Just as any disease can occur during pregnancy, it can also occur during the puerperium. I have seen patients with mumps, measles, chicken pox, scarlet fever, malaria, appendicitis, catarrhal, etc. The more frequent complications of the puerperium are: puerperal or childbed fever; mastitis or infection of the breast; pyelitis or infection of the uppermost portion of the tube which conducts the urine from the kidney to the bladder; abnormally excessive puerperal bleeding; and anemia from excessive blood loss at delivery.
Puerperal or Childbed Fever
The term puerperal fever or puerperal infection includes the various complications which are caused by harmful bacteria that may infect the female reproductive organs during labor and the first few days of the puerperium. The majority of these disease-begetting germs are unwittingly introduced at this time from the outside by the doctor, by the nurse, by inanimate objects of the environment, or by the patient’s own fingers.
Before the bacterial killers—the sulfa drugs, penicillin, and the various ‘mycins’—made their welcome debut, infection after childbirth was not only common but extremely dangerous. However, the picture has changed so completely that, as the director of an obstetric teaching service, I deplored today’s absence of virulent, typical cases of puerperal infection to demonstrate to medical students, residents, and nurses, though I thrill at the lives saved and the illness spared. Today less than 3 per cent of deliveries are followed by infection, usually in a form so mild that the only evidence is the telltale thermometer.
The reason the incidence of post-delivery infection is so low is mainly the increase in measures for its prevention. The ordinary measures consist in the avoidance during late pregnancy of careless pelvic examinations and sexual intercourse, for fear these may introduce harmful bacteria, which will be lurking in the vagina ready to infect the woman during her labor or puerperium. (If harmful germs are introduced into the vagina several days before labor begins, they are normally killed off in time.) During labor, clean surroundings and carefully performed rectal and vaginal examinations are imperative. At the time of delivery, the preparation of the vulva with antiseptics; surrounding the vagina with sterile drapings; a physician properly gowned, gloved, capped, and masked; and the skillful conduct of delivery with the elimination of unnecessary operations, all reduce the chances of infection. Keeping the blood loss at delivery to the minimum, and, in case of excessive blood loss, a prompt transfusion, are important. After delivery, sterile perineal pads, fresh linens, and proper nursing care by intelligent attendants do much to prevent the disease. If a case of puerperal infection develops, its isolation is essential to prevent the spread of the infection to other freshly delivered women.
If a patient who has had normal temperature develops a rise of temperature to 100.4 degrees Fahrenheit (38 degrees Centigrade) or above for two days during the puerperium, she is presumed to have puerperal infection unless there is some obvious source for the fever such as an inflamed breast or bronchitis. Fever from puerperal infection commonly begins on the third day, although it may appear earlier or later. In mild infections the temperature usually remains below 102 degrees Fahrenheit. Severe cases may be accompanied by chills and high temperatures.
On the rare occasions that the temperature postpartum rises above 100.4 degrees for two readings of the thermometer within a twenty-four-hour period, bacterial cultures of the interior of the uterus, of the blood, and of the urine are taken, and wide spectrum antibiotics are immediately begun. More than likely, by the time the bacteria have been grown and identified by the laboratory the patient’s temperature is normal and she is entirely well. However, if the infection is still present and the temperature continues elevated, tests are run on the bacteria cultured from the particular case to find out to which of a half-dozen different antibiotics the organisms are particularly sensitive. This special drug is then given in adequate dosage, and in 99 per cent of the cases even the most resistant infection clears up dramatically.
Mastitis, the development of localized inflammation of the breast, occurs uncommonly before delivery, but it occurs quite frequently in the puerperium. It is not to be confused with engorgement of the breasts or the normal caking which takes place on the third and fourth days after delivery, with the onset of lactation. Inflammation of the breast usually occurs several days or weeks later.
In the typical case of mastitis the patient develops a sudden and unexplained elevation of temperature with a localized area of tenderness in one of the breasts. On examination, the tender area is found to be hard and red. The skin overlying it is hot. The site of predilection is the outer and lower quadrant of the right breast, though any area of either breast can be involved. There are several theories to explain the origin of the condition. One is that bacteria invade from without inward, from the nipple, via the milk ducts, into the breast tissue itself. Another is that the breast tissue is unknowingly bruised, perhaps struck by the right arm in the course of ordinary activities, and the bruised area presents a site of lowered resistance against bacteria which happen to appear as transient wayfarers in the bloodstream. Finding this area of lessened resistance, they congregate and develop there. Albeit, one of the ‘mycin’ drugs, penicillin, or a sulfa drug, and bed-rest are immediately prescribed. Under this treatment the inflammation usually subsides, the potential abscess melts away, and the patient continues to nurse her baby.
If the inflammation and temperature do not subside within forty-eight hours, an abscess usually forms—suppurative mastitis. The temperature goes higher, the area becomes more tender, and the skin above the abscess assumes a doughy consistency. The baby is now weaned completely. The deep, hard mass commences to soften, and when the center of the inflamed area feels as though it has become liquefied, the patient is completely anesthetized and the abscess evacuated and drained.
In the past breast abscess was relatively common, occurring perhaps once in about every hundred deliveries. Fortunately the highly successful modern treatment of the inflamed breast has made actual abscess formation uncommon. A localized breast inflammation is about four times as common in first pregnancies and is rarely seen after a woman has had more than two children. The majority develop in the third and fourth week of the puerperium. If operation becomes necessary, the average time for its performance is the thirty-ninth day after delivery. The average case is operated on eleven days after the onset of symptoms. Cases may occur a year and even longer after delivery. The complication is far more frequent during the winter months, and apparently there is a definite association of the condition with the general prevalence of colds, bronchitis, sinus infections, etc. One breast abscess does not predispose to another in a future puerperium, so that the patient can nurse a subsequent baby with ordinary safety.
