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Lochia Patterns Among Normal Women: A Systematic Review
Abstract
Background:
We conducted a systematic review of the literature to determine the amount and duration of blood loss 24 hours to 12 weeks after delivery.
Methods:
We searched MEDLINE, CINAHL, and PubMed for studies between the years 1950 and 2011 that prospectively evaluated the amount and duration of blood loss from 24 hours to 12 weeks after delivery. Excluded were those that were only case studies, retrospective studies, studies not published in English, studies outside of the time frame, and studies that included only subjects from special populations.
Results:
From the 333 identified studies, 18 met inclusion criteria. There was variability in how the amount of blood loss was determined, ranging from subject self-assessment to objective measures, such as pad weight and spectrophotometric readings of hematin concentration. The reported duration of normal blood loss after delivery varied among the studies. Whereas the average duration of blood loss in these studies ranged from 24 to 36 days, in only 1 study was bleeding followed to cessation.
Conclusions:
An understanding of bleeding patterns after delivery is important for clinicians to recognize deviations from normal, identify women at risk for delayed postpartum hemorrhage, and limit unnecessary interventions, yet studies reveal significant variability in amount and duration of normal lochial blood loss and methods of assessment that are inconsistent. This review draws attention to the need for the establishment of valid, reliable, and feasible methods to quantify normal and abnormal postpartum blood loss.
... Lochia (Fletcher et al., 2012) Increased lochia associated with increased activity or return of lochia that extends beyond 6 weeks postpartum Potential medical sources of concern (NICE, 2015, 2021b; NICE CKS, 2021) (Leinweber et al., 2022;Wang et al., 2021) Low mood, inability to cope, anxiety that negatively impacts upon daily activity, lack of bonding or desire to care for newborn, loss of interest in things around them, extreme mood swings, lack of self-care, irrational and or negative thoughts and unable to sleep at night Birth trauma (Leinweber et al., 2022) Low mood, inability to cope, tearfulness, lack of bonding or desire to care for newborn, sexual dysfunction, scar tissue hypersensitivity and recall of a negative birth experience access medical reviews via public or privately sourced services, which are unlikely to be approached in the context of return-to-sport nor include all the recommended considerations within this review. If outside of the expertise of the reviewing medical professional, postpartum players should be signposted to appropriate health or exercise professionals who can oversee the return-to-sport process (World Rugby, 2024 individual player need(s) and oversee whether a review with a pelvic health physiotherapist has been completed. ...
Pregnancy and childbirth involve substantial physical, physiological and psychological changes. As such, postpartum rugby players should be supported and appropriately prepared to return to the demands of rugby alongside the additional demands of motherhood. This review aims to discuss specific perinatal considerations that inform a rugby player's readiness to return‐to‐sport postpartum and present an approach to rehabilitation. Before engaging in full rugby training and matchplay, postpartum players should have progressed through the initial phases of rehabilitation and graded sports‐specific training to prepare them for the loads they will be exposed to. Additional rehabilitation considerations include minimising deconditioning during pregnancy; medical concerns; the abdominal wall; the pelvic floor; perinatal breast changes, breastfeeding and risk of contact breast injury; body mass; nutritional requirements; hormonal considerations; athlete identity and psychological considerations; joining team training; return to contact and tackle training; evaluating player load tolerance and future research, policy and surveillance needs. A whole‐systems, biopsychosocial approach following an evidence informed return‐to‐sport framework is recommended when rehabilitating postpartum rugby players. Health and exercise professionals are encouraged to use the perinatal‐specific recommendations in this review to guide the development of postpartum rehabilitation protocols and resources.
... If safety netting is to be effective in helping people to safely identify the circumstances in which they need to seek further help, midwives need knowledge based on high-quality evidence about what to expect and what signs and symptoms might indicate a problem. This is often already available; for example, there is good evidence around the normal parameters for lochia following birth from the original BLiPP study (Marchant et al, 1999) and subsequent research (Marchant et al, 2002;Chi et al, 2010;Fletcher et al, 2012), although there do not appear to be any recent studies. Although lochia varies widely from woman to woman (Steen et al, 2020), the evidence provides objective information on normal parameters regarding amount, colour, consistency and duration of loss. ...
Providing clear, accurate and timely information to women and their families is central to the role of the midwife. It is key to empowering women to make informed decisions and promotes both safety and quality of care. The term ‘safety netting’ has been described as sharing information to help people identify the need to seek further help if their condition fails to improve, changes or if they have concerns about their health. While safety netting is a familiar term in some fields of medicine, it is rarely used in midwifery. This article discusses how safety netting could be a useful concept for midwifery and proposes a framework for providing safety net information. The article includes a clinical scenario that considers how the framework supports clear and comprehensive communication, and a student midwife perspective that reflects on different aspects of safety netting, its teaching and the practice experience. Clear teaching of safety netting has potential advantages for midwifery education and practice.
... The prolonged duration of lochia was defined as bloody lochia lasting for more than 14 days. 22 And postpartum weight retention (PPWR) was calculated by subtracting the pre-pregnancy body weight from the current self-reported body weight. ...
Background and objectives:
This study aimed to explore the associations of postpartum dietary quality and behavioral practices with maternal health in Guangzhou China.
Methods and study design:
We conducted a cross-sectional study among puerperal women in urban and suburban areas in Guangzhou, China (n=2013). Data for postpartum dietary and behavioral practices and health conditions were collected by a standardized questionnaire. Dietary balance index (DBI) was calculated to assess an individual's dietary quality. Logistic regression analysis was used to identify the factors related to women's health.
Results:
75.5% of women reported at least one postpartum disease, and the most common problems were prolonged duration of lochia (70.0%) and backache (43.0%), followed by constipation (23.6%), insufficient milk secretion (19.2%), breast swelling (18.5%) and hemorrhoids (13.8%). Average postpartum weight retention was 3.5 kg. Logistic regression analysis revealed that 12-18 h/d of bed rest time, breastfeeding, doing postpartum exercise, basking, getting out of bed within 2 days after delivery, higher intake of fish and shrimp, fruits, vegetable, milk were protective factors for at least one out of these health problems or weight retention (p<0.05). Bed rest time for more than 18 h/d or less than 12 h/d, ginger vinegar intake, doing housework, cesarean section, and excessive and inadequate intake of cereals had an adverse association (p<0.05).
Conclusions:
Some features of a traditional Chinese postpartum diet and behaviour are related to maternal morbidity during the puerperium. Further studies are needed to assess whether postpartum diet and behavioral intervention improve maternal health during the postpartum period.
... Then at around 10th day, because of an admixture of leukocytes and reduced fluid content, lochia assumes a white or yellow-white color known as lochia alba. The average duration of puerperial lochial discharge is from 24 to 36 days [1]. ...
Puerperium is the time following delivery during which pregnancy-induced maternal anatomical and physiological changes return to the nonpregnant state. Puerperium period of 6 weeks can be divided into: (a) immediate – within 24 hours (b) early – up to 7 days (c) remote – up to 6 weeks. The puerperal effects are seen in all organs and particularly in reproductive organs. Infection and haemorrhage are the common postpartum complications. Post partum care is very important. Advice on exclusive breast feeding and contraception is also mandatory after every childbirth.
... The postpartum period is complicated by physiological, biological, and emotional changes that could negatively in uence contraceptive method continuation. Lochia discharge is one of such physiological changes that hypothetically if excessive or prolonged could lead to IUD expulsion in the same way as excessive uterine bleeding does [4,[8][9][10][11]. In support of this connotation it can be observed that the critical period of IUD expulsion coincides with the early postpartum period of 4 to 6 weeks during which lochia discharge is ongoing and uterine involution is taking place [12,13]. ...
