CHAPTER 36: The Puerperium

The word puerperium is derived from Latin—puer, child + parus, bringing forth. Currently, it defines the time following delivery during which pregnancy-induced maternal anatomical and physiological changes return to the nonpregnant state. Its duration is understandably inexact, but is considered to be between 4 and 6 weeks. Although much less complex compared with pregnancy, the puerperium has appreciable changes as stated above by Williams (1903), and some of these may be either bothersome or worrisome for the new mother. Kanotra and colleagues (2007) analyzed challenges that women faced from 2 to 9 months following delivery. The Pregnancy Risk Assessment Surveillance System—PRAMS—of the Centers for Disease Control and Prevention (2016) listed concerns of new mothers that are shown in Table 36-1. At least a third of these women felt the need for social support, and 25 percent had concerns with breastfeeding.

Birth Canal

Return of the tissues in the birth canal to the nonpregnant state begins soon after delivery. The vagina and its outlet gradually diminish in size but rarely regain their nulliparous dimensions. Rugae begin to reappear by the third week but are less prominent than before. The hymen is represented by several small tags of tissue, which scar to form the myrtiform caruncles. The vaginal epithelium reflects the hypoestrogenic state, and it does not begin to proliferate until 4 to 6 weeks. This timing is usually coincidental with resumed ovarian estrogen production. Lacerations or stretching of the perineum during delivery can lead to vaginal outlet relaxation. Some damage to the pelvic floor may be inevitable, and parturition predisposes to urinary incontinence and pelvic organ prolapse.

Uterus

The massively increased uterine blood flow necessary to maintain pregnancy is made possible by significant hypertrophy and remodeling of pelvic vessels. After delivery, their caliber gradually diminishes to approximately that of the prepregnant state. Within the puerperal uterus, larger blood vessels become obliterated by hyaline changes. They are gradually resorbed and replaced by smaller ones. Minor vestiges of the larger vessels, however, may persist for years.

During labor, the margin of the dilated cervix, which corresponds to the external os, may be lacerated. The cervical opening contracts slowly, and for a few days immediately after labor, it readily admits two fingers. By the end of the first week, this opening narrows, the cervix thickens, and the endocervical canal re-forms. The external os does not completely resume its pregravid appearance. It remains somewhat wider, and typically, ectocervical depressions at the site of lacerations become permanent. These changes are characteristic of a parous cervix (Fig. 36-1). Cervical epithelium also undergoes considerable remodeling. This actually may be salutary because almost half of women have regression of high-grade dysplasia following delivery (Ahdoot, 1998; Kaneshiro, 2005).

After delivery, the fundus of the contracted uterus lies slightly below the umbilicus. It consists mostly of myometrium covered by serosa and internally lined by decidua. The markedly attenuated lower uterine segment contracts and retracts, but not as forcefully as the uterine corpus. During the next few weeks, the lower segment is converted from a clearly distinct substructure large enough to accommodate the fetal head to a barely discernible uterine isthmus located between the corpus and internal cervical os. Immediately postpartum, the anterior and posterior walls, which lie in close apposition, are each 4 to 5 cm thick (Buhimschi, 2003). At this time, the uterus weighs approximately 1000 g.

Myometrial involution is a truly remarkable feat of destruction or deconstruction that begins as soon as 2 days after delivery (Williams, 1931). The total number of myocytes does not decrease appreciably—rather, their size decreases markedly. As emphasized by Hytten (1995), the quality of studies that describe the degree of decreasing uterine weight postpartum are poor. Best estimates show that the uterus weighs approximately 500 g by 1 week postpartum, about 300 g by 2 weeks, and at 4 weeks, involution is complete and the uterus weighs approximately 100 g. After each successive delivery, the uterus is usually slightly larger than before the most recent pregnancy.

Sonographic Findings

Uterine involution and rapid dissipation of size progresses in the first week (Fig. 36-2). Sonographically, the uterus and endometrium return to pregravid size by 8 weeks postpartum (Bae, 2012; Steinkeler, 2012). In a study of 42 normal puerperas, Tekay and Jouppila (1993) identified fluid in the endometrial cavity in 78 percent of women at 2 weeks, 52 percent at 3 weeks, 30 percent at 4 weeks, and 10 percent at 5 weeks. Belachew and coworkers (2012) used three-dimensional sonography and visualized intracavitary tissue matter in a third on day 1, in 95 percent on day 7, in 87 percent on day 14, and in 28 percent on day 28. By day 56, the small cavity was empty. Sohn and associates (1988) described Doppler ultrasound results showing continuously increasing uterine artery vascular resistance during the first 5 days postpartum. Weintraub and colleagues (2013) posited that uterine involution may be different in preeclamptic women because they more likely had early diastolic notches seen on uterine artery velocimetry.

Decidua and Endometrial Regeneration

Because separation of the placenta and membranes involves the spongy layer, the decidua basalis is not sloughed. The in situ decidua varies markedly in thickness, it has an irregular jagged border, and it is infiltrated with blood, especially at the placental site. Within 2 or 3 days after delivery, the remaining decidua becomes differentiated into two layers. The superficial layer becomes necrotic and is sloughed in the lochia. The basal layer adjacent to the myometrium remains intact and is the source of new endometrium.

Endometrial regeneration is rapid, except at the placental site. Within a week or so, the free surface becomes covered by epithelium, and Sharman (1953) identified fully restored endometrium in all biopsy specimens obtained from the 16th day onward. Histological endometritis is part of the normal reparative process. Moreover, microscopic inflammatory changes characteristic of acute salpingitis are seen in almost half of women between 5 and 15 days, however, these findings are not thought to reflect infection (Andrews, 1951).

Clinical Aspects

Afterpains

Several clinical findings arise with uterine involution. In primiparas, the uterus tends to remain tonically contracted following delivery. In multiparas, it often contracts vigorously at intervals and gives rise to afterpains, which are similar to but milder than labor contractions. These are more pronounced as parity increases and worsen when the newborn suckles, likely because of oxytocin release (Holdcroft, 2003). Usually, afterpains decrease in intensity and become mild by the third day. We have encountered unusually severe and persistent afterpains in women with postpartum uterine infections.

