Intra-Partal Care to Post-Partal

Care

Prepared by:
Sheena Mae Buana- Cañezal, RN.MN.
Related Terminologies

Pre-term – labor begins before the fetus is

mature

Post-term – delayed labor, begins when

fetus and placenta have passed beyond
the optimum point of birth

Amniotomy – artificial rupture of amniotic

sac
Attitude – relationship of the fetal body
parts to one another such as flexion or
extension

Bloody show – cervical mucus and blood

from ruptured capillaries

Crowning – appearance of the fetal

presenting part at the vaginal opening
Engagement – descent of the widest
diameter of the fetal presenting part to at
least a zero station (level of Ischial spine
of the maternal pelvis)

Episiotomy – surgical incision at the

perineum

Fontanel – space at the intersection of

sutures connecting fetal or infant skull
bones
Lie – relationship of the long axis of the
fetus to the long axis of the mother

Lightening – descent of the fetus towards

the pelvic inlet before onset of labor
Lochia – vaginal discharge after birth
Molding – shaping of the fetal head during
movement through birth canal
Position – relationship of the fetal
presenting part to specific quadrant of the
woman’s pelvis
Presentation – fetal part that first enters
the pelvis inlet
Station – measurement of the fetal
descent in relation to the ischial spines
Sutures – membranous spaces where
bones of the skull meet
Effacement – thinning of cervical wall
Dilatation – enlargement of the external
cervical Os
Attitude:
• Normal Uterine attitude is FLEXION.
• EXTENSION – tends to present larger fetal diameters.
LIE:
• Longitudinal or vertical
• Transverse or horizontal
PRESENTATION Portion of the fetus thar enters the pelvic
inlet first.

CEPHALIC- head first. Has four variations : vertex,

military, brow and face.
BREECH- Buttocks present first. Delivery by cesarean may be
required. Has three variation, frank, full(complete) and footling.
SHOULDER- fetus is in transverse lie , arm, back, abdomen or side
could be present. Cesarean may be required.

PRESENTING PART- the

specific fetal structure
lying nearest to the cervix.
POSITION Relationship of assigned area of the presenting
part or landmark to the maternal pelvis.
STATION The measurement of the progress of descent of the
centimeters above or below the midplane from the presenting part to
the ischial part.

Station 0 – at
ischial spine.

Minus station-
Above ischial
spine.

Plus station-
below ischial
spine.
Mechanism of
Labor
ENGAGEMENT – (lightening or dropping) is the mechanism whereby the fetus nestles into
the pelvis.

DESCENT – is the process that the fetal head undergoes as it begins its journey through
the pelvis.

FLEXION – is a process of the fetal head’s nodding forward toward the fetal chest.

INTERNAL ROTATION – occurs most commonly from the occiput transverse position,
assumed at engagement into the pelvis, to the occipitoanterior while continuously
descending.

EXTENSION – enables the head to emerge when the fetus is in cephalic position. It begins
after the head crowns if cephalic position and completes when the head passes under
symphysis pubis to the perineum.

RESTITUTION – realignment of the fetal head with the body after the head emerges.

EXTERNAL ROTATION – shoulders externally rotate after the head emerges and restitution
occurs, so that the shoulders are in the anteroposterior diameter of the pelvis.

EXPULSION – is the birth of the entire body.

Labor
process by which the mature product of
conception are expelled from the uterus
through the birth canal
Consist of series of rhytmic, progressive
contractions of the uterus that cause
effaccement and dilation of the uterine
cervix
Dry Labor – term used when the
membrane ruptures before the onset
of true labor
False Labor – uterine contraction
misinterpreted as true labor
True Labor – implies dilatation of
cervix, regular uterine contraction
that becomes more frequent, forceful
and prolonged
Induce Labor – use of medical or surgical
intervention
Precipitate Labor – completed in less than
3 hours and usually unattended
Premature Labor – occurring between the
28th-32th week of gestation
Prolonged Labor - labor extending beyond
16 hours
Spontaneous Labor – labor without
artificial aid
Uterine stretch or mechanical distention
theory – any hollow organ when
stretched to capacity will necessarily
contract and empty. Results from
prostaglandin release

Mechanical Irritation Theory – Pressure

on the nerve endings on the cervix from
the presenting part causes labor pains

Oxytocin theory – oxytocin released by

the pituitary gland initiates contraction
Progesterone Deprivation Theory -
Change in ratio of estrogen and
progesterone – decreasing progesterone
stimulates uterine contraction

Placental Age – triggering contractions

Prostaglandin Theory – a precursor from

the fetal adrenal glands is conjugated in
the placenta into estrogen. As it reaches
a high level, prostaglandin precursor is
converted into prostaglandin which then
acted on the myometrium to contract
Remember:
Once membranes has ruptured:

Labor is inevitable and will set in

within the next 24 hours
Infection can easily sets in
Occurrence of umbilical cord
compression or prolapsed
1. Lightening
– occurs approximately10 to 14 days
before labor begins. This gives the woman
relief from diaphragmatic pressure and SOB.

