SLIDES PREPARED BY Ms.

Virgina Varghese
PRESENTER Ms.Virgina Varghese and Dr.Soniya
COLLEGE / CENTRE COHS
PROGRAM NURSING
SEMESTER Spring 2022-23

Puerperium and Management of Care

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Course Outcomes (From Course
Specifications)
• A1. Explain the physiological and psychosocial processes of pregnancy, birth,
puerperium and lactation.
• B2. Practice ethical principles while providing care to pregnant, parturient,
postpartum, newborn and gynecological clients while ensuring patient safety.
• C2. Integrate evidence-based in managing clients with maternity,
gynecological conditions and care of the newborn
• D1. Demonstrate intellectual flexibility in the management of gynecological,
maternal and newborn care.
• D2. Promote good time management practices when working in teams

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Objectives
• Define of normal puerperium
• Enumerate the various physiological changes during normal
puerperium
• Identify some aspects of lactation
• Discuss the care of a woman during puerperium
• Identify the postnatal exercises to be practiced during
puerperium.
 Postpartum Nursing
Puerperium – is the period of 6 wks after delivery during
which the reproductive system and the body returns to
normal.
 Adaptation to the maternal role and modification to the
family system

Classified into:
1. Immediate--first 24 hrs
2. Early--first week
3. Late--2nd to 6th week
Dramatic Changes in every body system
• Wt. Loss at 15-17 kg. Possibly more if breastfeeding.
Uterine Involution
• Blood vessels contract, uterus shrinks
• Involutes at 1cm/day; 1cm=1fingerbreadth
• Process for involution=autolysis of protein -1000gm at delivery, 60gm at 6
wks post partum period
Nursing care related to uterine changes
• Palpate fundus at frequent intervals
• q. 15” X 1hr
• q. 1hr X 2
• q. 4 hrs up to 24-48 hrs. post delivery
• Massage if not firm
• Deviation and above umbilicus may signal full bladder
Lochia
Vaginal discharge after delivery composed of leukocytes, epithelial cells,
decidua, autolysed protein and bacteria.
– 1. Rubra--delivery to 3rd day
– 2. Serosa--days 4-10
– 3. Alba—10days to several weeks post delivery
• Assess color, amount, odor, clots
Cramping or “Afterpains”
• Primigravida--uterus tonically contracted unless clots or tissues remain in
uterus.
• Multipara--uterus contracts and relaxes at intervals causing “afterpains”.
Breast Changes
• Colostrum secreted from third trimester until lactation begins. Milk--
lactation 3rd postpartum day
• Engorgement from increased vascular and lymphatic circulation
• Check breasts for engorgement, nipple cracks, soreness
Ways to help Suppression of Lactation
• Avoid breast stimulation
• Ice
• Tight bra
• Do not pump or express milk
• Homonal suppression (rarely)
Perineal Changes
• Pain for 24-48 hrs
• ice for 24 hrs then heat (sitz baths)
• Analgesics - systemic and topical
• Sit properly and Keep clean--perineal care
• Evaluate Episiotomy (Incision of the perineal muscles) or Perineum for
REEDA
• Redness
• Edema
• Ecchymosis
• Drainage
• Approximation
Vaginal Changes
• Edematous--venous congestion for 3 days and Rugae absent--return in 3
wks
• Lacerations
Urinary Elimination
• Bladder Changes
• edema and hyperemia, extravasation
• increased capacity, decreased sensitivity
• Over-distension with incomplete emptying
• urethral trauma may cause dysuria
Problems with urinary elimination
• Dysuria
• IV fluids cause bladder fullness
• Regional anesthesia and decreased abdominal pressure makes patient
unaware of full bladder
Bowel Elimination - Constipation r/t
• decreased peristalsis
• hemorrhoid discomfort
• perineal discomfort
Increase roughage and fluids, laxatives and suppositories—bowels normal
by 1wk pp
Endocrine Changes
• Placental estrogen and progesterone removed
• Prolactin increases, especially in breastfeeding women
• Estrogen begins to increase to follicular levels at 3-4 weeks post
Delivery
• Menstruation returns--6 weeks for those who are not breastfeeding, 2-
18 months if breastfeeding
Cardiovascular Changes
• Blood volume goes rapidly from hypervolemia to hypovolemia
• Blood loss 400-500cc vaginal delivery and 700-1000 cc for
Caesarian section
Abdominal Musculature
•  muscle tone--soft, weak, flabby
• diastasis recti remains - May do head and shoulder raises and lie on
abdomen
Sleep and Rest Patterns
• Sleep and rest patterns disrupted during third trimester and continue to
be disrupted during post partum (pp) period
• excitement
• anxiety
• Discomfort and baby feedings
Psychological Changes
The new mother must move from dependent to
independent in a short time
Reva Rubin's three stages of the postpartum
• 1.Taking in
• 2.Taking hold
• 3.Letting go (taking over)
1. Taking in phase - May last for several hours or days
• Focused on self (not infant)
• dependent on others for help in care, needs assistance
• decision making difficult
• comfort-rest-food needs paramount
2. Taking hold phase - Lasts from 2days to 1wk
• Moving from dependence to independence
•  energy level and  focus on infant
• Self care, focus on bowels, bladder, breastfeeding
3. Letting go phase – From 1 week
• Giving up previous role ; See self as separate from infant
• Readjustment
• Depression and grief work
Postpartum blues
• Reduction of progesterone, and changes in other placental hormones may
trigger emotional instability
• Over concern regarding infant and self, and emotional lability are
“normal” during the first 5-10 days after delivery
Postpartum depression
• Rejection of infant, or fears that she may harm infant call for immediate
intervention.
• Remind mom during postpartum teaching that these feelings sometimes
occur and help is available
Post Partum Assessment - BUBBLE-LE

