Normal periperium(PNC)

Kassa G.(BSc, MSc)

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• At the end of this chapter you will be able to:
• Define peurperium
• Explain physiological changes during
peurperium
• Describe postnatal care given for mother and
baby

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 Introduction
• Puerperium
– is the period of adjustment following
delivery when anatomic and physiologic
changes of pregnancy are reversed and the
body returns to normal, non pregnant state.
– Usually lasts 6 weeks.
– It is classified in to three phases
• Immediate: delivery to 24hours postpartum
• Early: 24hours to the end of the first week
• Late: end of the first week to complete
involution of the generative organs which is
traditionally 6weeks.

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Physiologic change of puerperium
Involution
• This is a process by which the
reproductive organs return to the pre-
gravid state.
– The uterus from a size of 20 weeks just after
delivery decreases in size at a rate of one
finger per day.
– By the end of the first week it is 12weeks,
– by 10-14days it becomes impalpable per
abdomen and reaches non gravid state by
6weeks.
– Its weight reduces from 1000grams at the
end of delivery to 50-100grams by 6weeks.
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Cont…
• In the first 2-3days after delivery the uterus contracts
strongly causing lower abdominal discomfort and pain.
This is called the after pain and it is commonly seen in
multiparas.
– It is worse after suckling.
• The endometrium, besides the placental site,
– differentiates into superficial and basal layers in 2-3
days.
– The superficial layer gets necrotic and is cast off as
lochia.
– Regeneration of the basal layer is completed in 10-
16days.
• The placental site is reduced by 50% following delivery.
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Regeneration starts by day 7 and is completed between 5
 Mechanism of involution
Step-1 Ischemia
- After the birth of the baby & placenta the uterine
muscle and B.V contracts so the blood circulation
decreases localized anemia  ischemia (necrosis)
2 Autolysis
– Muscle fibers that are necrotized are digested by
proteolytic enzyme, waste product then pass in to the
blood stream and eliminated by the kidneys.
3 Regeneration
- New endometrium from the basal layer develops.
- The superficial layer of the endometrium gets necrotic
and is cast off as lochia.
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 lochia
• It is the uterine discharge that occurs after birth.
• It has 3 types;

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 cont…
• The cervix up to the lower uterine segment
remains edematous , and thin for several
days after birth.
• The cervical os which is dilated to 10cm
during labor closes gradually, it may still
possible to introduce 2 fingers in to cervical
os for the first 4-6postpartum days
• It returns to its normal state at 4 weeks.
• Vagina, perineum and abdominal wall
regain their tone but some degree of laxity
remain.
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Traumatic lesions of the vagina and the 8
Systemic changes

• Enlargement of the kidneys persist for months,

• Glomerular filtration rate returns to normal in 8 weeks.

• Renal pelvis and Ureteric dilatation persists for 12weeks.

• Urinary bladder capacity is increased with little increase

in intravesical pressure.
– Incomplete emptying results in more residual urine.

• Diuresis of the excess extra cellular fluid starts between

days 2-5 and cause weight loss of 4 kilograms.

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Cont…
• There is rapid consumption of clotting factors in the first few

hours after delivery.

• But after the first day, there is rapid increase in clotting factors

which reaches maximum days 3-5 and maintained for 2 weeks.

• Leukocytosis of up-to 25000 per mm3 is common.

• Blood volume returns to normal in third week.

• Blood pressure tends to increase is the first 5 days owing to the

increase in peripheral resistance.

