Physiology

• The puerperium is the 6 weeks after delivery when the reproductive tract returns to its non-pregnant state.
• Immediately after delivery, the uterus shrinks down to the level of the umbilicus. By 2 weeks postpartum, it is no longer palpable above the symphysis. By 6 weeks, the uterus has returned to its non-pregnant size.
• Decidual sloughing after delivery results in a physiologic vaginal discharge, known as lochia.
• The abdomen will resume its pre-pregnancy appearance, with the notable exception of abdominal striae (“stretch marks”). These fade with time.
• Most women will experience the return of menstruation by 6–8 weeks postpartum.

Postpartum Care

• In the immediate postpartum period, maternal vital signs should be taken frequently, the uterine fundus should be palpated to ensure it is well contracted, and the amount of vaginal bleeding should be noted.
• Early ambulation is encouraged regardless of the route of delivery. Adequate pain management is essential.
• Shortly after birth, neonates should receive topical ophthalmic prophylaxis (to prevent ophthalmia neonatorum) and vitamin K (to prevent hemorrhagic disease of the newborn due to a physiologic deficiency of vitamin K-dependent coagulation factors).
• Before discharge, skilled nursing staff should be made available to prepare the mother for the care of the newborn. The mother should receive anti-D immunoglobulin (if she is rhesus [Rh] negative and her baby Rh-positive) and MMR (measles, mumps, rubella) vaccine (if she is rubella non-immune).
• Coitus can be resumed 2–3 weeks after delivery depending on the patient’s desire and comfort. Contraception is necessary to prevent conception.
• A routine visit is recommended 6 weeks postpartum. Contraceptive counseling and breastfeeding should be addressed.

Lactation and breastfeeding

Development of the Mammary Gland

Mammogenesis refers to the growth and development of the mammary gland which begins at puberty. Pregnancy is required for final alveolar growth. Lactogenesis refers to the production of breast milk which begins during pregnancy. Full milk synthesis, however, only occurs after delivery when estrogen levels decline thereby allowing prolactin to act unopposed to promote milk production.

• Advantages. Breastfed infants have a lower incidence of allergies, gastrointestinal infections, otitis media, respiratory infections, and (possibly) higher intelligence quotient (IQ) scores. Women who breastfeed appear to have a lower incidence of breast cancer, ovarian cancer, and osteoporosis. Breastfeeding is also a bonding experience between infant and mother.
• Contraindications. HIV, cytomegalovirus, and possibly chronic hepatitis B or C. Most drugs given to the mother are secreted to some extent into breast milk, but the amount of drug ingested by the infant is typically small. There are some drugs, however, in which breastfeeding is contraindicated (radioisotopes, cytotoxic agents).
• Physiology. Prolactin is essential for lactation. Women with pituitary necrosis (Sheehan syndrome) do not lactate. Cigarette smoking, diuretics, bromocriptine, and combined oral contraceptives (not the progestin-only pill) decrease milk production.
• Colostrum is a lemon-colored fluid secreted by the breasts during the first 4–5 days postpartum. It contains more minerals and protein than mature milk, but less sugar and fat. Mature milk production is established within a few days. It contains high concentrations of lactose, vitamins (except vitamin K), immunoglobulins, and antibodies.

Complications of the Puerperium

Breast Engorgement

• May occur on days 2–4 postpartum in women who are not nursing or at any time if breastfeeding is interrupted.
• Conservative measures (tight-fitting brassiere, ice packs, analgesics) are usually effective. Bromocriptine may be indicated in refractory cases.

Mastitis

• This refers to a regional infection of the breast parenchyma, usually by Staphylococcus aureus.
• Incidence. Uncommon. More than 50% of cases occur in primiparas.
• Mastitis is a clinical diagnosis with fever, chills, and focal unilateral breast erythema, edema, and tenderness. It usually occurs during the third or fourth week postpartum.
• Treatment. Overcome ductal obstruction (by continuing breastfeeding or pumping), symptomatic relief, and oral antibiotics (usually flucloxacillin). Ten percent of women will develop an abscess requiring surgical drainage.

Endometritis

• This refers to a polymicrobial infection of the endometrium that often invades the underlying myometrium.
• Incidence. Less than 5% after vaginal delivery, but 5- to 10-fold higher after cesarean section delivery.
• Risk factors. Cesarean section delivery, prolonged rupture of membranes, multiple vaginal examinations, manual removal of the placenta, and internal fetal monitoring.
• Endometritis is a clinical diagnosis with fever, uterine tenderness, a foul purulent vaginal discharge, and/or increased vaginal bleeding. It occurs most commonly 5–10 days after delivery.
• Treatment. Broad-spectrum antibiotics (until the patient is clinically improved and afebrile for 24–48 hours) and dilation and curettage (if retained products of conception are suspected).
• Complications. Abscess, septic pelvic thrombophlebitis.

Necrotizing Fasciitis

• Refers to necrotic infection of the superficial fascia that spreads rapidly along tissue planes to the abdominal wall, buttock, and/or thigh, leading to septicemia and circulatory failure. The maternal mortality rate approaches 50%.
• Diagnosis. Skin edema, blue–brown discoloration, or frank gangrene with loss of sensation or hyperesthesia.
• Treatment. Early diagnosis, antibiotics, aggressive surgical debridement.

Psychiatric Complaints

• A mild transient depression (“postpartum blues”) is common after delivery, occurring in >50% of women.
• Postpartum depression occurs in 8–15% of women. Risk factors include a history of depression (30%) or prior postpartum depression (70–85%). Symptoms develop 2–3 months postpartum and resolve slowly over the next 6–12 months. Supportive care and monthly follow-up are necessary.
• Postpartum psychosis is rare (1–2 per 1,000 live births). Risk factors include young age, primiparity, and a personal or family history of mental illness. Symptoms typically start 10–14 days postpartum. Hospitalization,
pharmacologic and/or electroconvulsive therapy (ECT) may be necessary. Recurrence of postpartum psychosis is high (25–30%).