OB LE 3 The Puerperium & Complications PDF

# Chapter 36: The Puerperium ## Yvonne D. Nacis, MD, FPOGS, MHA S.Y. 2023-2024 ## Puerperium - puer, child + parus, bringing forth - time following delivery during which pregnancy induced maternal anatomical and physiological changes return to the nonpregnant state - between 4 and 6 weeks. - ⅓:...

# Chapter 36: The Puerperium ## Yvonne D. Nacis, MD, FPOGS, MHA S.Y. 2023-2024 ## Puerperium - puer, child + parus, bringing forth - time following delivery during which pregnancy induced maternal anatomical and physiological changes return to the nonpregnant state - between 4 and 6 weeks. - ⅓: social support - 25%: breastfeeding concerns ## Pregnancy Risk Assessment Surveillance System-PRAMS® Concerns Raised by Women in the First 2-9 Months Postpartum | Concerns | Percent | | --------------- | -------- | | Need for social support | 32 | | Breastfeeding issues | 24 | | Inadequate education about newborn care | 21 | | Help with postpartum depression | 10 | | Perceived need for extended hospital stay | 8 | | Need for maternal insurance coverage postpartum | 6 | ## Reproductive Tract Involution - **Birth Canal:** - soon after delivery: vagina and its outlet diminish but rarely nulliparous dimensions - **3rd weeks:** Rugae but are less prominent than before. - hymen: several small tags of tissue: myrtiform caruncles. - **4 to 6 weeks:** vaginal epithelium: hypoestrogenic - coincidental with resumed ovarian estrogen production - **Uterus:** - pelvic vessels caliber gradually diminishes to approximately that of the prepregnant state - larger blood vessels become obliterated by hyaline changes - gradually resorbed and replaced by smaller ones. - Minor vestiges of the larger vessels, however, may persist for years. - **fundus of the contracted uterus**: below the umbilicus. - **lower uterine segment**: contracts and retracts, but not as forcefully as the uterine corpus. - barely discernible uterine isthmus located between the corpus and internal cervical os. - **anterior and posterior walls**: lie in close apposition, are each 4 to 5 cm thick - **Myometrial involution**: remarkable feat of destruction or deconstruction that begins Day 2 - **myocytes size decreases markedly.** - **weighs approximately 1000 g** - **Weight**: 500 g by 1 week postpartum, about 300 g by 2 weeks, and at 4 weeks, involution is complete, and the uterus weighs approximately 100 g - **Note**: each successive delivery, the uterus is usually slightly larger than before the most recent pregnancy - **Cervix:** - cervical opening contracts slowly - readily admits two fingers - end of the first week: narrows, the cervix thickens, and the endocervical canal re-forms. - external os does not completely resume its pregravid appearance - Wider - ectocervical depressions at the site of lacerations become permanent. - parous cervix - Cervical epithelium: remodeling - ½: regression of high-grade dysplasia ## Sonographic Findings - uterus and endometrium: pregravid size by 8 weeks postpartum - day 56: cavity was empty - sloughed in the lochia: spongy layer, superficial layer - decidua basalis is not sloughed. - fully restored endometrium: 16th day onward - Histological endometritis is part of the normal reparative process. - not thought to reflect infection ## Clinical Aspects - **After pains:** - primiparas: remain tonically contracted - multiparas: contracts vigorously at intervals - worsen when the newborn suckles - because of oxytocin release - decrease in intensity and become mild by the third day - severe and persistent: uterine infection - **Lochia:** - sloughing of decidual tissue: vaginal discharge of variable quantity - erythrocytes, shredded decidua, epithelial cells, and bacteria - lochia rubra: red, 3-4 days - lochia serosa: pale color, after 3-4 days - lochia alba: white or yellow-white color, 10th day (admixture of leukocytes and reduced fluid content) - average duration of lochial discharge: 24 to 36 days - (expected leukocyte component, saline preparations of lochia for microscopic evaluation in cases of suspected puerperal metritis are typically uninformative and not