THE PUERPERIUM

(from Williams, APMC, and SGD)

March 03, 2009 / KC Chua Sec A 2011

PUERPERIUM
period of confinement during and just after birth
usually includes the 6 subsequent weeks (or 42 days (APMC))
immediately after delivery of placenta return of reproductive
organs to normal non-pregnant condition (APMC)
Clinical and Physiological Aspects of the Puerperium
* Afterpains
Primiparas = uterus remains tonically contracted
Multiparas = uterus contracts vigorously at intervals afterpains
parity, suckling ( oxytocin) = afterpains
rd
3 day = afterpains decrease in intensity
Afterpain helps to keep the uterus involuted (APMC)

1. Uterine Changes * Lochia

Vaginal discharge of variable quantity
a. Uterine Vessels From sloughing of decidual tissue
After delivery caliber of extrauterine vessels Persists for up to 4 weeks
decreases to equal, or at least closely approximates, May stop and resume up to 8 weeks after delivery
that of the prepregnant state The following DO NOT influence duration of lochia
Larger blood vessels are obliterated by hyaline o Maternal age
changes, gradually resorbed, and replaced by smaller o Parity
ones o Infant weight
Minor vestiges of the larger vessels may persist for o Breast feeding
years Oxytocic agents = do NOT diminish blood loss & does NOT hastens
uterine involution
b. Cervix and Lower Uterine Segment Composition of lochia: (BEES)
Cervical opening few days immediately after labor = o Bacteria
readily admits two fingers o Erythrocytes
End of the first week = narrowed thickens canal o Epithelial cells
reforms o Shredded decidua
External os does NOT completely resume its pregravid 3 Types of Lochia (RSA)
appearance o Rubra (Day 1 4 or 5)
o Wider Red vaginal discharge
o Bilateral depressions at the site of First few days after delivery
lacerations = jagged transverse slits = fish o Serosa (Day 6 8 or 9)
mouth appearance (APMC) Pale, pinkish
th
o Cervical epithelium undergoes remodeling o Alba (after about the 10 day)
White / yellowish-white / creamy
Lower segment
Color attributed to:
o converted into a barely discernible uterine
isthmus located between the uterine Leukocytes (Williams)
corpus above and the internal cervical os Reduced fluid content (Williams)
below Cervical mucous (APMC)
o narrowed & collapsed (APMC) Debris from healing tissues (APMC)

c. Involution of the Uterine Corpus d. Endometrial Regeneration

Involution process by which the uterus returns to Within 2 or 3 days after delivery = remaining decidua
normal size, tone, and position (APMC) differentiated into two layers
Nulliparas = faster; multiparas = slower (APMC) Superficial layer = necrotic, sloughed
Immediately after placental expulsion = fundus of the Basal layer = intact, source of new
contracted uterus slightly below the umbilicus endometrium
Due to vessel compression by contracted myometrium Endometrium arises from proliferation of the
= uterus appears ischemic (when compared with the endometrial glandular remnants and the stroma of
reddish-purple hyperemic pregnant organ) the interglandular connective tissue
Rate of uterine involution = 1-2 cm / day (APMC) Rapid except at placental site
2 days after delivery = uterus shrinks Within 1 week = free surface covered by epithelium