Background The insertion of Intrauterine Contraceptive Device (PPIUD) for the purpose of contraception immediately after delivery is becoming popular in countries where the use of IUD for contraception has been extremely low. Since 2015, Tanzania implemented the initiative by the International Federation of Gynecology and Obstetrics (FIGO) to institutionalize PPIUD. As a result of capacity building and information delivery under the initiative, there have been increased uptake of the method. Working in this context, the focus of the study was to generate evidence on the effect of TCu380A IUD on amount and duration of lochia and equip service providers with evidence-based knowledge which can help them in counselling their PPIUD clients.
Objective Establish impact of postpartum TCu380A on amount and duration of lochia.
Methods A prospective cohort study of delivered women in two teaching hospitals in Tanzania with immediate insertion of TCu380A or without use of postpartum contraception in 2018. TCu380A models; Optima (Injeflex Co. Brazil) and Pregna (Pregna International, Chakan, India) were used. Follow-up was done by weekly calls and examination at 6th week. Lochia was estimated by Likert Scale 0-4 relative to the amount of lochia on the delivery day. An estimated 250 women sample (125 each group) would give 80% power to detect a desired 20% difference in the proportion of women with prolonged lochia discharges among the Exposed and Unexposed groups. Data analysis was by SPSS.
Results 275 women were analysed, 142 Exposed and 133 Unexposed. Medical complaints were reported by 41 (28.9%) Exposed and 37 Unexposed (27.8%), p=0.655. Lack of dryness by end of 6th week was to 32 (22.5%) Exposed and 8 (6.0%) Unexposed, p<0.001. Exposed had higher weekly mean lochia scores throughout with varience most marked in week 5 (F=3.818, p<0.001) and week 6 (F=2.949, p=0.004).
Conclusion PPIUD is associated with increased amount of lochia and slows progression to dryness within 6 weeks of delivery. The implications of PPIUD clients’ need to be informed about the possibility of delayed dryness of lochia at the time of counseling are discussed.
... The postpartum period is complicated by physiological, biological, and emotional changes that could negatively influence contraceptive method continuation. Lochia discharge is one of such physiological changes that hypothetically if excessive or prolonged could lead to IUD expulsion in the same way as excessive uterine bleeding does [4,[8][9][10][11]. In support of this connotation it can be observed that the critical period of IUD expulsion coincides with the early postpartum period of 4 to 6 weeks during which lochia discharge is ongoing and uterine involution is taking place [12,13]. ...
Abstract Background The insertion of Intrauterine Contraceptive Device (PPIUD) for the purpose of contraception immediately after delivery is becoming popular in countries where the use of IUD for contraception has been extremely low. Since 2015, Tanzania implemented the initiative by the International Federation of Gynecology and Obstetrics (FIGO) to institutionalize PPIUD. As a result of capacity building and information delivery under the initiative, there have been increased uptake of the method. Working in this context, the focus of the study was to generate evidence on the effect of TCu380A IUD on amount and duration of lochia and equip service providers with evidence-based knowledge which can help them in counselling their PPIUD clients. Objective Establish impact of postpartum TCu380A on amount and duration of lochia. Methods A prospective cohort study of delivered women in two teaching hospitals in Tanzania with immediate insertion of TCu380A or without use of postpartum contraception in 2018. TCu380A models; Optima (Injeflex Co. Brazil) and Pregna (Pregna International, Chakan, India) were used. Follow-up was done by weekly calls and examination at 6th week. Lochia was estimated by Likert Scale 0–4 relative to the amount of lochia on the delivery day. An estimated 250 women sample (125 each group) would give 80% power to detect a desired 20% difference in the proportion of women with prolonged lochia discharges among the Exposed and Unexposed groups. Data analysis was by SPSS. Results Two hundred sixty women were analysed, 127 Exposed and 133 Unexposed. Medical complaints were reported by 41 (28.9%) Exposed and 37 Unexposed (27.8%), p = 0.655. Lack of dryness by end of 6th week was to 31 (23.3%) Exposed and 9 (7.1%) Unexposed, p
... The postpartum period is complicated by physiological, biological, and emotional changes that could negatively in uence contraceptive method continuation. Lochia discharge is one of such physiological changes that hypothetically if excessive or prolonged could lead to IUD expulsion in the same way as excessive uterine bleeding does [4,[8][9][10][11]. In support of this connotation it can be observed that the critical period of IUD expulsion coincides with the early postpartum period of 4 to 6 weeks during which lochia discharge is ongoing and uterine involution is taking place [12,13]. ...
Background
The insertion of Intrauterine Contraceptive Device (PPIUD) for the purpose of contraception immediately after delivery is becoming popular in countries where the use of IUD for contraception has been extremely low. Since 2015, Tanzania implemented the initiative by the International Federation of Gynecology and Obstetrics (FIGO) to institutionalize PPIUD. As a result of capacity building and information delivery under the initiative, there have been increased uptake of the method. Working in this context, the focus of the study was to generate evidence on the effect of TCu380A IUD on amount and duration of lochia and equip service providers with evidence-based knowledge which can help them in counselling their PPIUD clients.
Objective
Establish impact of postpartum TCu380A on amount and duration of lochia.
Methods
A prospective cohort study of delivered women in two teaching hospitals in Tanzania with immediate insertion of TCu380A or without use of postpartum contraception in 2018. TCu380A models; Optima (Injeflex Co. Brazil) and Pregna (Pregna International, Chakan, India) were used. Follow-up was done by weekly calls and examination at 6th week. Lochia was estimated by Likert Scale 0-4 relative to the amount of lochia on the delivery day. An estimated 250 women sample (125 each group) would give 80% power to detect a desired 20% difference in the proportion of women with prolonged lochia discharges among the Exposed and Unexposed groups. Data analysis was by SPSS.
Results
260 women were analysed, 127 Exposed and 133 Unexposed. Medical complaints were reported by 41 (28.9%) Exposed and 37 Unexposed (27.8%), p=0.655. Lack of dryness by end of 6th week was to 31 (23.3%) Exposed and 9 (7.1%) Unexposed, p<0.001. Exposed had higher weekly mean lochia scores throughout with the difference most marked in 5th week (3.556 Versus 2.039, p<0.001) and 6th week (1.44 Versus 0.449, p˂0.001) .
Conclusion
PPIUD is associated with increased amount of lochia and slows progression to dryness within 6 weeks of delivery. The implications of PPIUD clients’ needs to be informed about the possibility of delayed dryness of lochia at time of counseling are discussed.
... Lochia was divided into bloody lochia, serous lochia and white lochia, which lasted about 3 ~ 4 days, 10 days and 3 weeks, respectively. The prolonged uterine bleeding was de ned as bloody lochia lasting for more than 14 days [21]. And postpartum weight retention was calculated as current self-reported body weight minus pre-pregnancy body weight. ...
Background: Maternal health problems during postpartum period are highly prevalent worldwide, which may be related to unhealthy dietary and behavioral practices of postpartum women. Accordingly, this study aimed to explore postpartum dietary and behavioral practices, and their relationship with maternal health in Guangzhou, China.
Methods: We conducted a cross-sectional study among postpartum women in urban and suburban area in Guangzhou China. Data about postpartum dietary and behavioral practices and health conditions were collected by a standardized questionnaire. Logistic regression analysis was used to identify the factors related to women’s health.
Results: A total of 2040 women were recruited, 2013 of which complete the questionnaire, including 1007 from urban area and 1006 from suburban area. The consumption of animal food was triple the recommended intake, while the intakes of fruits, milk and seafood were deficient; and most women were lack of physical activities. 75.5% of women reported at least one postpartum disease, and the most common problems were prolonged uterine bleeding (70.0%) and backache (43.0%), followed by constipation (23.6%), insufficient milk secretion (19.2%), breast swelling (18.5%) and hemorrhoids (13.8%). Median of postpartum body weight retention was 3.5 kg. Logistic regression analysis revealed that 12-18 h/d of bed rest time, breastfeeding, doing postpartum exercise, basking, getting out of bed within 2 days after delivery, intake of animal food (250-350 g/d), vegetables (>500 g/d), grain and potato (250-450 g/d) were protective factors for at least one out of these health problems or weight retention (P<0.05). Bed rest time for more than 18 h/d or less than 12 h/d, ginger vinegar intake, doing housework, cesarean section, and excessive intake of grain and potato (>450 g/d) had adverse association (P<0.05).
