Normal and Abnormal Puerperium - An Overview

What Is Puerperium?

Puerperium is described as the period of time beginning with the delivery of the placenta and lasting for the first several weeks following delivery. Typically, this time frame is seen as lasting about six weeks. Most pregnancy, labor, and delivery-related alterations subside by six weeks after delivery, and the body returns to its pre-pregnancy form.

The postpartum period has been arbitrarily divided into three phases:

• The immediate puerperium, or the first 24 hours after parturition, during which acute postanesthetic or postdelivery complications may arise.

• The early puerperium lasts until the first week postpartum.

• The remote puerperium, which includes the time needed for the genital organs to involute and the menstrual cycle to resume, typically lasts about six weeks.

What Happens During a Normal Puerperium?

It is the phase of adjustment following delivery when the body returns to its pre-pregnancy state, and the anatomical and physiological alterations of pregnancy are reversed.

It includes-

• Wound recovery.

• Hormonal changes.

• Involution of the organs.

• Evolution of the breast.

The following changes occur in the female body after the baby is delivered-

1. Uterus - The weight of the term pregnant uterus is about 1000 g (without the baby, placenta, and fluids). The uterus loses weight from 50 g to 100 g in the six weeks after delivery.

• The uterine fundus is palpable at or close to the level of the mother's umbilicus immediately following delivery. The majority of the subsequent shrinkage in size and weight takes place in the first two weeks, by which time the uterus has contracted sufficiently to return to the actual pelvis. The uterus gradually returns to its non-pregnant state during the coming weeks, while its overall size is still higher than it was before gestation.

• By the seventh day, endometrial glands are already visible due to the uterine lining's quick regeneration. Except for the placental location, the endometrium has returned to the uterus by day 16.

• A significant volume of red blood leaves the uterus right after delivery and continues to flow until the contraction phase starts. Following that, the amount of vaginal discharge (lochia) quickly declines.

• Lochia - After giving delivery, the uterus typically releases blood and mucus, known as lochia or postpartum bleeding. The strongest flow is during the first 10 to 14 days following delivery, and it can last for up to four weeks.

2. Cervix - The cervix similarly starts to quickly transition to a non-pregnant condition but never fully does so. By the end of the first week, the external os (external opening of the cervix) has closed enough to make it difficult to insert a finger.

3. Vagina - The vagina shrinks as well. However, it does not fully regain its pre-pregnancy size. By three weeks, the increased vascularity and edema are resolved, and in women who are not nursing, the vaginal rugae start to resurface. By weeks six to ten, this is back to normal; however, breastfeeding mothers experience further delays due to consistently low estrogen levels.

4. Perineum - During labor and delivery, the perineum is stretched, traumatized, and occasionally ripped or sliced. Within one to two weeks, the inflamed and engorged vulva rapidly fades away. By six weeks, the majority of the muscle tone has returned, and over the next few months, things continue to get better. Depending on the severity of the injury to the muscle, nerve, and associated tissues, the muscle tone may or may not return to normal.

5. Ovaries - Breastfeeding the baby has a big impact on the ovaries' ability to resume normal function, which is highly variable. Breastfeeding mothers experience amenorrhea and anovulation for a longer time than formula-feeding mothers.

6. Abdominal Wall - For many weeks, the abdominal wall has been soft and untoned. Exercise by the mother has a significant impact on the recovery to a prepregnant state.

7. Breasts - Throughout pregnancy, the breasts undergo modifications that get the body ready for breastfeeding. As early as 16 weeks of gestation, lactogenesis—the formation of the capacity to secrete milk—occurs. High levels of circulating progesterone from the placenta activate mature alveolar cells in the breast, causing them to release trace amounts of milk.

• Progesterone levels drop quickly after placenta delivery, which leads to the start of milk production and subsequent engorgement of the breasts in the postpartum period. The first liquid secreted by the breasts in the first two days to four days following delivery is known as colostrum.

• Colostrum - This liquid is protective for the baby due to its high protein content and abundance of antibodies. The colostrum, which the newborn obtains in the first few days after birth, is already present in the breasts and is released when the baby suctions.

• The process of continuing to secrete large amounts of milk is called lactation. Regular milk removal (breast emptying) and nipple stimulation (suckling) are necessary during lactation.

• If the mother is not breastfeeding, the lack of milk evacuation causes the alveolar lumen to fill with milk, raising intramammary pressure.

What Is Abnormal Puerperium?

The confinement period that occurs right before and during childbirth is known as the puerperium. Following childbirth, the vaginal organ, in particular, returns to a state that is roughly morphologically and physiologically similar to that of pre-pregnancy. At various points, some of these carefully planned modifications may disappear, leading to difficulties that may put lives in danger.

The following complications can occur during an abnormal puerperium-

1. Hemorrhage - Excessive blood loss during or after the third stage of labor is referred to as postpartum hemorrhage. 500 mL of blood is lost on average after vaginal delivery and 1000 mL with cesarean section.

• Causes: Early postpartum hemorrhage can be caused by retained fetal tissue, uterine rupture, uterine inversion, placenta accreta, lower genital tract lacerations, coagulopathy, and hematoma. The most frequent underlying factors for late postpartum hemorrhage are coagulopathy, infection, subinvolution of the placental location, and retained fetal products.

• Management: Initial treatment options may include uterine massage for atony, bimanual uterine massage to identify and treat obstetric lacerations, manual sweeps to remove any blood clots or retained pregnancy products from the uterus, and administration of uterotonic medicines. Emergency hysterectomy is frequently a critical and life-saving procedure when all other treatments fail.

