The Puerperium

• It defines the time following delivery during which pregnancy-induced

maternal anatomical and physiological changes return to the nonpregnant
state.
• Its duration is understandably inexact, but is considered to be between 4
and 6 weeks.
 INVOLUTION OF THE
REPRODUCTIVE TRACT
• Birth Canal
• Vagina and its outlet gradually diminish in size but rarely
regain their nulliparous dimensions.
• Rugae begin to reappear by the third week but are less
prominent than before.
• The hymen is represented by several small tags of tissue,
which scar to form the myrtiform caruncles.
• Vaginal epithelium begins to proliferate by 4 to 6 weeks,
usually coincidental with resumed ovarian estrogen
production.
 INVOLUTION OF THE
REPRODUCTIVE TRACT
Uterus • By the end of the first week, this opening
narrows, the cervix thickens, and the
• Within the puerperal uterus, larger blood endocervical canal reforms. The external os does
vessels become obliterated by hyaline not completely resume its pregravid appearance.
changes, are gradually resorbed, and are • It remains somewhat wider, and typically,
replaced by smaller ones. ectocervical depressions at the site of lacerations
become permanent.
• During labor, the margin of the dilated
• These changes are characteristic of a parous
cervix, which corresponds to the external cervix
os, may be lacerated.
• The cervical opening contracts slowly and
for a few days immediately after labor,
readily admits two fingers.
 INVOLUTION OF THE
REPRODUCTIVE TRACT
• Postpartum, the fundus of Myometrial involution is a truly remarkable
the contracted uterus lies tour de force of destruction or
slightly below the umbilicus.
deconstruction that begins as soon as 2 days
• It consists mostly of after delivery
myometrium covered by
serosa and internally lined
by basal decidua.

• The anterior and posterior

walls, which lie in close
apposition, are each 4 to 5
cm thick
 INVOLUTION OF THE
REPRODUCTIVE TRACT
Decidua and Endometrial Regeneration

• Because separation of the placenta and
membranes involves the spongy layer,
the decidua basalis is not sloughed.
• The remaining decidua has striking
variations in thickness, it has an
irregular jagged appearance, and it is
infiltrated with blood, especially at the
placental site
• Within 2 or 3 days after delivery, the
remaining decidua becomes
differentiated into two layers.
• The superficial layer becomes necrotic
and is sloughed in the lochia.
• The basal layer adjacent to the
myometrium remains intact and is the
source of new endometrium.
• This arises from proliferation of the
endometrial glandular remnants and the
stroma of the interglandu- lar connective
tissue.
 Clinical Aspects
Afterpains

• In primiparous women, the uterus tends to remain tonically

contracted following delivery.

• In multiparas, however, it often contracts vigorously at

intervals and gives rise to afterpains, which are similar to
but milder than labor contractions.

• Usually, afterpains decrease in intensity and become mild

by the third day.
 Clinical Aspects
Lochia.
• Early in the puerperium, sloughing of
decidual tissue results in a vaginal
discharge of variable quantity.
• The discharge is termed lochia and
contains erythrocytes, shredded
decidua, epithelial cells, and bacteria.
• For the first few days after delivery,
there is blood sufficient to color it
red—lochia rubra.
• After 3 or 4 days, lochia becomes
progressively pale in color—lochia
serosa.
• After approximately the 10th day,
because of an admixiture of leukocytes
and reduced fluid content, lochia
assumes a white or yellow-white
color—lochia alba.
• The average duration of lochial
discharge ranges from 24 to 36 days

