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MADDA WALABU UNIVERSITY
GOBBA REFERRAL HOSPITAL
School of Health Science
Department of Midwifery

Course: Obstetrics (Post Partum Care)

Target Students: 3rd Year Midwifery Students
Prerequisite: Preconception,ANC,Labor & Delivery
Instructor: Usman H.
01/07/22 1
 Normal Puerperium
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01/07/22 2
Outline
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 Definition
 Physiologic changes during puerperium
 Maternal postpartum care
 Nutrition in a lactating women

01/07/22 3
 Normal Puerperium
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• Definition: Puerperium is the period following

childbirth during which the body tissues, especially
the pelvic organs revert back approximately to the
prepregnant state both anatomically and
physiologically.
• The postpartum period also called the puerperium.
• The words "postpartum" and "postnatal" are
sometimes used interchangeably.

01/07/22 4
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• Biologically, the postpartum period is the time after

birth, a time in which the mother's body, including
hormonal levels and uterine size, return to pre-
pregnancy conditions and extends up to the 6th week
postpartum.
• The retrogressive changes are mostly confined
to the reproductive organs with the exception of
the mammary glands which in fact show
features of activity.

01/07/22 5
 LOGO
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• is the period of adjustment following pregnancy and

delivery when anatomic and physiologic changes of
pregnancy are reversed and the body returns to non
pregnant state.

01/07/22 6
 Definition…
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• The period is arbitrarily divided into —

 (a) immediate – within 24 hours,
 (b) early – up to 7 days and
 (c) remote/late – up to 6 weeks.

01/07/22 7
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NORMAL ANATOMIC AND PHYSIOLOGIC

CHANGES OF PUERPERIUM

01/07/22 8
  Involution
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• is the process whereby the genital organs

revert back approximately to the state as they
were before pregnancy.
• The woman is termed as a puerpera.

01/07/22 9
 Anatomic Changes that occur in the reproductive tract
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Uterine Involution
• Immediately postpartum, the uterus weighs approximately 1000gm.
• At level of umbilicus/20wks GA
• just after delivery reduces in size at a rate of one finger per day.
By 1 week
» it weighs about 500 g & it is equal with 12 weeks GA
After 2weeks
Returned to pelvis, weighs approximately 300gm
By 4 week
Pre pregnant size, weighs approximately 50-100gm

01/07/22 10
 Anatomic change…
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• This process is affected by
 parity ( the uterus is
slightly larger in
multiparous women)
 mode of delivery (is
slightly larger post
cesarean delivery), and
 breastfeeding (the uterus is
slightly smaller in women
who are BF)

01/07/22 11
  Physiological Consideration
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• The physiological process of involution is most

marked in the body of the uterus.
• Changes occur in the following components:
 (1) Muscles,
 (2) Blood vessels,
 (3) Endometrium.

01/07/22 12
 Physiological Consideration…
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Muscles: The total number of muscle cells probably does
not decrease.
• Instead, the individual cells decrease markedly in size
• Involution of the connective tissue framework occurs
equally rapidly.
• Within the first 2- 3 days after delivery the uterus
contracts strongly causing lower abdominal discomfort
and pain. This pain is called afterpains
• Afterpains assist in involution (shrinking or return to a
former size)
are more pronounced as parity increases and
worsen when the infant suckles.
decrease in intensity and become mild by the third day
How to treat After pain? 13
01/07/22
 Muscle…
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• Withdrawal of the steroid hormones, estrogen and

progesterone, may lead to increase in the activity of the
uterine collagenase and the release of proteolytic enzyme.
• Autolysis of the protoplasm occurs by the proteolytic enzyme
with liberation of peptones which enter the bloodstream.
These are excreted through the kidneys as urea and
creatinine.
• This explains the increased excretion of the products in the
puerperal urine.
• The connective tissues also undergo the same type of
degeneration

01/07/22 14
 LOGO
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The conditions which favor involution are:-

(a) efficacy of the enzymatic action and
(b) relative anoxia induced by effective
contraction and retraction of the uterus.

01/07/22 15
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 Blood vessels: The changes of the blood vessels are

pronounced at the placental site.
• The arteries are constricted by contraction of its wall
and thickening of the intima followed by
thrombosis. During the 1st week, arteries undergo
thrombosis, hyalinization and fibrinoid endarteritis.
• Veins are obliterated by thrombosis, hyalinization
and endophlebitis.

01/07/22 16
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 Endometrial Regeneration
 Starts within 2 to 3 days.
 Decidua differentiate into two layers.
 The superficial part containing the degenerated decidua, blood cells and
bits of fetal membranes becomes necrotic and is cast off and removes in
the form of discharge, this discharge is called lochia.
 The basal layer adjacent to the myometrium remains intact and is the
source of new endometrium.
 the entire endometrium is restored by the day 16, except at the
placental site where it takes about 6 weeks.

Why Endometrial Regeneration is delayed at placental site than other site?