Lochia

Early in the puerperium, sloughing of decidual tissue results in a vaginal discharge of variable quantity. The discharge is termed lochia and contains erythrocytes, shredded decidua, epithelial cells, and bacteria. For the first few days after delivery, there is blood sufficient to color it red—lochia rubra. After 3 or 4 days, lochia becomes progressively pale in color—lochia serosa. After approximately the 10th day, because of an admixture of leukocytes and reduced fluid content, lochia assumes a white or yellow-white color—lochia alba. The average duration of lochial discharge ranges from 24 to 36 days (Fletcher, 2012). Because of this expected leukocyte component, saline preparations of lochia for microscopic evaluation in cases of suspected puerperal metritis are typically uninformative and not recommended.

Placental Site Involution

Complete extrusion of the placental site takes up to 6 weeks. Immediately after delivery, the placental site is approximately palm-sized. Within hours of delivery, it normally contains many thrombosed vessels that ultimately undergo organization. By the end of the second week, it is 3 to 4 cm in diameter.

Placental site involution is an exfoliation process, which is prompted in great part by undermining of the implantation site by new endometrial proliferation (Williams, 1931). Thus, involution is not simply absorption in situ. Exfoliation consists of both extension and “downgrowth” of endometrium from the margins of the placental site, as well as development of endometrial tissue from the glands and stroma left deep in the decidua basalis after placental separation. Anderson and Davis (1968) concluded that placental site exfoliation results from sloughing of infarcted and necrotic superficial tissues followed by a remodeling process.

Subinvolution

In some cases, uterine involution is hindered because of infection, retained placental fragments, or other causes. Such subinvolution is accompanied by varied intervals of prolonged lochia as well as irregular or excessive uterine bleeding. During bimanual examination, the uterus is larger and softer than would be expected. With bleeding, pelvic sonography may help exclude retained placenta or, less-commonly, vascular malformations as the source (Iraha, 2017). Methylergonovine (Methergine), 0.2 mg orally every 3 to 4 hours for 24 to 48 hours, is recommended by many, but its efficacy is questionable. If there is infection, antimicrobial therapy usually leads to a good response. In an earlier study, Wager and coworkers (1980) reported that a third of these late cases of postpartum metritis are caused by Chlamydia trachomatis. For mild infection, empirical therapy with azithromycin or doxycycline usually prompts resolution regardless of bacterial etiology. At our institution, common oral options taken for 7 to 10 days include doxycycline, 100 mg twice daily; azithromycin, 500 mg twice daily; or ampicillin-clavulanate (Augmentin), 875 mg twice daily. Serious metritis is treated with intravenous broad-spectrum antibiotics listed in Table 37-2.

Another cause of subinvolution is incompletely remodeled uteroplacental arteries (Andrew, 1989; Kavalar, 2012). These noninvoluted vessels are filled with thromboses and lack an endothelial lining. Perivascular trophoblasts are also identified in the vessel walls, which suggests an aberrant interaction between uterine cells and trophoblasts.

Late Postpartum Hemorrhage

Secondary postpartum hemorrhage is defined as bleeding 24 hours to 12 weeks after delivery. Clinically worrisome uterine hemorrhage develops within 1 to 2 weeks in perhaps 1 percent of women. Such bleeding most often is the result of abnormal involution of the placental site. It occasionally is caused by retention of a placental fragment or by a uterine artery pseudoaneurysm. Usually, retained products undergo necrosis with fibrin deposition and may eventually form a so-called placental polyp. As the eschar of the polyp detaches from the myometrium, hemorrhage may be brisk. As discussed in Chapter 56 (Von Willebrand Disease), delayed postpartum hemorrhage may also be caused by von Willebrand disease or other inherited coagulopathies (Lipe, 2011).

In our experiences, few women with delayed hemorrhage are found to have retained placental fragments. Thus, we and others do not routinely perform curettage (Lee, 1981). Another concern is that curettage may worsen bleeding by avulsing part of the implantation site. Thus, in a stable patient, if sonographic examination shows an empty cavity, then oxytocin, methylergonovine, or a prostaglandin analogue is given. Suitable dosing is found in Table 20-2. Antimicrobials are added if uterine infection is suspected. If large clots are seen in the uterine cavity with sonography, then gentle suction curettage is considered. Otherwise curettage is carried out only if appreciable bleeding persists or recurs after medical management.

Normal pregnancy-induced glomerular hyperfiltration persists during the puerperium but returns to prepregnancy baseline by 2 weeks (Hladunewich, 2004). Dilated ureters and renal pelves return to their prepregnant state by 2 to 8 weeks postpartum. Because of this dilated collecting system, coupled with residual urine and bacteriuria in a traumatized bladder, symptomatic urinary tract infection remains a concern in the puerperium.

Funnell and colleagues (1954) used cystoscopy immediately postpartum and described varying degrees of submucosal hemorrhage and edema. Bladder trauma is associated most closely with labor length and thus to some degree is a normal accompaniment of vaginal delivery. Postpartum, the bladder has an increased capacity and a relative insensitivity to intravesical pressure. Thus, overdistention, incomplete emptying, and excessive residual urine are frequent (Buchanan, 2014; Mulder, 2014). Acute urinary retention is also more common with narcotic analgesia (Kandadai, 2014). Their management is discussed in Perineal Care.

It is unusual for urinary incontinence to manifest during the puerperium. That said, much attention has been given to the potential for subsequent development of urinary incontinence and other pelvic floor disorders in the years following delivery. A more detailed discussion is found in Chapter 30 (Cesarean Delivery Risks).

The broad and round ligaments require considerable time to recover from stretching and loosening during pregnancy. As a result of ruptured elastic fibers in the skin and prolonged distention by the pregnant uterus, the abdominal wall remains soft and flaccid. If the abdomen is unusually flabby or pendulous, an ordinary girdle is often satisfactory. An abdominal binder is another temporary measure. Several weeks are required for these structures to return to normal, and recovery is aided by exercise. These may be started anytime following vaginal delivery. After cesarean delivery, a 6-week interval to allow fascia to heal and abdominal soreness to diminish is reasonable. Silvery abdominal striae commonly develop as striae gravidarum (Chap. 4, Breasts). Except for these, the abdominal wall usually resumes its prepregnancy appearance. When muscles remain atonic, however, the abdominal wall also remains lax. Marked separation of the rectus abdominis muscles—diastasis recti—may result.

