WELCOM

E
SEMINAR ON: NORMAL PUERPEIUM
AND ITS MANAGEMENT

PRESENTED BY :
MRS HARIKALA ATADIYA
MSC NURSING 1ST YEAR
GENERAL OBJECTIVES

 AtThe end of the session student will be able to

know about normal puerperium and its
management.
SPECIFIC OBJECTIVES
 At the end of the session student will be able to know about-.
 Introduction of puerperium.
 Definition of puerperium.
 duration of normal labour.
 Anatomical consideration- uterus, lower uterine segment, cervix.
 Physiological consideration -muscles, blood vessels, endometrium.
 Clinical assessment of involution.
 Involution of other pelvic structures.
 Lochia.
 Lactation.
 Management of normal puerperium.
 conclusion.
 Review of literature.
 Summary.
CONT…

 Involution of other pelvic structures.

 Lochia.
 Lactation.
 Management of normal puerperium.
 conclusion.
 Review of literature.
 Summary.
 Bibliography.
INTRODUCTIO
N
 The puerperium, or postpartum period, generally lasts
6 weeks or 42 days and is the period of adjustment
after delivery when the anatomical and physiologic
changes of pregnancy are reversed, and the body
returns to the normal, its pre-pregnant state. The
retrogressive changes are mostly confined to the
reproductive organ with the exception of the
mammary glands which in fact show features of
activity. The women are termed as a puerpera.
DEFINITION
“Puerperium is define as the time from the
delivery of the placenta through the first few
weeks(42 days) after the delivery. This period
is usually considered to be 6 weeks in
duration”.
DURATION OF NORMAL
PUERPERIUM
DURATION OF NORMAL PUERPERIUM:
Puerperium begins as soon as the placenta is expelled and lasts
for approximately 6 weeks when the uterus becomes regressed
almost to the non- pregnant size. The period is arbitrarily divided
into-
 (a)immediate- within 24 hours.
 (b)early- up to 7 days.

ANATOMICAL CONSIDERATION:

UTERUS: immediately following delivery, the uterus becomes

firm and retract with alternate hardening and softening. The
measures about 20x 12x 7.5cm (length, breadth, and thickness)
and weights about 1000gm. At the end of 6 weeks, its
measurement is almost similar to that of the non-pregnant state
and weighs about 60 gm
LOWER UTERINE SEGMENT

immediately following delivery, the lower segment becomes a

thin, flabby, collapsed structure. It takes a few weeks to revert
to the normal shape and size of the isthmus, i.e., the part
between the body of the uterus and internal os of the cervix .
CONT…
CERVIX

The cervix contracts slowly; the external os admits two

fingers for a few days but by the end of first week, narrows
down to admit the tip of a finger only. The contour of the
cervix takes a longer time to regain (6 weeks) and the
external os never reverts back to the nulliparous state.
CONT…..
 PHYSIOLOGICAL CONSIDERATION

The physiological process of involution is most marked in the

body of the uterus. changes occur in the following components:
(1)muscles

(2)blood vessels
(3)endometrium
MUSCLES

 There is marked hypertrophy and hyperplasia of muscle

fibres during pregnancy and the individual muscle fiber
enlarges to the extent of 10 times in length and 5 times
in breadth.
 During puerperium, the number of muscle fibers is not
decreased but there is substantial reduction of the
myometrial cell size.
Blood vessels

 The changes of the blood vessels are pronounced at the

placental site. The arteries are constricted by contraction
of its wall and thickening of the intima followed by
thrombosis. During the first week, the arteries undergo
thrombosis, hyalinisation and fibrinoid end arteritis. The
veins are obliterated by thrombosis, hyalinisation and
endophlebitis new blood vessels grow inside the
thrombi.
Endometrium
Following delivery, the major part of the decidua is
cast off with the expulsion of the placenta and the
membranes, more at the placental site. The
endometrium left behind varies in thickness from 2-
5 mm. Regeneration of the epithelium is completed
by 10th day and the entire endometrium is restored
by the day 16-except at the placental site where it
takes about 6 weeks.
INVOLUTION OF OTHER PELVIC
STRUCTURES

