The document discusses the normal puerperium period following childbirth. It describes how over 6 weeks postpartum, a woman's body returns to its non-pregnant state as various physiological changes are reversed. Hormone levels fall, the uterus involutes to its pre-pregnant size, lactation is established, and the mother recovers from childbirth while bonding with her new infant. The management of a postnatal mother focuses on monitoring this recovery process and physiological changes.

1. NORMAL PUERPERIUM
G. Kasonde

2. INTRODUCTION
 Following the birth of the baby and expulsion of
the placenta, the mother enters a period of
physical and psychological recuperation (buckley
2006). The puerperium’ starts immediately after
delivery of the placenta and membranes and
continues for 6 weeks.

3. …..
 The overall expectation is that by 6 weeks after
the birth all systems in the woman’s body will
have recovered from the effects of pregnancy and
returned to their non pregnancy state, other
changes which occur during pregnancy are
reversed and lactation is established, the
foundation of the relationship between the infant
and his parents are laid.

4. …..
 The mother recovers from the stresses of
pregnancy and delivery and assumes the
responsibility for the care and nurture of her
infant.

5. GENERAL OBJECTIVE
 At the end of the lesson you must be able
to demonstrate the knowledge and the skill
on the management of a woman in normal
puerperium.

6. Specific objectives
At the end of this lesson you should be able
to:-
 Define normal puerperium
 Describes the physiological changes in
normal puerperium
 Describe the management of a postnatal
mother

7. DEFINATION OF PUERPERIUM
 Is the period of 6 weeks after delivery
which begins as soon as the placenta is
expelled bonnet and brown,(1996)
 Is the period from the completion of the
delivery (end of the third stage of labour)
to the end of the first 6 postpartum weeks,
during which the womans body returns to
the non gravida state. sellers p (2008)

8.  In latin -Puer means a child
 Parere means to bear

9. PHYSIOLOGICAL CHANGES in
PUERPERIUM
 Reproductive organs return to non-
pregnant state
 Physiological changes which took place
during pregnancy are reversed
 Lactation is established

10.  Bonding is established between mother
and the baby.
 Recovery from stress of pregnancy and
delivery.
 The mother assumes care and nurture of
the child.

11. 1. ENDOCRINE OR HORMONAL CHANGES
 A. The levels of Human chorionic
gonadotrophine (HCG), human placental
lactogen ( HPL), oestrogen and
progesterone
in the blood fall when the placenta
becomes detached from the uterine wall
and is expelled

12.  Normally after 2 days HPL is not detectable
in plasma
 After 7 days, HCG hormone is no longer
detectable in the womans urine, oestrogen
and progesterone reached non pregnant
levels

13. B. PROLACTIN
 The fall in oestrogen allows prolactin,
which is secreted by the anterior
pituitary gland, to act upon the alveoli of
the breast to stimulate the production of
milk.
 The more the woman breastfeeds, the
higher the levels of prolactin remain and
the resumption of follicle stimulation in
the ovary is suppressed.

14.  In women who do not breastfeed, the levels
of circulating prolactin fall within 14- 21
days of birth

15.  This fall allows the FSH secreted by the
APG to act upon the ovary leading to
normal resumption of oestrogen and
progesterone production, follicle growth,
ovulation and menstruation
 In a non lactating mothers, ovulation and
menstruation usually recommences
within 7- 10 weeks.

16.  C. Oxytocin
 This is secreted by the posterior pituitary
gland.
 It acts upon uterine muscle and on breast
tissue. During the 3rd stage of labour, the
action of oxytocin brings about the
separation of the placenta.
 It then continues to act upon the uterine
muscle fibres maintaining their
contraction, reducing the placental site
and preventing haemorrhage

17.  In breastfeeding mothers, the suckling of
the baby stimulates further secretion of
oxytocin and this aids the continuing
involution of the uterus and expulsion of
milk

18. 2. CHANGES IN THE REPRODUCTIVE
ORGANS
 INVOLUTION- This is the term to describe
the return of the organs of reproduction
to their non gravid state
A. THE UTERUS
 The greatest amount of involution takes
place in the uterus because it undergoes
changes in pregnancy and labour

19.  After delivery the excess muscle fibres are
broken. The catabolism is brought about by
two factors:-

20. 1. Ischaemia of the myometrium
 Caused by the continous contraction and
retraction of the uterus after the expulsion of
the placenta, rendering the uterus relatively
anaemic and causing atrophy of the muscle
fibres.
 The vast amount of blood which was contained
within the uterus is pushed into the blood
stream.
 This greatly increases the volume of fluid in
circulation which is removed by the kidneys
which leads to major diuresis in the early
puerperium.

