Normal Puerperium

1. Fahmida Rashid Swati
Assistant Professor
Ob-Gyn
Chittagong Medical College
E-mail: dr.fahmidaswati@gmail.com

2. Period (Time)
Following child birth
Body tissues(pelvic organs)
Revert back
to pre-pregnant state
Anatomically and Physiologically

3. INVOLUTION → Process
Retrogressive
changes confined to
reproductive organ
Activity –
Mammary glands

4. Time
↓
Puerperium
Process
↓
Involution
Women
↓
Puerpera

5. Immediate
• Within 24
hrs
Early
• Up to 7
days
Remote
• Up to 6
weeks
Duration- 6 weeks
Begins :As soon as the placenta is expelled

6. I. ANATOMICAL
Uterus:-
 Lower Uterine
segment
 Cervix
I. PHYSIOLOGICAL
Muscles
Blood vessels
Endometrium
Involution most marked
in body of the uterus.

7. Immediately- uterus
firm and retract
with alternate hardening and
softening.
Immediate Postpartum At 6 weeks
Uterus
1000 gm 20 x 12 x7.5 cm About 60 gm

8. Just after delivery:
 7.5 cm
 contracts and raised
Placental site :
At 6 weeks
1.5 cm.

9. After delivery:
Fibre –Number Not ↓
Size- ↓
Withdrawal of
steroid
hormones-
E& P
↑ collagenase
and
proteolytic
enzyme
Autolysis of
protoplasm
Pregnancy –
Hypertrophy and Hyperplasia,
Individual fibre - ↑ 10 times in length
5 times in breadth
Muscle Fibre

10. BLOOD VESSELS
The arteries constricted -
followed by thrombosis.

11. DAY 7
regeneration
starts
Day 10
Regeneration
completed.
Day 16
Restored
6th wks
placental
site is
restored
ENDOMETRIUM
Following delivery-2-3 mm.

12. ASSESSMENT OF INVOLUTION OF UTERUS
By fundal Height of uterus in relation to symphysis
pubis.
At a fixed time every day
Preferably by same observer.
Bladder emptied
 Preferably bowel emptied too.
Uterus -centralized
With a measuring tape fundal height is
measured above the symphysis pubis

13. Following delivery-
SFH-13.5 cm
First 24 hours-
No change
Thereafter-
↓ in by 1.25 cm/day
by the end of 2nd wk -
uterus pelvic organ.

14. Cervix
Rapidly revert to a non-pregnant state
• External os: admits two fingers for a few days
• End of first week, narrow down to admit the tip of
finger only.
• It never returns to the nulliparous state
Internal os: Internal os closes
as before.

15. Subinvolution -
When Involution
affected adversely
Superinvolution -
Lactation

16. Vagina
VASCULARITY
EDEMA
FLATTENED
ATROPHIC
Decreased
estrogen levels
Mucosa -delicate for first
few weeks and
submucous venous
congestion persists longer
 Need to withhold surgery

17. “It is the vaginal discharge for the
first fortnight during puerperim.”
Peculiar offensive fishy smell.
Reaction - alkaline
Amount- 250 ml

18. Immediately after
Delivery
Bleeding
Uterine contraction
Lochia rubra
1-4 days
Brownish red
Lochia serosa
5-9 days
Yellow/ pink/ pale brownish
Cease
5-6week
Lochia alba
Depending upon variation of
color discharge names as-
10-15 days
pale white color

19. 1.Lochia Rubra –
blood
shreds of fetal
membranes and
decidua,
vernix caseosa
lanugo and
meconium.
2.Lochia Serosa
less RBC
more
leukocytes,
wound
exudates,
mucus from
cervix and
microorganisms
3.Lochia Alba:
plenty of decidual
cells &
leukocytes,
mucus,
cholestrin
crystals,
fatty granular
epithelial cells
and
microorganism.
Composition

20. Clinical importance
The vulval pads inspected
Character
Odor- malodor-infection
Amount-
scanty or absent- lochiometra(distension of the
uterus by retained lochia.)
Excessive- infection
Colour-
red color beyond normal - subinvolution or
retained bites of conceptus
Duration- more than 3wk – genital lesion