Vagina: : The distensible vagina, noticed soon after

birth takes a long time (4-6 weeks) to involute. It
regains its tone but never to the virginal state.
Pelvic floor and pelvic fascia take a long time to
involute from the stretching effect during parturition.
CLINICAL ASSESSMENT OF INVOLUTION

The measurement should be taken carefully at a fixed time

every day, preferably by the same observer.
Bladder must be emptied beforehand and preferably the bowel
too, as the full bladder and the loaded bowel may raise the
level of the fundus of the uterus. Following delivery, the
fundus lies about 13.5 cm (5 1/2:” ) above the symphysis
pubis.
CONT.

. During the Following first 24 hours, the level

remains constant; thereafter there is a steady
decrease in height by 1.25cm (1/2”) in 24 hours, so
that by the end of second week the uterus becomes a
pelvic organ. The rate of involution, thereafter,
slows down until by 6 weeks, the uterus becomes
almost normal in size.
INVOLUTION OF OTHER PELVIC
STRUCTURES

 Vagina: : The distensible vagina, noticed soon after

birth takes a long time (4-8 weeks) to involute. It
regains its tone but never to the virginal state.
 Pelvic floor and pelvic fascia take a long time to
involute from the stretching effect during parturition.
 POSTNATAL ASSESSMENT

Examination of the mother

 THE BUBBLE HE
 B-breast
 U-uterus
 B-bladder
 B-bowels
 L-lochia
 E-episiotomy
 H-Homans sign

 LOCHIA

It is the vaginal discharge for the first fortnight during

puerperium. The discharge originates from the uterine
body cervix and vagina.
ODER AND REACTION

( 1) Lochia rubes (red)1-4 days

(2) Lochia serosa (5-9) days-the colour is yellowish

or pink or pale brownish.

(3) Lochia alba- (pale white)-10-15 days.

COLOUR

Depending upon the variation of the colour of the discharge, it is

named as
(1) Lochia rubes (red)1-4 days
(2) Lochia serosa (5-9) days-the colour is yellowish or pink or pale
brownish.
(3) Lochia alba- (pale white)-10-15 days.
COMPOSITION

Lochia rubra consists of blood, shreds of fetal

membranes and decidua, vernix caseosa lanugo and
meconium.
Lochia serosa2 consists of less RBC but more
leucocytes, wound exudate, mucus from the cervix and
micro-organisms (anaerobic Streptococci and
Staphylococci). The presence of bacteria is not
CONT…

Lochia alba contains plenty of decidual cells,

leucocytes, mucus, cholesteric crystals, fatty and
granular epithelial cells, and micro-organisms.
Amount: The average amount of discharge for the
first 5-6 days, is estimated to be 250 ml.
NORMAL DURATION

The normal duration may extend up to 3 weeks. The red

lochia may persist for longer duration specially in women
who get up from the bed for the first time in later period. The
discharge may be scanty, especially following premature
labour or may be excessive in twin delivery or hydramnios. .
CLINICAL IMPORTANCE

The character of the Lochiel discharge gives useful

information about the abnormal puerperal state.
Odour: If malodorous, indicates infection. Retained plug or
cotton piece inside the vagina should be kept in mind.
Amount: Scanty or absent-signifies infection or
lochometritis. If excessive-indicates infection.
CONT.

 Colour: Persistence of red colour beyond the normal

limit signifies subinvolution or retained bits of
conceptus.

