REPRODUCTIVE

CHANGES OCCURING IN
THE PUERPERIUM
7/10/21
Stages of Puerperium
• 3 distinct but continuous phases:
• Acute phase or immediate puerperium: first 24 hours after delivery. rapid
change-potential for postpartum hemorrhage, uterine inversion, amniotic
fluid embolism, and eclampsia.
• Early Puerperium /Subacute Postpartum Period, 24 hrs to the first week
after delivery.
• the body is undergoing major changes-changes are less rapid
• self-identifying problems mostly minor or severe
• The Remote Puerperium-period of time required for involution of the
genital organs and return of menses, usually approximately 6 weeks.
The delayed postpartum period
• 6weeks up to 6 months. Changes during this phase are extremely
gradual, and pathology is rare.
• This is the time of restoration of muscle tone and connective tissue to
the pre-pregnant state.
• Although change is subtle during this phase, it behooves caregivers to
remember that a woman’s body is nonetheless not fully restored to
pre-pregnant physiology until about 6 months post-delivery.

• Each phase has its unique clinical considerations and challenges.

Why is the puerperium important?
• The patient recovers from her labour, which often leaves her tired,
even exhausted. There is, nevertheless, a feeling of great relief and
happiness.
• The patient undergoes what is probably the most important
psychological experience of her life, as she realizes that she is
responsible for another human being, her infant.
• Breastfeeding should be established.
• The patient should decide, with the guidance of a midwife or doctor,
on an appropriate contraceptive method.
REPRODUCTIVE CHANGES
OCCURING IN THE PUERPERIUM
UTERUS
• Immediately after the delivery of the baby, the uterus has two main
aims –
• control bleeding
• revert back to its former state
Uterus -Uterine Involution
• Immediately after placental expulsion, the fundus of the contracted uterus
lies slightly below the umbilicus-weighs ~ 1000 g.
• Involution is the term given to the process of reproductive organs
returning to their prepregnant state following three mechanism:
• Ischemia: the uterus, and the placental site contracts rapidly leading to
abdominal pain or cramps after childbirth
• uterus has an increased tone, feels firm, and weighs 1000 gms, and at the
end of the first week-500 gms, and by six weeks-50 gms.
• Initially, the contraction of the uterus is due to a substantial reduction in
myometrial cell size; it constricts the blood vessels and limits the bleeding.
• The subsequent decrease in size is
due to autolysis and infarction
Autolysis: muscle fibers are
digested by proteolytic enzyme,
waste product then pass in to the
blood stream and are eliminated
by the kidneys.
• The withdrawal of estrogen and
progesterone leads to an increase
in the activity of uterine
collagenase and other proteolytic
enzymes, accelerating the process
of autolysis.
cont.
• The intima and elastic tissues in the uterine blood vessels also
undergo fibrosis and hyaline degeneration, leading to infarction and
shedding of more uterine cells, which are removed by macrophages
• The superficial and basal layers of the endometrium become necrotic
and sloughed.
• Because separation of the placenta and membranes involves the
spongy layer, the decidua basalis is not sloughed
• The endometrium is usually fully restored within 2 to 3 weeks.
Lochia
• vaginal discharge that originates from the uterus, cervix, and vagina.
Composition
• blood,
• decidual fragments,
• cervical mucus,
• vaginal transudate
• bacteria.
Characteristics of lochia
• visual appearance-normally, lightens progressively in both volume and
colour.
• about day 7 after delivery, the fibrinous mesh deposited over the
placental site may be shed as part of the normal healing process so
the vaginal loss may be transiently heavier and flushed with fresh
blood.
• By day 10, the lochia is normally scant and pink in colour although
discharge of lochia may persist for up to 6 weeks.
X’tics cont. Odour and reaction
• It has a peculiar, unpleasant odour which is not offensive.
• Alkaline tending to become acidic towards the end.
• The alkalinity of the lochia favours the growth of microorganisms.
• Since lochia is akaline in reaction, micro orgnaisms can flourish more
rapidly than in the normal acidic secretions of the vagina.
•
X’tics cont. Composition
• From day 1 to 4 it consists of blood, sheds of fetal membranes and
decidua, amniotic fluid, lanugo, vernix caseosa and meconium.
• As time goes on it has less blood and more serum and mainly consists of
less RBC but contain more leucocytes, wound exudates, mucus from the
cervix and microorganisms (anaerobic Streptococci and Staphylococci).
• The presence of the bacteria is not pathognomonic unless associated
with clinical signs of sepsis.
• It contains plenty decidual cells, leucocytes, cervical mucus, cholestrin
crystals, fatty and granular epithelial cells, microorganisms and debris
from healing tissues from the tenth day onwards.
X’tics cont. Colour
• Depending upon the variation of the colour of the
discharge, it is named as
• Lochia Rubra (Red) 1-4 days
• Lochia Serosa (yellowish or Pink or pale brownish ) 5-9
days
• Lochia Alba (pale White)10 – 15 days
X’tics cont. Amount
• The average amount of the discharge for the first 5-6 days is estimated to be
250 ml.
• One gram of weight of perineal pads equals 1 ml of blood
• The amount of lochia is often estimated in the following terms which are
commonly described with the approximate size of the area soiled in an hour
• Scanty-Less than 1 inch stain on a perineal pad
• Small (slight) - Smaller than a 4 – inch stain
• Moderate-Smaller than a 6 – inch stain
• Heavy (large) - Larger than a 6 – inch stain
• Excessive-Pad saturation is within 15 minutes.
Sequences / Types of Lochia
• As involution progresses the lochia undergoes orderly changes and depending upon the
