Care during Pregnancy
Amenorrhoea / Lack of Menses
Sexually Transmitted Diseases (STD)
Written by : Dr.M.D.Mazumdar, MD
Certain important aspects of the puerperium are:
Involution of the Genital organs
Involution of the Uterus :
The process by which the uterus and the other genital organs return to their normal pre-pregnant state in the postpartum period after the delivery of the fetus is called ‘involution’.
The gradual decrease in size of the uterus during involution occurs due to a decrease in size but not a decrease in the number of uterine muscles.
This decrease is in response to the withdrawal of placental hormones after the childbirth.
The uterus, which weighs about 900 grams at the end of labour, weighs only about 60 grams at the end of the postpartum period, 6 weeks after childbirth.
Rate of Involution : Immediately after the delivery, the upper margin of the uterus lies about 5 inches above the pubic symphysis (upper margin of the pubic bones). In an average sized woman, this will be at the level of the umbilicus. But, by the 7th day, the uterus becomes much smaller and only its upper border can just be felt at the level of the symphysis.
The size of the uterus decreases at the rate of ½ inches per 24 hours in the first 14 days of the postpartum period . It regains its pre-pregnancy size at the end of 6 weeks.
Involution of the cervix: The cervix involutes more slowly than the uterus. Immediately after the delivery of the baby, it is a loose opening with irregular edges. But by the end of the first week, it becomes more clearly defined, regaining its canal like structure. Its opening in the vagina now is much smaller and can admit only the tip of the finger. While the internal os, which is the opening of the cervix near the uterus involutes completely, the external os, which is the outer opening of the cervix in the vagina, never regains its pre-pregnant state.
Involution of the vagina: The vagina involutes more slowly than the uterus. The normal rugosity (wrinkles) of the vaginal walls reappear at about the 3rd week of the postpartum period. But the size and elasticity of the tissues never regain the pre-pregnancy state.
Other pelvic organs: Other pelvic organs like the ligaments of the uterus, muscles of the perineum, ovaries and fallopian tubes also involute and completely regain their normal appearance by the end of 6 weeks after delivery.
The lochia is the physiological postpartum uterine discharge consisting mainly of blood and necrotic tissue that occur during the first 4 weeks after delivery of the baby.The discharge originates from the uterus, the cervix and the vagina. It may be scanty after a premature delivery but more than normal after a twin pregnancy or other conditions in which the uterus becomes larger than an average-size pregnancy uterus.
Types of Lochia: Depending on the color, lochia can be of three types:
- Lochia Rubra: Lochia rubra occurs in the first 3-4 days after childbirth. It is reddish in colour – hence the term 'rubra'. It is made up of mainly blood, bits of fetal membranes, decidua, meconium and cervical discharge.
- Lochia Serosa: The lochia rubra gradually changes colour to brown and then yellow over a period of about I week. It is called lochia serosa at this stage. The lochia seroa contains less red blood cells but more white blood cells, wound discharge from the placental and other sites, and mucus from the cervix.
- Lochia Alba: The Lochia alba is a whitish, turbid fluid which drains from the vagina for about another 1 - 2 weeks. It mainly consists of decidual cells, mucus, white blood cells, and epithelial cells.
The lochia has a characteristic ‘fishy’ odour which is easily recognizable. But in puerperal or postpartum infections, there may be a foul smell due to the presence of bacteria and pus in the discharge.
RETURN OF MENSTRUATION
The return of the first menstrual period after the delivery of the baby is variable and depends to a great extent on whether the woman is breastfeeding.
In women who do not breastfeed, ovulation returns 4 weeks after delivery and menstruation returns after 6 weeks in about 40% of all women. By the end of the 12th week, almost 80% of all women who do not breastfeed have got their first menstrual period.
In women who breastfeed, menstruation returns about 6 - 7 months after childbirth. But this, too, depends on how long the woman breastfed her baby exclusively without any supplementary feeds.
According to most pediatricians, babies need to be exclusively breastfed for the first 6 months of life. In such a case, menstruation may return later than 6-7 months.
Sex is not advisable for at least 6 weeks after delivery, i.e. in the postpartum period, as the tissues are fragile at this time and need time to recover. But, if necessary, barrier contraceptives like condoms should be used.
In fact, barrier contraceptives are the ideal birth control method which should be used for the first 6 months after childbirth. This is because other birth control methods like oral contraceptive pillspills can cause a decrease in the milk production of the breasts.
After 6 months, when the baby can be started on supplementary food, oral contraceptive pills can be prescribed. It is also possible to use intra-uterine devices like Copper-T after this period.
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