Puerperium is 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. 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.

1. Physiological changes
during puerperium
Shrooti Shah
M.Sc. Nursing
Batch 2011

2. Objectives
 Introduce to puerperium
 Explain anatomical and physiological
changes during puerperium.

3. Introduction
 Puerperium is 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.
 Involution is the process whereby the
reproductive organs return to their
nonpregnant state.

4. Introduction cont…
 Duration: 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 –
 Immediate- within 24 hours
 Early- upto 7 days
 Remote- upto 6 weeks.

5. Reproductive system changes
Involution of the uterus
Anatomical consideration
 Immediately following delivery, the uterus
becomes firm and retracted with alternate
hardening and softening.
 The uterus measures about 20 X 12 X 7.5
cm.
 Weight :about 1000 gms.

6. Anatomical consideration cont…
 At the end of the first week, it weighs
500gm. By the 6 weeks, it weighs approx.
50g.
 The placental site contracts rapidly
presenting a raised surface which measures
about 7.5 cm and remains elevated even at
6 weeks when it measures about 1.5 cm.

7. Lower uterine segment
 Immediately following delivery, the lower
segment becomes a thin, flabby, collapsed
structure.
 It takes a few weeks to revert back to the
normal shape and size of the isthmus.

8. Cervix
 The cervix contracts slowly.
 External os: admits two fingers for a few days
but by the end of first week, narrow down to
admit the tip of finger only. It never returns back
to the nulliparous state, usually remains slightly
open and appear slitlike or stellate (star shaped).
 Internal os: Internal os closes as before.

9. 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

10. Muscles
 During puerperium, the number of muscles
fibers is not decreased but there is
substantial reduction of the myometrial cell
size.
 Withdrawal of the steroid hormones,
oestrogen and progesterone may lead to
increase in the activity of the uterine
collagenase and the release of the
proteolytic enzyme.

11. Blood vessels
 The arteries are constricted by contraction of its
wall and thickening of the intima followed by
thrombosis.
 New blood vessels grow inside thrombi.
 Fibrous tissue on the wall undergoes hyaline
degeneration and the products are removed by
macrophages.
 There is also degeneration of the elastic tissues.

12. Endometrium
 The superficial layer becomes necrotic and
is sloughed in the lochia.
 The basal layer adjacent to the myometrium
remains intact and is the source of new
endometrium.
 The endometrium arises from proliferation of
the endometrial glandular remnants and the
stroma of the inter glandular connective
tissue.

13. Endometrium
 By the 10th day: Regeneration of the
epithelium is completed.
 By the day 16: the endometrium is
restored.
 At about 6 weeks: the endometrium of
placental site is restored

14. Placental site involution
 Complete extrusion of the placental site
takes up to 6 weeks.
 When this process is defective, late-onset
puerperal hemorrhage may ensue.
 Size of placental site:
 Immediately after delivery: approx. the size of the
palm, but it rapidly decreases thereafter.

15. Placental site involution
cont…
 Within hours of delivery: normally consists of
many thrombosed vessels.
 By the end of the 2nd week: 3 to 4 cm in
diameter.
 Williams described placental site involution as
a process of exfoliation, which is in great part
brought about by the undermining of the
implantation site by growth of endometrial
tissue.

16. Uterine involution

17. Vagina
 Takes a long time(4-8 weeks) to involute.
 It regains its tone but never to the virginal state.
 The mucosa remains delicate for the first few
weeks and submucous venous congestion
persists even longer.
 Rugae partially reappear at third week.
 The introitus remains permanently larger than
the virginal state.

18. Abdominal Wall
 As a result of ruptured elastic fibers in the
skin and prolonged distension caused by
the pregnant uterus, the abdominal wall
remains soft and flaccid.
 Several weeks are required for these
structures to return to normal.

19. Lochia
 It is the vaginal discharge for the first
fortnight during puerperium.
 The discharge originates from the uterine
body, cervix and vagina.
 Odour and reaction: it has got a peculiar
offensive fishy smell.
 Its reaction is alkaline tending to become
acid towards the end.

20. Lochia cont..
 Colour: depending upon the colour
 Lochia rubra (red): 1-4 days
 Lochia serosa (5-9) days: the color is yellowish
or pink or pale brownish
 Lochia alba (plae white):10-15 days.
 Composition
 Amount: for the first 5-6 days, is estimated
to be 250 ml.

21. Lochia cont…
 Normal duration: may extend up to 3 weeks.
Clinical aspects
1. Persistence of red lochia means subinvolution
2. Offensive lochia means infection
3. In severe infection with septicaemia, lochia is
scanty and not offensive
4. The period of time the lochia can last varies,
although it averages approximately 5 weeks

22. General Physiological changes
Endocrine system
Placental hormones
 Insulinaze causes the diabetogenic effects of
pregnancy to be reversed.
 Estrogen and progesterone levels decrease
markedly after expulsion of the placenta,
reaching their lowest levels 1 week into the
postpartum period.
 The estrogen levels in nonlactating women
begin to increase by 2 weeks after birth, and
higher by postpartum day 17.

23. Pituitary hormones and ovarian function
 Lactating and non-lactating women differ in the
time of the first ovulation.
 In women who breast feed, prolactin levels
remain elevated into the sixth week after birth.
 Prolactin levels decline in nonlactating women,
reaching the prepregnant range by third week.

