POST PARTUM CARE

(PUERPERIUM)
Iril I. Panes, RN, MAN

DEFINITIONS
A. Puerperium/Postpartum refers to the
six-week period after delivery of the baby
B. Involution the return of the
reproductive organs to their pre- pregnant
state

Principles of Postpartum Care

A. Promote healing and return to normal
(involution) of the 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
within 5-10 minutes after placental delivery. Implication:
the first 5-10 minutes after placental delivery is crucial to
gravido-cardiacs because the weak heart may not be
able to handle such workload

 b. White blood cell (WBC) count increases

to 20,000-30,000/rm3.
Implication: WBC count, therefore, cannot be
sued as an indicator of postpartum infection.

c. There is extensive activation of the

clotting factors, which encourages
thrombo- embolization. This is the reason
why:
Ambulation is done early after 4-8 hours in
normal vaginal delivery.
Massage is contraindicated

 d. All blood values are back to prenatal

levels by the third or fourth week
postpartum

2. Genital changes
a. Uterine involution is assessed by
measuring the fundus by fingerbreadths
(= 1 cm). On PPD 1 fundus is one
fingerbreadth below the umbilicus; on PPD
2, 2 fingerbreadths below umbilicus and
so forth until on the 10th day postpartum,
it can no longer be palpated because it is
already behind the symphysis pubis

 b. To encourage return of the uterus to its

usual anteflexed position, prone and kneechest positions are advised.
c. Afterpains/after birth pains strong
uterine contractions felt more particularly
by multis, those who delivered large
babies or twins and those who breastfeed.
Management:
NEVER apply heat on abdomen
Give analgesics, as ordered
Explain that it is normal and rarely lasts for more
than 3 days

 d. Lochia uterine discharge consisting of

blood, decidua, WBC mucus and some
bacteria
Pattern:
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;
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. Otherwise, it means
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.

 e. Pain in perineal region may be relieved

by:
Sims position minimizes strain on the
suture line
Perineal heat lamp or warm Sitz baths
twice a day
vasodilatation increases blood supply and,
therefore, promotes healing

Application of topical analgesics or

administration of mild oral analgesics, as
ordered

 f. Sexual activity maybe resumed by the

third or fourth week postpartum if bleeding
has stopped and episiorrhaphy has
healed. Decreased physiologic reactions
to sexual stimulation are expected for the
first 3 months and emotional factors

 g. 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
(IMPORTANT: Amenorrhea during lactation is no
guarantee that the woman will not become
pregnant. She may be ovulating and the absence
of menstruation may be her bodys way of
conserving fluids for lactation. Implication: She
should be protected against a subsequent
pregnancy by observing a method of contraception
but not the pill.)

 h. Postpartum check-up should be done

after the 6th week postpartum to assess
involution.

 3. Urinary changes
a. There is marked diuresis within 12 hours postpartum to
eliminate excess tissue fluid accumulation during
pregnancy.
b. Some newly delivered mothers may complain of frequent
urination in small amounts; explain that it 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
maybe initiated by pouring warm and cold water alternately
over the vulva, encouraging patient to go to the comfort
room and let her listen to the sound of running water. If
these measures fail, catheterization, done gently and
aseptically, is the last resort on doctors 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:
a. Decrease muscle tone
b. Lack of food + enema during labor
c. Dehydration
d. Fear of pain from perineal tenderness
due to episiotomy, lacerations or
hemorrhoids

 5. Vital Signs
a. 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.
b. Bradycardia ( = heart rate of 50-70 per
minute) is common for 6- 8 days
postpartum
c. There is no change in respiratory rate.

 6. Weight there is an immediate weight

loss of 10-12 lbs representing the weights
of the fetus, placenta, amniotic fluid and
blood. Further weight loss will occur during
the next days due to diaphoresis.

B. Psychological Phases
Provide emotional support the
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.

 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
feelings of inadequacy in taking care of a
new baby.
Management: Explain that it is normal and
that crying is therapeutic, in fact.

3. Letting go Phase
The mother is now ready for her new role as a
parent

C. Prevent postpartum complications

1. Hemorrhage blood loss of more than
500 cc. (normal blood loss during labor
and delivery is 250-350 cc); leading cause
of maternal mortality associated with
childbearing

 Classification of Postpartum Hemorrhage

I. Early postpartum hemorrhage occurs

during he first 24 hours postpartum
A. Uterine Atony uterus is not well contracted,
relaxed or boggy; most frequent cause
1. Predisposing factors:
a. Overdistention of the uterus e.g., multiple
pregnancy, multiparity, excessively large baby,
polyhydramnios
b. Cesarean section
c. Placental accidents (previa or abruptio)
d. Prolonged and difficult labor

 2. Management:
a. Massage first nursing action
b. Ice compress
c. Oxytocin administration
d. Emptying the bladder
e. Bimanual compression to explore retained
placental fragments
f. Hysterectomy last resort

B. Lacerations
C. Hypofibrinoginemia a clotting defect

Late postpartum hemorrhage

A. Retained placental fragments
Management: dilatation and curettage (D&C)

B. Hematoma due injury to blood

vessels during delivery
1. Incidence: Commonly seen in
precipitate delivery and those with perineal
varicosities

Late postpartum hemorrhage

2. Treatment:
a. Ice compress during the first 24 hours
b. Oral analgesic, as ordered
c. Site is incised and bleeding vessel is
ligated

 2. Infection
a. Sources:
Endogenous (primary) sources bacteria
in the normal flora become virulent when
tissues are traumatized and general
resistance is lowered
Exogenous sources pathogens
introduced from external sources.
Organism most frequently responsible for
postpartum

infections: Anaerobic streptococci.

