Physiological changes during puerperium

1. NORMAL PUERPERIUM
Dr L.Dabashini Devi
Professor & HOD
Department of OBG Nursing

2. TERMINOLOGIES
 PUERPERIUM: the period between childbirth and t
he return of the uterus to its normal size
 INVOLUTION: The process of involution, the
process by which the uterus attempts to return to
its prepregnancy size and condition.
 LOCHIA: is post-partum vaginal discharge,
containing blood , mucus, and placental tissue.
 LACTATION: Lactation is the medical term used
for breastfeeding. It also specifically refers to the
synthesis and secretion of milk.

3. CNTD….
 EXCLUSIVE BREAST FEEDING:
Exclusive breastfeeding means that the infant receives
only breast milk from his or her mother
 ROOMING IN: The process of keeping baby with the
mother
 COLOSTRUM: Colostrum is a thick yellow fluid, rich in
protein, growth factors, and immune factors. It is
secreted by the mammary glands of all female
mammals during the first few days of lactation
 MILK LET DOWN REFLEX: The release of the
hormone oxytocin leads to the milk ejection or let-down
reflex. Oxytocin stimulates the muscles surrounding the
breast to squeeze out the milk

4. CNTD……..
 POSTPARTUM: immediate period following child
birth.
 BOGGY UTERUS: Uterus that is soft when palpate.
It’s a sign of involution of uterus.
 AUTOLYSIS: The destruction of tissues or cells by
the action of one’s own enzymes.
 LOCHIOMETRA: Retention of lochia in the uterus.

5. DEFINITION
 Puerperium is the period following childbirth during
which the body tissues specially the pelvic organ
revert back to approximately to the pre-pregnancy
state both anatomically and physiologically.
 Puerperium starts soon after the expulsion of the
placenta till 6 weeks. The women is term as
puerperal. This period is also known as postnatal,
postpartum and post-delivery period.

6. 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 size. This period is
again divided into three i.e.
 Immediate – within 24hrs.
 Early – up to 7 days.
 Remote – up to 6 weeks.

7. PHYSIOLOGICAL CHANGES IN THE
REPRODUCTIVE SYSTEM
1. INVOLUTION OF THE
UTERUS:
Anatomical consideration
Physiological consideration

8. ANATOMICAL CONSIDERATION
 After the delivery the uterus become more retracted and
firm with alternate hardening and softening.
 The uterus measures about 20*12*7.5 and weighing about
1000gms.
 At the end of the 6weeks, the size will return to pre-
pregnancy state 7.5*5*2.5 and weighing about 60gms.
 The reduction in the weight and size is not in the number
of cells but its size through the process of autolysis of the
muscles fibres and ischemia of the uterus.
 The contraction and reduce in cells size, compress the
blood vessels and reduce in uterine blood supply.

9. PHYSIOLOGICAL CONSIDERATION
The physiological process of involution is most
marked in the body of uterus. Changes occur in the
following components:
 Muscles
 Blood vessels
 Endometrium

10. MUSCLES
 There is marked hypertrophy and hyperplasia of muscle
fibres during pregnancy and the individual muscle fibre
enlarges to the extent of 10 times in length and 5 times in
breadth.
 During puerperium the number of muscle fibres is not
decreased but there is substantial reduction of the
myometrial cells size.
 Withdrawal of the steroid hormones oestrogen and
progesterone may lead to increase in the activity of the
uterine collagenase and the release of proteolytic
enzymes.
 Autolysis of the protoplasam occurs by the prteolytic
enzyme with liberation of peptones which enter the blood
stream.

11. BLOOD VESSELS
 The changes in the blood vessels are pronounced in the
placental sites.
 The arteries are constricted in the contraction of its wall
and thickening of the intima followed by thrombosis.