recommended) ## Placental Site Involution - 6 weeks: Complete extrusion of the placental site - Immediately after delivery: placental site: palm-size - thrombosed vessels that ultimately undergo organization - end of the second week: 3 to 4 cm in diameter - **Involution:** - exfoliation: extension and "downgrowth" of endometrium from the margins of the placental site, as well as development of endometrial tissue from the glands and stroma left deep in the decidua basalis placental separation - sloughing of infarcted and necrotic superficial tissues followed by a remodeling process - proliferation - absorption in situ - **Subinvolution** - **etiology:** - Infection - retained placental fragments - incompletely remodeled uteroplacental arteries - **S/S:** - prolonged lochia - irregular or excessive uterine bleeding - uterus: larger and softer - **Dx:** - pelvic sonography: retained placenta, vascular malformations - **Tx:** - Methylergonovine (Methergine), 0.2 mg orally every 3 to 4 hours for 24 to 48 hours - antimicrobial therapy (Chlamydia trachomatis) - empirical: azithromycin or doxycycline ## Late Postpartum Hemorrhage - **Secondary postpartum hemorrhage:** bleeding 24 hours to 12 weeks after delivery - **1 to 2 weeks: 1%**: abnormal involution of the placental site - retention of a placental fragment: placental polyp - uterine artery pseudoaneurysm. - von Willebrand disease or other inherited coagulopathies - **delayed:** - stable patient, if sonographic examination shows an empty cavity: - oxytocin, methylergonovine, or a prostaglandin analogue - Antimicrobials retained placental fragments. - do not routinely perform curettage - may worsen bleeding by avulsing part of the implantation site. - **If with large clots** - gentle suction curettage - curettage is carried out only if appreciable bleeding persists or recurs after medical treatment ## Urinary Tract - **2 weeks** - glomerular hyperfiltrationn - **2 to 8 weeks**: Dilated ureters and renal pelves - residual urine and bacteriuria in a traumatized bladder, symptomatic urinary tract infection - submucosal hemorrhage and edema - labor length - Postpartum, the bladder: increased capacity and a relative insensitivity to intravesical pressure. - overdistention, incomplete emptying, and excessive residual urine - **Acute urinary retention**: narcotic analgesia - **urinary incontinence** - **pelvic floor disorders** ## Peritoneum and Abdominal Wall - **broad and round ligaments**: long recovery - **skin**: ruptured elastic fibers: abdominal wall remains soft and flaccid. - flabby or pendulous, - girdle - abdominal binder - **Exercise:** - anytime following vaginal delivery - CS: 6-week interval to allow fascia to heal and abdominal soreness to diminish - **Silvery abdominal striae**: striae gravidarum - **Marked separation of the rectus abdominis muscles**: diastasis recti ## Blood and Blood Volume - **Hematological and Coagulation Changes during and after labor** - Marked leukocytosis and thrombocytosis - white blood cell count seldom exceeds 25,000/μL(granulocytes) - relative lymphopenia - absolute eosinopenia - **first few postpartum days** - hemoglobin and hematocrit decrease: blood loss - markedly higher plasma fibrinogen level (first week) - hypercoagulability - deep-vein thrombosis - pulmonary embolism (12 weeks) ## Pregnancy-Induced Hypervolemia - returns to its nonpregnant level by 1 week - Cardiac output usually remains elevated for 24 to 48 hours postpartum and declines to nonpregnant values by 10 days - Heart rate changes follow this pattern, and blood pressure similarly returns to nonpregnant values - systemic vascular resistance remains in the lower range characteristic of pregnancy for 2 days postpartum and then begins to steadily rise to normal nonpregnant values - reduced arterial stiffness persists following pregnancy. - significant favorable effect of pregnancy on maternal cardiovascular remodeling. - mechanism by which preeclampsia risk is reduced in subsequent pregnancies. ## Postpartum Diuresis - **Normal pregnancy** - **extracellular sodium and water retention** - **postpartum diuresis** - physiological: 