24. Menstruation and ovulation
 If the woman does not breast fed her baby, the
menstruation returns by 6th week following
delivery in about 40% and by 12th week in 80%
of cases.
 In non-lactating mothers, ovulation may occur
as early as 4 weeks and in lactating mothers
about 10 weeks after delivery.
 A women who is exclusively breastfeeding, the
contraceptive protection is about 98% upto 6
months postpartum. Thus, lactation provides a
natural method of contraception.

25. Menstruation and ovulation cont..
 However ovulation may precede the first
menstrual period in about one-third and it is
possible for the patient to become pregnant
before she menstruates following her
confinement.
 Non-lactating mother should use
contraceptive measures after 3 weeks and
the lactating mothers after 3 months of
delivery.

26. Urinary system
 The bladder wall becomes oedematous and
hyperaemic and often shows evidences of
submucous extravasation of blood.
 Because of relative insensitivity to the raised
intravesical pressure due to trauma sustained to
the nerve plexus during delivery, the bladder
may be overdistended without any desire to
pass urine.
 Dilated ureters and renal pelvis return to normal
size within 8 weeks

27. Blood and fluid changes
 Diuresis evident between second and fifth
day after birth, as well as blood loss at birth,
acts to reduce the added volume
accumulated during pregnancy.
 Rapid reduction occurs, so that blood volume
returns to its normal prepregnancy level by
first or second week after birth.

28. Blood and fluid changes
 The white blood cell count sometimes
reaches 30,000/L, with the increase
predominantly due to granulocytes.
 There is a relative lymphopenia and an
absolute eosinopenia.
 Normally, during the first few postpartum
days, hemoglobin concentration and
hematocrit fluctuate moderately.

29. Blood and fluid changes
 Blood volume: Returned to normal level by
1 week after delivery
 Cardiac Output: Remains elevated for 24 to
48 hrs postpartum and declines to
nonpregnant values by 10 days.
 Heart rate changes follow this pattern
 SVR: follows inversely

30. The gastrointestinal system
 Digestion and absorption begin to be active
again soon after birth.
 Bowel sounds are active, but passage of
stool through the bowel may be slow
because of the still present effect of relaxin
on the bowel.
 Bowel evacuation may be difficult because
of the pain of episiotomy sutures or
hemorrhoids.

31. Weight loss
 Rapid diuresis and diaphoresis during 2nd to 5th
days after birth result in weight loss of 5 lb (2 to
4kg), in addition to approx. 12 lb (5.8 kg) lost at
birth.
 Lochia flow- 2-3 lb(1kg) loss
 Total weight loss- 19 lb
 Additional weight loss depend on amount of
weight gain in pregnancy and active measures
to reduce weight.

32. Integumentary system
 Stretch marks in women’s abdomen still appear
reddened and may be even more prominent than
pregnancy.
 Excessive pigment on face and neck (Chloasma) and
on abdomen (Linea nigra) barely detectable in 6
weeks time.
 Diastasis recti ( Overstretching and separation of the
abdominal musculature) if present, the area will be
slightly indented.
 Abdominal wall and ligaments require 6 weeks time to
return to their former state.

33. Lactation
 Since midway through pregnancy, she has
been secreting colostrum, a thin, watery,
prelactation secretion.
 She continues to excrete this fluid the first 2
postpartum days.
 On the third day, her breasts become full
and feel tense or tender as milk forms within
breast ducts.

34. Lactation cont…
 When breast milk first begins to form, the
milk ducts become distended. The nipple
secretion changes from the clear colostrum
to bluish white, the typical color of breast
milk.
 This feeling of tension in the breasts on the
third or fourth day after birth is termed
primary engorgement.

35. Vital sign changes
Temperature
 A woman may show a slight increase in
temperature during the first 24 hours after
birth.
 Occasionally, when a woman’s breasts fill
with milk on the third or fourth postpartum
day, her temperature rises for a period of
hours because of the increased vascular
activity involved.

36. Pulse
 After the initial tachycardia associated with
labour and delivery, a bradycardia often
develops in the early puerperium.
 A woman’s pulse rate during the postpartal
period is usually slightly slower than normal.
 This increased stroke volume reduces the
pulse rate to between 60 and 70 beats per
minute.

37. Pulse cont…
 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 returned to normal.

38. Blood pressure
 Systolic and diastolic blood pressures
remain unchanged from late pregnancy
values until about 12 weeks post partum,
after which they increase.
 Within 2 weeks post partum, systemic
vascular resistance increases by 30%

39. References
1. Dutta D.C. Textbook of obstetrics. Sixth
edition. Calcutta, India; New Central Book
agency (P) Ltd: 2004.
2. Pillitteri A. Maternal and child health nursing.
Care of the childbearing and childrearing
family. Sixth edition. Philadelphia; Lippincott
Williams & wilkins: 2010.
3. Jacob A. A comprehensive textbook of
midwifery. Second edition. India; Jaypee
Brothers Medical publishers (P) ltd.

40. References
4. Fraser DM, Cooper MA. Myles Textbook of
Midwives. Fourteenth edition. Edinburgh;
Churchill Livingstone: 2003.
5. Cunningham, Leveno, Bloom. William’s
obstetrics. 23rd edition. United states of
America; Mcgraw Hill companies: 2010.
6. Silversides Ck, Colman JM. Retrieved from
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