Postnatal Care ppt

Sarah Edwin
Bule Hora University
Bule Hora
Ethiopia

1. PHYSIOLOGY AND MANAGEMENT OF NORMAL PUERPERIUM

2. 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.

3. DEFINITION The puerperium is defined as the period following childbirth during which the body tissue, specially the pelvic organs revert back approximately to the pre- pregnant state both anatomically and physiologically ----- DC DUTTA

4. DUR A TION Puerperium begins as soon as the placenta i s expelled and last s for approximately 6 weeks when uterus regressed almost to non- pregnant size.

5. 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 of post partum. The remote puerperium, which includes the period of time required for involution of the genital organs through the sixth weeks postpartum.

6. REPRODUCTIVE SYSTEM UTERUS Involution : -is the return of the uterus to a non-pregnant 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 and measures about 20*12*7.5(length , breadth and thickness) in cms

7. CON T … 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.

8. 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

9. - Subinvolution:- is the failure of the uterus to return to a nonpregnant state. - The most common causes of sub involution are retained placenta fragments and infection

10. LOWER UTERINE SEGMENT Immediately following delivery the lower segment becomes thin flabby ,collapsed structure It takes a few weeks to revert back to normal shape and size of the isthmus

11. 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 .

12. Characteristic of after pain: Occur during the 1 st 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 1 st 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.

13. CE R VIX 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

14. PHYSIO L OGICAL 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

15. MUSCLES There is marked hypertrophy and hyperplasia of muscle fibers during pregnancy and the individual muscle fiber enlarges to the extent of 10times and 5 times of breadth During puerperium the number of muscle fibers is not decreased but th ere is substantial reduction of the myometrial cell size Withdrawal of the steroid hormones estrogen and progesterone may lead to increase in the activity of the uterine collganese and release of proteolytic enzyme

16. BLOOD VESSELS The arteries are constricted by contraction of its wall and thickening of the intima followed by thrombosis During the first week the arteries undergo thrombosis hyalinsation and fibrinsed end arteries The veins are obliterated by thrombosis hyalinsation and endophelebitis New blood vessels grow inside the thrombi.

17. ENDOMETRIUM Following delivery the major part of the decidua is cast off with expulsion of the placenta and the membranes more at the placenta site The endometrium left behind varies in thickness from 2-5mm The superficial part containing the degenerated decidua, blood cells and bits of fetal membranes becomes necrotic and is cast off in the lochia .

18. Cont … Regeneration starts by 7 th completed by 10th day and restored by 16 th day except placental site it takes 6weeks It occur from the epithelium of the uterine gland mouths and interglandular stromal cells

19. INVOLUTION OF OTHER PELVIC STRUCTURES VAGINA The distensible vagina notices soon after birth takes a long time-4- 8weeks It regains its tone but never to the virginal state The mucosa remains delicate for the first few weeks and sub- mucous venous congestion persist even longer, it is the reason to withhold surgery on puerperal vagina

20. CONT… Rugae partially reappear at 3 rd week but nerve to the same degree as in pre-pregnant state The introits remains permanently larger than the virginal state The hymen is lacerated and represented by nodular tags the carunculae myritiformes

21. BROAD LIGAMENT AND ROUND LIGAMENT Requires considerable time to recover from the stretching and laxation PELVIC FLOOR AND PELVIC FASCIA Takes a long time to involute from the stretching effect during parturition.

22. LOCHIA It is the vaginal discharge that occurs after birth. Lochia is discharge originates from the uterine body, cervix and vagina 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.

23. LOCHIA-ODOUR AND REACTIONS It has got a peculiar sm e ll It reactions is alkaline leading to become acid towards the e nd

24. COL O U R LOCHIA RUBRA-RED COLOR (1-4DAYS) It consists of blood, shreds of fetal membranes and decidual , vernix caseosa,lanugo and meconium. LOCHIA SEROSA-YELLOWISH OR PINK OR PALE BROWNISH COLOUR(5-9 DAYS) It consists of old blood, less of rbc, but more of leukocytes, and wound exudates mucus from cervix and micro organism (anaerobic streptococci and staphylococci LOCHIA SEROSA-PALE WHITE(10-15DAYS) Contains plenty of decidual cells,leucocytes,mucus,cholestrin crystals,fatty and granular epithelial cells and micro organism.

25. AMOUNT The average amount of discharge for the first 5-6 days is estimated to be 250ml

26. NORMAL DURATION The normal duration may extend upto 3 weeks The lochia rubra may persist for longer specially in woman with twins and scanty in premature labour Can be more when women get up from bed in the later period

27. CLINICAL IMPO R T ANCE OF LOCHIA Odor: If offensive indicates retained placental lobes or cotton pieces inside the vagina should be kept in mind

28. CON T .. Amount: Scanty or absent signifies infection or lochiametra If excessive also indicates infection

29. CON T .. Color: Persistence of lochia rubra beyond normal limit signifies Subinvolution or retained bits of conceptus

30. CON T .. Duration: Duration of the lochia alba beyond 3 weeks suggest local genital lesions

31. CHANGES PULSE After the initial tachycardia associated with labour and delivery, a bradycardia often develops in the early puerperium. A woman’s pulse rate during the postpartal period is usually slightly slower than normal. This increased stroke volume reduces the pulse rate to between 60 and 70 beats per minute. As diuresis diminishes the blood volume and causes blood pressure to fall, the pulse rate increases accordingly. By the end of the first week, the pulse rate will have returned to normal.