Common exogenous sources:
Hospital personnel
Excessive obstetric manipulations
Breaks in aseptic techniques faulty hand
washing,
Unsterile equipments and supplies
Coitus in late pregnancy
Premature rupture of the membranes

 b. General symptoms: malaise, anorexia,

fever, chills and headache
c. General management: complete bed
rest (CBR), proper nutrition, increased
fluid intake, analgesics, antipyretics and
antibiotics, as ordered

Types of infection
A. Infection of the perineum
Specific symptoms:
Pain, heat and feeling of pressure in the
perineum
Inflammation of the suture line, with 1 or 2
stitches sloughed off
With or without elevated temperature
Specific management:
Doctor removes sutures to drain area and resutures
Hot Sitz bath or warm compress

 B. Endometritis inflammation/infection of
the lining of the uterus
Management:
Oxytocin
Fowlers position to drain out lochia and
prevent pooling of infected discharge

 C. Thrombophlebitis infection of the

lining of a blood vessel with formation of
clots; usually an extension of endometritis
Specific symptoms:
Pain, stiffness and redness in the affected part
of the leg
Leg begins to swell below the lesion because
venous circulation has been blocked
Skin is stretched to a point to shiny whiteness,
called milk leg phlegmasia alba dolens
Positive Homans Sign pain in the calf when
the foot is dorsiflexed

 Side effects: hematuria & increased lochia

Considerations:
Discontinue breastfeeding
Monitor prothrombin time
Always have Protamin sulfate or Vitamin at
bedside to counteract toxicity
Analgesics are given but NEVER Aspirin
because it inhibits prothrombin formation; since
patient is already receiving an anticoagulant,
bleeding may occur

D. Establish successful lactation

Physiology of Breastmilk Production
DECREASED ESTROGEN AND PROGESTERONE levels
after the
delivery of the placenta
stimulates anterior pituitary gland to produce prolactin
acts on acinar cells to produce foremilk
stored in collecting tubules.
WHEN INFANT SUCKS
posterior pituitary gland is stimulated to produce oxytocin
causes contraction of smooth muscles of collecting tubules
milk ejected forward
LET-DOWN or MILK EJECTION REFLEX
hindmilk is produced

Implications of physiology of
breastmilk production
a. Regardless of the mothers physical
condition, method of delivery or breast
size, condition, milk will be produced.
b. Lactation does not occur during
pregnancy because estrogen and
progesterone are present and therefore,
inhibit prolactin production

Implications of physiology of breastmilk

production
c. Lactation-suppressing agents are to be
given immediately after placental delivery
to be effective
d. Oral contraceptives are contraindicated
in lactating mothers because they
decrease milk supply
e. After pains are felt more by
breastfeeding women because of oxytocin
production; they also have less lochia and
experience more rapid involution

Implications of physiology of
breastmilk production
f. If emergency delivery when the uterus
does not contract, put the infant to the
breast.
During initial contact in emergency delivery,
determine whether the woman in labor is a primi
or a multi, the EDC and also assess the stage of
labor. And if not sterile equipment is available to
cut the cord, wrap the baby and the placenta
together; never cut the cord unless sterile
equipments are available

Advantages of breastfeeding
a. For mother:
Economical in terms of time, money and
effort
More rapid involution
Less incidence of cancer of the breast,
according to some studies

Advantages of breastfeeding
b. 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

Health Teachings
a. 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

Health Teachings
b. Method as suggested by the La
Leche League
Side-lying position with a pillow under the
mothers head while holding the bulk of
breast tissues way from the infants 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

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

Sore nipples
Management:
Expose nipples to air by leaving bra unsnapped
for 10 to 15 minutes after a feeding
When normal air drying is not effective,
exposure to a 20-watt bulb place 12-18 inches
away will cause vasodilatation, increase
circulation and promote healing
Do not use plastic liners that are found in some
nursing bras because they prevent air from
circulating around the breasts

d. 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. Nonbreastfeeding women can have the same
requirements as in pregnancy

E. Motivate use of family planning methods

the success of the family planning
program depends to a great extent on the
motivation of both husband and wife.

ANY QUESTIONS?

Critical Thinking:
Christine gave birth to her baby at 8am. Your
assessment findings at 8pm are as follows:
BP: 120/80
PR: 70
RR: 16
T: 37.8C
You found that the uterine fundus is 1cm above
the umbilicus and right of midline. Christine says
she has been perspiring a lot.

 Questions:
1. What is probably causing Christines
slightly elevated temperature? (5 pts)
2. What could be the implication of the data
fundus 1cm above the umbilicus and
right of midline for the mother? What will
be your nursing interventions? (15 pts)