Primiparas - occurs early

Multiparas – usually occurs on the day
of the labor or even after her
labor has begun
Signs

a. Increase in abdominal pressure

b. Shooting leg pains
c. Increased amounts of vaginal discharge
d. Urinary frequency
2. Increased level of activities
due to an increase in epinephrine release
that is initiated by a decrease in
progesterone produced by the placenta to
prepare the woman’s body for the work of
labor ahead
3. Braxton Hicks Contraction

Strong Braxton Hicks Contractions

can cause real discomfort which can be
misinterpreted as true labor
contractions
4. Ripening of the cervix
- seen only on pelvic examination

Goodell’s sign, at term, it can be described as butter-soft

1. Uterine Contractions

The surest sign that labor has

begun is the initiation of effective,
productive, involuntary uterine
contractions
Types of Uterine Contraction

a. Typical – occurs every 2-5 minutes during

active labor and typically last 30 to 90
seconds
b. Hypotonic – evident by a rise in pressure
of no more than 10 mmHg during a
contraction
c. Hypertonic – don’t allow the uterus to rest
between contractions, as shown by a
resting pressure of 40 to 50 mmHg
 False Contractions True Contractions

Irregular Irregular but become

regular and predictable
Felt first abdominally Felt first in the lower
and Remain confined to back and sweep around
the abdomen and groin To the abdomen in a
wave
Often disappear with And ambulation
sleep And ambulation woman’s level of
activity
 Do not increase in Increase in duration,
duration, Frequency frequency
or intensity and intensity

Do not achieve Achieve cervical

cervical dilation dilation
2. Show

Pink-tinge cervical mucous plug is expelled

3. Ruptures of Membranes

Maybe experienced as either a sudden gush or

scanty, slow seeping of clear fluid from the
vagina
Early rupture becomes advantage if it causes
the fetal head to settle snugly into the pelvis-
can actually shorten the labor
Will induce after 24 hours if labor has not
occurred
Green (meconium); yellow (bilirubin)
Possible complications
1. Intrauterine infection
2. Prolapsed of the Umbilical cord
3. Cord compression
4. Uterine Changes

Upper Uterine Segment – becomes

thick and active in order to expel
the fetus

Lower Uterine Segment – becomes

thin-walled, supple and passive so
that fetus can be pushed out easily
Physiologic Effects Of Birth Process
Maternal
1. Reproductive System
Coordinated contractions (begins at
the fundus and spread downward
towards the cervix)
Involuntary contractions
Intermittent contractions
Uterine Body
Upper 2/3 – contracts actively and
becomes thick (upper active contractive
zone)
Lower 1/3 – less active and becomes thin
and pulled upward during labor (lower
passive zone)

Physiologic Retraction Ring/ Braun’s

retraction – marks the division between
the upper and lower segment of the
uterus
Cervical Changes

a. Effacement - Effacement is shortening and

thinning of the cervical canal
Ideally, the cervix should be ripe at the onset of
labor. A ripe cervix is:
1. Soft
2. Less than 1.3 cm in length
3. Admits a finger easily
4. Dilatable
b. Dilation - Refers to the
enlargement of the cervical canal

Takes place gradually, resulting in

softening, shortening and partial
dilation of cervix. These changes
may begin as early as the 24th to
28th week of pregnancy
Nulliparra completes cervical effacement early in
the process of dilation. In parrous, cervix is
usually thicker than a nullipara’s cervix at any
point during labor
Women whose cervix ripens early
are likely to begin labor before 40
weeks. When the cervix remains
unripe until late in pregnancy,
prolongation of the gestation past
40 weeks is common
2. Cardiovascular

relative increase in maternal blood volume that

temporarily increases the BP and slows her pulse
Supine hypotension
Decrease blood flow to the placenta
3. Respiratory

Increase depth and rate

Symptoms of hyperventilation
Tingling of hands and feet
Numbness
Dizziness
4. Gastrointestinal
Reduced gastric motility

5. Urinary System
Decrease sensation of full bladder
6. Hematopoietic
Elevated fibrinogen to promote coagulation at the
placental site
Fetal Response

1. Placental Circulation

Maternal blood supply to the

placenta intermittently stops during
strong contraction
Fetal hgb are more readily to take in
oxygen and releases carbon dioxide
Placental exchange occurs during
intervals
2. Cardiovascular
Increase fetal heart rate ranging from 110-160 bpm at
term

3. Pulmonary
Decrease fetal lung fluid and increase absorption
 To determine the beginning of a contraction
without a monitor, rest a hand on the
woman’s abdomen at the fundus of the
uterus very gently to sense the gradual
tensing and upward rising of the fundus that
accompanies a contraction

Low – Risk

Assess contractions
30 mins – latent phase
15 to 30 mins – active phase
15 minutes – transition phase
High Risk

Assess every:

30 mins – latent phase

15 mins – active phase
5 mins – transition phase
Contractions are palpable when the intrauterine
pressure reaches approx. 20 mmHg

