Unit-IV

Physiology and
management of
normal
puerperium
 Introduction
 The puerperium is a period of
approximately 6 weeks which commences
following completion of third stage of
labour.
During this time the women recovers from
stresses of pregnancy & delivery & the
physiological adaptations which occur during
pregnancy subside, facilitating the restoration
of the non pregnant state.
 Definitions
 The puerperium is defined as the 6 weeks period
commencing after the completion of third stage of
labour.
-E.M SYMONDS

 The puerperium is refers to the 6 weeks period

following child birth, when considerable adjustments
occur before return to the pre pregnant state.
-PHILIP N. BAKER

 Puerperium is defined as the time from delivery of

the placenta through the first few weeks after the
delivery.
(cont….)
 The postpartum period is the period of time
following the delivery of the child during which
the body tissues, especially the reproductive
system reverts back to the pre-pregnant state,
both anatomically and physiologically.

 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)
 Stages of puerperium
 The post partum period has been divided
into:

 The immediate puerperium, the first 24 hours

after parturition; 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.
 Reproductive system
Uterus
Involution:-is the return of the uterus to a nonpregnant state
after childbirth
Involution process begins immediately after expulsion of the
placenta with contraction of uterine smooth muscles
At the end of third stage of labor, the uterus is in the midline,
about 2cm below the level of the umbilicus and weighs 1000g

By 24 hours postpartum the uterus is about the same size it was

at 20 gestational weeks
The fundus descends about 1 to 2cm every 24 hours, and by the
sixth postpartum day it is located halfway between the
symphysis pubis and the umbilicus.
-The uterus lies in the true pelvis within 2 weeks after childbirth.
 Involution of the uterus
 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
 50g 6 weeks after birth
 The endometrial lining rapidly regenerates (16 days)
 The placental site undergoes a series of changes in
the postpartum period
Its fundus level approximates that of a 20 week
pregnancy at the level of umbilicus, at the end first post
partum week it is palpable at the symphysis pubis

-Autolysis:-it is a self destruction of excess

hypertrophied tissue.

-Subinvolution:-is the failure of the uterus to return to a

nonpregnant state.

-The most common causes of subinvolution are

retained placenta fragments and infection
Contraction
The hormone oxytocin strengths and coordinates
uterine contraction, which compress blood vessels
and promotes homeostasis

During the first 1 to 2 postpartum hours, uterine

contractions may decrease in intensity and become
uncoordinated
 Exogenous oxytocin is usually administered
immediately after expulsion of the placenta to
maintain the uterus firm and contracted.

Mothers are encouraged to put the baby to breast

immediately after birth to stimulate the release of
oxytocin.
Placental site
-Immediately after the expulsion of the placenta and
membranes, vascular constriction and thrombosis
cause the placental site to be reduced to an irregular
nodular and elevated area.
Upward growth of endometrium causes the sloughing
of necrotic tissues and prevents scar formation.

Endometrial regeneration is completed by postpartum

day 16, except the placental site is not complete until
6 weeks after birth.
Lochia
It is the uterine discharge that occurs after birth.
Lochia is initially bright red changing later to a pinkish
red or reddish brown

-For the first 2 hours after birth the amount of lochia

should be about that of a heavy menstrual period,
after that time the lochial flow should steadily
decrease.
Lochia passes through 3 stages:-

1-lochia rubra:-it consists of blood, decidual and

trophoplastic debris
It lasts 3-4 days after childbirth
.
2-lochia serosa:-it consists of old blood, serum,
leukocytes, and tissue debris. the flow becomes pink
or brown.
It is expelled 3-10 days postpartum
3-lochia alba:-it consists of leukocytes, decidua, epithelial
cells, mucus, and bacteria. it is yellow to white in
color.

Lochia alba may continue to drain for up to and beyond

6 weeks after childbirth.
The amount of lochia is usually increases with
ambulation, and breastfeeding.
Persistence of lochia rubra early in the postpartum
period suggests continued bleeding as a result of
retained fragments of the placenta or membranes.

The another common source of vaginal bleeding is

vaginal or cervical laceration.
 After Pain
 After expulsion of fetus and placenta the uterus contracts to
regain its normal size, weight and site, this called involution of
uterus. Oxytocin is released from posterior lobe of the pituitary
gland in response to the sucking, which facilitate uterine
contraction.
 Characteristic of after pain:
 Occur during the 1st 2-3 days of puerperium
 Abdominal pains (like cramps) and back pain.
 Strong, regular, and coordinated.
 The intensity, frequency and regularity of contraction decrease
after the 1st postpartum day.
 Primigravida--uterus tonically contracted unless clots or tissue
remain in uterus.
 Multipara--uterus contracts and relaxes at intervals causing
“afterpains”.
More severe when breasfeeding in both primiparas and multiparas.
 Constipation
 It is common in the first few days of puerperium and
is due to many factors. The woman‘s food intake is
interrupted, there may be dehydration during labor,
the abdominal muscles are lax and perineal
lacerations make defecation painful.
 Cervix
It is soft immediately after birth

-The cervix up to the lower uterine segment

remains edematous, and thin for several
days after birth.

