PUERPERIUM &

PERINEAL
RUPTURE

 Dr.Dona Wirniaty,
MKed(OG),SpOG
 PUERPERIU
M

 the period of time encompassing the first few

weeks following birth.

 The duration of this "period"  considered by

most to be between 4 and 6 weeks.
CLINICAL ASPECTS IN
PUERPERIUM

 Birth Canal
 Vagina and Vaginal Outlet
✴ Early in the puerperium, gradually diminishes in size
but rarely returns to nulliparous dimensions.
 Cervix and Lower Uterine Segment

 The cervical opening contracts slowly and for a few days

immediately after labor readily admits two fingers. By the end
of the first week, this opening narrows, the cervix thickens,
and the endocervical canal reforms.
 Uterine Involution
à Immediately after placental expulsion, the fundus of the contracted
uterus lies slightly below the umbilicus.
à Two days after delivery, the uterus begins to involute, and at 1 week,
it weighs about 500 g. By 2 weeks, it weighs about 300 g and has
descended into the true pelvis.
à Around 4 weeks after delivery, it regains its previous nonpregnant size
of 100 g or less.
à in multiparas, it often contracts vigorously at intervals and gives rise to
afterpains,

à Subinvolution  describes an arrest or a retardation of involution. It

is accompanied by prolongation of lochial discharge and irregular or
excessive uterine bleeding, which sometimes may be profuse. On
bimanual examination, the uterus is larger and softer than would be
expected
 Endometrial Regeneration
à Within 2 or 3 days after delivery, the remaining decidua
becomes differentiated into two layers  The
superficial layer becomes necrotic and is sloughed in the
lochia. The basal layer adjacent to the myometrium
remains intact and is the source of new endometrium.
à The endometrium arises from proliferation of the
endometrial glandular remnants and the stroma of the
interglandular connective tissue.
 Lochia
 Early in the puerperium, sloughing of decidual tissue results in a vaginal
discharge of variable quantity. lochia  consists of erythrocytes, shredded
decidua, epithelial cells, and bacteria.
 For the first few days after delivery, there is blood sufficient to color it
red— lochia rubra.
 After 3 or 4 days, lochia becomes progressively pale in color— lochia
serosa.
 After about the 10th day, because of an admixture of leukocytes and
reduced fluid content, lochia assumes a white or yellowish-white color—
lochia alba.
 Lochia persists for up to 4 to 8 weeks after delivery
BREAST PROBLEMS
 FU
LL
BR
EA
ST
BREAST
 SORE
ENGGORGEMEN
NIPPLE
T

 BREAS
T  MAS
ABCES TITIS
S
Full breasts
Symptoms:
 occur from 3–5 days after delivery
 The mother feels uncomfortable
 breasts feel heavy, hot and hard.
 The milk flows well, and sometimes drips from the breast

Cause: normal fullness.

Management:
The baby needs to be well attached, and
to breastfeed frequently to remove the milk.
Breast engorgement
Symptoms:
 breasts are swollen and oedematous,
 skin looks shiny and diffusely red.
 Usually the whole of both breasts are affected, and they are
painful.
 fever that usually subsides in 24 hours
 The nipples may become stretched tight and flat which makes it
difficult for the baby to attach and remove the milk. The milk does
not flow well.

Cause: Failure to remove breast milk because delayed initiation of

breastfeeding, infrequent feeds,
poor attachment and ineffective suckling.
Management:
 The mother must remove the breast milk.
 If the baby can attach well and suckle then she
should breastfeed as frequently as the baby is
willing.
 If the baby is not able to attach and suckle
effectively  she should express her milk by hand
or with a pump a few times until the breasts are
softer
 apply warm compresses to the breast or take a
warm shower before expressing
 use cold compresses after feeding or
expressingto reduce the oedema.
Mastitis
Symptoms:
 hard swelling in the breast, with redness of the overlying skin and severe
pain.
 Usually only a part of one breast is affected,
 fever and feels ill
 commonest in the first 2–3 weeks after delivery but can occur at any time

Causes:
 long gaps between feeds,
 Poor attachment, with incomplete removal of milk;
 Staphylococcus aureus was the most commonly isolated organism
 Unrelieved engorgement;
 frequent pressure on one part of the breast from fingers or tight clothing
 trauma.
Management:
 Improve the removal of milk
 try to correct any specific cause that is identified.
 Advise the mother to rest, to breastfeed the baby frequently
and to avoid leaving long gaps between feeds.
 apply warm compresses, to start breastfeeding the baby
with the unaffected breast,
 take analgesics (ibuprofen,or paracetamol).
 Severe  if there is an infected nipple fissure or if no
improvement is seen after 24 hours of improved milk
removal penicillinase-resistant antibiotics (e.g.,
flucloxacillin).
SORE / FISSURED NIPPLE
Symptoms:
 severe nipple pain when the baby is suckling.
 visible fissure across the tip of the nipple or around the base
 Nipple may look squashed from side-to-side at the end of a feed,
with a white pressure line across the tip.