rd
2 weeks after delivery = uterus descended into the 3 week = restoration of entire endometrium
cavity of the true pelvis Histological endometritis, acute salphingitis = part of
4 weeks after delivery = regains its previous the normal reparative process; inflammatory changes
nonpregnant size do NOT reflect infection
Immediately postpartum = 1000 g
* Subinvolution
1 week postpartum = 500 g
Arrest or retardation of involution
2 weeks postpartum = 300 g
Observations:
Nonpregnant g = 100 g
o Prolongation of lochial discharge
6 weeks postpartum = 70 g (APMC)
o Irregular or excessive uterine bleeding
Decrease in size, not number of cells o Uterus = larger and softer than expected
Spongy layer = sloughed Causes:
Decidua basalis = not sloughed o Retention of placental fragments
Has striking variations in thickness o Pelvic infection
Has irregular jagged appearance 1/3 of cases = Chlamydia trachomatis
Infiltrated with blood Rx: azithromycin & doxycycline
Failure of uterus to contract: (PACID) (APMC) Usually amenable to early diagnosis and treatment = Ergonovine
1) Retained Placental cotyledons or methylergonovine = efficacy is questionable
2) Uterine Atony Metritis responds to oral antimicrobial therapy
3) Clot formation
4) Infections e. Placental Site Involution
5) Inadequate Drainage of tissues 6 weeks = complete extrusion of the placental site
takes
Interference = late-onset puerperal hemorrhage (APMC)
Immediately after delivery = placental site about the
size of the palm rapidly decreases
End of the 2nd week = 3 to 4 cm in diameter
Involving a process of exfoliation = brought about by
the undermining of implantation site by growth of
endometrial tissue both extension and
 downgrowth of endometrium development of Rupture of elastic fibers in the skin and the prolonged
endometrial tissue distention abdominal wall remains soft and flaccid
Involution is not brought about by absorption in situ Recovery is aided by exercise
Consequence of sloughing of infarcted and necrotic Except for silvery striae (striae abdominis), the abdominal
superficial tissues followed by a reparative process wall usually resumes its prepregnancy appearance
Atonic muscles lax abdominal wall marked separation
f. Late Postpartum Hemorrhage of rectus muscles = diastasis recti
1 to 2 weeks into the puerperium o the midline abdominal wall is formed only by
Causes: peritoneum, attenuated fascia, subcutaneous fat,
o Abnormal involution of the placental site and skin.
(most common)
o Retention of a portion of the placenta 5. Blood and Fluid Changes
Retained piece necrosis Marked leukocytosis and thrombocytosis
form placental polyp eschar o leukocyte count = 30,000/L (predominantly
detaches from myometrium granulocytes); 15,000/L at first week is common as
hemorrhage defense against infections and for tissue repair
Best initial treatment = control of the bleeding with o Relative lymphopenia and an absolute eosinopenia
intravenous oxytocin, ergonovine, methylergonovine, Hgb & Hct = fluctuate moderately
or prostaglandins RBC count below prelabor values = blood loss
Prompt curettage = treatment of late postpartum 1 week postpartum = return of non-pregnant blood volume
hemorrhage but may worsen the hemorrhage by 2 days postpartum = cardiac output remains elevated due to
traumatizing the implantation site and inciting more increased stroke volume from venous return; heart rate falls
bleeding. Curettage is carried out only if appreciable 2 weeks postpartum = cardiac output return to normal
bleeding persists or recurs after medical management. 1 week postpartum = ESR & plasma fibrinogen
st

2. Urinary Tract Changes * Weight Loss

UT returns to normal 4 to 6 weeks postpartum (APMC) 5 to 6 kg = via uterine evacuation and normal blood loss
Between 2 and 5 day = Postpartum diuresis =
nd th
Further decrease of 2 to 3 kg = via diuresis and diaphoresis
physiological reversal of increase of extracellular water (integumentary loss (APMC))
during pregnancy 6 months postpartum = attain non-pregnant weight (APMC)
Corresponds with loss of residual pregnancy
hypervolemia
Preeclampsia = fluid retention and diuresis BREAST / LACTATION / BREAST FEEDING
Bladder = capacity, overdistention, incomplete
emptying, residual urine I. Breast Anatomy
Overdistention avoided by emptying Composed of 15 to 25 lobes arranged radially
bladder at least every 6 to 8 hours (APMC) Lobe > lobules > alveoli > small ducts > large ducts > opens to
Analgesics (epidural & spinal blocks) = paralyzing effect nipples
contributes to UT changes Alveolar secretory epithelium = synthesizes the various milk
Within 3 days = ketonuria (due to starvation) disappears constituents.
(APMC)

st
1 week = glucosuria due to lactose production of
II. Breast Feeding
breast (APMC)

nd
2 day postpartum = colostrum deep lemon-yellow-
2 to 8 weeks after delivery = dilated ureters and renal
colored liquid
pelvis return to non-pregnant state (Williams)
Minerals and protein colostrum > mature milk ( globulin,
Monitor excessive residual urine to avoid
sugar and larger fat globules)
o Urinary tract infection
o Bladder atony Colostrum: (APMC)
1) Ideal food starter

