The puerperium

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Chapter 55 The puerperium

Michael Flynn

Definition. The puerperium is the period from the completion of the third stage of labour to the return of the prepregnant physiological state. It is said to last 6 weeks.

Physiology. Involution of the uterus is due to catabolism of the uterine muscle bulk, with the fundal height decreasing from the level of the umbilicus on day 1 postpartum to not being palpable abdominally on days 10–14. It returns to a non-pregnant size within 4 weeks. The cervix involutes with the uterus and the os is closed by 2–3 weeks. The endometrium starts to regenerate 2–3 days postpartum.

The lochia or vaginal discharge is usually red (lochia rubra) for 2–14 days, then serous (lochia serosa) for up to 20 days, and gradually ceases by 4–8 weeks (lochia alba). Ovulation is often inhibited in breastfeeding before 10 weeks; if lactation is suppressed, it may occur at 7–10 weeks.

Afterbirth pains are tonic contractions of the uterus. They are increased in multiparas and with breastfeeding. Diuresis occurs 2 days after birth, and there is a return of plasma volume and other blood parameters to normal within 2 weeks.

Abnormal postpartum bleeding

Normal duration of blood loss is a mean of 24 days, with approximately 10% of women still bleeding at 8 weeks. Treatment is investigation with ultrasound to exclude retained pregnancy tissue prior to antibiotic treatment and, if required, surgical management with curettage.

Puerperal infections

Incidence. Puerperal infections occur in 2% of women after delivery.

Sites

• The genital tract is the commonest site of infection.
• Other sites include respiratory, wound and breast.
• Milk fever can occur with engorgement on days 3–4 but does not imply infection.
• A urinary tract infection is uncommon unless catheterisation has been performed.
• On days 2–5 postpartum, the infection is commonly genital or urinary tract (Escherichia coli or haemolytic Streptococcus).
• During week 2 postpartum, sites are more likely wound, breast or complicated pelvic infections.
• Deep venous thrombosis and pulmonary embolism are possible.

Postpartum endometritis

Risk factors

• prolonged rupture of membranes
• emergency caesarean section
• excessive blood loss
• prolonged surgery
• multiple vaginal examinations
• preterm delivery

Microbiological causes (mostly polymicrobial)

• 60% anaerobic endometritis: Peptostreptococcus, Bacteroides, Clostridium
• 40% aerobic causes: Streptococcus, Enterococcus, E. coli, Staphylococcus aureus
• Bacteroides fragilis, which may cause invasive anaerobic endometritis, often with adnexal involvement
• Mycoplasmas common although pathogenesis unsure

Management

• General examination should specifically assess the patient for infections of the breast, uterus, genital tract, chest, abdomen/wound and urinary tract. Deep venous thrombosis may present as a febrile illness.
• Microbiological assessment includes urine and blood for culture. Microbiological cultures of the genital tract are often not helpful, as the infective organisms are usually vaginal commensals.
• In the woman who is febrile with no other clinical symptoms and signs, empirical therapy of amoxycillin/potassium clavulanate 500/125 mg orally every 8 hours may be tried.
• If fever persists for more than 48 hours, add erythromycin 500 mg orally every 8 hours, as Mycoplasma may be involved.
• In the clinically unwell woman, intravenous therapy is indicated. A combination of (amoxy)ampicillin, gentamicin and metronidazole is used.

Breast infection

Incidence. Breast infection occurs in 1%–5% of postpartum infections.

Causes

• mostly S. aureus
• Streptococcus
• E. coli
• usually nosocomial, with transfer from infant to nipple (the causative organism can often be isolated from milk or pus)

Treatment

• The aim of early treatment with antibiotics is to avoid abscess formation.
• Breastfeeding should be continued or the breast manually emptied to avoid milk stasis and further abscess risks.
• Oral antibiotic treatment consists of flucloxacillin 500 mg to 1 g every 6 hours, dicloxacillin or cephalexin 500 mg to 1 g every 6 hours.
• Failure of antibiotic therapy may represent the presence of an abscess.

