Puerperium # Dr. Fida Al-Asali

Definition:

The period from the delivery of the placenta up to 6 weeks post delivery.

Diagnosis of NVD is retrospective. We dont say its a NVD until puerperium has passed without

complications. Otherwise its not a normal vaginal delivery.

Any complication the mother encounters in the first 6 weeks post delivery, she is referred to her

obstetric physician. After puerperium any complaint is considered a gynecological problem.

Normal anatomical and physiological changes during puerperium:

All the changes that happened during pregnancy are reversed.

1. Lower genital tract:

During pregnancy, the lower genital tract enlarges and is engorged due to the elevated

estrogen levels. In puerperium, the

estrogen level goes down and the lower

genital tract atrophies. This change is

remarkable in a breast-feeding woman as

shes in an anovulation period.

i. Rapid decrease in the size of valva,

vagina, and the cervix.

ii. The internal cervical os closes 2

weeks post delivery, but the

external os will still have a slit-like opening and it will never go back to its pre-

pregnancy state. However, if the mother has delivered by a C/S she would still have a

nulliparous cervix.

iii. Decrease secretions from the vagina and cervical glandular tissue (poorly lubricated).

iv. Inflammation of the transformation zone (the zone between the original

squamocolumnar junction and the newly formed junction after delivaery) is expected.

v. Lacerations are expected to heal 2 weeks after delivery.

Remember that the anovulation periods after

the menarche and premenopausal are

associated with high estrogen levels, in

contrast to the anovulation period during

lactation which is associated with low

estrogen levels.

2. Involution of the uterus:

i. The uterine muscle contracts and is reabsorbed to go back to its pre-pregnancy state.

Oxytocin has a role in this contraction, so its faster for the uterus to get back to its normal

state in a breast-feeding mother.

ii. Uterine muscle cells and other cells will be broken down by autolysis resulting in

proteinuria. The uterine muscle weighs around 1000g during pregnancy and it goes down

to 120-150gm 6 weeks post delivery.

3. Lochia:

Duration of lochia flow is variable between women but usually remains for 2 weeks. In 1/10

women it may continue 6 weeks after delivery. Loss is characteristically intermittent as it ends.

Stages of lochia:

i. Lochia rubra: its the initial lochia, red in color, contains blood, residual tissues, and

trophoblasts. The duration is variable but usually lasts from day 1 to day 3 post

delivery. If the duration is extended think of PPH secondary to infection.

ii. Lochia serosa: 2nd stage of lochia, brownish in color, watery in its consistency, contains

old blood, serum, leukocytes and tissue debris. Lasts for 4-10 days.

iii. Lochia alba: yellowish to whitish in color.

Subinvolution of the uterus is when the uterus isnt in its expected place post delivery.

Immediately after delivery it should be at the level of the umbilicus, and it shouldnt be

palpable at all (completely a pelvic organ) on week 2 post delivery.

Always suspect infection in cases of suninvolution of the uterus.

Some women may describe a passage of a 6 cm-long clot on day 4-5. This is only ONCE

during this period. Its thought to be a part of the uterine cavity. Any complaint of

passage of more than one clot or a complaint of heavy bleeding leads you to think of

secondary PPH.

4. Endometrium:

There is shedding of the endometrium from the basal layer of the decidua. It is affected by

breast-feeding.

5. Ovulation:

Ovulation will be delayed if the mother is breast-feeding. The time when the next ovulation

will take place is variable but usually in a breast-feeding woman it is after 6 months of delivery

(lactational amenorrhea), and as early as 3-12 weeks post delivery if she is not lactating.

As we said, the next cycle post delivery is unpredictable and once the lady has a cycle it means

shes ovulating, so ladies have to use a proper contraceptive method during puerperium.

6. Abdomen:

i. Abdominal muscles initially protrude (diverication of the recti) and it takes them 6 weeks

to go back to the pre-pregnancy state. You can consider it a type of herniation. Factors

affecting the reversal of the abdominal muscles to the pre-pregnancy state are:

a. The pre-pregnancy state of the muscles themselves.

b. Parity

c. Physical activity. Mothers are advised not to exercise before 6 weeks post partum.

ii. The skin regains most of its elasticity. However, some striae will continue to be present.

7. Skeleton:

During pregnancy, the high levels of estrogen and progesterone lead to increased laxity and

relaxation of the ligaments causing sacroiliac joint dysfunction and pelvic girdle pain. This all

will resolve slowly during puerperium.

8. CVS:

All the changes during pregnancy are reversed within 6 weeks.

