Puerperium

Def
• Puerperium : The period following childbirth which
the body tissues, esp pelvic organs revert back
approx to the prepregnant state both anatomically
physiologically.

• Involution : Process whereby the genital organs

revert back approx to the state as they were before
pregnancy.
 Involution of the Uterus
Anatomical consideration
• Uterus : Delivery → uterus firm & retracts with
alternate hardening & softening ; L=20cm & weighs
abt 1kg → 60g after 6 wks
• Lower uterine segment : Delivery → thin, flabby &
collapsed → revert back in few weeks
• Cervix : Delivery → contracts slowly, external os
admits 2 fingers (few days) → tip of finger on 7th
day → but nvr revert back to null state → contour
returns in 6 wks
 Involution of the Uterus
Physiological consideration
• Muscles : Reduction in myometrial cell size ; Favor
involution : a) efficacy of enzymatic action b)
relative anoxia induced by effective contraction &
retraction of uterus
• Blood vessels : Arteries constricted ; New blood
vessels grow inside the thrombi
• Endometrium : Regeneration starts by 7th day
 Clinical Assessment of Involution
• Delivery → fundus lies 13.5cm above symphysis
pubis → steady ↓ in height by 1.25 cm every 24 hrs
after 2nd day.

• Subinvolution
• Superinvolution in lactating women
 Involution of other pelvic structures
• Vagina : Involute in 6-10 wks ; Mucosa remains
delicate for first few wks, submucous venous
congestion persists even longer (withhold surgery
on puerperal vagina), Rugae reappear at 3rd week,
Hymen lacerated & represented by nodular tags
(carunculae myrtiformes)
• Broad ligaments & round ligaments
• Pelvic floor & pelvic fascia
 Lochia
• Vaginal discharge for the first fortnight during puer.
• Originates from uterine body, cervix & vagina.
• Odor : Offensive fishy smell
• Reaction : Alkali → acid
• Color :
a) Lochia rubra (red) 1-4 days
b) Lochia serosa (yellowish or pink) 5-9 days
c) Lochia alba (pale white) 10-15 days
• Composition :
a) Lochia rubra : blood, shreds of fetal membranes &
decidua, vernix caseosa, lanugam, meconium
b) Lochia serosa : less RBC but more leukocytes, wound
exudate, mucus from cervix & microorganism
(anaerobic strep & staph)
[Presence of bacteria is not pathognomonic unless
signs of sepsis]
c) Lochia alba : decidual cells, leukocytes, mucus,
cholesterin crystals fatty & granular epithelial cells &
microrganisms
• Amount : 250mL for first 5 days
• Duration : may extend up to 3 wks ; Scanty in prem
labors ; Excessive in twin delivery or hydramnios
• Clinical importance : Vulval pads inspected
– Odor : Malodorous → infection / retained plug or cotton
piece inside vagina
– Amount : Scanty or absent → infection or lochiometra ;
Excessive → infection
– Color : Persistence of red color → subinvolution or
retained conceptus
– Duration : Lochia alba > 3 wks → local genital lesion
 General Physiological Changes
• Pulse : ↑ in a few hrs → = during 2nd day
• Temp : < 37.2˚C/99˚F within 24 hrs → ↑ 0.5˚F → =
within 12 hrs → ↑ due to breast engorgement but <
24 hrs
• Urinary tract : Edematous & hyperemic (submucous
extravasation of blood) ; bladder capacity ↑ ;
Overdistension, incomplete emptying, + residual
urine ; Diuresis on 3rd day of puerperium ; ↑ risk
UTI & dilated renal pelvis return to normal in 8 wks
• GIT : ↑ thirst due to loss of fluid during labor, lochia,
diuresis & perspiration ; Constipation (delayed GI
motility, mild ileus following delivery, perineal
discomfort)
• Weight loss : 5kg due to explusion of fetus,
placentae, liquor, blood loss → 2kg during
puerperium due to diuresis
• Fluid loss : Net fluid loss of >2L in 1st wk → 1.5L in
nxt 5 wk ; Preeclampsia & eclampsia have larger
loss of salt & water
• Blood values
– Blood volume : Slight ↓ due to blood loss & dehydration
– Cardiac output ↑ after delivery to 80% above prelabor
value but returns to normal within 1 wk
– RBC vol & hematocrit normalizes by 8 wk
– Leukocytosis due to stress of labor
– Platelet ↓ after separation of placenta → ↑ with ↑
adhesiveness 4-10 days
– Fibrinogen ↑ till 2nd week
– Hypercoagulable state persist 48 hrs & fibrinolytic
activity enhanced in first 4 days
• Ovarian function (menstruation & ovulation)
– If no breastfeeding, menstruation returns arnd 7-9 wks
following delivery.
– Suckling → ↑ prolactin → amenorrhea & anovulation
→ contraceptive protection up to 6 mth postpartum
• Thyroid function : Normalizes by 4 wks postpartum
 Lactation
• Colostrum
– deep yellow serous fluid
– Alkaline
– High protein, vit A, Na, Cl but lower carbs, fat & K than
breast milk
– IgA, IgG, IgM, complements, macrophages,
lymphocytes, lactoferrin (humoral factors),
lactoperoxidase
– Adv : Immunological defense & laxative action due to
large fat globules