Presented

to:
Dr/Esraa

Suez Canal Univercity Hospital

FON/SCU
2022-2023

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 Presented by /
1. Eman Mohamed Ahmed
2. Esraa Mohamed Salama
3. Nada Mahmoud morsy
4. Norhan Mahmoud ebrahim
5. Hadeer Nabil Salah
6. Hayam magde Mahmoud

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OBJECTIVE
Definition of postpartum period
General and local physiological changes
Psychological changes during postpartum period
Danger signs during postpartum period
Nursing ,management during postpartum

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Definition of postpartum period
It is the period following labor during which the maternal body in general, and the genital tract, in pa
Duration of the postpartum is 40 days or 6-8 weeks (maximum involution).
Another 4 to 6 weeks is needed for complete involution. The puerperal period is much shorter after a
General and local physiological changes

Uterus:
The uterus should be firm, well contracted and in the midline.
Size of the uterus:
Immediately after labor the level of the fundal height should be at or below the level of the umbilic
The level of the fundus descends gradually at a rate of about I finger breadth every day.
So, by the end of 1stweek the fundus is midway between umbilicus and symphsis pubis. By the 2n

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Weight of uterus :
• The weight of the uterus also decreases gradually throughout the postpartum.
By the end of the postpartum it weighs 50 gm instead of 1000 gm during
pregnancy.
Involution of the uterus
is the return of the uterus to its pre—pregnant condition.
-Mechanisms of involution.
1- Autolysis (Self Digestion)

The protein material of the muscle fibers is broken down by certain enzymes and
absorbed in the blood stream, and excreted by the kidneys in the urine.
2- Ischemia (Decreased Blood Supply)

Contraction and retraction of the uterine muscle fibers compress the blood vessels
and reduces the blood Supply to the uterus. The old blood vessels become
obliterated by thrombosis, and then undergo degenerative changes.
 The Endometrium
• All except the basal layer of endometrium is shed off in the lochia.
• A new endometrium is formed in the next weeks except at the placental site,
which is a raised area of thrombotic sinuses. This area is finally healed and
covered by a new endometrium by the end of 7 week (40 days).
• If the process of involution is slow, or delayed, the condition is known as
―subinvolution‖, while rapid involution of the uterus is cal led ―hyperinvolution‖.

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After-pains:
It is a spasmodic colicky pain in the lower abdomen (like miniature labor pains that come and go)
It is more common and more severe in multiparas(It is due to weak muscle tone ), multiple pregna
After—pains can be precipitated by the presence of blood clots, a piece of membrane. or placental

• After—pains increase during breastfeeding because the infant’s suckling

stimulates further milk production, which in turn stimulates the posterior pituitary
gland to secrete oxytocin that results in more uterine contractions causing
increase in after—pains.
 Lochia:
• It is the uterine discharge coming through the vagina during the first. 3—4 weeks
of the postpartum. It is alkaline in reaction; the amount is rather more than the
menstrual flow, with fleshy odor. It contains blood, fibrin, leucocytes, decidual
tissue, vaginal epithelial cells, peptone, cholesterol, and numerous nonpathogenic
bacteria.
Types of Lochia:
1- Lochia Rubra:
presence of a the discharge is red in color due to the high amount of blood, shreds
of the deciduas, large amount of chorion, amniotic fluid lanugo hair, vernix
caseosa, and meconium may also be present. This discharge lasts from the 1st
postpartum day to the 4th day’ (and sometimes to 7th day).

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2-Lochia serosa: a pink yellow discharge containing less blood and more serum, and extends for a

3- Lochia alba: a creamy or white colored discharge containing leucocytes and

mucus. It remains for the 10 days postpartum
Abnormal lochia:
• Offensive lochia denotes the presence of infection and/or stagnation.
• Sudden suppression may be due to severe infection.
• prolongation or recurrence of lochia rubra may suggest retained parts of the
placenta, membranes, RVF, subinvolution, tumors, as fibromyomas.
 Cervix
✓ it never returns to the nulliparous state.
✓ os looks like a slit instead of a circle or dot
 Genital Organs
Vagina:
• The vagina diminishes in size. but not as the pregravid state.
• Rugae reappears in the third week.
• Cystocele, rectocele or uterine prolapse, may develop with heavy
household duties. Rest in bed, elevation and tightening exercises prevent
these lesions.
Vulva:
• Edema disappears gradually in a few days while lacerations, if not properly
mended by sutures, may lead to the formation of a postpartum ulcer which is
a septic very tender ulcer .

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Ligaments and pelvic floor muscles
The ligaments that support the genital organs are now relaxed and will take a considerable time to
Other structures such as the peritoneum, pelvic floor muscles involutes near to their original state,

Diastasis rect

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Breast
During pregnancy the breasts prepared for lactation by estrogen and progesterone hormones.
Prolactin hormone increase gradually during pregnancy, but high level of
estrogen inhibit milk production.
After placenta separation ,estrogen falls during 48 hours that stimulate increasing secretion of prol

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General physiological changes
 Vital
Signs A-
Temperature
The temperature is slightly elevated 0.5 degrees for the 1st 24 hours.
This rise in temperature is due to the absorption of waste products of muscular
contractions of labor ( effort).
Transient rise in temp. later on is due to:
* Milk engorgement (by the 4th day postpartum).
B- Pulse:
The pulse is full and slows (60 – 70 b/m) and is known as physiological
bradycardia. (for 24– 48 hrs after labor). It is due to:
- The increase in the circulating blood volume on account of the elimination of
the placental pool.
- The rest period after labor
C- Respiration:
Decrease in respiration rate. This is in the usual relation with pulse and
temperature. Because of a reduction in the size of the uterus and relaxation of the
abdominal muscles.
Deviation from the normal may Suggest pneumonia or embolism.
D- Blood pressure:
No change is counted.
If hypotension is present,Post partum hemorrhage may Suspected.
If hypertension is present (over 140/90mmhg) Post partum toxemia may be
Suspected.

