The Puerperium
- 6 week period following childbirth
Physiological changes
Uterine Involution
- Process by which the postpartum uterus (weighing 1kg) returns to pregnant state (100g)
- Occurs by a process of autolysis
- Accelerated by the release of oxytocin in women who are breast feeding
Genitial Tract Changes
- Becomes increasingly difficult to insert fingers into the cervix as internal cervical os closes
- Stretched vagina goes from smooth and oedematous from the first few days to having rugae after 3 weeks
Lochia
- Bloodstained uterine discharge composed of the necrotic decidua and blood
- Starts off red during first few days then turns pink and finally becomes serous by the second week
- Persistent red lochia suggests delayed uterine involution associated with infection or retained placental tissue
Puerperal disorders
Perineal complications
- Greatest in women who have had spontaneous tears or an episiotomy and especially following instrumental delivary
- Spontaneous opening of repaired perineal tears or episiotomies is usually secondary to infection
Bladder function
- Voiding difficulty and over distension of the bladder can occur particularly if regional anaesthesia has been used
- May tack 8hr for bladder sensation to return to normal are an epidural, during this time the urinary retention can occur which can damage the overstretched detrusor muscle
- During the puerperium there is increased urine production due to the antidiuretic affect of oxytocin, increased post partum diuresis and increased fluid intake in breast feeding mothers
- A traumatic delivery may result in pain upon voiding
Bowel function
- Constipation is a common problem
- May be due to changes in diet or dehydration or pain due to a sutured perineum, prolapsed haemorrhoids or anal fissure
- Avoidance of constipation and straining is very important if woman has had a third or four degree tear
Secondary Postpartum haemorrhage
- Defined as fresh bleeding from the genital tract between 24 hours and 6 weeks after delivery
- Most commonly occurs between days 7 and 14
- Most commonly caused by retained placental tissue
- Other causes include,
- Endometriosis
- Hormonal contraception
- Bleeding disorders e.g. von Willebrand’s disease
- Choriocarcinoma
- Management is
- IV infusion
- Cross match of blood
- Syntocinon
- Examination under anaesthesia
- Uterine evacuation
Obstetric Palsy
- Condition by which one or both of the lower limbs may develop signs of motor and/or sensory neuropathy following delivery
- Features include, sciatic pain, foot drop, hypoaesthesia and muscle wasting
- Managed orthopaedically
- May be due to compression or stretching of the lumbosacral plexus as it crosses the sacroiliac joint during decent of the fetal head. Herniation of the lumbosacral discs (L4/L5) may also occur
Symphysis pubis diastasis
- Spontaneous separation of the symphysis pubis can occur and is associated with
- Forceps delivery
- Rapid second stage of delivery
- Severe abduction of the thighs during delivery
- Signs include
- Pain aggravated by waling and weight bearing
- Waddling gait
- Pubic tenderness
- Palpable interpubic gap
- Treatments
- Bed rest
- Anti-inflammatories
- Physiotherapy
- Pelvic corset
Thromboembolism
- Risk of thromboembolic disease is 5 times higher in pregnancy and the puerperium. Most common after C-section.
Puerperal pyrexia
- Defined as a temp of 38 degrees or higher on any two of the first 10 days postpartum exclusive of the first 24hr
- Common sites associated with puerperal pyrexia are,
- Chest
- Throat
- Breasts
- Urinary tract
- Pelvic organs
- Caesarean or perineal wounds
- Genital tract infection is mostly due to group B streptococcus, Chlamydia and mycoplasma
- To prevent prophylactic antibiotics are given for Caesarean section
Breast Disorders
- Bloodstained nipple discharge – believed to be due to epithelial proliferation. Most common in second and third trimester are rarely exists 2 months post partum. Self limiting
- Painful nipples – usually due to poor positioning of baby on the breast although candidiasis can also cause soreness
- Galactocele – a retention cyst of the mammary ducts following blackage. Identified as a fluctuant swelling with minimal pain and inflammation
- Breast engorgement – may give rise to puerperal fever
- Mastitis – a blocked duct obstructs milk flow and extends the alveoli. Affected segment of breast if painful, red and oedematous. Flu-like symptoms develop along with tachycardia and pyrexia. Can be infective but not always. Most common infection is Staph aureus.
Contraception
- IUD may increase rate of uterine perforation and it shouldn’t be fitted before 4 weeks to ensure uterine involution
- Combined oral contraceptive can increase the risk of thrombosis and can have an adverse effect on the constituents of breast milk
- Progesterone only pill is therefore preferred and should be commenced about 21 days after delivery