Hematological and Coagulation Changes

Marked leukocytosis and thrombocytosis may occur during and after labor. The white blood cell count sometimes reaches 30,000/μL, with the increase predominantly due to granulocytes. There is a relative lymphopenia and an absolute eosinopenia. Normally, during the first few postpartum days, hemoglobin concentration and hematocrit fluctuate moderately. We routinely check these on the first postpartum day or earlier if indicated. If they fall much below the levels present just before labor, a considerable amount of blood has been lost.

By the end of pregnancy, laboratory values that assess coagulation are altered (Kenny, 2014). These changes are discussed in Chapter 4 (Leukocytes and Lymphocytes) and listed in the Appendix (Serum and Blood Constituents). Many persist variably in the puerperium. For example, a markedly increased plasma fibrinogen level is maintained at least through the first week and hence so is an elevated sedimentation rate. Hypercoagulability appears to be greater and is reflected by the likelihood of deep-vein thrombosis and pulmonary embolism in the 12 weeks following childbirth (Kamel, 2014). This is depicted in Figure 36-3 and is discussed further in Chapter 52 (Pathophysiology).

Pregnancy-Induced Hypervolemia

When the amount of blood attained by normal pregnancy hypervolemia is lost as postpartum hemorrhage, the woman almost immediately regains her nonpregnant blood volume (Chap. 41, Definition and Incidence). If less has been lost at delivery, blood volume generally nearly returns to its nonpregnant level by 1 week after delivery. Cardiac output usually remains elevated for 24 to 48 hours postpartum and declines to nonpregnant values by 10 days (Robson, 1987). Heart rate changes follow this pattern, and blood pressure similarly returns to nonpregnant values (Fig. 36-4). Correspondingly, systemic vascular resistance remains in the lower range characteristic of pregnancy for 2 days postpartum and then begins to steadily increase to normal nonpregnant values (Hibbard, 2014). Despite this, Morris and coworkers (2015) found that reduced arterial stiffness persists following pregnancy. They suggest a significant favorable effect of pregnancy on maternal cardiovascular remodeling, which may represent a mechanism by which preeclampsia risk is reduced in subsequent pregnancies.

Postpartum Diuresis

Normal pregnancy is associated with an appreciable increase in extracellular sodium and water retention, and postpartum diuresis is a physiological reversal of this process. Chesley and coworkers (1959) demonstrated a decrease in sodium space of approximately 2 L during the first week postpartum. This also corresponds with loss of residual pregnancy hypervolemia. In preeclampsia, pathological retention of fluid antepartum and its diuresis postpartum may be prodigious (Chap. 40, Long-Term Consequences).

Postpartum diuresis results in relatively rapid weight loss of 2 to 3 kg, which is additive to the 5 to 6 kg incurred by delivery and normal blood loss. Weight loss from pregnancy itself is likely to be maximal by the end of the second week postpartum. It follows that any residual increased weight compared with prepregnancy values probably represents fat stores that will persist. According to Schauberger and associates (1992), women approach their self-reported prepregnancy weight 6 months after delivery but still retain an average surplus of 1.4 kg (3 lb).

Breast Anatomy and Secretory Products

Each mature mammary gland or breast is composed of 15 to 25 lobes. They are arranged radially and are separated from one another by varying amounts of fat. Each lobe consists of several lobules, which in turn are composed of numerous alveoli. Each alveolus is provided with a small duct that joins others to form a single larger duct for each lobe as shown in Figure 36-5. These lactiferous ducts open separately on the nipple, where they may be distinguished as minute but distinct orifices. The alveolar secretory epithelium synthesizes the various milk constituents.

After delivery, the breasts begin to secrete colostrum, which is a deep lemon-yellow liquid. It usually can be expressed from the nipples by the second postpartum day. Compared with mature milk, colostrum is rich in immunological components and contains more minerals and amino acids (Ballard, 2013). It also has more protein, much of which is globulin, but less sugar and fat. Secretion persists for 5 days to 2 weeks, with gradual conversion from “transitional” to mature milk by 4 to 6 weeks. The colostrum content of immunoglobulin A (IgA) offers the newborn protection against enteric pathogens. Other host resistance factors found in colostrum and milk include complement, macrophages, lymphocytes, lactoferrin, lactoperoxidase, and lysozymes.

Mature milk is a complex and dynamic biological fluid that includes fat, proteins, carbohydrates, bioactive factors, minerals, vitamins, hormones, and many cellular products (Table 36-2). The concentrations and contents of human milk change even during a single feed and are influenced by maternal diet and by newborn age, health, and needs. A nursing mother easily produces 600 mL of milk daily, and maternal gestational weight gain has little impact on its quantity or quality. Milk is isotonic with plasma, and lactose accounts for half of the osmotic pressure. Essential amino acids are derived from blood, and nonessential amino acids are derived in part from blood or synthesized in the mammary gland. Most milk proteins are unique and include alpha-lactalbumin, beta-lactoglobulin, and casein. Fatty acids are synthesized in the alveoli from glucose and are secreted by an apocrine-like process. Most vitamins are found in human milk, but in variable amounts. Vitamin K is virtually absent, and thus, an intramuscular dose is given to the newborn (Chap. 33, Polycythemia and Hyperviscosity). Vitamin D content is low— 22 IU/mL, and newborn supplementation is also recommended by the American Academy of Pediatrics (Wagner, 2008).

Whey is milk serum and has been shown to contain large amounts of interleukin-6 (Saito, 1991). Human milk has a whey-to-casein ratio of 60:40, considered ideal for absorption. Prolactin appears to be actively secreted into breast milk. Epidermal growth factor (EGF) has been identified, and because it is not destroyed by gastric proteolytic enzymes, it may be absorbed to promote growth and maturation of newborn intestinal mucosa (McCleary, 1991). Other critical components in human milk include lactoferrin, melatonin, oligosaccharides, and essential fatty acids.

