The puerperium

The puerperium The puerperium refers to the 6 week period following childbirth when considerable adjustments occur before return to the pre-pregnant state. (By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery have resolved and the body has reverted to the non pregnant state). During this period of physiological change, the mother is also vulnerable to psychological disturbances, which may be aggravated by adverse social circumstances.

Physiological changes 1-Uterine involution Involution is the process by which the postpartum uterus, weighing about 1kg, returns to its pre-pregnancy state of less than 100g. Immediately after delivery, the uterine fundus about 4cm below the umbilicus. Within 2 weeks, the uterus can no longer be palpable above the symphysis. By 6 weeks postpartum, the uterus has returned to its normal size.

Involution occur by process of autolysis. Involution appears to be accelerated by the release of oxytocin in women who are breast feeding. The height of uterine fundus is measured daily to ascertain the trend in involution.

Causes of delayed involution: Full bladder. Loaded rectum. Uterine infection. Retained process of conception. Fibroids. Broad ligament haematoma. A delay in involution in absence of any other signs or symptoms, e.g. bleeding is of no clinical significance.

2-Genital tract changes The cervix: In the first few days, the cervix can readily admit two fingers. By the end of the first week it should become increasingly difficult to pass more than one finger. By the end of second week the internal os should be closed. However the external os can remain open permanently, giving the characteristic appearance to the parous cervix.

3- Lochia: Lochia is the blood stained uterine discharge that is comprised of blood and necrotic decidua. Immediately after delivery, a large amount of red blood flows from the uterus until the contraction phase occurs. Thereafter, the volume of vaginal discharge (lochia) rapidly decreases. The duration of this discharge, known as lochia rubra, is variable.

The red discharge progressively changes to brownish red, with a more watery consistency (lochia serosa). Over a period of weeks, the discharge continues to decrease in amount and color and eventually changes to yellow (lochia alba). The period of time the lochia can last varies, although it averages approximately 5 weeks.

Offensive lochia, which may be accompanied by pyrexia and a tender uterus, suggest infection and should be treated by broad spectrum antibiotic.

4- Abdominal wall: The abdominal wall remains soft and poorly toned for many weeks. The return to a pre pregnant state depends greatly on maternal exercise.

Routine observations During the patient’s stay in hospital, the mother is monitored for blood loss, signs of infection, abnormal blood pressure, contraction of the uterus, and ability to void. The perineum should be inspected daily if there has been any trauma and the episiotomy or other wounds checked for sign of infection. Observations should also include breast examination and examination of the leg. Women are encouraged to ambulate and to eat a regular diet.

It is traditional to check haemoglobin level on day 3 unless otherwise indicated. And most women who are particularly symptomatic should be transfused if their haemoglobin level at this time is <8g/dl.

Ambulation in the puerperium It is now well established that early mobilization after childbirth is extremely important (as soon as possible) Limb exercise will be particularly important to encourage venous flow in the leg veins of any mother who has been immobilized in bed for any reason. Exercise to the abdominal and pelvic floor muscles are most valuable in restoring normal tone which may have been lost during pregnancy.

Complications of the puerperium The most serious complications are: thromboembolism, infection, haemorrhage, mental disorders, breast problems.

Other problems include perineal discomfort, disturbance of bladder and bowel function, obstetric palsy, symphysis pubis diastesis.

Perineal complications Discomfort is greatest in women who sustain spontaneous tear or have an episiotomy, but especially following instrumental delivery. Treatment: local cooling (with crushed ice, or tap water). Topical anaesthetics such as 5%lignocain gel. Analgesic as paracetamol or diclofenac suppositories. Codeine derivative are not preferable as they have tendency to cause constipation.

Infections of the perineum are generally uncommon considering the risk of bacterial contamination during delivery. Management: Swab for microbiological culture from the infected perineum. Broad spectrum antibiotic. If there is collection of pus, drainage should be encouraged by removal of any skin sutures; otherwise infection would spread, with increasing morbidity and poor anatomical result.

Bladder function Voiding difficulty and over-distension of the bladder are not uncommon after childbirth, especially if regional anasthesia has been used. Women who have undergone traumatic delivery such as a difficult instrumental delivery, or who have suffered multiple/extended lacerations or a vulvovaginal haematoma, may find it difficult to void because of pain or periurethral oedema.

Fistulae: pressure necrosis of the bladder or urethra may occur following prolonged obstructed labour, and incontinence usually occurs in the second week when the slough seperates.

Bowel function Constipation is a common problem in the puerperium. This may be due to: An interruption in the normal diet. Possible dehydration during labour (so advice on adequate fluid intake and increase in fibre intake may be all that is necessary). Constipation may also be the result of fear of evacuation due to pain from a sutured perineum, prolapsed haemorrhoids or anal fissures.

