Complications of the Puerperium

Puerperal Pyrexia

Women who have just had a baby may suffer from any incidental disease or illness which has nothing to do with their pregnancy or delivery. Occasionally women get infectious diseases such as mumps, measles, German measles, influenza, simple colds or bronchitis and may even develop surgical emergencies such as acute appendicitis. If a mother develops an infectious disease it is most unlikely that her baby will suffer from it, since new-born babies have not only a transmitted but also a natural immunity which lasts for several weeks after birth.

Puerperal PyrexiaPuerperal Pyrexia

A puerperal pyrexia is defined as a rise in temperature on one or more occasions during the first 28 days after a woman has been delivered. It used to be a statutory requirement for a puerperal pyrexia to be notified to the local Medical Officer of Health. This was a legacy dating back 3o or 40 years to the time when puerperal pyrexia was very much feared as a disease which killed quite a large number of newly delivered mothers. Up to nearly 40 years ago, if a vicious infection gained access to the uterus it was uncontrollable because no satisfactory treatment existed and it could spread from one woman to another with alarming speed. The control and cure of puerperal infection began in 1935 with the introduction of the first sulphon- amides, and as better sulphonamides and subsequently antibiotics were introduced puerperal fever became controllable. It is today a preventable disease. The organism most feared was the haemolytic streptococcus, which was eventually conquered by the use of penicillin, to which it is nearly always sensitive. Puerperal pyrexia today is a condition that is treated with respect, but it is no longer feared or notified, because the bacteria that cause puerperal pyrexia are easily controlled by modern antibiotics.

Up to 1935 many women dared not have their babies in hospital because of the risk of contracting puerperal fever by cross infection. This argument is still put forward by some people for preferring home to hospital confinement. The incidence, however, of all types of puerperal pyrexia today is less than 4 per cent and even then the infection is usually in the urinary tract. Severe infections of the uterus are extremely rare, so much so that it is difficult today to appreciate the severity of puerperal fever that existed only a few decades ago.

The reasons for the reduction in puerperal infection are many and a full appreciation of their extent can only be achieved if one considers all the preventive measures as well as those used in the early treatment of the condition. Samples of urine are taken during pregnancy to detect those women in whom a urinary tract infection is liable to occur. These infections arc treated vigorously in the antenatal period. Swabs are taken of any vaginal discharge and the organisms cultured so that they can be eliminated before the onset of labour. The care of breasts and instruction given to facilitate breast-feeding during the antenatal period renders them less liable to infection. The prevention of anaemia and the correction of many other minor abnormalities or deficiencies during pregnancy all help to avoid puerperal infection.

Sexual intercourse, however, which has long been blamed as a major factor in causing infection during pregnancy and after delivery, is in no way responsible. Normal sexual intercourse can continue right up to the onset of labour in a normal pregnancy without any risk of infection.

Rigid antiseptic measures taken during labour and delivery also help to eliminate infection. The cleansing of the vulva, the use of antiseptic creams and lotions during examinations, the avoidance of catheterization if possible, the use of sterile instruments and towels, as well as the extensive measures taken to ensure that infection should not be passed from the midwife or doctor to the patient, are just a few of the aspects in the care of the pregnant woman which have gone such a long way towards the control of infection. Last, and probably most important, is that when an infection does begin the organism can be rapidly cultured, isolated and killed with an antibiotic before it has had time to cause damage to the woman herself or be transmitted to another person.

Uterine Infection

Infection in the uterus used to be the classic cause of puerperal fever and a uterine infection caused by the haemolytic streptococcus was a dreaded disease before the introduction of sulphonamides and penicillin. Today this particular infection is not only rare but con trollable. It is nevertheless true that uterine infections do occasionally happen in women who are looked after by the most modern and up-to-date techniques.

