• Puerperium: definition
• Physiology
• Psychosocial aspects
• Management of normal puerperium
• Common abnormalities

• The period during which the maternal body returns to the non-pregnant state after delivery
• Usually the 6 weeks period after the delivery (variable)
• Includes breast feeding

• Involution of uterus: return of uterus to normal size (however, some do not ever return to normal size)

• Day 1: umbilical level: still v large
• Decreases in size at "1 finger breadth per day" (from umbilicus)
• Day 10 to 14: not palpable abdominally (cannot feel uterus via abdomen at 2 weeks)
• 6 weeks: non-pregnant size
• Internal cervical os closed by week 2 (cervix very dilated after delivery because baby's head is v large) (closed = pelvic exam: cannot put finger through os)
• Involution usually faster in breastfeeding (effect of oxytocin on the uterus)

• Shredding of decidua (endometrium which has undergone deciduisation)
• Somewhat like menstruation
• Also contains: RBC, WBC, epithelial cells (endometrial), bacteria (most not pathological)
• Day 1-4: red lochia (more blood)
• Day 4-8: brown lochia (no active bleeding anymore; old blood)
• Day 9 on: serous-like discharge, occasionally brownish spotting
• Stops 2 weeks to 4 weeks, can sometimes persist till return of menstruation

• During pregnancy, high oestrogen inhibits ovulation
• After delivery, ovulation is suppressed by high levels of prolactin (inhibits pulsatile release of GNRH)
• When prolactin returns to non-pregnant level, ovulation will occur
• Important: ovulation seldom occurs before 3 weeks after delivery, unless prolactin release is suppressed with drugs (eg. Bromocriptine to suppress prolactin release from pituitary)
• Median time for ovulation to occur is 6 weeks after delivery in non-breast feeding women and even longer in breast-feeding women (high prolactin, effect of suckling on pituitary and hypothalamus) (but the range is wide)

• Menstruation occur 2 weeks after ovulation
• Earliest return of menstruation after delivery is 5 weeks unless prolactin release is suppressed with drugs
• Median time of return of menstruation after delivery is 8 weeks, but is variable
• Return of menstruation in lactating women is variable and usually later than in non-lactating women

• Contraception: needed before return of menstruation (because ovulation returns before menstruation)
• Increased vaginal bleeding within 5 weeks of delivery is unlikely to be due to return of menstruation (menstruation doesn't return so soon)
• Amenorrhoea after delivery need not be investigated until 6 months after delivery or 6 months after weaning in the lactating mother (ovulation return is variable after deliver)

• Subinvolution of the uterus: involution < 1 finger-breadth per day
• Usually associated with abnormal lochia

1. Persistent red lochia (bleeding persists)
2. Excessive lochia: secondary postpartum haemorrhage (bleeding causing cardiovascular decompensation)
3. Foul smelling lochia

• These can be signs of retained products of gestation and/or endometritis
• Retained products of gestation: small pieces of placenta cause subinvolution, infection causes bleeding, usu. occurs 1w after delivery
• Endometritis: decidua becomes infected; excessive and/or foul-smelling lochia, subinvolution of uterus
• Secondary post-partum haemorrhage: infection of products of gestation, placenta is a good bacterial-culture medium (assume infection involved in secondary post-partum haemorrhage)
• Primary post-partum haemorrhage: occurs in 24hr after delivery
• Note: ask if lochia is like usual menstrual flow. Normal lochia is heavier than menstruation. But at 4d we do not expect lochia to remain bright red, or to decrease then increase

FIRST: Confirm whether it is subinvolution

Uterus may be decreasing in size but may be pushed up by

1. Bladder
2. Bowel
3. Cyst

Note:

Distinguish between secondary PPH or return of menstruation

Within 6 weeks Beyond 5 weeks

Uterus subinvoluted Uterus normal size

Os often open Os usually closed

• If secondary PPH, give antibiotics
• Evacuation of uterus only when retained products of gestation is suspected (clinical or ultrasound) under antibiotic cover

• Symptoms:

1. Have to exclude oliguria first
2. Unable to void (complete retention) (most women do not have complete retention)
3. Void small volume frequently (incomplete/ partial retention or UTI) (more common)
4. Incontinence (can be overflow incontinence - UB unable to contract so cannot void, but when UB is full, urine leaks out)

• Signs:

1. Uterine fundus too high or deviated (uterus may have involuted but UB prevents it from descending)
2. Bladder palpable
3. Confirmation: checking residual urine after voiding - by catherisation, US

• Encourage voiding by:

1. Toilet/commode (bedside toilet) instead of bedpan
2. Running warm tap water over perineum
3. Adequate pain relief for perineal pain
4. Suprapubic pressure
5. Instruct woman, once voided, try to void again immediately

