POSTNATAL CARE

LEARNING OUTCOMES 2

At the end of the session, the students should be able

to:
 define puerperium;
 describe the physiology of puerperium;
 discuss the nursing care for mother in puerperium;
 describe the process of lactation;
 state the management of complications in
puerperium.
 DEFINITION OF PUERPERIUM 3

 Puerperium refers to a period of 6 weeks following

delivery when most of the anatomical and
physiological changes of pregnancy revert to its
normal state.

 During this time, the pelvic organs return to the

nongravid state, the physiological changes of
pregnancy are reserved, and lactation is established.
 PHYSIOLOGY CHANGES
4
 Following a normal labor, the mother shows signs of fatigue
and exhaustion
 She may shiver, feel cold or vomit following the oxytocic
injection
 Tachycardia persists for a few hours, blood pressure gradually
returns to normal over the next few hours
 Blood pressure may not normalize for a few weeks if mother has
PIH or pre-eclampsia
 Mother with PROM, prolonged labor and operative surgery
may have pyrexia
 By the second or third day, a slight pyrexia is due to
engorgement of the breasts and onset of lactation
 PHYSIOLOGY CHANGES (cont..)
5
 Fairly common for women to exhibit a mild degree of
depression a few days after delivery – known as
‘postpartum blues’
 Probably due to disturbed sleep patterns and
adaptation to changed lifestyle with anxiety of caring for
newborn baby.
 Understanding and reassurance from health staff and
family is important
 Usually resolves by day 10 postnatal.
 UTERUS
• Immediately after the delivery, the uteruscan be palpated at
or near theumbilicus.

• Size and weight reduction occurs in the first 2 weeks.

• 2 weeks postpartum, the uterus should be located in the true
pelvis and thesize reduces from 1000g (1KG)→ 50-100g by the
process called autolysis.
• The endometrial lining rapidly regenerates (16 days)
• The placental site undergoes necrosis & a series of changes.
Postnatal Uterus
 PHYSIOLOGY CHANGES
8
Involution of uterus
 The fundus of uterus is slightly below the umbilicus
immediately after the delivery of placenta
 The uterus begins to shrink
 No longer palpable on abdominal examination by the 10th –
12th day after delivery
 The process by which the postpartum uterus returns almost to
its prepregancy state is known as involution
 In primipara, the uterus usually remains contracted;
multipara’s uterus often contract vigorously  cause
afterpains
 PHYSIOLOGY CHANGES (cont..)
10
Lochia
 Vaginal discharge known as lochia is present during the puerperium
 Lochia can be classified based on the characteristic of the discharge
i. Rubra
 Red colour
 Flow diminishes over the next 3 – 4 days
ii. Serosa
 Reddish brown color
 5 – 9 days or longer
iii. Alba
 Pale, yellow-white in colour
 Lighter in flow
 10 – 15 days or longer
 PHYSIOLOGY CHANGES
11
After pain
 After pains are the uterine contractions that are felt
during suckling of baby
 Caused by oxytocin release during suckling
 Analgesics help to relieve after pain
 They are more complaints of afterpains as parity
increases- in multiparas, the uterus contracts vigorously
at intervals whereas in primiparas the uterus remains
topically contracted.
 CERVIX, VAGINA, PERINEUM
Tissues revert to a non pregnant state but never return to the nulliparous state.
 Wounds heals with good perinealcare.
 Pelvic floor muscle returns to normal state with good Kegel’s exercise.

Cervix
 it never returns to the nulliparous state; the external os is closed to the extent
that a finger could not be easily introduced.

Vagina
 Shrinks to a non pregnant state but never return to its pre pregnant elasticity;
resolution of the increased vascularity and edema occurs by 3 weeks
 The vaginal epithelium appears atrophic on smear. Thisis restored by weeks 6-
10.
 PERINEUM
 Swelling and engorgement are completely gone within
1-2 weeks, with goodperineal care.
 The muscle tone may or may not return to normal,
depending on the extent of injury & exercise.

Abdominal Wall
•Remains soft and poorly toned for many weeks depending
on exercise.
•Return to a pre pregnant state dependson exercise
 SYSTEMIC CHANGE
Cardiovascular System

 Blood volume returns to non pregnant levels by

the tenth days of puerperium

 Cardiac output (immediately after delivery) →

slowly declines → normal 2-6 weeks.
 PHYSIOLOGY CHANGES
15
Menstruation and ovulation
 Menstruation and ovulation depend greatly upon the
duration and frequency of lactation
 A non-lactating woman may start menstruating 2 months
after the delivery; a fully lactating woman may remain
amenorrhea for 6 months
 If the woman breastfeeds the baby for at least 6 months
during the day and once at night, the ovulation is
delayed  a form of contraception
 SUMMARY :ANATOMICAL CHANGES OF 16
PUERPERIUM
 The abdominal wall is lax and striae gravidarum are seen
as white streaks
 The uterus is palpable and fundus reaches the level of
umbilicus soon after childbirth
 The intermittent uterine contractions are felt and the
uterus appears firm
 The breasts shows full activity within 48 hours
 Milk secreted at this period called colostrum
 Early suckling and breastfeeding establishes lactation
early
 CARE OF MOTHER IN PUERPERIUM 17
General management of puerperium:
 Observe the general conditions of the mother, the
vital signs must be stable, uterus well contracted and
she is encouraged to pass urine
 Establish lactation
 Prevent infection and maintain asepsis
 Monitor for development of PPH
 Observe amount of lochia
 CARE OF MOTHER IN PUERPERIUM (cont..) 18