The cervical os which is dilated to 10cm

during labor closes gradually, it may still
possible to introduce 2 fingers into
cervical os for the first 4-6 postpartum
days.
 The external cervical os never regains
its prepregnancy appearance, it is no
longer shaped like a fish mouth.
 It return to its normal state at 4
weeks after birth
Vagina and perineum

-The greatly distended, smooth walled vagina gradually

returns to its prepregnancy size by 6-10 weeks after
childbirth.
-The mucosa remains atrophic in lactating woman at
least until menstruation begins again.
-Thickening of vaginal mucosa occurs with the return of
ovarian function.
The reduced estrogen levels also responsible for
causing a decreased amount of vaginal lubrication, so
localized dryness and dyspareunia may persist until
ovarian function returns and menstruation
resumes.

-Initially the introitus is erythematous and edematous

especially in the area of the episiotomy or laceration
repair.
If episiotomy and laceration have been carefully
repaired, hematomas are prevented or treated early.
- usually healing should occur within 2-3 weeks

- Hemorrhoids usually decrease in size within 6 weeks

of childbirth.
Pelvic muscular support

The supporting structure of the uterus and vagina may

be injured during childbirth.

the supportive tissues of the pelvic floor that are torn

or stretched during childbirth may require up to 6
months to regain tone

Women are encouraged to do kegel

exercises after birth to strengthen perineal muscles and
promote healing
 Perineum
 Swelling completely gone within 1-2 weeks
 The muscle tone may or may not return to
normal, depending on the extent of injury.
The muscular walls of the pelvic
organs
 The voluntary muscles of the pelvic floor and pelvic
supports gradually regain their tone during the
puerperium. Tearing or overstretching of the
musculature or fascia at the time of delivery
predispose to genital hernias. Over distention of the
abdominal wall during pregnancy may result in
rupture of the elastic fibers, persistent striae, and
diastases of the recti muscles. Involution of the
abdominal musculature may require 6-7 weeks and
vigorous exercises are not recommended until after
that time.
 Breasts
Anatomy
A ducts
B lobules
C dilated section of duct to
hold milk
D nipple
E fat
F pectoralis major muscle
G chest wall/rib cage
Enlargement:
A normal duct cells
B basement membrane
C lumen (center of duct)
Physiology of Lactation
 During pregnancy estrogen and progesterone
secreted by the placenta prepare the breasts
for lactation. The estrogen inhibits milk
production until the end of pregnancy. In the
3rd trimester of pregnancy colostrum is
present and remains for the first 3 days
postpartum.
 By the 3rd stage of labor (delivery of the
placenta), the hormonal production is reduced,
and during the next 48 hrs, the blood level of
estrogen and progesterone fall. This stimulates
the anterior pituitary gland to produce the
lactogenic hormone (prolactin hormone)
which acts on the acini cells in the breast, and
milk is formed.
The milk is pushed along the lactiferous ducts
and some is stored in the ampullae which lie
just under the areola. When the infant sucks,
he takes the nipple and the areola into his
mouth, and partly by a vacuum which is
created mostly by a chewing action of his jaws,
milk is pushed into his mouth and he swallows.
As the ampulla and lower ducts are emptied,
milk is pushed from the alveoli by contraction
of the myoepithelial cells. So, the act of sucking
by the infant is the stimulus that provokes
lactation.
 This effects a neuro-hormonal reflex
mechanism which activates the anterior
pituitary lobe to produce lactotropin, and the
posterior pituitary lobe to produce oxytocin
which reaches the breast through the blood
stream, leading to contraction of myoepithelial
cells, and the expulsion of milk.
 Oxytocin also stimulates uterine contractions
causing after pains and lochial discharge
during breastfeeding.
 With the onset of milk the breasts become
larger firmer, heavier, and full of milk that can
be expressed on pressure, or may escape
spontaneously. This procedure is associated
with a considerable local throbbing pain
extending the axillae.
 Characteristics of breast milk. It is suited to
the infant’s needs, easily digestible, germ-free,
fresh, warm and contains antibodies, vitamins,
calcium, lactose, casein protein, fat, mineral
salt and water. It is also readily available, and
costs little.
Types of Breast milk