st
Urinary retention may occur in the 1 24 hours due to:
(APMC) 2) Natural newborn laxative
o Edema and congestion of vulva, urethra, and 3) Help baby get rid of meconium
bladder trigone Colostrum secretion persists for about 5 days
o Edema and reflex spasm of urethral sphincter Colostrum mature milk takes 4 weeks (gradual
o Bladder atony conversion starts in about 5 days (APMC))
Incomplete emptying of bladder caused by: Immunoglobulin A (IgA) may offer protection for the
o Prolonged labor newborn against enteric pathogens
o Birth trauma Other host resistance factors that are found in colostrum
o Vaginal lacerations and milk include:
o Episiotomy o Complement
o Analgesia & anesthesia o Macrophages
o Lymphocytes
* Incontinence o Lactoferrin
3 to 6 months after delivery o Lactoperoxidase
Stress incontinence after delivery o Lysozymes
o length of second-stage labor
o infant head circumference III. Milk
o birthweight Suspension of fat and protein in a carbohydrate-mineral
o episiotomy solution
Proposed pathophysio = Impaired muscle function in or around Gestational weight gain has little, if any, impact on the
the urethra as a result of vaginal delivery subsequent milk quantity or quality
Volume of milk per day = 600 mL
3. Vaginal Outlet Relaxation and Uterine Prolapse Isotonic with plasma
Rarely returns to nulliparous dimensions Lactose accounts for half of the osmotic pressure
3 week = vaginal rugae reappear (Williams)
rd
Major proteins:
4 week = vaginal rugae reappear (APMC)
th
o -lactalbumin
Hymen = represented by several small tags of tissue = during o -lactoglobulin
cicatrization converted to myrtiform caruncles (Williams) o casein
Hymenal tags remnants = caruncle myrtiformes (APMC) Essential amino acids = from blood,
Extensive laceration of perineum relaxation of vaginal Nonessential amino acids = from blood or synthesized in the
outlet predispose to uterine prolapsed and urinary stress mammary gland
incontinence Most milk proteins are unique and not found elsewhere
1 to 2 weeks = fully healed lacerations & episiotomy; return Whey = IL-6 = local IgA production by the breast
of fallopian tubes and ovaries to the pelvis (APMC) 30 to 40 hours postpartum = sudden lactose kidneys
glucosuria
4. Peritoneum and Abdominal Wall
Broad and round ligaments
 Has ALL vitamins except Vitamin K (Vitamin K administration o The following do NOT contraindicate breast
to the infant soon after delivery is required to prevent feeding:
hemorrhagic disease of the newborn) maternal cytomegalovirus infection
(virus and antibodies are present in
IV. Endocrinology of Lactation breast milk)
Hormones that stimulate growth and development of hepatitis B virus (not contraindicated
mammary glands lactation: if hepatitis B immune globulin is given
o Progesterone to infants of seropositive mothers)
o Estrogen maternal hepatitis C infection
o Placental lactogen herpes simplex virus (if there are no
o Prolactin breast lesions and if particular care is
o Cortisol directed to hand washing before
o Insulin nursing)
With delivery = progesterone & estrogen removes
the inhibitory influence of progesterone on production of - X. Care
lactalbumin by the rough endoplasmic reticulum - Cleaning of the areola with water and mild soap = dried milk
lactalbumin stimulates lactose synthase milk lactose is likely to accumulate and irritate the nipples
Progesterone withdrawal = allows prolactin to act For irritated nipples = use nipple shield for 24 hours or
unopposed in its stimulation of -lactalbumin production longer
Intensity and duration of lactation = controlled by repetitive Inverted or retracted nipples = gently pull with the finger
stimulus of nursing and thumb (best begun during pregnancy to prepare the
Women with extensive pituitary necrosis, or Sheehan nipples for subsequent nursing)
syndrome, do not lactate Proper technique for positioning the mother and infant
Suckling prolactin-inhibiting factor (hypothalamus) Proper techniques for latch-on of the infant during suckling
prolactin secretion milk production
Suckling neurohypophysis secretes oxytocin cause XI. Drugs Secreted in Milk
contraction of myoepithelial cells in the alveoli and small Factors that influence drug excretion in milk:
milk ducts milk letdown reflex / milk ejection o concentration of drugs in plasma
Milk let down provoked = cry of infant o degree of protein binding
Milk let down inhibited = fright or stress o plasma and milk pH
o degree of ionization
V. Immunological Consequences of Breast Feeding o lipid solubility
Antibodies are poorly absorbed, if at all, by infants o molecular weight
Secretory IgA = predominant immunoglobulin in milk The amount of drug ingested by the infant typically is small
IgA has important antimicrobial functions Milk-to-plasma drug-concentration ratio = ratio of drug
IgA exerts its action by preventing bacterial adherence to concentrations in breast milk to those in maternal
epithelial cell surfaces, thus preventing tissue invasion Most drugs have a milk-to-plasma ratio of 1 or less
Human milk also provides protection against rotavirus
a
infections Drug Reported Effect
Milk contains both T and B lymphocytes Acebutolol Hypotension, bradycardia, tachypnea
5-Aminosalicylic Diarrhea
VI. Nursing acid
Human milk is ideal food for neonates Aspirin (salicylates) Metabolic acidosis
Mothers milk is natures best food for babies (APMC) Atenolol Cyanosis, bradycardia
It provides species- and age-specific nutrients for the infant Bromocriptine Suppresses lactation, may be hazardous to the
In addition to the proper balance of nutrients, mother
immunological factors, and antibacterial properties, human Clemastine Drowsiness, irritability, refusal to feed, high-pitched
milk contains factors that act as biological signals for cry, neck stiffness (one case)
promoting cellular growth and differentiation Cyclophosphamide Interfere with the cellular metabolism of the infant
65% of women who have undergone augmentation Cyclosporine and potentially cause immune suppression or
mammoplasty have lactation insufficiency Doxorubicin neutropenia, affect growth, or, at least theoretically,
Methotrexate increase the risk of cancer
VII. Lactation Inhibition Ergotamine Vomiting, diarrhea, convulsionsdoses used in
Elect not to breast feed migraine medications
Breast pain Lithium A third to half therapeutic blood concentration in
Engorgement infants
3 to 5 days postpartum = Milk leakage, engorgement, and Phenindione Anticoagulant increased prothrombin and partial
breast pain peak thromboplastin time in one infant not used in
Bromocriptine = drug for lactation inhibition United States
Measures to alleviate breast pain: Phenobarbital Sedation; infantile spasms after weaning from milk
o Well-fitting brassiere containing phenobarbital; methemoglobinemia
o Ice packs Primidone Sedation, feeding problems
Sulfasalazine Bloody diarrhea
o Oral analgesics for 12 to 24 hours