21. 2. Autolysis - process of self digestion
 This is the process in which proteolytic
enzymes digest the muscle fibres which
had increased during pregnancy to 10
times their normal thickness.
 The end products of autolysis are
removed by the phagocytic action of
polymorphs and macrophages in the
blood and lymphatic systems.

22.  The hypertrophy (increased thickness) and
hyperplasia (increase in number) of muscle
fibres increases during pregnancy now need
to be reduced through the process of
autolysis.
 The process (autolysis) Is further assisted
by the contraction and retraction of the
uterine muscles under the influence of
oxytocin and this results in compressing the
blood vessels and reducing the uterine
blood supply.

23.  Breast feeding stimulates the continuing
secretion of oxytocin thus assisting
involution.
 The contraction and retraction of the
uterine muscles reduce the size of the
placenta and prevent excessive bleeding,
and the site is gradually covered first by
granular tissue and then by endometrium.

24.  At the completion of labour the uterus weighs
approximately 1kg. By the end of puerperium it
returns to its pre-pregnant state of 60g
 The most marked reduction in the size of the
uterus takes place during the first 10 days of
the puerperium but involution is not complete
until after 6 weeks when it attains the
anteversion and anteflexion position.
 Immediately following the 3rd stage of labour
the fundus of the uterus is found about
halfway between the symphysis pubis and the
umbilicus.

25.  Within 24hrs the lower uterine segment
regains its tone and pushes up the fundus
to the level of the umbilicus. One week
after delivery it is palpable just above
the symphysis pubis and by the 10th -12th
day it is no longer palpable because it has
sunk below the symphysis pubis.
 The uterine fundus decreases or receeds
by 1 to 1.5cm or about a finger breadth
per day.

26.  The size of the uterus diminishes from
about 15x10x7.5cm to about 7.5x5x2.5cm
thick and weighs 60g (other books say
57g).
 The uterus never returns to its initial
pregravid state (size and weight), but
with each pregnancy, the muscle weight
and collagen content of the uterus is
slightly increased and elastin is deposited
around the blood vessels.

27.  Therefore, the elastin and collagen
contents increases with each successive
pregnancy leading to uterine muscles to
become less elastic and resulting in the
uterus becoming a progresively less
efficient organ for pregnancy and labour.

28. Placental site
 It diminishes rapidly and by the day after
delivery, has reduced to about 7.5cm (
normally the placenta would have a
diameter of 20cm). By the 10th day after
delivery, the site will be about 2.5cm. By
the end of 5-6 weeks regeneration of the
epithelial covers the site leaving only a
small depression but no scar.

29. The endometrium
 The epithelial layer of the endometrium,
except for the placental site, has
regenerated by the end of 2 weeks.

30. Lochia
 This is the term used to describe the discharge
from the uterus during the puerperium.
 It has an alkaline reaction in which organisms
can flourish more rapidly than in the normally
acid secretions of the vagina.
 Normal lochia has a characteristic of strong
(heavy) but not offensive smell.
 This varies in different women in amount and
duration

31. Types of lochia
Lochia undergoes sequential changes as
involution progresses.
 1. LOCHIA RUBRA (red lochia) lasts 3-4
days. It is red in colour and consists of
blood from the placental site, debris from
the decidua, chorion, meconium, vernix
caseosa and liquor amnii.

32. 2. LOCHIA SEROSA (pink lochia)
Lasts from 5-9 days. It consists of serum,
lymph and luecocytes from the placental
site and varies from pinkish to yellowish
brown colour
3. LOCHIA ALBA ( pale, creamy brown
lochia) from 10th- 15th day. It can go upto
3 weeks and contains lymph, leucocytes,
cervical mucus, and other debris from
the healing process.

33.  A persistent red or heavy lochia for more than
10 days denotes that the uterus is not involuting
and may suggest retained products.
 This may lead to secondary postpartum
hemorrhage and infection. A lochia with an
offensive smell would also indicate infection.
 For the 1st 4-5 days postpartum days, the lochia
in the uterine cavity is sterile but become
contaminated by organisms as it passes down
the vagina.
 These organisms may invade the vagina and
spread to the uterine cavity.