In some cases mastitis follows a cracked or fissured nipple, although the two conditions may and do occur quite independently of each other. When there is difficulty with the nipple, the patient complains of pain whenever the child sucks; and on inspection the nipple looks raw and deeply furrowed in one area, and a little bloody material exudes from the small wounds. Various treatments may be employed for this condition, but they are all planned to give the nipple a chance to heal through rest and the application of healing drugs. Many obstetricians take the child off the breast until the nipple is completely healed, and in the interim use either a breast pump or mere stripping of the breast with the fingers. Others allow the child to nurse through a nipple shield, a round glass rim which fits tightly over the area. The child nurses through a rubber nipple attached to the shield. This prevents the child’s mouth from coming in direct contact with the nipple. Among the many healing drugs applied are tincture of benzoin, silver nitrate, castor oil and bismuth paste, balsam of Peru, and creams containing antibiotics. After a day or two the tender nipple usually heals and the baby can be put back on the breast
Pyelitis and Cystitis
Bacterial infections of the urinary tract postpartum are less common now, since early ambulation has reduced the necessity of repeated catheterization. However, they still occur. Pyelitis, infection of the collecting funnel within the kidney, may cause acute pain and tenderness in the kidney region on the affected side, or the condition may be locally asymptomatic. Under such circumstances the patient runs unexplained fever, but a specimen of urine carefully obtained from the bladder through a catheter will show pus cells and bacteria on microscopic study. The right kidney is more likely to be involved than the left. Since the organism causing the infection is usually a bacterium called colon bacillus, antibiotics particularly lethal to this variety of germ are prescribed. If the urine culture shows another type of organism to be the cause, the variety of antibiotic can be appropriately modified. Cystitis is a local infection of the bladder without involvement of the upper urinary tract. It ordinarily causes severe burning and pain on urination, with a marked frequency of voiding. It too can be successfully treated with antibiotics.
As explained earlier in this article, it is normal to have a bloody vaginal discharge for about ten days to two weeks after delivery. The bleeding may be irregular, and the passage of occasional clots the size of a quarter is not abnormal. However, the rate of bleeding should not exceed that seen during the menses, and the amount should gradually taper off.
In occasional cases, often around the seventh or eighth day, the bleeding may increase acutely, with or without the passage of large clots. If this occurs, call your doctor immediately. The cause for the abnormal bleeding may be either subinvolution—failure of the uterus to involute properly— or the retention of placental fragments. The latter is not due to the neglect or incompetence of the physician, as the layman is prone to imagine. In the third stage of labor, during the process of separation of the placenta, some isolated portion may be so firmly attached that when the placenta sheers itself loose the adherent tissue remains behind. Treatment of the excessive bleeding may be initiated at home or in the hospital, depending upon the gravity of the blood loss.
Ergotrate is prescribed by mouth in repeated doses to cause the uterus to contract; this may be supplemented by Pitocin, ordinarily administered by intravenous drip. When necessary, a transfusion is given. If after approximately twelve hours the bleeding has not virtually stopped, a curettage of the uterine cavity is carried out under general anesthesia. The scraping away of the offending tissue, whether it be portions of the pregnancy uterine lining which through faulty involution have not sloughed off or fragments of placenta, cures the condition.
Anemia from Blood Loss
Transfusions are given so frequently on an obstetric service that the staff views them as a commonplace procedure. Usually they are done merely to shorten convalescence or to forestall complications rather than to save a life. This is often misunderstood, and when the obstetrician suggests a transfusion patient and family become unnecessarily alarmed.
If a patient loses as much as a quart of blood at delivery, transfusion from a suitable donor is usually performed in the early puerperium. In addition, she is given some medicine containing iron, and liver is added to the diet. These measures are to stimulate blood formation in her own body.
This very infrequently appears as a prolongation and exaggeration of the ‘blues,’ .
It was believed years ago that there was a special brand of mental illness following childbirth which was termed a puerperal psychosis. Actually, we now know that childbirth and the early weeks of motherhood simply impose a mental strain which does not affect an emotionally stable woman, but may affect a vulnerable, emotionally unstable woman. In other words, delivery and motherhood may cause mental illness in the vulnerable person, who may have reacted similarly to a multitude of situations, such as loss of money, death of a loved one, or some domestic crisis. Therefore, the treatment of a puerperal psychosis is similar to any other psychosis: tranquilizing drugs, hospitalization when necessary, even shock treatments, and almost always psychotherapy. The prognosis of a puerperal psychosis does not differ from a psychosis unassociated with pregnancy.
The sleeplessness and discomforts of late pregnancy are a mental strain. Then too, there are the understandable fears of the unknown, of the pains of labor, and above all, worry about the normalcy of the unborn infant. Conscious and subconscious readjustments must be made. The relationships to parents, in-laws and even to one’s husband may pose a problem. Can the love which you have for him be divided with a baby without taking any love from him? Airing these problems in discussions with your obstetrician may be very helpful; it may act as the necessary safety valve.
A previous puerperal psychosis does not automatically preclude other children. I have delivered four such cases without a recurrence of the emotional difficulty. Before considering another baby, you should discuss the whole matter thoroughly with your psychiatrist. I am sure he will not give you a green light unless you are sincerely secure that you will be all right. If so, he may sanction another pregnancy. You may require his emotional support by occasional consultations during the nine months of pregnancy and the early months of new motherhood.
And so we leave the puerperal woman, having followed her through both normal and abnormal convalescence.