Physiology of puerperium

1. PHYSIOLOGY AND
MANAGEMENT OF
NORMAL PUERPERIUM
MRS.JAGADEESWARI.J
M.SC NURSING

2. INTRODUCTION
The puerperium is a period of
approximately 6 weeks which commences
following completion of third stage of labour.
During this time the women recovers from
stresses of pregnancy & delivery & the
physiological adaptations which occur during
pregnancy subside, facilitating the restoration
of the non pregnant state.

3. DEFINITION
•The puerperium is defined as the period
following childbirth during which the
body tissue, specially the pelvic organs
revert back approximately to the pre-
pregnant state both anatomically and
physiologically
• -----DC DUTTA

4. DURATION
Puerperium begins as soon as the
placenta id expelled and last for
approximately 6 weeks when uterus
becomes regressed almost to non-
pregnant size.

5. STAGES OF PUERPERIUM
The post partum period has been divided into:
The immediate puerperium, the first 24 hours after
parturition; 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.

6. REPRODUCTIVE SYSTEM
Uterus
Involution:-is the return of the uterus to a non-pregnant
state after childbirth
Involution process begins immediately after expulsion
of the placenta with contraction of uterine smooth
muscles
At the end of third stage of labor, the uterus is in the
midline, about 2cm below the level of the umbilicus
and weighs 1000g and measures about
20*12*7.5(length , breadth and thickness)

7. CONT…
By 24 hours postpartum the uterus is about the
same size it was at 20 gestational weeks
The fundus descends about 1 to 2cm every 24
hours, and by the sixth postpartum day it is
located halfway between the symphysis pubis and
the umbilicus.
-The uterus lies in the true pelvis within 2 weeks
after childbirth.

8. INVOLUTION OF THE UTERUS
 RETURN TO THE PELVIS BY ABOUT 2 WEEKS
 BE AT NORMAL SIZE BY 6 WEEKS
 THE WEIGHT CHANGES OF UTERUS
 1000G IMMEDIATELY AFTER BIRTH (EXCLUDING THE
FETUS,
PLACENTA, MEMBRANE AND AMNIOTIC FLUID.
 500G 1 WEEKS AFTER BIRTH
 300G 2 WEEKS AFTER BIRTH
 50G 6 WEEKS AFTER BIRTH
THE ENDOMETRIAL LINING RAPIDLY REGENERATES (16
DAYS)
THE PLACENTAL SITE UNDERGOES A SERIES OF
CHANGES IN THE POSTPARTUM PERIOD

10. -Subinvolution:-is the failure of the uterus to
return to a nonpregnant state.
-The most common causes of sub involution are
retained placenta fragments and infection

11. LOWER UTERINE
SEGMENT
• Immediately following delivery the lower
segment becomes thin flabby ,collapsed
structure
• It takes a few weeks to revert back to normal
shape and size of the isthmus

12. 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 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

13. PHYSIOLOGICAL
CONSIDERATION
The physiological process of involution is most
marked in the body of the uterus changes occur in
the following components
A. Muscles
B. Blood vessels
C. Endometrium

14. MUSCLES
• There is marked hypertrophy and hyperplasia of muscle
fibers during pregnancy and the individual muscle fiber
enlarges to the extent of 10times and 5 times of breadth
• During puerperium the number of muscle fibers is not
decreased but this 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 collganese and release of proteolytic enzyme

15. BLOOD VESSELS
• The arteries are constricted by contraction of its wall
and thickening of the intima followed by thrombosis
• During the first week the arteries undergo thrombosis
hyalinsation and fibrinsed end arteries
• The veins are obliterated by thrombosis hyalinsation
and endophelebitis
• New blood vessels grow inside the thrombi.

16. ENDOMETRIUM
Following delivery the major part of the decidua is cast off with
expulsion of the placenta and the membranes more at the placenta
site
The endometrium left behind varies in thickness from 2-5mm
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 completed by 10th day and restored by
16th day except placental site it takes 6weeks
It occur from the epithelium of the uterine gland mouths and
interglandular stromal cells

17. INVOLUTION OF OTHER PELVIC
STRUCTURES
VAGINA
• The distensible vagina notices soon after birth takes a long time-4-
8weeks
• It regains its tone but never to the virginal state
• The mucosa remains delicate for the first few weeks and sub-
mucous venous congestion persist even longer, it is the reason to
withhold surgery on puerperal vagina
• Rugae partially reappear at 3rd week but nerve to the same degree
as in pre-pregnant state
• The introits remains permanently larger than the virginal state
• The hymen is lacerated and represented by nodular tags the
carunculae myritiformes

18. BROAD LIGAMENT AND ROUND
LIGAMENT
•Requires considerable time to recover
from the stretching and laxation
PELVIC FLOOR AND PELVIC
FASCIA
Takes a long time to involute from the
stretching effect during parturition.