32. TEMPER A TURE A woman may show a slight increase in temperature during the first 24 hours after birth. Occasionally, when a woman’s breasts fill with milk on the 3 rd or 4 th postpartum day, her temperature rises for a period of hours because of the increased vascular activity involved. Genito-urinary tract infection should be excluded if there is rise of temperature

33. URINARY TRACT The bladder wall becomes oedematous and hyperaemic and often shows evidences of sub mucous extravasations of blood. Because of relative insensitivity to the raised intravesical pressure due to trauma sustained to the nerve plexus during delivery, the bladder may be over distended without any desire to pass urine. Dilated ureters and renal pelvis return to normal size within 8 weeks

34. GASTR O INTESTINAL SYSTEM Digestion and absorption begin to be active again soon after birth. Bowel sounds are active, but passage of stool through the bowel may be slow because of the still present effect of relaxin on the bowel. Bowel evacuation may be difficult because of the pain of episiotomy sutures or haemorrhoids. Increased thirst in early puerperium Slight intestinal paresis leads to constipation

35. WE I GHT o Rapid diuresis and diaphoresis during 2nd to 5th days after birth result in weight loss of 5 lb (2 to 4kg), in addition to approx. 12 lb (5.8 kg) lost at birth. o Lochia flow- 2-3 lb(1kg) loss o Total weight loss- 19 lb o Additional weight loss depend on amount of weight gain in pregnancy and active measures to reduce weight.

36. FLUID LOSS Net fluid loss of at least 2 liters during 1 st week Additional 1.5 liters during the next 5 th weeks The amount depends on amount retained during pregnancy ,dehydration during labour and blood loss during delivery.

37. BLOOD VALUES Diuresis evident between 2 nd to 5 th day after birth, as well as blood loss at birth, acts to reduce the added volume accumulated during pregnancy. Rapid reduction occurs, so that blood volume returns to its normal prepregnancy level by 2 nd week after birth. Cardiac output rises soon after delivery to about 60% above the pre labour value but gradually returns to normal within one week.

38. RBC VOLUME AND HEM A T OCRIT It returns to normal by the end of 1 st week after the hydaemia disappears Leukocytosis to the extent of 30000 per cu mm occurs following delivery probably in response to stress of labour Platelet count decreases soon after the separation of the placenta but secondary elevation occurs with increase in platelet adhesiveness between 4-10dyas Fibrinogen level remains high upto the 2 nd week of puerperium resulting in persistent high level of esr in puerperium as during pregnancy A hypercoagulable state persist for 48hrs postpartum and fibrolytic activity is enhanced in first 4 days.

39. MENSTRUATION AND ovulation If the woman does not breast feeds her baby,the menstruation returns by 6th week following delivery in about 40% and by 12th week in 80% of cases. In non-lactating mothers, ovulation may occur as early as 4 weeks and in lactating mothers about 10 weeks after delivery. A women who is exclusively breastfeeding, the contraceptive protection is about 98% upto 6 months postpartum. Thus, lactation provides a natural method of contraception .

40. However ovulation may precede the first menstrual period in about one-third and it is possible for the patient to become pregnant before she menstruates following her confinement. Non-lactating mother should use contraceptive measures after 3 weeks and the lactating mothers after 3 months of delivery.

41. 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.

42. 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 .

43. 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.

44. 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 .

45. 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

46. The bladder wall may become edematous, hyperemic, and the bladder might be overdistended without the urge to pass urine . The retention of urine in the first few days after labor may be due to the laxity of the abdominal musculature, tone of pelvic floor muscles, atony of bladder, compression of urethra by edema or hematoma, reflex inhibition of micturition due to genitourinary trauma .

47. Conversely, urinary incontinence, especially urge incontinence, affects 30% of postpartum females and is attributed most commonly to psychological stress associated with childbirth. The mother may complain of painful micturition or dysuria that could be due to tears, laceration of the cervix or vagina, or episiotomy .

48. During pregnancy, the compressive forces of the gravid uterus and the progesterone-induced decrease in ureteral tone, peristalsis, and contraction pressure lead to the dilation of the calyceal system, increasing the volume of kidneys by 30% from the pre-pregnant state. The dilated ureters and renal pelvis usually return to the pre-pregnant state within four-eight weeks. There is an increased risk of developing urinary tract infections. It is important to counsel the mother to void every 3 to 4 hours

49. 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 .

