The normal puerperium period lasts 6 weeks following childbirth as the body returns to its non-pregnant state. The uterus undergoes rapid involution, decreasing in size by about 1 cm per day as the endometrium regenerates and vascularity decreases. Lochia changes color and amount over time. Other pelvic organs like the cervix and vagina also involute. The mother's metabolic, circulatory and respiratory systems return to pre-pregnancy levels within a few weeks. Proper postpartum care includes rest, ambulation, perineal care, breastfeeding support, immunizations, and family planning education to aid the body's recovery process over the 6-week period.

1. Normal Puerperium
BY
Mrs.Shanthi.P
Associate Professor
SRMTCON

2. Puerperium
• Period of 6 weeks following childbirth during
which the maternal organs, especially
reproductive organs return to the non
pregnant/near normal state
• Breasts are an exception: active during the
period

3. Physiology
• Involution : normalization in the size of pelvic
organ
• Involution of uterus
• Involution of other pelvic organs
• Pelvic musculature
• Changes in non reproductive organs
• Menstruation, ovulation
• Breast feeding

4. Involution of uterus
• Decrease in size
– Reduction in size of muscle
fibers: removal of excess of
cellular cytoplasm by
intracellular,
autolytic,proteolytic enzymes in
form of peptones-blood stream-
excreted by kidneys
• Reduction in vascularity:
thrombosis & degeneration of
uterine vessels
• Regeneration of endometrium:
glandular remnants,
interglandular stroma ,
completed in 4-6wks

5. Involution of uterus
• Involution is the rapid decrease in the size of the uterus as it returns to the non-
pregnant state and the beast feed may experience a more rapid involution.
Assessment:
 Weight of the uterus decreases
 Endometrium regenerate
 Fundus descends in to the pelvis
 Fundus height decreases about 1 finger (1 cm)/day.
 By 10 days postpartum the uterus cannot be palpated abdominally
 Note that a flaccid fundus indicate uterine atony and should be massaged until
firm a tender fundus indicate an infection.

6. Lochia-(vaginal discharge following delivery)
• Lochia rubra:
– color is red
– Blood, leucocytes, sloughed decidua, mucus
– Rubra is a bright red discharge that occurs from delivery day to day 3.
• Lochia serosa:
-progressively pale, blood tinged ,thinner in consistency
-Serosa is brownish pink discharge that ocuure from days 4 to 10.
• Lochia alba:
– yellowish white in color, scanty
– Mucus, serous exudates, epithelia cells, leucocytes
– Alba is white discharge that occurs from days 10 to 14.
• Clinical significance: odour, duration

7. Assessment of lochia:
 The discharge should smell like normal menstrual flow
 Discharge decreases daily in amount
 Discharge may be increase with ambulation
 Breast feeding may increase lochia.
 Foul – smelling lochia and scant may indicate an infection.
 Bright red blood indicate cervical or vaginal laceration.

8. Involution of other pelvic organs
• Cervix:
– loose ,flabby, thrown into folds after delivery
– Contracts ,thickens feels tubular but remain
patulous, by 6 weeks involution is complete
• Vagina:
– soft, dusky, engorged, stretchable
– diminishes in size, caliber, never to pre pregnant
state

9. Urinary tract changes
• Renal pelvi calyceal dilatation:
Normal in 8wks,may persist 12
weeks postpartum
• Increased renal plasma flow, GFR,
creatinine clearance: normal by 6
wks
• Bladder:
– During labor: edematous, hyperemic
– trauma to bladder innervations:
instrumental, difficult vaginal
delivery: relatively insensitive,
retention of urine, infection

10. Bowel changes
• Constipation
• Intestinal paresis following
delivery
• Altered tone of perineal
muscles following delivery
• Painful perineal lesion
• Early ambulation, increased
fluids, high fibre diet

11. • Metabolic changes: reversal of changes
(hyperlipidemia , raised blood sugar)
• Circulation:
– CO increases by 70% following delivery: prelabor
values by 1 hr PP & pre-pregnant levels by 4wks
– Increase in peripheral resistance(loss of progesterone
effect)
– Normal total circulating blood volume by 3-6 wks
• Respiratory changes: rapid normalization of
residual volume, FRC

12. Menstruation& ovulation
• Onset of menstruation: lactating/non lactating
• Lactation: increased prolactin levels-
– inhibits ovarian response to FSH(less follicular
growth),no menstruation
– Suppresses release of LH, no LH surge, no
ovulation