9. Hematology and blood tests:

i. Her hemoglobin level, regardless the iron supplementation, will be raised 1 gram as a

consequence of the reversal of the physiological changes. More elevation is attributed to

post partum diuresis and reduction of the plasma volume.

ii. WBCs might go up to 25,000 and might continue high for up to 8 weeks.

iii. Platelets continue to be normal or decrease if they were high during pregnancy. They are

elevated post C/S.

iv. Fibrinolytic activity goes back to normal within 30 mins. Its the fastest thing that goes back

to normal after delivery.

v. Ferritin returns back to normal 5-8 weeks post delivery. Remember that it was decreased

during pregnancy.

vi. Liver enzymes increase initially after vaginal delivery and delivery by C/S. Thats why you

have to have a baseline for the ladys liver enzymes as the post partum elevation of liver

enzymes is confusing: is it a sign of pre-eclampsia or is it the normal physiological

elevation?

vii. Prolactin level is increased.

viii. Requirements of thyroxin during pregnancy are increased but they immediately go back to

the pre-pregnancy state after delivery.

10. Urinary system:

i. Reduced renal function most probably due to the reduction in the steroids.

ii. Increased urea due to uterine muscle cells autolysis.

iii. +1 proteinuria 1-2 days post delivery. Its important to differentiate the normal

physiological proteinuria from the pre-eclampsic proteinuria. The latter is associated with

other SSx such as high blood pressure.

iv. Diuresis starts within 2 hrs post delivery as the woman starts to lose the excess tissue fluids

that were accumulated during pregnancy. Not to forget that she might also complain of

excessive sweating as well.

v. Bladder tone will go back to normal 5-7 days after delivery.

vi. Sensation of full bladder may not be immediately felt especially if the lady had epidural

anesthesia, in such cases sensation would be delayed to 6 hrs post delivery. Thats why you

have to encourage your patient to empty her bladder continually to prevent permanent

damage to the bladder.

11. Skin:

i. Chloasma, known as mask of pregnancy, usually disappears.

ii. Hyperpigmentation of the areola and linea nigra might not disappear completely.

iii. Stretch marks, as we mentioned before, do not disappear. The lady might use baby oil to

keep her skin hydrated but usually the commercial topical agents arent of that help in

treating the striae.

iv. Hair growth slows after delivery. Usually it needs around 2 months to get back normal.

12. Psychological symptoms: Important for MCQs!

i. Initially, some ladies may have some hives (post-natal hives) which is a degree of

feeling elated and high. It could be normal as the mother is satisfied with her child and

the whole delivery process or it might be due to the sudden fall in her hormones. It is

temporary and self-limiting.

ii. Baby blues is a transient, short-acting, self-limiting period of labile mood. It typically

occurs between days 4-10 after delivery affecting 50-70% of women. It should be

differentiated from pathological disorders. These cases dont need any treatment, only

explain that this is transient, educate, support, and advise the lady to rest.

13. Breast:

The hormones progesterone, estrogen, prolactin, GH, and steroids all lead to breast

hypertrophy during pregnancy. After delivery, only prolactin and human placental lactogen

(this hormone was suppressed by estrogen during pregnancy) act on the breast as lactogenic

hormones producing milk.

Components of human milk:

a. Colostrum:

The initial phase of breast milk, presents in the first 2-4 days.

It is high in protein, fat, IgA and IgG.

Thick, sticky, light yellow.

b. Mature milk:

3-6 days later.

Composed of foremilk (at the beginning of breast-feeding) and hindmilk (at

the end of feeding).

Very important..!

Remember that nipple stimulation stimulates prolactin secretion from the anterior

pituitary gland which is needed for the synthesis of milk.

Oxytocin is stimulated by skin to skin contact with the baby and some studies say

that visual stimulation has a role. It is needed for milk ejection and is responsible for

the let-down reflex.

Breast engorgement may occur when mature milk is established.

Management of breast engorgement:

a. Encourage the lady to breast-feed from the affected side.

b. Encourage her to massage her breast for manual expression of milk.

c. Use hot compresses

d. Give adequate analgesia

Benefits of breast-feeding: Important for MCQs!

Breast milk has lactoferrin that binds to iron thus preventing the colonization of E-

coli and protecting the child from infections.

IgA in breast milk is formed by the mothers peyers patches in her gut.

Indications for lactation suppression:

Perinatal death.

Maternal HIV

How to suppress lactation?

Non-medically if she hadnt breast-fed her baby at all by applying cold compresses

and wearing tight bras to apply mechanical compression on her breasts.

Medically if she breast-fed her child:

o Bromocriptine. One of its side effects is the rebound lactation once the drug

is stopped.

o Cabergolin (Dostinex). Used as a single dose.

o Give analgesia.

Common problems encountered during puerperium:

1. PPH:

Primary PPH is when bleeding is before the mother is discharged.

Secondary PPH is any bleeding that occurs after sending the mother home or at the second

day of delivery.