Conclusion: Postpartum low physical activity and adherence to the diet with high intake of animal food and inadequate intake of fruits, vegetables and milk were very common in Guangzhou. Further studies are needed to assess whether postpartum diet and behavioral intervention improve maternal health during postpartum period.
... After delivery, postpartum bleeding gradually ceases over approximately 6 weeks. 35 During this time, factor levels decline exponentially and reach baseline about 3 weeks postpartum. 24 In women whose factor levels are less than 50%, factor concentrates may be continued for several days or weeks. ...
Severe and moderate factor VIII (FVIII) or IX (FIX) deficiencies in female carriers of haemophilia are rarely observed, but mild deficiency is quite frequent, although insufficiently recognized and registered. The confusion between the genetic diagnosis of the carriership, mainly assessed at adult age and the diagnosis of the bleeding disorder for those who have low factor levels often prevents early diagnosis of a potential bleeding risk. The factor levels in obligate or potential carriers of haemophilia can be assessed during childhood, possibly apart from genetic assays. The absence of early recognition of the bleeding disorder precludes the anticipation of menarche and the prevention of potential heavy menstrual bleeding to heavy menstrual bleeding. Standardized bleeding assessment tools (BAT) have demonstrated that women and girls with haemophilia (WGWH) have increased bleeding scores as compared to the general female population, however weakly correlating with factor levels. More recent evidence has highlighted that hemarthroses affect 4% to 19% of carriers and that some of them could experience sub-clinical joint bleeding. Desmopressin for women with FVIII deficiency and abnormal ISTH-BAT scores had a significantly lower FVIII response to DDAVP compared to those with normal bleeding scores, which could at least partially explain more postsurgical bleeding. Management of delivery of haemophilia carriers requires attention to the risks of maternal bleeding, the risks of foetal bleeding, preconception and prenatal care, strategies to reduce maternal bleeding, choice of mode of delivery to reduce foetal/neonatal bleeding, and postpartum care. Either prior to pregnancy, or during early pregnancy, a plan should be developed that addresses the needs of both the mother and her unborn baby. If the unborn baby is a male proven to be or potentially affected by moderate or severe form of haemophilia, there is a risk of severe foetal bleeding, so a planned caesarean delivery may be preferred. If the unborn baby is a carrier, or potentially affected carrier, there is still the risk of non-severe bleeding so invasive foetal procedures and operative vaginal delivery (forceps or vacuum) should be avoided. Further studies based on large cohorts will help the community to favour earlier diagnosis, increase knowledge on WGWH and promote better care.
... The postpartum period is complicated by physiological, biological, and emotional changes that could negatively influence contraceptive method continuation. Lochia discharge is one of such physiological changes that hypothetically if excessive or prolonged could lead to IUD expulsion in the same way as excessive uterine bleeding does [4,[8][9][10][11]. In support of this connotation it can be observed that the critical period of IUD expulsion coincides with the early postpartum period of 4 to 6 weeks during which lochia discharge is ongoing and uterine involution is taking place [12,13]. ...
Background The insertion of Intrauterine Contraceptive Device (PPIUD) for the purpose of contraception immediately after delivery is becoming popular in countries where the use of IUD for contraception has been extremely low. Since 2015, Tanzania implemented the initiative by the International Federation of Gynecology and Obstetrics (FIGO) to institutionalize PPIUD. As a result of capacity building and information delivery under the initiative, there have been increased uptake of the method. Working in this context, the focus of the study was to generate evidence on the effect of TCu380A IUD on amount and duration of lochia and equip service providers with evidence-based knowledge so as to minimize unnecessary interventions and method discontinuation.
Objective Establish impact of postpartum TCu380A on amount and duration of lochia.
Methods A prospective cohort study of delivered women in two teaching hospitals in Tanzania with immediate insertion of TCu380A or without use of postpartum contraception in 2018. TCu380A models; Optima (Injeflex Co. Brazil) and Pregna (Pregna International, Chakan, India) were used. Follow-up was done by weekly calls and examination at 6 th week. Lochia was estimated by Likert Scale 0-4 relative to the amount of lochia on the delivery day. An estimated 250 women sample (125 each group) would give 80% power to detect a desired difference. Data analysis was by intention to treat using SPSS.
Results 275 women were analysed, 142 exposed and 133 unexposed. Medical complaints were reported by 41 (28.9%) exposed and 37 unexposed (27.8%), p=0.655. Lack of dryness by end of 6 th week was to 32 (22.5%) exposed and 8 (6.0%) unexposed, p<0.001. Exposures had higher weekly mean lochia scores throughout with varience most marked in week 5 (F=3.818, p<0.001) and week 6 (F=2.949, p=0.004).
Conclusion PPIUD is associated with increased amount of lochia and slows progression to dryness within 6 weeks of delivery. The implications of excess amount and duration of lochia in care of PPIUD clients are discussed.
... Bipedalism is also hypothesized to have contributed to the evolution of the human placenta and to postpartum bleeding. In humans, vaginal bleeding persists for weeks following birth-a recent systematic review found that blood loss persists for a mean of 24 to 36 days after birth, with durations as long as 90 days in some studies (Fletcher, Grotegut, & James, 2012). Abrams and Rutherford (Abrams & Rutherford, 2011) link postpartum bleeding to bi pedal ism. ...
In this chapter, we use an evolutionary lens to deepen understanding of maternal and family needs in the early postpartum period so that health care can be more aligned with confronted realities. The discussion is centered around the concept of the 4th trimester, which is the period between birth and the first 3 months postpartum. This framework encourages a holistic understanding of perinatal health by drawing attention to evolved maternal-infant needs. By addressing these ultimate-level contributors to health issues, we can facilitate more effective clinical support, comprehensive research, and a fuller “village” to enable new families to thrive. Core to this approach is the concept of trade-offs between parents and offspring, exemplified by lactation as a prime example of the complexities of dyadic needs and gap between the current culture of health and optimal support.
... This may somewhat help to reduce unnecessary intervention. 49,50 Most women would not need a pelvic ultrasound scan to exclude retained products, and in those who have one, nothing 'treatable' is usually found. 51 A cornerstone of overall management is to be aware of the wide variation in normal post-partum bleeding that is not life-threatening. ...
... Nei primi 5-6 giorni le perdite sono stimate in circa 250-300 grammi/die, come detto perlopiù ematici, per poi diminuire gradualmente fino alla scomparsa. 4 tra le varie complicanze patologiche, oltre al già menzionato rischio di emorragia tardiva, di frequente riscontro è la problematica infettiva a carico dell'apparato genitale femminile in involuzione dopo il parto. le infezioni più comuni sono quelle che si verificano a carico dei margini cruentati di una episiorrafia o di una lacerazione spontanea. ...
... However, there is a report of red lochia lasting up to puerperium day 12, which is longer than that reported by classic studies on the subject (Sherman, Lurie, Frenkel, et al., 1999, pp.399-400). Systematic review conducted by Fletcher, Grotegut, & James (2012) reported that the average duration of postpartum blood loss was stable during 24 to 36 days. Comparative investigation of the changes in lochia color and duration of these changes by type of birth is required. ...
Purpose
The purpose of this study was to elucidate the chronological changes that take place during involution of the uterus after Caesarian section (CS) to obtain basic data for use in the assessment of an involution state.
