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Puerperium

Puerperium. 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. Puerperium.

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Puerperium

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  1. Puerperium

  2. 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

  3. 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

  4. 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

  5. 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

  6. Cervix, Vagina, Perineum • Tissues revert to a nonpregnant state but never return to the nulliparous state

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

  8. 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

  9. 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

  10. 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

  11. 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

  12. Sexual Intercourse May resume when… • Red bleeding ceases • Vagina and vulva are healed • Physically comfortable • Emotionally ready *Physical readiness usually takes ~3 weeks

  13. Concerns - Puerperal Period

  14. Hemorrhage

  15. 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

  16. Postpartum Hemorrhage Incidence • Vaginal birth: 3.9% • Cesarean: 6.4% • Delayed postpartum hemorrhage: 1-2% Mortality • 5% of maternal deaths

  17. 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

  18. 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

  19. Lower genital tract lacerations • Result of obstetrical trauma • More common with operative vaginal deliveries • Forceps • Vacuum extraction Other predisposing factors: • Macrosomia • Precipitous delivery • Episiotomy

  20. Infection

  21. 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

  22. 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

  23. Clinical presentation Fever Chills Lower abdominal pain Malodorous lochia Increased vaginal bleeding Anorexia Malaise Exam findings Fever Tachycardia Fundal tenderness Treatment Antibiotics Endometritis

  24. Urinary Tract Infection • Bacterial inflammation of the bladder or urethra • 3-34% of patients • Symptomatic infection in ~2%

  25. 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

  26. 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

  27. 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%)

  28. 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

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

  30. 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

  31. 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

  32. Endocrine Disorders

  33. 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

  34. 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

  35. 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)

  36. 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)

  37. 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

  38. Psychiatric Disorders

  39. 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)

  40. 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)

  41. 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

  42. 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

  43. 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

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

  45. 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)

  46. 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

  47. 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

  48. Postpartum Psychosis Signs and symptoms • Acute psychosis • Schizophrenia • Manic depression

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

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