K.

NYIRENDA
BSc.Mw
INTRODUCTION
• Following the birth of the baby and expulsion of the
placenta, the mother enters a period of physical and
psychological recuperation (Buckley 2006).
• Puerperium starts immediately after delivery of the placenta
and membranes and continues for 6 weeks.
• The overall expectation is that by 6 weeks after the birth of
the baby, all systems in the woman’s body will have
recovered from the effects of pregnancy and returned to
their non pregnancy state.
INTRODUCTION
• Other changes which occur during pregnancy are reversed
and lactation is established, the foundation of the
relationship between the infant and his parents is also laid.
GENERAL OBJECTIVE
At the end of the Lecture/ Discussion, students should be able to gain
knowledge and skills needed to nurse a woman in Puerperium.
SPECIFIC OBJECTIVES
At the end of the Lecture/ Discussion, students should be able to:
1. Define Normal Puerperium
2. Outline the Physiological changes that take place in Puerperium
3. Explain the specific Nursing management of a mother during in the
first 6 hours of Puerperium
DEFINITION
• Puerperium is defined as the period from the completion of delivery of
the placenta and membranes to the end of the first six (6) postpartum
weeks, during which time the woman’s body returns to the normal non
gravid state. (Myles 2009, P 651)
• Puerperium is the period following child birth in which the
Reproductive organs and other systems return as much as possible to
their pre gravid state and takes six (6) weeks.
• Puerperium as the period from the completion of delivery(end of the
third stage of labour) to the end of six weeks, during which the time the
woman’s body returns to the normal non gravid state (Sellers 2010,
p583).
PHYSIOLOGY OF PUERPERIUM
• It is a series of events that take place in different systems of the body
in an effort to reverse the effects of pregnancy to the pre gravid state.
• At the end of labour, the uterus weights approximately 900 –
1000gms, by the end of 6 weeks it will have returned to its pre gravid
weight of about 60gms and measuring 7.5 x 5 x 2.5 cm.
• The reduction in the size of the uterus is most rapid during the first 7
– 10 days when the uterus loses about 50% of its weight.
• The remaining 50% will be lost gradually during the last 5 weeks of
puerperium.
CHANGES TO REPRODUCTIVE
SYSTEM
• 1. Involution of the uterus
• Involution is a process by which the uterus returns to its
normal size from 900grams (12.5cm diameter) at term to
60grams (2.5cm diameter) after the expulsion of the
products of conceptions.
• Involution is a process by which the uterus returns to its
normal site, tone and position of non pregnant state.
REPRODUCTIVE SYSTEM
Involution is achieved by:
i. Autolysis
• Referred to as self digestion
• The proteolytic enzymes digest muscle fibres of the enlarged
uterus.
• The digested materials (waste product) are then passed into
the blood stream and are eliminated by the kidneys.
REPRODUCTIVE SYSTEM
(ii) Ischemia
• After the delivery of the baby and placenta, the uterine
muscle and blood vessels contract decreasing the blood
flow to endometrium decidua leading to (localised
anaemia).
• This causes ischemia and weakening of the endometrium
decidua which is shed in the lochia discharge.
REPRODUCTIVE SYSTEM
(iii) Contraction and Retraction of the Uterus
• Contraction and retraction of the uterus is facilitated by
oxytocin released from the posterior pituitary gland which
causes the uterus to return to normal size from 900g to 60g
by the end of 6 weeks.
• This process continues until the uterus returns to its normal
size.
REPRODUCTIVE SYSTEM
Progress of change in the uterus after delivery
• Weight of uterus versus diameter of placental site:
• End of labor 900grams, 12.5cms
• End of 1 week 450grams, 7.5cms
• End of 2 weeks 200grams, 5cms
• End of 6 week 60grams, 2.5cms
REPRODUCTIVE SYSTEM
Involution is marked within 10 days but continues up to the end of
Puerperium
Fundal height
• The fundus decreases by 1cm to 1.5cm per day or about a finger’s
breadth per day.
• After delivery - uterus is at the level or 2cm below the umbilicus
• At 7 days - above the symphysis pubis
• At 10-12 days - no longer palpable, becomes a pelvic organ.
REPRODUCTIVE SYSTEM
2. Lochia is the normal vaginal discharge which comes out
after delivery or during Puerperium.