URINARY TRACT
• Normal pregnancy-induced
glomerular hyperfiltration persists on
the first postpartum day but returns to
prepregnancy base- line by 2 weeks
• Also, dilated ureters and renal pelves
return to their prepregnant state
during the course of 2 to 8 weeks
postpartum.
• Because of this dilated collect- ing
system, coupled with residual urine
and bacteriuria in a traumatized
bladder, urinary tract infection is a
concern in the puerperium.
PERITONEUM AND
ABDOMINAL WALL
• The broad and round ligaments
require considerable time to recover
from stretching and loosening during
pregnancy.
• As a result of ruptured elastic fibers
in the skin and prolonged distention
by the pregnant uterus, the
abdominal wall remains soft and
flaccid.
• Several weeks are required for these
structures to return to normal, and
recovery is aided by exercise.
 HEMATOLOGICAL PARAMETERS AND
PREGNANCY HYPERVOLEMIA
Hematological and Coagulation
Changes
• Marked leukocytosis and thrombocytosis
may occur during and after labor.
• The white blood cell count sometimes
reaches 30,000/μL, with the increase
predominantly due to granulocytes.
• Normally, during the first few postpartum
days, hemoglobin concentration and
hematocrit fluctuate moderately.
• If they fall much below the levels present
just before labor, a considerable amount of
blood has been lost.
Pregnancy-Induced Hypervolemia
• If less has been lost at delivery, it appears
that in most women, blood volume has
nearly returned to its nonpregnant level
by 1 week after delivery.
• Cardiac output usually remains elevated
for 24 to 48 hours postpartum and
declines to non- pregnant values by 10
days
• Postpartum diuresis results in relatively
rapid weight loss of 2 to 3 kg, which is
added to the 5 to 6 kg incurred by
delivery and normal blood loss.
• Weight loss from pregnancy itself is
likely to be maximal by the end of the
second week postpartum.
 Breast Anatomy and Products
• Each mature mammary gland or breast is
composed of 15 to 25 lobes.
• They are arranged radially and are separated
from one another by varying amounts of fat.
• Each lobe consists of several lobules, which in
turn are composed of numerous alveoli.
• Each alveolus is provided with a small duct
that joins others to form a single larger duct
for each lobe.
• These lactiferous ducts open separately on the
nipple, where they may be distinguished as
minute but distinct orifices.
• The alveolar secretory epithelium synthesizes
the various milk constituents, described next.
• After delivery, the breasts begin to secrete colostrum, which
is a deep lemon-yellow liquid.
• It usually can be expressed from the nipples by the second
postpartum day.
• Compared with mature milk, colostrum is rich in
immunological components and contains more minerals
and amino acids.
• It also has more protein, much of which is globulin, but less
sugar and fat.
• Secretion persists for 5 days to 2 weeks, with gradual
conversion to mature milk by 4 to 6 weeks.
• The colostrum content of immunoglobulin A (IgA) offers
the newborn protection against enteric pathogens. Other
host resistance factors found in colostrum and milk include
complement, macrophages, lymphocytes, lactoferrin,
lactoperoxidase, and lysozymes.
 Breast Anatomy and Products
• Mature milk is a complex and dynamic biological fluid that
includes fat, proteins, carbohydrates, bioactive factors, minerals,
vitamins, hormones, and many cellular products.
• Milk is isotonic with plasma, and lactose accounts for half of the
osmotic pressure. Essential amino acids are derived from blood,
and nonessential amino acids are derived in part from blood or
synthesized in the mammary gland. Most milk proteins are
unique and include α-lactalbumin, β-lactoglobulin, and casein
• Human milk has a whey-to-casein ratio of 60:40, considered ideal
for absorption.
 Endocrinology of Lactation
• With delivery, there is an abrupt and profound decrease in the levels of
progesterone and estrogen.

• This decrease removes the inhibitory influence of progesterone on α-

lactalbumin production and stimulates lactose synthase to increase milk lactose.

• Progesterone withdrawal also allows prolactin to act unopposed in its

stimulation of α-lactalbumin production.

• Serotonin is produced in mammary epithelial cells and has a role in

maintaining milk production.

• This may explain the decreased milk production in women taking selective
serotonin-reuptake inhibitors—SSRIs
 Endocrinology of Lactation
• resumably a stimulus from the breast curtails the release of dopamine,
also known as prolactin-inhibiting factor, from the hypothalamus. This in
turn transiently induces increased prolactin secretion.

• The posterior pituitary secretes oxytocin in pulsatile fashion. This

stimulates milk expression from a lactating breast by causing contraction
of myoepithelial cells in the alveoli and small milk ducts.

• Milk ejection, or letting down, is a reflex initiated especially by suckling,

which stimulates the posterior pituitary to liberate oxytocin. The reflex
may even be provoked by an infant cry and can be inhibited by maternal
fright or stress.
 Immunological Consequences
of Breast Feeding
• Human milk contains several
protective immunological
substances, including secretory
IgA and growth factors.

