Normal Postpartum

Normal Postpartum

It is a period following labor during which the maternal

body in general, and the genital organs, in particular
return to the pre-pregnant condition.
Duration is 40 days or 6- 8 weeks.
Another 4 to 6 weeks is needed for complete involution.
The puerperal period is much shorter after abortion.
The first ten days are called early postpartum, and the
days after are called the late postpartum.
 General physiological changes

Immediately following labor, the general condition of the

mother is one of physical fatigue.

Vital signs:
* Temperature:
- is slightly elevated: 0.5 degree for the first 24 hours
and up to 38 degrees is known. This is due to
absorption of waste products of muscular contractions
of labor.
 General physiological changes

Vital signs:
* Temperature:
- Transient rise in temperature later on is due to:
@ milk engorgement.
@ Constipation.
@ Nervous excitation.
* Pulse:
- Physiological bradycardia ( for 24-48 hrs after labor) due to:
@ Rest period after labor.
@ Increase in circulating blood volume after elimination of
placental pool.
 General physiological changes

Vital signs:

* Respiration:
- is in usual relation with pulse and temperature.
- is more abdominal in character.

* Blood pressure:
- no change is counted, but if hypotension is present, postpartum
hemorrhage is suspected.
- if hypertension is present , postparum toxemia may be suspected.
 General physiological changes

Skin:
- Excessive sweating, particularly in patients who
were subjected to edema in late pregnancy. This
gradually ceases within 1st week and the skin
reacts as usual.

- skin pigmentation gradually disappears.

 General physiological changes

Kidneys and urinary output:

- Physiological diuresis.
- Painful, difficult micturition due to tears, lacerations,
or episitomy.
- Traces of albumin may be present as a result of muscle
involution.
- Lactosuria is common with milk engorgement on the
4th day at the start of lactation.
 General physiological changes

Kidneys and urinary output:

- The parturient may experience retention of urine in first few days
after labor due to:
* Laxity of the abdominal muscles.
* Inability to micturate in recumbent position.
* Reflex inhibition due to stitched perinum or bruised urethra.
* Atony of the bladder.
* Compression of the urethra by edema or hematoma.
 General physiological changes

Bowel function and intestinal elimination:

- Thirst is present due to the marked fluid loss through sweat and
urine.
- Tendency to atony of gastrointestinal tract, with flatulence and
constipation.
- Constipation may be present due to:
* Intestinal atony.
* Anorexia after labor.
* Loss of body fluids.
* Laxity of abdominal wall.
* Hemorrhoids, reflex inhibition, enema in labor.
 General physiological changes

Blood picture:
- With proper antenatal care, the amount of blood loss
during 3rd stage of labor doesnt cause anemia.
- A moderate increase in leucocytic count.
- RBCc count and content and blood constitutes usually
return to the non- pregnant levels in 4 6 weeks.
 General physiological changes

Body weight:
- Loss of weight is observed during the 1st 10 days
especially in non-lactating women.

- There is about 4-5 kg ( sometimes 8 kg) due to

evacuation of uterine contents and diuresis.
 General physiological changes

After pains:
- it is spasmodic colicky pain in the lower abdomen during early
postpartum days.
- it is more common and more sever in multiparas ( due to weak
muscle tone), mutiple pregnancy, polyhydraminios, and large sized
infants.
- can be precipitated by the presence of blood clots, a piece of
membrane, or placental tissue.
- it increases during breast feeding as a result of oxytocin secretion
stimulation by suckling reflex of infant.
 General physiological changes

Return of menstruation:

- Non-lactating women begin to menstruate again in 6 -8

weeks.
- In lactating women, usually reappears in 4 -5 months , and in
sometimes as late as 24 months.
- The first period is usually prolonged and profuse.
- it should be mentioned that ovulation can commence in the
absence of menstruation, and another pregnancy can occur.
 General physiological changes