21. Perineum
SWOLLEN & ENGORGED VULVA
Resolves within 1-2 weeks

22. Abdominal wall
Remains soft and poorly
toned for many weeks
The return to a
pre-pregnant state
depends greatly on
maternal exercise

23. The bladder mucosa -
edematous.
Bladder capacity -
May be overdistended
without any desire to pass
urine.
Common problems :
Over distension,
Incomplete emptying
Presence of residual
urine.
Urinary stasis in >50 %
Risk of UTI - high.
URINARY TRACT

24. ↑ thirst in early puerperium
Constipation-common
GASTROINTESTINAL TRACT

25. WEIGHT LOSS
5-6 kg -expulsion of the fetus, placenta,
liqour and blood loss,
Further 2 kg - by diuresis.
continue up to 6 wk

26. amount depend on – amount retained during
pregnancy, dehydration and blood loss during
delivery
Loss of salt and water-pre-eclampsia and
eclampsia.
2 liters during 1st wk
Additional 1.5 liters –next 5 wk
FLUID LOSS

27. BLOOD VALUE
At delivery- ↓due to blood loss and dehydration
By 2nd wk – Near normal
Cardiac output- rise 80% -
-Returned to normal by 1st wk

28. Fibrinogen level remains high up to 2nd week
A hypercoagulable state persists for 48 hours
postpartum
RBC and haematocrit- Normal at 8wk
Platelet- Return to Normal by 4th -10th
days
WBC –Reaches upto 30,000/L - stress

29. • Menstruation
returns by
• 6th wk- 40%
• 12 wks- 80%
Not
feed her
baby
Onset of 1st menstruation variable &
depends on lactation.
Mean time to first menses is 7-9 weeks.
Menstruation

30. • Ovulation return-4th wk
• Need contraceptive
from 3rd post partum
wk
Non-
lactating
mothers
Greatly influenced by breastfeeding
Ovulation

31. Contraception-
Caused by the suppression of ovulation
due to ↑ in prolactin.
Lactating
mother
• Ovulation -10wks
• Need contraceptive - 3rd pp
month
• Contraceptive protection -
98% up to 6 month of pp

32. Breast feeding
↑ prolactin level
GnRH secretion
Suppress release of LH
no LH surge
anovulation
Inhibits ovarian
Response to FSH
Less follicular growth
↓estrogen
No menstruation

33. Breasts
The changes to prepare for breastfeeding
occur throughout pregnancy.
Lactation can be established as early as 16
weeks' gestation
.

34. Although lactation starts following delivery, the
preparation for effective lactation starts during
pregnancy.
The physiological basis of lactation is divided in to
four phases:
1. Mammogenesis -Preparation of breast
2. Lactogenesis -Synthesis and secretion from
the breast alveoli
3. Galactokinesis -Ejection of milk
4. Galactopoiesis -Maintenance of lactation

35. Colostrum
Liquid that is initially released during the first 2-4 days
after delivery.
Protective for the newborn.
 High in protein content, this liquid is
It is already present in the breasts during delivery , and
suckling by newborn triggers its release.
Removal of milk from stimulates more milk production

36.  Over the first 7 days-
milk matures and contains all necessary nutrients in the
neonatal period
 Milk change throughout period of breastfeeding to
meet changing demands of the baby.
COMPOSITION
 deep yellow serous fluid, alkaline in reaction.
 higher specific gravity, a higher protein, vitamin A, sodium and
chloride content
 lower carbohydrate, fat and potassium than the breast milk.
 contains antibody (IgA)

37. ADVANTAGES
The antibodies (IgA, IgG, IgM) and hormonal factors
(lactoferrin) provides immunological defense to the new born.
It has laxative action on the baby because of large fat
globules.

38. MILK PRODUCTION
500-800 ml of milk a day.
This require about 700 Kcal/day
For this purpose a store of about 5 kg of fat during
pregnancy is essential

39. STIMULATION OF LACTATION
Mother is motivated since the early pregnancy.
No prelacteal feeds (honey, water)
Following delivery important steps are:
1. To put the baby to the breast at 2-3 hours interval
from t first day.
2. Plenty of fluids to drink.
3. To avoid breast engorgement.
Early (1/2-1 hour) and exclusive breastfeeding in
correct position are encouraged.