12. ENDOMETRIUM
 Following delivery the major part of the decidua is cast off
with the expulsion of the placenta and the membranes at
the placental sites.
 The endometrium left behind varies in thickness from 2-
5mm.
 The superficial part containing the degenerated decidua,
blood vessels and foetal membranes becomes necrotic
and is cast off in the lochia.
 Regeneration occurs from epithelial of the uterine gland
mouths and interglandular stromal cells.
 It is completed at 10th day and entire endometrium in 3rd
week except the placental site which takes 6weeks.

13. CLINICAL ASSESSMENT OF INVOLUTION
 After labour the fundus is 13.5cms above symphysis
pubis.
 First 24hrs uterus remains constant and then steady
decrease in height by 1.25cms in 24hrs, at the end of 2nd
week uterus becomes pelvic organ and by 6th weeks it
becomes almost normal.
 Immediately after delivery uterus lies between the
symphysis pubis and umbilicus.
 After 12hrs, the uterus rises at the level or slightly above
umbilicus
 Uterus begins to decent into the pelvic cavity at the rate
of 1 cm a day till 10th day when it is palpable at or below
symphysis pubis.

14. CNTD
 The fundus should feel firm and hard when palpate
due to the strong myometrial contractions, which
control the blood flow. If the fundus is soft it is
called Boggy uterus.
 Clinical assessment of the involution can be
assessed by measuring the height of the fundus
with a measuring tape with relation to the
symphysis pubis. The bladder and bowel should be
emptied before and measurement should take
place in the same time every day.

15. CERVIX:
 After delivery the lower uterine segment and cervix remain
loose, thin and stretched.
 It may also become oedematous and bruised from the
delivery and may have small tears and lacerations.
 In few days it will narrowed down to admit 2 fingers and
by the end of first weeks it will admits only the tips of the
fingers.
 Here involution will take 3-4months as cervix sustained
trauma and external os will never revert back to the
nulliparous state.

16. OVARIES:
The ovaries is inactive during
the last two trimesters of
pregnancy, because of the
drop in the placental hormones
level and gradually resumes
the pre- pregnancy cycle.

17. VAGINAL CANAL:
It appears swollen and smooth after
delivery, gradually becomes small but
never become like pre-pregnancy
state.
he hymen become lacerated and is
represented by nodular tags-
carunculae myrtiformes.
The introitus remain permanently
larger than the virginal state.

18. LOCHIA:
 It is the vaginal discharge for the first fortnight during
puerperium.
 It originates from the uterine body, cervix and vagina.
 It contains blood, decidual tissue, epithelial cells, fragments
of membrane and small blood clots.
 It has got a peculiar offensive fishy smell. Its reaction is
alkaline tending to become acid towards the end.

19. CNTD’
It is divided into three types:
 Lochia Rubra: The first phase of lochia when discharge is
red and bloody. It last for 1-4 days, and contains only
blood clots.
 Lochia Serosa: It contains less RBC but more leucocytes,
wound exudates, mucus from the cervix and micro-
organisms. Occurs next 5-10 days and it is yellowish pink
or pale brownish colour.
 Lochia Alba: It contains plenty of decidual cells,
leucocytes, mucus, cholestrin crystals, fatty and granular
epithelial cells and micro-organisms. It last for 10-14 days
and it is pale white in colour.
The amount of discharge for the first 5-6 days is around
250ml.

20. IMPORTANCE OF INSPECTING LOCHIA
It gives information about the puerperal state of the
mother – pads to be inspect daily.
 Odour : If offensive –Infection, retained cotton pieces or
plug inside the vagina to be kept in mind.
 Amount : Scanty or Absent- Infection or Lochiometra,
excessive – infection.
 Colour : Persistence red – subinvolution retained bits of
conception.
 Duration : Lochia alba beyond 3 weeks – local genital
lesion.

21. GENERAL PHYSIOLOGICAL
CHANGES
Pulse
 For a few hours after normal delivery, the pulse rate
is likely to be raised, which settles down to normal
during the second day. However the pulse rate
often rises with after pain or excitement.
 Temperature
 The temperature should not be above 37.20C within
the first 24 hours, there may be slight reactionary
rise following delivery by 0.50F but comes down to
normal within 12 hours. On the third day there may
be slight rise of temperature due to breast
engorgement which should not last for more than
24 hours.