The pain of a contraction is not usually felt until

pressure reaches approx. 25 mmHg

The duration of a contraction is timed from the

moment the uterus first tenses until it has
relaxed again.
Contraction Cycle
3 Phases of Contraction

a. Increment – contraction begins at the

fundus and spread throughout the uterus
b. Acme or Peak – contraction is most
intense
c. Decrement – uterine relaxation
Pattern:

1. Frequency – from the beginning of one

contraction to the beginning of the next (A-
C). Expressed in minutes and fractions of
minutes. (2-3 minutes)

2. Duration – from the beginning of one

contraction to the end of the same (A-B).

early labor – 20-30 secs

late labor – 60-70 secs
3. Interval – from the end of one contraction
to the beginning of the next (B-C)

early labor – 40-45 mins

late labor – 2-3 mins
4. INTENSITY OF CONTRACTIONS

Mild – the uterus is contracting but does not

become more than minimally tense. Described
as like tip of the nose

Moderate – the uterus feels firm. Described as

like the chin

Strong – the contraction so intense the uterus

feels as hard as a wooden board at the peak of
contraction. Described as like the forehead
1. Auscultation of Fetal Heart Sounds

Fetal heart sounds are transmitted through the

convex portion of the fetus, because that is the
part lying in close contact with the uterine wall.
FHR should be counted every 30 minutes in
beginning labor, every 15 during active labor, and
5 minutes the second stage of labor. This can be
done by viewing the FHR monitoring strip or
periodic auscultation.
Electronic Monitoring

FHR is screened at least for a short time

in early labor by an external monitoring
system

The monitoring is left in place for

continuous monitoring on women who
are categorized as high risk for any
reason or who have oxytocin stimulation
E.g. of external fetal monitoring device

Ultrasound transducer
Tocotransducer
Internal Electronic Monitoring

Called direct monitoring.

Invasive procedure that uses a spiral
electrode attached to the presenting
part
Determine fetal response to uterine
contractions, measures intrauterine
pressure, frequency, duration, baseline
strength and the peak contractions.
E.g. of internal fetal monitoring device

Fetal heart rate monitoring with scalp electrode

Scalp Electrode
Fetal Heart Rate Patterns

Involves valuating 3 parameters: the

baseline rate, variability in the
baseline rate (long term and short
term), and periodic changes in the
rate (acceleration and deceleration)
A normal rate is between 120 – 160
bpm. The rate fluctuates slightly (5
to 15 bpm) when the fetus moves or
sleeps
Fetal Bradycardia occurs when FHR is below
120 for 10 minutes.

A moderate bradycardia of 100 to 119 is

not considered serious and is probably
due to a vagal response elicited by the
fetal head being compressed during labor

Marked bradycardia (under 100) is a sign

of hypoxia is considered dangerous.
Fetal tachycardia occurs when the
rate is 160 beats or more per minute
(for a 10-minute period)

Moderate Tachycardia is 161 to 180

bpm

Marked Fetal Tachycardia is more

than 180 bpm. This may be due to
fetal hypoxia, maternal fever, fetal
arrythmia or maternal anemia or
hyperthyroidism
Periodic Patterns in Fetal Heart Rate

A. Acceleration
refers to temporary increase in the FHR
that peaks at least 15 bpm above the
baseline and lasts at least 15 seconds

Often occurs with fetal movements

Usually a sign that fetus has responsive

CNS and is not in acidosis
B. Decelerations- are temporary drops
in the fetal heart rate.
3 types
b.1 Early deceleration
Lowest point in the FHR that occurs
with the peak of contraction

Increase ICP from fetal head

compression causes a decrease in FHR
by the vagus nerve

Occurs as the fetal head is pressed

against the woman’s pelvis or soft
tissue
b.2 Late Deceleration

Occur after the contraction begins often near

the peak
May result from uteroplacental insufficiency
b.3 Variable deceleration

Results from reduce blood flow

through the umbilical cord

FHR fall or rise abruptly (within

30 seconds) with the onset and
relief of cord compression
2. Variability

Baseline variabilty is variation or

differing rhythmicity in the heart
rate over time and is reflected on
the FHR tracing as a slight
irregularity or “jitter” to the wave

Describes fluctuation in the

baseline FHR
Types

2.1 Short-term variability (STV)

changes in the FHR from one beat
to the next beat
difference between successive
heartbeats, usually 3 to 5.
2.2 Long-term variability (LTV)
broader fluctuation that are apparent
over 1 minute interval
fluctuations in FHR of 6 to 10 beats
occurring 3 to 10 times per minute.
Causes:
Fetal sleep
Narcotics or sedatives such as MgSO4
Alcohol
Fetal tachycardia
AOG less than 28 weeks
Fetal anomalies e.g. anencephaly
Severe hypoxia
Abnormalities in CNS
Maternal acidemia or hypoxemia
Techniques used in assessment of fetal
acidosis

