Obstetrics and Gynaecology chapters
Puerperium and its complications
The six weeks after childbirth: how the uterus involutes, the types of lochia, normal recovery, and the main complications, including puerperal pyrexia and sepsis, secondary PPH, thromboembolism, breast problems and postnatal mood disorders.
- The puerperium is the 6 weeks after delivery of the placenta: the uterus shrinks from about 1 kg to under 100 g and is not palpable abdominally by 2 weeks; lochia passes from rubra to serosa to alba.
- Puerperal pyrexia = 38°C or more on two separate days within days 1-10, not counting the first 24 hours; the key cause is genital tract sepsis (group A streptococcus is the killer); secondary PPH is usually endometritis or retained products.
- Mood: blues are common and pass by 2 weeks; depression peaks around 6 weeks; puerperal psychosis starts abruptly around day 5 and is an emergency.
On this page
Overview
The puerperium is the 6-week period after the end of the third stage of labour, during which the body returns to its non-pregnant state.
- It is a dangerous time: most maternal deaths, most fatal thromboembolism and about half of eclamptic fits happen after delivery.
- It is also the time of highest risk in a woman's life for serious mental illness.
- Main problems: infection, bleeding, thromboembolism, hypertension, bladder and bowel trouble, breast problems and mood disorders.
Normal physiological changes
Uterine involution
- Weight falls from about 1 kg after delivery to under 100 g.
- Mechanism: autolysis; muscle cells shrink, their number does not fall. The released protein is excreted in the urine.
- Fundal height: just after delivery about 12 cm above the symphysis (a little below the umbilicus).
| Day | Approximate uterine size |
|---|---|
| 1 | 18-week size, just below the umbilicus |
| 7 | 14-week size |
| 14 | 12-week size; no longer palpable above the symphysis |
- Breastfeeding speeds involution (oxytocin release). The uterus is larger after caesarean section and in multiparas.
- Causes of slow involution: full bladder, loaded rectum, retained products or clots, infection, fibroids, broad ligament haematoma.
Cervix
- Admits two fingers in the first days, one finger by the end of week 1; the internal os is closed by 2 weeks.
- The external os may stay slightly open for good (the parous cervix).
Lochia
Lochia is the discharge of blood and shed superficial decidua from the healing placental bed. The basal decidua regenerates the endometrium by about 3 weeks.
| Type | Colour | Timing |
|---|---|---|
| Lochia rubra | Red | First few days |
| Lochia serosa | Pink to serous | By the second week |
| Lochia alba | Scanty yellow-white | Lasts up to about a month |
Persistent red lochia or offensive lochia is not normal; think of retained placental tissue or endometritis.
"Red, Serous, White: Rubra, Serosa, Alba", in the same order as the colours fade.
Other systems
- Bladder: after an epidural, sensation can take up to 8 hours to return while urine output is high; retention can damage the detrusor. She should pass a reasonable volume (at least 300 mL) by 6 hours; otherwise catheterise.
- Bowel: constipation is common; after a third- or fourth-degree tear give lactulose and a bulking agent to avoid straining.
- Breasts: colostrum, then milk by around day 2-3.
Postnatal care
- BP is the only routine test at every visit in the first week.
- Give anti-D to Rh D-negative mothers of Rh D-positive babies; offer MMR to non-immune women.
- Check Hb on day 1-3 after PPH or complicated birth; transfuse if symptomatic or Hb below 70 g/L, otherwise oral iron.
- Ask about mood at each contact; check for danger signs: heavy bleeding, fever and offensive loss, headache with visual upset, unilateral leg swelling, chest pain or breathlessness.
- Six-week check: physical and mental health, BP, urine, bladder, bowel and sexual function, contraception, pelvic floor exercises, baby's progress and vaccines.
Puerperal pyrexia
Definition: a temperature of 38°C or above on two separate days within the first 10 days after delivery, ignoring the first 24 hours.
| Site | Clues |
|---|---|
| Genital tract (endometritis, parametritis) | Offensive lochia, tender bulky uterus, secondary PPH |
| Urinary tract | Dysuria, frequency, loin pain; catheter use |
| Breast | Engorgement (days 2-3) or mastitis (later) |
| Wound (caesarean or perineal) | Red, swollen, discharging wound |
| Chest | Atelectasis or aspiration (Mendelson syndrome) after general anaesthesia, mostly in the first 24 hours |
| Legs | DVT: unilateral calf swelling and pain |
| Throat and others | Consider other infections (malaria, dengue, typhoid in Pakistan) |
A raised temperature in the first 24 hours after a vaginal birth often has no infective cause (about 80% have none), but fever after a caesarean section should be taken as infection (wound, uterus, urine, chest) until proved otherwise.
Puerperal sepsis (genital tract infection)
Organisms
- Usually polymicrobial, from the bowel and lower genital tract.
- Group A beta-haemolytic streptococcus (Streptococcus pyogenes) causes more than half of maternal sepsis deaths and can kill within hours.
- Others: group B and D streptococci, Staphylococcus aureus, E. coli, Klebsiella, Proteus, anaerobes (Bacteroides, Peptostreptococcus, Clostridium), Chlamydia, mycoplasmas.
