Postpartum problems

Published on 09/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 09/03/2015

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Postpartum problems

Shankari Arulkumaran

Learning outcomes

After studying this chapter you should be able to:

Knowledge criteria

• Describe the normal maternal changes in the puerperium

• Describe the aetiology, diagnosis and management of the common abnormalities of the postpartum period, including thromboembolism, problems with lactation, puerperal pyrexia, anaemia and maternal collapse

• Describe the normal changes in the neonatal period

• Discuss the sequelae of obstetric complications (e.g. preterm delivery)

• Describe the principles of resuscitation of the newborn

Clinical competencies

• Carry out a newborn baby examination

• Carry out a routine postnatal clinical review

• Provide contraceptive advice to a woman in the postnatal period

Professional skills and attitudes

• Consider the importance of breastfeeding on childhood health

The normal postpartum period

Puerperium is the Latin word for childbirth, so we use it with license to mean the postpartum period from the birth of the baby through to involution of the uterus at 6 weeks. Emptying the uterus of the baby and the placenta is necessary for lactation or a return to fertility.

Physiological changes

Genital tract

The uterus weighs 1 kg after birth, but less than 100 g by 6 weeks. Uterine muscle fibres undergo autolysis and atrophy and within 10 days the uterus is no longer palpable abdominally (Fig 13.1). By the end of the puerperium, the uterus has largely returned to the non-pregnant size. The endometrium regenerates within 6 weeks and menstruation occurs within this time if lactation has ceased. If lactation continues, the return of menstruation may be deferred for 6 months or more.

Fig. 13.1 Uterine involution in the puerperium results in a rapid reduction in size.

Discharge from the uterus is known as lochia. At first this consists of blood, either fresh or altered (lochia rubra) and lasts 2–14 days. It then changes to a serous discharge (lochia serosa), and finally becomes a slight white discharge (lochia alba). These changes may continue for up to 4–8 weeks after delivery. Abnormal persistence of lochia rubra may indicate the presence of retained placental tissue or fetal membranes.

Cardiovascular system

Cardiac output and plasma volume return to normal within approximately 1 week. There is a fluid loss of 2 L during the first week and a further loss of 1.5 L over the next 5 weeks. This loss is associated with an apparent increase in haematocrit and haemoglobin concentration. There is an increase of serum sodium and plasma bicarbonate as well as plasma osmolality. An increase in clotting factors during the first 10 days after delivery is associated with a higher risk of deep vein thrombosis and pulmonary embolism. There is also a rise in platelet count and greater platelet adhesiveness. Fibrinogen levels decrease during labour but increase in the puerperium.

Endocrine changes

There are rapid changes in the endocrine system in all facets. There is a rapid fall in the serum levels of oestrogens and progesterone and they reach non-pregnant levels by the 7th postnatal day. This is associated with an increase in serum prolactin levels in those women who breastfeed. By the tenth postnatal day, human chorionic gonadotrophin (hCG) is no longer detectable.

The importance of breastfeeding

Colostrum

Colostrum is the first milk and is present in the breast from 12–16 weeks of pregnancy. Colostrum is produced for up to 5 days following birth before evolving into transitional milk, from 6–13 days and finally into mature milk from 14 days onwards. It is thick and yellow in colour, due to β-carotene and has a mean energy value of 67 kcal/dL, compared to 72 kcal/dL in mature milk. The volume of colostrum per feed varies from 2–20 mL in keeping with the size of the newborn’s stomach.

Linked with the importance of the baby having colostrum as its first food, is the importance of the baby being skin-to-skin with its mother after birth. This has the benefit of the baby being colonized by its mother’s bacteria. Colonizing starts during the birth process for vaginally born infants, while those born via caesarean section are more likely to colonize bacteria from the air. Early breastfeeding also promotes tolerance to antigens, thus reducing the number of food allergies in breast-fed babies. The development of healthy intestinal flora also reduces the incidence of allergic disease, inflammatory gut disease and rotavirus diarrhoea in infants.

While breastfeeding is desirable and women should be encouraged, the overall wishes of the woman should not be ignored. There are social and often emotional reasons why a woman may choose not to breastfeed. In some cases, it is not possible or even advisable, such as inverted nipples, previous breast surgery, breast implants, cracked or painful nipples or because the mother may have a condition, e.g. HIV positive mothers, or may be on medical treatment, e.g. chemotherapeutic agents that serve as a contraindication to breastfeeding.

