries
      • Forceps
      • Vacuum extraction

Other predisposing factors:

    • Macrosomia
    • Precipitous delivery
    • Episiotomy
endometritis
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
endometritis1
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
endometritis2
Clinical presentation

Fever

Chills

Lower abdominal pain

Malodorous lochia

Increased vaginal bleeding

Anorexia

Malaise

Exam findings

Fever

Tachycardia

Fundal tenderness

Treatment

Antibiotics

Endometritis
urinary tract infection
Urinary Tract Infection
  • Bacterial inflammation of the bladder or urethra
  • 3-34% of patients
    • Symptomatic infection in ~2%
urinary tract infection1
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
urinary tract infection2
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

Urinary Tract Infection
mastitis
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%)
mastitis1
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

Mastitis

stasis

wound infection
Perineum

(episiotomy or laceration)

3-4 days postpartum

rare

Abdominal incision

(C-section)

Postoperative day 4

3-15%

prophylactic antibiotics

2%

Wound Infection
wound infection1
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

Wound Infection
wound infection2
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

Wound Infection
postpartum thyroiditis ppt
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
postpartum thyroiditis ppt1
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 ppt2
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)
postpartum thyroiditis ppt3
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)

Postpartum Thyroiditis (PPT)
postpartum graves disease
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
slide38
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
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

Risk factors
incidence
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
Mood lability

Headache

Confusion

Forgetfullness

Insomnia

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

Signs and symptoms

  • Sadness
  • Crying
  • Anxiety
  • Irritation
  • Restlessness
postpartum blues1
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)
postpartum depression ppd1
Postpartum Depression (PPD)

Consult a psychiatrist if…

  • Comorbid drug abuse
  • Lack of interest in the infant
  • Excessive concern for the infant’s health
  • Suicidal or homicidal ideations
  • Hallucinations
  • Psychotic behavior
  • Overall impairment of function
postpartum depression ppd2
Postpartum Depression (PPD)
  • Lasts 3-6 months
    • 25% are still affected at 1 year
  • Affects patient’s ADLs

Treatment

  • Supportive care and reassurance (healthcare professionals and family)
  • Pharmacological treatment for depression
  • Electroconvulsive therapy
postpartum psychosis
Postpartum Psychosis

Signs and symptoms

  • Acute psychosis
    • Schizophrenia
    • Manic depression
postpartum psychosis1
Postpartum Psychosis

Treatment

  • Therapy should be targeted to the patient’s specific symptoms
  • Psychiatrist
  • Hospitalization

*Generally lasts only 2-3 months