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 on 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.
.

 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.

 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.

 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.

 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.

 Kidneys and urinary output:
- The woman 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 perineum or bruised urethra.
* Atony of the bladder.
* Compression of the urethra by edema or hematoma.

 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.

 Blood picture:
- With proper intranatal care, the amount of blood loss
during 3rd stage of labor doesn’t cause anemia.
- A moderate increase in leucocytic count.
- RBCs count and blood constitutes usually return to the
non- pregnant levels in 4 – 6 weeks.

 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.

 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.

 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.

 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 on 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.

 Mechanisms through which involution of
uterus occurs:
- Autolysis.
- Ischemia ( decreased blood supply)

 In the endometrium:
 - Separation of placenta and membranes occur in the deeper portion of
the spongy layer of decidua.
 - All 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.

 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.

 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.

 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.

 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.

 Breasts:
- Anatomy.
- Shape.
- Situation.
- Structure:
* Axillary tail. * Areola.
* Montogomery’s glands.
* Nipples
* 15 – 20 lobes: Alveoli, myoepithelial cells, lactiferous
tubules, lactifeorus ducts, sinuses.

Psychological changes during postpartum
 Phases of Maternal Role:
• Taking – in phase.
• Taking – Hold phase.
• Letting – go phase,

 Taking – in phase:
- 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 is quite talkative during this phase about every
detail of her labor and delivery experience.

 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.

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

Postpartum blues
 Is the gap between the ideal and reality: the new
mother’s 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 woman’s 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 Homan’s 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 oxytocin 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.
 Check lochia for color, amount, odor, consistency, and clots.
 Observe perinum and suture line for redness, ecchymosis,
edema or gapping.
 Provide sufficient periods of rest and sleep.

 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.

 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 anit D
(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.

Normal postpartum

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