2 liter decline in sodium space during the first week postpartum - loss of residual pregnancy hypervolemia - preeclampsia, pathological retention of fluid antepartum and then its normal diuresis postpartum may be prodigious - **rapid weight loss of 2 to 3 kg,(5 to 6 kg incurred by delivery and normal blood loss)** - Weight loss: second week postpartum - residual weight: fat stores that will persist ## Lactation and Breastfeeding - **Breast Anatomy and Secretory Products** - **Each breast** - 15 to 25 lobes - arranged radially - **Each lobe several lobules:** alveoli. - **Each alveolus:** - with duct that joins others to form a single larger duct for each lobe - lactiferous ducts open separately on the nipple - alveolar secretory epithelium synthesizes the various milk constituents - **After delivery** - colostrum, which is a deep yellow liquid. - second postpartum day to 5 to 14 days, - rich in immunological components and contains more minerals and amino acids - more protein, much of which is globulin, less sugar and fat. - immunoglobulin A (IgA): protection against enteric pathogens. - complement, macrophages, lymphocytes, lactoferrin, lactoperoxidase, and lysozymes. - **mature milk:** - 4 to 6 weeks - complex and dynamic biological fluid that includes fat, proteins, carbohydrates, bic factors, minerals, vitamins, hormones, a many cellular products ## Breast Milk - influenced by maternal diet and by newborn age, health, and need but not by the mother’s weight - 600 mL of milk daily - isotonic with plasma - **lactose:** - accounts for half of the osmotic pressure. - **Essential amino acids:** - derived from blood - **nonessential amino acids:** - derived in part from blood or synthesized in the mammary gland - **milk proteins are unique:** - alpha-lactalbumin, beta-lactoglobulin, and casein. - **Fatty acids:** - synthesized in the alveoli from glucose and are secreted by an apocrine-like process. - **Vitamins** - K: absent, intramuscular dose is given to the newborn - D: low, and newborn supplementation is recommended ## Average Composition Of Human Breast Milk | Fat | g/100 mL | | ----------- | -------- | | Total | 4.2 | | Fatty acids | Trace | | PUFA | 0.6 | | Cholesterol | 0.016 | | Protein | g/100 mL | | ----------- | -------- | | Total | 1.1 | | Casein | 0.3 | | α-Lactalbumin | 0.3 | | Lactoferrin | 0.2 | | Carbohydrate | g/100 mL | | ----------- | -------- | | Lactose | 7 | | Oligosaccharides | 0.5 | PUFA = Polyunsaturated fatty acids ## Lactation Endocrinology - **Complex** - Progesterone, estrogen, and placental lactogen prolactin, cortisol, and insulin - to stimulate the growth and development of the milk-secreting apparatus - Delivery: progesterone and estrogen decline abruptly and profoundly. - drop removes the inhibitory influence of progesterone on alpha-lactalbumin production and stimulates lactose synthase to raise milk lactose levels. - Progesterone withdrawal also allows prolactin to act unopposed in its stimulation of alpha-lactalbumin production. - Activation of calcium-sensing receptors in mammary epithelial cells downregulates parathyroid hormone-related protein (PTHrP) and increases calcium transport into milk - Serotonin also is produced in mammary epithelial cells and has a role in maintaining milk production - **intensity and duration of subsequent lactation:** - controlled, by the repetitive stimulus of suckling and emptying of milk from the breast. - **Prolactin: essential** - extensive pituitary necrosis-Sheehan syndrome-do not lactate - **Dopamine:** - stimulus from the breast curtails the release prolactin-inhibiting factor-from the hypothalamus. - In turn, this transiently induces increased prolactin secretion. - **Oxytocin: posterior pituitary** - pulsatile fashion. - stimulates milk expression by contraction of myoepithelial cells in the alveoli and small milk ducts - **Milk ejection, or letting down:** - reflex initiated by suckling, which stimulates the posterior pituitary to liberate oxytocin. - infant cry VS inhibited by maternal fright or stress ## Lactation - **within an hour of birth:** - ideal time to begin breastfeeding - **Human milk** - ideal food for newborns - **it provides** - age-specific nutrients, immunological factors, and antibacterial substances. - factors that act as biological signals for promoting cellular growth and differentiation. - **long-term benefits for both the mother and the infant.