Uterus:
- Involution of uterus is the return of uterus to its non-pregnant condition.
- Size:
* Immediately after labor, the fundal level is at the level of umbilicus.
* At the end of first week, the fundus os midway between umbilicus and
symphysis pubis.
* By the end of 2nd week, the fundus is just behind the symphysis pubis, and
thereafter it becomes a pelvis organ.
- Weight:
* By the end of postpartum it weighs 50 gms instead of 1000 gms during
pregnancy.
 General physiological changes

Mechanisms through which involution of

uterus occurs:
- Autolysis.
- Ischemia ( decreased blood supply)
 General physiological changes
In the endometrium:
- Separation of placenta and membranes occur in the deeper portion of
the spongy layer of decidua.
- All but the basal layer is shed off in the lochia.
- If the involution process is slow or delayed , known as subinvolution.
- If the involution process is rapid , known as hyperinvolution.
- Lochia:
* It is the uterine discharge coming through the vagina during the first
3-4 weeks postpartum.
* It is alkaline with fleshy odor, and contains blood, leucocytes, dead
decidual tissues, vaginal epithilial cells, cholesterol, and non-
pathogenic bacteria.
 General physiological changes

Types of lochia:

* Lochia rubra:
the discharge is red in color, and lasts from 1st postpartum day, to
4th day ( and sometimes 7th day).
* Lochia serosa:
a pink yellow discharge containing less blood blood and more
serum, and extends for another 3 to 4 days.
* Lochia alba:
a creamy or white clored discharge containg leucocytes and mucus.
It remains for the 10th day postpartum.
 General physiological changes

Clinical significance of abnormal lochia:

- Fetid lochia denotes the presence of infection and/or

stagnation.

- Sudden suppression may be due to sever infection.

- Prolongation or recurrence of lochia rubra may suggest

retained parts of placenta, membranes, subinvolution,
tumors.
 General physiological changes

Vagina:
- the vagina diminishes in size, but not as pregravid stae.
- Rugae reappear in third week.
- The anterior and posterior walls may be sagging immediately
after labor.

Vulva:
- Edema, minute or frank lacerations may be seen immediately
after labor.
- the vulva tends to gap for some time after delivery.
 General physiological changes

The abdominal wall:

- The muscles were over-stretched during pregnancy
and strained during labor, are slow to regain their
normal tone and elasticity.
- The recti muscles may separate widely so that the
uterus may be felt between them.
- Diastasis recti.
 General physiological changes

Breasts:
- Anatomy.
- Shape.
- Situation.
- Structure:
* Axillary tail. * Areola.
* Montogomerys glands.
* Nipples
* 15 20 lobes: Alveoli, myoepithelial cells,
lactiferous tubules, lactifeorus ducts, sinuses.
Physiology of Lactation
Psychological changes during postpartum

Phases of Maternal Role:

Taking in phase.
Taking Hold phase.
Letting go phase,
Psychological changes during postpartum

Taking in phase:
- It takes 2-3 days, during which time the mothers first
concern is with her own needs(sleep and food).
- The woman reacts passively, mostly dependent on others
to meet her needs.
- She is quite talkative during this phase about every detail
of her labor and delivery experience.
Psychological changes during postpartum

Taking Hold phase:

- It starts 3rd day postpartun.
- The emphasis is placed on the present.
- She progresses from the passive individual to the one
who is in command of the situation.
- this phase lasts about 10 days.
- Acceptance her role as a mother.
Psychological changes during postpartum

Letting go phase:
- This generally occurs when the mother returns home.
- Must realize and accept physical seperation from the
infant.
- Must relinquish her former role as a childless person and
accept the enormous implications and responsibilties of
her new situation
 Postpartum blues

Is the gap between the ideal and reality: the new mothers
self expectation may exceed her capabilities, resulting
in cyclic feelings of depression.

Let-down feelings, irritabiilty, and tears.

