Normal Postpartum

Normal Postpartum

Normal Postpartum 

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It is a period following labor during which the maternal body in general, and the genital organs, in particular return to the pre-pregnant condition. Duration is 40 days or 6- 8 weeks. Another 4 to 6 weeks is needed for complete involution. The puerperal period is much shorter after abortion. The first ten days are called early postpartum, and the days after are called the late postpartum.

General physiological changes 

Immediately following labor, the general condition of the mother is one of physical fatigue.

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Vital signs: * Temperature: - is slightly elevated: 0.5 degree for the first 24 hours and up to 38 degrees is known. This is due to absorption of waste products of muscular contractions of labor.

General physiological changes 

Vital signs: * Temperature: - Transient rise in temperature later on is due to: @ milk engorgement. @ Constipation. @ Nervous excitation. * Pulse: - Physiological bradycardia ( for 24-48 hrs after labor) due to: @ Rest period after labor. @ Increase in circulating blood volume after elimination of placental pool.

General physiological changes 

Vital signs: * Respiration: - is in usual relation with pulse and temperature. - is more abdominal in character. * Blood pressure: - no change is counted, but if hypotension is present, postpartum hemorrhage is suspected. - if hypertension is present , postparum toxemia may be suspected.

General physiological changes 

Skin: - Excessive sweating, particularly in patients who were subjected to edema in late pregnancy. This gradually ceases within 1st week and the skin reacts as usual. - skin pigmentation gradually disappears.

General physiological changes 

Kidneys and urinary output: - Physiological diuresis. - Painful, difficult micturition due to tears, lacerations, or episitomy. - Traces of albumin may be present as a result of muscle involution. - Lactosuria is common with milk engorgement on the 4th day at the start of lactation.

General physiological changes 

Kidneys and urinary output: - The parturient may experience retention of urine in first few days after labor due to: * Laxity of the abdominal muscles. * Inability to micturate in recumbent position. * Reflex inhibition due to stitched perinum or bruised urethra. * Atony of the bladder. * Compression of the urethra by edema or hematoma.

General physiological changes 

Bowel function and intestinal elimination: - Thirst is present due to the marked fluid loss through sweat and urine. - Tendency to atony of gastrointestinal tract, with flatulence and constipation. - Constipation may be present due to: * Intestinal atony. * Anorexia after labor. * Loss of body fluids. * Laxity of abdominal wall. * Hemorrhoids, reflex inhibition, enema in labor.

General physiological changes 

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

General physiological changes 

Body weight: - Loss of weight is observed during the 1st 10 days especially in non-lactating women. - There is about 4-5 kg ( sometimes 8 kg) due to evacuation of uterine contents and diuresis.

General physiological changes 

After pains: - it is spasmodic colicky pain in the lower abdomen during early postpartum days. - it is more common and more sever in multiparas ( due to weak muscle tone), mutiple pregnancy, polyhydraminios, and large sized infants. - can be precipitated by the presence of blood clots, a piece of membrane, or placental tissue. - it increases during breast feeding as a result of oxytocin secretion stimulation by suckling reflex of infant.

General physiological changes 

Return of menstruation: - Non-lactating women begin to menstruate again in 6 -8 weeks. - In lactating women, usually reappears in 4 -5 months , and in sometimes as late as 24 months. - The first period is usually prolonged and profuse. - it should be mentioned that ovulation can commence in the absence of menstruation, and another pregnancy can occur.

General physiological changes 

Uterus: - Involution of uterus is the return of uterus to its non-pregnant condition. - Size: * Immediately after labor, the fundal level is at the level of umbilicus. * At the end of first week, the fundus os midway between umbilicus and symphysis pubis. * By the end of 2nd week, the fundus is just behind the symphysis pubis, and thereafter it becomes a pelvis organ. - Weight: * By the end of postpartum it weighs 50 gms instead of 1000 gms during pregnancy.

General physiological changes

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

General physiological changes 

In the endometrium: - Separation of placenta and membranes occur in the deeper portion of the spongy layer of decidua. - All but the basal layer is shed off in the lochia. - If the involution process is slow or delayed , known as subinvolution. - If the involution process is rapid , known as hyperinvolution. - Lochia: * It is the uterine discharge coming through the vagina during the first 3-4 weeks postpartum. * It is alkaline with fleshy odor, and contains blood, leucocytes, dead decidual tissues, vaginal epithilial cells, cholesterol, and nonpathogenic bacteria.

General physiological changes 

Types of lochia: * Lochia rubra: the discharge is red in color, and lasts from 1st postpartum day, to 4th day ( and sometimes 7th day). * Lochia serosa: a pink yellow discharge containing less blood blood and more serum, and extends for another 3 to 4 days. * Lochia alba: a creamy or white clored discharge containg leucocytes and mucus. It remains for the 10th day postpartum.

General physiological changes 

Clinical significance of abnormal lochia: - Fetid lochia denotes the presence of infection and/or stagnation. - Sudden suppression may be due to sever infection. - Prolongation or recurrence of lochia rubra may suggest retained parts of placenta, membranes, subinvolution, tumors.