Breastfeeding

The breasts and nipples should be washed regularly. The breasts should be comfortably supported and aqueous-based emollient creams may be used to soften the nipple and thus avoid cracking during suckling. Suckling is initially limited to 2–3 minutes on each side, but subsequently this period may be increased. Once the mother is comfortably seated, the whole nipple is placed in the infant’s mouth, taking care to maintain a clear airway (Fig. 13.2). Correct attachment of the baby to the breast is essential to the success of breastfeeding. The common problems such as sore nipples, breast engorgement and mastitis usually occur because the baby is poorly attached to the breast or is not fed often enough. Most breastfeeding is given on demand and the milk flow will meet the demand stimulated by suckling. Once the baby is attached correctly to the nipple, the sucking pattern changes from short sucks to long deep sucks with pauses. It may, on occasions, be necessary to express milk and store it, either because of breast discomfort or cracked nipples or because the baby is sick. Milk can be expressed manually or by using hand or electric pumps. Breast milk can be safely stored in a refrigerator at 2–4°C for 3–5 days or frozen and stored for up to 3 months in the freezer.

Fig. 13.2 The mother should be comfortable and the child placed well on to the breast to ensure adequate suckling.

In women who choose not to breastfeed, have suffered a stillbirth or intrauterine death or where there is a contraindication to breast feeding, suppression of lactation may be achieved by conservative methods or by drug therapy. Firm support of the breasts, restriction of fluid intake, avoidance of expression of milk and analgesia may be sufficient to suppress lactation. The administration of oestrogens will effectively suppress lactation but carries some risk of thromboembolic disease. The preferred drug therapy is currently the dopamine receptor agonist cabergoline. This can be given as a single dose and will inhibit prolactin release and hence suppress lactation. Bromocriptine is also effective, but the dosage necessary to produce this effect tends to create considerable side effects.

Complications of the postpartum period

Puerperal infections

Puerperal sepsis has been reported as far back as the 5th century BC. The Centre for Maternal and Child Enquiries (CMACE 2006–2008) has highlighted the re-emergence of sepsis (in particular group A β-haemolytic streptococci) as a leading cause of maternal morbidity and mortality in the UK. Other common causes of infection are urinary tract infections, wound infections (perineum or caesarean section scar) and mastitis (Box 13.1 and Fig 13.3).

Fig. 13.3 The pathogenesis of puerperal pyrexia.

In the puerperium, the placental surface in the womb is vulnerable to infection. This is exposed to the vagina, which harbours aerobic and anaerobic bacteria. Peripartum events, such as prolonged rupture of membranes, chorioamnionitis, repeated vaginal examinations, poor personal hygiene, bladder catheterization, invasive fetal monitoring, instrumental deliveries, caesarean sections, perineal trauma and manual removal of placenta lead to introduction of pathogens into the uterus and thus contribute to puerperal infections.

Endometritis

The patient with endometritis usually presents with fever, lower abdominal pain, secondary postpartum haemorrhage and foul smelling vaginal discharge. The organisms involved are group A β-haemolytic streptococci, aerobic Gram negative rods and anaerobes. On examination, the patient often has a fever, is tachycardic and is tender on palpation of the lower abdomen. There may be foul smelling vaginal discharge, bleeding and cervical excitation. The white cell count and C-reactive protein may be raised. Vaginal or blood cultures may identify the organism responsible. Broad spectrum antibiotics are the first-line treatment and resolution should start to occur within the first 48 hours. The complications of endometritis are parametritis, peritonitis, septic pelvic thrombophlebitis, pelvic abscesses and rarer is toxic shock syndrome.

Urinary tract infections (UTIs)

UTIs are the most common cause of puerperal infections. The predisposing factors include a history of previous UTIs, polycystic kidneys, congenital abnormalities of the renal tract, neuropathic bladder, urinary tract calculi but most are idiopathic. Patients present with voiding difficulties (e.g. urgency and frequency), dysuria, fever and pain in the renal angle. Urine analysis may be positive for protein and leucocytes, though nitrites are more sensitive. Urine should be sent for culture before commencing antibiotic treatment. The commonest organisms are Escherichia coli, Enterococcus, Klebsiella, Proteus and Staphylococcus epidermidis.

Mastitis and breast abscess

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