VIII. Contraception for Breast Feeding Women XII. Breast Fever

3 weeks postpartum = ovulation may resume First 24 hours after commencement of lactation
Ovulation resumption depends on: Puerperal fever from breast engorgement is common
o individual biological variation Fever ranging from 37.8 to 39C
o intensity of breast feeding Fever seldom persisted for longer than 4 to 16 hours
Progestin-only contraceptivesmini-pills and depot Other causes of fever, especially those due to infection,
medroxyprogesterone do NOT affect the quality or must be excluded
decrease milk volume = hormonal contraceptives of choice Treatment consists of:
for breast feeding women by the American College of o supporting the breasts with a binder or brassiere
Obstetricians and Gynecologists (2000) o applying an ice bag
o analgesics
IX. Contraindications to Breast Feeding o pumping of the breast or manual expression of
Taking street drugs milk
Alcohol use may be necessary at first, but in a few
Infants with galactosemia days the condition is usually alleviated
HIV and the infant is able to nurse
TB normally
Undergoing treatment for breast CA
 XIII. Mastitis
Rare
Occasionally observed during the puerperium and lactation
rd th
Symptoms appear at the 3 or 4 week postpartum, seldom
st
before the end of 1 week postpartum
Infection almost invariably is unilateral
Marked engorgement usually precedes the inflammation
1st sign of inflammation = chills or actual rigor (followed by
fever and tachycardia)
Breast becomes hard and reddened
Severe pain
10 percent of women with mastitis develop an abscess
Most common organism = Staphylococcus aureus
o Rx: Dicloxacillin 500mg every 6 hours (4x a day)
o Erythromycin penicillin-sensitive patients
o Vancomycin MRSA
Source of organism = infants nose & throat
XIV. Breast Abscess
From failure of defervescence within 48 to 72 hours
Development of a palpable mass
Traditional therapy = surgical drainage
XV. Galactocele
Result of clogging of a duct by inspissated secretion
Milk may accumulate in one or more lobes of the breast.
Excess may form a fluctuant mass pressure symptoms
Resolve spontaneously or require aspiration
XVI. Supernumerary Breasts
One or more accessory breasts (polymastia)
Usually below the main breasts
Also found in the axillae
XVII. Abnormalities of the Nipples
Lactiferous ducts open directly into a depression at the
center of the areola
Severely depressed nipples = nursing not possible
Depression not very deep = use breast pump
Inverted nipples = traction with fingers
Fissures = render nursing painful; portal of entry for
pyogenic bacteria = use nipple shield & topical medication
and empty regularly with a suitable pump until the lesions
are completely healed
XVIII. Abnormalities of Secretion
Mostly dependent on the development of the glandular
portions of the breasts
Agalactia complete lack of mammary secretion
Polygalactia mammary secretion is excessive
CARE OF THE MOTHER DURING PUERPERIUM
I. Hospital Care
BP & PR = take every 15 minutes
Monitor amount of vaginal bleeding
Palpate fundus if well-contracted (if relaxed = massage
abdominal wall)
Trained attendant should remain with the mother for at
least 1 hour after delivery = risk of postpartum hemorrhage
II. Early Ambulation
Within a few hours after delivery
Advantages of early ambulation:
o bladder complications
o constipation
o frequency of puerperal venous thrombosis
o pulmonary embolism
III. Care of the Vulva
Cleanse the vulva from anterior to posterior (vulva anus)
An ice bag applied to the perineum = reduce edema and
discomfort during the first several hours after episiotomy
repair
24 hours after delivery = moist heat (warm sitz baths) used
to reduce local discomfort
Tub bathing after uncomplicated delivery is allowed (Williams)
Tub baths are not allowed (APMC)
IV. Bladder Function
