Obstentrics_Williams

Obstentrics_Williams. Parents are ofered and encouraged to allow a full autopsy. That said, valuable information can still be obtained from limited studies. Pinar and coworkers (2012) described the autopsy protocol used by the Stillbirth Collaborative Research Network. As an alternative, gross external examination combined with photography, radiography, MR imaging, bacterial cultures, and selective use of chromosomal and histopathological studies often aids determination.


Obstentrics_Williams

Obstentrics_Williams. A complete autopsy is more likely to yield valuable data. An analysis of 400 consecutive fetal deaths in Wales showed that autopsy altered the presumed cause of death in 13 percent and provided new information in another 26 percent (Cartlidge, 1995). Other investigators have found that autopsy results changed the recurrence risk estimates and parental counseling in 25 to 50 percent of cases (Faye-Petersen, 1999; Silver, 2007). For example, Miller and associates (2016) recently demonstrated that placental examination with autopsy altered future medical management in 45 percent of cases.


Obstentrics_Williams

Obstentrics_Williams. According to the survey by Goldenberg and coworkers (2013), most hospitals do not audit stillbirths. In other centers, however, maternal records and autopsy findings are reviewed on a monthly basis by a stillbirth committee composed of obstetricians, maternal-fetal medicine specialists, neonatologists, clinical geneticists, and perinatal pathologists. If possible, the cause of death is assigned based on available evidence. Most importantly, parents are then contacted and ofered counseling regarding the reason for the death, the potential recurrence risk, and possible strategies to avoid recurrence.


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Obstentrics_Williams. Fetal death is psychologically traumatic for a woman and her family. Further stressors are an interval of more than 24 hours between the diagnosis of fetal death and labor induction, not seeing her infant for as long as she desires, having no tokens of remembrance, and poor communication (Radestad, 1996; Siassakos, 2017). The importance of seeing and holding a stillborn fetus for parental psychological well-being was recently summarized by Kingdon and colleagues (2015). As discussed in Chapter 61 (p. 1176), a woman experiencing a stillbirth or early miscarriage is at increased risk for depression and should be closely monitored (Nelson, 2013).


Obstentrics_Williams

Obstentrics_Williams. Nuzum and coworkers (2014) reported that few obstetrical providers receive formal training in perinatal bereavement care. At Parkland Hospital, this care includes time with the infant, keepsake items, photographs, chaplaincy consultation, and bereavement support information. Care is coordinated through a dedicated nursing team ailiated with labor and delivery.


Obstentrics_Williams

Obstentrics_Williams. Table 35-3 lists an outlined approach for women with prior stillbirth. Importantly, these recommendations are based primarily on limited or inconsistent scientiic evidence or on expert opinions. Unfortunately, few studies address management of afected women. Those with modiiable risk factors for stillbirth, such as hypertension or diabetes, warrant speciic prevention strategies. Given that obesity has been identiied as a risk factor for stillbirth and other obstetrical complications, preconceptional weight loss would seem prudent. Logically, women with a prior fetal death due to placental vascular events, that is, placental insuiciency, are also at increased risk for subsequent adverse perinatal outcomes (Monari, 2016). According to Reddy (2007), because almost half of fetal deaths are associated with growth restriction, fetal sonographic anatomical assessment beginning at midpregnancy is recommended. his is followed by serial growth studies beginning at 28 weeks. Supplementation with


Obstentrics_Williams

Obstentrics_Williams. with growth restriction, fetal sonographic anatomical assessment beginning at midpregnancy is recommended. his is followed by serial growth studies beginning at 28 weeks. Supplementation with vitamin C or E in pregnancy has not been demonstrated to reduce the risk of fetal death (Rumbold, 2015a,b).


Obstentrics_Williams

Obstentrics_Williams. Weeks and associates (1995) evaluated fetal biophysical testing in 300 women whose only indication was prior stillbirth. There was one subsequent stillbirth, and only three fetuses had abnormal testing results before 32 weeks. Notably, no relationship was found between the gestational age of the previous stillborn fetus and the incidence or timing of abnormal test results or fetal jeopardy in the subsequent pregnancy. These investigators concluded that antepartum surveillance should begin at 32 weeks or later in the otherwise healthy woman with a history of stillbirth. This recommendation is supported by the American College of Obstetricians and Gynecologists (2016a) with the caveat that it increases the iatrogenic preterm delivery rate. Although fetal movement counting strategies are routinely employed as described in Chapter 17 (p. 332), few data guide its use in clinical practice for those with a prior stillbirth (Mangesi, 2015).


Obstentrics_Williams

Obstentrics_Williams. Delivery at 39 weeks' gestation is recommended. Labor induction is suitable, and cesarean delivery is elected for those with a contraindication to induction. his timing minimizes TABLE 35-3. Management of Subsequent Pregnancy after Stillbirth Review evaluation of prior stillbirth Determination of recurrence risk Discuss recurrence of comorbid obstetric complications Thrombophilia screen: antiphospholipid antibodies First-trimester screen: pregnancy-associated plasma protein A, human chorionic gonadotropin, and nuchal Sonographic screening for fetal-growth restriction, Delivery before 39 weeks only with documented fetal aprovides risk modification but does not alter management. Modified from Reddy, 2007. fetal mortality rates, although the degree of risk reduction may be greater for older women (Page, 2013).


Obstentrics_Williams

Obstentrics_Williams. Following declines between 2000 and 2006, the United States fetal mortality rate has been relatively unchanged since 2006 (MacDorman, 2015). Interpretation of these fetal mortality rates in the context of changing national healthcare strategies has spawned considerable debate. One example is the efort to prevent non-medically indicated deliveries before 39 weeks and its subsequent efect on term stillbirth rates. he value of this practice for neonatal outcome is described in Chapter 26 (p. 504). To analyze whether implementation of this "39week rule" has altered the term stillbirth rate, Nicholson and coworkers (2016) examined data from 45 states and the District of Columbia during a 7 -year period. The proportion of births before 39 weeks progressively declined from 2007 and 2013, but the term stillbirth rate rose. his suggested that the 39-week rule may cause unintended harm. MacDorman and associates (2015) also evaluated trends in stillbirth rates by gestational ages in the United


Obstentrics_Williams

Obstentrics_Williams. term stillbirth rate rose. his suggested that the 39-week rule may cause unintended harm. MacDorman and associates (2015) also evaluated trends in stillbirth rates by gestational ages in the United States between 2006 and 2012. They used a "traditional stillbirth rate," which was calculated using a denominator composed of the live-birth number plus the stillbirth number at a given gestational age. They found increased rates at 24 to 27, 34 to 36, and 38 weeks' gestation. Alternatively, no diferences were found in "prospective stillbirth rates." These rates were calculated using a denominator composed of the number of women who are pregnant at a given gestational age for weeks 21 through 42. he discrepancies in stillbirth rates appear to be primarily due to the decline in the number of births in the preterm and early-term gestational ages.


Obstentrics_Williams

Obstentrics_Williams. To summarize, implementation of the 39-week rule has reduced the number of elective births before 39 weeks' gestation, although an unintended consequence may be an increase in term stillbirths-especially among women with medical complications. he importance of induction at less than 39 weeks in pregnant women with complications to prevent stillbirth is underscored by Little and colleagues (2015). These authors performed a retrospective multistate analysis of earlyterm deliveries (37°/7 to 386/7 weeks) from 2005 to 2011a. They noted a decline in the number of early-term deliveries during this time but not a signiicant change in the term stillbirth rates. There was, however, a 25-percent rise in the rate of term, singleton stillbirths among women with diabetes, and this was attributed to clinicians misapplying early-term delivery policies to high-risk women. Undoubtedly, continued surveillance of stillbirth rates is warranted for both high-and low-risk pregnancies at a state and


Obstentrics_Williams

Obstentrics_Williams. to clinicians misapplying early-term delivery policies to high-risk women. Undoubtedly, continued surveillance of stillbirth rates is warranted for both high-and low-risk pregnancies at a state and national level.


