ANATOMY AND PHYSIOLOGY OF

NORMAL PUEPERIUM
INTRODUCTION
Puerperium is the period following childbirth during which the body tissues,
specially the pelvic organs revert back approximately to the pre-pregnant state both
anatomically and physiologically.
It is a period of approximately 6 weeks which commences following completion
of third stage of labour.

Definitions

 The puerperium is defined as the 6 weeks period commencing after the

completion of third stage of labour.
-E.M SYMONDS
 The puerperium is refers to the 6 weeks period following child birth, when
considerable adjustments occur before return to the pre pregnant state.
-PHILIP N. BAKER
 Puerperium is defined as the time from delivery of the placenta through the first
few weeks after the delivery.

Stages of puerperium
The post partum period has been divided into:
 The immediate puerperium, the first 24 hours after delivery; when acute
post anesthetic or post delivery complications may occur.

 The early puerperium, which extends until the first week post partum.

 The remote puerperium, which includes the period of time required for
involution of the genital organs through the sixth weeks postpartum.

Physiological and psychological changes during puerperium:-

A)Reproductive system changes
Involution of the uterus
Anatomical consideration
 Immediately following delivery, the uterus becomes firm and retracted with
alternate hardening and softening.
 The uterus measures about 20 X 12 X 7.5
cm.
 Weight :about 1000 gms.
At the end of the first week, it weighs 500gm. By the 6 weeks, it weighs approx.
50g.
 The placental site contracts rapidly presenting a raised surface which measures
about 7.5 cm and remains elevated even at 6 weeks when it measures about 1.5 cm.

Reduction Of Uterus Size –(assessment of involution)

The rate of involution is assessed by the height of fundus of uterus in relation to
symphysis pubis.
The measurement is taken by same observer and fixed time every day. Bladder
should be emptied and bowel too. Following delivery , the fundus lies about 13.5cn
above the pubic symphysis, during first 24 hour, the level remain constant
thereafter it decreases in height by 1.25 cm in 24 hours. By the end of 2nd week
uterus become the pelvic organ. The rate of involution thereafter slows down by
6weeks, the uterus become almost normal in size.

Lower uterine segment

 Immediately following delivery, the lower segment becomes a thin, flabby,
collapsed structure.
 It takes a few weeks to revert back to the normal shape and size of the isthmus.
Cervix
It is soft immediately after birth
-The cervix up to the lower uterine segment remains edematous, and thin for
several days after birth.
The cervical os which is dilated to 10cm during labor closes gradually, it may still
possible to introduce 2 fingers into cervical os for the first 4-6 postpartum after
than it narrow down and admit the tip of finger only.
days.
 The external cervical os never regains its prepregnancy appearance, it is no
longer shaped like a fish mouth.
 It return to its normal state at 4 weeks after birth

PHYSIOLOGICAL CHANGES

The physiological process of involution in uterus occur in following components-

1. muscles 2. Blood vessels 3. Endometrium
1. MUSCLES- During puerperium, the number of muscle fibers is not decreased, but
there is substantial reduction of the myometrial cell size. Due to Withdrawal of the steroid
hormones, estrogen and progesterone, may lead to increase in the activity of the uterine
collagenase and the release of proteolytic enzyme. This proteolytic enzyme does
Autolysis of the protoplasm with liberation of peptones which enter the bloodstream.
These are excreted through the kidneys as urea and creatinine. This explains the increased
excretion of the products in the puerperal urine.

2. Blood vessels: The changes of the blood vessels are pronounced at the placental site.
The arteries are constricted by contraction of its wall and thickening of the intima
followed by thrombosis. During the 1st week, arteries undergo thrombosis, hyalinization
and fibrinoid endarteritis. Veins are obliterated by thrombosis, hyalinization and
endophlebitis. New blood vessels grow inside the thrombi.

