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Chapter 17. The Puerperium. OBGY R1 변정미 `. Definition. Period of confinement during and just after birth   includes 6 subsequent weeks postpartum during which normal pregnancy involution occurs . Chapter. 17 Puerperium. Clinical and Physiological Aspects of the Puerperium. Uterine Changes

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  • Period of confinement during and just after birth  
  • includes 6 subsequent weeks postpartum during which normal pregnancy involution occurs

Chapter. 17 Puerperium

clinical and physiological aspects of the puerperium
Clinical and Physiological Aspects of the Puerperium
  • Uterine Changes
  • Urinary Tract Changes
  • Relaxation of the Vaginal Outlet and Prolapse of the Uterus
  • Peritoneum and Abdominal Wall
  • Blood and Fluid Changes

Chapter. 17 Puerperium

mammary glandes

Chapter. 17 Puerperium

Mammary Glandes
  • Breast Anatomy
  • Breast Feeding
care of the mother during the puerperium
Care of the Mother during the Puerperium
  • Hospital Care
  • Care at Home

Chapter. 17 Puerperium

uterine changes

Chapter. 17 Puerperium

Uterine Changes

Changes in the uterine vessels

  • Caliber of extrauterine vessels

: decrease to equal size of prepregnant state

after delivery

  •   Blood vessels within puerperal uterus

      :  obliterated by hyaline change

replaced by smaller vessels

uterine changes7

Chapter. 17 Puerperium

Uterine Changes

Changes in the Cervix & Lower Uterine Segment

  • Cervical opening contracts slowly and for a few days immediately after labor ( ≒ 2fingers )

 :  by the end of the 1st wk → it has narrowed

  • As the opening narrows the cervix thickens and a

canal reforms.

  • Bilateral depression at the site of lacerations remain as permanent changes that characterize the parous cervix
uterine changes8

Chapter. 17 Puerperium

Uterine Changes

Changes in the Cervix & Lower Uterine Segment

  • Markedly thinned-out lower uterine segment

    : contracts & retracts

   → uterine isthmus located between the uterine corpus above

and the internal cervical os below - over the course of few


uterine changes9

Chapter. 17 Puerperium

Uterine Changes

Involution of uterine corpus

  • Fundus of contracted uterus

   : slightly below umbilicus

immediately after placental expulsion

- within 2 wks

: descend into a cavity of true pelvis    

       - within about 4 wks

: regain previous nonpregnant size

uterine changes10

Chapter. 17 Puerperium

Uterine Changes

Involution of uterine corpus

  • Weight of uterus  

    : immediately postpartum, 1000g

        - 1 week later : 500g 

        - at the end of 2nd week : 300g,

 - soon thereafter 100g or less  

    : total number of muscle cells does not decrease

→ individual cells decrease markedly in size

  •  Separation of the placenta and membrane involves the spongy layer

→decidua basalis remains in the uterus

uterine changes11

Chapter. 17 Puerperium

Uterine Changes


  • Primiparas: puerperal uterus tends to remain tonically


  • Multiparas : contracts vigorously at interval → afterpain
  • Infant suckles →oxytocin release →Ut. contraction

→ afterpain

  • Occasionally severe enough to require an analgesic

   : usually become mild by the 3rd postpartum day

uterine changes12

Chapter. 17 Puerperium

Uterine Changes


  Early in the puerperium, sloughing of decidual tissue  → vaginal discharge of variable quantity

  • lochia rubra : first few days after delivery

blood in lochia

  • lochia serosa : after 3 or 4 days

becomes progressively pale in color

  • lochia alba    : after 10th day

white or yellowish-white color,

  • lasted for approximately 2weeks after delivery
uterine changes13

Chapter. 17 Puerperium

Uterine Changes

Endometrial regeneration

the remain decidua becomes differentiated into 2 layers within 2 or 3 days after delivery   