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• Cardiac output takes months to return to normal.
Endocrine changes

HPL become undetectable within 1 day

HCG level gradually decline and disapear by
11-16 day
Estrogen and progestron level also decline
to reach the lowest b/n 3-7 day
Oxytocin is secreted by posterior pituitary
gland
 In women who choose to breast feed their
babies, the sucking of the infant stimulates
further secretion of oxytocin and this aids the
continuing involution of the uterus and
expulsion of milk.
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 Return of fertility and menstruation

• Menstruation resume in six week in 30 % and 12 week

in 70% of non lactating women
• In lactating women, the range for resumption of
menstruation is 2-18 month, with 70 % starting to
have ovulation by 36 weeks
• In non lactating women, ovulation resume as early
as 33 days
• In lactating women, this is highly variable & is largly
dependent on strength of suckling (frequency &
duration of each feeding and weaning)
• The earliest time of ovulation in lactating women is 10
week, with only 20% ovulating in 6 month
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 Initiation and
maintenance of lactation
• Two events needed for initiation of
lactation are:
 Drop in placental hormones mainly
progesterone and estrogen and
 The release of Oxytocin and prolactin by
suckling reflex (milk letdown reflex)
• This is neuroendocrine reflex
• The first milk (colostrum) has high
fat and antibody content
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 Cont…
Prolactin is a necessary hormone for
milk production but lactogenesis also
requires low estrogen environment
Advantages of breast feeding
includes:-
acceleration of uterine involution,
 provides postpartum contraception,
 provides nutrients and antibodies to the
neonate,
it is ideal food at right temperature and is
sterile,
does no need preparation and enhances
mother to child bonding.
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Risk of BF
• MTCT in HIV positive mother
• Development of cracked nipple
Lactation suppression can be achieved
by
Tight fitting brassiere
Giving estrogen alone or combined
and bromocryptine

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Musculoskeletal system
 The softened pelvic joints and ligaments of
pregnancy gradually return to normal over
a period of about 3 months.
 The abdominal and pelvic floor muscles
gradually regain their tone with the
assistance of postnatal exercise.

Psychological state
 Emotional liability is very common during
the early days of the puerperium.
 After delivery most women experience of
mood elevation but a few days later they
may be depressed and tearful.
 It is probably a reaction to the physical 16
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 Management of the
Puerperium
An important aspect of the health works whether
in hospital or at home is the educational role.
Advice the mother to care for her self and for her
baby covering a wide range of subjects like
hygiene, nutrition, immunization, family
planning, etc.

Component of post natal care:

 A) promotion health and preventing disease.

 B)early detection and management of
complication.
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 mgt…
Admission to post natal ward
• The mother and baby are usually
transferred to the post natal ward with in
an hour or 2 hr after delivery.
• The health care provider should well
come the mother and help her to settle in
the ward.
• Observe her general condition, palpate
the uterus to note whether it is
contracted or not and observe the lochia.
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 mgt …
Sleep and rest
• The mother should have sufficient sleep and rest.
• Keep a quiet comfortable atmosphere with out
disturbance.
• Inability to sleep must be regarded with concern
and physicians should be consulted.
• Hypnotics may be needed and it is given with out
hesitation.
• Undue anxiety, sleeplessness and loss of appetite
should be rewarded as serious.
• Rest is usually encouraged during the day
preferably in prone position as this aids drainage
from the uterus and vagina.
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 mgt…
Ambulation
• Early ambulation as of the 2nd day
• Mothers is benefited such as a feeling of well
being from this early activity
• This also reduces the incidence of
thrombi ,embolic disorders & constipation.
• It will also accelerate involution
• Help in draining lochia
• Usual house hold activities should be started
after 3 week including postpartum exercise

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 mgt…
Diet
• A good balanced diet should be taken as advised in
pregnancy
• The woman’s appetite usually returns very quickly after
labor is ended & has had some sleep.
• Proteinious foods are important particularly if she is breast
feeding.
• Excess fruit should be avoided as substances from this will
pass to the baby in the milk & may cause diarrhea.
The daily fluid intake should be from 2.5-3 liters of which at
least 600 ml should be milk.
Sexual intercourse may resume when bright lochia ceases
• The vulval lacerations have healed and the women is
physically
comfortable and emotionally ready
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Physical readiness usually takes three weeks 21
 mgt…
Postnatal exercises:-Advantages
1. Gives the women a sense of wellbeingness
2. Maintains good circulation, lessens possibility of
venous thrombosis.
3. Restores muscle tone of the abdominal wall &
pelvic floor.
4. Promotes for normal drainage of lochia
5. Prevents hypostatic pneumonia
6. Helps in emptying the bladder, bowels and uterus
7. Permits her to enjoy a daily bath
8. Enables her to take early care of her baby
9. Restores her body figure

