PUERPERIUM

A. DEFINITION OF TERMS
 Puerperium/Post-partum – refers to the six-week period after delivery of the baby.
 Involution – return of the reproductive organs to their prepregnant state.

B. PRINCIPLES OF POST-PARTUM CARE

 Promote healing and return to n normal (involution) of the different parts of the body.

Vascular Changes

 The 30%-50% increase in total cardiac volume during pregnancy will be absorbed 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/mm3. Implication: the WBC count, therefore,
cannot be used a s 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:
o Kegel and abdominal breathing on post-partum day one (PPD 1)
o Chin-to-chest on PPD2 to tighten and form up abdominal muscles.
o Knee-to-abdomen when perineum has healed, to strengthen abdominal and gluteal muscles.

c. Massage is contraindicated
o All blood values are back to prenatal levels by the 3 rd or 4th week postpartum.

1. Genital Changes
o Uterine involution is assessed by measuring the fundus by fingerbreadth (= 1 cm.) on PPD1, fundus is 1
fingerbreadth below the umbilicus; on PPD2, 2 fingerbreadths below and so forth until on PPD10, it can no
longer be palpated because it is already behind the symphisis pubis. Subinvoluted uterus is a uterus larger
than normal and vaginal bleeding with clots. Since blood clots are good media for bacteria; it is, therefore, a
sign of puerperal sepsis.
o To encourage the return of the uterus to its usual anteflexed position, the prone and knee chest positions
are advised.
o Afterpains/ 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.
1. 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 postpartum; colorless and minimal in amount

2. Characteristics:
o Pattern should not reverse.
o It should approximate menstrual flow. However, it increases with activity and decreases with breastfeeding.

o 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.
o It should not contain large clots.
o It should not be absent, regardless of method of delivery. Lochia has the same pattern and amount,
whether CS or normal vaginal delivery.
o Pain in perineal region may be relieved by:

a. Sim’s position – minimizes strain on the suture line.

b. Perineal o heat lamp or warm Sitz baths twice a day – vasodilation increases blood supply and,
therefore, promote healing.
c. Application of topical analgesics or administration of mild oral analgesics as ordered.

o Sexual activity – ideally sexual activity resumes at 6 weeks postpartum but it may be resumed by the 3 rd 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.

o Menstruation – if not breastfeeding, return of menstrual flow is expected within 8 weeks after delivery. If
breastfeeding, menstrual return is expected after 3-4 months; 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.)

o Postpartum Check-Up – should be done after the 6th week postpartum to assess involution.

3. Urinary Changes
o There is marked diuresis within 12 hours postpartum to eliminate excess tissue fluid accumulation during
pregnancy.
o 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:

- 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.)

4. Gastrointestinal Changes – delayed bowel evacuation postpartally may be due to:

o Decreased muscle tone
o Lack of food + enema during labor
o Dehydration
o Fear of pain from perineal tenderness due to episiotomy, lace rations or hemorrhoids.

5. Vital signs
o 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 sign of postpartum infection.
o Bradycardia (heart rate of 50-70 per minute) is common for 6-8 days postpartum.
o There is no change in the respiratory rate.

6. Weight – there is an immediate weight loss o 10-20 pounds representing the weights of the fetus, placenta,
amniotic fluid and blood. Further weight loss will occur during the next days due to diaphoresis.

o 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 relieves 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 a therapeutic, in fact.

d. Letting-Go Phase
- The mother redefines her new role.
- Gives up the fantasized image of her child and accepts the real one.

o Prevent postpartum complications:

- Hemorrhage
- Infection

o Establish successful lactation.

7. Implications of the physiology of breastmilk production.

o Regardless of the mother’s physical condition, method of delivery, or breast size/condition, milk will be
produced.
 o Lactation does not occur during pregnancy because estrogen and progesterone are present and therefore
inhibit prolactin production.
o Lactation-suppressing agents are to be given immediately after placental delivery to be effective.
o Oral contraceptives are contraindicated in lactating mothers decreasing milk supply.
o Afterpains are felt more by breastfeeding women because oxytocin production; they also have less lochia
and experience more rapid involution.
o 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 oxytocin which causes uterine contraction.

a. Advantages of breastfeeding for the mother:

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

Advantages of breastfeeding for the baby:

 closer mother-infant relationship
 contains antibodies that protect against common illnesses
 less incidence of gastrointestinal diseases.
 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 nipples and cause sore nipples.
Wash hands before and after every feeding.
- Insert clean OS squares or piece of cloth in the brassiere top 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 breasts 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:
 baby’s mouth parts “hike will up” into the areola
 mother feels afterpains as the baby sucks
 other nipple flows with milk while baby is feeding on other breasts.

- To prevent nipple 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 breasts 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 will only half-refill and after some time, they 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 bay is hungry, especially during the first few days, because he is receiving colostrum
which is not very fulfilling; 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 nervous circulation.
Management:
- Advise the use of firm-fitting brassiere for good support. It will not only decrease the discomfort from the
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 be done if the mother is not going to
breastfeed, since either will stimulate milk production.

a. Sore nipples - not contraindications to breastfeeding.

Management:
- Expose nipples to air by leaving bra unsnapped for 10-15 minutes after feeding.
- When normal air drying is not effective, exposure to a 20-watt bulb placed 12-418 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.

b. Mastitis – inflammation of the breasts; symptoms include:

- Localized pain; swelling and redness in breasts tissues
- Lumps in the breasts
- Milk becomes scanty

Management:
- Antibiotics as ordered
- Ice compress
- Proper breast support
 - Discontinue breastfeeding in affected breast.

c. 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.
d. Contraindications
 Drugs – oral contraceptives, atropine, anticoagulants, antimetabolites, cathartics, tetracyclines.
(Insulin, epinephrine, most antibiotics, antidiarrheals and antihistamines 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 feeing. (However, mothers may use masks to prevent droplet spread.) TB germs,
however, are not transmitted thru breast milk.
e. Motivate the use of family planning program depends to a large extent on the motivation of both husband
and wife.
a. Artificial Methods

 Physiologic method: Oral Contraceptive pill

Action: Suppresses the pituitary gland, thus inhibiting ovulation.

Types:

Combined – estrogen and progesterone ion the same dosage each day for 20 days, starting on the 5 th day of the
menstrual cycle, after which it is discontinued and ten resumed on the 5 th 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

 Nausea and vomiting

 Headache and weight gain – due to fluid retention because of progesterone.
 Breasts tenderness
 Dizziness
 Breakthrough bleeding/spotting between periods.
 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
 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.
 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 be kept in place during such time, but
should not stay for more than 24 hours because stasis of semen can lead to infection.
 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 of lessening the chance of contracting sexually- transmitted
diseases (STDs, esp. AIDS)
- Most common complaint of users: it interrupts the sexual act to apply.
 Chemical methods: spermicidals (kill sperms) in the form of jellies, creams, foaming tablet and suppositories.
 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 a long as 6 months. Implication: couple should still observe a form
of contraception during this time to ensure protection against subsequent pregnancy.)

c. Natural

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 for 12 continuous months in order to determine the shortest and the
longest cycles.

- The first fertile day is determine 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.
26 32
- 18 - 11
8 21

- 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
- Abstinence
- Withdrawal/coitus interruptus