After studying this chapter you should be able to:
Knowledge criteria
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Describe the normal maternal changes in the puerperium
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Describe the aetiology, diagnosis and management of the common abnormalities of the postpartum period, including thromboembolism, problems with lactation, puerperal pyrexia, anaemia and maternal collapse
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Describe the normal changes in the neonatal period
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Discuss the sequelae of obstetric complications (e.g. preterm delivery)
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Describe the principles of resuscitation of the newborn
Clinical competencies
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Carry out a newborn baby examination
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Carry out a routine postnatal clinical review
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Provide contraceptive advice to a woman in the postnatal period
Professional skills and attitudes
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Consider the importance of breastfeeding on childhood health
The normal postpartum period
Puerperium is the Latin word for childbirth, so we use it with license to mean the postpartum period from the birth of the baby through to involution of the uterus at 6 weeks. Emptying the uterus of the baby and the placenta is necessary for lactation or a return to fertility.
Physiological changes
Genital tract
The uterus weighs 1 kg after birth, but less than 100 g by 6 weeks. Uterine muscle fibres undergo autolysis and atrophy and within 10 days the uterus is no longer palpable abdominally ( Fig 13.1 ). By the end of the puerperium, the uterus has largely returned to the non-pregnant size. The endometrium regenerates within 6 weeks and menstruation occurs within this time if lactation has ceased. If lactation continues, the return of menstruation may be deferred for 6 months or more.
Discharge from the uterus is known as lochia. At first this consists of blood, either fresh or altered (lochia rubra) and lasts 2–14 days. It then changes to a serous discharge (lochia serosa), and finally becomes a slight white discharge (lochia alba). These changes may continue for up to 4–8 weeks after delivery. Abnormal persistence of lochia rubra may indicate the presence of retained placental tissue or fetal membranes.
Cardiovascular system
Cardiac output and plasma volume return to normal within approximately 1 week. There is a fluid loss of 2 L during the first week and a further loss of 1.5 L over the next 5 weeks. This loss is associated with an apparent increase in haematocrit and haemoglobin concentration. There is an increase of serum sodium and plasma bicarbonate as well as plasma osmolality. An increase in clotting factors during the first 10 days after delivery is associated with a higher risk of deep vein thrombosis and pulmonary embolism. There is also a rise in platelet count and greater platelet adhesiveness. Fibrinogen levels decrease during labour but increase in the puerperium.
Endocrine changes
There are rapid changes in the endocrine system in all facets. There is a rapid fall in the serum levels of oestrogens and progesterone and they reach non-pregnant levels by the 7th postnatal day. This is associated with an increase in serum prolactin levels in those women who breastfeed. By the tenth postnatal day, human chorionic gonadotrophin (hCG) is no longer detectable.
The importance of breastfeeding
Colostrum
Colostrum is the first milk and is present in the breast from 12–16 weeks of pregnancy. Colostrum is produced for up to 5 days following birth before evolving into transitional milk, from 6–13 days and finally into mature milk from 14 days onwards. It is thick and yellow in colour, due to β-carotene and has a mean energy value of 67 kcal/dL, compared to 72 kcal/dL in mature milk. The volume of colostrum per feed varies from 2–20 mL in keeping with the size of the newborn’s stomach.
Linked with the importance of the baby having colostrum as its first food, is the importance of the baby being skin-to-skin with its mother after birth. This has the benefit of the baby being colonized by its mother’s bacteria. Colonizing starts during the birth process for vaginally born infants, while those born via caesarean section are more likely to colonize bacteria from the air. Early breastfeeding also promotes tolerance to antigens, thus reducing the number of food allergies in breast-fed babies. The development of healthy intestinal flora also reduces the incidence of allergic disease, inflammatory gut disease and rotavirus diarrhoea in infants.
While breastfeeding is desirable and women should be encouraged, the overall wishes of the woman should not be ignored. There are social and often emotional reasons why a woman may choose not to breastfeed. In some cases, it is not possible or even advisable, such as inverted nipples, previous breast surgery, breast implants, cracked or painful nipples or because the mother may have a condition, e.g. HIV positive mothers, or may be on medical treatment, e.g. chemotherapeutic agents that serve as a contraindication to breastfeeding.
Breastfeeding
The breasts and nipples should be washed regularly. The breasts should be comfortably supported and aqueous-based emollient creams may be used to soften the nipple and thus avoid cracking during suckling. Suckling is initially limited to 2–3 minutes on each side, but subsequently this period may be increased. Once the mother is comfortably seated, the whole nipple is placed in the infant’s mouth, taking care to maintain a clear airway ( Fig. 13.2 ). Correct attachment of the baby to the breast is essential to the success of breastfeeding. The common problems such as sore nipples, breast engorgement and mastitis usually occur because the baby is poorly attached to the breast or is not fed often enough. Most breastfeeding is given on demand and the milk flow will meet the demand stimulated by suckling. Once the baby is attached correctly to the nipple, the sucking pattern changes from short sucks to long deep sucks with pauses. It may, on occasions, be necessary to express milk and store it, either because of breast discomfort or cracked nipples or because the baby is sick. Milk can be expressed manually or by using hand or electric pumps. Breast milk can be safely stored in a refrigerator at 2–4°C for 3–5 days or frozen and stored for up to 3 months in the freezer.
