UNIT VI: NORMAL PUERPERIUM

Total – 4 Hours

SL.NO CONTENT PAGE.NO

1. INTRODUCTION
2. DEFINITION
3. DURATION
4. PHYSIOLOGICAL CHANGES DURING
PUERPERIUM
- Involution of uterus
- Involution of other pelvic structures
- Lochia
- General physiological changes
5. PSYCHOLOGICAL CHANGES DURING
PUERPERUM
- Taking - in phase
- Taking - hold phase
- Letting - go phase
6. POSTNATAL ASSESSMENT – BUBBLE HE
- Breast
- Uterus
- Bowel
- Bladder
- Lochia
- Episiotomy
- Homan’s sign
- Emotional status

7. MANAGEMENT OF NORMAL PUERPERIUM

8. POSTNATAL EXERCISES
9. MANAGEMENT OF MINOR AILMENTS
10. L LACTATION: PHYSIOLOGY AND
MANAGEMENT
11. EMOTIONAL NEEDS DURING POSTNATAL
PERIOD
12. FAMILY DYNAMICS AFTER CHILD BIRTH
- Parenting process
- Parental acquaintance, bonding and attachment
- Communication between parent and child
- Paternal adjustments
- Sibling adaptation
- Grandparent adaptation
13. FAMILY WELFARE SERVICES, METHODS AND
COUNSELING
- Need of family welfare services
- Family welfare services
- Family planning

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I. INTRODUCTION
The word puerperium is originated from latin words ‘puer’ – child and ‘pams’ – bringing
forth. This period is also known as post-partum, post-natal or post-delivery period. It begins as
soon as the placenta is expelled. Puerperium is the period of about 6 weeks after child birth during
which the mother’s reproductive organs return to their original non-pregnant condition. Lactation
is initiated during this period and mother relieves from the physical, hormonal and emotional
experiences of parturition. The mother during puerperium is termed as puerpera.

II.DEFINITION
1. Puerperium is the period following childbirth during which the body tissues, especially the
pelvic organs revert back approximately to the pre-pregnant state both anatomically and
physiologically. - D C Duttta
2. Puerperium is the period following child birth when the endocrine influences of the placenta
removed the physiological changes of pregnancy is reversed. This is characterized by the
following features:
 The reproductive organs return back approximately to their pregravid state both
anatomically and physiologically
 Lactation is initiated
 Recuperation from the physical, hormonal and emotional experiences of parturition
- Nima Baskar

III. DURATION
Puerperium begins as soon as placenta is expelled and tests for approximately 6 weeks.
This period is divided into;

1. Immediate – within 24hrs

2. Early – upto 7 days
3. Remote – upto 6 wks
IV. PHYSIOLOGICAL CHANGES DURING PUERPERIUM
a). INVOLUTION OF UTERUS
Anatomical considerations
 Uterus :Immediately following delivery, uterus becomes firm and retract with alternate
hardening and softening. Uterus measures about 20×12×7.5 cm (L×B×T) and weighs
about 1000gms. At the end of 6 wks, it became almost similar to non-pregnant state and
weighs about 60 gms.

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  Lower uterine segment :Immediately following delivery, the lower uterine segment
became a thick, flattened and collapsed structure.
 Cervix :The cervix contracts slowly, the external os admits two fingers for a few days but
by the end of first week, narrows down to admit two fingers for few days. But by the end
of first week, narrows down to admit the tip of a finger only. The external os never revert
back to the nulliparous state.
Physiological considerations
 Muscles: During puerperium, the number of muscle fibres are not decreased but there is
substantial reduction of myometrial cell size.
 Blood vessels: Change of blood vessels occurs at the placental site
 Endometrium: Following delivery, the major part of the decidua is cast off with the
expulsion of placenta and the membranes. Regeneration starts by 7th day and the entire
endometrium is restored by the day 16, except at the placental site where it takes about 6
wks.
Clinical assessment of Involution
Involution is the process whereby the genital organs revert back approximately to the state as
they were before pregnancy.
- The rate of involution of the uterus can be assessed clinically by noting the height of the
fundus of the uterus in relation to the symphysis pubis.
- The measurement should be taken carefully at a fixed time everyday, preferably by same
observer. Bladder must be emptied and bowel too beforehand, as the full bladder and
loaded bowel may raise the level of the fundus of the uterus.
- During assessment, the uterus is to be centralised and with a measuring tape, the fundal
height is measured above the symphysis pubis. After labor, fundus is 5cm below
umbilicus or 12 cm above the symphysis pubis.During the first 24 hrs, the level remains
constant, the consistency of uterus will be firm and retracted.Thereafter there is a steady
decrease in height by 1.25 cm in 24 hrs, so that by the end of second week the uterus
becomes a pelvic organ. The rate of involution thereafter slows down until by 6 wks, the
uterus becomes almost normal in size.
b). INVOLUTION OF OTHER PELVIC STRUCTURES
 Vagina :The distensible vagina, noticed soon after birth takes a long time (4-8 wks) to
involute. It begins its tone but never to the virginal state.
 Broad ligaments and round ligaments require considerable time to recover from the
stretching and relaxation.