Risk factors
| Group | Factors |
|---|---|
| Maternal | Obesity, diabetes, HIV |
| Antenatal | Prolonged rupture of membranes, chorioamnionitis, cervical cerclage |
| Intrapartum | Prolonged labour, many vaginal examinations, instrumental birth, caesarean section (especially in labour), manual removal of placenta, retained products |
Spread
- Ascending to tubes and ovaries: salpingo-oophoritis, pelvic peritonitis, pelvic abscess.
- Direct into myometrium and parametrium: endometritis, parametritis (pelvic cellulitis).
- Lymphatic and blood-borne: septic thrombophlebitis, septicaemia and septic shock.
Features and management
- Malaise, fever, rigors, lower abdominal pain, offensive lochia, secondary PPH; tachycardia, boggy tender enlarged uterus, peritonism, ileus.
- Tests: blood cultures, high vaginal swab, MSU, wound swab, FBC, CRP, lactate; ultrasound for retained products or abscess.
- Mild or moderate: co-amoxiclav, or a cephalosporin plus metronidazole, starting IV if unwell.
- Severe sepsis: early high-dose IV broad-spectrum antibiotics, IV fluids, high-dependency care, remove the source (evacuate retained products, drain pus).
- Necrotising fasciitis of a perineal or caesarean wound (often Clostridium perfringens among mixed anaerobes): urgent wide surgical debridement.
Prevention: hand hygiene (Semmelweis), aseptic technique, and a single dose of prophylactic antibiotic before the skin incision at caesarean section.
Secondary postpartum haemorrhage
Definition: fresh bleeding from the genital tract from 24 hours to 6 weeks after delivery; it peaks between days 7 and 14. Primary PPH (loss of 500 mL or more within 24 hours) is covered in its own chapter.
| Feature | Endometritis | Retained products |
|---|---|---|
| Pain | Constant lower abdominal pain | Crampy pain |
| Uterus | Tender | Larger than expected, may be tender |
| Internal os | Closed | Open |
| History | Risk factors for infection | Prolonged third stage, ragged membranes or incomplete placenta, passing tissue |
- Both may cause fever and smelly lochia.
- Management: resuscitate if heavy; antibiotics (broad-spectrum, e.g. cephalosporin plus metronidazole); uterotonics (e.g. ergometrine); evacuation of retained tissue under antibiotic cover.
- Ultrasound helps only if the cavity is clearly empty; clots and debris are normal.
- Rarer causes: bleeding disorders (von Willebrand disease), hormonal contraception, choriocarcinoma.
Bleeding with an open os and a bulky uterus points to retained products; a closed os and tender uterus points to endometritis.
Thromboembolism
- Risk rises about fivefold in pregnancy and the puerperium; most fatal cases are postnatal, especially after caesarean section.
- Extra risks: obesity, multiple pregnancy, hypertension, PPH, immobility.
- Prevention: early mobilisation, hydration, low-molecular-weight heparin for 1-6 weeks in women with several risk factors.
- If DVT or PE is suspected, start full anticoagulation first, then confirm with compression Doppler ultrasound or a lung scan.
Other puerperal problems
| Problem | Key points |
|---|---|
| Postnatal hypertension and pre-eclampsia | Risk persists in the first week; continue antihypertensives (labetalol, nifedipine) and reduce as BP settles |
| Perineal pain and wound breakdown | Cooling, paracetamol, NSAID; avoid codeine; breakdown is usually infection: clean, antibiotics, heal by secondary intention, resuture only when clean |
| Urinary retention | After epidural, instrumental birth, big tears or haematoma; catheterise |
| Obstetric fistula | After prolonged obstructed labour: pressure necrosis; constant leakage starts around the second week when slough separates. Still common in Pakistan |
| Obstetric palsy | Foot-drop and sensory loss after prolonged or obstructed labour (lumbosacral plexus compression) or common peroneal nerve pressure from lithotomy poles |
| Symphysis pubis diastasis | Pubic pain on walking, waddling gait; rest, analgesia, physiotherapy, pelvic support |
Breasts and breastfeeding
- Colostrum: yellowish, rich in protein (especially IgA), less sugar and fat; replaced by milk from about day 2.
- Prolactin (anterior pituitary) makes milk; suckling suppresses hypothalamic dopamine (prolactin-inhibiting factor).
- Oxytocin (posterior pituitary) causes the let-down (milk ejection) reflex and the after-pains.
- Breast milk has less protein and sodium than cow's milk, more lactose; iron is poorly concentrated but well absorbed (lactoferrin). It lacks vitamin K, so babies receive vitamin K at birth.
- Bromocriptine or cabergoline (dopamine agonists) suppress lactation, but a firm bra and simple analgesia are usually preferred.