Breast milk at different stages of

lactation is defined by different terms.
Colostrum: is a thick, sticky and light
yellowish in colour which is produced
during the first few days after delivery.
Although secreted in small quantities
(30-90ml), it is sufficient to meet the
caloric needs of a normal newborn in
the first few days of life.
 Transition milk :During a period of 1-2 weeks
that follow the colostrum stage the milk
increases in quantity and changes in
appearance and composition as per the baby's
needs, protein contents decrease while fat and
sugar contents increase. At this time the
breasts feel full, hard and heavy.
Mature milk: This milk is thinner and watery but
contains all the nutrients essential for
optimum physical and mental development of
the child. Mature milk changes even during the
length of a single feed to exactly suit the needs
of a baby.
The mature milk consists of
Foremilk and Hind milk:
 Foremilk :The milk which comes at the start
of a feed. It has a low level of fat and is high in
lactose, sugar, protein, vitamins, mineral and
water. It satisfies the baby's thirst and is
produced in larger amounts than hind milk.
 Hind milk: which comes later in a feed, is richer in
fat which makes it look whiter and thicker than
foremilk. It satisfies the babies hunger and supplies
much of the energy of a breastfeed. It should be
noted that a baby needs both the foremilk and the
hind milk for appropriate weight gain. Also, babies
who are fed both foremilk and hind milk sleep well.
 Preterm milk: is a milk produced by a woman who
has delivered prematurely.This milk has more
proteins, minerals, immunoglobulin and lactoferrin
than the mature milk, making it suitable for the
needs of a preterm baby.The preterm milk is ideal
food for low birth weight babies.Term milk is
produced by a woman who has a full term delivery.
Its composition is suitable for normal term baby
Breast feeding in the correct position
Art and technique of breast feeding
Step 1:
Find a comfortable
position for your self.
You may lie down; sit
on a chair on the bed
or on the floor to
feed your baby. Most
important is that you
must feel
comfortable and
your back must be
supported
Step 2:
Hold your baby in your arm
so that her head and neck
rest in the bend of their
elbow , the back along
forearm and the buttocks
in your hands if your
feeding on your right
breast your right arm
should be used to cradle
your baby.
Step 3:
Turn the baby's entire body towards yours so that
the baby's tummy touches your tummy. The
babies head and neck should be supported
Step 4:
Raise the baby to the level of your breast so that
the babies mouth can easily reach the nipple and
the areola. This could be made possible by
putting a pillow below your arm or raising your
thigh if your sitting crossed leg on the floor.
 Make sure that the baby is not exclusively clothed so
that the baby can be brought really close to you. Some
times you may need to tuck your babies arm away. So
that it does not come in the way.You may use your free
hand to hold your breast or to fondle your baby once
your baby is really attached.
Step 5:
When the nipple touches, the baby's lips or the cheek,
your baby's mouth will reflexively open to draw the
nipple and part of the areola in to form a teat. this is
known as "attachment to the breast" the lactiferous
sinuses which are the storehouses of milk are situated
beneath the areola.
 To effectively suckle milk from the breast, both the
nipple and the areola should go into the baby's mouth.
Proper attachment is the key to successful breast
feeding, improper attachment is responsible for most
of the problems related to breast feeding like sore
nipple, congested breast and inadequate milk supply
 Body position: The mother should feed her baby in any
comfortable position such as lying or sitting with good
eye contact. Good and bad body positions are shown in
Fig. a & b.
A B
Pic . a: Good body position
Baby’s head and neck is straight or bend slightly
back.
Baby’s body is turned towards the mother.
Baby’s body is close to the mother facing breast.
Baby’s whole body is supported.
Mother baby eye contact is there
Pic . b: Bad body position
Baby’s head and neck not straight.
Baby’s body is turned away from the mother.
Baby’s body is away from the mother.
Baby’s body is not supported.
There is no eye contact between the mother
and baby
 Attachment
attachment refers to the
emotional connection
between a patient and her
infant. This attachment is
reciprocal; both the mother
and the infant exhibit
attachment behaviors. The
infant responds to the
patient by cooing, grasping,
smiling, and crying.
However, these behaviors are nondiscriminatory
before approximately 8 weeks. Nurses can assess
for attachment behaviors by observing the
interaction between the mother and her infant.
Behaviors indicating a positive attachment
include:
 Touching
 Holding
 Kissing
 Cuddling
 Talking and singing
 Choosing the "en face" position
 Expressing pride in the infant
 Endocrine system
Placental hormones
Expulsion of the placenta results in dramatic decreases of
hormones produced by placenta.

The placental enzyme insulinaze causes the diabetogenic

effects of pregnancy to be reversed, resulting in
significantly lower blood sugar levels in the immediate
postpartum period
- Estrogen and progesterone levels decrease markedly after
expulsion of the placenta, reaching their lowest levels 1
week into the postpartum period.
- 2- Decreased estrogen level associated with; breast
engorgement, and diuresis of excess extracellular fluid
that has accumulated during pregnancy.
The estrogen levels in nonlactating women begin to increase
by 2 weeks after birth, and higher by postpartum day 17.
Pituitary hormones and ovarian function:-
-Lactating and nonlactating women differ in the time of the
first ovulation.
-The persistence of elevated serum prolactin levels in breast
feeding women appears to the responsible for suppressing
ovulation
In women who breast feed, prolactin levels remain elevated
into the sixth week after birth.
Serum prolactin levels are influenced by the frequency of
breastfeeding, the duration of each feeding, and the degree
to which supplementary feedings are used.
Prolactin levels decline in nonlactating women, reaching the
prepregnant range by third week
About 70% of nonlactating women resume menstruation by
3 months after birth.
-The mean time to ovulation in women breast feed is
about 6 months.
-The resumption of ovulation and the return of menses
in lactating women are determined by breastfeeding
patterns.
-The first menstrual flow after childbirth is usually
heavier than normal, within 3-4 cycles, the amount of
menstrual flow returned to woman’s prepregnant
volume
 Abdomen
-Abdominal muscles protrude during the first days after
birth.

-During the first 2 weeks after birth the abdominal wall

is relaxed and it takes approximately 6 weeks to
return almost to its nonpregnant state

-The skin regains most of its previous elasticity, but

some striae may present

-The return of muscle tone depends on previous tone,

proper exercise, and the amount of adipose tissue.
 Urinary system
The diminishing steroids levels after birth may explain
the reduced renal function that occurs during the
pueriperium.

Urine components

BUN level increases during puerperium as autolysis of

the involuting uterus occurs. This breakdown of
excess protein in the uterine muscle cells results in a
mild (+1)proteinurea for 1-2 days after childbirth
Postpartal diuresis
-Within 12 hours of birth, women begin to lose the
excess tissue fluid that has accumulated during
pregnancy.

-One mechanism responsible for reducing these

retained fluids is the profuse diaphoresis that often
occurs for the first 2-3 days after childbirth

-The fluid loss through increased urinary output

accounts for weight loss of approximately 2.25kg
during the puerperium
Urethra and bladder
If trauma to the urethra and bladder occur during the birth
process, the bladder wall becomes hyperemic and
edematous, often with small areas of hemorrhage.

