Cesarean Birth

Caesarean birth may be a planned or an

emergency procedure. Factors that lead to
cesarean birth may be maternal, placental,
or fetal in nature.
 Cesarean factors
Maternal:
 Cephalopelvic disproprotion

 Active genital herpes or papilloma

 Previous cesarean birth by classic incision

 Disabling conditions, such as severe pregnancy-

induced hypertension and heart disease, that
prevent pushing to accomplish the pelvic
division of labor
 Cesarean factors
Placental:

 Placenta previa

 Premature separation of the placenta

 Cesarean factors
Fetal :
 Transverse fetal lie

 Extremely low fetal size

 Fetal distress

 Compound conditions, such as macrosomic

fetus in a breech lie
Types of Skin Incisions
Types of Uterine Incisions
Postpartum
WHAT IS PUERPERIUM?
 Important characteristic features of
the puerperium are

1. The reproductive organs return to their

normal pre-gravida state through a process
known as involution.
2. Lactation is initiated or started.
3. Recovery from the physical and emotional
experience of childbirth takes place.
PHYSIOLOGIC CHANGES
 UTERUS
Involution
• Autolysis
• Ischemia

• Uterus
– After delivery : midway of S.P. and navel
– Within 24 hours : level of the navel
– Descends to 1cm/day until the 10th to 12th day
 Lochia
• LOCHIA RUBRA (RED)
• LOCHIA SEROSA (PINK)
• LOCHIA ALBA (WHITE)

Persistent red lochia in considerable amounts for more

than two weeks maybe a sign of:
• retention of small portion of the placenta or
membranes
• sub-involution of the placental site. Sub-involution
refers to any delay in the normal process of return to
normal,
 Cervix
• Tone is developed within the first 24 hours.
• The cervix gradually closes so that by the end
of the first week, there is a well developed
cervical canal and the external os can hardly
admit one finger.
However, at the completion of involution, the
external os can does not resume its pre-gravid
appearance.
 VAGINA and PERINEUM
• The vagina rarely returns completely to
normal there will always be evidence of
relaxation.
• Wider vaginal outlet.
• The hymenal ring is replaced by healed tags of
tissue, the carunculae myrtiforms.
• The labia majora becomes flabby
• Perineum with healed perineorrhaphy or
episiorrhaphy
 Peritoneum and Ligaments
• Lax ligaments due to stretching
 Bladder
The wall of the urinary bladder, during the puerperium, shows
edema or swelling, redness, and even small areas of hemorrhages
as a result of trauma or injury during the process of childbirth.

As a result, the puerperal bladder is :

a.) atonic (lacks muscle tone)
b.) less sensitive to increased distention from accumulation of urine.

These factors are mainly responsible for the frequency of urinary

retention or incomplete emptying of the bladder during the
puerperium. Another factor which may contribute to retention of
urine is reflex spasm of the urethral sphincter as a result of pain
from vulvar swelling bruising or perineal stitches.
 Gastro-Intestinal Tract
• Gastro-intestinal atony with varying degree of
tympanism (gas) is common.
• Constipation is usual because of:
• intestinal atony
• patient's inactivity
• decreased-abdominal pressure
• reflex spasm of the anal sphincter from the pain of
bruising and stitches in the perineum.
 Abdominal Wall
• soft and flabby for a while.
• Presence of silvery striae gravidarum, the
abdominal wall may regain its normal
appearance but may remain lax if the muscle
are atonic.
• There maybe a permanent diastasis recti (a
marked separation of the rectus muscle at the
midline.)
 Breasts
• Condition is maintained during the first two days postpartum.
• At this time, they do not contain milk, but a small amount of colustrum may
expressed, from the nipples.