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Obstentrics_Williams. American College of Obstetricians and Gynecologists: Management of still birth. Practice Bulletin No. 102, March 2009, Reairmed 2016a American College of Obstetricians and Gynecologists: Microarrays and next-generation sequencing technology: the use of advanced genetic diagnostic tools in obstetrics and gynecology. Committee Opinion No. 682, December 2016b American College of Obstetricians and Gynecologists: Prenatal diagnostic test ing for genetic disorders. Practice Bulletin No. 162, May 2016c Blencowe H, Cousens 5, Bianchi JF, et al: National, regional, and worldwide estimates of stillbirth rates in 2015, wi th trends from 2000: a systematic analysis. Lancet Glob Health 4(2):e98, 2016 Cartlidge PH, Stewart JH: Efect of changing the stillbirth deinition on evalu ation of perinatal mortality rates. Lancet 346:486, 1995 Faye-Petersen OM, Guinn DA, Wenstrom KD: Value of perinatal autopsy.


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Obstentrics_Williams. Obstet Gynecol 94(6):915, 1999 FrettS RC: Etiology and prevention of stillbirth. Am J Obstet Gynecol 193(6):1923,t2005 Goldenberg L, Farrow V, McClure EM, et l: Stillbirth: knowledge and practice among U.S. obstetrician-gynecologists. Am J Perinatol30(l 0):813, 2013 Joseph KS, Kinniburgh B, Hutcheon JA, et al: Rationalizing deinitions and stillbirth. Obstet GynecoIt125(4):784, 2015 Kingdon C, Givens JL, O'Donnell E, et al: Seeing and holding Baby: systematic review of clinical management and parental outcomes ater stillbirth. Birth 42(3):206,t2015 Korteweg FJ, Bouman K, Erwich J,et al: Cytogenetic analysis after evaluation of 750 fetal deaths. Obstet Gynecol 111 :865, 2008 Little SE, Zera CA, Clapp A, et al: A multi-state analysis of early-term delivery trends and the association with term stillbirth. Obstet Gynecol 126(6):1138,t2015 MacDorman MF, Gregory EC: Fetal and perinatal mortaliry, United States, 2013. Natl Vital Stat Rep 64(8):1, 2015


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Obstentrics_Williams. MacDorman MF, Gregory EC: Fetal and perinatal mortaliry, United States, 2013. Natl Vital Stat Rep 64(8):1, 2015 MacDorman MF, Reddy UM, Silver M: Trends in stillbirth by gestational age in the United States, 2006-2012. Obstet GynecoIt126(6):1146, 2015 Mangesi L, Hofmeyr GJ, Smith V, et al: Fetal movement counting for assess ment offetal wellbeing. Cochrane Database Syst Rev 1O:CD004909, 2015 McPherson E, Nestoridi E, Heinke D, et al: Alternatives to autopsy for fetl and early neonatal (perinatal) deaths: insights from the Wisconsin stillbirth service program. Birth Defects Res September 12, 2017 [Epub ahead of print] Miller ES, Minturn L, Linn R, et al: Stillbirth evaluation: a stepwise assessment of placental pathology and autopsy. Am J Obstet Gynecol 214: 115, 2016 Monari F, Pedrielli G, Vergani P, et al: Adverse perinatal outcome in subsequent pregnancy after stillbirth by placental vascular disorders. PLoS One 11(5):e0155761,t2016


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Obstentrics_Williams. Monari F, Pedrielli G, Vergani P, et al: Adverse perinatal outcome in subsequent pregnancy after stillbirth by placental vascular disorders. PLoS One 11(5):e0155761,t2016 Nelson DB, Freeman MP, Johnson NL, et al: A prospective study of postpartum depression in 17,648 parturients. J Matern Fetal Neonatal Med 26(12):1155,t2013 Nicholson JM, Kellar LC, Ahmad S, et al: US term stillbirth rates and the 39-week rule: a cause for concern? Am J Obstet Gynecol 214:621, 2016 Nuzum D, Meaney S, O'Donoghue K: he impact of stillbirth on consultant obstetrician gynaecologists: a qualitative study. BJOG 121:1020,t2014 Page JM, Christiansen-Lindquist L, horsten V, et al: Diagnostic Tests for Evaluation of Stillbirth: Results From the Stillbirth Collaborative Research Network. Obstet Gynecolt129(4):699, 2017 Page JM, Snowden JM, Cheng W, et al: he risk of stillbirth and infant death by each additional week of expectant management stratiied by maternal age. Am J Obstet GynecoI209(4):375.e1, 2013


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Obstentrics_Williams. Page JM, Snowden JM, Cheng W, et al: he risk of stillbirth and infant death by each additional week of expectant management stratiied by maternal age. Am J Obstet GynecoI209(4):375.e1, 2013 Pauli M, Reiser CA: Wisconsin Stillbirth Service Program: II. Analysis of diagnoses and diagnostic categories in the irst 1,000 referrals. Am J Med Genet 50: 135, 1994 Pinar H, Goldenberg L, Koch MA, et al: Placental indings in singleton stillbirths. Obstet Gynecol 123:325,t2014 Pinar H, Koch A, Hawkins H, et al: The stillbirth collaborative research network postmortem examination protocol. Am J Perinatol 29:187, 2012 Radestad I, Steineck G, Nordin C, et al: Psychological complications after stillbirth-influence of memories and immediate management: population based study. BMJ 312:1505, 1996 Rasmussen S, Irgens LM, Skjaerven R, et al: Prior adverse pregnancy outcome and the risk of stillbirth. Obstet Gynecol 114(6): 1259, 2009


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Obstentrics_Williams. Rasmussen S, Irgens LM, Skjaerven R, et al: Prior adverse pregnancy outcome and the risk of stillbirth. Obstet Gynecol 114(6): 1259, 2009 Reddy UM: Prediction and prevention of recurrent stillbirth. Obstet Gynecol 110:1151,t2007 Reddy UM, Laughon SK, Sun L, et al: Prepregnancy risk factors for antepartum stillbirth in the United States. Obstet Gynecol 116:11t19,t2010 Reddy UM, Page GP, Saade GR, et al: Karyotype versus microarray testing for genetic abnormalities after stillbirth. N Engl J Med 367(23):2185,t2012 Rumbold A, Ota E, Hori H, et al: Vitamin E supplementation in pregnancy. Cochrane Database Syst Rev 9:CD004069, 2015a Rumbold A, Ota E, Nagata C, et al: Vitamin C supplementation in pregnancy. Cochrane Database Syst Rev 9:CD004072, 2015b Saller DN Jr, Lesser KB, Harrel U, et al: he clinical utility of the perinatal autopsy. JAMA 273:663, 1995 Sharma PP, Salihu HM, Oyelese Y, et al: Is race a determinant of stillbirth recurrence? Obstet Gynecol 107(2 Pt 1):391,2006


