The puerperium

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15 The puerperium

Definition

The puerperium is the time during which physiology and anatomy return to normal after pregnancy. It is usually quoted as starting at delivery of the placenta and ending after 6 weeks, but puerperal problems may in fact present up to 6 months after the birth.

Physiological and anatomical changes in the puerperium include:

• Reduction in cardiac output

• Lowering of respiratory rate

• Loss of the hypercoagulable state

• Return of hormone levels to the normal range

• Involution of the uterus, cervix and vagina

• Lactation.

Normal postnatal events

Lochia

Lochia is the bloody discharge lost from the uterus after delivery, which gradually becomes serosanguineous. It may continue for up to 6 weeks. Any offensive smell or fresh blood loss after the first few days should be investigated for possible infection (endometritis) or retained products of conception (RPOC).

Uterine involution

The uterus is usually at the level of the umbilicus after delivery. It is no longer palpable in the abdomen at 2 weeks and has returned to the prepregnancy size within 6 weeks of delivery.

Sexual intercourse

There is no evidence about when sexual intercourse may be resumed after delivery, but endometritis may be more common from sexual intercourse soon after delivery and it is generally recommended to avoid intercourse for 3 weeks or so.

Many couples do not resume sexual intercourse for weeks or months after delivery. Factors inhibiting intercourse include tiredness, pain from perineal or caesarean section wounds, vaginal bleeding and fear after childbirth.

Breastfeeding

Physiology

In pregnancy, progesterone stimulates proliferation of the alveoli and breast enlargement. Oestrogen causes darkening of the areola and an increase in the number of lactiferous ducts. At delivery, prolactin acts on the alveoli to initiate lactation and sucking further stimulates this. Colostrum, a high-protein, low-volume fluid is released initially and at day 2–3 milk ejection occurs in response to oxytocin.

The advantages of breastfeeding for the baby are:

• Reduced diarrhoea

• Reduced respiratory infection

• Reduced otitis media

• Reduced necrotizing enterocolitis

• Mildly increased IQ

• Half the risk of eczema

• Half the risk of juvenile-onset diabetes mellitus.

The advantages for the mother are:

• Reduced incidence of osteoporosis

• Reduced breast cancer

• Reduced ovarian cancer

• Bonding with the baby.

It is important to encourage breastfeeding as the ideal, although one third of women do not breastfeed at all. This is particularly common if the woman was not breastfed herself, or if her partner does not actively support her breastfeeding.

A small number of women are unable to breastfeed for the following reasons:

• Inverted nipples (2% incidence), which do not evert with attempts at breastfeeding

• Medications that are transmitted into breast milk and harmful to the baby

• Maternal human immunodeficiency virus (HIV) infection

• Inability to establish breastfeeding

• Some types of breast surgery

• Neonatal problems, such as cleft palate.

These women may feel stigmatized by their inability to give their baby ‘the best’ type of feeding.

Inability to establish feeding

Many women have difficulty breastfeeding. This may have various causes, such as an irritable and hungry baby, tired mother, dehydration, pain or anaemia. Some women find breastfeeding embarrassing, physically repellent or have anxiety about their ability to produce milk. The mother should be assessed for exacerbating factors and the baby reviewed if it is crying excessively or sleepy. Otherwise, management involves consideration of positioning of the baby, reassurance and emotional support, ideally with a specialist breastfeeding counsellor. When the baby is properly attached it should have the whole areola in the mouth (not just the nipple) and the jaw should be seen moving as the baby sucks. Women also need an adequate fluid and calorie intake and rest.

Postnatal visits

Community midwives visit women at home until at least 10 days postpartum. If there are no specific obstetric problems then care is handed over to the health visitor and general practitioner (GP). If there are ongoing obstetric issues, the midwife may continue to visit for up to 1 month following delivery.

Contraception

All postnatal women should be given appropriate contraception advice within the first few postnatal days. Factors to consider are previous contraceptive history, wishes for further fertility, age, smoking, weight, breastfeeding and medical problems. Ovulation can occur within 3 weeks of delivery so contraception is essential, especially in non-breastfeeding women:

• The progesterone-only pill is safe with breastfeeding and can be started immediately.

• The combined oral contraceptive pill reduces the quality and quantity of breast milk and is, therefore, contraindicated in lactating women. It should also be avoided for 6 weeks after delivery in non-lactating women due to the increased risk of thrombosis.

• Intrauterine contraceptive devices and the levonorgestrel-releasing intrauterine system can be fitted at 6 weeks postpartum, after uterine involution.

• Injectable progestogens are safe with breastfeeding, but should be delayed until 6 weeks postpartum, because of risks of erratic bleeding.