Fetal Blood Sampling – minute amount of blood is

extracted at the scalp. Done only to high risk
fetus. (n – 7.25 to 7.35)
Scalp Stimulation – pressure is applied to the
fetal scalp through dilated cervix. Tactile
response is assessed that will momentarily
accelerate FHR (acceleration of 15 bpm for at
least 15 seconds suggest normal oxygenation and
acid-base balance)
Neurologic System

Increase intracranial pressure

Heart rate decreases by as much

as 5 bpm during contraction
(strength of 40 mmHg) and shown
as an early deceleration pattern
Cardiovascular

Reduced placental nutrients and

oxygen exchange (slight fetal hypoxia)

Increased intracranial pressure from

uterine pressure on the fetal head
serves to keep circulation from failing
below normal during the duration of a
contraction
Integumentary System

Minimal petechiae or ecchymotic

areas of the fetus

Edema of the presenting part

(caput succedaneum)
Musculoskeletal System

The force of uterine contractions

tends to push fetus into a position of
full flexion. A fully flexed position is
the most advantageous for birth
because it can speed labor.
Respiratory System

The process of labor appears to

aid in maturation of surfactant
production by alveoli in the fetal
lung

The pressure applied to the chest

from contractions and passage
through the birth canal clears it of
lung fluid
• Assist the patient into lithotomy
position and attend to the
patients’ needs and comfort.

• Places patient hand on hand grip

and explain the procedure

• Perform the perineal preparation.

• Perform surgical handwashing.

• Donn sterile gown and gloves

(double gloving).

• Drape the client properly, apply

leggings and towels.
Donning sterile gown and gloves (double
gloving).
• Instruct the client to bear
down properly, coaches to
take deep breath as soon
as the contraction begins.

• Encourage to push her

flexed knee against the
stirrups.

• Performs Ritgen’s
Maneuver properly
(support the perineum)
 ESSENTIAL NEWBORN
CARE
• Once the baby is out, pronounce the time
of birth and ask assistant to record.

• Use the first linen/towel to dry the baby

for 30 seconds.

• Do a rapid assessment while you dry the

newborn.
❑ Assess the baby’s breathing.
❑ Resuscitation equipment should always
be close to where the baby is being. It
should be ready for use.

• Remove the wet cloth.

• Initiate skin-to-skin contact by placing the

baby on the mother’s abdomen or
between her breasts.
• Cover the baby’s head with bonnet.
• Use the second linen to cover’s the baby’s back.
• Wipe eyes with separate piece of dry clean cloth and put a
small amount of eye ointment on the inside of the baby’s
lower eye lid.
• Remove the first pair of gloves.
• Do not cut the cord immediately. Allow pulsation to stop
without milking the cord.
• Clamp the cord at 2cm from the umbilical base and the
apply the 2nd clamp at 5cm from the base of the umbilicus.
• Cut the ties with a sterile equipment. Use cord clamp if
available. Observe for oozing of blood.
❖ If blood oozes, place a second tie between the skin and first
tie. The baby receives needed blood from the placenta in
the first minutes, to tie and cut the cord if the baby is
receiving routine care and the mother has no bleeding
problem.
❖ Do not apply any substance to stump.
• Do not bind or bandage stump.
• Leave stump uncovered.
• Inject 10 “IU” into the mother’s arms (depending on Doctor’s order).

• Leave the baby between the mother’s breast to start skin to skin care.
 ACTIVE MANAGEMENT ON THIRD STAGE OF LABOR
• While maintaining skin to skin contact, check the
mother’s condition while delivering the
placenta.
• Deliver the placenta when signs of placental
separation are noted using CCT (counter cord
traction) correctly.
• Note the time of placental delivery and
presentation and check the number of
cotyledons. (Schultz/Duncan).
• Check the mount and characteristic of bleeding
and examine the perineum, vagina and vulva for
tears.
• Provide comfort to mother by applying adult
diaper and change soiled gown.
• Place an identity label on the baby and mother.
• Encourage the initiation of breastfeeding within 1 hour,
when the baby is ready.
✓ Signs of readiness to breastfeed are baby looking
around/moving, mouth open, searching.
✓ Keep the mother and baby together for as long as possible
after delivery.
✓ A baby’s first breastfeed of colostrum is very important
because it helps protect from many common diseases and
contains many important growth factors which help to
develop the gut, the brain and nerves and the eyes.
• Assist IW (institutional worker0 to transfer patient from
DR table to stretcher.
• Evaluate patient’s condition and health status.
• Document patient’s postpartum and record pertinent data
on chart accurately.
2 PHASES
1. Placental separation
Active bleeding on the maternal surface of
the placenta
After complete separation the placenta sinks
into the lower uterine segment or the upper
vagina

Signs:
– Lengthening of the umbilical cord
– Sudden gush of vaginal blood
– Change in the shape of the uterus
2 Mechanism of Placental Separation

1. Schultze’s mechanism – if the placenta

separate first from the center and last at
the edges, appears as shiny and glistening
on the vaginal opening

2. Duncan Mechanism – placenta separates

first on its edges and appears raw, red and
irregular (maternal surface)
2. Placental expulsion

