 Itis 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.
 Itis the process whereby the reproductive
organs return to their non-pregnant state.
Duration:

Puerperium begins as soon as the placenta is

expelled and lasts for approximately 6 weeks
when the uterus becomes regressed almost
to the non-pregnant state.

 The period is arbitrarily divided into –

 Immediate – within 24 hours
 Early – up to 7 days
 Remote – up to 6 weeks
 Anatomical Consideration

 Immediatelyfollowing 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 grams

 Atthe end of the first week, it weighs 500
grams.

 By6 weeks, it weighs approximately 50

grams.

 Theplacental 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.
 Lower Uterine Segment

 Immediatelyfollowing delivery, the lower

segment becomes a thin, flabby, collapsed
structure.

 Ittakes a few weeks to revert back to the

normal shape and size of the isthmus.
 The cervix contracts slowly.

Appearance of the cervical os

A. Before the first pregnancy
B. After pregnancy
 The physiological process of involution is
most marked in the body of the uterus.
Changes occur in the following components:

1. Muscles
2. Blood Vessels
3. Endometrium
 During puerperium, the number of muscles
fibers is not decreased but there is
substantial reduction of the myometrial cell
size.

 Withdrawal of the steroid hormones,

estrogen and progesterone may lead to
increase in the activity of the uterine
collagenase and the release of the
proteolytic enzyme.
 The arteries are constricted by contraction
of its wall and thickening of the intima
followed by thrombosis.

 New blood vessels grow inside thrombi.

 Fibrous
tissue on the wall undergoes hyaline
degeneration and the products are removed
by macrophages.

 There is also degeneration of the elastic

tissues.
 Thesuperficial layer becomes necrotic and is
sloughed in the lochia.

 Thebasal layer adjacent to the myometrium

remains intact and is the source of new
endometrium.

 The endometrium arises from proliferation of

the endometrial glandular remnants and the
stroma of the inter glandular connective
tissue.
 Bythe 10th day: Regeneration of the
epithelium is completed.

 By the day 16: the endometrium is restored.

 Atabout 6 weeks: the endometrium of

placental site is restored.
 Complete extrusion of the placental site
takes up to 6 weeks.

 Whenthis process is defective, late-onset

puerperal hemorrhage may ensue.

 Size of placental site:

 Immediately after delivery: approximately
the size of the palm, but it rapidly decreases
thereafter.
 Within
hours of delivery: normally consists of
many thrombosed vessels.

 Bythe end of the 2nd week: 3 to 4 cm in

diameter

 J.Whitridge Willimans (1903) described

placental site involution as a process of
exfoliation, which is in great part brought by
the undermining of the implantation site by
growth of endometrial tissue.
 Takes a long time (4-8 weeks) to involute.

 Itregains its tone but never to the virginal

state.

 The mucosa remains delicate for the first

few weeks and submucous venous congestion
persists even longer.

 Rugae patially reapppear at third week.

 The introitus remains permanently larger

than the virginal state.
 Asa result of ruptured elastic fibers in the
skin and prolonged distension caused by the
pregnant uterus, the abdominal wall remains
soft and flaccid.

 Severalweeks are required for these

structures to return to normal.
 Itis the vaginal discharge for the first
fortnight during puerperium.

 The discharge originates from the uterine

body, cervix and vagina.

 Odour and reaction: it has got a peculiar

offensive fishy smell.

 Itsreaction is alkaline tending to become

acid towards the end.
 Colour: depending upon the colour
 Lochia Rubra (red): 1-4 days
 Lochia Serosa (yellowish or pink or pale
brownish) : 5-9 days
 Lochia Alba (pale white): 10-15 days

 Composition

 Amount: for the first 5-6 days, is estimated

to be 250 ml.
 Normal Duration: may extent up to 3 weeks.

 Clinical Aspects:
1. Persistence of red lochia means
subinvolution
2. Offensive lochia means infection
3. In severe infection with septicemia, lochia
is scanty and not offensive
4. The period of time the lochia can last
varies, although it averages approximately
5 weeks
 Placental Hormones

 Insulinaze causes the diabetogenic effects of

pregnancy to be reversed.

 Estrogen and Progesterone levels decrease

markedly after expulsion of the placenta,
reaching their lowest levels 1 week into the
postpartum period.

 The estrogen levels in nonlactating women begin

to increase by 2 weeks after birth, and higher by
postpartum day 17.
 Lactating and non-lactating women differ in
the time of the first ovulation.

 In women who breast feed, prolactin levels

remains elevated into the sixth week after
birth.

 Prolactinlevels decline in nonlactating

women, reaching the prepregnant range by
third week.
 If the woman does not breast fed her baby, the
menstruation returns by 6th week following
delivery in about 40% and by 12th week in 80% of
cases.