13. menstruation ovulation
Non lactating
women
By 6th wk(40%)
By 12 th
wk(80%)
4wks
Lactating
women
By 12 wks(70%)
6 months
10wks

14. Management of normal puerperium:
objectives
• Restoration of health to pre-pregnancy state
• Promotion of lactation
• Prevent infection
• Care of the infant
• Advice on immunization
• Advice on discharge

15. Immediate care
• Examine vital parameters : PR,BP
• P/A: uterus well retracted
• L/E: amount of bleeding, perineal wound( if any)
dressing by antiseptic, dry, application of sterile
pad
• Encouraged to pass urine
• Meet relatives, baby put to breast feed
• Allowed drinks, food
• Shifted to room/ward

16. changes in post delivery period
• Pulse : tachycardia, settles in a day
• Blood pressure: normal/raised: increased
venous return, normalizes in 24 hrs
• Temperature: transient rise (99.0°F)
• Urine output: diuresis following delivery
• Emotional instability: anxiety, unfamiliar to
newborn, change in lifestyle, newer demands
cause psychological stress, puerperal blues

17. Care during puerperium
• Rest & ambulation: adequate rest, no
specified period
• Early ambulation encouraged:
• Restores self confidence
• Accelerates recovery, encourages drainage of lochia,
involution
• Lessens venous thrombosis-embolism
• Hospital stay: 48 hrs( normal delivery)
5-7 days (cesarean delivery)

18. Care during puerperium
• Diet: lots of fluid, easy to digest diet(milk,
green leafy vegetables, fresh fruits)
• Care of breasts
• Care of bowel & bladder: encouraged to pass
urine frequently, having more roughage,fluids
in diet corrects constipation
• Care of perineum: kept clean, dry after every
act of urination/defecation

19. Rooming –in
• allowing mother & her baby to stay together
after birth
• Advantages:
– mother responds to her baby whenever is hungry
– helps bonding & breast feeding
– Confident about breast feeding, feeds on demand
– Better understanding of mother about baby

20. Immunization
• Non immunized Rh negative mothers: fetal
cord blood- anti D immuno-
prophylaxis(300µg) IM ,within 72 hrs of birth
• Tetanus toxoid: booster dose, if not given
during pregnancy
• Rubella vaccine

21. Management of ailments
• After pains: infrequent, spasmodic lower pain
abdomen after delivery
• Pain on the perineum: analgesics, sitz baths,
examination to rule out vulvovaginal
hematomas
• Correction of anemia: iron(oral/parenteral)
supplementation
• Treatment of BP

22. Involution of uterus
• Immediately following
delivery: at umbilicus
• Rate of involution: 1cm
/day
• Becomes pelvic organ
by 10-12 days

23. Postpartum FP services
• Barrier methods
• PPIUCD
• Oral pills ( progesterone only pills)
• Injectables (DIMPA)
• Sterilization (Tubectomy)
• LAM( Lactational amenorrhea method)

24. Postpartum exercises
• To tone up the pelvic floor muscles
– Contract pelvic muscles (withhold act of
urination/defecation) & relax
• To tone up the abdominal muscles
– Dorsal, knees bent, contract & relax abdominal
muscles alternatively
• To tone up the back muscles
– Prone, arms by side, head & shoulders are slowly
moved up & down

25. Postpartum exercises
• When to start: as soon as the pt appears to be
fit
• Initially: deep breathing, leg movements
• Adv:
– improves muscle tone
– Minimizes risk of DVT
– Prevent gynecological complications: prolapse
• Continued for 3 months

26. Discharge
• Thorough checkup of mother & baby
• Measures to improve general health of
mother: diet,hematinics
• Postnatal exercises
• Breast feeding & care of newborn,
immunization
• Family planning advice
• Follow up after 6 wks

27. Postnatal checkup /care
• Minimum of three checkups
• First <48hrs of delivery
• Second within 7 days
• Third at 6th week

28. Objective
• Assess health status of mother
• Reassess ,detect & treat any
medical/gynecological complication
• Assess progress of baby
• Immunization of baby
• Impart family planning options to mother

29. Postnatal checkup
• Examination of mother : general, breasts, local
examination if required
• Examination of baby: well baby clinic
• Advice
– General: health, feeding, immunization
– Postnatal exercises
– Impart family planning methods

30. Postnatal assessment
BUBBLE-HE
• B: Breast
• U: Uterus
• B: Bladder
• B: Bowels
• L: Lochia
• H: Homan’s
• E: Episiotomy and perineum
• B: Breast Assessment

31. THANK YOU