puerperium.pptx

peurperium

1. Physiology and management of normal puerperium DR.AMRIN ASSISTNT PROFESSOR, DEPT OF OBG, NIMRA

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 o f t h e n o n p r egnant s t at e .

3. 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 . B AKER Puerperium is defined as the time from delivery of the placenta through the first few weeks after the delivery. (cont….)

4. 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 sta te, 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 retu r ns to i t s norma l , non - p r egnancy st a te)

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 de l i v e r y comp l ic a tio n s m a y occu r . 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 th r ough the sixth w e e ks postpa r tu m .

6. Reproductive system Uterus I n v o l uti o n : - i s the r eturn of the uterus to a nonp r egn a nt state after chi ldbi r th Involution process begins immediately after expulsion of the placenta with contraction of uterine smooth muscles At the e n d of th i r d stage of l ab o r , the uterus i s i n the mid l i n e , 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 g e stational w e e ks The fundus descends about 1 to 2cm every 24 hours, and by the sixth postpartum day it is located halfway between the symp h ysis pubis a nd the umbil i cus. -The uterus lies in the true pelvis within 2 weeks after childbirth.

7. Involution of the uterus   r eturn t o th e pelvis b y a b out 2 weeks be at normal si z e b y 6 weeks th e w eight c han g es of uterus 1000g immediately after birth (excluding the fetus, p l acen t a, memb r a n e a n d a m n i oti c flu i d. 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

8. Its fundus l e v el a pp r o ximates tha t o f a 20 week p r egn a ncy at the l e v el of umbi l icus , a t th e end f i r s t post pa r tu m wee k i t i s pa l pab l e at the symp h ysis pubis -Autolysis:-it is a self destruction of excess hypertrophied tissue. -Subi n v o l utio n : - i s the fa i lu r e o f the uterus to r eturn to a nonpregnant state. -The most common causes of subinvolution are r eta i ned pl a centa fragments and in f ecti o n

9. Contraction The hormone oxytocin strengths and coordinates uterine contrac t i o n, wh i ch comp r ess bl o od v esse l s and p r omotes homeostasis During the first 1 to 2 postpa r tum hours, uterine contractions may decrease in intensity and become uncoordinated

10. Exoge nous o xytocin i s usual l y admin i ste r ed immediately after expulsion of the placenta to mainta i n the uterus firm and contracted. Mothers are encouraged to put the baby to breast immediately after birth to stimulate the release of oxytocin.

11. 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 el e vated a r ea. Upward growth of endometrium causes the sloughing of n e c r otic tissues and p r e v ents scar f orma t i o n. Endometrial r ege neration i s co mpleted b y postpa r tum day 16, except the placental site is not complete until 6 w e e ks after bi r th.

12. 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.

13. Lochia passes through 3 stages:- l o chia rub r a : - i t consists of b l ood, dec i dual and trophoplastic debris It last s 3 - 4 d a ys after childb i r th . l o chia se r osa : - i t consists of o l d bl o od, serum, l e u k ocytes, and tissue debris. the fl o w becomes pink or brown. It i s exp e l l ed 3 - 10 d a ys postpa r tum

14. 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 w e e ks after chi ldbi r th. The amount of lochia is usually increases with ambulat i on, and b r east f e e ding. P ersistence of l o chia rub r a ear l y i n the postpa r tum period suggests continued bleeding as a result of retained fragments of the placenta or membranes. The another common source of vaginal bleeding is vag i nal or ce r vical l a ceration.

15. 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 pai n : Occu r during the 1 s t 2 - 3 d a ys of puerperium Abdominal pains (like cramps) and back pain. Strong, regular, and coordinated. The intensity, frequency and regularity of contraction decrease after the 1 s t postpa r tum d a y . Primigravida--uterus tonically contracted unless clots or tissue r emain i n uterus . Multipara--uterus contracts and relaxes at intervals causing “afterpains”. More severe when breasfeeding in both primiparas and multiparas.

16. Constipation It i s com m on i n the first f e w d a ys of pu e rperium and i s due to ma n y facto r s . The w oman‘s f ood inta k e i s interrupted, there may be dehydration during labor, the abdominal m uscl e s a r e l ax and perin e al lacerations make defecation painful.