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Obstentrics_Williams. Sharma PP, Salihu HM, Oyelese Y, et al: Is race a determinant of stillbirth recurrence? Obstet Gynecol 107(2 Pt 1):391,2006 Shruthi M, Gupta N, Jana M, et al: Comparative study of conventional and virtual autopsy using postmortem MRI in the phenotypic characterization of stillbirths and malformed fetuses. Ultrasound Obstet Gynecol March 13, 2017 [Epub ahead of print] Siassakos D, Jackson S, Gleeson K, et al: ll bereaved parents are entitled to good care after stillbirth: a mixed-methods multicentre study (INSIGHT). B JOG July 31, 2017 [Epub ahead of print] Silver M:Fetal death. Obstet Gynecol 109: 153, 2007 Silver RM, Parker CB, Reddy UM, et al: Antiphospholipid antibodies in stillbirth. Obstet GynecoIt122(3):641, 2013 Silver RM, Saade GR, Thorsten V, et al: Factor V Leiden prothrombin G20210A, and methylene tetrahydrofolate reductase mutations and stillbirth: the Stillbirth Collaborative Research Network. Am J Obstet Gynecol 215:468,t2016


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Obstentrics_Williams. Society for Maternal-Fetal Medicine: he use of chromosomal micro array for prenatal diagnosis. Sociery for Maternal-Fetal Medicine (SMFM) Consult Series No. 41, October 2016 Stillbirth Collaborative Research Network Writing Group: Association between stillbirth and risk factors known at pregnancy conirmation. JAMA 306(22):2469,t2011a Stillbirth Collaborative Research Network Writing Group: Causes of death among stillbirths. JAMA 306(22):2459, 2011b The Lancet's Ending Preventable Stillbirths Series Study Group: Stillbirths: economic and psychosocial consequences. Lancet 387:604, 2016a The Lancet's Ending Preventable Stillbirths Series Study Group: Stillbirths: ending preventable deaths by 2030. Lancet 387:703, 2016b The Lancet's Ending Preventable Stillbirths Series Study Group: Stillbirths: progress and uninished business. Lancet 387:574, 2016c


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Obstentrics_Williams. The Lancet's Ending Preventable Stillbirths Series Study Group: Stillbirths: progress and uninished business. Lancet 387:574, 2016c The Lancet's Ending Preventable Stillbirths Series Study Group: Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet 387:587, 2016d The Lance's Ending Preventable Stillbirths Series Study Group: Stillbirths: recall to action in high-income countries. Lancet 387: 691, 2016e The Lancet's Stillbirths Series Steering Committee: Stillbirths: how can health systems deliver for mothers and babies? Lancet 377:1610, 20lla The Lancet's Stillbirths Series Steering Committee: Stillbirths: the vision for 2020. Lancet 3 7:1798,2011b The Lancet's Stillbirths Series Steering Committee: Stillbirths: the way forward in high-income countries. Lancet 7:1703,t2011c The Lancet's Stillbirths Series Steering Committee: Stillbirths: what diference can we make and at what cost? Lancet :1523, 2011d


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Obstentrics_Williams. The Lancet's Stillbirths Series Steering Committee: Stillbirths: what diference can we make and at what cost? Lancet :1523, 2011d The Lancet's Stillbirths Series Steering Committee: Stillbirths: where? When? Why? How to make the data count? Lancet 377: 1448, 2011e The Lancet's Stillbirths Series Steering Committee: Stillbirths: why they matter. Lancet 377:1353, 2011f Varner JW, Silver M, Rowland Hogue CJ, et al: Association between stillbirth and illicit drug use and smoking during pregnancy. Obstet Gynecol 123:113,t2014 Weeks JW, Asrat T, Morgan MA, et al: Antepartum surveillance for a history of stillbirth: when to begin? Am J Obstet Gynecol 172:486, 1995 The Puerperi um REPRODUCTIVE TRACT INVOLUTION ................ 652 PLACENTAL SITE INVOLUTION.. . . . . . . . . . . . . . . . .. 654 URINARY TRACT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 654 PERITONEUM AND ABDOMINAL WALL ............. 655 BLOOD AND BLOOD VOLUME .........0............ 655


Obstentrics_Williams

Obstentrics_Williams. PERITONEUM AND ABDOMINAL WALL ............. 655 BLOOD AND BLOOD VOLUME .........0............ 655 LACTATION AND BREASTFEEDING ................ 656 HOSPITAL CARE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 659 HOME CARE ................................... 663 Although the changes occurring during the puerperium are considered as physiological, they border vey closey upon the pathological, in as much as under no other circumstances does such marked and rapid tissue metabolism occur without a departure rom a condition of health. -J. Whitridge Williams (1903)


Obstentrics_Williams

Obstentrics_Williams. -J. Whitridge Williams (1903) 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.


Obstentrics_Williams

Obstentrics_Williams. Return of the tissues in the birth canal to the nonpregnant state begins soon ater delivery. he 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. he hymen is represented by several small tags of tissue, which scar to form the mytom caunces. 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 loor may be inevitable, and parturition predisposes to urinary incontinence and pelvic organ prolapse.


Obstentrics_Williams

Obstentrics_Williams. The massively increased uterine blood flow necessary to maintain pregnancy is made possible by signiicant hypertrophy and remodeling of pelvic vessels. After delivery, their caliber gradually diminishes to approximately that of the prep regnant 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 The Puerperium 653 TABLE 36-1 . Pregnancy Risk Assessment Surveillance System-PRAMSa Concerns Raised by Women in the First 2-9 Months Postpartum


Obstentrics_Williams

Obstentrics_Williams. The Puerperium 653 TABLE 36-1 . Pregnancy Risk Assessment Surveillance System-PRAMSa Concerns Raised by Women in the First 2-9 Months Postpartum Help with postpartum depression 10 aCenters for Disease Control and Prevention, 201n6. Data from Kanotra 5, D'Angelo 0, Phares TM, et al: Challenges faced by new mothers in the early postpartum period: an analysis of comment data from the 2000 Pregnancy Risk Assessment Monitoring System (PRAMS) survey. Matern Child Health J 11 (6):549,n2007.


Obstentrics_Williams

Obstentrics_Williams. labor, it readily admits two ingers. 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).


Obstentrics_Williams

Obstentrics_Williams. Ater 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 forceully 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.


Obstentrics_Williams

Obstentrics_Williams. Myometrial involution is a truly remarkable feat of destruction or deconstruction that begins as soon as 2 days ater 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 (8) cervices. 12.8 12.4 10 9 Cavity length 7.6 6.7 AP diameter 6.4 E) 10 12 ;:) 8 6 FIGURE 36-2 Sonographic measurements of uterine involution during the first 9 days postpartum. AP = anteroposterior. (Data from Hytten F: The Clinical Physiology of the Puerperium. London, Farrand Press, 1995.) 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. Ater each successive delivery, the uterus is usually slightly larger than before the most recent pregnancy.


Obstentrics_Williams

Obstentrics_Williams. 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) identiied 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 (l9��) 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 diferent in preeclamptic women because they more likely had early diastolic notches seen on


Obstentrics_Williams

Obstentrics_Williams. during the first 5 days postpartum. Weintraub and colleagues (2013) posited that uterine involution may be diferent in preeclamptic women because they more likely had early diastolic notches seen on uterine artery velocimetry.


Obstentrics_Williams

Obstentrics_Williams. 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 ater delivery, the remaining decidua becomes diferentiated into two layers. he 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 ully restored endometrium in all biopsy specimens obtained from the 16th day onward. Histological endometritis is part of the normal reparative process.


Obstentrics_Williams

Obstentrics_Williams. vforeover, 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). 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 aterpains, which are similar to but milder than labor contractions. hese 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.


