Normal Puerperium

Presented by: marium Hussein

Obstetric &gynecological nursing department

Objectives

By the end of these session you will be able to

1. Define the key terms.

2. Describe the systemic physiologic changes

occurring in the woman after childbirth.

3. Identify the phases of maternal role adjustment

as described by Reva Rubin.

4. Discuss the psychological adaptations occurring

after delivery.

Cont..

Definition

It is the period of adjustment after

pregnancy and delivery when anatomical

and physiological changes of pregnancy are

reversed and the body returns to the normal

non pregnant state (reproductive tract

returns to its normal, non-pregnancy state).

Begins as soon as placenta is expelled

lasts for about 6 weeks(42 days).

The post partum period has been

divided into:

The immediate puerperium, the first 24

hours ,when acute post anesthetic or post

delivery complications may occur.

The early puerperium, which extends

until the first week post partum.

The remote puerperium, which includes

the period of time required for involution

of the genital organs through the sixth

weeks postpartum.

Physiological Changes During

Puerperium

Reproductive System:-

Involution of the Uterus

Involution is the process whereby the pelvic

reproductive organs returns to their pre pregnant

size and position and the placental site of

endometrial heals. Failure to complete this

process is known as sub-involution.

Causes of delayed involution (Sub involution ):

1. Full bladder .

2. Loaded rectum.

3. Uterine infection.

4. Retained product of conception.

5. Fibroid.

6. Broad ligament hematoma.

Sometimes of unknown reason (in the absence of any symptoms & signs ).

. Uterine involution depends on three processes: -

(1) Contraction of muscle fibers.

(2) Catabolism(Destructive process that converts

living cells into simpler compounds; process

involved in involution of the uterus after childbirth).

(3) Regeneration of uterine epithelium.

return to the pelvis by about 2 weeks.

be at normal size by 6 weeks.

the weight changes of uterus:-

1000g immediately after birth (excluding the fetus,

placenta, membrane and amniotic fluid).

500g 1 weeks after birth

300g 2 weeks after birth

60g 6 weeks after birth

Position of the uterus

Immediately after delivery the uterus lies midway

between the symphysis pubis and the umbilicus.

Within 12 hours, it rises to the level of umbilicus

or slightly above it. Uterus begins to descent into

the pelvic cavity at a rate of about 1 cm a day

until the 10th day, when it may be palpated at or

below the level of symphysis pubis.

GW Bubble He.mp4

Lochia

It is the vaginal discharge for the first fortnight

during puerperium. It originates from the

uterine body, cervix and vagina. It contains

blood, decidua tissue, epithelial cells from the

vagina mucus, bacteria and on occasion,

fragments of membranes and small clots. Its

odor is fleshy but not offensive.

Types of lochia are:

Lochia Rubra: The first phase of lochia when

discharge is red and bloody called lochia rubra

means ‘red’. Lasts from 1-4 days, may contain

few small blood clots.

Lochia Serosa: Occurs next 5-9 days, the

color is yellowish pink or pale brownish.

Lochia-Alba: Pale white because of the

presence of leukocytes, lasts from 10-14

days.

The color of lochia indicates the healing

stage of the placental site. The average

amount of discharge for the first 5-6 days is

about 250 ml.

After pains

Painful uterine contractions occur in early

puerperium increasing with suckling due to

oxytocin release. If intolerable use analgesics.

All women experience after pains, but they are

more acute in multiparous women secondary

to repeated stretching of the uterine muscles

Cervix

The cervix typically returns to its pre pregnant

state by week 6 of the postpartum period. The

cervix gradually closes but never regains its pre

pregnant appearance .Immediately after

childbirth, the cervix is shapeless and edematous,

and is easily distensible for several days.

The cervical os gradually closes and returns to

normal by 2 weeks, where as the external os

widens and never appears the same after child

birth. The external cervical os is no longer shaped

like a circle, but instead appears as a jagged slit-

like opening, often described as a “fish mouth

Appearance of the cervical os. (A) Before

the first pregnancy. (B) After pregnancy.

Vagina

The vagina and vaginal introits are greatly

stretched during birth to allow passage of

the fetus. Soon after childbirth, the

vaginal walls appear edematous, and

multiple small lacerations may be present.

Very few vaginal rugae (folds) are present.

Although the vaginal mucosa heals and rugae

are regained by 3 to 4 weeks, 6 to 10 weeks

are needed for the vagina to complete

involution and to gain approximately the same

size and contour it had before pregnancy.

During the postpartum period, vaginal

mucosa becomes atrophic and vaginal

walls do not regain their thickness until

estrogen production by the ovaries is

reestablished.