 Duration: Duration of the lochia alba beyond 3

weeks suggests local genital lesion.
GENERAL PHYSIOLOGICAL CHANGES

PULSE: For a few hours after normal delivery, the

pulse rate is likely to be raised, which settles down
to normal during the second day. However, the pulse
rate often rises with after-pain or excitement.
CONT…
 TEMPERATURE -The temperature should not be
above 37.2°C (99°F) within the first 24 hours.
 URINARY TRACT: The bladder mucosa
becomes oedematous and hyperaemic and often
shows evidence of submucous extravasation of
blood.
CONT…

GASTRO-INTESTINAL TRACT: Increased thirst in

early puerperium is due to loss of fluid during labour, in
the lochia, diuresis and perspiration.
FLUID LOSS: There is a net fluid loss of at least 2 litres
during the first week and an additional 1.5 litres during the
next weeks The amount of loss depends on the amount
retained during pregnancy, dehydration during labour and
blood loss during delivery.
CONT…
BLOOD VALUES: Immediately following
delivery, there is slight decrease of blood volume
due to blood loss and dehydration. Blood volume
returns to non-pregnant level by the second week.
LACTATION

For the first two days following delivery, no

further anatomic changes in the breasts occur.
The secretion from the breasts called colostrum
which starts during pregnancy becomes more
abundant during the period.
COMPOSITION OF THE COLOSTRUM

 it is deep yellow serous fluid, alkaline in

reaction .
 it has got a higher specific gravity, a high protein,
vitamin A sodium and chloride content but has got
lower carbohydrate, fat and potassium than the
breast milk.
 It contains antibody (IgA) produced locally.
MICROGRAPHICALLY

 it contains fat globules, colostrum corpuscles and acinar epithelial cells.

 The colostrum corpuscles are large polynuclear leucocytes, oval or

round in shape containing numerous fat globules.

 ADVANTAGES: (1) The antibodies (IgA, IgG, IgM) and humoral

(lactoferrin) provides immunological defence to the newborn.

 (2) It has laxative action on the baby because of large fat globules.
PHYSIOLOGY OF LACTATION

Although lactation starts following delivery, the preparation for effective

lactation starts during pregnancy.
The physiological basis of lactation is divided into four phases:
 Mammogenesis: Preparation of breasts.
 Lactogenesis: Synthesis and secretion from the breast alveoli.
 Galactokinesis : Ejection of milk
 Galactopoints: Maintenance of lactation (Galactopoiesis).
MILK PRODUCTION

A healthy mother will produce about 500-800 ml of

milk a day to feed her infant. This requires about
700 Kcal/day for the mother which must be made up
from diet or from her body store. For this purpose, a
store of about 5 kg of fat during pregnancy is
essential to make up any nutritional deficit during
lactation.
STIMULATION OF LACTATION

Mother is motivated as regard the benefits of breast feeding since the early
pregnancy. No prolateral feeds (honey, water) are given to the infant. Following
delivery important steps are:

(1) To put the baby to the breast at 2-3 hours interval from the first day.

(i) Plenty of fluids to drink.

(ii) (iii) To avoid breast engorgement.

(iii)Early (1/2-1 hour) and exclusive breast feeding in correct position. are encouraged .
CONT…
INADEQUATE MILK PRODUCTION

lactation failure: It may be due to infrequent suckling or

due to endogenous suppression of prolactin (ergot
preparation, pyridoxin, diuretics or retained placental
bits). Pain, anxiety and insecurity may be the hidden
reasons. Unrestricted feeding at short interval (2-3 hrs) is
helpful.
DRUGS TO IMPROVE MILK
PRODUCTION
galactagogues: Metoclopramide (10 mg thrice
daily) increases milk volume (60-100%) by
increasing prolactin levels. Sulpuride (dopamine
antagonist) has also been found effective. Intranasal
oxytocin contracts myoepithelial cells and causes
milk let down.
MANAGEMENT OF NORMAL
PUERPERIUM

The principles in management are:

 (1) To restore the health of the mother

 (2) To prevent infection.

 (3) To take care of the breasts, including promotion of breast feeding.

 (4) To motivate the mother for contraception.