  • superficial layer

: become necrotic, sloughed in the lochia

  • basal layer 

: remains intact, source of new endometrium

uterine changes14

Chapter. 17 Puerperium

Uterine Changes

Endometrial regeneration

  • Endometrial regeneration is rapid, except at the placental site

     - free surface becomes covered by epithelium within

a week or so

 - entire endometrium is restored during the 3rd week

- endometritis & salpingitis

: not infection but only part of the involutional


uterine changes15

Chapter. 17 Puerperium

Uterine Changes


  • an arrest or retardation of involution , the process by which the puerperal uterus is normally restored to its original proportions
  • Cause

   : retention of placental fragments, pelvic infection

  • Accompanied by prolongation of lochial discharge & irregular or excessive uterine bleeding and sometimes by profuse hemorrhage
uterine changes16

Chapter. 17 Puerperium

Uterine Changes


  • Bimanual examination

   : uterus is larger & softer than normal

for the particular period of puerperium

  • Treatment

  : ergonovine or methylergonovine(Methergine)

     oral antibiotics : usually effective in metritis

uterine changes17

Chapter. 17 Puerperium

Uterine Changes

Placental site involution  

: Complete extrusion of placental site takes up to 6 weeks

  • Immediately after delivery, palm size

   → 3-4cm in diameter (end of 2nd week, )

  • Placental site

  : normally consists of many thrombosed vessels within hours of delivery

→ ultimately undergo organization of thrombus

  • Placental site exfoliation

: as the consequence of sloughing of infarcted and necrotic superficial

tissues followed by a reparative process

- Anderson and Davis (1968)-

uterine changes18

Chapter. 17 Puerperium

Uterine Changes

Late postpartum hemorrhage

Serious uterine hemorrhage occasionally develops 1-2 weeks after delivery

  • Cause

abnormal involution of placental site (most often)

retention of a portion of the placenta

          → usually undergo necrosis with deposition of fibrin

          → form a placental polyp

  • Treatment

intravenous oxytocin, ergonovine, methylergonovine,



urinary tract change

Chapter. 17 Puerperium

Urinary Tract Change
  • dilated renal pelvis & ureters

      : return to prepregnant state 2-8 weeks after delivery 

  • Puerperal diuresis

     physiological reversal of pregnancy-induced increase in extracellular water

      : regularly occurs between 2nd and 5th day

  • Puerperal bladder create optimal condition for development of UTI

: increased capacity & relative insensitivity to intravesical fluid pressure

      → overdistention, incomplete emptying, excessive residual urine  

urinary tract change20

Chapter. 17 Puerperium

Urinary Tract Change
  • most women returned to normal micturition by 3months


  • Careful attention to all postpartum women, with prompt catheterization for those who cannot void, will prevent most urinary problems
relaxation of the vaginal outlet and prolapse of the uterus

Chapter. 17 Puerperium

Relaxation of the vaginal outlet and prolapse of the Uterus
  • Vagina and vaginal outlet gradually diminishes in size

but rarely returns to nulliparous dimensions

  • Rugae : reappear by the 3rd week
  • hymen: represented by several small tags of tissue, which during cicatrization

are converted into the myrtiform caruncles

  • Relaxation of vaginal outlet

    ← extensive laceration or overstretching of perineum during delivery

  • Changes in pelvic supports during parturition

      : predispose to uterine prolapse & urinary stress incontinence

         → operative correction is usually postponed until childbearing is ended

peritoneum and abdominal wall

Chapter. 17 Puerperium

Peritoneum and Abdominal wall
  • Broad & round ligaments

     : much more lax than nonpregnant

     : require considerable time to recover from stretching

& loosening

  • Abdominal wall

    : return to normal → requires several weeks

(aided by exercise)

    : usually resumes its prepregnancy state except for silvery


blood and fluid changes

Chapter. 17 Puerperium

Blood and Fluid Changes
  • leukocytosis and thrombocytosis occur during and after labor

