Subinvolution is not a normal obstetric condition. After delivery, the uterus gradually returns to its pregravid state and this physiologic process is called involution. However, when there is impaired or retarded involution, otherwise known as subinvolution.
However, under normal circumstances, the uterus supposed to return its pregravid state. The factors that facilitate involution are:
- Good maternal wellness: Healthy women tend to have faster recuperation following delivery unlike unhealthy ones.
- Active management of third stage of labour: Because of uterotonics used, the uterus is far more likely to contract firmly thereby returning to non-pregnant size.
- Initiation of breastfeeding: Oxytocin released during breastfeeding helps to contract the uterus firmly.
- Good nutrition and personal hygiene: As the body is in optimal functioning, involution tends to be faster.
- Resuming domestic chores: This encourages early ambulation thereby preventing impaired involution.
- Postnatal exercises: These improve overall maternal health as well as favours involution.
What is subinvolution?
Subinvolution is defined as the inability of the uterus to return to non-pregnant state following 6 weeks of postpartum period. Subinvolution can be called impaired involution or retarded involution.
Impaired uterine involution is one of leading causes of maternal morbidity and mortality because a poorly involuted uterus can cause postpartum haemorrhage. This postpartum haemorrhage secondary to subinvolution can cause shock with consequential maternal death.
What are risk factors of subinvolution?
Subinvolution is associated with the following conditions:
- Grand multiparity
- Over-distension related to multiple pregnancy and polyhydramnios
- Maternal ill-health
- Caesarean section
- Uterine prolapse or fibroids
- Retroverted uterus
- Prolonged labour or difficult delivery
- Full bladder or loaded rectum
- Uterine infections e g. endometritis, puerperal sepsis
- Retrained products of conception (e.g. retained placenta)
Signs and symptoms of impaired involution
- The fundal height remains stationary for few days
- Prolonged or excessive abnormal lochia discharge (persistent reddish brown lochia or fresh bleeding)
- Bulky/Boggy and tender uterus on palpation.
- Puerperal pyrexia in case of uterine sepsis
- Encourage early ambulation of patients.
- Percuss the suprapubic area to exclude full bladder and constipation should also be excluded.
- Encourage adequate breastfeeding
- Encourage adequate diet and copious intake of fluids
- Give uterotonic drugs such as ergometrine, oxytocin or misoprostol to facilitate uterine contractions.
How to prevent subinvolution
- Initiate breastfeeding once the baby is born and advise the mother to breastfeed frequently and on demand. If there is no milk supply, the nipples can be stimulated. This helps to release natural oxytocin that makes the uterus to contract firmly.
- Ensure active management of third stage of labour. This helps to contract the uterus well and prevent both subinvolution and postpartum haemorrhage.
- Teach the mother on how to feel her uterus to ensure that it is contracted an possibly how to massage it when need arises.
- Properly empty the uterus of any blood clots and encourage the patient to empty her bladder timely as this could prevent involution.
- Encourage early ambulation and resumption as well as postnatal exercises as they help improve maternal circulation and in turn facilitate uterine involution.
- Advise the mother to maintain adequate nutrition, copious fluid intake, personal and environmental hygiene.
- Encourage the mother to report to hospital promptly if she notices excessive abnormal lochia discharge or persistent reddish brown lochia or fresh bleeding because this may be indication of subinvolution.
- Ask her to come back for postnatal examination after 6 weeks as this would enable you assess the overall maternal health.
The Bottom line
No woman deserves to die from complications of pregnancy, labour and puerperium. It is therefore our desire that every skilled birth attendant especially the midwife provided women with respectful and evidence-based care maternity. To see both mother and baby healthy after childbirth remains the core of modern midwifery practice.
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