Obstentrics_Williams

Obstentrics_Williams. Lochia. Early in the puerperium, sloughing of decidual tissue results in a vaginal discharge of variable quantity. he discharge is termed lochia and contains erythrocytes, shredded decidua, epithelial cells, and bacteria. For the irst few days ater delivery, there is blood suicient to color it red-lochia rubra. Ater 3 or 4 days, lochia becomes progressively pale in color-lochia serosa. ter approximately the 10th day, because of an admixture of leukocytes and reduced fluid content, lochia assumes a white or yellow-white color-lochia alba. he 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.


Obstentrics_Williams

Obstentrics_Williams. 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 supericial tissues followed by a remodeling process.


Obstentrics_Williams

Obstentrics_Williams. 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 soter than would be expected. With bleeding, pelvic sonography may help exclude retained placenta or, less-commonly, vascular malformations as the source (lraha, 2017). Methylergonovine (Methergine), 0.2 mg orally every 3 to 4 hours for 24 to 48 hours, is recommended by many, but its eicacy 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 Chamydia trachomatis. For mild infection, empirical therapy with azithromycin or doxycycline usually prompts resolution regardless of bacterial etiology. At our institution, common oral


Obstentrics_Williams

Obstentrics_Williams. are caused by Chamydia 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.


Obstentrics_Williams

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


Obstentrics_Williams

Obstentrics_Williams. Seconday pospartum hemorrhage is deined as bleeding 24 hours to 12 weeks ater delivery. Clinically worrisome uterine hemorrhage develops within 1 to 2 weeks in perhaps 1 percent of women. Such bleeding most oten 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 ibrin deposi tion and may eventually form a so-called placental poyp. As the eschar of the polyp detaches from the myometrium, hemorrhage may be brisk. As discussed in Chapter 56 (p. 1090), delayed postpartum hemorrhage may also be caused by von Willebrand disease or other inherited coagulopathies (Lipe, 2011).


Obstentrics_Williams

Obstentrics_Williams. In our experiences, few women with delayed hemorrhage are found to have retained placental fragments. hus, 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 (p. 392). 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.


Obstentrics_Williams

Obstentrics_Williams. Normal pregnancy-induced glomerular hyperiltration persists during the puerperium but returns to prepregnancy baseline by 2 weeks (Hladunewich, 2004). Dilated ureters and renal pelves return to their prep regnant 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


Obstentrics_Williams

Obstentrics_Williams. Funnell and colleagues (1954) used cystoscopy immediately postpartum and described varying degrees of submucosal hemorrhage and edema. Bladder trauma is associated most The Puerperium 655 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. hus, 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). heir management is discussed on page 660. It is unusual for urinary incontinence to manifest during the puerperium. hat said, much attention has been given to the potential for subsequent development of urinary incontinence and other pelvic loor disorders in the years following delivery. A more detailed discussion is found in Chapter 30 (p. 568).


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Obstentrics_Williams. The broad and round ligaments require considerable time to recover from stretching and loosening during pregnancy. As a result of ruptured elastic ibers in the skin and prolonged distention by the pregnant uterus, the abdominal wall remains soft and laccid. If the abdomen is unusually labby or pendulous, an ordinary girdle is often satisfactory. n abdominal binder is another temporary measure. Several weeks are required for these structures to return to normal, and recovery is aided by exercise. hese may be started anytime following vaginal delivery. Ater 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 graviarum (Chap. 4, p. 53). Except for these, the abdominal wall usually resumes its prep regnancy appearance. When muscles remain atonic, however, the abdominal wall also remains lax. Marked separation of the rectus abdominis muscles-diastasis recti-may result.


Obstentrics_Williams

Obstentrics_Williams. Marked leukocytosis and thrombocytosis may occur during and after labor. The white blood cell count sometimes reaches 30,000/�L, with the increase predominantly due to granulocytes. There is a relative lymphopenia and an absolute eosinopenia. Normally, during the irst few postpartum days, hemoglobin concentration and hematocrit luctuate moderately. We routinely check these on the irst 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.


Obstentrics_Williams

Obstentrics_Williams. By the end of pregnancy, laboratory values that assess coagulation are altered (Kenny, 2014). These changes are discussed in Chapter 4 (p. 59) and listed in the Appendix (p. 1256). Many persist variably in the puerperium. For example, a markedly increased plasma ibrinogen level is maintained at least through the irst week and hence so is an elevated sedimentation rate. Hypercoagulability appears to be greater and is relected by the likelihood of deep-vein thrombosis and pulmonary embolism in the 12 weeks following childbirth (Kamel, 2014). his is depicted in Figure 36-3 and is discussed further in Chapter 52 (p. 1004). FIGURE 36-3 Risk of deep-vein thrombosis or pulmonary embolism following childbirth. (Data from Kamel H, Navi S, Sriram N, et al: Risk of a Thrombotic Event after the 6-week postpartum period. N Engl J Med 370:1307,o2014.)


Obstentrics_Williams

Obstentrics_Williams. 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, p. 756). 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 stifness persists following pregnancy. They suggest a signiicant favorable


Obstentrics_Williams

Obstentrics_Williams. FIGURE 36-4 During the early puerperium, blood pressure normally rises toward nonpregnant values. MAP = mean arterial pressure. efect of pregnancy on maternal cardiovascular remodeling, which may represent a mechanism by which preeclampsia risk is reduced in subsequent pregnancies. 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. his also corresponds with loss of residual pregnancy hypervolemia. In preeclampsia, pathological retention of luid antepartum and its diuresis postpartum may be prodigious (Chap. 40, p. 744).


Obstentrics_Williams

Obstentrics_Williams. 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 Ib).


Obstentrics_Williams

Obstentrics_Williams. Each mature mammary gland or breast is composed of 15 to 25 lobes. hey 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 lacterous ducts open separately on the nipple, where they may be distinguished as minute but distinct orifices. he alveolar secretory epithelium synthesizes the various milk constituents.


Obstentrics_Williams

Obstentrics_Williams. 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) ofers the newborn protection against enteric pathogens. Other host resistance factors found in colostrum and milk include complement, macrophages, lymphocytes, lactoferrin, lactoperoxidase, and lysozymes.


Obstentrics_Williams

Obstentrics_Williams. Mature milk is a complex and dynamic biological luid 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 inluenced by maternal diet and by newborn age, health, and needs. A nursing mother easily produces 600 mL of milk daily, and maternal gestational FIGURE 36-5 Schematic of the alveolar and ductal system during lactation. Note the myoepithelial fibers (M) that surround the outside of the uppermost alveolus. The secretions from the glandular elements are extruded into the lumen of the alveoli (A) and ejected by the myoepithelial cells into the ductal system (0), which empties through the nipple. Arterial blood supply to the alveolus is identified by the upper right arrow and venous drainage by the arrow beneath.


Obstentrics_Williams

Obstentrics_Williams. PUFA = Polyunsaturated fatty acids. The Puerperium 657 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, p. 626). Vitamin D content is low 22 IU/mL, and newborn supplementation is also recommended by the American Academy of Pediatrics (Wagner, 2008).


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Obstentrics_Williams. 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 octor (EGF) has been identiied, and because it is not destroyed by gastric proteolytic enzymes, it may be absorbed to promote growth and maturation of newborn intes tinal mucosa (McCleary, 1991). Other critical components in human milk include lactoferrin, melatonin, oligosaccharides, and essential fatty acids. • Endocrinology of Lactation


Obstentrics_Williams

Obstentrics_Williams. • 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 milksecreting apparatus (Stuebe, 2014). With delivery, the maternal serum levels of progesterone and estrogen decline abruptly and profoundly. This drop removes the inhibitory inluence 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).


Obstentrics_Williams

Obstentrics_Williams. 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 necrosisSheehan syndrome�o not lactate (Chap. 58, p. 1133). 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 octor, from the hypothalamus. In turn, this transiently induces increased prolactin secretion.