    : by 1 week after delivery, blood volume return nearly to

nonpregnant level

  •  Cardiac output remains elevated for at least 48 hours


      (due to increased stroke volume from venous return)

weight loss

Chapter. 17 Puerperium

Weight loss
  • Uterine evacuation & normal blood loss : 5-6 kg
  • Further decrease through diuresis        : 2-3 kg  
  • factors of Weight loss
    • weight gain during pregnancy
    • primiparity
    • early return to work (outside the home)
    • smoking
  • not affect weight loss
    • breastfeeding
    • age
    • marital status
breast anatomy

Chapter. 17 Puerperium

Breast anatomy
  • A ducts
  • B lobules
  • C dilated section of duct to hold milk
  • D nipple
  • E fat
  • F pectoralis major muscle
  • G chest wall/rib cageEnlargement:
  • A normal duct cells
  • B basement membrane
  • C lumen (center of duct)
breast feeding

Chapter. 17 Puerperium

Breast Feeding


  • Colostrum

the deep lemon-yellow colored liquid secreted initially by the breasts

       - expressed from the nipples by the second postpartum day

       - contains more minerals and protein - globulin

less sugar and fat

       - Abs esp. IgA       

       - persists for about 5days

- gradual conversion to mature milk during the ensue 4weeks

  • Milk

  - 600mL/day

    - major proteins -including α-lactalbumin, β-lactoglobulin

and casein

 - interleukin -6, epidermal growth factor 

breast feeding27

Chapter. 17 Puerperium

Breast Feeding

Endocrinology of lactation 

  • Progesterone, estrogen, placental lactogen, prolactin, cortisol, insulin

      : appear to act in concert to stimulate the growth & development of

          milk-secreting apparatus of mammary glands

  • Prolactin is essential for lactation

      Although plasma prolactin falls after delivery, suckling triggers a rise

  • Milk ejection or letting down reflex

      : initiated especially by suckling

      → stimulates neurohypophysis to liberate oxytocin

      → contraction of myoepithelial cells in the alveoli & small milk ducts

      → milk expression from lactating breast     

breast feeding28

Chapter. 17 Puerperium

Breast Feeding

Immunological Consequences of Breast Feeding

  • Predominant immunoglobulin in milk is secretory IgA

      : contains secretory IgA antibodies against E. coli

→ breast-fed infants are less prone to enteric infections

  • Contains both T & B lymphocytes


  • Even though the milk supply at first appears insufficient, it become adequate

if suckling is continued

  • Nursing accelerates uterine involution

: repeated stimulation of nipples release oxytocin

→ contracts uterine muscle 

breast feeding29

Chapter. 17 Puerperium

Breast Feeding

Lactation Inhibition

  • Milk leakages, engorgement, & breast pain peak at 3 to 5 days postpartum

   → support with well-fitting brassiere or breast binder, ice packs oral


  • Inhibitors


bromocriptine has been associated with strokes, myocardial infarction,

seizures, and psychiatric disturbances in puerperal women 

breast feeding30

Chapter. 17 Puerperium

Breast Feeding


  • Not needed in the first 3 weeks postpartum
  • Progestin only contraceptives

     : mini-pills, depot medroxyprogesterone, levonorgestrel implant

     : do not affect the quality & increase the volume of milk very


         → contraceptives of choice for breast feeding women

  • Estrogen-progestin contraceptives

    : reduce the quantity & quality of breast milk

: puerperal women have predisposition to venous thrombosis

          → increased by combination contraceptive pills   

           ⇒ low dose pills are preferred if used in lactating women   

breast feeding31

Chapter. 17 Puerperium

Breast Feeding


  • take street drugs
  • do not control alcohol use
  • have an infant with galactosemia
  • have HIV infection
  • have active, untreated tuberculosis
  • take certain medications
  • are undergoing breast cancer treatment         (ACOG, 2000)
  • Cytomegalovirus and hepatitis B virus are excreted in milk
  • Women with active herpes simplex virus
breast feeding32