General management of puerperium:

 Administer anti-D globulin to a Rhesus-negative
mother if her baby is Rh-positive
 Provide emotional support
 The newborn baby is kept by the mother’s side 
“rooming in” to promote bonding
 Advise on use of family planning
 CARE OF MOTHER IN PUERPERIUM (cont..)
19
1. Hygiene
• Bathe at least once a day
• Wear clean and comfortable clothes
• Clothing must be changed every day
• Hair shampoo
• Keep skin clean and moist
2. Perineal care / vulva swabbing
• Perineal care is required after each micturition
• Vulva swabbing every 4 – 6 hourly especially in the presence of episiotomy wound
• Mother is instructed to cleanse the vulva from anterior to posterior aspect to
minimize infection
• Sitz bath to relieve pain
• Change pad every 4 hourly
 CARE OF MOTHER IN PUERPERIUM
20
3. Nutrition
• Consume well-balanced diet
• Drink at least 6 – 8 glasses of water and milk to help breastfeeding
• Eat more vegetables and fruits to provide the vitamins and minerals
• Consume more protein and calories for lactating woman
• Continue to take iron tablets for the next 3 months
4. Care of Bladder.
5. Breastfeeding
• Baby is put to the breast as soon as possible after birth
• Breastfeed baby on demand
• Support mother on breastfeeding
• Correct technique and positioning in breastfeeding
 CARE OF MOTHER IN PUERPERIUM (cont..)
21
5. Breast care
• Wear a good supporting brassiere to support breast
• Clean breast everyday
• The nipples should be cleaned before and after each feed
6. Care of bowel
7. Rest
• Mother needs 8 – 10 hours of sleep at night and 2 hours of rest in the day
8. Ambulation and exercise
• Encourage early ambulation to improve circulation and prevents
thromboembolic complications
• Advice on postnatal exercise to regain the pelvic muscle tone and improve
general well-being
 CARE OF MOTHER IN PUERPERIUM (cont..)
22
8. Family planning
• Contraceptive counseling
9. Follow-up
• Advise to attend postnatal clinic 6 weeks after the delivery
• Pap smear may be performed
10. Observe for warning signs and symptoms
• Seek medical treatment if the following signs and symptoms found
- High fever - leg edema
- Heavy flow of lochia - pain at calf / lower limbs
- Anemia - difficulty in micturition
- Giddy / persistent headache - pain, redness or discharge from wound
METHODS OF CONTRACEPTION 28-23
 ABNORMAL PUERPERIUM 24
 Unexpected complications may occur during puerperium
 Most complications occur in the first 24 hours – first10 days
 Emergency complications include
 Post-partum eclampsia
 Post-partum shock
 Secondary PPH
 Pulmonary embolism
 Amniotic fluid embolism
 Cardiomyopathy

 Genital hematoma
 ABNORMAL PUERPERIUM (cont..) 25

 Other puerperium complications that may occur

 Puerperal pyrexia
 Chest infection Mastitis
 Breast problems
 Retracted nipples
 Breast engorgement
 Mastitis Cracked nipple

 Cracked nipple Retracted nipple

 Breast abscess
 Urinary tract infection
 ABNORMAL PUERPERIUM (cont..) 26

Puerperal pyrexia
• Causes
 Genital tract infection
 Urinary tract infection
 Breast infection
 Thrombophlebitis

 Chest infection / pneumonia

 ABNORMAL PUERPERIUM (cont..) 27

Puerperal pyrexia
• Nursing care
 Initiate intravenous fluid if in hospital
 Advise to increase oral fluid intake
 Administer broad spectrum antibiotics as ordered
 Administer antipyrexia
 Observe for puerperal sepsis
 Anticipate surgical treatment for cases with abscess
 ABNORMAL PUERPERIUM (cont..) 28
Breast engorgement
• Breast are swollen, tender, tense and warm
• Mother’s temperature may be mildly elevated
• Nursing care and management
- Manual emptying of the breasts following each breastfeeding
- Wear supportive brassiere
- Administer analgesic as ordered
- Advised hot compress to breast prior to breastfeeding
 POST-NATAL EXERCISES 29

Importance of Post-Natal
Exercises
Improve circulation
Strengthen pelvic floor
muscle
Prevent backache
Strengthen the tummy
muscles
 BENEFITS OF EXERCISES 30

 Reduces the risk of developing

heart disease, diabetes, and
cancer
 Reduces high blood pressure, high
cholesterol
 Reduces body weight, depression,
anxiety and improves psychological
wellbeing
 Builds and maintains healthy
muscles, bones and joints
31