1. Sreelakshmi. M

2. Normal puerperium

3.  Six weeks following childbirth during which the
pelvic organs return to prepregnant state &
physiological changes of pregnancy are all
reversed.
 Immediate: within 24 hours
 Early : up to 7 days
 Woman in puerperal period: puerpera

4. Physiological
changes

5. 1. Involution of the uterus
• process by which postpartum uterus returns
to prepregnant state
• End of 3rd stage of labor: fundus just below
umbilicus
• By 2 weeks: descends into abdomen not palpable
through abdomen
• Weight: 1000g (immediately after delivery) 500g
by 1 wk. 300g by end of 2nd wk.
• Returns to prepregnant state 4 wks. after delivery
• Achieved by decrease in size of muscle fibers
• by autolysis of cytoplasm by proteolytic enzymes

7. • After pains : infrequent, spasmodic pain in
lower abdomen for up to 3-4 days : common
due to uterine contraction
: during breast feeding (oxytocin)
Due to blood clots uterus contract
attempt to remove clot
More in primipara
If severe: antispasmodics

8. 2. Endometrium
• Decidua shed after childbirth
• S.compactum & S.spongiosum shed
• S.basale remains new endometrium from
remnants of endometrial glands completed in 14
days.
3. Placental site
• Takes longer to recover
• Arteries: obliterated by endarteritis & hyaline(1wk)
• Veins: thrombosis
• Last to involute
• Regeneration: 6wks

9. 3. Lochia
• Vaginal discharge for first few wks. following delivery
• Blood from placental site + necrotic decidua
• Lochia rubra: red color, 1st few days following
delivery
• Lochia serosa: paler , 3-4 days
leucocytes, necrotic decidua + red cells
• Lochia alba: yellowish white,
after 10th day
• Persists up to 4 wks.
• Gives information about any
abnormality like infection

10. 4. Cervix
• Contract immediately after delivery
• Remains patulous for few days
• Starts closing (at end of 1st wk.), cervical canal
reforms, completed by 6th week.
• External os wont regain original appearance
parous cervix has characteristic transverse
slit
• Lower segment: contract form small
uterine isthmus (6 wks.)

11. Other Pelvic Organs
 Vagina: smooth & stretchable for first few days
size reduced & rugose within 4 wks.
 Hymen: represented by caruncle myrtiformes
(small tags of tissue)
 Relaxation of vaginal outlet & pelvic floor

12. Urinary system
Bladder: sustains trauma mucosal edema
& submucosal hemorrhages disappear in
few days
Prolonged& difficult delivery injury to bladder
innervation insensitive bladder capacity &
insensitive to intravesical fluid pressure
Over distension
Incomplete emptying
Residual urine / retention
Exaggerated in epidural & spinal anesthesia
After 1st week, recedes during the following weeks

13. Dilated ureters & pevicalyceal system:
normal in 8 wks
Renal plasma flow, GFR & creatinine clearance :
normal by end of puerperium
Increased extracellular water( in normal pregnancy)
becomes normal with postpartum diuresis
(2nd-5th days)
Urea & creatinine elimination : remain high for 2
wks

14. Delivery intestinal paresis constipation
Pain in perineum also contributes (episiotomy &
lacerations)
Early ambulation, high fiber diet, increased fluid
intake

15. • Rapid fall of plasma volume in 1st day
• Slowly to non-pregnant volume: end of 1st week.
• Red cell mass : normal within 24hours
• Hb concentration: minimum on 4th day & normal by
6 weeks
• ESR: in 1st week & normal by 4 weeks.
• Increased leukocytosis (during & after labor) :
subsides after 1 week
• Platelets: in no. with adhesiveness
• Fibrinogen: in 1st week.
• Coagulation factors: increased & persists in

16. • Heart size returns to normal slowly
• Heart sounds returns more rapidly
• 3rd sound & systolic ejection murmurs: disappear in
1wk
• C.O: for 24 hours : steady fall till 10th day: almost
normal
• Actual non-pregnant value: only by 6 months
• C.O : due to in SV & HR
• Heart rate ~ C.O
• Fall in stoke volume is slow
• BP : rises in 1st days & normal by 1 week
• Peripheral Resistance: rises rapidly to

17. • Uterine evacuation
• Normal blood loss
• Further 2-3kg : diuresis
• Prepregnant weight in 6 months

