Physiology and Management of Normal

Puerperium

Jan, 2024
AU, Ethiopia
PREPARED BY: BEKER A 1
Physiologic Changes During Puerperium

and

Midwifery are

By: Beker A
PREPARED BY: BEKER A 2
 Objectives

After going through this session, the learners are able to:

Define puerperium.

List stages of puerperium

Identify the physiologic changes during puerperium.

Determine Midwife cares performed during puerperium.

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PREPARED BY: BEKER A 4
Normal Puerperium
Introduction

 It is the period of adjustment after pregnancy and

delivery when anatomical and physiological changes
of pregnancy are reversed and the body returns to the
normal non pregnant state.

 It is the period in which reproductive tract returns to its

normal, non-pregnancy state.

 It takes 6 weeks (42 days)

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 Puerperium
 Puerperium is the period following child birth.
 Also known as
 post-partum
 post-natal
 post-delivery period.

 Begins as soon as placenta is expelled and lasts for six

weeks through the process of involution.
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Stages of Puerperium
1. Immediate postpartum: the first 24 hours after delivery

 Acute post delivery complications may occur.

2. Early postpartum: from day two until the first week post partum.

3. Late postpartum: From second week till end of six weeks.

Includes the period of time required for involution of the genital

organs through the sixth weeks postpartum .

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 Cont,…
During the puerperium;

 The reproductive organs and associated structures return to

their pre-pregnancy state both anatomically and physiologically.

 Lactation process is started

 The mother recuperate from physical and emotional stress

 The family adjusts to the new neonate or infant

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Involution of Reproductive Tract

Involution of Uterus

 Involution is the process whereby the pelvic

reproductive organs returns to their pre-pregnant size
and position.

 Failure to complete this process is known as sub-

involution( Caused by infection(endometritis),
retained tissue and anemia .

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 Involution of Reproductive Tract
 Perineum

 Swelling completely gone within 1-2 weeks

 The muscle tone various depending on the extent of injury.

 Vulva

Edema, laceration may be seen immediately after birth.

Disappears gradually in a few days

Laceration relates with proper management at time

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 Cont,…
Vagina

Vagina and its outlet gradually diminish in size

Rugae begin to reappear by the third week.

Vaginal mucosa becomes atrophic and vaginal walls do

not regain their thickness until estrogen production by

the ovaries.
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 Cont,…
Vaginal epithelium begins to proliferate by 4 weeks,
usually coincidental with resumed ovarian estrogen
production

Breastfeeding mothers are likely to experience vaginal

dryness and may experience dyspareunia or discomfort
during intercourse.
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 Cont,…
 Cervix

Immediately after childbirth the cervix is formless, flabby,

and open wide enough to admit the entire hand.

Rapid healing takes place, and by the end of the first

week the cervix feels firm and the external os is 1 cm in

diameter
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 Cont,…
The internal os closes as before pregnancy.

The external os remains slightly open and appears slit like

rather than round.

Fig. 1:Appearance of
cervices nulliparous (A)
and parous (B)

Source: Williams Obstetrics 24th ed., 2014).14

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 Cont,…
Uterus

The Uterine involution depends on the following

processes:
Contraction of muscle fibers,

Catabolism and

Regeneration of uterine epithelium

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 Cont’d…
 This contraction controls bleeding from the area left
denuded when the placenta separated.

 The uterus decreases in size as muscle fibers, which

have been stretched for many months, contract and
gradually regain their former contour and size.
 It should feel firm and round.

 If the fundus is soft, it is called as boggy uterus,

indicates that contractions are inadequate allowing
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Involution of the uterus
Compress 3 process
Contraction of the uterus
Disposal of tissue(Lochia)
Regeneration of endometrium

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Cont’d…

 The uterus measures about 20×12×7.5 cm (length, breadth

and thickness) and weighs about 1000 gm.

 At the end of 6 weeks it return to pre-gravid size of 7.5×5×2.5 cm

and weighs 50-80 gm.

