THE PUERPERIUM o Multipara Uterus contracts more vigorously

o Primipara Uterus contracts tonically

- r/t release of Oxytocin & relieved by Analgesics
PUERPERIUM
- delivery of the Placenta lasting until 6 weeks after delivery. ----------------------------------------------------------------------------------------------------------
- Physiologic changes during pregnancy return to pre-pregnancy state. CHANGES IN THE LOWER REPRODUCTIVE TRACT
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CHANGES IN THE REPRODUCTIVE TRACT - Lower Uterine Segment contracts & retracts
---------------------------------------------------------------------------------------------------------- - Cervix contracts & the Cervical Opening narrows.
- External Os remain wider with bilateral depressions r/t lacerations
Involution of the Uterus during delivery Fish Mouth Appearance
- Uterus contracts tonically, reducing its size - Vaginal Canal forms a smooth-walled passage, decreasing in size;
o Fundus is slightly below the umbilicus Rugae reappear at 3rd week.
o Myometrial Blood Vessel compression Hemostasis - Hymen gets torn, forming the Myrtiform Caruncles
(prevents Post-Partum Hemorrhage)
- 10th-12th Post-Partum Day = Uterus descends into the Pelvic Cavity & Perineal Care
becomes impalpable abdominally. - Water & Mild Soap from ANTERIOR to POSTERIOR.
- 6 weeks = Non-Pregnant size - Ice Packs applied to the Episiotomy Wound to reduce swelling &
- from 1000 grams to 70 grams discomfort; Analgesics may help
- r/o Hematoma/Cellulitis if perineal pain is severe/persistent.
Involution of the Placental Site - Stool Softeners for 4th Degree Lacerations
- Placental Vessels undergo Thrombosis & Hyalinization
o Extruded with the slough of the necrotic Placental Site, ----------------------------------------------------------------------------------------------------------
which is gradually exfoliated & extruded out. CHANGES IN THE URINARY TRACT
o Complete extrusion may last up to 6 weeks ----------------------------------------------------------------------------------------------------------
- Infiltration with Granulocytes & Mononuclear Cells extending into
the Endometrium & Superficial Myometrium - Increased Urinary Bladder capacity & is insensitive to Intravesical
- 7th Day = regeneration of Endometrial Glands & Stroma (from Fluid Pressure Overdistention, Incomplete Emptying, & Increased
Placental Site Margin & Decidua Basalis) Residual Urine
o Aggravated by exposure to paralyzing effects of Regional
Endometrial Regeneration Block Anesthesia & trauma during delivery Hyperemia
- 2-3 Days Post-Partum = remaining Decidua is split into 2 layers. & Edema
o Superficial Layer = necrotic & is sloughed in the Lochia - Diuresis during the 1st week as compensation of excess ECF
o Basal Layer = remains viable; source f new endometrium - Dilated Collecting Duct System returns to normal size by 6 weeks.
- Full restoration of the entire endometrium at 3rd week Post-Partum - Patients are encouraged to void within a few hours after delivery.

Imaging Findings ----------------------------------------------------------------------------------------------------------

