OBSTETRICS

PUERPERIUM
4S-2 | CEU-SOM A & B
Dr. Elyneth Valencia, MD, FPOGS, FPSUOG,

OUTLINE because almost half of women have regression

of high-grade dysplasia following delivery
INVOLUTION OF THE REPRODUCTIVE TRACT
PLACENTAL SITE INVOLUTION
URINARY TRACT
PERITONEUM AND ABDOMINAL WALL
HEMATOLOGICAL PARAMETERS AND PREGNANCY HYPERVOLEMIA
BREASTS AND LACTATION
MATERNAL CARE DURING THE PUERPERIUM

I. DEFINITION

 puerperium is derived from Latin—puer,— child + parus,

bringing forth.
 defines the time following delivery during which pregnancy-
induced maternal anatomi-cal and physiological changes
return to the nonpregnant state.
 Its duration is understandably inexact, but is considered to be
between 4 and 6 weeks.
II. INVOLUTION
 Birth canal
 Return of the tissues in the birth canal to the
nonpregnant state begins soon aer delivery. The
vagina and its outlet gradually diminish in size
but rarely regain their nulliparous dimensions.
Rugae begin to reappear by the third week but
are less prominent than before. The hymen is
represented by several small tags of tissue,
which scar to form the myrtiform caruncles. The
vaginal epithelium reflects the hypoestrogenic
state, and it does not begin to proliferate until
4 to 6 weeks. This timing is usually coincidental
with resumed ovarian estrogen production.
Lacerations or stretching of the perineum during
delivery can lead to vaginal outlet relaxation.
Some damage to the pelvic floor may be
inevitable, and parturition predisposes to urinary
incontinence and pelvic organ prolapse.
 Uterus
 The massively increased uterine blood flow
necessary to maintain pregnancy is made
possible by significant hypertrophy and
remodeling of pelvic vessels. Aer delivery, their
caliber gradually diminishes to approximately
that of the prepregnant state. Within the
puerperal uterus, larger blood vessels become
obliterated by hyaline changes. They are
gradually resorbed and replaced by smaller
ones. Minor vestiges of the larger vessels,
however, may persist for years. During labor, the
margin of the dilated cervix, which corresponds
to the external os, may be lacerated. The
cervical opening contracts slowly, and for a few
days immediately aer labor, it readily admits two
fingers. By the end of the first week, this
opening narrows, the cervix thickens, and the
endocervical canal re-forms. The external os
does not completely resume its pregravid
appearance. It remains somewhat wider, and
typically, ectocervical depressions at the site of
lacerations become permanent. These changes
are characteristic of a parous cervix (Fig. 36-1).
Cervical epithelium also undergoes considerable
remodeling. This actually may be salutary
4S-1 ANTENATAL AND INTRAPARTUM FETAL SURVEILLANCE
Common appearance of nulliparous (A) and parous (B) cervices.
After del fundus is at the level of
6weeks return to non preg state from 1000g to 50g
 Cervical epithelium also undergoes considerable
remodeling,and this actually may be salutary.
Ahdoot and associates (1998) found that
approximately half of women showed regression of
high-grade dysplasia following vaginal delivery.
Kaneshiro and coworkers (2005) found similar
regression—about 60 percentoverall—regardless
of delivery mode.Postpartum, the fundus of the
contracted uterus lies slightly below the umbilicus.
It consists mostly of myometrium coveredby serosa
and internally lined by basal decidua. The
anteriorand posterior walls, which lie in close
apposition, are each 4 to 5 cm thick (Buhimschi,
2003). At this time, the uterus weighs approximately
1000 g. Because blood vessels are compressed by
the contracted myometrium, the uterus on section
appears ischemic compared with the reddish-
purple hyperemic preg-nant organ.
 Myometrial involution is a truly remarkabletour de
forceof edestruction or deconstruction that begins
as soon as 2 days afterdelivery as shown in Figure
36-2. As emphasized by Hytten(1995), studies that
describe the degree of decreasing uterine weight
postpartum are poor quality. Best estimates are that
by 1 week, the uterus weighs approximately 500 g;
by 2 weeks, about 300 g; and at 4 weeks, involution
is complete and theuterus weighs approximately
100 g. After each successive deliv-ery, the uterus is
usually slightly larger than before the most recent
pregnancy. The total number of myocytes does not
decrease appreciably—rather, their size decreases
markedly.
 Afterpains. In primiparous women, the uterus tends
to remaintonically contracted following delivery. In
multiparas, however,it often contracts vigorously at
intervals and gives rise toafter-rrpains, which are
similar to but milder than labor contractions. These
are more pronounced as parity increases and
worsen whenthe infant suckles, likely because of
oxytocin release (Holdcroft, 2003). Usually,
afterpains decrease in intensity and become mild by
the third day. We have encountered unusually
severe and per-sistent afterpains in women with
postpartum uterine infections.
 Lochia. Early in the puerperium, sloughing of
decidual tissueresults in a vaginal discharge of
variable quantity. The dischargeis termedlochia and
RAMOS @wonderpill4558 | REYES @yourroyalkateness│ROCHA @giannisrocha
PAGE 1 of 12
 contains erythrocytes, shredded decidua,aepithelial
cells, and bacteria.
 For the first few days after delivery,there is blood
sufficient to color it red—lochia rubra. After 3 or 4
days, lochia becomes progressively pale in color—
lochia serosa. After approximately the 10th day,
because of an admix-ture of leukocytes and
reduced fluid content, lochia assumes a white or
yellow-white color—lochia alba.The average
durationof lochial discharge ranges from 24 to 36
days
 Placental Site Involution
 Complete extrusion of the placental site takes up to
6 weeks (Williams, 1931). Immediately after
delivery, the placentalsite is approximately palm-
sized. Within hours of delivery, itnormally consists
of many thrombosed vessels that ultimately
undergo organization (see Fig. 36-2). By the end of
the secondweek, it is 3 to 4 cm in
diameter.Placental site involution is an exfoliation
process, which is prompted in great part by
undermining of the implantationsite by new
endometrial proliferation (Williams, 1931).
Thus,involution is not simply absorption in situ.
Exfoliation consistsof both extension and
“downgrowth” of endometrium fromthe margins of
the placental site, as well as development of
endometrial tissue from the glands and stroma left
deep in the decidua basalis after placental
separation. Anderson and Davis(1968) concluded
that placental site exfoliation results from sloughing
of infarcted and necrotic superficial tissues
followedby a remodeling process.
 SubinvolutionIn some cases, uterine involution is
hindered because of infec-tion, retained placental
fragments, or other causes. Such sub-involution is
accompanied by varied intervals of prolongedlochia
as well as irregular or excessive uterine bleeding.
On bimanual examination, the uterus is larger
and softer, boggy than would be expected.
Ergonovine (Ergotrate) or methylergono-vine
(Methergine), 0.2 mg orally every 3 to 4 hours for
24 to 48 hours, is recommended by many, but its
efficacy is question-able. Of these, only
methylergonovine is currently available inthe United
States. If there is infection, antimicrobial therapy
usually leads to a good response. In an earlier
study, Wager and coworkers (1980) reported that a
third of these late casesof postpartum metritis are
caused by Chlamydia trachomatis. Empirical
therapy with azithromycin or doxycycline bid for
7d usually prompts resolution regardless of
bacterial etiology.Another cause of subinvolution is
incompletely remodeleduteroplacental arteries
(Andrew, 1989; Kavalar, 2012). These noninvoluted
vessels are filled with thromboses and lack
anendothelial lining. Perivascular trophoblasts are
also identifiedin the vessel walls, suggesting an
aberrant interaction between uterine cells and
trophoblasts.
 defines secondary postpartum hemorrhageas
bleeding e24 hours to 12 weeks after delivery.
Clinically worrisome uterine hemorrhage develops
within 1 to 2 weeks in perhaps 1 percent of women.