19. LOCHIA
It is the vaginal discharge that occurs
after birth.
Lochia is discharge originates from the
uterine body, cervix and vagina
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.

20. LOCHIA-ODOUR AND
REACTIONS
It has got a peculiar small
It reactions is alkaline leading
to become acid towards the end

21. COLOR
1-lochia rubra-red color (1-4days)
It consists of blood, shreds of fetal membranes and decidual
,vernix caseosa,lanugo and meconium.
2-lochia serosa-yellowish or pink or pale brownish colour(5-9
days)
It consists of old blood, less of rbc, but more of leukocytes, and
wound exudates mucus from cervix and micro organism
(anaerobic streptococci and staphylococci
3-lochia serosa-pale white(10-15days)
Contains plenty of decidual cells,leucocytes,mucus,cholestrin
crystals,fatty and granular epithelial cells and micro organism.

22. AMOUNT
The average amount of
discharge for the first 5-6 days
is estimated to be 250ml

23. NORMAL DURATION
• The normal duration may extend upto 3 weeks
• The lochia rubra may persist for longer
specially in woman with twins and scanty in
premature labour
• Can be more when women get up from bed in
the later period

24. CLINICAL
IMPORTANCE OF
LOCHIA
•Odor:
If offensive indicates retained
plus or cotton pieces inside the
vagina should be kept in mind

25. CONT..
•Amount:
Scanty or absent signifies
infection or lochiametra
If excessive also indicates
infection

26. CONT..
•Color:
Persistence of lochia rubra
beyond normal limit signifies
Subinvolution or retained bits of
conceptus

27. CONT..
•Duration:
Duration of the lochia
alba beyond 3 weeks suggest local
genital lesions

28. GENERAL PHYSIOLOGICAL
CHANGES
PULSE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.
This increased stroke volume reduces the pulse rate to between 60
and 70 beats per minute.
 As diuresis diminishes the blood volume and causes blood
pressure to fall, the pulse rate increases accordingly.
By the end of the first week, the pulse rate will have returned to
normal.

29. TEMPERATURE
 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 3rd or 4th postpartum day, her temperature rises for a
period of hours because of the increased vascular activity
involved.
Genito-urinary tract infection should be excluded if
there is rise of temperature

30. URINARY TRACT
The bladder wall becomes oedematous and hyperaemic
and often shows evidences of sub mucous extravasations
of blood.
 Because of relative insensitivity to the raised
intravesical pressure due to trauma sustained to the
nerve plexus during delivery, the bladder may be over
distended without any desire to pass urine.
Dilated ureters and renal pelvis return to normal size
within 8 weeks

31. GASTROINTESTINAL
SYSTEM
 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.
 Bowel evacuation may be difficult because of the pain
of episiotomy sutures or haemorrhoids.
Increased thirst in early puerperium
Slight intestinal paresis leads to constipation

32. WEIGHT
oRapid diuresis and diaphoresis during 2nd to
5th days after birth result in weight loss of 5 lb
(2 to 4kg), in addition to approx. 12 lb (5.8 kg)
lost at birth.
o Lochia flow- 2-3 lb(1kg) loss
oTotal weight loss- 19 lb
oAdditional weight loss depend on amount of
weight gain in pregnancy and active measures to
reduce weight.

33. FLUID LOSS
• Net fluid loss of at least 2 liters during 1st
week
• Additional 1.5 liters during the next 5th
weeks
• The amount depends on amount retained
during pregnancy ,dehydration during
labour and blood loss during delivery.

34. BLOOD VALUES
• Diuresis evident between 2nd to 5th 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 2nd week
after birth.
• Cardiac output rises soon after delivery to about
60% above the pre labour value but gradually
returns to normal within one week.

35. RBC VOLUME AND
HEMATOCRIT• It returns to normal by the end of 1st week after the hydaemia
disappears
• Leukocytosis to the extent of 30000 per cu mm occurs following
delivery probably in response to stress of labour
• Platelet count decreases soon after the separation of the placenta
but secondary elevation occurs with increase in platelet
adhesiveness between 4-10dyas
• Fibrinogen level remains high upto the 2nd week of puerperium
resulting in persistent high level of esr in puerperium as during
pregnancy
• A hypercoagulable state persist for 48hrs postpartum and
fibrolytic activity is enhanced in first 4 days.

