PHYSIOLOGY OF PUERPERIUM. THIS TOPIC IS VERY IMPORTANYT OF POSTGRADUATE STUDENTS

1. DISCUSSION ON
PHYSIOLOGY OF
PUERPERIUM
PRESENTED BY
SANCHAYEETA DEY
1ST YEAR M.SC NURSING

2. INTRODUCTION
• The puerperium is a period of approximately 6 weeks which
commences following completion of third stage of labour.
• During this time women recovers from stresses of pregnancy
and delivery and the physiological adaptations which occur
during pregnancy subside, facilitating the restoration of the
non pregnant state.

3. DEFINITION
• The puerperium is defined as the period following
childbirth during which the body tissues, specially the
pelvic organs revert back approximately to the pre-
pregnant state both anatomically and physiologically.
• -D.C DUTTA

4. DURATION
• Puerperium begins as soon as the placenta expelled
and last for approximately 6 weeks when uterus
becomes regressed almost to non- pregnant size.

5. STAGES OF PUERPERIUM
• The post partum period has been divided into:
1. The immediate puerperium:- the first 24 hours after
parturition; when acute post anesthetic or post delivery
complication may occur.
2. The early puerperium :- it extends until the first week post
partum.
3. The remote puerperium:- it includes the period of time
required for involution of the genital organs through the sixth
weeks postpartum

6. REPRODUCTIVE SYSTEM
UTERUS
Involution: it is the return of the uterus to a non pregnant state after
childbirth.
Involution process begins immediately after expulsion of the placenta
with contraction of uterine smooth muscles.
At the end of 3rd stage of labour, the uterus is in the midline, about
2cm below the level of the umbilicus and weighs 1000g and measures
about 20×12×7.5 ( length, breadth and thickness)

7. Cont..
• By 24 hours postpartum the uterus is about the same size it was at
20 gestational weeks.
• The fundus descends about 1to 2 cm every 24 hours, and by the
sixth postpartum day it is located halfway between the symphysis
pubis and umbilicus.
• The uterus lies in the true pelvis within 2 weeks after childbirth.

8. INVOLUTION OF THE UTERUS
Return to the pelvis by about 2 weeks
Normal size by 6 weeks
The weight changes of uterus
i) 1000g immediately after birth (excluding the fetus, placenta,
membrane and amniotic fluids)
ii) 500g- 1 week after birth
iii) 300g- 2 weeks after birth
iv) 50g - 6 weeks after birth.
The endometrial lining rapidly regenerates( 16 days)
The placental site undergoes series of changes in the
postpartum period.

10. • SUBINVOLUTION: Is the failure of the uterus to return to a non-
pregnant state.
• The most common causes of sub involution are retained
placenta fragments and infection.

11. LOWER UTERINE SEGMENTS
• Immediately following delivery the lower segments becomes
thin flabby, collapsed structure.
• It takes a few weeks to revert back to normal shape and size of
the isthmus.

12. CERVIX
• It is soft immediately after birth.
• The cervix up to the lower uterine segment remains
edematous, and thin for several days after birth.
• The cervical os which is dilated to 10cm during labor closes
gradually, it may still possible to introduce 2 fingers into
cervical os for the first 4-6 postpartum days.
• The external cervical os never regains its pregnancy
appearance, it is no longer shaped like a fish mouth.
• It return to its normal state at 4 weeks after birth.

14. PHYSIOLOGICAL CONSIDERATION
• The physiological process of involution is most marked in the
body of the uterus changes occur in the following components
A) Muscles
B) Blood vessels
C) Endometrium

15. MUSCLES
• There is marked hypertrophy and hyperplasia of muscle fibers
during pregnancy.
• During puerperium the number of muscle fibers is not
decreased but this is substantial reduction of the myometrial
cell size.
• Withdrawal of the steroid hormones estrogen and progesterone
may lead to increase in the activity of the uterine collagenase
and release of proteolytic enzymes.