Cold compresses are advised here as we want to decrease the blood flow to the breasts which

ultimately suppresses lactation. On the contrary, we advise applying hot compresses in cases of

mastitis and breast engorgement to increase the blood flow thus helping the healing process.

2. Psychiatric illnesses at some time were the leading cause of maternal death.

i. Post-natal depression: occurs in the first year after delivery especially within the first 4

weeks. Its not a psychotic illness and should be differentiated from baby blues. It affects

10-20% of ladies and is diagnosed by the Edinburgh postnatal depression scale. It has

effects on the mother, the baby and the marital relationship.

If the case is severe enough admit the patient. Otherwise, anxiolytics, antidepressants, SSRI

as fluoxetine, supportive psychotherapy and cognitive behavioral therapy must be

sufficient.

Remember that these patients are managed in a mother-baby unit (never separate the

mother from her baby) and its a multidisciplinary team composed of Obs., neonatologists

and psychiatrists that is working on them.

ii. Psychosis and schizophrenia may occur in the first month especially in the first 2-4 weeks.

Its less common than depression. If theres a previous history of depression, theres 30%

increase in the risk of having postnatal depression again. The same goes for psychosis.

The patient presents early complaining of acute symptoms like mania, delusions,

hallucinations, agitation, confusion, restlessness, and sleep disorders. The risk of

infanticide and homicide is increased.

You manage her by admitting her to the hospital and if you give lithium remember that its

contraindicated to breast-feed her baby then.

We have to know the medications that are contraindicated in breast-feeding mothers. MCQ!

iii. Bipolar disorder might occur.

3. Post partum anemia is corrected with iron supplements and if the anemia is symptomatic, its

contraindicated to breast-feed the baby.

4. 80% of women will complain of perineal pain for 3 days post delivery. It is transient but 10% of

them will have a prolonged perineal pain for 18 months post delivery.

Managed with analgesia, NSAIDs, paracetamol, and local lidocaine. Codeine must be avoided

especially in a breast-feeding woman as it causes dehydration and ultimately constipation.

5. Constipation might be due to dehydration, perineal trauma, iron supplements, C/S delivery, and

immobility. Managed by increasing fluid and fiber intake and laxatives.

6. Hemorrhoids: this is a problem of both pregnancy and delivery.

Risk factors include: constipation, enlarged uterus, decreased blood flow, pushing down

during delivery, perineal trauma and any surgical repair.

Symptoms: pain and constipation.

Management: usually it is external hemorrhoids and does not need surgical management.

Stool softeners, analgesia and worm baths are sufficient. On the contrary, internal

hemorrhoids may need surgical management.

7. Domestic violence: intentional and repeated physical and psychological violence may be seen in 4-

20% regardless of the ethnic, cultural or socioeconomical status. It may be seen in pregnancy as

well but its more common in the puerperium. Suspect domestic violence when there are multiple

sites of trauma in the body especially in the abdomen, genitalia and breasts. You have to be aware

of this!

8. Immunization:

i. If the antenatal screening for rubella antibodies was negative, we give MMR vaccine and

the ladies shouldnt get pregnant for a month after the vaccination. To be in the safe side

as we cant be sure that the lady wont get pregnant after taking the vaccine we give it to

her after delivery.

ii. Anti-D is given within 72 hrs post delivery in cases where the mother is Rh and the baby is

Rh.

We either give both the MMR vaccine and the anti-D at the same occasion (two separate

injections and two separate sites) or three months apart.

9. Puerpural pyrexia/ septic shock:

uerperal pyrexia is fever 3 over 24 hrs recurring in the first 10 days.

Remember that low grade fever immediately after delivery is expected especially for

someone who was given prostaglandins for the induction of labour.

Causes: respiratory tract infection, mastitis, wound infection, UTI, endometritis and DVT

just to name a few.

Keep in mind..!

Keep in mind that DVT may present as puerperal pyrexia or as lower abdominal pain.

10. Post partum sepsis:

Sepsis is the infection of the blood.

Most common site of origin is the genital

tract mainly endometritis.

Group A beta hemolytic streptococci (GAS) is

the most common organism.

Risk factors include: obesity, systemic

disorders, impaired immunity, infection,

procedures, and manual removal of the

placenta.

Management: supportive therapy, give

fluids, IV antibiotics, and remove any

retained tissue.

11. UTI is very common during pregnancy and puerpeium. It could be a simple UTI, pyelonephritis,

recurrent urinary tract infections, or interstitial nephritis. Dont forget that E-coli is the most

common organism.

12. Wound infection: it could be infection of the C/S wound, episiotomy wound, or infection of the

lacerations.

Usually present on day 3-4.

Risk factors include: poor hygiene or fecal incontinence especially in perineal wounds

infections. If this is the case educate your patient.

Dont forget to examine the wound as you learned in surgery.

