NORMAL PUERPERIUM

Presented By:-
Ms.Dharati Prajapati
Definition:-
 Puerperium is the period following child birth during
which the body tissues, especially the pelvic organs
revert back approximately to the pre-pregnant state
both anatomically & physiologically.
 INVOLUTION:-
It is the process whereby the genital organs revert
back approximately to the state as they were before
pregnancy.
 The women is termed as a puerpera.
DURATION:-

 It begin soon after the expulsion of the

placenta & normaly lasts for around 6
weeks. Generally devide thise period
into...
a) Immediate - within 24 hours
b) Early- upto 7 days
c) Remote - upto 6 weeks
Features of Normal Puerperium :-
 Anatomically & physiologically, the generative organs
come back to their pregravid state.
 Rccuperation from physical, hormonal & emotional
experience of paturition.
 Lactation is started during puerperium.

 PHYSIOLOGICAL CHANGES:-
Involution of the uterus -
 There is alternate harding and softning of the uterus
after the delivery.
 Involution is the process by which the reproductive
organs especilly bulky uterus following the delivery
progrssively returns to normal pregravid state.
 Cont....
 Rate of involution of uterus is assessed by
taking fundal height in relation to symphysis
pubis with measuring tap.
 It should be measured at fixed time everday
Before measuring fundal height, ask the
woman to empty bowel & bladder, as this can
give rise to raised level of fundal height.
 Postnatal period starts after the delivery of the
placenta.
 It is very crucial period for the mother as well
as the baby.
 Weight of the uterus after delivery is reduced
from 900 gm to 60 gm.
Rate of Involution :-
 First 24 hours-no changes; from 2 nd to 11th
day-fundus at the rate of 1.25 cm per 24 hours.
 By 11th dayuterus sinks behind symphysis &
becomes pelvic organ.
 By 2 weeks, uterus can not be palpated by
abdominal examination.
 Character Changes

Length From 20 cm to 7.5 cm

Breadth From 12 cm to 5 cm

Thickness From 7.5 cm to 2.5 cm

Weight
Placement of uterus after delivery
Placement of uterus after 24 hour
After one week placenta of uterus
After 12 days
Placental site end of 6 weeks
Position of uterus
Consistency of the uterus
from 1000 gm to 60 gm
Fundus of uterus 5 cm below the
umblicus or 12 cm above symphysis pibis
At level of umblicus
7.5 cm above symphysis pubis
Fundus is not palpable
1.5 cm
Uterus after 24 hour of deliviry reduces at
rate of 1.25 cm until 11t day
Firm,Round,hard after delivery
Blood Vessels :-
 Myometrial contraction and retraction compress the
blood vessels of the uterus and so control the bleeding
until the vessels are thrombosed. Within them new
blood vessels grow. Fibroelastic tissue of old blood
vessels degenerate and is removed by phagocytes.

Placental Site :-
 Involution of placental site takes upto 6 weeks.
Placental site gets elevated immediately after delivery.
It gets irrigular,friable and is composed of thrombosed
vascular sinusoid. These undergo hyalinization. Most
of deciduas basalis is shed over a period of weeks
and is replaced by regenerating endometrium.
 LOCHIA
 Definition:- It is the vaginal discharge for the
first fortnight during puerperium. This discharge
originates from the uterine body, cervix &
vagina.
 Odour & Reaction:- It has got a peculiar
offencine fishy smell. It's rection is alkaline
tending to become acid towards the end
 Colour:- Depending upon the varition of the
colour of the discharge, it's named as
1.Lochia Rubra (Red) - 1 to 4 days
2.Lochia Serosa (Yellowish,pink,pale brownish) -
5 to 9 days.
3.Lochia Alba (pale white) - 10 to 15 days
Composition
1. Lochia Rubra:- Consists of blood,shreds of
fetal membranes & decidua, vernix caseosa,
lanugo & meconium.
2. Lochia Serosa:- Consists of less RBC but
more leucocytes, wound exudate, mucus from
the cervix & microorganisms. The presence of
bacteria it not pathoenic unless associated with
clinical sign of sepsis.
3. Lochia Alba:- Contains plenty of decidual cell,
leucocytes,mucus,cholestrin crystals, fatty &
gramular epithelial cells & micro organisms
Amount:-
The average amount of discharge for the first
5-6 days, is estimated to be 250 ml.
 Normal duration:-
Normal duration may extend upto 3 weeks.
the red lochia may persist for longer duration
specially following premature labour or may be
excessive in twin delivery or hydramnios.
 Clinical Importance:-
The character of the lochial discharge gives
useful information about the abnormal
puerperal state
The vulval pads are to be inspected daily to
get information.
I. Odour:- It malodorous indicates infection
retained plug or cotton piece inside the vagina
should be kept in mind
II. Amount:- Scanty or absent signifies infection
or lochiometra .If rxcessive indecates infection
III. Duration:- Duration of the lochia alba beyond
3 weeks suggest local genital lesion.
 LACTATION
 Lactation is inflenced by sucking of baby & also on maternal emotions
lactation establishment and maintance depend on three factors as
discussed below
Lactation
(Establishment & maintenance)

