PUERPERUM

I.DEFINITION OF TERMS
A. Puerperium/Postpartum – refers to the six – week period after delivery of the baby
B. Involution - return of the reproductive organs to their prepregnant state

II. PRINCIPLS OF POSTPARTUM CARE

A. Promoting and return to normal (involution) of different parts of the body.
1. Vascular changes
1. The 30% - 50% increase in total cardiac volume during pregnancy will be
reabsorbed into the general circulation with 5 – 10 minutes after placental delivery.
Implication: the first 5 – 10 minutes after placental delivery is crucial to
gravidocardiacs because the weak heart may not be able to handle such workload.
2. While blood cell (WBC) count increases to 20,000 – 30,000/mm . implication: the
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WBC count, therefore, cannot be used as a indicationor sign of postpartum

infection
3. Thre is extensive activation of the clothing factors, which encourages
thromboembolization. This is the reason why:
1. Ambulationis done early – 4 – 8 hours after normal vaginal delivery. When
ambulating the newly – delivered patient for the first time, the nurse should
hold on to the patient’s arm.
2. Recommended exercises
1. Kegal and abdominal breathing on postpartum day one (PPD1).
2. Chin – to – chest – on PPD2 to tighten and firm up abdominal muscles
3. Knee – to – abdomen – when perineum has healed, to strengthen abdominal and
gluteal muscles.
3. Massage is contraindicated
4. All blood values are back to prenatal levels by the 3 or 4 week postpartum
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2. Genital Changes
1. Uterine involution is assessed by measuring the fundus by fingerbreadth (=1 cm.).
on PPD1, fundus is 1 finger breadth below the umbilicus; on PPD2, 2 fingerbreaths
below and so forth until on PPD10, it can no longer be palpated because it is already
behind the symphysis pubis. Subinvoluted uterus is aa uterus larger than normal
and vaginal bleeding with clots since blood cltos are good media for bacteria, it is
, therefore, a sign of puerperal sepsis.
2. To encourage the return of the uterus to its usual anteflexed position, prone and
knee chest positions are advised.
3. Afterpains/afterbirth pains – strong uterine contractions felt more particularly by
multis, those who delivered large babies or twins and those who breastfeed. It is
normal and rarely lasts for more than 3 days.
Management:
1. Never apply heat on the abdomen
2. Give analgesics as ordered
4. Lochia – uterine discharge consisting of blood, deciduas, WBC, mucus and some bacteria.
1. Pattern
• Rubra – first 3 days postpartum; red and moderate in amount
• Serosa – net 4 – 9 days; pink or brownish and decreased in amount
• Alba – from 10 day up to 3 – 6 weeks postpartum; colorless and
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minimal in amount
2. Characteristics
• Pattern should not reverse
• It should approximate menstrual flow. However, it increases with
activity and decreases with breastfeeding.
• It should not have any offensive odor. It has the same fleshy odor as
menstrual blood. If fol smelling, may mean either poor hygiene or
infection
• It should not contain large clots.
• It should never be absent, regardless of method of delivery. Lochia has
the same pattern and amount, whether CS or normal vaginal delivery
5. Pain in perineal region may be relieved by:
1. Sim’s Position – minimizes strain on the suture line