Breastfeeding

Physiology of lactation

During pregnancy, breast tissue is stimulated and hypertrophy of alveolar lobular structures occurs. Oestrogen, progesterone and prolactin are required for growth of the milk-collecting ducts. The milk production is inhibited in pregnancy by high levels of oestrogen and progesterone.

Milk production is regulated by prolactin, which causes glandular cells to secrete milk in response to a suckling reflex. Oxytocin is also released by suckling, although by different neuroendocrine pathways. Oxytocin acts on myoepithelial cells to induce milk ejection. The 600 mL breast milk made per day contains all vitamins except for vitamin K.

Establishing and maintaining lactation is complex, but several studies demonstrate beneficial effects of early contact of mother with baby. There appears to be no critical period for the first feed in the establishment of lactation. Colostrum, a yellow fluid, is made in the first 2 days. It differs from breast milk due to its increased fat globules and higher mineral and protein content. Immunoglobulin A can also be found.

Correct positioning of the baby on the breast is crucial to the avoidance of sore nipples and the successful establishment of feeding. In the correct position, the nipple forms the distal third of a teat and the baby’s lower jaw and tongue are opposed to breast tissue, which makes the milk flow.

Frequency and duration of feeds

• Babies who are allowed to regulate their own feeds tend to gain weight more quickly and maintain breastfeeding longer than those on feeding schedules.
• There is no reason to restrict feeding duration, as small-volume high-caloric milk is present at the end of the feed.
• There is no evidence to support the use of routine supplemental formula or fluids.
• The combined oral contraceptive pill increases breastfeeding failure, and the progesterone-only pill is indicated in the postpartum period.

Common breastfeeding problems

• Nipple trauma: this is usually due to incorrect positioning, and education is required.
• Breast engorgement: this occurs when the volume of milk exceeds the capacity of alveoli to store it. Management involves correct positioning of the baby and the use of firm breast support.
• Insufficient milk: although a common reason for ceasing breastfeeding, objective evidence suggests that only 1%–5% of lactating mothers have inadequate milk supply. The treatment includes unrestricted feeding and dopamine antagonists (metoclopramide).

Lactational amenorrhoea

• This is due to a suckling-induced change in hypothalamic sensitivity to the negative feedback of ovarian steroids.
• Inhibition of lactation occurs with the combined oral contraceptive pill and smoking.
• Bromocriptine may suppress lactation if required.

Common postpartum problems

• Anaemia: postpartum anaemia occurs in 25%–30% of women, and sustained iron intake is recommended.
• Perineum: breakdown of sutures occurs in 2%–3% of cases, and primary resuturing with antibiotic cover may be appropriate. Dyspareunia is more common with episiotomy.
• Urinary problems include voiding difficulty and urinary tract infections.
• Constipation and haemorrhoids are also potential problems.

Postnatal mood disorders

During the lifetime of a woman, the postpartum period is the time of highest risk for psychiatric illness. Postpartum mood disorders are common and are usually divided into three diagnostic categories:

• the ‘blues’
• postnatal depression
• postpartum psychosis

The ‘blues’

• This is a common, minor and usually self-limiting condition, occurring in up to 80% of new mothers.
• The peak incidence is at days 3–5 postpartum.
• Symptoms include weepy, flat, emotional lability and feelings of inadequacy.
• Support is required.

Postnatal depression

• Clinical depression associated with pregnancy may occur both antenatally and postnatally. However, it most commonly follows birth.
• Incidence is 1%.
• Symptoms include: a mood that is not reactive to circumstances and is lowest in the morning; decreased appetite, energy, interest, concentration and confidence; sleep disturbance; alteration of the mother’s feelings for the baby; panic attacks; feelings of inadequacy; bonding failure.
• The Edinburgh Postnatal Depression Scale can be used as a screening device for postnatal depression.
• Management includes recognition, appropriate referral for psychiatric assessment and management, and a social support structure.
• Management is advanced by antenatal identification of at-risk groups: those with a previous history of depression or severe premenstrual syndrome; recent significant life event (significant bereavement or relationship break-up); recent migrants; low or high maternal age; low socioeconomic status.
• As both psychological and biological aetiologies are present, a multifactorial treatment regimen, including psychotherapy, social service and pharmacological treatment, is required.