Endocrinology of Lactation

The precise humoral and neural mechanisms involved in lactation are complex. Progesterone, estrogen, and placental lactogen, as well as prolactin, cortisol, and insulin, appear to act in concert to stimulate the growth and development of the milk-secreting apparatus (Stuebe, 2014). With delivery, the maternal serum levels of progesterone and estrogen decline abruptly and profoundly. This drop removes the inhibitory influence of progesterone on alpha-lactalbumin production and stimulates lactose synthase to increase milk lactose. Progesterone withdrawal also allows prolactin to act unopposed in its stimulation of alpha-lactalbumin production. Activation of calcium-sensing receptors (CaSR) in mammary epithelial cells downregulates parathyroid hormone-related protein (PTHrP) and increases calcium transport into milk (Vanhouten, 2013). Serotonin is also produced in mammary epithelial cells and has a role in maintaining milk production (Collier, 2012).

The intensity and duration of subsequent lactation are controlled, in large part, by the repetitive stimulus of nursing and emptying of milk from the breast. Prolactin is essential for lactation, and women with extensive pituitary necrosis— Sheehan syndrome—do not lactate (Chap. 58, Acromegaly). Although plasma prolactin levels fall after delivery to levels lower than during pregnancy, each act of suckling triggers a rise in levels (Pang, 2007). Presumably a stimulus from the breast curtails the release of dopamine, also known as prolactin-inhibiting factor, from the hypothalamus. In turn, this transiently induces increased prolactin secretion.

The posterior pituitary secretes oxytocin in pulsatile fashion. This stimulates milk expression from a lactating breast by causing contraction of myoepithelial cells in the alveoli and small milk ducts (see Fig. 36-5). Milk ejection, or letting down, is a reflex initiated especially by suckling, which stimulates the posterior pituitary to liberate oxytocin. The reflex may even be provoked by an infant cry and can be inhibited by maternal fright or stress (Stuebe, 2014).

Immunological Consequences of Breastfeeding

Human milk contains several protective immunological substances, including secretory IgA and growth factors. The antibodies in human milk are specifically directed against maternal environmental antigens such as Escherichia coli (Iyengar, 2012). According to the Centers for Disease Control and Prevention (Perrine, 2015), breastfeeding decreases the incidence of ear, respiratory, and gastrointestinal infections; necrotizing enterocolitis; and sudden infant death syndrome.

Much attention has been directed to the role of maternal breast milk lymphocytes in neonatal immunological processes. Milk contains both T and B lymphocytes, but the T lymphocytes appear to differ from those found in blood. Specifically, milk T lymphocytes are almost exclusively composed of cells that exhibit specific membrane antigens. These memory T cells appear to be an avenue for the neonate to benefit from the maternal immunological experience.

Nursing

Human milk is ideal food for newborns in that it provides age-specific nutrients, immunological factors, and antibacterial substances. Milk also contains factors that act as biological signals for promoting cellular growth and differentiation. A list of the advantages of breastfeeding is shown in Table 36-3. For both mother and infant, the benefits of breastfeeding are long-term. For example, women who breastfeed have a lower risk of breast and reproductive cancer, and their children have increased adult intelligence independent of a wide range of possible confounding factors (Jong, 2012; Kramer, 2008). Breastfeeding is associated with decreased postpartum weight retention (Baker, 2008). In addition, rates of sudden-infant-death syndrome are significantly lower among breastfed infants. Bartek and colleagues (2013) estimate that a 90-percent breastfeeding rate for 12 months would save more than $3 billion annually in excess infant and maternal morbidity costs. For all these reasons, the American Academy of Pediatrics (2017) and American College of Obstetricians and Gynecologists (2016a, 2017b) supports the World Health Organization (2011) recommendations of exclusive breastfeeding for up to 6 months.

The Surgeon General of the U.S. Department of Health and Human Services (2011) lists some barriers to breastfeeding and suggests practical means of overcoming them. Educational initiatives that include father and peer counseling may improve these rates (Pisacane, 2005; Wolfberg, 2004). The Baby Friendly Hospital Initiative is an international program to increase rates of exclusive breastfeeding and to extend its duration. It is based on the World Health Organization (1989) Ten Steps to Successful Breastfeeding (Table 36-4). Worldwide, almost 20,000 hospitals are designated as “baby-friendly,” however, only 10 to 15 percent of hospitals in the United States are so designated (Centers for Disease Control and Prevention, 2014; Perrine, 2015). Forrester-Knauss and coworkers (2013) described successful trends toward exclusive breastfeeding in Switzerland during 9 years in which a Baby-Friendly Hospital Initiative was implemented. In a large population-based study done in the United States, fewer than two thirds of term neonates were exclusively breastfed at the time of discharge (McDonald, 2012).

Various individual resources available are available for breastfeeding mothers that include online information from the American Academy of Pediatrics (http://www.aap.org) and La Leche League International (http://www.llli.org).

Care of Breasts

The nipples require little attention other than cleanliness and attention to skin fissures. Fissured nipples render nursing painful, and they may have a deleterious influence on milk production. These cracks also provide a portal of entry for pyogenic bacteria. Because dried milk is likely to accumulate and irritate the nipples, washing the areola with water and mild soap is helpful before and after nursing. When the nipples are irritated or fissured, some recommend topical lanolin and a nipple shield for 24 hours or longer. Although specific evidence supporting this practice is lacking, nipple pain usually subsides by 10 days (Dennis, 2014). If fissuring is severe, the newborn should not be permitted to nurse on the affected side. Instead, the breast is emptied regularly with a pump until the lesions are healed. Poor latching of the neonate to the breast can create such fissures. For example, the newborn may take into its mouth only the nipple, which is then is forced against the hard palate during suckling. Ideally, the nipple and areola are both taken in to evenly distribute suckling forces. Moreover, the force of the hard palate against the lactiferous sinuses aids their efficient emptying, while the nipple is thereby positioned closer to the soft palate.