Birth-induced trauma increased bladder capacity and the

effects of conduction anesthesia combine to cause a
decrease in the urge to void. In addition to pelvic soreness
from the forces of labor, vaginal laceration, or an episiotomy
which they reduce the voiding reflex.

Decreased voiding, along with postpartal diuresis may result in

bladder distention.

-Distended bladder pushes the uterus up and to the side and

this prevents the uterus from firmly contracting which may
cause excessive bleeding.
-Bladder tone is usually restored 5-7days after childbirth .
 Gastrointestinal system
Appetite

The mother is usually hungry shortly after giving birth.

Bowel evacuation

A spontaneous bowel evacuation may be delayed until

2-3 days after childbirth. This can be explained by
decreased muscle tone of the intestines during labor
and the immediate puerperium, prelabor diarrhea,
lack of food, or dehydration
 GI/hepatic function
GI tone and motility decreases in the early postpartum
period, commonly causing constipation.

-Normal bowel function returns approximately 2 to 3

days postpartum.

-Liver function returns to normal approximately 10 to

14 days postpartum.

-Gall bladder contractility increases to normal, allowing

for expulsion of small gallstones
 Cardiovascular function
Most dramatic changes occur in this system.
Cardiac output decreases rapidly and returns to normal
by 2 to 3 weeks postpartum.

Hematocrit increases and increased red blood cell

(RBC) production stops.

Leukocytosis with increased white blood cells (WBCs)

common during the first postpartum week.
Blood volume
The blood volume which increase during pregnancy is
eliminated within the first 2 weeks after birth, with
return to nonpregnant values by 6 weeks postpartum.
Cardiac output

Immediately after the birth, the pulse rate, stroke

volume and cardiac output remain elevated or
increase for 30 to 60 minutes as the blood that
shunted through uteroplacental circuit suddenly
returns to the maternal systemic venous circulation
 Vital Signs
 Temperature:
 The temperature is slightly elevated: 0.5
degrees for the first 24 hours and up to 38
degrees is known. This rise in temperature is
due to the absorption of waste products of
muscular contractions of labor.
 Transient rise in temperature later on is due
to:
• Milk engorgement (by the 4th day
postpartum).
• Constipation.
• Nervous excitation.
• Infection.
 The pulse:
 The pulse is full and slow (about 60-70 B/mm)
and is known as physiological bradycardia (for
24-48 hrs 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.
• The pulse should remain below 100 B/mm if
all is going well. A rapid pulse may be
brought on by pain, visitors, excitement,
exhaustion, the nursing infant, hemorrhage
or infection.
 Respiration:
 Thisis in the usual relation with pulse and
temperature. Because of a reduction in the
size of the uterus and relaxation of the
abdominal wall respiration is more abdominal
in character. Deviation from the normal may
suggest pneumonia or embolism.
 Blood Pressure:
 Nochange is counted, but if hypotension is
present, postpartum hemorrhage may be
suspected. If hypertension is present (over
140/90 mm Hg) postpartum toxemia may be
suspected.
 Blood and Fluid Changes
Marked leukocytosis and thrombocytosis occur during
and after labor
The leukocyte count sometimes reaches 30,000L, with
the increase
. There is also a relative lymphopenia and an absolute
eosinopenia.
Normally, during the first few postpartum days,
hemoglobin concentration and hematocrit fluctuate
moderately.
If they fall much below the levels present just prior to
labor, a considerable amount of blood has been lost

By 1 week after delivery, the blood volume has returned

nearly to its nonpregnant level.
 Respiratory function
-Returns to normal by approximately 6 to 8 weeks
postpartum.

-Basal metabolic rate increases for 7 to 14 days

postpartum, secondary to mild anemia, lactation, and
psychological changes-
 Neurological system
Discomfort and fatigue are common.

Afterpains and discomfort from the delivery, lacerations,

episiotomy, and muscle aches are common.

Frontal and bilateral headaches are common and are

caused by fluid shifts in the first week postpartum.

The elimination of physiologic edema through the

diuresis that occurs after childbirth relieves carpal
tunnel syndrome by easing the compression of the
median nerve.
 Musculoskeletal function

-Generalized fatigue and weakness is common.

-Decreased abdominal tone is common.
-Diastasis recti heals and resolves by the 4th to 6th
week postpartum.
-Until healing is complete, abdominal exercises are
contraindicated
 Integumentary system
- Chloasma of pregnancy usually disappears at the end
of pregnancy.
- Hyperpigmentation of the areolae and linea nigra may
not regress completely after childbirth, and it may be
permanent in some women.
- Stretch marks on breasts, abdomen, hips, and thighs
may fade but usually do not disappear
- Hair growth slows during postpartum period, and
some women may actually experience hair loss.
Immune system
No significant changes occur during postpartum period
 psychological changes during
Postpartum
Phases of the
Maternal Role:
 Emotional changes
in the mother
during the
postpartum period
(restorative process)
as described by Reva
Rubin pass through
three phases. They
are:
 Taking-in phase.
 Taking-hold phase.
 Letting-go phase.
 Taking-in Phase (Turning in):

