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
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
Lochia
Red Duration is variable Brownish red, more watery consistency Continues to decrease in amount Yellow
Lochia serosa
Lochia alba
Tissues revert to a nonpregnant state but never return to the nulliparous state
Abdominal Wall
Ovulation
Breastfeeding Longer period of amenorrhea and anovulation
Highly variable
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
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
Considerations
Vaginal Birth Swelling and pain in the perineum
Episiotomy? Laceration?
Hemorrhoids
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
Hemorrhage
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%
Postpartum Hemorrhage
May result from: Uterine atony Most common Lower genital tract lacerations Retained products of conception Uterine rupture Uterine inversion Placenta accreta
Coagulopathy Hematoma
Uterine Atony
Risk factors:
Overdistension of the uterus secondary to multiple gestations Polyhydramnios Macrosomia Rapid or prolonged labor Grand multiparity Oxytocin administration Intra-amniotic infection
Infection
Endometritis
1-3% vaginal births 5-15% scheduled C-sections 30-35% C-section after extended period of labor
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
Exam findings
Fever Chills Lower abdominal pain Malodorous lochia Increased vaginal bleeding Anorexia Malaise
Treatment
Antibiotics
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
Exam Findings
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
Treatment
Exam Findings
Moist heat stasis Massage Fluids Rest Proper positioning of the infant during nursing Nursing or manual expression of milk Analgesics
Antibiotics
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
Perineum
Risk Factors:
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
Clinical Presentation
Perineal Infection: Pain Malodorous discharge Vulvar edema Abdominal Infection Persistent fever (despite antibiotics)
Diagnosis
Endocrine Disorders
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
Risk Factors Positive antithyroid antibody testing History of PPT Family or personal history of thyroid or autoimmune disorders
Hypothyroid Phase: Fatigue Dry skin Coarse hair Cold intolerance Depression Memory & concentration impairment
Treatment
Thyrotoxicosis
Lab testing
Hypothyroid
Increased thyroid hormone production and release Les common than PPT Accounts for 15% of postpartum thyrotoxicosis
Psychiatric Disorders
Postpartum Blues
Transient disorder
Postpartum Depression
Weeks to months
S&S of depression
First postpartum year Group of severe and varied disorders (psychotic symptoms)
Postpartum Psychosis
Etiology
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
Postpartum Blues
Postpartum Blues
Incapacity for familial love Feelings of inadequacy Ambivalence or negative feelings towards the infant Inability to cope
Treatment Supportive care and reassurance (healthcare professionals and family) Pharmacological treatment for depression Electroconvulsive therapy
Postpartum Psychosis
Signs and symptoms Acute psychosis
Postpartum Psychosis
Treatment Therapy should be targeted to the patients specific symptoms Psychiatrist Hospitalization