• Originates from the uterine body, cervix and the vagina.
• Its alkaline in nature in which organisms can flourish rapidly.
• The odour is unpleasant but not offensive and the amount
varies from woman to woman.
REPRODUCTIVE SYSTEM
Constituents of Lochia
• Blood
• Decidua tissue
• Epithelial cells
• Bacteria
• Products of conception(fragments of membranes)
• Small clots of blood
REPRODUCTIVE SYSTEM
Types of Lochia (3)
1. Lochia Rubra/Red Lochia
• From 1st – 4th day
• Consists of blood from the placental site and as such it is red
in colour.
REPRODUCTIVE SYSTEM
2. Lochia Serosa / Serous lochia
• From 5th – 9th day
• Consists of more serum than blood and leucocytes from the
placenta site as such it is purple in colour.
3. Lochia alba / White Lochia
• From the 9th-12th day
• Consists of cervical mucus, it is creamish pale discharge in
colour.
REPRODUCTIVE SYSTEM
3. Cervical Changes
• Cervix is soft after delivery.
• Regains its shape and form within 3 days after delivery.
• Internal Os closes completely while the external Os changes
to a slightly open slit and not the O shaped.
• At 7 days, the external os closes such that the finger cant be
introduced easily.
REPRODUCTIVE SYSTEM
4. Vaginal changes
• The vagina regains most of its tone by the end of Puerperium
• The vagina decreases in size and rugae returns within 4 to
6weeks (Vaginal folds, wrinkles or creases).
ENDOCRINE SYSTEM
Hormonal changes
• Expulsion of the fetus and placenta cause a drop in the levels
of oestrogen, progesterone, human placental hormone and
the human chorionic gonadotrophic hormone, causing a
number of physiological changes.
• Production of Prolactin hormone is initiated from the
anterior pituitary gland after the deliver of the placenta
• It act on the Acini cells of the alveoli in the breast to produce
more milk.
ENDOCRINE SYSTEM
• Colostrum is secreted in 1-2 days
• The breast becomes heavy and engorged, this however
reduces as the baby begin to suckle
• Oxytocin is also produced from the posterior pituitary gland
which acts on the myoepithelial cells of the alveoli, making
them to contract and propel the milk.
• Oxytocin also facilitates the contraction of the uterus and
this prevents post parturm Haemorrhage.
CARDIOVASCULAR / CIRCULATORY
SYSTEM
• During pregnancy, the blood volume increases to accommodate the
increased blood flow to the placenta and the uterine blood vessels.
• After delivery, there is marked diuresis (excessive discharge of urine)
leading to reduced plasma volume.
• Muscle tone of blood vessels improves, cardiac output normalizes
from 7 litres cardiac out put to 5 litres per minute and blood
pressures returns to its usual level.
• These actions takes place within the first 24 – 48hrs after delivery.
URINARY SYSTEM
• There is increased renal flow in the first 48 hours as the body tries to
maintain normal blood volume and excrete waste products of
autolysis.
• This results in substantial loss of fluid and the woman is often very
thirsty in the first week.
• During labour the bladder is displaced into the abdomen stretching
the urethra and ureters to a considerable degree.
• Passing urine becomes difficult due to pain as these structures may as
well be bruised and sometimes become edematous.
RESPIRATORY SYSTEM
• During pregnancy, the enlarged uterus compresses the lung
resulting in difficulties with breathing
• After delivery, there is full ventilation because the lungs are
no longer compressed by the uterus.
MUSCULOSKELETAL SYSTEM
Abdominal muscles
• Stretch marks gradually fade but often do not disappear all
together and instead, become silvery white streaks (stretch
marks).
• Muscles of the abdominal wall take a few weeks to regain
their tone but in multipara and elderly women, the skin and
muscles take even longer to regain their tone.
MUSCULOSKELETAL SYSTEM
Pelvic ligaments
• These tissues become overstretched during pregnancy and
labour.
• Exercises are therefore important to help them regain their
tone.
MUSCULOSKELETAL SYSTEM
Pelvis
• The pelvic joints regain their normal form by the end of
Puerperium.
• The symphysis pubis becomes stabilized by 6 to 8 weeks.
• The abdominal and pelvic floor muscles gradually regain
their tone with the assistance of postnatal exercise.