Such bleeding most often is the result of abnormal
invo-lution of the placental site. It occasionally is
caused by retentionof a placental fragment or by a
uterine artery pseudoaneurysm.Usually, retained
products undergo necrosis with fibrin deposi-tion
and may eventually form a so-called placental
polyp.As theeschar of the polyp detaches from the
myometrium, hemorrhagemay be brisk. As
discussed in Chapter 56 (p. 1118),
delayedpostpartum hemorrhage may also be
caused by von Willebranddisease or other inherited
1S-1 NAME OF TOPIC
coagulopathies (Lipe, 2011).In our experiences,
few women with delayed hemorrhage arefound to
have retained placental fragments. Thus, we and
others do not routinely perform curettage (Lee,
1981). Another con-cern is that curettage may
worsen bleeding by avulsing part of the implantation
site. Thus, in a stable patient, if sonographic
examination shows an empty cavity, then oxytocin,
methylergo-novine, or a prostaglandin analogue is
given. Antimicrobials are added if uterine infection
is suspected. If large clots are seen in the uterine
cavity with sonography, thengentlesuction
curettageeis considered. Otherwise curettage is
carried out only if appre-ciable bleeding persists or
recurs after medical management.
 Urinary Tract
 Normal pregnancy-induced glomerular
hyperfiltration persists on the first postpartum day
but returns to prepregnancy base-line by 2 weeks.
Also, dilated ureters and renal pelves return to their
prepregnant state during the courseof 2 to 8 weeks
postpartum. Because of this dilated collect-ing
system, coupled with residual urine and bacteriuria
in a traumatized bladder, urinary tract infection is
a concern in thepuerperium.Bladder trauma is
associated most closely with labor length and thus
to some degree is a normal accompaniment of vagi-
nal delivery. Funnell and colleagues (1954) used
cystoscopy immediately postpartum and described
varying degrees of sub-mucosal hemorrhage and
edema. Postpartum, the bladder hasan increased
capacity and a relative insensitivity to intravesi-cal
pressure. Thus, overdistention, incomplete
emptying, and excessive residual urine are
common. Their management is dis-cussed on page
676.It is unusual for urinary incontinence to
manifest during the puerperium. That said, much
attention has been given to the potential for
subsequent development of urinary inconti-nence
and other pelvic floor disorders in the years
following delivery.
 PERITONEUM AND ABDOMINAL WALL
 The broad and round ligaments require
considerable time torecover from stretching and
loosening during pregnancy. As a result of ruptured
elastic fibers in the skin and prolonged dis-tention
by the pregnant uterus, the abdominal wall remains
softand flaccid. If the abdomen is unusually flabby
or pendulous, an ordinary girdle is often
satisfactory. An abdominal binder is at best a
temporary measure. Several weeks are required
forthese structures to return to normal, and
recovery is aided by exercise. These may be
started anytime following vaginal deliv-ery and as
soon as abdominal soreness diminishes after
cesareandelivery. Silvery abdominal striae
commonly develop asstriae gravidarum(Chap. 4, p.
51). Except for these, the abdominal wall usually
resumes its prepregnancy appearance. When mus-
cles remain atonic, however, the abdominal wall
also remainslax. Marked separation of the rectus
abdominis muscles—dias-tasis recti—may result.
 Hematological and Coagulation Changes
 Marked leukocytosis and thrombocytosis may
occur dur-ing and after labor. The white blood cell
count sometimesreaches 30,000/μL, with the
increase predominantly due to granulocytes. There
is a relative lymphopenia and an absolute
eosinopenia. Normally, during the first few
postpartum days, hemoglobin concentration and
hematocrit fluctuate mod-erately. If they fall much
below the levels present just beforelabor, a
considerable amount of blood has been lost By the
end of pregnancy, there are many changes in labo-
TRANS TEAM LAST NAMES
PAGE 2 of 12
 ratory findings that assess coagulation Many
persist in the puerperium. One example isthat the
markedly increased levels of plasma fibrinogen are
maintained at least through the first week, and
hence, so is the increase in sedimentation rate.
 When the amount of blood attained by normal pregnancy
hyper-volemia is lost as postpartum hemorrhage, the woman
almostimmediately regains her nonpregnant blood volume. If
less has been lost at delivery, it appears that in most women,
blood volume has nearly returned to its nonpregnantlevel by
1 week after delivery. Cardiac output usually remains elevated
for 24 to 48 hours postpartum and declines to non-pregnant
values by 10 days. Heart rate changes follow this pattern.
Systemic vascular resistance and blood pres-sure rise.
Systemic vascular resistance remains in the lower range
characteristic of pregnancy for 2 days postpartum and then
begins to steadily increase to normal nonpregnant val-ues. 28
wks aog, delivery, 10 days pp
 POSTPARTUM DIURESIS
 Normal pregnancy is associated with an
appreciable increase in extracellular sodium and
water, and postpartum diuresis is a physiological
reversal of this process. demonstrated a decrease
in sodium space of approxi-mately 2 L during the
first week postpartum. This also cor-responds with
loss of residual pregnancy hypervolemia.
Inpreeclampsia, pathological retention of fluid
antepartum andits diuresis postpartum may be
prodigious. Postpartum diuresis results in relatively
rapid weight loss of 2 to 3 kg, which is added to the
5 to 6 kg incurred by delivery and normal blood loss.
Weight loss from pregnancy itself islikely to be
maximal by the end of the second week
postpartum.
 Breast and lactation
 breasts begin to secrete colostrum, whichis a deep
lemon-yellow liquid.
 It usually can be expressed fromthe nipples by the
second postpartum day.
 Compared with mature milk, colostrum is rich in
immunological components IgA (protection against
intestinal pathogens) and contains more minerals
and amino acids
 host resistancefactors found in colostrum and milk
include complement,macrophages, lymphocytes,
lactoferrin, lactoperoxidase, and lysozymes.
 more protein, much of which is globulin, but
lesssugar and fat.
 Secretion persists for 5 days to 2 weeks,
withgradual conversion to mature milk by 4 to 6
weeks.
 Mature milk is a complex and dynamic biological
fluid thatincludes fat, proteins, carbohydrates,
bioactive factors, minerals, vitamins, hormones,
and many cellular products. The concen-trations
and contents of human milk change even during a
single feed and are influenced by maternal diet, as
well as infant age, health, and needs. A nursing
mother easily produces 600 mLof milk daily, and
maternal gestational weight gain has little impact on
its quantity or quality
 Milk is isotonic with plasma, and lactose accounts
for half of the osmotic pressure. Essential amino
acids are derived from blood,and nonessential
amino acids are derived in part from blood or
synthesized in the mammary gland. Most milk
proteins are unique and include α-lactalbumin,β-
lactoglobulin, and casein. Fatty acids are
synthesized in the alveoli from glucose and are
secreted by an apocrine-like process. Most vitamins
are foundin human milk, but in variable amounts.
Vitamin K is virtually absent, and thus, an
intramuscular dose is given to the newborn
1S-1 NAME OF TOPIC
 Progesterone, estrogen, and placental lacto-gen,
as well as prolactin, cortisol, and insulin, appear to
actin concert to stimulate the growth and
development of the milk-secreting apparatus
 With delivery, there isan abrupt and profound
decrease in the levels of progesterone and
estrogen. This decrease removes the inhibitory
influence of progesterone onα-lactalbumin
production and stimulateslactose synthase to
increase milk lactose. Progesterone with-drawal
also allows prolactin to act unopposed in its stimula-
tion of α-lactalbumin production. Serotonin is
produced inmammary epithelial cells and has a role
in maintaining milk production. This may explain the
decreased milk production inwomen taking
selective serotonin-reuptake inhibitors—SSRIsThe
intensity and duration of subsequent lactation are
con-trolled, in large part, by the repetitive stimulus
of nursing and emptying of milk from the breast.
Prolactin is essential for lac-tation, and women with
extensive pituitary necrosis—
Sheehansyndrome—do not lactateAlthough
plasma ——prolactin levels fall after delivery to
levels lower than during preg-nancy, each act of
suckling triggers a rise in levels Presumably a
stimulus from the breast curtails the releaseof
dopamine, also known as prolactin-inhibiting factor,
from the hypothalamus. This in turn transiently
induces increased prolac-tin secretion.
