A.

DEFINITION OF TERMS

• puerperium/postpartum - refers to the six-week period after delivery of the baby

 involution - return of the reproductive organs to their pre-pregnant state.

B. PRINCIPLES OF POST-PARTUM CARE

• Promote healing and return to normal involution) of the different parts of the body.

1. Vascular changes
o The 30%-50% increase in total cardiac volume during pregnancy will be reabsorbed into the
general circulation within 5-10 minutes after placental delivery. Implication: The first 5-10
minutes after placental delivery is crucial to gravidocardiacs because the weak heart may
not be able to handle such workload.
a) White blood cell (WBC) count increases to 20,000- 30,000/mm). Implication: The WBC
count, therefore, cannot be used as an indication or sign of postpartum infection.
b) There is extensive activation of the clotting factors, which encourages
thromboembolization. This is the reason why:
1. Ambulation is done early, 4-8 hours after normal vaginal delivery. When ambulating,
the newly-delivered patient for the first time, the nurse should hold on to the
patient's arm.
2. Recommended exercises
 Kegel and abdominal breathing on postpartum day one (PPD).
 Chin-to-chest on PPD2 to tighten and firm up abdominal muscles
 Knee-to-abdomen when perineum has healed, to strengthen abdominal and
gluteal muscles.
c) Massage is contraindicated.
 All blood values are back to prenatal levels by the 3rd or 4th week postpartum.

2. Genital Changes
 Uterine involution is assessed by measuring the fundus by fingerbreadth (1 cm). On PPDI,
fundus is fingerbreadth below the umbilicus; on PPD2, 2 lingerbreaths below and so forth
until on PPDIO, it the symphysis pubis, Subinvoluted uterus is a uterus can no longer be
palpated because it is already behind larger than normal and vaginal bleeding with clots.
Since blood clots are good media for bacteria, it is, therefore, a sign of puerperal sepsis:
 To encourage the return of the uterus to its usual anteflexed position, the prone and knee
chest positions are advised.
 After pains/afterbirth pains - strong uterine contractions felt more particularly by multis,
those who delivered large babies or twins and those who breastfeed. It is normal and rarely
lasts for more than 3 days.

Management:

a) Never apply heat on the abdomen.

b) Give analgesics as ordered.
 c) Lochia - uterine discharge consisting of blood, decidua, WBC, mucus and some bacteria.
a) Pattern: R-S-A (rubra-serosa-alba)
 rubra - first 3 days postpartum; red and moderate in amount
 serosa - next 4-9 days: pink or brownish and decreased in amount
 alba - from 10th day up to 3-6 weeks post-partum; colorless and minimal in
amount
b) Characteristics:
 Pattern should not reverse.
 It should approximate menstrual flow. However, it increases with activity and
decreases with breastfeeding.
 It should not have any offensive odor. It has the same fleshy odor as menstrual
blood. If it is foul-smelling, it may mean either poor hygiene or infection
 It should not contain large clots.
 It should never be absent, regardless of method of delivery. Lochia has the same
pattern and amount, whether CS or normal vaginal delivery

 Pain in perineal region may be relieved by:

a) Sim's position - minimizes strain on the suture line
b) Perineal heat lamp or warm Sitz baths twice a day vasodilatation increases blood.
c) Application of topical analgesics or administration of mild oral analgesics, as ordered.

 Sexual activity - Ideally, sexual activity resumes at 6 weeks postpartum but it maybe resumed by
the 3rd or 4th week postpartum if bleeding has stopped and episiorrhaphy has healed.
Decreased physiologic reactions to sexual stimulation are expected for the first 3 months
postpartum because of hormonal changes and emotional factors.

 Menstruation - If not breastfeeding, return of menstrual flow is expected within 3 weeks after
delivery. If breastfeeding, menstrual return is expected in 3-4months in some women, no
menstruation occurs during the entire lactation period. (Important: Amenorrhea during
lactation is no guarantee that the woman will not become pregnant. She may be ovulating: the
absence of menstruation may be her body's way of conserving fluids for lactation. Implication:
She should be protected against a subsequent pregnancy by observing a method of
contraception, except the pill).