3. Endometrium: Following delivery, the major part of the decidua is cast off with the
expulsion of the placenta and the membranes, more at the placental site. The
endometrium left behind varies in thickness from 2 mm to 5 mm. The superficial part
containing the degenerated decidua, blood cells and bits of fetal membranes becomes
necrotic and is cast off in the lochia. Regeneration starts by 7th day. It occurs
from the epithelium of the uterine gland mouths and interglandular stromal cells.
Regeneration of the epithelium is completed by 10th day and the entire endometrium is
restored by the day 16, except at the placental site where it takes about 6 weeks.
Vagina and perineum
-The greatly distended, smooth walled vagina gradually returns to its prepregnancy
size by 6-10 weeks after childbirth.
-The mucosa remains atrophic in lactating woman at least until menstruation
begins again.
-Thickening of vaginal mucosa occurs with the return of ovarian function.
Pelvic muscular support
The supporting structure of the uterus and vagina may be injured during childbirth.
the supportive tissues of the pelvic floor that are torn or stretched during childbirth
may require up to 6 months to regain tone
Women are encouraged to do kegel exercises after birth to strengthen perineal
muscles and promote healing.

Perineum
 Swelling completely gone within 1-2 weeks
 The muscle tone may or may not return to normal, depending on the extent of
injury.
Lochia
It is the uterine discharge that occurs after birth. Lochia is initially bright red
changing later to a pinkish red or reddish brown
-For the first 2 hours after birth the amount of lochia should be about that of a
heavy menstrual period, after that time the lochial flow should steadily decrease.
Lochia passes through 3 stages:-
1- lochia rubra:-it consists of blood, decidual and trophoplastic debris
It lasts 3-4 days after childbirth
.
2- lochia serosa:-it consists of old blood, serum, leukocytes, and tissue debris.
the flow becomes pink or brown.
It is expelled 3-10 days postpartum

3- lochia alba:-it consists of leukocytes, decidua, epithelial cells, mucus, and

bacteria. it is yellow to white in color.
Lochia alba may continue to drain for up to and beyond 6 weeks after
childbirth.
The amount of lochia is usually increases with ambulation, and
breastfeeding.
B) Endocrine system
Placental hormones
Expulsion of the placenta results in dramatic decreases of hormones produced by
placenta.
The placental enzyme insulinaze causes the diabetogenic effects of pregnancy to be
reversed, resulting in significantly lower blood sugar levels in the immediate
postpartum period
-1- Estrogen and progesterone levels decrease markedly after expulsion of the
placenta, reaching their lowest levels 1 week into the postpartum period.
- 2- Decreased estrogen level associated with; breast engorgement, and diuresis of
excess extracellular fluid that has accumulated during pregnancy .
Pituitary hormones and ovarian function:-
-Lactating and nonlactating women differ in the time of the first ovulation.
-The persistence of elevated serum prolactin levels in breast feeding women
appears to the responsible for suppressing ovulation
-In women who breast feed, prolactin levels remain elevated into the sixth week
after birth.
-Serum prolactin levels are influenced by the frequency of breastfeeding, the
duration of each feeding, and the degree to which supplementary feedings are used.
-Prolactin levels decline in nonlactating women, reaching the pre pregnant range
by third week
-About 70% of non lactating women resume menstruation by 3 months after birth.

C) Urinary system
The diminishing steroids levels after birth may explain the reduced renal function
that occurs during the puriperium.
Urine components
-BUN level increases during puerperium as autolysis of the involuting uterus
occurs. This breakdown of excess protein in the uterine muscle cells results in a
mild (+1)proteinurea for 1-2 days after childbirth Postpartal diuresis
-Within 12 hours of birth, women begin to lose the excess tissue fluid that has
accumulated during pregnancy.
-The fluid loss through increased urinary output accounts for weight loss of
approximately 2.25kg during the puerperium
Urethra and bladder
-If trauma to the urethra and bladder occur during the birth process, the bladder
wall becomes hyperemic and edematous, often with small areas of hemorrhage.
Birth-induced trauma increased bladder capacity and the effects of conduction
anesthesia combine to cause a decrease in the urge to void. In addition to pelvic
soreness from the forces of labor, vaginal laceration, or an episiotomy
which they reduce the voiding reflex. Decreased voiding, along with postpartal
diuresis may result in .
-Distended bladder pushes the uterus up and to the side and this prevents the uterus
from firmly contracting which may cause excessive bleeding.
-Bladder tone is usually restored 5-7days after childbirth .

