INTRODUCTION
After nine months of housing a growing baby, the uterus has to shrink back down to its
pre-pregnancy shape and size. For reference, that means going from a structure that can hold
about 10 L volume to one which can hold a teaspoon volume.
This starts with uterine contractions after the birth, and you may feel these contractions as
afterbirth pains (postpartum cramps). The worst of the afterbirth pains are usually over within the
first day or 2 days after giving birth, but the uterus continues to contract after this. If the process
happens too slowly, the uterus remains enlarged. This condition is called subinvolution.
DEFINITION
When the involution is impaired or retarded it is called subinvolution. The uterus is the
most common organ affected by sub involution. As it is the most accessible organ to be
measured per abdomen, the uterine involution is considered clinically as an index to assess
subinvolution.
CAUSES
1. Caesarian Section - this causes delayed healing of the incised uterine muscles.
2. Multiple pregnancies like twin or triplet pregnancies cause excessive stretching of the
muscles fibers and these may take longer than normal to come back to the normal state.
3. Secondary infection - Postpartum Infection can delay healing and involution.
4. If the bladder is not completely emptied, the uterus may appear to be at a higher level than
normal and a wrong diagnosis of sub involution made. The uterus should always be measured
after the bladder has been emptied.
5. Retained placental tissue
If the uterus is not completely empty after the childbirth and there is retained products of
conception like bits of the placenta or membranes, involution may be hampered. These can also
form the focus of infection and cause postpartum infection.
6. Prolonged labour - exhausts the uterine muscles and delays healing, leading to subinvolution.
7. Oxytocin levels
You may have heard of oxytocin as the “love hormone”. It’s what makes your heart melt
when you look down at your nursing baby, but it’s also what triggers uterine contractions. If
you’re not producing enough oxytocin, the contractions may be weak and it can result in uterine
subinvolution.
8. Activity levels
Excessive activity is thought to slow the healing process and put you at risk of uterine
subinvolution.
9. Ill maternal health
10. Uterine fibroid
SIGNS AND SYMPTOMS
The condition may be asymptomatic. The predominant symptoms are:
1. Abnormal lochial discharge either excessive or prolonged
` Postpartum bleeding or lochia can be a sign of how the uterine contraction process is
progressing. Some lochia bleeding is normal, and will resolve on its own within about a month of
delivery. It starts off as heavy like a menstrual period, becoming progressively lighter in color
and amount until it’s indistinguishable from normal vaginal discharge.
But if the uterus isn’t contracting properly, you may see:
Lochia flow that contains large clots
Lochia lasts longer than 4 weeks
Irregular bleeding alongside lochia discharge
2. Irregular or at times excessive uterine bleeding
3. Irregular cramp like pain is cases of retained products or rise of temperature in sepsis
4. The uterine height is greater than the normal for the particular day of puerperium. Normal
puerperal uterus may be displaced by a full bladder or a loaded rectum. It feels boggy and
softer upon palpation.
5. Presence of features responsible for subinvolution may be evident.
6. Chronic diseases : Chronic diseases like tuberculosis can cause subinvolution. The
tuberculous toxins appear to have a special affinity for the ovary and the uterine
endometrium.
7. Nutritional Causes : Severe starvation as seen in malabsorption syndromes and during
war and famine can cause subinvolution after childbirth.
TREATMENT
Subinvolution is one of the leading causes of dangerous postpartum hemorrhage, so if
you’re showing signs like abnormal lochia bleeding, it’s important to see a doctor to identify the
cause.
If an ultrasound scan shows you have retained placenta fragments in there, you may need
to be treated with antibiotics and have the tissue removed in hospital. If your case is only mild
and you’re not bleeding too heavily, you may be treated as an outpatient and given a course of
drugs to promote contractions.
Antibiotics in endometritis
Exploration of the uterus in retained products
Ergometrine so often prescribed to enhance the involution process by reducing the blood
flow of the uterus is of no value in prophylaxis.
PREVENTION
It’s not always possible to prevent subinvolution, but there are ways to reduce your risk.
It’s important to listen to your body and not push yourself too hard when recovering from birth.
Breastfeeding also releases the oxytocin that triggers uterine contractions, so that’s one
more perk you can enjoy if you’re nursing. Go easy on yourself, and give your body the right
balance of rest and gentle activity while you recover from birth.