CASE STUDY

ON NORMAL
PUERPERIUM
Submitted By
Ankita Manna
M.Sc Nursing 1st Year
EBMCON
 INTRODUCTION
The puerperium is a period of approximately 6
weeks which commences following
completion of third stage of labour. During this
time the women recovers from stresses of
pregnancy & delivery & the physiological
adaptations which occur during pregnancy
subside, facilitating the restoration of the non
pregnant state.
 DEFINITION
The puerperium is defined as the period
following childbirth during which the body
tissue, specially the pelvic organs revert back
approximately to the pre- pregnant state both
anatomically and physiologically.
-----DC DUTTA
 DURATION
Puerperium begins as soon as the placenta
expelled and last for approximately 6 weeks
when uterus becomes regressed almost to non-
pregnant size.
 STAGES OF PUERPERIUM
The post partum period has been divided into:
• The immediate puerperium, the first 24 hours
after parturition; when acute post anesthetic or
post delivery complications may occur.
• The early puerperium, which extends until the
first week post partum.
• The remote puerperium, which includes the
period of time required for involution of the
genital organs through the sixth weeks postpartum.
 REPRODUCTIVE SYSTEM
Uterus
Involution:-is the return of the uterus to a non-
pregnant state after childbirth. Involution process
begins immediately after expulsion of the placenta
with contraction of uterine smooth muscles.
At the end of third stage of labor, the uterus is in
the midline, about 2cm below the level of the
umbilicus and weighs 1000g and measures about
20*12*7.5(length , breadth and thickness)
 CONT…
By 24 hours postpartum the uterus is about the
same size it was at 20 gestational weeks.
The fundus descends about 1 to 2cm every 24
hours, and by the sixth postpartum day it is
located halfway between the symphysis pubis
and the umbilicus.
-The uterus lies in the true pelvis within 2
weeks after childbirth.
 INVOLUTION OF THE UTERUS
RETURN TO THE PELVIS BY ABOUT 2 WEEKS
 BE AT NORMAL SIZE BY 6 WEEKS
THE WEIGHT CHANGES OF UTERUS
 1000G IMMEDIATELY AFTER BIRTH (EXCLUDING THE
FETUS, PLACENTA, MEMBRANE AND AMNIOTIC FLUID.
 500G 1 WEEKS AFTER BIRTH
 300G 2 WEEKS AFTER BIRTH
 50G 6 WEEKS AFTER BIRTH THE ENDOMETRIAL
LINING RAPIDLY REGENERATES (16 DAYS)
THE PLACENTAL SITE UNDERGOES A SERIES OF
CHANGES IN THE POSTPARTUM PERIOD
 Subinvolution:-is the failure of the uterus to
return to a nonpregnant state.
-The most common causes of sub involution are
retained placenta fragments and infection
LOWER UTERINE SEGMENT
• Immediately following delivery the lower
segment becomes thin flabby ,collapsed
structure
• It takes a few weeks to revert back to normal
shape and size of the isthmus
 CERVIX
 It is soft immediately after birth
 The cervix up to the lower uterine segment remains
edematous, and thin for several days after birth.
 The cervical os which is dilated to 10cm during labor
closes gradually, it may still possible to introduce 2 fingers
into cervical os for the first 4-6 postpartum days.
 The external cervical os never regains its prepregnancy
appearance, it is no longer
shaped like a fish mouth.
 It return to its normal state
at 4 weeks after birth
PHYSIOLOGICAL CONSIDERATION

