1. Normal puerperium & lactation The puerperium is the time following labour during which the pelvic organs return to their non pregnant state, the metabolic & physiological changes of pregnancy are reversed & lactation is established. Physiology of puerperium Following delivery when the endocrine influences of the placenta are removed, the physiological changes of pregnancy are reversed & the body tissues, spatially the pelvic organs, return to their previous state & this occur during 6 – 8 weeks & this return occur more rapidly during the 1 st 2 weeks & slower there after.

2. The pelvic organs The principle changes is the uterine involution. After delivery the uterine fundus is at the level of umbilicus & descend gradually till about 10- 14 days later it will disappear behind the symphysis pubis. At time of delivery the uterus weight is about 1 kg & decreases to 70 gm by the process of autolysis & there is a negative nitrogen balance. The cervix It is very flaccid & is curtain like after delivery but within few days it will return to its normal form & consistency. The external os remain dilated for weeks or months or permanently, but the internal os will be closed during the 2 nd week of the puerperium.

3. The vagina In the 1 st few days of puerperium the vaginal wall is smooth,soft & edematous. Tears or episiotomy will heal quickly provided adequate suturing is undertaken. The presence of infections or heamatomas will impair their healing The desidua The desidua will cast off from the endometrial cavity as a result of ischemia & is lost as the lochia which consist of blood, leucocytes, shred of desidua & organisms. Initially the lochia are red in color for the 1 st 3-4 days, then the color is changed to pink then serousfluid

4. & this will last for an average of 3-4 weeks. If the lochia remain red in color & excessive in amount then this indicate delayed involution which may be due to infection or retained placental tissue. New endometrium will grow from the basal layer of the desidua & this will be influenced by the method of infant feeding. If lactation is suppressed then the endometrial cavity will be covered by a new endometrium within 3 weeks & the 1 st menstruation occur at 6 weeks after delivery. In breast feeding mothers were ovulation is suppressed then resumption of menstruation may be delayed for many months.

5. Other systems Urinary system Within 2-3 weeks the hydroureter & caliceal dilatation which are observed during pregnancy, are less evident & disappear completely after 6-8 weeks from delivery. Also there will be diuresis during 1 st days or so of the puerperium when the excessive fluid of pregnancy is eliminated & there will be a decrease in plasma volume & hemoglobin conc. will increase. C V S The heart rate will decrease so as the cardiac output & the stroke volume.

6. Clotting system The level of clotting factors & platelets count will increases after delivery, but the inhibition of the fibrinolytic system which occur during pregnancy is reversed within 30 min. after delivery of placenta. All other changes involving other systems will revers spontaneously within 6 weeks after delivery.

7. Management of the pueperium The objectives in the management of the puerperiumare: 1. 1.To monitor the physiological changes of the puerperium. 2. 2.To diagnose & treat any postnatal complications. 3. 3.To establish infant feeding. 4. 4.To give the mother emotional support. 5. 5.To advice about contraception & other measures which will contribute to continuing health.

8. Management of normal puerperium Immediate management Immediately after delivery, the mother must remain in the delivery room for close observation for the following things: 1. 1.The uterine fundus should be checked at frequent intervals to establish that it remain contracted firmly.The level of the fundus should also be checked regularly. If it is rising this may indicate that the uterus is atonic or is pushed by up by pelvic swelling such as distended bladder or pelvic heamatoma. 2. 2.Regular check for pulse rate, blood pressure, respiration & external vaginal blood loss.

9. 3. 3.The bladder should be checked & if it is thought to be full, the mother should be encouraged to pass urine. If retention of urine occur then catheterization is under aseptic technique should be don to avoid over distention of the bladder. The after delivery management After delivery during the puerperium the following points should be considered: 1.Prevention of infection Precaution should be taken to prevent implantation of exogenous pathogenic organism into the birth canal during labor & puerperium

10. The vulva & the perineum should be kept as clean and dry as possible with the use of sterile pads. The perineum should be washed with soap & water& dried. 2. Rest & time of getting up After the physical & mental strain of pregnancy & labour, the woman needs a period of rest. If labor was normal & there is no gross injury to the pelvic floor or other complications, the woman is allowed to get up in the same day of delivery with moderate exercise that will encourage recovery in the tone of the pelvic floor & circulation of the legs will be improved& the incidence of venous thrombosis is reduced

11. After operative delivery it may be necessary to keep the mother in bed for a further day befor active mobilization. 3.Diet In the day after a normal delivery the woman should be given a normal diet. During lactation she will need an adequate but not excessive intake of fluid. The food should contain adequate vitamins, proteins should be increased. 4.Bowel habit Constipation may develop due to laxity of abdominal muscle & perineal tears or lacerations & this should be avoided by increasing fluid intake or by giving bulk forming drugs as methylcellolose or giving laxative suppositories.

12. Postnatal examination This is don at the end of the 6 th week after delivery. During this examination we will discuss any spesific complain of the woman & ask her about any complication of pregnancy & labour, her general health, whether lochia stopped or not, about bladder function & infant feeding problems. Inspection of the perineum & pelvic examination spatially for laceration or tears, look for vaginal wall prolaps & if the uterus has involuted normally. A cervical smear is taken if it had not been taken during antenatal period.

13. Family planning advice Contraceptive advice should be available at the time of postnatal visit & the method of contraception will vary according to each woman. Pills containing estrogen should not be given to women who are breast feeding before 6 months because they may inhibit lactation& progesterone only pills can be used. Sterilization may be performed during puerperium if she had completed her family, but usually this is delayed till 6-12 weeks later to be sure that the woman really want this & the fallopian tubes retuned to their normal size