Anal incontinence and faecal urgency may occur following childbirth due to trauma to anal sphincter (either occult trauma or associated with a third or fourth degree tear). Anovaginal /rectovaginal fistulae may occur. It is therefore important to consider a fistula as a cause of anal incontinence in the postpartum period.

Obstetric palsy Obstetric palsy Is a condition in which one or both lower limbs may develop signs of a motor and/or sensory neuropathy following delivery. Presenting features include sciatic pain, foot-drop, parasthesia, hyposthesia and muscle wasting.

Possible mechanisms: Compression or stretching of the lumbosacral trunk as it crosses the sacroiliac joint during descent of the fetal head. Herniation of lumbosacral discs (usually L4 or L5) can occur, particularly in the exaggerated lithotomy position and during instrumental delivery.

Symphysis pubis diastesis Seperation of symphysis pubis can occur spontaneously in at least 1 in 800 vaginal deliveries. It has been associated with: Forceps delivery. Rapid second stage of labour. Severe abduction of the thigh during delivery.

The vagina: In the first few days, the stretched vagina is smooth and oedematous, but by the third week rugae begin to reappear.

Common signs and symptoms include: Symphyseal pain aggravated by weight-bearing and walking. Waddling gait. Pubic tenderness and a palpable interpubic gap. Treatment includes: Bed rest. Anti-inflammatory agents. Physiotherapy. Pelvic corset to provide support and stability.

Secondary postpartum haemorrhage Definition: fresh bleeding from the genital tract between 24 hours and 6 weeks after delivery. The most common time is between days 7 &14

Aetiology: Retained placental tissue (most common). Endometritis. Hormonal contraception. Bleeding disorders, e.g. von Willebrand’s disease. choriocarcinoma

In presence of retained placental tissue, suction evacuation of the uterus is the treatment of choice under antibiotic cover which is best started at least 12 h beforehand. Great care must be taken at the time of curettage as the infected uterus is soft and easy to perforate.

Thromboembolism The risk rises five fold during pregnancy and the puerperium. The majority of deaths occur in the puerperium (after the first week of the puerperium, hence after discharge from hospital) and are more common after caesarean section.

Is defined as a temperature of 38°C (104°F) or higher on any two of the first 10 days postpartum, exclusive of the first 24 hours. There are many causes of such a fever, but in the days prior to antibiotics it was a sign which was very much dreaded as it had a very poor prognosis. These days, with prompt recognition and treatment of the underlying cause, the outcome is considerably better.

Common sites associated with puerperal pyrexia include: Chest. Throat. Breast. Urinary tract. Pelvic organs. Caesarean or perineal wounds. Legs.

Genital tract infection Genital tract infection following delivery is referred to as puerperal sepsis. Currently, the incidence of puerperal sepsis is approximately 3% (range 1- 8%) and excluding death after abortion, it account for 7% of all direct maternal deaths.

Aetiology of genital tract infections Following delivery, natural barriers to infection are temporarily removed and therefore organisms with a pathogenic potential can ascend from the lower genital tract into the uterine cavity. Placental separation exposes a large raw area equivalent to an open wound, and retained products of conception and blood clots within the uterus can provide an excellent culture medium for infection.

Furthermore, vaginal delivery is almost invariably associated with laceration of genital tract (uterus, cervix and vagina). Although these laceration may not need surgical repair, they can become a focus for infection.

Puerperal infection is usually polymicrobial Puerperal infection is usually polymicrobial. The organism that usually contribute to this condition include group A and B beta-haemolytic streptococci, aerobic gram negative rods, Neisseria gonorrhoeae, and certain anaerobic bacteria.

Common risk factors for puerperal infection Antenatal intrauterine infection. Prolonged rupture of membranes. Prolonged labour. Multiple vaginal examination. Internal fetal monitoring. Instrumental delivery. Manual removal of the placenta. Retained products of conception. Non obstetric, e.g. obesity, diabetes, HIV.

Clinical features of puerperal sepsis Symptoms: Malaise, headache, fever, rigors. Abdominal discomfort,vomiting and diarrhoea. Offensive lochia. Secondary postpartum haemorrhage.

Signs: Pyrexia and tachycardia. Uterus-boggy, tender and larger. Infected wounds-caesarean/perineal. Peritonism. Paralytic ileus. Indurated adnexia (parametritis). Bogginess in pelvis (abscess).

Investigation for puerperal sepsis Full blood count--------anaemia, leukocytosis,thrombocytopenia Urea & electrolytes------fluid and electrolyte imbalance High vaginal swab and blood culture------infection screen

Pelvic ultrasound--------retained product, pelvic abscess. Clotting screen (haemorrrhage, shock)------disseminated intravascular coagulation. Arterial blood gas (shock)------acidosis & hypoxia.

