Nursing Care of a Woman and Family (Puerperium)

Chapter 22
Postpartal Period
Also puerperium (Latin)
 Puer – “child”
 Parere – “to bring forth”
Refers to the 6-week period after childbirth
“4th trimester of pregnancy”

2 Maternal changes involved:

Retrogressive changes
 Involution of the uterus, vagina
Progressive changes
 Production of milk for lactation
 Restoration of normal menstrual cycle
 Beginning of a parenting role (psychological changes)

Protecting a woman’s health as these changes occur is important

 For preserving her future childbearing function and
 For ensuring she is physically well enough to incorporate her new child
into her family

Phases of the Puerperium

1. Taking – in
 1st phase experienced
 Time of reflection
 2- to 3-day period
 Woman is largely passive
 Depends entirely on a nurse or other individuals for her needs, even
decision-making
Due partly to:
 Physical discomfort - due to perineal stitches, after pains,
hemorrhoids
 Uncertainty in caring for her newborn
 Extreme exhaustion that follows childbirth
Woman would usually want to talk about her pregnancy, esp. about her
labor and delivery
Holds her new child w/ a sense of wonder
She rests to regain her physical strength and to calm and contain her
swirling thoughts
Encouraging her to talk about the birth helps her integrate it into her new
life experiences

2. Taking-Hold Phase
Woman begins to initiate actions
Begins to do things for herself gradually
Takes interest in caring for the baby
Best to give woman brief demonstrations of baby care and then allow her
for her child herself – w/ watchful guidance
Taking-Hold Phase
Still feels insecure about her ability to care for her new child
Needs positive reinforcement
 Praise for things she does well – to give her confidence
Do not rush the woman thru the phase

3. Letting Go Phase
Woman finally defines her new role
She gives up the fantasized image of her child and accepts the real one
Gives up her old role of being childless or mother of 1 or 2
Requires some grief work and readjustment
Extended and continues during the child’s growing years
Dev’t of Parental Love and Positive Family Relationship
During pregnancy – almost q woman worries about her ability to be a
“good” mother

Dyana M M Saplan, RN PhD 2019

  Does not evaporate as soon as baby is born
 Many may not experience maternal feelings for their infants until
days or even weeks after giving birth
 Until as late as 3 mos. after birth – child begins to smile, coo,
interact more directly
“Claiming” or bonding
 Feeling motherly or fatherly love toward the new child
 Holds child more, express more warmth, touching child w/ palms
of hand (rather than fingertips)
 Become a mother tending to her child
En face position, engrossment
 looking directly @ newborn’s face, w/ direct eye contact
 Sign mother or father is beginning effective interaction or is
relating well w/ child
 Rooming – In
Infant stays w/ mother in the room rather than in a central
nursery
She can become better acquainted w/ her child and begin to
feel more confident in her ability to care for her/him after
discharge
2 Types of Rooming – In
Complete
 Mother and child together 24 hours/day
Partial
 Infant remains in woman’s room for most of the time,
then taken to a small nursery (near woman’s room) or
returned to a central nursery for the night

Postpartal Maternal Concerns

Breast soreness
Regaining her figure
Regulating demands of housework, partner, and children
Coping w/ emotional tension and sibling jealousy
Fatigue

Postpartal Maternal Feelings

Abandonment
 Feeling less important after giving birth
 Feeling of jealousy
 Help woman move past these feelings by verbalizing the problem
Disappointment
 Child does not meet their expectations
 Expecting different sex, size or look of child
 Handle child warmly – to show infant is satisfactory or even special
 Comment on child’s good points – long fingers, lovely eyes . . .
Postpartal Blues
 50% of women experience feelings of overwhelming sadness
 Burst into tears easily, feel let down, or irritable
 Temporary feeling known as “baby blues”
 Hormonal changes -  estrogen and progesterone that occurs after
delivery of placenta
May be a response to dependence and low self-esteem caused by
 exhaustion, being away from home, physical discomfort, tension in
assuming a new role, not receiving enough support from partner
evidenced by
 Tearfulness, feelings of inadequacy, mood lability, anorexia, sleep
disturbance
Nursing Mgt. on Postpartal Blues
Reassure sudden crying episodes are normal
Anticipatory guidance and individualized support – to help parents
understand that this is normal
Allow to verbalize feelings
Allow to make as many decisions as possible – give her sense of control
over her life
Postpartal Depression
30% of women
Dyana M M Saplan, RN PhD 2019
 More serious level of sadness after birth
Require formal counseling or psychiatric care (12%)
Complication of puerperium = psychosis

