Normal Puerperium

Definition

1. Uterine Involution

• The uterus loses more than half its postpartum weight within the first week.
• If the mother lactates, involution is faster because suckling suppresses ovarian hormones, keeping the uterus in a relatively hypoestrogenic state.
• Uterine contractions during involution cause afterpains, especially in multiparous women; these may require analgesics.
• The placental site on the endometrium undergoes autolysis, producing the vaginal discharge called lochia.

2. Lochia

3. Changes in Other Systems

Cardiovascular and Hematological

• Pulse rate drops within the first 24 hours.
• Temperature may be slightly elevated in the first 24 hours (physiologic, due to the exertion of labor).
• Leukocytosis is normal - WBC count may rise to 20,000/μL in the first 24 hours postpartum.
• Diuresis occurs, especially when oxytocin infusion is stopped, with temporary proteinuria and glycosuria possible.
• The diuresis reduces intravascular volume, which artificially elevates the hematocrit for a few days.

Urinary Tract

• Regional anesthesia (spinal/epidural) can delay spontaneous urination.
• Urinary retention and bladder overdistension must be avoided.
• Catheterization is recommended if significant urine output is not achieved by 12 hours with a distended bladder.

Cervix and Vagina

• The cervix gradually closes; within about 1 week it is closed to external examination.
• The vaginal walls regain tone over the weeks following delivery.

Gastrointestinal

• Regular diet can be resumed as soon as desired after normal vaginal delivery.
• Constipation is common; laxatives/mild cathartics may be needed if no bowel movement within 3 days.
• Hemorrhoids can be managed with warm sitz baths and dietary measures.

4. Hormonal Changes and Lactation

Colostrum

• Secreted during the last few days before and first few days after delivery.
• Contains proteins and lactose similar to mature milk but almost no fat.
• Rich in immunoglobulins (especially IgA) providing passive immunity to the newborn.

Mature Milk Production

• Begins 1-7 days after delivery once prolactin is no longer suppressed by placental hormones.
• Each suckling episode triggers a 10-20 fold surge in prolactin (lasting ~1 hour) via nipple-hypothalamus neural reflexes.
• Oxytocin causes myoepithelial cells around the alveoli to contract → milk let-down reflex. This begins 30 seconds to 1 minute after suckling starts.
• Psychogenic factors and sympathetic stimulation (stress, pain, anxiety) can inhibit milk ejection.

Breast Engorgement

• Occurs in the early days of lactation as milk supply increases.
• In non-breastfeeding mothers, lactation is suppressed by firm breast support (avoiding gravity-stimulated let-down) and fluid restriction; lasts 3-5 days.

5. Return of Menstruation and Ovulation

• In breastfeeding mothers: suckling signals suppress hypothalamic GnRH → suppressed LH and FSH → ovarian cycles typically do not resume until weeks after weaning. Some nursing mothers resume cycles within several months even while breastfeeding.
• In non-breastfeeding mothers: menstruation typically resumes within 6-8 weeks postpartum.
• Ovulation can precede the first menstrual period, meaning pregnancy is possible before the return of menses.

6. Psychological Changes

7. Routine Postpartum Care

• Uterine monitoring: Massage for 1 hour after the third stage of labor; oxytocin (10 U IM or dilute IV) if uterus fails to contract adequately.
• Ambulation: Full ambulation encouraged as soon as possible.
• CBC before discharge: To rule out significant anaemia.
• Rubella immunization: On day of discharge if mother is seronegative.
• Rh(D) immune globulin 300 μg IM: Within 72 hours for Rh-negative, unsensitized mothers with Rh-positive infants.
• Contraception: Can resume intercourse whenever comfortable; oral contraceptives can be started at discharge (low-dose estrogen or progestogen-only preferred in breastfeeding mothers). Diaphragm fitting deferred until 6-8 weeks postpartum when uterine involution is complete.
• Episiotomy care: Hot sitz baths several times daily; analgesics as needed.

Key Summary Points

1. Puerperium = 6 weeks from delivery of placenta to return to pre-pregnant state.
2. Uterus involutes from ~1000 g at delivery to ~50 g (non-pregnant) by 6 weeks.
3. Lochia progresses rubra → serosa → alba over approximately 10 days.
4. Leukocytosis up to 20,000/μL and mild fever in the first 24 hours are physiological.
5. Prolactin drives milk production; oxytocin drives milk ejection (let-down reflex).
6. Suckling suppresses GnRH → lactational amenorrhoea in breastfeeding mothers.
7. Baby blues (peak day 4-5, resolves by day 10) is distinct from postpartum depression (~10% incidence).