Placenta is delivered either by natural

bearing down effort of the mother or gentle
pressure on the contracted uterine fundus by
the physician or midwife (Crede’s Maneuver)

Pressure must never be applied to uterus in

non contracted state otherwise it may evert
hemorrhage
Manual removal can be done if it cannot
be delivered spontaneously
Methods of Placental Separation

1. Modified Crede’s method – a process of

delivery of the placenta from lower uterine
segment or vagina by a downward pressure
along the axis of birth canal applied on the
contacting fundus using it as a piston which
simultaneously tracting the cord
2. Brandt-Andrews method – expelling the
separated placenta in which the umbilical
cord is held taut with left hand and the right
hand placed over the lower abdomen then
pressure is exerted on the lower uterine
segment down the vulva while
simultaneously tracting the cord

3. Original Crede’s method – delivering the

placenta in which the body of the uterus
vigorously squeezed to produce a placental
separation
Examination of the Membranes, Placenta
and Umbilical Cord

1. Membrane carefully examined for the following

Completeness – the state of membrane must be
properly recorded in the chart as either
complete, incomplete or ragged – refers to torn
out apparently complete membrane
Presence of blood vessel in the membrane
Site of rupture of the membrane – refers to hole
in the membrane through which the baby was
born
2. Placenta both maternal and fetal surface
are examined

3. Umbilical Cord – the following are noted

length of the cord
number of arteries and vein
any abnormalities like presence of
knots
POSTPARTUM
POSTPARTUM

• Period when the reproductive tract returns to the normal,

nonpregnant state.
• The post partum period starts immediately after delivery
and is usually completed by week 6 following delivery.
Intervention to prevent bleeding during third
stage of labor

slow delivery of the shoulder and body of the

baby – to allow the uterus to contract and
retract its diminishing content
shortening the duration of the third stage by
expelling the placenta as soon signs of
placental separation appears
preventing the occurrence of laceration
• administration of oxytocic
Oxytoxic – substance which stimulates contraction
of the uterine musculature and is therefore
useful in the prevention and control of bleeding

a. Syntocinon – synthetic oxytocin

(Methylergonovine Maleate)
b. Methergin – a semi synthetic derivatives of
Ergonovine
Conditions that requires referral to the
physician

Profuse bleeding before placental separation

Profuse bleeding from vaginal or perineal
laceration
Retained placenta
Uterine atony
Retained placental cotyledons/membrane
Multiple perineal vaginal lacerations
Inversion of uterus due to strong traction
to umbilical cord
Increase or decease vital signs
Dyspnea
Convulsion
 PHYSIOLOGICAL
MATERNAL CHANGES

INVOLUTION:
❖ Is the rapid decrease in the size of the uterus as it returns to the
nonpregnant state.
ASSESSMENT:
✓ By 10 days postpartum, the uterus cannot be palpated abdominally.
✓ Afterpain decreases in frequency after the first few days.
LOCHIA:
**Discharge from the uterus that consist of blood from the vessels of the placental site
and debris from the decidua.
ASSESSMENT:
RUBRA- is bright red discharge that occurs from delivery to day 3.
SEROSA- brownish pink discharge that occurs from days 4-10.
ALBA- is white discharge that occurs from day 10-14.
The discharge should smell like normal menstruation.

CERVIX:
• Cervical Involution occurs and after 1 week the muscles begin to
regenerate.
VAGINA:
• Vaginal distention decreases, although muscle tone is never restored
completely to the pregravid state.
Lochia – a uterine discharge which consist
of erythrocytes, leukocytes, deciduas,
epithelial cells and bacteria. Has a
characteristic of fleshy odors and not
offensive odor. The blood should not
contain large clots and never be absent
regardless of methods of delivery
PATTERNS ONSET CHARACTER COMPOSITION
Lochia Rubra first 3 days the color is red Blood and
following and moderate in fragments of
delivery amount decidua and mucus

Lochia Serosa 4-9 days Light red Blood mucus and

invading leukocytes

Lochia Alba 10th day to 3-6 whitish Admixture of

weeks leukocytes and
reduced fluid
content
URINARY TRACT:
*Diuresis usually begins within the first 12 hours after delivery.

GASTRO INTESTINAL TRACT:

*Constipation can occur, with bowel movement (soft, formed stool) by second or third
postpartum day.
*Hemorrhoids are common.