variation of the colour of the discharge, it is named as follows.
• Lochia Rubra (Red)
• Lochia rubra is present during the first 1-4 days. It consists of blood, sheds of fetal membranes
and decidua, amniotic fluid, lanugo, vernix caseosa and meconium. It may contain few small
blood clots.
• Lochia Serosa (Yellowish or Pink or Pale Brownish)
• Lochia Serosa is pink in colour and discharged during the next 5 – 9 days.
• It has less blood and more serum and mainly consists of less RBC but contain more leucocytes,
wound exudates, mucus from the cervix and microorganisms (anaerobic Streptococci and
Staphylococci).
• The presence of the bacteria is not pathognomonic unless associated with clinical signs of
sepsis.
Sequences / Types of Lochia
-Lochia Alba (Pale White)
• The discharges are pale white because of the presence of leukocytes
• It contains plenty decidual cells, leucocytes, cervical mucus, cholestrin
crystals, fatty and granular epithelial cells, microorganisms and debris
from healing tissues.
• It normally discharged from the 10th to the 15th day
• The colour of lochia indicates the healing stage of the placental site.
Clinical Importance / Abnormalities of
Lochia
• The character of the lochia gives useful information about the
abnormal puerperium state of the mother
• It is very important for the midwife to recognize any deviation from
normal and any abnormality detected must be noted and reported.
• The vulval pads are to be inspected daily to get information.
• Abnormalities of the lochia can be detected in the composition,
amount, colour, consistency and the odour.
Clinical Importance / Abnormalities of
Lochia
• Colour- Persistent red lochia beyond the normal limit signifies sub-involution or
retained bits of conception which is suggestive of infection.
• Amount- scanty or absent indicates infection or lochiometra and if offensive also
indicates infection
• Odour – if offensive indicates infection. Retained pug or cotton pieces inside the
vagina should be kept in mind offensive lochia- poor vulva hygiene. If vulva
hygiene is improved and lochia is still offensive, then genital or uterine infection
could be indicated.
• duration- duration of the lochia alba beyond 3 weeks suggests local genital lesion
• The presence of small blood clots during the first 24 hours may be normal
especially in multiparous women
• Where pain is associated with clots then products of conception were not
completely expelled.
• In summary, the most important change occurring in the uterus is
involution.
• After delivery the uterus is about the size of a 20-week pregnancy. By
the end of the first week it is about 12 weeks in size.
• At 14 days the fundus of the uterus should no longer be palpable
above the symphysis pubis.
• After 6 weeks it has decreased to the size of a normal multiparous
uterus, which is slightly larger than a nulliparous one.
• In other words immediately after the delivery, the upper margin of
the uterus lies about 5 inches above the pubic symphysis (upper
margin of the pubic bones).
In an average sized woman,
this will be at the level of the
umbilicus.
The rate of involution is
maximum in the first five days
(about 1 cm per day) of the
postpartum period and then
gradually slows down.
By the 7th day, the uterus
becomes much smaller and
only its upper border can just
be felt at the level of the
symphysis.
Cont.
• The persistence of red lochia beyond one week might be an indicator
of uterine subinvolution.
• The presence of an offensive odor or large pieces of tissue or blood
clots in lochia or the absence of lochia might be a sign of infection.
Afterpains
• In primiparas, the uterus tends to remain tonically
contracted following delivery.
• However, in multiparas, it often contracts vigorously at
intervals and gives rise to afterpains, which are similar to but
milder than the pain of labor contractions.
• They are more pronounced as parity increases and worsen
when the infant suckles, likely because of oxytocin release.
• Usually, afterpains decrease in intensity and become mild by
the third day
THE CERVIX
• involutes more slowly than the uterus.
• Immediately after the delivery of the baby, it is a loose opening with
irregular edges.
• It is soft and toneless, bluish-red with deep fissures along its edges and
there is often a lateral laceration.
• It involutes along with the uterus, so that by 2-3 weeks the internal os
is closed.
• But by the end of the first week, it becomes more clearly defined,
regaining its canal like structure.
• Its opening in the vagina now is much smaller and the internal os can
admit only the tip of the finger.
THE CERVIX – cont.
• While the internal os, involutes completely, the external os, never
regains its pre-pregnant state.
• It remains slightly open and its edge always presents one or more
fissure.
• For the first few days after delivery the cervix remains partially open,
admitting 1 or 2 fingers.
• Especially after the first vaginal delivery the circular external os of the
nullipara becomes slit-like.
VAGINA:
• Immediately after delivery the vagina is large, smooth walled, oedematous
and congested.
• It rapidly shrinks in size and rugae return by week 3 once the ovarian
function resumes in females that are not breastfeeding.
• The recovery delays in breastfeeding females due to low estrogen levels.
• The vaginal walls remain laxer than before and some degree of vaginal
prolapse (cystocoele and/or rectocoele) is common after a vaginal delivery.
• The patient may develop perineal edema, lacerations, tears, or undergo an
episiotomy in the immediate postpartum period that may lead to discomfort
and pain but usually heal in seven to 10 days.
VULVA:
•
• The vulva is swollen and congested after
delivery, but these features rapidly disappear.
• Tears and/or an episiotomy usually heal easily.