Uterine InfectionThe uterus may become infected by a variety of bacteria: the signs and symptoms vary according to the organism concerned and the severity of the infection. The first sign is usually that the lochia becomes slightly offensive, perhaps more profuse and brighter in colour than previously. The uterus may be slightly tender or the woman may become aware of lower abdominal discomfort which is more marked on one side than on the other. The temperature and probably the pulse are slightly raised. There is nothing very sinister or serious about any of these symptoms, but they will be noted by the midwife, who will suspect that there is an infection if the uterus is slightly tender on palpation and movement. A swab is taken from the vagina and sent to the laboratory for bacteriological culture and isolation of the organism to find its antibiotic sensitivities. The doctor is notified and the woman examined and given an antibiotic to control the infection.

One of the commonest causes of a uterine infection is the presence within the uterus of some products of conception, such as a small portion of the placenta which failed to be delivered with the majority of the placenta during the third stage of labour. Any foreign body in the uterine cavity forms an ideal culture for bacteria and the possibility of some retained products of conception must always be considered, especially if the infection is accompanied by some vaginal bleeding.

Perineal Infection

The perineum can only become infected after a perineal laceration or an episiotomy, when an infection may begin in the stitch line or in the deeper layers of the perineum. This may be first noticed because of considerable discomfort in the perineum. Infection in the superficial stitches does not have any lasting ill effect, and is relieved when the stitches are removed on the fifth or sixth day. It clears up very quickly indeed but sometimes there is a slight discharge for several days or even weeks after the stitches have been removed.

If the infection is deep seated it forms a small abscess in the deeper layers of the perineum, which discharges through a small hole in the stitch line. This continues for several days before the abscess heals, which it does quite spontaneously and naturally.

When the infection has been extensive the perineal wound breaks down and will then need re-suturing after the infection has been controlled by giving an oral antibiotic and warm saline baths two or three times daily. On about the tenth day after delivery the infection should be sufficiently controlled to permit re-suturing, which is done under general anaesthesia in hospital. If the infection is less severe and the perineal wound breaks down only partially, it may be left to heal on its own during the following two or three weeks.

Breast InfectionBreast Infection

Infections of the breast are very rare during pregnancy but, unfortunately, they are more frequent after delivery and during lactation. Breast infection must not be confused with engorgement. The breasts normally become engorged on the third or fourth day after delivery, when it may be associated with a slight rise in temperature but there is no infection present. Breast infection, or acute mastitis, occurs in a localized part of the breast being the result of infection gaining access to a part of the breast itself. Breast infections are usually,- but not always, preceded by a crack in the nipple and it is for this reason that cracked or sore nipples are treated with such respect.

A baby who is sucking normally at the breast will seldom cause a break in the skin of the nipple. This results because the baby has been chewing rather than sucking the nipple. It is of paramount importance, therefore, to make sure that the nipple is always placed well inside the baby’s mouth where he cannot ‘chew’ it.

A cracked nipple is painful and requires expert attention and treatment. Since it causes pain the mother does not allow the baby to feed satisfactorily, which results in the breast becoming engorged and tender. The milk must be expressed by hand or by a breast pump and the nipple rested until it has completely healed, which usually takes 24 to 36 hours, after which normal breast-feeding can be resumed. If the crack becomes infected bacteria gain access to neighbouring milk ducts where they grow and flourish and then infect the tissue of the breast itself unless the breast is properly emptied. The first sign that infection has entered the breast is usually a sharp rise in temperature, with a rise in pulse rate and tenderness, frequently in the outer part of the breast. This may be accompanied by a flushing or reddening of the skin over the affected part of the breast, which will be tender to touch and also rather engorged. Treatment with a wide spectrum antibiotic such as tetracycline may arrest the infection so that the reddening of the skin disappears, the soreness goes and the breast gradually returns to normal, providing it is satisfactorily emptied by manual expression or breast pump.

Sometimes the inflammation does not subside; the temperature continues to rise and an abscess forms in the deeper tissues of the breast. When this happens breast feeding is stopped and lactation suppressed. A specimen of milk is collected from the nipple and sent to the laboratory so that the organism concerned can be cultured and tested against various antibiotics. Once an abscess has formed, however, it is unlikely that it will be cured by antibiotics alone. The area of the breast in which it has formed becomes extremely reddened, firm or even hard and very tender. Eventually, when the centre of the abscess liquefies, it can be opened and drained under a general anaesthetic. A breast abscess is not only extremely disappointing for the mother (because breast-feeding has to be discontinued) but is also a very painful and demoralizing experience. Inflammation of the breast is much more common following a first pregnancy and is very unusual once a woman has breastfed one child.

