The puerperium

Published on 09/03/2015 by admin

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Last modified 09/03/2015

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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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