The Puerperium

Puerperium
• Definition: Time following delivery during which
pregnancy-induced maternal anatomical and
physiological changes return to the nonpregnant
state

• Period:
a. Immediate – within 24 hours
b. Early – up to 7 days
c. Remote – up to 6 weeks
 Uterine Involution
Factors:
Weight Changes
1. Myometrium: deconstruction 
decrease size of the myocytes Immediately after birth 1000 gram
2. Blood vessels: large blood vessels
obliterated by hyaline changes  1 weeks after birth 500 gram
small blood vessels
2 weeks after birth 300 gram
3. Endometrium: regeneration of
basal layer of decidua to form 6 weeks after birth 100 gram
new endometrium

Fundal Height
Immediately after delivery Slightly below umbilicus
2 weeks after delivery Return to the pelvis
6 weeks after delivery Normal size
 Subinvolution
• A medical condition in which after childbirth, the
uterus does not return to its normal size
• Sign and symptoms:
– Intervals of prolonged lochia
– Excessive uterine bleeding
– Bimanual: uterus is larger and softer then would be
expected
• Etiology:
– Retained placenta
– Vascular malformation
– Infection (commonly Chlamydia trachomatis)
 Lokhia
• Stages:
– Rubra (1 – 3 days)
– Serosa (3/4 – 10 days)
– Alba (>10 days)
• Assessment:
– Volume: approximately 250cc during the first 5-6 days
– Duration: 24 – 36 days
– Colour: red  pink yellowish  pale white
– Odor: peculiar offensive fishy smell
General Physiological Changes
1. Temperature
2. Urinary tract
3. GI tract
4. Fluid loss
5. Blood loss
6. Menstruation
7. Lactation
 Lactation
• Mammogenesis
– Midpregnancy: Lobules of alveoli form lobes separated by
stromal tissue, with secretion in some alveolar cells.
– T3: Alveolar lobules are almost fully developed
– Postpartum : Rapid↑in cell size and number of secretory
organelles. Alveoli distend with milk.

• Lactogenesis
– At delivery, the abrupt, large ↓ in progesterone and
estrogen  milk production.
– Colostrum  second postpartum day and is secreted by
the breasts for 5 days postpartum.
• Galactokinesis
• Galactopoiesis
 Urinary Retention
• The puerperal bladder has an ↑ capacity and is
relatively insensitive to intravesical fluid pressure
 urinary tract infection (UTI).
• days 2 and 5 postpartum, “puerperaldiuresi” 
reverse the ↑ in extracellular water associated
with normal pregnancy.
• return to their pre-pregnant state 2–8 weeks
postpartum.
• Instrument-assisted delivery, regional and general
anesthesia are risk factors for postpartum urinary
retention.
 Puerperium Emergency
a. Immediate
a. Postpartum hemorrhage
b. Shock
c. Pulmonary embolism
d. Inversion.
b. Early (within one week)
a. Acute retention of urine
b. Urinary tract infection
c. Puerperal sepsis
d. Breast engorgement
e. Mastitis and breast abscess
c. Delayed
a. Secondary postpartum hemorrhage
b. Thromboembolic manifestation—pulmonary embolism, thrombophlebitis
c. Psychosis
d. Postpartum cardiomyopathy
e. Postpartum hemolytic uremic syndrome
 Post natal care
• Hospital care
– For 2 hours after delivery: BP & pulse @15 min, temp @4 hours
for the first 8 hours and then at least @8hours, amount of
vaginal bleeding, fundus contraction
– Out of bed within few hours after delivery
– No dietary restriction
• Perineal Care: from ant to post
• Bladder Function
• Pain, mood, and cognition
• NMS problems: obstetrical neuropathies, musculoskeletal
problems
• Immunization: e D-negative woman who is not isoimmunized and
whose infant is D-positive is given 300 μg of anti-D immune globu-
lin shortly after delivery
• Hospital discharge: vaginal 48 hours, sc 96 hours
• Contraception: family planning education
• Home care: coitus, follow up care, late maternal morbidity