17. Cervix It is soft immediately after birth - The ce r vix up to the l o w er uterine segment r emains edematous, and thin f or s e v eral d a ys after bi r th. The ce r vical os wh i ch i s d i l a ted to 10cm during labor closes gradually, it may still possib l e to int r oduce 2 f i ngers into ce r vical os f or the first 4 - 6 postpa r tum days. The external ce r vical os n e v er r eg a ins it s p rep r egnancy a ppearanc e , i t i s no l o nger sh a ped l i k e a f i sh mouth. It r eturn t o its normal state a t 4 weeks after bi r th

18. Vagina and perineum - The greatly distended, smooth walled vagina gradually returns to its prepregnancy size by 6-10 weeks after childbirth. - The m ucosa r ema i ns at r oph i c i n l a ctating w oman at l e ast until menst r uation beg i ns aga in. -Thickening of vaginal mucosa occurs with the return of o varian functi o n.

19. 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.

20. If ep i sioto m y and l acerati o n h a v e be e n ca r efu l l y repaired, hematomas are prevented or treated early. usually healing should occur within 2-3 weeks Hemorrhoids usually decrease in size within 6 weeks of ch i ldb i r th.

21. Pelvic muscular support The suppo r ting st r uctu r e of the uterus and vag i na m a y be i nju r ed during chi ldbi r th. the suppo r ti v e tissues of the pe l vic fl o or that a r e torn or stretched during childbirth may require up to 6 months to r eg a i n tone W omen a r e e ncouraged to do k ege l e x e rcis e s after bi r th to st r ength e n perin e al m uscl e s and promote healing

22. Perineum Swelling completely gone within 1-2 weeks The muscle tone may or may not return to norm a l, depen di n g o n t h e e xtent o f i n j u r y .

23. The voluntary muscles of the pelvic floor and pelvic suppo r ts gradual l y r ega i n their tone du r in g the puerperium. T ear i ng or o v erst r etching of the m usculatu r e or fascia at the time of d e l i v e r y predispose to genital hernias. Over distention of the abdominal wall during pregnancy may result in rupture of the elastic fibers, persistent striae, and diastas e s of the r ecti m uscl e s. I n v o l ution of the abdominal musculature may require 6-7 weeks and vi g o rous e x e r cises a r e not r ecom m ended until after that tim e . The muscular walls of the pelvic organs

24. 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)

25. Physiology of Lactation

26. During pregnancy estrogen and progesterone secreted by the placenta prepare the breasts for lactation.The estrogen inhibits milk p r oduct i o n un t il t h e end o f p r egnanc y . In t h e 3rd trimester of pregnancy colostrum is present and remains for the first 3 days postpartum.

27. By the 3rd stage of labor (delivery of the p l acen t a), t h e hormonal p r oduct i o n is r educed, a n d d u r i ng t h e n e xt 48 h r s, t h e b lood l e v el of estrogen and progesterone fall.This stimulates the anterior pituitary gland to produce the lactogenic hormone (prolactin hormone) w h ich a c ts o n t h e a ci ni cel l s in t h e b r eas t , a n d milk is formed.

28. 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 mout h , a n d p a r t l y by a vac u um w h ich 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.

29. 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 st r eam, le a d i ng to contr a cti o n o f m y o e p i t h eli a l cells, a n d t h e e xpul sion o f mi l k.

30. 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 e xp r essed o n p r essu r e , o r m a y esc a pe spontaneously.This procedure is associated with a considerable local throbbing pain extending the axillae.

31. C h a r ac teris t ics o f b r east m i lk. It is sui ted 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.

32. T ype s o f B r eas t milk Breast milk at different stages of lactation is defined by different terms. Colostr u m : is a t hick, sticky and l i ght yellowish in colour which is produced during the first few days after delivery. Although secreted in small quantities (3 - 90ml ), it is suf f icient to m eet the caloric needs of a normal newborn in the first few days of life.

33. 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, p r otei n conten ts dec r ease w h i l e fat and sugar contents increase. At this time the b r easts f eel ful l , h a r d a n d he a v y .

34. Mature milk:This milk is thinner and watery but contains all the nutrients essential for optimum physical and mental development of t h e ch i l d . Ma t u r e m i lk ch a n g es e v en du r i n g t h e length of a single feed to exactly suit the needs of a baby.

35. Th e matur e mil k consist s of F o r emil k an d H i n d mi l k: 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 w ate r . It sa t isfies t h e b a b y's t h irst a n d is produced in larger amounts than hind milk.