Reproductive System Changes

Involution
 Process whereby the reproductive organs return to their non-pregnant
state
 Woman is in danger of hemorrhage from the denuded surface of the
uterus until involution is complete
 Area where placenta was implanted is sealed off = bleeding prevented
 Uterus is reduced to its approximate non-pregnant state

Physiologic Changes of the Postpartal Period

Uterus
Involution of uterus involves 2 main processes
1. Area where placenta was implanted is sealed off = preventing bleeding
2. Uterus is reduced to its approximate progestational size
Mechanism (Sealing of placenta site)
Accomplished by rapid contraction immediately after delivery of
placenta

Pinches blood vessels in the area left denuded by placenta

Stopping bleeding

Thrombi form w/in uterine sinuses to permanently seal the area

Endometrial tissue undermines site and obliterates organized
thrombi
Mechanism cont’d
Endometrial tissue undermines site and obliterates organized
thrombi

Covering and sealing area completely

Leaving no scar tissue w/in the uterus and does not compromise
future implantation sites
Mechanism
(Reduction of bulk of uterus)
Devoid of the placenta and membranes – walls of uterus thicken
and contract

Gradually reducing uterine size

Main mechanism – CONTRACTION

 Similar w/ a rubber band that’s been stretched for many months
and now regaining its normal contour
 Not destroyed but shape is altered
Uterus weight
Immediately after delivery – uterus weighs 1000g
End of 1st week – 500g
Time Involution is complete (6 weeks) – 50g (pre-pregnant weight)
Fundus
Immediately post delivery – halfway bet. umbilicus and symphysis pubis
1H after to the next 24H – level of umbilicus
Decreases 1 fingerbreadth/day (about 1 cm)
Ave. woman – by 9th or 10th day – uterus have w/drawn into the pelvis an no
longer detected by abdominal palpation

Uterine involution
 Uterus es in size @ a predictable rate during postpartal period
 After 10 days – receds under pubic bone, no longer palpable

Breastfeeding mother

Dyana M M Saplan, RN PhD 2019

  Uterus contract more quickly and forcefully
 Release of oxytocin
 Stimulating uterine contraction
 Not enough to protect against postpartum hemorrhage

Causes of Delayed uterine involution

Birth of multiple fetuses
Hydramnios
Exhaustion from prolonged labor or difficult birth
Grand multiparity
Physiological effects of excessive analgesia
Retained placenta or membranes – contraction may be difficult

Well-nourished woman
Early ambulation – gravity
1stH after birth – potentially the most dangerous
 Relaxed uterus = Uterine atony – lose blood very rapidly because no
thrombi have yet formed @ the placental site
After – pains = contractions of uterus after birth causes intermittent cramping
(similar to menstruation)
 Noticed most by multiparas, women given birth to large babies, over-
distended uterus
 so uterus must contract more forcefully to regain pre-pregnancy size and
difficulty maintaining steady contracted state
 Ice compress over uterus

Lochia
 Uterine flow consisting of blood, fragments of decidua, white blood cells,
mucus, and some bacteria
Normal discharge postpartum
Uterus where placenta was not attached is fully cleansed by this sloughing
process – will be in a reproductive state in about 3 weeks

Types of Lochia
1. Lochia Rubra
 1 – 3 days
 Consists entirely of blood, fragments of decidua, and mucus
 Red in color
 Moderate in amount
2. Lochia serosa
 About 4th – 10th day
 Discharge becomes pink or brownish
 Blood, mucus, and invaing leukocytes
 Small in amount compared to rubra
3. Lochia alba
 10th – 14th day
 may last 3rd – 6th week
 Amount decreases
 Becomes white – colorless
 Largely mucus, leukocyte count high

Evaluating Lochia Flow

Evaluate Amount
Shd approximate to a menstrual flow
Breast-feeding mothers – less lochia
Oxytocin – strengthens uterine contractions
Conservation of fluid for labor
es on strenuous exercise/activity
Abnormal: if perineal pad becomes saturated in less than an hour

Check consistency
Shd contain no large clots
 May indicate a portion of placenta has been retained – preventing
closure of maternal uterine blood sinuses
 Denote poor uterine contraction

Dyana M M Saplan, RN PhD 2019

 Observe the pattern
Pattern should not reverse
Red flow after a pink or white
retained placental fragments, or
ing uterine contraction and new bleeding is beginning

Assess color
Odor same as menstrual flow
Shd not have an offensive odor
Indicates uterine infection
Immediate intervention is needed to halt postpartal infection