• The anti- bodies in human milk are

specifically directed against
maternal environmental antigens
such as against Escherichia coli

• Human milk also provides

protection against rotavirus
infections, a major cause of infant
gastroenteritis
 Care of Breasts Breast Engorgement

• Fissured nipples render nursing • This is common in women

painful, and they may have a
deleterious influence on milk who do not breast feed and
production.
is typi- fied by milk leakage
• These cracks also provide a portal and breast pain. These peak
of entry for pyogenic bacteria. 3 to 5 days after delivery
• Because dried milk is likely to
accumulate and irritate the nipples, • Fever caused by breast
washing the areola with water and
mild soap is helpful before and engorgement was common
after nursing. before the renaissance of
• When the nipples are irritated or
breast feeding.
fissured, it may be necessary to use
 MATERNAL CARE DURING THE
PUERPERIUM
Hospital Care

• For 2 hours after delivery, blood pressure and pulse should be taken every 15
minutes, or more frequently if indicated.

• Temperature is assessed every 4 hours for the first 8 hours and then at least
every 8 hours subsequently

• The amount of vaginal bleeding is monitored, and the fundus palpated to

ensure that it is well contracted.

• If relaxation is detected, the uterus should be mas- saged through the

abdominal wall until it remains contracted.

• Uterotonics are also sometimes required.


Perineal Care
• The woman is instructed to
cleanse the vulva from
anterior to posterior—the
vulva toward the anus.
• A cool pack applied to the
perineum may help reduce
edema and discomfort during
the first 24 hours if there is a
laceration or an episiotom
Pain, Mood, and
Cognition
• During the first few days after
vaginal delivery, the mother
may be uncomfortable because
of afterpains, episiotomy and
lacerations, breast engorgement,
and at times, postdural puncture
headache.
• Mild analgesics containing
codeine, aspirin, or
acetaminophen, preferably in
combinations, are given as
frequently as every 3 hours
during the first few days.
 Contraception
• Women not breast feeding have return
of menses usually within 6 to 8 weeks.
• At times, however, it is difficult
clinically to assign a specific date to
the first menstrual period after deliv-
ery.
• Ovulation occurs at a mean of 7
weeks, but ranges from 5 to 11 weeks .
• Women who become sexually active
during the puerperium, and who do
not desire to conceive, should initiate
contraception
• Women who breast feed ovulate
much less frequently compared with
those who do not, but there are great
variations.
• Timing of ovulation depends on
individual biological variation as well
as the intensity of breast feeding.
• Lactating women may first
menstruate as early as the second or
as late as the 18th month after
delivery.
 Home Care
Coitus

• After 2 weeks, coitus may be resumed based on desire and comfort

• Intercourse too soon may be unpleasant, if not frankly pain- ful, due to incomplete healing of
the episiotomy or lacerations. Moreover, the vaginal epithelium is thin, and very little lubri-
cation follows sexual stimulation.

Follow Up

• By discharge, women who had an uncomplicated course can resume most activities, including
bathing, driving, and household functions

• The American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists (2012) recommend a postpartum visit between 4 and 6 weeks. This has proven
quite satisfactory to identify abnormalities beyond the immedi- ate puerperium and to initiate
contraceptive practices.
Puerperal Complications
 PUERPERAL INFECTIONS
puerperal infection describes any bacterial infection of the genital
tract after delivery

 Puerperal Fever
 Uterine Infection
 Abdominal Incisional Infections
 Adnexal Abscesses and Peritonitis
 Parametrial Phlegmon
 Septic Pelvic Thrombophlebitis
 Perineal Infections Toxic Shock Syndrome
 Breast Infections
 Puerperal Fever
• A number of factors can cause fever—a temperature of 38.0°C (100.4°F) or
higher—in the puerperium. Most persistent fevers after childbirth are caused by
genital tract infection.

• It must be emphasized that spiking fevers of 39°C or higher that develop within the
first 24 hours postpartum may be associated with virulent pelvic infection caused by
group A streptococcus

• Approximately 15 percent of women who do not breast feed develop postpartum

fever from breast engorgement.

• Acute pyelonephritis has a variable clinical picture. The first sign of renal infection
may be fever, followed later by costover- tebral angle tenderness, nausea, and
vomiting.
 Uterine Infection
Postpartum uterine infection or puerperal sepsis has been called
variously endometritis, endomyometritis, and endoparametritis.
Because infection involves not only the decidua but also the
myometrium and parametrial tissues, we prefer the inclusive term
metritis with pelvic cellulitis.
 Predisposing Factors
• Vaginal Delivery.
• Women at high risk for infection because of membrane rupture, prolonged labor, and multiple
cervical examinations have a 5-to 6-percent frequency of metritis after vaginal delivery. If there is
intra- partum chorioamnionitis, the risk of persistent uterine infection increases to 13 percent

• Cesarean Delivery.
• Single-dose perioperative antimicrobial prophylaxis is recommended for all women undergo- ing
cesarean delivery
• Such single-dose antimicrobial prophy- laxis has done more to decrease the incidence and
severity of postcesarean delivery infections

• Other Risk Factors.