01/07/22 17
 Clinical Assessment Of Ux Involution
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• The rate of involution of the uterus can be assessed clinically

by noting the height of the fundus of the uterus in relation to
the symphysis pubis.
• The measurement should be taken carefully at a fixed time
every day, preferably by the same observer.
• Bladder must be emptied beforehand and preferably the
bowel too, as the full bladder and the loaded bowel may raise
the level of the fundus of the uterus.
• The uterus is to be centralized and with a measuring tape, the
fundal height is measured above the symphysis pubis.
• Following delivery, the fundus lies about 13.5 cm(5 1/2”)
above the symphysis pubis.

01/07/22 18
 Clinical Assessment Of Involution….
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• During the first 24 hours, the level remains constant; there
after, there is a steady decrease in height by 1.25 cm (0.5") in
24 hours, so that by the end of 2nd week the uterus becomes
a pelvic organ.
• The rate of involution thereafter slows down until by 6
weeks, the uterus becomes almost normal in size.
• The involution may be affected adversely,delayed to return in
to normal size and this process is called subinvolution.
• Sometimes, the involution may be continued in women who
are lactating so that the uterus may be smaller in size —
superinvolution.

01/07/22 19
 Other Pelvic Structures…
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Broad ligaments and round ligaments

require considerable time to recover from the
stretching and laxation.
 Pelvic floor and pelvic fascia take a long time to
involute from the stretching effect during parturition.

01/07/22 20
 Cont’d…
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Cervix
 Regression of the cervical epithelium begins within the first
4 days after delivery
 At the end of the first week, it is little more than 1 cm
dilated
 External os is converted into a transverse slit
 Complete healing and reepithelialization will occur by the
end of 6 weeks in most case.

01/07/22 21
 Involution Of Other Pelvic Structures
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 Vagina: The distensible vagina, noticed soon after birth
takes a long time (6–10 weeks) to involute.
 It regains its tone but never to the virginal state. The
mucosa remains delicate for the first few weeks and
submucousa venous congestion persists even longer.
o It is the reason to withhold surgery on puerperal vagina.
 Rugae partially reappear at 3rd week but never to the
same degree as in prepregnant state.
 Introitus remains permanently larger than the virginal
state.
 Hymen is lacerated and is represented by nodular tags —
the carunculae myrtiformes.
01/07/22 22
 Lochia
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• It is the vaginal discharge for the first fortnight during
puerperium.
• The discharge originates from the uterine body, cervix and
vagina.
• It is characterized in terms of:-
 Amount: is about 200 to 500ml
 Odor : It has got a peculiar offensive fishy smell.
 Reaction :Its reaction is alkaline, tending to become acid
toward the end.
 Color:
 Composition
 Duration
01/07/22 23
 Lochia…
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• Based on the color of the discharge

Lochia rubra
» Stays for 3 to 4 days
» red
Lochia serosa
» Stays for 5 to 9 days
» Yellowish or pink
Lochia alba
» Stays for 4 weeks
» Pale or white
01/07/22 24
 lochia
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 Composition:
 Lochia rubra consists of blood, shreds of fetal membranes
and decidua, vernix caseosa, lanugo and meconium.
 Lochia serosa consists of less RBC but more leukocytes,
wound exudate, mucus from the cervix and microorganisms
(anaerobic streptococci and staphylococci).
 The presence of bacteria is not pathognomonic unless associated with
clinical signs of sepsis.
 Lochia alba contains plenty of decidual cells, leukocytes,
mucus, cholesterin crystals, fatty and granular epithelial cells
and microorganisms.

01/07/22 25
 lochia
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 Normal duration: The normal duration may extend

up to 4 weeks. The red lochia may persist for longer
duration especially in women who get up from the
bed for the first time in later period.
 The discharge may be scanty, especially following
premature labors or may be excessive in twin
delivery or hydramnios.

01/07/22 26
 Lochia….
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 Clinical importance: The character of the lochial discharge
gives useful information about the abnormal puerperal state.
• The vulval pads are to be inspected daily to get information of:
•  Odor: If malodorous—indicates infection. Retained plug or
cotton piece inside the vagina should be kept in mind.
•  Amount:
– Scanty or absent — signifies infection or lochiometra.
– If excessive — indicates infection.
•  Color: Persistence of red color beyond the normal limit
signifies subinvolution or retained bits of conceptus.
•  Duration: Duration of the lochia alba beyond 4 weeks
suggests local genital lesion.

01/07/22 27
 Quize
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1.What is –puerperium?
_puerperia?
_Involution?
2.What is after pain & how to treat it ?
3.List types of lochia & their characteristic
4.What clinical correlation it indicate if
lochia is malodorous & red in color beyond
normal limit?