50. 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

51. The mother may develop flatulence or constipation due to intestinal ileus (induced by pain or presence of placental hormone relaxin in the circulation), loss of body fluids, laxity of abdominal wall, and hemorrhoids. The postpartum constipation is due to the progesterone-induced decrease in gastrointestinal transit time.

52. The compressive effects of the gravid uterus on the stomach, a decrease in lower esophageal sphincter tone due to high progesterone levels, and hypersecretion of acid due to high gastrin levels cause an increase in the incidence of acid reflux during pregnancy. After delivery, the levels of progesterone and gastrin drop within 24 hours, and the acid reflux and associated symptoms resolve in the next three to four days.

53. 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

54. 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.

55. 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.

56. Resp i ratio n : This is 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.

57.  Blood Pressure : No change 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.

58. 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.

59. 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-

60. 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.

61. 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

62. 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

63. 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 .

64. 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.

65. 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

66. 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.

67.  Someone to listen and help them solve their dependency-independency conflict.  Physical needs of comfort, nourishment and hygiene should be properly fulfilled.

68. LAC T A TION 1 st two days following delivery no further anatomical changes in the breast occur The secretion from the breast called colostrum which starts during pregnancy becomes more abundant during this period

69. COMPOSITION OF THE COLOSTRUM It is deep yellow serous fluid alkaline in reaction It has got a higher specific gravity ,high protein, vitamin A, sodium and chloride content but has got lower carbohydrate ,fat and potassium than the breast milk It contains antibody (IgA)

70. COMPOSITION OF COLOSTRUM AND BREAST MILK MILK PROTEIN FAT CARBO H YDRA TE WATER COLOSTRUM 8.6 2.3 3.2 86 BREAST MILK 1.2 3.2 7.5 87

71. AD V AN T AGES The antibodies (IgA,IgG,IgM) and hormonal factor (lactoferrin)provides immunological defense to the newborn It has laxative action on the because of large fat globules

72. PHYSIOLOGY OF LAC T A TION The physiological basis of lactation is divided into four phases Preparation of breast (mammogenesis) Synthesis and secretion from the breast alveoli (lactogenesis) Ejection of milk (galactokinesis) Maintenance of lactation (galactopoiesis)

73. MAMMOG E NESIS Pregnancy is associated with a remarkable growth of both the ductal and lobuloalveolar systems. An intact nerve supply is not essential for growth of the mammary glands during pregnancy.

74. LACTOGENESIS Milk secretion actually starts on 3rd or 4th postpartum day. Around this time, the breasts become engorged, tense, tender and feel warmth. When the progesterone and oestrogen are withdrawn following delivery, prolactin begins its milk secretary activity in previously fully developed mammary gland.

75. GALACTOKINESIS Discharge of milk from the mammary glands depends not only on the suction exerted by the baby during suckling but also on the contractile mechanism which expresses the milk from the alveoli into the ducts. oxytocin is a the major galactokinesis.

76. CONT….

77. CONT…

78. GALACTOPOIESIS Prolactin appears to be the single most important galactopoietics hormone. Continuous suckling is essential for removal of milk from glands, also release prolactin. Secretion is the continuous process unless suppressed by congestion or emotional disturbances

79. MILK PRODUCTION A healthy mother will produce about 500-800 ml of milk/day with about 500 kcal /day. This requires 600 kcal/day for the mother which must be made up from the mothers diet or from her body store. For this purpose a store of about 5 kg of fat during pregnancy is essential to make up any nutritional deficit during lactation.

80. STIMULATION OF LAC T A TION Mother is motivated about the benefits of breast feeding No prelacteal feed like honey ,water Following delivery important steps are….. To put baby to the breast at 2-3 hours interval from the first day. Plenty of fluids to drink To avoid breast engorgement. Early and exclusive breast feeding in correct position are encouraged as soon as 30minutes to 1hour

81. INADEQUATE MILK PRODUCTION/ LACTATION FAILURE It may be due to infrequent suckling or due to endogenous suppression of prolactin (ergot preparation, pyridoxine, diuretics or retained placental bits). Unrestricted feeding at short interval (2-3hrs.) Is helpful

82. DRUGS T O IMPROVE MILK PRODUCTION Metoclopramide (10 mg thrice daily) increases milk volume (60-100%) by increasing prolactin levels. Sulpuride (dopamine antagonist) has also been found effective. Intranasal oxytocin contracts myoepithelial cells and causes milk let down reflex.

83. LACTATION SUPPRESSION Suppression of lactation is necessary if the baby is born dead or dies in the neonatal period or if breast feeding is contradicted Mechanical methods : To stop breast feeding To avoid pumping or milk expression To wear brassieres Ice pack to relive pain and breast engorgement A tight compression bandage is applied for 2-3 days

84. CONT… Bromocriptine (dopamine agonist that inhibits prolactin) 2.5 mg, 1 tab daily for 10-14 days. Side effects are: hypotension, rebound breast engorgement, secretion, myocardial infarction and puerperal stroke

85. THANK YOU