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 mgt…
Teach about danger symptom that include
persistent bloody lochia, offensive lochia, sever pernial
pain or swelling, fever, unilateral painful swelling of leg
and painful swollen breast
• Provision of medication: analgesics for after pain,
sedative for insomnia, sitzbath for episiotomy and
perinial lacerations, haemthenics for anemia, anti D
gamma globulin for RH negative unsensitized women
with Rh positive neonate, antibiotics if needed
• Post natal follow up: it is usually conducted after 6
weeks
at 6 hr, 6 day and 6 week

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 Postnatal care (Daily
care)
Care of the mother
After the birth of the baby & expulsion of the
placenta
1. Clean perineum & apply sterile pad
2. Make her comfortable
3. Give her a cup of tea and something light to
eat (immediate)
4. Allow her to rest
5. Record vital sign
6. Check for any bleeding

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 Postnatal care (Daily care)
Care for the baby
1. Check frequently for bleeding.
2. Change napkin whenever wet or soiled have
mother do it.
3. Take temperature twice daily or & hourly if
necessary
4. If the baby’s condition is good mother should be
allowed to feed, as often as she wishes to do so.
6 Test breast feeding and body activity of the child.
7. Bring up baby’s wind often feeds.
8. Check cord for bleeding and signs of infection,
9. Immunization,

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At 6 Days follow up Mother

• General well-being, micturition, and other

possible complaints
• Fundal height, distended bladder
• Perineum, vaginal bleeding, lochia,
haemorrhoids.
• Thrombophlebitis, signs of thrombosis
• Temperature, if infection is suspected
• Supplementation of micronutrients (iron,
folate, iodized salt, Vit. A) .
• Counseling on safe disposal of potentially
infectious soiled pads or other materials.
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 At 6day follow up Baby
• Concerns about breastfeeding and growth of
baby as mother perceives it
• Assess general condition of baby: Activity,
feeding, color .
• Observe how baby is breast feeding*
• Observe skin for signs of pallor and jaundice
• Assess vital sign if baby is not active
• Immunization with BCG, and OPV 0 if not
provided already
• Advise on direct sunlight exposure

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At 6 week follow up mother
Routine postpartum physical examination
• Assessment for signs of postpartum complications
• Counseling on appropriate nutrition, and
micronutrient supplementation
• Counseling on family planning and safe sex
practices
• Counseling on breastfeeding and support as needed
• Counseling on personal hygiene and disposal of
soiled pads.
• Encourage on continued use of ITN for women living
in malaria endemic areas
• Routine offering of HIV testing if not already done
• Plan for revisit and immunization of baby

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At 6week follow up Baby

• Identify warning signs of

complications
• Routine examination of the baby
• Advise on direct sunlight exposure
• Immunization OPV1, Pentavalent1 pcv
1(at 6,10, 14 weeks)

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At 6 month follow up mother
• Counseling on family planning and safe sex practices

• Counseling on breastfeeding and initiate appropriate

complementary feedings
• Encourage on continued use of ITN for women living in malaria
endemic areas
• Routine offering of HIV testing if not already done

At 6month follow up Baby

• Assess growth and development

• Provide Vitamin A supplement

• Ensure immunization

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Continue sun light exposure 30
 Reference Books
• Alban H De Cherney, Current obstetrics & Gynecology
text book, 2007.
• Kaplan obstetrics and gynecology, 2005-2006.
• Novak and Berek’s obstetrics and gynecology, text book,
14th edition.

• Integrated Management of pregnancy and child birth a

guide for midwives and doctors.
• National protocol management of obstetric
FMOH(2010).
• BeMONC 2010 WHO.
• William’s obstetrics and gynecology, text book, 22nd
edition, 2005.
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 Thank you

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