36. MENSTRUATION AND
OVULATION• 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% upto 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-lactating mother should use contraceptive measures after 3
weeks and the lactating mothers after 3 months of delivery.

37. LACTATION
• 1st two days following delivery no further
anatomical changes in the breast occur
• The secretion from the breast called
colostrum which starts during pregnancy
becomes more abundant during this period

38. COMPOSITION OF THE
COLOSTRUM
• It is deep yellow serous fluid alkaline in
reaction
• It has got a higher specific gravity ,high
protein, vitamin A, sodium and chloride
content but has got lower carbohydrate ,fat
and potassium than the breast milk
• It contains antibody (IgA)

39. COMPOSITION OF
COLOSTRUM AND BREAST
MILK
MILK PROTEIN FAT
CARBOHYDRA
TE
WATER
COLOSTRUM 8.6 2.3 3.2 86
BREAST MILK 1.2 3.2 7.5 87

40. ADVANTAGES
• The antibodies (IgA,IgG,IgM) and
hormonal factor (lactoferrin)provides
immunological defense to the newborn
• It has laxative action on the because of
large fat globules

41. PHYSIOLOGY OF
LACTATIONThe physiological basis of
lactation is divided into four phases
1. Preparation of breast (mammogenesis)
2. Synthesis and secretion from the breast
alveoli (lactogenesis)
3. Ejection of milk (galactokinesis)
4. Maintenance of lactation (galactopoiesis)

42. MAMMOGENESIS
• Pregnancy is associated with a
remarkable growth of both the ductal and
lobuloalveolar systems.
• An intact nerve supply is not essential for
growth of the mammary glands during
pregnancy.

43. LACTOGENESIS
• Milk secretion actually starts on 3rd or 4th
postpartum day.
• Around this time, the breasts become engorged,
tense, tender and feel warmth.
• When the progesterone and oestrogen are
withdrawn following delivery, prolactin begins
its milk secretary activity in previously fully
developed mammary gland.

44. GALACTOKINESIS
• Discharge of milk from the mammary
glands depends not only on the suction
exerted by the baby during suckling but
also on the contractile mechanism which
expresses the milk from the alveoli into
the ducts.
• oxytocin is a the major galactokinesis.

45. CONT….

46. CONT…

47. GALACTOPOIESIS
• Prolactin appears to be the single most
important galactopoietics hormone.
• Continuous suckling is essential for removal of
milk from glands, also release prolactin.
• Secretion is the continuous process unless
suppressed by congestion or emotional
disturbances

48. MILK PRODUCTION
• A healthy mother will produce about 500-800 ml
of milk/day with about 500 kcal /day.
• This requires 600 kcal/day for the mother which
must be made up from the mothers diet or from
her body store.
• For this purpose a store of about 5 kg of fat
during pregnancy is essential to make up any
nutritional deficit during lactation.

49. STIMULATION OF
LACTATION• Mother is motivated about the benefits of breast feeding
• No prelacteal feed like honey ,water
• Following delivery important steps are…..
I. To put baby to the breast at 2-3 hours interval from the first day.
II. Plenty of fluids to drink
III. To avoid breast engorgement.
IV.Early and exclusive breast feeding in correct position are
encouraged as soon as 30minutes to 1hour

50. INADEQUATE MILK
PRODUCTION/
LACTATION FAILURE
• It may be due to infrequent suckling or due to
endogenous suppression of prolactin (ergot
preparation, pyridoxine, diuretics or retained
placental bits).
• Unrestricted feeding at short interval (2-3hrs.)
Is helpful

51. DRUGS TO IMPROVE
MILK PRODUCTION
 Metoclopramide (10 mg thrice daily) increases
milk volume (60-100%) by increasing prolactin
levels.
Sulpuride (dopamine antagonist) has also been
found effective.
 Intranasal oxytocin contracts myoepithelial
cells and causes milk let down reflex.

52. LACTATION SUPPRESSION
• Suppression of lactation is necessary if the baby is born
dead or dies in the neonatal period or if breast feeding is
contradicted
Mechanical methods :
1. To stop breast feeding
2. To avoid pumping or milk expression
3. To wear brassieres
4. Ice pack to relive pain and breast engorgement
5. A tight compression bandage is applied for 2-3 days

53. CONT…
• Bromocriptine (dopamine agonist that
inhibits prolactin) 2.5 mg, 1 tab daily for
10-14 days.
• Side effects are: hypotension, rebound
breast engorgement, secretion, myocardial
infarction and puerperal stroke

54. THANK
YOU