Methods
The participants were 70 women who underwent CS of a single, full-term fetus and experienced a normal postoperative course thereafter. Fundal length and height of the uterus were measured from puerperium day 0 to puerperium day 7. Forty-eight of the 70 women were included in color analysis of the lochia using a self-administered questionnaire to record daily changes in lochia color. Statistical analysis was performed using SPSS ver. 22.0 software, and P < 0.05 was considered statistically significant.
Results
Mean fundal length gradually decreased from 18.1±0.32 (mean±SE) cm on puerperium day 0 to 15.6±0.21cm on puerperium day 3 and 13.4±0.20cm on puerperium day 7. Mean length decreased approximately 1 cm per day on puerperium days 1 and 2 (p < 0.01) and an additional 1 cm on puerperium day 4 and puerperium day 6 (p < 0.01). Median fundal height was one finger-width below the navel on puerperium day 0, two finger-widths on puerperium day 3, and three finger-widths on puerperium day 6, although there was wide variation in the measurements.
Lochia color, as checked by the puerperal women, showed significant change starting on puerperium day 6 (p < 0.05); however, 30% of the puerperal women still had red-colored lochia.
Conclusion
Post-CS fundal length was longer and showed more marked changes in comparison to vaginal births. Our investigation of changes in fundal height, as determined via palpation, indicated that three days were required for the height to decrease by one finger-width below the navel and that there was wide variation in the data. Notably, assessments dependent upon palpation are particularly susceptible to individual interpretation. In comparison to vaginal births, in CS births, lochia color change and involution of the uterus take longer to occur and the uterus is softer.
The results of this study, wherein satisfactory postpartum progress was observed after normal, standard CS of single full-term fetuses, represented basic data related to early puerperium involution of the uterus following CS; these data can be utilized as assessment criteria in the future.
... 9 Postpartum patients may continue to have lochia for up to 6 to 8 weeks postdelivery, which can lead to contamination of the urine specimen and a false-positive result. 10 Therefore, evaluation of hematuria in this case may be delayed depending on the clinical presentation. Of note, if a clean catch specimen is required due to symptomatology, a tampon may be inserted into the vagina and a urine specimen obtained after an adequate cleansing of the perineum. ...
There have been widely documented beneficial role of vaginal Lactobacillus species as an important biomarker for vaginal health and healthy pregnancy progression. When translating this to clinical settings, pregnant women with low proportions of Lactobacillus and commensurately high proportion of rich and highly diverse abnormal microbiota are most likely to encounter negative pregnancy outcome such as preterm birth and postpartum complications. However, multiple literatures have also addressed this notion that the absence of a Lactobacillus-dominated microbiota does not appear to directly imply to a diseased condition and may not be a major determinant of negative obstetric outcome. Caesarian delivery is notably a risk factor for preterm birth and postpartum endometritis, yet recent data shows a trend in the overuse of CS across several populations. Growing evidence suggest the potential role of vaginal/uterine cleaning practice during CS procedures in influencing postpartum infections, however there is a controversy that this practice is associated with increased rates of postpartum endometritis. The preponderance of bacterial vaginosis associated bacteria vagitype at postpartum which persist for a long period of time even after lochia regression in some women may suggest why short interpregnancy interval may pose a potential risk for preterm birth, especially multigravidas. While specifically linking a community of microbes in the female reproductive tract or an exact causative infectious agent to preterm birth and postpartum pathologies remains elusive, clinical attention should also be drawn to the potential contribution of other factors such as short interpregnancy interval, birth mode, birth practices and the postpartum vaginal microbiome in preterm birth which is explicitly described in this narrative review.
Pregnant women and their partners often ask healthcare professionals whether sex is safe during pregnancy, and what consequences may result from sexual activity. Many clinicians can also be unsure of the answers to these type of questions, leading to both patient and clinician resorting to the internet for advice, which can be inaccurate and anxiety-inducing. Here, the authors provide clinicians with an insight into the information offered by 'Dr Google' so that they can reassure and advise their patients as necessary. Aimed at obstetricians and other physicians caring for pregnant women, this book reviews the implications of sex during pregnancy such as those complicated by medical conditions, those at risk of preterm birth and multiple pregnancies. Other chapters cover physiological changes during pregnancy that may affect sexual function and intimacy, as well as the differing guidelines provided by various global obstetric societies.
Postpartum hemorrhage is a major world-wide cause of maternal death. Risk factors and approaches to reduce death are presented. It is one of several clinical situations that the obstetrician may consult the hematologist for treatment and advice. Pregnancy among patients having congenital or acquired hemorrhagic disorders are discussed as well as other obstetrical disorders having hemostatic manifestations such as preeclampsia, the HELLP syndrome, acute fatty liver of pregnancy and pregnancy-related TTP.
Objectives:
To evaluate whether timing of etonogestrel (ENG) implant insertion during the postpartum period affects maternal bleeding patterns, body mass index (BMI) and 12-month satisfaction and continuation rates.
Study design:
This is a secondary analysis of an open, randomized, controlled trial. Postpartum women were block-randomized to early (up to 48 h postpartum) or delayed (6 weeks postpartum) insertion of an ENG implant. Bleeding patterns and BMI were evaluated every 90 days for 12 months. At 12 months, we measured implant continuation rates and used Likert and face scales to measure users' satisfaction. The level of significance was 0.4% (adjusted by Bonferroni test for multiplicity).
Results:
We enrolled 100 postpartum women; we randomized 50 to early and 50 to delayed postpartum ENG implant insertion. Bleeding patterns were similar between groups. Amenorrhea rates were high in both groups during the follow-up (52%-56% and 46%-62% in the early and delayed insertion group, respectively). Prolonged bleeding episodes were unusual in both groups during the follow-up (0-2%). Maternal BMI was similar between groups and decreased over time. Twelve-month continuation rates were similar between groups (early insertion: 98% vs. delayed insertion: 100%, p=.99). Most participants were either very satisfied or satisfied with the ENG implant in both groups (p=.9).
Conclusion:
Women who underwent immediate postpartum insertion of the ENG implant have similar bleeding patterns, BMI changes, and 12-month satisfaction and continuation rates compared to those who underwent delayed insertion.
Implications:
Our results from a secondary analysis of a clinical trial support that satisfaction, continuation and bleeding patterns do not differ when women received contraceptive implants immediately postpartum or at 6 weeks. However, the emphasis on infant growth in the trial and easy access to delayed placement may have influenced results.
Im Wochenbett finden Uterusrückbildung mit Wundheilung und Laktationsbeginn statt. Die Subinvolutio uteri kann über eine Endometritis/Endomyometritis zur Puerperalsepsis oder gar zum Toxic-shock-Syndrom (TTS) durch Streptococcus pyogenes oder Staphylococcus aureus führen.
Jedes Fieber, eine plötzlich auftretende Verschlechterung des Allgemeinzustands oder gar ein „systemic inflammatory response syndrome“ (SIRS) müssen abgeklärt und behandelt werden, um nicht zur schweren Sepsis oder septischen Schock zu führen. Auch an eine septische Ovarialvenenthrombose ist zu denken. Bei Sepsismanifestationen sollten großzügig die operative Entfernung des Infektionsherdes, eine hochdosierte antibiotische Kombinationstherapie und ggf. intensivmedizinische Maßnahmen erfolgen.
Auch Harnverhalt, Harnwegsinfektionen, Urininkontinenz oder Hämorrhoidalbeschwerden kommen im Wochenbett vor.
Es ist wichtig, den häufigen „maternity blues“ von der Post-partum-Depressionen und der Puerperalpsychose abzugrenzen.
Background
Etonogestrel (ENG) implants (Implanon®/Nexplanon®/Implanon NXT®) are employed as contraception in early postpartum patients. Follow-up is often not conducted by the hospital prescriber. Little is known about duration of lochia, in a modern setting, and even less is known about the effect of ENG implants on lochia.
Aims
To determine if early postpartum (pre-discharge) insertion of Implanon for contraception was associated with a significant difference in duration of lochia. To record the number of patients who went on to have their Implanon removed during the study period and the reasons for removal.