 It takes 2-3 days, during which time the

mother’s first concern is with her own needs
(sleep and food). The woman reacts passively,
mostly dependent on others to meet her
needs. She initiates little activity on her own.
She is quite talkative during this phase about
every detail of her labor and delivery
experience.
 Taking-Hold Phase (Taking
Responsibility as a Mother):
 It starts the 3rd day postpartum. The emphasis
is placed on the present. She becomes
impatient and is driven to organize herself and
her life. She progresses from the passive
individual to the one who is in command of
the situation. This phase lasts about 10 days.
Once the mother has taken control of her
physical being and accepted her role as a
mother, she is able to extend her energies to
her mate and other children.
 Letting-go Phase:

As her mothering functions become more

established the mother enters the letting-go
phase. This generally occurs when the mother
returns home. In this phase there are two
separations that the mother must accomplish.
One is to realize and accept physical
separation from the infant.
The other is to relinquish her former role as a
childless person and accept the enormous
implications and responsibilities of her new
situation. She must adjust her life to the
relative dependency and helplessness of her
child.
 Bonding:

 also known as attachment: process by which

parents form emotional relationship with
infant over time; influenced by many factors:
family, stability of home environment,
nurturing she received as child. Certain
characteristics important: level of trust, level of
self esteem, reactions to present pregnancy;
interest in child rearing.
Postpartum Blues (Depression)

Definition

 Rubin defined postpartum depression as the

gap between the ideal and reality: the new
mother’s self-expectation may exceed her
capabilities, resulting in cyclic feelings of
depression.

 During Postpartum, and for no apparent

reason that the mother can think of, she may
experience a let-down feeling accompanied by
irritability and tears. Occasionally her appetite
and sleep patterns are disturbed. These are the
usual manifestations of the postpartum or
“infant” blues .
 This depression is usually temporary and may
occur in the hospital. It is thought to be
related, in part, to hormonal changes, and in
part, to the ego adjustment that accompanies
role transition. Discomfort, fatigue and
exhaustion certainly contribute to this
condition. Crying often relieves the tension,
but if the parents are not knowledgeable about
the condition the mother may feel rather
guilty for being depressed.
 Understanding and anticipatory guidance will
help the parent be aware that these feelings
are a normal accompaniment to this role
transition.
 Predisposing Factors

 The first pregnancy.

 A pregnancy in late child bearing years.
 Ambivalence toward the woman’s own
mother.
 Social isolation.
 Long or hard labor.
 Anxiety regarding finances.
 Marital disharmony.
 Crisis in the extended family
 The Emotional Needs of the
Woman during Postpartum
 Recognition of the effort made during labor:
approval of behavior during labor as well as in
the immediate postpartum period.
 Support and encouragement in her care for
the infant.
 Attention from family members particularly
from the husband: this is very significant as
most of the attention in the immediate
postpartum period is directed suddenly
toward the newborn.
 Someone to listen and help them solve their
dependency-independency conflict.
 Physical needs of comfort, nourishment and
hygiene should be properly fulfilled.
 A good method to remember how to
check the postpartum changes is the use
of the acronym BUBBLERS:
 B: Breast.
 U: Uterus.
 B: Bladder.
 B: Bowel.
 L: Lochia.
 E: Episiotomy.
 R: Emotional response.
 S: Homans' sign.
 Nursing Management of the
Postpartum Period
Introduction
Nursing care during the postpartum provides
the means by which the parturient can restore
her physical and emotional health, as well as
gain experience in caring for her new born
infant.
 Components of Care during
the Postpartum Period
Care of the mother:
Immediate care.
Subsequent daily care.
Care of the newborn infant.
Objectives of Care during the
Postpartum Period.

Immediate care of the mother:

 Secure physical and mental 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.
 To encourage breastfeeding
Nursing Assessment

The first hour, after placental

separation and birth, is under the
management of the labor ward
nurse:
 Observation of bleeding signs and
symptoms by:
Palpating the fundus of the uterus
through the abdominal wall.
Normally,
Inspecting the perineum and
perineal pad for obvious signs of
bleeding.
Taking and recording vital signs
every 15 minutes for the first hour
after labor.
 Observation of legs for signs and
symptoms of deep vein thrombosis
(DVT): pain, warmth, tenderness,
swollen reddened vein that feels
hard or solid and positive Homan’s
sign
Postnatal Exercises
 Pelvic floor exercise
 Abdominal tightening
 Pelvic tilting or rocking
 Rectus gap
 Hip hitching
 Foot and Leg Exercise
 Nursing Diagnosis Based on
Assessment.
Potential for :
 Postpartum bleeding.
 Deep vein thrombosis.
 Infection.
 Nursing Plan and Implementation