• Breast • Lochia
• Uterus • Episiotomy
• Bladder • Legs
• Bowel • Emotion
Nursing assessment includes
• Frequent fundal checks and massage of fundus if bogginess is detected
• Frequent perineal pad checks for excessive bleeding
• Prevention of over distention of the bladder and encourage woman to
void frequently
• Assess incision and Frequent vital sign assessments for infection
• Assessment for signs of postpartum “blues” or depression
• Assess breast for cracking, plugged ducts, and signs of mastitis. Teach
mother proper latching on techniques and breast care
• Assess lower extremities for signs of thrombophlebitis, encourage early
ambulation and for DVT
Assess for DVT - Homans’ Sign

 No pain or discomfort should be expressed

 Pain is only present 50% of the time
Clinical assessment- redness warmth in calf unequal calf
circumference( not always reliable )
Nursing Care
Use good hand washing techniques to prevent transmission of infective
material
• Check bladder frequently post delivery
• Full bladder can inhibit uterine contraction=bleeding
• If no void in 4-6hrs, catheterize
• Check amount of voiding (retention with overflow possible)
• Early ambulation
• Avoid strenuous activities for 6 weeks
• 8-10 hours sleep
• Needs 300 calories more
• Care of nipples and areola.
• Episiotomy care
Postpartum Blues
• Remind mom that the “Blues” are normal
• Encourage rest
• Utilize relaxation techniques
• Share her feelings with her partner
• If symptoms do not resolve and progress to depression medical treatment
needs to be sought
Postnatal Exercise
• Pelvic floor exercise
• Abdominal tightening
• Pelvic tilting or rocking
• Foot and Leg Exercise
Breast Feeding - Lactogenesis- secretion of milk and Milk ejection
reflex- “let down” reflex
• Optimal method of feeding infant
• Breast milk- bacteriologically safe, fresh, readily available
Positions for breastfeeding:
• Cradle hold
• Foot ball
• Side lying
 POST PARTUM
• POSTPARTUMCOMPLICATIONS
HEMORRHAGE Postpartum hemorrhage involves a loss of 500 mL or more
of blood; it occurs most frequently in the first hour after delivery.
Early postpartum hemorrhage
1.Uterine atony—relaxation of the uterus secondary to:
a. Multiple pregnancy—causes overdistention of uterus and a larger placental site
b. Polyhydramnios (excessive amniotic fluid)
c. High parity
d. Prolonged labor with maternal exhaustion
e. Deep anesthesia
f. Fibromyomata—prevents uterus from contracting
g. Retained placental fragments—result from manual removal of placenta, abnormal adherent
placenta (placenta accreta)
2.Laceration of the vagina, cervix, or perineum secondary to:
a. Forceps delivery, especially rotation forceps
b. Large infant
c. Multiple pregnancy
Clinical
Manifestations Managemen
1. With uterine atony uterus is soft or
boggy, often difficult to palpate, and
will not remain contracted; excessive
t atony, oxytocin (Pitocin)
1. For uterine
or methylergonovine (Methergine)
vaginal bleeding occurs.
are prescribed.
2. Lacerations of the vagina, cervix, or 2. Pain medication may be needed to
perineum cause bright red, counter uterine contractions.
continuous bleeding even when the
3. If placental fragments have been
fundus is firm. retained, curettage of the uterus is
3. Hemorrhage usually occurs about indicated.
the tenth postpartum day with
retained placental fragments.(late 4. Lacerations may need to be repaired
postpartum hemorrhage)
 Nursing Assessment
1. Assess for hypotension, tachycardia, change in respiratory rate, decrease in
urine output, and change in mental status—may indicate hypovolemic shock.
2. Assess location and firmness of uterine fundus.
3. Percuss and palpate for bladder distention, which may interfere with
contracting of the uterus.
4. Monitor amount and type of bleeding or lochia present and the presence of
clots.
5. Inspect for intactness of any perineal repair
NURSING DIAGNOSIS
A. Anxiety related to unexpected blood loss and uncertainty of outcome
B. Fluid Volume Deficit related to blood loss
C. Risk for Infection related to blood loss and vaginal examinations
 Perineal hematoma
• Postpartum hematomas are localized collections of blood in loose
connective tissue beneath the skin that covers the external
genitalia, beneath the vaginal mucosa, or in the broad ligaments.