Methods
Prospective cohort study of 152 postpartum patients from a tertiary maternity unit in Hobart, Tasmania, Australia. The treatment group was women requesting Implanon prior to discharge. Controls were recruited from the same unit over the same time period, with the aim to match for birth weight and parity. Information was collected during face-to-face interviews or via telephone contact. Multivariate survival analysis was used to investigate lochia duration.
Results
There were 73 controls and 79 women who had early postpartum Implanon inserted. Fourteen (17.7%) patients in the treatment group had their Implanon removed during the postpartum study period. In all of these cases the reason for removal was bleeding disturbance – prolonged or intermittent vaginal bleeding beyond 50 days postpartum. There was no significant difference in duration of lochia between the groups [median predicted duration 25 days (95% CI 22–27) in controls and 24 days (95% CI 21–26) in the treatment group].
Conclusions
Early postpartum insertion of Implanon for contraception was not associated with a statistically or clinically significant difference in duration of lochia.
Objectives: The aim of this study was to assess the duration of lochia in women hospitalized at Korean medical postpartum care center and to identify factors that influence duration of lochia. Methods: On the obstetric variables of 315 cases, the duration of lochia was analyzed. In the postpartum care center, the obstetric variables were asked of 315 cases of women, and who examined a body composition. After discharge, women were surveyed for the duration of lochia by telephone. Results: The median duration of lochia was 30 days and the range was 18~53 days. Maternal age, parity and mode of delivery were associated with its duration. So, its duration was longer on women over the age of 35, multipara and women had a Cesarean section. Its duration was correlated with gestational age and BMI before pregnancy, but not neonatal gender, birth weight, maternal BMI change during pregnancy, maternal body weight gain, BMI before delivery. Conclusions: It was 30 days that the median duration of lochia of women who had been got Korean medical postpartum care management, and which was slightly different from previous studies. And it was influenced by maternal age, parity, mood of delivery, gestational age and BMI before pregnancy. In future more studies or surveys for the duration of lochia of women with no treatment, lochial pattern and so on should be done.
Meta-analyses of postpartum blood loss and the effect of uterotonics are biased by visually estimated blood loss.
To conduct a systematic review of measured postpartum blood loss with and without prophylactic uterotonics for prevention of postpartum haemorrhage (PPH).
We searched Medline and PubMed terms (labour stage, third) AND (ergonovine, ergonovine tartrate, methylergonovine, oxytocin, oxytocics or misoprostol) AND (postpartum haemorrhage or haemorrhage) and Cochrane reviews without any language restriction.
Refereed publications in the period 1988-2007 reporting mean postpartum blood loss, PPH (> or =500 ml) or severe PPH (> or =1000 ml) following vaginal births.
Raw data were abstracted into Excel by one author and then reviewed by a co-author. Data were transferred to SPSS 17.0, and copied into RevMan 5.0 to perform random effects meta-analysis.
The distribution of average blood loss (29 studies) is similar with any prophylactic uterotonic, and is lower than without prophylaxis. Compared with no uterotonic, oxytocin and misoprostol have lower PPH (OR 0.43, 95% CI 0.23-0.81; OR 0.73, 95% CI 0.50-1.08, respectively) and severe PPH rates (OR 0.61, 95% CI 0.29-1.29; OR 0.74, 95% CI 0.52-1.04, respectively). Oxytocin has lower PPH (OR 0.65, 95% CI 0.60-0.70) and severe PPH (OR 0.71, 95% CI 0.56-0.91) rates than misoprostol, but not in developing countries.
Oxytocin is superior to misoprostol in hospitals. Misoprostol substantially lowers PPH and severe PPH. A sound assessment of the relative merits of the two drugs is needed in rural areas of developing countries, where most PPH deaths occur.
To explore traditional beliefs and practices, to assess puerperal morbidity, and to understand care-seeking behaviors, a qualitative and quantitative study was conducted in low socio-economic settlements of Karachi, Pakistan. Five focus group discussions and 15 in-depth interviews were conducted in July and August 2000. 525 Muslim women, who were 6-8 weeks post-partum, were then interviewed at home. Maternal care was relatively good-more than three-quarters of recent mothers sought antenatal care and more than half (267/525) delivered in a hospital or maternity home. Counseling to attend post-partum clinics among facility deliveries was 16% (43/267), of which only 26% (11/43) attended. Practices during the delivery and puerperium, such as massaging the vaginal walls with mustard oil during labor to facilitate delivery and inserting vaginal or rectal herbal pessaries to facilitate 'shrinkage of the uterus' and/or 'strengthening of the backbone', were pervasive. The core symptoms that are clinically significant during the puerperium are heavy vaginal bleeding and high fever, since they are potentially fatal symptoms if appropriate and timely care is not sought. About half of the study women (53.3%) reported at least one illness symptom, high fever (21.1%), heavy vaginal bleeding (13.9%), and foul smelling vaginal discharge (9.6%). Women did not know the underlying biologic cause of their perceived post-partum morbidity; weakness was frequently mentioned. Women sought care initially from close relatives or traditional healers and if they continued to suffer from their morbidity they finally approached a trained health care (allopathic) provider. The high prevalence of perceived post-partum morbidity illustrates the demand for post-partum community-based health care programs. We suggest promoting maternal health education that encourages women to seek appropriate and timely care by accessing public or private health services.
To establish normal ultrasonographic findings for the postpartum uterus after vaginal delivery, and to characterize associated bleeding patterns.
Postpartum women were scanned by transabdominal ultrasound within 48 h after normal vaginal delivery. Uterine length, uterine width, endometrial stripe thickness and endometrial contents were evaluated by a single sonographer. Patients maintained a daily symptom diary for 6 weeks and were interviewed by telephone at 2 weeks. Statistical analysis was performed using chi2, Fisher's exact test, Student's t test and Pearson correlation.
Mean endometrial stripe thickness was 1.1 +/- 0.6 cm, mean uterine length was 16.1 +/- 1.7 cm and mean uterine width was 8.7 +/- 1.0 cm. Postpartum bleeding requiring more than four protective pads per day for > or =10 days was associated with a thicker endometrial stripe (1.5 +/- 0.7 cm vs. 0.9 +/- 0.4 cm, p = 0.006). However, no patients experienced postpartum bleeding complications requiring intervention. Of the 40 women evaluated, 16 had echogenic material in the uterine cavity (mean size 12.7 +/- 6.9 cm2). The presence of echogenic material was not associated with the amount or duration of bleeding.
Frequent postpartum ultrasonographic findings include a thickened endometrial stripe and echogenic material in the uterine cavity. The echogenic material commonly seen in the endometrial cavity of asymptomatic patients was not associated with the development of bleeding complications.
To test the hypotheses that: (1) standard definitions of common obstetric terms exist and (2) frontline workers in daily obstetric practice have common understandings of these terms, we undertook (a) a review of definitions for nine common terms from latest editions of standard texts and resources, and (b) an exploratory questionnaire survey of these definitions applied in a work setting among four groups; trainee and consultant obstetricians, student and qualified midwives (five of each). Definitions for nine selected obstetric terms in common use (labour, parity, precipitate labour, primary postpartum haemorrhage, primiparity, PROM, secondary postpartum haemorrhage, term and viability) were inconsistent in standard texts. Obstetric staff had no agreed perception of the precise definitions. There is a potentially hazardous lack of clarity about obstetric terms, and a need to develop standard definitions. This would benefit students, practitioners, information technology experts and, most importantly, patients.
