Download - NORMAL PUERPERIUM
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.
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.
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
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.
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.
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.