2. Perineal heat lamp or warm Sitz baths twice a day – vasodilatation increases
blood supply and, therefore, promotes healing
3. Application of topical analgesics or administration of mild oral analgesics as
ordered
6. Sexual activity – maybe resumed by the 3 or 4 week postpartum if bleeding has stopped
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and episiorrhappy has healed. Decreased physiologic reactions to sexual stimulation are expected
for the first 3 months postpartum because of hormonal changes and emotional factors.
7. Menstruation – if not breastfeeding, return of menstrual flow is expected
within 8 weeks after delivery. If breastfeeding, menstrual return is expected in 3-4
months; in some women, no menstruation occurs during the entire lactation period.
(important: amenorrhea during lactation is no guarantee that the woman will not
become pregnant. She may be ovulating the absence of menstruation may her
body’s way of conserving fluids for lactation. Implication: she should be protected
against a subsequent pregnancy by observing a method of contraception, except the
pill).
8. Postpartum check – up – should be done after the 6 week postpartum to
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assess involution.
3. Urinary Changes
1. There is marked diuresis within 12 hours postpartum to eliminate excess tissue fluid
accumulation during pregnancy.
2. Some newly delivered mothers may complain of frequent urinatin in small
amounts; explain that this is due to urinary retention with overflow. Other, on the
other hand, may have difficulty voiding because of decreased abdominal pressure
or trauma to the trigone of the bladder. Voiding may be initiated by:
1. Pouring warm and cold water alternately over the vulva
2. Encouraging the client to go the comfort room
3. Let her listen to the sound of running water
 4. If these measures fail, catheterization, done gently and aseptically, is the
last resort on doctor’s order. (if there is resistance to the catheter when it
reaches the internal sphincter, ask patient to breathe through the mouth
while rotating the catheter before moving it inward again).
4. Gastrointestinal changes – delayed bowel evacuation postpartally may be due to:
1. Decreased muscle tone
2. Lack of food + enema during labor
3. Dehydration
4. Fear of pain from perineal tenderness due to episotomy, lacerations or hemorroids
5. Vital Signs
1. Temperature may increase because of the dehydrating effects of labor. Implication:
any increase in body temperature during the first 24 hours postpartum is not
necessarily a sign of postpartum infection.
2. Bradycardia (heart rate of 50 – 70 per minute) is common for 6 – 8 days
B. Provide emotional support – the psychological phases during the postpartum period are:
1. Taking – in phase – first 1 – 2 days postpartum when mother is passive and relies on
others to care for her and her newborn. She keeps on verbalizing her feelings regarding
the recent delivery for her to be able ot integrate the experience into herself.
2. Taking hold phase – begins to initiate action and make decisions. Postpartum blues
(an overwhelming feeling of sadness that cannot be accounted for) may be observed.
Could be due to hormonal changes, fatigue or feeling of inadequacy in taking care of a
new baby. Management: explain that it is normal; crying is therapeutic, in fact.
C. Prevent postpartum complications
1. Hemorrhage (see page 68-69)
2. Infection
D. Establish successful lactation (Table 12)0