This investigation sought to characterize the syndrome of severe delayed postpartum hemorrhage. We defined the syndrome as hemorrhage requiring hospitalization and/or surgical intervention, occurring after the patients' initial hospital discharge. We evaluated hospital admissions to two tertiary institutions. During a 10-year period, 113 women (57,089 deliveries) suffered severe delayed postpartum hemorrhage. The incidence of the syndrome was 0.2% of deliveries. The mean time of presentation of delayed hemorrhage was 18 days post-delivery. However, 11% of bleeding began 6 weeks or more after delivery. Curettage was an effective management, with successful resolution of symptoms in 91 of 99 patients. Histologic examination of curettage material demonstrated retained products of conception in 55% of cases; 35% of patients required transfusion. Pre-existing medical diseases were not associated with postpartum bleeding. The only predisposing cause was postpartum hemorrhage that had occurred at delivery (22 patients); 19 of these women were later found to have retained products of conception. Combining our series with other series reported in the literature, severe delayed postpartum hemorrhage occurs in 0.2-0.5% of deliveries. Major etiologies include retained products of conception 30-50% of the time, as well as subinvolution of the placenta. Uterine curettage is an effective management option.
Secondary postpartum haemorrhage (SPPH) is an important post-natal issue, whose significance is perceived differently between practices, settings and probably within cultures. It is generally less focussed upon, in contrast to its primary counterpart. Patients prefer that it is treated promptly, even when it is not life-threatening. Intensity of blood loss, and the lesser popularity of conservative management drive clinicians towards the active options. Remarkably, none of the current treatment options is based on any evidence. Suction evacuation of the uterus may be complicated by life-threatening complications and blood transfusion. There are a few guidelines, and probably no protocols. In this review, we highlight salient factors to take into consideration, and propose a locally adaptable flowchart, which may be of use to General Practice doctors, Community Midwives and Obstetricians.
PIP
185 postpartum women were inserted with 30-mm Lippes loops on the third or fourth postpartum day to determine the effects of lochia and menstrual patterns. 100 postpartum without IUDs were used as a control group. Hemoglobin and bacteriological studies were done periodically in both groups and amount of lochial discharge and menstrual patterns were recorded. The period of lochia averaged 31.2 days in the study group and 23.3 days in the control group. The amount of lochia was excessive in 40% of the study group as compared with 11% of the controls, and menorrhagia was more often seen in the study group (20% and 7%, respectively). No difference in hemoglobin levels or bacterial count was noted.
Post-partum bleeding was estimated during the first 72 hours in 106 women with normal delivery at term, all had live child with a body weight between 2.5 and 3.5 Kg. Three groups of women were studied: Group 1 comprised 41 volunteers with normal deliveries to whom no medication had been administered; Group 2 comprised 39 volunteers receiving 20 IU of oxytocin in 250 ml of a 5% glucose solution, immediately after delivery; and in Group 3, 26 volunteers received 0.2 mg of ergonovine maleate, orally three times daily for three days. The average post-partum blood loss in Group 1 during the first 72 hours after delivery was 151.5 +/- 12.5 ml; for Group 2, 155.9 +/- 13.9 ml; and for Group 3, 135.5 +/- 15.9 ml. There were no significant differences among the groups and, most of the blood loss occurred during the first 24 hours after delivery.
To assess the quantity and duration of lochia in women with or without inherited bleeding disorders and to identify factors that influence lochial loss.
Pictorial blood assessment chart was completed by 115 pregnant women (21 with or carriers of inherited bleeding disorder and 94 without bleeding disorder) using standardized sanitary products.
The median duration of lochia was significantly longer in women with (or carriers of) inherited bleeding disorder (39 days; range 21-58) compared with women without bleeding disorder (31 days; range, 10-62; P = .03); however, the median lochial loss were similar (441 mL; range, 135-1290 vs 429 mL; range, 112-1295; P = .59). Long labor and instrumental delivery were associated with heavier lochia.
Pictorial blood assessment chart is potentially a useful tool in the assessment of lochia. Women with inherited bleeding disorders experience longer period of lochia compared with women without bleeding disorder. Labor duration and mode of delivery influence lochial loss.
In this study, we sought to (1) define trends in the incidence of postpartum hemorrhage (PPH), and (2) elucidate the contemporary epidemiology of PPH focusing on risk factors and maternal outcomes related to this delivery complication.
Hospital admissions for delivery were extracted from the Nationwide Inpatient Sample, the largest discharge dataset in the United States. Using International Classification of Diseases, Clinical Modification (ninth revision) codes, deliveries complicated by PPH were identified, as were comorbid conditions that may be risk factors for PPH. Temporal trends in the incidence of PPH from 1995 to 2004 were assessed. Logistic regression was used to identify risk factors for the most common etiology of PPH-uterine atony.
In 2004, PPH complicated 2.9% of all deliveries; uterine atony accounted for 79% of the cases of PPH. PPH was associated with 19.1% of all in-hospital deaths after delivery. The overall rate of PPH increased 27.5% from 1995 to 2004, primarily because of an increase in the incidence of uterine atony; the rates of PPH from other causes including retained placenta and coagulopathy remained relatively stable during the study period. Logistic regression modeling identified age <20 or > or =40 years, cesarean delivery, hypertensive diseases of pregnancy, polyhydramnios, chorioamnionitis, multiple gestation, retained placenta, and antepartum hemorrhage as independent risk factors for PPH from uterine atony that resulted in transfusion. Excluding maternal age and cesarean delivery, one or more of these risk factors were present in only 38.8% of these patients.
PPH is a relatively common complication of delivery and is associated with substantial maternal morbidity and mortality. It is increasing in frequency in the United States. PPH caused by uterine atony resulting in transfusion often occurs in the absence of recognized risk factors.
To identify risk factors for immediate postpartum hemorrhage after vaginal delivery in a South American population.
This was a prospective cohort study including all vaginal births (N=11,323) between October and December 2003 and October and December 2005 from 24 maternity units in two South American countries (Argentina and Uruguay). Blood loss was measured in all births using a calibrated receptacle. Moderate postpartum hemorrhage and severe postpartum hemorrhage were defined as blood loss of at least 500 mL and at least 1,000 mL, respectively.
Moderate and severe postpartum hemorrhage occurred in 10.8% and 1.9% of deliveries, respectively. The risk factors more strongly associated and the incidence of moderate postpartum hemorrhage in women with each of these factors were: retained placenta (33.3%) (adjusted odds ratio [OR] 6.02, 95% confidence interval [CI] 3.50-10.36), multiple pregnancy (20.9%) (adjusted OR 4.67, CI 2.41-9.05), macrosomia (18.6%) (adjusted OR 2.36, CI 1.93-2.88), episiotomy (16.2%) (adjusted OR 1.70, CI 1.15-2.50), and need for perineal suture (15.0%) (adjusted OR 1.66, CI 1.11-2.49). Active management of the third stage of labor, multiparity, and low birth weight were found to be protective factors. Severe postpartum hemorrhage was associated with retained placenta (17.1%) (adjusted OR 16.04, CI 7.15-35.99), multiple pregnancy (4.7%) (adjusted OR 4.34, CI 1.46-12.87), macrosomia (4.9%) (adjusted OR 3.48, CI 2.27-5.36), induced labor (3.5%) (adjusted OR 2.00, CI 1.30-3.09), and need for perineal suture (2.5%) (adjusted OR 2.50, CI 1.87-3.36).
Many of the risk factors for immediate postpartum hemorrhage in this South American population are related to complications of the second and third stage of labor.
II.
The clinical features of 106 women who had a secondary postpartum haemorrhage were examined in detail; 39 were managed conservatively, 3 had a vaginal laceration resutured and 64 had a curettage. In 46 patients, material obtained by curettage was examined histologically. The clinical features associated with retained products of conception are defined and comparisons are made between conservative and surgical management of secondary postpartum haemorrhage.
A study was conducted to introduce a standardized method of measuring and describing blood loss on peripads. This report of practice-ready research demonstrates the significant difference that resulted in accuracy of estimations.
