ASSESMENT AND MANAGEMENT OF WOMEN
DURING POSTNATAL PERIOD/puerperium
Definition
Puerperium is the period following childbirth
during which the body tissues, specially the
pelvic organs revert back approximately to the
pre-pregnant state both anatomically and
physiologically.
Involution is the process whereby the
reproductive organs return to their nonpregnant
state.
Duration
Puerperium begins as soon as the placenta is
expelled and lasts for approximately 6 weeks
when the uterus becomes regressed almost to the
non- pregnant size. The period is arbitrarily
divided into –
Immediate- within 24 hours
Early- upto 7 days
Remote- upto 6 weeks.
Physiological changes during
puerperium
Involution of the uterus
Anatomical consideration : Immediately
following delivery, the uterus becomes firm and
retracted with alternate hardening and softening.
The uterus measures about 20 X 12 X 7.5 cm.
Weight :about 1000 gms.
At the end of the first week, it weighs 500gm. By
the 6 weeks, it weighs approx. 50g. The placental
site contracts rapidly presenting a raised surface
which measures about 7.5 cm and remains
elevated even at 6 weeks when it measures about
1.5 cm.
Lower uterine segment : Immediately following
delivery, the lower segment becomes a thin,
flabby, collapsed structure. It takes a few weeks
to revert back to the normal shape and size of the
isthmus.
Cervix : The cervix contracts slowly.
External os: admits two fingers for a few days
but by the end of first week, narrow down to
admit the tip of finger only. It never returns back
to the nulliparous state, usually remains slightly
open and appear slitlike or stellate (star shaped).
Internal os: Internal os closes as before.
Muscles : During puerperium, the number of
muscles fibers is not decreased but there is
substantial reduction of the myometrial cell size.
Withdrawal of the steroid hormones, oestrogen and
progesterone may lead to increase in the activity of
the uterine collagenase and the release of the
proteolytic enzyme.
Blood vessels : The arteries are constricted by
contraction of its wall and thickening of the intima
followed by thrombosis. New blood vessels grow
inside thrombi. Fibrous tissue on the wall undergoes
hyaline degeneration and the products are removed
by macrophages. There is also degeneration of the
elastic tissues.
Endometrium : The superficial layer becomes
necrotic and is sloughed in the lochia. The basal
layer adjacent to the myometrium remains intact
and is the source of new endometrium. The
endometrium arises from proliferation of the
endometrial glandular remnants and the stroma of
the inter glandular connective tissue. By the 10th
day: Regeneration of the epithelium is completed.
By the day 16: the endometrium is restored. At
about 6 weeks: the endometrium of placental site
is restored
Vagina : Takes a long time(4-8 weeks) to involute.
It regains its tone but never to the virginal state.
Lochia :
Lochia :
It is the vaginal discharge for the first fortnight during puerperium. The
discharge originates from the uterine body, cervix and vagina.
Odour and reaction: it has got a peculiar offensive fishy smell.
Its reaction is alkaline tending to become acid towards the end.
Colour: depending upon the day.
Lochia rubra (red): 1-4 days . it consists of blood, decidual and trophoplastic
debris It lasts 3-4 days after childbirth .
Lochia serosa (5-9) days: the color is yellowish or pink or pale brownish. it
consists of old blood, serum, leukocytes, and tissue debris.
Lochia alba (plae white):10-15 days. it consists of leukocytes, decidua,
epithelial cells, mucus, and bacteria.
Amount: for the first 5-6 days, is estimated to be 250 ml.
Normal duration: may extend up to 3 weeks.
Clinical aspects 1. Persistence of red lochia means subinvolution 2. Offensive
lochia means infection 3. In severe infection with septicaemia, lochia is scanty
and not offensive 4. The period of time the lochia can last varies, although it
averages approximately 5 weeks
Endocrine system
Placental hormones : Insulinaze causes the diabetogenic
effects of pregnancy to be reversed. Estrogen and
progesterone levels decrease markedly after expulsion
of the placenta, reaching their lowest levels 1 week into
the postpartum period. The estrogen levels in
nonlactating women begin to increase by 2 weeks after
birth, and higher by postpartum day 17.
Pituitary hormones and ovarian function : Lactating
and non-lactating women differ in the time of the first
ovulation. In women who breast feed, prolactin levels
remain elevated into the sixth week after birth.
Prolactin levels decline in nonlactating women,
reaching the prepregnant range by third week.
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. Non-lactating mother should use
contraceptive measures after 3 weeks and the
lactating mothers after 3 months of delivery.
The 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.
Urinary system
The bladder wall becomes oedematous and
hyperaemic the bladder may be overdistended
without any desire to pass urine. Dilated ureters
and renal pelvis return to normal size within 8
weeks.