22. CNTD
Urinary Tract
 The bladder mucosa becomes oedematous and
hyperaemic and often shows evidences of submucous
extravasation of blood . the bladder capacity is
increased. The common urinary problems are: over
distension, incomplete emptying and presence of
residual urine.
Gastro- Intestinal Tract
 Increased thirst during early puerperium is due to loss of
fluid during labour, lochia, diuresis and perspiration.
Constipation is a major problem for the reasons such as
delayed motility, mild ileus following delivery, together
with perineal discomfort.

23. BLOOD VALUES
 Immediately following delivery, there is slight decrease of
blood volume due to blood loss and dehydration.
 Blood volume returns to non pregnant level by the second
week.
 Cardiac output rises soon after delivery to about 80% above
the pre- labour value but slowly returns to normal within one
week.
 RBC volume and haematocrit values returns to normal by 8
weeks postpartum after the hydraemia disappears.
 Leucocytosis to the extent of 25,000 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 4-10 days.
 Fibrinogen level remains high up to the second week of
puerperium.

24. MENSTRUATION AND OVULATION
 The onset of the first menstrual period following delivery
is very variable and depends on lactation.
 If the woman does not breast feed 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 breast feeding, the
contraceptive protection is about 98% upto 6 months
postpartum.
 Thus lactation provides a natural method of
contraception.

25. MANAGEMENT OF NORMAL PUERPERIUM:
CARE OF THE MOTHER:
The management of puerperium consists of providing the
means whereby the women can recuperate physically and
emotionally and gain supervised experience in the care of
the baby.
Its consists the following principles:
 To restore the health status of mother.
 To prevent infection.
 To take care of breasts including promotion of breast
feeding.
 To provide for care of the baby.
 To motivate and guide for family planning.
 To give need based health education.

26. IMMEDIATE CARE:
 The first hour after delivery does not end the
recovery process.
 The clinical phase of recovery continues throughout
hospitalization and weeks after discharge.
 During this time acute observations, nursing history
and physical assessment allow formation of
appropriate nursing diagnosis and effective plan of
care.

27. INITIAL OBSERVATIONS:
 First impression of women provide an
overview of how she is recovering of childbirth.
 The mother’s general appearance and
presence of pain, the mother’s colour reflects
the circulation and perfusion.
 Observe for pallor, flushing or cyanosis.
 Note whether the mother is very fatigue, quiet,
excited or anxious.
 Assess the IV line in place, amount of fluid and
medication etc. and if the mother had surgery,
see whether the catheter is in place.

28. PHYSICAL ASSESSMENT:
 Vital signs: pulse, respiration, blood pressure,
temperature. Post-partum checks include vital
signs every 15mins for one hour, then 30
minutes in the second hour and then every 4
hours for 24 hours.
 Uterus: For vaginal delivery, check the fundus
for consistency, height and descent.
Measurement of the abdominal girth after
LSCS.
 LSCS: Check the dressing for the presence of
bleeding.

29. PERINEAL AREA:
 Check perineal pad for amount, colour of lochia.
 Odour, clots, intact sutures, oedema, pain and anus for any
repaired lacerations or haemorrhoids.
Rest and Ambulation:
 For most women 8-12 hrs of rest is enough following delivery.
 After that the mother should be encourage to feed the baby,
move out of bed and go to toilet. Benefits for early ambulation
are:
 Provides a sense of well being.
 Reduces bladder and bowel complications.
 Facilitates uterine drainage and involution.
 Reduces puerperal venous thrombosis and embolism
phenomenon.
 Early ambulation does not mean to return to normal activities,
as these should be restricted for at least 6 weeks. During
these periods the mother should take as much rest as possible
and avoid strenuous activities.