Cause:
poor attachment (baby pulling the nipple / rubbing the skin agains;
incorrect suckling.)

Management:
the mother should be helped to improve her baby’s position and
attachment.
Breast abscess
Symptoms:
 A painful swelling in the breast, which feels full of fluid.
 discoloration of the skin at the point of the swelling.

Cause: secondary to mastitis that has not been effectively managed.

Management:
 An abscess needs to be drained (by catheter through a small
incision, or by needle aspiration ) guided by ultrasound
 treated with penicillinase-resistant antibiotics. .
 Feeding from an infected breast does not affect the infant (unless
the mother is HIV-positive,
Inverted, flat, large and long
nipples
Cause: Different nipple shapes are a natural physical feature of the breast.
Management:
 The same principles apply for the management of flat, inverted, large or long nipples.
 Antenatal treatment is not helpful.
 As soon as possible after delivery, the mother should be helped to position and try to attach
her baby
 takes a different position,
 give the baby plenty of skin-to skin contact near the breast, and let the baby try to find his
or her own way of taking the breast
 If a baby cannot attach in the first week or two  express her breast milk and feed it by
cup.
 baby grows the mouth soon becomes larger,and he or she can attach more easily.
 Feeding bottles or dummies, which do not encourage a baby to open the mouth wide,
should be avoided.
 For flat or inverted nipples, a mother can use a 20 ml syringe, with the adaptor end cut off
and the plunger put in backwards to stretch out the nipple just before a feed
 CARE OF THE MOTHER DURING THE
PUERPERIUM
 Hospital Care
à For the first hour after delivery, blood pressure and pulse should be
taken every 15 minutes, or more frequently if indicated.
à The amount of vaginal bleeding is monitored, the fundus palpated to
ensure that it is well contracted.
à If regional analgesia or general anesthesia is used for labor or
delivery, the mother should be observed in an appropriately
equipped and staffed recovery area.

 Early Ambulation
à Women are out of bed within a few hours after delivery.
à An attendant should be present for at least the first time, in case the
woman becomes syncopal.
 Perineal Care
à The woman is instructed to cleanse the vulva from
anterior to posterior—the vulva toward the anus.
à An ice bag applied to the perineum may help reduce
edema and discomfort during the first several hours
if there is a laceration or an episiotomy.
à Severe perineal, vaginal, or rectal pain always
warrants careful inspection and palpation
 Bladder Function
à Bladder filling after delivery may be variable.
à Bladder sensation and capability to empty spontaneously 
diminished by local or conduction analgesia, by episiotomy
or lacerations, and by instrumented delivery.
à Urinary retention with bladder overdistension is common in
the early puerperium.
à If a woman has not voided within 4 hours after delivery, it is
likely that she cannot  examination for perineal and genital-
tract hematomas is made.
à overdistended bladder  indwelling catheter until the factors
causing retention have abated.
à When the catheter is removed  necessary subsequently to
demonstrate ability to void appropriately.
 Depression
 Diet
à There are no dietary restrictions for women who
have been delivered vaginally.
à Continue iron supplementation for at least 3
months after delivery.
 Neuromuscular and Joint Problems
 Pain in the pelvic girdle, hips, or lower extremities
may be due to stretching or tearing injuries sustained
at normal or difficult delivery
 Early Discharge
à The length of hospital stays following labor and
delivery is now regulated by federal law.
à The norms are hospital stays of up to 48 hours
following uncomplicated vaginal delivery and up to
96 hours following uncomplicated cesarean
delivery (American Academy of Pediatrics and the
American College of Obstetricians and Gynecologists, 2007).
EXTERNAL ANAL
SPHINCTER
INTERNAL ANAL SPHINCTER
ANORECTAL MUCOSA