Normal postpartum changes
- Uterus: Involution begins immediately after delivery. At umbilicus by 24 hrs, halfway to symphysis pubis by 1 wk, non-palpable by 2 wks, normal size by 6 wks.
Lochia
Postpartum uterine discharge (erythrocytes → leukocytes)
- Lochia Overview: Normal PP vaginal discharge (decidual tissue, blood, mucus); lasts 4-6 weeks (up to 8 wks normal).
- Normal Progression:
- Lochia Rubra (Days 1-4): Dark red; RBCs/decidua; small clots allowed (< 2.5 cm / quarter-size).
- Lochia Serosa (Days 4-10): Serosanguinous / pink-brown; decreased RBCs, increased WBCs.
- Lochia Alba (Days 10-14 up to 6-8 wks): Creamy white/yellow; predominantly WBCs/mucus.
- Abnormal Red Flags:
- Excessive volume: Soaking ≥ 1 heavy pad/hr for ≥ 2 consecutive hrs (indicates secondary PPH).
- Foul odor: Pathognomonic for postpartum endometritis.
- Persistent rubra: Lasting > 2 weeks PP (indicates RPOC, atony, or subinvolution).
- Associated findings: Fever (> 38.0°C), uterine tenderness, tachycardia, large clots (> 2.5 cm).
- Abnormal lochia etiologies & management:
- Postpartum Endometritis (Most common cause of PP fever, esp. post-C-section):
- Clinical presentation: Foul-smelling lochia + fever + uterine tenderness.
- Tx: IV Clindamycin + Gentamicin.
- Retained Products of Conception (RPOC):
- Clinical presentation: Persistent heavy rubra, large clots, boggy uterus.
- Dx: TVUS (hyperechoic intrauterine mass w/ vascular flow).
- Tx: Uterine evacuation (D&C).
- Uterine Atony / Subinvolution:
- Clinical presentation: Soft/boggy uterus, persistent rubra.
- Tx: Bimanual uterine massage → Oxytocin (1st-line uterotonic).
- Postpartum Endometritis (Most common cause of PP fever, esp. post-C-section):
Mnemonic
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- Cardiovascular: ↑ CO immediately post-delivery, then normalizes over 2 wks. Transient bradycardia common. Diuresis of excess fluid.
- Hematologic: Hypercoagulable state persists for ~6-8 wks (↑ risk of DVT/PE). Leukocytosis is common.
- Endocrine: Abrupt ↓ in estrogen, progesterone, hCG. Prolactin levels ↑ with breastfeeding, suppressing ovulation. Non-lactating women may ovulate as early as 4-6 wks postpartum.
- Routine Care: Pain control (NSAIDs), perineal care (sitz baths), bowel regimen (stool softeners), monitor for bleeding/infection. Contraception discussion.