Contraindications to Breastfeeding

Nursing is contraindicated in women who take street drugs or do not control their alcohol use; have an infant with galactosemia; have human immunodeficiency virus (HIV) infection; have active, untreated tuberculosis; take certain medications; or are undergoing breast cancer treatment (American Academy of Pediatrics, 2017; Faupel-Badger, 2013). Breastfeeding has been recognized for some time as a mode of HIV transmission and is proscribed in developed countries in which adequate nutrition is otherwise available. Other viral infections do not contraindicate breastfeeding. For example, with maternal cytomegalovirus infection, both virus and antibodies are present in breast milk. And, although hepatitis B virus is excreted in milk, breastfeeding is not contraindicated if hepatitis B immune globulin is given to the newborns of affected mothers. Maternal hepatitis C infection is not a contraindication because breastfeeding has not been shown to transmit infection (Society for Maternal-Fetal Medicine, 2017). Women with active herpes simplex virus may suckle their infants if there are no breast lesions and if particular care is directed to hand washing before nursing.

Drugs Secreted in Milk

Most drugs given to the mother are secreted in breast milk, although the amount ingested by the infant typically is small. Many factors influence drug excretion and include plasma concentration, degree of protein binding, plasma and milk pH, degree of ionization, lipid solubility, and molecular weight (Rowe, 2013). The ratio of drug concentration in breast milk to that in maternal plasma is the milk-to-plasma drug-concentration ratio. Ideally, to minimize infant exposure, medication selection should favor drugs with a shorter half-life, poorer oral absorption, and lower lipid solubility. If multiple daily drug doses are required, then each is taken by the mother after the closest feed. Single daily-dosed drugs may be taken just before the longest infant sleep interval—usually at bedtime (Spencer, 2002).

Only a few drugs are absolutely contraindicated while breastfeeding (Berlin, 2013; Bertino, 2012). Cytotoxic drugs may interfere with cellular metabolism and potentially cause immune suppression or neutropenia, affect growth, and at least theoretically, increase the risk of childhood cancer. Examples include cyclophosphamide, cyclosporine, doxorubicin, methotrexate, and mycophenolate. If a medication presents a concern, then the importance of therapy should be ascertained. It should be determined whether there is a safer alternative or whether neonatal exposure can be minimized if the medication dose is taken immediately after each breastfeeding (American Academy of Pediatrics, 2017). Finally, recreational drugs such as marijuana and alcohol should be avoided (American College of Obstetricians and Gynecologists, 2017a). Data on individual drugs are available through the National Institutes of Health website, LactMed, which can be found at toxnet.nlm.nih.gov.

Radioactive isotopes of copper, gallium, indium, iodine, sodium, and technetium rapidly appear in breast milk. Consultation with a nuclear medicine specialist is recommended before performing a diagnostic study with these isotopes (Chap. 46, Radiographic Contrast Agents). The goal is to use a radionuclide with the shortest excretion time in breast milk. The mother should pump her breasts before the study and store enough milk in a freezer to feed the infant. After the study, she should pump her breasts to maintain milk flow but discard all milk produced during the time that radioactivity is present. This ranges from 15 hours to 2 weeks, depending on the isotope used. Importantly, radioactive iodine concentrates and persists in the thyroid. Its special considerations are discussed in Chapter 63 (Thyroid Cancer).

Breast Engorgement

This is common in women who do not breastfeed. It is typified by milk leakage and breast pain, which peak 3 to 5 days after delivery (Spitz, 1998). Up to half of affected women require analgesia for breast pain relief, and as many as 10 percent report severe pain for up to 14 days.

Evidence is insufficient to firmly support any specific treatment (Mangesi, 2016). That said, breasts can be supported with a well-fitting brassiere, breast binder, or sports bra. Cool packs and oral analgesics for 12 to 24 hours aid discomfort. Pharmacological or hormonal agents are in general not recommended to suppress lactation.

Fever caused by breast engorgement was common before the renaissance of breastfeeding. In one study, Almeida and Kitay (1986) reported that 13 percent of puerperas had fever from engorgement that ranged from 37.8 to 39°C. Fever seldom persists for longer than 4 to 16 hours. The incidence and severity of engorgement and of the fever associated with it are much lower if women breastfeed. Other causes of fever, especially those due to infection, must be excluded. Of these, mastitis is infection of the mammary parenchyma. It is relatively common in lactating women and is discussed in Chapter 37 (Breast Infections).

Other Issues with Lactation

With inverted nipples, lactiferous ducts open directly into a depression at the center of the areola. With these depressed nipples, nursing is difficult. If the depression is not deep, milk sometimes can be drawn out by a breast pump. If instead the nipple is greatly inverted, daily attempts are made during the last few months of pregnancy to draw or “tease” the nipple out with the fingers.

Extra breasts—polymastia, or extra nipples—polythelia, may develop along the former embryonic mammary ridge. Also termed the milk line, this line extends from the axilla to the groin bilaterally. In some women, rests of accessory breast tissue can be found in the mons pubis or vulva (Wagner, 2013). In the general population, the incidence of accessory breast tissue ranges from 0.22 to 6 percent (Loukas, 2007). These breasts may be so small as to be mistaken for pigmented moles, or if without a nipple, for lymphadenopathy or lipoma. Polymastia has no obstetrical significance, although occasionally enlargement of these accessory breasts during pregnancy or engorgement postpartum may result in patient discomfort and anxiety.

Galactocele is a milk duct that becomes obstructed by inspissated secretions. The amount is ordinarily limited, but an excess may form a fluctuant mass—a galactocele—that may cause pressure symptoms and have the appearance of an abscess. It may resolve spontaneously or require aspiration.

Among individuals, the volume of milk secreted varies markedly. This depends not on general maternal health but on breast glandular development. Rarely, there is complete lack of mammary secretion—agalactia. Occasionally, mammary secretion is excessive—polygalactia.

