Physiology of puerperium,management of mother during puerperium,postnatal exercise,rooming

physiological changes during puerperium is very important to bsc nursing students to understand that what are exactly changes occure in mother during post natal periods.

1. PHYSIOLOGICAL CHANGES DURING PUERPERIUM PRESENTED BY:- P reeti shukla Lecturer, RCN, Kanpur

2. SPECIFIC OBJECTIVES Define the normal Puerperium. Discuss the features of normal Puerperium. Explain the physiological changes during Puerperium. Discuss the management of normal Puerperium.

3. DEFINITION Puerperium is the period following childbirth during which the body tissues ,specially the pelvic organs revert back approximately to the pre-pregnant state both anatomically and physiologically.

4. DURATION :- Puerperium begins as soon as placenta is expelled . Lasts for approximately 6 weeks. The period is divided into – Immediate within 24 hrs Early upto 7 days Remote upto 6 weeks

5. ANATOMICAL AND PHYSIOLOGICAL CHANGES OF THE PUERPERIUM ANATOMICAL CONSIDERATION Uterus:- Immediately after delivery uterus is hard , reduced in size and fundus is generally felt about 10-12cm above the symphysis pubis. Uterus weigh 500gm by the end of the first post –partal week,300-350 by the end of second post- partal week and 100gm by the sixth partal week.

6. INVOLUTION OF UTERUS :- It is process whereby the genital organs revert back approximately to the state as they were before pregnancy. An arrest or retardation or delay of involution is called subinvolution. The causes of subinvolution include retained placental fragments and pelvic infection.

7. CLINICAL FEATURE OF SUBINVOLUTION Prolongation of lochial discharge and irregular and excessive uterine bleeding. On examination uterus is larger and softer for the period of Puerperium.

8. UTERINE ATONY :- Failure of the uterus to remain firmly contracted ,can lead to postpartum haemorrhage. A full bladder is a major cause of uterine atony.

9. CERVIX:- Lower Uterine segment and cervix remains loose ,thin and stretched. Immediately after birth ,the cervix is extremely soft ,flabby.

10. It looks congested and rarely admit 2-3 fingers. The cervix contracts slowly ,the external OS admits 2 fingers for a few days and by the end of the first week narrows down to admit the tip of finger. External OS never revert to nulli parous state.

11. PHYSIOLOGICAL CONSIDERATION The physiological process of involution is most marked in the body of the uterus .Changes occur in the following components : Muscles Blood Vessels Endometrium

12. INVOLUTION OF OTHER PELVIC STRUCTURE VAGINA Takes a long time (4-8 weeks ) to involute . It regains its tone but never to the virginal state . The mucosa remains delicate for the first few weeks and sub mucous venous congestion persists even longer . Rugae partially re appear at third week . The introitus remains permanently larger than the virginal state.

13. LOCHIA It is the vaginal discharge for the first fortnight during Puerperium. The discharge originates from the uterine body,cervix and vagina. Odour and reaction :-It has got a peculiar offensive fishy smell. Colour :- Depending upon colour lochia rubra lochia serosa lochia alba

14. LOCHIA RUBRA: It is red in color as it contains blood shreds of fetal membrane , decidua,vernix caseosa,lanugo and meconium. It starts immediately after the delivery and continues for the 3-4 days.

15. LOCHIA SEROSA: Lochia serosa:- it is pale than rubra and is serous and pink. It contain less RBC’s but more leukocytes, wound exudates, decidual tissues and mucus from the cervix. It last for 5-9 days.

16. LOCHIA ALBA: It starts about the 10th post partum day till week. It is pale creamy white and contains leukocytes, decidual cells & mucus.

17. URINARY TRACT :-the bladder may be over distended without any desire to pass urine.. Dilated ureters and renal pelvis return to normal size within 8 weeks.

18. BOWEL :- Soon after delivery ,there is some degree of intestinal paresis which predisposes to constipation. Early ambulation , a high residual diet and increase in intake of fluids generally help to overcome this problem.

19. BREAST :- The secretion from the breast is thick ,sticky and yellowish in colour for the initial 2-3 days ,is called colostrums.

20. SOME OF THE OTHER PHYSIOLOGICAL CHANGES PULSE :- For a few hours after normal delivery ,the pulse rate is likely to be raised, which settle down to normal during the second day. TEMPERATURE :- The temperature should not be above 37.2 ˚ with the first 24 hrs. On the 3 rd day ,there may be slight rise if temperature due to breast engorgement which should not last for more than 24 hrs.