 In non-lactating mothers, ovulation may occur as

early as 4 weeks and in lactating mothers about
10 weeks after delivery.

 A women who is exclusively breastfeeding, the

contraceptive protection is about 98% up to 6
months postpartum. Thus, lactation provides a
natural method of contraception.
 However ovulation may precede the first
menstrual period in about one-third and it is
possible for the patient to become pregnant
before she menstruates following her
confinement.

 Non-lactatingmother should use

contraceptive measures after 3 weeks and
the lactating mothers after 3 months of
delivery.
 Thebladder wall becomes oedematous and
hyperaemic and often shows evidences of
submucous extravasation of blood.

 Because of relative insensitively to the raised

intravesical pressure due to trauma sustained
to the nerve plexus during delivery, the
bladder may be overdistended without any
desire to pass urine.

 Dilated
ureters and renal pelvis return to
normal size within 8 weeks.
 Diuresisevident between second and fifth
day after birth, as well as blood loss at birth,
acts to reduce the added volume
accumulated during pregnancy.

 Rapid reduction occurs, so that blood volume

returns to its normal prepregnancy level by
first or second week after birth.

 Thewhite blood cell count sometimes

reaches 30,000 L, with the increase
predominantly due to granulocytes.
 Thereis a relative lymphopenia and an
absolute eosinopenia.

 Normally,
during the first few postpartum
days, hemoglobin concentration and
hematocrit fluctuate moderately.

 Blood
volume: Returned to normal level by 1
week after delivery
 Cardiac Output: Remains elevated for 24 to
48 hrs. Postpartum and declines to non-
pregnant values by 10 days.

 Heart rate changes follow this pattern.

 SVR(Sytemic Vascular Resistance): Follows

inversely
 Digestion
and absorption begin to be active
again soon after birth.

 Bowel sounds are active, but passage of stool

through the bowel may be slow because of
the still present effect of relaxin on the
bowel.

 Bowelevacuation may be difficult because of

the pain of episiotomy sutures or
hemorrhoids.
 Rapid diuresis and diaphoresis during 2nd to
5th days after birth result in weight loss of
5lb (2 to 4kg), in addition to approximately
12 lb ( 5.8 kg) at birth.

 Lochia flow – 2 to 3 lbs (1kg) loss

 Total weight loss – 19 lb

 Additional
weight loss depend on amount of
weight gain in pregnancy and active
measures to reduce weight.
 Stretch marks in women’s abdomen still
appear reddened and may be even more
prominent than pregnancy.
 Excessive pigment on face and neck
(Chloasma) and on abdomen (Linea nigra)
barely detectable in 6 weeks time.
 Diastasis recti (Overstretching and seperation
of the abdominal musculature) if present,
the area will be slightly intended.
 Abdominal wall and ligaments reqire 6 weeks
time to return to their former state.
 Sincemidway through pregnancy, she has
been secreting colostrum, a thin, watery,
prelactation secretion.

 Shecontinues to excrete this fluid the first 2

postpartum days.

 Onthe third day, her breasts become full and

feel tense or tender as milk forms within
breast ducts.
 When breast milk first begins to form, the
milk ducts become distended. The nipple
secretion changes from the clear colostrum
to bluish white, the typical color of breast
milk.

 Thisfeeling of tension in the breasts on the

third or fourth day after birth is termed
primary engorgement.
 A woman may show a slight increase in
temperature during the first 24 hours after
birth.

 Occasionally, when a woman’s breasts fill

with milk on the third or fourth postpartum
day, her temperature rises for a period of
hours because of the increased vascular
activity involved.
 After
the initial tachycardia associated with
labour and delivery, a bradycardia often
develops in the early puerperium.

A woman’s pulse rate during the postpartal

period is usually slightly slower than normal.

 Thisincreased stroke volume reduces the

pulse rate to between 60 to 70 beats per
minute.
 Asdiuresis diminishes the blood volume and
causes blood pressure to fall, the pulse rate
increases accordingly.

 Bythe end of the first week, the pulse rate

will have returned to normal.
 Systolic
and Diastolic blood pressures
remains unchanged from late pregnancy
values until about 12 weeks post partum,
after which they increase.

 Within2 weeks post partum, system vascular

resistance increased by 30%.
 Narcissistic response is an early reaction.

 Extroversion, glowing behavior is common.