Obstentrics_Williams

Obstentrics_Williams. 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 relex initiated especially by suckling, which stimulates the posterior pituitary to liberate oxytocin. he reflex may even be provoked by an infant cry and can be inhibited by maternal fright or stress (Stuebe, 2014). Human milk contains several protective immunological substances, including secretory IgA and growth factors. The antibodies in human milk are speciically 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.


Obstentrics_Williams

Obstentrics_Williams. 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 difer from those found in blood. Speciically, milk T lymphocytes are almost exclusively composed of cells that exhibit speciic membrane antigens. These memory T cells appear to be an avenue for the neonate to beneit from the maternal immunological experience.


Obstentrics_Williams

Obstentrics_Williams. Human milk is ideal food for newborns in that it provides agespeciic nutrients, immunological factors, and antibacterial substances. Milk also contains factors that act as biological signals for promoting cellular growth and diferentiation. A list of the advantages of breastfeeding is shown in Table 36-3. For both mother and infant, the beneits 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 (J ong, 2012; Kramer, 2008). Breastfeeding is associated with decreased postpartum weight retention (Baker, 2008). In addition, rates of sudden-infant-death syndrome are signiicantly 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


Obstentrics_Williams

Obstentrics_Williams. TABLE 36-3. Advantages of Breastfeeding Data from American Academy of Pediatrics and the American College of Obstetricians and Gynecologists: Guidelines for Perinatal Care, 8th ed, Elk Grove Village, AAP, 2017. TABLE 36-4. Ten Steps to Successful Breastfeeding 1n. Have a written breastfeeding policy that is regularly communicated to all health-care staff 2. Train all staf in skills necessary to implement this policy 3. Inform all pregnant about the beneits and management of breastfeeding 4. Help mothers initiate breastfTeding within an hour of birth 5. Show mothers how to breastfeed and how to sustain lactation, even if they should be separated from their infants 6. Feed newborns nothing but breast milk, unless medi cally indicated, and under no circumstances provide breast milk substitutes, feeding bottles, or paCiiers free of charge or at low cost 7. Practice rooming-in, which allows mothers and newborns to remain together 24 hours a day 8. 9.


Obstentrics_Williams

Obstentrics_Williams. Practice rooming-in, which allows mothers and newborns to remain together 24 hours a day 8. 9. Give no artiicial paCiiers to breastfeeding newborns 10. Help start breastfeeding support groups and refer mothers to them Adapted with permission from World Health Organization: Protecting, promoting and supporting breast-feeding: the special role of maternity services. Geneva, World Health Organization, 1989. American Academy of Pediatrics (2017) and American College of Obstetricians and Gynecologists (2016a, 20 17b) supports the World Health Organization (201r1) recommendations of exclusive breastfeeding for up to 6 months.


Obstentrics_Williams

Obstentrics_Williams. 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 Friendy 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 Successul Breaseeding (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 successul 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,


Obstentrics_Williams

Obstentrics_Williams. 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).


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Obstentrics_Williams. 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://ww.llli.org). • Care of Breasts


Obstentrics_Williams

Obstentrics_Williams. The nipples require little attention other than cleanliness and attention to skin issures. 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 ater 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 issuring is severe, the newborn should not be permitted to nurse on the afected 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 issures. For example, the newborn may take into its mouth only the nipple, which is then is forced against the hard


Obstentrics_Williams

Obstentrics_Williams. the lesions are healed. Poor latching of the neonate to the breast can create such issures. 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 eicient emptying, while the nipple is thereby positioned closer to the soft palate.


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• Contraindications to Breastfeeding

Obstentrics_Williams. • Contraindications to Breastfeeding


Obstentrics_Williams

Obstentrics_Williams. Nursing is contraindicated in women who take street drugs or do not control their alcohol use; have an infant with galactosemia; have human immunodeiciency 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 afected mothers. Maternal hepatitis C infection is not a contraindication because breastfeeding has not been shown to transmit infection (Society for MaternalFetal


Obstentrics_Williams

Obstentrics_Williams. is given to the newborns of afected mothers. Maternal hepatitis C infection is not a contraindication because breastfeeding has not been shown to transmit infection (Society for MaternalFetal Medicine, 2017).Women with active herpes simplex virus may sucle their infants if there are no breast lesions and if particular care is directed to hand washing before nursing.


Obstentrics_Williams

Obstentrics_Williams. 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 halflife, poorer oral absorption, and lower lipid solubility. If multiple daily drug doses are required, then each is taken by the mother ater the closest feed. Single daily-dosed drugs may be taken just before the longest infant sleep interval-usually at bedtime (Spencer, 2002).


Obstentrics_Williams

Obstentrics_Williams. 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, afect growth, and at least theoretically, increase the risk of childhood cancer. Examples include cyclophosphamide, cyclosporine, doxorubicin, metho trexate, and mycophenolate. If a medication presents a con cern, 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 of Obstetricians and Gynecologists, 2017 a). Data on individual drugs are available through the National Institutes of Health website, LactMed, which can be found at toxnet.nlm.nih.gov.


Obstentrics_Williams

Obstentrics_Williams. Radioactive isotopes of copper, gallium, indium, iodine, sodium, and technetium rapidly appear in breast milk. Con sultation with a nuclear medicine specialist is recommended before performing a diagnostic study with these isotopes (Chap. 46, p. 908). he 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 low but discard all milk produced during the time that radioactivity is present. his 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 (p. 1201).


Obstentrics_Williams

Obstentrics_Williams. his 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 afected women require analgesia for breast pain relief, and as many as 10 percent report severe pain for up to 14 days. Evidence is insuicient to irmly support any speciic treatment (Mangesi, 2016). hat said, breasts can be supported with a well-itting 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.


Obstentrics_Williams

Obstentrics_Williams. 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. I t is relatively common in lactating women and is discussed in Chapter 37 (p. 675). • 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 diicult. If the depression is not deep, milk sometimes can be drawn out by a breast pump. If instead the


Obstentrics_Williams

Obstentrics_Williams. The Puerperium 659 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-poymastia, or extra nipples-poythelia, 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). hese 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 occasion ally enlargement of these accessory breasts during pregnancy and anxiety.


Obstentrics_Williams

Obstentrics_Williams. Polymastia has no obstetrical significance, although occasion ally enlargement of these accessory breasts during pregnancy and anxiety. Galactocele is a milk duct that becomes obstructed by inspis sated secretions. The amount is ordinarily limited, but an excess 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-poygalactia.


Obstentrics_Williams

Obstentrics_Williams. 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. U terotonics are also sometimes required. Blood can accumulate within the uterus without external bleeding. his may be detected early by uterine enlargement during fundal palpation in the irst postdelivery hours. Because the likelihood of signiicant 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 (p. 758). If regional analgesia or general anesthesia was used for labor or


Obstentrics_Williams

Obstentrics_Williams. the uterus is closely monitored for at least 1 hour after delivery. Postpartum hemorrhage is discussed in Chapter 41 (p. 758). If regional analgesia or general anesthesia was used for labor or delivery, the mother should be observed in an appropriately equipped and stafed recovery area.


Obstentrics_Williams

Obstentrics_Williams. Women are out of bed within a few hours after delivery. n attendant should be present for at least the irst time, in case the woman becomes syncopal. he many conirmed advantages of early ambulation include fewer bladder complications, less frequent constipation, and reduced rates of puerperal venous thromboembolism. As discussed on page 655, 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 (p. 1004).