IMMEDIATE ATTENTION

 Immediately following delivery, the patient should be closely

observed, as outlined in the management of the fourth stage of
labour.
 She may be given a drink of her choice or Something to eat, if she
is hungry. Emotional support is essential Usually the first feeling
of mother is the sense happiness and relief, with the birth of a
healthy baby. The woman needs emotional support when she
suffers from postpartum blues or stress.
REST AND AMBULANCE

Early ambulation after delivery is beneficial. After a good

resting period, the patient becomes fresh and can breast feed
the baby or moves out of bed to go to the toilet.

 Early ambulation is encouraged. Advantages are:

 (1) Provides a sense of well-being

 (2) Bladder complications and constipation less

CONT…

 (3) Facilitates uterine drainage and hastens involution of

the uterus

 (4) Lessens puerperal venous thrombosis and embolism.

Following an uncomplicated delivery, climbing stairs,
lifting objects, daily household work, cooking may be
resumed
HOSPITAL STAY

Early discharge from the hospital is an almost

universal procedure.
If adequate supervision by trained health visitors is
provided, there is no harm in early discharge.
Most women are discharged fit and healthy after 2
days of spontaneous vaginal delivery with proper
education and instructions.
DIET

 DIET: The patient should be take normal diet of her

choice.
 If the patient is lactating high calories, adequate
protein, fat, plenty of fluids, minerals and vitamins are
to be given.
 However, in non-lactating mothers, a diet as in non-
pregnant is enough.
CARE OF THE BLADDER

 The patient is encouraged to pass urine following delivery as soon as

convenient.

 At times, the patient fails to pass urine and the causes are.

 (1) Unaccustomed position. (2) Reflex pain from the perineal injuries.
 This is common after a difficult labour or a forceps delivery. If the patient
still fails to pass urine, catheterisation should be done. Catheterisation is
also indicated in case of incomplete emptying of the bladder evidenced by
CARE OF THE BOWEL:

 The problem of constipation is much less because of

early ambulation and liberalisation of the dietary intake.

 A diet containing sufficient roughage and fluids is

enough to move the bowel.

 If necessary, mild Laxative may be given at bedtime

SLEEP

*The patient needs rest, both physical and mental. So,

she should be protected against worries and undue
fatigue.
*Sleep is ensured providing adequate physical and
emotional support.
*If there is any discomfort, such as after pains or
painful piles or engorged breasts, they should be dealt
with adequate analgesics (ibuprofen).
CARE OF THE VULVA AND EPISIOTOMY
WOUND

* Shortly after delivery, the vulva and buttocks are Washed with
soap water down over the anus and a sterile pad is applied.

*The patient should look after personal cleanliness of the vulval

region.

*The perineal wound should be dressed with antiseptic ointment

CONT…

 The nurse should use sterilized gloves during

dressing.
 Cold (ice) sitz baths relieve pain.
 When the perineal pain is persistent, a. vaginal and
rectal examination is done to detect any hematoma,
wound gaping or infection.
CONT…..

 . The woman should be positioned in lithotomy position and good room light, or
flashlight is needed to visualize the stiches/ suture line adequate.
 REEDA should be observed,
 R-redness
 E- edema
 E-ecchymosis
 D-discharges
CARE OF THE BREASTS

The nipple should be washed with sterile water before each

feeding. It should be cleaned and kept dry after the feeding
is over. nursing brassiere provides comfortable support.
 Nipple Soreness is avoided by frequent short feedings
rather than the prolonged feeding, keeping the nipples
clear and dry. Candida infection may be another cause.
CONT…

 Nipple confusion is a situation where the infant

accepts the artificial nipple but refuses the
mother's nipple. This is avoid- by ​making the
mother's nipple more protractile and not offering
any supplemental fluids to the infant.
MATERNAL-INFANT BONDING
(ROOMING-IN)