General physiological changes 

Vagina: - the vagina diminishes in size, but not as pregravid stae. - Rugae reappear in third week. - The anterior and posterior walls may be sagging immediately after labor.

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Vulva: - Edema, minute or frank lacerations may be seen immediately after labor. - the vulva tends to gap for some time after delivery.

General physiological changes 

The abdominal wall: - The muscles were over-stretched during pregnancy and strained during labor, are slow to regain their normal tone and elasticity. - The recti muscles may separate widely so that the uterus may be felt between them. - Diastasis recti.

General physiological changes 

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

Physiology of Lactation

Psychological changes during postpartum  • • •

Phases of Maternal Role: Taking – in phase. Taking – Hold phase. Letting – go phase,

Psychological changes during postpartum 

Taking – in phase: - It takes 2-3 days, during which time the mother’s first concern is with her own needs(sleep and food). - The woman reacts passively, mostly dependent on others to meet her needs. - She is quite talkative during this phase about every detail of her labor and delivery experience.

Psychological changes during postpartum 

Taking – Hold phase: - It starts 3rd day postpartun. - The emphasis is placed on the present. - She progresses from the passive individual to the one who is in command of the situation. - this phase lasts about 10 days. - Acceptance her role as a mother.

Psychological changes during postpartum 

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

Postpartum blues 

Is the gap between the ideal and reality: the new mother’s self – expectation may exceed her capabilities, resulting in cyclic feelings of depression.

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Let-down feelings, irritabiilty, and tears.

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Usually is temporary, may be related to hormonal changes and role transition.

Postpartum blues 

Predisposing factors: - The first pregnancy. - A pregnancy in late child bearing years. - Ambivalence toward the woman’s own mother. - Social isolation. - Long and hard labor. - Anxiety regarding finances. - Marital disharmony. - Crisis in the extended family.

Nursing Management 

Objectives of care during the postpartum period: - Secure mental and physical rest, restore normal good muscle tone and maintain normal body functions. - Provide proper adequate nutrition. - Guard against infection. - Teach the mother how to care for herself and the infant. - Foster and maintain family ties and adjust the parents to their new role.

Nursing Management 

Nursing assessment during first hour after placental separation and birth: - Observation of bleeding signs and symptoms by: * Palpating the fundus of the uterus through the abdominal wall. Normally it should be firm, round, small, central, and well contracted. * Inspecting the perineum and perineal pad for obvious signs of bleeding. * Taking and recording vital signs every 15 minutes for first hour.

- Observation of legs for signs and symptoms of DVT: pain, warmth, swollen reddened that feels hard or solid, and positive Homan’s sign.

Nursing Management (Implementation) 

Palpate the uterus : - If it becomes soft and boggy because of relaxation, the fundus should be massaged immediately until it becomes contracted again. - If the uterus is atonic, blood collected in the cavity should be expressed by gentle, firm force in the direction of outlet. This is done after the fundus has been first massaged because it may result in inversion of uterus and serious complications.

Nursing Management (Implementation) 

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Administer oxytocics to control bleeding and promote involution. continue checking of vital signs. Encourage urination because full bladder impedes involution leading to excessive bleeding. Check lochia discharge for color, amount, consistency, and presence of clots. Aseptic perineal care. Breast care, and encourage early initiation of breast feeding to stimulate involution and lactation. Correct dehydration. Start leg exercises. Administer antcoagulant therapy as ordered.

Subsequent general daily care 

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Check vital signs twice daily (morning and evening) - A temperature of 38 C , or above for two consecutive days after first 24 hours is considered an early sign of puerperal infection. - Bradycardia is a normal physiological phenomenon. Palpate the uterus to assess firmness, level of fundus, and rate of involution. Administer oxytocic medications to promote invoultion. Check lochia for color, amount, odor, consistency, and clots. Observe perinum and suture line for redness, ecchymosis, edema or gapping. Provide for sufficient periods of rest and sleep.

Subsequent general daily care 

During the first 8 hours, the mother is encouraged to sleep in any comfortable position. After that, the prone position or lateral should be encouraged to facilitate involution and help drainage of lochia.

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Also, sitting position is recommended to promote contractions of abdominal muscles and drain lochia. Supine and semi-sitting should be avoided. Prevent infection. Provide diet high in protein and calories to restore tissues. Roughage and green vegetables to prevent constipation. Increase in fluid intake.

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Subsequent general daily care 

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Voiding should be encouraged within 6-8 hours after labor. If failed within 12 hours, catheterization is performed. Encourage early ambulation, and avoid heavy activities. Encourage postpartum exercises. Provide treatment for after pains. Monitor laboratory reports for Hb, HCT, and WBC. Observe for postpartal blues. If Rh negative mother, assess need for administration of RhO GAM. Discuss resumption of sexual relations. Discuss community resources that provide maternal services.

Subsequent special daily care 

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Breast care: - Encourage initiation of breastfeeding. - breast should be soft, until milk comes in. - Daily cleansing in shower. - Regular examination of breast for complications such as engorged breasts, cracked nipples, mastitis, and breast abscess. Pernium care: - Inspect and observe presence of episitomy. - Keep area clean and dry. - Teach the mother principles of self-care.