Obstentrics_Williams

Obstentrics_Williams. here 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, p. 167). 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 lushes, especially at night. Importantly, the patientr's temperature is assessed to diferentiate these physiological vasomotor events from infection.


Obstentrics_Williams

Obstentrics_Williams. 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. lternatively, 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 efectively relieve headaches by causing intracranial vasoconstriction.


Obstentrics_Williams

Obstentrics_Williams. he 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 irst 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 carul inspection and papation. Severe discomfort usually indicates a problem, such as a hematoma within the irst day or so and infection ater the third or fourth day (Chap. 37, p. 674 and Chap. 41, p. 764). 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.


Obstentrics_Williams

Obstentrics_Williams. Rarely, the cervix, and occasionally a portion of the uterine body, may protrude from the vulva following delivery. his is accompanied by variable degrees of anterior and posterior vaginal wall prolapse. Symptoms include a palpable mass at or past the introitus, voiding diiculties, 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 eicacy compared with conservative management.


Obstentrics_Williams

Obstentrics_Williams. In most delivery units, intravenous luids are inused during labor and for an hour or so ater delivery. Oxytocin, in doses that have an antidiuretic efect, is typically inused 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. he 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 durationr> 10 hours.


Obstentrics_Williams

Obstentrics_Williams. Prevention of bladder overdistention demands observation ater delivery to ensure that the bladder does not overill and that it empties adequately with each voiding. he enlarged bladder can be palpated suprapubically, or it is evident abdominally indirectly as it elevates the fundus above the umbilicus. he 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).


Obstentrics_Williams

Obstentrics_Williams. If a woman has not voided within 4 hours ater delivery, it is likely that she cannot. If she has trouble voiding initially, she also is likely to have further trouble. n 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. his prevents recurrence and allows recovery of normal bladder tone and sensation.


Obstentrics_Williams

Obstentrics_Williams. 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 sel-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


Obstentrics_Williams

Obstentrics_Williams. • Pain, Mood, and Cognition Discomfort and its causes following cesarean delivery are con sidered in Chapter 30 (p. 585). During the irst 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 contain ing codeine, aspirin, or acetaminophen, preferably in combina tions, are given as frequently as every 4 hours during the irst few days.


Obstentrics_Williams

Obstentrics_Williams. 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 pospartum blues, this likely is the consequence of several factors. hese 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, efective 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, p. 1176). Suicidal or infanticidal ideation is dealt with emergently. Because major postpartum depression recurs in at least a


Obstentrics_Williams

Obstentrics_Williams. an evaluation for symptoms of major depression is done (Chap. 61, p. 1176). 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.


Obstentrics_Williams

Obstentrics_Williams. Last, postpartum hormonal changes in some women may afect 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.


Obstentrics_Williams

Obstentrics_Williams. Pressure on branches of the lumbosacral nerve plexus during labor may manifest as complaints of intense neuralgia or cramplike 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 ibular nerves may be externally compressed when the legs are positioned in stirrups, especially during prolonged second-stage labor.


Obstentrics_Williams

Obstentrics_Williams. Obstetrical neuropathy is relatively infrequent. Wong and associates (2003) evaluated more than 6000 puerperas and found that approximately 1 percent had a conirmed nerve injury. Lateral femoral cutaneous neuropathies were the most The Puerperium 661 common (24 percent), followed by femoral neuropathies (14 percent). A motor deicit accompanied a third of injuries. Nul liparity, 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 iliohypo gastric and ilioinguinal nerves (Rahn, 2010). These are dis cussed further in Chapter 2 (p. 15).


Obstentrics_Williams

Obstentrics_Williams. Nerve injuries with cesarean delivery include the iliohypo gastric and ilioinguinal nerves (Rahn, 2010). These are dis cussed further in Chapter 2 (p. 15). Pain in the pelvic girdle, hips, or lower extremities may follow stretching or tearing injuries sustained at normal or diicult 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 antiinlammatory agents and physical therapy. Rarely, there may be septic pyomyositis such as with iliopsoas muscle abscess (Nelson, 2010; Young, 2010).


Obstentrics_Williams

Obstentrics_Williams. 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. heir 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 itted 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


Obstentrics_Williams

Obstentrics_Williams. 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.


Obstentrics_Williams

Obstentrics_Williams. FIGURE 36-6 Inhomogeneous mass of the right piriformis muscle consistent with a hematoma (yellow cursor measurements) is compared with the normal-appearing left piriformis muscle (yellow arrow), postpartum day following vaginal delivery of a 2840-g newborn. The patient had pain over the pubic bone and pain with ambulation. A shuffling gait was noted, and she had difficulty with leg elevation when supine. The patient was treated with physical therapy and analgesics. A pelvic binder was applied, and a rolling walker was provided. She improved quickly and was discharged home on postoperative day S.


Obstentrics_Williams

Obstentrics_Williams. 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 (p. 1129), the latter are more likely with osteoporosis associated with heparin or corticosteroid therapy (Cunningham, 2005). In rare bur serious cases, bacterial osteomyelitis-osteitis pubis-can be devastating. Lawford and coworkers (2010) reported such a case that caused massive vulvar edema.


Obstentrics_Williams

Obstentrics_Williams. he D-negative woman who is not isoimmunized and whose newborn is D-positive is given 300 -1g of anti-D immune globulin shortly after delivery (Chap. IS, p. 305). Women who are not already immune to rubella or varicella are excellent candidates for vaccination before discharge (Swamy, 2015). hose who have not received a tetanus/diphtheria or inluenza vaccine should be given these (American College of Obstetricians and Gynecologists, 2017 c). 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 (p. 171).


Obstentrics_Williams

Obstentrics_Williams. 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, p. 616). 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 .


Obstentrics_Williams

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


Obstentrics_Williams

Obstentrics_Williams. Women not breastfeeding have return of menses usually within 6 to 8 weeks. At times, however, it is diicult clinically to assign a speciic 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). hat said, ovulation before 28 days has been described (Hytten, 1995). hus, conception is possible during the artiicially deined 6-week puerperium. Women who become sexualy 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).


Obstentrics_Williams

Obstentrics_Williams. 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 empha 8..) 50 FIGURE 36-8 Cumulative proportion of breastfeeding women who ovulated during the first 70 weeks following delivery. (Data from Campbell OM, Gray RH: Characteristics and determinants of postpartum ovarian function in women in the United States. Am J Obstet Gynecol 169:5S, 1993.) sized, it does not invariably forestall it. Other findings in their study included the following: 1.


Obstentrics_Williams

Obstentrics_Williams. 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 afect the quality or quantity of milk. Success with the progesterone-releasing vaginal ring has also been described (Carr, 2016). hese 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. hese hormonal methods are discussed in Chapter 38.


Obstentrics_Williams

Obstentrics_Williams. 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 comort. 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).


Obstentrics_Williams

Obstentrics_Williams. Postpartum, the vulvovaginal epithelium is thin, and very little lubrication follows sexual stimulation. his 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 ofered once cystitis is excl uded. 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, The Puerperium 663 Gin 87 percent of all women, at least one symptom was reported. Data from Glazener CM, Abdalla M, Stroud P, et al:


Obstentrics_Williams

Obstentrics_Williams. The Puerperium 663 Gin 87 percent of all women, at least one symptom was reported. Data from Glazener CM, Abdalla M, Stroud P, et al: Postnatal maternal morbidity: extent, causes, prevention and treatment. BJOG 102:282, 1995. 3 percent required hospital readmission within 8 weeks (Glazener, 1995; hompson, 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.


Obstentrics_Williams

Obstentrics_Williams. 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 (20 l3) reported that 80 percent of women who worked during pregnancy resume work by 1 year ater 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.