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  Pelvic floor and pelvic fascia take a long time to involute from the stretching effect
during parturition.
c). LOCHIA
It is the vaginal discharge for the first fortnight during puerperium. The discharge originates from
the uterine body, cervix and vagina.
- Odour and reaction : it has got a peculiar offensive fishy smell. Its reaction is alkaline,
tending to become acid towards the end
- Colour : depending upon the variations of the colour of the discharge, it is named as;
1. Lochia Rubra : (red, 1-4 days) consists of blood, sheds of fetal membranes and
decidua, vernixcaseosa, lanugo and meconium.
2. Lochia Serosa : (yellowish/pink/pale brownish, 5-9 days) consists of less RBC but
more leukocytes, wound exudates, mucous from the cervix and micro-organisms
(anerobic streptococci and staphylococcus). The presence of bacteria is not
pathognomic unless associated with clinical signs of sepsis
3. Lochia Alba : (pale white, 10-15 days) consists of plenty of decidua cells, leukocytes,
mucus, cholestrin crystals, fatty and granular epithelial cells and micro-organisms
- Amount : the average amount of discharge for the first 5-6days is estimated to be 250 ml.
- Normal duration : the normal duration may extended upto 3 wks. The discharge may be
scanty, especially following premature labor or may be excessive in time of delivery or
hydramnios
- Clinical importance : the character of lochial discharge gives information about the
abnormal puerperal state
 Malodour indicate infection (retained plug/cotton pieces)
 Scanty/decreased amount indicates infection or lochiometra. If excessive –
infection
 Persistant red colour beyond the normal limit signifies subinvolution or retained
bits of conception
 Duration of lochia alba beyond 3 wks suggests local genital lesion
d). GENERAL PHYSIOLOGICAL CHANGES
 Pulse: For a few hours after normal delivery, the pulse rate is likely to be raised, which
settle down to normal during the second day. However the pulse rate often raises with
after-pain or excitement.
 Temperature: The temperature should not be above 37.2 degree (99 F) within the first 24
hrs. There may be slight reactionary rise following delivery by 0.5 degree F but comes

