1. Department of Obstetrics & Gynecology
The Puerperium
Dr. Dina Nawfal
Department of Obstetrics & Gynecology
College of Medicine
University of Mosul

2. The puerperium
It refers to the 6 week period following completion of third stage of labor, when considerable adjustments occur before return to the pre-pregnancy state.
physiological changes
Uterine involution:
Involution is the process by which the postpartum uterus (weighing about 1000gm) return to its pre pregnancy state (of less than 100gm).

3. immediately after delivery the uterine fundus lies about 4cm below the umbilicus.
within 2 weeks the uterus can no longer be palpable above the symphysis pubis.
involution occur by a process of autolysis, where by the muscle cells diminish in size as a result of enzymatic digestion of the cytoplasm.
the excess of protein produced from autolysis is absorbed into the bloodstream and excreted in urine.

4. Causes of delayed involution
full bladder
loaded rectum
uterine infection
retained products of conception
Fibroids
broad ligament hematoma.

5. Lochia:
Is blood stained uterine discharge that is comprised of blood and necrotic decidua
the basal layer of decidua that is adjacent to the myometrium is involved in the regeneration of the endometrium which is completed by third week.
during the first few days after delivery lochia is red in color (lochia rubra), and gradually change to pink as the endometrium is formed (lochia serosa), then become serous by the second week
(lochia alba).

6. Vagina:
Although the vagina may never return to its pre pregnancy state, the supportive tissues of the pelvic floor gradually regain their former tone.
women who deliver vaginally should be taught and encouraged to perform Kegel exercise (intermittent tightening of the perineal muscles) to maintain and improve the supportive tissues of the pelvic floor.

7. Cardiovascular system:
Immediately after delivery, there is a marked increase in peripheral vascular resistance due to removal of the uteroplacental circulation.
the cardiac output and plasma volume gradually return to normal during the first 2 weeks of the puerperium.
as a result of the loss of plasma volume and the diuresis of the extracellular fluid, a marked weight loss occurs in the first week.

8. Psychosocial changes:
The post partum pinks:
for the first hours after delivery it is fair common that the woman to experience an elevation of mood, a feeling of excitement, some over activity and difficulty in sleeping
The post partum blues:
It is fairly common for a woman to exhibit a mild degree of depression in the first 2weeks after delivery.
any prolonged episods of depression should receive urgent attention.

9. Return of menstruation and ovulation:
In women who do not nurse, menstrual flow usually return by 6 to 8 weeks, although this is highly variable.
contraceptive advice is necessary to avoid unplanned pregnancy.

10. Lactation:
Various hormones such as estrogen, progesterone, hCG, cortisol, insulin, prolactin and placental lactogen, play an important role in preparing the breasts for lactation.
at delivery, two events are instrumental in initiating lactation:
the drop in placental hormones, particularly estrogen, as before delivery these hormones interfere with the lactogenic action of prolactin.
suckling stimulate the release of prolactin and oxytocin, as oxytocin cause contraction of the myoepithelial cells in the alveoli and milk ducts.

11. on about second day post delivery colostrum is secreted which contains secretory IgA
after about 3 to 6 days the colostrum is replaced with mature milk
when the mother choose not to breastfeed, lactation suppression is indicated. the simplest way is by the use of tight fitting bra, ice packs and the discomfort managed with analgesics.

12. Complications of breastfeeding:
Cracked Nipples:
If the nipples of the breasts become fissured, nursing may become difficult, because fissures are also a portal of entry for bacteria, they should be managed aggressively with nipple shield and an appropriate cream, such as lanolin.
further breastfeeding should be temporarily stopped
milk can be expressed manually until the nipples heal.

13. Mastitis:
This is uncommon complication of breastfeeding and usually develops after 2 to 4 weeks
the first symptoms are usually slight fever and chills
these are followed by redness of a segment of the breast which become indurated and painful.

14. the etiological agent is usually Staphylococcus aureus, which come from the infant's pharynx.
milk should be obtained for culture and sensitivity, and the mother should start using penicillinase resistant antibiotic such as dicloxacillin
breastfeeding may be discontinued but it is not cotraindicated, if nursing is discontinued a breast pump can be used to maintain lactation.

15. Puerperal disorders:
In UK the community midwives perform daily maternal observation including temperature, pulse, blood pressure, urinary function, bowel function, breast examination and feeding, assessment of uterine involution, appearance of lochia, perineal inspection, examination of legs and pelvic floor exercise.
it is traditional to check maternal hemoglobin level on day 3 if it is less than 8gm/dL blood transfusion should be offered.

16. Perineal complications:
About 80% complain of pain in the first 3 days after delivery. a number of non pharmacological and pharmacological therapies can be tried with varying degrees of success.
local cooling ( with crushed ice or tap water) and topical anasthetics such as 5% lidocaine gel provide short term symptomatic relief, diclofenac given orally or rectally may also be added.
infection of the perineum is uncommon however when signs of infection appears swab should be taken for culture and sensitivity and broad spectrum antibiotics should be started, if pus is formed drainage should be done.

17. Bladder function:
Voiding difficulty and over distension of the bladder can occur after birth, specially after traumatic delivery and epidural anasthesia.
if overdistension of detrusor muscle occurs the bladder function will be impaired and overflow incontinence will result.
inorder to minimize the risk of over distension of the bladder in women undergoing a cesarean section under regional anasthesia a urinary catheter may be left in the bladder for the first hours.
women should be encouraged to void within 4 hours after delivery.

18. Bowel function:
Constipation is a common problem in the puerperium which may be due to an interruption in the normal diet and possible dehydration during labor.
constipation may results also from fear of evacuation due to pain from a sutured perineum, prolapsed hemorrhoids or anal fissures.
adequate pain relief with lactulose after perineal repair is offered for up to 2 weeks.
anal incontinence and fecal urgency some times recognized after delivery specially after third or fourth degree perineal tear.

19. Secondary post partum hemorrhage
It is defined as fresh bleeding from the genital tract that occur between 24 hours and 6 weeks after delivery
the cause usually attributed to retained placental tissue, the associated features include the uterus is subinvoluted, crampy abdominal pain, with symptoms and signs of infection.
an ultrasound examination is used to confirm the diagnosis of retained placental tissue.
other causes of secondary postpartum hemorrhage include:
endometritis, bleeding disorders, choriocarcinoma.

20. Obstetric palsy
This is a condition in which one or both lower limbs may develop signs of motor and or sensory neuropathy following delivery.
presenting features include sciatic pain, foot drop, parasthesia and muscle wasting
the mechanism of injury is unknown, it is thought to be due to herniation of lumbosacral disc ( usually L4 or L5 ) particularly in the exagerated lithotomy position or due to instrumental delivery
an orthopedic opinion should be sought, the management include bed rest and firm board beneath the matress, analgesia and physiotherapy

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