01/07/22 28
  General Systemic Changes
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• Pulse: For a few hours after normal delivery, the pulse rate is
likely to be raised, which settles down to normal during the
second day. However, the pulse rate often rises with after-pain
or excitement.
• Temprature: The temperature should not be above 37.2°C
(99°F) within the first 24 hours.
• There may be slight reactionary rise following delivery by
0.5°F but comes down to normal within 12 hours.
• On the 3rd day, there may be slight rise of temperature due to
breast engorgement which should not last for more than 24
hours. However, genitourinary tract infection should be
excluded if there is rise of temperature

01/07/22 29
 General Systemic Changes ….
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• Urinary Tract Changes:-Ureters and renal pelvis return
to their prepregnant state by 2- 8 weeks in most cases.
• postpartum bladder capacity increases but function
decreases.
 a relative insensitivity to intravesical pressure.
• Thus, over distension, incomplete emptying, and excessive
residual urine are common
• Bladder trauma is associated most closely with the length of
labor
– Submucosal hemorrhage and mucosal edema are
common
01/07/22 30
 General Systemic Changes ….
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Gastrointestinal Tract:
•Increased thirst in early puerperium is due to loss of
fluid during labor, in lochia, diuresis and perspiration.
•Constipation is a common problem for the following
reasons:
delayed gastrointestinal motility,
perineal discomfort.
Some women may have the problem of anal
incontinence.

01/07/22 31
 General Systemic Changes ….
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Weight Loss:
•In addition to the weight loss (5–6 kg) as a
consequence of the
– expulsion of the fetus,
– placentae,
– liquor and blood loss,
•a further loss of about 2 kg (4.4 lb) occurs during
puerperium chiefly caused by diuresis. This weight
loss may continue up to 6 months of delivery.

01/07/22 32
 General Systemic Changes ….
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• Cardiovascular System and Coagulation
• Immediately after delivery
• CO increases by 50%
 Due to increase in SV
• CO remains elevated for at least 48 hours postpartum
• It needs an extended time for those changes to return back in to
pre pregnant state
• 1 week after delivery blood volume will be returned to its
prepregnant level
• Venus tone will return to base line when blood volume
becomes normal
01/07/22 33
 General Systemic Changes ….
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• RBC volume and hematocrit values returns to normal

by 8 weeks postpartum after the hydremia disappears.
• Leukocytosis to the extent of 25,000/mm3 occurs
following delivery probably in response to stress of
labor.
• Platelet count decreases soon after the separation of the
placenta but secondary elevation occurs, with increase
in platelet adhesiveness between 4 and 10 days.

01/07/22 34
 …..
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• Fibrinogen level remains high up to the 2nd week of

puerperium.
• A hypercoagulable state persists for 48 hours
postpartum and fibrinolytic activity is enhanced in
first 4 days.
• The secondary increase in fibrinogen, factor VIII
and platelets in the 1st week increases the risk for
thrombosis.
• The increase in fibrinolytic activity after delivery
acts as a protective mechanism.

01/07/22 35
 …..
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Fluid Loss:
•There is a net fluid loss of at least 2 liters during the 1st week
and an additional 1.5 liters during the next 5 weeks.
•The amount of loss depends on the
– amount retained during pregnancy,
– dehydration during labor and
– blood loss during delivery.

01/07/22 36
  Endocrine changes
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• Most hormones, like human placental lactogen,

become undetectable within one day.
• HCG levels gradually decline and disappear by 11-
16 days.
• Estrogen and progesterone levels also decline to
reach their lowest between 3-7 days.

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• The pitutary gland, which has increased in size by

30- 100% during pregnancy, starts to regress after
the first week.
• In non lactating mother, prolactin level returns to non
pregnant level by 2 weeks.
• In lactating mother, it remains above the non
pregnant level with dramatic increase during
suckling.
• Depending on the frequency of feeding, this response
gradually declines over a period of 6- 12 months.

01/07/22 38
  Return of fertility and menustration
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Ovarian Function (Menstruation And Ovulation):

•The onset of the first menstrual period following
delivery is very variable and depends on lactation.
•The meantime for onset of first menstruation is 7 – 9
weeks.

01/07/22 39
 LOGO
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• In non lactating women, ovulation resumes as early as

28 days.
• In lactating women this is highly variable and is
largely dependent on the strength of suckling
(frequency and duration of each feeding and
weaning).
• The earliest time of ovulation in lactating women is
10 weeks, with only 20 % ovulating in six months.
• The physiological basis of anovulation and
amenorrhea is due to elevated levels of serum
prolactin associated with suckling.
01/07/22 40
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• Ovulation suppression in lactating women is due to

elevated prolactin levels
Inhibits response of ovary to FSH
Suppress release of LH
Decrease GnRH secretion
• prolactin levels fall to the normal range by the
– 3rd week postpartum in nonlactating women and
– 6 weeks in lactating women

01/07/22 41
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• Women who is exclusively breastfeeding, the

contraceptive protection is about 98% up to 6
months of 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.
• Nonlactating mother should use contraceptive
measures in 3rd postpartum week and the lactating
mother in 3rd postpartum month.
01/07/22 42
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• Patients after 1st TM abortion & ectopic pregnancy

ovulate earlier, as early as 14 days.