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 down to normal within 12 hrs. On the 3rd day, there may be slight rise of temperature due
to breast engorgement which should not last for more than 24 hrs. However genito-urinary
tract infection should be excluded if there is rise of temperature.
 Urinary tract: The bladder mucosa become edematous and hyperaemic and often shows
evidences of submucous extravasation of blood. The bladder capacity is increased.
Bladder may be over distended without any desire to pass urine. Urinary stasis is common,
therefore urinary tract infection is high. Dilated ureters and renal pelves return to normal
size within 8 wks. There is pronounced diuresis on the second or third day of the
puerperium
 GIT: Increased thirst in early puerperium is due to loss of fluid during labor, in the lochia,
diuresis and perspiration. Constipation is a common problem for the following reasons:
delayed GI mobility, mild ileus following delivery, together with perineal discomfort.
 Weight loss: In addition to the weight loss as a consequence of the expulsion of the
uterine contents, a further loss of about 2kg occurs during puerperium chiefly caused by
diuresis
 Fluid loss: There is a net fluid loss of at least 2 litres during the next 5 wks
 Blood values: Immediately following delivery, there is slight decrease of blood volume
due to dehydration and blood loss. Blood volume returns to the non-pregnant level by the
second week. Cardiac output rises soon after delivery but slowly returns to normal within
one week. RBC volume and Hct values returns to normal by 8 wks. Leucocytosis to the
extent of 25000/cu mm occurs following delivery probably in response to stress of labor.
Platelet count decreases soon after the separation of placenta, but secondary elevation
occurs with increase in platelet adhesiveness between 4-10 days. Fibrinogen level remains
high upto the second week of puerperium
 Ovulation: If the woman does not breast feed her baby, ovulation occurs by 6 wks
following delivery. A woman who is exclusively breast feeding, the contraceptive
protection is about 98% upto 6 months postpartum.
V. PSYCHOLOGICAL CHANGES OF PUERPERIUM
The post partum period is a time of transition, during which a couple given up concepts such
as children or parents of one and moves to the beginning of new parenthood.
Phases of puerperium
1. Taking - in phase
It is a time reflection. Change in direction. During this period, a women is largely passive
and dependent. This dependence result partly from her physical discomfort because of
after-pain, haemorrhoids, partly from the uncertainityin examining for her newbornand
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 partly from the extra fatigue exhaustion that follows childbirth. During this phase, she rest
and regains the physical strength and to calm and curtain her thoughts.
2. Taking - hold phase
Woman begins to initiate actions during the taking in phase and may have expressed little
into in caring for her child. Now, she begins to take a strong interest.
3. Letting - go phase
In the third phase, woman finally redefine her new role. She given up fantasized image of
her child and accepts the real one. She given up her old role of being childless. Looking
directly at her newborn with direct eye contact and beginning effective interaction. Many
fathers can be observedstairing at a newborn for long intervals in their small way termed
as engrossments.
VI. POSTNATAL ASSESSMENT
Head to toe assessment is performed, initially after the delivery and after 6 weeks.
In the initial check up; BUBBLE- HE examination
Breasts
Size of the breast : Symmetrical/asymmetrical
Palpable mass : Absent/if present specify the size, tenderness etc
Montgomery’s tubercles : Present/absent
Primary and secondary areola : Moist/dry
Nipples : Erect/flat/inverted/cracked
Colostrum : Present/absent
Breast engorgement : Absent/present
Uterus– Fundal height : …….cm
Bowel– Normal/constipated
Bladder – Normal voiding patter/retension of urine/haematuria/painful mictuation
Lochia – Type of lochia/amount/number of changing pads
Episiotomy – Healthy/presence of signs of infection (REEDA scale – Redness, Edema,
Ecchymosis, Discharge, Approximation)
Homan’s sign – Positive/negative
(Make the client to lie in supine position. Place one hand under the knee in the popliteal region for
support. Place the other hand on the foot and dorsiflex it. Presence of calf pain during sharp
dorsiflexion in either foot is a sign of deep vein thrombosis)
Emotional status – happy/sad/tensed/irritable

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VII. MANAGEMENT OF NORMAL PUERPERIUM
Goal : To promoting physiological and emotional wellbeing
 Immediate care: After the delivery, mother is exhausted. She should be observed
carefully as there is the crucial period. Something light should be given to the mother to
drink or eat. Emotional support is essential. Sedative can be given if the mother is tired.
 Rest and ambulance: As the mother is tired, she require rest. Mother who had
spinal/epidural anesthesia may have to rest 6-8 hrs flat in bed to prevent spinal headache.
At the same time early ambulation is also important. It provides a sense of wellbeing, less
bladder complications and constipation, facilitates uterine drainage, promote involution of
uterus, lessens puerperal venous thrombosis and embolism.
 Hospital stay: If adequate supervision by trained health visitor is provided, there is no
harm in early discharge (after 2-3 days of normal delivery), with proper education and
training.
 Diet: The patient should be on normal diet of her choice during postnatal period.
Additional 500 kcal are required for lactating mothers(2600 kcal/day). Woman who has
haemorrhaged, high protein diet (65g/day) is given to promote tissue healing. Adequate
fat, plenty of fluids, minerals and vitamins are also important. However, in non-lactating
mothers, a diet as in non-pregnant is enough.
 Drugs: For constipation, milk of magnesia or Cremaffin 4-6 teaspoon is given at bedtime.
Iron and folic acid is continued for 3 months.
 Sleep :The woman needs physical as well as mental rest. Sleep must be ensured. If there is
any discomfort, such as piles, after pains, breast engorgement etc it should be dealt with
adequate analgesics.
 Care of bladder: The mother is encouraged to urinate as soon as convenient after the
delivery and 4-6 hrs intervals thereafter. Catheterization may be needed if fails to empty
bladder.
 Care of bowel: If the woman ambulates early, the problem of constipation is much less.
Her diet must contain sufficient roughage and fluids to move the bowel. If necessary, mild
laxatives can be taken at bedtime.
 Care of vulva and episiotomy wound: Perineal care has to be worked and cleaning
should be performed each time after urination and defecation. The patient should look
after the personal cleanliness. The episiotomy wound should be wiped from front to back
across the stitches and should maintain sterile techniques for dressing the wound.

