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Transcript
Puerperium
Nazila Karamy –MD
Genecology and Obstetric Specialist
www.doctorkaramy.ir
Puerperium

The time 6 w from the delivery tht
body returns to the nonpregnant state
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

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

Tissues revert to a nonpregnant state but
never return to the nulliparous state
Abdominal Wall

Remains soft and poorly toned for many
weeks


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

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 Hemorrhage
Postpartum Hemorrhage
Incidence
 Vaginal birth: 3.9%
 Cesarean: 6.4%

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



adherence of the chorionic villi to the myometrium
Coagulopathy
Hematoma
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
Postpartum Hemorrhage
Lower genital tract lacerations

Result of obstetrical trauma

More common with operative vaginal deliveries


Forceps
Vacuum extraction
Other predisposing factors:



Macrosomia
Precipitous delivery
Episiotomy
Infection
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
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







Fever
Chills
Lower abdominal pain
Malodorous lochia
Increased vaginal
bleeding
Anorexia
Malaise
Exam findings



Fever
Tachycardia
Fundal tenderness
Treatment

Antibiotics
Urinary Tract Infection

Bacterial inflammation of the bladder or
urethra

3-34% of patients

Symptomatic infection in ~2%
Urinary Tract Infection
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
Clinical Presentation
Exam Findings
Urinary
frequency/urgency
 Dysuria
 Hematuria
 Suprapubic or lower
abdominal pain
OR…
 No symptoms at all




Stable vitals
Afebrile
Suprapubic tenderness
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




Fever
Chills
Myalgias
Warmth, swelling and
breast tenderness
Exam Findings

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

Antibiotics






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:




Infected lochia
Fecal contamination
Poor hygiene
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
Diagnosis





Abdominal Infection
 Persistent fever
(despite antibiotics)

Erythema
Induration
Warmth
Tenderness
Purulent drainage
With or without fever
Psychiatric Disorders
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)
BF NOT SUGGESTED

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
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


Mild, transient, self-limiting
Commonly in the first 2 weeks
Signs and symptoms
 Sadness
 Crying
 Anxiety
 Irritation
 Restlessness





Mood lability
Headache
Confusion
Forgetfullness
Insomnia
Postpartum Blue
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)
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)

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
Signs and symptoms
 Acute psychosis


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


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