If Chapter 13 is “How labor works,” Chapter 14 is “How the mother’s body recovers after birth.” It explains the remarkable physiologic changes that occur in the first hours, days, and weeks postpartum and helps you distinguish normal recovery from warning signs that require intervention.

For a midwife, this is a high-priority chapter, since much maternal morbidity and mortality occurs in the postpartum period.

Chapter 14 – The Puerperium

1. Read Coad, Anatomy & Physiology for Midwives, 4th edition, chapter 14.
2. Write out your answers to Coad, Chapter Case Study, page 420.
3. Create a Coad “Chapter 14 Study Sheet.” Include the following:

Learning Goals

□ Explain the physiologic processes that control postpartum hemostasis.

□ Describe normal postpartum physiologic changes.

□ Explain uterine involution.

□ Describe normal postpartum healing and recovery.

□ Recognize common postpartum discomforts.

□ Recognize abnormal postpartum conditions requiring evaluation.

Essential Vocabulary

General

• Puerperium
• Postpartum
• Involution
• Subinvolution
• Lochia
• Afterpains

Hemostasis

• Third stage of labor
• Hemostasis
• Uterine atony
• Oxytocin
• Placental site
• Myometrial contraction

Lochia

• Lochia rubra
• Lochia serosa
• Lochia alba

Breastfeeding

• Colostrum
• Lactogenesis
• Milk “coming in”
• Engorgement
• Let-down reflex

Perineum

• Perineal trauma
• Hematoma
• Episiotomy
• Pelvic floor

Pathology

• Postpartum hemorrhage (PPH)
• Endometritis
• Mastitis
• Venous thromboembolism (VTE)
• Postpartum depression

Draw

1. Uterine Involution

Birth

↓

Fundus at umbilicus

↓

Descends ~1 cm/day

↓

Pelvic organ by 2 weeks

↓

Near pre-pregnancy size by ~6 weeks

2. Lochia Progression

Draw a simple timeline.

Rubra

↓

Serosa

↓

Alba

Then write:

• Rubra = red
• Serosa = pink/brown
• Alba = yellow-white

3. Hemostasis

Placenta delivers

↓

Uterus contracts

↓

Blood vessels compressed

↓

Bleeding stops

This is one of the most important postpartum diagrams.

Systems I Must Know

Processes I Must Understand

• Hemostasis after placental delivery
• Uterine involution
• Lochia progression
• Lactogenesis
• Hormonal changes
• Fluid shifts
• Emotional adjustment
• Tissue healing

Midwifery Connections

Clinical Connections

Be able to explain:

• Why the uterus must remain firm after birth.
• Why oxytocin is so important in the immediate postpartum period.
• Why breastfeeding often causes afterpains (nipple stimulation increases oxytocin release).
• Why women experience heavy urination and sweating during the first postpartum days (mobilization of excess pregnancy fluid).
• Why lochia changes color over time.
• Why a boggy uterus is concerning.
• Why fever is never considered a normal postpartum finding after the first 24 hours.
• Why early ambulation reduces thromboembolism risk.

Things Worth Memorizing

Lochia

Know the sequence:

• Rubra
• Serosa
• Alba

Uterus

Normal:

• Firm
• Midline
• Descending daily

Abnormal:

• Boggy
• Enlarged
• Tender
• Rising instead of descending

Hormones

After birth:

• Estrogen ↓
• Progesterone ↓
• Oxytocin ↑ (especially with breastfeeding)
• Prolactin ↑ (if breastfeeding)

Breastfeeding

Understand:

• Colostrum
• Milk production
• Let-down reflex

Questions I Should Answer Without Looking

1. What is the puerperium?
2. What causes postpartum hemorrhage?
3. What is uterine involution?
4. How does oxytocin help after birth?
5. What are the stages of lochia?
6. Why do breastfeeding mothers often experience afterpains?
7. What findings suggest postpartum infection?
8. What is mastitis?
9. Why is early ambulation encouraged?
10. What emotional changes are expected versus concerning?

Compendium Entry

This chapter deserves six pages in your Midwifery Compendium.

Page 1 – Immediate Postpartum Physiology

• Third stage of labor
• Hemostasis
• Oxytocin
• Uterine contraction
• Placental site healing

Page 2 – Uterine Involution

Include:

• Fundal height changes
• Daily descent
• Normal involution timeline
• Factors that delay involution (e.g., retained placental tissue, infection, overdistended uterus)

Page 3 – Lochia

Create a table:

*Remember that timing varies among women; color and amount should be interpreted in the context of the overall clinical picture.

Page 4 – Breastfeeding Physiology

Include:

• Colostrum
• Milk production
• Oxytocin
• Prolactin
• Let-down reflex
• Engorgement
• Common breastfeeding challenges

Page 5 – Normal Recovery vs. Warning Signs

Page 6 – Postpartum Assessment

Use the classic BUBBLE-HE framework:

• B – Breasts
• U – Uterus
• B – Bladder
• B – Bowels
• L – Lochia
• E – Episiotomy/Perineum
• H – Homan’s/signs of thromboembolism (note that Homan’s sign itself is no longer considered reliable; focus on leg pain, swelling, warmth, and redness)
• E – Emotional status

This provides a structured way to remember a complete postpartum assessment.

Quick Reference Cards

This chapter naturally becomes a series of practical reference cards:

• Immediate Postpartum Assessment
• Uterine Involution
• Lochia
• Normal Fundal Findings
• Boggy Uterus
• Postpartum Hemorrhage
• Breastfeeding Hormones
• Lactogenesis
• Mastitis
• Endometritis
• Postpartum Mood Disorders
• Venous Thromboembolism
• BUBBLE-HE Assessment

One study technique I’d especially recommend

As a future home birth midwife, organize this chapter around the first six weeks after birth, asking one question at each stage:

“What should I expect to be normal today?”

For example:

This timeline mirrors how postpartum care is actually practiced. Instead of remembering isolated facts, you’ll learn to anticipate what physiologic changes should be occurring at each stage and recognize when recovery is not following the expected course. That kind of chronological thinking becomes invaluable during postpartum home visits.