30. 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.
Most women are discharged fit and
healthy after 2 days of spontaneous
vaginal delivery with proper education and
instruction.
Some need prolonged hospitalization due
to morbidities

31. DIET
 On the first day the mother should be given light
diet and normal diet from the second day.
 The lactating mothers should be given high
calories, adequate protein, fats, minerals,
vitamins, plenty of fluids and lots of green leafy
vegetables.
 The mother should consume iron, folic acid and
calcium tablets too. But for non-lactating
mothers normal diet is enough.

32. CARE OF BLADDER:
The mother should encourage to pass
urine within 6-8 hours of delivery and after
that every 4 hours interval.
 Privacy should be provided to the
mothers by allowing toilet facilities.
If urine is not passed, catheterization
should be done.
And continuous drainage is kept until
bladder tone is regained.

33. CARE OF BOWEL:
Abdominal should be palpate for any
distension, palpated for firmness or
rigidity and auscultate for presence of
bowel sound.
 Ask mother that she is passing flatus
of urge to defecate.

34. CARE OF BREAST:
Breast and nipple should be
washed and cleaned with boiled
cold water.
Mothers should be advised to give
feed from both the sides to
prevent any congestion and
solidification of milk.

35. IMMUNIZATION:
 Delivery of the foetus and placenta
increases the chances of foetal blood
entering maternal circulation for Rh negative
mother with Rh positive infant predisposes
to the formulation of antibodies that can be
endanger future pregnancies.
 Prevention of iso immunization is possible if
Rh- immunoglobulin is injected within 72
hours after delivery. (Anti-D gamma
globulin).

36. SLEEP:
 The amount of energy spends during laboured birth
leaves the mother in need of rest both physical and
mental.
 The mothers should be protected from worries and
fatigues.
 Care of baby should be planned so that mother can take
rest and other family members should help in doing so.
 Visitors should be limited.
 Because fatigue adversely affect milk production, can
precipitate depression and lower the self esteem.

37. CARE OF VULVA AND EPISIOTOMY WOUND:
After delivery vulva and buttocks can be
washed with saline or clean water with
soap.
 Antiseptic ointment or lotion applied
over the episiotomy stitches and sterile
pad given.
These can be done at least 3-4 times for
the first 24hours.
 Some mother feels comfortable with
warm water sitz bath.

38. MATERNAL INFANT BONDING (ROOMING IN):
 it starts from first few months after birth.
 This manifested by kissing, cuddling and gazing
at the infant.
 The baby should be kept in her bed or in a cot
besides her bed.
 This 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.
 Baby friendly hospital initiative promotes parent-
infant- bonding, baby rooming with the mother
and breast feeding.

39. ASEPSIS AND ANTISEPTICS
 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.
 Clean surroundings and limited number
of visitors could be of help in reducing
nosocomial infection

40. MANAGEMENT OF AILMENTS
After Pain:
 it is the infrequent, spasmodic pain felt in the lower
abdomen after delivery for a variable period of 2-4 days.
 Presence of blood clots or bits of the after births leads to
hypertonic contractions of the uterus in an attempt to
expel them out.
 This is commonly met in primipara.
 The pain may also be due to vigorous uterine contraction
specially in multipara.
 The treatment includes massaging the uterus with
expulsion of the clot followed by administration of
analgesics and antispasmodics

41. PAIN ON THE PERINEUM:
 never forget to examine the perineum when analgesic is
given to relieve pain.
 Early detection of vulvo vaginal haematoma can thus be
made.
 Sitz bath can give additional pain relief.
Correction of Anaemia:
 majority of the women in the tropics remain in an
anaemic state following delivery.
 Supplementary iron therapy (ferrous sulphate 200mg) is
to be given daily for a minimum period of 4-6 weeks.
 Hypertension is to be treated until it comes to a normal
limit.
 The physician should be consulted if proteinuria persists.