Chapter. 17 Puerperium

Breast Feeding

Drugs secreted in milk

  Most drugs given to the mother are secreted in breast milk

       : but amount of drug ingested by the infant is typically small

Care of the breasts and nipples

Dried milk is likely accumulate & irritate the nipples

  → cleaning of areola with water & mild soap is helpful before and after


breast feeding33

Chapter. 17 Puerperium

Breast Feeding

Breast fever

  • For the first 24 hours after development of lacteal secretion,

: breasts to become distended, firm, & nodular

       ← exaggeration of normal venous & lymphatic engorgement of

the breast

            (not the result of overdistention of lacteal system with milk)

  • Puerperal fever from breast engorgement is common

          : 37.8~39℃, seldom persists for longer than 4~16 hours

          : other causes (especially infection) of fever must be excluded

  • Treatment

          : binder or brassiere, ice bag, analgesics, pumping or manual


breast feeding34

Chapter. 17 Puerperium

Breast Feeding


  • Parenchymatous infection of mammary glands
  • seldom appear before the end of the 1st week postpartum not until the

3rd or 4th week.

  • unilateral, breast becomes hard, reddened and painful 
  • Signs : chills (1st), rigor, fever, tachycardia
  • Etiology

Staphylococcus aureus (most common) 

※ breast abscess : caused by group B streptococcus

- almost always from nursing infant's nose & throat

  → the organism enters the breast through the nipple at the site

of a fissure or abrasion      

breast feeding35

Chapter. 17 Puerperium

Breast Feeding
  • Treatment
    • swab and cultured 
    • antimicrovial therapy

       : penicillin or cephalosporin

      : MRSA →vancomycin

      - continued for about 7-10days

    • Continue breast feeding

     : early Tx & continued lactation is successful in avoiding

abscess formation

Breast abscess

    • surgical drainage (essential) & general anesthesia
hospital care

Chapter. 17 Puerperium

Hospital Care

Attention immediately after labor

  • for the first hour after delivery

   - BP & PR : should be taken every 15 minutes

  • monitor amount of vaginal bleeding
  • Fundus should be palpated to ensure that it is well contracted

if relaxation detected, uterus should be massaged through

abdominal wall until it remains contracted

hospital care37

Chapter. 17 Puerperium

Hospital Care

Early ambulation

  • Advantages

less frequent bladder complications & constipation

reduced frequency of puerperal venous thrombosis &

pulmonary embolism

Care of the Vulva

  • Should be instructed to cleanse vulva from anterior to posterior (vulva→anus)
  • Ice bag applied to perineum
  • Warm sitz bath

: beginning about 24 hours after delivery

  • Tub bathing after uncomplicated delivery is allowed
hospital care38

Chapter. 17 Puerperium

Hospital Care

Bladder function

  • Oxytocin : commonly infused after placental delivery

sudden withdrawal of antidiuretic effect of oxytocin

     → rapid bladder filling

  • both bldder sensation and its capability to empty

     → diminished by anesthesia (esp. conduction analgesia),

by episiotomy, laceration or hematomas

→ Urinary retention with bladder overdistention

         : common complication of the early puerperium

  • woman who has not voided within 4 hours after delivery

      → indwelling catheter → prevent overdistension        

hospital care39

Chapter. 17 Puerperium

Hospital Care
  • Tx of bladder overdistention

indwelling of catheter for at least 24 hours

    • empty the bladder completely
    • prevent prompt recurrence
    • allow recovery of normal bladder tone & sensation 
  • after catheter remove, if the woman cannot void after 4hours

    → should be catheterized and urine vol. measured

    • ≥200 cc of urine

       : catheter should be left in place and the bladder drained

for another day

    • ≤200cc of urine

: remove the catheter & recheck the bladder.