Postpartum psychosis

• Incidence is 0.2%.
• Postpartum psychosis is mostly affective, and rarely does schizophrenia present for the first time in this situation.
• Recurrence rate: if significant psychosis in the previous pregnancy is not resolved before the subsequent pregnancy, recurrence is highly likely. If the psychosis has resolved, the risk for the next pregnancy is 50%.
• Symptoms include delusions, hallucinations and extremes of behaviour.
• Management includes psychiatric admission to a specialised mother-and-baby unit. Treatment with neuroleptics, antidepressants, lithium or electroconvulsive therapy may be required. Breastfeeding is avoided if lithium or polypharmacy is used. Social support for the family and partner is required.
• Early psychiatric referral is advisable in the next pregnancy.

Further reading

Glazener C., MacArthur C. Postnatal morbidity. Obstetrician and Gynaecologist. 2001;3:179-183.

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Chapter 55 The puerperium

Michael Flynn

Definition. The puerperium is the period from the completion of the third stage of labour to the return of the prepregnant physiological state. It is said to last 6 weeks.

Physiology. Involution of the uterus is due to catabolism of the uterine muscle bulk, with the fundal height decreasing from the level of the umbilicus on day 1 postpartum to not being palpable abdominally on days 10–14. It returns to a non-pregnant size within 4 weeks. The cervix involutes with the uterus and the os is closed by 2–3 weeks. The endometrium starts to regenerate 2–3 days postpartum.

The lochia or vaginal discharge is usually red (lochia rubra) for 2–14 days, then serous (lochia serosa) for up to 20 days, and gradually ceases by 4–8 weeks (lochia alba). Ovulation is often inhibited in breastfeeding before 10 weeks; if lactation is suppressed, it may occur at 7–10 weeks.

Afterbirth pains are tonic contractions of the uterus. They are increased in multiparas and with breastfeeding. Diuresis occurs 2 days after birth, and there is a return of plasma volume and other blood parameters to normal within 2 weeks.

Abnormal postpartum bleeding

Normal duration of blood loss is a mean of 24 days, with approximately 10% of women still bleeding at 8 weeks. Treatment is investigation with ultrasound to exclude retained pregnancy tissue prior to antibiotic treatment and, if required, surgical management with curettage.

Puerperal infections

Incidence. Puerperal infections occur in 2% of women after delivery.

Sites

• The genital tract is the commonest site of infection.
• Other sites include respiratory, wound and breast.
• Milk fever can occur with engorgement on days 3–4 but does not imply infection.
• A urinary tract infection is uncommon unless catheterisation has been performed.
• On days 2–5 postpartum, the infection is commonly genital or urinary tract (Escherichia coli or haemolytic Streptococcus).
• During week 2 postpartum, sites are more likely wound, breast or complicated pelvic infections.
• Deep venous thrombosis and pulmonary embolism are possible.

Postpartum endometritis

Risk factors

• prolonged rupture of membranes
• emergency caesarean section
• excessive blood loss
• prolonged surgery
• multiple vaginal examinations
• preterm delivery

Microbiological causes (mostly polymicrobial)

• 60% anaerobic endometritis: Peptostreptococcus, Bacteroides, Clostridium
• 40% aerobic causes: Streptococcus, Enterococcus, E. coli, Staphylococcus aureus
• Bacteroides fragilis, which may cause invasive anaerobic endometritis, often with adnexal involvement
• Mycoplasmas common although pathogenesis unsure

Management

• General examination should specifically assess the patient for infections of the breast, uterus, genital tract, chest, abdomen/wound and urinary tract. Deep venous thrombosis may present as a febrile illness.
• Microbiological assessment includes urine and blood for culture. Microbiological cultures of the genital tract are often not helpful, as the infective organisms are usually vaginal commensals.
• In the woman who is febrile with no other clinical symptoms and signs, empirical therapy of amoxycillin/potassium clavulanate 500/125 mg orally every 8 hours may be tried.
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