ETIOLOGY
1.Trauma during spontaneous labor
2.Trauma during forceps application or delivery
3.Inadequate suturing of an episiotomy
Clinical
Manifestations
1. Complaints of pressure and pain,
often noting that the pain is
excruciating
2. Discolored skin that is tight, full
feeling, and painful to touch
3. Possible decrease in blood
pressure, tachycardia
Complications
1.Hypovolemia and shock
from extreme blood loss
2.Anemia, infection
3.Increased length of
postpartum recovery period
 Management
1.Small hematomas are left to resolve on their own - ice
packs may be applied.
2.Large hematomas may require evacuation of the blood
and ligation of the bleeding vessel.
3.Analgesics and antibiotics may be ordered (due to
increased chance of infection).
PUERPERAL INFECTION
• Puerperal infection is a postpartum infection of the genital tract,
usually of the endometrium, that may remain localized or may extend
to various parts of the body.

Clinical Manifestations
• sustained fever of 38°C (100.4°F) or higher occurring on any two of
the first 10 days postpartum, excluding the first 24 hours.
• Symptoms depend on site and extension of infection.
 Etiology
• Bacterial organisms either are introduced from external sources or are normally present
in the genital tract and are carried to the uterus.
• Predisposing factors include:
1.Prolonged labor or rupture of membranes (PROM)
2.Number of vaginal examinations
3.Infection elsewhere in the body
4.Anemia, malnutrition
5.Size and number of perineal lacerations
6.Intrauterine manipulation
7.Retained placental fragments of membranes
8.Lapse in aseptic technique
9.Poor perineal hygiene
10.Cesarean section
Birth Spacing
• Birth Spacing service is an integral part of the MCH services in Oman and are provided in
all regions of the Sultanate. The Ministry of Health provides, through MCH areas in all
health centers and extended health centers.
GOALS:
To improve the health of mothers, children and families by:
• Reduction of maternal morbidity and mortality.
• Reduction of infant morbidity and mortality.
OBJECTIVES:
Empower women to:
• Regulate her fertility safely and effectively by conceiving when desired.
• Remain free of diseases, disabilities or death associated with reproduction.
• Bear and raise healthy children

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ROLES OF BIRTH SPACING SERVICES: The Birth Spacing services will provide:
• Education
• Counseling
• Client’s clinical assessment
• Free contraceptives
• Follow up
SPECIFIC METHODS PROVIDED BY MOH
The Ministry of Health through its BS clinics is currently providing five BS modern
contraceptive methods, and intends to expand on the choice of methods others like
implant, if found appropriate, these methods are:
• Pills - COC : Combined oral Pill - POP : Progesterone Only Pills
• Injectables : Depo Provera (Depot Medroxy Progesterone)
• IUCD : Copper T 380 A
• Condoms : MM 52 non-colored