40. Principles in management
1.To restore the health of the mother.
2.To prevent infection.
3.To care of the breasts, including promotion
of breastfeeding.
4.To motivate the mother for contraception.

41. IMMEDIATE ATTENTION
Immediately –closely observed (fourth stage of labour).
given a drink of her choice or something to eat
Emotional support
REST AND AMBULANCE
Early ambulation.
After a good resting period, the patient becomes
fresh and can breastfeed the baby or moves out of bed
to go to the toilet.
DIET
on normal diet.
Lactating- high calories, adequate protein, fat, plenty of fluids,
minerals and vitamins.
non-lactating mothers- as in non- pregnant.

42. Advantages:-
1.Provides a sense of well-being.
2.Bladder complications and constipation are less
3.Facilitates uterine drainage and hastens involution
4.Lessens puerperal venous thrombosis and embolism.
Following an uncomplicated delivery, climbing stairs,
lifting objects, daily household work, cooking may be
resumed.

43. HOSPITAL STAY
Early discharge-If adequate supervision by trained
health visitors is provided.
discharged after 2 days of spontaneous vaginal
delivery with proper education and instructions.
Some need prolonged hopsitalization due to
morbidities. (infections of urinary tract, or the perineal
wound, pain, or breastfeeding problems).

44. CARE OF THE BLADDER
encouraged to pass urine following delivery as soon
as convenient.
If patient fails to pass urine due to:-
1. Unaccustomed position
2. Reflex pain from the perineal injuries.
after a difficult labour or a forceps delivery.
Counselled
Catheterization
If still fails to pass urine. or
incomplete emptying of bladder (residual urine>60 ml)
kept until the bladder tone is regained.

45. CARE OF THE BOWEL
constipation much less because of early ambulation
and liberalization of the dietary intake.
A diet containing sufficient roughage and fluids
If neccessary, mild laxative.
SLEEP
need rest,both physical and mental.
protected against worries and undue anxiety.
If any discomfort(after pains or painful piles or
engorged breasts)- adequate analgesics. (Ibuprofen)

46. CARE OF THE VULVA & EPISIOTOMY WOUND
vulva and buttocks washed with soap water down over
the anus and a sterile pad is applied.
personal cleanliness of the vulval region.
perineal wound -antiseptic after micturition and
defication or atleast twice a day.
Use of sterilised gloves during dressing.
Cold (ice) sitz baths relieve pain.
If perineal pain is persistant –P/V/E and P/R/E to detect
any hematoma, wound gaping or infection.
pain Ibuprofen is safe

47. CARE OF THE BREASTS
 nipple washed with sterile water before each feeding.
cleaned and kept dry after the feeding.
 nursing brassiere for comfort & support.
Nipple soreness :
is avoided by frequent short feedings rather than the
prolonged feeding, keeping the nipple clear and dry.
Candida infection may be another cause.
Nipple confusion -when infant accepts artificial nipple
but refuses mother's nipple.
 avoided by making mother's nipple more protractile
and avoiding any supplemental fluids

48. MATERNAL-INFANT BONDING (Rooming-In)
It starts from the first few moments after birth.
This is manifested by fondling, kissing, cuddling and
gazing at the infant.
The baby should be kept in her bed or in a cot besides
her bed.
establishes mother-child telationship & mother is
conversant with the art of baby care.
Baby friendly hospital initiative promotes parent-
infant-bonding, baby rooming with the mother and
breast feeding.

49. ASEPSIS AND ANTISEPTICS
Asepsis must be maintained
Liberal use of local antiseptics, aseptic measures,
clean bed linen and clothings.
Clean surroundings and limited number of visitors
IMMUNIZATION
anti-D-gamma globulin to unimmunized Rh-negative
mother bearing Rh-positive baby.
Rubella vaccine with attenuated rubella virus.
 booster dose of tetanus toxoid.

50. After pain
It is the infrequent, spasmodic pain felt in the
lower abdomen after delivery for a variable
period of 2-4 days.
Presence of blood clots or bits -lead to
hypertonic contractions of the uterus in an
attempt to expell them out.
Common in primipara.
In multipara due to vigorous uterine
contractions
excited during breastfeeding.