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Cont,…
The weight changes of uterus

 1000g immediately after birth

 500g after 1 weeks
 300g after 2 weeks
100g after 4 weeks
 60g after 6 weeks

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 Cont’d…
Fundal location

 Immediately after delivery return back to size 20weeks

 During the first 24hours no change takes place and at symphysis
pubis by the end first post partum week.
 From the 2nd days to 11th days the uterus descends by approximately
1 cm, or one fingerbreadth, per day.
 By 2 weeks the uterus become pelvic organ
 by the 14th day and cannot be palpated abdominally
 By six weeks return back to its normal pre-pregnant size

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Cont’d…

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Fig.3: Sagittal section showing uterus five days after delivery
Source: Dutta Textbook of Obstetrics 7th ed).
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 Endometrium

 It also undergoes involution after placenta is delivered.

 The major part of decidua cast off along with the

placenta and membranes, except the basal
portion of the decidua.

 The superficial part containing the degenerative

decidua, blood cells and bits of fetal membrane
become necrotic and is cast off in lochia.
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Cont’d…

 Regeneration of the endometrium occurs from

epithelium of the uterine gland and inter-glandular
stromal cells completed by 10th days.

 Regeneration of the endometrium, except at the site of

placental attachment, occurs by 16 days after birth

 Healing at the placental site occurs more slowly and

requires approximately 6 weeks
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 Afterpains
 Cramping pain after childbirth caused by alternating
relaxation and contraction of uterine muscles.

 The discomfort is more acute for multiparas because

repeated stretching of muscle fibers leads to loss of
muscle tone that results in repeated contraction and
relaxation of the uterus.
 Afterpains are particularly severe during breastfeeding.
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Cont’d…

Intervention

 Analgesics

 Lying in a prone position with a small pillow or

folded blanket under the abdomen helps keep
the uterus contracted and provides relief.

 Reassure the mother that afterpains are self-

limiting and decrease rapidly after 48 hours.
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 Lochia
Lochia is the blood-stained uterine discharge that is
comprised of blood and necrotic decidua

Vaginal discharges during puerperium for 15 days

Discharge from uterus, cervix and vagina

It has three stage

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 Lochia
Changes in the color and amount of lochia is also one of the indicator for progress of involution.
Types of lochia Timeframe Excepted finding Deviation from normal

Lochia Rubra 1-4 days Bloody with small clot Large clot
Moderate to scant amount Heavy amount
Increased flow on standing or Saturated pad within 15 minute-----
breastfeeding sign of hemorrhage
More RBC Foul odor -----sign infection
Placental fragment

Lochia serosa 5-9 days Pink or brown color Continuation of rubra stage after day
Scant amount 4
Increased flow during physical Heavy amount
activity Saturated pad within 15 minute-----
Less RBC more WBC sign of hemorrhage
Foul odor -----sign infection

Lochia Alba 10-15 days Yellow to white in color Bright red bleeding---sign of possible
Scant amount late hemorrhage
Plenty WBC Foul odor -----sign infection

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Cont’d…
Amount
 Estimating the amount of lochia on a perineal pad is
difficult.
 One method for recording the amount of lochia in 1 hour:
Scant: less than 2.5cm stain on the peripad
Light: 2.5-10cm stain
Moderate: 10- 15cm stain
Heavy: saturated peripad in 1 hour
Excessive: saturated peripad in 15 minutes
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Cont’d…
Scant

Light

Moderate

Heavy

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 Cont,…
FACTORS THAT ENHANCE FACTORS THAT SLOW
INVOLUTION INVOLUTION
 Prolonged labor.
 Uncomplicated labor
 Incomplete separation of placenta
and birth process.
 Distended (full) bladder.
 Breast-feeding.  Anesthesia
 Blood clots
 Early &frequent ambulation.
 Boggy uterus
 Fibroid
 Infection
 Anemia
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Changes in Urinary Tract
Glomerular hyperfiltration continues for the first postpartum
day but returns to prepregnancy baseline by 2 weeks.

Dilated ureters and renal pelvis return to their prepregnant

state during the course of 2 to 8 weeks postpartum .

Retention of urine may occur either due to the sphincter or

reflexly from perineal trauma.

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 Changes in Abdomen and Peritoneum
Abdominal wall become flat and flabby

It also becomes soft and flaccid due to:

o ruptured elastic fibers in the skin and

o prolonged distention by the pregnant uterus.

Striae gravidarum persist.

The peritoneal organs be in their pre pregnant positions as the uterus involutes.

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 Cardiovascular system
 Hypervolemia, which produces a 30% to 45% increase in blood volume
at term, allows the woman to tolerate a substantial blood loss
during childbirth without ill effect.