Oxytocin, in doses that have an antidiuretic effect, is
commonly infused after placental delivery
Sudden withdrawal oxytocin = rapid bladder filling
Anesthesia, episiotomy, & lacerations = bladder sensation
& capability to empty spontaneously
Urinary retention with bladder overdistention is a common
complication of the early puerperium
Prevent bladder overdistention
Woman should void within 4 hours after delivery
o Hematomas of the genital tract must be
considered.
o > 200mL urine in bladder = urine retention =
catheterize
o Bacteriuria = Rx: short course of antimicrobial
therapy
V. Subsequent Discomfort
Afterpains
rd
Episiotomy (healed by 3 week)
Lacerations
Breast engorgement
Postspinal puncture headache
Rx: codeine, 60 mg; aspirin, 600 mg; or acetaminophen, 500
mg, preferably in combinations, at intervals as frequent as
every 3 hours during the first few days after delivery.
Uterine contractions are commonly accentuated during
nursing, giving rise at times to troublesome afterpains.
Application of an ice bag may minimize swelling and
discomfort
Severe discomfort
st
o Within 1 day or so = hematoma
rd th
o 3 or 4 day = infection
VI. Depression
Postpartum blues = remits after 2 3 days, sometimes
persists up to 10 days
rd
3 day or baby blues (APMC)
Consequence of a number of factors:
o Emotional letdown that follows the excitement
and fears that most women experience during
pregnancy and delivery
o Discomforts of the early puerperium
o Fatigue from loss of sleep during labor and
postpartum
o Anxiety over her capabilities for caring for her
infant after leaving the hospital
o Fears that she has become less attractive
o Jealousy and insecurity (APMC)
o Inability to satisfy husbands needs (APMC)
Effective treatment:
o Anticipation
o Recognition
o Assurance
VII. Abdominal Wall Relaxation
Flabby abdomen = girdles
Exercise after soreness diminishes
VIII. Gastrointestinal Tract (APMC)
Atony = from prolonged labor; manifested by tympanism
Constipation = from patients inactivity, decreased
intraabdominal pressure, and painful perineum
Mild cathartics may be given after 48 hours
IX. Diet
No dietary restrictions
2 hours after a normal vaginal delivery = woman should be
allowed to eat if she desires
Diet should be increased in calories and protein
If mother does not breast feed = non-pregnant woman diet
Iron supplementation = at least 3 months postpartum
X. Thromboembolic Disease
Half of thromboembolic events associated with pregnancy
develop in the puerperium
Frequency of deep venous thrombosis and pulmonary
embolism complicating pregnancy and the puerperium has
decreased in recent years
XI. Obstetrical Neuropathies
2 months, with a range of 2 weeks to 18 months
Intense neuralgia / cramplike pains = due to pressure on
lumbosacral nerve plexus
Lateral femoral cutaneous neuropathies = most common
Independent rist factors for nerve injury
o nulliparity
o prolonged second-stage of labor
 XII. Pelvic Joint Separation
Separation of the symphysis pubis or one of the sacroiliac
synchondroses during labor may be followed by pain and
marked interference with locomotion
Treatment = rest in a lateral decubitus position and an
appropriately fitted pelvic binder
XIII. Immunizations
D-negative woman whose infant is D-positive = given 300 g
of anti-D immune globulin shortly after delivery
MMRI vaccine before discharge
diphtheria-tetanus toxoid booster injection (unless
contraindicated)
By the time of discharge, women who had a normal delivery
and puerperium can resume most activities, including
bathing, driving, and household functions.
Care and nurturing of the neonate should be provided by
the mother with ample help from the father
For the mother to provide this care, her presence at home
with the infant precludes her early return to full-time work
or school
~kc 03/03/09