For 2 hours after delivery, blood pressure and pulse are taken every 15 minutes, or more frequently if indicated. Temperature is assessed every 4 hours for the first 8 hours and then at least every 8 hours subsequently (American Academy of Pediatrics, 2017). The amount of vaginal bleeding is monitored, and the fundus palpated to ensure that it is well contracted. If relaxation is detected, the uterus should be massaged through the abdominal wall until it remains contracted. Uterotonics are also sometimes required. Blood can accumulate within the uterus without external bleeding. This may be detected early by uterine enlargement during fundal palpation in the first postdelivery hours. Because the likelihood of significant hemorrhage is greatest immediately postpartum, even in normal births, the uterus is closely monitored for at least 1 hour after delivery. Postpartum hemorrhage is discussed in Chapter 41 (Uterine Atony). If regional analgesia or general anesthesia was used for labor or delivery, the mother should be observed in an appropriately equipped and staffed recovery area.

Women are out of bed within a few hours after delivery. An attendant should be present for at least the first time, in case the woman becomes syncopal. The many confirmed advantages of early ambulation include fewer bladder complications, less frequent constipation, and reduced rates of puerperal venous thromboembolism. As discussed in Peritoneum and Abdominal Wall, deep-vein thrombosis and pulmonary embolism are common in the puerperium (see Fig. 36-3). In an audit of puerperal women at Parkland Hospital, the frequency of venous thromboembolism was found to be 0.008 percent after a vaginal birth and 0.04 percent following cesarean delivery. We attribute this low incidence to early ambulation. Risk factors and other measures to diminish the frequency of thromboembolism are discussed in Chapter 52 (Pathophysiology).

There are no dietary restrictions for women who have been delivered vaginally. Two hours after uncomplicated vaginal delivery, a woman is allowed to eat. With breastfeeding, the level of calories and protein consumed during pregnancy are increased slightly as recommended by the Food and Nutrition Board of the National Research Council (Chap. 9, Dietary Reference Intakes—Recommended Allowances). If the mother does not breastfeed, dietary requirements are the same as for a nonpregnant woman. We recommend oral iron supplementation for at least 3 months after delivery and hematocrit evaluation at the first postpartum visit.

As noted earlier, profound drops in estrogen levels follow removal of the placenta. Reminiscent of the menopause, postpartum women may experience hot flushes, especially at night. Importantly, the patient’s temperature is assessed to differentiate these physiological vasomotor events from infection.

In women with migraines, dramatic hypoestrogenism may trigger headaches. Importantly, severe headaches should be differentiated from spinal headache or hypertensive complications. Care varies depending on migraine severity. Mild headaches may respond to analgesics such as ibuprofen or acetaminophen. Alternatively, Midrin combines isometheptene mucate, which is a sympathomimetic agent; dichloralphenazone, which is a mild sedative; and acetaminophen and is compatible with breastfeeding. For more severe headaches, oral or systemic narcotics can be used. Instead of Midrin, a triptan, such as sumatriptan (Imitrex), can effectively relieve headaches by causing intracranial vasoconstriction.

Perineal Care

The woman is instructed to clean the vulva from anterior to posterior—the vulva toward the anus. A cool pack applied to the perineum may help reduce edema and discomfort during the first 24 hours if there is a perineal laceration or an episiotomy. Most women also appear to obtain a measure of relief from the periodic application of a local anesthetic spray. Severe perineal, vaginal, or rectal pain always warrants careful inspection and palpation. Severe discomfort usually indicates a problem, such as a hematoma within the first day or so and infection after the third or fourth day (Chap. 37, Perineal Infections and Chap. 41, Puerperal Hematomas). Beginning approximately 24 hours after delivery, moist heat as provided by warm sitz baths can be used to reduce local discomfort. Tub bathing after uncomplicated delivery is allowed. The episiotomy incision normally is firmly healed and nearly asymptomatic by the third week.

Rarely, the cervix, and occasionally a portion of the uterine body, may protrude from the vulva following delivery. This is accompanied by variable degrees of anterior and posterior vaginal wall prolapse. Symptoms include a palpable mass at or past the introitus, voiding difficulties, or pressure. Puerperal procidentia typically improves with time as the weight of the uterus lessens with involution. As a temporizing measure in those with pronounced prolapse, the uterus can be replaced and held in position with a suitable pessary.

Hemorrhoidal veins are often congested at term. Thrombosis is common and may be promoted by second-stage pushing. Treatment includes topically applied anesthetics, warm soaks, and stool-softening agents. Nonprescription topical preparations containing corticosteroids, astringents, or phenylephrine are often used, but no randomized studies support their efficacy compared with conservative management.

Bladder Function

In most delivery units, intravenous fluids are infused during labor and for an hour or so after delivery. Oxytocin, in doses that have an antidiuretic effect, is typically infused postpartum, and rapid bladder filling is common. Moreover, both bladder sensation and capability to empty spontaneously may be diminished by local or conduction analgesia, by trauma to the bladder, by episiotomy or lacerations, or by operative vaginal delivery. Thus, urinary retention and bladder overdistention is common in the early puerperium. The incidence in more than 5500 women studied with a bladder scanner was 5.1 percent (Buchanan, 2014). In another study, Musselwhite and coworkers (2007) reported retention in 4.7 percent of women who had labor epidural analgesia. Risk factors that increased the likelihood of retention were primiparity, cesarean delivery, perineal laceration, oxytocin-induced or augmented labor, operative vaginal delivery, catheterization during labor, and labor duration >10 hours.

Prevention of bladder overdistention demands observation after delivery to ensure that the bladder does not overfill and that it empties adequately with each voiding. The enlarged bladder can be palpated suprapubically, or it is evident abdominally indirectly as it elevates the fundus above the umbilicus. The use of an automated bladder scanner sonography system has been studied to detect high bladder volumes and thus postpartum urinary retention (Buchanan, 2014; Van Os, 2006).

If a woman has not voided within 4 hours after delivery, it is likely that she cannot. If she has trouble voiding initially, she also is likely to have further trouble. An examination for perineal and genital-tract hematomas is completed. With an overdistended bladder, an indwelling catheter should be left in place until the factors causing retention have abated. Even without a demonstrable cause, it usually is best to leave the catheter in place for at least 24 hours. This prevents recurrence and allows recovery of normal bladder tone and sensation.