MUSCULOSKELETAL SYSTEM
Perineal muscles
• Perineal tears and episiotomies should be healed within 7
days.
• Perineal muscles regain their tone after 5 to 6 weeks and this
is facilitated by perineal exercise.
• Due to over stretching and loss of muscle tone, constipation
is common. This is coupled with pain Exercises are therefore
important.
ALIMENTARY CANAL
• Heart burn improves due to hormonal fall and released
pressure on the sphincter.
• Constipation presents for few days; painful perineum inhibits
defecation.
PSYCHOLOGICAL CHANGES/ STATE
• Majority of the women are happy and content while others
are anxious, apprehensive and withdrawn.
• This is associated with worrying of how the baby will be
cared for and in an event of still birth, neonatal death or
abnormal baby.
IMMEDIATE POSTNATAL CARE
Aims
• To prevent postpartum haemorrhage
• To monitor observations
• To promote rest
• To encourage baby mother bonding.
IMMEDIATE POSTNATAL CARE
Environment
• The woman will be monitored in labour ward in the first one hour for
close observation.
• Ensure the environment is clean and keep the windows closed to
prevent the hypothermia to the new born baby.
Psychological care
• Explain to the woman that she will be kept in labour ward for one
hour for observation. Allow her to assess questions and answer them
accordingly to gain cooperation and to allay anxiety.
IMMEDIATE POSTNATAL CARE
Hygiene
• Wipe off fluids from the mother’s body and assist her to put on sanitary pads
and clothes. Ensure that you assist to put on clean clothing and her cover her in
clean linen for warmth.
Observations
• Check blood pressure, respirations, pulse, vaginal every 15 min for 1 hour.
• A lowered B.P may signify excessive bleeding; Low pulse and subnormal temp
are suggestive of impending shock. A high temp may be suggestive of infection.
• Monitor per vaginal bleeding by checking the number pads change in the first
one hour. This done to monitor if bleeding is minimal or excessive which can
suggest PPH.
IMMEDIATE POSTNATAL CARE
Uterine massage
• Massage the uterus every 15 minutes in the 1st 1hour to enhance
uterine contractions to ensure that it is well contracted to prevent
excessive bleeding (postpartum haemorrhage).
• Palpation of the uterus will also help to expel clots that might have
retained in the uterus. Encourage the mother to breastfeed to provide
nutrition and also to promote continues release of oxytocin which will
enhance uterine contractions.
IMMEDIATE POSTNATAL CARE
Bladder care
• Ensure that the woman passing urine to enhance uterine
contractions to prevent PPH and if she is unable pass
catheterize the patient.
• After an hour, when the general condition is good and the
uterus is well contracted she is then transferred to the
postnatal ward together with her baby where they are kept
for a minimum of 6 hours before discharge.
SUBSEQUENT POSTNATAL CARE
Aims
• To monitor observations
• Promote sleep and rest
• Provide a balanced nutrition
• Maintain good hygiene and breast care
• Facilitate bladder emptying
• Facilitate early ambulation
• Provide emotional support
• Promote maternal and child relationship
SUBSEQUENT POSTNATAL CARE
Environment
• The woman will be nursed in postnatal ward for next 6 hours. Ensure
that the room is well ventilated to promote free movement of air.
• The room should also be clean to prevent infections.
Psychological care
• Explain the reasons for keeping her in the post natal ward to allay
anxiety and to create a good rapport.
• Explain all the procedures
• Explain the importance of rooming in (need to be with the baby).
SUBSEQUENT POSTNATAL CARE
Observations
• While in postnatal ward, the receiving midwife ensures that
the uterus is well contracted, the woman is not bleeding
excessively and that the bladder is empty.
• The midwife also checks vital signs of blood pressure, pulse,
respirations and temperature to ensure that they are normal.
• Check blood pressure, respirations, pulse, vaginal bleeding
and palpate the uterus every 15 min for 1 hour , Every 30min
for 2 hrs. Every 1hr for 3 hrs.
SUBSEQUENT POSTNATAL CARE
Observations
• Observe for PV bleeding which should be minimal. PV
bleeding can be observed using a pad count.
• Too much clots and excessive PV bleeding may be as sign of
Post partum haemorrhage.
• Observe also full bladder and encourage the woman to pass
urine to promote uterine contraction to prevent PPH.
• Observe the Mood swings of the mother to exclude post
natal blues.