34. B. THE CERVIX
 The cervix is soft and vascular immediately
after delivery and may be seen protruding into
the vagina. Usually loses its vascularity rapidly
and regains its usual hard consistency within 2
or 3 days of the delivery. The cervical os
becomes a mere slit and not its normal original
state.

35. C. PELVIC FLOOR, PERINEUM, VAGINA
AND VULVA
 The vaginal wall may have been extensively
stretched during delivery leading to swelling,
redish-blue and flabby after delivery. An
episiotomy- should be healed by 7 days
 The perineal muscles regain their tone after 5-
6 weeks. This is speeded up and maintained by
exercising after the birth of the baby.

36.  The excess fluid in these tissues is usually
reabsorbed by 3rd or 4th day of puerperium.
 Lacerations heal by 6 weeks. The remains
of the hymen are now known as caranculae
myrtiforms

37. D. OVARIES AND FALLOPIAN TUBES
 These become pelvic organs.
 Following delivery of the placenta,
oestrogen and progesterone levels reduce
leading to a negative feedback mechanism
which triggers off the menstrual cycle.

38. E. THE ABDOMEN
 The skin of the abdomen which has been
greatly stretched during pregnancy
appears loose and flabby for weeks and
even months.
 The stretch marks fade gradually, but do
not disappear completely instead,
become silvery-white streaks (stretch
marks).
 The abdominal muscle tone is regained
with the help of postnatal exercises.

39. F. THE BREASTS
 An increase in the blood supply to breasts
enhances lactation. The rise in circulating
prolactin acts upon the alveoli of the breasts
and stimulates milk production.
 During the 3-4 days of the puerperium the
breasts become heavy and tender as they fill up
with milk, which would lead to engorgement.
 Engorgement is reduced as the baby begins to
suckle.
 But in women who do not breast feed
engorgement is reduced by the falling prolactin
levels.

40.  In the first 2-3 days the breasts secrete
colostrum.
 The secretion of milk usually begins on the
3rd day after delivery and the secretion of
prolactin is stimulated by the neuro-
hormonal reflex mechanism, which is
activated when the baby suckles.

41.  Lactation reduces the chances of pregnancy
but is not a very reliable method of
contraception.

42. 3.THE PELVIC GIRDLE
 The pelvis and the joint ligaments
gradually regains its former stability. The
Joints tighten due to reduction in
progesterone and backache disappears.
4. THE RESPIRATORY TRACT
 Returns to normal as the lung base is no
longer compressed

43. 5. THE CIRCULATORY SYSTEM
 The cardiac output which increases during
labour and rises further after the 3rd stage
when the large volume of blood from the uterus
is squeezed into the circulation, decreases
after the 1st few days of puerperium and
returns to normal output by end of the third
week.
 During pregnancy the normal blood volume
increases to accommodate the increased blood
flow needed by the placenta and uterine blood
vessels

44.  The withdrawal of oestrogen allows a
diuresis to take place, rapidly reducing
the plasma volume to normal
proportions. This action takes place
within the first 24-48 hours following
child birth.
 The cardiac out put reduces and returns
to normal by the end of the 3rd week.

45.  During the last few weeks of pregnancy, the
levels of fibrinogen, plasminogen and the
clotting factors in the blood increases.
 Few days after delivery these levels reduce
rapidly but the blood is more coagulable
with an increased viscosity and this will
lead to risk of thrombosis.
 Increased WBC helps to fight infection.

46. 6.URINARY SYSTEM
 Renal action is increased in the early part
of the puerperium because of diuresis and
the excretion of the waste products.
 The peak of this activity occurs within the
first 7 days of the puerperium

47. 7. GASTRO INTESTINAL TRACT
 There is gradual return of the motility of the
intestines.
 There is an increase in perspiration during
labour and loss of fluid during the diuresis
immediately after delivery.
 Usually there is loss of appetite the first few
days after delivery and the perineum maybe
painful preventing defecation leading to
constipation.