Obstentrics_Williams

Obstentrics_Williams. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) recommend a postpartum visit between 4 and 6 weeks. his has proven quite satisfactory to identiy abnormalities beyond the immediate puerperium and to initiate contraceptive practices. Ahdoot 0, Van Nostrand M, Nguyen NJ, et al: he efect of route of deliv ery on regression of abnormal cervical cytologic indings in the postpartum period. Am J Obstet Gynecol 178: 1116, 1998 Almeida 00 Jr, Kitay DZ: Lactation suppression and puerperal fever. m J Obstet Gynecol 154:940, 1986 Alonso-Burgos A, Royo P, Diaz L, et al: Labor-related sacral and pubic frac tures. J Bone Joint Surg 89:396, 2007 TABLE 36-5. Puerperal Morbidity Reported by 8 Weeks Morbidity PercentQ American Academy of Pediatrics: Breastfeeding and the use of human milk. Pediatrics 129(3):e827, 2012


Obstentrics_Williams

Obstentrics_Williams. TABLE 36-5. Puerperal Morbidity Reported by 8 Weeks Morbidity PercentQ American Academy of Pediatrics: Breastfeeding and the use of human milk. Pediatrics 129(3):e827, 2012 American Academy of Pediatrics, American College of Obstetricians and Gynecologists: Guidelines for Perinatal Care, 8th ed. Elk Grove Village, AAP, 2017 American College of Obstetricians and Gynecologists: Breastfeeding in underserved women: increasing initiation and continuation of breastfeeding. Committee Opinion No. 570, August 2013, Reairmed 2016a American College of Obstetricians and Gynecologists: Screening for perinatal depression. Committee Opinion No. 630, May 2015, Reairmed 2016b American College of Obstetricians and Gynecologists: Marijuana use during pregnancy and lactation. Committee Opinion No. 722, October 2017a American College of Obstetricians and Gynecologists: Optimizing support for breastfeeding as part of obstetric practice. Committee Opinion No. 658, February 2016, Reairmed 2017b


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Obstentrics_Williams. American College of Obstetricians and Gynecologists: Optimizing support for breastfeeding as part of obstetric practice. Committee Opinion No. 658, February 2016, Reairmed 2017b American College of Obstetricians and Gynecologists: Update on immunizationand pregnancy: tetanus, diphtheria, and pertussis vaccination. Committee Opinion No. 718, September 2017c Anderson R, Davis J: Placental site involution. Am J Obstet Gynecol 102:23, 1968 Andrew AC, Bulmer IN, Wells M, et al: Subinvolution of the uteroplacental arteries in the human placental bed. Histopathology 15:395, 1989 Andrews MC: Epithelial changes in the puerperal fallopian tube. Am J Obstet Gyneco1 62:28, 1951 Bae HS, m KH, Oh MJ, et al: Postpartum uterine involution: sonographic changes in the endometrium between 2 and 6 weeks postpartum related to delivery mode and gestational age at delivery. Ultrasound Obstet Gynecol 39(6):727, 2012


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Obstentrics_Williams. Baker JL, Gamborg M, Heitmann BL, et al: Breastfeeding reduces postpartum weight retention. Am J Clin Nutr 88(6):1543, 2008 Baldwin MK, Edelman AB: he efect of long-acting reversible contraception on rapid repeat pregnancy in adolescents: a review. J Adolesc Health 52(4 Suppl):S47, 2013 Ballard 0, Morrow L: Human milk composition: nutrients and bioactive factors. Pediatr Clin North Am 60(1):49, 2013 Bannbers E, Gingnell M, Engman J, et al: Prefrontal activity during response inhibition decreases over time in the postpartum period. Behav Brain Res 241:132, 2013 Barrett G, Pendry E, Peacock J, et al: Women's sexual health after childbirth. BJOG 107:186, 2000 Bartek MC, Stuebe M, Schwarz EB, et al: Cost analysis of maternal disease associated with suboptimal breastfeeding. Obstet Gynecol 122:111, 2013


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Obstentrics_Williams. BJOG 107:186, 2000 Bartek MC, Stuebe M, Schwarz EB, et al: Cost analysis of maternal disease associated with suboptimal breastfeeding. Obstet Gynecol 122:111, 2013 Belachew J, Axelsson 0, Mulic-Lutvica A, et al: Longitudinal study of the uterine body and cavity with three-dimensional ultrasonography in the puerperium. Acta Obstet Gynecol Scand 91(10):1184, 2012 Berlin CM Jr, van den Anker IN: Safety during breastfeeding: drugs, foods, environmental chemicals, and maternal infections. Semin Fetal Neonatal Med 18(1):13, 2013 Bertino E, Varalda A, Di Nicola P, et al: Drugs and breastfeeding: instructions for use. J Matern Fetal Neonatal Med 25(Supp1 4):78, 2012 Blumenfield J, El-sayed Y, Lyell DJ, et al: Risk factors for prolonged postpartum length of stay following cesarean delivery. Am J Perinatol 32:825, 2015 Buchanan J, Beckmann M: Postpartum voiding dysfunction: identiying the risk factors. Aust N Z J Obstet Gynaecol 54(1):41, 2014


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Obstentrics_Williams. Buhimschi CS, Buhimschi A, Malinow M, et al: Myometrial thickness during human labor and immediately postpartum. Am J Obstet Gynecol 188:553, 2003 Bunch K, Hope E: An uncommon case of bilateral peroneal nerve palsy following delivery: a case report and review of the literature. Case Rep Obstet Gyneco1 2014:746480, 2014 Campbell OM, Gray RH: Characteristics and determinants of postpartum ovarian function in women in the United States. Am J Obstet Gynecol 169:55, 1993 Carr SL, Gaield ME, Dragoman MV, et al: Safety of the progesterone-releasing vaginal ring (PVR) among lactating women. Contraception 94(3):253, 2016 Centers for Disease Control and Prevention: Breastfeeding Report CardUnited States, 2014. Available at: http://ww.cdc.gov/breastfeeding/data/ reportcard.htm. Accessed March 27, 2016 Centers for Disease Control and Prevention: PRAMS, the Pregnancy Risk Assessment Monitoring System. 2016. Available at: http://ww.cdc.gov/ PRAMS/index.htm. Accessed March 27, 2016


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Obstentrics_Williams. Centers for Disease Control and Prevention: PRAMS, the Pregnancy Risk Assessment Monitoring System. 2016. Available at: http://ww.cdc.gov/ PRAMS/index.htm. Accessed March 27, 2016 Chayachinda C, Titapant V, UngkanungdechaA: Dyspareunia and sexual dysfunction ater vaginal delivery in hai primiparous women with episiotomy. J Sex Med 12(5):1275, 2015 Chesley LC, Valenti C, Uichano L: Alterations in body fluid compartments and exchangeable sodium in early puerperium. Am J Obstet Gynecol 77: 1054, 1959 Collier RJ, Hernandez LL, Horseman ND: Serotonin as a homeostatic regulator of lactation. Domest Anim Endocrino1 43(2):161, 2012 Culligan P, Hill S, Heit M: Rupture of the symphysis pubis during vaginal delivery followed by two subsequent uneventful pregnancies. Obstet Gynecol 100:1114, 2002 Cunningham FG: Screening for osteoporosis. N Engl J Med 353(18):1975, 2005


