2. 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
3. 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
4. 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
5. Cervix, Vagina, Perineum
■ Tissues revert to a nonpregnant state but
never return to the nulliparous state
6. Abdominal Wall
■ Remains soft and poorly toned for many
weeks
❑ Return to a prepregnant state depends greatly on
exercise
7. 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
8. 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
9. Breastfeeding
“Breastfeeding is neither easy nor automatic.”
■ Should be initiated after delivery
■ Feed baby every 2-3 hrs to stimulate milk
production
❑ Production should be established by 36-96 hrs
10. 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
11. Sexual Intercourse
May resume when…
■ Red bleeding ceases
■ Vagina and vulva are healed
■ Physically comfortable
■ Emotionally ready
*Physical readiness usually takes ~3 weeks
14. 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
16. 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
17. INFECTION
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
18. Endometritis
Risk factors:
■ C-section
■ Young age
■ Prolonged labor
■ Prolonged rupture of
membranes
■ Multiple vaginal exams
■ Placement of
intrauterine catheter
■ Preexisting infection
■ Twin delivery
■ Manual removal of the
placenta
22. 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
23. 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%)
24. 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
25. Wound Infection
Perineum
(episiotomy or laceration)
■ 3-4 days postpartum
■ rare
Abdominal incision
(C-section)
■ Postoperative day 4
■ 3-15%
■ prophylactic antibiotics
❑ 2%
29. 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
30. 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
33. 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
35. Postpartum Blues
■ Transient disorder
❑ Lasts hours to weeks
■ Bouts of crying and sadness
Postpartum Depression(PPD)
■ More prolonged affective disorder
❑ Weeks to months
■ S&S of depression
Postpartum Psychosis
■ First postpartum year
■ Group of severe and varied disorders
(psychotic symptoms)
36. 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)
37. 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
38. 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
39. 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
40. Postpartum Blues
■ Often resolves by postpartum day 10
■ No pharmacotherapy is indicated
Treatment
■ Provide support and education
41. 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
42. 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
43. 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
45. Postpartum Psychosis
Treatment
■ Therapy should be targeted to the patient’s
specific symptoms
■ Psychiatrist
■ Hospitalization
*Generally lasts only 2-3 months