SUBSEQUENT POSTNATAL CARE
Rest and sleep
• Maintain noise free environment.
• Do nursing procedure in one block and visitors should be kept to a
minimum.
• Give analgesics for the after pain arising from contracting uterus.
• Rest helps woman to recover from the emotional and physical stress
of labour and pregnancy therefore woman should sleep well the first
night.
SUBSEQUENT POSTNATAL CARE
Nutrition
• Nutrition is important to facilitate good lactation and
healing.
• Encourage the woman to have a balanced diet (minerals,
vitamins, Proteins for repair of worn out tissues).
• Encourage also to take Carbohydrates for energy, fluids to
promote lactation and food containing roughage to prevent
constipation.
SUBSEQUENT POSTNATAL CARE
Medication
• Give Vitamin A 200,000 i.u stat P.O.
• Folic acid 5mg once daily and ferrous Sulphate 200mg TDS to
for blood formation to replace lost blood in labour.
• Paracetamol 1g t.d.s x 3/7
SUBSEQUENT POSTNATAL CARE
Hygiene
• The woman should have a bath after resting with support from the
nurse or care giver
• Advise the woman to use of Sanitary pads and Clean linen and change
clothes when soiled.
• Vulva care/ swabbing from front to back should be encouraged to
prevent introducing infection from anal region
• Perineal care ,sitz bathes with plain cool / warm water for healing of
tears, lacerations, episiotomy
• Do Catheter care/toilet if a catheter is in situ.
SUBSEQUENT POSTNATAL CARE
Bladder
• Encourage bladder emptying, a distended bladder will
interfere with the contraction of the uterus and may lead to
PPH.
• If unable to pass urine, catheterization should be done.
• Essentially large amounts of urine is passed in the first few
days to eliminate excess fluids after delivery.
SUBSEQUENT POSTNATAL CARE
Bowel care
• Constipation should be avoided by taking roughage diet and
exercise.
• Watch for constipation, it is common in the first three days
post-partum due to the following reasons.
• Pain on defaecation especially if she has bruises and stitches
from the perineum. Full rectum interferes with involution. An
aperient can be given.
SUBSEQUENT POSTNATAL CARE
Ambulation
• Encouraged the woman to practice early ambulation 6 – 12
hours after delivery and after having enough rest.
• Early ambulation also helps with drainage of Lochia and
involution of the uterus.
• Ambulation also prevents venous thrombosis in the legs.
• The woman should be encouraged to get out of bed and
have a short walk to the toilet accompanied.
SUBSEQUENT POSTNATAL CARE
Promotion of maternal and child relationship
• Allow mother to be with the baby (rooming)
• Early and frequent breastfeeding encouraged to promote mother to
child bonding.
SUBSEQUENT POSTNATAL CARE
Physical examination
• After six hours of observations and if the condition for both the
mother and baby is stable, a thorough physical examination is done
on both (mother and baby) before discharge from the hospital.
INFORMATION EDUCATION
COMMUNICATION ON DISCHARGE
• Good hygiene
• Well balanced diet
• Rest
• Bladder emptying
• Uterine rubbing
• Family planning
• Review dates
• Danger signs (both mother and neonate)
IEC Cont’
• Early ambulation and exercises
• Rooming in and Breast feeding
• Medication e.g. folic and feso4
COMPLICATIONS
• Puerperal sepsis
• Septicaemia
• Post partum blues or psychosis
• Secondary PPH
• Anaemia
• Shock secondary to Anaemia
• Thrombo embolism
• Mastitis/breast abscess due to breast engorgement
CONCLUSION
• Post Natal care is done at 6 hours following
delivery, 6 days and 6 weeks.
• The care is aimed at promoting the health of the
Mother and the Baby.
• Problems identified are treated and the Mother is
encouraged to come at 6 hours, 6 days and 6 weeks
so that early detection and treatment of
complications may prevent life long complications.
• This promotes the health of the Mother and Baby.
REFERENCES
1. Baker P. N. (2006) Obstetrics by Ten Teachers. 18th Edition.
Hodder Arnold, India.
2. Dutta D. C. (2006) Text-Book of Obstetrics. 6th Edition. New
Central Book Agency, Calcutta, India.
3. GNC (2001) Midwifery Procedure Manual. GNC, Lusaka