The duration of lochia and its association with a number of obstetric variables was studied in 236 women. Each woman completed a diary sheet describing the colour and duration of her lochia for up to 60 days post partum. The phases of lochia were divided according to the classical description; lochia rubra, serosa and alba. The median total duration of lochia was 33 days, lochia rubra 4 days and lochia serosa 22 days. Lochia persisted to 60 days in 13% of women. The duration of lochia was shorter in parous women and women with smaller babies.
To examine the postpartum bleeding experience of a cohort of breast-feeding women and to compare it with the conventional definition of lochia.
Four hundred seventy-seven experienced breast-feeding women in Manila, the Philippines, were followed prospectively from delivery and recorded vaginal bleeding in a menstrual diary. The median duration of lochia was calculated using survival analysis. In addition, all bleeding separate from lochia within the first 8 weeks postpartum was noted.
The median duration of lochia was 27 days and did not vary by age, parity, sex or weight of the infant, breast-feeding frequency, or level of supplementation. More than one-fourth of the women experienced a bleeding episode separated from the original lochial flow by at least 4 bleeding-free days and beginning no later than postpartum day 56. Ten breast-feeding women may have had their first menstrual bleed before day 56.
Lochia lasted substantially longer than the conventional assumption of 2 weeks. It was common for postpartum bleeding to stop and start again or to be characterized by intermittent spotting or bleeding. Return of menses is rare among fully breast-feeding women in the first 8 weeks postpartum.
To describe the range of normal vaginal loss as reported by women from 24 hours after delivery until three months postnatally.
Two health districts in the south of England.
A prospective survey of women's experiences and expectations of the duration, amount and colour of vaginal loss after childbirth. The term vaginal loss includes all types of fluid loss from the vagina following childbirth.
Five hundred and twenty-four women were recruited to the survey in 1995. Vaginal loss, as reported by the women, was considerably more varied in duration, amount and colour than descriptions in current midwifery textbooks. The median number of days reported for the duration of vaginal loss was 21 days and the interdecile range (10th to 90th percentile) was 10-42 days. For colour of lochia, women overall reported their vaginal loss to be more predominantly red/brown in colour and the traditional descriptions of the timing and colour phases of lochia rubra, serosa and alba are not supported by the majority of the women's experiences. Primiparous women were significantly more likely to report feelings of surprise or shock about their experiences of vaginal blood loss after the birth (odds ratio 4 [95% Confidence Interval 2-9]). Seven primiparous women (2%) were unaware that they would have a blood loss at all after the birth.
The findings from this survey have been used to develop information leaflets for women and health professionals about vaginal loss following childbirth. These leaflets include descriptions of normal ranges for the colour, amount and duration of vaginal loss in the first three months after childbirth.
The objective of this paper is to determine the characteristics of each phase of lochia and how these may be influenced by a number of obstetric variables. Thirty-nine healthy women who had spontaneous vaginal delivery following uncomplicated pregnancy volunteered to complete a diary sheet immediately postpartum. The women were instructed to assess the color of their lochia by a color slide with differential gradation from dark red to white. The color was labeled as rubra (red, red-brown), serosa (brown-pink, brown), or alba (yellow, white). The overall duration of lochia was 36.0 +/- 7.5 days (range 17 to 51 days, median 37 days). Three types of lochia color patterns were identified: type 1--rubra-->serosa-->alba sequence (n = 20); type 2-rubra-->serosa-->alba sequence with prolonged rubra phase and short serosa and alba phases (n = 11); and type 3-with two rubra phases (rubra-->serosa/alba-->rubra-->serosa/alba sequence with near-equal duration of each phase) (n = 8). The rubra phase lasts 12.1 +/- 6.7 days in type 1, 24.8 +/- 5.0 days in type 2, and 5.5 +/- 2.5 days (the first rubra) in type 3 pattern (p < 0.05). There was a higher proportion of lactating women among women with type 1 pattern as compared with type 2 (11/20 and 2/11, p < 0.05, respectively). Women with type 2 pattern were of higher parity (2.8 +/- 1.3) as compared with those with type 1 (1.8 +/- 0.8) (p < 0.05). There were no significant differences in infants' birth weight between the various color types (3,276.0 +/- 379.8 g, 3,564.4 +/- 737.9 g, and 3,080.0 +/- 180.0 g for type 1, type 2, and type 3, respectively. There were no significant differences in overall duration of lochia or gestational age at delivery between the various color types. The results confirm the clinical impression that lochia persists longer than classically reported and is of diverse patterns. Three unique types of color patterns were identified. Type 1 is the most prevalent and is associated with prolonged breast feeding and thus can be considered as the classic type. Type 2 is associated with short or no breast feeding and higher parity. Type 3 may be a variant of type 2. We suggest that traditional teaching on lochia characteristics needs reappraisal.
To determine the incidence, risk factors, presentation, treatment and morbidity associated with secondary postpartum haemorrhage.
Analysis of 132 consecutive women presenting with secondary postpartum haemorrhage occurring over a three-year period.
The maternity unit in a district general teaching hospital serving an annual delivery rate of around 6500 women.
Factors associated with the cause of the haemorrhage and the resulting morbidity.
Most women presented during the second week after delivery. A history of primary postpartum haemorrhage (OR 9.3; 95% CI 6.2-14.0) and manual removal of placenta (OR 3.5; 95% CI 1.6-7.5) were the only significant risk factors identified. There was a high associated morbidity, with 84% requiring hospital admission, 63% surgical evacuation, 17% blood transfusion, with three women suffering a uterine perforation, one managed by hysterectomy. In women undergoing evacuation only, 37% had retained placental tissue confirmed after surgery; pre-operative ultrasound examination did not provide a better discrimination over clinical assessment for this finding.
Secondary postpartum haemorrhage occurs in just under 1% of women, is associated with primary postpartum haemorrhage and retained placenta, and may result in significant maternal morbidity. This problem deserves more attention than it has received in recent years.
To describe the work of the Scottish Programme for Clinical Effectiveness in Reproductive Health (SPCERH) in order to draw lessons applicable to other clinical effectiveness programmes.
Overview of an integrated clinical effectiveness programme relating to reproductive health.
Scotland.
The programme is designed to reach all professionals who share responsibility for reproductive healthcare--including obstetrician/gynaecologists, midwives, general practitioners, family planning doctors, commissioners of services and NHS managers.
During its first three-year Workplan, SPCERH has conducted an integrated programme of audit, guideline and educational activities. Findings have been disseminated using multi-faceted approaches including publications, presentations and interactive meetings. Evidence from surveys undertaken within the Programme indicates that clinicians have changed or reconsidered their practice in several key areas in response to audit and guideline recommendations made by the Programme.
As a way of funding and organising clinical effectiveness activities, the integrated Programme has many advantages over the stand-alone Project. These advantages include: enabling the linkage of national audits to national guidelines and other forms of NHS guidance; enabling the re-audit of topics after a time interval sufficient to allow for the implementation of change; the building of expertise within a dedicated team and the use of that expertise across a range of linked projects; the availability of an experienced team which can respond to new priority issues at short notice.
• 1.1. Kutapressin, a new non-toxic selective vasoconstrictor, was successfully used in sixty-eight consecutive postpartum cases to suppress lochial discharges. By the sixth postpartum day, the lochial discharges were eliminated.
• 2.2. A daily parenteral injection of 2 cc. of kutapressin was administered to each patient during the hospital stay.
• 3.3. Uterine involution appeared to keep pace with lochial control under this therapy.
• 4.4. A definite increased lactogenic response was noted in those mothers who were nursing their offspring under kutapressin therapy.
• 5.5. Those postpartum patients who did not receive kutapressin therapy (control group) showed no similar findings.
To estimate the incidence of maternal morbidity during labour and the puerperium in rural homes, the association with perinatal outcome and the proportion of women needing medical attention.
Prospective observational study nested in a neonatal care trial.
Thirty-nine villages in the Gadchiroli district, Maharashtra, India.