 Difficulty staying focused

 Emotional mood swings

 Husbands need to be forewarned about these

changes to expect in wife.
 Multiple Births

 Children born within 10-12 months apart

 Moving

 Loss of security (job/illness of self or family)

 Loss of husband / or infant’s father

 Previous loss of a child

 Acceptance is also his major developmental
task to be achieved

 Need preparation for the changes that will

take place for his wife

 Narcissistic
or self-centered response of
mother may be misunderstood

 May have feelings of jelousy

 Hischildhood background will also influence
his preparation

 Needsto also identify a role-model or

parenting style he wants to mimic

 Preparation also includes fantasy and grief

work
 Episiotomy – a surgically planned incision on
the perineum and the posterior vaginal wall
during the second stage of labour.

Purpose:
 To enlarge the vaginal introitus
 To facilitate easy and safe delivery
 To minimize rupture of the perineal muscles
and fascia
 To reduce stress on fetal head
 In rigid perineum

 Anticipating perineal tear

 Big baby

 Face to pubis delivery

 Breech Delivery

 Shoulder Dystocia
 Threatened perineal injury

 Rigid perineum

 Forceps delivery
 Maternal Fetal

•Easy to repair •Minimizes intracranial injuries

especially in premature babies

•Reduction in duration of labour

•Reduction of trauma
 Bulging thinned perineum during contraction
just prior to crowning.
1. Medio lateral
2. Median
3. Lateral
4. J shaped
 Begins at the midpoint of the fourchette
 Directed at a 45 degree angle to the midline
 Towards a point midway between the ischial
tuberosity and the anus.

Merits Demerits
•Safety from rectal •Apposition of tissue not so
involvement good
•Incision can be extend. •Discomforts is more
•Wound disruption is more
 Midlineincision that follows the natural line
of insertion of the perineal muscles.

Merits Demerits
•Reduced blood loss •Extension may involve the
•Easy to repair rectum
•Lesser pain •Damage to anal spinchter
 Step 1: Preliminaries

 Step 2: Incision

 Step 3: Repair
 Sterile Drape
 Sterile Gown and gloves
 Gauze swabs and tampon
 Needle Holder
 Sponge Holder
 Scissors, 10 ml syringe
 Toothed forceps
 Suture material
 1% lignocaine
 The perineum is thoroughly swabbed with
antiseptic lotion.

 Draped properly

 Incision
line-infiltrated with 10ml of 1%
lignocaine solution.
 Twofingers are placed in the vagina between
the presenting part and posterior vaginal
wall.

 Theincision is made by straight or curved

blunt pointed sharp scissors.

 The open blades are positioned.

 Incision
should be made at the height of a
contraction
 Cut should be made starting from the center of
the forchette extending laterally either to the
left or right.

 It is directed diagonally in a straight line which

runs about 2.5 cm away from the anus.

 If delivery of the head does not follow

immediately, apply pressure to the episiotomy
site.

 Control delivery of the head to avoid extension

of the episiotomy.
 Structures involved:

 Posterior vaginal wall

 Superficial and deep transverse perineal muscles

 Fascia covering the muscles

 Transverse perineal branches of pudendal vessels

and nerves

 Subcutaneous tissue and skin

 Repair
is done soon after the expulsion of the
placenta.

Purpose of Repair
 To control bleeding
 To prevent infection
 To assist wound healing
 The patient is placed in lithotomy position.

A good light source from behind is needed to

find the apex first.

 Theperineum and the wound area is cleaned

with antiseptics.

 Blood
clots are removed from the vagina and
wound area.
 Thepatient is drapped properly and repair
should be done under strict precaution.

A vaginal pack is inserted and is placed high

up.
 Vaginal mucosa and submucosal tissue

 Perineal muscle

 Skin and subcutaneous tissue

 Inspect the repair to check that haemostasis has
been achieved.

 Remove the vaginal tampon, if used

 Account for all instruments, swabs and needles

 Discards sharps safely

 Apply sterile pad following thorough perineal

wash
 Apply sterile pad following thorough perineal
wash

 Waitfor minimum one hour to shift the

patient to ward

 Check for bleeding and urine output

 Immediate Remote
•Vulval hematoma •Dyspareunia
•Infection •Scar Endometriosis
•Recto Vaginal fistula
•Wound dehiscence
 Eat
a diet high in fiber and fluids to prevent
constipation

 Ask the women to walk with thighs apposed

 Not to use squatting position since the wound

is healing
 Change sanitary pads at least every 4 hours to
help prevent infection.

 Squirt warm tap water over the perineum,

beginning at the front and moving toward the
back.

 Sit in a tub of warm water

 Always wash hands thoroughly before and after

going to the bathroom

 Always keep the wound clean and dry after each

urination and defecation
 Squeeze the perineal muscles as if you were
trying to stop the flow of urine.

 Hold for 5 to 10 seconds and then relax. Do

this exercise 10 times a day to regain muscle
strength.