1. NORMAL PUERPERIUM

2. What is puerperium? Period following childbirth
Pelvic organs & other body tissues
Revert to pre-pregnant state
Anatomically & physiologically

3. Begins as soon as placenta is expelled
lasts for appx 6 weeks(42 days)
3 stages
Immediate-within 24hrs
Early -upto 7 days
Remote – upto 6wks

4. Involution of the Uterus
Anatomical consideration
At delivery-20 x 12 x 7.5cm and appox. 1000g
After involution-reverted to non-preg size of appox. 60g
Lower uterine segment isthmus in a few weeks
Contour of cervix regained in 6 wks
External os never reverts back to nulliparous state

6. Fibrinoid end arteritis
Steroid hormones withdrawn
Inc Collagenase & Proteolytic enzymes
Autolysis
Myometrial cell size reduced
Physiological Consideration
Muscles:
Endometrium:
regen starts on day 7
from uterine gland mouths and interglandular stromal cells
completed by day 16
placental site
Blood Vessels
Endophlebitis
Thrombosis
Fibrinoid end arteritis
Hyalinisation

7. Clinical assessment of Involution of uterus
Fundus lies 13.5cm above sypmphysis pubis for the 1st 24hrs following delivery
Steady decrease by 0.5'' in nxt 24 hrs
Day 14- not palpable- pelvic organ
Completed by 6 wks

8. Involution of other Pelvic structures
Vagina
4-8 weeks;
Does not revert to original state
Broad/round ligaments
Long time d/t stretching during parturition
Pelvic floor & Fascia
Involution of other Pelvic structures

9. Lochia Lochia Rubra Lochi Serosa Lochia Alba
Vaginal discharge for the 1st fortnight during puerperium
Odour: offensive fishy smell
Colour and composition
Lochia Rubra
Lochi Serosa
Lochia Alba
1-4 days
Blood,fetal memb & decidua shreds,lanugo,meconium
5-6 days
Leucocytes,Cx mucus,wound exudates,microorganisms
10-15 days
Decicual cells,leucocytes,mucus,cholestrin crystals,fatty epithelial cells,microorganisms

10. Clinical importance Puerperal Sepsis d\t E. Coli Malodorous Infection
Lochiometra
Scanty/absent
Excessive
Subinvolution
Retained conceptus
Causes secondary PPH
Red color persist
Local genital infection
L.Alba beyond 3 wks

11. Mamogenesis Lactogenesis Galactopoiesis Galactokinesis
Changes in breast & lactation
Mammary duct-gland growth & development
Mamogenesis
Initiation Of milk secretion in alveoli
Lactogenesis
Maintenance of Lactation
Galactopoiesis
Removal of Milk from Gland
Galactokinesis

12. General Physiological Changes Pulse: Temperature: Urinary Tract:
raises but settles down to normal on 2nd day
Temperature:
Any rise above 0.5C suggestive of infection of genito-urinary tract
Urinary Tract:
Pronounced Diuresis on 2nd - 3rd day
over distension
incomplete emptying
presence of residual urine
high risk of infection
GIT:
increased thirst
constipation
Weight Loss:
5-6kg expulsion of fetus placenta, liqour, blood
2kg- during puerperium d\t diuresis
Continued upto 6 months of delivery

13. Blood Values: Menstruation: Ovulation:
immediate-reduced blood volume; Normal in 2 weeks
rise in cardiac output; Normal in 1 week
leuycocyotsis d\t stress
Hypercoagulable state for 48 hrs
Fibrinolytic activity enhanced in 4 days
Menstruation:
if not breast feeding- resumes in 6 to 8 wks
Ovulation:
non-lactating mother- 4 wks
lactating mother- 10 weeks
Exclusive Breastfeeding- 98% contraception up 6 months

14. Management of normal Puerperium To restore health of Mother
Rest and Early ambulation
Emotional support
Diet of patients choice
Sleep
Immunization- anti-D- Gamma globulin
Maternal-infant Bonding
Postnatal exercise

15. To take care of the Breasts & promote breast feeding
To prevent infection
Care of bladder & Vulva
Care of episiotomy wound
Maintenance of asepsis and proper hygiene
Immunization- Rubella vaccine, TT
To take care of the Breasts & promote breast feeding
To motivate mother for contraception

16. Treatment of minor ailments
After pains
Uterus massage
Ibuprofen
Anti-spasmodic
Pain at site of perineum
Sitz bath
analgesics
Treatment of Anaemia
Supplementary Iron therapy

17. Abnormal Puerperium
Puerperal fever/ pyrexia
Puerperal Sepsis
Pelvic pain
Fever
Foul smelling vaginal discharge
Subinvolution

18. Breast Problems
Retracted/cracked nipples
Breast engorgement
Mastitis
Breast abscess
Failure of lactation

19. Urinary Problems
Retention
Incontinence
Infection
Venous thrombosis
Secondary Hemorrhage
Puerperal psychosis
Obstetric palsy

20. THANQ