Seven hundred and seventy-two women recruited over a one year period (1995-1996) and followed up from the seventh month in pregnancy to 28 days postpartum (up to 10 visits in total).
Observations at home by trained village health workers, validated by a physician. Diagnosis of morbidities by computer program.
Direct obstetric complications during labour and the puerperium, breast problems, psychiatric problems and need for medical attention.
The incidence of maternal morbidity was 52.6%, 17.7% during labour and 42.9% during puerperium. The most common intrapartum morbidities were prolonged labour (10.1%), prolonged rupture of membranes (5.7%), abnormal presentation (4.0%) and primary postpartum haemorrhage (3.2%). The postpartum morbidities included breast problems (18.4%), secondary postpartum haemorrhage (15.2%), puerperal genital infections (10.2%) and insomnia (7.4%). Abnormal presentation and some puerperal complications (infection, fits, psychosis and breast problems) were significantly associated with adverse perinatal outcomes, but prolonged labour was not. A third of the mothers were in need of medical attention: 15.3% required emergency obstetric care and 24.0% required non-emergency medical attention.
Nearly 15% of women who deliver in rural homes potentially need emergency obstetric care. Frequent (43%) postpartum morbidity, and its association with adverse perinatal outcome, suggests the need for home-based postpartum care in developing countries for both mother and baby.
To determine the incidence and risk factors for standard and severe postpartum haemorrhage (PPH) in vaginally delivering nulliparous women, before and after risk stratification.
A population-based cohort study in an unselected cohort nulliparous women (N = 3464) in 'The Zaanstreek' district, The Netherlands. Risk stratification is part of routine care, where midwives cover all obstetrical care for women with low risk pregnancies.
The incidence of standard PPH (> or = 500 ml) and severe PPH (> or = 1000 ml) were 19 and 4.2%, respectively. A retained placenta occurred in 1.8%. These data show consistently slightly higher values as compared to studies in literature. The most important risk factors for standard and severe PPH were related to an abnormal third stage of labour-third stage > or = 30 min and retained placenta (in severe PPH: odds ratio (OR) 14.1, 95% confidence interval (CI) 10.4-19.1). High birth weight and perineal damage were less important, but independent, significant risk factors. In the low risk group (N = 1416), incidence of severe PPH was 4.0%. Independent risk factors for severe PPH were third stage > or = 30 min (incidence 7.1%, OR 3.6) and retained placenta (incidence 1.2%, OR 21.6). In 25% of the women with a prolonged third stage (> or = 30 min), third stage was complicated due to retained placenta and/or severe PPH (1.8% of the low risk group).
The incidence of PPH in nulliparous women in this cohort was on average higher than published data, while the most important risk factors for standard and severe PPH, even after risk stratification, were the same. A prolonged third stage of labour has to be considered as abnormal, requiring specific action.
The purpose of this article is to help nurses understand how to quickly and effectively manage the nursing care of patients with perinatal hemorrhage. The etiology, symptoms, medical management, and nursing care of the patient experiencing a perinatal hemorrhage are discussed. Hemorrhage during the antepartum, intrapartum, or postpartum period is a life-threatening emergency for the mother and/or fetus. Early antepartum hemorrhage (before 20 weeks gestation) can be related to abortion/miscarriage, ectopic pregnancy, or gestational trophoblastic disease; late antepartum hemorrhage (after 20 weeks gestation) may result from placental abruption and placenta previa. Intrapartum hemorrhage is most commonly due to placental abruption, or to uterine rupture, uterine inversion, invasive conditions of the placenta, or complications of Cesarean birth. Postpartum hemorrhage is defined as blood loss greater than 500 ml in a vaginal delivery or 1000 ml in a Cesarean birth; early postpartum hemorrhage occurs during the first 24 hours after delivery; late postpartum hemorrhage occurs after the first 24 hours after delivery. The most common cause of postpartum hemorrhage is uterine atony; however, lacerations, hematomas, and subinvolution of the uterus can also cause postpartum hemorrhage. Nurses who understand how to assess, plan, intervene, and evaluate outcomes for perinatal hemorrhage are in the position to prevent the major tragedies that can accompany hemorrhage in pregnancy and shortly afterward.
Labor and delivery units are often used to provide care for nonlaboring patients requiring intensive medical and nursing care. The utilization of labor beds in this manner, however, can result in a shortage of beds for those patients who are truly in labor. Unfortunately, patient dissatisfaction, use of supplemental staffing, and ill-prepared, overworked nurses can then become the result of this practice. Clearly, an improved, innovative model of providing care for high-risk perinatal patients is needed. The purpose of this article is to describe how one hospital and its interdisciplinary team met the challenge of providing expert care for complex perinatal patients by creating a unique model of patient care delivery, the perinatal special care unit (PSCU). An advanced practice nursing role, the perinatal nurse practitioner (PNNP) was implemented to provide collaborative care for these patients. This article includes a discussion of positive and negative outcomes that occurred after the PSCU became a reality. Overall, housing patients on the PSCU has eliminated inappropriate use of labor and delivery beds and has led to a more satisfying childbearing experience for all involved.
To describe delivery-related complications and postpartum morbidity of women living in slum areas of Dhaka, Bangladesh.
From November 1993 to May 1995, 1506 women were interviewed regarding delivery-related complications and postpartum morbidities. Operational definitions were applied to maternal reports to categorize serious delivery-related complications and postpartum morbidity. Corroborating information was identified from medical records for facility-based deliveries and physical examinations by female physicians 14 to 22 days postpartum.
Thirty-six percent of women described serious delivery-related complications and 75% of women reported postpartum morbidity. There were two maternal deaths among 1471 live births. When maternal reports were related to corroborating information, the proportion of women's reports of serious complications and morbidity appears reasonably accurate for some conditions.
A large proportion of urban slum women in Dhaka experience serious delivery-related complications and/or postpartum morbidity. Information on delivery practices that contribute to morbidity and factors that influence appropriate care seeking is needed.
To determine whether there is a relationship between the findings of routine postpartum ultrasonographic scanning and puerperal uterine complications such as heavy delayed postpartum hemorrhage, retained products of conception, and need for uterine curettage; and to estimate the value of both routine ultrasonographic scanning and clinical data in the prediction of these complications.
In this cohort study 265 women were examined ultrasonographically on postpartum Days 1, 14, 42 following uncomplicated vaginal or cesarean deliveries. They were divided into a low-risk (n=149) and a high-risk (n=116) group according to predefined risk factors for puerperal uterine complications. The ultrasonographic findings were dichotomized into no masses (endometrial strip, endometrial fluid, or hyperechoic foci) or a definite intrauterine echogenic/heterogeneous mass (IUM, >15 mm in diameter).
The presence of risk factor(s) was significantly associated with uterine subinvolution, IUM, heavy delayed postpartum hemorrhage (PPH), and a need for uterine curettage. Multivariable logistic regression analysis for the risk factor(s) that can predict the occurrence of heavy delayed PPH showed that the presence of an IUM was the most predictive variable. The presence of an IUM and heavy delayed PPH predicted uterine curettage in 61.3% and 37.5% of patients, respectively.
Routine uterine scanning on Day 1 and Day 14 postpartum is an easy, inexpensive, valuable method that can be offered to women at high risk for delayed PPH due to subinvolution or the presence of an IUM. Accordingly, it may be predicted which women will benefit from uterine curettage in up to two-thirds of cases.
Scottish confidential audit of severe ma-ternal morbidity : Annual report (data from 2009)
- C Lenox
- Marr
Lenox C, Marr L. Scottish confidential audit of severe ma-ternal morbidity : Annual report (data from 2009), 7th ed.
Treatments for second-ary postpartum haemorrhage
- Thomas P Sanghera
Alexander J, Thomas P, Sanghera J. Treatments for second-ary postpartum haemorrhage. Cochrane Database Syst Rev 2002:CD002867.