D) Gastrointestinal system
Appetite
The mother is usually hungry shortly after giving birth.
Bowel evacuation
A spontaneous bowel evacuation may be delayed until 2-3 days after childbirth.
This can be explained by decreased muscle tone of the intestines during labor
and the immediate puerperium, prelabor diarrhea, lack of food, or dehydration

E) Cardiovascular function
Most dramatic changes occur in this system.
Cardiac output decreases rapidly and returns to normal by 2 to 3 weeks
postpartum.
Hematocrit increases and increased red blood cell (RBC) production stops.
Leukocytosis with increased white blood cells (WBCs) common during the first
postpartum week.
Blood volume
The blood volume which increase during pregnancy is eliminated within the first 2
weeks after birth, with return to nonpregnant values by 6 weeks postpartum.

E) Respiratory function
-Returns to normal by approximately 6 to 8 weeks postpartum.
-Basal metabolic rate increases for 7 to 14 days postpartum, secondary to mild
anemia, lactation, and psychological changes

F) Musculoskeletal function
-Generalized fatigue and weakness is common.
-Decreased abdominal tone is common.
-Diastasis recti heals and resolves by the 4th to 6th week postpartum.
-Until healing is complete, abdominal exercises are contraindicated

G) Neurological system
-Discomfort and fatigue are common.
-Afterpains and discomfort from the delivery, lacerations, Episiotomy, and muscle
aches are common.
-Frontal and bilateral headaches are common and are caused by fluid shifts in the
first week postpartum.
H) Integumentary system
- Chloasma of pregnancy usually disappears at the end of pregnancy.
- Hyperpigmentation of the areolae and linea nigra may not regress completely
after childbirth, and it may be permanent in some women.
- Stretch marks on breasts, abdomen, hips, and thighs may fade but usually do not
disappear
- Hair growth slows during postpartum period, and some women may actually
experience hair loss.

I) Immune system
Puerperal women are at special risk for wound infection and infections of uterus,
urinary tract, respiratory tract or breast.
Predisposing factors for infection:- diabetes, chronic respiratory problems, anemia,
malnutrition, substance abuse, etc. These factors alert the nurse in cases of
prolonged labour, difficult delivery, multiple pregnancy, hematoma or cesarean
delivery.
Puerperial sepsis is the most common post partum infection of the genital tract in
post partum period before 10th day post delivery.
An elevated temperature in the first 24 hours after delivery may be caused by
dehydration, fatigue, chilling and blood loss.
Low grade fever is related to engorgement of breast.

J) Vital Signs

Temperature:
 The temperature is slightly elevated: 0.5 degrees for the first 24 hours and up to
38 degrees is known. This rise in temperature is due to the absorption of waste
products of muscular contractions of labor.
Transient rise in temperature later on is due to:
• Milk engorgement (by the 4th day postpartum).
• Constipation.
• Nervous excitation.
• Infection.

The pulse:
 The pulse is full and slow (about 60-70 B/mm) and is known as physiological
bradycardia (for 24-48 hrs after labor). It is due to:
• The rest period after labor .
• The increase in the circulating blood volume on account of the elimination of the
placental pool.
• The pulse should remain below 100 B/mm if all is going well. A rapid pulse may
be brought on by pain, visitors, excitement, exhaustion, the nursing infant,
hemorrhage or infection.
Respiration:
 This is in the usual relation with pulse and temperature. Because of a reduction
in the size of the uterus and relaxation of the abdominal wall respiration is more
abdominal in character. Deviation from the normal may suggest pneumonia or
embolism.
Blood Pressure:
No change is counted, but if hypotension is present, postpartum hemorrhage
may be suspected. If hypertension is present (over 140/90 mm Hg) postpartum
toxemia may be suspected.
CONCLUSION:
Puerperium period is the most critical and yet the most neglected phase in the lives
of mothers and baby.
 psychological changes :-
Emotional changes in the mother during the postpartum period (restorative
process) as described by Reva Rubin pass through three phases. They
are: Taking-in phase.
Taking-hold phase.
 Letting-go phase.
Taking-Hold Phase (Taking Responsibility as a Mother):
 It starts the 3rd day postpartum. The emphasis is placed on the present. She
becomes impatient and is driven to organize herself and her life. This phase lasts
about 10 days.
Once the mother has taken control of her physical being and accepted her role as a
mother, she is able to extend her energies to her mate and other children.
Letting-go Phase: As her mothering functions become more established the
mother enters the letting-go phase. This generally occurs when the mother returns
home. In this phase there are two
separations that the mother must accomplish. One is to realize and accept physical
separation from the infant.
Bonding:
 also known as attachment: process by which parents form emotional
relationship with infant over time; influenced by many factors: family, stability of
home environment, nurturing she received as child. Certain characteristics
important: level of trust, level of self esteem, reactions to present pregnancy;
interest in child rearing.