 A transient increase in maternal cardiac output occurs after childbirth

due to:

 An increased flow of blood back to the heart when blood from

the utero- placental unit returns to the central circulation

 Decreased pressure from the pregnant uterus on the vessels

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 Cont’d…
 The rise in cardiac output, caused by an increase in
stroke volume, persists for about 48 hours after
childbirth.

 Gradually, cardiac output returns to normal non-

pregnant levels in most women by 6 to 12 weeks
after childbirth

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 Cont,…
Cardiac Out put stays elevated for at least 48 hours

Needs an extended time for those changes to return back in

to pre pregnant state

Blood volume returns to its prepregnant level after a week

Venus tone will return to base line when blood volume

becomes normal

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 Cont’d…
 The body rids of excess plasma volume needed during
pregnancy by
 diuresis and diaphoresis.

 Diuresis is facilitated by a decline in the adrenal

hormone aldosterone and decrease in oxytocin level
(promotes reabsorption of fluid).
 As aldosterone production decreases, sodium
retention declines and fluid excretion
accelerates.
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 Cont’d…
 Diaphoresis occurs during the first few postpartum
weeks in response to the decreased estrogen levels.
 This profuse sweating, which often occurs at
night, assists the body in excreting the increased
fluid accumulating during pregnancy.
 Can be uncomfortable and unsettling for the
mother and reassurance and provision of comfort
measures, such as showers and dry clothing may be
employed.
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 Cont’d…
 An increased risk of orthostatic hypotension, a sudden drop in
the blood pressure when the woman stands up, which is due to
decreased vascular resistance in the pelvis.
 Most women will experience an episode of feeling cold and shaking
during the first few hours following birth (postpartum chills).
 Assess excessive blood loss
– Estimate blood loss and assess hemoglobin and hematocrit levels
• Hgb decreases by 1 to 1.5 g/dl and Hct decreases 3% to 4% per 500 mL of
blood loss

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 Coagulation

 During pregnancy, levels of plasma fibrinogen and other factors

necessary for coagulation increase as a protection against
postpartum hemorrhage.

 Elevations in levels of clotting factors continue for several days or

longer, causing a continued risk of thrombus formation.

 It takes 4 to 6 weeks before the hemostasis returns to normal non-

pregnant levels

 ‘Early postpartum ambulation’

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 Cont’d…
Assess for venous thrombosis.
Assess for Homans‟ sign(calf pain at dorsiflexion).
Assess the legs for calf tenderness and sensation of
warmth.
Expected assessment findings:
Negative Homans’ sign
No tenderness or sensation of warmth
31

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 Blood cell count
 Marked leukocytosis occurs during labor and the
immediate postpartum period
Neutrophils, which increase in response to
inflammation, pain, and stress to protect against
invading organisms, account for the major increase in
WBCs.
32
The white blood count (WBC) falls to normal values by 6
days after birth
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 Prevention of Rh
Isoimmunization
 Rho immune globulin given to Rh-negative women at
28 weeks’ gestation.
 Rh-negative women who gave birth to an Rh-positive
neonate, are screened for anti- Rh antibodies (Coombs’
test).
 A second injection of Rho immune globulin is given to
the woman if she is Coombs’ negative. 43

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 Cont’d…
• Anti-D immunoglobulin:
– Indication: Administered to Rh-negative women who
have given birth to an Rh- positive neonate
– Action: Prevents production of anti-Rh (D) antibodies
– Adverse reactions: Pain at the injection site
– Route and dose: 300 mcg IM within 72 hours post-
birth
44

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 Gastrointestinal System
 Decrease in gastrointestinal muscle tone and motility post-birth
with a return to normal bowel function by the end of the 2nd
postpartum week.

 After childbirth, the mother usually is hungry because of the

energy expended in labor.

