Puerperium: Understanding the Postpartum Period

The amount of time needed to regain pre-pregnancy physiology, size, and shape is known as the Puerperium. The time frame is from the time of delivery to 42 days, or six weeks. Since the woman's immune system is still compromised, her menstruation needs to be closely watched.

Reproductive Organ Changes In Puerperium

• Puerperial uterus
  • In the first week, it weighs approximately 500 grams.
  • In the second week, it weighs 300 grams.
  • After four weeks involution is complete and the uterus weighs approximately 100 grams.
  • This size of the uterus immediately after delivery is just below the umbilicus and the uterus becomes a pelvic organ by 10 to 14 days.
• Lochia is a vaginal discharge which occurs after the birth. If it mainly consists of blood (1^st to 4^th day) then it is called as Lochia Rubra. 
• If the discharge is yellow which is mostly mucus at 5^th to 9^th day then it is called as lochia serosa.
• After the 10^th day the discharge becomes white or yellow white which mainly consists of mostly epithelial cells with leukocytes, it is called lochia alba.
• Cervix becomes firm after delivery and closes by a three weeks period. It is very important to note that the woman is most susceptible to cervical dysplasia or cancer immediately after delivery and early in puberty.
• Vagina starts shrinking and rugae starts to reform from the second to third weeks onwards. The epithelium starts growing by 6 weeks.

Breast Puerperium

• Colostrum starts forming and it persists for five days to up to two weeks.
• It is a deep lemon-yellow liquid that comes for the first few days of breast milk.
• It is rich in IgA antibodies and provides protection against enteric pathogens.
• It has host resistance factors like complement, macrophages, lymphocytes, and lysozymes.
• It has more protein and less sugar and fat.
• The prolactin level falls after delivery and the basal levels are low after delivery.
• The milk ejection reflex is initiated especially by suckling and stimulates the posterior pituitary to release oxytocin. The contraction of myoepithelial cells in the alveoli and small milk ducts causes the expression of milk from lactating breasts.

Abnormal Puerperium

• For Puerperal fever, If there is any occurrence of fever in 1^st to 10 days after delivery on 2 occasions. Then it can be sensed that an abnormal perpetuum has occurred. There are some causes of Puerperial fever:
  • Endometritis
  • Breast engorgement
  • Respiratory infection
  • Pyelonephritis
  • Thrombophlebitis

1. Endometritis
   • It is the inflammation of the inner lining of the endometrium. There are multiple reasons for endometritis:
   • Prolonged fever
   • Premature rupture of membranes
   • Frequent cervical assessment
   • Anemia
   • Chorioamnionitis 
   • There are multiple bacteria which are responsible for endometritis but the most common is Group A beta-hemolytic streptococci. The other bacteria responsible for endometritis are enterococci, E coli, and anaerobes like Peptostreptococcus and chlamydia.
   • Symptoms of Endometritis
     • The patient will present with the symptoms of fever and pain abdomen.
     • There will be dirty and foul-smelling discharge.
     • The patient will also complain of fatigue and weakness.
   • Signs of Endometritis
     • Lower abdomen tenderness
     • On per vaginal examination, uterine and adnexal tenderness will be observed. There will be fullness in the pouch of Douglas due to blood collection and Abscess formation.
   • Investigations of Endometritis
     • Increase in leukocyte count on CBC.
     • Increase in ESR and CRP
     • High platelet count
   • Treatment of Endometritis
     • Clindamycin and gentamicin combination is given for the treatment of endometritis.
     • If sepsis is suspected then ampicillin is added.
2. Subinvolution of Uterus
   • The normal rate of reduction of the size of the uterus is 1-2 cm per day but if the rate of reduction of the size of the uterus is lesser than this then we can call it as sub-involution of the uterus.
   • Causes
     • Infection is the most common cause of subinvolution.
     • Retained bits of plus enter and membranes
     • Blood clots and fibroids.
   • Clinical features
     • The uterus will be boggy or flabby and it will be palpable beyond ten days per abdomen.
     • The uterus will be tender and in many cases, fever will be present.
   • Treatment
     • If there are retained bits of placenta then we need to empty the uterus by gentle curettage after doing ultrasonography.
     • Oral antibiotics like azithromycin and doxycycline should be prescribed for 7 to 10 days.

Hope you found this blog helpful for your Principles and Practice of Gynaecology OBS-GYN preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.