PUERPERUM

ZCMIRAFLORES
 Puerperium /Postpartum

 refers to the six – week

period after delivery of the
baby
 Involution

- return of the
reproductive organs to
their prepregnant state

PRINCIPLS OF POSTPARTUM CARE

A.Promoting and return to normal (involution) of

different parts of the body.

1.Vascular changes
a.The 30% - 50% increase in total cardiac volume
during pregnancy will be reabsorbed into the general
circulation with 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.
b. While blood cell (WBC) count increases
to 20,000 – 30,000/mm3.

Implication: the WBC count, therefore,

cannot be used as a indicationor sign of
postpartum infection
c. There is extensive activation of the clothing factors,
which encourages thromboembolization.

This is the reason why:

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.
Recommended exercises

1. Kegel and abdominal breathing on postpartum day

one (PPD1).
2. Chin – to – chest – on PPD2 to tighten and firm up
abdominal muscles
3. Knee – to – abdomen – when perineum has healed,
to strengthen abdominal and gluteal muscles.
NOTE: Massage is contraindicated
**All blood values are back to prenatal levels by the
3rd or 4th week postpartum
Genital Changes

 Uterine involution is assessed by measuring the fundus by

fingerbreadth (=1 cm.)

 on PPD1, fundus is 1 finger breadth below the umbilicus;

 on PPD2, 2 fingerbreaths below and so forth until on
PPD10, NOTE: it can no longer be palpated because it is
already behind the symphysis pubis.

 Subinvoluted uterus is a uterus larger than normal

and vaginal bleeding with clots since blood clots are good
media for bacteria, a sign of puerperal sepsis.
NOTE: To encourage the
return of the uterus to its
usual anteflexed position,
prone and knee chest
positions are advised.
Afterpains/afterbirth pains

– strong uterine contractions felt more

particularly by:
1. multiparas
2. those who delivered large babies or twins
3.those who breastfeed.
It is normal and rarely lasts for more than 3 days.
Management:
1.Never apply heat on the abdomen
2.Give analgesics as ordered
Lochia

– uterine discharge consisting of blood, deciduas,

WBC, mucus and some bacteria.

Pattern:

 Rubra – first 3 days postpartum; red and moderate

in amount
 Serosa – net 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
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 fol smelling, may

mean either poor hygiene or infection
 It should not contain large clots.

 It should never be absent, regardless of method of

delivery.
NOTE: Lochia has the same pattern and amount,
whether CS or normal vaginal delivery
Pain in perineal region may be relieved by:
1. Sim’s Position – minimizes strain on the
suture line
2. Perineal heat lamp or warm Sitz baths twice
a day – vasodilatation increases blood supply
and, therefore, promotes healing
3. Application of topical analgesics or
administration of mild oral analgesics as
ordered
Sexual activity

– maybe resumed by the 3rd or 4th week

postpartum if bleeding has stopped and
episiorrhappy 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 8 weeks after delivery.

If breastfeeding, menstrual return is expected in 3-4 months;

in some women, no menstruation occurs during the entire

lactation period. NOTE: amenorrhea during lactation is no
guarantee that the woman will not become pregnant. She may be
ovulating the absence of menstruation may 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 6th week

postpartum to assess involution.
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.
 Other, 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:

1. Pouring warm and cold water alternately over the vulva

2. Encouraging the client to go the comfort room
3. Let her listen to the sound of running water
4. If these measures fail, catheterization, done gently and
aseptically, is the last resort on doctor’s order.

NOTE: (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).
Gastrointestinal changes
– delayed bowel evacuation postpartally may be due to:

1. Decreased muscle tone

2. Lack of food + enema during labor
3. Dehydration
4. Fear of pain from perineal tenderness due to
episotomy, lacerations or hemorroids
Vital Signs

Temperature may increase because of the

dehydrating effects of labor.
Implication: NOTE: 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
Psychological phases during the
postpartum period are:

1.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.
MGT: provide emotional support
2.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.
Could be due to hormonal changes, fatigue or feeling
of inadequacy in taking care of a new baby.

Management: explain that it is normal; crying is

therapeutic.
Prevention of postpartum complications

1.Hemorrhage
2.Infection
 Establish successful lactation
Estrogen and progesterone levels after placental delivery

Stimulates anterior pituitary gland to produce proclatin acts on

Acinar cells to produce foremilk stored in collecting tubules.

When infant sucks

posterior pituitary gland is stimulated to
Produced oxytocin

causes contraction of smooth muscles of

Collecting tubules

milk ejected forward let – down or milk ejection

Reflex

hindmilk is produced
 Lactation is the production of breast milk.
Colostrum is present immediately after birth;
milk forms on the third to fourth postpartal day. A
feeling of fullness and firmness on this day is
termed filling; if warmth and discomfort occur, it
is termed engorgement.
 ● Women may need various comfort measures to
alleviate pain from sutures, uterine pain
(afterpains), and breast tenderness. Application
of cold or heat and administration of analgesics
are important nursing interventions.
 Mothers should conscientiously return for a
visit at 6 weeks after childbirth, to be certain
their reproductive organs have returned to
their nonpregnant state.
A menstrual flow should return within 6
to 10 weeks in the non-breastfeeding
mother, or 3 to 4 months in the
breastfeeding mother.
POSTPARTUM DEPRESSION
 Postpartum depression (PPD) is a complex mix of physical, emotional, and
behavioral changes that happen in some women after giving birth.

 Symptoms of postpartum depression can be hard to detect. Many women

have these symptoms following childbirth:

 Difficulty sleeping

 Appetite changes

 Excessive fatigue

 Decreased libido

 Frequent mood changes

 accompanied by other symptoms of major depression, which
aren’t typical after childbirth, and may include:

 Depressed mood

 Loss of pleasure

 Feelings of worthlessness, hopelessness, and helplessness

 Thoughts of death or suicide

 Thoughts of hurting someone else