Normal and Abnormal Puerperium: MBBS Final Year Notes

PART A: NORMAL PUERPERIUM

1. Definition and divisions

• The puerperium is the period when the mother's altered anatomy, physiology and biochemistry return to the non-pregnant state. It starts with the third stage of labour and ends about 6 weeks (42 days) after delivery. The changes are physiological and should not be confused with disease. - Textbook of Family Medicine 9e, The Puerperium
• Immediate: first 24 hours.
• Early: up to 7 days.
• Remote: up to 6 weeks.

2. Physiological changes

Uterus (involution)

• Mechanisms: myometrial retraction and contraction, ischaemia, autolysis of muscle protein, and fall in oestrogen and progesterone.
• Weight: about 1000 g immediately after delivery, about 500 g at 1 week, about 300 g at 2 weeks, and 50 to 100 g at 6 weeks. Guyton records that the weight falls to less than half within 1 week. In a lactating mother the uterus may be as small as before pregnancy by 4 weeks. - Guyton and Hall, p. 1044
• Fundal height:
  • At delivery the fundus is at or just below the umbilicus.
  • It falls about 1 cm (one fingerbreadth) per day.
  • By days 5 to 7 it is firm, non-tender and midway between the symphysis and umbilicus.
  • By about 2 weeks it is no longer palpable abdominally. - Textbook of Family Medicine 9e
• Endometrium: regenerates in about 10 days, except at the placental site, which heals by about 6 weeks. This avoids scar formation. Healing at the placental site is by exfoliation (sloughing and endometrial regrowth beneath).
• Afterpains: intermittent uterine contractions, worse in multiparas and during suckling (oxytocin release). They are treated with simple analgesics.

Lochia

Cervix, vagina and pelvic floor

• The cervix is soft and patulous at first. The internal os closes by about 1 week. The external os stays as a transverse slit, so the parous cervix never returns to the nulliparous shape.
• Vaginal rugae reappear at about 3 weeks. The vagina remains relatively lax.
• Pelvic floor muscles recover over weeks. Pelvic floor exercises should be taught.

Breast and lactation

• Placental expulsion causes a sudden fall in oestrogen and progesterone, so prolactin acts freely (lactogenesis).
• Colostrum is secreted for the first 2 to 3 days. Transitional milk follows, and mature milk is established by about 10 days. Engorgement occurs on days 3 to 4.
• Suckling triggers two reflexes:
  • The prolactin reflex produces milk.
  • The oxytocin (let-down) reflex ejects milk and also contracts the uterus.
• Early breastfeeding promotes uterine contraction and involution and minimises bleeding. - Textbook of Family Medicine 9e

Cardiovascular and haematological

• Cardiac output rises sharply just after delivery because of autotransfusion from uterine involution and relief of caval compression. It returns toward normal over 1 to 2 weeks.
• Pulse slows (physiological bradycardia, 50 to 70 per minute). The textbook notes that the pulse drops in the first 24 hours.
• The WBC count rises, with marked leucocytosis up to 20,000/µL in the first 24 hours. The ESR stays raised for some weeks.
• Fibrinogen and platelets rise, so the puerperium is a hypercoagulable state with high thromboembolic risk.
• Haematocrit is artificially high for a few days because of diuresis. - Textbook of Family Medicine 9e

Urinary

• Diuresis occurs from about day 2 to 5. The urine may contain protein and sugar transiently.
• The bladder is hypotonic after labour, so retention and overdistension are common. Dilated ureters and renal pelvis return to normal by 6 to 8 weeks.

Gastrointestinal

• Constipation is common because of reduced tone, perineal pain, dehydration and fear of straining.

Endocrine and menstruation

• hPL disappears within about 1 day, and hCG within about 2 weeks.
• Oestrogen and progesterone fall to non-pregnant levels within about 3 days.
• In non-lactating women, ovulation can return by about 6 weeks (earliest about 4 weeks), and menses by 6 to 8 weeks.
• In lactating women, high prolactin suppresses gonadotropins and ovarian hormones, so amenorrhoea is prolonged. Lactation is not a reliable contraceptive unless the criteria for the lactational amenorrhoea method (LAM) are met.