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  Skin:
- Excessive sweating (diaphoresis), particularly in patients who were subjected
to edema in late pregnancy, In order to get rid of excess fluids that were retained
in the tissues.
- This gradually ceases within the 1st week and the skin reacts as usual.
- Skin pigmentation gradually disappears.
 Kidneys and urinary output:
• There is usually physiological diuresis (polyuria).
• Painful, difficult micturition.
• Traces of albumin and peptone may be present as a result of muscle involution.
• Lactosuria is common with milk engorgement on the 4th day at the start
of lactation.
• Retention of urine
N.B
Retention of urine in the first few days after labor due to:
- Laxity of the abdominal muscles.
- Reflex inhibition due to stitched perineum or bruised urethra.
- Atony of the bladder.
- Compression of the urethra by edema or hematoma.

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  Gastrointestinal tract:
• Thirst is present due to marked fluid loss through sweat and urine.
• Tendency to atony of the gastrointestinal tract, with flatulence and constipation.
Constipation is due to:
• Intestinal atony.
• Loss of body fluid.
• Laxity of the abdominal wall.
• Hemorrhoids
• Anorexia after labor.
• Enema in labor.
 Blood Picture:
• The amount of blood loss during the 3rd stage of labor does not cause anemia.
• Hydremia of pregnancy disappears ( Blood volume decreases.
• A moderate increase in the leucocytic count, fibrinogen and sedimentation
rate occurs during the first postpartum period.
• RBC count and the blood constituents, usually return to the non—pregnant levels
in 4—6 weeks.
 Body Weight:
• Loss of weight is observed during the first 10 days. There is about a 4-5 kg,
sometimes 8 kg.
• loss of body weight due to evacuation of uterine contents and diuresis.

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  Return of Menstruation:
• Non—lactating mothers begin to menstruate again in 6— 8 weeks. it may
be delayed for a longer period without any abnormal condition being present.
• In lactating mothers, menstruation usually reappears not earlier, than 4—5
months, and sometimes as late as 24 months.
• The first period is generally profuse and prolonged.
• It should be remembered that ovulation start and another pregnancy can occur
before menstruation occur.

3. Psychological changes during postpartum period

Emotional changes in the mother during the postpartum period pass through
three phases:
1- Taking in phase.
It take 2-3 days. The mother is passive and concerning in her own
needs 2- Taking-hold phase.
It starts the 3rd day postpartum. She emphasis on the present and start to organize
her self and her life.
3- Letting-go phase.
The mother in this phase must to accept physically separation from her infant, and
accept the enormous responsibilities as a mother and her former role as a childless
person.

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 4. Danger signs during postpartum period
Early/ first weeks - danger signs
– Perineum not intact, pronounced edema, signs of infection, marked discomfort
– Positive Homans’ sign, painful/reddened area and/or warmth on posterior
aspect of calf
– Homans’ sign
Breasts – redness, heat, pain, cracked and fissured nipples, inverted nipples,
palpable mass
First weeks - danger signs
– Urine retention, dysuria
– Bowel – constipation, diarrhea
– Lack of appetite
– Lethargy, extreme fatigue
– Inability to rest or sleep

Nursing management during postpartum

Assessment
Observation of bleeding signs and symptoms by:
Palpating the fundus of the uterus through the abdominal wall. Normally, the uterus should be firm, ro
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.

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 2-Observation of legs for signs and symptomsof deep vein thrombosis (DVT):
pain, warmth, tenderness, swollen reddened vein that feels hard or solid. (specially after C.S)
Nursing Diagnosis
Potential for:
Postpartum bleeding. Deep vein thrombosis. Infection.
Planning and Implementation

Measures to prevent bleeding

Palpate the uterus If it remains firm well contracted and does not increase in size, it is neither neces
Administer oxytocics (e.g. ergometrine 5 mg.IM) as ordered to control bleeding and to promote inv
Check lochial discharge for color, amounts consistency and presence of
clots.
Encourage urination because full bladder impedes involution and may cause atony of the uterus lead
Checking of vital signs 2 times daily; observe signs of hemorrhage or infection.
Encourage early initiation of breast. feeding to stimulate involution, lactation and to enhance emotio
Proper positioning; prone position , lateral or sitting position help drainage of lochia and promote in

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Measures to prevent Deep vein thrombosis
Start early ambulation, and leg exercises especially following Operative delivery. Heavy activities
Administer prophylactic anticoagulant therapy as ordered
Correct dehydration promptly by offering fluid intake (orally), or starting IV
fluid as ordered.

Measures to prevent infections

Perineal care
-Inspect and observe for presence of episiotomy, lacerations, edema, pain or laceration.
Keep the area clean and dry by employing perineal care under aseptic
technique to Prevent infection..
Teach the mother principals of self—care

Other aspects of care

General hygiene: shower may be permissible to clean, comfort and refresh the mother (after vital
nutrition: Offer food to mother, after vital signs are stable. Diet high in protein, calories, iron, and
Abdominal muscle exercise
Pelvic floor muscles exercise
4-Provide sufficient periods of rest and sleep; 8hr. At night and 2hr.afternoon
are needed.

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Assist mother with self care and infant care.
Health teaching about:
Postpartum Examination, visits

• Family planning methods

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