Detty Nurdiati

Dept of Obstetric & Gynecology

Fac of Medicine, Gadjah Mada University
Yogyakarta

Period of confinement during and just after birth

includes 6 subsequent weeks postpartum during
which normal pregnancy involution occurs
The period of adjustment after delivery when the
anatomic and physiologic changes of pregnancy are
reversed and the body returnd to the normal
nonpregnant state.

Immediate Puerperium
The first 24 hours after parturition
Acute postanesthetic or post-delivery complications may
occur

Early Puerperium
Extends until the first week postpartum

Remote Puerperium
The period of time required for involution of the genita
organs and returns od menses, usually by 6 weks in
nonlactating women and the return od normal
cardiovascular and physiological function.

1.

Uterine Changes

2.

Urinary Tract Changes

3.

Relaxation of the Vaginal Outlet and

Prolapse of the Uterus

4.

Peritoneum and Abdominal Wall

5.

Blood and Fluid Changes

6.

Weight Loss

Changes in the uterine vessels

In pregnancy: arteries & veins within the
uterus, especially to the placental site,
enlarge and grow remarkably
After delivery: the caliber of extrauterine
vessels decreases to equal of prepregnant
state

Changes in the Cervix & Lower Uterine Segment

Cervical opening contracts slowly
For a few days immediately after labor it readily admits 2 fingers
By end of the 1st week, it has narrowed the cervix thickenss and the
canal reforms

At the completion of involution

The external os does not resume its prepregnant appearance completely
Bilateral depression at the site of lacerations remain as permanent
changes that characterize the parous cervix

Changes in the Cervix & Lower Uterine Segment

Markedly thinned-out lower uterine segment contracts &
retracts
The lower segment is converted from a clearly evident
structure into a barely discernible uterine isthmus located
between the uterine corpus above and the internal cervical os
below - over the course of few weeks

Involution of uterine corpus

Immediately after placental expulsion
Fundus of contracted uterus is slightly below umbilicus
After the first 2 days the uterus begins to shrink

Within 2 wks
descend into a cavity of true pelvis

Within about 4 wks

regain previous nonpregnant size

Involution of uterine corpus

Weight of uterus
immediately postpartum: 1000g
1 week later: 500g
at the end of 2nd week: 300g
soon thereafter 100g or less
Total number of muscle cells does not decrease
individual cells decrease markedly in size
Separation of the placenta and membrane involves the spongy
layer
decidua basalis remains in the uterus

Afterpains
Primiparas: puerperal uterus tends to remain tonically
contracted
Multiparas: contracts vigorously at interval afterpain
Infant suckles oxytocin release Uterine contraction
afterpain
Occasionally severe enough to require an analgesic
Usually become mild by the 3rd postpartum day

Lochia
Early in the puerperium, sloughing of decidual tissue vaginal
discharge of variable quantity
Consists of erythrocytes, shred of decidua, epithelial cells and
bacteria

lochia rubra: first few days after delivery

red-colored lochia, blood in lochia
lochia serosa: after 3 or 4 days
becomes progressively pale in color
lochia alba: after 10th day
white or yellowish-white color,
Lochia persists for up to 4 weeks, and may stop and resume up
to 56 days after delivery

Endometrial regeneration
the remain decidua becomes differentiated into 2 layers within 2
or 3 days after delivery
superficial layer
: become necrotic, sloughed in the lochia
basal layer
: remains intact, source of new endometrium

Endometrial regeneration
Endometrium arises from proliferation o the endometrial
glandular remnants and the stroma of the interglandular
connective tissue.
Endometrial regeneration is rapid, except at the placental site
- free surface becomes covered by epithelium within
a week or so
- entire endometrium is restored during the 3rd week

Subinvolution
an arrest or retardation of involution , the process by
which the puerperal uterus is normally restored to its
original proportions
Cause: retention of placental fragments, pelvic infection
Accompanied by prolongation of lochial discharge &
irregular or excessive uterine bleeding and sometimes by
profuse hemorrhage

Subinvolution
Bimanual examination
: uterus is larger & softer than normal
for the particular period of puerperium
Treatment
: ergonovine or methylergonovine(Methergine)
oral antibiotics : usually effective in metritis

Placental site involution

Complete extrusion of placental site takes up to 6 weeks
Immediately after delivery palm size
3-4cm in diameter by end of 2nd week

Placental site
normally consists of many thrombosed vessels within hours of
delivery ultimately undergo organization of thrombus

Late postpartum hemorrhage

Serious uterine hemorrhage occasionally develops 1-2 weeks after
delivery
Cause
abnormal involution of placental site (most often)
retention of a portion of the placenta
usually undergo necrosis with deposition of fibrin
form a placental polyp
Treatment
intravenous oxytocin, ergonovine, methylergonovine,
prostaglandins
curettage

Puerperal diuresis
physiological reversal of pregnancy-induced increase in
extracellular water
regularly occurs between 2nd and 5th day
Puerperal bladder
increased capacity & relative insensitivity to intravesical fluid
pressure
overdistention, incomplete emptying, excessive residual urine
residual urine, bacteriuria in traumatic bladder, coupled with the
dilated renal pelves and ureters create optimal condition for UTI

