The puerperium

Published on 09/03/2015 by admin

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Last modified 09/03/2015

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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

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.

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