01/07/22 43
 Initiation and maintenance of lactation
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• Two events needed for the initiation of lactation are

 drop in placental hormones mainly progesterone and
estrogen and
 release of oxytocin and prolactin by suckling reflex
(letdown reflex).
• This reflex is a neuroendocrine reflex.

01/07/22 44
 LACTATION……
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• For the first 2 days following delivery, no further anatomic

changes in the breasts occur. The secretion from the breasts
called colostrum, which starts during pregnancy becomes
more abundant during the period.
• Composition Of The Colostrum: It is deep yellow serous
fluid, alkaline in reaction. It has got a higher specific gravity;
a high protein, vitamin A, sodium and chloride content but
has got lower carbohydrate, fat and potassium than the breast
milk .
• Colostrum and milk contains immunologic components such
as immunoglobulin A (IgA), complements, macrophages,
lymphocytes, lactoferrin and other enzymes(lactoperoxidase).

01/07/22 45
 Breast feeding
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01/07/22 46
 Breastfeeding
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“Breastfeeding is neither easy nor automatic.”
• Should be initiated ASAP after delivery; best within
one hr !!
• Feed baby every 2-3 hrs to stimulate milk production
• Inverted or retracted nipples may be troublesome;
teased out by gently pulling with the finger and
thumb. This is best done during pregnancy .

01/07/22 47
Advantages of breastfeeding
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• Perfect nutrients
• Easily digested;
efficiently used
• Protects against Infection
•Costs less than artificial feeding
Breastfeeding
• Helpsbonding
and development
• Helps delay a new
pregnancy
• Protects mothers’
health
Percentage Composition of Colostrum and Breast
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protein fat carbohydrate Water

Colostrum 8.6 2.3 3.2 86

Breast milk 1.2 3.2 7.5 87

Advantages:
(1) The antibodies (IgA, IgG, IgM) and humoral factors (lactoferrin)
provides immunogical defense to the new born .
(2) It has laxative action on the baby.

01/07/22 49
 Reading Assignment
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• Physiology Of Lactation

01/07/22 50
 POSTPARTUM CARE
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• Post-natal care is a care that is provided to a mother and

newborn baby after delivery and within the first 42 days after
child birth.
• It is the attention given to the general
– social, mental, and physical welfare of the mother and
infant during the postpartum period
• CLASSIFICATION – is based on
 A. Type of care
• i. Postpartum care: care that is provided to a mother
• ii. Postnatal care: care that is provided to a newborn

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 B. Timing of care:
– i. Immediate PNC: Care provided to the mother and/or
newborn within the first 24 hours after delivery
– ii. Early PNC: Care provided to the mother and/or
newborn between 3rd to 7th day after delivery or birth
– iii. Late PNC: At least three additional postnatal contacts
are recommended for all mothers and newborns, on day 3
(48–72 hours), between days 7–14 after birth, and six
weeks after birth.

01/07/22 52
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• The postpartum period is a very special phase in the

life of a woman and her newborn.
– The majority of the maternal deaths and morbidities
occur during the postpartum period
• Quality postpartum services are a long-term
investment in the future health of women and their
newborn.

01/07/22 53
 postpartum care….
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Components of postpartum care

•1. Early detection and management of complications.
•2. Promoting health and preventing disease.
•3. Providing woman-centered education and
counseling.

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AIMS AND OBJECTIVES:

• To assess the health status of the mother.

• To detect and treat at the earliest any gynecological

condition arising out of obstetric legacy.
• To note the progress of the baby including the
immunization schedule for the infant.
• To impart family planning guidance

01/07/22 55
 ROUTINE POSTPARTUM/ POSTNATAL CARE
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• Immediate postpartum/ postnatal care (first 24 hours

after birth)
• For the MOTHER
• Monitor mother every 15’ for the first hour; then every 4 hrs
• Measure and document blood pressure (BP), temperature and pulse
every 30 min within the first 2 hours
• If first BP measurement is normal,take the second measurement
within six hours
• Check uterine tone
• Check for bleeding,pallor ,any perineal problem,
• inspect episiotomy site if done

01/07/22 56
 Immediate PPC/PNC For Mother….
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• Monitor urine output within 6 hours

• Encourage voiding of urine
• Encourage for mobility

01/07/22 57
 Immediate PPC/PNC For Mother….
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Give preventive measures

• Counsel on BF, Encourage early initiation of BF
• Counsel about family planning and provide if needed
• Counsel on danger signs of the mother and NEW BORN
• Counsel on nutrition
• Advise on postpartum care and hygiene
• If RPR positive, treat woman, partner and newborn
• Provide tetanus toxoid (TT) per immunization status
• Give mebendazole once in 6 months based on when last dose of
mebendazole was given
• Check woman’s supply of iron/folate and give 3 month’s supplies

