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The Puerperium (Postpartum Period) — Lecture Notes
1. Definition
- Puerperium = the 6 weeks following delivery
- Characterised by:
- Involution — reproductive organs returning toward pre-pregnancy state
- Lactation — breast and hormonal system gearing up to produce milk
2. Uterine Involution
Immediately after delivery
| Parameter | Value |
|---|---|
| Length | 15–18 cm |
| Wall thickness | 4–5 cm |
| Mass | ~1000 g |
The uterus is hypermobile immediately after delivery — this is normal.
Fundal height regression
- Drops ~2 cm/day
- Day 10: no longer palpable above the pubic symphysis
- Week 4: back to pre-pregnancy size
Uterine mass over time
| Time | Mass |
|---|---|
| End of week 1 | ~500 g |
| End of week 2 | ~300 g |
| End of week 3 | ~250 g |
| End of week 4 | 50–100 g |
3. Cervical Involution
- 12 hours post-delivery: cervix is 5–6 cm wide (admits a hand — explains risk of ascending infection)
- Day 10: internal os closes
- Weeks 2–3: external os closes
- The external os never returns to its nulliparous shape — it changes from a small round os to a transverse slit (useful for estimating parity on exam)
4. Lower Uterine Segment Involution
- Immediately after delivery: only 0.5 cm thick (very thin — reason why lower segment C-section incisions are used)
- Over several weeks involutes back into the supravaginal portion of the cervix
5. Endometrial Regeneration
| Process | Timeline |
|---|---|
| Source of regeneration | Basal layer (stratum basalis) of the decidua |
| Epithelialisation of uterine cavity | Day 7–10 |
| Epithelialisation of placental site | End of weeks 3–4 |
| Granulation tissue formation | Day 2–4 |
Why granulation matters: the subepithelial granulation tissue forms a physical and immunological barrier against ascending bacterial infection before full re-epithelialisation is complete.
6. Lochia
Definition: postpartum vaginal discharge containing necrotic decidual tissue and blood, produced during endometrial regeneration.
| Stage | Name | Timing | Appearance |
|---|---|---|---|
| 1 | Lochia rubra | Days 1–3 | Red/bloody |
| 2 | Lochia serosa | Days 3–10 | Pinkish/serosanguinous |
| 3 | Lochia alba | Day 10 onwards | Yellowish-white |
- Total duration: 5–6 weeks
- Total volume: 500–1500 g
- pH: alkaline or neutral (important — the alkaline environment is less hostile to pathogens; normal vaginal flora and acidic pH are not yet re-established)
7. Vaginal Involution
- Immediately after delivery: loose, smooth, oedematous, bluish-pink
- Postpartum:
- Gradually reduces in size
- Rugae reappear by week 3
- Rarely returns completely to nulliparous dimensions
8. Ovarian Changes
- Ovaries decrease in size
- Corpus luteum involutes into scar (corpus albicans)
- Menses returns at ~36–42 days in non-breastfeeding mothers
- Breastfeeding mothers: lactational amenorrhoea (prolactin suppresses GnRH → no ovulation)
9. Breast Changes — The Four Processes
| Term | Meaning |
|---|---|
| Mamogenesis | Development/growth of breast tissue during pregnancy |
| Lactogenesis | Initiation of milk secretion |
| Galactopoesis | Maintenance of ongoing milk production |
| Galactokinesis | Milk ejection (let-down reflex) |
Breast Anatomy (micro)
- Each breast: 15–20 lobes → lobules → alveoli (secretory units)
- Each alveolus has a small milk canal
- Alveolar canals → lobule ducts → lobe ducts → lactiferous ducts → nipple openings
- Myoepithelial cells line the walls of alveoli and ducts — they contract on oxytocin stimulation to eject milk
10. Hormonal Control of Lactation
Prolactin (Lactogenesis & Galactopoesis)
- Suckling → sensory signals to hypothalamus → anterior pituitary releases prolactin
- Prolactin stimulates milk synthesis in alveolar cells
- Blood levels peak ~45 minutes after suckling starts
- More prolactin released at night → night feeds are important for maintaining supply
- Prolactin suppresses ovulation (mechanism of lactational amenorrhoea)
Oxytocin (Galactokinesis)
- Suckling → sensory impulses → posterior pituitary releases oxytocin
- Oxytocin contracts myoepithelial cells → milk ejection ("let-down")
- Oxytocin also contracts uterine smooth muscle → explains afterpains (uterine cramping during breastfeeding, more notable in multiparous women)
11. Breast Milk Stages
| Stage | Timing | Key Features |
|---|---|---|
| Colostrum | Days 1–5 | Thick, yellow; high IgA, proteins, growth factors, minerals, macrophages, lysozymes |
| Transitional milk | Days 5–10 | Increasing fat and lactose |
| Mature milk | After day 10 | Full volume; foremilk (watery, quenches thirst) + hindmilk (fat-rich, caloric) |
| Involution milk | Weaning phase | Still immunologically protective |
Colostrum Functions
- Protective — passive immunisation via secretory IgA
- Energetic — high protein and growth factors for rapid cell growth
- Laxative — promotes meconium passage, reducing jaundice risk
Components of Mature Breast Milk
Protective: IgA, leucocytes, oligosaccharides (bifidus factor), lactoferrin, lactalbumin, casein, lysozymes, Vitamins A & C
Maturing agents: Growth factors, immunomodulators
Other: Digestive enzymes, hormones, water (~88%)
A nursing mother produces approximately 600 ml/day. Most milk proteins are unique to human milk and are not found in other species' milk.