Impaired muscle function in or around the urethra during

vaginal delivery the pathophysiology underlying
puerperal incontinence
Most women returned to normal micturition by 3 months
postpartum
Careful attention to all postpartum women, with prompt
catheterization for those who cannot void, will prevent
most urinary problems

Vagina and vaginal outlet gradually diminishes in size but rarely

returns to nulliparous dimensions
Rugae: reappear by the 3rd week
Hymen: represented by several small tags of tissue, which during
cicatrization are converted into the myrtiform caruncles
Relaxation of vaginal outlet extensive laceration or
overstretching of perineum during delivery
Changes in pelvic supports during parturition
: predispose to uterine prolapse & urinary stress incontinence

Broad & round ligaments

: much more lax than nonpregnant
: require considerable time to recover from stretching
& loosening
Abdominal wall
: return to normal requires several weeks
(aided by exercise)
: usually resumes its prepregnancy state except for silvery
striae

By 1 week after delivery the blood volume has returned nearly

to its nonpregnant level
Leukocytosis and thrombocytosis occur during and after labor
Hemoglobin and hematocrit fluctuate moderately
Cardiac output remains elevated for at least 48 hours
postpartum, due to increased stroke volume from venous
return

Uterine evacuation & normal blood loss : 5-6 kg

Further decrease through diuresis
: 2-3 kg
factors of weight loss
weight gain during pregnancy
primiparity
early return to work (outside the home)
smoking
not affect weight loss
breastfeeding
age
marital status

Breast Anatomy
Breast Feeding

A ducts
B lobules
C dilated section of duct to hold milk
D nipple
E fat
F pectoralis major muscle
G chest wall/rib cage

Enlargement:
A normal duct cells
B basement membrane
C lumen (center of duct)

Lactation

Colostrum

the deep lemon-yellow colored liquid secreted initially by the breasts

- expressed from the nipples by the second postpartum day

- contains more minerals and protein - globulin
less sugar and fat
- Abs esp. IgA
- persists for about 5days
- gradual conversion to mature milk during the ensue 4weeks

Milk
- 600mL/day
- major proteins -including -lactalbumin, -lactoglobulin
and casein
- interleukin -6, epidermal growth factor

Endocrinology of lactation
Progesterone, estrogen, placental lactogen, prolactin, cortisol,
insulin appear to act in concert to stimulate the growth &
development of milk-secreting apparatus of mammary glands
Prolactin is essential for lactation
Although plasma prolactin falls after delivery, suckling triggers a
rise
Milk ejection or letting down reflex
initiated especially by suckling
stimulates neurohypophysis to liberate oxytocin
contraction of myoepithelial cells in alveoli & small milk ducts
milk expression from lactating breast

Immunological Consequences of Breast Feeding

Predominant immunoglobulin in milk is secretory IgA
: contains secretory IgA antibodies against E. coli
breast-fed infants are less prone to enteric infections
Contains both T & B lymphocytes

Nursing
Even though the milk supply at first appears insufficient, it become
adequate if suckling is continued
Nursing accelerates uterine involution
: repeated stimulation of nipples release oxytocin
contracts uterine muscle

6-12 hours postpartum

Blood loss
Pain
Blood pressure
Advice/warning signs
3-6 days postpartum
Breast care
Temperature
Lochia
Sign of infection
Mood

6 weeks postpartum
Recovery
Anemia
Contraception problems

6 months postpartum
General health
Contraception
Continuing morbidity

Attention immediately after labor

for the first hour after delivery
- BP & PR : should be taken every 15 minutes
monitor amount of vaginal bleeding
Fundus should be palpated to ensure that it is well contracted
if relaxation detected, uterus should be massaged through
abdominal wall until it remains contracted

The first week postpartum

A healthy mother and newborn need not be in a hospital
The length of hospital stay postpartum
Vaginal delivery: 24-48 hours
Caesarean birth: 72-96 hours

Maternal Assessment
General well-being, micturition, possible complaints
Abdomen: fundal height, distended bladder
Perineum, vaginal hemorrhage, lochia, haemorrhoids
Legs: thrombophlebitis, sign of thrombosis
Temperature: suspec infection, >= 38 C is abnormal, especially during
the first days after delivery
Assessment and help with breastfeeding to prevent problems

Maternal Advice
Maternal and newborn physical, psychosocial and culturo-environmental
needs, including nutrition and breastfeeding
Information regarding warning signs of problems and where to seek help
Counseling to women and men on sexual issues related to the postpartum
period, infertility regulation and provision of contraceptives, LAM
Voluntary counseling and testing of HIV/AIDS if necessary
Immunization of the newborn/infant and the women

Adjustment to parenthood
Changes in mood or behavior
Need for information about child care
Sexual relationship
Weight change
Contraception
Follow-up of any complication that arose in pregnancy or
during childbirth