Palpate the uterus: if it remains firm,

well contracted and does not
increase in size, it is neither
necessary nor desirable to stimulate
it.
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 which collects
in the cavity should be expressed with firm,
but gentle, force in the direction of the
outlet. This is done only after the fundus
has been first massaged because it may
result in inversion of the uterus and lead to
serious complications.
 Administer oxytocin (e.g. ergometrine 5
mg.TM) as ordered to control bleeding and
to promote involution.
 Continue checking of vital signs.
 Encourage urination because full bladder
impedes involution and may cause atony of
the uterus leading to excessive bleeding.
 Check lochial discharge for color, amount,
consistency and presence of clots.
 Perineal care is performed under aseptic
technique to prevent infection.
 Offer food to mother if the policy permits,
and after vital signs are stable.
 Breast care may be employed.
 General hygiene: shower may be
permissible to clean, comfort and refresh
the mother (after vital signs are stable)
according to the hospital policy.
 Encourage early initiation of breastfeeding
to stimulate involution, lactation and to
enhance emotional bonding.
 Correct dehydration promptly by
offering fluid intake (orally), or
starting IV fluid as ordered.
 Start leg exercises and early
ambulation, especially following
operative delivery.
 Administer prophylactic
anticoagulant therapy as ordered.
 Nursing Care Plan and
Implementation
 After admission to the postnatal ward,
subsequent daily care is implemented as
follows:
General Aspects of Care
 Check vital signs 2 times daily (morning
and evening); observe for symptoms of
hypovolemic shock and hemorrhage
(fainting).
 A temperature of 380C, or above, for two
consecutive days after the first 24 hrs. is
considered an early sign of puerperal
infection.
 Bradycardia is a normal physiological
phenomenon.
 Palpate the uterus to assess
firminess, level of fundus, and rate of
involution of the uterus.
 Administer oxytocin medication as
ordered to promote involution.
 Check lochia for color, amount, odor,
consistency and presence of blood
clots.
 Observe perineum and suture line - if present - for
redness, ecchymosis, edema or gapping. Check healing
and cleanliness.
 Provide for sufficient periods of rest and sleep in order
to maintain physical and mental health, as well as to
promote lactation (8 hr. night-time sleep and 2 hr.
afternoon-nap are needed).
 Proper positioning. During the first 8 hrs after labor, the
mother is allowed to sleep in any comfortable position.
After that, prone position or either lateral positions
should be encouraged in order to facilitate involution,
and to help drainage of lochia.
Sitting position is also recommended since it promotes
contraction of the abdominal muscles, aids pelvic
circulation, and helps drainage of lochia. Knee-chest
position is indicated in certain conditions because it
prevents RVF of the uterus and hastens its involution.
 On the other hand, both supine and
semi-sitting positions should be
avoided.
 Prevent infection: complete aseptic
and antiseptic precautions should be
followed during the early postpartum
period to prevent infection.
 Monitor laboratory reports for Hb,
HCT, and WBC.
 Observe for postpartum blues, which
may be caused by a drop in hormonal
levels on the 4th or 5th day.
 Meet the mother’s needs to enable her to
meet the infant’s needs.
 Assist the mother with self-care and care
of the infant as needed.
 Stress the importance of postpartum
examination, visits and follow up to assess
involution, general health and wellbeing of
the mother.
 Evaluate client’s response and revise plan
as necessary.
 Discuss community resources that provide
maternal services.
 Regular and frequent examination for early
detection of complications such as
engorged breast, cracked nipples, mastitis
and breast abscess.
Promote bladder and bowel function:
 Bladder: Marked diuresis is expected for 2-3 days
following delivery: voiding should be encouraged
within 6-8 hrs after labor. If no urine is passed after 12
hrs., usually occurs due to lax abdominal and bladder
walls, spasm of the bladder sphincter secondary to
pain from an episiotomy wound or lacerations and
bruising of the urethra during delivery.
Being at bed rest for long periods of time with
decreased movements of the body also contribute to
the inability to pass urine. initiate simple nursing
measure to induce voiding. If failed, catheterization,
under complete aseptic technique is performed.
 Bowel: there may be no bowel action for a couple of
days because the bowel has probably been emptied
during labor. Glycerin suppository may be used to
relieve constipation.
Diet:
Provide diet high in proteins and calories to restore
tissues. A daily requirement of 3000-3500 cal/day is
needed in the form of a well balanced diet rich in
class proteins, calcium, iron, vitamin A, thiamine,
riboflavin, and ascorbic acid. Liberal amounts of fluids
are required (e.g. milk, juice ... etc.). Roughage and
green vegetables are provided to prevent
constipation.
Care of the perineum:
The acronym REEDA is often used to assess an
episiotomy or laceration of the perineum. REEDA
stands for redness, edema, ecchymosis, discharge, and
approximation.
Redness is considered normal with episiotomies and
lacerations—however, if there is significant pain
present, further assessment is necessary.
Excessive edema can delay wound
healing and the use of ice packs during
the immediate postpartum period is
generally indicated.
 Inspect and observe for presence of
episiotomy, lacerations, edema, pain or
ulceration.
 Only sterile vaginal pads should be
used
 Keep the area clean and dry by
employing perineal care.
 use a sitz bath to aid in perineal
healing.To avoid infection
 Teach the mother principals of self-
care.
Medication :
 Antibiotics must be prescribed if an
episiotomy has been done or the
vaginal tissues manipulated excessively.
Ergometrine can be given to help in
contracting the uterus better.
Laxatives may be given if the patient
suffers from constipation (very
common at this stage). Supplements of
calcium, iron and Vit B-complex tablets
may be given.
 If Rh negative mother, assess need for
administration of RhO GAM.
 Give rubella vaccine if indicated.
Homan's Sign (DVT):
 Homan's sign can be obtained by
dorsiflexion of the foot.The presence
of pain when eliciting the Homan's
sign, is indicative of a deep vein
thrombosis (DVT).
is important to note that that a DVT
may be present despite a negative
Homan's sign so nurses must monitor
patients for other signs of a DVT.
Specifically, the lower extremities should
be assessed for the following:
 presence of hot, red, painful, and
edematous areas, all indicative of a
DVT.
 Assess the legs for adequate
circulation by checking the pedal
pulses and noting temperature and
color, Pedal edema is normally present
for several days after delivery as fluids
in the body shift. However, lasting
edema should be reported for further
assessment.
 Get patients to ambulate as soon as
possible after delivery to improve
circulation and prevent the
development of thrombi. Teach them
not to cross their legs for long periods
of time and to keep the legs elevated
while
 Care of the newborn infant:

