PHYSIOLOGY OF

LACTATION AND
PUERPERIUM
VARSHA SHARMA
Msc NURSING FIRST YEAR

WHAT IS PUERPERIUM?
Period following childbirth
Pelvic organs & other body tissues
Revert to pre-pregnant state
Anatomically & physiologically

I.
II.
III.

Begins as soon as placenta is

expelled
lasts for appx 6 weeks(42 days)
3 stages
Immediate-within 24hrs
Early -upto 7 days
Remote upto 6wks

INVOLUTION OF THE UTERUS

Anatomical consideration
At delivery-20 x 12 x 7.5cm and appox. 1000g
After involution-reverted to non-preg size of
appox. 60g
Lower uterine segment
isthmus in a few weeks
Contour of cervix regained in 6 wks
External os never reverts back to nulliparous state

Physiological Consideration

Autolysis

Muscles:
Steroid
hormones
withdrawn

Myometrial
cell size
reduced

Inc
Collagenase
& Proteolytic
enzymes

Endophlebitis

Thrombosis
Blood Vessels

Fibrinoid end arteritis

Hyalinisation

Endometrium:

regen starts on day 7

from uterine gland mouths and interglandular stromal cells
completed by day 16
except @ placental site

Clinical assessment of Involution of uterus

Fundus lies 13.5cm above sypmphysis pubis
for the 1st 24hrs following delivery
Steady decrease by 0.5'(1.25Cm)in nxt 24
hrs
Day 14- not palpable- pelvic organ
Completed by 6 wks

4-8 weeks;

Broad/round
ligaments

Vagina

Does not revert

to original state

Long time d/t

stretching
during
parturition

Pelvic floor & Fascia

Involution of other Pelvic structures

Long time d/t

stretching
during
parturition

LOCHIA
Vaginal discharge for the 1st fortnight during puerperium

Odour: offensive fishy smell

Colour and composition

Lochia Rubra

1-4 days
Blood,fetal memb & decidua
shreds,lanugo,meconium

Lochi Serosa

5-9 days
Leucocytes,Cx mucus,wound
exudates,microorganisms

Lochia Alba

10-15 days
Decicual
cells,leucocytes,mucus,cholestrin
crystals,fatty epithelial
cells,microorganisms

Clinical importance
Malodorous

Scanty/absent

Excessive

Puerperal Sepsis d\t E. Coli

Infection
Lochiometra

Infection

Red color persist

Subinvolution
Retained conceptus
Causes secondary PPH

L.Alba beyond 3 wks

Local genital infection

General Physiological Changes

Pulse:

Temperature:

Pronounced Diuresis on 2nd - 3rd day

over distension
incomplete emptying
presence of residual urine
high risk of infection

GIT:

Any rise above 0.5C suggestive of infection of genito-urinary tract

Urinary Tract:

raises but settles down to normal on 2nd day

increased thirst
constipation

Weight Loss:

5-6kg expulsion of fetus placenta, liqour, blood

2kg- during puerperium d\t diuresis
Continued upto 6 months of delivery

Blood Values:

Menstruation:

immediate-reduced blood volume; Normal in 2 weeks

rise in cardiac output; Normal in 1 week
leuycocyotsis d\t stress
Hypercoagulable state for 48 hrs
Fibrinolytic activity enhanced in 4 days
if not breast feeding- resumes in 6 to 8 wks

Ovulation:

non-lactating mother- 4 wks

lactating mother- 10 weeks
Exclusive Breastfeeding- 98% contraception up 6 months

SCHEME OF MECHANISM OF AMENORRHOEA AND

ANOVULATION IN LACTATING MOTHERS

:-

BRESTFEEDING- SUCKING*

*FREQUENCY
*INTENSITY

INCREASES PROLACTIN LEVEL

*DURATION

INHIBITS OVARIAN RESPONSE TO FSH

DECRESE GNRH SECRETION
LESS FOLLICULAR GROWTH

HYPO-OESTROGENIC STATE

SUPPRESSES THE RELEASE GNRH

NO LH SURGE

NO MENSURATION
ANOVULATION

The effect of lactation on ovulation and fertility.

.Abstract
It has long been recognized that women who breastfeed
their children have a longer period of amenorrhea and
infertility following delivery than do those women who do
not breastfeed. The length of postpartum amenorrhea is
quite variable, and depends on several factors, including
maternal age and parity, and the duration and frequency
of breastfeeding. In general, it would appear that the more
frequent and the longer the episodes of breastfeeding, the
longer will be the period of anovulation, and the longer the
period of infertility.