When the catheter is removed, a voiding trial is completed to demonstrate an ability to void appropriately. If a woman cannot void after 4 hours, she should be catheterized and the urine volume measured. If more than 200 mL, the bladder is not functioning appropriately, and the catheter is left for another 24 hours. Although rare, if retention persists after a second voiding trial, an indwelling catheter and leg bag can be elected, and the patient returns in 1 week for an outpatient voiding trial. Intermittent self-catheterization is another option (Mulder, 2017).

During a voiding trial, if less than 200 mL of urine is obtained, the catheter can be removed and the bladder subsequently monitored clinically as described earlier. Harris and coworkers (1977) reported that 40 percent of such women develop bacteriuria, and thus a single dose or short course of antimicrobial therapy against uropathogens is reasonable after the catheter is removed.

Pain, Mood, and Cognition

Discomfort and its causes following cesarean delivery are considered in Chapter 30 (Postoperative Care). During the first few days after vaginal delivery, the mother may be uncomfortable because of afterpains, episiotomy and lacerations, breast engorgement, and at times, postdural puncture headache. Mild analgesics containing codeine, aspirin, or acetaminophen, preferably in combinations, are given as frequently as every 4 hours during the first few days.

It is important to screen the postpartum woman for depression (American College of Obstetricians and Gynecologists, 2016b). It is fairly common for a mother to exhibit some degree of depressed mood a few days after delivery. Termed postpartum blues, this likely is the consequence of several factors. These include emotional letdown that follows the excitement and fears experienced during pregnancy and delivery, discomforts of the early puerperium, fatigue from sleep deprivation, anxiety over the ability to provide appropriate newborn care, and body image concerns. In most women, effective treatment includes anticipation, recognition, and reassurance. This disorder is usually mild and self-limited to 2 to 3 days, although it sometimes lasts for up to 10 days. Should these moods persist or worsen, an evaluation for symptoms of major depression is done (Chap. 61, Postpartum Depression). Suicidal or infanticidal ideation is dealt with emergently. Because major postpartum depression recurs in at least a fourth of women in subsequent pregnancies, some recommend pharmacological prophylaxis beginning in late pregnancy or immediately postpartum.

Last, postpartum hormonal changes in some women may affect brain function. Bannbers and colleagues (2013) compared a measure of executive function in postpartum women and controls and observed a functional decline in postpartum subjects.

Neuromusculoskeletal Problems

Obstetrical Neuropathies

Pressure on branches of the lumbosacral nerve plexus during labor may manifest as complaints of intense neuralgia or cramp- like pains extending down one or both legs as soon as the head descends into the pelvis. If the nerve is injured, pain may continue after delivery, and variable degrees of sensory loss or muscle paralysis can result. In some cases, there is footdrop, which can be secondary to injury at the level of the lumbosacral plexus, sciatic nerve, or common fibular (peroneal) nerve (Bunch, 2014). Components of the lumbosacral plexus cross the pelvic brim and can be compressed by the fetal head or by forceps. The common fibular nerves may be externally compressed when the legs are positioned in stirrups, especially during prolonged second-stage labor.

Obstetrical neuropathy is relatively infrequent. Wong and associates (2003) evaluated more than 6000 puerperas and found that approximately 1 percent had a confirmed nerve injury. Lateral femoral cutaneous neuropathies were the most common (24 percent), followed by femoral neuropathies (14 percent). A motor deficit accompanied a third of injuries. Nulliparity, prolonged second-stage labor, and pushing for a long duration in the semi-Fowler position were risk factors. The median duration of symptoms was 2 months, and the range was 2 weeks to 18 months.

Nerve injuries with cesarean delivery include the iliohypogastric and ilioinguinal nerves (Rahn, 2010). These are discussed further in Chapter 2 (Innervation).

Musculoskeletal Injuries

Pain in the pelvic girdle, hips, or lower extremities may follow stretching or tearing injuries sustained at normal or difficult delivery. Magnetic resonance (MR) imaging is often informative (Miller, 2015). One example is the piriformis muscle hematoma shown in Figure 36-6. Most injuries resolve with antiinflammatory agents and physical therapy. Rarely, there may be septic pyomyositis such as with iliopsoas muscle abscess (Nelson, 2010; Young, 2010).

Separation of the symphysis pubis or one of the sacroiliac synchondroses during labor leads to pain and marked interference with locomotion (Fig. 36-7). Estimates of the frequency of this event vary widely from 1 in 600 to 1 in 30,000 deliveries (Reis, 1932; Taylor, 1986). In our experiences, symptomatic separations are uncommon. Their onset of pain is often acute during delivery, but symptoms may manifest either antepartum or up to 48 hours postpartum (Snow, 1997). In suspected cases, radiography is typically selected. The normal distance of the symphyseal joint is 0.4 to 0.5 cm, and symphyseal separation >1 cm is diagnostic for diastasis. Treatment is generally conservative, with rest in a lateral decubitus position and an appropriately fitted pelvic binder (Lasbleiz, 2017). Surgery is occasionally necessary in some symphyseal separations of more than 4 cm (Kharrazi, 1997). The recurrence risk is high in subsequent pregnancy, and Culligan and coworkers (2002) recommend consideration for cesarean delivery.

In rare cases, fractures of the sacrum or pubic ramus are caused by even uncomplicated deliveries (Alonso-Burgos, 2007; Speziali, 2015). As discussed in Chapter 58 (Hypoparathyroidism), the latter are more likely with osteoporosis associated with heparin or corticosteroid therapy (Cunningham, 2005). In rare but serious cases, bacterial osteomyelitis—osteitis pubis—can be devastating. Lawford and coworkers (2010) reported such a case that caused massive vulvar edema.

Immunizations

The D-negative woman who is not isoimmunized and whose newborn is D-positive is given 300 μg of anti-D immune globulin shortly after delivery (Chap. 15, Prevention of Anti-D Alloimmunization). Women who are not already immune to rubella or varicella are excellent candidates for vaccination before discharge (Swamy, 2015). Those who have not received a tetanus/diphtheria or influenza vaccine should be given these (American College of Obstetricians and Gynecologists, 2017c). Morgan and colleagues (2015) reported that implementation of a best-practices alert in the electronic medical record was associated with a tetanus/diphtheria immunization rate of 97 percent at Parkland Hospital. Vaccination is also discussed in Chapter 9 (Automobile and Air Travel).