VITAL SIGNS:
• Bradycardia is common during the first week, with a range of 50-70bpm.
• Blood remains unchanged.
POSTPARTUM INTERVENTION:
Monitor v/s.
Assess pain level.
Assess height consistency and location of the fundus.
Monitor amount, color and odor of lochia discharges.
Assess breast for engorgement.
Monitor perineum for swelling or discoloration.
Monitor episiotomy for healing.
Assess incisions or dressings of cesarean birth client.
Monitor bowel status.
Monitor intake and output. Encourage frequent voiding.
Assess extremities for thrombophlebitis.
Assess bonding with the newborn infant and emotional status.
POSTPARTUM DISCOMFORTS:
AFTER BIRTH PAINS:
❖ Occurs as a result of contractions of the uterus.
• PERINEAL DISCOMFORTS:
• Apply icepacks to the perineum for the first 24 hours.
• Warm sitz bath after 24 hours.
EPISIOTOMY:
• Instruct perineal care after voiding.
• Administer analgesic as prescribed.
CONSTIPATION:
• Encourage adequate fluid intake.
• Encourage high fiber diets.
• Encourage ambulation.
• POSTPARTUM BLUES: ( A condition caused by physiological and emotional stress. May progressed to
post partum depression if unresolved.)
• Verbalization or ventilation of feelings.
Weight – there is an immediate blood
loss to about 11 lbs as consequences
of evacuation of the contents of the
uterus then there is generally
further loss of body weight during
the puerperium at about 15 lbs
Sexual Activity – may be resumed by the
third to fourth week of postpartum;
bleeding has stopped and episiorrhapy
has healed
Nursing Care during Pueperium

Personal hygiene
Early ambulation – encouraged 8 hours
after delivery
Monitoring of vital signs
Nutrition – should contain
approximately 2.600 to 2,800 calories
daily. A diet in proteins, vitamins and
minerals is essential
Post partum blues – drastic changes in all
body system and sudden withdrawal of
hormones on the third or fourth postpartal
day may cause depression or sudden let down
feeling

Return of menstruation and ovulation - if

breastfeeding is initiated, menstrual flow
return 3-4 mos If not breastfeeding, return of
menstrual flow is expected within 6-8 weeks
after delivery
 RUBIN’S POSTPARTUM
PHASES OF REGENARATION
TAKING IN PHASE : First 3 days
✓ Mother focuses on her own primary needs (sleep and food).
✓ This phase is not an optimum time to teach the mother about baby care.
TAKING HOLD PHASE: Days 3-10
✓ The woman is more control of independence. Assume task of motherhood.
✓ This phase is an optimum time to teach the mother about baby care.
LETTING GO PHASE:
✓ Mother may feel deep loss over separation of the baby from part of the body.
✓ Maybe in dependent or independent role.
 NUTRITIONAL COUNSELLING
❖ If the mother is breastfeeding, calorie needs increase by 200/500
calories/day. Mother may require increased fluids and continuance
of vitamins and minerals.
Breast care
Establish successful lactation

Colostrum – a thin milky fluid that is

secreted by the mammary gland. It
contains more protein and minerals
but less in sugar and fat. Also contains
maternal antibodies
Let-down Reflex – actual secretion or
ejection of milk from the breast
OVARIAN FUNCTION AND MENTRUATION:

*Menstrual flow resumes within 1-2 months in non breastfeeding mothers.

*Menstrual flow usually resumes within 3-6 months in breastfeeding mothers.
*Breastfeeding mothers may experience amenorrhea during the entire period of
lactation.
BREAST:
• Breast continue to secrete colostrum for the first 48-72 hours after delivery.
• Breast become distended with milk on the 3rd day.
• Engorge occurs approximately day 4 in non breast-feeding mothers.
CARE FOR THE BREAST:
• Avoid nipple stimulation.
• The mother can apply a breast binder, wear a tight fitting bra, apply ice pack, or take mild analgesic.
• Engorgement usually resolves 24- 36 hours after it begins.
• Do not use soap on the breast.
• If cracked nipples develop, expose nipples to air for 10-20 minutes. Rotate infant position for each feeding.
Milk Composition

Foremilk – comes at a beginning of a

feed. It looks blue and watery and
rich in protein, lactose, vitamins,
minerals and water

Hind milk – comes at the end. It looks

whiter than foremilk because it
contains more fat
Decrease estrogen and progesterone

Stimulation of ant. Pituitary to secrete

prolactin

Acts on acinar cells to produce foremilk

stored in collecting tubules

Sucking movement of infant

Production of oxytocin by Pituitary Gland

Contraction of smooth muscle of

collecting tubules

Milk ejection

Let-down reflex and hind milk production

IMPLICATION TO PHYSIOLOGY

Regardless of the mother physical

condition, method of delivery, size and
condition of the breast, milk will be
produced after delivery
Lactation does not occur during pregnancy
because estrogen and progesterone inhibit
prolactin production
Oral contraceptives are contraindicated
After pains are felt more by breastfeeding
woman because of oxytocin production,
less lochia production and more rapid
involution
Interventions

Be kind and supportive

Help her not to worry
Reassure her that she can breastfeed
Initiates infant’s reflexes (rooting,
sucking and swallowing)
CARE OF THE
Newborn
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ASSESSMENT:
• Observe or assess with the initiation of respiration
• Assess for APGAR Score.
• Observe newborn for hypothermia.

INTERVENSIONS:
• Suction mouth, then nares with bulb syringe.
• Dry newborn and stimulate crying by rubbing.
• Keep the newborn with mother to facilitate bonding.
Encouraged breast feeding. Kept warm and thermo regulated.
• Ensures newborn’s proper identification.