16. BLOOD VESSELS
• 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
hyalinsation and fibrinsed end arteries.
• The veins are obliterated by thrombosis by hyalinasation and
endophelebitis
• New blood vessels grow inside the thrombi.

17. ENDOMETRIUM
• Following delivery the major part of the decidua is cast off with
expulsion of the placenta and the membranes more at the placenta
site.
• The endometrium left behind varies in thickness from 2-5mm
• The superficial part containing the degenerated decidua, blood cells
and bits of fetal membranes becomes necrotic and is cast off in the
lochia.
• Regeneration starts by 7th completed by 10th day and restored by 16th
day except placental site it takes 6 weeks.
• It occurs from the epithelium of the uterine gland mouths and
interglandular stromal cells.

18. INVOLUTION OF OTHER PELVIC STRUCTURES
VAGINA
• The distensible vagina notices soon after birth takes a long time
( 4-8 weeks)
• It regains its tone but never to the virginal state.
• The mucosa remains delicate for the first few weeks and
submucous venous congestion persist even longer, it is the
reason to withold sugery on puerperal vagina.
• Rugae partially reappears at 3rd week but never to the same
degree as in pre- pregnant state.
• The hymen is lacerated and represented by the nodular tags the
carunculae myritiforms.

19. CONT..
Broad ligament and round ligament:
-Requires considerable time to recover from the stretching and
laxation.
Pelvic floor and pelvic fascia:
-Takes a long time to involute from the stretching effect during
parturition.

20. LOCHIA
• It is the vaginal discharge that occurs after birth.
• Lochia is discharge originates from the uterine body, cervix and
vagina.
• For the first 2 hours after birth the amount of lochia should be
about that of a heavy menstraul period, after that time the lochial
flow should steadily decrease.
LOCHIA – ODOUR AND REACTIONS:
• It has got peculiar smell.
• It reactions is alkaline leading to become acid towards the end.

21. COLOR
• LOCHIA RUBRA- red color (1-4days)
It consists of blood , shreds of fetal membranes and decidual, vernix
caseosa, lanugo and meconium.
• LOCHIA SEROSA- yellowish or pink or pale brownish colour (5-
9days)
It consists of old blood, less of RBC, but more in leukocytes and
wound exudates mucus from cervix and microorganism
• LOCHIA ALBA- pale white (10-15days)
It contains of plenty of decidual cells, leucocytes, mucus, cholestrin
crystals, fatty and grandular epithelial cells and micro organisms.

22. • AMOUNT
• The average amount of discharge for the first 5-6 days is
estimated to be 250ml
• NORMAL DURATION
• The normal duration may extend upto 3 weeks
• The lochia rubra may persist for longer specially in women with
twins and scanty in premature labour.
• Can be more when women get up from bed in the later period.

23. CLINICAL IMPORTANCE OF LOCHIA
• ODOUR:
If offensive indicates retained pls or cotton pieces inside the vagina
should be kept in mind.
• AMOUNT:
Scanty or absent signifies infection. If excessive also indicates
infection.
• COLOUR:
Persistence of lochia rubra beyond normal limit signifies.
Subinvolution or retained bits of conceptus.
• DURATION:
Duration of the lochia alba beyond 3 weeks suggest local genital
lesions.

24. GENERAL PHYSIOLOGICAL CHANGES
1. PULSE:
• After the initial tachycardia associated with labour and delivery, a
bradycardia often develops in the early puerperium.
• A women’s pulse rate during the post partal period is usually slightly
slower than normal.
• This increased stroke volume which reduces the pulse rate between
60-70beats/min.
• As diuresis diminishes the blood volume and causes blood pressure to
fall, the pulse rate increases accordingly
• By the end of the first week, the pulse rate will have returend to
normal.

25. 2.TEMPERATURE

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32. Conclusion
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33. Appendix
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