1. The Puerperium (suite de couche
normale).
Plan:
Definition.
Objectives:-Monitor physiological changes of
the puerperium.
-Diagnose and treat postpartum omplications.
-Discuss breast feeding.
-Provide emotional support.
-Disacuss family planning and contraception.
-Postpartum consultation.

2. Physiological Changes.
• Involution of the Genital and Urinary tracts.
I- Uterus, Uterine height 30-35cm, 1-1.5kgs, involutes by 1-
2cm dailly, 10-14 days becomes a pelvic organ.
By 4 weeks non gravid size(50-70gms).
3wks <100gms, 2wks 300gms, 1wk 500gms.
Uterine involution occurs by reduction in the size of
individual cells(autolysis).
Lower segment disappears(junction between cervix and
body of uterus).
Dr. Nana

3. Physiological Changes(1).
Cervix regresses, internal OS is closed, infra vaginal1.5-
2cm,by a week, external OS remains dehiscent.
Ectropion, endocervical mucosa may remain visible for a
long period.
• Regeneration of the Endometrium.
Separation of placenta / membranes involves only spongy
layer.
2-3 days later basal portion differentiates into superficial
layer, becomes necrotic and basal layer, regenerates the
new endometrium. Dr. Nana

4. Physiological Changes(2).
• Involution of the Placenta site.
At delivery, size of a palm, 2 weeks 3-4cm in diameter,
complete extrusion <6 weeks.
Involution of endometrium and placenta site can be
summarised into four stages:
1. Regression delivery to day five.
2. Scarring of placenta site day five to 25 without hormonal
stimulation.
3. Proliferation of endometrium day 25-45 influenced by
oestrogens. Dr:Nana

5. Physiological Changes(3).
4 Resumption of menses triggered by ovulation by 40th
day. Sometimes ovulation doesnot occur,bleeding is
withdrawal in origin, ovulation usually occurs by the
60th day.
• Vagina,vaginal outlet.
Sperficial erosion scar quickly, some degree of
colpocele occurs at delivery , regresses quick,
myrtiforme caruncles may be seen, intriotus closes
with time, perineum regains ist tonicity but must be
reinforced with appropriate gymnastics. Dr.Nana

6. Physiological Changes(4).
• Abdomen. Rupture of elastic fibers, diastases of the
rectus abdominus muscle.
• A slow regression of other changes, biliary and urinary
tracts(cholecystography and IVP interpretation difficult).
• Relative insensitivity to intravesical pressure, Retention.
• Biochemistry: several modifications progressively
regress to normal, tolerance to glucose or
carbohydrates, changes in lipid
levels( HDL,LDL,Cholesterol,trigycerldes), clotting
factors, antithrobine III.

7. Physiological Changes(5).
• Hormonolgy:
1. Oestrgens decrease at delivery, increases from the
25th day inflenced by FSH.
2. Progesterone decreases within 10 days of delivery,
appears only after the 1st ovulation.
3. LHrh is low until the 25th day, LH peak occurs at about
the 40th day.
4. FSH increases from the 25th day.

8. Breast Feeding.
• Colostrum ( 2nd half of pregnancy-delivery).
1. It contains more amino-acids (cystine, arginine,
histidine), minerals.
2. It contains less sugars (lactose) and fats (linoloeic acid).
3. Rich in immunoglobulins-secretory IgA.
4. Other host resistance factors in milk and colostrum
include: IgA, components of complements,
macrophages, lymphocytes, lactoferrin,
lactoperoxidase, lysozymes
5. Colostrum has a laxative action. Dr.Nana

9. Breast Feeding(1).
• Breast Milk (2-5days).
1. Volume increases, maximum by the 3rd month. Volume
varies between 500-750ml /day by 3 months.
2. Volume inceased in twin delivery.
3. Hypogalactia or low milk secretion is rare.
4. It may be of 1ary or 2ary origin, primary rare and is due
to hypothalamo-pituitary disorder.
Dr.Nana

10. Breast Feeding(2).
5-Secondary is common: maternal fatigue, emotional
breakdown, change of lifestyle. Reversible with
emotional support, frequent breast feeding, complete
emptying of breast at each feed, bedrest, increase fluid
intake and galactogil.
6-Breast milk is isotonic to water, contains proteins, fats
and water.
7-All vitamins are found in breast milk but for vitamin K.
8-Breast milk has several advantages over artificial milk.
Dr.Nana