Breast abscesses were once relatively common but are now much less so, because modem antenatal instruction teaches a woman to breast-feed her baby correctly, and because modern treatment with both antibiotics and breast expression is very effective.

Cracked nipples usually develop on about the ninth or tenth day and the midwife is nearly always able to treat the condition so that breast-feeding can be resumed satisfactorily. Inflammation of the breast causing-flushing or redness of the skin also happens at about the tenth day. Immediate treatment by antibiotics and satisfactory emptying of the breast usually cures the infection and breast-feeding can be resumed. Inflammation of the breast also tends to occur during the fourth week after delivery, when the mother is usually unaware that a crack has developed in the nipple and the first thing she realizes is that the breast is painful and tender. This should be reported immediately, and if it is treated early an abscess can be avoided.

Once a woman has had a breast abscess most obstetricians consider that breast-feeding should not be attempted in a subsequent pregnancy. Every case is considered on its own merits, however, and there are instances where satisfactory breast-feeding has been accomplished after an abscess has been previously operated on and drained.

Infections of the Urinary Tract

Infections of the urinary tract (pyelonephritis and cystitis) are now much less common than they used to be because the majority of potential infections are eliminated during the antenatal period. A certain number of women do have bacteria in their urine during pregnancy and if anything happens to disturb the function of their urinary tract they are always liable to develop an infection. Women who develop a urinary tract infection during pregnancy are treated in the antenatal clinic or may even require admission to hospital for efficient therapy. Occasionally a urinary tract infection may develop after delivery.

Infections of the Urinary TractThere are two main varieties: cystitis, in which the symptoms are localized to the bladder itself, and pyelonephritis, where the symptoms involve the kidney and the person feels more ill.

Cystitis may develop as a result of catheterization during a prolonged or difficult labour, or may follow a forceps delivery or even a Caesarean section. Pain and discomfort on micturition are often accompanied by an urgency and desire to pass urine at frequent intervals. All these symptoms indicate an inflammation in the bladder itself. Cystitis alone does not usually cause much rise in temperature, but the symptoms can be very annoying. The urine is cultured and the infection is treated by a wide spectrum antibiotic and usually subsides within 24 hours.

Pyelonephritis develops when the organisms extend up from the bladder towards the kidney. There is usually a rapid rise in temperature which may be accompanied by a rise in the pulse rate, although the pulse itself may remain surprisingly normal. There is pain not only in the region of die bladder, but also over one or other kidney, with quite severe discomfort in the loin which may radiate downwards to the groin. The sudden rise in temperature may be associated with a rigor (shivering attacks) and sweating. The condition starts quite suddenly and is equally dramatic in its relief when the appropriate antibiotic is given. A mid-stream specimen of urine is sent to the laboratory for culture and the organism tested to find the most efficient antibiotic, but meanwhile treatment with a wide spectrum antibiotic is usually started.

Uterine Haemorrhage

Bleeding which occurs immediately after delivery of the baby is known as primary postpartum haemorrhage. A secondary postpartum haemorrhage is one that occurs more than 24 hours after completion of delivery. The lochia, which is bright red blood for the first two or three days, then becomes pinkish and later brown, and may become red again as a result of exercise or a return to household chores. Excessive bleeding occasionally occurs and may be the result of infection (when the bleeding is not usually severe and does not generally require any specific treatment other than for the infection itself) or retention of a small piece of placenta, known as a cotyledon. If the bleeding becomes more serious and the woman starts to pass clots then the presence of a retained cotyledon is always considered.

Subinvolution

Subinvolution follows a low grade infection inside the uterus so that the uterus does not involute, or return to its normal size, properly. Because the involution is not satisfactory there is a tendency to excessive bleeding. When the infection is treated, normal involution ensues and bleeding ceases.