Other

• Temperature may be slightly raised in the first 24 hours (up to 38°C) from dehydration.
• Weight loss is about 5 to 6 kg at delivery (baby, placenta, liquor, blood) and a further 2 to 3 kg from diuresis.
• Striae turn silvery. The linea nigra fades.

3. Management of the normal puerperium

• Observe for 1 hour after the third stage. Check uterine tone, bleeding, pulse and BP, and give periodic fundal massage to prevent atony.
• Breastfeeding can start now to aid uterine contraction. If the uterus stays boggy, give oxytocin (10 units IM, or a dilute IV infusion). - Textbook of Family Medicine 9e

• Breasts: engorgement, nipple cracks, technique.
• Uterus: fundal height, tone, tenderness.
• Bladder: voiding, retention.
• Bowel: first stool, constipation.
• Lochia: amount, colour, smell.
• Episiotomy or perineum: wound, haematoma.
• Homans/calves: leg pain, swelling.
• Emotions: blues, bonding.
• Also record temperature, pulse and BP.

• Early ambulation reduces thromboembolism, retention and constipation.
• Give a normal diet as desired, with adequate fluids and protein.
• Perineal hygiene, with sitz baths and analgesia for episiotomy pain. No vaginal douching. - Textbook of Family Medicine 9e
• Bladder: encourage voiding and avoid catheterisation if possible. Watch for silent overfilling, especially after oxytocin is stopped. - Textbook of Family Medicine 9e
• Bowel: laxatives if needed.
• Analgesia must be chosen with breastfeeding in mind. Pethidine is not preferred, because of its long-acting metabolite in the infant. - Textbook of Family Medicine 9e
• Iron and folic acid supplements and calcium for lactation (standard Indian programme: IFA for 180 days postpartum).
• Immunisation: anti-D immunoglobulin within 72 hours if the mother is Rh-negative and the baby is Rh-positive. Rubella vaccine if the mother is non-immune. Tdap or Td if indicated.
• Postnatal exercises: pelvic floor, abdominal and leg exercises.
• Examination at 6 weeks to confirm involution. Park's objectives of postpartal care are to prevent complications, restore health, check breastfeeding, offer family planning and give health education. - Park's Textbook of PSM
• Visit schedule (WHO and Indian programme): within 24 hours, day 3, day 7, 6 weeks.

• LAM works if all three apply: exclusive breastfeeding, amenorrhoea and baby under 6 months.
• Postpartum IUCD can be inserted within 10 minutes to 48 hours of delivery, or after 4 weeks.
• Postpartum sterilisation is done within 7 days, or after 6 weeks.
• Progestin-only methods can start by 6 weeks.
• Combined oral contraceptives are avoided for the first 6 weeks while breastfeeding, and for at least 3 weeks in non-breastfeeding women because of clotting risk.
• Barrier methods can be used at any time.

PART B: ABNORMAL PUERPERIUM

1. Puerperal pyrexia

1. Womb: endometritis, retained products.
2. Wound: perineal, episiotomy or caesarean wound.
3. Water: UTI, pyelonephritis.
4. Wind: atelectasis, pneumonia.
5. Walking: DVT and thrombophlebitis.
6. Weaning (breasts): engorgement, mastitis, abscess.
7. Wonder drugs: drug fever.

2. Puerperal sepsis

• Antenatal: anaemia, malnutrition, diabetes, vaginal infection (bacterial vaginosis, GBS), low socio-economic status.
• Intrapartum: prolonged labour, premature rupture of membranes (PROM), repeated vaginal examinations, operative delivery, caesarean section (the biggest single risk), retained placental bits, perineal trauma, poor asepsis, PPH.
• Postnatal: poor hygiene, hospital cross-infection.