• women of lower socioeconomic status
• Bacterial colonization of the lower geni- tal tract with certain microorganisms—for example,
group B streptococcus, Chlamydia trachomatis, Mycoplasma hominis,
• Ureaplasma urealyticum, and Gardnerella vaginalis—has been associated with an increased
postpartum infection risk
Pathogenesis
• Puerperal infection following vaginal delivery
primarily involves the placental implantation site,
decidua and adjacent myometrium, or
cervicovaginal lacerations
• The pathogenesis of uterine infection following
cesarean delivery is that of an infected surgical
incision
• Bacteria that colonize the cervix and vagina gain
access to amnionic fluid during labor. Postpartum,
they invade devitalized uterine tissue. Parametrial
cellulitis next follows with infection of the pelvic
retroperitoneal fibroareolar connective tissue.
 Clinical Course
• Fever is the most important criterion for the diagnosis of post-
partum metritis.

• Temperatures commonly are 38 to 39°C.

• Chills that accompany fever suggest bacteremia or endotoxemia.

• Women usually complain of abdominal pain, and parametrial

tenderness is elicited on abdominal and bimanual examination.

• Leukocytosis may range from 15,000 to 30,000 cells/μL, but recall

that cesarean delivery itself increases the leukocyte count
 Treatment
• If nonsevere metritis develops following vaginal delivery,
then treatment with an oral antimicrobial agent is usually
sufficient.
• For moderate to severe infections, however, intravenous
ther- apy with a broad-spectrum antimicrobial regimen is
indicated. Improvement follows in 48 to 72 hours in nearly
90 percent of women treated with one of several regimens.
• Persistent fever after this interval mandates a careful search
for causes of refractory pelvic infection.
Choice of Antimicrobials
 Perioperative Prophylaxis
• administration of antimicrobial prophylaxis at the time of cesarean
delivery has remarkably reduced the post- operative pelvic and wound
infection rates

• Single-dose prophylaxis with ampicillin or a first-generation cephalosporin

is ideal, and both are as effective as broad- spectrum agents or a multiple-
dose regimen

• Extended-spectrum prophylaxis with azithromycin added to standard

single-dose prophylaxis has shown a further reduction in postcesarean
metri- tis rates (Tita, 2008). These findings need to be verified.

• Women known to be colonized with methicillin-resistant Staphylococcus

aureus—MRSA—are given vancomycin in addition to a cepha- losporin
 Abdominal Incisional
Infections
• Wound infection is a common cause of persistent fever in women treated
for metritis.

• Other wound infection risk factors include obesity, diabetes, corticosteroid

therapy, immuno- suppression, anemia, hypertension, and inadequate
hemostasis with hematoma formation.

• Treatment includes antimicrobials, surgical drainage, and debridement of

devitalized tissue. The fascia is carefully inspected to document integrity.

• Necrotic tissue is removed, and the wound is repacked with moist gauze.
At 4 to 6 days, healthy granulation tissue is typi- cally present, and
secondary en bloc closure of the open lay- ers can usually be accomplished
 Abdominal Incisional Infections
Wound Dehiscence

• Wound disruption or dehiscence refers to separation of the fascial layer.

• This is a serious complication and requires secondary closure of the incision in the operating room.

Necrotizing Fasciitis

• This uncommon, severe wound infection is associated with high mortality rates.

• Risk factor diabetes, obesity, and hypertension—are relatively common in pregnant women.

• these wound complications usually are polymicrobial and are caused by organisms that make up the
normal vaginal flora. In some cases, however, infection is caused by a single virulent bacterial species
such as group A b-hemolytic streptococcus.