 The posterior pituitary secretes oxytocin in pulsatile
fashion.This stimulates milk expression from a
lactating breast by caus-ing contraction of
myoepithelial cells in the alveoli and smallmilk
ducts Milk ejection, orletting down, isa reflex
initiated especially by suckling, which stimulates
theposterior pituitary to liberate oxytocin. The reflex
may even beprovoked by an infant cry and can be
inhibited by maternalfright or stress.
 Immunological Consequences of Breast Feeding
 Human milk contains several protective
immunological sub-stances, including secretory IgA
and growth factors. The anti-bodies in human milk
are specifically directed against maternal
environmental antigens such as against
Escherichia coli
TRANS TEAM LAST NAMES
PAGE 3 of 12
1. Have a written breastfeeding policy that is regularly communicated
to all health-care staff
2. Train all staff in skills necessary to implement this policy
3. Inform all pregnant women about the benefits and management of
breastfeeding
4. Help mothers initiate breastfeeding within an hour of birth
5. Show mothers how to breastfeed and how to sustain lactation, even
if they should be separated from their infants
6. Feed newborns nothing but breast milk, unless medically indicated,
and under no circumstances provide breast milk substitutes, feeding
bottles, or pacifiers free of charge or at low cost
7. Practice rooming-in, which allows mothers and newborns to
remain together 24 hours a day
8. Encourage breastfeeding on demand
9. Give no artificial pacifiers to breastfeeding newborns
10. Help start breastfeeding support groups and refer mothers to
them
 Care of Breasts
 The nipples require little attention other than
cleanliness and attention to skin fissures.
Fissured nipples render nursing painful, and they
may have a deleterious influence on milk
production. These cracks also provide a portal
of entry for pyogenic bacteria. Because dried
milk is likely to accumulate and irritate the
nipples, washing the areola with water and mild
soap is helpful before and aer nursing. When
the nipples are irritated or fissured, some
recommend topical lanolin and a nipple shield for
24 hours or longer. Although specific evidence
supporting this practice is lacking, nipple pain
usually subsides by 10 days
 If fissuring is severe, the newborn should not
be permitted to nurse on the aected side.
Instead, the breast is emptied regularly with a
pump until the lesions are healed. Poor latching
of the neonate to the breast can create such
fissures. For example, the newborn may take
into its mouth only the nipple, which is then is
forced against the hard palate during suckling.
Ideally, the nipple and areola are both taken in
to evenly distribute suckling forces. Moreover,
the force of the hard palate against the
lactiferous sinuses aids their eicient emptying,
while the nipple is thereby positioned closer to
the so palate.
 Contraindications to Breastfeeding
 Nursing is contraindicated in women who take
street drugs or do not control their alcohol use;
have an infant with galactosemia; have human
immunodeficiency virus (HIV) infection; have
active, untreated tuberculosis; take certain
medications; or are undergoing breast cancer
treatment
 Breastfeeding has been recognized for some
time as a mode of HIV transmission and is
proscribed in developed countries in which
adequate nutrition is otherwise available. Other
viral infections do not contraindicate
breastfeeding. For example, with maternal
cytomegalovirus infection, both virus and
antibodies are present in breast milk. And,
although hepatitis B virus is excreted in milk,
breastfeeding is not contraindicated if hepatitis
B immune globulin is given to the newborns of
aected mothers. Maternal hepatitis C infection is
not a contraindication because breastfeeding has
not been shown to transmit infection Women
with active herpes simplex virus may suckle their
infants if there are no breast lesions and if
particular care is directed to hand washing
before nursing.
 Breast Engorgement
1S-1 NAME OF TOPIC
 This is common in women who do not breastfeed.
It is typified by milk leakage and breast pain, which
peak 3 to 5 days aer delivery (Spitz, 1998). Up to
half of aected women require analgesia for breast
pain relief, and as many as 10 percent report
severe pain for up to 14 days. Evidence is
insuicient to firmly support any specific
treatment (Mangesi, 2016). That said, breasts
can be supported with a well-fitting brassiere,
breast binder, or sports bra. Cool packs and
oral analgesics for 12 to 24 hours aid
discomfort. Pharmacological or hormonal agents
are in general not recommended to suppress
lactation. Fever caused by breast engorgement
was common before the renaissance of
breastfeeding. In one study, Almeida and Kitay
(1986) reported that 13 percent of puerperas
had fever from engorgement that ranged from
37.8 to 39°C. Fever seldom persists for longer
than 4 to 16 hours. The incidence and severity of
engorgement and of the fever associated with
it are much lower if women breastfeed. Other
causes of fever, especially those due to
infection, must be excluded. Of these, mastitis is
infection of the mammary parenchyma. It is
relatively common in lactating women
 HOSPITAL CARE
 For 2 hours aer delivery, blood pressure and pulse
are taken every 15 minutes, or more frequently if
indicated. Temperature is assessed every 4
hours for the first 8 hours and then at least
every 8 hours subsequently (American Academy
of Pediatrics, 2017). The amount of vaginal
bleeding is monitored, and the fundus palpated
to ensure that it is well contracted. If relaxation
is detected, the uterus should be massaged
through the abdominal wall until it remains
contracted. Uterotonics are also sometimes
required. Blood can accumulate within the
uterus without external bleeding. This may be
detected early by uterine enlargement during
fundal palpation in the first postdelivery hours.
Because the likelihood of significant hemorrhage
is greatest immediately postpartum, even in
normal births, the uterus is closely monitored
for at least 1 hour aer delivery. Postpartum
hemorrhage is discussed in Chapter 41 (Uterine
Atony). If regional analgesia or general
anesthesia was used for labor or delivery, the
mother should be observed in an appropriately
equipped and staffed recovery area.
 Women are out of bed within a few hours aer
delivery. An attendant should be present for at
least the first time, in case the woman becomes
syncopal. The many confirmed advantages of early
ambulation include fewer bladder complications,
less frequent constipation, and reduced rates of
puerperal venous thromboembolism. As discussed
in Peritoneum and Abdominal Wall, deep-vein
thrombosis and pulmonary embolism are common
in the puerperium In an audit of puerperal
women at Parkland Hospital, the frequency of
venous thromboembolism was found to be 0.008
percent aer a vaginal birth and 0.04 percent
following cesarean delivery. We attribute this
low incidence to early ambulation. Risk factors
and other measures to diminish the frequency of
thromboembolism are discussed in Chapter 52
(Pathophysiology). There are no dietary
restrictions for women who have been delivered
vaginally. Two hours aer uncomplicated vaginal
delivery, a woman is allowed to eat. With
breastfeeding, the level of calories and protein
consumed during pregnancy are increased
slightly as recommended by the Food and
TRANS TEAM LAST NAMES
PAGE 4 of 12
 Nutrition Board of the National Research Council.
If the mother does not breastfeed, dietary
requirements are the same as for a nonpregnant
woman. We recommend oral iron supplementation
for at least 3 months aer delivery and hematocrit
evaluation at the first postpartum visit. As noted
earlier, profound drops in estrogen levels follow
removal of the placenta. Reminiscent of the
menopause, postpartum women may experience
hot flushes, especially at night. Importantly, the
patient’s temperature is assessed to dierentiate
these physiological vasomotor events from
infection. In women with migraines, dramatic
hypoestrogenism may trigger headaches.
Importantly, severe headaches should be
dierentiated from spinal headache or hypertensive
complications. Care varies depending on
migraine severity. Mild headaches may respond
to analgesics such as ibuprofen
acetaminophen. Alternatively, Midrin combines
isometheptene mucate, which is
sympathomimetic agent; dichloralphenazone,
which is a mild sedative; and acetaminophen and
is compatible with breastfeeding. For more severe
headaches, oral or systemic narcotics can be
used. Instead of Midrin, a triptan, such as
sumatriptan (Imitrex), can eectively relieve
headaches by causing intracranial
vasoconstriction.
 Perineal Care
 The woman is instructed to clean the vulva from
anterior to posterior—the vulva toward the anus.