Nursing assessment:
 Observing the general condition.
 Checking the cord.
 Checking the infant’s physical needs:
cleanliness, feeding, warmth, sleep,
protection from unsuitable
environment.
 Checking psychological needs:
bonding, attachment.
Nursing diagnosis: Potential for:
 Cord abnormalities: bleeding, discharge, hernia.
 Heat loss, hypothermia.
 Hazardous environmental factors.
 Psychological disturbance due to lack of bonding and
attachment.
Nursing plan and implementation:
 Carry out partial or complete bath to ensure
cleanliness and comfort.
 Use proper clothing to keep the infant warm.
 Perform cord dressing.
 Encourage early, on demand and exclusive
breastfeeding.
 Ensure adequate hours of sleep.
 Protect from environmental hazards.
 Discuss infant care with mother:
cleanliness, handling, clothing, cord
care, feeding, bonding, diapering,
circumcision of male infant,
immunization, registration, and
community resources.
 Encourage early skin to skin contact,
bonding and attachment
Contraceptive Methods
 Sex is not advisable for at least 6 weeks after
delivery, i.e. in the postpartum period, as the
tissues are fragile at this time and need time
to recover. But, if necessary, barrier
contraceptives like condoms should be used.
 barrier contraceptives are the ideal birth
control method which should be used for the
first 6 months after childbirth. This is because
other birth control methods like oral
contraceptive pills can cause a decrease in the
milk production of the breasts.
 After 6 months, when the baby can be started
on supplementary food, oral contraceptive
pills can be prescribed. It is also possible to use
intra-uterine devices like Copper-T after this
period.
 Minor Discomforts during the
Postpartum Period
Minor Complaints
They are minor complaints felt by the parturient
during postpartum period. Simple nursing
measures (interventions) are needed to alleviate
these complaints.
After-pains
 It is a spasmodic colicky pain in the lower
abdomen during the early postpartum. days due
to vigorous contractions of the uterus. It is more
common and more severe in multiparas due to
weak muscle tone. Conditions with increased
intra abdominal pressure e.g. polyhydraminos,
multiple pregnancy, large size infant.
 Predisposing factors:
 Presence of blood clots, piece of
membranes or placental tissue.
 Breastfeeding increases after-pain.
 Nursing management:
 Simple uterine Massage.
 Reassurance and simple explanation of the
cause. Proper positioning (prone, sitting).
 Offering warm drinks.
 Mild sedatives on doctor’s orders (before
feeding).
 Avoid full bladder.
 Encourage abdominal muscle exercises and
pelvic floor muscle exercises.
 Urinary Retention
 It is the inability to excrete urine, i.e. urine is
accumulated within the urinary bladder. A
common complaint during the first few days
after labor.
 Causes:
 Laxity of the abdominal muscles.
 Inability to micturate in the recumbent position.
 Reflex inhibition due to stitched perineum or
bruised urethra.
 Atony of the bladder.
 Compression of the urethra by edema or
haematoma.
 Treatment:
 Urine should be passed approximately 8-12
hrs. after delivery. If not, the following
measures should be attempted:
◦ Perineal care with warm water.
◦ Privacy and reassurance.
◦ Warm bedpan.
◦ Listening to the sound of running water.
◦ Hot-water bottle over the symphysis pubis.
 If these measures fail, catheterization should
be performed using complete aseptic
technique.
 Constipation
An abnormal infrequent and difficult evacuation
of feces may occur during the first few days
postpartum.
 Nursing management: health teaching should
consider the following:
 Diet rich in roughage.
 Increase fluid intake.
 Milk before bedtime.
 Exercises.
 After 72 hrs a glycerin suppository, or mild
laxative, may be administered as ordered.
Engorged Breast

 It is an accumulation of increased
amounts of blood and other body
fluids as well as milk in the breasts.This
condition occurs frequently about the
3rd day postpartum, especially in
primiparas. It is due to lymphatic and
venous engorgement, and is relieved
when milk comes out.
 Causes:
Inadequate and/or infrequent
breastfeeding.
 Inhibited milk ejection reflex.
 Signs and symptoms:

Breasts are firm, heavy (due to blocked ducts),
swollen, tender and hot (37.80C).
 Pain may be present leading to irritability and
insomnia. The mother may refuse to nurse the
infant.
 Nursing management:

 Apply moist warm packs to the involved

breast 2-3 minutes before each feeding.
 Massage and manual expression of milk to
relieve areolar engorgement before feeding.
This facilitates attachment.
Massaging the Breast

Stroking the Breast

 Cold application after feeding.
 A well-fitting bra should be used to
provide support and comfort.
 Mild analgesics may be ordered.
Syntocinon inhalation may be
prescribed. In severe cases,
administration of 2 doses of diuretic
(as Lasix 40 mg) is effective.
 Cracked Nipple
 Fissured nipple occurs in about half of the nursing
mothers at one time or another. Nipple tenderness
and soreness are usually the result of trauma and
irritation.
 Causes
 Improper antenatal care.
 Improper technique of breastfeeding.
 Unnecessary prolonged lactation.
 Flat or large size nipple excoriation.
 The use of irritating substances e.g. soaps, lotions.
 Conditions as candidiasis, and contact dermatitis.
 Engorgement of the breast.
 Blond and redheaded women usually have delicate
skin that may be predisposed to cracking.
 Signs and symptoms:
Irritation of the nipple in the form of minute blisters, or
petechial spots.
 Persistent pain and tenderness.
 Bleeding.
 Inflammation signs.

