puerperium

1. PRAMODHIYA SANDUNI PERERA
TAMADI KULATHILAKE
ZAYNAB FIYAZ
MOHAMMED SHAYAN
The Puerperium

2. The Puerperium
 the time following delivery during which pregnancy-induced maternal
anatomical and physiological changes return to the nonpregnant
state.
 Its duration is understandably inexact, but is considered to be
between 4 and 6 weeks.
 Involves-
• Involutional changes in the mother’s body
• Intensive functioning of breast
• And hormonal system inducing lactation.

3. Changes to the UTERUS
The body of the uterus-
• The uterus gradually decreases in size
- The fundus lowers 2 cm daily
- On the 10th day - can not be examined above
the pubic bone
- At the end of 4 weeks - pre-pregnancy size
The mass of uterus decreases by following rate:
_ At the end of the first week ≈ 500 g
_ At the end of the second week ≈ 300 g
_ At the end of the third week ≈ 250 g
_ At the end of the forth week ≈ 50 - 100 g
The lower segment of the uterus-
• Immediately after delivery the
lower segment of uterus is 0,5
cm thick
• In several weeks after delivery
the power segment of uterus
involutes into the supra-vaginal
portion

5. Changes to the endometrium
• The endometrium regenerates from the basal lamina of the decidual layer
• Granulation tissue is formed in the subepithelial layer after 2-4 days
• Granulation is a protective barrier against the penetration of microbes
• Epithelization of the free surface of cavity completes by the 7-10th day
• Epithelization of the placental lining - by the end of III-IV weeks

6. Involution of the CERVIX
• The cervix diameter is 5-6cm after
12 hours
• The internal os is closed by the
10th day
• The external os is closes by the end
of the II-III weeks
• Cervix never reverse back to its
original form

7. LOCHIA
 Lochia is post-partum vaginal discharge
during the regeneration of endometrium,
containing necrotic decidual tissue and
blood clots
• Evaluation:
-lochia rubra -2-3 days after the
delivery
-lochia serosa-3-10 days from delivery
-lochia alba-from the 10th day after
delivery
• Typically lasts for 5-6 weeks after
delivery
• Total amount -500-1500g
• The reaction- alkaline or neutral

8. Involution of the Vagina
• Immediately after the delivery vagina is:
-Loose, Smooth,Flabby,bluish-pink muscle tube
• In postpartum period vagina:
-Gradually decreases in size
-Ruga (structures of the vagina that are transverse ridges formed out of the
supporting tissues and vaginal epithelium in females) reappear by the third
week
-Rarely returns to its initial size

9. Changes to the OVARIES
• Ovaries gradually decrease in size
• Corpus luteum regenerates into the scar tissue
• Menses returns in about 36-42 days
• Breastfeeding mothers usually have lactational
amenorrhea

10. Changes in the BREAST
• The breast is composed of:
-Connective tissue
-Adipose tissue
-Glandular tissue
• Each breast is composed of 15-20 lobes
• Each lobe consists of smaller lobules
• Each lobule consists of large number of areoli
• Each areolus has small milk canal
• Alveoli canals form the lobule duct
• Lobule ducts unite into the lobe duct
• Lobes lactiferous duct drains into openings in the
nipple
• Myoephitelial cells are located in ducts
• Myoephitelial cells are located in the walls of areoli
• Myoepithelial cells can contract
Postpartum changes in breast:
• Mamogenesis
• Lactogenesis
• Galactopoesis
• Galactokinesis

11. Mammogenesis
 is the process of growth and development of the mammary gland in
preparation for milk production.
 This process begins when the mammary gland is exposed to estrogen at
puberty and is completed during the third trimester of pregnancy.
 Before pregnancy, the breast is predominantly adipose tissue without
extensive glandular or ductal development. Under the influence of
uninterrupted and rising concentrations of estrogen, progesterone,
and prolactin during pregnancy, the breast increases in water,
electrolyte, and fat content.
 The increase in volume is accompanied by a marked increase in the
vascular supply to the breast; the dilated subcutaneous mammary veins
become prominent, and the blood flow increases twofold.