hospital care40

Chapter. 17 Puerperium

Hospital Care

Bowel function

early ambulation and early feeding

   → constipation ↓

Subsequent discomfort

  • during the first few days after vaginal delivery

uncomfortable by afterpains, episiotomy & lacerations, breast engorgement

   → codeine, aspirin, acetaminophen

  • Episiotomy & lacerations

    - early application of an ice bag

    - local analgesic spray

     - healed and nearly asymptomatic by the 3rd weeks

hospital care41

Chapter. 17 Puerperium

Hospital Care

Mild depression

  • Some degree of depression a few days after delivery is fairly common

: Postpartum blues (= transient depression)

  • Cause
    • The emotional letdown that follows the excitement and fears that most women experience during pregnancy and delivery
    • The discomforts of the early puerperium
    • Fatigue from loss of sleep during labor and postpartum in most hospital settings
    • Anxiety over her capabilities for caring for her infant after leaving the hospital
    • Fears that she has become less attractive
  • self-limited & usually remits after 2~3 days
hospital care42

Chapter. 17 Puerperium

Hospital Care

Abdominal wall relaxation

Exercise to restore abdominal wall tone

      : any time after vaginal delivery,

as soon as abdominal soreness diminishes after cesarean delivery


No dietary restrictions for women who have been delivered vaginally

   2 hours after normal vaginal delivery, (if, no Cx)

  • lactating women : should be increased in calories and protein
  • not breast feeding : dietary requirement as for a nonpregnant woman
hospital care43

Chapter. 17 Puerperium

Hospital Care


  • Anti D-immune globulin 300 μg

: nonimmunized women

   - within 72 hours of the birth of a D-positive infant

  • Rubella vaccination  
  • Diphtheria-tetanus toxoid booster infection
  • Measles immunization

Time of discharge

      if, no complication (at vaginal delivery)

          hospitalization period ≤ 48 hours 

care at home

Chapter. 17 Puerperium

Care at Home


  • Median interval between delivery and intercourse

: 5 weeks (1~12 weeks)

  • Best rule is one of common sense after 2 weeks, coitus may be resumed based on the pt's desire & comfort

* breast feeding : cause a prolonged period of suppressed estrogen

production with a resulting vaginal atrophy and dryness

care at home45

Chapter. 17 Puerperium

Care at Home

Return of menstruation and ovulation 

  • If not nursing

: usually return within 6-8 weeks

  • Lactating woman       

    : first period may occur 2nd~18th months after delivery 

  • Ovulation

- as early as 36-42 days(5-6 wks) after delivery

      - delayed resumption of ovulation with breast feeding

           but early ovulation is not precluded by persistent lactation

            → pregnancy can occur with lactation   

care at home46
Care at Home

Chapter. 17 Puerperium

Follow-up care

  • Normal delivery and puerperium

: women can resume most activities (bathing, driving, household

functions) by the time of discharge

  • Follow-up examination during 3rd postpartum wk has proven quite satisfactory

    - identify any abnormalities of later puerperium

   - initiate contraceptive practice

care at home47

Chapter. 17 Puerperium

Care at Home

Thromboembolic disease

in recent year : decreased

identified during the antepartum period

Pelvic venous thrombosis

  • during the puerperium a thrombus may transiently form in any of the dilated pelvic veins
  • without associated thrombophlebitis – not incite clinical signs or symptoms
  • The massive and fetal pulm. emboli that develop without warning in the puerperium

: symptomatic puerperal pelvic thrombosis is most commonly associated

with uterine infection    

care at home48

Chapter. 17 Puerperium

Care at Home

Obstetrical paralysis 

  • Pressure on branches of lumbosacral plexus during labor

     : complaints of intense neuralgia or cramplike pains

extending down one or both legs as soon as the fetal head

begins to descend the pelvis          

  • Involved external popliteal n. femoral n. obturator n, sciatic n.
  • the gluteal m. are affected.
  • Separation of the symphysis pubis or one of the sacroiliac synchondroses during labor may be followed by pain and marked interference with locomotion.