It starts from first few moments after birth. This is

manifested by fonding, kissing, cuddling and gazing
at the infant. The baby should be kept in her bed or
in a cot besides
ASEPSIS AND ANTISEPTICS

Asepsis must be maintained especially during the first week

of puerperium.
Liberal use of local antiseptics, aseptic measures during
perineal wound dressing, use of clean bed linen and clothing
are positive steps. Clean surroundings and limited number of
visitors could be of help in reducing nosocomial infection.
MANAGEMENT OF AILMENTS

 After pain- It is the infrequent, spasmodic pain felt in the lower

abdomen after delivery for variable period of 2-4 days. Presence of
blood clots or bits of the after births lead to hypertonic contractions
of the uterus in an attempt to expel them out. The Treatment
includes massaging the uterus with expulsion of the clot
followed by administration of analgesics (Ibuprofen) and
PAIN ON THE PERINEUM

Never forget to examine the perineum when analgesic

is given to relieve pain. Early detection of Volvo-
vaginal hematoma can thus be made. Sitz baths (hot or
cold) can give additional pain relief.
CORRECTION OF ANAEMIA

 Correction of anaemia: Majority of the women in the tropics

remain in an anaemic state following delivery. Supplementary
iron therapy (ferrous sulphate 200 mg) is to be given daily for a
minimum period of 4-6 weeks.

 Hypertension is to be treated until it comes to a normal limit.

The physician should be consulted if proteinuria persists.
TO MAINTAIN A CHART

A progress chart is to be maintained noting the following:

 (1) Pulse, respiration, and temperature recording 6 hourly or
at least twice a day
 (2) Measurement of the height of the uterus above the
symphysis pubis once a day in a fixed time with prior
evacuation of the bladder and preferably the bowel too.
CONT…..

 (3) Character of the lochia.

 (4) Urination and bowel movement.

POST-PARTUM EXERCISE

The objectives of postpartum exercises are: (1) To

improve the muscle tone which are: stretched during
pregnancy and labour especially the abdominal and
perineal muscles
POSTNATAL CARE

Postnatal care includes systematic examination of the

mother and the baby and appropriate advice given to the
mother during postpartum period. The first postnatal
examination is done, and the advice is given on
discharge of the patient from the hospital. This has
already been discussed. The second routine postnatal
care is conducted at the end of 6 th week postpartum.
AIMS AND OBJECTIVES

*To assess the health status of the mother. Medical disorders like diabetes,
hypertension should be reassessed.

*To detect and treat at the earliest gynaecological condition arising out of obstetric
legacy.

* To note the progress of the baby including the immunisation schedule for the
infant.
PROCEDURE:

PROCEDURE:

(1) Examination of the mother

 THE BUBBLE HE
 B-breast
 U-uterus
 B-bladder
 B-bowels
 L-lochia
 E-episiotomy
 H-Homans sign

CONT…..

(1)Advice given to the mother.

(2) Examination of the baby and
(3)Examination of the mother
EXAMINATION OF THE MOTHER:

 Routine examination includes

 Pelvic examination should be done only when
indicated
 Laboratory investigations
HOMANS SIGN

 HOMANS SIGN-

 *Ask the mother to flex the leg at the knee level and relax. Support at the calf muscle with other hand dorsiflex
the foot. If the mother experiences pain at the calf region, then Homans sign is positive.

 * Problems related to venous stasis generally begin during the last few months of the pregnancy when the
enlarged uterus restricts the return of the blood to the heart. These problems are further aggravated by pressure on
the femoral veins during bearing down and use of stirrups during delivery. Impaired venous return increases the
risk of thrombus formation.

 * The nurse inspects both the legs for any signs of superficial or deep vein thrombosis (DVT)formation, such as
pain in the calf muscles, warmth, redness or swelling.
EMOTIONAL STATUS

 *Relationship with the newborn and family dynamics.