2. Infections - The greatest significant risk factor for maternal postpartum infection is cesarean delivery. Women who have a cesarean delivery have a five to 20-fold higher risk of developing a postpartum infection than those who give birth vaginally in the absence of antibiotic prophylaxis.

Endometritis - It is a progressive polymicrobial infection. Typically, intestinal bacteria or natural vaginal flora are the causes.

Causes: The main factor for postpartum infection is endometritis. Cesarean birth, early age, low socioeconomic status, protracted labor, protracted membrane rupture, numerous vaginal exams, implantation of an intrauterine catheter, pre existing infection or colonization of the lower genital tract, twin deliveries, and manual placenta removal are known risk factors for endometritis.

Management: Antibiotics administered intravenously are used to treat endometritis. Once the patient has been febrile for 24 hours to 48 hours, is able to tolerate a regular meal, and can walk without assistance, parenteral antibiotics are typically withdrawn. Clindamycin and Gentamicin combined with broad-spectrum antibiotics coverage is a widely used and highly efficient endometritis therapy regimen.

Urinary Tract Infections (UTI) - A bacterial infection of the bladder or urethra is known as a urinary tract infection (UTI).

Causes: Cesarean birth, forceps or vacuum delivery, tocolysis, inducement of labor, maternal renal illness, hypertension, eclampsia, epidural anesthesia, bladder catheterization, length of hospital stay, and prior UTI during pregnancy are all risk factors for postpartum UTI.

Management: Because the typical pathogens have predicted susceptibility profiles, treatment is initiated empirically in uncomplicated infections. Antibiotics like Ciprofloxacin, Norfloxacin, Trimethoprim, or Sulfamethoxazole are frequently used. Although Amoxicillin is still frequently used, its efficacy has decreased due to the rise of E-coli resistance. Quinolones should not be used in nursing mothers.

Mastitis - Mastitis is characterized as breast gland irritation.

Causes: Mastitis is caused by a combination of causes, including milk stasis and damaged nipples, which facilitate the inflow of skin flora. Additionally, primiparity, insufficient breast emptying, and poor nursing technique are linked to mastitis.

Management: Mastitis can be treated with moist heat, massage, water, rest, optimal placement of the newborn during nursing, breastfeeding, or manual expression of milk, and analgesics.

Wound Infection - Infections of the perineum that appear at the site of an episiotomy or laceration, as well as infections of the abdominal incision following a cesarean birth, are examples of wound infections in the postpartum period.

Causes:

a. Perineal Infections: Perineal infections are quite uncommon. They typically start to show up on the third or fourth postpartum day. Infected lochia, fecal infection of the wound, and poor hygiene are all recognized risk factors.

b. Abdominal Wound Infections: Vaginal flora contamination is most usually the cause of abdominal wound infections. Diabetes, high blood pressure, obesity, corticosteroid use, immunosuppression, anemia, hematoma formation, chorioamnionitis, protracted labor, protracted membrane rupture, protracted recovery time, abdominal twin delivery, and significant blood loss are all known risk factors.

Management: Perineal infections can be treated with NSAIDs (non-steroidal anti-inflammatory drugs), topical anesthetic spray, and sitz baths for symptomatic relief. It is necessary to drain any identified abscesses before starting broad-spectrum antibiotics. Infections in abdominal wounds are treated with antibiotics, drainage, and checked to make sure the fascia is intact. If the patient is afebrile, antibiotics could be prescribed.

3. Perineal Lacerations- Since the perineum and pelvic floor muscles are under tension during vaginal childbirth; lacerations are a frequent side effect. Depending on the extent of the tissue involvement, perineal tears are divided into four kinds-

• First-degree lacerations only affect the vaginal epithelium, subcutaneous perineal tissue, and skin.

• The perineal body's deep and superficial transverse muscles, the bulbocavernosus muscle, and the pubococcygeus muscle are all affected by second-degree lacerations.

• More severe types of obstetric tears are known as obstetric anal sphincter injuries (OASIS), which are third- and fourth-degree perineal lacerations.

4. Septic Pelvic Thrombophlebitis - Venous inflammation in the belly or pelvis with thrombus formation is known as septic pelvic thrombophlebitis. It causes fever and is resistant to antibiotic treatment.

5. Endocrine Disorders- Thyroid dysfunction after delivery can happen at any moment within the first year after delivery. It may be brought on by secondary disorders of the hypothalamic-pituitary axis, such as Sheehan syndrome and lymphocytic hypophysitis, or by primary thyroid problems like postpartum thyroiditis (PPT) and Graves’ disease.

6. Psychiatric Disorders - Postpartum depression (PPD), postpartum psychosis, and postpartum blues are three mental conditions that can develop after giving birth.

• Postpartum blues are a brief condition that causes sobbing and unhappiness for periods of time that can range from hours to weeks.

• PPD is a more severe and protracted form of APD (auditory processing disorder) that can linger for weeks or months. While other symptoms of depression, including changes in sleep, appetite, and libido, may be acceptable in the context of pregnancy, anxiety is a prevalent component of perinatal mood disorders.

• The term "postpartum psychosis" refers to a range of serious and diverse conditions that cause psychotic symptoms and develop in the first postpartum year.

Conclusion:

The period known as the puerperium includes the weeks immediately following delivery of the placenta. This time frame is typically regarded as lasting six weeks. Most of the changes associated with pregnancy, labor, and delivery have subsided by six weeks after delivery, and the body has returned to its pre-pregnancy form. Various of these carefully choreographed modifications may disappear at some points, causing difficulties that may put lives in danger. Most of the conditions can be easily managed with the help of various specialists and counselors.