• Full breastfeeding is effective contraception for at least 6 months, as long as no formula supplements are given and the woman remains amenorrhoeic.

• Condoms can be used at any time after delivery.

Further information on contraception options is given in Chapter 9.

Problems in the puerperium

Breast engorgement

The breasts become full and tense on the third to fourth days, resulting in pain, discomfort and mild pyrexia. The management is a tight-fitting bra, paracetamol and continuation of feeding.

Cracked nipples

These are extremely painful and may bleed. Correction of the baby’s position, oral analgesia and camomile cream should be tried.

Mastitis and breast abscess

Mastitis is an infection of the lactiferous ducts and occurs in 5% of lactating women. It may be secondary to cracked nipples or to a blocked duct. The common organisms are Staphylococcus aureus, S. epidermidis and streptococci. The symptoms are pain, fever and malaise or anorexia and signs of redness, swelling and tenderness may be present. Breast milk can be cultured for identity and sensitivity of the organism. Treatment is with fluids, analgesia and antibiotics (flucloxacillin or erythromycin) with continuation of feeding.

Mastitis can develop into an abscess with increased pain and a localized fluctuant swelling. Treatment is repeat aspiration, ideally under ultrasound guidance, and antibiotics. Incision and drainage are rarely indicated. Breastfeeding from that breast should be avoided until resolution, but the woman should continue to express and discard milk to maintain lactation during recovery.

Headache

Headache is commonly caused by:

Intracranial pathology, for example from cerebrovascular accident or meningitis, is very rare. However, a severe headache may occur from cerebrospinal fluid leakage during epidural insertion.

A full examination should include temperature, pulse and blood pressure; meningism and gross neurological signs should be excluded. Blood pressure and full blood count should always be checked.

Treatment of the cause may include iron for anaemia or treatment of hypertension. Where possible, tiredness should be managed with support in caring for the baby.

Constipation

Constipation may occur from the pregnancy hormone effect, dehydration, altered diet, breastfeeding, the progesterone-only pill or due to pain from a tear or sutures. Management involves high-fibre diet, fluids and laxatives.

Hair loss

Women commonly lose hair between 4 and 20 weeks postpartum. This is caused by an increased proportion of hairs entering the telogen (resting) phase in pregnancy. Recovery usually occurs within 6 months.

Postpartum pyrexia

Assessment

The history may reveal the likely source of pyrexia, such as heavy bleeding with endometritis or cough with infection.

A full examination includes checking the lungs for evidence of infection, the breasts for engorgement or mastitis, the abdomen for a tender boggy uterus, the perineum for haematoma or infection and the legs for calf tenderness.

Full blood count, blood culture, vaginal swabs and midstream urine should always be sent. A chest X-ray should also be requested in the presence of chest signs or symptoms.

Treatment

Treatment of the pyrexia depends on the cause. Mild pyrexia in labour is common, especially after prostaglandin induction, and should be investigated only if persistent for more than a few hours after delivery or if the temperature exceeds 37.5 °C.

Perineal wound problems

Twenty-three per cent of women report discomfort 10 days after normal vaginal delivery and 66% 10 days after instrumental delivery.

Women with perineal tears or sutures should be advised:

• To take analgesia (paracetamol and non-steroidal anti-inflammatories) as needed, for up to 2 weeks

• To keep the area clean by regular bathing or showering, without soap

• To dry the area with a clean towel or cool hairdryer

• To observe for signs of infection (increased swelling or pain, offensive discharge)

• That the sutures dissolve spontaneously over a few weeks and stitch debris may be seen during this time.

Examination prior to discharge should check for signs of wound dehiscence, haematoma or infection. Occasionally, women feel one or two sutures are particularly ‘tight’. In such circumstances individual sutures can be divided 1 week after delivery without compromising healing.

Perineal wound dehiscence is rare and should generally be treated conservatively with wound hygiene and antibiotics if there are signs of infection. Revision of the perineum can be arranged after 6–8 weeks if necessary for perineal deficiency. Haematomas are also managed conservatively with antibiotics and analgesia. Surgical drainage is indicated only where an abscess has developed or the haematoma is increasing in size. Infected perineal wounds should be swabbed and treated with a broad-spectrum antibiotic with anaerobic cover.

Postpartum haemorrhage (PPH)

Endometritis

Postpartum endometritis is still a potential cause of serious morbidity and mortality. Common organisms are Streptococcus and anaerobic bacteria. Endometritis is more common after caesarean section than vaginal delivery.

Assessment

Presentation may be with bleeding, offensive discharge, abdominal pain, fever, general malaise or anorexia. Clinical signs are fever, excessive vaginal bleeding, abdominal tenderness, bimanual uterine tenderness and a poorly contracted, soft uterus. High vaginal and endocervical swabs and blood cultures should be sent urgently, with full blood count and C-reactive protein.