XIV. Time of Discharge

Hospital stay = about 48 hours (2 days)
Primiparas = 2 3 days (APMC)
Multiparas = 1 2 days (APMC)
Woman should receive instructions concerning the
anticipated normal physiological changes of the puerperium:
o lochia patterns
o weight loss from diuresis
o when to expect milk let-down
o what to do if she:
becomes febrile
has excessive vaginal bleeding
develops leg pain, swelling, or
tenderness
Instruct regarding self-care, baby care, breast feeding,
breast care/self-examination, and parenthood (APMC)
Any shortness of breath or chest pain warrants immediate
concern.

XV. Contraception
If no breast feeding = menses return within 6 to 8 weeks
(55-60 days; range: 20-120 days (APMC))
Ovulation = less frequent in women who breast feed
Menses may not appear if the infant is nursed
There is delayed resumption of ovulation with breast
feeding
Other findings:
Resumption of ovulation was
frequently marked by return of
normal menstrual bleeding
Breast feeding episodes lasting 15
minutes 7x each day delayed
resumption of ovulation
Ovulation can occur without bleeding
Bleeding can be anovulatory

HOME CARE

I. Coitus
No definite time after delivery when coitus should be
resumed
Resumption of intercourse too soon = unpleasant, painful
due to incomplete healing of the episiotomy or lacerations
Perineal repair = 1 2 weeks; coitus should be avoided until
all wounds have healed (APMC)
After 2 weeks = coitus may be resumed based on the
patient's desire and comfort
Breast feeding causes a prolonged period of suppressed
estrogen production vaginal atrophy and dryness
decreased vaginal lubrication during sexual arousal

II. Infant Follow-Up

Neonate discharged early should be:
o Term
o Normal
o Have stable vital signs.
Initial hepatitis B vaccine should be administered,
Include testing for hypothyroidism and phenylketonuria
(PKU).

III. Late Maternal Morbidity

Possible sequelae of labor epidural analgesia

IV. Follow-Up Care

rd
Follow-up at 3 week postpartum
o To identify abnormalities
o Initiate contraceptive practices
Estrogen plus progestin oral contraceptives started at this
time have proven to be effective without increased
morbidity