• Mostly polymicrobial and endogenous. Gram-positive: streptococci, enterococci. Gram-negative: E. coli. Anaerobes: peptostreptococci and Bacteroides. Also Mycoplasma hominis, Chlamydia trachomatis (more than 7 days postpartum) and N. gonorrhoeae. Gardnerella is more frequent in younger women. - Tintinalli's Emergency Medicine
• Group A streptococci (β-haemolytic) are less common but increasing, and are the most virulent cause. They can spread in epidemics from carriers among staff, and the patient should be isolated.
• Rare: Clostridium perfringens (gas gangrene, haemolysis), Staph. aureus (toxic shock).

1. Local: infection of perineal, vaginal or cervical wounds, and endometritis (uterine tenderness, subinvolution).
2. Spreading:
   • Via lymphatics: parametritis (pelvic cellulitis).
   • Via lumen: salpingitis, oophoritis and peritonitis.
   • Via veins: septic pelvic thrombophlebitis, pyaemia.
3. Systemic: septicaemia, septic shock, ARDS and DIC.

• Fever, tachycardia, pelvic pain and uterine tenderness.
• Foul-smelling lochia, although scant discharge is possible, especially with group B streptococci.
• Leucocytosis.
• Following caesarean section there may be wound tenderness and purulent exudate. - Tintinalli's Emergency Medicine

• CBC, CRP and procalcitonin, urine culture, and blood culture. Vaginal swabs are of little value because of local flora, and blood cultures are rarely positive. Culture any purulent wound material. - Tintinalli's Emergency Medicine
• Ultrasound, CT or MRI to find retained products, collections, pelvic abscess or septic thrombophlebitis.
• Lactate and coagulation profile if septic.

• General: rest, fluids, analgesia and antipyretics. Isolate the patient if group A streptococcal infection is suspected. Treat sepsis early with fluids, oxygen and antibiotics within the first hour.
• Antibiotics: clindamycin 900 mg IV every 8 hours plus gentamicin 5 mg/kg IV once daily (or 1.5 mg/kg every 8 hours) remains the most effective empiric regimen for postpartum endometritis. - Tintinalli's Emergency Medicine
  • Alternatives: amoxicillin-clavulanate, cefotetan, meropenem or imipenem for severe disease.
  • Oral options for mild cases with follow-up assured: oral clindamycin plus gentamicin, amoxicillin-clavulanate, amoxicillin plus metronidazole, or doxycycline plus metronidazole. Doxycycline is contraindicated in breastfeeding. - Tintinalli's Emergency Medicine
  • Add ampicillin if enterococcal cover is needed (not covered by cephalosporins).
  • IV antibiotics are typically continued until the woman has been afebrile for 24 to 48 hours.
• Surgical:
  • Evacuate retained products.
  • Drain pelvic abscesses (a pouch of Douglas abscess can be drained by colpotomy).
  • Debride necrotic tissue and wound infections.
  • Laparotomy with hysterectomy for gangrenous uterus, uncontrolled sepsis or clostridial infection.
• Septic pelvic thrombophlebitis: suspect when fever persists after 48 to 72 hours of appropriate antibiotics with no abscess found. It is a diagnosis of exclusion. Treat with antibiotics plus heparin.

3. Secondary (delayed) postpartum haemorrhage

• Resuscitate and cross-match blood.
• Ultrasound, plus a urine pregnancy test or serum β-hCG when trophoblastic disease is possible.
• IV antibiotics.
• Uterotonics: oxytocin, methylergometrine, misoprostol.
• Evacuate retained products gently under antibiotic cover (use cautious suction, as the uterus is soft and perforation risk is high).
• Tranexamic acid.
• Uterine artery embolisation for vascular lesions.
• Hysterectomy as a last resort.

4. Subinvolution

• Causes: retained products, endometritis, uterine fibroids, full bladder or rectum, overdistended uterus (twins, polyhydramnios), prolonged labour, grand multiparity, and a retroverted uterus.
• Features: persistent red lochia, irregular or excessive bleeding, backache, and a bulky soft uterus.
• Treatment: treat the cause, with antibiotics, oral methylergometrine, and evacuation of retained products if present.