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• Advise on insecticide treated bed net use for mother and baby as required

• Counsel on safer sex including use of condoms

• Counsel on continued abstinence from tobacco, alcohol and drugs

• Counsel for return visit

• Give appropriate supportive care for mothers with stillborn or dead baby

• Provide PPFP if not initiated earlier as Implants and Post placental insertion
of IUCD using Kelly placental forceps based on counseling during ANC and
availability of commodity, instruments and trained personnel. PM could be
BTL by mini-laparotomy or vasectomy in those who want to limit in the
presence of instruments and trained personnel
01/07/22 59
 Immediate PPC/PNC For New Born
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Monitor newborn every 15’ until the first hr. then before discharge
• Assessment of the newborn as per standards on breathing; movements; the
presenting part for swelling and bruises; abdomen for pallor and distension;
malformations; feel the tone; feel for warmth: if cold, or very warm, measure
temperature; weigh the baby.
• Provide essential new born care
• Warm baby by keeping mother and baby together, skin to skin contact
• Initiate BF with in the first one hour
• Frequent observation of baby by the mother for danger signs (unable to
feed, convulsion, fast breathing, lethargy....)
• Check color, umbilical cord for oozing, sucking/feeding.
• Immunization with BCG, and OPV0
• Advise on cord care

01/07/22 60
 Immediate PPC/PNC For New Born…
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• Counsel to delay bathing until after 24 hours

• Counsel on appropriate clothing of the newborn for ambient
temperature (one to two layers of clothes more than adults and
use of hats/caps)
• Encourage Communication and play with the newborn
• Preterm and low-birth-weight babies should be identified
immediately after birth and should be provided special care as
per existing guidelines
• Schedule return visit

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 Pain management
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Common causes of pain: after-pain and episiotomy

After pain - It is infrequent, spasmodic pain felt in
the lower abdomen after delivery for a variable period
of 2–4 days.
– Presence of blood clots or bits of after births lead
to hypertonic contractions of the uterus in an
attempt to expel them out. This is commonly met
in primipara.
– Pain may also be due to vigorous uterine
contraction especially in multipara.

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 MANAGEMENT OF AILMENTS….
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• The mechanism of pain is similar to cardiac anginal pain

induced by ischemia. Both the types are excited during
breastfeeding.
• The treatment includes :-
 massaging the uterus with expulsion of the clot
 followed by administration of analgesics
 Aspirin 600 mg,
 Acetaminophen 650 mg
 Ibuprofen 400 mg orally every 4 to 6 hours and
 antispasmodics.

01/07/22 63
 MANAGEMENT OF AILMENTS….
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• Correction of anemia: Majority of the women in

the tropics remain in an anemic state following
delivery.
– Supplementary iron therapy (ferrous sulfate 200 mg) is to
be given daily for a minimum period of 4–6 weeks.
• Hypertension is to be treated until it comes to a
normal limit. Physician should be consulted if
proteinuria persists.

01/07/22 64
 Post partum care
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 Rest And Ambulance

Early ambulation after delivery is beneficial. After a good
resting period, the patient becomes fresh and can breastfeed
the baby or moves out of bed to go to the toilet. Early
ambulation is encouraged.
• Advantages are:
 (1) provides a sense of well-being,
 (2) bladder complications and constipation are less,
 (3) facilitates uterine drainage and hastens involution of the uterus and
 (4) lessens puerperal venous thrombosis and embolism.
Following an uncomplicated delivery, climbing stairs, lifting
objects, daily household work and cooking may be resumed

01/07/22 65
 Cont’d…
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 Nutrition
• A regular diet should be offered as soon as the woman
requests food and is conscious.
• Intake should be increased to cover energy cost of lactation.
• Women should be advised to eat a diet that is rich in
proteins and fluids.
 Eating more of staple food (cereal or tuber)
 Greater consumption of non-saturated fats
 ƒEncourage foods rich in iron (e.g., liver, dark green leafy
vegetables, etc.)
• Avoid all dietary restrictions
01/07/22 66
 Maternal nutrition during lactation
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Mother's capacity to produce milk is resistant to nutritional
deprivation

Milk production affects maternal body composition & nutritional

status

Chronically deficient diet can deplete maternal nutrient stores

Nutritional requirements to support lactation are even higher than

pregnancy

01/07/22 67
 Maternal nutrition during lactation
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01/07/22 68
 Cont’d…
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 Care of the bladder
• Serious bladder distention may occur within the 1st
12 hrs
 Increased bladder capacity
 Relative insensitivity to intravesical fluid
pressure
 Trauma to base of bladder in case of difficult
labour
Pain or spinal anesthesia
Encourage the women to void if not possible (in 6hrs)
intermittent catheterization for 1 to 2 days
01/07/22 69
  Personal hygiene and perineal care
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• If delivery was uncomplicated, showering and bathing are

allowed.
• Vaginal douching is avoided in early puerperium, till after
bleeding stops completely and all wounds are healed.
• The vulva should be cleaned from front to back.
• Women are encouraged to defecate before leaving the
hospital, although with early discharge, this recommendation
is often impractical.
• Maintaining good bowel function can prevent or help relieve
existing hemorrhoids, which can be treated with warm sitz
baths.