The physiological process of involution is

most marked in the body of the uterus changes
occur in the following components.
A. Muscles
B. Blood vessels
C. Endometrium
 MUSCLES
• There is marked hypertrophy and hyperplasia of muscle
fibers during pregnancy and the individual muscle fiber
enlarges to the extent of 10times and 5 times of breadth
• During puerperium the number of muscle fibers is not
decreased but this is substantial reduction of the
myometrial cell size
• Withdrawal of the steroid hormones estrogen and
progesterone may lead to increase in the activity of the
uterine collagens and release of proteolytic enzyme
 BLOOD VESSELS
• The arteries are constricted by contraction of its
wall and thickening of the intima followed by
thrombosis
• During the first week the arteries undergo
thrombosis hyalinsation and fibrinsed end
arteries
• The veins are obliterated by thrombosis
hyalinisation and endophlebitis
• New blood vessels grow inside the thrombi.
 ENDOMETRIUM
• Following delivery the major part of the decidua is cast off
with expulsion of the placenta and the membranes more at the
placenta site
• The endometrium left behind varies in thickness from 2-5mm
• The superficial part containing the degenerated decidua, blood
cells and bits of fetal membranes becomes necrotic and is cast
off in the lochia.
• Regeneration starts by 7th completed by 10th day and restored
by 16th day except placental site it takes 6weeks
• It occur from the epithelium of the uterine gland mouths and
interglandular stromal cells
 INVOLUTION OF OTHER PELVIC
STRUCTURES
VAGINA
• The distensible vagina notices soon after birth takes a long
time-4- 8weeks
• It regains its tone but never to the virginal state
• The mucosa remains delicate for the first few weeks and
sub- mucous venous congestion persist even longer, it is the
reason to withhold surgery on puerperal vagina
• Rugae partially reappear at 3rd week but nerve to the same
degree as in pre-pregnant state
• The introits remains permanently larger than the virginal
state
 BROAD LIGAMENT AND ROUND
LIGAMENT
Requires considerable time to recover from the
stretching and laxation
PELVIC FLOOR AND PELVIC
FASCIA
Takes a long time to involute from the
stretching effect during parturition.
 LOCHIA
 It is the vaginal discharge that occurs after birth.
 Lochia is discharge originates from the uterine
body, cervix and vagina
 For the first 2 hours after birth the amount of
lochia should be about that of a heavy menstrual
period, after that time the lochial flow should
steadily decrease.
 COLOUR
1-lochia rubra-red color (1-4days) It consists of blood,
shreds of fetal membranes and decidual ,vernix
caseosa,lanugo and meconium.
2-lochia serosa-yellowish or pink or pale brownish
colour(5-9 days) It consists of old blood, less of rbc,
but more of leukocytes, and wound exudates mucus
from cervix and micro organism (anaerobic
streptococci and staphylococci
3-lochia serosa-pale white(10-15days) Contains plenty
of decidual cells,leucocytes,mucus,cholestrin
crystals,fatty and granular epithelial cells and micro
organism.
CLINICAL IMPORTANCE OF LOCHIA

• Odor: If offensive indicates retained pus or cotton

pieces inside the vagina should be kept in mind
• Amount: Scanty or absent signifies infection or
lochiametra. If excessive also indicates infection
• Color: Persistence of lochia rubra beyond normal
limit signifies Subinvolution or retained bits of
conceptus
• Duration: Duration of the lochia alba beyond 3
weeks suggest local genital lesions
 GENERAL PHYSIOLOGICAL
CHANGES
PULSE
• After the initial tachycardia associated with labour and
delivery, a bradycardia often develops in the early puerperium.
• A woman’s pulse rate during the postpartal period is usually
slightly slower than normal.
• This increased stroke volume reduces the pulse rate to between
60 and 70 beats per minute.
• As diuresis diminishes the blood volume and causes blood