 Postpartum check-up - should be done after the 6 th week postpartum to assess involution

c) Urinary changes
 There is marked diuresis within 12 hours postpartum to eliminate excess tissue fluid
accumulation during pregnancy
 Some newly-delivered mothers may complain of frequent urination in small amounts; explain
that this is due to urinary retention with overflow. Others, on the other hand, may have
difficulty voiding because of decreased abdominal pressure or trauma to the trigone of the
bladder. Voiding may be initiated by:
  Provide privacy
 pouring warm and cold water alternately over the vulva;
 encouraging the client to go to the comfort room; or
 let her listen to the sound of running water.
 if these measures fail, catheterization, done gently and aseptically, is the last resort on
doctor's order. (if there is resistance to the catheter when it reaches the internal sphincter,
ask patient to breathe through the mouth while rotating the catheter before moving it
inward again).

d) Gastrointestinal changes - delayed bowel evacuation postpartally may be due to:

 decreased muscle tone
 lack of food + enema during labor
 dehydration
 fear of pain from perineal tenderness due to episiotomy, lacerations or hemorrhoids.

e) Vital signs
 Temperature may increase because of the dehydrating effects of labor. Implication: Any
increase in body temperature during the first 24 hours postpartum is not necessarily a sign of
postpartum infection.
 Bradycardia (heart rate of 50-70 per minute) is common for 6-8 days postpartum
 There is no change in the respiratory rate.

f) Weight - there is an immediate weight loss of 10-12 pounds representing the weights of the fetus,
placenta, amniotic fluid and blood. Further weight loss will occur during the next days due to
diaphoresis.
 Provide emotional support - the psychological phases during the postpartum period are:
a) Taking-in phase
 First 1-2 days postpartum when mother is passive and relies on others to care for her
and her newborn
 She keeps on verbalizing her feelings regarding the recent delivery for her to be able to
integrate the experience into herself.
b) Taking-hold phase
 Begins to initiate action and make decisions
 Postpartum blues (an overwhelming feeling of sadness that cannot be accounted for)
may be observed Blues could be due to hormonal changes, fatigue or feelings of
inadequacy in taking care of a new baby. Management: Explain that it is normal. Crying
is therapeutic, in fact.
c) Letting-Go Phase
 The mother redefines her new role.
 Gives up the fantasized image of her child and accepts the real one.

 Prevent postpartum complications:

 hemorrhage
 infection
  Establish successful lactation

Estrogen and progesterone levels after Prolactin acts on the acinar cells to
placental delivery stimulates the APG produce foremilk stored in collecting
to produce prolactin. tubules.

Oxytocin cause contraction of smooth When the infant sucks, the posterior pituitary
muscles of the collecting tubules. gland is stimulated to produce oxytocin.

Milk is ejected forward "let-down or milk ejection reflex Hind milk is produced

g) Implications of the physiology of breastmilk production

 Regardless of the mother's physical condition, method of delivery, or breast size/condition, milk will
be produced.
 Lactation does not occur during pregnancy because estrogen and progesterone are present and
therefore inhibit prolactin production.
 Lactation suppressing agents are to be given immediately after placental delivery to be effective.
 Oral contraceptives are contraindicated in lactating mothers because they contain estrogen and
progesterone, thereby decreasing milk supply
 Afterpains are felt more by breastfeeding women because of oxytocin production: they also have
less lochia and experience more rapid involution
 In an emergency delivery:
 Determine the EDC, whether the woman in labor is a primi or a multi, as well as the stage of
labor she is in.
 If no sterile equipment is available to cut the cord, wrap the baby and placenta together; never
cut the cord unless sterile equipment is/are available.
 If the uterus fails to contract after delivery, put the infant to the breast; the sucking of the infant
produces oxytocin which causes uterine contraction

a) Advantages of breastfeeding for the mother:

o economical in terms of time, money and effort
o more rapid involution
o lower incidence of cancer of the breast, according to some studies

Advantages of breastfeeding for the baby:

o closer mother-infant relationship

o contains antibodies that protect against common illnesses
o less incidence of gastrointestinal diseases
o always available at the right temperature
b) Health teachings
1. Hygiene
 Wash breasts daily at bath or shower time.
 Soap or alcohol should never be used on the breasts as they tend to dry and crack the nipples
and cause sore nipples.
 Wash hands before and after every feeding. Insert clean OS squares or piece of cloth in the
brassiere to absorb moisture when there is considerable breast discharge.