36. 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 m uch o f the ener g y o f a b r east f eed. It should be noted that a baby needs both the foremilk and the hind milk f o r a pp r opriat e w eight gain. Als o , babies who are fed both foremilk and hind milk sleep well. P r eterm milk: is a milk p r oduce d by a w oman who has delivered prematurely.This milk has more proteins, minerals, immunoglobulin and lactoferrin than the matu r e milk, making it suita b le f o r 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

37. Breast feeding in the correct position A r t an d t ech n iqu e o f b r eas t f eedi n g Step 1: Find a comfortable position for your self. Y o u m a y l i e d o wn; sit on a chair on the bed or on the floor to f eed y ou r ba b y . Mo s t important is that you must feel comfortable and your back must be supported

38. Step 2: Hold your baby in your arm so that her head and neck rest in the bend of their el b o w , t h e b ack a l ong forearm and the buttocks in y ou r h a nds if y our feeding on your right breast your right arm should be used to cradle your baby.

39. 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.

40. Make sure that the baby is not exclusively clothed so t h at t h e b a by can be b r ought r ea l l y close t o y ou . S o me t i mes y o u m a y need to t uck y ou r b a b i es a r m a w a y . 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 t h e n i pp l e touches, t h e b a b y's l i ps o r t h e 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.

41. T o ef f ect i v e l y suckle mi l k f r o m t h e b r east, both t h e 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 e y e cont a ct. Go o d a n d b a d body posit i ons a r e sh o wn in Fig. a & b.

42. A B

43. Pi c . a: Go o d body posit i on 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

44. Pi c . b: B a d body posit i on 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

45. Attachment attachment refers to the emotional connection between a patient and her infant.This attachment is r ecip r ocal ; both t h e mother and the infant exhibit attachment behaviors.The infant responds to the p a t i ent by co o i n g, grasp i ng, smi l i n g, a n d c r yi n g .

46. H o w e v e r , t h ese beh a viors a r e non d isc r i m in a t o r y be f o r e a pp r o xim a te l y 8 w eek s . Nurse s 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

47. Endocrine system Plac e ntal hormones Expulsion of the placenta results in dramatic decreases of hormones p r oduced b y pl a centa. The placental enzyme insulinaze causes the diabetogenic ef f ects of p r egn a ncy to be r e v ersed, r esu l ting in significantly lower blood sugar levels in the immediate postpartum period Est r oge n and p r oge ste r one l e v e l s dec r ease mar k ed l y after expulsion of the placenta, reaching their lowest levels 1 w e e k i nto the postpa r tum peri o d. 2 - Dec r eased est r ogen l e v el associated w i th; b r east engorgement, and diuresis of excess extracellular fluid that has accu m ul a ted during p r egn a nc y .

48. 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 f e e ding w omen a ppears to the r espons i ble f or supp r ess i ng ovulation In women who breast feed, prolactin levels remain elevated int o the sixth w e e k a fter bi r th. Serum prolactin levels are influenced by the frequency of b r east f e e ding, the duration of e ach f e e ding, and the deg r ee to which supplementary feedings are used. Prolactin levels decline in nonlactating women, reaching the p rep r egn a nt range b y thi r d w e e k About 70% o f non l actating w omen r esume menst r uation b y 3 months after bi r th.

49. - The mean time to o vulat i on i n w omen b r east f e e d is about 6 months. - The r esumption of o vulat i on and the r eturn of mens e s i n l a ctating w omen a r e d e ter m in e d b y b r east f e e ding patterns. -The first menstrual flow after childbirth is usually heavier than normal, within 3-4 cycles, the amount of menst r ual fl o w r eturned to w oma n ’ s p rep r egn a nt volume

50. 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 st r i a e m a y p r es ent -The return of muscle tone depends on previous tone, p r oper e x e rcis e , and the amount of ad i pose tissu e .

51. Urinary system The diminishing steroids levels after birth may explain the r educed r enal func t io n that occu r s du r in g the pueriperium. Urine components BUN l e v el inc r eas e s during puerperium as auto lysis 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

52. 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 accoun t s f or w e i ght los s of a pp r o ximate l y 2.25 kg during the puerperium

53. 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 th e y r educe the v oiding r eflex. Dec r eased v oiding, along wit h postpa r tal diu r esis m a y r esult in bla d der distention. -Distended bladder pushes the uterus up and to the side and this p r e v ents the uterus f r om firm ly contra c ting which m a y cause excessi v e bleeding. -Bladder tone is usually restored 5-7days after childbirth .