A cool pack applied to the perineum may help
reduce edema and discomfort during the first 24
hours if there is a perineal laceration or an
episiotomy. Most women also appear to obtain
a measure of relief from the periodic application
of a local anesthetic spray. Severe perineal,
vaginal, or rectal pain always warrants careful
inspection and palpation. Severe discomfort
usually indicates a problem, such as a
hematoma within the first day or so and
infection aer the third or fourth day
 Beginning approximately 24 hours aer delivery,
moist heat as provided by warm sitz baths
can be used to reduce local discomfort. Tub
bathing aer uncomplicated delivery is allowed.
The episiotomy incision normally is firmly healed
and nearly asymptomatic by the third week.
Rarely, the cervix, and occasionally a portion of
the uterine body, may protrude from the vulva
following delivery. This is accompanied by
variable degrees of anterior and posterior vaginal
wall prolapse. Symptoms include a palpable
mass at or past the introitus, voiding diiculties,
or pressure. Puerperal procidentia typically
improves with time as the weight of the uterus
lessens with involution. As a temporizing
measure in those with pronounced prolapse, the
uterus can be replaced and held in position with
a suitable pessary. Hemorrhoidal veins are oen
congested at term. Thrombosis is common and may
be promoted by second-stage pushing. Treatment
includes topically applied anesthetics, warm
soaks, and stool-soening agents. Nonprescription
topical preparations containing corticosteroids,
astringents, or phenylephrine are oen used, but
no randomized studies support their eicacy
compared with conservative management.
 Bladder Function In most delivery units, intravenous fluids
are infused during labor and for an hour or so aer
delivery. Oxytocin, in doses that have an antidiuretic eect,
is typically infused postpartum, and rapid bladder filling is
common. Moreover, both bladder sensation and capability
to empty spontaneously may be diminished by local or
1S-1 NAME OF TOPIC
conduction analgesia, by trauma to the bladder, by
episiotomy or lacerations, or by operative vaginal delivery.
Thus, urinary retention and bladder overdistention is
common in the early puerperium. The incidence in more
than 5500 women studied with a bladder scanner was 5.1
percent (Buchanan, 2014). In another study, Musselwhite
and coworkers (2007) reported retention in 4.7 percent of
women who had labor epidural analgesia. Risk factors that
increased the likelihood of retention were primiparity,
cesarean delivery, perineal laceration, oxytocin-induced or
augmented labor, operative vaginal delivery, catheterization
during labor, and labor duration >10 hours. Prevention of
bladder overdistention demands observation aer delivery
to ensure that the bladder does not overfill and that it
empties adequately with each voiding. The enlarged
bladder can be palpated suprapubically, or it is evident
abdominally indirectly as it elevates the fundus above the
umbilicus. The use of an automated bladder scanner
or sonography system has been studied to detect high bladder
volumes and thus postpartum urinary retention (Buchanan,
a 2014; Van Os, 2006). If a woman has not voided within 4
hours aer delivery, it is likely that she cannot. If she has
trouble voiding initially, she also is likely to have further
trouble. An examination for perineal and genital-tract
hematomas is completed. With an overdistended bladder,
an indwelling catheter should be le in place until the
factors causing retention have abated. Even without a
demonstrable cause, it usually is best to leave the
catheter in place for at least 24 hours. This prevents
recurrence and allows recovery of normal bladder tone
and sensation. When the catheter is removed, a voiding trial
is completed to demonstrate an ability to void
appropriately. If a woman cannot void aer 4 hours, she
should be catheterized and the urine volume measured. If
more than 200 mL, the bladder is not functioning
appropriately, and the catheter is left for another 24 hours.
Although rare, if retention persists aer a second voiding
trial, an indwelling catheter and leg bag can be elected,
and the patient returns in 1 week for an outpatient voiding
trial. Intermittent self-catheterization is another option
(Mulder, 2017). During a voiding trial, if less than 200
mL of urine is obtained, the catheter can be removed
and the bladder subsequently monitored clinically as
described earlier. Harris and coworkers (1977) reported
that 40 percent of such women develop bacteriuria, and
thus a single dose or short course of antimicrobial therapy
against uropathogens is reasonable aer the catheter is
removed.
 Pain, Mood, and Cognition Discomfort and its causes
following cesarean delivery are considered in Chapter 30
(Postoperative Care). During the first few days aer vaginal
delivery, the mother may be uncomfortable because of
aerpains, episiotomy and lacerations, breast engorgement,
and at times, postdural puncture headache. Mild analgesics
containing codeine, aspirin, or acetaminophen, preferably
in combinations, are given as frequently as every 4 hours
during the first few days. It is important to screen the
postpartum woman for depression (American College of
Obstetricians and Gynecologists, 2016b). It is fairly
common for a mother to exhibit some degree of depressed
mood a few days aer delivery. Termed postpartum blues, this
likely is the consequence of several factors. These include
emotional letdown that follows the excitement and fears
experienced during pregnancy and delivery, discomforts
of the early puerperium, fatigue from sleep deprivation,
anxiety over the ability to provide appropriate newborn
care, and body image concerns. In most women, eective
treatment includes anticipation, recognition, and
reassurance. This disorder is usually mild and self-limited
to 2 to 3 days, although it sometimes lasts for up to&
10 days. Should these moods persist or worsen, an
evaluation for symptoms of major depression is done (Chap.
61, Postpartum Depression). Suicidal or infanticidal ideation
is dealt with emergently. Because major postpartum
depression recurs in at least a fourth of women in
TRANS TEAM LAST NAMES
PAGE 5 of 12
 subsequent pregnancies, some recommend
pharmacological prophylaxis beginning in late pregnancy
or immediately postpartum. Last, postpartum hormonal
changes in some women may aect brain function. Bannbers
and colleagues (2013) compared a measure of executive
function in postpartum women and controls and observed a
functional decline in postpartum subjects.
 Neuromusculoskeletal Problems Obstetrical Neuropathies
Pressure on branches of the lumbosacral nerve plexus
during labor may manifest as complaints of intense neuralgia
or cramp- like pains extending down one or both legs as
soon as the head descends into the pelvis. If the nerve is
injured, pain may continue aer delivery, and variable
degrees of sensory loss or muscle paralysis can result. In
some cases, there is footdrop, which can be secondary
to injury at the level of the lumbosacral plexus, sciatic
nerve, or common fibular (peroneal) nerve (Bunch, 2014).
Components of the lumbosacral plexus cross the pelvic brim
and can be compressed by the fetal head or by forceps. The
common fibular nerves may be externally compressed when
the legs are positioned in stirrups, especially during
prolonged second-stage labor. Obstetrical neuropathy is
relatively infrequent. Wong and associates (2003)
evaluated more than 6000 puerperas and found that L
approximately 1 percent had a confirmed nerve injury.
Lateral femoral cutaneous neuropathies were the most
common (24 percent), followed by femoral neuropathies (14
percent). A motor deficit accompanied a third of injuries.
Nulliparity, prolonged second-stage labor, and pushing for
a long duration in the semi-Fowler position were risk
factors. The median duration of symptoms was 2 months,
and the range was 2 weeks to 18 months. Nerve injuries with
cesarean delivery include the iliohypogastric and
ilioinguinal nerves.
 Musculoskeletal Injuries Pain in the pelvic girdle, hips, or
lower extremities may follow stretching or tearing injuries
sustained at normal or diicult delivery. Magnetic resonance
(MR) imaging is oen informative (Miller, 2015). One
example is the piriformis muscle hematoma shown in
Figure 36-6. Most injuries resolve with antiinflammatory
agents and physical therapy. Rarely, there may be septic
pyomyositis such as with iliopsoas muscle abscess
Separation of the symphysis pubis or one of the sacroiliac
synchondroses during labor leads to pain and marked
interference with locomotion (Fig. 36-7). Estimates of the
frequency of this event vary widely from 1 in 600 to 1
in 30,000 deliveries (Reis, 1932; Taylor, 1986). In our
experiences, symptomatic separations are uncommon.