12. Estrogen
 The rising plasma estrogen levels, which greatly stimulate the ductal arborization begun at
puberty and the differentiation of epithelial cells into ductal, acinar, and myoepithelial
elements.
 As the acinar-ductal system expands, it replaces much of the fatty tissue of the breast and is
organized into mature, functional, lobular-alveolar-ductal units surrounded by hypertrophied
myoepithelial elements
 In addition to its effect on the mammary cells themselves, estrogen stimulates the synthesis
and release of prolactin from the pituitary lactotrophs.
 Rising prolactin levels appear to be necessary for estrogen to exert its biologic effects on the
mammary gland. In addition, prolactin induces the enzymes necessary for the acinar secretory
activity seen after delivery.
 Prolactin levels increase from 20–200 ng/ml during pregnancy.

13. Progesterone
 secretion increases from 3–300 mg/day during pregnancy.
 In the presence of estrogen and prolactin, progesterone stimulates acinar proliferation and
inhibits lactose synthesis.
 The high plasma concentrations of estrogen and progesterone present before delivery inhibit
the active secretory effects of prolactin on mammary alveolar epithelium.
 The initial stimulation of mammary epithelium occurs during the first few weeks of
pregnancy.
 By the second trimester, colostrum, the first milk, appears in the alveoli of the acinar glands in
small quantities, reflecting the beginning of protein synthesis under the influence of prolactin.
 By the third trimester, the alveoli contain significant amounts of colostrum, the epithelial cells
are laden with fat droplets, and the adipose tissue of the breast has been markedly reduced
and replaced by functioning glandular units.

15. Lactogenesis
• lactogenesis is ensured by hormone
prolactin
• During suckling a massage is
delivered to the brain
• Prolactin synthesis increases In
the hypophysis
• Prolactin stimulates the milk
production in areoli
• Prolactin level in blood peaks in 45
minutes
• Prolactin is more intensively
synthesized at night
• Prolactin suppresses ovulation
STAGES OF LACTOGENESIS DESCRIPTION
Stage I (secretory
differentiation)
Beginning in mid-pregnancy to day
two or day three postpartum, the
breasts develop the capacity to
secrete breast milk, including the
secretion of colostrum.
Stage II (secretory
activation)
Beginning on day two or day three
postpartum until day eight, breast
milk volume increases rapidly and
then abruptly levels off.
Stage III (galactopoiesis)
From approximately day nine
postpartum and onwards, the
volume of breast milk produced is
maintained through a supply and
demand mechanism.
Stage IV (involution)
Involution occurs, on average, 40
days after the last breastfeed, when
breast milk secretion ceases.

17. GALACTOPOIESIS
 Galactopoiesis is the maintenance of milk production once it has been established by completion of lactogenesis.
 The single most important factor in successful galactopoiesis is regular and frequent milk removal from the mammary
gland.
 First, regular suckling promotes the regular synthesis and release of both prolactin and oxytocin, which are necessary
for continued milk secretion.
 Second, the breast has the capacity to store milk for a maximum of 48 hours before there is a substantial decrease in
production. This reduced milk production is caused by the diminished stimulation of the glandular epithelium by
prolactin and the vascular stasis caused by increased intramammary pressure resulting from distention of the
mammary ducts and alveoli with stored milk. Blood flow to the mammary glands is significantly reduced by this
increased intramammary pressure, which diminishes the nutrient and hormonal supply necessary for milk
production.
 Third, as in other milk-producing animals, the amount of milk produced daily is fairly closely related to the demand
(i.e. the amount of milk removed the previous day), as long as the nutritional and hormonal requirements are met.