• Catheterisation of bladder

1. Indwelling catheter usually required when retained volume > 500 ml; keep for 48 hours
2. Exclude UTI and treat if UTI (urine culture)

• The perineum may be torn during delivery or deliberately cut (episiotomy) to facilitate the delivery
• Even when the perineum appeared intact, some muscle fibres may be damaged -> results in pain
• Infection may complicate injuries
• Long term complications: urinary and faecal incontinence

• Pelvic floor physiotherapy: with time nerve endings may grow again (studies: with active pelvic floor exercise, pelvic floor can continue to improve up to 6m after delivery)
• Consider surgical repair (strengthening of the pelvic floor and elevating the bladder neck), if physiotherapy not effective

• Tends to constipation because of perineal pain (stool softeners, drink more water)
• Haemorrhoids are common because of increased in intra-abdominal pressure during pregnancy aggravated during delivery
• Pelvic floor weakening, damage to anal sphincter can lead to faecal incontinence (need surgical repair; exercises do not help)

• Change in the family structure and relationship due to the arrival of a new member
• Additional responsibilities
• Change in the role of the mother: esp. if 1st baby

1. Wife to mother
2. Working woman to housewife
3. Loss of freedom

• Change in the role of the father

• Newborn baby is entirely dependent
• Physiological changes in the puerperium is rapid and can cause some discomfort
• Fatigue from the labour and delivery aggravated by the burden of childcare (new-borns wake every 2hr)
• Anxiety caused by inexperience and vulnerability of the newborn baby
• Mother and father: coming to terms with the new role

• Common mood change in the puerperium
• 50% of mothers
• Day 4 or 5
• Transient half to 2-3 days
• Tearful, labile mood, irritable
• If symptoms persist > 1w need to exclude depression

• Postpartum depression

1. Affects 10% of mothers
2. Within 6 months of delivery
3. Symptoms similar to depression during other periods (Tx the same)

• Puerperal psychosis

1. Rare, 1/2000 - 4000 deliveries
2. Psychotic, loss of insight (presents similar to schizophrenia)
3. Auditory/ Visual hallucination common
4. Psychosis can relapse in later life

• Blues

1. Symptoms transient, at most a few days
2. No suicidal thoughts
3. Little guilt feeling
4. No loss of self esteem
5. No psychomotor retardation

• Depression

1. Symptoms persist over a week
2. Loss of self esteem
3. Guilt feeling, fear of harm
4. Psychomotor retardation and suicidal thought in severe cases

• Common
• Suffering of the mother
• Affects the family
• Affects the development of the child (initial bonding of baby important for later psychosocial dev of child; post-partum depression: child more likely to have psychosocial dev problems, even after age 5-8y)
• Severe cases: suicide, infanticide

• Medical profession: low index of suspicion, often attribute symptoms to fatigue
• Patient and family: attribute symptoms to fatigue, afraid of stigmatisation, do not seek help
• Help not readily available: both social support and medical help

• Reduce

1. Planned pregnancy
2. Supportive partner and family
3. Well adjusted at work and at home
4. Female relative or experienced helper for postpartum care and support

• Increase

1. Unplanned pregnancy
2. Poor family and marital relationship
3. Poorly adjusted
4. Socially isolated
5. Previous history of depression
6. Other life events occurring during pregnancy

• Traditional

1. Extended family
2. Female relative or employed female helper for postpartum support
3. Close social network
4. Friendly neighbours
5. Women usually full time homemakers

• Industrialised

1. Nuclear family
2. No experienced help from female relatives (busy working), helpers sometimes inexperienced
3. Isolated socially
4. No neighbours
5. Working mothers (mothers with outside employment)

• Common

1. Haemorrhoids
2. Wound pain: in perineum
3. Back pain

• Rare

1. Perineal/vaginal haematoma
2. Deep vein thrombosis: increased coagulation factors (natural mechanism to decrease bleeding during puerperium)
3. Faecal incontinence
4. Urinary fistulae: extremely rare, occurs in obstructed labour (baby too big to pass through pelvis, C-section not performed, woman in labour for several days, ischaemic necrosis of UB wall and vaginal wall); urinary fistula complication of C-section
5. Sheehan Syndrome: severe primary post-partum haemorrhage -> shock -. Ischaemia and hypoxia to pituitary - results in pituitary failure after delivery

• Objectives

1. Early detection of deviation from normal
2. Help mother adjust to the changes

• Aspects

1. Physical: uterine involution, lochia, bowel, wound, urine, breasts, temperature (infection)
2. Education: personal care, infant feeding and care
3. Postnatal exercises: strengthen pelvic floor and anterior ab wall (RA weakened)
4. Contraceptive advice
5. Psychosocial: esp. midwives, follow up and screening for post-partum depression