11. Breast Feeding(3).
• Complications of Breast Feeding.
1. Nipple cracks/ lacerations: occur in 1:4 breast feeding
mothers, occurs within 2 weeks of delivery.
Risk factors: clear skin women, synthetic breast wears,
prolonged breast feeding and poor breast feeding
techniques.
Treatment,expose to air or sunlight, use topical lotions
containing vitamin A and E, 1% aqueous eosin etc.
Dr.Nana

12. Breast Feeding(4).
2-Engorgement: 1st week, 15% of breast feeding mothers
affected.
Risk factors, poor feeding (SFD, sickchild), nipple cracks,
pains, maternal anxiety, weaning etc. Breast
distended, hard tender with low-grade fever.
Treatment: massage, topical ointment, continue breast
feeding. May complicate with breast lymphangitis or
abscess.
Dr.Nana

13. Breast Feeding(5).
3-Lymphangitis: 5%, Risk factors:nipple cracks,
engorgement. Germs skin flora, swollen warm tender
breast , fever 39-40 `C.
Treatment, humid dressing, ATBs, Anti-inflammatory,
bedrest.
4-Galactophoritis: complicates lymphangitis/
engorgement. Hard painful nodule in the breast, fever
and axilla nodes. Budin sign positive. Treament: ATBs,
Anti-inflammatory, stop breast feeding but empty breast.
Dr.Nana

14. Breast Feeding(6).
5- Breast Abscess: 1%, complicates a poorly treated
lymphangitis or galactophoritis. Pain, fever 39- 40 ` C,
fatique, insomnia.
Treament: Drainage, ATBs, stop breast feeding, empty
breast.
Contra-indications to breast feeding: Active TB infection,
congestive heart failure, viral hepatitis, HIV, some drugs.
Dr. Nana

15. Clinical Aspects of the puerperium.
• Useful parameters: BP, pulse, temperature,duiresis.
• Day 1: 0-2hrs Immediate postpartum
2-24hrs Early postpartum.
>24hrs- 6weeks Late postpartum.
• Other Days: complete examination.
• After birth pains, Lochia rubra 1-3 days, lochia serosa 4-
7 days, lochia alba >7days,
• Lochia contains epithelial cells, RBCs, shreds of
decidua, bacteria.
Dr.Nana

16. Clinical Aspects of the
Puerperium(1).
• Duiresis increase (day 2-5).
• Leucocytosis (labour, delivery and immediate
postpartum).
• Weight loss ( content ofuterus, uterine involution,
duiresis).
• Check for depression ( Transient depression or
postpartum blues).
Dr.nana

17. Clinical Aspects of the
puerperium(2).
Risk factors:-Emotional breakdown that follows the
excitement and fear of pregnancy and delivery.
-Discomfort of the early puerperium.
-Fatique from loss of sleep at labour /postpartum.
-Fear of becoming less attractive and anxiety.
Dr.Nana

18. Clinical Aspects of the
Puerperium(3).
• Preventive Measures – Haemorrhage
-Immunisation, Rh –ve, ATT, vaccination of baby.
-Deep vein thrombosis.
-Personal hygiene, vulva, breast, exercise.
-Supplementation(Fe).
-Mentruation and ovulation, 6-8weeks without breast
feeding, majority between 2-18 months, 8% after one
month, 61% at a year, 25% become pregnant by one
year. Intermittent bleeding.

19. Pathologic Puerperium.
• Several complications occur within 2 weeks of delivery:
Infections, thrombo-embolism, haemorrhage, anaemia,
postpartum hypertension and /or psychosis.
• Risk factors for infection in the puerperium:
-Anaemia, UTI in pregnancy.
-PROM >24hrs.
-Prolonged labour.
-Intrapartum fever.
-Obstetric manoeuvres.Intrumental deliveries, manual
delivery of placenta, uterine revision. Dr.Nana

20. Pathologic Puerperium(1).
• Risk factors for Thrombo-embolism:
-Age >35 years.
-C/S.
-P/H thrombo-embolic disease.
-Varices.
-Cardiopathies.
-Prolonged hospitalisation.
-Postpartum haemorrhage.
-Postpartum BTL. Dr.Nana

21. Postpartum Consultation.
• Objectives:Verify
- Regression of physiologic changes.
- Involution of the uterus/ genital tract.
- Persistence of pathologies developed during pregnancy.
- Counsel for sexual life and family planning.
NB: Late complication of the puerperium: haemorrhage,
amenorrhoea, postpartum thyroiditis, stress etc.
Dr.Nana