Normal Puerperium

Normal Puerperium

• Definition: The time from the delivery of the placenta through the first few weeks after delivery (6 weeks postpartum)
• Importance: By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery have resolved and the body has reverted to the non-pregnant state

Uterus

• Size: Immediately after delivery, the uterus can be palpated at or near the umbilicus, reducing to 500g after 1 week, 300g at the end of 2 weeks, and 100g or less thereafter
• Weight: Most of the reduction in size and weight occurs in the first 2 weeks
• Tissues revert to a non-pregnant state, but never return to the nulliparous state

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

• Shrinks to a non-pregnant state
• Resolution of the increased vascularity and edema occurs by 3 weeks
• The vaginal epithelium appears atrophic on smear, restored by weeks 6-10
• Tissues revert to a non-pregnant state, but never return to the nulliparous state

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

• Duration: Moderate pain for 2 days, mild pain by the 3rd day postpartum
• Causes:
  • Multipara: The uterus contracts vigorously at intervals
  • Primiparas: The uterus tonically contracts
  • Infant suckling (breastfeeding): Oxytocin release → uterine contraction → afterpain

Lochia

• Duration: Variable, lasts about 5 weeks, with 15% of women having lochia at week 6 postpartum
• Types:
  • Lochia rubra: Red, variable duration
  • Lochia serosa: Brownish-red, more watery consistency, decreases in amount
  • Lochia alba: Yellow

Ovulation and Menstruation

• There is no ovulation immediately postpartum due to prolactin hormone inhibiting gonadotrophin releasing hormone (GnRH) release from the hypothalamus
• Ovulation is restored after a duration depending on whether the woman is breastfeeding or not
• Menstrual cycles resume when ovulation is restored

Breastfeeding

• Changes to the breast that prepare for breastfeeding occur throughout pregnancy
• Lactation can occur by 16 weeks' gestation
• Colostrum: High in protein and immune factors, first 2-4 days after delivery
• Mature milk: Contains all the necessary nutrients, changes throughout the period of breastfeeding
• Initiation: Should be initiated as soon as possible after delivery, feeding every 2-3 hours to stimulate milk production

Contraindications to Breastfeeding

• Alcohol use and street drugs
• Certain medications
• Active untreated tuberculosis (TB)
• Infections: HIV, Cytomegalovirus, and hepatitis B virus
• Women with active herpes simplex virus
• An infant with galactosemia
• Mother undergoing breast cancer treatment

Physiologic Weight Loss

• Mean weight loss from delivery of the fetus, placenta, and amniotic fluid is 6 kg
• Additional loss of 2 to 7 kg during the puerperium due to contraction of the uterus, loss of lochial fluid, and loss of excess intra- and extracellular fluid
• Approximately one-half of gestational weight gain is lost in the first six weeks after delivery, with a slower rate of loss through the first six months postpartum

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
  • Emotionally ready
• Physical readiness usually takes ~3 weeks

Concerns - Puerperal Period

• Physical activity and exercise during the postpartum period
• Pelvic floor rehabilitation:
  • Prevent and manage pelvic organ prolapse
  • Prevent and manage urinary incontinence
  • Improve sexual function
• Benefits of postnatal exercise:
  • Restores physical health
  • Improves sleep quality
  • Relieves stress
  • Prevention of depressive disorders
  • Reduced body weight
  • Stimulates lactation
  • Alleviates postnatal issues such as diastasis recti, urinary incontinence, pelvic organ prolapse, and pelvic girdle pain

Role of Women's Health Physiotherapist

• Physical therapy can improve health outcomes for new mothers in the postnatal period
• Benefits:
  • Improve mood
  • Improve cardio-respiratory fitness
  • Promote weight loss
  • Reduce the risk of postpartum depression and anxiety
  • Enhance psychological well-being
  • Improve sexual health and sexual dysfunction
  • Lead to better outcomes assessing quality of life