Anatomical Lactogenesis Sucking of

structur of baby

Mammary Development Ducts Nipples

Glands of alveoli
 LACTOGENESIS
Lactogenesis means milk initation which
occur during later weeks of pregnancy as
discussed below.
Placental lactogen (A prolactin like substance)

Mammary alveolar

Secretion of colostrum
 Cont....
 Lactogenesis depend on sufficient production of
prolactin (from pituitary gland) & nutrition of mother.
 When a baby sucks at the breast, milk moved from
alveoli to mouth of infant, which is known as 'let down
reflex' It is also known as milk ejection reflex. This is
an active process.
 True milk production occur in between 3rd & 5th post
partum day.
 Before true milk colostrum is released.
 Milk which is coming out at beginning of feeding is
known as fore milk.
 Lactation depend on the sucking of baby. Newborn
baby possess reflexes to suck at breast. These
reflexes are rooting,sucking & swallowing reflex.
Characteristics of COLOSTRUM :-

 Yellow in colour &

pre-milk substance
 High in protein
 Contain antibodies
Fore milk Hind milk

Milk coming at beginning of feeding Milk at end of feeding

It has less fat Contain more fat

Flows at faster rate Flows at slower rate

Less calories More calories

POSTNATAL ASSESSMENT AND MANAGEMENT
 Assessment during postnatal period is very
important. Head to toe assessment is
performed. It one of the most neglected in India.
The postnatal checkups should be performed,
first after the discharge of the delivered woman
and second at 6 weeks after the delivery.
 During the inital check up, general health of the
mother including vital sign and breast are
checked.
 Involution of the uterus is assessed.
 perineum is incepted & special attention is
given to the lochia
 Bladder & bowel function are enquired
 Infant is also assessed from head to toe
 Cont...
 During 2nd postnatal checkup mother is assessed for
duration of lochia,onset of first
menses,sleep,bladder,bowel,perineal,wound,breast
feeding etc...
 Weight,pulse,blood pressure is checked
 Pelvic organ are assessed for involution
 Breast are examined & presence of anaemia is
checked
 Advantages of postnatal care:-
 Hypertension and medical disease are treated.
Anaemia is prevented
 Progress of the baby can be checked and effective
therapy can be given for ailments, if detected.
 Positive health during postnatal period is maintained.
 Cont...
 Breast feeding practices & other related advice
can be given
 Motivation & acceptance of family planning
methods can be best imparted during the
period
 Maternal morbidity is minimized
 Growth of the baby can be monitored and
infant morbidity and mortality is minimized.
Management of the discomforts of the
puerperium :-
 After-Pains :- This pain is felt for 2-4 days after
the delivery due to continuning sequential
contraction and relaxation of the uterus
occuring because of certain reasons such as,
presence of blood clots, increased parity or the
woman who is breast feeding.
 An empty bladder can give relief from the pain