- UTZ = Uterus retroverted & the cavity empty in early Puerperium. CHANGES IN THE BREAST & LACTATION
o Fluid & Debris in the Cavity (Mid-Puerperium) ----------------------------------------------------------------------------------------------------------
o Day 56 = empty Cavity appearing as a thin white line
- Positive correlation between Parity & Uterine Diameter (larger - complex Humoral & Neural Mechanisms involving several hormones
Uterus in the Multiparous group) prepare the Breast for Lactation.
- Route of Delivery = Uterus larger at 1-3 months after CS delivery. o Progesterone, Estrogen, HPL, Prolactin, Insulin, & Cortisol
- Regular Breast Feeding = smaller Uteri (3 months Post-Partum) - Growth & Development of Lactiferous Ducts & Alveolar Secretory
Epithelium System.
Fourth Stage of Labor - Prolactin = stimulates unopposed milk lactose formation; levels
- 1st hour after delivery of the Placenta. increase by suckling.
- Time of greatest risk of significant hemorrhage - Oxytocin = pulsatile secretion & stimulates milk expression (Let
- Monitor Vital Signs q15 minutes or more often as necessary. Down Reflex); may also be stimulated by cry of the infant, while
- Palpate Uterus periodically to ensure well contraction. fright/stress inhibits it.
o Massage via Abdominal Wall if relaxation is noted
- Monitor amount of vaginal bleeding by inspection Phases of Milk Secretion
- Uterine Atony = Uterine Relaxation & increased Vaginal Bleeding. - quality varies as time progresses Post-Partum.
- Colostrum = 1st milk secreted (lasts for 5 days)
Lochia o Thick & yellowish
- Vaginal Discharge from the Uterus during Post-Partum. o High CHON (-Lactalbumin, -Lactoglobulin, & Casein) &
- Erythrocytes, Decidua, Epithelial Cells, & Bacteria Mineral Content; Less CHO
- Lochia Rubra = reddish-brown discharge (3-4 days) o Larger Fat Globules
- Lochia Serosa = paler in color (4-10 days) o Immunoglobulin A = protection against Enteric Pathogens
- Lochia Alba = yellowish white; consists of Leukocytes & reduced fluid - Mature Milk is more watery & contains more Fat & Lactose
content (> 10 days) concentration.
- May persist from 4-8 weeks. o Also rich in Antibodies
- Sudden but transient increased Uterine Bleeding may occur between o Contains all Vitamins except Vitamin K.
7-14 days Post-Partum. o Changes composition to match infants nutritional needs
o Slough of eschar over the site of Placental attachment o Contains Growth Fx promoting cellular growth &
o Self-limited differentiation Organ System Maturation of the NB
o Retained Placental Tissue = if does not subside within a
few hours Local Setting
- Exclusive Breastfeeding for the 1st 6 months
After Pain - Republic Act No. 7600 (Rooming-In & Breastfeeding Act of 1992)
- intermittent, crampy lower abdominal pain Post-Partum o Requires all Private & Government Health Institutions
- duration & intensity increased with parity. adopt Rooming-In & Breastfeeding practices.
 o Requires that all well infants delivered vaginally without - Presence of Silver Striae (Stretch Marks)
complications shall be given to their mothers to hold & - Diastasis Recti = marked separation of the Rectus Muscles.
caress immediately after birth & through the assistance of o Midline Abdominal Wall formed only by Peritoneum,
a hospital staff, initiate Breastfeeding in the Delivery attenuated Fascia, SC Fat, & Skin
Room (Latching-On). o Self-limited; exercise may improve the condition
o Infants should be roomed0in with their mothers 30
minutes to 1 hour after delivery to promote & facilitate ----------------------------------------------------------------------------------------------------------
breastfeeding. OTHER ISSUES
o Mothers shall be given their babies to hold & caress after ----------------------------------------------------------------------------------------------------------
waking up from Anesthesia in CS Deliveries (roomed-in
within 3-4 hours after birth) PHYSICAL ACTIVITY
- Very early Skin-to-Skin Contact enhanced breastfeeding during early - Early Ambulation is encouraged
Post-Partum Period. o Done gradually r/t dizziness
o Only for uncomplicated Vaginal Delivery
Benefit to the Woman o Associated with less Bladder Cx & incidence of
- Oxytocin released during Milk Let-Down increases contractions & Thromboembolic Disease
lessens maternal blood loss.
o Together with Prolactin, it promotes feeling of WEIGHT LOSS
attachment & relaxation - after delivery with Uterine evacuation & Blood Loss, women
- Breastfeeding is associated with decreased incidence of Ovarian & generally lose 5-6 kg.
Breast Cancer & promotes birth spacing by delaying the return of the - Diuresis = 2-3 kg
Ovulatory Cycle. - Failure to lose weight in 6 months predicts future Obesity.
o Attenuates unfavorable metabolic risk factor changes by
reducing LDL & Fasting Insulin levels POST-NATAL CARE
o May result in Bone Demineralization r/t maternal transfer - enables identification of complications & provide the mother with
of Ca2+ to the Breast Milk even with supplementation. information on how to take care of herself & the baby.
o Remineralization occurs following weaning. - Post-Natal Check Up within 2 days after delivery.
o Mothers are encouraged to drink milk during lactation.
- 2500 Calories = recommended daily caloric requirement for lactating EARLY DISCHARGE
women during the 1st 6 months. - no evidence associating early discharge with adverse outcome.
- No impact in Breastfeeding.
Breast Fever - Done 6-72 hours after delivery
- 37.8C to 39C; accompanies Breast Engorgement during the 1st 24
hours after start of lactation
o Support Breast with a Binder/Brassier
o Apply Ice Bag
o Analgesics
- will not last longer than 16 hours; exclude other causes of fever

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RETURN OF OVULATION & MENSTRUATION
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- women who do not Breastfeed experience Ovulation as early as 4

weeks after delivery (Mean Period of 10 weeks)
o Menstruation by the 12th week after delivery (average 7
weeks)
- Lactating mothers may delay their Ovulation for 6-10 months.
o r/t persistently elevated Serum Prolactin level, making
Ovaries unresponsive to FSH Stimulation

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CHANGES IN THE CARDIOVASCULAR SYSTEM
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- Plasma Volume is diminished approximately 1 Liter r/t Blood Loss.

o Increases the same amount by 3rd day Post-Partum r/t ECF
Shift into the Vascular Space.
o 1 week Post-Partum = Blood Volume returns nearly to
Non-Pregnant levels.
- Cardiac Output remains elevated for 2 days Post-Partum but
gradually decreases until reaching normal by the 2nd week.
- Blood Coagulation Fx remain elevated.
o Greatest level of Coagulability during the 1st 48 hours
o Fibrinogen levels remain elevated during 1st week &
progressively declines.

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CHANGES IN THE ABDOMINAL WALL
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- Abdominal Wall remains soft & flaccid but eventually returns to Pre-
Pregant state.