42. BREAST ENGORGEMENT:
it is due to exaggerated normal venous and
lymphatic engorgement of the breasts which
precedes lactation. This in turn prevents escape
of milk form the lacteal system.
 It can be prevented by:
 Avoiding pre lacteal feeds
 To initiate breast feeding early and unrestricted.
 Exclusive breast feed on demand
 Feeding in correct position

43. TO MAINTAIN A CHART
A progress chart is to be maintained noting
the following:
Pulse, respiration an temperature
recording 6 hourly or at least twice a day
Measurement of the height of the uterus
above the symphysis pubis once a day in a
fixed time with prior evacuation of the
bladder and the bowel too.
Character of the lochia
Urination and bowel movement

44. CHECKUP AND ADVICE ON DISCHARGE
The general advices include:
Continuance of supplementary iron
therapy
Postnatal exercises
Procedures for a gradual return to day to
day activities
Breast feeding and care of the newborn
Avoidance for intercourse for a reasonable
period of 4-6 weeks until lacerations or
episiotomy wound are well healed

45. LACTATION
DEFINITION
For the first two days following delivery, no
further anatomic changes in the breasts
occur.
The secretion from the breasts called
colostrum which starts during pregnancy
becomes more abundant during the
period.

46. PHYSIOLOGY OF LACTATION
The physiological basis of
lactation is divided into four
phases:
Preparation of breasts
Synthesis and secretion from the
breast alveoli
Ejection of milk
Maintenance of lactation

48. MAMMOGENESIS
Preparation of breast :
There is remarkable growth of both the
ductal and lobulo-alveolar systems.
 An intact nerve supply is not essential for
the growth of the mammary glands during
pregnancy.

49. LACTOGENESIS
Synthesis and Secretion from the breast alveoli :
 The actual milk secretion starts from 3rd - 4th days
postpartum, before this a yellowish fluid called
colostrum is secreted.
 In spite of the high prolactin level, the effect of
oestrogen and progesterone circulating during
pregnancy make the breast tissue unresponsive
to the prolactin.
 But after delivery, prolactin starts milk production
as oestrogen and progesterone is withdrawn.
 For milk to secrete nursing effort is not required.

50. GALACTOKINESIS
Ejection of milk :
 Discharge of milk depends on the amount of
suction applied by the baby as well as the
contractile mechanism.
 During sucking, a conditioned reflexes is set up.
 The ascending tackle impulses from the nipple and
areola pass via thoracic sensory afferent neural arc
to the para-ventricular and supra-opticnuclei of the
hypothalamus to synthesize and transport oxytoxin
to the posterior pituitary.

51.  This oxytoxin produces contraction of the myoepithelial
cells of the alveoli and the ducts containing the milk.
 This is called as “milk ejection” or “let down” reflex
where the milk is forced down into the ampulla of the
lactiferous ducts, where from it can be expressed by the
mother or suck by the baby.
 Presence of infant or infant’s cry can induce let down
reflex without sucking.
 The sensation of high pressure in the breast by milk
experienced by the mother at the beginning of sucking
is called as ‘draught’.
 The milk ejection is inhibited by factors like pain, breast
engorgement or adverse psychic conditions.

52. GALACTOPOIESIS
Maintenance of lactation :
Prolactin is the single most
Galactopoietic hormones.
For maintenance of effective and
continuous lactation.

53. MANAGEMENT
Stimulation of lactation: mother is
motivated as regard the benefits of breast
feeding since the early pregnancy.
Following delivery important steps are:
To put the baby to the breast at 2-3 hours
interval from the first day
Plenty of fluids to drink
To avoid breast engorgement

54. INADEQUATE MILK PRODUCTION:
also known as lactation failure.
 It may be due to infrequent
suckling or due to endogenous
suppression of prolactin.
Pain, anxiety and insecurity may
be the hidden reasons

55. Drugs to improve the milk production: also
known as galactogogues. Metoclopramide
(10mg thrice daily) increases milk volume (60-
100%) by increasing prolactin levels.
Intranasal oxytocin contracts myoepithelial
cells and causes milk let down.
Medical Methods: Suppression with
oestrogen, androgen or bromocriptine is not
recommended. The side effects of
bromocriptine are hypotension, seizures,
myocardial infarction and puerperal stroke