Because ovarian function, and therefore

estrogen production, is not well

established during lactation, breastfeeding

mothers are likely to experience vaginal

dryness and may experience dyspareunia

or discomfort during intercourse.

Perineum

The perineum is often edematous and

bruised for the first day or two after birth.

If the birth involved an episiotomy or

laceration, complete healing may take as

long as 4 to 6 months in the absence of

complications at the site, such as

hematoma or infection.

Perineal lacerations are classified in degrees

to describe the amount of tissue involved.

Some physicians or nurse-midwives also use

degrees to describe the extent of midline

episiotomies:-

First-degree: Involves the superficial vaginal

mucosa or perineal skin.

Second-degree: Involves the vaginal mucosa,

perineal skin ,and deeper tissues, which may

include muscles of the perineum.

•Third-degree: Same as second-degree

lacerations but involves the anal sphincter.

• Fourth-degree: Extends through the anal

sphincter into the rectal mucosa.

Nurses can encourage all women to

practice Kegel exercises to improve pelvic

floor tone, strengthen the perineal

muscles, and promote healing.

Changes in other Body Systems

Cardiovascular System

The maternal cardiac output is

significantly elevated above pre labor

levels for 1 to 2 hours postpartum and

remains high for 48 hours postpartum.

The cardiac output returns to pre-pregnant

levels within 2 to 4 weeks after childbirth.

Temperature

Is slightly elevated 0.5 degree for the first

24hrs and up to 38 degree is know. The

exertion and dehydration that accompany

labor are the primary causes for the

temperature elevation.

Pulse

The pulse is full and slow (about 60-70 B/min)

and is known as physiological bradycardia (for

24-48hrs after labor) it is due to:-

the rest period after labor

The increase in the circulating blood volume

on account of the elimination of the placental

pool.

Blood Pressure

Blood pressure values should be similar to those

obtained during the labor process. In some

women there may be a slight transient increase

lasting for about a week after childbirth. A

significant increase accompanied by headache

might indicate preeclampsia and requires further

investigation.

A decreased blood pressure may suggest

orthostatic hypotension or uterine

hemorrhage.

Respiratory System Adaptations

Respirations usually remain within the normal adult

range of 16 to 24 breaths per minute. As the

abdominal organs resume their non pregnant

position, the diaphragm returns to its usual position.

Skin

Excessive sweating (diaphoresis),particularly

in patients who were subjected to edema in

late pregnancy.

Gradually ceases within first week and the

skin reacts as usual.

Skin pigmentation gradually disappears.

Coagulation

Coagulation factors remain elevated for 2 to 3

weeks postpartum.

This hyper coagulable state, combined with

vessel damage during birth and immobility,

places the woman at risk for thromboembolism

(blood clots) in the lower extremities and the

lungs.

Urinary System Adaptations

During pregnancy, the GFR and renal plasma flow

increase significantly. Both usually normalize by 6

weeks after birth. Many women have difficulty

with feeling the sensation to void after giving birth

if they have received an anesthetic block during

labor (which inhibits neural functioning of the

bladder), or if they received oxytocin to induce or

augment their labor (antidiuretic effect).

These women will be at risk for

incomplete emptying, bladder distention,

difficulty voiding and urinary retention.

Gastrointestinal System

Abdominal discomfort results from gaseous

distention related to decreased motility and

abdominal muscle relaxation.

Constipation is a common due to :-

1-Intestinal a tony.

2-Anorexia after labor.

3-Loss of body fluids.

Straining to pass hard stool can cause

hemorrhoids and tear episiotomy sutures.

Stool softeners may be necessary.

Thirst is present due to the marked fluid loss

through sweat and urine.

Although spontaneous bowel movements usually

resume by the second or third day after childbirth.

Musculoskeletal System

During the first few days after childbirth, the woman

may experience muscle fatigue and general body

aches from the exertion of labor and delivery of the

baby.

The progressive stretching causes a decrease in the

muscle tone of the rectus muscles of the abdomen

and results in the soft, flabby, and weak muscles

experienced after birth.

Nurses should teach them to maintain

correct posture when performing activities

such as lifting, carrying, and bathing the

baby for at least 12 weeks after birth.

Endocrine System Adaptations

The endocrine system undergoes several changes

rapidly after birth.

Levels of circulating estrogen and progesterone drop

quickly with delivery of the placenta.

Decreased estrogen levels are associated with breast

engorgement and with the diuresis of excess

extracellular fluid accumulated during pregnancy .

Estrogen is at its lowest level a week after

birth.

HPL is undetectable within 1 day after birth.

Progesterone levels are undetectable by 3

days after childbirth

Prolactin levels decline within 2 weeks

for the non breast- feeding mother and

remain elevated for the lactating woman.

