PUERPERIUM

CONTENTS

 Introduction – what is puerperium?

 Duration
 Changes during puerperium – general
physiological, uterus, vagina
 Lochia
 Lactation
 Management of normal puerperium
 Management of minor ailments
 Postnatal advice
DEFINITION

 Period following childbirth.

 Maternal anatomical and physiological

changes, especially pelvic organs revert back
to pre-pregnant state.
DURATION

 Begins after expulsion of placenta

 Lasts for approximately 6 weeks postpartum

Can be divided as:

 Immediate – first 24 hours of delivery
 Early – first week following delivery (upto 7 days)
 Remote – 2nd week to 6th week post delivery
UTERINE CHANGES

Immediately after delivery After 6 weeks

 Uterus firm  Uterus involuted

 Size - 20× 12 × 7.5 cm2  Size –similar to pre-pregnant
state
 Weight = 1000 gm  Weight = 60 gm
 Placental site – 7.5 cm  Placental site – 1.5 cm

 LUS- thin, flabby,  LUS- normal shape ad size

collapsed  Cervix – Parous Os
 Cervix admits 2 fingers
 UTERINE INVOLUTION
 Process by which genital organs revert back approximately to the
pre-pregnant state

 Immediately following delivery – corresp. to 20 weeks

 Shrinks at a rate – 1.25-1.5 cm per day
 At 1 week postpartum – 12 weeks
 At 2 weeks postpartum – Not palpable
 After 6 weeks – approx. pre-pregnant state

 Endometrial regeneration – within 2 weeks completed; except

placental site (6 weeks)
Cervix
VAGINA

 Takes long time to involute (6-10 weeks)

 Regains tone
 Rugae reappear at 3rd week
 Never like virgin state
Pelvic floor

 Takes a long time to come back to

approximately the original state
 LOCHIA
 The vaginal discharge for the first fortnight during
puerperium
 Depending on the colour, it is named as:

LOCHIA DURATION COLOUR COMPOSITION

LOCHIA RUBRA 1-4 days Red Blood, shreds of membranes, decidua,

vernix

LOCHIA SEROSA 5-9 days Yellowish or Leukocyte> RBCs, wound exudate, mucus
pink or pale from cervix, microorganisms (anaerobic
brown streptococci and staph)

LOCHIA ALBA 10-15 days Pale white Decidual cells, leukocytes, mucus,
cholesterin crystals, epithelial cells and
microorganisms
LOCHIA
LOCHIA

 AMOUNT – average amount for first 5-6 days = 250

ml. May be scanty following premature delivery or
excessive following twin delivery or polyhydramnios.

 NORMAL DURATION – may continue upto 3 weeks.

May persist for longer who get ambulatory late.

 ODOUR – peculiar fishy smell.

LOCHIA

CLINICAL IMPORTANCE
(Important to check or ask about Lochia)

 Odor - If malodorous  indicates infection

 Amount - Scanty or absent  infection or
lochiometra. If excessive  infection.
 Color - excessive red colored discharge 
subinvolution or retained bits of conception
 Duration – if Lochia alba beyond 3 weeks 
local lesion
 General Physiological Changes
 Pulse – raised for few hours after delivery. D2 – normal.
Raises if pain.
 Temperature - Reactionary rise of temperature – comes
to normal within 12 hours. If rise of temperature after 3 rd
day  pathological.
 Urinary tract - overdistention, incomplete emptying,
presence of residual urine. Risk of UTI is high. GFR,
dilated ureters come back to normal by 8 weeks.
 Gastrointestinal tract – increased thirst due to fluid
loss, constipation, anal incontinence.
General Physiological Changes
 Weight loss – 5-6 kg due to expulsion of fetus and placenta,
liqour, blood loss
 Fluid loss – about 2 L during 1st week; 1.5 L during next 5
weeks

 Hematological changes – blood volume decreases: cardiac

output increases immediately after delivery then returns to
normal within 1 week.
 RBC and hematocrit – normal by 8 weeks
 Leucocytes – slight elevation post delivery; then normal
 Platelets – slight decrease immediately then increase with
increased platelet aggregation.
 Resumption Of Menstruation
 Variable
 Depends on lactation
 In non-lactating mother – menstruation returns by
12th week (7-9 weeks)
 Ovulation – in non-lactating – 4 weeks
 Ovulation – in lactating – 10 weeks
 Physiology of Lactation
 Four phases:

1. Preparation of breasts
(mammogenesis)
2. Synthesis and secretion from the
breast alveoli (lactogenesis)
3. Ejection of milk (galactokinesis)
4. Maintenance of lactation
(galactopoiesis)
 LACTATION & BREAST FEEDING
 Milk production – about 500-800 ml per day
 Colostrum – deep yellow; contains fat globules, rich in
proteins, antibodies (IgA, IgG, IgM) and humoral factors
 immunological defense to newborn. Also laxative
action.
 Stimulation of Lactation –
i. Put the baby to breast at 2-3 hours interval
ii. Plenty of fluids
iii. Avoid breast engorgement
iv. Exclusive breastfeeding
v. On- demand feeding
LACTATION & BREAST FEEDING
Lactation failure or
inadequate production
 May be due to infrequent
suckling or endogenous
suppression of prolactin;
pain, anxiety
 Put baby to breast, massage,
breast pumps
 Drugs – Metoclopramide,
domperidone DA antagonist;
intranasal oxytocin
Lactation suppression
 If a baby is born dead or
neonatal death or can’t
breastfeed
 Stop breastfeed; wear
support; icepacks to prevent
engorgement
 Drugs – cabergoline
Management of Normal Puerperium

Aims

I. To restore health of mother

II. To prevent infections
III. To encourage breastfeeding
IV. To motivate for contraception
Management of Normal Puerperium

 Immediate attention
 Emotional support
 Rest, sleep and ambulation
 Hospital stay
 Diet
 Care of bladder
 Care of bowel
 Care of vulva and episiotomy wound
 Care of breasts
 Immunization
Management of Normal Puerperium
Ask the patient
 Any complaints? - Pain,
excessive bleeding,
giddiness, foul smelling
lochia
 What she ate?
 Breastfeeding started?
 Passed urine?
 Ask about well-being of
baby also
 On Examination
 Monitor vitals
 Pallor/ icterus
 Per abdomen- any tenderness,
uterine size, scar (if LSCS)
 Breast
 Check pads for amount of
bleeding or lochia; any foul
smell
 Perineal wound any
hematoma or gaping
Management of Minor ailments

 After pains
 Pain in perineum
 Correction of anemia
 Control hypertension
 Cracked nipple
Danger Signs

 Fever
 Foul smelling lochia
 Excessive bleeding
 Severe abdominal pain
 Difficulty in breathing
 Convulsions
POSTNATAL ADVICE

1. Improve general health

2. Good diet
3. Supplementary Iron and Calcium
4. Breastfeeding and care of newborn
5. Postnatal exercises
6. Contraceptive advice
7. Report in case of any danger signs or any
other problem
CONTRACEPTION
 Natural methods – Lactation

 Combined oral contraceptives

 Progesterone only contraceptives (POP, DMPA)

 IUCDs

 Permanent methods
THANK YOU