 * The early postpartum period is the ideal time for bonding between
mother and newborn. The immediate family should have the opportunity
to spend time with each other and the newborn while their emotional and
level of excitement are high.
 * The nurse should provide privacy and encourage the family to interact
with a minimum amount of interruption
EXAMINATION OF THE BABY

This should be conducted by a paediatrician. In this

respect, an attached well baby clinic to the postpartum
unit is an absolute necessity. the progress of the baby is
evaluated, and preventive or curative steps are to be
taken. Immunisation to the baby is started.
CONT….

 Advice given: General- (1) If the patient is in sound

health, she is allowed to do her usual duties.

 (2) Postpartum exercises may be continued for

another 4-6 weeks.
 (3) To evaluate the progress of the baby periodically
and to continue breast feeding for 6 months
MANAGEMENT OF SOME COMMOM
GYNAECOLOGICAL PROBLEMS ARE
GIVEN BELOW
Some women need psychological support also.
 Irregular vaginal bleeding
 Leucorrhoea
 Cervical ectopy (erosion)
 Backache
 Retroversion
 Slight degree of uterine descent
BREAST FEEDING BENEFITS
BREST
FEEDING
POSITION
MANAGEMENT OF SOME COMMOM
GYNAECOLOGICAL PROBLEMS ARE
GIVEN BELOW
Some women need psychological support also.
Irregular vaginal bleeding
Leucorrhoea
Backache
Retroversion
Slight degree of uterine descent
CONCLUSION

The puerperium, or postpartum period, generally lasts 6 weeks and is the

period of adjustment after delivery when the anatomic and physiologic
changes of pregnancy are reversed, and the body returns to the normal, its
pre-pregnant state.
At the end of 6 weeks, its measurement is almost similar to that of the non-
pregnant state and weighs about 60 gm.

It is the vaginal discharge for the first fortnight during puerperium. The
discharge originates from the uterine body cervix and vagina.
REVIEW OF LITERATURE

NORMAL PUERPERIUM-February 2021

Subrat panda, ananya das.
ABSTRACT-puerperium is the time following delivery during
which pregnancy induced maternal anatomical and
physiological changes return to the nonpregnant state.
puerperium period of 6 weeks can be divided into:
(a) immediate-within 24hours
(b)early – up to 7 days
© remote –up to 6 weeks.
 CONT…

PHISIOLOGICAL UTERINE INVOLUTION IN

PRIMIPAROUS AND MULTIPAROUS WOMEN:
ULTRASOUND STUDY- 2017
ENRIQUE HERNANDEZ
ABSTRACT-to examine the uterine involution period after
uncomplicated delivery in primiparous and multiparous women.
Measurements of primiparous and multiparous were carried out
after labour on the 1st ,3rd ,10th,30th,42nd,60th postpartum days.
SUMMARY

Introduction
Definition
,involution of the uterus- anatomical consideration of
uterus, lower uterine segment, cervix physiological
consideration of- muscles, blood vessels, endometrium.
Involution of other pelvic structure – vagina.
 CONT….
Lochia.
General physiological changes , lactation, physiology of
lactation.
Management of normal puerperium, management of
ailments.
postnatal care.
Conclusion
Review of literature
BIBLIOGRAPHY

 Bhasker Nima “midwifery & obstetrical nursing” 3 rd edition publisher Manjunath S.

Hedge EMMESS MEDICAL Publisher.
 Dutta’s D.C. Konar Hiralal “textbook of obstetric” 7 th edition new central book
agency (P)ltd. Page No. 144 to 153.
 Daffary Shirish N. Chakravarti Sudip “MANUAL OF OBSTETRICS “3 rd edition
ELESEVIER A division of reed Elsevier Indian private limited publisher.
 Rao Kamini “Textbook of midwifery and obstetrics for nurses Elsevier a division of
reed Elsevier Indian private limited.
 Net reference:
 https://www.intechopen.com
 https://accessmedicine.mhmedical.com