Their onset of pain is oen acute during delivery, but symptoms
may manifest either antepartum or up to 48 hours postpartum
(Snow, 1997). In suspected cases, radiography is typically
selected. The normal distance of the symphyseal joint is
0.4 to 0.5 cm, and symphyseal separation >1 cm is
diagnostic for diastasis. Treatment is generally
conservative, with rest in a lateral decubitus position and
an appropriately fitted pelvic binder (Lasbleiz, 2017).
Surgery is occasionally necessary in some symphyseal
separations of more than 4 cm (Kharrazi, 1997). The
recurrence risk is high in subsequent pregnancy, and
Culligan and coworkers (2002) recommend consideration
for cesarean delivery.
 Immunizations
 D-negative woman who is not isoimmunized and
whose newborn is D-positive is given 300 μg of anti-
D immune globulin shortly aer delivery (Chap. 15,
Prevention of Anti-D Alloimmunization).
 Women who are not already immune to rubella
or varicella are excellent candidates for
vaccination before discharge.
 Those who have not received a tetanus/diphtheria
or influenza vaccine should be given these.
 Morgan and colleagues (2015) reported that
implementation of a best-practices alert in the
electronic medical record was associated with a
1S-1 NAME OF TOPIC
tetanus/diphtheria immunization rate of 97
percent at Parkland Hospital.
 Hospital Discharge
 Following uncomplicated vaginal delivery,
hospitalization is seldom warranted for more
than 48 hours. A woman should receive
instructions concerning anticipated normal
physiological puerperal changes, including lochia
patterns, weight loss from diuresis, and milk
let-down. She also should receive instructions
concerning fever, excessive vaginal bleeding, or
leg pain, swelling, or tenderness. Persistent
headaches, shortness of breath, or chest pain
warrant immediate concern. Hospital-stay length
following labor and delivery is now regulated
by federal law (Chap. 32, Rooming In and
Hospital Discharge). Currently, the norms are
hospital stays up to 48 hours following
uncomplicated vaginal delivery and up to 96
hours following uncomplicated cesarean delivery
Earlier hospital discharge is acceptable for
appropriately selected women if they desire it.
 Contraception During the hospital stay, a concerted eort
is made to provide family planning education. Various forms
of contraception are discussed throughout Chapter 38 and
sterilization procedures in Chapter 39. Women not
breastfeeding have return of menses usually within 6 to 8
weeks. At times, however, it is diicult clinically to assign a
specific date to the first menstrual period aer delivery. A
minority of women bleed small to moderate amounts
intermittently, starting soon aer delivery. Ovulation occurs
at a mean of 7 weeks, but ranges from 5 to 11 weeks
(Perez, 1972). That said, ovulation before 28 days has been
described (Hytten, 1995). Thus, conception is possible during
the artificially defined 6-week puerperium. Women who
become sexually active during the puerperium, and who
do not desire to conceive, should initiate contraception.
Kelly and associates (2005) reported that by the third
month postpartum, 58 percent of adolescents had
resumed sexual intercourse, but only 80 percent of these
were using contraception. Because of this, many
recommend long-acting reversible contraceptives—LARC
(Baldwin, 2013). Women who breastfeed ovulate much
less frequently compared with those who do not, but
variation is great. Timing of ovulation depends on individual
biological variation and the intensity of breastfeeding.
Lactating women may first menstruate as early as the
second or as late as the 18th month aer delivery.
Campbell and Gray (1993) analyzed daily urine specimens
to determine the time of ovulation in 92 lactating women.
As shown in Figure 36-8, breastfeeding in general delays
resumption of ovulation, although as already emphasized,
it does not invariably forestall it.
 For the breastfeeding woman, progestin-only
contraceptives, such as progestin pills, depot
medroxyprogesterone, or progestin implants, do not aect
the quality or quantity of milk. Success with the
progesterone-releasing vaginal ring has also been
described (Carr, 2016). These may be initiated any time
during the puerperium. Estrogen-progestin contraceptives
likely reduce the quantity of breast milk, but under the
proper circumstances, they too can be used by
breastfeeding women.
 Guidelines ro remember:
1. Resumption of ovulation was frequently marked by return
of normal menstrual bleeding.
2. Breastfeeding episodes lasting 15 minutes seven times
daily delayed ovulation resumption.
3. Ovulation can occur without bleeding.
4. Bleeding can be anovulatory. 15/24
5. The risk of pregnancy in breastfeeding women was
approximately 4 percent per year.
 HOME CARE
 Coitus
TRANS TEAM LAST NAMES
PAGE 6 of 12
  No evidence-based data guide resumption of beyond the immediate puerperium and to initiate
coitus aer delivery, and practices are contraceptive practices.
individualized (Minig, 2009). Aer 2 weeks, coitus
may be resumed based on desire and comfort.
Barrett and colleagues (2000) reported that
almost 90 percent of 484 primiparous women
resumed sexual activity by 6 months. And
although 65 percent of these reported problems,
only 15 percent discussed them with a health-care
provider. Intercourse too soon may be
unpleasant, if not frankly painful, and this may
be related to episiotomy incisions or severe
lacerations. In a study of women without an
episiotomy, only 0.4 percent of those with a
first- or second-degree tear had dyspareunia
(Ventolini, 2014). Conversely, in primiparas with
an episiotomy, 67 percent had sexual
dysfunction at 3 months, 31 percent at 6
months, and 15 percent at 12 months
(Chayachinda, 2015). Dyspareunia was also
common following cesarean delivery (McDonald,
2015). Postpartum, the vulvovaginal epithelium
is thin, and very little lubrication follows sexual
stimulation. This stems from the hypoestrogenic
state following delivery, which lasts until
ovulation resumes. It may be particularly
problematic in breastfeeding women who are
hypoestrogenic for many months postpartum
(Palmer, 2003). For treatment, small amounts
of topical estrogen cream can be applied daily
for several weeks to vulvar tissues. Additionally,
vaginal lubricants may be used with coitus. This
same thinning of the vulvovaginal epithelium can
lead to dysuria. Topical estrogen can again be
oered once cystitis is excluded.
 Late Maternal Morbidity
 Taken together, major and minor maternal
morbidity are surprisingly common in the months
following childbirth. In a survey of 1249 British
mothers followed for up to 18 months, 3 percent
required hospital readmission within 8 weeks
(Glazener, 1995; Thompson, 2002). Milder
health problems during the first 8 weeks were
reported by 87 percent (Table 36-5). Moreover,
almost three fourths continued to have various
problems for up to 18 months. Practitioners
should be aware of these potential issues in
their convalescing patients.
 Follow-Up Care
 By discharge, women who had an uncomplicated
vaginal delivery can resume most activities,
including bathing, driving, and household
functions. Jimenez and Newton (1979) tabulated
cross-cultural information on 202 societies from
various international geographical regions.
Following childbirth, most societies did not
restrict work activity, and approximately half
expected a return to full duties within 2
weeks. Wallace and coworkers (2013) reported
that 80 percent of women who worked during
pregnancy resume work by 1 year aer delivery.
Despite this, Tulman and Fawcett (1988) reported
that only half of mothers regained their usual
level of energy by 6 weeks. Women who
delivered vaginally were twice as likely to have
normal energy levels at this time compared with
those with a cesarean delivery. Ideally, the care
and nurturing of the infant should be provided
by the mother with ample help from the father.
The American Academy of Pediatrics and the
American College of Obstetricians and
Gynecologists (2017) recommend a postpartum
visit between 4 and 6 weeks. This has proven
quite satisfactory to identify abnormalities

1S-1 NAME OF TOPIC TRANS TEAM LAST NAMES

PAGE 7 of 12

Obstetrical Anesthesia Services The American College of Obstetricians
and Gynecologists (2017a) recognizes that a woman’s request for
labor pain relief is suicient medical indication for its provision.
Identification of any of the risk factors shown in Table 25-2 should
prompt consultation with anesthesia personnel to permit a joint
management plan. This plan should include strategies to minimize
the need for emergency anesthesia.