54. Gastrointestinal system Appetite The mother is usually hungry shortly after giving birth. Bowel evacuation A spontan e ous b o w el e vacuation m a y be de l a y ed unt i l 2-3 days after childbirth. This can be explained by decreased muscle tone of the intestines during labor and the immedi a te puerperium , p r e l abor dia r rhea, lac k of f ood, or de h yd r ation

55. GI/hepatic function G I tone a nd motil i ty dec r eas e s i n the ear l y postpa r tum period, com m on l y causing cons t ipatio n . -Normal bowel function returns approximately 2 to 3 d a ys postpa r tu m . -Liver function returns to normal approximately 10 to 14 d a ys postpa r tu m . -Gall bladder contractility increases to normal, allowing f or expulsion of small g a l l stones

56. Cardiovascular function Mo s t d r ama t i c changes occur i n this syst e m . Cardiac output decreases rapidly and returns to normal b y 2 to 3 w e e ks p o stpa r tu m . Hematocrit increases and increased red blood cell (RBC) production stops . Leukocytosis with increased white blood cells (WBCs) com m on during the first postpa r tum w e e k . Blood volume The bl o od v o l ume wh i ch inc r ease during p r egn a ncy is eliminated within the first 2 weeks after birth, with r eturn to nonp r egn a nt valu e s b y 6 w e e ks p o stpa r tu m .

57. Cardiac output Im m ed i ate l y after the bi r th, the pulse rat e , st r o k e volume and cardiac output remain elevated or inc r ease f or 30 to 60 mi n utes as the bl o od that shun t ed th r ough ute roplacental ci r cuit su d den l y returns to the maternal systemic venous circulation

58. 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.

59. The pulse: The pulse is full and slow (about 60-70 B/mm) and is known as physiological bradycardia (for 24 - 48 h r s af t er l a bor). 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 a l l is g oin g w ell. A r a p i d pu l se m a y be brought on by pain, visitors, excitement, e xha u st i on , t h e n urs i ng i n fan t , hemo r rh a g e or infection .

60. Respiration : This is in the usual relation with pulse and te m per a t u r e . Bec a use o f a r ed u c t ion in t h e size of the uterus and relaxation of the abdominal wall respiration is more abdominal in ch a ra cte r . D e vi a t i o n f r o m t h e norm a l m a y suggest pneumonia or embolism.

61. Blood Pressure: No change is counted, but if hypotension is p r esent, postp a r t u m hemo r rh a g e m a y be suspected. If hypertension is present (over 140 / 90 mm Hg) po s tp a r tum t o x emia m a y be suspected.

62. Blood and Fluid Changes Marked leukocytosis and thrombocytosis occur during and after l abor The leukocyte count sometimes reaches 30,000L, with the inc r ease . Th e r e i s a ls o a r e l ati v e l ymphopenia and an abso l ute eosinopenia. No r mal l y , du r in g the first f e w postpa r tum d a ys, 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 near l y to it s nonp r egn a nt l e v e l .

63. Respiratory function - R e tu r ns to normal b y a pp r o ximate l y 6 to 8 w e e ks postpartum . - Basal metabol i c rate inc r eas e s f or 7 to 14 d a ys postpartum, secondary to mild anemia, lactation, and psychological changes -

64. Neurological system Discom f o r t and fat i gue a r e co m m on . 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 e l imin a tion o f p h ysio l og i c ed e ma th r ough the diu r esis that occurs after chi ldbi r th r e l i e v es carpal tunnel syndrome by easing the compression of the median ne r v e .

65. Musculoskeletal function -Generalized fatigue and weakness is common . -Decreased abdominal tone is common . -Diastasis recti heals and resolves by the 4th to 6th w e e k p o stpa r tu m . -Until healing is complete, abdominal exercises are contraindicated

66. Integumentary system Chloasma of p r egn a ncy usual l y dis a ppears at the end of p r egnanc y . Hyp e rpigmentation of the a r eo l ae and l i nea ni g ra m a y not regress completely after childbirth, and it may be permanent i n some w omen. Stretch marks on breasts, abdomen, hips, and thighs m a y fade but usual l y do not dis a ppear Hair growth slows during postpartum period, and some women may actually experience hair loss. Im m une system No significant changes occur during postpartum period

67. 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.