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APGAR SCORING SYSTEM

• Perform and record the Apgar score at 1 minute and at 5 minutes.
• Assess each of five items to be scored and assign value of 0 (very poor) to 2 (excellent) for each item.
• Add the points to determine the newborn’s total score.

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What is the Ballard tool used for?

A system for estimating newborn gestational age by rating physical and neuromuscular
characteristics of maturity. For infants born between 20 and 28 weeks' gestation, Ballard
tools are more accurate than other systems of estimating gestational age.

What are the components of the Ballard score?

These are:
• Skin.
• Ear/eye.
• Lanugo hair.
• Plantar surface.
• Breast bud.
• Genitals.
Scoring
Each of the above criteria are scored from 0 through 5, in the original Ballard Score. The
scores were then ranged from 5 to 50, with the corresponding gestational ages being 26
weeks and 44 weeks. An increase in the score by 5 increases the age by 2 weeks. The New
Ballard Score allows scores of -1 for the criteria, hence making negative scores possible.
The possible scores then range from -10 to 50, the gestational range extending up to 20
weeks. (A simple formula to come directly to the age from the Ballard Score is
Age=((2*score)+120)) / 5
The Neuromuscular Criteria
These are:

• Posture:muscle tone is reflected in the infant's preferred posture at rest. As

maturation progresses, the foetus gradually assumes increasing passive flexor tone
at rest that precedes in a centripetal direction with lower extremities slightly ahead of
upper extremities. Term newborn (flexed posture) and preterm newborn (extended
posture).
• Square window, assessing the flexibility of the wrist. Wrist flexibility and resistance
to extensor stretching are responsible for the resulting angle of flexion at the wrist.
The examiner strengthen the infant's fingers and applies gentle pressure on the
dorsum of the hand, close to the fingers. From extremely preterm to post term, the
resulting angle between the palm of the infant's hand and forearm is gradually
diminished
• Arm recoil: Arm recoil examines the passive flexor tone of the biceps muscle by
measuring the angle of recoil following very brief extension of the upper extremity.
With the infant lying supine, the examiner places one hand beneath the infant's
elbow for support taking the infant's hand, the examiner briefly sets the elbow in
flexion, then momentarily extents the arm before releasing it. The angle of recoil, to
which the forearm springs back into flexion is noted.
• Popliteal angle: This maneuver assesses the maturation of passive flexor tone
of the knee extensor muscles by testing for resistance to extension of the lower
extremity. With the neonate lying supine, the thigh is placed gently on the
abdomen of the knee fully flexed. The examiner gently grasps the foot at the
sides with one hand while supporting the side of the thigh with the other. Care
is taken not to exert pressure on the hamstrings. The leg is extended until a
definite resistance to extension is appreciated. At this point the angle formed at
the knee by the upper and lower leg is measured.
• Scarf sign: It is tests the passive tone of the flexors about the shoulder girdle.
With infant lying supine, the examiner adjusts the infant's head to the midline
and supports the infant's hand across the upper chest with one hand. The
thumb of the examiner's other hand is placed on the infant's elbow. The
examiner tries to pull the elbow gently across the chest, feeling for the
resistance.
• Heel To ear: This measures the passive flexor tone of the posterior hip flexor
muscles. The infant is placed supine and the flexed lower extremity is brought
to rest on the cot. The examiner supports the infant's thigh laterally alongside
the body with the palm of one hand. The other hand is used to grasp the infant's
foot at the sides and to pull it towards the ipsilateral ear. The examiner feels for
the resistance to extension of the posterior pelvic girdle flexors and notes the
location of the heel where significant resistance is appreciated.
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INITIAL PHYSICAL EXAMINATION:

VITAL SIGNS
• Heart rate – (resting) 100-160bpm (apical) for 1 full minute.
• Respiratory rate – 30-60 breaths/min assess for 1 full minute.
• Axillary temperature – 96.8F to 99F
• Blood pressure – 73/55mmhg

BODY MEASUREMENT
• Length – 45 to 55 cm (18 to 22 inches)
• Weight – 2500 to 4300 g (5.5 to 9.5 lb)
• Head and chest circumference.
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INITIAL PHYSICAL EXAMINATION:

HEAD
• Bones of the skull are not fused.
• Sutures are palpable and may be overlapping because of head molding but not
widened.
• Caput succedaneum is edema of the soft tissue over bone, subsides of over a few
days.

EYES
• Slate gray (light skin), dark blue, or brown – gray (dark skin)
• Symmetrical and clear.
• Pupils equal, round, react to light and by accommodation.
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INITIAL PHYSICAL EXAMINATION:

EARS
• Top of pinna on or above the line drawn from outer cantus of the eye.

NOSE
• Nares are patent and should flare.
• Flat, broad, in center of face.

MOUTH
• Assess for thrush (candida albicans) white patchy areas evident on tongue or gums that cannot be removed
with a wash cloth.
• Epstein’s pearl (small, white cyst) may be present on hard palate.
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INITIAL PHYSICAL EXAMINATION:

NECK
• Assess for torticollis.
• Good range of motion and ability to flex and extend.