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  Care of breasts: Attention should be given to proper washing and cleaning to prevent
infection. Palpation can be done to look for any areas of tenderness.
 Maternal-infant bonding (rooming- in): It starts from first few moments after birth. It is
manifested by fonding, kissing, cuddling and gazing at the infant. The baby should be kept
in her bed or in a cot beside her bed so that she can take full care of the baby. Baby
friendly hospital initiative promote parent infant bonding.
 Asepsis and antiseptics : Asepsis must be maintained specially during the first week of
puerperium. Liberal use of local antiseptic, aseptic measures during wound dressing, use
of clean bed linen and clothings are positive steps. Clean surroundings and limited number
of visitors could be of help in reducing nosocomial infections.
 Immunization : Administration of anti -D gamma globulin to unimmunized Rh negative
mother bearing Rh positive baby. Women who are susceptible to rubella can be vaccinated
safely with live attenuated rubella virus. Mandatory postponement of pregnancy for at
least 2 months following vaccination can be achieved. The booster dose of tetanus toxoid
should be given at the time of discharge, if it is not given during pregnancy.
 Exercises: Exercises should be encouraged once the mother is fit. It helps to strengthen
the muscles especially in the pelvic and abdominal regions
VIII. POSTNATAL EXERCISES
Objectives
 To improve the muscle tone which are stretched during pregnancy and labor, specially the
abdominal and perineal muscles
 To educate about correct posture to be attained when the patient is getting up from the bed
1. Deep breathing :Instruct to lie in supine position with knees bend. Mother is taught to raise
her abdominal wall as she takes deep breaths and then exhale slowly. (Place one hand over the
chest and one hand on the abdomen when inhaling). Repeat for 4-5 times. This exercise
strengthens the diaphragm
2. Head raising :Mother is made to lie flat on the bed without the pillow and arms outstretched.
Instruct to inhale deeply at first and then exhale while lifting the head slowly, to hold the position
for a few second and relax. It will strengthen the abdominal muscles.
3. Head and shoulder raising:Lie flat without pillow and raise head until chin touches the
chest.Mother should be told to raise both the head and shoulder off the bed and lower them
slowly. It also will strengthen abdominal muscles.
4. Leg raising :In this exercise, mother is made to lie on the floor without pillow, point toe and
leg is raised slowly keeping the knee straight. Lower the leg slowly. After performing this

