The normal puerperium period lasts 6 weeks following childbirth. During this time, the pelvic organs and body return to their pre-pregnant state. Physiological changes include the involution of the uterus, shedding of the endometrium and lochia discharge, closing of the cervix, and normalization of other organs and systems. Care during this period involves monitoring for complications, encouraging rest and early ambulation, perineal care, lactation support, nutrition, immunizations, contraception counseling, and postnatal checks to ensure full recovery.

1. Sreelakshmi. M

2. Normal puerperium

3.  Six weeks following childbirth during which the
pelvic organs return to prepregnant state &
physiological changes of pregnancy are all
reversed.
 Immediate: within 24 hours
 Early : up to 7 days
 Woman in puerperal period: puerpera

4. Physiological
changes

5. 1. Involution of the uterus
• process by which postpartum uterus returns
to prepregnant state
• End of 3rd stage of labor: fundus just below
umbilicus
• By 2 weeks: descends into abdomen not palpable
through abdomen
• Weight: 1000g (immediately after delivery) 500g
by 1 wk. 300g by end of 2nd wk.
• Returns to prepregnant state 4 wks. after delivery
• Achieved by decrease in size of muscle fibers
• by autolysis of cytoplasm by proteolytic enzymes

7. • After pains : infrequent, spasmodic pain in
lower abdomen for up to 3-4 days : common
due to uterine contraction
: during breast feeding (oxytocin)
Due to blood clots uterus contract
attempt to remove clot
More in primipara
If severe: antispasmodics

8. 2. Endometrium
• Decidua shed after childbirth
• S.compactum & S.spongiosum shed
• S.basale remains new endometrium from
remnants of endometrial glands completed in 14
days.
3. Placental site
• Takes longer to recover
• Arteries: obliterated by endarteritis & hyaline(1wk)
• Veins: thrombosis
• Last to involute
• Regeneration: 6wks

9. 3. Lochia
• Vaginal discharge for first few wks. following delivery
• Blood from placental site + necrotic decidua
• Lochia rubra: red color, 1st few days following
delivery
• Lochia serosa: paler , 3-4 days
leucocytes, necrotic decidua + red cells
• Lochia alba: yellowish white,
after 10th day
• Persists up to 4 wks.
• Gives information about any
abnormality like infection

10. 4. Cervix
• Contract immediately after delivery
• Remains patulous for few days
• Starts closing (at end of 1st wk.), cervical canal
reforms, completed by 6th week.
• External os wont regain original appearance
parous cervix has characteristic transverse
slit
• Lower segment: contract form small
uterine isthmus (6 wks.)

11. Other Pelvic Organs
 Vagina: smooth & stretchable for first few days
size reduced & rugose within 4 wks.
 Hymen: represented by caruncle myrtiformes
(small tags of tissue)
 Relaxation of vaginal outlet & pelvic floor

12. Urinary system
Bladder: sustains trauma mucosal edema
& submucosal hemorrhages disappear in
few days
Prolonged& difficult delivery injury to bladder
innervation insensitive bladder capacity &
insensitive to intravesical fluid pressure
Over distension
Incomplete emptying
Residual urine / retention
Exaggerated in epidural & spinal anesthesia
After 1st week, recedes during the following weeks

13. Dilated ureters & pevicalyceal system:
normal in 8 wks
Renal plasma flow, GFR & creatinine clearance :
normal by end of puerperium
Increased extracellular water( in normal pregnancy)
becomes normal with postpartum diuresis
(2nd-5th days)
Urea & creatinine elimination : remain high for 2
wks

14. Delivery intestinal paresis constipation
Pain in perineum also contributes (episiotomy &
lacerations)
Early ambulation, high fiber diet, increased fluid
intake

15. • Rapid fall of plasma volume in 1st day
• Slowly to non-pregnant volume: end of 1st week.
• Red cell mass : normal within 24hours
• Hb concentration: minimum on 4th day & normal by
6 weeks
• ESR: in 1st week & normal by 4 weeks.
• Increased leukocytosis (during & after labor) :
subsides after 1 week
• Platelets: in no. with adhesiveness
• Fibrinogen: in 1st week.
• Coagulation factors: increased & persists in

16. • Heart size returns to normal slowly
• Heart sounds returns more rapidly
• 3rd sound & systolic ejection murmurs: disappear in
1wk
• C.O: for 24 hours : steady fall till 10th day: almost
normal
• Actual non-pregnant value: only by 6 months
• C.O : due to in SV & HR
• Heart rate ~ C.O
• Fall in stoke volume is slow
• BP : rises in 1st days & normal by 1 week
• Peripheral Resistance: rises rapidly to