48. WEIGHT
Metabolism returns to normal. The fat
deposited in pregnancy covers up during
the breast-feeding period
PSYCHOLOGICAL CHANGES
 Mood swings or emotional lability are
common in puerperium.
 This is due to the great joy, sense of
achievement and fulfilment which a
woman felt after the birth of the baby

49.  Then give way to tiredness,anxiety and
dawning sense of her responsibilities
which predispose to depression
 The postpaturm blues (also known as 3rd
day or 4th day blues)alternate with
feelings of great happiness and pride of
motherhood(swings of mood).If this
worsens may lead to puerperal psychosis.

50. MANAGEMENT OF A POSTNATAL MOTHER
AIMS OF MANAGEMENT
 To promote the general wellbeing of the
woman
 To prevent complications in the puerperium
 To give psychological care to the mother
 Early recognition and immediate treatment
of any complications which may arise

51. 1. ADMISSION TO LABOUR WARD
 Initially when the woman has delivered
she will be nursed in the postnatal ward
i.e. within labour ward or sent to the
actual postnatal ward after informing the
staff on duty about the transfer of the
client. A bed will be arranged for her.

52.  When the arrives, welcome and greet her.
Get handover from the nurse about the
delivery.
 Ensure the uterus is well contracted by
massaging it.

53.  Ensure lochia is not coming out
excessively.
 Bladder should be empty.
 Check the vulva for lacerations and if
episiotomy has been sutured
 Check general condition and identity of
the baby and conduct a quick
examination of the baby.

54.  Ensure the labour ward notes are correct
and check the vital signs and general
condition.
 Orient mother to the bathroom and toilet
before resting.
 Find out if the baby was put on the breast

55. 2.ENVIRONMENT
 It should be quiet, well ventilated and warm
environment
3. HISTORY TAKING
 Note the following
 Age and parity
 Blood group and rhesus factor
 Hb

56.  Events of labour and delivery and blood loss
 Babys condition at birth and birth weight
 Mothers chosen method of infant feeding
 HIV status and any other relevant
information antenatally and intrapartally.
Check antenatal card

57. 4. OBSERVATION
 Vital signs.- temperature, pulse and
respiration to detect rule out fever,
tachycardia or breathlessness
 BP to rule out hypertension
 The vital signs in the 1st 6 hours of the
puerperium will be conducted as follows:-
 First 2 hours -1/4 hourly
 Second 1 hour – ½ hourly
 Third 3 hours – hourly

58.  Mental status – for mood swings. Whether
happy, sad or depressed
 Head to toe examination (quick
assessment) refer to procedure manual.
 Head-observe the hair for hygiene and
nutrition status

59.  Face- for oedema and if it extends to the
whole body.
 Eyes-Pallor in the conjunctiva and nail
beds to detect any abnormalities like
anaemia, cyanosis and jaundice
 Check for Lymphadenopathy on palpation
of the neck and behind the ears which
could indicate systemic infection

60.  Hands-for oedema if there is generalised
oedema, palm pallor which could indicate
anaemia.
 Breasts- for lumps and later for
engorgement, also check if there is
lactation, check the state and size of the
nipples and attachment of the baby to
the breasts

61.  Abdomen- palpate the uterus if well
contracted for involution and measure
the fundal height.
Ask the mother about the after pains.

62.  Bladder- if emptied to assist in involution
 Legs- for calf tenderness, varicose veins which
may predispose to deep vein thrombosis
 Perinium- Check for the vaginal bleeding
Lochia – amount, colour, type, consistency and
odour
 Inspect the Genitalia – for lacerations or
episiotomy if sutured, state of stitches

63.  Record all the findings in the file and
chart and inform the client about their
condition. The patient is reviewed at 6
hours, 6 days and 6 weeks after delivery.

64. 5. Psychological care
 Explain to the client every procedure
carried out and her condition this is to
allay anxiety.
 Reassurance is very important
 Answer all questions asked
 Involve the support person in the care of
the patient.

65. 6. MENTAL STATUS
 Check for mood swings.
 Identify any causes of mood swings.
 Is she overjoyed, sad or depressed.
 How is the relationship to the baby?
 Has she accepted the baby?

66. 7. REST AND SLEEP
 Rest and sleep are very important in the healing
process
 Provide quiet environment to promote rest
 Assist with care of the baby to allow rest
 Analgesia and sedatives may be given to relieve
pain and promote rest.
 Ward routine should be done at the same time to
avoid disturbing the client.
 Rest and sleep builds up her psychological and
physical wellbeing. It also promotes lactation.