Retained Products

Although the placenta is carefully inspected at delivery it sometimes happens that small fragments, retained within the uterus, are too small to be detected as missing. Retained products of conception may result in the sudden onset of brisk bleeding often associated with the passage of clots. This usually starts about the tenth day after delivery.

If bleeding suddenly begins the midwife or doctor must be notified immediately. The treatment follows two principles. Firstly, the administration of ergometrine or syntometrine will make the uterus contract and stop bleeding for at least 3 to 4 hours, and secondly, admission of the woman to hospital where (under a general anaesthetic) a gentle curettage operation is performed to remove the remaining cotyledon. Once an injection has been given to make the uterus contract, the bleeding will cease and from then on everything will be under control. If much blood has been lost a blood transfusion may be necessary even before a general anaesthetic is given. When the offending cotyledon has been removed from the uterus, there will be no further haemorrhage and the uterus will continue to involute normally.

AnaemiaAnaemia

Anaemia is due to a reduction either in the amount of blood in the body or in the haemoglobin level. The quantity of blood in the body is assessed by measuring the level of haemoglobin either in gm. per 100 ml. or as a percentage; 100 per cent is equivalent to 14 gm. (i.e. 1 gm. = 7 per cent).

Antenatal care ensures that normal haemoglobin levels are maintained throughout pregnancy. If anaemia is allowed to develop in the antenatal period then it will almost certainly be present after delivery; therefore, the best insurance against postpartum anaemia is adequate antenatal care. In this respect anaemia is no different from most of the other complications of pregnancy.

An excessive blood loss at or immediately after delivery may also result in anaemia in the puerperium. The average quantity of blood lost at delivery varies from about 75-250 ml. and this amount is unlikely to affect the level of haemoglobin adversely. However, if this amount of blood loss is exceeded, or if a woman loses a half litre or even 1 litre of blood, then postpartum anaemia is likely to develop.

Postpartum haemorrhage is now comparatively rare, although some instances are unavoidable. The loss of 1 litre of blood at the time of the delivery is usually an indication for an immediate blood transfusion to replace the blood loss and therefore prevent anaemia. A blood transfusion immediately after delivery is a precaution taken when blood loss has been greater than expected. This may happen during complicated deliveries, or Caesarean section. It does not mean that anything has gone wrong and it should give no cause for alarm. If a woman has in fact lost a half litre or even a litre of blood’at Caesarean scction it is much better that this should be replaced so that she is fit and healthy in the puerperium rather than anaemic and likely to suffer from the associated weakness, lethargy and susceptibility to infection. Anaemia also makes lactation less efficient.

Unsuspected Anaemia

The midwife and doctor know all the haemoglobin levels during pregnancy and will therefore be aware of any tendency to anaemia. They will thus be warned to look out for any anaemia that might develop after delivery. Unsuspected anaemia may be the result of this tendency and an excessive blood loss at delivery, for example, in a woman whose haemoglobin level has been just within the normal range during the latter part of pregnancy, that is about 74 or 75 per cent (or 11 gm.), and who loses slightly more than the expected amount of blood at delivery (about 300 or even 400 ml.).

Symptoms of Anaemia

These are all rather indefinite. The complexion is pale and has a rather pasty appearance. Excessive tiredness associated with adequate sleep, impatience, shortness of breath, irritability and lethargy as well as a feeling that everything is too much trouble, are all minor symptoms of anaemia. The nails, Ups and also the inner aspect of the lower eyelid are a pale colour. The pulse rate may remain persistently high, over 100 per minute, and this in itself is one of the most significant of all recordings in the puerperium.

The Natural Prevention of Anaemia

The total amount of blood normally circulating in the female body is approximately 5 litres. This amount is gradually increased in pregnancy by about 30 per cent to a total of 6-5 litres. This initially results in some dilution of the blood but if adequate iron and vitamins and a good diet are taken during the antenatal period then the haemoglobin level should be 80 per cent or higher when labour begins.

