**2.5 Blood and blood volume**

Marked leukocytosis and thrombocytosis may occur during and after labor. The greatest level of coagulability is observed immediately after delivery and remains for the following 48 hours. Fibrinogen concentrations gradually diminish over the first 2 weeks postpartum. Increased fibrinolytic activity is seen in the initial 4 days following delivery. The fibrinolytic activity is back to normal in a week and is shown by plasminogen activation inhibitor 1levels. D-dimer levels are more than pregnancy levels, but are a poor marker of thrombus formation. Protein-S levels and activated protein-C resistance are less for around 6 weeks in puerperium. The changes in the coagulation system, together with vessel trauma and immobility, account for the increased risk for thromboembolism noted in the puerperium, especially when an operative delivery has occurred.

## **2.6 Cardiovascular system**

Plasma volume is diminished by about 1000 mL just after delivery and that is due to blood loss during delivery.

Due to the shift of extracellular fluid into the vascular space. The plasma volume is replenished by the 3rd day of puerperium. Also, the total blood volume declines by 16% of the pre delivery value, and that manifests as transient anemia.

By 8 weeks of puerperium, the red cell mass rebounds and the hematocrit becomes normal in most women. Since, the blood volume becomes normal, venous tone also gets to baseline. Pulse rate increases throughout gestation, like stroke volume and cardiac output. Just after delivery, these remain elevated or may rise even higher for initial 30 to 60 minutes. Following delivery, a transient rise of about 5% occurs in both diastolic and systolic blood pressures and that continues for the first 4 days postpartum.

#### **2.7 Thyroid function**

Thyroid volume increases to about 30% during pregnancy and then gets back to normal in a 12-week period in puerperium. Both thyroxine and triiodothyronine increase throughout pregnancy and becomes normal within 4 weeks post delivery. For women on thyroid medications, it is advisable to check thyroid profile at 6 weeks postpartum to titrate the dosage. Sometimes, during the postpartum period, there is an increased risk for the development of a transient autoimmune thyroiditis that may later evolve into permanent hypothyroidism.

#### **2.8 Immune system**

The immune system gets compromised during pregnancy—particularly cellularmediated immunity. The rebound of cellular mediated immunity after delivery leads to "flare-ups" of autoimmune diseases and subclinical infections with inflammatory reactions. Autoimmune thyroiditis, multiple sclerosis, and lupus erythematosus are examples of auto immune diseases that show flare ups in the first few months of puerperium.

#### **2.9 Urinary tract**

Normal pregnancy-induced glomerular hyperfiltration persists during the puerperium but returns to prepregnancy baseline by 2 weeks [2].

Dilated ureters and renal pelves return to their prepregnant state by 2 to 8 weeks postpartum.

Postpartum, the bladder has an increased capacity and a relative insensitivity to intravesical pressure. Thus, over distention, incomplete emptying, and excessive residual urine are frequent in puerperium [3, 4].

#### **2.10 Lactation**

Breasts begin to secrete colostrum after delivery. It is a dark yellow liquid and usually can be expressed from the nipples by the second postpartum day. In comparison to mature milk, colostrum is rich in both immunological components and minerals and amino acids [5]. It also has more protein, mostly globulin, but contains less sugar and fat.

Colostrum secretion continues for 5 days to 2 weeks post partum, with later conversion from "transitional" to mature milk in next 4 to 6 weeks.

### **3. Management of puerperium**

#### **3.1 Hospital stay**

For most parturients, the immediate puerperium is spent in the hospital or birthing center.

In the 1950s, the lying-in period after delivery used to be around 8 to 14 days. Now, most women stay in the hospital only for 24 to 48 hours after a vaginal birth. For patients with an uncomplicated postoperative course after caesarean delivery, the post partum stay is only 2 to 4 days. During the hospital stay, the focus should be on preparation of the mother for newborn care, infant feeding including the special issues involved with breastfeeding, and also the required newborn laboratory testing.

There are no dietary restrictions for women who have been delivered vaginally. Two hours after uncomplicated vaginal delivery, a woman is allowed to eat.