2. Method
 Side-lying position with a pillow under the mother's head while holding the bulk of breast
tissues away from the infant's nose.
 Stimulate the baby to open his mouth to grasp the nipples by means of the rooting reflex.
 Infant should grasp not only the nipple but also the areola for effective sucking motion.
Effectiveness is ensured when the:
o baby's mouth parts "hike wil up" into the areola
o mother feels afterpains as the baby sucks
o other nipple flows with milk while baby is feeding on other breast

 To prevent nipples from becoming sore and cracked, infant should be introduced to the breast
gradually. The baby should be fed for only 5 minutes at each breast during each feeding on the
first day, increasing the time at each breast by 1 minute per day until the infant is nursing for 10
minutes at each breast, making a total feeding time of twenty minutes per feeding
 For continuous milk production, at each feeding, the infant should be placed first on the breast
he fed on last during the previous feeding. This ensures that each breast will be completely
emptied at every other feeding. If breasts are completely emptied, they completely refill. If they
are only half-emptied, they will only half-refill and after some time, will become insufficient.
 To break away from the closed suction at the breast after feeding, insert a clean little finger in
the corner of the infant's mouth to release the suction, then pull the chin down. This also helps
prevent sore nipples.
 Feed as often as the baby is hungry, especially during the first few days, because he is receiving
colostrum which is not very filling, however, it contains gamma globulin (antibodies), the only
group of substances that can never be replicated by any artificial formula.
 Advise the mother to learn how to relax during feedings because tension prevents good let-
down.

3. Associated problems
a) Engorgement
 Feeling of tension in the breasts during the third postpartum day sometimes accompanied by an
increase in temperature (milk fever)
 The breasts become full, feel tense and hot, with throbbing pain.
 It lasts for about 24 hours and is due to increased lymphatic and venous circulation
 Management:

 Advise the use of firm-fitting brassiere for food support. It will not only decrease the discomfort
from breast engorgement but will also prevent contamination of the nipples and areolae.
 Cold compress is applied if the mother does not intend to breastfeed; warm compress is applied
if she will breastfeed
 Breast pump should not be used and breast massage should not done if the mother is not going
to breastfeed, since either will stimulate milk production

b) Sore nipples - not contraindications tobbreastfeeding.

Management:

 Expose nipples to air by leaving bra unsnapped for 10-15 minutes after a feeding
 When normal air drying is not effective, exposure to a 20-watt bulb placed 12-18 inches away
will cause vasodilation and therefore promote healing.
 Do not use plastic liners that are found in some nursing bras because they prevent air from
circulating around the breasts.
 Use a nipple shield

c) Mastitis - inflammation of the breasts; symptoms include:

 localized pain, swelling and redness in breast tissues
 lumps in the breasts
 milk becomes scanty

Management:

o antibiotics as ordered
o ice compress
o proper breast support
o discontinue breastfeeding in affected breast

4. Nutrition - lactating mothers should take 3000 calories daily and should have larger amounts of
proteins (96 Gms per day), calcium, iron, Vitamins A, B and C. Non-breastfeeding women can
have the same requirements as in pregnancy.

5. Contraindications:
 Drugs - oral contraceptives, atropine, anticoagulants, antimetabolites, cathartics, tetracyclines
(Insulin, epinephrine, most antibiotics, antidiarrheals and histamines are generally not
contraindicated. Therefore, diabetics and those with asthma can breastfeed.)
 Certain disease conditions, specifically tuberculosis, because of the close contact between
mother and baby during feeding, droplet spread) TB germs, however, are not (However,
mothers may use masks to prevent transmitted thru breast milk.