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Obstentrics_Williams. Dennis CL, Jackson K, Watson J: Interventions for treating painful nipples among breastfeeding women. Cochrane Database Syst Rev 12:CD007366, 2014 Faupel-Badger JM, Arcaro F, Balkam J], et al: Postpartum remodeling, lactation, and breast cancer risk: summary of a National Cancer Institute-sponsored workshop. J Nat! Cancer Inst 105(3):166, 2013 Fletcher S, Grotegut CA, James AH: Lochia patterns among normal women: a systematic review. J Womens Health (Larchmt) 21(12):1290, 2012 Forrester-Knauss C, Merten S, Weiss C, et al: The Baby-Friendly Hospital Initiative in Switzerland: trends over a 9-year period. J Hum Lact 29(4):510, 2013 Funnell JW, Klawans AH, Cottrell TL: he postpartum bladder. Am J Obstet Gyneco1 67:1249, 1954 Glazener CM, Abdalla M, Stroud P, et al: Postnatal maternal morbidity: extent, causes, prevention and treatment. BJOG 102:282, 1995 Harris E, homas L, Hui GW: Postpartum suveillance for urinary tract infection: patients at risk of developing pyelonephritis after


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Obstentrics_Williams. extent, causes, prevention and treatment. BJOG 102:282, 1995 Harris E, homas L, Hui GW: Postpartum suveillance for urinary tract infection: patients at risk of developing pyelonephritis after catheterization. South MedJ 70:1273, 1977 Hibbard JU, Schrof SG, Cunningham FG: Cardiovascular alterations in normal and preeclamptic pregnancy. In Taylor N, Roberts JM, Cunningham FG (eds): Chesley's Hypertensive Disorders in Pregnancy, 4th ed. Amsterdam, Academic Press, 2014 Hladunewich A, Lafayette A, Derby GC, et al: The dynamics of glomerular iltration in the puerperium. Am J Physiol Renal Physiol 286:F496, 2004 Holdcrot A, Snidvongs S, Cason A, et al: Pain and uterine contractions during breast feeding in the immediate post-partum period increase with parity. Pain 104:589, 2003 Hytten F: he Clinical Physiology of the Puerperium. London, Farrand Press, 1995 Iraha Y, Okada M, Toguchi M, et al: Multimodality imaging in secondary postpartum or postabortion hemorrhage: retained products of


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Obstentrics_Williams. Clinical Physiology of the Puerperium. London, Farrand Press, 1995 Iraha Y, Okada M, Toguchi M, et al: Multimodality imaging in secondary postpartum or postabortion hemorrhage: retained products of conception and related conditions. Jpn J Radiol October 19, 2017 [Epub ahead of print]


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Obstentrics_Williams. Iyengar SR, Walker WA: Immune factors in breast milk and the development of atopic disease. J Pediatr Gastroenterol Nutr 55(6):641, 2012 Jimenez MH, Newton N: Activity and work during pregnancy and the postpartum period: a cross-cultural study of 202 societies. Am J Obstet Gynecol 135:171, 1979


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Obstentrics_Williams. Jong DE, Kikkert HR, Fidler V, et al: Efects of long-chain polyunsaturated fatty acid supplementation of infant formula on cognition and behavior at 9 years of age. Dev Med Child Neurol 54(12):1102, 2012 Kamel H, Navi B, Sriram N, et al: Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med 370: 1307, 2014 Kandadai P, Kandadai V, Saini J, et al: Acute urinary retention after cesarean delivery: a case-control study. Female Pelvic Med Reconstr Surg 20(5):276, 2014 Kaneshiro BE, Acoba JD, Holzman J, et al: Efect of delivery route on natural history of cervical dysplasia. Am J Obstet Gynecol 192(5): 1452, 2005 Kanotra S, D'Angelo 0, Phares TM, et al: Challenges faced by new mothers in the early postpartum period: an analysis of comment data from the 2000 Pregnancy Risk Assessment Monitoring System (PRAMS) survey. Matern Child Health J 11 (6):549, 2007 Kavalar R, Arko D, Fokter Dovnik N, et al: Subinvolution of placental bed vessels: case report and review of the


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Obstentrics_Williams. Assessment Monitoring System (PRAMS) survey. Matern Child Health J 11 (6):549, 2007 Kavalar R, Arko D, Fokter Dovnik N, et al: Subinvolution of placental bed vessels: case report and review of the literature. Wien Klin Wochenschr 124(19-20):725, 2012 Kelly LS, Sheeder J, Stevens-Simon C: Why lightning strikes twice: postpartum resumption of sexual activity during adolescence. J Pediatr Adolesc Gynecol 18:327, 2005 Kenny LC, McCrae R, Cunningham FG: Platelets, coagulation, and the liver. In Taylor N, Roberts JM, Cunningham FG (eds): Chesley's Hypertensive Disorders in Pregnancy, 4th ed. Amsterdam, Academic Press, 2014 Kharrazi FD, Rodgers B, Kennedy JG, et al: Parturition-induced pelvic dislocation: a report oHour cases. J Orthop Trauma 11:277, 1997 Kramer MS, Aboud F, Mironova E, et al: Breastfeeding and child cognitive development: new evidence from a large randomized trial. Arch Gen Psychiatry 65(5):578, 2008 Lasbleiz J, Sevestre FX, Moquet PY: Using an elastic band device after a


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Obstentrics_Williams. Breastfeeding and child cognitive development: new evidence from a large randomized trial. Arch Gen Psychiatry 65(5):578, 2008 Lasbleiz J, Sevestre FX, Moquet PY: Using an elastic band device after a severe obstetric pubic symphyseal separation: clinical and imaging evaluation. Obstet Gynecol 130(3):625, 2017 Lawford M, Scott K, Lust K: A case of massive vulvar oedema due to septic pubic symphysitis complicating pregnancy. Aust N Z J Obstet Gynaecol 50(6):576, 2010


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Obstentrics_Williams. Lee CY, Madrazo B, Drukker BH: Ultrasonic evaluation of the postpartum uterus in the management of postpartum bleeding. Obstet Gynecol 58:227, 1981 Lipe BC, Dumas MA, Ornstein DL: Von Willebrand disease in pregnancy. Hematol Oncol Clin North Am 25(2):335, 201n1 Loukas M, Clarke P, Tubbs RS: Accessory breasts: a historical and current perspective. Am Surg 73(5):525, 2007 Mangesi L, Zakarija-Grkovic I: Treatments for breast engorgement during lactation. Cochrane Database Syst Rev 6:CD006946, 2016 McCleary MJ: Epidermal growth factor: an important constituent of human milk. J Hum Lact 7:123,n1991 McDonald EA, Gartland D, Small R, et al: Dyspareunia and childbirth: a ptospective cohort study. BJOG 122:672,n2015 McDonald SD, Pullenayegum E, Chapman B, et al: Prevalence and predictors of exclusive breastfeeding at hospital discharge. Obstet Gynecol 119(6):1171, 2012


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Obstentrics_Williams. McDonald SD, Pullenayegum E, Chapman B, et al: Prevalence and predictors of exclusive breastfeeding at hospital discharge. Obstet Gynecol 119(6):1171, 2012 Miller JM, Low LK, Zielinski R, et al: Evaluating maternal recovery from labor and delivery: bone and levator ani injuries. Am J Obstet Gynecol 213:188e1,2015 Minig L, Trimble EL, Sarsotti C, et al: Building the evidence base for postoperative and postpartum advice. Obstet Gynecol 114(4):892, 2009 Morgan JL, Baggari SR, Chung W, et al: Association of a Best-Practice Alert and prenatal administration with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccination rates. Obstet Gynecol 126(2):333, 2015 Morris EA, Hale SA, Badger GJ, et al: Pregnancy induces persistent changes in vascular compliance in primiparous women. Am J Obstet Gynecol 212(5):633.e1,n2015