During the first three days after delivery the total circulating blood volume gradually returns to normal, which means that it is reduced by 1-5 litres to its usual non-pregnant level of 5 litres. This reduction in the circulating blood is accomplished by removing some of the serum from the blood stream itself, leaving the red cells and the other blood constituents, which means there is some concentration of these factors and the haemoglobin level therefore rises. This is nature’s way of compensating automatically for the amount of blood lost during delivery and for the blood lost in the lochia during the postpartum days. Some women can lose almost half a litre of blood at delivery and yet on the fourth postpartum day have a haemoglobin level higher than before the onset of labour.

Blood Tests after Delivery

Blood is usually taken on the third or fourth day after delivery for a haemoglobin estimation. If there is mild anaemia extra iron and vitamin tablets are given. If there is severe anaemia a blood trans-usion may be considered necessary. If so there is no cause for alarm, because it is much better to be fit and well after receiving a transfusion than to have to struggle along for the several weeks, or even months, that it may require to raise a very low haemoglobin level to normal.

All women who have recently had a baby should continue to case their iron and vitamin tablets for at least 3 months after delivery.

Venous Thrombosis

Superficial Venous Thrombosis

Varicose veins do sometimes develop during pregnancy and tend to become more severe with each subsequent pregnancy, although they regress somewhat after delivery. Comparatively severe varicose veins arc always liable to become inflamed after delivery and this is known as superficial phlebitis, or superficial thrombosis. The superficial varicose vein, usually on the inner side of the thigh or on the inner side of the calf, becomes slightly inflamed and then extremely tender. The vein itself can be felt as a firm, rather hard, very tender, cord-like structure lying immediately beneath the skin. The inflammation may extend along the vein for several inches and may be extremely painful on standing or walking. If this sort of inflammation should occur in the region of a varicose vein it should be reported to the midwife or doctor, who usually arrange for the leg to be bandaged and rested as much as possible until the inflammation has subsided. There is no specific or dramatic cure for superficial phlebitis or thrombosis and the painful swelling may continue for several days. The only real consolation is that the phlebitis results in obliteration and cure of the affected varicose vein. Above all, there is no need to worry about superficial thrombosis, because it never causes any real harm and although the terms ‘thrombosis ’ and ‘phlebitis’ can conjure up in most people’s minds pictures of terrible complications, no serious complications or disasters ever follow a superficial thrombosis. It is merely a rather painful, and annoying, but quite safe, complication of childbirth.

Deep Venous Thrombosis

A deep venous thrombosis is a condition where the veins in the centre of the leg become thrombosed. This may or may not be associated with superficial varicose veins but is very seldom associated ‘with a superficial thrombosis or superficial phlebitis. Deep venous thrombosis is unlikely when newly delivered mothers get up on the day after delivery and wear proper bedroom slippers with 1-inch heels. The worst type of shoes to wear after delivery are those without a heel or with just a strap across the front of the foot so that the toes have to be curled up to keep the slipper In place.

The condition usually starts on about the fifth day following delivery and the first thing noticed is a tightness in the middle of the calf in one leg. There is a certain discomfort or even pain on walking, and the calf is tender, especially between the two parts of the main muscle. There may be some swelling or oedema of the foot, or the ankle itself and even the calf of the leg may feel thickened and swollen. Pain may be felt in the back of the leg if the foot is forcibly pushed upwards, which is why there is pain on walking or on leaning forward.

Deep venous thrombosis used to be considered a potentially dangerous condition since it was feared that a blood clot could be dislodged from the thrombosed vein in the calf and could circulate back to become lodged either in the heart or the lungs—a condition known as a pulmonary embolus, which is not only painful but can also be very serious.

A woman who develops a deep venous thrombosis is usually instructed to rest in bed as much as possible. A crepe bandage is put on the foot and the leg to above the knee. A simple antibiotic such as penicillin or ampicillin may be administered. In some hospitals heparin is given by injection .every 6 hours, or as a continuous intravenous drip to reduce the coagulation time of the blood. The heparin usually relieves the pain in the leg within a few hours. After 24 hours a slower acting anticoagulant drug, such as dicoumarin, is given for 7 to 10 days or even longer. If such thrombosis can be shown, by tests, to extend above the knee, anticoagulant therapy may be continued for three months.