5. Venous thromboembolism

• Superficial thrombophlebitis: tender, red cord along a vein. Treat with analgesia and compression.
• DVT: unilateral leg pain, swelling and warmth. Confirm with compression duplex ultrasound. Homans sign is unreliable. Park lists thrombophlebitis as a postpartal complication associated with varicose veins, with a tender, pale, swollen leg. - Park's Textbook of PSM
  • Femoral vein thrombosis causes phlegmasia alba dolens ("milk leg" or "white leg").
• Pulmonary embolism: sudden breathlessness, pleuritic pain and tachycardia. Use CTPA or V/Q scan.
• Treatment: therapeutic LMWH, then LMWH or warfarin for at least 6 weeks postpartum and for a total of at least 3 months. Warfarin and heparin are compatible with breastfeeding.
• Prophylaxis: early ambulation, hydration, and LMWH for high-risk women (risk-score-based).

6. Urinary complications

• Retention of urine: overt (painful) or covert (painless, with high residual volume). Causes include perineal pain, epidural or spinal anaesthesia, haematoma and atonic bladder. Treat with analgesia and ambulation, then catheterise for 24 to 48 hours.
• UTI and pyelonephritis: associated with catheterisation and retention. Treat with antibiotics per culture.
• Incontinence: stress or overflow. Offer pelvic floor exercises.
• Genitourinary fistula (VVF): follows obstructed labour, with leakage of urine from day 7 to 10.

7. Breast complications

8. Postpartum psychiatric disorders

9. Other puerperal complications (short notes)

• Postpartum eclampsia and hypertension: can occur up to 6 weeks after delivery. Treat with magnesium sulphate and antihypertensives.
• Peripartum cardiomyopathy: heart failure in the last month of pregnancy or within 5 months of delivery, with LVEF below 45% and no other cause. Treat with standard heart failure therapy, with or without bromocriptine. Advise against further pregnancy if LV function does not recover.
• Sheehan syndrome: pituitary necrosis after massive PPH and hypotension. Presents with failure of lactation, amenorrhoea and fatigue. Hormone replacement is needed.
• Postpartum thyroiditis: hyperthyroid phase at 1 to 4 months, then hypothyroid phase at 4 to 8 months.
• Uterine inversion: acute (shock out of proportion to blood loss) or subacute. Treat with manual replacement (Johnson's manoeuvre), hydrostatic (O'Sullivan) correction, or Huntington's or Haultain's operation.
• Perineal complications: haematoma, infection or breakdown of the episiotomy, third and fourth degree tears (with faecal incontinence).
• Postdural puncture headache: after spinal or epidural; worse upright. Treat with fluids, caffeine, analgesics, and epidural blood patch if severe.
• Postpartum anaemia: iron therapy (oral, or IV iron if severe or intolerant).
• Backache, pelvic girdle pain, diastasis recti, haemorrhoids, constipation: conservative management.

PART C: QUICK REVISION

• Puerperium lasts 6 weeks. The uterus becomes a pelvic organ by about 2 weeks.
• Lochia: rubra (1 to 4 days), serosa (5 to 9 days), alba (over 10 days).
• A foul smell, with fever and a tender uterus, means endometritis.
• Commonest cause of puerperal pyrexia: genital tract infection (endometritis).
• Commonest cause of secondary PPH: retained products and infection.
• Persistent fever despite antibiotics with no abscess: think septic pelvic thrombophlebitis.
• Blues peak at day 3 to 5. Psychosis is an emergency.
• Postpartum pituitary failure: Sheehan syndrome.
• Warfarin, heparin and most antibiotics are compatible with breastfeeding. Avoid doxycycline.

1. Define puerperium. Describe the changes in the genital tract and the management of a normal puerperium.
2. Define puerperal pyrexia. Discuss causes, diagnosis and management of puerperal sepsis.
3. Short notes: lochia, subinvolution, secondary PPH, postpartum blues versus psychosis, mastitis, DVT in the puerperium, postpartum contraception.