18. Galatokynesis
• During suckling sensory impulses are transferred to the brain
• Oxytocin is secreted from posterior pituitary
• Oxytocin contracts the myoepithelial cells of the breast
• Oxytocin reflex causes “milk ejection”
• Oxytocin contracts the smooth muscle of the uterus

20. Four main principles of postpartum care for moms and
newborns
1. Ensure mother’s and child’s good physical health
2. Provide support in early and successful
breastfeeding
3. Convince mother in her abilities
4. Counsel mother about newborn’s care and family
planning methods

21. Four main needs for the newborn
1. Love
 Love And Affection Are Essential To A Child’s Healthy Brain
Development.
2. Warmth
 Babies Can't Regulate Their Body Temperature.
 Skin-to-skin Contact With The Mother Or Kept In An Incubator Or
Open Bed With Radiant Warmer.
 Help Them Feel Safe And Secure.
3. Breastfeeding
 Transfer Of Normal Skin Flora From Mother To Infant
 Promote Healthy Growth.
4. Prevention Of Infections.
 Infants Do Not Have Fully Developed Immune Systems, So They Are
More Susceptible To Infectious Illnesses.

22. Postpartum care practices
Evaluation of
diuresis and
defecation
Pulse
Prevention of
postnatal
infections for
moms
General well-
being
Convincing
mother in her
abilities
State of the core
organs
Type of lochia Breast health
Height of
uterine fundus
Body
temperature -
during 10 days,
2 times a day
State of external
genital organs
Early activation,
postpartum
physical
exercises
Counseling in
family planning
Mother and
babies all 24
hours together

23. Keeping mother & child together during 24H
• Mother and her newborn child should be together since the very moment
of birth
• Routine care of a newborn is done by mother
• Medical personnel supports mother in newborn care
• Household members assist mother in newborn care

24. Advantages of keeping mother & child together during the 24H
Benefits for baby:
• Protecting infants from possible
infections. / Babies exposed to normal
bacteria on mother’s skin, which may
protect them from becoming sick due to
harmful germs.
• Mother-child bonding and
establishing warm relations
• More frequent and long breast
feedings
• Better quality sleep. Your baby will develop
a more regular sleep-wake cycle earlier, and
may help ease the transition to day/night
routines
• More stable body temperatures
• Generally more content, less crying
• More stable blood sugar
• Breastfeed sooner, longer, and more easily
• Lower levels of stress hormones
Benefits for mother:
• Convincing mother in her abilities
• Preventing of breast-feeding
complications
• Better quality sleep
• Increased confidence in handling and caring for
baby
• Ability to learn what your baby’s cues are
(sleepy, stressed, in need of quiet time, or
hungry)
• Earlier identification of early feeding cues
(rooting, opening mouth, and sucking on
tongue, fingers, or hand)
• Improved breastfeeding experience
• Less infant crying and distress (they love to be
near you)
• Less “baby blues” and postpartum depression
• Parents are better-rested and more relaxed by
the end of the first week home.
• Increases opportunity for skin-to-skin contact

25. Danger signs & Common postpartum symptoms
 Vaginal bleeding(2-3 pads during 30 minutes)
 High temperature
 Tachypnoe
 Abdominal pain/ Cramping
 Breast and nipple pains
 Swollen breasts
 Urinary incontinence or pains at urination
 Pain in your perineum (area between
your vagina, anus)
 Odorous vaginal discharge
 Pain in your back, neck, or joints
 Pain around your incision (if you had a cesarean birth)
 Bladder problems
 Bowel problems
 Hemorrhoids

26. Common postpartum problems
Postpartum pains
 How long does postpartum pain last?
The type, intensity, and duration of postpartum symptoms will vary from person to person. Some
symptoms may last a few days, while others may last several weeks.
 What can mother do about postpartum pain?
There are many ways to control pain, including self-help treatments, over-the-counter
medications, and prescription medications. Talk with your obstetrician–gynecologist (ob-gyn)
about your options for pain relief before you leave the hospital.
 When should mother call doctor?
While most postpartum discomforts are normal, they should not prevent you from being able to
take care of yourself and your baby. Some symptoms may be a sign there is a serious problem.
 What pain relievers are safe to take while breastfeeding?
Ibuprofen is usually the preferred first step because little of it passes through breastmilk.
Acetaminophen also is safe to take while breastfeeding. Talk with your ob-gyn if you feel you need
other options, or before combining two or more pain medications. They may prescribe low doses
of a mild opioid (a pain reliever such as codeine) for you to take for a short period of time.

