puerperium franzblau n, witt k. normal and abnormal
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Puerperium
Franzblau N, Witt K. Normal and Abnormal Puerperium. Emedicine available at www.emedicine.com/med/topic3240.htm; accessed 13 December 2005.
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Puerperium
The time from the delivery of the placenta through the first few weeks after the delivery
Usually considered to be 6 weeks Body returns to the nonpregnant state
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Uterus
Immediately after the delivery, the uterus can be palpated at or near the umbilicus
Most of the reduction in size and weight occurs in the first 2 weeks
2 weeks postpartum, the uterus should be located in the true pelvis
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Lochia
Vaginal discharge, lasts about 5 weeks 15% of women have lochia at 6 weeks
postpartum
Lochia rubra Red Duration is variable
Lochia serosa Brownish red, more watery consistency Continues to decrease in amount
Lochia alba Yellow
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Cervix, Vagina, Perineum
Tissues revert to a nonpregnant state but never return to the nulliparous state
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Abdominal Wall
Remains soft and poorly toned for many weeks Return to a prepregnant state depends greatly on
exercise
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Ovulation
Breastfeeding Longer period of amenorrhea and
anovulation Highly variable
50-75% return to periods within 36 weeks
Not breastfeeding As early as 27 days after delivery Most have a menstrual period by 12 weeks
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Breasts
Changes to the breast that prepare for breastfeeding occur throughout pregnancy
Lactation can occur by 16 weeks’ gestation
Colostrum 1st 2-4 days after delivery High in protein and immune factors
Milk matures over the first week* Contains all the nutrients necessary
*Continues to change thoughout the period of breastfedeing to meet the changing demands of the baby
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Breastfeeding
“Breastfeeding is neither easy nor automatic.”
Should be initiated ASAP after delivery Feed baby every 2-3 hrs to stimulate milk
production Production should be established by 36-96 hrs
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Considerations
Vaginal Birth Swelling and pain in the perineum
Episiotomy? Laceration? Hemorrhoids
Often resolve as the perineum recovers
Cesarean Delivery Pain from the abdominal incision Slower to begin ambulating, eating, and voiding
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Sexual Intercourse
May resume when… Red bleeding ceases Vagina and vulva are healed Physically comfortable Emotionally ready
*Physical readiness usually takes ~3 weeks
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Concerns - Puerperal Period
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Hemorrhage
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Postpartum Hemorrhage
Excessive blood loss during or after the 3rd stage of labor Average blood loss is 500 mL
Early postpartum hemorrhage 1st 24 hrs after delivery
Late postpartum hemorrhage 1-2 weeks after delivery (most common) May occur up to 6 weeks postpartum
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Postpartum Hemorrhage
Incidence Vaginal birth: 3.9% Cesarean: 6.4%
Delayed postpartum hemorrhage: 1-2%
Mortality 5% of maternal deaths
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Postpartum Hemorrhage
May result from: Uterine atony Lower genital tract lacerations Retained products of conception Uterine rupture Uterine inversion Placenta accreta
adherence of the chorionic villi to the myometrium Coagulopathy Hematoma
Most common
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Uterine Atony
Lack of closure of the spiral arteries and venous sinuses
Risk factors: Overdistension of the uterus secondary to multiple
gestations Polyhydramnios Macrosomia Rapid or prolonged labor Grand multiparity Oxytocin administration Intra-amniotic infection
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Lower genital tract lacerations Result of obstetrical trauma
More common with operative vaginal deliveries Forceps Vacuum extraction
Other predisposing factors: Macrosomia Precipitous delivery Episiotomy
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Infection
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Endometritis
Ascending polymicrobial infection Usually normal vaginal flora or enteric bacteria
Primary cause of postpartum infection 1-3% vaginal births 5-15% scheduled C-sections 30-35% C-section after extended period of labor
May receive prophylactic antibiotics
<2% develop life-threatening complications
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Endometritis
Risk factors: C-section Young age Low SES Prolonged labor Prolonged rupture of
membranes
Multiple vaginal exams Placement of
intrauterine catheter Preexisting infection Twin delivery Manual removal of the
placenta
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Endometritis
Clinical presentation Fever Chills Lower abdominal pain Malodorous lochia Increased vaginal
bleeding Anorexia Malaise
Exam findings Fever Tachycardia Fundal tenderness
Treatment Antibiotics
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Urinary Tract Infection
Bacterial inflammation of the bladder or urethra
3-34% of patients Symptomatic infection in ~2%
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Urinary Tract Infection
Risk factors C-section Forceps delivery Vacuum delivery Tocolysis Induction of labor Maternal renal disease
Preeclampsia Eclampsia Epidural anesthesia Bladder catheterization Length of hospital stay Previous UTI during
pregnancy
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Urinary Tract Infection
Clinical Presentation Urinary
frequency/urgency Dysuria Hematuria Suprapubic or lower
abdominal pain
OR… No symptoms at all
Exam Findings Stable vitals Afebrile Suprapubic tenderness
Treatment antibiotics
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Mastitis