Common microorganisms: GI flora, E-coli, Staph aureus, and Streptococcus pyogenes.

If the infected wound isnt treated properly you may end up with necrotizing fasciitis,

which is a fatal situation.

13. Epidural site infection:

The diagnosis is clinical.

Management is medical, rarely, if ever, surgical.

Always..

Any women presents to you post delivery with pyrexia, do a complete septic workup.

GAS was used to be very common

previously but due to the good hygienic

status its becoming less common.

Its important to differentiate whether

the infection is a social infection or a

hospital acquired infection in which all

the involved medical personnel must

be screened and managed.

14. Endometritis:

The patient presents with secondary PPH, lower abdominal pain, and fetor smell of lochia.

Approach:

o V/S: the patient is feverish, and tachycardic.

o Abdominal ex.: tender, subinvoluted uterus.

o On speculum ex.: theres smelly discharge with bleeding.

o On PV ex.: the uterus is tender and larger than you expect.

Causative organism: Multimicrobial.

Treatment: Oral or IV broadspectrum antibiotics depending on the severity.

Complications: If its not properly treated, chronic endometritis will end up with

intrauterine adhesions, the patient will continue to have dysmenorrhea, chronic pelvic

pain, and infertility in the long term.

15. Abscess is a rare condition.

It is usually seen post C/S but it could be a complication of vaginal delivery especially if

there are hematomas.

Usually caused by GI pathogens.

The patient presents with pelvic pain that is followed by septic shock.

Management: incision and drainage.

16. VTE is 4 times more common in puerperium compared to pregnancy, and 10 times more common

in pregnant compared to non-pregnant women.

Sometimes, endometritis releases microorganisms into the venous circulation causing DVT,

thrombophlebitis, and septic pelvic thrombophlebitis.

In cases of DVT, diagnosis depends on the clinical assessment and judgment, but duplex is

used to confirm the diagnosis. It usually affects the left leg.

Very important..!

DVT is a life-threatening condition, so when you suspect DVT, immediately start treating the

patient. If your diagnosis was confirmed objectively, continue the treatment. If DVT was ruled

out by duplex but you still have a clinical suspicion, continue the treatment and repeat duplex

after one week, if its negative, you can stop the medications.

17. Ovarian venous thrombosis (OVT):

The patient presents with lower abdominal pain that radiates to the flank, groin, and the

upper abdomen.

On examination the patient is feverish, tachycardic, and has a tender, rod-like mass.

CT and MRI confirm the diagnosis.

Managed with heparin and antibiotics.

18. Symphysis pubis dysfunction (SPD): in which the joint is slightly mobile and painful. For such

patients we only teach them how to walk properly decreasing the angle between their legs thus

reducing the pain and we advise them to climb the stairs by placing both feet on each step rather

than climbing one step at a time.

19. Endocrine dysfunctions:

i. ostpartum thyroiditis: Usually, its transient. Initially it starts as thyrotoxicosis then

followed by symptoms of hypothyroidism. Its only managed if symptomatic either with

beta blockers if thyrotoxicosis is dominant or with thyroxin if hypothyroidism is dominant.

i. Graves disease is rarely seen.

ii. Sheehans syndrome as a secondary endocrine disorder following H.

iii. Lymphocytic hypophysitis as a secondary endocrine disorder.

20. Breast complications:

i. Breast engorgement.

ii. Mastitis:

Inflammation of the mammary gland parenchyma.

Mostly its non-infectious. Only in 4% of cases its infectious caused by staph

aureus.

Subclinical mastitis is when there is no apparent SSx.

Congestive mastitis is when mastitis is a result of inflammatory response to

accumulated milk.

Primiparous is a major risk factor for mastitis as primi may not know the proper

way in breast-feeding. Other breast complications seen in primiparous women are:

incomplete emptying, cracked nipples, and milk stasis.

Presentation: flu-like symptoms, myalgia, feeling unwell, and in cases of infectious

mastitis fever and chills.

On ex.: Usually unilateral, red, swollen, and tender breast especially on the upper

outer quadrant. Always examine the lymph nodes as infection may extend to the

axilla causing axillary lymphadenopathy.

Management: massage, hot compresses, CONTINUE feeding from the affected

breast as she needs to empty her breast, increase fluid intake to keep the mother

well hydrated, and give flucloxacillin.

Complications if left untreated: abscess formation, necrotizing fasciitis, and toxic

shock syndrome.

iii. Breast abscess: In addition to all SSx of mastitis theres a fluctuant, painful mass in the

breast. Its managed by incision and drainage.

iv. Nipple pain is thought to be associated with fungal infection but theres no evidence

proving that. Its usually seen in primiparous women but once the mother learns how to

breast-feed her baby properly, symptoms are relieved. If not, antifungal medications are

given to BOTH the mother and her baby.