 Nursing management:
Proper technique of breastfeeding should be followed.
 Apply moist heat and massage before feeding (3-5 mm).
 Frequent, short feedings.
 Air/sun exposure.
 Avoid engorged breast.
 Avoid irritating materials.
 Use supportive bra.
 Mild analgesic and panthenol ointment may be used.
 Treatment of candidiasis and dermatitis.
 Perineal Discomfort
 It usually occurs due to presence of tears, lacerations,
episiotomy and edema.
 Nursing management:
 Frequent perineal care under aseptic technique. (the area
should be kept clean and dry).
 Soaks of magnesium sulphate compresses in case of edema.
 Expose to dry heat (electric lamp) will help the healing
process.
 Health education that includes:
◦ Perineal self care.
◦ Position (lateral with a pillow between thighs).
◦ Diet: rich in protein.
◦ Sources of strain such as coughing, constipation and
carrying heavy objects should be avoided.
◦ Encourage pelvic floor muscle exercises.
◦ Avoid infection.
◦ The use of cotton underwear
 Postpartum Blues (Depression)
 Reva Rubin defined postpartum blues as “the gap
between the ideal and reality: the new mother’s
expectations may exceed her capabilities, resulting in
cyclic feelings of depression”.This condition is usually
temporary and may occur in the hospital.The
condition is partly due to hormonal changes, and
partly due to the ego adjustment that accompanies
role transition.
 Manifestations:
Disturbed appetite and sleeping patterns.
Discomfort, fatigue and exhaustion.
 Episodes of crying for no apparent cause.
 The mother may experience a let down feeling
accompanied by irritability and tears which often
relieves the tension.
 Guilt feeling at being depressed.
 Predisposing factors:
 The first pregnancy or pregnancy in late
childbearing age.
 Social isolation.
 Ambivalence toward the woman’s own
mother.
 Prolonged, hard labor.
 Anxiety regarding finances. Marital
disharmony.
 Crisis in the family.
Nursing management:
Reassurance, understanding, and anticipatory
guidance will help the parents become aware
that these feelings are a normal
accompaniment to this role transition.
 Postpartum Visits
The First Visit
 This visit is carried out 3-4 weeks after labor in
order to assess the degree of involution of the
body in general, and of the genital tract in
particular. General and local examinations are
performed. The client’s condition is evaluated
through various medical and nursing activities
that include:
 Measuring and recording of blood pressure.
 Estimation of the hemoglobin percentage, and
aggressive treatment of anemia, if present.
 Urine analysis for sugar and albumen.
 Thorough examination of the breasts and nipples
for early detection and treatment of
abnormalities.
 Examination of abdominal muscles, perineum, perineal
wounds and nature of lochia to asses the degree of
involution of these parts, and to exclude the presence of
infection.
 Careful and thorough examination of: size of the uterus,
its position, adnexal masses, tenderness, the condition of
the cervix (such as lacerations or erosions) as well as the
condition of the pelvic floor. Management of any lesion
should be readily started
The Second Visit
 This visit is done at the end of the 6 postpartum week. It
is carried out along the same lines as the first postnatal
visit with the institution of more active treatment for
certain lesions:
 If retroversion flexion (RVF) is still present a pessary
must be inserted.
 Cervical erosion may call for cauterization.
 Subinvolution calls for more energetic treatment.
 Health teaching items at this time include advice in
relation to:
 Sexual intercourse, which should be prohibited
during the first six postpartum weeks, and allowed
after that, provided that the woman is in good
health, with a perfectly healed genital tract.
 Spacing of pregnancies and counseling about the
appropriate contraceptive method, which should be
prescribed and may be started at once.
 If prolapse of the genital tract is present, it should be
treated by pelvic floor muscle exercises and/or the
insertion of a ring pessary.The patient should be
advised to abstain from bearing down. Chronic
cough and constipation should be treated for this
purpose. However, operative treatment is not
considered before the lapse of six months when total
involution of the genital tract is established.
 Health education to puerperal women at this
time should also include instructions related
to the possibility of encountering menstrual
irregularities during the following months.
These irregularities range from complete
amenorrhea to oligo-menorrhea,
hypomenorrhae or polymenorrhea.
Bleeding is expected at the end of the 6th
puerperal week in the majority of patients. In
non-lactating mothers, however, menstruation
usually appears after 6-8 weeks. On the other
hand, lactating women may have great
variations in this respect: about 1/3 of them
will start menstruation 3 months postpartum,
and by the 6 month more than half of them
will menstruate.
The Third Visit
 This is performed at the end of 3 months
(12 weeks) by which time complete
involution of the genital tract has occurred.
 General and local examinations are carried
out, and any discovered lesion should be
dealt with:
 Cervical erosions must be cauterized.
 Persistent RVF and/or prolapse should be
managed properly.
 If lactational amenorrhea is present, the
client should be instructed that this is not a
bar against another pregnancy, and suitable
contraceptive measures should be
instituted.
 Discharge Instructions

Patients and their families should be

instructed to call the healthcare
provider if the patient has any of the
following:
 Fever
 Foul-smelling lochia
 Large blood clots, or bleeding that
saturates a pad in 1 hour
 Discharge or severe pain from
incisions
 Hot, red, painful areas on the breasts
or legs
 Bleeding and severe pain in the
nipples
 Severe headaches or blurred vision
 Chest pain or dyspnea without
exertion
 Frequent, painful urination
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