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COMBINED ORAL CONTRACEPTIVES (COCs)- MECHANISM OF ACTION
• Suppression of ovulation
• Thickening of cervical mucus
• Alteration of endometrium (making implantation less likely)
• Reduces sperm transport in upper genital tract (fallopian tubes)
When to start the pills ?
• First day of menstrual period. If a client comes between day 2-5 during menstruation.
Pills can be started.
• If > 5 days from the first day of menstruation but she is sure about not being
pregnant. In addition to pills, advice her to use condom for the first 7days for extra
protection.
• Post partum: If breast feeding: after 6 months.
• If not breast feeding: at 6 weeks post partum.
• After miscarriage or spontaneous abortion: Immediately within 7 days. If > 7 days,
make sure she is not pregnant and advice her to use condom for the first 7 days.
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PROGESTOGEN ONLY PILLS (POPs) MECHANISM OF ACTION
• Thickening of the cervical mucus (preventing sperm penetration).
• Changes in the endometrium, making it less receptive to implantation.
• Decreased tubal motility (reducing sperm transport).
• Inhibition of ovulation, follows 3 patterns : Ovulation every month: periods remain regular No
ovulation: periods very irregular Ovulation irregular: periods irregular
PROGESTOGEN ONLY INJECTABLES MECHANISM OF ACTION:
• Suppresses ovulation.
• Thickens the cervical mucus and stops the sperm from entering the uterus.
• Changes endometrium, making implantation less likely.
• Reduces sperm transport in upper genital tract (fallopian tubes).
When to start:
• Within the first 7 days of menstrual period: If still bleeding, no need for back up method.
• If stopped bleeding, give back up method (condom) for 7 days after the injection.
• More than 7 days of menstrual period: injection can be given any time if client is reasonably certain she
is not pregnant, give back up method (condom) for 7 days after the injection.
• Postpartum (breast feeding and non-breast feeding): At 6 weeks
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 COPPER BEARING INTRAUTERINE
• Intra Uterine Contraceptive Devices (IUCDs) are small flexible (T) shaped devices, inserted in
DEVICE
the uterine cavity for effective long-term contraception. They are made of plastic and are
usually medicated with “Copper” and in (Nova) type with “Progestin.” Currently MOH is
providing (Copper T 380 A) type, which is effective for 10 years.
MECHANISM OF ACTION:
• Works primarily by causing a chemical change that damages sperm and egg before they can meet, thus it
prevents fertilization.
• Copper released from the device inhibits sperm penetration, reducing sperm motility thus decreasing the
number of sperm reaching to fertilize the egg.
• Copper prevent implantation.
• Although labeled for up to 10 years of use, studies found that it is effective for 12 years.
When to insert?
During or towards the end of the menstruation
Post partum: at 6 weeks.
After miscarrage (if no infection is present): Immediately, within 12 days.

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Care after CU-T
• Unusual Situations: Cramping and pain
• What to do if the IUCD is Expelled? Advice client to return immediately to the
clinic to have another IUCD inserted. She should use another contraceptive
method until the IUCD is replaced.
• Missing strings Ask client: When she last felt the strings

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EMERGENCY CONTRACEPTIVE
PILLS
• Emergency contraceptive pills help to prevent pregnancy when taken up to
five days after unprotected sex.
• The sooner they are taken, the better.
Types of emergency contraceptive pills are:
• Progestin only Pills.
• Combined Oral Contraceptives.
MECHANISM OF ACTION: Work primarily by preventing or delaying the
ovulation. They do not work if a woman is already pregnant.

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References
• Lowdermilk,Perry,Cashion, “Maternity Nursing” 8th edition revised reprint ,
Mosby Elsevier. Page no 168- 188.
• Williams, Obstetrics Nursing book, 23rd Edition
• DC Dutta (2004). Text book of obstetrics .6th edn.central publications
• Pilliterri, Adele, Maternal and Child Health Nursing, 7th edition 2014,Wolters
Kluwer Health/ Lippincott Williams and Wilkins

•https://
www.moh.gov.om/documents/272928/4017900/Birth+spacing+guid
elines.pdf/74ce32cd-3b80-2a7a-8344-3a3f4dc2ab8d

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Thank You
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