SESSION 2

PHYSICAL & PHYSIOLOGICAL

CHANGES IN THE POST-
PARTUM PERIOD(CONT)
RETURN OF MENSTRUATION &
OVULATION
 OBJECTIVES
At the end of the session, students should be able to;

1. Recognize the Physiological & systemic changes occuring

during puerperium.

2. Identify deviations from the normal.

3. List down the hormones responsible for breastfeeding.

4. Explain the physiology of breast milk secretion and the

hormones responsible for it.

5. Enumerate the care of woman in the Post-partum period.

6. Application of knowledge into practice.

 RETURN OF MENSTRUATION & OVULATION
 In 80% of the women, menstruation resumes by 12 weeks in those
who are not lactating.
 Women who choose to breast feed their infants will be
amenorrhoeic for long periods of time and may not ovulate for
about six months.
 In non-lactating women, ovulation may occur as early as 27 days
(4 wks) after delivery and in lactating mothers about 10 weeks after
delivery.
 The risk of ovulation within the first 6 months post-partum in
women exclusively breastfeeding is between 1 and 5%.
 The hormone responsible for puerperial ovulation suppression in
lactating women is the persistence of elevated serum prolactin
levels.
 Duration of anovulation depends upon the frequency (>8/24
hours), intensity and duration of breastfeeding (>8/24h).
 Therefore, non-lactating mothers should use contraceptives
before ovulation occurs or as early as 21 days.
 GENERAL PHYSIOLOGICAL CHANGES DURING
THE PUERPERIUM
1. Cardiovascular changes
 Heart rate fall by 14% in 48 hrs in early puerperium and
reaches normal by 2 weeks post partum.
 Stroke volume rises over 48 hrs and normalizes by 2 weeks
post partum.
 Cardiac output remains elevated to almost 80% above the
pre-labor values and then falls during the 48 hrs and then
normalizes by 24 weeks.
 Blood pressure rises over 4 days in early puerperium and
 Pulse: For a few hours after normal delivery, the pulse rate is
likely to be raised, which settles down to normal during the
second day. However, the rate is dependent on other factors
such as pain, anxiety, fever, infection.
 Temperature: Should not be above >37.2°C (99°F) in the first
24 hrs. However, there may be slight reactionary rise
following delivery by 0.5°F but comes down to normal within
12 hrs. On the 3rd day, there may be slight rise of temperature
due to breast engorgement which should not last for more than
24 hours. UTI should be ruled out if there is rise in temp.
2. Blood values
 Plasma volume increases initially and then declines and
thereafter declines progressively in the 1st week of post
partum.
 Fibrinogen and other clotting factors rises and remains
elevated in the 1st week and returns to its normal ranges by
3-6 weeks.
 Platelet count fall and then rise in the early puerperium and
then normalizes by 6 wks.
 This rise in the clotting/coagulation factors makes it high
risk for women to develop thromboembolic disease such
as DVT. Immediately following delivery, there is slight
decrease of blood volume due to blood loss and
dehydration.
 Blood volume returns to non-pregnant level by the 2nd
week.
 RBC volume and hematocrit values returns to normal by 8
weeks postpartum after the hydremia disappears.
 Leukocytosis to the extent of 25,000/mm3 occurs
following delivery probably in response to stress of labor.
3. Urinary Tract & Renal Function
 During the first few days, the bladder wall and urethra may
show evidences of mild trauma sustained during delivery
associated with localized oedema. This change is transient
and may not remain for long.
 Sometimes, due to the injury and because of the oedema, the
bladder may seem to be over-distended without the desire to
void.
 Dilated ureters and renal pelvis returns to normal by 6-8
weeks post partum.
 Fluid Loss: There is a net fluid loss of at least 2 liters during
the 1st week and an additional 1.5 liters during the next 5
weeks.
 The amount of loss depends on the amount retained during
pregnancy, dehydration during labor and blood loss during
delivery.
 The loss of salt and water are larger in women with
preeclampsia and eclampsia.
4. The GI system
 Digestion & absorption begins to be active soon after birth.
 Increased thirst in early puerperium is due to loss of fluid during
labor, in lochia, diuresis and perspiration.
 Bowel sounds are active but passage of bowels may be hampered
because of the pain associated with episiotomy or haemorrhoids
 There is an immediate loss of 4.5–6 kg following birth due to the
placenta, amniotic fluid and blood loss that occurs at delivery. A
further loss of 2 kgs occurs as a result of diuresis during
peuperium.
 By 6 weeks post-partum, 28% of women will have returned to
their pre-pregnancy weight and may continue till 6 months.
5. Integumentary system:
 Abdominal wall muscles & ligaments will take 6 weeks
time to return to their normal state and function.
 Stretch marks and chloasma will fade away in due course
of time.
 Women who have suffered from urticaria of pregnancy will
be relieved once baby is delivered.
 Hair growth slows in the puerperium and women will often
experience hair loss. This is a transient phenomenon may
take between 6 months and a year to return to normal.
 MANAGEMENT OF NORMAL PUEPERIUM
The principles in management are:
 To restore the health of the mother.
 To prevent infection.
 To take care of the breasts, including promotion of
breastfeeding.
 To motivate the mother for contraception.