Treatment Management should consist of supportive therapy to ensure hydration and, where necessary the administration of regular paracetamol, which acts as an antipyretic and improve patient comfort, whilst not altering the clinical course of the disease precess.

The mainstay of treatment is appropriate antibiotic therapy Mild to moderate infections can be treated with a broad spectrum antibiotic, e.g. co-amoxiclav, or a cephalosporin such as cefalexin plus metronidazole. Depending on the severity, the first few doses should b e given intravenously. Treatment should be continued for at least 10 days. Once culture results are available, it may be necessary to change the antibiotic regime according to the sensitivity pattern.

If there is retained placental tissue within the uterine cavity, this acts as a focus of infection and it is best that the uterine cavity is evacuated under anasthesia. The diagnosis of retained products may be suggested by a dilated internal os and confirmed by feeling placental tissue in the cervical canal or by visualizing the tissue on ultrasonic examination.

Surgical intervention may be required if it is thought that an abscess has formed, as in this case the fever will not settle until the abscess has been incised and drained. In cases of severe septicemia, transfer to a critical care unit may be required so that inotropic support can be initiated.

Breast disorders Breast engorgement: It usually begins by the second or third postpartum day. The over-distended and engorged breasts can be very uncomfortable and the condition may give rise to fever of up to 39°C, however, it rarely lasts more than 16 hours.

The most effective method of treatment and prevention is by allowing the baby easy access to the breast. (A number of remedies have been recommended as manual expression, firm support, applying an ice bag and electric breast pump)

Mastitis : The affected segment of the breast is painful and appears red and oedematous. This associated with flu like symptoms with a tachycardia and pyrexia (in contrast to breast engorgement, the pyrexia develops later and persists longer) In general, suppurative mastitis usually presents in the third to fourth postpartum week and is usually unilateral The most common infecting organism is Staphylococcus aureus (40%). Other bacteria include coagulase-negative staphylococci and Streptococcus viridans The most common sources of infections is from the baby’s nose or throat

Management includes isolation of the mother and baby, ceasing breast feeding from the affected breast, expression of milk either manually or by electric pump, and micobiological culture and sensitivity of a sample of milk. Flucloxacillin can be commenced while awaiting sensitivity results.

Breast abscess: About 10% of women with mastitis develop a breast abscess. There will be a red, painful fluctuant swelling and the patient will feel feverish and unwell. Treatment is by radial surgical incision and drainage under general anasthesia

Painful nipples: The nipple can become very painful if the covering epithelium is denuded or if a fissure develops giving rise to ‘cracked nipples’ Causes: -poor positioning of the baby on the breast. -thrush (candiasis) may also cause soreness. Treatment: involves resting of the affected nipple and manually expressing milk. Breast feeding should be re-introduced gradually.

Puerperal psychological disorders: Baby blues (postpartum blue): Is the term used to describe the transient tearfulness, anxiety and irritability. More than 50% of women suffer from postpartum blues. It frequently occurs in the first few days following delivery (usually commencing on the 4th or 5th postpartum day). It is commoner in women following their first delivery and sufferers are not more likely to have a past psychiatric history than non sufferer. Lack of sleep, hospitalization, and pain have been implicated in the aetiology of this condition.

Management: Providing supportive care for the new mother (by professional and the family). Drug therapy is not indicated as the condition is usually self limiting. Those in whom the condition persists difficulties appear to have an increased risk obeyond 10-14 days and those who have marital f developing puerperal psychosis.

Postnatal depression: The symptoms do not differ from those of depression at other times of life. The onset of symptoms should commence within 3-6 months of delivery. The incidence is approximately 10-15% It is associated with a past history of psychiatric illness. Management: early involvement of a psychiatric with experience in this condition is essential. Increased caregiver support with subsequent addition of fluoxetine if necessary.

Puerperal psychosis: Is a severe mental disorder usually occurring in the first 4 weeks of delivery. It is rare, occurring in 0.1%. It characterized by an increased degree of anxiety, a combination of mania and depression, suicidal thought an expression of delusion and a wish to self-harm or to harm the baby. It does appear to be more common following the first delivery and in patients with previous bipolar disorders.

It has a 25% risk of recurrence in subsequent pregnancies It has a 25% risk of recurrence in subsequent pregnancies. Many patients also suffer from recurrent relapsing affective disorders for the remainder of their lives. Management: This is a psychiatric emergency. It requires hospitalization in special baby and mother unit. Antidepressant, neuroleptic Aggressive treatment may be required (electroconvulsive therapy)

The postnatal examination This is carried out about 6 weeks postpartum. It includes assessment of the woman’s mental and physical health as well as the progress of baby. Direct questions must be asked about urinary, bowel function Weight, urine analysis and Bp are checked and a complete general, abdominal and pelvic examination is performed. If cervical smear is due, it can be taken, although it preferable to take one after three months postpartum. Contraception and pelvic floor exercise are also discussed.