In women who choose not to breastfeed, have suffered a stillbirth or intrauterine death or where there is a contraindication to breast feeding, suppression of lactation may be achieved by conservative methods or by drug therapy. Firm support of the breasts, restriction of fluid intake, avoidance of expression of milk and analgesia may be sufficient to suppress lactation. The administration of oestrogens will effectively suppress lactation but carries some risk of thromboembolic disease. The preferred drug therapy is currently the dopamine receptor agonist cabergoline. This can be given as a single dose and will inhibit prolactin release and hence suppress lactation. Bromocriptine is also effective, but the dosage necessary to produce this effect tends to create considerable side effects.
Complications of the postpartum period
Puerperal infections
Puerperal sepsis has been reported as far back as the 5th century bc . The Centre for Maternal and Child Enquiries (CMACE 2006–2008) has highlighted the re-emergence of sepsis (in particular group A β-haemolytic streptococci) as a leading cause of maternal morbidity and mortality in the UK. Other common causes of infection are urinary tract infections, wound infections (perineum or caesarean section scar) and mastitis ( Box 13.1 and Fig 13.3 ).
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Genital tract infections
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Urinary infection
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Wound infection
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Mastitis
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Thromboembolism
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Incontinence/urinary retention
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Anal sphincter dysfunction
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Breakdown of episiotomy wound
In the puerperium, the placental surface in the womb is vulnerable to infection. This is exposed to the vagina, which harbours aerobic and anaerobic bacteria. Peripartum events, such as prolonged rupture of membranes, chorioamnionitis, repeated vaginal examinations, poor personal hygiene, bladder catheterization, invasive fetal monitoring, instrumental deliveries, caesarean sections, perineal trauma and manual removal of placenta lead to introduction of pathogens into the uterus and thus contribute to puerperal infections.
Endometritis
The patient with endometritis usually presents with fever, lower abdominal pain, secondary postpartum haemorrhage and foul smelling vaginal discharge. The organisms involved are group A β-haemolytic streptococci, aerobic Gram negative rods and anaerobes. On examination, the patient often has a fever, is tachycardic and is tender on palpation of the lower abdomen. There may be foul smelling vaginal discharge, bleeding and cervical excitation. The white cell count and C-reactive protein may be raised. Vaginal or blood cultures may identify the organism responsible. Broad spectrum antibiotics are the first-line treatment and resolution should start to occur within the first 48 hours. The complications of endometritis are parametritis, peritonitis, septic pelvic thrombophlebitis, pelvic abscesses and rarer is toxic shock syndrome.
Urinary tract infections (UTIs)
UTIs are the most common cause of puerperal infections. The predisposing factors include a history of previous UTIs, polycystic kidneys, congenital abnormalities of the renal tract, neuropathic bladder, urinary tract calculi but most are idiopathic. Patients present with voiding difficulties (e.g. urgency and frequency), dysuria, fever and pain in the renal angle. Urine analysis may be positive for protein and leucocytes, though nitrites are more sensitive. Urine should be sent for culture before commencing antibiotic treatment. The commonest organisms are Escherichia coli , Enterococcus , Klebsiella , Proteus and Staphylococcus epidermidis .
Mastitis and breast abscess
Presenting symptoms include breast pain, fever and erythema. The commonest organisms are S. aureus , S. epidermidis , or group A, B and F streptococci. Oral antibiotics are usually sufficient for mastitis but intravenous treatment is required for an abscess. In the case of an abscess, fluctuance will be elicited and surgical drainage may be warranted.
Caesarean wound infections and perineal infections
Puerperal infection is more common in caesarean sections than vaginal deliveries. Intraoperative antibiotics have helped reduce the incidence. The commonest organisms involved are S. aureus , methicillin-resistant S. aureus (MRSA), skin flora and those involved with endometritis. Complications include wound dehiscence and necrotizing fasciitis. Infection may also occur in episiotomy wounds or perineal tears, although these infections are relatively uncommon because the vascularity of the perineum provides a higher resistance to infection. The perineum becomes tender and reddened and may be seen to exude purulent discharge. Where wound breakdown occurs, the wound should be kept clean and allowed to heal by secondary intention. Resuturing should not be performed unless the wound is clean and there is no residual inflammation around the wound margins.
Other infections
Once more common sites of infection have been excluded, one must consider other sites of infection or sepsis. These include pneumonia, meningitis, bacterial endocarditis or even influenza, malaria and H1N1. The incidence of chest infection is greater in caesarean sections than vaginal births due to reduced mobility and reduced air entry secondary to pain or if the patient has had a general anaesthetic.