** - lower risk of breast and reproductive cancer - higher adult intelligence scores - independent - less postpartum weight retention - SIDS are significantly lower - **Recommendation:** - exclusive breastfeeding for up to 6 months. - **55%: breastfeed at 6 months** - **Baby-Friendly Hospital Initiative:** an international program to raise rates of exclusive breastfeeding and to extend its duration. - **3 months**: less than half of these infants are exclusively breastfed ## Advantages of Breastfeeding - Nutritional - Immunological - Developmental - Psychological - Social - Economic - Environmental - Optimal growth and development - Decrease risks for acute and chronic diseases ## Table 36-5. Ten Steps To Successful Breastfeeding 1. Have a written breastfeeding policy that is regularly communicated to all healthcare staff 2. Train all staff in skills necessary to implement this policy 3. Inform all pregnant women about the benefits and management of breastfeeding 4. Help mothers initiate breastfeeding within an hour of birth 5. Show mothers how to breastfeed and how to sustain lactation, even if they should be separated from their infants 6. Feed newborns nothing but breast milk, unless medically indicated, and prioritize donor breast milk when supplementation is needed 7. Practice rooming-in, which allows mothers and newborns to remain together 24 hours a day 8. Encourage breastfeeding on demand 9. Give no artificial pacifiers to breastfeeding newborns 10. Help start breastfeeding support groups and refer mothers to them Adapted from the World Health Organization, 2018. ## Breast Care - **Poor latching** - only the nipple, which is then is forced against the hard palate during suckling. - **skin fissures** - Painful - deleterious influence on milk production - portal of entry for pyogenic bacteria. - **Mild:** - topical lanolin and a nipple shield for 24 hours or longer - **Severe:** - not be permitted to nurse on the affected side. - emptied regularly with a pump until the lesions are healed. - **Cleanliness** - washing the areola with water and mild soap - **Proper latching** - nipple and areola - hard palate: lactiferous sinuses aids - nipple: soft palate ## Breastfeeding Contraindications - Maternal intake of street drugs - uncontrol alcohol use - infant galactosemia - human immunodeficiency virus (HIV) infection - active, untreated tuberculosis - undergoing breast cancer treatment - active breast herpes simplex - **NOT contraindicated:** - Hepa B with neonatal immunoglobulin - Hepa C - CMV - Covid 19 with mask ## Drugs Secreted in Milk - Most drugs given to the mother are secreted in breast milk - **Factors influencing drug excretion:** - plasma concentration - degree of protein binding - plasma and milk pH - degree of ionization - lipid solubility - molecular weight - **absolutely contraindicated:** - Cytotoxic drugs may interfere with cellular metabolism and potentially cause immune suppression or neutropenia, affect growth, and at least theoretically, increase the childhood cancer risk. - cyclophosphamide, cyclosporine, doxorubicin, methotrexate, and mycophenolate - recreational drugs - marijuana and alcohol - LactMed: www.ncbi.nlm.nih.gov/books/NBK501922/ ## Ways to Minimize Infant Exposure - **choose:** - shorter half-life - poorer oral absorption - lower lipid solubility - **If multiple daily drug doses are required, each is taken by the mother after the closest feed** - **Single daily-dosed drugs may be taken just before the longest infant sleep interval-usually at bedtime.** - **Radioactive isotopes:** - copper, gallium, indium, iodine, sodium, and technetium - radionuclide with the shortest excretion time in breast milk is selected - mother should pump her breasts before the study and store enough milk in a freezer to feed the infant - After the study, she should pump her breasts to maintain milk production but discard all milk produced during the time that radioactivity is present. - 15 hours to 2 weeks - **radioactive iodine concentrates and persists in the thyroid.