6. Motivate the use of family planning methods – the success of the family planning program
depends to a large extent on the motivation of both husband and wife.
a) Artificial Methods
o Physiologic method Oral contraceptive pill
Action: Suppresses the pituitary gland, thus inhibiting ovulation
Types:
combined - estrogen and progesterone in the same dosage each day for 20 days,
starting on the 5th day of the menstrual cycle, after which it is discontinued and then
resumed on the 5th day of the next menstrual cycle.
sequential - estrogen alone for 15 days, then estrogen and progesterone for the next 5
days
mini-pill - taken continuously.
Side effects: same complaints of pregnant women because of estrogen and
progesterone
o nausea and vomiting
o headache and weight gain - due to fluid retention because of progesterone
o breast tenderness
o dizziness
o breakthrough bleeding/spotting between periods
o Chloasma

Contraindications:

 Breastfeeding
 Certain diseases
 Thromboembolism - because there is increased tendency towards clotting in the
presence of estrogen
 Diabetes mellitus and liver disease because estrogen tends to interfere with
carbohydrate metabolism
 Migraine, epilepsy, varicosities
 Cancer, renal disease; recent hepatitis
 Women who smoke more than 2 packs of cigarettes per day
 Strong family history of heart attack
 Should the woman forget to take the pill on the scheduled time, she should take
one as soon as she remembers and take the next pill on its regular taking time. If
she still fails to do so, withdrawal bleeding will occur because of the sudden
decrease in hormonal levels

b) Mechanical methods
o Intrauterine device (IUD)
 Specific action: Prevents implantation by setting up a non-specific cell inflammatory
reaction to the device
 Inserted during menstruation to ensure that the woman is not pregnant: septic abortion
can result if she is pregnant
 Side effects:
1. Increased menstrual flow
2. Spotting or uterine cramps during the first 2 weeks after insertion
 3. Increased risk of infection
4. When pregnancy occurs with the IUD in place, it need not be removed since it stays
outside the membranes and, therefore, will not in any way harm the fetus.

o Diaphragm
 Specific action: A circular rubber disc that fits over the cervix and forms a barrier against
the entrance of sperms
 Initially inserted by the doctor who determines the depth of the vagina
 May be coated with spermicide jelly or cream for double protection
 May be washed with soap and water after use; is reusable
 Sperms remain viable in the vagina for 6 hours, so the device should kept in place during
such time, but should not stay for more than 24 hours because stasis of semen can lead
to infection.

o Condom
 Specific action: Sperms are deposited at the tip of the rubber sheath, which has been
placed on an erect penis prior to coitus. Has the added potential or lessening the chance
of contacting sexually transmitted diseases (STDs, esp AIDS)
 Most common complaint of users: it interrupts the sexual act to apply

o Chemical methods: spermicidals (kill sperms) in the form of jellies, creams, foaming tablet
and suppositories,

o Surgical methods:
 tubal ligation - the Fallopian tubes are ligated in order to prevent passage of sperms
Menstruation and ovulation continue
 vasectomy - small incision made into each side of the scrotum and the vas deferens is
cut and tied, blocking the passage of sperms. Sperm production continues, only passage
into the exterior is prevented, (Sperms in the vas deferens at the time of surgery remain
viable for as long as 6 months. Implication: Couple should still observe a form of
contraception during this time to ensure protection against subsequent pregnancy.)

c) Natural
o Biological method, Rhythm/Calendar/Ogino-Knause Formula
Specific action: the couple abstains on days that the woman is fertile.
Procedure:
 The woman charts her menstrual cycles or 12 continuous months in order to determine
the shortest and the longest cycles
 The first fertile day is determined by subtracting "18" from the shortest menstrual cycle
and '11" from the longest menstrual cycle, e.g., if a woman's shortest menstrual cycle is
26 days and her longest is 32 days, her fertile period would be the 8th to the 21st day of
her cycle. Therefore, she should not have sexual intercourse during these days.
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 Rhythm/calendar/Ogino-Knause. A woman can discern her fertile and infertile days based on
her sensory and visual observations of the cervical mucus (when it becomes thin and watery -
spinnbarkheit). Intercourse is avoided 4 days prior to and 3 days after the spinnbarkheit.
 Billings method/cervical mucus. When cervical discharges are thin and watery, couple resumes
sexual intercourse 3-4 days after
 Symptothermal method/basal body temperature (BBT) involves daily observation of the
temperature of the woman at rest, free from any factor that may cause it to fluctuate
(immediately upon waking up, before brushing teeth, drinking, etc). Only 3-4 days after the
temperature drops slightly and then increases (which means ovulation has taken place), can
sexual intercourse be resumed. Fertile and infertile days are determined after having
established an accurate record of the six immediately preceding menstrual cycles then watching
out for BBT fluctuations.
 Social methods
o abstinence
o withdrawal/coitus interruptus