16-The Puerperium

THE PUERPERIUM
Puerperium
• The post partum period
• Anatomic, physiologic & biochemical changes
regress back to the non-pregnant state & certain
essential postnatal processes are initiated
• Also a period of considerable maternal morbidity
& mortality due to immediate & late puerperal
complications
• Essential health education & care should be
provided to the postnatal mother & her neonate
Physiology
• The major physiology of the puerperium is involution
of the genital tract as well as regression of the
anatomic, physiologic and biochemical changes of
pregnancy to their non-pregnant state
• The puerperal physiological changes proceed over the
six weeks following delivery and the six weeks interval
is taken as the end of the puerperal period
• Most puerperal changes in fact occur in the first two or
three weeks at most
• The breast is the only organ that shows an increase in
size and initiate milk production during the
puerperium unlike involutionary changes in other
organ systems
Physiology…
Organ Puerperal changes
system
Genital Uterine involution – immediately at delivery- 20 weeks size; 7th day –
tract at symphysis pubis; 10th day – not palpable per abdomen. Main
reason for uterine involution is enzymatic autolysis of proteins and
involution and obliteration of blood vessels also occurs. In addition,
placental site is invaded by white blood cells and begins the process
of re-epithelization within 48 hours.
Cervix admits two fingers (three cms) immediately after delivery. By
the seventh day admits tip of finger only and is completely closed by
14 days. Pin pointed os of the nulliparous cervix changes to the slit
like appearance of the multiparous cervix.
Vaginal wall also undergoes involution to its non pregnant state,
gradually regaining its pre pregnant tone.
4
Physiology…
Organ system Puerperal changes
Breast Increase in the size of the breast due to further proliferation of
glandular tissue. Initiation of milk production due to the relief of
the inhibition on prolactin production due to the high estrogen
and progesterone levels of pregnancy. Milk production achieves
rates of 800 ml per day within a week of the suckling reflex is
maintained.
Cardiovascular Reduction of plasma and blood volume to non-pregnant levels.
system Heart rate and blood pressure changes of pregnancy also return
to their non-pregnant state.
Urinary tract Post partum diuresis within the first 48 hours to gradually lose
the total water gain of pregnancy. Hydronephrosis and
hydroureters of mild degree induced by pregnancy are also
relieved following delivery. Post partum urinary retention may
occur due to trauma and pressure on the base of the bladder by
the fetal presenting part. Will usually resolve by itself in a few
hours to days.
5
Physiology…
Vaginal discharge First three to four days – lochia rubra( red colored whitish
( Lochia) discharge); followed by lochia alba- yellowish scanty vaginal
discharge and finally lochia serosa- scanty watery vaginal
discharge. Lochia is normally not malodorous. Lochia should
never be pure blood or have an increase in its blood content.
Ovulation and Resumption of ovulation and menstruation depends primarily on

menstruation whether the mother is lactating or not. In lactating mothers, it
also depends on the frequency and duration of lactation. In
mothers exclusively breastfeeding, menstruation may be delayed
from six months until two years or longer after delivery
( lactational amenorrhea). The earliest documented time of
ovulation following term delivery is 23 days. This implies that
family planning provision should be conducted at the time of
discharge of the mother from the delivery suite.
Temperature First 24 hours temperature upto 38 degrees is possible due to
the trauma of labor.
6
Physiology…
Hematologic system No significant change in Hgb unless there was a post
partum hemmorhage. Leucocytosis of labor may persist
into the puerperium ( <16,000/ml). The most important
hematologic change of the puerperium is the rapid
increase in platelet count in the first ten days increasing
the hypercoagulability of blood significantly. This is the
predominant reason that deep vein thrombosis is highest
during the puerperium.
Blood glucose Upon placental delivery, the serum progesterone and

control estrogen levels fall dramatically within 12 hours. The
diabetogenic effect of pregnancy regresses rapidly within
the first 8-12 hours. Diagnosis of gestational diabetes is not
possible following 12 hours after delivery due to this fact.
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Mgt of the Puerperium
• Immediate puerperium
first hr after delivery – observe for vaginal
bleeding and uterine contractions every 15
minutes for the first two hours
 can be discharged after six hours if no bleeding;
vital signs are stable; uterus is well contracted
• Discharge instructions
breast cleanliness and feeding – exclusive breast
feeding up to 6months
 FP methods and where to receive them
 immunization schedule for the child
 danger signs and reporting- fever, heavy
bleeding, headache, visual disturbance, epigastric
pain, failure to suck ( neonate), malodorous
lochia, breast pain, engorgement
• Appointment – individualized
Depends on whether there are complications that
need follow up ( PE, operative delivery … etc)
If normal delivery can be appointed at 45th day
with instructions on discharge to report danger
signs at any time
Some also recommend a visit on the 7th day to
document that the process of uterine involution
and other puerperal changes are normal and for
family planning advise

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THE PUERPERIUM

Ovulation and Resumption of ovulation and menstruation depends primarily on

Blood glucose Upon placental delivery, the serum progesterone and

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