Lactation

Lactation is the secretion of milk by the

breasts. It is thought to be brought by the

interaction of progesterone, estrogen,

prolactin, and oxytocin.

Breast milk typically appears 3 days after

childbirth.

During pregnancy, prolactin, estrogen,

and progesterone cause synthesis and

secretion of colostrum, which contains

protein and carbohydrate, but no milk fat.

It is only after birth takes place, when the

high levels of estrogen and progesterone are

abruptly withdrawn, that prolactin is able to

stimulate the glandular cells to secrete milk

instead of colostrum. This takes place within

2 to 3 days after giving birth.

Body weight

Loss of weight during the first 10 days

particularly in the non lactating mothers

about a (4-5 kg) ,sometimes (8 kg) due to

evacuation of the uterine contents and

diuresis.

Return of Menstruation

Ovulation can return as early as 6-8 weeks after

childbirth in non–breast-feeding women, with a

mean time frame of 3 months.

The mean time to ovulation in breast-feeding

women is approximately 4-6 months, sometimes

as late as 24 months, but can vary greatly

depending on breast-feeding patterns.

Psychological Adaptations

The woman experiences a variety of responses

as she adjusts to a new family member,

postpartum discomforts ,changes in her body

image, and the reality of change within her

life. In the early 1960s, Reva Rubin (1984)

identified three phases that a mother goes

through to adjust to her new maternal role

Taking-In Phase:-

The taking-in phase is the time immediately

after birth when the client needs sleep, depends

on others to meet her needs, and relives the

events surrounding the birth process. This

phase is characterized by dependent behavior.

Taking-Hold Phase:-

The taking-hold phase is the second phase of

maternal adaptation, characterized by dependent

and independent maternal behavior.

This phase typically starts on the second to third

day postpartum and may last several weeks.

Letting-Go Phase:-

The letting-go phase is the third phase of

maternal adaptation, occurring later in the

postpartum period when the woman

reestablishes relationships with other people.

Postpartum Danger Signs

Fever more than 38° C (100.4° F).

Foul-smelling lochia or an unexpected change in color or amount.

Visual changes, such as blurred vision or spots, or Headaches.

Swelling, redness, or discharge at the episiotomy site.

Dysuria, burning, or reports of incomplete emptying of the bladder.

Shortness of breath or difficulty breathing.

Depression or extreme mood swings.

Nursing Management During

the Postpartum Period

Nursing management during the

postpartum period focuses on assessing

the woman’s ability to adapt to the

physiologic and psychological changes

occurring at this time.

(1)Assessment

Vital Signs:-

During the postpartum period, vital signs can alert the

nurse to the presence of hemorrhage or infection and

should be monitored according to hospital policy. vital

signs are typically monitored every 15 minutes during the

first hour after childbirth, then every 30 minutes during

the second hour, once during the third hour, and then

every 8 hours until discharge or until they are stable.

The REEDA Acronym to Guide the

Perineal Assessment

• The episiotomy the same as with any incision.

◦ R – redness

◦ E – edema or swelling

◦ E – ecchymosis or bruising

◦ D – drainage

◦ A – approximated

(2) Rest and exercises:

- Rest in bed for 2 days is advised after uncomplicated vaginal

delivery and for a longer few days in complicated or operative

delivery.

- Semi sitting position encourage drainage of lochia with 2

hours in prone position daily to encourage ante version of the

uterus.

- Movement in and outside the bed and breathing exercises are

advised during this period to minimize the risk of deep venous

thrombosis (DVT).

Pelvic floor exercise is started in the 3rd day if there is no

perennial wound by alternating contraction and relaxation

of the pelvic floor muscles. Abdominal exercises are done

later on. These exercises have the following advantages:

1) Diminish respiratory and vascular complications.

2) Minimize future prolapse and stress incontinence.

3) Give a better cosmetic appearance later on.

4)Maintain good circulation, lessens

possibility of venous thrombosis.

5) Restores muscle tone of the abdominal wall

& pelvic floor.

6) Promotes for normal drainage of lochia

(2) Local asepsis:

- The vulva and perineum are washed with

antiseptic solution after each micturition and

defecation and a sterile vulvar pad is applied.

- If there is perineal stitches add local antibiotic.

(3) Diet:

rich in proteins, vitamins, minerals and fluids.

(4) Care of the bowel:

Constipation is prevented by plenty of green vegetables and

fruits, sufficient fluids and local glycerin suppositories if

needed.

(5) Care of the bladder:

Patient is encourage to micturate frequently. If there is

retention a catheter is applied under aseptic conditions.

(6) Care of the breasts:

- Wash the nipple and areola with warm water

before each feed.

(7) Observations:

1. Mother : Pulse, temperature, breasts, lochia

and involution of the uterus.