Colostrum
• Colostrum is the thin milky fluid that is secreted by the mammary glands a
few days before or after parturition.
• It contains large fat globules known as colostrum corpuscles.
• Compared with breast milk which is ultimately secreted by the mammary
glands, colostrum contains more protein and minerals but less sugar and
fat.
• It also contains maternal antibodies which help protect the newborn from
infections.
• It also has a laxative effect on the newborn. The secretion of colostum
persists for about a week after which gradual conversion to mature breast
milk occurs.
 Lactation
• During pregnancy, estrogen, progesterone and chorionic
somatomammotrophin (or human placental lactogen) produced by the
placenta stimulate mammary growth. Estrogen promotes development of
the ductal system; progesterone the acinar or alveolar system; human
placental lactogen has lactogenic (milk-producing) properties. Together,
these 3 hormones inhibit or prevent the anterior pituitary gland from
releasing its lactogenic hormone, prolactin (also known as lactotorophic
hormone, luteotrophic honnore or LTH).

• With the delivery of the placenta, there is an abrupt decrease in the levels
removing the inhibition on the anterior or pituitary so that prolactin is
released which results in the initiation or beginning of lactation
(production of milk). Prolactin is also responsible for the main source of
lactation. On or about the third day of puerperium the breasts suddenly
become heavy, larger and firmer indicating filling up of the breast milk
(engorgement).
 Lactation

• Oxytocin in addition to its oxytoxic properties, aids in the ejection

of milk already formed and retained in the mammary gland by
bringing about contraction of the myoepithelial cells in the alveoli
and ducts. The letting down reflex maybe inhibited or prevented by
fright or any form of stress on the part of the mother.

• Mother’s milk is usually bluish white, sometimes yellowish in color.

Most drugs given to the mother are secreted in the milk. The list
includes antibiotics and sulfa drugs, aspirin and other salicylates,
ergot alkaloids, purgatives, nicotine (in cigarettes), tranquilizers or
sedatives.

Unless large doses are administered or therapy is continued

for a long period of time, the content of drugs in milk is
generally not harmful to the infant.
Assessment of the Patient’s Condition
• Observations on the vital signs
• Condition of the uterus
• The status of the urinary bladder
• The character and amount of lochia and general
condition of the patient are noted.
These observations should be continued more or
less regularly until the l0th postpartum day. If the
patient had a hospital delivery and was
discharged on the 2nd or 3rd postpartum day,
observations may be continued less regularly
during home visits made for this purpose.
 Temperature
Normal but occasionally, a rise may be observed:
• at the end of labor and within the first 24 hours
• on the 3rd or 4th postpartum day at the time of
extreme breast congestion (mistakenly referred
to as “milk fever”).

These possible rises of temperature are transient

and last only for a few hours. All temperature
elevations should be considerable signs of
infection unless proven otherwise, and should be
reported to the physician.
 Pulse
• a slowing of the pulse rate to 60-80 minutes and a
return to normal by the 10th day.
• A slow pulse is a good sign; The possible causes of
slowing of the pulse rate are:
• the horizontal or recumbent position of the patient
• release from the stress of labor
• decreased food intake and activity
• decreased cardiac load

• a rapid pulse (100-120 minute or more) may mean

hemorrhage, cardiac disease, or infection (especially
if together with a rise in temperature.)
 Blood Pressure
• checked at least once a day during her hospital stay. It is wise for the
midwife to compare the patient's blood pressure and pulse rate with the
rates recorded during her pregnancy and labor.

• High Blood Pressure

– This may be a transient reaction from oxytocic injection she received in the
delivery room, in which case it should go down to normal levels within an hour
or so.
– If persistently high beyond this time and/or reaching levels of 150/100 mm.
Hg. and above this condition should be reported to a physician. An elevated
blood pressure may indicate pre-eclampsia during early postpartum period.