Hospital Discharge

Following uncomplicated vaginal delivery, hospitalization is seldom warranted for more than 48 hours. A woman should receive instructions concerning anticipated normal physiological puerperal changes, including lochia patterns, weight loss from diuresis, and milk let-down. She also should receive instructions concerning fever, excessive vaginal bleeding, or leg pain, swelling, or tenderness. Persistent headaches, shortness of breath, or chest pain warrant immediate concern.

Hospital-stay length following labor and delivery is now regulated by federal law (Chap. 32, Rooming In and Hospital Discharge). Currently, the norms are hospital stays up to 48 hours following uncomplicated vaginal delivery and up to 96 hours following uncomplicated cesarean delivery (American Academy of Pediatrics, 2017; Blumenfield, 2015). Earlier hospital discharge is acceptable for appropriately selected women if they desire it.

Contraception

During the hospital stay, a concerted effort is made to provide family planning education. Various forms of contraception are discussed throughout Chapter 38 and sterilization procedures in Chapter 39.

Women not breastfeeding have return of menses usually within 6 to 8 weeks. At times, however, it is difficult clinically to assign a specific date to the first menstrual period after delivery. A minority of women bleed small to moderate amounts intermittently, starting soon after delivery. Ovulation occurs at a mean of 7 weeks, but ranges from 5 to 11 weeks (Perez, 1972). That said, ovulation before 28 days has been described (Hytten, 1995). Thus, conception is possible during the artificially defined 6-week puerperium. Women who become sexually active during the puerperium, and who do not desire to conceive, should initiate contraception. Kelly and associates (2005) reported that by the third month postpartum, 58 percent of adolescents had resumed sexual intercourse, but only 80 percent of these were using contraception. Because of this, many recommend long-acting reversible contraceptives—LARC (Baldwin, 2013).

Women who breastfeed ovulate much less frequently compared with those who do not, but variation is great. Timing of ovulation depends on individual biological variation and the intensity of breastfeeding. Lactating women may first menstruate as early as the second or as late as the 18th month after delivery. Campbell and Gray (1993) analyzed daily urine specimens to determine the time of ovulation in 92 lactating women. As shown in Figure 36-8, breastfeeding in general delays resumption of ovulation, although as already emphasized, it does not invariably forestall it. Other findings in their study included the following:

1. Resumption of ovulation was frequently marked by return of normal menstrual bleeding.

2. Breastfeeding episodes lasting 15 minutes seven times daily delayed ovulation resumption.

3. Ovulation can occur without bleeding.

4. Bleeding can be anovulatory.

5. The risk of pregnancy in breastfeeding women was approximately 4 percent per year.

For the breastfeeding woman, progestin-only contraceptives, such as progestin pills, depot medroxyprogesterone, or progestin implants, do not affect the quality or quantity of milk. Success with the progesterone-releasing vaginal ring has also been described (Carr, 2016). These may be initiated any time during the puerperium. Estrogen-progestin contraceptives likely reduce the quantity of breast milk, but under the proper circumstances, they too can be used by breastfeeding women. These hormonal methods are discussed in Chapter 38.

Coitus

No evidence-based data guide resumption of coitus after delivery, and practices are individualized (Minig, 2009). After 2 weeks, coitus may be resumed based on desire and comfort. Barrett and colleagues (2000) reported that almost 90 percent of 484 primiparous women resumed sexual activity by 6 months. And although 65 percent of these reported problems, only 15 percent discussed them with a health-care provider.

Intercourse too soon may be unpleasant, if not frankly painful, and this may be related to episiotomy incisions or severe lacerations. In a study of women without an episiotomy, only 0.4 percent of those with a first- or second-degree tear had dyspareunia (Ventolini, 2014). Conversely, in primiparas with an episiotomy, 67 percent had sexual dysfunction at 3 months, 31 percent at 6 months, and 15 percent at 12 months (Chayachinda, 2015). Dyspareunia was also common following cesarean delivery (McDonald, 2015).

Postpartum, the vulvovaginal epithelium is thin, and very little lubrication follows sexual stimulation. This stems from the hypoestrogenic state following delivery, which lasts until ovulation resumes. It may be particularly problematic in breastfeeding women who are hypoestrogenic for many months postpartum (Palmer, 2003). For treatment, small amounts of topical estrogen cream can be applied daily for several weeks to vulvar tissues. Additionally, vaginal lubricants may be used with coitus.

This same thinning of the vulvovaginal epithelium can lead to dysuria. Topical estrogen can again be offered once cystitis is excluded.

Late Maternal Morbidity

Taken together, major and minor maternal morbidity are surprisingly common in the months following childbirth. In a survey of 1249 British mothers followed for up to 18 months, 3 percent required hospital readmission within 8 weeks (Glazener, 1995; Thompson, 2002). Milder health problems during the first 8 weeks were reported by 87 percent (Table 36-5). Moreover, almost three fourths continued to have various problems for up to 18 months. Practitioners should be aware of these potential issues in their convalescing patients.

Follow-Up Care

By discharge, women who had an uncomplicated vaginal delivery can resume most activities, including bathing, driving, and household functions. Jimenez and Newton (1979) tabulated cross-cultural information on 202 societies from various international geographical regions. Following childbirth, most societies did not restrict work activity, and approximately half expected a return to full duties within 2 weeks. Wallace and coworkers (2013) reported that 80 percent of women who worked during pregnancy resume work by 1 year after delivery. Despite this, Tulman and Fawcett (1988) reported that only half of mothers regained their usual level of energy by 6 weeks. Women who delivered vaginally were twice as likely to have normal energy levels at this time compared with those with a cesarean delivery. Ideally, the care and nurturing of the infant should be provided by the mother with ample help from the father.

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) recommend a postpartum visit between 4 and 6 weeks. This has proven quite satisfactory to identify abnormalities beyond the immediate puerperium and to initiate contraceptive practices.