2. Fetus : jaundice and umbilical stump.

Minor discomforts during the

postpartum period

1-After –pains

Predisposing factors:-

presence of blood clots, piece of membranes or placental

tissue.

Breast feeding.

Nursing management:-

-Simple uterine massage.

-Proper position (prone, sitting).

-Worm drink.

-Mild sedatives on doctors orders (before

feeding).

-Avoid full bladder.

-Encourage abdominal muscle exercise and

pelvic floor muscle exercise.

2-Urinary retention

Management :- the urine should be passed approximately

8-12 hours after delivery. If not ,the following measure

should be attempted:-

-Perineal care with worm water.

-Worm bedpan .

-listening to sound of running water.

- Hot water bottle over the symphysis pubis.

If these measure fail, catheterization should be performed.

Constipation

Nursing management:-

Diet rich in roughage.

Increase fluid intake.

Milk before bedtime.

Exercises.

Engorged Breast

Causes:-

Inadequate or infrequent breast feeding.

inhibited milk ejection reflex.

Signs and symptoms:-

Breasts are firm, heavy(due to blocked

ducts),swollen tender and hot (37.8 C).

Pain may be present.

Nursing management:-

Apply moist worm packs 2-3 minutes before each feeding.

Massage and manual expression of milk before feeding.

Cold application after feeding.

A well fitting bra should be used to provide support and

comfort.

Mild analgesics may be ordered .in severe cases

,administration of 2 doses of diuretic (as Lasix 40 mg) is

effective.

Cracked nipple

Causes :-

Improper antenatal care.

Improper technique of breastfeeding.

Unnecessary prolonged lactation.

Flat or large size nipple.

The use of irritating substances e.g. soaps, lotions.

Engorgement of the breast.

Signs and symptoms:-

Irritation of the nipple.

Persistent pain and tenderness.

Bleeding.

Inflammation signs.

Nursing management:-

Proper technique of breast feeding.

Apply moist heat and massage before feeding.

Frequent ,short feeding.

Avoid irritation and engorged breast.

Use supportive bra .

Mild analgesic.

Role of Nurse-midwives in Postnatal

Care

The role of nurse midwife during postnatal period is to

provide care and support to the mother and baby based on

the following principles :

1) Promoting physical and psychological well-being of the

mother, her baby and the family unit.

2) Identification of deviation from normal physiological or

psychological progress and make prompt referral as required.

3) Encourage sound methods of infant care and feeding and

prompt development of effective parent-infant relationship.

4)Support and strengthen woman, her husband and family’s

confidence within their family and culture environment.

5) Monitor progress of mother and child according to the needs,

expectations and attitudes of a particular mother and baby.

6) Promotion of a relaxed environment

conducive to establish effective

communication between mother and her

family.

7) Provide non-judgment approach, offer

guidance, advise when ever necessary.

8) Promote breast feeding when ever possible. Respect

individual choice and support the mother concerning

method of feeding. In case of artificial feeding advise

about preparation and sterilization equipment.

9) Follow these important elements of maternity nursing

care:-

a) Use universal precautions and gloves when there is

contact with blood or other body fluids.

b) Obtain clients consent before any procedure or treatment

and explain the findings after a procedure is completed.

c) Provide individualize care by determining clients’ needs

for nursing interventions.

d) Encourage and teach self care during every

contact with client.

e) Provide privacy respecting cultural needs.

f) Support patient-infant and sibling-infant

interaction during hospital stay.

10) Maintain proper records and reports.

Advices on Discharge

-Measures to improve general health of the mother,

continuation of supplementary therapy.

-Breast care, personal hygiene.

-Post-natal exercises to be done at least for 6 weeks.

-Breast feeding demand/schedule, exclusive till 6

months.

-Care of newborn baby vaccinations to be

done.

-Abstinence for intercourse for 6 weeks.

-Family planning advice and guidance to

prevent accidental pregnancy.

-Post-natal checkup after 6 weeks.

Summary

The postpartum period or puerperium refers to the first 6

weeks after delivery. During this period, the mother

experiences many physiologic and psychological

adaptations to return her to the pre pregnant state.

● Involution involves three processes: contraction of

muscle fibers , catabolism and regeneration of uterine

epithelium.

Lochia passes through three stages: lochia rubra, lochia

serosa, and lochia alba during the postpartum period.

Maternal blood volume decreases rapidly after birth and

returns to normal within 4 weeks postpartum.

Reva Rubin (1984) identified three phases the

mother goes through to adjust to her new maternal

role.

The postpartum assessment using the

acronym BUBBLE-HE (breasts, uterus,

bowel, bladder,lochia,episiotomy/perineum,

Homan s’ sign, emotions) is a helpful guide

in performing a systematic head-to-toe

postpartum assessment.