27. Common postpartum problems
Psychological problems
 Third day melanchony- 80%
- Melancholic is a type of depression.
- Symptoms of melancholic depression include:
A distinct quality of depressed mood characterized by profound
despondency, despair, or emptiness.
Depression that is consistently worse in the morning.
Early morning waking.
Psychomotor disturbances.
complete loss of pleasure in all or almost everything.

28. Common postpartum problems
Psychological problems
 Postpartum depression (14-20%)&
Postpartum psychosis(1% and less)
- Some new moms experience a more severe, long-lasting
form of depression known as postpartum depression.
- Rarely, an extreme mood disorder called postpartum
psychosis also may develop after childbirth.
- Postpartum depression symptoms - Depressed mood or
severe mood swings, Excessive crying, Difficulty bonding
with your baby, Withdrawing from family and friends, Loss
of appetite or eating much more than usual, Inability to
sleep or sleeping too much, fatigue, Reduced interest,
Intense irritability and anger, Fear that you're not a good
mother, Hopelessness, Restlessness, Severe anxiety and
panic attacks, and Recurrent thoughts of death or suicide
- Postpartum psychosis symptoms - Confusion and
disorientation, Obsessive thoughts about your baby,
Hallucinations and delusions, Sleep disturbances,
Excessive energy and agitation, and Attempts to harm
yourself or your baby.
Complications
Left untreated, can interfere with mother-
child bonding and cause family problems.
For mothers. sometimes becoming a
chronic depressive disorder. Even when
treated, postpartum depression increases a
woman's risk of future episodes of major
depression.
For children. have emotional and
behavioral problems.

29. What are the postpartum infections?
 Most common - endometritis, cesarean section incision infection, and
mastitis.
 Less common postpartum infections — for instance, urinary tract infections
caused by catheters.
 Can happen after someone has left the hospital or they could develop while
they're still in the hospital.
 risk factors - someone who had their water broken for a long time while they
were in labor or if someone was in labor then had to have an emergency C-
section.

30. Mother’s infectious disease prevention
• Prevention of breast infections
- Early breastfeeding
- Exclusive breastfeeding
- Proper latch on techniques
- Feeding a baby on demand
• Personal hygiene
- Wash hands
- Take shower
- Breast hygiene
- Keep the perineum clean
- Frequent change of pads
• Endometritis treatment
- Can treat it with oral antibiotics or
IV and it goes away fairly quickly.
• cesarean section incision
infection treatment
- Sometimes they have to be in the
hospital for a few days to receive IV
antibiotics
- require more intervention that could
include a drainage tube to allow the
infection to drain over time or
reopening the C-section to inspect
and remove infected tissue.

31. Newborn infectious disease
 An infection acquired after birth occurs when a newborn has close contact with an infected mother directly or
through breastfeeding. An infection acquired after birth can also occur if newborns have contact with infected
health care practitioners, family, or visitors in the hospital or at home.
 Infections in newborns are usually caused by bacteria or viruses and less commonly by fungi or parasites.
 The more common bacteria- group B streptococci, Escherichia coli (E. coli), Listeria monocytogenes,
gonococci, and chlamydiae.
 The more common viruses causing infection in newborns include herpes simplex viruses (HSV), human
immunodeficiency virus (HIV), cytomegalovirus (CMV), and hepatitis B virus (HBV).
 pneumonia, sepsis, and meningitis
Newborn infectious disease prevention
• Keeping clean delivery kits
• Keeping newborns warm
• Umbilical cord stump - open and dry care
• Early latch on and exclusive breastfeeding
• Conjunctivitis prevention
• Keeping proper hand wash techniques
• Early discharge from the hospital

32. Ineffective postpartum care for mothers and newborns
 Routine medication
 Routine examinations without indications
 Restrictions for household members and relatives
 Limitations for mother-child contacts
 Use of liniments and ointments for nipple care
 Use of antiseptics for umbilical cord care
 Tight swaddling of a newborn
 Control weighing of a newborn before and after feeding