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 exercise for 1-2 days, both the legs should be raised. It will strengthen abdominal muscles. Repeat
it 5-10 times
5. Pelvic tilting/rocking : Make the mother to lie flat on the floor with pillows, knees bend and
feet flat. Place one hand under the back and other on the top of abdomen. Mother is told to inhale
and while exhaling flatten the back against the floor so that no space is left between the back and
the floor. Muscles of the buttocks and the abdomen should be tightened while performing the
exercise. This exercise will strengthen the abdominal muscles and muscles of the buttocks.
6. Knee and leg rolling: Mother lies flat on her back with knees bend and feet flat on the
floor/bed. Keep the shoulder and feet stationary and roll the knees to side to touch first on the side
of the bed, then the other. Repeat it 5 times. It will strengthen the oblique abdominal muscles.
7. Sit ups : After 2-3 wks, sit ups can be started by the mother. In this the mother has to lie flat on
the floor and slowly head, shoulder and trunk is raised.
8. Kegal’s exercise : This exercise can be performed in sitting, standing or lying positions. In
this, mother has to tighten the muscles of anus, vagina and urethra as if to control bowel
movements and to stop urine in midstream. Tighten and relax pelvic muscles alternatively.It helps
to strengthen pelvic floor muscles and regain the bladder control.
IX. MANAGEMENT OF MINOR AILMENTS/(Discomforts during puerperium)
1. Afterpain: It is the infrequent spasmodic pain felt in the lower abdomen after delivery for
a variable period of 2-4 days. Presence of blood clots or bits of the afterbirths led to
hypertonic contractions of the uterus in an attempt to expel them out. This is commonly
met in primipara. Clients treated with oxytocin, mothers who had over distended uterus
and breast feeding etc also prone for afterpain. The pain may be due to vigorous uterine
contractions, especially in multipara. The pain is similar to cardiac anginal pain. It can be
managed by massaging the uterus with expulsion of the clots, administration of antibiotics
and antispasmodics.
2. Pain on the perineum :Discomfort on the perineal region due to child birth and
episiotomy. To manage this, perineum has to be examined for vulval hematoma and
provide analgesics and sitz bath (cold/hot)
3. Hypertension :Increased BP during puerperium period. It should be treated until it comes
to the normal limit. Urine analysis also should be done for proteinuria.
4. Breast engorgement :It is due to exaggerated normal venous and lymphatic engorgement.
Encourage breast feeding, warm sock, analgesics etc gives better result.
5. Anemia:Majority of the women will be in an anemic state following delivery. So
supplementary iron therapy (Iron sulphate 200 mg) is to be given daily, for 4-6 wks

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 6. Constipation : Mild laxatives or stool softeners can be advised to the mothers to prevent
constipation
X. LACTATION
It is the process of breast feeding results from interplay of hormones, instinctive reflexes
and learned behaviour of mother and newborn.
Colostrum is the first milk secretion. It is around 40 ml on first day, then gradually
increases. It has got a higher specific gravity (1.040-1.060), protein, vitamin A, sodium and
chloride content, but has got lower carbohydrate, fat and potassium than the breast milk. It contain
antibody (IgA)
Protein Fat CHO H2 O
Colostrum 8.6 2.3 3.2 8.6
Breast milk 1.2 3.2 7.5 8.7

PHYSIOLOGY OF LACTATION
Although lactation starts following delivery, the preparation for effective lactation starts
during pregnancy. The physiological basis of lactation is divided into four phases;
1.Mammogenesis (Preparation of breasts): Pregnancy is associated with a remarkable growth of
both the ductal and lobulo-alveolar systems, which begins during the early pregnancy itself.
2. Lactogenesis (Synthesis and secretion from the breast alveoli)
- Though some secretary activity of colostrum is evident during pregnancy and accelerated
following delivery, milk secretion actually starts on 3rd or 4th postpartum day.
- Around this time breast engorgement may be evident
- In spite of the high prolactin during pregnancy, breast tissues are unresponsive to
prolactin, probably due to increased level of estrogen and progesterone in the blood
circulation.
- When estrogen and progesterone withdrawn following delivery, prolactin begins its milk
sectary action in fully developed mammary glands
- Prolactin and gluco-corticosteroids are the important hormones in this stage. The secretary
activity is directly or indirectly enhanced by growth hormone, thyroid and insulin also.
3. Galactokinesis (Ejection of milk)
- It is the discharge of milk from the mammary glands (alveoli- where it is secreted),
depends on the suction exerted by the baby during suckling and the contractile mechanism
which expresses the milk from the alveoli into the ducts.
- Oxytosin is the major galactokinetic hormone