56. MECHANICAL METHODS:
 it can be used in cases where the lactation is to
be suppressed after the establishment of milk
secretion.
 The patient should stop breast feeding
 She should not express or pump out the milk from
the breast
 A tight compression bandage is applied for about
2-3 days
 Analgesic tablet containing aspirin and ice packs
are given to relieve pain breast engorgement

57. EXCLUSIVE
BREAST
FEEDING

58. COLOSTRUM
 A yellow pre milk substances, high in protein
and contains antibodies.
 Its production decreases gradually and by 3-5th
day the true milk production started.
 The milk at the beginning of the feed is called
fore milk, which contains less fat and flows at a
greater rate.
 Hind milk is the milk at the end of the feed.
 This is white in colour, contains more fats and
calories and its believe to satisfy the baby and
signals that feeding should come to an end.

59. POSITIONS
FOR BREAST
FEEDING

60. CROSS CRADLE POSITION

61. CRADLE HOLD POSITION

62. FOOT BALL POSITION

63. SIDE LYING POSITION

64. BABY
FRIENDLY
HOSPITAL
INITIATIVE
(BFHI)

65. POSTNATAL CARE
Definition
Postnatal care includes systematic
examination of the mother and the baby
and appropriate advice given to the mother
during postpartum period.
The first postnatal examination is done and
the advice is given on discharge of patient
from the hospital.
The second routine postnatal care is
conducted at the end of 6th week
postpartum.

66. AIMS AND OBJECTIVES
To assess the health status of the mother.
Medical disorders like diabetes,
hypertension should be reassessed.
To detect and treat at the earliest any
gynaecological condition
To note the progress of the baby including
the immunization schedule for the infant.
To impart family planning guidance

67. PROCEDURE
Examination of the
mother
Advice given to the
mother
Examination of the
baby

68. EXAMINATION OF THE MOTHER
 Routine examination includes recording weight,
pallor, blood pressure and tone of the abdominal
muscles and examination of the breasts.
 Pelvic examination should be done only when
indicated.
 The following should be noted: a cervical smear
may be taken for exfoliative cytological examination
if this has not been done previously and insertion of
intrauterine contraceptive device may be done
when desired.
 Laboratory investigations (e.g. haemoglobin)
depending on the clinical need may be advised.

69. EXAMINATION OF THE BABY
This should be conducted by a
paediatrician.
 In this respect, an attached well baby
clinic to the post partum unit is
necessary.
The progress of the baby is evaluated
and preventive or curative steps are to
be taken. Immunization to the baby is
started.

70. ADVICES GIVEN:
General:
If the patient is sound health she is allowed
to do her usual duties.
Postpartum exercises may be continued
for another 4-6 weeks
To evaluate the progress of the baby
periodically and to continue breast feeding
for 6 months
Family planning counselling and guidance

71. MANAGEMENT OF AILMENTS
They mainly include:
 Irregular vaginal bleeding: it is not uncommon to
encounter irregular or at times, heavy bleeding
after 4-6 weeks following an uneventful period
after delivery. This is usually the first period
specially in non lactating women and simple
assurance is enough.
 Leucorrhoea : profuse white discharge might
be due to ill health, vaginitis, cervicitis or sub
involution. Improvement of the general health
and specific therapy cures the condition

72.  Cervical ectopy: met during this period without any
symptom should not be treated surgically. Hormone
induced ectopy during pregnancy takes a longer time to
regress. Thus, assymptomatic ectopy should be
examined again after 6 weeks and if it still persists,
cauterization is to be considered.
 Backache: it is mostly due to sacroiliac or lumbosacral
strain. Backache situated over the sacrum is likely due to
the pelvic pathology, but it is over the lumbar region, it
might be due to an orthopaedic condition and is often
relieved by physiotherapy.
 Slight degree of uterine descent with cystocoele, stress
incontinence and relaxed perineum are the common
findings at this stage. These can be cured by effective
pelvic floor exercise. However if the prolapse is marked,
effective surgery should be done after three months.