Watch for absence

Watch for Absence of Lochia
Shd never be absent
Scant in amount in cesarean section – but never absent
Cervical changes
Immediately ff. delivery, it is soft and malleable
Both internal and external os are open
By end of 7 days – external os has narrowed to size of pencil opening
 Cervix feels and non-gravid again
External os remains slightly open and appears slit-like or stellate (star-shaped) –
previously round
Vagina
Soft, w/ few rugae, and diameter is considerably greater than normal
Hymen permanently torn and heals w/ small, separate tags of tissue
Takes 6 weeks (entire postpartal period) to involute until gradually returns to
pre-pregnant state
Vagina
Thickening of walls – depend on renewed estrogen stimulation from ovaries
 Breast-feeding – delayed ovulation
 Thin-walled or fragile vaginal cells – slight bleeding on intercourse until 6
week’s time
Outlet remains slightly more distended than before
Kegel exercises – strength and tone of vagina will increase more rapidly
 May be important for sexual enjoyment of couples

Perineum
Edema and generalized tenderness – pressure during birth
Ecchymosis on the surface – from ruptured capillaries
Majora and minora – typically remain atrophic and softened, never returning to
pre-pregnant state
To alleviate discomfort:
Hot sitz bath
Analgesia
Heat lamps or infrared lamps
Nursing Care – focus on perineal area
 Douching – prevent infection due to proximity to anal canal; for faster
healing also
 Advice early ambulation – prevent complication

Systemic Changes
Pregnancy hormones begin to decrease as soon as placenta is no longer present
hCG and hPL levels – almost negligible by 24H
Week 1 – progestin, estrone, estradiol are @ pre-prenancy levels
FSH remains low for about 12 days then begins to rise as a new menstrual cycle
is initiated

Urinary System
Extensive diuresis takes place almost immediately – to rid body of excess fluid
accumulated during pregnancy
  urinary output to as much as 3000mL (1500mL, normal) during 2 nd – 5th
day after birth
 During vaginal birth – fetal head exerts pressure on bladder and urethra
 bladder w/ transient loss of tone , together w/ edema surrounding urethra =
es woman’s ability to sense when she has to void
Dyana M M Saplan, RN PhD 2019
  Assess for over distention of bladder
 Urinary System
Hydronephrosis or ed size of ureters – remains present for about 4 weeks after
delivery
 In conjunction w/ reduced bladder sensitivity = es possibility of urinary
stasis and UTI postpartum
Diaphoresis - excessive perspiration
 Another way of body to rid itself of excess fluid
 Prevent chills; change clothing; daily bath

Circulatory system
Diuresis + blood loss @ birth – act to reduce added blood volume accumulated
during pregnancy
 Reduction occurs rapidly – blood volume to normal pre-pregnant state by
1st – 2nd week after delivery
High level of plasma fibrinogen continues during 1st postpartal week
 Protective measure against hemorrhage
 es risk of thrombus formation
ed WBC – 30,000 cells/mm3 – particularly in prolonged and difficult labor
 Part of body’s defense against infection and aid in healing
Varicosities – recede but rarely return to completely pre-pregnant state
Vascular blemishes – spider angiomas – fade slightly but may not disappear
completely

Gastrointestinal System
Digestion and absorption begin to be active again soon after birth
Woman feels hungry and thirsty
 Due to long period of restricted fluid during labor and beginning
diaphoresis
Hemorrhoids (distended rectal veins) – often present due to the effort pelvic-
stage pushing
Bowel sounds active but passage of stool may be slow due to still-present effect
of relaxin
Bowel evacuation may be difficult – due to pain of episiotomy sutures or
hemorrhoids

Integumentary System
Stretch marks (striae gravidarum) – still appear reddened and may even be
more prominent than during pregnancy
Excessive pigment on face and neck (chloasma) and linea nigra – barely
detectable in 6 week’s time

Effects of Retrogressive Changes

Exhaustion
As soon as birth is completed – woman experiences total exhaustion
 Last several months of pregnancy – experienced difficulty in sleeping
 Near end of pregnancy – unable to find comfortable position in bed and
fetus’ activity, back or leg pain
 “sleep hunger” – difficult for her to cope w/ new experiences and
stressful situations
Weight Loss
Rapid diuresis and diaphoresis (2nd – 5th day after birth) – result in weight loss of
5 lb (2 – 4 kg) in addition to aprox. 12 lbs (5.8 kg) loss @ birth
Lochia flow causes additional 2- to 3-lb (1 kg) loss
Total weight loss: 19 lbs
 Influenced by nutrition, exercise, breastfeeding
Weight woman reaches @ 6 weeks after birth – baseline postpartal weight