Usually is temporary, may be related to hormonal

changes and role transition.
 Postpartum blues

Predisposing factors:
- The first pregnancy.
- A pregnancy in late child bearing years.
- Ambivalence toward the womans own mother.
- Social isolation.
- Long and hard labor.
- Anxiety regarding finances.
- Marital disharmony.
- Crisis in the extended family.
 Nursing Management

Objectives of care during the postpartum period:

- Secure mental and physical rest, restore normal good muscle
tone and maintain normal body functions.
- Provide proper adequate nutrition.
- Guard against infection.
- Teach the mother how to care for herself and the infant.
- Foster and maintain family ties and adjust the parents to their
new role.
 Nursing Management

Nursing assessment during first hour after placental separation and birth:
- Observation of bleeding signs and symptoms by:
* Palpating the fundus of the uterus through the abdominal wall.
Normally it should be firm, round, small, central, and well
contracted.
* Inspecting the perineum and perineal pad for obvious signs of bleeding.
* Taking and recording vital signs every 15 minutes for first hour.

- Observation of legs for signs and symptoms of DVT: pain, warmth,

swollen reddened that feels hard or solid, and positive Homans sign.
 Nursing Management
(Implementation)
Palpate the uterus :
- If it becomes soft and boggy because of relaxation, the
fundus should be massaged immediately until it becomes
contracted again.

- If the uterus is atonic, blood collected in the cavity

should be expressed by gentle, firm force in the direction
of outlet. This is done after the fundus has been first
massaged because it may result in inversion of uterus and
serious complications.
 Nursing Management
(Implementation)
Administer oxytocics to control bleeding and promote involution.
continue checking of vital signs.
Encourage urination because full bladder impedes involution leading to
excessive bleeding.
Check lochia discharge for color, amount, consistency, and presence of
clots.
Aseptic perineal care.
Breast care, and encourage early initiation of breast feeding to stimulate
involution and lactation.
Correct dehydration.
Start leg exercises.
Administer antcoagulant therapy as ordered.
 Subsequent general daily care

Check vital signs twice daily (morning and evening)

- A temperature of 38 C , or above for two consecutive days after
first 24 hours is considered an early sign of puerperal infection.
- Bradycardia is a normal physiological phenomenon.
Palpate the uterus to assess firmness, level of fundus, and rate of
involution.
Administer oxytocic medications to promote invoultion.
Check lochia for color, amount, odor, consistency, and clots.
Observe perinum and suture line for redness, ecchymosis, edema or
gapping.
Provide for sufficient periods of rest and sleep.
 Subsequent general daily care

During the first 8 hours, the mother is encouraged to sleep in any

comfortable position. After that, the prone position or lateral should
be encouraged to facilitate involution and help drainage of lochia.

Also, sitting position is recommended to promote contractions of

abdominal muscles and drain lochia.
Supine and semi-sitting should be avoided.
Prevent infection.
Provide diet high in protein and calories to restore tissues. Roughage
and green vegetables to prevent constipation. Increase in fluid
intake.
 Subsequent general daily care

Voiding should be encouraged within 6-8 hours after labor. If failed

within 12 hours, catheterization is performed.
Encourage early ambulation, and avoid heavy activities.
Encourage postpartum exercises.
Provide treatment for after pains.
Monitor laboratory reports for Hb, HCT, and WBC.
Observe for postpartal blues.
If Rh negative mother, assess need for administration of RhO GAM.
Discuss resumption of sexual relations.
Discuss community resources that provide maternal services.
 Subsequent special daily care

Breast care:
- Encourage initiation of breastfeeding.
- breast should be soft, until milk comes in.
- Daily cleansing in shower.
- Regular examination of breast for complications such as engorged
breasts, cracked nipples, mastitis, and breast abscess.

Pernium care:
- Inspect and observe presence of episitomy.
- Keep area clean and dry.
- Teach the mother principles of self-care.