• Low Blood Pressure: (Below 90/60 mm. Hg.) This is usually due to blood
loss especially if together with an increase the pulse rate and should be
immediately reported to the physician.
 Respiration
No remarkable change: It may increase after
the third day because of increased activity.
 Uterus

• The reduction in the size of the uterus as

indicated by the height of the fundus uteri during
the first few days postpartum that has been
described. Early constipation of the uterus also
gives the midwife the opportunity to note the
consistency of the uterus;

• the presence of tenderness (pain or pressure)

which may indicate infection and the presence of
a distended bladder.
Involution of the uterus. A, Immediately after delivery of
the placenta, the fundus is midline and halfway between the
symphysis pubis and the umbilicus. B. Within 24 hours
after birth, the fundus is at the level of the umbilicus. It then
descends one finger breadth (approximately 1 cm) each day.
 Bladder Distention/Retention of Urine
(incompletely Emptying Retention of
Urine)
• is less common since the practice of early ambulation but may occur;
– following a difficult delivery
– when the bladder had not been previously emptied during labor
– in a mother who received obstetric received obstetric analgesic and anesthesia in the
presence of swelling or bruising of the vulva and painful perineal stitches.

• Incomplete emptying of the bladder results in residual urine (urine

remaining in the bladder after emptying) which becomes stagnant and is
good medium for the growth of bacteria resulting in urinary tract
infections.

• As a general rule checked for distention four hours after delivery and if
distended, measures to induce urination should be started catheterization
under aseptic technique must be done.

• A voiding in order to be satisfactory must pass a urine volume of at least

100-150 cc.
 Lochia
• The character and amount of lochia during
the puerperium is noted. Perineal pads should
be inspected and the amount of discharge
noted from the number of pads soaked. A
moderate amount of lochia usually covers or
wets a perineal pad fairly well in one hour.
Suggested guideline for assessing lochia volume.
 REEDA Scale for Incisions
• Redness
• Edema
• Ecchymosis
• Discharge
• Approximation
 General Condition
• Patients have different reactions after
delivery. Some are excited and talkative;
others are quiet and want only to sleep and
rest; still, others are hungry and want to drink
and eat right away.
Psychosocial Needs
• Promoting bonding
• Rubin’s Phases
Taking in – wants to be
taken care of

Taking hold – takes charge

Letting go – more realistic

 DIFFERENTIATION OF PPB, PPD AND PPP
Characteristics Postpartum Blues Postpartum Depression Postpartum Psychosis

INCIDENCE 70 % to 80 % of new mothers, 7 % to 20 % of new 1 % to 2% of mothers

26 % in adolescent mothers mothers per 1,000 livebirths

ONSET 3-5 days after childbirth Usually within six months Usually within two to
after childbirth four weeks following
childbirth
SYMPTOMS Periodic crying spells, Anorexia, weight loss, Early symptoms may
sadness, confusion, insomnia, insomnia, fear of harming resemble depression
and anxiety the baby, neglect of and then suddenly
personal care, escalate to delirium,
Self-destructive feelings of hallucinations, anger
worthlessness, guilt, towards self and baby,
fatigue, hypochondria, and bizarre behavior,
low self esteem manifestations of
mania, and thoughts of
hurting self and baby
CONTACT WITH Maintained consistently Intact but can be Loss of touch with
REALITY disoriented; sense of reality, severe
suicidal thoughts and regressive breakdown,
depersonalization when high risk of schedule
severe and/or infanticide
 MANAGEMENT

Postpartum Blues Supportive care and education is important

Postpartum Depression 1. Monitor for signs of suicidal tendencies

2. Provide assistance in performing activities
3. Support groups
4. Screening: Edinburgh Postnatal Depression
5. Individual Counseling
6. Therapeutic Communication
7. Group therapy
8. Medications

Postpartum Psychosis 1. Immediate psychiatric evaluation and treatment in the hospital

2. Removal of infant from the mother
3. Medications
4. ECT
5. Psychotherapy
 BUBBLEHE Assessment
• Breasts – Soft, filling, firm, Nipples
• Uterus – consistency, position, height, C/S
• Bladder – voiding pattern
• Bowels – bowel sounds, hemorrhoids, BM
• Lochia – type, amt, clots, odor
• Episiotomy – laceration, bruising, swelling
• Homan sign – present or not
• Emotional status – bonding, blues
RELIEF /COMFORT MEASURES
• Perineal Care
• Care of Episiotomy
• Hemorrhoids
• Afterpains
• Bowel Elimination
• Bath
• Breast Care
ROUTINE CARE AND HEALTH CARE
INSTRUCTIONS
 Routine Postpartum Care