33. Stages of breast milk
Colostrum
• ls produced during the first 2-5
days after birth
• Colostrum is high in protein,
fat-soluble vitamins, minerals,
and immunoglobulins.
Immunoglobulins are
antibodies that pass from the
mother to the baby and provide
passive immunity for the baby
Transitional
milk
• Is produced till the 10th day
after birth
• includes high levels of fat,
lactose, and water-soluble
vitamins. It contains more
calories than colostrum
Mature milk
• Production begins after the 10th
day after birth
• Fore-milk: This type of milk is
found during the beginning of the
feeding and contains water,
vitamins, and protein.
• Hind-milk: This type of milk
occurs after the initial release of
milk. It contains higher levels of
fat, protein and is necessary for
weight gain.

34. Colostrum
 The first stage of breast milk. It occurs during pregnancy and lasts for several days after the birth of the baby. It is either
yellowish or creamy in color. It is also much thicker than the milk that is produced later in breastfeeding.
It is rich of:
• Proteins
-globulins
• β- Lactose
• Growth factors
• Minerals
-rich in magnesium, which supports
your baby’s heart and bones, and
copper and zinc, which also support
immunity
• Macrophages, lymphocytes,
lysozymes, complements
Colostrum functions:
• Protective
immunoglobulin A (IgA) offers the newborn
protection against enteric pathogens. Other
host resistance factors found include
complement, macrophages, lymphocytes,
lactoferrin, lactoperoxidase, and lysozymes,
Colostrum is an infants’ first
immunization against many bacteria
and viruses.
• Energetic
• Laxative
helps your baby clear meconium (your baby's
first poop) and lessens the chance of jaundice

35. Breast milk
 Mature milk is a complex and dynamic biological
fluid that includes fat, proteins, carbohydrates,
bioactive factors, minerals, vitamins, hormones,
and many cellular products.
 Essential amino acids are derived from blood, and
nonessential amino acids are derived in part from
blood or synthesized in the mammary gland. Most
milk proteins are unique and include alpha-
lactalbumin, beta-lactoglobulin, and casein. Hence
milk proteins are not elsewhere together in such
high amounts.
 A nursing mother easily produces 600 mL of milk
daily.
Advantages of breast milk-
•The ideal source of nutrition
•Easily digested
•Optimal composition
•Suitable temperature
•Unique composition

36. COMPONENTS OF BREAST MILK
• Protective components
• Immunoglobulins
• Leucocytes
• Oligosaccharides, bifidus factor
• Lactoferrin, lactalbumin, casein
lactoferrin binds iron and is transferred via a
variety of receptors into and between cells, serum,
bile, and cerebrospinal fluid. It has important
immunological properties, and is both
antibacterial and antiviral
Casein protein is a protein found in milk that
gives milk its white color, it contributes to the
amino acid pattern of human milk, and is highly
digestible. It also has the ability to form stable
aggregates that include calcium and phosphorus.
• Lysozymes
• Vitamins A and C
• Maturing agents
• Growth factors
• Immunomodulators
• Other components
• Alimentary enzymes
• Hormones
• Water

37. • Benefits Emotional contact
Breastfeeding parents learn to read their infant’s cues, and babies learn to trust caregivers. This helps shape your baby’s
early behavior.
• Protects from infections
• Contraceptional method
Lactation amenorrhea means you aren’t menstruating due to lactation. Because your body produces prolactin, which
reduces the amount of LH in your body, which helps trigger ovulation. If you aren’t producing enough LH, you can’t ovulate
or get your period.
• Economic
Breastfeeding may have some initial costs like nursing bras and nipple cream, but it’s more affordable long term
• Benefits for mother’s health
-recovery-Breastfeeding produces the hormone oxytocin which helps your uterus contract after delivery. This helps it return
to its normal size and reduces the amount of vaginal bleeding after delivery.
-It lowers your risk for several diseases and conditions, like cancers, cardiovascular disease, and post partum depression.
Advantages of breast feeding