pressure to fall, the pulse rate increases accordingly.
• By the end of the first week, the pulse rate will have returned to
normal.
 TEMPERATURE
• A woman may show a slight increase in
temperature during the first 24 hours after birth.
• Occasionally, when a woman’s breasts fill with
milk on the 3rd or 4th postpartum day, her
temperature rises for a period of hours because of
the increased vascular activity involved.
• Genito-urinary tract infection should be excluded
if there is rise of temperature
 URINARY TRACT
• The bladder wall becomes oedematous and
hyperaemic and often shows evidences of sub
mucous extravasations of blood.
• Because of relative insensitivity to the raised
intravesical pressure due to trauma sustained to the
nerve plexus during delivery, the bladder may be
over distended without any desire to pass urine.
• Dilated ureters and renal pelvis return to normal
size within 8 weeks
 GASTROINTESTINAL SYSTEM
• Digestion and absorption begin to be active again
soon after birth.
• Bowel sounds are active, but passage of stool
through the bowel may be slow because of the still
present effect of relaxin on the bowel.
• Bowel evacuation may be difficult because of the
pain of episiotomy sutures or haemorrhoids.
• Increased thirst in early puerperium
• Slight intestinal paresis leads to constipation
 WEIGHT
Rapid diuresis and diaphoresis during 2nd to 5th
days after birth result in weight loss of 5 lb (2 to
4kg), in addition to approx. 12 lb (5.8 kg) lost at
birth.
Lochia flow- 2-3 lb(1kg) loss
Total weight loss- 19 lb
Additional weight loss depend on amount of
weight gain in pregnancy and active measures to
reduce weight.
 FLUID LOSS
• Net fluid loss of at least 2 liters during 1st
week
• Additional 1.5 liters during the next 5th weeks
• The amount depends on amount retained
during pregnancy ,dehydration during labour
and blood loss during delivery.
 BLOOD VALUES
• Diuresis evident between 2nd to 5th day after
birth, as well as blood loss at birth, acts to reduce
the added volume accumulated during pregnancy.
• Rapid reduction occurs, so that blood volume
returns to its normal prepregnancy level by 2nd
week after birth.
• Cardiac output rises soon after delivery to about
60% above the pre labour value but gradually
returns to normal within one week.
 RBC VOLUME AND HEMATOCRIT
• It returns to normal by the end of 1st week after the hydraemia
disappears
• Leukocytosis to the extent of 30000 per cu mm occurs following
delivery probably in response to stress of labour
• Platelet count decreases soon after the separation of the placenta
but secondary elevation occurs with increase in platelet
adhesiveness between 4-10dyas
• Fibrinogen level remains high upto the 2nd week of puerperium
resulting in persistent high level of esr in puerperium as during
pregnancy
• A hypercoagulable state persist for 48hrs postpartum and fibrolytic
activity is enhanced in first 4 days.
 MENSTRUATION AND OVULATION
• If the woman does not breast fed her baby, the menstruation
returns by 6th week following delivery in about 40% and by
12th week in 80% of cases.
• In non-lactating mothers, ovulation may occur as early as 4
weeks and in lactating mothers about 10 weeks after delivery.
• A women who is exclusively breastfeeding, the contraceptive
protection is about 98% upto 6 months postpartum. Thus,
lactation provides a natural method of contraception.
• However ovulation may precede the first menstrual period in
about one-third and it is possible for the patient to become
pregnant before she menstruates following her confinement.
• Non-lactating mother should use contraceptive measures after 3
weeks and the lactating mothers after 3 months of delivery.
 LACTATION
• 1st two days following delivery no further
anatomical changes in the breast occur
• The secretion from the breast called colostrum
which starts during pregnancy becomes more
abundant during this period
COMPOSITION OF THE COLOSTRUM