White Leg

White leg is now extremely rare. It is a serious complication of pregnancy in which there is a thrombosis of the main femoral vein which drains most of the blood from the leg. The thrombosis occurs in the groin and in the outer side of the pelvis and its onset is usually quite sudden causing quite severe bursting-like pain in the whole leg, especially in the thigh and the calf. The whole leg rapidly becomes very swollen, right up to the groin, and the skin becomes tender; the swelling of the leg makes it become pale and white—hence the term white leg. There is continuous aching, nagging, bursting, heavy discomfort in the leg.

White leg is nearly always caused by an infection in the pelvis, invariably the uterus, which may follow a prolonged and difficult labour. The leg is treated by bandaging, to give some relief from discomfort, and the administration of antibiotics and anticoagulant drugs.

Pulmonary Embolus

Pulmonary embolus is a condition in which a blood clot moves from one of the veins in the leg or pelvis, travels along the great vessels to the heart and is transmitted to the lungs, where it lodges and obstructs the blood supply. The part of the lung obstructed by the dot cannot obtain any blood supply and collapses. The patient experiences sudden and severe pain, usually in the lower part of the chest. Occasionally, if the diaphragm itself is affected, pain is felt either in the upper abdomen or in the shoulder. The onset of this severe pain is accompanied by shortness of breath and a feeling of faintness and tightness in the chest. The pain itself is sharp and knife-like usually causing a considerable amount of distress. It is worse on breathing or coughing, and is severe on taking a deep breath. A small amount of blood-stained sputum may be coughed up.

The treatment of pulmonary embolus is complete bed-rest, sedation and the administration of drugs to relieve the pain. Opinion is divided concerning the administration of anticoagulant drugs but if these are administered they are usually continued for several weeks or even months.

Pulmonary emboli are much less common than they used to be. Careful antenatal care, the treatment of anaemia and pelvic infection, adequate supervision in labour and the elimination of destructive or complicated obstetric procedures and extensive lacerations, are all factors which have hdped to reduce its inddence. The more frequent use of intravenous injections, or drips, of dextrose or saline prevent dehydration which has always been a cause of pulmonary embolus.

Anticoagulants and Breast feeding

If anticoagulant therapy is given orally it is usually considered inappropriate to breast feeding, some of the drug reaching the baby via the milk and possibly thinning its blood. This effect is usually minimal but the continuance of feeding ‘will necessitate repeated, blood tests on the baby and possible injections to restore its blood to normal.

Puerperal DepressionPuerperal Depression

Some emotional disturbance, together with the ‘postpartum blues’, is present in varying degrees in almost every woman who has had a baby. It used to be believed that there was a special type of mental illness known as puerperal psychosis which particularly affected women after childbirth. In actual fact there is no such condition, but some women who are liable to mental illness may become emotionally unstable, and pregnancy, delivery, the puerperium and responsibility of the new baby may impose an unreasonable strain upon them, leading to the onset of mental illness. There is nothing specific about pregnancy or delivery which causes a woman to develop a mental illness. Any other stress, strain or emotional disturbance of similar severity may quite easily provoke mental illness in such a person.

The treatment of puerperal psychosis is exactly the same as the treatment of any other mental illness: expert advice, reassurance, treatment with the appropriate drugs and perhaps rest in hospital. The doctor usually arranges for a psychiatrist to be consulted, because he is the ideal person to know exactly what dose or which type of drug should be administered in each instance. The prognosis of puerperal psychosis is similar to that of any other mental illness, with the exception that the new born baby imposes an additional strain upon the newly delivered mother.

When one considers the stresses and strains of pregnancy, labour and the puerperium it is rather surprising that puerperal psychosis is not more frequent. The anxieties of pregnancy, fears of the unknown, perhaps lack of sleep, concern as to whether the baby will be normal, whether the delivery will be easy, and then, when delivery has been completed, the progress of the baby (more especially the anxiety which may arise over breast-feeding) could impose an intolerable burden on any woman. The best intentioned of relatives and friends often add a very considerable strain.

Puerperal depression is frequently underestimated. It can occasionally be severe, prolonged and very distressing especially because few doctors understand its depressing effect upon the mother and the fact that it may continue for several months.