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 Personal hygiene and perineal care…
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 Sleep
• The patient is in need of rest, both physical and
mental. So she should be protected against worries
and undue fatigue.
• Sleep is ensured providing adequate physical and
emotional support.
• If there is any discomfort, such as after pain or
painful piles or engorged breasts, they should be
dealt with adequate analgesics (Ibuprofen).

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Maternal-infant Bonding (Rooming-in):

• It starts from first few moments after birth. This is manifested
by bonding, kissing, cuddling and gazing at the infant.
•The baby should be kept in her bed or in a cot besides her bed.
•This not only establishes the mother-child relationship but the
mother is conversant with the art of baby care so that she can
take full care of the baby while at home.

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 Care Of The Breasts

• The nipple should be washed with sterile water
before each feeding.
• It should be cleaned and kept dry after the feeding is
over.
• A nursing brassiere provides comfortable support.
• What is-
– Nipple soreness ?
– Nipple confusion?

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 Breastfeeding
• Early skin to skin contact of mother and baby and immediate
initiation of breast feeding
– Encourage early initiation of breast feeding within 1hr of SVD
– Initiate breastfeeding within 2-3 hours of CS; when the
mother is conscious
Incase breast feeding can’t be started due to either maternal or
newborn illness, feeding the baby has to be initiated if
possible by milk sucked from the mother herself.

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• Breastfeeding…..
• Women should be
– encouraged to maintain exclusive breast feeding for six months and
– educated about effective breastfeeding practices, as well as common
breastfeeding problems, how to continue breast feeding for two years
– to start complementary feeding after six months

• Exclusive breast feeding means giving a baby only breast

milk, and no other liquids or solids, not even water.
• Drops or syrups consisting of vitamins, mineral supplements
or medicines are permitted

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Exclusive Breast feeding
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BF When ever
the baby wants,
Day and night, 8-
12 a day to grow
well
 Complementary Feeding
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• After six months of age, all

babies require other foods
to complement breast milk
• we call these
complementary foods.

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  Immunization
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• (i) Women with Rh-negative blood group, who have an infant
with Rh-positive blood and are not sensitized, should be given
Rh0(D) immune globulin 300 μg IM, as soon as possible
(preferably within 72 hours of delivery) to prevent sensitization.
• (ii) Women who are susceptible to rubella can be vaccinated
safely with live attenuated rubella virus.
• Mandatory postponement of pregnancy for at least 2 months
following vaccination can be easily achieved.
• (iii) The booster dose of tetanus toxoid, HepB, Tdap, should be
given at the time of discharge, if it is not given during
pregnancy.
• All are safe during breastfeeding.

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 Immunization…..
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Tetanus Toxoid Immunization Schedule
TT Time for administration Duration of protection
Injection
TT 1 At first contact with woman of child No protection
bearing age or as early as possible in
pregnancy (at 1st ANC visit)
TT 2 At least 4 weeks after TT 1 3 years
TT 3 At least 6 months after TT 2 5 years
TT 4 At least 1 year after TT 3 10 years
TT 5 At least 1 year after TT 4 thirty years (throughout a
woman’s reproductive life

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01/07/22
 Immunization….
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• Expose to sun light

20-30min (Morning
and Evening the
sun rays helps to
develop Vit D

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 Time of discharge
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• Could be made 6-24 hrs postnatal
Mother should be well educated about
Cares that she should take for her self
Infant feeding &care
Identification of danger signs in either the infant
or herself

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 Routine postpartum care visits/ followup
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  Advise on danger signs
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MOTHER New Born

− Sudden and profuse blood
loss, persistent or increased
blood loss
− Fainting, dizziness,
palpitations
− Fever, shivering, abdominal
pain, and/or offensive vaginal
discharge
− Painful or hot breast(s)
− Abdominal pain
− Cord red or draining pus
− Suckling poorly
− Eyes swollen, sticky or draining
pus
− Cold to touch in spite of re-
warming
− Hot to touch in spite of undressing
− Difficulty breathing
− Lethargy
− Convulsions

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 Advise on danger signs…
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MOTHER New Born

− Calf pain, redness or • …..
swelling
− Shortness of breath or chest
pain
− Excessive tiredness
− Severe headaches
accompanied, visual
disturbances
− Edema in hands and face

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  Sexual activity in postpartum women
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Desire to resume sexual activity in the puerperium varies
greatly among women
Vaginal incisions and lacerations
Amount of vaginal atrophy due to breast-feeding
Route of delivery=c/s
Return of libido
Median time to resume intercourse is 6 to 7 weeks
Couples can safely resume coitus.
Perineum is comfortable.
Bleeding diminishes.