Treatment with oral antibiotics should be commenced until the culture results are available. Severe infections should be treated with intravenous antibiotics (for example, clindamycin and gentamicin), fluids and careful haemodynamic monitoring. ‘Puerperal sepsis’ is a historically important cause of maternal death. Aggressive treatment and monitoring are essential to prevent such severe infection.

Retained products of conception

RPOC may consist of small placental fragments or a whole placental lobe. RPOC may not necessarily be suspected when the placenta is inspected after delivery, especially if the retained lobe is a succenturiate lobe, that is, an accessory or ‘satellite’ lobe, separate from the main body of the placenta.

Clinical features

Women present with bleeding either as continued fresh loss or as a sudden PPH up to 2 weeks after delivery. Bleeding may be very heavy with haemodynamic compromise. RPOC also predisposes to secondary infection, which may be subclinical or be evident as overt sepsis.

Pyrexia, tachycardia, hypotension and anaemia may be found on general examination. Speculum may reveal an open cervical os and bimanual examination may reveal a soft, bulky uterus.

Investigation

Full blood count, C-reactive protein and vaginal swabs should be taken. Transvaginal ultrasound scan should be performed to confirm the diagnosis of RPOC. Interpretation of the findings may be difficult in the first 5 days postpartum as RPOC may be difficult to differentiate from blood clot.

Management

Antibiotics should be commenced immediately and blood or fluid replacement given as indicated. Evacuation of retained products should normally be delayed until antibiotics have been administered for at least 24 hours. This reduces the risk of haemorrhage at operation.

Urinary retention

Acute urinary retention may occur after delivery where there has been:

• Failure to catheterize a woman with a dense epidural

• Failure to check for bladder emptying within 8 hours of delivery

• Lack of sensation to pass urine after spinal or epidural for caesarean section or other obstetric surgical procedure

• Urinary tract infection

• Inhibition of voiding due to a painful perineum.

Assessment

Symptoms of suprapubic discomfort and the need to pass urine may be present, but some women are unaware of a full bladder and are falsely reassured by passing frequent very small volumes of urine. The full bladder is usually palpable on examination, though tenderness postpartum and the large uterus make examination difficult.

Management

A Foley urethral catheter should be inserted and residual volume checked. If the residual is moderate (<1000 ml), then a trial without catheter can be performed after 24 hours. For severe retention (residual >1000 ml) the catheter should be left for 3–5 days to allow full recovery. Failure to pass good urinary volumes after a trial without catheter necessitates a suprapubic catheter for 10 days and urogynaecological review.

Midstream urine should be sent for culture to exclude infection.

Stress urinary incontinence

Stress incontinence symptoms (the involuntary loss of urine with increases in intra-abdominal pressure) occur in up to 40% of women after delivery. From 3% to 12% of women still report symptoms 6 months after delivery. The mechanism is a combination of mechanical injury, denervation and ischaemic damage. It is more common after vaginal delivery, but can still occur with caesarean section (8%). Other risk factors are pre-existing incontinence, prolonged second stage, assisted vaginal delivery, episiotomy, high birth weight and multiparity.

Assessment

Examination may be normal or reveal uterovaginal prolapse. Midstream urine sample should be sent to exclude infection.

Management

Pelvic floor exercises, taught by a physiotherapist, are effective if performed both antenatally and postnatally, but the benefit of weighted vaginal cones and electrical biofeedback is unclear. A proportion of women will remain incontinent and may need surgical treatment, usually after completion of their family.

Faecal incontinence

Vaginal delivery is the primary cause of faecal incontinence in women. Symptoms include flatus incontinence, faecal urgency and stool incontinence. The incidence of incontinence varies from 11% to 35% after the first delivery, and from 3% to 12% after subsequent deliveries. Recognized third-degree tears only occur in 3% of deliveries, but occult injury can be seen on endoanal ultrasound in up to 36% of women. Of women with occult injury on ultrasound, only a third have symptoms of incontinence.

Risk factors for faecal incontinence are recognized third-degree perineal tear, high birth weight, forceps delivery, prolonged second stage and persistent occipitoposterior position.

Initial management is conservative with pelvic floor exercises. Referral to a colorectal surgeon should be made if symptoms persist, for consideration of secondary repair of the anal sphincter.

Postpartum thyroiditis

Postpartum thyroiditis occurs in 5% of women, usually 3–4 months postpartum. Antithyroid antibodies cause destruction of the gland, with an initial increase in release of thyroxine followed by a decrease. Hypothyroidism, hyperthyroidism or both may occur, with typical symptoms. However, some women are asymptomatic and symptoms in others may be dismissed as related to the pregnancy and puerperium.