21. GASTROINTESTINAL TRACT :- Increased thirst in early Puerperium is due to loss of fluid during labour. Constipation is a common problem for the following reasons : delayed GI motility ,together with perineal discomfort.

22. WEIGHT LOSS:- In addition to the weight loss (5-6 kg) as a consequence of the expulsion of the foetus ,placenta, liquor and blood loss .The weight loss may continue upto 6 months of delivery . FLUID LOSS :- There is a net fluid loss of about 2 litres during the 1 st week and an additional 1.5 litres during the next 5weeks.

23. ABDOMINAL WALL :- The abdominal striae are never eradicated completely but they do change to fine, silvery white lines. Women who take exercise regain their abdominal muscle tone. however regaining complete muscle tone becomes difficult with increasing parity.

24. HAEMATOLOGICAL CHANGES :- Immediately following delivery ,there is slight decreases of blood volume due to dehydration and blood loss . Cardiac output rises soon after delivery to about 60% above the pre labour value but gradually returns to normal within 1 week .

25. MENSTRUATION AND OVULATION:- If the woman does not breast fed her baby ,the menstruation returns by 6 th week following delivery in about 40% and by 12 th week in 80% of cases.

26. In non lactating mothers ,ovulation may occur as early as 4 weeks and in lactating mothers about 10 weeks after delivery .

27. POSTNATAL CARE Postnatal Check Up Detection of risk at earlier stage & its management Management of Normal Puerperium Treatment of Minor Ailments Treatment of anemia Health & nutrition education Postnatal Exercise

28. POSTNATAL CHECK-UP General health check up Monitoring of involution process For satisfactory establishment of lactation For examination of newborn

29. MANAGEMENT OF NORMAL PUERPERIUM

30. 1)Immediate care - After about 2 hrs of observation following delivery, the patient is examined thoroughly before shifting her to room or ward. 2)Hospital stay- All patient’s with perineal stitches should preferably be hospitalized for 2 -4 days to ensure satisfactory healing &to safeguard her against infection.

31. 3)Diet - encourage the patient to drink lots of fluids &to take simple easy to digest diet. Fatty foods should be restricted. 4)Sleep - it is important to ensure adequate rest and sleep .it is good restrict visiting hours and to prescribe mild hypnotics to ensure sound restful sleep.

32. 5)Care of the bladder - The patient is encouraged to pass urine following delivery,if fails than catheterization should be done. 6)Care of perineum - Perineal wound should receive proper surgical attention to promote healing & prevent infection. Perineal wound should be kept clean & dry.

33. 7)Well baby care - care of the baby should be explained and direct her to the pediatrician. 8)Contraception - couples should be provided with necessary information & counseled to adopt the method of their choice.

34. 9) Medication - All medication prescribed to the mother must be consulted as many of these drugs may pass through breast milk to new born baby & can be harmful..

35. 10)Advice on discharge - Thorough examination of the mother and child is to be taken before discharge Gradual return to normal activity at home. Care of the newborn & breast feeding . Iron and vitamin supplements to improve mother’s health. Contraception. For regular follow up.

36. MANAGEMENT OF AILMENTS After pains Pain at site of perineum Engorgement of breast Treatment of Anemia Hypertension

37. Health and nutrition education Family planning advise Sexual intercourse can be resumed till to 6 weeks after delivery Breast feeding is best Immunization of child Calorie need per day-2200+700 =2900 Role of post natal exercises

38. POSTNATAL EXERCISE Deep breathing Exercise Foot and ankle exercise Pelvic floor Exercise Pelvic Tilting Exercise Abdominal Breathing Head and shoulder raising Leg raising Knee rolling Hip hitching or leg shortening.

39. SUMMARY So today we have discussed about:- Definition of Puerperium Duration of Puerperium Anatomical and physiological changes during puerperium General physiological changes Management of normal Puerperium Management of ailments Postnatal Exercise

40. 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.

41. BIBLIOGRAPHY Jacob annamma” text book of obstetric nursing”, 3rd edition, published by Jaypee brothers, page no. 438-441. Dr.B.T Basavanthapa, “Child health nursing , First edition, published Ahuja Publishing house no., Pageno.222-225. D.C Dutta :Obstetric Nursing 7 th edition ,Published by Jaypee Brothers ,Pg no.144-153.