Obstetric Topic 46. Physiologic puerperium

I. Definition

• Puerperium: period after delivery during which maternal reproductive organs and physiology return toward the nonpregnant state.
• Duration: classically about 6 weeks postpartum.

II. Physiologic Changes

Uterus, Vagina and Lochia

• Uterine involution: uterus decreases from ~1000 g after delivery to ~50-100 g by 6 weeks.
• Fundus descends gradually; firm, central uterus is normal immediately postpartum.
• Lochia: postpartum vaginal discharge from serous exudate, RBCs, WBCs, decidua, epithelial cells and bacteria.
• Lochia rubra: red, days 1-4.
• Lochia serosa: brown/pale yellow, days 5-10.
• Lochia alba: white/yellow-white, after day 10.
• Cervix regains tone and firmness; vagina and pelvic floor gradually recover.
• Warning: heavy bleeding, large clots, foul smell, fever or pelvic pain → evaluate for PPH, retained POC or infection.

Ovaries, Menstruation and Breasts

• Ovulation/menstruation may resume by 6-8 weeks in non-breastfeeding women.
• Breastfeeding delays ovulation via prolactin suppression of GnRH, but contraception is still needed.
• Milk secretion: after placental delivery estrogen/progesterone fall → prolactin effect predominates.
• Oxytocin causes milk ejection and postpartum uterine contractions.

Systemic Changes

• Cardiovascular: ↑ total peripheral resistance after removal of uteroplacental circulation.
• Cardiac output and plasma volume usually normalize over 1-2 weeks.
• Postpartum hypercoagulability persists → highest VTE risk in early puerperium.
• GI/urinary: constipation and increased diuresis are common; urinary retention/UTI risk may increase early.
• After GDM: postpartum glucose follow-up/OGTT is needed.

Psychological Changes

• Postpartum blues ("baby blues"): tearfulness, mood lability, anxiety; common and usually resolves by ~2 weeks.
• Postpartum depression: persistent low mood, anhedonia, guilt, impaired bonding or suicidal thoughts → treat.
• Postpartum psychosis: hallucinations, delusions, disorganized behavior or danger to mother/infant → emergency.

III. Postpartum Care

Hospital Care

• Typical stay: ~2 days after uncomplicated vaginal delivery; ~3-4 days after C-section.
• Monitor vitals, bleeding/lochia, uterine tone/involution, pain, urination, wound/perineum, breastfeeding and mood.
• Maintain hygiene; provide perineal care and C-section wound care when needed.
• Encourage early mobilization, hydration, breastfeeding support and pelvic floor exercises.

Prevention, Contraception and Follow-Up

• Contraception counseling before discharge/early postpartum; classic exam point: start/choose contraception by 6-week visit.
• Immunization: MMR and varicella postpartum if nonimmune; Tdap if not given antenatally.
• Rh-negative non-sensitized mother with Rh-positive infant → anti-D within 72 h postpartum.
• Follow-up: traditional 6-week postpartum visit; earlier review if symptoms or high-risk condition.

Danger Signs

• Heavy bleeding, fever/foul lochia/pelvic pain, severe headache/visual symptoms, dyspnea/chest pain, unilateral leg swelling or severe mood symptoms.