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The Puerperium

The puerperium is defined as the period from birth to the first 6 weeks postpartum. Multiple anatomic and physiologic changes occur during this time, and there is the potential for significant complications such as infection or hemorrhage.

PHYSIOLOGY

Involutional Changes

The uterus usually undergoes complete involution by 6 weeks postpartum, going from a weight of 1,000 g to a weight of 100 g or less. The endometrium begins to regenerate early in the postpartum period, essentially completing the regeneration by the third week. The last part of the uterus to return to normal is the placental attachment site, which may take up to 6 weeks to regenerate. The sloughed tissue becomes part of the

Anatomically, the dilatation of the calyces, renal pelvis, and ureters that is characteristic of pregnancy may persist as long as 8 weeks postpartum. Functionally, the increased renal plasma flow, glomerular filtration rate, and creatinine clearance rate associated with pregnancy return to normal by 6 weeks after puerperium, lactation, breast feeding, brest feeding, mastitis, hemorrhage, endomyometritis, uterine infection, postpartum depression delivery .

The changes in the cardiovascular system that occurred during pregnancy (ie, increase in heart rate, cardiac output, and blood volume) generally return to baseline by approximately 6 weeks postpartum. Peripheral vascular resistance also returns to the prepregnancy level by this time. Most of these parameters return to normal within the first 2 weeks postpartum puerperium, lactation, breast feeding, brest feeding, mastitis, hemorrhage, endomyometritis, uterine infection, postpartum depression.

Ovulation and Menstruation

After delivery, ovulation occurs at an average of 10 weeks but may occur as early as 27 days after delivery in non-lactating women. In women who breast-feed for at least 3 months, the average time to ovulation is 17 weeks. In non-lactating women, the

Lactation

Breast-feeding should be encouraged for several reasons. First and foremost, breast milk is the ideal source of nutrients for the neonate. Breast milk also provides some degree of immunologic protection for the neonate. Nursing is contraindicated in

The breast and nipples of a woman who is nursing her infant require little attention in the puerperium other than attention to cleanliness and fissures. Some parturients may

LACTOGENESIS

One distinguishing characteristic of mammals is their capacity to nourish their young with secretions from the mammary glands. On the basis of studies in animals, lactogenesis can be arbitrarily divided into two stages. During the first stage, which occurs during the third trimester of pregnancy, the lobular-alveolar complex is stimulated to differentiate such that there are increases in synthesis of enzymes necessary for

In concert with cortisol, insulin, estrogen, progesterone, and placental lactogen, prolactin stimulates growth and development of the milk-secreting apparatus of the mammary gland. Prolactin is the principal hormone

NEUROENDOCRINE REGULATION

The production of milk is determined largely by the frequency and intensity of suckling. With suckling, a nerve reflex is initiated that causes nerve impulses to be transmitted from intercostal nerves IV-VI to the spinal cord, eventually terminating in the supraoptic and paraventricular nuclei of the hypothalamus. This stimulus induces the central release of neuronal oxytocin. In addition, there is a prompt, but not

POSTPARTUM CARE

Immediate Postpartum Period

After delivery, the placenta and membranes should be examined for completeness. The uterus should be palpated to ascertain whether the fundus is firm, with its upper margin below the umbilicus. If the uterus is

Postpartum Depression

The postpartum period may be time of uncertainty and anxiety for new parents. Many readjustments are often necessary, and mild depression is not unusual. However, it can be a precursor of more severe depression or psychosis. Referral to a mental health professional may be required.

Postpartum blues is a transient disturbance occurring in 50-80% of puerperal women, starting within 2-3 days of delivery and remitting within a few days to 2-3 weeks. It is characterized by emotional lability, anxiety, irritability, insomnia, poor appetite, and fatigue. Postpartum depression is a major depressive disorder occurring in the first weeks to months after delivery (occasionally starting during pregnancy) in about 10-12% of women. The risk of recurrence is approximately 30% in women with a history of depression.

Women with mild depression generally can be managed with supportive therapy. Women with major postpartum depression generally require pharmacologic intervention with antidepressants or anxiolytic agents.

Postpartum psychoses, occurring in about 1-2 of 1,000 births, usually start in the first 2 weeks after delivery, but occasionally begin later. These are severe mental illnesses that often require hospitalization. Most

Preconception Counseling

The postpartum visit is an opportune time to begin preconception counseling for patients who may wish to

COMPLICATIONS

The clinician always should be alert to postpartum complications. The most common complications include hemorrhage, genital tract infections, urinary tract infections, and mastitis.

Hemorrhage

The diagnosis of postpartum hemorrhage is based primarily on the estimate and judgment of the clinician. However, it generally implies bleeding to a degree that threatens to cause, or is associated with, hemodynamic instability. Postpartum hemorrhage is classified as either early (first 24 hours after delivery) or late (after 24 hours but before 6 weeks after delivery).

EARLY HEMORRHAGE

The etiology of early postpartum hemorrhage can be summarized as follows:

Uterine atony

Retained placental fragments

Lacerations

Uterine inversion

Uterine rupture

Coagulopathy

The most common cause of postpartum hemorrhage is uterine atony, which in turn may be associated with

UTERINE INFECTION

Cesarean delivery is the major predisposing clinical factor for pelvic infection. The frequency and severity of infection are greater after abdominal delivery than after vaginal delivery. The incidence of infection after vaginal delivery is only 1-3% in most studies, whereas the incidence after abdominal delivery is 5-10 times greater.

Urinary Tract Infections

Primarily caused by coliform bacteria, urinary tract infections occur in approximately 5% of patients during the puerperium. Predisposing factors include a prolonged labor, indwelling catheters, the infusion of large amounts of intravenous fluids, and the administration of conduction anesthesia. The last two factors may

Mastitis

Pregnancy and lactation may be complicated by the development of mastitis. With the usual form of puerperal mastitis, there is a localized area of inflammation and tenderness and a slight elevation in temperature. Treatment includes continuation of Breast-feeding or emptying of the breast with a pump and the use of appropriate antibiotics. Penicillin or one of its derivatives (ie, an antistaphylococcal antibiotic)

Episiotomy Infection

Episiotomy infections are relatively uncommon, but when they do occur, especially if associated with a third- or fourth-degree laceration, they are often associated with significant morbidity. Diagnosis is generally based on purulent discharge in association with redness and induration. Treatment consists of opening the episiotomy and removing all sutures. The episiotomy should be irrigated with copious fluid and the wound should be débrided. The area should be inspected for necrotizing fasciitis. The wound should be cleaned at...