Normal puerperium - Obstetrical and Gynecological Nursing

The word puerperium is originated from the Latin words ‘puer’ – child and ‘pams’ – bringing forth.
Also known as the post-partum, post-natal, or post-delivery period.
The mother during puerperium is termed as puerpera.

1. NORMAL PUERPERIUM

2. INTRODUCTION The word puerperium is originated from Latin words ‘ puer ’ – child and ‘ pams ’ – bringing forth. A lso known as post-partum, post-natal or post-delivery period. The mother during puerperium is termed as puerpera .

3. DEFINITION Puerperium is the period following childbirth during which the body tissues, especially the pelvic organs revert back approximately to the pre-pregnant state both anatomically and physiologically. Puerperium is the period following child birth when the endocrine influences of the placenta removed the physiological changes of pregnancy is reversed. This is characterized by the following features: The reproductive organs return back approximately to their pre gravid state both anatomically and physiologically Lactation is initiated Recuperation from the physical, hormonal and emotional experiences of parturition

4. DURATION Puerperium begins as soon as placenta is expelled and last for approximately 6 weeks when the uterus becomes regressed almost to the non pregnant size. The period is divided into; Immediate – within 24hrs Early – upto 7 days Remote – after 7 days upto 6 weeks

5. PHYSIOLOGICAL CHANGES DURING PUERPERIUM

6. A) INVOLUTION OF UTERUS Uterine Involution Return of the uterus to its pre-pregnancy size and condition, which begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle. Uterine Fundal Descent After labour, fundus is 5cm below umbilicus or 12 cm above the symphysis pubis. During the first 24 hrs, the level remains constant, the consistency of uterus will be firm and retracted. There after there is a steady decrease in height by 1.25 cm in 24 hrs, so that by the end of second week the uterus becomes a pelvic organ. The rate of involution thereafter slows down until by 6 weeks, the uterus becomes almost normal in size .

7. B) INVOLUTION OF OTHER PELVIC STRUCTURES Vagina : The distensible vagina, noticed soon after birth takes a long time (6-10 weeks) to involute. It begins its tone but never to the virginal state. Broad ligaments and round ligaments require considerable time to recover from the stretching and relaxation. Pelvic floor and pelvic fascia take a long time to involute from the stretching effect during parturition.

8. C) LOCHIA

9. GENERAL PHYSIOLOGICAL CHANGES Pulse Temperature Urinary tract GIT Weight loss Fluid loss Blood values Ovulation

10. PSYCHOLOGICAL CHANGES

11. POST PARTUM ASSESSMENT

12. MANAGEMENT OF NORMAL PUERPERIUM

13. POSTPARTUM COMPLICATIONS

14. Pulmonary Embolism

15. POSTNATAL CARE

16. POSTNATAL CARE Postnatal care includes systematic examination of the mother and the baby and appropriate advice given to the mother during postpartum period. The first postnatal examination is done on discharge of the patient from the hospital. The second routine postnatal care is conducted at the end of 6th week postpartum. Aims and objectives To assess the health status of the mother. To detect and treat at the earliest any gynaecological condition arising out of obstetric legacy. To note the progress of the baby including the immunization schedule for the infant. To impart family planning guidance.

17. POSTNATAL CARE Examination of the mother Routine examination Pelvic examination should be done only when indicated Laboratory investigations (e.g. haemoglobin) depending on the clinical need may be advised. Examination of the baby C onducted by a paediatrician, the progress of the baby is evaluated. Immunization to the baby is started. Advice given If the patient is in sound health she is allowed to do her usual duties. Postpartum exercises may be continued for another 4-6 weeks. To evaluate the progress of the baby periodically and to continue breastfeeding for 6 months. Family planning counselling and guidance

18. POSTNATAL CARE MANAGEMENT OF AILMENTS Irregular vaginal bleeding Leukorrhea Backache Urinary and anal incontinence

19. POSTNATAL EXERCISES

20. Objectives To improve the muscle tone which are stretched during pregnancy and labor , specially the abdominal and perineal muscles To educate about correct posture to be attained when the patient is getting up from the bed POSTNATAL EXERCISES

21. POSTNATAL EXERCISES Deep Breathing Head & Shoulder Raising Head Raising Leg Raising Knee & Leg Rolling Pelvic Tilting