67. 8. PAIN RELIEF
 Explain to the patient about the physiology
of the after pains which are caused by mild
contractions of the uterus especially in the
multiparous women due to flaccid uterus
 Paracetamol 1000mg tds/oral can be given
if need be.

68. 9. NUTRITION (DIET)
The nutrition should be composed of
wholesome or well balanced diet:
 High in protein to build up worn out tissues
 High roughage to prevent constipation
 High vitamins for healing and prevention of
infection
 High fluid intake to prevent constipation
 High iron content to prevent anaemia.

69. 10. AMBULATION
 Early ambulation is essential to prevent
Deep Vein Thrombosis and promote
drainage of lochia and involution of uterus.
 Encourage walking to the toilet and
bathroom
If they can

70. 11. EXERCISES
Assist them with:
 Leg exercises to prevent Deep Vein
thrombosis
 ‘KAGEL’ exercises to promote muscle tone
to the perineum
 Abdominal exercises also important to
improve muscle tone

71. 12. GENERAL HYGIENE/ PREVENTION OF
INFECTION
 Vulval toilet or swabbing should be done 8
hourly in the first 24 hours
 Shower bath or big bath is more ideal in this
period
 Wash hands after use of toilet and before
feeding the baby
 Encourage frequent change of pads and Wearing
of clean pants.
 Discourage touching the vulva with dirty hands.

72. 13. CARE OF THE BREASTS
 Advise the mother to wear a proper fitting
brassiere
 Observe for proper attachment of baby to
the breasts to prevent cracked nipples
 Ensure that the baby empties the breasts at
each feed to prevent breast engorgement
 Check for any tenderness and redness
which could be a sign of infection

73. 14. ELIMINATION
 BLADDER- encourage frequent emptying of
the bladder to aid in involution of the
uterus. Check the bladder after micturation
abdominally to ensure that there is no
residual urine. If unable to pass urine, do
catheterisation
 BOWEL- high roughage, high fluids and
exercises to prevent constipation

74. 15. DRUGS
 Feso4 OD, folic acid OD in the first 40
days to replace the lost blood cells
 Vitamin B complex 1 OD
 Vitamin C to assist in the absorption of
iron tablets
 Deworming if necessary – mebendazole
500mg stat every 6 months or 100mg
BDx3 days
vitamin A 200,000 I.U stat

75. 16. INVESTIGATIONS
• Check Hb (normal is 10.5g/dl) if
clinically pale- estimated 24 hours after
delivery and the day before discharge
• Urinalysis- to rule out urinary tract
infection
• Pap smear- to rule out cervical cancer
• HIV/ AIDS Counseling and testing

76. 17. CARE OF THE BABY
 Assist the mother in the care of the baby or
involve the support person.
 Ensure the baby is breastfed, bathed, kept
warm and sleeps well.
 Observe for any minor disorders of the
newborn e.g. heat rash, constipation etc

77. 18. MOTHER BABY BONDING
 Encourage mother to participate in the
care of her baby. Allow her to stay with the
baby, talk to her and curdle her for
bonding. The baby needs to know who the
mother is.
 Never isolate the baby from the mother
unless the condition of the mother or baby
does not allow.

78. 19. Information education and
communication
Educate the postnatal mother on the following:
 Nutrition
 Rest and sleep
 Hygiene/prevention of infection
 Importance of postnatal review .i.e at 6 days,
6 weeks
 Disorders of the puerperium e.g. after pains,
breast engorgement

79.  Danger signs to the mother e.g. sub-involution of
the uterus, persistent red lochia, fever etc.
 Prevention of malaria and the importance of
medication such as iron and helminthics
 Family planning- dual protection of HIV/AIDS
 Resumption of sexual activity
 Resumption of menses
 Importance of exercise
 Self examination of the breasts

80. IEC on the baby
 Danger signs of the baby e.g. fever, unable
to feed, jaundice, high pitched cry.
 Care of the baby at home – warmth,
breastfeeding, danger signs, immunisations,
hygiene and prevention of infection
 Dangers of application of traditional
medicines on the umbilical area.

81.  The care given has to be documented. On
discharge, fill in the post natal part on the
antenatal card and a date is given for
review.
 Domicilliary visits to be carried out during
the first 10 days of delivery
 Carry out a thorough examination of the
mother and baby before discharge.