Minor Discomforts during the Purperium

Urinary Retention Management of normal
Constipation puerperium :-
Engorged Breast
Immediately following delivery, the
Cracked Nipple patient should be closely observed.
Postpartum Blues (Depression) She may be given
a drink of her choice or something
to eat, if she is hungry.
`
Principles - 
- To give all out attention in to restore the health status of the mother.
- To prevent infection.
- To take care of the breasts, including promotion of lactation and nursing of the
child.
- To motivate the mother for contraception.

General management -

Rest and ambulance -

It is indeed difficult to categories an uniform period of rest. After a good resting
period, the patient becomes fresh and can breast feed the baby or moves out of bed
to go to the toilet. Early ambulation is encouraged.

Advantages of early ambulation are:

           - Provide a sense of well-being.
           - Bladder complications and constipation are reduced.
           - Facilitates uterine drainage.
           - Hastens involution of uterus.
           - Lessens puerperal venous thrombosis and embolism.

Hospital stay -
Early discharge from the hospital is an almost universal procedure. If adequate
supervision by trained health visitors is provided, there is no harm in early
discharge.

Diet -
The patient should be on normal diet of her choice. If the patient is lactating, high
calories, adequate protein, fat, plenty of fluids, minerals and vitamins are to be
given.

Care of the bladder -

The patient is encouraged to pass urine following delivery as soon as convenient. If
the patient fails to pass urine, catheterisation should be done. Catheterisation is
also indicated in case ofincomplete emptying of bladder.

Care of the bowel -

The problem of constipation is much less because of early ambulation and
liberalisation of the dietary intake. A diet containing sufficient roughage and fluids
is enough to move the bowel. If necessary, mild laxative such as Igol (isopgol
husk) two teaspoons may be given at bed time.

Sleep -
The patient is in need of rest, both physical and mental. So she should be protected
against worries and undue fatigue. Sleep is ensured providing adequate physical
and emotional support.

Care of the vulva and episiotomy -

Shortly after delivery, the vulva and buttocks are washed with soapwater down
over the anus and a sterile pad is applied. The patient should look after personal
cleanliness of the vulval region. The perineal wound should be dressed with spirit
and antiseptic power after each act micturition and defaecation or at least twice a
day.

Care of the breast -

The nipple should be washed with sterile water before each feeding. It should be
cleaned and kept dry after the feeding is over. Nipple soreness is avoided by
frequent short feeding rather than the prolonged feeding, keeping the nipple clean
and dry.

Maternal-infant bonding - 
It starts from first few moments after birth. This is manifested by fording, kissing,
cuddling and gazing at the infant. The baby should be kept in her bed or in a cot
besides her bed. This is not only establishes the mother-child relationship but the
mother is conversant with the art of baby care so that she can take full care of the
baby while at home.

Asepsis and antiseptic -

Asepsis must be maintained specially during the first week of puerperium. Liberal
use of local antiseptics, aseptic measures during perineal wound dressing, use of
clean bed linen and clothing are positive steps.

Immunization - 
Administration of anti-D-gamma globulin to unimmunized Rh-negative mother
bearing Rh-positive baby. The booster dose of tetanus toxoid should be given at
the time of discharge, if it is not given during pregnancy.
CONCLUSION:
Puerperium period is the most critical and yet the most neglected phase in the lives
of mothers and baby.