Investigations may reveal increased or decreased thyroid hormones.

Most cases (97%) resolve spontaneously but symptomatic treatment may be needed with beta-blockers or thyroxine, depending on the presentation.

Puerperal cardiomyopathy

Puerperal cardiomyopathy is a dilated cardiomyopathy with presentation from 1 month before to 6 months after delivery. The severity of disease is variable, but some women have severe sudden onset of symptoms, with a high mortality. Other women have a slower, less serious course of disease.

Diagnosis is made on a combination of clinical findings and echocardiography. Treatment is supportive with diuretics and occasionally inotropes. In most women recovery is spontaneous, but this may take a few months. Some women continue to have impaired cardiac function.

Recurrence is common and women are generally advised to avoid future pregnancies.

Psychological, emotional and psychosexual problems in the puerperium

Many women find the emotional experience difficult during the puerperium. Contributing factors are:

• Sleep disturbance and tiredness

• Physical pain or discomfort from perineal or caesarean wounds

• Lack of control over the baby’s sleep or crying

• Dependence of the baby and lack of freedom

• Change in self-image from partner or lover to mother

• Fear of sexual intercourse due to perineal pain or memory of delivery

• Concerns about body image, lax perineum or weight changes

• Relationship difficulties.

Management involves a careful investigation of the underlying feelings and contributing factors. Counselling and reassurance are generally effective, but women with persistent symptoms should be referred for formal psychosexual or psychological counselling, after addressing the physical factors such as sleep problems.

Postpartum psychiatric illness

Postpartum blues

‘Postpartum blues’ is a normal feature in about half of postnatal women, commonly occurring from the third postpartum day. Features include tearfulness, anxiety, fatigue, irritability, feeling unable to cope and concern about the baby’s well-being. Symptoms may be exacerbated by a difficult delivery, tiredness, difficulty caring for the baby, for example because of pain, and fear about going home with the baby. Symptoms resolve spontaneously within a few days.

Postpartum depression

Postpartum depression occurs in 10% of women. Features are persistent low mood and crying, anxiety about their own or their baby’s health, guilt or feeling unable to cope with caring for the baby. Panic attacks, excessive tiredness, poor appetite and poor concentration may also occur. Onset may be from a few days to 6 months after delivery, with the commonest presentation at about 3 months.

Management

Risk of self-harm, suicide or harm to the baby must be assessed urgently. Thereafter, management is with the health visitor, GP, community psychiatric team and psychologist. Family and social support is important. Counselling and antidepressants are the main treatments. Progesterone and oestrogen treatments have not been shown to be effective. Antidepressants are not licensed for breastfeeding, but do not appear to cause harm and breastfeeding is usually continued unless there are signs of drowsiness or irritability in the baby.

Postpartum psychosis

Postpartum psychosis occurs in 1 in 500 women. Clinical features are delusions, hallucinations and impaired perception of reality, with onset within 6 weeks of delivery, usually within the first few days. Some women report delusional ideas relating to their baby, such as their baby is evil or that the baby will be harmed by themselves or someone else. Some women are manic with rapid speech, pressure of speech and feelings of power. Sleep may be minimal. Predisposing factors are a family history of psychotic illness (in 30%), a previous personal history of mental illness, absence of social or partner support, traumatic delivery and age over 30 years.

Management

Psychiatric referral and assessment of the safety of the baby are needed immediately. The baby may be at risk from direct harm or from neglect due to the illness. Treatment with antidepressants or antipsychotics is usually indicated. Severe cases may need sedation, for example with haloperidol or chlorpromazine. Electroconvulsive therapy is used occasionally where the woman is in a psychotic stupor and not eating or drinking.

Prognosis

Recovery usually takes 4–8 weeks, with 15% recurrence in the next pregnancy. There is also a 30% incidence of a repeat psychotic episode outside pregnancy.

Summary

• Lochia may continue for up to 6 weeks but any offensive smell or fresh bleeding after the first few days should be investigated.

• Breastfeeding confers significant advantages to the mother and baby but care should be taken to avoid stigmatization of women who are unable to breastfeed.

• Contraception advice should be given prior to hospital discharge and at the 6-week postnatal check.

• Postnatal depression occurs in 10% of women and is distinct from ‘postpartum blues’, which only lasts a few days.

• Puerperal sepsis is still associated with serious maternal morbidity and mortality and should always be investigated and treated aggressively.

• Voiding after delivery, after removal of a urinary catheter and after an epidural or spinal anaesthetic should be ensured to minimize the risk of urinary retention and its consequences.

Essentials of Obstetrics and Gynaecology

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