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  postpartum family planning
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• All postpartum women should receive family planning

education and counseling before discharge
• Women should be informed about the advantages of birth
spacing for at least two years before getting pregnant again
and about different family planning options.
• Facilitate free informed choice for all women

• Women who will have elective C-section could be counseled

pre-operatively.

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 Contraception in postpartum women
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- Isn’t needed in the 1st 3 wks postpartum because of a delay in return of
ovulation in all women who breast feed.
• Choice of contraceptive based on:-
Woman’s preference
Medical hx
Breast feeding or not
• Sterilization is suitable for those who have completed their families.
can be performed immediately after delivery within 24 hours
Delaying the procedure for more than seven days after birth
increases the risk of infection

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 Cont’d…
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In non lactating mother
Long-acting injectables & levonorgestrel implants can be
started or placed anytime following delivery.

COC can be started 3 weeks after delivery.

Diaphragm should be fitted only after complete involution of

the uterus.

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 Cont’d…
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IUCD are also a satisfactory method irrespective of
breastfeeding status. Insertion of IUD immediately
following delivery (postplacental IUD insertion) is
currently done.
Perforation rate are less.

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 Thank You
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IF YOU HAVE ANY QUESTION

??????????

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 NEWBORN CARE AT THE TIME OF BIRTH
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 Session Objective LOGO
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• Define essential elements of early newborn care

• Discuss best practices for promoting newborn health

• Use relevant data and information to develop appropriate essential

newborn recommendations

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 ESSENTIAL NEWBORN CARE (ENC)
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DEFINITION:- It is care given to all newborn infants at birth to

optimize their chances of survival and wellbeing.

is a package of basic care provided to newborns to support their

survival and wellbeing.

most babies breath and cry at birth with only the provision of
essential newborn care.

The care you give immediately after birth is simple but

important.

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• Remember that the baby has just come out from the most
comfortable uterine environment.
• It was warm and quiet in the uterus and the amniotic fluid
and walls of the uterus gently touched the baby.

• You too should be gentle, observant and vigilant with the

baby when you handle them and also keep them warm

always.

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COMPONENTS OF ENC AT BIRTH FOR ALL BABIES

• Prevent hypothermia
• Observe for the first breath (spontaneous breathing)
• Any difficulty to establish spontaneous breathing, immediately
start bag and mask ventilation
• Cord and eye care
• Provide vitamin k
• Put the baby skin to skin contact with mother
• Start exclusive breast feeding within one hour of life.
• Vaccination of BCG, HBV and polio 0.

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 STANDARDIZED PROCEDURES IN ENC
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Step 1: Dry and stimulate

•Immediately dry the whole body including the head and limbs.
• Keep the newborn warm by placing on the abdomen of the
mother
• Stimulate by rubbing the back or flicking the soles of the feet
• Remove the wet towel
• Don’t let the baby remain wet, as this will cool the body and
make it hypothermic.
• Let the baby stay in skin to skin contact on the abdomen and
cover the baby quickly including the head with a clean dry cloth
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 STANDARDIZED PROCEDURES IN ENC ….
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Step 2: Evaluate Breathing

• Check if the baby is crying while drying it. I

• If the baby does not cry, see if the baby is breathing properly.
• If the baby is not breathing and/or is gasping:
 Call for help. The assistant can provide basic care for the mother
while you provide the more specialized care for the baby who is not
breathing.
 Cut the cord rapidly and start resuscitation.
• If the baby breathes well, continue routine essential newborn
care.
• Do not do suction of the mouth and nose as a routine.
 Do it only if there is thick meconium, mucus or blood obstructing the
airway
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NORMAL BREATHING
•Normal breathing rate in a newborn baby is 30 to 60 breaths
per minute.
•The baby should not have any chest in-drawing or grunting.
– Small babies (less than 2.5 kg at birth or born before 37 weeks
gestation) may have some mild chest in-drawing and may
periodically stop breathing for a few seconds.

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 STANDARDIZED PROCEDURES IN ENC ….
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Step 3. Cord care

Optimal cord care consists of the following:
•Clamping /tying the cord: If the baby does not
need resuscitation, wait for cord pulsations to cease or
approximately 1-3 minutes after birth, whichever comes first,
and then place one metal clamp /cord tie 2 centimeters from the
baby’s abdomen and the second clamp / tie another 2
centimeters from the first clamp/tie.
•Cutting the cord soon after birth can decrease the amount of
blood that is transfused to the baby from the placenta and, in
preterm babies; it is likely to result in subsequent anemia and
increased chances of needing a blood transfusion.