Vital sign
Changes 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 third or fourth postpartum day, her
temperature rises for a period of hours because of the increased
vascular activity involved.
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.
Blood pressure
Systolic and diastolic blood pressures remain unchanged
Psychological changes during
Postpartum
Phases of the Maternal Role: Emotional changes
in the mother during the postpartum period
(restorative process) as described by Reva Rubin
pass through three phases. They are:
Taking-in phase.
Taking-hold phase.
Letting-go phase.
Taking-in Phase (Turning in): It takes 2-3 days,
during which time the mother’s first concern is
with her own needs (sleep and food). The woman
reacts passively, mostly dependent on others to
meet her needs. She initiates little activity on her
own. She is quite talkative during this phase
about every detail of her labor and delivery
experience.
Taking-Hold Phase (Taking Responsibility as a
Mother): It starts the 3rd day postpartum. The
emphasis is placed on the present. She becomes
impatient and is driven to organize herself and
her life. She progresses from the passive
individual to the one who is in command of the
situation. This phase lasts about 10 days. Once
the mother has taken control of her physical
being and accepted her role as a mother, she is
able to extend her energies to her mate and other
children.
Letting-go Phase: As her mothering functions
become more established the mother enters the
letting-go phase. This generally occurs when the
mother returns home. In this phase there are two
separations that the mother must accomplish.
One is to realize and accept physical separation
from the infant. The other is to relinquish her
former role as a childless person and accept the
enormous implications and responsibilities of her
new situation. She must adjust her life to the
relative dependency and helplessness of her
child.
A good method to remember how to check the postpartum
changes is the use of the acronym BUBBLERS:
B: Breast.
U: Uterus.
B: Bladder.
B: Bowel.
L: Lochia.
E: Episiotomy.
R: Emotional response.
S: Homans' sign.
POSTNATAL CARE AND ADVICES
Hygiene- personal and environmental
Maternal and neonate’s personal hygiene should
be maintained to prevent infection. Vulval care
and daily bathing should be done as lochia
drainage occurs. Cleanliness helps her to fresh and
activates energy to care.
Perineal care should be done to observe the
amount, colour, odour and consistency of the
lochia, to keep the stitch clean, dry and help in fast
healing, to prevent local and ascending infection.
Breast Care
Breast care is very important for both mother and
baby because it prevents from infection, so the
mother should advised to clean her breast before
and after each feed with clean water and hand
washing too. Advice to wear clean supportive
undergarments.
Breast Feeding of infant
Breast milk has anti infective properties that
protect the infant from infection in the early
months. It is a complete food and provides all
nutrients needed to infant in the first few months.
So encourage mother to feed the breast feeding
for her baby.
Care of the umbilical cord
Cleanliness of the umbilical cord is essential
the cord should be cleaned at least twice a day
and should be observed if there is bleeding from
the site of the cord. And also advice the mother
and family members not to enclosed within the
baby’s napkin where contamination by urine or
faces may occur.
Diet
should eat highly nutritious foods and soups high
in protein and carbohydrate
Postnatal Exercise
Postnatal exercise is the exercise done after
delivery in postnatal period which is very
important to improve blood circulation, to help in
involution of reproductive organs, to prevent
thrombosis and thrombophlebitis, to promote
well being of the postnatal mother, to restore the
tone of the abdominal the pelvic muscles, for
proper drainage of lochia. So advice mother to do
postnatal exercise.
Bonding
Keeping the baby aside to the mother
Rooming in
Kangaroo mother care
Motivates breast feeding
Rest, sleep and activity
Mother should have 10 hours rest at night and 1-
2 hours at afternoon till 40-60 days of delivery.
Heavy working, heavy lifting should be avoided
in puerperium because it predispose to uterine
prolapse.
Prevention of infection in the baby
Midwives have an important role to play in creating a safe
environment that decreases the chance of infant acquiring
infection after birth.
› Encouraging and assisting the mother for breast feeding thus increasing
infant’s immune protection.
› Ensuring careful and frequent hand washing by all careers; the simple
procedure remains the single most important method of preventing the
spread of infection in infants.
› Rooming in the infants with his/ her mothers.
› Adequately spacing costs when infants are in the nursery with other
infants.
› Always use individual equipment for each infant.
› Avoiding any irritation or trauma to the infant’s skin and mucous
membrane, as intact skin provides a barrier against infection.
› Controlling extra visitor.
Birth registration
Need to register the birth accoding to the policies
of the government
Pregnancy spacing
Mother and family members should be advised
about the importance of pregnancy spacing.
There should be at least the gap of 2 years of
pregnancy spacing.
Health check up for mother and baby
Regular health check up and follow up for
mother and baby is very important with in
puerperium period.