Vital Sign Changes

Vital sign changes in the postpartum period reflect the internal adjustments
that occur as the woman’s body returns to its prepregnant state
Temperature
Always taken orally or tympanically (never rectally) during puerperium
 Danger of vaginal contamination and discomfort involved in rectal
intrusion
Slight  during 1st 24H – due to DHN that occurred during labor
Dyana M M Saplan, RN PhD 2019
  Adequate fluid 1st 24H – temp returns to normal
 Not a problem since most women are thirsty immediately after births
If oral temp. rises above 38C after 1st 24H period = postpartal infection
3rd or 4th postpartum day – woman may have ed temp
 Woman’s breasts fill w/ milk
 Due to  vascularity of breast tissues
 If lasts longer than a few hours – infection
Pulse
Usually slightly slower than normal
 ed stroke volume reduces PR to bet. 60 – 70 bpm
End of 1st week – PR returned to normal
Rapid, thready pulse during postpartal period = sign of hemorrhage
Blood Pressure
Shd be monitored carefully postpartum
  can indicate bleeding
 Elevation above 140 mmHg (systolic) or 90 mmHg (diastolic) – indicate
devt of postpartal PIH – unusual but serious complication of the
puerperium
Compare woman’s pre-pregnancy BP level w/ postpartal level
Oxytocin - es BP
 Check BP prior to administration
 Withhold if BP is > 140/90 mmHg and notify AP – to prevent HPN and
possibly, cerebrovascular accident (stroke)

Orthostatic hypotension
 Occurs on standing due to lack of adequate blood volume to maintain
nourishment of brain cells
 Advise to always sit up slowly and “dangle” feet on the side of her bed
before attempting to ambulate
 Caution not to walk carrying baby

Progressive Changes
2 physiologic changes that occur during puerperium involve progressive
changes, or the building of new tissue
Building new tissue requires good nutrition
 Caution women against strict dieting that would limit cell-building ability
during the 1st 6 weeks after childbirth

Lactation
Begins in a postpartal woman whether or not she plans to breast-feed
Continues to excrete colostrum the 1st 2 postpartum days
3rd day – breasts become full and feel tense of tender as milk forms w/in
breast ducts
Breast milk forms in response to  in estrogen and progesterone levels that
follows delivery of placenta
 Stimulating prolactin production, and
 Milk production
Nipple secretion changes from clear colostrum to bluish white – typical color
of breast milk
Many women experience feeling of heat or throbbing pain
Breast tissue may appear reddened – stimulating acute inflammatory or
infectious process
Distention not limited to milk ducts but also occurs in surrounding tissue
 Blood and lymph enter area to contribute fluid to the formation of milk
Feeling of tension in breasts on the 3rd or 4th day after delivery is termed as
primary engorgement
 Fades as infant begins effective sucking
Milk production depends on sucking of the infant or the use of breast pump
 Release oxytocin  contract milk ducts  and push milk forward to
cause a let-down reflex
To treat breast engorgement:
 Breast feeding
 Breast pump
 Alternate heat and cold
 Analgesic – severe cases
Return of Menstrual Flow
Dyana M M Saplan, RN PhD 2019
 Woman not breast-feeding – menstrual flow return in 6 – 10 weeks after
birth
Breast-feeding – flow may not return for 3 – 4 mos (lactational
amenorrhea)
 Some women – flow may not return the entire lactation period
Absence of menstrual flow – not a guarantee woman will not conceive
during this time
 She may ovulate well before menstruation returns

Early Ambulation
Advantages:
 Prevents circulatory complication like thrombophlebitis
 Assess for thrombophlebitis – dorsiflex woman’s ankle and ask if she feels
pain in her calf on that motion (Homan’s sign)
 Assess for redness in calf area
 Fewer bowel and bladder complications
 Prevent abdominal distention

Preparation for Discharge

Greatest need of a postpartal woman before discharge from a health care
agency is EDUCATION to prepare her to care for herself and her newborn @
home
 She must be aware of danger signs to look for and to know whom to call
for if she notices any
 Must understand safe baby care
As she enters taking-hold period
 She grows increasingly receptive to advice and looks to the nurse for
information she needs
 Best time to impart health teachings
Before discharge, woman will be given instructions by health care provider
concerning her care @ home
Make sure woman is aware that
 she has to return for an examination 4 – 6 weeks after birth
 She shd make an appointment to take baby to primary care provider @ 2 –
4 weeks of age
Discharge instructions are given verbally and in writing
 Review instructions to parents to be sure they understand them

Dyana M M Saplan, RN PhD 2019