• It is deep yellow serous fluid alkaline in

reaction
• It has got a higher specific gravity ,high
protein, vitamin A, sodium and chloride
content but has got lower carbohydrate ,fat and
potassium than the breast milk
• It contains antibody (IgA)
 COMPOSITION OF COLOSTRUM AND
BREAST MILK MILK
MILK PROTEIN FAT CARBOHYDR WATER
ATE
COLOSTRUM 8.6 2.3 3.2 86

BREASTMILK 1.2 3.2 7.5 87

 ADVANTAGES
• The antibodies (IgA,IgG,IgM) and hormonal
factor (lactoferrin)provides immunological
defense to the newborn
• It has laxative action because of large fat
globules
 PHYSIOLOGY OF LACTATION

The physiological basis of lactation is divided

into four phases
1. Preparation of breast (mammogenesis)
2. Synthesis and secretion from the breast alveoli
(lactogenesis)
3. Ejection of milk (galactokinesis)
4. Maintenance of lactation (galactopoiesis)
 MAMMOGENESIS
• Pregnancy is associated with a remarkable
growth of both the ductal and lobuloalveolar
systems.
• An intact nerve supply is not essential for
growth of the mammary glands during
pregnancy.
 LACTOGENESIS
• Milk secretion actually starts on 3rd or 4th
postpartum day.
• Around this time, the breasts become engorged,
tense, tender and feel warmth.
• When the progesterone and oestrogen are
withdrawn following delivery, prolactin begins
its milk secretary activity in previously fully
developed mammary gland.
 GALACTOKINESIS
• Discharge of milk from the mammary glands
depends not only on the suction exerted by the
baby during suckling but also on the
contractile mechanism which expresses the
milk from the alveoli into the ducts.
• oxytocin is a the major galactokinesis.
 GALACTOPOIESIS
• Prolactin appears to be the single most
important galactopoietics hormone.
• Continuous suckling is essential for removal of
milk from glands, also release prolactin.
• Secretion is the continuous process unless
suppressed by congestion or emotional
disturbances
 MILK PRODUCTION
• A healthy mother will produce about 500-800
ml of milk/day with about 500 kcal /day.
• This requires 600 kcal/day for the mother
which must be made up from the mothers diet
or from her body store.
• For this purpose a store of about 5 kg of fat
during pregnancy is essential to make up any
nutritional deficit during lactation.
 STIMULATION OF LACTATION
• Mother is motivated about the benefits of breast feeding
• No prelacteal feed like honey ,water
• Following delivery important steps are…..
I. To put baby to the breast at 2-3 hours interval from the
first day.
II. Plenty of fluids to drink
III. To avoid breast engorgement.
IV.Early and exclusive breast feeding in correct position
are encouraged as soon as 30minutes to 1hour
INADEQUATE MILK PRODUCTION/
LACTATION FAILURE
• It may be due to infrequent suckling or due to
endogenous suppression of prolactin (ergot
preparation, pyridoxine, diuretics or retained
placental bits).
• Unrestricted feeding at short interval (2-3hrs.)
Is helpful
 DRUGS TO IMPROVE MILK
PRODUCTION
• Metoclopramide (10 mg thrice daily) increases
milk volume (60-100%) by increasing
prolactin levels.
• Sulpuride (dopamine antagonist) has also been
found effective.
• Intranasal oxytocin contracts myoepithelial
cells and causes milk let down reflex.
 LACTATION SUPPRESSION
Suppression of lactation is necessary if the baby is
born dead or dies in the neonatal period or if breast
feeding is contradicted Mechanical methods :
1. To stop breast feeding
2. To avoid pumping or milk expression
3. To wear brassieres
4. Ice pack to relive pain and breast engorgement
5. A tight compression bandage is applied for 2-3
days
• Bromocriptine (dopamine agonist that inhibits
prolactin) 2.5 mg, 1 tab daily for 10-14 days.
• Side effects are: hypotension, rebound breast
engorgement, secretion, myocardial infarction
and puerperal stroke
 NURSING DIAGNOSIS
• Knowledge deficit
• Fluid and electrolyte imbalance
• Risk for infection
• Imbalance nutrition less than body
requirement
NURSING PROCESS
ACCORDING TO
OREM’S THEORY
APPLICATION
diagnosis Goal planning implementatio evaluation
n

Knowledge To gain •Assessment is to •Assessment is Mother gained

deficit related knowledge be done regarding done. some
to self care and knowledge of the knowledge.
baby care. mother.
•Health education is •Health
to be given education is
regarding self care given regarding
and baby care, breastfeeding
breastfeeding technique and
technique, time of physiological
breastfeeding, changes.
physiological
changes etc.
•Demonstration of •Demonstration
breastfeeding is given
techniques is to be regarding
shown. breastfeeding
technique.
diagnosis Goal planning implementatio evaluation
n

Fluid To maintain •Assessment is •Assessment is Fluid and

electrolyte fluid and to be done. done electrolyte
imbalance electrolyte •I/O chart is to •I/O chart is balance are
related to balance. be maintained. maintained stable now.
dehydration, •Frequent fluid •Fluid and juice
less intake of or any juice is is given
water. to be given •Dehydration is
•Dehydration is checked
to be checked
regularly.
•Health •Health
education is to education is
be given given regarding
regarding fluid fluid and
and electrolyte electrolyte
imbalance. imbalance.
diagnosis Goal planning implementation evaluation

Risk for infection To reduce •Assessment is to be •Assessment is Risk of infection

infection done in the episiotomy done. is reduced.
area or incision site if
any redness or pus is
present and
subinvolution of uterus
and extreme uterine
tenderness.
•Mother is to be Mother is
encouraged semi- encouraged for
fowlers position and position
position changing every changing.
half an hour.
•Early ambulation is to Early ambulation
be started ASAP. is started.
• prophylactic Antibiotic Prophylactic
is o be given as per antibiotic is
doctor’s advice given as per
doctor’s order.
diagnosis Goal planning implementatio evaluation
n

Imbalance To •Discussion is to be •Discussion is Mother

nutrition less maintain done regarding done regaring maintained
than body proper eating habit meeting ahbit. proper diet.
requirement nutrition. including food
related to preferences and
anorexia, intolerances.
nausea/vommi •I/O chart is to be •I/O chart is
ting and maintained maintained
medical including calorie including
restriction. intake and pattern patterna nd
and time of eating. time of eating.
•Encourage choice •Mother is
of foods high in encouraged to
protein, iron and take high
vit. C when oral protein, iron
intake permitted. and vit. C diet.
•Mother is to be •Mother is
encouraged for encouraged for
adequate adequate
sleep/rest. sleep/rest.