• Early diagnosis, surgical debridement, antimicrobials, and intensive care are paramount to successfully
treat necrotizing soft-tissue infections
 Adnexal Abscesses and Peritonitis
• An ovarian abscess rarely develops in
the puerperium.
• These are presumably caused by
bacterial invasion through a rent in
the ovarian capsule
• The abscess is usually unilateral, and
women typically present 1 to 2 weeks
after delivery. Rupture is common,
and peritonitis may be severe.
• Peritonitis most often is caused by
uterine incisional necrosis and
dehiscence, but it may be due to a
ruptured adnexal abscess or an
inadvertent bowel injury at cesarean
delivery.
• Importantly in postpartum women,
abdominal rigidity may not be
prominent with puerperal peritonitis
because of abdominal wall laxity from
pregnancy. Pain may be severe, but
frequently, the first symptoms of
peritonitis are those of adynamic ileus.
 Parametrial Phlegmon
• For some women in whom metritis
develops following cesarean delivery,
parametrial cellulitis is intensive and
forms an area of induration—a
phlegmon—within the leaves of the broad
liga- ment

• These infections should be considered

when fever persists longer than 72 hours
despite intravenous antimi- crobial
therapy

• Phlegmons are usually unilateral, and

they frequently are limited to the
parametrium at the base of the broad
ligament.
 Parametrial Phlegmon
• If the inflammatory reaction is more intense, cellulitis
extends along natural lines of cleavage.
• In most women with a phlegmon, clinical improvement
follows continued treatment with a broad-spectrum
antimicrobial regimen.
• Typically, fever resolves in 5 to 7 days, but in some cases,
it persists longer.
• Absorption of the induration may require several days to
weeks.
 Parametrial Phlegmon
• In some women, severe cellulitis of the
uterine incision may lead to necrosis and
separation

• Extrusion of purulent material as shown in

Figure 37-4 leads to intraabdominal abscess
formation and peritonitis as described above.

• Surgery is reserved for women in whom

uterine incisional necrosis is suspected
because of ileus and peritonitis.

• For most, hysterectomy and surgical

debridement are needed and are predictably
difficult because the cervix and lower uterine
segment are involved with an intense
inflammatory process that extends to the
pelvic sidewall.
 Septic Pelvic Thrombophlebitis
• This was a frequent complication in the
preantibotic era.

• Septic embolization was common and

caused a third of maternal deaths during
that period. With the advent of
antimicrobial therapy, the mortality rate
and need for surgical therapy for these
infections diminished.

• Septic phlebitis arises as an extension

along venous routes and may cause
thrombosis as shown in Figure 37-6.
Lymphangitis often coexists. The ovarian
veins may then become involved because
they drain the upper uterus and therefore
the placental implantation site
 Septic Pelvic Thrombophlebitis

• Women with septic thrombophlebitis usually have

symptomatic improvement with antimicrobial
treatment, however, they continue to have fever.
• Although there occasionally is pain in one or both
lower quadrants, patients are usually asymptomatic
except for chills.
• Diagnosis can be confirmed by either pelvic CT or
MR imaging
 BREAST INFECTIONS
• Symptoms of suppurative mastitis seldom appear before
the end of the first week postpartum and as a rule, not
until the third or fourth week.
• Infection almost invariably is unilateral, and marked
engorgement usually precedes inflammation.
• Symptoms include chills or actual rigors, which are soon
followed by fever and tachycardia.
• There is severe pain, and the breast(s) becomes hard and
red
 BREAST INFECTIONS
• Staphylococcus aureus,
especially its methicillin-resistant
strain, is the most commonly
isolated organism
• The immediate source of
organisms that cause mastitis is
almost always the infant’s nose
and throat. Bacteria enter the
breast through the nipple at the
site of a fissure or small
abrasion.
• Dicloxacillin, 500 mg orally four
times daily, may be started
empirically.
• Erythromycin is given to women who
are penicillin sensitive.
• If the infection is caused by resistant,
penicillinase- producing staphylococci
or if resistant organisms are suspected
while awaiting the culture results, then
vancomycin or another anti-MRSA
antimicrobial should be given.
• Even though clinical response may be
prompt, treatment should be
continued for 10 to 14 days.
 Breast Abscess
• An abscess should be suspected when
defervescence does not follow within 48 to
72 hours of mastitis treatment or when a
mass is palpable.

• Again, sonographic imaging is valuable

• Traditional therapy is surgical drainage,

which usually requires general anesthesia.

• The incision should be made corresponding

to Langer skin lines for a cosmetic result

• A more recently used technique that is less

invasive is sonographically guided needle
aspiration using local analgesia. This has an
80- to 90-percent success rate
TERIMA KASIH