Body mass index >30 kg/m2 Short or thick neck or skeletal neck
abnormality Obstructive lesions: edema, anatomical abnormalities,
trauma Decreased range of motion in opening the mouth or small
mandible Thyromegaly or other neck tumor Severe preeclampsia
syndrome Bleeding disorders Obstetrical complications with a high
risk of operative delivery Maternal medical complications such as
cardiopulmonary disease Previous anesthetic complications
These stimuli are modified by emotional, motivational, cognitive,
social, and cultural circumstances. Labor pain caused by uterine
contractions and cervical dilation is transmitted through visceral
aerent sympathetic nerves entering the spinal cord from T10
through L1. Later in labor, perineal stretching transmits painful
stimuli through the pudendal nerve and sacral nerves S2 through S4.
Cortical responses to pain and anxiety during labor are complex
and may be influenced by maternal expectations for childbirth, her
age, preparation through education, emotional support, and other
factors. Pain perception is heightened by fear and the need to
move into various positions. A woman may be motivated to have a
certain type of birthing experience, and these opinions will influence
her judgment regarding pain management. Sources of pain during
labor and maternal physiological responses. Maternal physiological
responses to labor pain can influence maternal and fetal well-being and
labor progress. For example, hyperventilation may inducehypocarbia. A
1S-1 NAME OF TOPIC
greater metabolic rate augments oxygen consumption. Increases in
cardiac output and vascular resistance may raise maternal blood
pressure. Pain,stress, and anxiety trigger release of stress hormones
such as cortisol and β-endorphins. The sympathetic nervous system
response to pain leads to a markedelevation in circulating
catecholamines that can adversely affMect uterine activity and
uteroplacental blood flow. Eective analgesia attenuates or eliminates
theseresponses.
ANALGESIA AND SEDATION DURING LABOR
If uterine contractions and cervical dilatation cause discomfort, pain
relief is oered. If neuraxial analgesia is contraindicated or unavailable or
is declined, a narcoticfrom Table 25-3 plus one of the tranquilizer-
antiemetic drugs such as promethazine (Phenergan) is usually
appropriate. With a successful program of analgesia andsedation, the
mother ideally rests quietly between contractions. In this circumstance,
discomfort usually is felt at the acme of an eective uterine contraction.
Some Parenteral Analgesic Agents for Labor Pain IV = intravenously;
IM = intramuscularly; Q = every.
Meperidine * and PromethazineMeperidine, 50 to 100 mg, with
promethazine, 25 mg, may be administered intramuscularly at intervals
of 2 to 4 hours. A more rapid eect is achieved by givingmeperidine
intravenously in doses of 25 to 50 mg every 1 to 2 hours. Whereas
analgesia is maximal 30 to 45 minutes aer an intramuscular injection, it
developsalmost immediately following intravenous administration.
Meperidine readily crosses the placenta and can have a prolonged half-
life in the newborn (AmericanCollege of Obstetricians and
Gynecologists, 2017a). Its depressant eect in the fetus follows closely
behind the peak maternal analgesic eect.According to Bricker and
Lavender (2002), meperidine is the most common opioid used
worldwide for pain relief during labor. In one randomized study at
ParklandHospital, patient-controlled intravenous analgesia with
meperidine was found to be an inexpensive and reasonably eective
method for labor analgesia (Sharma,1997). Women randomized to self-
administered analgesia were given a 50-mg meperidine plus 25-mg
promethazine dose intravenously as an initial bolus.Thereaer, an
infusion pump was set to deliver 15 mg of meperidine every 10 minutes
as needed until delivery. Neonatal sedation, as measured by the need
fornaloxone treatment in the delivery room, was identified in 3 percent
of newborns. Both meperidine and its metabolite, normeperidine, are
lipophilic and readilycross the placenta. Analgesia with meperidine was
associated with lower Apgar scores in comparison to epidural analgesia
(Sharma, 2004). Normeperidine is astrong respiratory depressant that
has a significantly longer half-life than meperidine and is likely
responsible for the fetal side eects of meperidine.
Butorphanol This synthetic opioid receptor agonist–antagonist
analgesic, given in 1- to 2-mg intravenous doses, compares
favorably with 40 to 60 mg of meperidine. Its major side eects are
somnolence, dizziness, and dysphoria. Neonatal respiratory
depression is reported to be less than with meperidine. Importantly,
the two drugs are not given contiguously because butorphanol
antagonizes the narcotic eects of meperidine. Butorphanol has been
associated with transient sinusoidal fetal heart rate patterns
(Severe fetal anemia).
Nalbuphine * This is another mixed opioid receptor agonist–
antagonist analgesic. It can be given intramuscularly, intravenously,
or subcutaneously. The usual dose is 10 to 20 mg, administered
every 4 to 6 hours irrespective of the route of administration. Small
TRANS TEAM LAST NAMES
PAGE 8 of 12
doses of nalbuphine may also be used to treat pruritus associated
with neuraxial opioids.
Fentanyl This short-acting and potent synthetic opioid may be given
in doses of 50 to 100 μg intravenously every hour. Its main
disadvantage is its short duration of action, which requires frequent
dosing or use of a patient-controlled intravenous infusion pump.
Remifentanil This is a synthetic opioid with an extremely rapid onset
of action. It is hydrolyzed rapidly, resulting in a half-life of 3.5
minutes (Ohashi, 2016). Although it readily crosses the placenta, it
is quickly metabolized or redistributed within the fetus (Kan, 1998).
Various dosing regimens have been studied, and single boluses
appear to mirror the periodic uterine contraction pattern. Infusions,
on the other hand, have been reported to cause maternal apnea
(Waring, 2007). Due to the aforementioned risks, only trained
personnel should administer it, and only under strictly controlled
circumstances.
Efficacy and Safety of Parenteral
Agents Hawkins and colleagues (1997) reported that four of 129
maternal anesthetic-related deaths were from parenteral sedation—
one from aspiration, two from inadequate ventilation, and one
from overdosage. Opioids used during labor may cause newborn
respiratory depression. Naloxone is a narcotic antagonist capable
of reversing this respiratory depression. It acts by displacing the
narcotic from specific receptors in the central nervous system.
Withdrawal symptoms may be precipitated in recipients who are
physically dependent on narcotics. For this reason, naloxone is
contraindicated in a newborn of a narcotic-addicted mother.
Nitrous Oxide
Inhaled nitrous oxide has a rapid onset and oset that provides
analgesia during episodic contractions. It can be self-administered
as a mixture of 50-percent nitrous oxide and 50-percent oxygen
premixed in a single cylinder (Entonox) or using a blender that
mixes the two gases from separate tanks (Nitronox). The gases
are connected to a breathing circuit through a one-way valve that
opens only during inspiration. The use of intermittent nitrous oxide
for labor pain is generally regarded as safe for the mother and
newborn, but pain control is less effective than epidural analgesia
(Barbieri, 2014; Likis, 2014). In many cases, nitrous oxide simply
serves to delay more definitive neuraxial analgesia. For maximal
eicacy, nitrous oxide is inhaled 30 seconds prior to the start of a
contraction, although this prevents adequate rest for the mother.
Nitrous oxide is also associated with nausea and vomiting. The
environmental and health risk of its use without proper scavenging
remains to be carefully evaluated (King, 2014).
REGIONAL ANALGESIA
pudendal,
paracervical,
neuraxial blocks
*spinal, epidural, and combined spinal-epidural techniques.
Bupivacaine and lidocaine most commonly used in Ph
TOXICITY
Most often, serious toxicity follows inadvertent intravenous injection.
Systemic toxicity from local anesthetics typically manifests in the
central nervous and cardiovascular systems. For this reason, when
epidural analgesia is initiated, dilute epinephrine is sometimes
added and given as a test dose. A sudden significant rise in the
maternal heart rate or blood pressure immediately aer administration
suggests intravenous catheter placement. This should halt further
injection and should prompt catheter repositioning. Local anesthetic
agents are manufactured in more than one concentration and
ampule size, which raises the potential for dosing errors.
Central Nervous System Toxicity
Early symptoms are those of stimulation, but as serum levels rise,
depression follows. Symptoms may include light-headedness,
dizziness, tinnitus, metallic taste, and numbness of the tongue and
mouth. Patients may show bizarre behavior, slurred speech, muscle
1S-1 NAME OF TOPIC
fasciculation and excitation, and ultimately, generalized convulsions,
followed by loss of consciousness.