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 - The ascending impulse from the nipple and areola (as a result baby’s sucking) pass via
thoracic sensory afferent neural arc to the hypothalamus. Thus oxytocin is synthesized and
transported to the posterior pituitary. Oxytocin is liberated from posterior pituitary and
produce contraction on the myoepithelial cells of the alveoli and ducts containing the milk.
This is the milk ejection/ let down reflex.
- Here milk is forced down into the lactiferous ducts, where from it can be expressed by the
mother or sucked out by the baby.
- Presence of the infant or infant’s cry can induce let down reflex without suckling
- Milk ejection reflex is inhibited by pain, emotional stress, breast engorgement or adverse
psychic condition
4. Galactopoiesis (Maintenance of lactation)
- For maintenance of effective and continuous lactation, suckling is essential
- It is not only essential for the removal of milk from the glands but also causes the release
of prolactin
- Prolactin appears to be single most important galactopoietic hormone.
- Milk secretion is a continuous process unless suppressed by congestion or emotional
disturbances
- Periodic breast feeding is necessary to relieve the milk pressure in the breast, which can
reduce milk production rate.
Management of lactation
- Initiate breast feeding within half an hour after birth and exclusively breast feed till 6
months
- Encourage mother to take nutritive diet with plenty of fluids and milk intake. Food
containing calcium (milk, cheese, high class protein etc) should be given.
- Promote 2 hourly feeding to stimulate prolactin and oxytocin production and demand
feeding
- Support and educate the mother about the benefits of breast feeding in antenatal period
itself to reduce emotional disturbance in later life
- Discourage bottle feeding and encourage regular feeding
- Follow proper hygienic measures
- Prevent the mother from any diseases such as infections and dehydration
- Use drugs to improve milk production in case of inadequacy (Metoclopramide 10 mg tid,
sulpride- dopamine antagonist, intra nasal oxytocin etc)
Suppression of lactation may be needed in case of still birth, HIV infected mother etc . So
- Stop feeding

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 - Avoid pumping or milk expression
- Apply ice packs to prevent engorgement
- Give analgesics to relieve pain
- Apply tight compression bandage for 2-3 days
- Use drugs such as bromocriptin 2.5 mg orally bd for 14 days, which inhibit prolactin and
supress lactation
XI. EMOTIONAL NEEDS DURING POSTNATAL PERIOD
Mother experiences many hopes and fears at the beginning of new human life and family
relationship. Mother need to be supported as she adjusts to her experiences.
1. Mother need support because she is taking a major responsibility: It is a gradual process to
cope up with caring of baby and to meet the needs of her family
2. Rest and relaxation: Mother needs adequate rest, sleep and relaxation during puerperium
3. No comparisons: There should not be a routine pattern of care, each mother will follow
varying sequence in caring the baby
4. Praise and encouragement: Some mothers will be highly competent irritative by receiving
too much advises and help. Mother should be praised to increase her confidence and
responsibilities
5. Consistent advice: Anxious mother needs to have instructions repeated on a number of
occasions before they can take information in fully.
6. Mother’s self esteem: Each mother should be helped to realize her uniqueness
XII. FAMILY DYNAMICS AFTER CHILD BIRTH
The birth of a child poses a fundamental challenge to the existing interactional structure of
the family. Becoming a parents creates a period of instability that requires behaviours that
promote the transition parenthood. Parents must explore their relationship with the infant as well
as redefine the relationship between themselves. The nurse who understands the parenting
process, including adjustments of parents, siblings and grandparents is well prepared to assist
family members with the transition of parenthood.
a). Parenting process
It is the process in which an adult (a mature, capable, caring, self-sufficient person)
assumes the care of an infant. Either parent may exhibit motherliness.
It has got two components;
The first component, being practical or mechanical in nature, involves cognitive and motor skills.
The second component, emotional in nature, involves cognitive and affective skills
 Cognitive – motor skills :The process of parenting includes child care activities such as
feeding, holding, clothing and cleaning the infant, protecting it from harm and providing
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 mobility for it. These are task oriented activities. Many parents have to learn how to do
these task and this learning process care be difficult for them
 Cognitive – affective skills :The psychologic component in parenting, motherliness or
fatherliness, appears to stem from the parents earliest experiences with a loving and
accepting mother. The cognitive affective skills of parenting includes an attitude of
tenderness, awareness and concern for the child needs and desires. Erickson’s concept of
basic trust (development of a sense of trust) determines the infant responses to others
throughout life
b). Parental acquaintance, bonding and attachment
Bonding is defined as the initial mutual attraction between people, such as between parent
and child at first meeting. Attachment is a process that begins during pregnancy, intensifying
during the early postpartum period and being constant consistent once established. Mercer list five
precautions that influence attachment.
1. A parent’s emotional health (including the abilities to trust another person)
2. A social support system encompassing mate, family and friends
3. A component level of communication of care giving skills
4. Parent proximity to the infant
5. Parent-infant fit
c). Communication between parent and child
Attachment is strengthened through the use of sensual responses or abilities by both parents in
parent-child interaction.
1. Touch : Tactile sense is used extensively by parents and other care given as means of
becoming acquainted with newborn. Care giver begins with a finger tip exploration of the
infant’s head and extremities. Gentle strocking motions are used to smooth and quiet the
infant
2. Eye to eye contact : As newborn become functionally able to sustain eye contact, parents
and infant spend much time gazing at one another. Lights can be dimmed so that the
child’s eyes will open
3. Voice : Voice is remarkable in the shared response of parents and infant. As parent talk in
high pitched voice, the infant is calmed and turns towards them
4. Odour : Mother comment on the smell of their baby when first born and have noted that
each child has a unique odour. Infant also learns rapidly to distinguish the odour of their
mother