17. • Uterine evacuation
• Normal blood loss
• Further 2-3kg : diuresis
• Prepregnant weight in 6 months

18. • Variable
• Depends on lactation
• Non-lactating: early resumption by 6-8 weeks
• In nursing mothers: 70 % amenorrhea till 4-6
months
• Total protection only for 10weeks: ovulation return
by the end of lactational amenorrhea.
• Additional contraceptives : after 3 months ( even in
completely breast feeding)

19. Care in
puerperium

20. • Observed for minimum 2hours in labor ward : vital
signs, bleeding, micturition
• Uterus : well contracted. Bleeding: within normal
limits
• Before shifting to ward:
>examine perineum, episiotomy site
>sterile dressing with antiseptic
• Relatives, food, fluids, good sleep
• Encourage early ambulation

21. • Assessed by noting height of fundus above
symphysis pubis
• Day after delivery: 12 cm above symphysis
• 1cm decrease per day
• By end of 2nd week: no longer
palpable

22. • Encouraged to void soon after delivery
• Doesn’t void within 6-8 hours : bladder atony
• Retention : common in early puerperium (esp. in
epidural analgesia & traumatic delivery with perineal lacerations)
: vulvovaginal hematoma
 Uterine atony hemorrhage
 Urinary infection
• Local analgesics
• Catheterization (for 24 hours) till tone restoration

23. • Constipation
• Increase fluid intake & roughage
• Prescription of mild laxatives

24. • Immediately start normal diet
• Plenty of fluids & milk daily : lactation
• Calorie & protein intake
• Additional daily requirement: 500kcal & 25g
proteins
• Fresh fruits & green leafy veg : vitamins
• Iron: continued for 3 months / whole lactating
period

25. • Regular antiseptic cleaning of episiotomy wound
• Wash with warm water & use sterile pads
• Analgesics
• Severe pain: hematoma
• Infection : antibiotics
• Episiotomy wound: healed by 3 weeks

26. • Must be adequate,
• Rooming in : baby on mother’s cot
Early ambulation
• Venous thrombosis & embolism

27. • Baby breast fed as soon as possible
• No frequent & early feeding engorged & painful
• Correct positioning &clean nipples
• Draw out retracted nipples
• Cracked nipples: painful
: emollient creams after feeds

28. • Episiotomy & perineal lacerations, breast
engorgement & after pains ( uterine contraction )
• Caesarean section: pain at incision site, post spinal
headache
• Analgesics

29. • Common in early puerperium : postpartum blues
• Reassurance & support
Hospital stay
 Vaginal delivery: after 48hrs
 Caesarian section : 4-5 days

30. 1. Immunization of mother
Anti-D IgG within 72hrs
Rubella vaccine / MMR
2. Contraception
Post partum sterilization
Interval sterilization
Counseling

31. 3. Medications
 Adviced to avoid medications as far as possible
 Take only on medical advice
4. Infant advice
 Adequate follow up
 Rooming in
 BCG vaccine prior to going home
 Immunisation schedule
 Advice mother to feed on demand

32. 4. Postnatal exercises
Early in puerperium
Move limbs, deep breathing
exercises, abdominal muscle tightening
exercises everyday
Repeated 3-4 times a day
Perineal muscle exercises: improve vaginal muscle
tone, prevent vaginal laxity & stress incontinence
Back muscle toning

34. Postnatal
check-up

35. • Scheduled at 6 weeks
• Maternal problems discussed
• Breast-feeding
• Lochia & menses
• Clinical examination, abdomen, breasts
• Local examination : episiotomy & discharge
• Pelvic examination
• PIH, GDM
• Any medical problems
• Advice on resuming job, coitus,
other activities

36. • Breast feeding alone wont suffice as contraception
• Various options given, partner included
• IUCD inserted if acceptable
• Other options which wont reduce breast milk amount
Progesterone only pill
Injectable progestogens
(depot medroxy progesterone acetate)

37. Inform about possible side-effects
Should avoid estrogen-pregesterone
combination: affect quantity & quality of milk
Permanent sterilizations: postpartum/ interval
sterilization/

38. • Seen by pediatrician
• Checked for any problems
• Weight , feeding problems
• Reinforce immunization schedule

39. Restoration of maternal health to prepregnant state
Promotion of breast feeding
Correction of any problems arising due to delivery
Advice on baby care & immunization
Contraceptive advice

40. Thank you