Normal Puerperium

Normal Puerperium

• Puerperium is the time from delivery of the placenta to 6 weeks postpartum
• By 6 weeks, most changes of pregnancy, labor, and delivery have resolved and the body has reverted to a non-pregnant state

Uterus

• Immediately after delivery, the uterus can be palpated at or near the umbilicus
• By 2 weeks postpartum, the uterus should be located in the true pelvis
• The uterus shrinks rapidly in the first 2 weeks, with a significant reduction in size and weight
• Weight: 1000g immediately postpartum, 500g at 1 week, 300g at 2 weeks, and 100g or less thereafter

Cervix

• The external os is closed to the extent that a finger could not be easily introduced
• The external os never resumes its pre-gravid shape; it becomes a large, transverse, stellate slit after childbirth

Vagina

• The vagina shrinks to a non-pregnant state, with resolution of the increased vascularity and edema by 3 weeks
• The vaginal epithelium appears atrophic on smear, restored by weeks 6-10

Perineum

• Swelling and engorgement are completely gone within 1-2 weeks
• The gapping of the vulva that occurs during vaginal delivery remains for 2-3 weeks then gradually disappears, but never returns to the pre-pregnancy state
• Muscle tone may or may not return to normal, depending on the extent of injury

Afterpain

• Moderate pain for 2 days, mild pain by the 3rd day postpartum
• Occasionally severe enough to require an analgesic
• Causes: uterine contractions, infant suckling (breastfeeding)

Lochia

• Duration: variable, lasts about 5 weeks
• At week 6 postpartum, only 15% of women have lochia
• Types:
  • Lochia rubra: red, variable duration
  • Lochia serosa: brownish-red, more watery consistency, decreasing in amount
  • Lochia alba: yellow

Ovulation and Menstruation

• No ovulation immediately postpartum due to prolactin hormone inhibiting GnRH release
• Ovulation restored after a duration depending on whether the woman is breastfeeding or not
• Menstrual cycles resume when ovulation is restored
• Breastfeeding: variable duration, ovulation may be as early as 27 days after delivery
• 50-75% of women return to periods within 12 weeks, the rest may not have periods until stopping breastfeeding

The Breasts

• Changes prepare for breastfeeding throughout pregnancy
• Lactation can occur by 16 weeks' gestation
• Colostrum: high in protein and immune factors, 1st 2-4 days after delivery
• Milk: matures over the first week, containing all necessary nutrients

Breastfeeding

• Initiation: neither easy nor automatic, should be initiated as soon as possible after delivery
• Feed the baby every 2-3 hrs to stimulate milk production
• Contraindications: alcohol use, certain medications, active untreated tuberculosis, infections, and galactosemia

Physiologic Weight Loss

• Mean weight loss from delivery of fetus, placenta, and amniotic fluid: 6 kg
• Additional loss of 2-7 kg during the puerperium
• Approximately one-half of gestational weight gain is lost in the first six weeks

Abdominal Wall

• Remains soft with poor tone for many weeks
• Return to a pre-pregnant state depends greatly on exercise

Sexual Intercourse

• May resume when red bleeding ceases, vagina and vulva are healed, physically comfortable, and emotionally ready
• Physical readiness usually takes ~3 weeks