Cardiovascular Toxicity
These manifestations generally develop later than those of cerebral
toxicity. Moreover, no symptoms may develop because signs are
usually induced by higher serum drug levels. The notable
exception is bupivacaine, which is associated with
neurotoxicity and cardiotoxicity at virtually identical levels
(Mulroy, 2002). Because of its toxicity risk, use of a 0.75-percent
solution of bupivacaine for epidural injection has been proscribed
by the FDA. Similar to neurotoxicity, cardiovascular toxicity is
characterized first by stimulation and then by depression.
Accordingly, hypertension and tachycardia are soon followed by
hypotension, cardiac arrhythmias, and impaired uteroplacental
perfusion.
Management of Local Anesthetic Systemic Toxicity
Seizures and severe ventricular arrhythmias can follow large doses
of local anesthetics that are given inadvertently. Labor and delivery
units should be stocked with a 20-percent lipid emulsion solution
(Intralipid). It is administered as a rapid intravenous bolus
followed by an infusion upon the first sign of local anesthetic
systemic toxicity (Neal, 2012). Controlling seizures and securing
the airway are essential to prevent aspiration and hypoxemia.
Benzodiazepines, such as midazolam or lorazepam, may be
used to help control seizures, particularly if lipid emulsions are
not available. Magnesium sulfate also controls convulsions
(Chap 40, Management of Eclampsia). Abnormal fetal heart rate
patterns that include late decelerations or bradycardia can
follow and stem from maternal hypoxia. With proper
management, including supportive measures, the fetus usually
recovers. Therefore, it is best for the fetus and mother to delay
delivery until the mother is stabilized. With proper treatment of
local anesthetic systemic toxicity (LAST) with lipid emulsions, vital
signs usually return to normal. The woman, however, should be
monitored, placed in the lateral decubitus position to avoid
aortocaval compression, and provided continued supportive
care. Vasopressors can be used to support blood pressure.
With cardiac arrest, emergency cesarean delivery is considered
if maternal vital signs have not been restored within 5 minutes
As with convulsions, however, the fetus is likely to recover more
quickly in utero once maternal cardiac output is reestablished.
Pudendal Block
Pain with vaginal delivery arises from stimuli from the lower genital
tract. These are transmitted primarily through the pudendal nerve,
the peripheral branches of which provide sensory innervation to
the perineum, anus, vulva, and clitoris. The pudendal nerve
passes beneath the sacrospinous ligament just as the ligament
attaches to the ischial spine. Sensory nerve fibers of the
pudendal nerve are derived from ventral branches of the S2
through S4 nerves. The pudendal nerve block is a relatively safe
and simple method of providing analgesia for spontaneous
delivery.
a tubular introducer is used to sheathe and guide a 15-cm-long
22-gauge needle into position near the pudendal nerve. The end of
the introducer is placed against the vaginal mucosa just beneath
the tip of the ischial spine. The introducer allows 1.0 to 1.5 cm
of needle to protrude beyond its tip, and the needle is pushed
beyond the introducer tip into the mucosa. A mucosal wheal is made
with 1 mL of 1-percent lidocaine solution or an equivalent dose of
another local anesthetic (see Table 25-4). To guard against
intravascular infusion, aspiration is attempted before this and
all subsequent injections. The needle is then advanced until it
touches the sacrospinous ligament, which is infiltrated with 3 mL
of lidocaine. The needle is advanced farther through the
ligament. As the needle pierces the loose areolar tissue behind
the ligament, resistance against the plunger drops. Another 3
mL of solution is injected in this region. Next, the needle is
withdrawn into the introducer, which is moved to a point just above
the ischial spine. The needle is inserted through the mucosa and
TRANS TEAM LAST NAMES
PAGE 9 of 12
a final 3 mL is deposited. The procedure is then repeated on the
other side.
Within 3 to 4 minutes of injection, a successful pudendal block will
allow pinching of the lower vagina and posterior vulva bilaterally
without pain. If delivery occursbefore the pudendal block becomes
eective and an episiotomy is indicated, then the fourchette, perineum,
and adjacent vagina can be infiltrated with 5 to 10 mL of1-percent
lidocaine solution directly at the planned episiotomy site. By the time of
repair, the pudendal block usually has become eective. Pudendal block
usually does not provide adequate analgesia when delivery
requires extensive obstetrical manipulation. Moreover, such
analgesia is usually inadequate for women in whom complete
visualization of the cervix and upper vagina or manual exploration
of the uterine cavity is indicated.
intravascular injection of a local anesthetic agent may cause
serious systemic toxicity. Hematoma formation from perforation
of a blood vessel is most likely when there is a coagulopathy
severe infection may originate at the injection site. The
infection may spread posteriorly to the hip joint, into the
gluteal musculature, or into the retropsoas space
Paracervical Block
 This block usually provides satisfactory pain relief
during first-stage labor.
 However, because the pudendal nerves are not blocked
during paracervical blockade, additional analgesia is
required for delivery.
 For paracervical blockade, usually 5 to 10 mL of lidocaine
(1 to 2 percent) or chloroprocaine (3 percent) is injected
into the cervix laterally at 3 and 9 o’clock. Because these
anesthetics are relatively short acting, this block may have
to be repeated during labor.
 Fetal bradycardia is a worrisome complication that occurs
with approximately 15 percent of paracervical blocks .
Bradycardia usually develops within 10 minutes and may
last up to 30 minutes. Doppler studies have shown a rise in
the pulsatility index of the uterine arteries following
paracervical blockade. These observations support the
1S-1 NAME OF TOPIC
hypothesis of drug-induced arterial vasospasm as a cause
of fetal bradycardia. For these reasons, paracervical block
is not used in situations of potential fetal compromise.
NEURAXIAL ANALGESIA
Epidural, spinal, or combined spinal-epidural techniques are
the most common methods used for pain relief during labor
and delivery. In the United States in 2008, epidural analgesia
was used in nearly 70 percent of mothers during labor and
had a success rate of 98.8 percent.
Spinal (Subarachnoid) Block Anesthetic in this block can be
given as a single dose, can be partnered with an epidural
catheter as combined spinal-epidural analgesia, or can be
administered as a continuous infusion. Injection of a local
anesthetic into the subarachnoid space to eect analgesia has
long been used for delivery.
Advantages :
 rapid analgesia onset,
 short duration of action,
 high success rate.
The subarachnoid space during pregnancy is smaller,
which likely results from internal vertebral venous plexus
engorgement. Thus, in parturients, the same amount of
anesthetic agent in the same volume of solution produces a
much higher blockade than in nonpregnant women.
Vaginal Delivery
 The first stage of labor requires a sensory block to
the level of the umbilicus (T10).
 During the second stage of labor and for operative
vaginal delivery, a sensory block of S2 through S4 is
usually adequate to cover pain from perineal
stretching and/or instrumentation.
Analgesic options
 continuous lumbar epidural analgesia, combined
spinal-epidural, continuous spinal analgesia, and
other blocks such as pudendal and paracervical
blocks.
 Local anesthetic agents are usually given to
establish a sensory block to the desired
dermatome level. They are almost exclusively
used in conjunction with neuraxial opioids. The
mechanism of action is a function of the
administration route and lipid solubility. Analgesia
is induced by absorption into the vascular system
(supraspinal), actions on the dorsal horns, and
direct spread in the cerebrospinal fluid to the
brainstem. Highly-soluble lipid opioids such as
fentanyl and sufentanil have a rapid onset of action.
But, because they are absorbed into lipid
membranes and the epidural vasculature, their
duration of action is short. Hydrophilic solutions
such as morphine, on the other hand, provide
extended analgesia (Lavoie, 2013). The major
advantages of using such a combination are the
rapid onset of pain relief, a decrease in shivering,
and less dense motor blockade.
 Side eects are common and include pruritus and
urinary retention.
 Nalbuphine, 2.5 to 5 mg intravenously, can be
used to treat pruritis without diminishing the
analgesic eect.