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 5. Entrainment: New born move in tune with the structure of adult speech. They wave their
arms, lift their head, kicks their leg, dancing in time to their parent’s voice. This means
infant has developed culturally determined rhythms
6. Biorhythmicity: The unborn child can be said to be in time with the mother’s natural
rhythms such as heart beats. After birth, a crying infant may be soothed by being held in
position in mothers arm where her heart beat can be saved
7. Early contact : The first hours or day after birth may be a sensitive time for parent infant
interaction. Early close contact may facilitate the attachment process between parent and
child
8. Extended contact : One method of family centered care is the provision of rooming in
facilities for the mother and her baby
d). Paternal adjustments
Father feel a sense of increased self esteem, a sense of well being, proud, bigger, more mature
and older.
– Stage 1 : coming to the experience with preconceptions about what it will be like when
they take the baby home
– Stage 2 : it is the uncomfortable reality of being a new father. Some fathers begin to
realize that their expectations are not based on facts. Feeling of sadness and ambivalence
often accompany reality
– Stage 3 : it involves a conscious decision to take control and become more actively
involved in their infant’s life
e). Sibling adaptation
Older children have to assure new positions with in the family hierarchy. Older child’s gole is
to maintain a leading position. Mother and father face a number of tasks related to sibling rivalry
and adjustments. The task include;
- Making the older child feel loved and wanted
- Managing guilt arising from feelings that older children are being deprived of parental
time and attention
- Developing feelings of confidence in their ability and nurture it
- Adjusting time and space to accommodate the new baby
- Monitoring behaviour of older children toward the more vulnerable infant and diverting
aggressive behaviour
f). Grandparent adaptation
Amount of grand parent involvement in the new born care depends on many factors
- Willingness of grand parents

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 - Proximity of grandparent’s and ethnic and cultural expectations of the role
- One way to help grandparents bridge the generation gap and help them understand
parenting concepts that their adult children are using is to offer classes. Infant care,
feeding, safety, exploration of roles of grandparents.
XIII. FAMILY WELFARE SERVICES, METHODS AND COUNSELING
Family planning is a key intervention for improving the health of women and children
along with considering human rights
NEED OF FAMILY WELFARE SERVICES
1. While maternal mortality risk is slightly less with the second and third pregnancies than
the first. The risk arises with each pregnancy beyond the fifth
2. A number of complication of pregnancy and delivery increases with the number of
children born have been shown to have a statistical association with high parity
3. Nutritional deficiency in the mother resulting in anemia, calcium deficiency and
difficulties in breast feeding of the child also increases with high parity
FAMILY WELFARE SERVICES
1. Clinical services
MCH services are provided through (antenatal, intranatal, postnatal and infant
care) regular clinic sections. Those who have completed their family size (2 children) are
motivated to obtain for a terminal method of contraception. Those who wish to postpone
are advised spacing methods. The IUD insertion is daily done in clinics. Tubectomies are
performed at the clinics attached to primary health centre and health district hospital
2. Domicillary services
o Education and motivation of eligible couples individually
o Follow up of IUD and pill users, and post operative follow up of vasectomy and
tubectomy are given
o Domicillary care of intranatal, postnatal infant and toddler
o Referral services for those having special problems of post-operative complications
3. Community services
o Family planning survey
o Identification of community leader
o Educational activities
o Motivational effort
o Maintaining adequate supplies
o Organizing special campaigns

