The puerperium is a six-week period following childbirth during which a woman's body undergoes physiological changes to return to a non-pregnant state. This process includes the involution of the uterus and other reproductive organs, as well as changes in hormone levels and various bodily systems. Monitoring lochia, vital signs, and hormonal fluctuations is crucial during this time to ensure proper recovery and identify potential complications.

1. PHYSIOLOGY OF
PUERPERIUM
PRESENTED BY
SHANTI SORENG
1ST YEAR 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 women recovers from
stresses of pregnancy and delivery and
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 tissues, specially the
pelvic organs revert back
approximately to the pre- pregnant
state both anatomically and
physiologically.
• -D.C DUTTA

4. DURATION
• Puerperium begins as soon
as the placenta 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:
1. The immediate puerperium:- the
first 24 hours after parturition;
when acute post anesthetic or
post delivery complication may
occur.
2. The early puerperium :- it extends
until the first week post partum.
3. The remote puerperium:- it includes
the period of time required for
involution of the genital organs
through the sixth weeks postpartum

6. REPRODUCTIVE
SYSTEM
UTERUS
Involution: it 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 3rd stage of labour, 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,

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

8. Return to the pelvis by about 2 weeks
Normal size by 6 weeks
The weight changes of uterus
i)1000g immediately after birth (excluding
the fetus, placenta, membrane and amniotic
fluids)
ii)500g- 1 week after birth
iii)300g- 2 weeks after birth
iv)50g -6 weeks after birth.
INVOLUTION
OF THE
UTERUS

9. The endometrial lining
rapidly regenerates( 16 days)
The placental site
undergoes series of
changes in the
postpartum period.
CONT.

10. • SUBINVOLUTION: Is the failure of the
uterus to return to a non- pregnant
state.
• The most common causes of sub
involution are retained
placenta fragments and infection.

11. LOWER UTERINE SEGMENTS
• Immediately following delivery the
lower segments 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.

13. • The external cervical os never
regains its pregnancy
appearance, it is no longer
shaped like a fish mouth.
• It return to its normal state at 4
weeks after birth.
CONT.

14. 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

15. MUSCLES
• There is marked hypertrophy and hyperplasia of muscle
fibers during pregnancy.
• During puerperiumthe 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 collagenase and release of proteolytic enzymes.

16. 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 by hyalinasation
and endophelebitis
• New blood vessels grow inside the thrombi.

17. Endometrium
 The superficial layer becomes necrotic and is
sloughed in the lochia.
 The basal layer adjacent to the myometrium
remains intact and is the source of new
endometrium.
 The endometrium arises from proliferation of the
endometrial glandular remnants and the stroma of
the inter glandular connective tissue.

18. CONT.
 By the 10th
day: Regeneration of the
epithelium is completed.
 By the day 16: the endometrium is
restored.
 At about 6 weeks: the endometrium of
placental site is restored

19. Vagina
 Takes a long time(4-8 weeks) to involute.
 It regains its tone but never to the virginal state.
 The mucosa remains delicate for the first few weeks
and submucous venous congestion persists even longer.
 Rugae partially reappear at third week.
 The introitus remains permanently larger than the
virginal state.

20. 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 menstraul
period, after that time the lochial flow
should steadily decrease.
LOCHIA – ODOUR AND REACTIONS:
• It has got peculiar smell.
• It reactions is alkaline leading to become acid
towards the end.

21. COLOR
• LOCHIA RUBRA- red color (1-4days)
It consists of blood , shreds of fetal membranes and
decidual, vernix caseosa, lanugo and meconium.
• LOCHIA SEROSA- yellowish or pink or pale brownish
colour (5- 9days)
It consists of old blood, less of RBC, but more in
leukocytes and wound exudates mucus from cervix
and microorganism
• LOCHIA ALBA- pale white (10-15days)
It contains of plenty of decidual cells, leucocytes, mucus,
cholestrin crystals, fatty and grandular epithelial cells
and micro organisms.

22. • AMOUNT
• The average amount of discharge
for the first 5-6 days is estimated
to be 250ml
• NORMAL DURATION
• The normal duration may extend
upto 3 weeks
• The lochia rubra may persist for longer
specially in women with twins and
scanty in premature labour.
• Can be more when women get up from
bed in the later period.
CONT.

23. CLINICAL IMPORTANCE OF LOCHIA
• ODOUR:
If offensive indicates retained pls or cotton pieces inside the
vagina
should be kept in mind.
• AMOUNT:
Scanty or absent signifies infection. If excessive also
indicates infection.
• COLOUR:
Persistence of lochia rubra beyond normal limit
signifies. Subinvolution or retained bits of
conceptus.
• DURATION:
Duration of the lochia alba beyond 3 weeks suggest local

24. General Physiological changes
Endocrine system
Placental hormones
 Insulinaze causes the diabetogenic effects of pregnancy to be
reversed.
 Estrogen and progesterone levels decrease markedly after
expulsion of the placenta, reaching their lowest levels 1
week into the postpartum period.
 The estrogen levels in nonlactating women begin to increase
by 2 weeks after birth, and higher by postpartum day 17.


25. Pituitary hormones and ovarian function
 Lactating and non-lactating women differ in the time
of the first ovulation.
 In women who breast feed, prolactin levels remain
elevated into the sixth week after birth.
 Prolactin levels decline in nonlactating women,
reaching the prepregnant range by third week.

26. 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.

27. Menstruation and ovulation cont..
 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.

28. Urinary system
 The bladder wall becomes oedematous and hyperaemic
and often shows evidences of submucous extravasation
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 overdistended
without any desire to pass urine.
 Dilated ureters and renal pelvis return to normal size
within 8 weeks

29. Blood and fluid changes
 Diuresis evident between second and fifth 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
first or second week after birth.

30. Blood and fluid changes
 Blood volume: Returned to normal level by 1 week
after delivery
 Cardiac Output: Remains elevated for 24 to 48 hrs
postpartum and declines to nonpregnant values by
10 days.
 Heart rate changes follow this pattern
 SVR: follows inversely

31. The 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 hemorrhoids.

32. Weight loss
 Rapid 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.
 Lochia flow- 2-3 lb(1kg) loss
 Total weight loss- 19 lb
 Additional weight loss depend on amount of weight
gain in pregnancy and active measures to reduce
weight.

33. Vital sign changes
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 third or fourth postpartum day, her
temperature rises for a period of hours because
of the increased vascular activity involved.

34. 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.

35. Pulse cont…
 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.

36. Blood pressure
 Systolic and diastolic blood pressures remain
unchanged from late pregnancy values until
about 12 weeks post partum, after which
they increase.
 Within 2 weeks post partum, systemic
vascular resistance increases by 30%

37. THAN
K
YOU…