CHANGES IN BREAST & LACTATION

Mammogenesis

Pregnancy is associated with a remarkable growth of

both the ductal and lobuloalveolar systems.
An intact nerve supply is not essential for growth of the
mammary glands during pregnancy.

Lactogenesis

Milk secretion actually starts on 3rd or 4th postpartum day.

Around this time, the breasts become engorged, tense, tender and
feel warmth.
When the progesterone and estrogen are withdrawn following
delivery, prolactin begins its milk secretory activity.

Lactogenesis

Milk secretion actually starts on 3rd or 4th postpartum day.

Around this time, the breasts become engorged, tense, tender
and feel warmth.

When the progesterone and estrogen are withdrawn following

delivery, prolactin begins its milk secretory activity.

The secretory activity is enhanced directly or indirectly

by growth hormone, thyroxine, glucocorticoids and
insulin.
Prolactin stimulates mammary glandular ductal growth
and epithelial cell proliferation and induces milk protein
synthesis.

Galactokinesis
Discharge of milk from the mammary
glands depends not only on the
suction exerted by the baby during
suckling but also on the contractile
mechanism which expresses the milk
from the alveoli into the ducts.

DURING SUCKLING, A CONDITIONED REFLEX IS SET UP:

Ascending impulses from the nipple and areola
thoracic sensory (4, 5 and 6) afferent neural arc

paraventricular and supra optic nuclei of the hypothalamus

Oxytocin from the posterior pituitary produces contraction of

the myoepithelial cells of the alveoli and the ducts containing
milk. ("milk ejection" or "milk let down" reflex)

Milk is forced down into the ampulla of lactiferous ducts,

wherefrom it can be expressed by the mother or sucked by
The baby.

Neural reflex arc

Galactopoiesis

Prolactin appears to be the single most

important galactopoietic hormone.
Continuous suckling is essential for removal of
milk from glands, also release prolactin.
Secretion is the continuous process unless
suppressed by congestion or emotional
disturbances.

Milk production
A healthy mother will produce about 500-800 ml of milk/day
with about 500 Kcal /day.
This requires 600 Kcal/day for the mother which must be
made up from the mother's diet or from her body store.

For this purpose a store of about 5 kg of fat during

pregnancy is essential to make up any nutritional deficit
during lactation.

Stimulation of lactation

Following delivery important steps are:

i.

To put baby to the breast at 2-3 hours

interval from the first day.

ii.

Plenty of fluids to drink

iii. To avoid breast engorgement.

Inadequate milk production/lactation

failure
It may be due to infrequent suckling or due to
endogenous suppression of prolactin (ergot
preparation, pyridoxin, diuretics or retained
placental bits).
Unrestricted feeding at short interval (2-3hrs.) is
helpful.

Drugs to improve milk

production/galactogogues
Metoclopramide (10 mg thrice daily)
increases milk volume (60-100%) by increasing
prolactin levels.
Sulpuride (dopamine antagonist) has also
been found effective.
Intranasal oxytocin contracts myoepithelial
cells and causes milk let down reflex.

Lactation suppression
Bromocriptine (dopamine agonist that
inhibits prolactin) 2.5 mg, 1 tab daily for
10-14 days.
Side effects are: hypotension, rebound
breast
engorgement,
secretion,
myocardial infarction and puerperal
stroke.

Suppression
of
lactation
is
necessary if the baby is born
dead or dies in the neonatal
period or if breast feeding is
contradicted.

Management of normal Puerperium

To restore health of Mother

Rest and Early ambulation

Emotional support
Diet of patients choice
Sleep
Immunization- anti-D- Gamma globulin
Maternal-infant Bonding
Postnatal exercise

To prevent infection

Care of bladder & Vulva

Care of episiotomy wound
Maintenance of asepsis and proper hygiene
Immunization- Rubella vaccine, TT

To take care of the Breasts & promote breast

feeding
To motivate mother for contraception

Treatment of minor ailments

After pains
Uterus massage
Ibuprofen
Anti-spasmodic

Pain at site of perineum

Sitz bath
analgesics

Treatment of Anaemia
Supplementary Iron therapy

Abnormal Puerperium

Puerperal fever/ pyrexia

Puerperal Sepsis
Pelvic pain
Fever
Foul smelling vaginal discharge
Subinvolution

 Breast Problems
Retracted/cracked nipples
Breast engorgement
Mastitis
Breast abscess
Failure of lactation

 Urinary Problems
Retention
Incontinence
Infection
Venous thrombosis
Secondary Hemorrhage
Puerperal psychosis
Obstetric palsy

THANQ