** - **magnetic resonance (MR) imaging, breastfeeding should not be interrupted after gadolinium administration** ## Breast Engorgement - common in women who do not breastfeed. - **s/s:** - milk leakage and breast pain - peaks 3 to 5 days after delivery - well-fitting brassiere, breast binder, or sports bra - Cool packs and oral analgesics for 12 to 24 hours aid discomfort. - Pharmacological or hormonal agents in general are not recommended to suppress lactation. - **Fever** - 37.8 to 39°C - seldom persists for longer than 4 to 16 hours - **Mastitis:** infection of the mammary parenchyma ## Other Lactation Issues - **inverted nipples** - lactiferous ducts open directly into a depression at the center of the areola. - nursing is difficult - breast pump - daily attempts are made during the last few months of pregnancy to draw or "tease" the nipple out with the fingers. - **Extra breasts-polymastia, or extra nipples-polythelia** - Along mammary ridge or milk line, - no obstetrical significance - discomfort and anxiety. - **Galactocele** - milk duct that becomes obstructed by inspissated secretions - fluctuant mass - pressure symptoms and have the appearance of an abscess - resolves spontaneously or require aspiration. - **Agalactia** - complete lack of mammary secretion - **Polygalactia** - mammary secretion is excessive ## Lactation-Associated Osteoporosis - rare disorder of unknown etiology - severe back pain or vertebral fractures - Tx: bisphosphonates ## Hospital Care - **2 hours after delivery:** - blood pressure and pulse q15 minutes - Temperature q 4 hours for the first 8 hours and then at least every 8 hours - subsequently - **If regional analgesia or general anesthesia**: recovery area. - **vaginal bleeding is closely monitored** - uterine fundus: palpated to ensure that it is well contracted - relaxation: massaged, uterotonics - uterine enlargement: hematometra - **Early ambulation**: syncope - fewer bladder complications - less frequent constipation - reduced rates of puerperal venous thromboembolism. - **Diets** - Not restricted for women who give birth vaginally (2 hours). - **oral iron supplementation** - 3 months - hematocrit evaluation at the first postpartum visit ## Pain, Mood, and Cognition - **Uncomfortable** - S/S: afterpains, episiotomy and lacerations, breast engorgement, postdural puncture headache - Tx: codeine, ibuprofen, or acetaminophen every 4 hours - **postpartum blues** - depressed mood - emotional letdown that follows the excitement and fears experienced during pregnancy and delivery, discomforts of the early puerperium, fatigue from sleep deprivation, anxiety over the ability to provide appropriate newborn care, and body image - mild and self-limited to 2 to 3 days(10 days) - TX - anticipation, recognition, and reassurance - **major depression** ## Neuromusculoskeletal Problems - **Obstetrical Neuropathies** - 1 percent - Pressure on branches of the lumbosacral nerve plexus during labor - neuralgia or cramp like pains extending down one or both legs as soon as the head descends into the pelvis - variable degrees of sensory loss or muscle paralysis - 1: Lateral femoral cutaneous neuropathies - 2. femoral neuropathies - most common (24 percent), - (14 percent). - 3. motor deficit - **Risk Factors:** - Nulliparity - prolonged second stage labor - pushing for a long duration in the semi-Fowler position - median duration of symptoms: 2 months, (2 weeks to 18 months) - **footdrop** - lumbosacral plexus, sciatic nerve, or common fibular (peroneal) nerve - **lumbosacral plexus** - cross the pelvic brim and can be compressed by the fetal head or by forceps. - **common fibular nerves** - legs: prolonged positioned in stirrups - **iliohypogastric and ilioinguinal nerves** - cesarean delivery - **lumbar arachnoiditis** - epidural analgesia causing severe bilateral neuropathic pain ## Musculoskeletal Injuries - **stretching or tearing injuries** - Pain in the pelvic girdle, hips, or