Puerperium and Sepsis
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Direct answer
The puerperium is the six weeks after delivery in which the genital tract returns to its prepregnant state: the uterus involutes from the umbilicus at delivery to a pelvic organ by about two weeks, lochia passes through rubra, serosa and alba over roughly two to three weeks, and ovulation may resume within four to six weeks even while breastfeeding. Puerperal sepsis demands broad-spectrum intravenous antibiotics with evacuation of retained products when present. The puerperium is also the time for feeding support, contraception — lactational amenorrhoea when the three criteria hold, or postpartum intrauterine device insertion — and vigilance for blues, depression and psychosis.
What you must remember
- Involution: the fundus sits at the umbilicus after delivery, falls about a centimetre a day and becomes a pelvic organ beyond two weeks; afterpains are commoner in multiparae and with breastfeeding.
- Lochia: rubra (days one to about four), serosa (to about day ten) and alba (to about two to three weeks); foul smell or clots mean retained products or infection.
- Puerperal pyrexia: 38 C (100.4 F) or more within 14 days, excluding the first 24 hours by the classical definition — work through genital sepsis, urinary infection, mastitis, wound infection, thrombosis and systemic fevers.
- Sepsis risk factors: prolonged rupture of membranes, prolonged labour, retained products, frequent vaginal examinations, anaemia and unhygienic delivery; treat with culture-guided antibiotics covering anaerobes and gram-negatives, evacuating the uterus once covered.
- Mastitis: a painful, red, unilateral breast segment with fever — continue breastfeeding or expressing, and treat with antibiotics; a fluctuant swelling is an abscess needing drainage.
- Lactational amenorrhoea gives about 98 per cent protection only when all three criteria hold: exclusive breastfeeding day and night, amenorrhoea, infant under six months.
- Contraception and mental health: the postpartum intrauterine device is inserted post-placentally (within 10 minutes), within 48 hours or at caesarean, and progestin-only methods suit lactation; blues — brief tearfulness peaking around days four to five — resolve in days, while depression and psychosis need referral.
Common confusion
The examinable separations are blues versus depression versus psychosis (transient self-limiting sadness against persistent impaired mood against delusions), and engorgement versus mastitis (bilateral engorgement against a unilateral painful inflamed segment with fever). Healthy lochia — rubra to serosa to alba — is normal, but foul odour or clots are not; engorgement fever in the first three days settles with milk expression.
Exam-focused takeaway
FMGE quizzes the lochia sequence, the involution timeline, the pyrexia definition (38 C within 14 days), and the cause list in a febrile puerperal vignette. LAM's three criteria and PPIUCD timing are repeated one-liners, as is the blues-depression-psychosis matching and the sepsis principle — antibiotics before evacuation.
Frequently asked questions
What are the stages of lochia?
Lochia rubra (red, days one to about four), serosa (pinkish-brown, to about day ten) and alba (pale, up to two to three weeks); persistence of rubra, foul odour or clots suggests retained products or infection.
What is puerperal pyrexia?
A temperature of 38 C or more within the first 14 days after delivery (excluding the first day classically), prompting a search for genital sepsis, urinary infection, mastitis, wound infection, thrombosis or systemic illness.
How is puerperal sepsis managed?
Broad-spectrum intravenous antibiotics covering gram-negatives and anaerobes, supportive care, and evacuation of retained products once antibiotic cover is running.
When does the lactational amenorrhoea method work?
Only with all three criteria — exclusive breastfeeding on demand including nights, amenorrhoea, and the baby under six months — giving about 98 per cent protection.