Thromboembolism
Thrombophlebitis
This is the commonest form of thromboembolic disease and tends to arise within the first 3–4 days after delivery. Localized inflammation, tenderness and thickening occur in the superficial leg veins. Although the condition is painful and may spread along the leg veins, it rarely leads to serious embolic disease and does not require anticoagulant treatment. Anti-inflammatory drugs and local applications of glycerine and ichthyol should be used.
Phlebothrombosis (see also Chapter 9 )
Deep vein thrombosis (DVT) is a much more serious complication that tends to arise 7–10 days after delivery and is particularly likely to occur after operative delivery or prolonged immobilization. Clotting occurring in deep veins may be silent and presents only when the clot breaks loose and lodges in the lung as a pulmonary embolus, with consequent chest pain dyspnea and haemoptysis. Clinical signs include local rhonchi and pleural rub on auscultation and a pulmonary perfusion. A ventilation scan or chest CT scan should help to confirm or refute the diagnosis. Massive pulmonary embolus (PE) results in sudden death unless treated by prompt surgical management. Successful treatments with antithrombolytic agents and fragmenting the clots with percutaneous arterial catheters have been reported.
Postnatal anticoagulation
National guidelines in the UK recommend that in non-pregnant patients, anticoagulant therapy should be continued for 6 weeks for calf vein thrombosis and three months for proximal DVT or PE when venous thromboembolism (VTE) has occurred in relation to a temporary risk factor and 6 months for a first episode of idiopathic VTE. The presence of continuing risk factors and the safety of low molecular weight heparin (LWMH) have led authorities to propose that anticoagulant therapy should be continued for the duration of the pregnancy and until at least 6 weeks postpartum, and to allow a total duration of treatment of at least 3 months. Both heparin and warfarin are satisfactory for use postpartum.
Neither heparin nor warfarin is contraindicated in breastfeeding. If the woman chooses to continue with LMWH postnatally, then either the doses that were employed antenatally can be continued or the manufacturers’ recommended doses for the non-pregnant patient can be employed. If the woman chooses to commence warfarin postpartum, this should be avoided until at least the third postnatal day. Daily testing of the international normalized ratio (INR) is recommended during the transfer from LMWH to warfarin to avoid over anticoagulation. Warfarin administration should be delayed in women with risk of postpartum haemorrhage.
Postnatal clinic review for women who develop VTE during pregnancy or the puerperium should ideally be at an obstetric medicine clinic or a joint obstetric haematology clinic. At the postnatal review, the continuing risk of thrombosis should be assessed, including a review of personal and family history of VTE and any thrombophilia screen results. Advice should be given on the need for thromboprophylaxis in any future pregnancy and at other times of increased risk. Hormonal contraception should be discussed.
Primary and secondary postpartum haemorrhage (PPH)
Please see Chapter 12 .
Anaemia
If the haemoglobin (Hb) is less than 7–8 g/dL in the postnatal period, where there is no continuing or threat of bleeding, the decision to transfuse should be made on an informed individual basis. In fit, healthy, asymptomatic patients there is little evidence of the benefit of blood transfusion. If severe bleeding was encountered and if bleeding disorders were suspected, appropriate investigations should be made. These investigations should be repeated on a non-urgent basis at least 3–6 months after delivery when pregnancy-related coagulation changes have settled.
Oral iron should be the preferred first-line treatment for iron deficiency. Parenteral iron is indicated when oral iron is not tolerated, absorbed or patient compliance is in doubt. Parenteral therapy offers a shorter duration of treatment and a quicker response than oral therapy. It is, however, more invasive and expensive to administer. Iron sucrose is given in multiple doses whereas iron dextran may be given as a single total-dose infusion. Recombinant human erythropoietin (rHuEPO) is mostly used in the anaemia of end-stage renal disease.
Maternal collapse
Maternal collapse is defined as an acute event involving the cardiorespiratory systems and/or brain, resulting in a reduced or absent conscious level (and potentially death), at any stage in pregnancy and up to 6 weeks after delivery. An obstetric early warning score chart should be used routinely for all women, to allow early recognition of the woman who is becoming critically ill. In some cases maternal collapse occurs with no prior warning, although there may be existing risk factors that make this more likely. Antenatal care for women with significant medical conditions at risk of maternal collapse should include multidisciplinary team input with a pregnancy and delivery management plan in place.
There are many causes of collapse, and these may be pregnancy-related or result from conditions not related to pregnancy and possibly existing before pregnancy. The common reversible causes of collapse in any woman can be remembered using the 4 Ts and the 4 Hs employed by the Resuscitation Council (UK) ( Table 13.1 ). In the pregnant woman, eclampsia and intracranial haemorrhage should be added to this list.