51. Treatment-
Massaging the uterus
administration of analgesics (Ibuprofen) and
antispasmodics.
Pain on the perineum
examine pernium when analgesic is given
to relieve pain.
Early exclsion of vulvo-vaginal hematoma
Sitz baths (hot or cold)

52. Correction of anemia
Supplimentary iron therapy (ferrous sulfate 200
mg) -4-6 weks.
Hypertension treated
TO MAINTAIN A CHART
A progress chart maintained-
Pulse, respiration and temperation recording
6 hourly or at least twice a day.
Measurement of the height of the uterus
Charater of lochia
Urination and bowel movement.

53. POSTPARTUM EXERCISE
The objectives of postpartum execises are:-
To improve the muscle tone- especially abdominal
and perineal muscles.
To educate about correct posture when getting up
from bed.
Educate correct principle of lifting and working
positions during day-to- day activities.
Advantages
To minimize risk of puerperal venous thrombosis
To prevent backache
To prevent genital prolapse and stress incontinence
of urine.

54.  Physical activity should be resumed without delay.
 Sexual activity may be resumed (after 6 weeks)
when the perineum is comfortable and bleeding has
stopped.
 Some women may get “flaring response” of some
autoimmune disorders due rebound effect of the
immune supression during pregnancy.

55. CHECK-UP & ADVICE ON DISCHARGE
A thorough check-up of the mother and the
baby is mandatory prior to discharge of the
patient from the hospital.
Discharge certificate should have all the
important information as regard the mother
and baby.

56. Advices include
Measures to improve her general health.
Continuation of supplimentary iron therapy.
Postnatal exercises
Procedures for a gradual return to day-to-day activities
Breastfeeding and care of the newborn
Avoidance of intercourse for a reasonable period of 4- 6
weeks until lacerations or episiotomy wound are well
healed.
Family planning advice and guidance-
Non lactating woman -after 3 weeks and
lactating women -from 3 months after delivery

57. method of contraception depend upon
breastfeeding status,
state of health and
number of children.
Natural methods -until mentrual cycles are
regular.
Exclusive breastfeeding provides 98%
contraceptive protection for 6 months.
Barrier methods.
Steroid contraceptions- combined preparations
are suitable for non-lactating women and should
be started 3 weeks after.

58. In lactating women -avoided due to its
suppressive effects.
Progestin only pill -better choice.
Other progestins (DMPA, Levonorgestrel
implants) may be used.
IUDs -irrespective of breastfeeding status.
Sterilization (puerperal) -who completed
families.

59. Postnatal care includes systematic
examination of the mother and the baby and
appropriate advise given to the mother during
postpartum period.
The first postnatal examination is done and
the advise is given on discharge of the patient
from the hospital.
The second routine postnatal care is
conducted at the end of 6th week postpartum.

60. Aims and objectives
To assess the health status of the mother.
Medical disorders like diabetes, hypertension
should be reassessed.
To detect and treat at the earliest any
gynecological condition arising out of obstetric
legacy.
To note the progress of the baby including the
immunization schedule for the infant.
To impart family planning guidance.

61. Procedure
Examination of the mother
Advice given to the mother
Examination of the baby and
advice

62. Examination of the mother
Routine examination includes recording weight, pallor,
blood pressure and tone of the abdominal muscles and
examination of the breasts.
Pelvic examination should be done only when indicated.
The following should be noted:
A cervical smear may be taken for exfoliative cytological
examination if this h not been done previously and
insertion of intrauterine contraceptive device may be done
when desired.
Laboratory investigations depends on the clinical need
may be advised.

63. Examination of the baby
This should be conducted by a pediatrician.
In this respect, an attached well baby clinic to the
postpartum unit is an ansolute necessity.
The progress of the baby is evaluated and
preventive or curative steps are to be taken.
Immunization to the baby is started.

64. Ad vice given
General:
If the patient is in sound health she is
allowed to do her usual duties.
Postpartum excercise may be continued for
another 4-6 weeks.
To evaluate the progress of the baby
periodically and to continue breastfeeding for
6 months.
Family planning counseling and guidance

65. Thank You