 Cesarean Delivery A level of sensory blockade
extending to the T4 dermatome is desired for
cesarean delivery. Depending on maternal size,
10 to 12 mg of bupivacaine in a hyperbaric
solution or 50 to 75 mg of lidocaine hyperbaric
solution is administered. The addition of opioid
increases the rapidity of blockade onset, reduces
shivering, and minimizes referred pain and other
TRANS TEAM LAST NAMES
PAGE 10 of 12
 symptoms such as nausea and vomiting. The
addition of a preservative-free morphine
(Duramorph or Astramorph), 0.1 to 0.3 mg intrathecal
or 2 to 4 mg epidural, provides pain control up
to 24 hours postoperatively.
Hypotension
 Pcommon complication that may develop soon
aer injection of the local anesthetic agent. It is
the consequence of vasodilatation from
sympathetic blockade and is compounded by
obstructed venous return due to uterine
compression of the great vessels. In the
supine position, even in the absence of
maternal hypotension measured in the brachial
artery, placental blood flow may still be
significantly reduced.
 Treatment includes uterine displacement by
left lateral patient positioning, intravenous
crystalloid hydration, and intravenous bolus
injections of ephedrine or phenylephrine.
 Ephedrine is a sympathomimetic drug that
binds to α- and β-receptors but also indirectly
enhances norepinephrine release. It raises
blood pressure by raising heart rate and
cardiac output and by variably elevating
peripheral vascular resistance. In early
animal studies, ephedrine preserved
uteroplacental blood flow during pregnancy
compared with α1-receptor agonists.
Accordingly, it had been the preferred
vasopressor for obstetrical use.
 Phenylephrine is a pure α-agonist and
elevates blood pressure solely through
vasoconstriction. A metaanalysis of seven
randomized trials by Lee (2002a) suggests
that the safety profiles of ephedrine and
phenylephrine are comparable. Following
their systematic review of 14 reports, Lee
(2002b) questioned whether routine
prophylactic ephedrine is needed for elective
cesarean delivery. Although fetal acidemia
has been reported with prophylactic
ephedrine use, this was not observed with
prophylactic phenylephrine use (Ngan Kee,
2004).
High or Total Spinal Blockade
 Most oen, high or total spinal blockade follows
administration of an excessive dose of local
anesthetic or inadvertent injection into the subdural
or subarachnoid space.
 6Subdural injection manifests as a high but patchy
block even with a small dose of local anesthetic
agent, whereas subarachnoid injection typically leads
to complete spinal blockade with hypotension and
apnea. These conditions must be immediately treated to
prevent cardiac arrest. In the undelivered woman: (1)
the uterus is immediately displaced laterally to
minimize aortocaval compression; (2) eective
ventilation is established, preferably with tracheal
intubation; and (3) intravenous fluids and
vasopressors are given to correct hypotension. If
chest compressions are to be performed, the woman
is placed in the le-lateral position to allow le uterine
displacement.
1S-1 NAME OF TOPIC
Postdural Puncture Headache
 Leakage of cerebrospinal fluid (CSF) from the dura
mater puncture site can lead to postdural puncture
or “spinal headache.”
 Presumably, when the woman sits or stands, the
diminished CSF volume creates traction on pain-
sensitive central nervous system structures.
 Another mechanism may be the compensatory
cerebral vasodilation in response to the loss of CSF—
the Monro-Kellie doctrine.
 Rates of this complication can be reduced by using
a small-gauge spinal needle and avoiding multiple
punctures. Postdural puncture headaches are much
less frequent with epidural blockade because the
dura mater is not intentionally punctured.
 There is no good evidence that placing a woman
absolutely flat on her back for several hours is
eective in preventing this headache. Once headache
develops, it is managed aggressively, as expectant
management increases hospital-stay lengths and
subsequent emergency-room visits.
 Conservative management, such as fluid
administration and bed rest, is largely ineective. If
not eectively treated, postdural puncture headache
can persist as a chronic headache (Webb, 2012).
 Epidural blood patch is considered the gold
standard for treatment. Typically, 10 to 20 mL of
autologous blood obtained aseptically by
venipuncture is injected into the epidural space.
Further CSF leakage is halted by either mass effect
or coagulation. Relief is almost always immediate,
and complications are uncommon.
Convulsion
 In rare instances, postdural puncture cephalgia is
associated with temporary blindness and
convulsions. Shearer and associates (1995)
described eight such casesassociated with 19,000
regional analgesic procedures done at Parkland
Hospital. It is presumed that these too are caused
by CSF hypotension. Immediate treatmentof
seizures and a blood patch were usually eective in
these cases.
Bladder Dysfunction
With neuraxial analgesia, bladder sensation is likely to
be obtunded and bladder emptying impaired for several
hours aer delivery. As a consequence, bladderdistention
is a frequent postpartum complication, especially if
appreciable volumes of intravenous fluid are given. Millet
and colleagues (2012) randomized 146women with
neuraxial analgesia to either intermittent or continuous
bladder catheterizations and found that the intermittent
method was associated withsignificantly higher rates of
bacteriuria. That said, we do not recommend routine
postpartum use of indwelling catheters following
uncomplicated vaginal delivery.
Arachnoiditis and Meningitis
Local anesthetics are no longer preserved in alcohol,
formalin, or other toxic solutes, and disposable
equipment is usually used. These practices, coupled
withaseptic technique, have made meningitis and
arachnoiditis rare.
TRANS TEAM LAST NAMES
PAGE 11 of 12
 Epidural Analgesia
Relief of labor and childbirth pain, including cesarean
delivery, can be accomplished by injection of a local
anesthetic agent into the epidural or peridural space
(Fig.25-3). This potential space contains areolar tissue,
fat, lymphatics, and the internal vertebral venous plexus.
This plexus becomes engorged during pregnancy
suchthat the volume of the epidural space is appreciably
reduced. Entry for obstetrical analgesia is usually
through a lumbar intervertebral space. Although only
oneinjection may be elected, usually an indwelling
catheter is placed for subsequent agent boluses or
infusion via a volumetric pump. The American College
ofObstetricians and Gynecologists (2017a) concludes
that under appropriate physician supervision, labor and
delivery nursing personnel who have been
specificallytrained in the management of epidural
infusions should be able to adjust dosage and also
discontinue infusions.

Continuous Lumbar Epidural BlockComplete analgesia

for the pain of labor and vaginal delivery necessitates a
block from the T10 to the S5 dermatomes (see Fig. 25-
1). For cesarean delivery, a blockextending from the T4
to the S1 dermatomes is desired. The eective spread of
anesthetic depends on the catheter tip location; the
dose, concentration, and volumeof anesthetic agent
used; and whether the mother is head-down, horizontal,
or head-up (Setayesh, 2001). Individual variations in
anatomy or presence of synechiaemay preclude a
completely satisfactory block. Finally, the catheter tip
may migrate from its original location during
labor.TechniqueOne example of the sequential steps
and techniques for performance of epidural analgesia is
detailed in Table 25-7. Before injection of the local
anesthetictherapeutic dose, a test dose is given. The
woman is observed for features of toxicity from
intravascular injection and for signs of high or total
blockade fromsubdural or subarachnoid injection. If
these are absent, only then is a full dose given.
Analgesia is maintained by intermittent boluses of similar
volume or by smallvolumes delivered continuously by
infusion pump (Halpern, 2009). Current pumps used for
epidural analgesia oer a programmed intermittent
epidural bolus (PIEB)mode, which reduces the required
concentration of local anesthetics, the degree of lower
extremity motor blockade, and rates of operative vaginal
delivery(Capogna, 2011). The addition of small doses of
a short-acting narcotic—fentanyl or sufentanil—has
been shown to improve analgesic eicacy while avoiding
motorblockade (Chestnut, 1988). As with spinal
blockade, close monitoring, including the level of
analgesia, is imperative and must be performed by
trained personnel.Appropriate resuscitation equipment
and drugs must be available during administration of
epidural analgesia.

1S-1 NAME OF TOPIC TRANS TEAM LAST NAMES

PAGE 12 of 12