CHEST
• Nipples prominent and often edematous; milky secretion (witch’s milk) common.
• Circular appearance because anteroposterior and lateral diameter are about equal.

SKIN
• Pinkish-red (light-skinned newborn) to pinkish - brown or pinkish – yellow (dark – skinned newborn).
• Vernix caseosa, cheesy white substance, can be seen, especially on back.
• Milia, small white sebaceous glands, appearing on forehead, nose and chin.
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INITIAL PHYSICAL EXAMINATION:

SKIN
• Dark red color common in premature newborns.
• Cyanosis, common with hypothermia, infection, cardiac, respiratory, neurologic problem.
• Acrocyanosis (peripheral cyanosis) normal for first few hours after birth and then may be noted intermittently
for next 7 to 10 days.
• Harlequin sign
• Birthmarks

ABDOMEN
• Umbilical cord should have 3 vessels. AVA
• Cord should be clamped for at least the first 24 hours.

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INITIAL PHYSICAL EXAMINATION:
GASTROINTESINAL
• Monitor bowel sounds , which should occur within 1-2 hours after birth.
• Monitor meconium.
a) Meconium which is greenish-black with thick, sticky , tar- like consistency, usually is passed within the first
24 hours in life.
b) Transitional stool, the second type of stool excreted by the newborn, is greenish brown and of looser
consistency than meconium.
c) Seedy, yellow stools are noted in breast fed newborns.

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REFLEXES:
SUCKING AND ROOTING REFLEX
• Touch the newborn’s lip, cheek, or corner of the mouth with a nipple. Newborn’s head will turn toward nipple.

SWALLOWING REFLEX
• Newborn swallows in coordination with sucking without gagging, coughing or vomiting.

TONIC OR FENCING REFLEX

• As the newborn face the left side, the left arm and left leg extend outward, while
the right arm and right leg flex.
• As the newborn face the right side, the right arm and right leg extend outward, while
the left arm and left leg flex.

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REFLEXES:
PALMAR PLANTAR GRASP REFLEX
• Place a finger in the palm of newborn’s hand and then place a finger at the base of the toes.

MORO - STARTLE REFLEX

• Place a newborn on a flat surface and strike the surface to make it sound, or the examiner
will make a loud noise or claps hand s to elicit response.
• The newborn symmetrically abducts and extends the arms. The newborn fans the fingers out and forms a
“C” with the thumb and forefinger. Somehow the hands stay clenched.
• The Moro reflex is present at birth, complete response may occur up to 8 weeks.
• The startle reflex should dis appear within 4 months.

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REFLEXES:
PULLING TO SIT RESPONSE REFLEX
• Pull the newborn up from the wrist while the newborn is in supine position.
• The head will lag until the newborn is in an upright position, and the head will be level with the chest and
shoulder’s momentarily before failing forward. The head will the lift for a few minutes.

BABINSKI SIGN: PLANTAR REFLEX

• The reflex will disappear after the newborn is one year old. Absence of this reflex indicates the need for a
neurological examination.
• Beginning at the heel of the foot , gently stroke upward along the lateral aspect of the sole, and then move
the finger along the ball of the foot. The toes hyperextend while the big toes dorsiflex.

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REFLEXES:
STEPPING OR WALKING REFLEX
• Hold the newborn in a vertical position, allowing the foot to touch a table surface and stimulates walking.
Alternately flexing and extending the feet. Reflexes present for 3-4 months.

CRAWLING REFLEX
• Place the newborn on the abdomen. The newborn begins making crawling
movement. Usually disappears after about 6 weeks.

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NEWBORN BATH
• Washes hands before the procedure.

• Assembles all necessary equipment.

• Makes sure the room is free from the drafts by closing

the windows.

• Keeps small articles away from the reach of the infant.

• Wipes feces on the perineum with cotton balls before

bath.

• Undress and wraps the baby in the towel.

• Cleanse the eyes with water using cotton balls,

starting from the inner to outer cantus of the eye. One
cotton ball each.

• Washes baby’s face neck and ears and pat to dry.

• Cleans the inside of the ear with damped wisp of

rolled cotton balls in gentle rotating manner.
Hold the baby in a football position over basin.

Lather scalp using mild soap and massage it fingers

tips, soft bristled brush or baby comb.

Rinses and dry scalp well.

Places baby lying on his back.

Soaps, rinses and dries arms and hands particularly in

axilla.

Soaps, rinses and dries baby’s chest and abdomen

(keeps baby covered between soap and rinsing).

Soaps, rinses and dries baby’s leg and feet exposing

one leg at a time particularly the areas between the
toes.

Turns the baby on his side, and soaps, rinses and

dries his back.
• Cleans and dries the perineal area
(anterior) from front to back.

• Soaps, rinses and dries the posterior

perineum and buttocks.

• Applies drops of alcohol at the base of

the cord.

• Puts on a clean clothing and diaper.

• Keeps the baby warm and comfortable.