38. Ten steps to successful breastfeeding
 Have a written breastfeeding policy that is routinely communicated to all health care staff
 Train all health care staff in skills necessary to implement this policy
 Inform all pregnant women about the benefits and management of breastfeeding.
 Help mothers initiate breastfeeding within the first hour of birth
 Prepare mothers how to keep to rules of proper breastfeeding techniques
• Give newborn infants no food or drink other than breast-milk
• Allow mothers and infants to remain together 24 hours a day
• Encourage breastfeeding on demand
• Give no artificial teats or pacifiers
• Foster the establishment of breastfeeding support groups
Immediate breastfeeding-
Within 15-55 minutes after birth newborns shows the signs of readiness to suckle, the infant begins suckling
when he/she is ready for it and should be allowed to suck as long as he/she wants

39. Signs of proper latch-on
• Infant should have its mouth widely open
• Infant’s lips should be everted
• Infant’s tongue is seen between its mouth and mother’s breast
• The entire nipple and most of the areola should be in the baby's
mouth
• Infant’s chin should be pressed into the breast
• Baby’s body should be closely attached to the mother’s body

41. Breastfeeding positions

43. THREE TIME PERIODS;
 JUST AFTER BIRTH
 4-6 WEEKS
 AFTER 6 WEEKS
1. Methods that can be used immediately after
birth:
-CONDOMS
-SPERMICIDES
-INTRAUTERINE DEVICES
-STERILIZATION
-LACTATIONAL AMENORRHEA
METHOD (LAM)

44. LACTATIONAL AMENORRHEA
METHOD
-BREASTFEEDING ONLY
-AMENORRHEA
-LESS THAN 6 MONTHS
-BREASTFEED AT LEAST EVERY
FOUR HOURS DURING THE DAY
AND AT LEAST EVERY SIX HOURS
AT NIGHT

45. 2. Methods that can be used after 4-6 weeks after the birth:
- DIAPHRAGMS
- INTRAUTERINE DEVICES
3. Methods that can be used after 6 weeks after the birth:
- COMBINED ORAL CONTRACEPTIVES (COC)
-CALENDAR METHOD
- INJECTION CONTRACEPTION

46. DISCHARGE
-THE OPTIMAL TIME FOR DISCHARGING THE MOTHER FROM THE
-MATERNITY SHOULD BE ESTABLISHED ACCORDING TO THE MOTHER’S
AND NEWBORNS GENERAL CONDITION.
-NOWADAYS IT IS NORMAL TO DISCHARGE WOMAN AT 24 -48 HOURS
AFTER NORMAL VAGINAL DELIVERY.

47. ADVANTAGES:
•LOWER RISKS OF INFECTIONS
•MORE COMFORTABLE CONDITIONS AT HOME
•LOWER RATE OF URINARY AND DIGESTIVE COMPLICATIONS
•REDUCED RISK OF THROMBOEMBOLIC COMPLICATIONS
•THE RATE OF REPEATED HOSPITALIZATION IS VERY LOW

48. SATISFACTORY STATE
•NO COMPLAINTS
•STABLE HEMODYNAMICS
•NO BLEEDING
•NO SIGNS OF INFECTION
•MOTHER SHOULD RECEIVE THE COMPREHENSIVE COUNSELING ON
FOLLOWING ISSUES:
-BREASTFEEDING
-POSTPARTUM CONTRACEPTION
-DANGER SIGNS IN POSTPARTUM PERIOD
-MOTHER HAS GAINED THE SKILLS FOR CHILD CARE AND
OBSERVATION

49. CRITERIA FOR DISCHARGE OF THE
NEW BORN
-ESTABLISHMENT OF EFFECTIVE FEEDING
-INFANT’S ABILITY TO MAINTAIN BODY
TEMPERATURE
-UMBILICAL CORD STUMP WITHOUT THE SIGNS
OF
INFLAMMATION
-NO DANGER SIGNS

50. THANK YOU