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Puerperium
Puerperium
Puerperium
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.
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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.
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.
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:
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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.
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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.
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Fibrinolytic activity goes back to normal within 30 mins. Its the fastest thing that goes back
to normal after delivery.
Ferritin returns back to normal 5-8 weeks post delivery. Remember that it was decreased
during pregnancy.
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?
Prolactin level is increased.
Requirements of thyroxin during pregnancy are increased but they immediately go back to
the pre-pregnancy state after delivery.
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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.
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.
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.
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.
Benefits of breast-feeding:
Breast milk has lactoferrin that binds to iron thus preventing the colonization of Ecoli and protecting the child from infections.
IgA in breast milk is formed by the mothers peyers patches in her gut.
Perinatal death.
Maternal HIV
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.
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.
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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!
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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.
Keep in mind..!
Keep in mind that DVT may present as puerperal pyrexia or as lower abdominal pain.
Always..
Any women presents to you post delivery with pyrexia, do a complete septic workup.
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.
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.
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.
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