Inflammation of the mammary gland Milk stasis & cracked nipples contribute to the
influx of skin flora
2.5-3% in the USA Neglected, resistant or recurrent infections can
lead to the development of an abscess (5-11%)
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Mastitis
Clinical Presentation Fever Chills Myalgias Warmth, swelling and
breast tenderness
Exam Findings Area of the breast that is
warm, red, and tender
Treatment Moist heat Massage Fluids Rest Proper positioning of the
infant during nursing Nursing or manual
expression of milk Analgesics
Antibiotics
stasis
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Wound Infection
Perineum (episiotomy or laceration) 3-4 days postpartum rare
Abdominal incision (C-section) Postoperative day 4 3-15% prophylactic antibiotics
2%
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Wound Infection
Perineum Risk Factors:
Infected lochia Fecal contamination Poor hygiene
Abdominal incision Risk factors:
Diabetes Hypertension Obesity Corticosteroid treatment Immunosuppression Anemia Prolonged labor Prolonged rupture of
membranes Prolonged operating time Abdominal twin delivery Excessive blood loss
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Wound Infection
Clinical Presentation
Perineal Infection: Pain Malodorous discharge Vulvar edema
Abdominal Infection Persistent fever
(despite antibiotics)
Diagnosis Erythema Induration Warmth Tenderness Purulent drainage With or without fever
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Endocrine Disorders
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Postpartum Thyroiditis (PPT)
Transient destructive lymphocytic thyroiditis occuring within the 1st year after delivery
Autoimmune disorder
1. Thyrotoxicosis 1-4 months postpartum; self-limited Increased release (stored hormone)
2. Hypothyroidism 4-8 months postpartum
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Postpartum Thyroiditis (PPT)
~4% develop transient thyrotoxicosis 66-90% return to normal 33% progress to hypothyroid
10-3% develop permanent thyroid dysfunction
Risk Factors Positive antithyroid antibody testing History of PPT Family or personal history of thyroid or autoimmune
disorders
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Postpartum Thyroiditis (PPT)
Clinical Presentation Fatigue Palpitations Eat intolerance Tremulousness Nervousness Emotion liability
*mild & nonspecific (may go undiagnosed)
Hypothyroid Phase: Fatigue Dry skin Coarse hair Cold intolerance Depression Memory &
concentration impairment
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Postpartum Thyroiditis (PPT)
Exam findings Tachycardia Mild exopthalmos Painless goiter
Lab testing TSH thyrotoxicosis TSH hypothyroid
Treatment
Thyrotoxicosis No treatment (mild) Beta-blocker
Hypothyroid No treatment (mild) Thyroxine (T4)
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Postpartum Graves Disease
Autoimmune disorder Diffuse hyperplasia of the thyroid gland
Response to antibodies to the thyroid TSH receptors Increased thyroid hormone production and release
Les common than PPT Accounts for 15% of postpartum thyrotoxicosis
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Psychiatric Disorders
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Postpartum Blues Transient disorder
Lasts hours to weeks Bouts of crying and sadness
Postpartum Depression More prolonged affective disorder
Weeks to months S&S of depression
Postpartum Psychosis First postpartum year Group of severe and varied disorders
(psychotic symptoms)
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Etiology
Unknown Theory: multifactorial
Stress Responsibilities of child rearing
Sudden decrease in endorphins of labor, estrogen and progesterone
Low free serum tryptophan (related to depression) Postpartum thyroid dysfunction (psychiatric
disorders)
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Risk factors
Undesired pregnancy Feeling unloved by
mate <20 years Unmarried Medical indigence Low self-esteem Dissatisfaction with
extent of education
Economic problems Poor relationship with
husband or boyfriend Being part of a family
with 6 or more siblings Limited parental
support Past or present
evidence of emotional problems
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Incidence
50-70% develop postpartum blues 10-15% of new mothers develop PPD 0.14-0.26% develop postpartum psychosis
History of depression 30% chance of develping PPD
History of PPD or postpartum psychosis 50% chance of recurrence
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Postpartum Blues
Mild, transient, self-limiting Commonly in the first 2 weeks
Signs and symptoms Sadness Crying Anxiety Irritation Restlessness
Mood lability Headache Confusion Forgetfullness Insomnia
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Postpartum Blues
Often resolves by postpartum day 10 No pharmacotherapy is indicated
Treatment Provide support and education
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Postpartum Depression (PPD)Signs and symptoms Insomnia Lethargy Loss of libido Diminished appetite Pessimism
Incapacity for familial love Feelings of inadequacy Ambivalence or negative
feelings towards the infant Inability to cope
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Postpartum Depression (PPD)Consult a psychiatrist if… Comorbid drug abuse Lack of interest in the infant Excessive concern for the infant’s health Suicidal or homicidal ideations Hallucinations Psychotic behavior Overall impairment of function
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Postpartum Depression (PPD) Lasts 3-6 months
25% are still affected at 1 year Affects patient’s ADLs
Treatment Supportive care and reassurance (healthcare
professionals and family) Pharmacological treatment for depression Electroconvulsive therapy
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Postpartum Psychosis
Signs and symptoms Acute psychosis
Schizophrenia Manic depression
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Postpartum Psychosis
Treatment Therapy should be targeted to the patient’s
specific symptoms Psychiatrist Hospitalization
*Generally lasts only 2-3 months