Breast problems
| Problem | Timing and features | Management |
|---|---|---|
| Engorgement | Days 2-3; tense, painful breasts; fever up to 39°C lasting under a day | Feed on demand with good attachment |
| Cracked nipples | After the first week; pain during feeds | Correct positioning; rest the side and express |
| Mastitis | Usually week 3-4; red, hot, tender segment, flu-like illness | Massage, analgesia; if worse, culture milk and give flucloxacillin; keep breastfeeding |
| Breast abscess | About 10% of mastitis; fluctuant tender lump (ultrasound) | Incision and drainage (radial incision) |
| Galactocele | Painless milk-filled cyst | Usually settles; aspirate if needed |
The commonest organism in puerperal mastitis is Staphylococcus aureus; breastfeeding or expressing should continue from the affected breast.
Postnatal psychiatric disorders
| Feature | Postnatal blues | Postnatal depression | Puerperal psychosis |
|---|---|---|---|
| Frequency | Up to 80% | About 10-15% in the first year | 1 in 500 to 1 in 1,000 |
| Onset | Within the first 2 weeks | Gradual, commonly around 6 weeks | Abrupt, rarely before day 3, typically day 5, usually within 4 weeks |
| Features | Tearful, irritable, poor sleep, mild | Low mood, loss of interest, early waking, guilt, poor appetite, thoughts of self-harm or harming the baby | Agitation, confusion, insomnia, delusions and hallucinations, loss of insight; high suicide and infanticide risk |
| Main risk factors | Hormonal changes | Past depression, social isolation, poor support, adverse events, severe blues | Previous puerperal psychosis, bipolar disorder (personal or family) |
| Management | Reassurance; review if lasting over 2 weeks | Support, counselling, CBT; SSRIs or tricyclics are compatible with breastfeeding | Urgent psychiatric admission, ideally a mother-and-baby unit; antipsychotics, lithium for mania, ECT for severe depressive psychosis |
- Screen mood at booking and at least twice after birth with two short questions (feeling down or hopeless; little interest or pleasure); the Edinburgh Postnatal Depression Scale is a common tool.
- Check thyroid function in women with low mood in the first year (postpartum thyroiditis can cause hypothyroidism).
- After puerperal psychosis, the recurrence risk is about 1 in 2 in a later pregnancy; consider prophylactic lithium from the first postnatal day.
Progestogens do not treat postnatal depression and should not be used for it.
Postpartum contraception
- Lactational amenorrhoea: less than 2% chance of pregnancy in the first 6 months if fully breastfeeding and still amenorrhoeic.
- Progestogen-only pill: start around day 21; safe in breastfeeding.
- Combined pill: avoid in the early puerperium (clot risk; reduces milk); non-breastfeeding women can start at 3 weeks, because ovulation can return by 4-6 weeks.
- Injectable (DMPA): preferably at 5-6 weeks (earlier use causes irregular bleeding).
- IUCD: after 4-8 weeks to allow involution; insert carefully in breastfeeding women (higher perforation risk).
- Sterilisation: at caesarean section, by minilaparotomy in the first days, or better laparoscopically after 6 weeks.
Expect: the length of the puerperium; the uterus no longer palpable by about 2 weeks and involution by autolysis; the order and timing of lochia rubra, serosa and alba; the definition of puerperal pyrexia; the commonest sites of fever and the meaning of fever after caesarean section; group A streptococcus as the main cause of fatal sepsis and risk factors for sepsis; secondary PPH timing and the closed-os endometritis versus open-os retained products; mastitis with Staphylococcus aureus, flucloxacillin and continued feeding; breast abscess drainage; the timing, frequency and treatment of blues, depression and psychosis; obstetric fistula after obstructed labour; when to start the POP, combined pill, IUCD and injectable after birth.
Quick revision
- Puerperium = 6 weeks; uterus 1 kg → under 100 g; not palpable by 2 weeks.
- Lochia: rubra (days) → serosa (week 2) → alba (up to a month); persistent red = retained tissue or infection.
- Puerperal pyrexia: 38°C or more on 2 of days 1-10, excluding the first 24 hours.
- Sepsis: polymicrobial; group A strep kills; co-amoxiclav or cephalosporin plus metronidazole.
- Secondary PPH: 24 hours to 6 weeks, peak days 7-14; endometritis (closed os) or retained products (open os).
- Mastitis: Staph aureus, flucloxacillin, keep feeding; abscess → drainage.
- Blues 80% (pass in 2 weeks); depression 10-15% (around 6 weeks); psychosis 1 in 500-1,000 (abrupt, day 5).
- POP from day 21; combined pill at 3 weeks if not breastfeeding; IUCD 4-8 weeks.
Written by The House Job from standard references (Obstetrics by Ten Teachers).
FAQ
When is fever after childbirth called puerperal pyrexia?
When the temperature reaches 38°C or more on any two of the first ten days after delivery, not counting the first 24 hours.
Should a woman with mastitis stop breastfeeding?
No. Emptying the breast helps the inflammation settle; she should keep feeding or expressing while taking flucloxacillin if infection is likely.
How do you tell puerperal psychosis from postnatal blues?
Blues are mild, very common and settle within two weeks; psychosis is rare, starts suddenly in the first weeks with confusion, delusions or hallucinations, and needs urgent psychiatric admission.
What causes secondary postpartum haemorrhage?
Most cases are due to endometritis or retained placental tissue, often together; rare causes include bleeding disorders and choriocarcinoma.