Table 12. Physiology of Breastmilk Production

1. Implications of physiology of Breastmilk production

1. Regardless of the mother’s physical condition, method of delivery, or breast
size/condition, milk will be produced.
2. Lactation does not occur during pregnancy because estrogen and progesterone are
present and therefore inhibit prolactin production.
3. Lactation – suppressing agents are to be given immediately after placental
delivery to be effective.
 4. Oral contraceptives are contraindicated in lactating mother because they contain
estrogen and progesterone, thereby decreasing milk supply.
5. Afterpains are felt more by breastfeeding women because of oxytocin production;
they also have less lochia and experience more rapid involution.
6. In an emergency delivery;
1. Determine the EDC, whether the woman in labor is a primi or a multi, and the
stage of labor.
2. If no sterile equipment is available to cut the cord, wrap the baby and placenta
together; never cut the cord unless sterile equipment is are available.
3. If the uterus fails to contract after delivery, put the infant to the breast; the
sucking of the infant produces oxytocin which causes uterine contraction
2. Advantages of Breastfeeding
1. For mother
1. Economical in terms of time, money and effort
2. More rapid involution
3. Less incidence of cancer of the breast, according to some studies
2. For the baby
1. Closer mother – infant relationship
2. Contains antibodies that protect against common illnesses
3. Less incidence of gastrointestinal diseases
4. Always available at the right temperature
3. Health Teachings
1. Hygiene
1. Wash breasts daily at bath or shower time.
2. Soap or alcohol should never be used on the breasts as they tend to dry and crack the
nipples and cause sore nipples.
3. Wash hands before and after every feeding.
4. Insert clean OS squares or piece of cloth in the brassiere to absorb moisture when there
is considerable breast discharge.
2. Method – as suggested by the La Leche League
1. Side-lying position with a pillow under the mother’s head while holding the bulk of
breast tissues away from the infant’s nose.
2. Stimulate the baby to open his mouth to grasp the nipples by mans of the rooting reflex.
3. Infant should grasp not only the nipple but also the areola for effective sucking
motion. Effectiveness is ensured when the:
• baby’s mouth parts “hike well up” into areola
• mother feels after pains as the baby sucks
• other nipple flows with milk while baby is feeding on other breast
4. To prevent nipples from becoming sore and cracked, infant should be introduced
to the breast gradually. The baby should be fed for only 5 minutes at each breast during
each feeding on the first day, increasing the time at each breast by 1 minute per day
until the infant is nursing for 10 minutes at each breast, making a total feeding time of
twenty minutes per feeding.
5. For continuous milk production, at each feeding, the infant should be placed first
on the breast he fed last in the previous feeding. This ensures that each breast will be
completely emptied at every other feeding. If breasts are completely emptied, they
completely refill; if only half-emptied will also half-refill and after some time, will
become insufficient.
6. To break away from the closed suction at the breast after feeding, insert a clean little finger in the
corner of the infant’s mouth to release the suction, then pull the chin down. This also helps prevent sore
nipples.
7. Feed as often as the baby is hungry, especially during the first few days, because
he is receiving colostrums which is not very filling; however, it contains gamma
globulin (antibodies), the only group of substances that can never be replicated by any
artificial formula.
8. Advise the mother to learn how to relax during feedings because tension prevents good let-down.
3. Associated problems
1. Engorgement – feeling of tension in the breasts during the third postpartum day
sometimes accompanied by an increase in temperature (milk fever). The breasts
become full, feel tense and hot, with throbbing pain. It lasts for about 24 hours and is
due to increased lymphatic and venous circulation. Management:
• Advise use of firm-fitting brassiere for good support. It will not only decrease
the discomfort from breast engorgement but will also prevent contamination
of the nipples and areolae.
• Cold compress is applied if the mother does not intend to breastfeed; warm
compress is applied if she will breastfeed.
• Breast pump should not be used and breast massage should not done if the
mother is not going to breastfeed, since either will stimulate milk production.
2. Sore nipples – not contraindications to breastfeeding. Management:
• Do not use plastic liners that are found in some nursing bras because they
prevent air from circulating around the breasts.
• Use nipple shield.
3. Mastitis – inflammation of the breasts
• Symptoms
• Localized pain, swelling and redness in breast tissues
• Lumps in the breasts
• Milk becomes scantly
• Management
• Antibiotics as ordered
• Ice compress
• Proper breast support
• Discontinue breastfeeding in affected breast
4. Nutrition – lactating mothers should take 3000 calories daily and should have larger amounts of
proteins (96 Gms per day), calcium, iron Vitamins A, B and C. Non-breastfeeding women can have the
same requirements as in pregnancy.
5. Contraindications
1. Drugs – oral contraceptives, atropine, anticoagulants, antimetabolites, cathartics,
tetracyclines. (Insulin, epinephrine, most antibiotics, antidiarrheals and histamines are
generally not contraindicated. Therefore, diabetics and those with asthma can
breastfeed.)
2. Certain disease conditions, specifically tuberculosis, because of the close contact
between mother and baby during feeding. (However, mothers may use masks to
prevent droplet spread) TB germs, however, are not transmitted thru breast milk.
E. Motivate use of family planning methods – the success of the family planning program depends to
a large extent on the motivation of both husband and wife.
1. Artificial Methods
1. Physiological method – oral contraceptive.
1. Action: Suppresses the pituitary gland, thus inhibiting ovulation.
2. Types
 • Combined – estrogen and progesterone in the same dosage each
day for 20 days, starting on the 5 day of the menstrual cycle, after
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which it is discontinued and then resumed on the 5 day of the next