22. Sit Ups Kegel Exercise POSTNATAL EXERCISES

23. MANAGEMENT OF MINOR AILMENTS DURING PUERPERIUM

24. MANAGEMENT OF MINOR AILMENTS DURING PUERPERIUM After pain: It is the infrequent spasmodic pain felt in the lower abdomen after delivery for a variable period of 2-4 days, commonly met in primipara & may be due to vigorous uterine contractions, especially in multipara. The pain is similar to cardiac anginal pain. It can be managed by massaging the uterus with expulsion of the clots, administration of antibiotics and antispasmodics. Pain on the perineum: P erineum has to be examined for vulval haematoma and provide analgesics and sitz bath (cold/hot) Hypertension: Increased BP during puerperium period. Urine analysis also should be done for proteinuria. Breast engorgement: Encourage breast feeding, warm sock, analgesics etc gives better result. Anaemia: S upplementary iron therapy (Iron sulphate 200 mg) is to be given daily, for 4-6 weeks Constipation: Mild laxatives or stool softeners can be advised to the mothers

25. LACTATION

26. LACTATION It is the process of breast feeding results from interplay of hormones, instinctive reflexes and learned behaviour of mother and newborn. Colostrum is the first milk secretion

27. MANAGEMENT OF LACTATION Initiate breast feeding within half an hour after birth and exclusively breast feed till 6 months Encourage mother to take nutritive diet with plenty of fluids and milk intake. Food containing calcium should be given. Promote 2 hourly feeding Support and educate the mother about the benefits of breast feeding in antenatal period itself Discourage bottle feeding and encourage regular feeding Follow proper hygienic measures Prevent the mother from any diseases such as infections and dehydration Use drugs to improve milk production in case of inadequacy Suppression of lactation may be needed in case of still birth, HIV infected mother etc . So Stop feeding Avoid pumping or milk expression Apply ice packs to prevent engorgement Give analgesics to relieve pain Apply tight compression bandage for 2-3 days Use drugs such as bromocriptine 2.5 mg orally bd for 14 days, which inhibit prolactin and suppress lactation .

28. EMOTIONAL NEEDS DURING POSTNATAL PERIOD

29. EMOTIONAL NEEDS DURING POSTNATAL PERIOD Mother experiences many hopes and fears at the beginning of new human life and family relationship. Mother need to be supported as she adjusts to her experiences. Mother need support because she is taking a major responsibility Rest and relaxation No comparisons Praise and encouragement Consistent advice Mother’s self esteem  

30. ROLE OF NURSE

31. N URSE’S RESPONSIBILITY The role of nurse midwife during postnatal period is to provide care and support to the mother and baby based on the following principles : Promoting physical and psychological well-being of the mother, her baby and the family unit. Identification of deviation from normal physiological or psychological progress Encourage sound methods of infant care and prompt development of effective parent-infant relationship. Support and strengthen woman, her husband and family's confidence. Monitor progress of mother and child. Promotion of a relaxed environment Provide non-judgemental approach, offer guidance, advise whenever necessary. Promote breast feeding whenever possible.

32. SUMMARY This lesson deals with Puerperium -its definition, duration, anatomical, physiological and psychological changes during puerperium, management of normal puerperium. It also discusses about postnatal assessment, postnatal exercise, and care. Further management of minor ailments, lactation and role of nurse is also explained.

33. CONCLUSION Puerperium is the period following childbirth during which the body tissues, especially the pelvic organs, revert approximately to the pre-pregnant state both anatomically and physiologically. During the postpartum period, assessment of maternal condition must be done on a regular basis and a progress record to be maintained.

34. RESEARCH ABSTRACT

35. RESEARCH ABSTRACT Ji Yeon Lee et. al (2015) conducted a study to identify the physical and mental state of Korean women after delivery, to investigate the factors that influence those, and to examine the effects of postpartum care performance . The study targeted 148 women who visited hospital for postpartum check-up on the 2nd week or 6th week after delivery. Questionnaire method was used and the women were asked to self-evaluate their postpartum symptoms. The findings were 72 women had depression. Factors related to postpartum symptoms and depression were smoking before pregnancy, low marital satisfaction, bad mood during and after pregnancy, lack of support from husbands, and bad quality of sleep during puerperium . Treating the joints of hands carefully when milking breasts, and avoiding squatting down, demonstrated a negative correlation with the average points of postpartum symptoms. Multivariate linear regression analysis showed that the degree of support from husbands and mood during pregnancy were statistically related with depression. Many women complained of postpartum discomfort. Although, while some postpartum care methods which are traditionally believed to be appropriate care in Korea can be helpful to women's recovery, most of them are not. It was confirmed that physical symptoms and depression are closely related to each other.