lower extremities - MRI - antiinflammatory agents and physical therapy. - **septic pyomyositis** - iliopsoas muscle abscess - **Separation of the symphysis pubis or one of the sacroiliac synchondroses** - pain and marked interference with locomotion - 1 in 600 to 1 in 30,000 deliveries - X ray - normal distance of the symphyseal joint is 0.4 to 0.5 cm, and symphyseal separation >1 cm is diagnostic for diastasis. - TX: rest in a lateral decubitus position and an appropriately fitted pelvic binder - Surgery: >4 cm - recurrence risk is high: cesarean delivery ## Immunizations - **300 µg of anti-D immune globulin** - unisoimmunized D-negative woman and with Dpositive newborn - shortly after delivery - **rubella or varicella** - not immuned to - before discharge - **tetanus/diphtheria (Tdap/Td) or influenza vaccine** - **COVID-19 vaccine** ## Contraception - **family planning education** - ideal time for consideration of long-acting reversible contraception-LARC - **not breastfeeding** - menses: within 6 to 8 weeks - Ovulation: mean of 7 weeks(5 to 11 weeks) - **Breastfeeding: LAM** - ovulate much less frequently - variation and the intensity of breastfeeding. - 18th month after delivery - **1. Resumption of ovulation was frequently marked by return of normal menstrual bleeding.** - **2. Breastfeeding episodes lasting 15 minutes seven times daily delayed ovulation resumption.** - **3. Ovulation can occur without bleeding.** - **4. Bleeding can be anovulatory.** - **5. The risk of pregnancy in breastfeeding women was approximately 4 percent per year.** - **Artificial FP in breastfeeding** - **do not affect the quality or quantity of milk** - **progestin-only contraceptives** - progestin pills, depot medroxyprogesterone, or progestin implants or IUDs - progesterone-releasing vaginal ring ## Hospital Discharge - **48 hours** - uncomplicated vaginal delivery - up to 96 hours - uncomplicated cesarean delivery - **instructions concerning anticipated normal physiological puerperal changes** - lochia patterns, weight loss from diuresis, and milk let-down - fever, excessive vaginal bleeding, or leg pain, swelling, or tenderness - Persistent headaches, shortness of breath, or chest pain: immediate concern. ## Home Care - **Coitus** - After 2 weeks: based on desire and comfort. - **primiparas with an episiotomy** - 67 percent had sexual dysfunction at 3 months, 31 percent at 6 months, and 15 percent at 12 months - **hypoestrogenic state** - topical estrogen cream - vaginal lubricants - **Dyspareunia** - **dysuria** ## Follow-Up Care - **uncomplicated vaginal delivery can resume most activities** - 50%: regained their usual level of energy by 6 weeks. - 50%: return to full duties within 2 weeks. - **comprehensive visit within 12 weeks after delivery.** - to identify abnormalities beyond the immediate puerperium - to initiate contraceptive practices. ## Bladder Function - **intravenous fluids** - **Oxytocin** - antidiuretic effect - **rapid bladder filling** - **bladder sensation and capability to empty spontaneously may be diminished** - **urinary retention and bladder overdistention** - 5 percent - **Risk factors** - primiparity, epidural analgesia, cesarean delivery, perineal lacerations, operative vaginal delivery, catheterization during labor, and prolonged second-stage labor - **has not voided within 4 hours after delivery** - examination for perineal and genital-tract hematomas - indwelling catheter should be placed and left at least 24 hours - prevents recurrence and allows recovery of normal bladder tone and sensation. - **voiding trial** - If a woman cannot void after 4 hours, urine volumes are measured sonographically. - If more than 200 mL, the bladder is not functioning appropriately, and the catheter is replaced and remains for another 24 hours. - **if retention persists after a second voiding trial** - indwelling catheter and leg bag can be elected, and the patient returns in 1 week for an outpatient voiding trial - **if less than 200 mL of urine is obtained, the catheter can be removed** - **40 percent**: bacteriuria: single dose or short course of antimicrobial therapy