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menstrual cycle.
• Sequential – estrogen alone for 15 days, then estrogen and
progesterone for the next 5 days.
• Mini-pill – taken continuously.
3. Side effects – same complaints of pregnant women because of estrogen and progesterone
• Nausea and vomiting
• Headache and weight gain - due to fluid retention because of
progesterone
• Breast tenderness
• Dizziness
• Breakthrough bleeding/spotting between periods
• Chloasma
4. Contraindications
• Breastfeeding
• Certain diseases
• Thromboembolism – because there is increased tendency
towards clotting in the presence of estrogen
• Diabetes mellitus and liver disease because estrogen tends
to interfere with carbohydrate metabolism
• Migraine; epilepsy; varicosities
• Cancer; renal disease; recent hepatitis
• Women who smoke more than 2 packs of cigarettes per day
• Strong family history of heart attack
5. Should the woman forget to take the pill on the scheduled time, she should take one as soon as she
remembers and take the next ill on its regular taking time. If she still fails to do so, withdrawal bleeding
will occur because of the sudden decrease in hormonal levels.
2. Mechanical methods
1. Intrauterine device (IUD)
• Specific action: Prevent implantation by setting up a non-specific
cell inflammatory reaction to the device
• Inserted during menstruation to ensure that the woman is not
pregnant; septic abortion can result if she is pregnant
• Side effects
• Increased menstrual flow
• Spotting or uterine cramps during the first 2 weeks after
insertion
• Increased risk of infection
• When pregnancy occurs with the IUD in place, it need not be
removed since it stays outside the membranes and, therefore, will
not in any harm the fetus.
2. Diaphragm
• Specific action: A circular rubber disc that fits over the cervix and
forms a barrier against the entrance of sperms
• Is initially inserted by the doctor who determines the depth of the
vagina
• May be coated with spermicide jelly or cream for double protection
• Maybe washed with soap and water after use; us reusable
 • Sperms remain viable in vagina for 6 hours, so the device should be
kept in place during such time, but should not stay for more than 24
hours because stasis of semen can lead to infection
3. Condom
• Specific action: Sperms are deposited at the tip of the rubber sheath,
which has been placed on an erect penis prior to coitus. Has the added
potential of lessening the chance of contracting sexually-transmitted
diseases (STDs, esp. AIDS)
• Most common complaint of users: it interrupts the sexual act to apply.
3. Chemical methods – are spermicidals (kill sperms) E.g., jellies, creams, foaming tablet, and
suppositories.
4. Surgical method
1. Tubal ligation – the Fallopian tubes are ligated in order to prevent passage of
sperms. Menstruation and ovulation continue
2. Vasectomy – small incision made into each side of the scrotum and the vas
deferens is cut and tied, blocking the passage of sperms. Sperm production
continues, only passage into the exterior is prevented. (Sperms in the vas
deferens at the time of surgery remain viable for as long as 6
months. Implication: Couple should still observe a form of contraception
during this time to ensure protection against subsequent pregnancy.)
2. Natural
1. Biological method – Rhythm/Calendar/Ogino-Knause Formula
1. Specific action: the couple abstains on days that the woman is fertile
2. Procedure
• The woman charts her menstrual cycles for 12 continuous
months in order to determine the shortest and the longest
cycles

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18 11
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3. Rhythm/Calendar/Ogino-Knause – a woman can discern her fertile and infertile days based on her
sensory and visual observations of the cervical mucus (when it becomes thin and watery –
spinnbarkheit). Intercourse is avoided 4 days prior to and 3 days after the spinnbarkheit.
4. Billings method/cervical mucus – when cervical discharges are thin and watery, couple resumes
sexual intercourse 3-4 days after
5. Symptothermal method/Basal Body Temperature (BBT) – involves daily observation of the
temperature of the woman at rest, free from any factor that may cause it to fluctuate (immediately upon
waking up, before brushing teeth, drinking, etc.). Only 3-4 days after the temperature drops slightly and
then increases (which means ovulation has taken place), can sexual intercourse be resumed. Fertile and
infertile days are determined after having established an accurate record of the six immediately preceding
menstrual cycles then watching out for BBT fluctuations
2. Social methods
1. Abstinence
2. Withdrawal/Coitus Interruptus