Mother feels well Give any treatment

BP, pulse & temperature or prophylaxis due
normal Iron
No breast problems, Vitamin A
breastfeeding well Tetanus
Uterus well contracted Advise and Counsel
Health education
No problem with urination Schedule return visit
No pain or other concern
 Abnormalities in Postpartum Period

Elevated BP Pus or perineal pain

Pallor Feeling unhappy
Vaginal Bleeding Vaginal discharge
Foul smelling lochia Breast Problem
Infection/ Breast abscess
Dribbling Urine Sore or cracked nipple
Engorgement
Insufficient milk
Cough or breathing
REFER difficulty
 Postpartum Bleeding
• Women who develop vaginal bleeding >24
hours postpartum have LATE postpartum
bleeding.
• May be due to retained placental fragments
• Uterus is soft and larger than expected
• REFER!
• If excessive bleeding: insert IVF, give 10 u
oxytocin IM
 Elevated BP
• Blood pressure > 140/90
• Look for signs that could indicate severe pre-
eclampsia
– Severe headache
– Blurring of vision
– Epigastric pain
– Severe breathing difficulty
 Treatment and Prophylaxis
1. Prevent anemia with iron/folate
supplementation.

2 tablets of iron/folate daily for 2 months (or

more if mother is pale)

2. Give one capsule Vitamin A (200,000 IU) if

none was given antepartum --- to protect
the baby from nutritional blindness and
infections.
 ADVISE AND COUNSEL

1. Postpartum care and hygiene

– Wash hands before handling baby
– Wash perineum daily
– Have enough rest and sleep
– Avoid sexual intercourse until perineal wound
heals.

2. Nutrition
– Eat a greater amount and variety of healthy foods
– Spend more time on nutrition couselling with thin
women and adolescents.
Encourage Breastfeeding

Importance, benefits and management of

breastfeeding
Teach correct positioning and attachment for
breastfeeding
Support exclusive breastfeeding for the first 6
months of life
Encourage breastfeeding on demand
Need to avoid supplementary feeds
 Birth Spacing & Family Planning

• Counsel on importance of family planning

• Inform about all contraceptive choices in postpartum
period (ideally done antenatal)
• Facilitate free informed choice for all women
• Reinforce that non-hormonal methods (LAM, barrier
methods, IUD and sterilization) are best options for
lactating mothers
• Discuss other method options for the breastfeeding
& non-breastfeeding woman
 Birthspacing and Family Planning
• Importance of family planning
– A woman who is not exclusively breastfeeding can
become pregnant as soon as 4 weeks after delivery if she
has sex.
Method options for
Method options for breastfeeding woman
non-breastfeeding woman Immediately postpartum:
Immediately postpartum: LAM, Condom, BTL, IUD
Condoms, IUD, BTL Delay 6 weeks: Progestin
Progestogen only OCP and only pills and injectables
injectables (DMPA)
Delay 6 months:
Delay 3 weeks: combined OCP, Natural
Combined OCP/injectables family planning
Natural family planning
Lactation Amenorrhea Method (LAM)
• 1st line contraceptive for postpartum women
• 3 conditions
– Exclusive breastfeeding
– Menstruation has not returned (amenorrhea)
– Within 1st 6 months of delivery
 Schedule Return Visits
All postpartum women should have at least 2 routine
postpartum visits.

• 1st visit: 1st week postpartum,

preferably within 48 -72 hours.

• 2nd visit 6 weeks postpartum

Women who do not return for postpartum visits

should be visited at home.
 “ Because the more a
mother is cared for,
the more easily she
can care for her
baby.”
"Imagine Infinite Potential" -Shivam Rachana
by Mara Friedman