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• Cutting the cord: Cut the cord with sterile scissors or surgical blade,
under a piece of gauze in order to avoid splashing of blood. At every
delivery, a clean separate pair of scissors or blade should be
designated for this purpose.
• Counseling on cord care:
– Check for bleeding/oozing and retie if necessary.
– The cord may be tied by using sterile cotton ties, elastic bands, or pri
-sterilized disposable cord tie.
– Advise the mother not to cover the cord with the diaper
– Don’t use bandages as it may delay healing and introduce infection.
– Don’t use alcohol for cleansing as it may delay healing.
– Don’t apply traditional remedies to the cord as it may cause tetanus and other
infections.
– Apply 4% chlorhexdine immediately after cutting the cord and continue daily
for 7 days (3-5).
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Watch out for

 Pus discharge from the cord stump.
 Redness around the cord especially if there is swelling.
 Fever (temperature more than 38°C) or other signs of
infection

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Step 4. Keep the newborn warm (Prevent Hypothermia)

oKeep the baby warm by placing it in skin-to-skin contact on
the mother’s chest.
oCover the baby’s body and head with pre-warmed clean cloth
including hat and socks.
oIf the room is cool (<25 ºC), use a blanket to cover the baby

over the mother.

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Step 5. Initiate breastfeeding in the first one hour

oSkin-to-skin contact and early breastfeeding are the best ways
to keep an infant warm and prevent hypoglycaemia.
oEarly breastfeeding means breastfeeding within the first hour,
with counseling for correct positioning.
oEarly breastfeeding reduces the risk of postpartum hemorrhage
for the mother.
oColostrum (the "first milk") has many benefits for the baby,
especially anti-infective properties.
oBreastfeeding delays the mother's return to fertility because of
lactation.
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o Breastfeeding provides the best possible nutrition for the
baby.
o Feed day and night, at least 8 times in 24 hours, allowing on-demand
sucking by the baby.
o If the baby is small (less than 2,500 grams), wake the baby to feed
every 3 hours.
o If the baby is not feeding well, seek help.
o Successful breastfeeding requires support for the mother
from the family and health institutions.
o There is no need for extra bottle feeds or water for normal
babies, even in hot climates
o Avoid the use of the bottles and pacifiers

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Step 6. Administer eye drops/eye ointment

oWash your hands with soap and water
oClean eyes immediately after birth with swab soaked in sterile
water, using separate swab for each eye. ENCC 3 1

oClean from medial to lateral side.

o Give tetracycline eye ointment/drops within 1 hour of birth
usually after initiating breast feeding.
oDon’t put anything else in baby's eyes as it can cause infection.
oWatch out for discharge from the eyes, especially with redness
and swelling around the eyes

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Step 7. Administer vitamin K Intramuscularly (IM)

o1 mg for babies with gestational age of 34 weeks or above

o0.5 mg for premature babies less than 34 weeks gestation

Step 8. Place the newborn’s identification bands on the wrist

and ankle
oPutting the identification bands on the hands and ankle will
save you from misshaping babies in busy delivery rooms.

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Step 9. Weigh the newborn when it is stable and warm

Place a clean linen or paper on the pan of the weighing scale.
Adjust the pointer to zero on the scale with the linen/paper on
the pan.
Place the naked baby on the paper/linen. If the linen is large,
cover the baby with the cloth.
Note the weight of the baby when the scale stops moving.
Never leave the baby unattended on the scale.
Record the baby ’s weight in partograph/maternal/ newborn
charts and delivery room
Register and inform the mother

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Step 10. Record all observations and treatment provided in

the registers/appropriate chart/cards
NB. Defer the bath for at least 24 hours.

Clean the newborn of an HIV-infected mother as

recommended
Organize transport if necessary

Inform the mother of the newborn’s weight

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  APGAR SCORE
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• APGAR score is not used to initiate or make decision about

resuscitative measures. However, it is useful for assessing the
effectiveness of resuscitation efforts.

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 APGAR SCORE
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Sign score
0 1 2
1 Heart rate absent <100bt/minute >100bt/minutes
2 respiratory absent Slow/irregular Good baby,crying
3 Muscle tone limb Some flexion of Active motion
extrimities
4 reflex No response grimace Cough/sneeze
5 color Total body Pink body All pink
blue/pink blue extremities

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 APGAR SCORE …
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• One minute Apgar score, generally correlates with umbilical

cord blood PH and is an index of intra-partum asphyxia.
• Normal Apgar score is >7 out of ten and babies with a score
of 0 to 4 have been shown to have significant acidosis and
higher Pco2 value than those with normal Apgar score.
• Beyond one minute, APGAR score reflects the neonates
changing condition and adequacy of the resuscitative efforts.
When 5 minute Apgar score is < 7 additional scores should
be obtained every 5 minutes up to 20 minutes of age unless
two successive scores are ≥ 8.

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 Summary
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The essential components of

normal newborn care include:
•Clean delivery and cord care
•Thermal protection
•Early and exclusive
breastfeeding
•Cord care with chlorhexidine
•Eye care
•Immunization
•Vit K

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