12. Advantages of Exclusive Breastfeeding
- Emotional bonding (mother-infant)
- Protection from GI infections, respiratory infections, otitis media
- Health benefits for mother (faster uterine involution, reduced risk of breast/ovarian cancer)
- Acts as a natural contraceptive (LAM)
- Economic (no formula cost)
13. Signs of Proper Latch-On
A correct latch prevents nipple trauma and ensures adequate milk transfer:
- Mouth widely open
- Lips everted (flanged outward)
- Tongue visible between mouth and breast
- Entire nipple + most of areola inside baby's mouth
- Chin pressed into the breast
- Baby's body aligned (head, neck, body in one line) and pressed close to mother
14. Breastfeeding Positions
- Cradle hold — classic position, baby across the lap
- Football hold — baby tucked under the arm; useful after C-section or for large breasts
- Back-lying — mother reclined, baby on top
- Side-lying — both lying on their sides; useful at night
15. Postpartum Care Practices
Monitoring (Daily)
- General well-being
- Temperature (twice daily for first 10 days — fever may indicate infection)
- Pulse
- Uterine fundal height
- Lochia character
- Perineum and genital organs
- Breast health
- Diuresis and bowel function
Active Care
- Early mobilisation + pelvic floor exercises (reduces DVT risk, aids recovery)
- Mother and baby together 24 hours/day (rooming-in)
- Counselling on infant care, danger signs, contraception
16. Danger Signs — Seek Help Immediately
| Sign | Possible Cause |
|---|---|
| Soaking 2–3 pads in 30 min | Postpartum haemorrhage |
| High fever | Endometritis, mastitis, UTI |
| Tachypnoea | PE, sepsis, pneumonia |
| Abdominal pain | Retained products, endometritis |
| Breast/nipple pain + hardness | Mastitis, engorgement, abscess |
| Dysuria/urinary incontinence | UTI, perineal injury |
| Purulent perineal discharge | Wound infection |
| Foul-smelling lochia | Endometritis |
17. Postpartum Psychological Problems
| Condition | Incidence | Features |
|---|---|---|
| Baby blues | ~80% | Mild, transient, peaks day 3; self-resolving |
| Postpartum depression | 14–20% | Persistent low mood, anxiety, interferes with function; requires treatment |
| Postpartum psychosis | <1% | Severe; hallucinations, confusion; psychiatric emergency |
Baby blues are due to the rapid fall in oestrogen/progesterone after delivery. If symptoms persist beyond 2 weeks, screen properly for PPD (e.g. Edinburgh Postnatal Depression Scale).
18. Family Planning Postpartum
| Timing | Methods Available |
|---|---|
| Immediately | Condoms, spermicides, IUD, sterilisation, LAM |
| After 4–6 weeks | Diaphragm, IUD (if not inserted immediately) |
| After 6 weeks | Combined oral contraceptives (COC), calendar method, injectable contraception |
Lactational Amenorrhoea Method (LAM) — Effective if ALL THREE met:
- Exclusive breastfeeding (no supplements)
- Amenorrhoea present
- Baby less than 6 months old
- Must feed at least every 4 hours during day and every 6 hours at night
LAM works because frequent suckling keeps prolactin levels high enough to suppress the hypothalamic-pituitary-gonadal axis. If any condition is not met, additional contraception must be used.
19. Discharge Criteria
Mother
- No complaints; stable vitals
- No haemorrhage or signs of infection
- Counselled on breastfeeding, danger signs, contraception, newborn care
- Normal delivery: discharge 24–48 hours postpartum
Newborn
- Effective feeding established
- Thermoregulation intact
- Umbilical stump clean, no signs of omphalitis
- No danger signs
Advantages of Early Discharge
- Lower nosocomial infection risk
- Reduced thromboembolic risk
- Better comfort and family support at home
- Low re-admission rates (evidence-based)
20. WHO Ten Steps to Successful Breastfeeding (Baby-Friendly Hospital)
- Written breastfeeding policy communicated to all staff
- Train all staff in breastfeeding skills
- Inform all pregnant women about breastfeeding benefits
- Help mothers initiate within the first hour of birth
- Teach correct breastfeeding technique
- Give newborns no food or drink other than breast milk
- Room-in mother and baby 24 hours/day
- Encourage on-demand feeding
- No artificial teats or pacifiers
- Foster breastfeeding support groups
21. Ineffective Practices to Avoid
| Practice | Why It's Ineffective/Harmful |
|---|---|
| Routine medication without indication | Unnecessary drug exposure |
| Separating mother and baby | Disrupts bonding, reduces milk supply |
| Nipple creams/ointments | No evidence of benefit; may discourage good latch |
| Antiseptics on umbilical cord | Delays natural separation; "dry care" is recommended |
| Tight swaddling | Restricts movement, interferes with feeding cues |
| Pre/post-feed weighing | Causes maternal anxiety without benefit |
Source: Tbilisi State Medical University — UNICEF Georgia, The Puerperium lecture series
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