NORMAL PUERPERIUM

• The puerperium is the period between delivery and 6 weeks postpartum.

Physiological changes

• Temperature: normal but a slight rise may occur during the early puerperium due to engorgement of the breasts.
• After pains: suckling releases oxytocin from the posterior pituitary. This causes painful uterine contractions. Simple analgesia would help.
• Breasts: Colostrum is secreted in the first 2-3 days. Breast engorgement can occur. Encourage suckling.
• Bowel:  Women may complain of constipation. Contributory factors include effects of progesterone on the intestines, laxity of abdomen wall and perineum, dietary factors
• Cardiovascular: usually back to pre pregnant state by 6 weeks
• Renal: usually back to pre pregnant state by 6 weeks except for the renal collecting system which can take up to 12 weeks.
• Blood: increased blood coagulability continues during the first two weeks despite the decrease in a number of coagulation factors. Encourage mobility and adequate hydration.
• Menstruation: if not breastfeeding, menstruation starts by 6th - 8th weeks after delivery. In breastfeeding women, a variable period of amenorrhoea is seen. Consider contraception.
• The uterus undergoes significant changes. Obliteration of blood vessels and autolysis of myometrium occurs. Weight (about 1,000 g just after delivery) decreases to almost pre pregnant size (50 – 70g) by 6 weeks.
• Lochia: this refers to the discharge from the genital tract following delivery. Consists of blood, cervical mucous, decidual fragments.  The normal transition is from:

Lochia rubra (red) which consists mainly of blood and decidua, to
Lochia serosa: (pale): due to relative decrease in RBCs and predominance of     leukocytes, and then to
Lochia alba (white): consists mainly of leukocytes and mucus. Each stage can last up to 4-5 days. Offensive lochia suggests endometritis.

• Cervix: usually closed by 7 days.
• Perineum: tone is generally regained by the end of puerperium while persistence of its laxity predisposes to prolapse.

Management of the normal puerperium

Perineum

• Keep perineum clean. Encourage pelvic floor exercises.

Diet

• Encourage a balanced diet including high fibre diet and fluids.

Care of the bowel

• Constipation is prevented by plenty of green vegetables and fruits and sufficient fluids. Laxatives can be offered if needed.

Care of the bladder

• Patient is encouraged to void frequently. If there is retention a catheter is inserted.

Care of the breasts

• Keep breasts clean in between feeds.

THE 6 WEEK POST-NATAL REVIEW

This is generally done by GPs but should occur earlier if pregnancy or delivery was complicated. The aims of this visit are:

• Detection and / or follow up of complications of pregnancy or labour.
• To ensure involution of the genital tract.
• Discuss contraception and ensure future pregnancies are planned
• To assess wellbeing of the infant
• To discuss impact on and plans for future pregnancies

History

• Genital tract symptoms – onset of menstruation, vaginal bleeding, offensive discharge, dyspareunia
• Breast disorders – pain, swelling, redness,  
• Urinary or gastrointestinal symptoms – dysuria, constipation, urinary or faecal incontinence
• Infants feeding habits and general health
• Discussion of future pregnancies and contraception.

Physical examination

• Basics - pulse, temperature, BP
• Breasts- only if symptoms present
• Abdominal examination - to assess for involution of the uterus.
• Pelvic examination - Vulva / vagina / perineum: healing of perineal or vaginal tears, tone of pelvic floor, uterine size and tenderness. Not necessary if perineum was intact or the woman is asymptomatic