68. Taking-in Phase (Turning in): It t a k es 2 - 3 d a ys, du r i n g w h ich t i me t h e 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 i n i t i a tes l i t t le ac t iv i ty o n her o w n . She is quite talkative during this phase about every detail of her labor and delivery experience.

69. Taking-Hold Phase (Taking Responsibility as a Mother): It starts the 3rd day postpartum.The emphasis is pl a ced o n t h e p r esent . She becomes impatient and is driven to organize herself and her l i f e . She p r o g r ess e s f r o m t h e p a ssi v e 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 mothe r , she is a b le to e xtend her energies to her mate and other children.

70. Letting-go Phase: As her mothering functions become more established the mother enters the letting-go phase.This generally occurs when the mother retu r ns hom e . In t h is ph a se t h e r e a r e t w o 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 si t u a t i on . She m ust a d j u st her l i f e to the relative dependency and helplessness of her child.

71. Bonding: also known as attachment: process by which parents form emotional relationship with i n fant o v er t i me; i n fluenced by m a n y fac t ors: fam i l y , st a b i l i ty o f home e n vi r onment, n u r t u rin g she r ecei v ed as ch i l d . Ce r t a in characteristics important: level of trust, level of self esteem, r eact ions to p r esent p r egnancy; interest in child rearing.

72. Postpartum Blues (Depression) Definition Rubin defined postpartum depression as the g a p bet w een t h e i d eal a n d r ea l i t y: t h e n e w mother ’ s self-expectation may exceed her c a p a b i l i t i es, r esul ti n g in cycl i c f eeli n gs of depression. During Postpartum, and for no apparent reason that the mother can think of, she may experience a let-down feeling accompanied by i r r i t a b i l i ty a n d te a rs . Occ a sion a l l y her a p p et i te and sleep patterns are disturbed.These are the usual manifestations of the postpartum or “ infant ” blues .

73. This depression is usually temporary and may occu r in t h e hospi t a l . It is t h ought to be r el a ted, in p a r t, to hormonal ch a n g es, a n d in p a r t, to t h e e g o ad j us t me n t t h at a c comp a n i es r ole t r a n si t ion. Discom f o r t, fa t igue a n d 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.

74. 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

75. 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 f r o m t h e husb a nd: t h is is v e r y signif i ca n t as most of the attention in the immediate postpartum period is directed suddenly toward the newborn.

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

77. A g ood method t o r emem b er h o w to check th e postpa r tum cha n ges i s th e use of th e ac r o n ym BUB B LER S : B: B r eas t . U: Uterus . B: Bla d de r . B: B o w e l . L : Loch i a . E: Ep is i oto m y . R: Emotion a l r esponse . S: Homan s ' sign .

78. 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.

79. Components of Care during the Postpartum Period Care of the mother: Immediate care. Subsequent daily care. Care of the newborn infant.

80. 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.

81. 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

82. Nursin g Assessment The first ho u r , after placental separation and bi r th, is unde r 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,

83. 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 ( D VT) : pain, warmth, tenderness, swollen reddened vein that feels hard or solid and positive Homan ’ s sign

84. Postnatal Exercises P elv i c floor e x e r cise Abdomi n al tig h tening P elv i c ti ltin g or r ocki n g Rectus g a p Hip hitching F oot and Le g E x e r cise

85. If t he ut e ru s is a t oni c , b lo o d which c o llects in the cavity should be expressed with firm, but g en t le , f o r ce in the di r ection o f t he 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 o xytocin ( e .g. er g o m etrine 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.

86. Ch e ck lo c hial dischar g e f o r c o lo r , am o un t , 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. Gener a l h ygiene: sh o w er m a y be permissi b le to clean, c o m f o r t and r ef r esh the mother (after vital signs are stable) according to the hospital policy. Encourage early initiation of breastfeeding to s t i m ula t e i n v olution , lact a tion and to enhance emotional bonding.

87. Correct dehydration promptly by of f ering fluid inta k e (or al l y), or starting IV fluid as ordered. Start leg exercises and early ambu lati on , especial l y f oll o w i ng operative delivery. Administer prophylactic anticoagulant therapy as ordered.

88. Palpate the uterus to assess firmines s , l e v el o f fu n du s , and rat e of involution of the uterus. Administer oxytocin medication as ordered to promote involution. Check loc h ia f o r c o lo r , am o unt, od o r , consistency and presence of blood clots.