18. • Variable
• Depends on lactation
• Non-lactating: early resumption by 6-8 weeks
• In nursing mothers: 70 % amenorrhea till 4-6
months
• Total protection only for 10weeks: ovulation return
by the end of lactational amenorrhea.
• Additional contraceptives : after 3 months ( even in
completely breast feeding)

19. Care in
puerperium

20. • Observed for minimum 2hours in labor ward : vital
signs, bleeding, micturition
• Uterus : well contracted. Bleeding: within normal
limits
• Before shifting to ward:
>examine perineum, episiotomy site
>sterile dressing with antiseptic
• Relatives, food, fluids, good sleep
• Encourage early ambulation

21. • Assessed by noting height of fundus above
symphysis pubis
• Day after delivery: 12 cm above symphysis
• 1cm decrease per day
• By end of 2nd week: no longer
palpable

22. • Encouraged to void soon after delivery
• Doesn’t void within 6-8 hours : bladder atony
• Retention : common in early puerperium (esp. in
epidural analgesia & traumatic delivery with perineal lacerations)
: vulvovaginal hematoma
 Uterine atony hemorrhage
 Urinary infection
• Local analgesics
• Catheterization (for 24 hours) till tone restoration

23. • Constipation
• Increase fluid intake & roughage
• Prescription of mild laxatives

24. • Immediately start normal diet
• Plenty of fluids & milk daily : lactation
• Calorie & protein intake
• Additional daily requirement: 500kcal & 25g
proteins
• Fresh fruits & green leafy veg : vitamins
• Iron: continued for 3 months / whole lactating
period

25. • Regular antiseptic cleaning of episiotomy wound
• Wash with warm water & use sterile pads
• Analgesics
• Severe pain: hematoma
• Infection : antibiotics
• Episiotomy wound: healed by 3 weeks

26. • Must be adequate,
• Rooming in : baby on mother’s cot
Early ambulation
• Venous thrombosis & embolism

27. • Baby breast fed as soon as possible
• No frequent & early feeding engorged & painful
• Correct positioning &clean nipples
• Draw out retracted nipples
• Cracked nipples: painful
: emollient creams after feeds

28. • Episiotomy & perineal lacerations, breast
engorgement & after pains ( uterine contraction )
• Caesarean section: pain at incision site, post spinal
headache
• Analgesics

29. • Common in early puerperium : postpartum blues
• Reassurance & support
Hospital stay
 Vaginal delivery: after 48hrs
 Caesarian section : 4-5 days

30. 1. Immunization of mother
Anti-D IgG within 72hrs
Rubella vaccine / MMR
2. Contraception
Post partum sterilization
Interval sterilization
Counseling

31. 3. Medications
 Adviced to avoid medications as far as possible
 Take only on medical advice
4. Infant advice
 Adequate follow up
 Rooming in
 BCG vaccine prior to going home
 Immunisation schedule
 Advice mother to feed on demand

32. 4. Postnatal exercises
Early in puerperium
Move limbs, deep breathing
exercises, abdominal muscle tightening
exercises everyday
Repeated 3-4 times a day
Perineal muscle exercises: improve vaginal muscle
tone, prevent vaginal laxity & stress incontinence
Back muscle toning

34. Postnatal
check-up

35. • Scheduled at 6 weeks
• Maternal problems discussed
• Breast-feeding
• Lochia & menses
• Clinical examination, abdomen, breasts
• Local examination : episiotomy & discharge
• Pelvic examination
• PIH, GDM
• Any medical problems
• Advice on resuming job, coitus,
other activities

36. • Breast feeding alone wont suffice as contraception
• Various options given, partner included
• IUCD inserted if acceptable
• Other options which wont reduce breast milk amount
Progesterone only pill
Injectable progestogens
(depot medroxy progesterone acetate)

37. Inform about possible side-effects
Should avoid estrogen-pregesterone
combination: affect quantity & quality of milk
Permanent sterilizations: postpartum/ interval
sterilization/

38. • Seen by pediatrician
• Checked for any problems
• Weight , feeding problems
• Reinforce immunization schedule

39. Restoration of maternal health to prepregnant state
Promotion of breast feeding
Correction of any problems arising due to delivery
Advice on baby care & immunization
Contraceptive advice

40. Thank you