 She is thirsty because of the decreased oral intake during labor

and the fluid loss from exertion, mouth breathing, and early
diaphoresis.
 Provide food and fluids soon after childbirth
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 Cont’d…
 Constipation is a common problem during the postpartum period.
 Bowel tone and gastric motility, which were diminished during
pregnancy as a
 result of progesterone, remain sluggish for several days.
 Relaxation of the abdominal wall increases constipation and
distention with gas.
 Restricted food and fluid intake during labor often results in small,
hard stools.
 Perineal trauma, episiotomy, and hemorrhoids cause discomfort
and interfere with effective bowel elimination.
 Stool softeners and laxatives to prevent or treat constipation
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 Cont’d…
 It is common for women to develop hemorrhoids during
pregnancy and/or the birthing process.
 Instruct the woman to increase fluid intake and increase fiber and
roughage in diet to decrease risk of constipation.
 Encourage the woman to avoid sitting for long periods of time by
lying on her side.
 Instruct the woman to take Sitz baths, which are helpful in
promoting circulation and reducing pain.
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Cont’d…
• It is common for women to develop hemorrhoids during
pregnancy and/or the birthing process.
• Instruct the woman to increase fluid intake and increase fiber
and roughage in diet to decrease risk of constipation.
• Encourage the woman to avoid sitting for long periods of time
by lying on her side.
• Instruct the woman to take Sitz baths, which are helpful
in promoting circulation and reducing pain.
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 Return of Ovulation & Menstruation
Mean time is 6-8 weeks in non nursing women.

The mean time delays about 2-18 months for nursing

women.

Estrogen levels fall immediately after delivery and remain

depressed in lactating patients.

Menstruation occurs at day 14 on average following

ovulation and ovulation also occurs at day 14 on average
following menstruation. PREPARED BY: BEKER A 49
 Cont,…

For exclusively breastfeeding women, the contraceptive

protection is about 98% up to 6 months of postpartum.

Non-lactating mother should use contraceptive

measures in 3rd postpartum week and the lactating

mother in 3rd postpartum month

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 Sexual activity

The desire to resume sexual activity in the puerperium

varies greatly from women to women due to the following
factors.
-vaginal incisions and lacerations

-amount of vaginal atrophy due to breast-feeding

-Route of delivery

-return of libido PREPARED BY: BEKER A 51

Cont,…
Median time to resume intercourse is 6 to 7 weeks

Better if avoided or reduced until

Perineum is comfortable

Bleeding diminishes

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Midwifery Care

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 Cont,…
Blood Pressure & pulse : every 15 minutes, or more for the first two
hours after delivery.

Temperature: every 4 hours for the first 8 hours and then at least every
8 hours. (American College of Obstetricians and Gynecologists, 2012).

Vaginal bleeding, fundus palpation to ensure its well contraction.

Uterus is massaged through the abdominal wall until contracted (Dutta

Textbook of Obstetrics 7th ed).

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 Cont,…
If anesthesia is used, the woman should appropriately be
managed in recovery room.

Ambulation: Woman should be out of bed within a few hours

after delivery to minimize bladder complications, less frequent
constipation, increases sense of well being, hastens involution of
uterus and reduce venous thromboembolism.

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 Cont,…
♠Involution of uterus: needs close assessment and
management to prevent related maternal problems.

Research indicated that the regular check for involution

of uterus reduced complications

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Cont,…
♠Lochia: carefully assess for lochia, odor, color

♠Care Of Breast: wash breast after each feed with mild soap & water
gentle message of areola and pull nipple out to prevent nipple inversion.

♠Values of lab. results (if there)

♠Be alert for any complications

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 Cont,…
►Care of the bladder: Encourage the women to void in
6hrs, if not possible intermittent catheterization for 1 to
2 days, because it affects involution of uterus.

►Perinal Care: for repaired episiotomies; wash with

water &soap 1 to 2 per day, wash after voiding
&defecation.

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 Midwife assessment
The health care provider should assess for the following:

♠Pain: rule out clot retention, rupture of uterus; analgesics

♠Fever: 100F0 in first 24 hrs urinary or uterine infection

♠Pulse: raised pulse infection

♠Blood pressure: decreased blood pressure dehydration or shock

♠Diet: total of Caloric requirement: 2900Kcal/Day

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 Cont,…
♠Bowel & bladder habits

♠Status of the breast

♠Values of lab. results

♠Look for any complications

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Evaluation
Pain relieved

Blood pressure is 120/80mmHg

Urine out put is normalized

The temperature is normothermic

Bleeding is managed/ stopped, etc

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 Summary
Puerperium is the period in which reproductive tract and other

systems returns to its normal, non-pregnancy state.

Effective management in the stages of labor plays an essential role

for the normal puerperium.

Nursing care of puerperium is performed in a holistic manner, so

the health care providers should be alert to handle accordingly.

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THANK YOU !!!

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 s

wisdom

love Peace

Thank you!!!
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