89. 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 p r omo t e lact a tion ( 8 h r . night - time sleep and 2 h r . 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, p r on e position o r eithe r later a l 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.

90. On the o ther hand, bo th s u pine and semi-sitting positions should be avoided. P r e v ent in f ection: co m plete ase p tic and antiseptic precautions should be followed during the early postpartum period to prevent infection. Monitor laboratory reports for Hb, HC T , and WB C . Ob s e r v e f o r pos tpa r tum b lue s , which may be caused by a drop in hormonal levels on the 4th or 5th day.

91. 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 i n v olution , g ener a l he a lth and w ellbeing 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 en g or g ed b r ea s t, c r ac k ed nipples, masti t is and breast abscess.

92. 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., usu a l l y occ u r s due to l ax a b do m inal and b la d der 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 dur ing labo r . G l yce rin sup p osito r y m a y be use d to relieve constipation.

93. Diet: Provide diet high in proteins and calories to restore ti s sue s . A d ai l y r equi r ement o f 3000 - 350 cal / d a y is needed in the form of a well balanced diet rich in cla s s p r otei ns, calcium , i r o n , v it a min A, t hiamin e , 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 epi s ioto m y o r lac e ratio n o f the p erineu m . REE D A stands for redness, edema, ecchymosis, discharge, and approximation. Redness is considered normal with episiotomies and lacerations — however, if there is significant pain p r es ent, fu r ther a s s e s s ment is nec e s s a r y .

94. 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 epis i oto m y , lacerati o ns, ede m a, 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.

95. 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 co m m o n at this st a g e). Supple m ents of calc i u m , i r o n and Vi t B - co m pl e x ta b lets may be given. If Rh negati v e mothe r , assess need f or administration of RhO GAM. Gi v e rubella vaccine if ind i cated.

96. 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 ind icati v e o f a deep v ein 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: p r esence o f hot, r ed, painful, and ede m atous a r eas, all ind icati v e o f a DVT.

97. Assess the legs for adequate circulation by checking the pedal pulses and noting temperature and col o r , P edal ede m a is n o rm a l l y p r esent 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

98. Care of the newborn infant: Observing the general condition. Checking the cord. Checking the infant ’ s physical needs: cleanline s s, f eeding, warmth, sle e p , protection from unsuitable environment. Checking psychological needs: bo n ding, attachment.

99. Discuss infant care with mother: cleanline s s, ha n dli n g, clothing, c o r d ca r e , f eeding, bo n ding, di a pering, circumcision of male infant, immunization, registration, and community resources. Encourage early skin to skin contact, bonding and attachment

100. Contraceptive Methods Sex is not advisable for at least 6 weeks after del i v e r y , i . e . in t h e postp a r t u m peri o d , as t h e tissues are fragile at this time and need time to r ec ov e r . Bu t , if necessa r y , b a r rier 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 decr ease in the milk production of the breasts . Af t er 6 mont h s, w h en t h e b a by can be st a r ted on supplementary food, oral contraceptive p i l l s can be p r escribed. It is a l so poss i b le to use intra-uterine devices like Copper-T after this period.

101. Minor Discomforts during the Postpartum Period Minor Complaints They are minor complaints felt by the parturient d u r i ng post p a r tum per i od . Si m p l e n u r si n g measures (interventions) are needed to alleviate these complaints. After-pains It is a spasmodic colicky pain in the lower a b domen du r i n g t h e ear l y postp a r t u m . d a ys due to vigorous contractions of the uterus. It is more common and more severe in multiparas due to w eak m usc l e ton e . Con d i t ions w i th i n c r eased intra abdominal pressure e.g. polyhydraminos, m u l t i p l e p r egnanc y , l a r g e si z e infa n t.

102. Predisposing factors: Presence of blood clots, piece of membranes or placental tissue. Breastfeeding increases after-pain. 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.

103. Urinary Retention It is the inability to excrete urine, i.e. urine is acc u m u l a t ed w i t h in t h e uri n a r y b l a dde r . 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.

104. Treatment: Urine should be passed approximately 8-12 hrs. af t er del i v e r y . If not, t h e f oll o w i ng 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.

105. Constipation An abnormal infrequent and difficult evacuation of feces may occur during the first few days postpartum. Nursin g m a n a g ement: hea l th te a ch i ng should consider the following: Diet rich in roughage. Increase fluid intake. Milk before bedtime. Exercises. After 72 hrs a glycerin suppository, or mild l a xa t i v e , m a y be a d m i n is t e r ed as o r de r ed.

