Download Puerperium

Puerperium
Nazila Karamy –MD
Genecology and Obstetric Specialist
www.doctorkaramy.ir
Puerperium
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The time 6 w from the delivery tht
body returns to the nonpregnant state
Uterus
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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
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2 weeks postpartum, the uterus should be located
in the true pelvis
Lochia
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Vaginal discharge, lasts about 5 weeks
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15% of women have lochia at 6 weeks postpartum
Lochia rubra
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Red
Duration is variable
Lochia serosa
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Brownish red, more watery consistency
Continues to decrease in amount
Lochia alba
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Yellow
Cervix, Vagina, Perineum
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Tissues revert to a nonpregnant state but
never return to the nulliparous state
Abdominal Wall
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Remains soft and poorly toned for many
weeks
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Return to a prepregnant state depends greatly on
exercise
Not depend on the root of delivery (c/s,nvd)
Ovulation
Breastfeeding
 Longer period of amenorrhea and
anovulation
Not breastfeeding
 As early as 1 month after delivery
 Most have a menstrual period by 3 months
 Suggest birth control &R/O PREGNANCY in
doubtful cases
Sexual Intercourse
May resume when…
 Red bleeding ceases
 Vagina and vulva are healed
 Physically comfortable
 Emotionally ready
*Physical readiness usually takes ~3 weeks
Postpartum Period
Concerns - Puerperal Period
Hemorrhage
Postpartum Hemorrhage
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Excessive blood loss during or after the 3rd
stage of labor
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Average blood loss is 500 mL
Early postpartum hemorrhage
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1st 24 hrs after delivery
Late postpartum hemorrhage
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1-2 weeks after delivery (most common)
May occur up to 6 weeks postpartum
Postpartum Hemorrhage
Postpartum Hemorrhage
Incidence
 Vaginal birth: 3.9%
 Cesarean: 6.4%
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Delayed postpartum hemorrhage: 1-2%
Mortality
 5% of maternal deaths
Postpartum Hemorrhage
May result from:
 Uterine atony
Most common
 Lower genital tract lacerations
 Retained products of conception
 Uterine rupture
 Uterine inversion
 Placenta accreta
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adherence of the chorionic villi to the myometrium
Coagulopathy
Hematoma
Uterine Atony
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Lack of closure of the spiral arteries and venous
sinuses
Risk factors:
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Overdistension of the uterus secondary to multiple
gestations
Polyhydramnios
Macrosomia
Rapid or prolonged labor
Grand multiparity
Oxytocin administration
Intra-amniotic infection
Postpartum Hemorrhage
Lower genital tract lacerations
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Result of obstetrical trauma
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More common with operative vaginal deliveries
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Forceps
Vacuum extraction
Other predisposing factors:
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Macrosomia
Precipitous delivery
Episiotomy
Infection
Endometritis
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Ascending polymicrobial infection
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Usually normal vaginal flora or enteric bacteria
Primary cause of postpartum infection
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1-3% vaginal births
5-15% scheduled C-sections
30-35% C-section after extended period of labor
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May receive prophylactic antibiotics
<2% develop life-threatening complications
Endometritis
Risk factors:
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C-section
Young age
Low SES
Prolonged labor
Prolonged rupture of
membranes
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Multiple vaginal exams
Placement of
intrauterine catheter
Preexisting infection
Twin delivery
Manual removal of the
placenta
Endometritis
Clinical presentation
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Fever
Chills
Lower abdominal pain
Malodorous lochia
Increased vaginal
bleeding
Anorexia
Malaise
Exam findings
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Fever
Tachycardia
Fundal tenderness
Treatment
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Antibiotics
Urinary Tract Infection
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Bacterial inflammation of the bladder or
urethra
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3-34% of patients
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Symptomatic infection in ~2%
Urinary Tract Infection
Risk factors
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C-section
Forceps delivery
Vacuum delivery
Tocolysis
Induction of labor
Maternal renal disease
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Preeclampsia
Eclampsia
Epidural anesthesia
Bladder catheterization
Length of hospital stay
Previous UTI during
pregnancy
Urinary Tract Infection
Clinical Presentation
Exam Findings
Urinary
frequency/urgency
 Dysuria
 Hematuria
 Suprapubic or lower
abdominal pain
OR…
 No symptoms at all
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Stable vitals
Afebrile
Suprapubic tenderness
Treatment
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antibiotics
Mastitis
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Inflammation of the mammary gland
Milk stasis & cracked nipples contribute to the
influx of skin flora
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2.5-3% in the USA
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Neglected, resistant or recurrent infections can
lead to the development of an abscess (5-11%)
Mastitis
Clinical Presentation
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Fever
Chills
Myalgias
Warmth, swelling and
breast tenderness
Exam Findings
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Area of the breast that is
warm, red, and tender
Treatment

Moist heat
stasis
Massage
Fluids
Rest
Proper positioning of the
infant during nursing
Nursing or manual
expression of milk
Analgesics
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Antibiotics
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Wound Infection
Perineum
Abdominal incision
(episiotomy or laceration)
 3-4 days postpartum
 rare
(C-section)
 Postoperative day 4
 3-15%
 prophylactic antibiotics

2%
Wound Infection
Perineum
Abdominal incision
Risk Factors:
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Infected lochia
Fecal contamination
Poor hygiene
Risk factors:
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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
Diagnosis
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Abdominal Infection
 Persistent fever
(despite antibiotics)
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Erythema
Induration
Warmth
Tenderness
Purulent drainage
With or without fever
Psychiatric Disorders
Postpartum Blues
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Transient disorder
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Lasts hours to weeks
Bouts of crying and sadness
Postpartum Depression
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More prolonged affective disorder
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Weeks to months
S&S of depression
Postpartum Psychosis
First postpartum year
 Group of severe and varied disorders
(psychotic symptoms)
BF NOT SUGGESTED
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Etiology
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Unknown
Theory: multifactorial
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Stress
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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
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Undesired pregnancy
Feeling unloved by
mate
<20 years
Unmarried
Medical indigence
Low self-esteem
Dissatisfaction with
extent of education
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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
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50-70% develop postpartum blues
10-15% of new mothers develop PPD
0.14-0.26% develop postpartum psychosis
History of depression
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30% chance of develping PPD
History of PPD or postpartum psychosis
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50% chance of recurrence
Postpartum Blues
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Mild, transient, self-limiting
Commonly in the first 2 weeks
Signs and symptoms
 Sadness
 Crying
 Anxiety
 Irritation
 Restlessness
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Mood lability
Headache
Confusion
Forgetfullness
Insomnia
Postpartum Blue
Postpartum Blues
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Often resolves by postpartum day 10
No pharmacotherapy is indicated
Treatment
 Provide support and education
Postpartum Depression (PPD)
Signs and symptoms
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Insomnia
Lethargy
Loss of libido
Diminished appetite
Pessimism
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Incapacity for familial love
Feelings of inadequacy
Ambivalence or negative
feelings towards the infant
Inability to cope
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
Postpartum Depression (PPD)
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Lasts 3-6 months
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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
Signs and symptoms
 Acute psychosis
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Schizophrenia
Manic depression
Danger
Postpartum Psychosis
Treatment
 Therapy should be targeted to the patient’s
specific symptoms
 Psychiatrist
 Hospitalization
*Generally lasts only 2-3 months
Breastfeeding
 Breastfeeding is the best feeding method for
most infants
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Contraindications include galactosemia of
neonate, breast cancer,maternal hepatitis
C,breast abcess,post partum psychosis, HIV
infection, chemical dependency(immune
suppressive medication), and use of certain
medications
Structured behavior counseling and
breastfeeding-education programs may