1. Immediate attention: Closely observe as outlined in the

care during 4th stage of labor. Provide her a drink or
something to eat.
2 Emotional support is essential: The woman experiences a
sense of happiness and relief, with the birth of a healthy baby.
However she may need emotional support when she suffers
from postpartum blues or stress due to newborn’s prematurity,
illness, congenital malformation, death or if she is a single
mother

3. Rest & Sleep: The patient needs rest, both physical and
mental. So, she should be protected against worries and undue
fatigue. Ensure adequate physical and emotional support. If
there is any discomfort, such as after pain or painful piles or
4.Ambulation:Early ambulation after delivery is encouraged to
 Provide a sense of well-being.
 Decrease bladder & bowel complications.
 Facilitates uterine drainage and hastens involution of the
uterus.
 lessens puerperal venous thrombosis and embolism.
 Following an uncomplicated delivery, climbing stairs, lifting
light objects, daily household work and cooking may be
resumed.
5.Diet:

The patient should be allowed on normal diet of her choice. If

the patient is lactating, high calories, adequate protein, fat,
plenty of fluids, minerals and vitamins are to be given.
6. Care of Bowel & Bladder:
 Early ambulation & dietary advice. If necessary, mild
laxative can be advised during bedtime.
 Encourage to pass urine following delivery as soon as
convenient.
 If the patient still fails to pass urine due to causes such as
unaccustomed position, pain from the perineal injuries,
catheterization may be advised.
 Catheterization is also indicated in case of incomplete
emptying of the bladder when there is residual urine of
more than 60 ml.
 Continuous drainage is kept until the bladder tone is
regained. The underlying principle of the bladder care is to
ensure adequate drainage of urine so that infection and
cystitis are avoided.
7. Care of the vulva and episiotomy wound:
 Change your pads every 2 to 4 hours.
 Keep the area around the stitches clean and dry.
 Pat the area dry with a clean towel after you bath.
 After you urinate or have a bowel movement, clean
with warm water over the area and pat dry with a clean
towel or baby wipe.
8. Care of the Breasts & management of Breastfeeding
problems (Read PED301/ Session 9/ Breast feeding problems
& their solutions)

9. Maternal-Infant bonding (Rooming-In):

10. Management of ailments such as ‘after pains’, pain on the

perineum/ episiotomy site, Cesarean section and anemia.

11. Sexual activity may be resumed (after 6 weeks) when the

perineum is comfortable and bleeding has stopped. Some
women may get “flaring response” of some autoimmune
disorders due to rebound effect of the immune suppression
during pregnancy.
12. Postpartum exercise is advised to;
 Improve the muscle tone & strength which are stretched
during pregnancy and labor especially the abdominal and
perineal muscles.
 Educate about correct posture to be maintained.
 Minimize the risk of puerperal venous thrombosis by
promoting arterial circulation and preventing venous stasis,
 Prevent backache.
 Prevent genital prolapse and stress incontinence of urine.

13. Check up & dischar.e with all the above advice.

 REFERENCES
1.Konar, H. (2015). D.C. Dutta’s Textbook of obstetrics.
(8th ed.). New Delhi: Jaypee Brothers Medical Publishers
(P) ltd.
2.Marshall, J. E. & Raynor, M.D.(2014). Myles textbook
for midwives (16th ed.). Edinburgh, UK: Churchill
Livingstone.
3.Reproductive Health Unit, (2009). Standards for
Midwifery Practice for Safe Motherhood. (2nd ed.)
Department of Public Health, Ministry of Health:
Thimphu