106. 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 3 r d d a y p o stpa r tum, espec i al l y in primi p aras . It is due to l ymphatic and v eno u s en g or g emen t, and is r eli e v ed when milk comes out. Causes: Inadequate and/or infrequent breastfeeding. Inhibited milk ejection reflex.

107. Signs and symptoms: ⚫ Breasts are firm, heavy (due to blocked ducts), s wollen , ten d er a n d hot ( 37.80 C). Pain may be present leading to irritability and insomnia.The mother may refuse to nurse the infant. 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.

108. Stroking the Breast Massaging the Breast

109. 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 p r escri b e d . I n s e v e r e cases, administration of 2 doses of diuretic (as Lasix 40 mg) is effective.

110. 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 o f i r ritat i ng su b st a nces e .g. so a ps, lotion s. Conditions as candidiasis, and contact dermatitis. Engorgement of the breast. Blond and redheaded women usually have delicate skin that may be predisposed to cracking.

111. Signs and symptoms: Irritation of the nipple in the form of minute blisters, or petechial spots. Persistent pain and tenderness. Bleeding. Inflammation signs. Proper technique of breastfeeding should be followed. Apply moist heat and massage before feeding (3-5 mm). F r equ e nt, s h o r t f ee dings. 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.

112. 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). D i et: r ich in p r otein. 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

113. 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 pa r t l y due to hormonal chan g es, and partly due to the ego adjustment that accompanies role transition. Manifestations: Disturbed appetite and sleeping patterns. Discom f o r t, fatigue and e xhaustion. 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.

114. Predisposing factors: The first pregnancy or pregnancy in late childbearing age. Social isolation. Ambivalence toward the woman ’ s own mother. P r olon g ed, h a r d l a bo r . A n xie t y r ega r d i ng fi n a n ces. M a r i t a l disharmony. Crisis in the family. ADVICE: Reassurance, understanding, and anticipatory guidance will help the parents become aware that these feelings are a normal accompaniment to this role transition.

115. P ostpa r tu m Visits Th e Firs t 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. Est i m a t i o n o f t h e hem o globin pe r cent a g e , a n d 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.

116. Exa m i n ation o f abd o minal m us c les, per i neu m, per i neal 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 p o siti o n, adn e xal ma s ses, tendern ess, the c o nditi o n of the cervix (such as lacerations or erosions) as well as the c o nditi o n o f the pe l vic flo o r . Man a g ement o f a n y les i on should be readily started Th e Se c on d 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.

117. Health teaching items at this time include advice in relation to: Sexual intercourse, which should be prohibited d u rin g the first si x po stpa r tum we e k s , and all o w ed a f ter that, p r o vided that the w o m an i s in g ood hea l th, with a per f e c t l y heal e d g eni tal trac t . Spacing of pregnancies and counseling about the appropriate contraceptive method, which should be prescribed and may be started at once. If p r ol a pse o f the g enit a l tract is p r es ent, it sh o uld be treated by pelvic floor muscle exercises and/or the insertion of a ring pessary.The patient should be advis e d to abst a in f r o m be a rin g d o wn. C h r o n ic 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.

118. 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 puer peral w eek in t h e m a jori t y o f pa t ien t s. In no n - l a ct a ting mothers, h o w e v e r , menst r u a t i on usu a l l y a ppe a r s af t er 6 - 8 w eek s . On t h e other h a n d , l a c t a t i n g w ome n m a y h a v e g r eat va r i a t i ons in t h is r espect: a b ou t 1 / 3 o f them will start menstruation 3 months postpartum, and by the 6 month more than half of them will menstruate.

119. Th e Thi rd Vis i t 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 , a n d a n y disc o v e r ed lesion sho u ld be dealt with: Cervical erosions must be cauterized. Persistent RVF and/or prolapse should be managed properly. If lact a tional ameno r rhe a is p resen t , the client should be instructed that this is not a bar against another pregnancy, and suitable contraceptive measures should be instituted.

120. Discharge Instructions Patients and their families should be instructed to call the healthcare p r o vider if the pati ent ha s a n y o f t he following : Fever Foul-smelling lochia Lar g e b lood clots, o r b l e eding that saturates a pad in 1 hour

121. 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 F r equent , painfu l urination

122. TH A NK Y OU