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FAMILY PLANNING
Definition
According to WHO, Family planning is defined as a way of thinking and living that is
adopted voluntarily upon the basis of knowledge, attitudes and responsible decision by
individuals and couples in order to promote the health and welfare of the family and this
contribute effectively to the social development of a country.
Objectives of family planning
 To avoid unwanted births
 To bring about wanted births
 To regulate the interval between pregnancies
 To control the time at which birth occur in relation to age of the parent
 To determine number of children in the family
Methods
A. Temporary methods/Spacing methods
- Barrier method
- Intrauterine contraceptive devices
- Hormonal methods
- Postconceptional method
- Miscellaneous
B. Permanent methods/Terminal methods
- Tubectomy
- Vasectomy
Temporary/Spacing methods of contraception
1. Barrier methods
Physical methods
a) Condom : widely accepted barrier method, easily available and easy to use
b) Diaphragm : it is a female vaginal barrier, it is a shallow cup made of synthetic rubber or
plastic material
c) Vaginal sponge : it is a small polyurethane foam sponge, saturated with the spermicide. It
is less effective than the diaphragm
Chemical methods : It may be jellies, paste, tablets, suppositories, aerosols, soluble films etc
Combined methods : use of both physical and chemical methods together
2. IUCD
 There are first generation, second generation and third generation IUCDs.

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  First generation IUCDs are non-medicated .eglippes loop, a double ‘S’ shaped device
made of polythene. It contains a small amount of barium sulphate to allow x-ray
observation. The loop exist in 4 sizes A, B, C, D.
 Second generation IUCDs, T shaped, contain metallic copper which has strong anti-
fertility property
 Third generation IUCDs are hormonal IUCDs, which is filled with progesterone. The
hormone released slowly in the uterus.
Mechanism of action : It will cause a foreign body reaction in the endometrium and reduce the
chance of fertilization
Side effects : Bleeding due to perforation, pain, pelvic infection, accidental pregnancy, ectopic
pregnancy, expulsion, cancer
3. Hormonal methods
Oral pills:
 Combined pills : One of the major spacing methods of contraception. It contains no more
than 30-35 mcg of a synthetic estrogen and 0.5-1 mcg of progesterone. The pill is given
for 21 consecutive days beginning on the fifth day of the menstrual cycle, followed by a
break of 7 days during which period menstruation occurs
 Progesterone only pill/mini pill/micro-pill : It contains only progesterone, which is given
in small doses throughout the cycle. The commonly used progesterones are norethisterone
and levanogestrel
 Post coital contraception/Emergency method : It is recommended within 48 hrs of an
unprotected sex.
- The simplest technique is to insert an IUD if acceptable, especially a copper device
- More often a hormonal method is preferred. Levonogesterol 0.75 mg within 72 hrs and
second tablet after 12 hrs
 Once a month/ long acting pill :Quinestrol, a long acting estrogen is given in combination
with a short acting progesterone. But pregnancy rate is too high
 Male pill : prevent spermatogenesis
Depot formulations
They are slow releasing, long acting and highly effective. They may be injections or implants
 Injectables : for suppression of ovulation
There are two types of injectables
- Progesterone only injectables
 DMPA (Depot medroxy progesterone acetate), standard dose is 150 μg IM
every 3 months.
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  NET-EN (Norethisteroneenantate), 200 mg IM every 2 months
- Once a month combined injectables
 This contain progesterone and estrogen given at monthly interval
 Subcutaneous implants :Norplant is a highly effective estrogen free long acting contraceptive.
It contains only progesterone (levonorgestrel). It is implanted subdermally.
 Vaginal rings : It contains levanorgestrel and is absorbed through the mucosa
4. Postconceptional method: for termination of pregnancy
 Menstrual regulation : Aspiration of uterine contents 6-14 days of missed period
 Menstrual induction : Intra-uterine application of 1-5 mg of solution of prostaglandin to
disturb the normal progesterone and prostaglandin balance
 Oral abortifacient : Mifepristone 200 mg PO in day 1 followed by misoprostol 800 mg PV
immediately or within 6 hrs. OR Mifepristone 600 mg on day one followed by
misoprostol 400 mg orally on day 3
5. Miscellaneous
 Abstinence : complete avoidance of sex
 Coitus interrupts : male withdraws before ejaculation to prevent deposition of semen into
the vagina
 Safe period/Calendar method: it is based on the fact that ovulation occurs from 12-16
days before the onset of menstruation. Periodic abstinence during this period prevent
fertilization. This method is useful only for women who have consistent and regular cycle
 Natural family planning method : Methods used to prevent or plan pregnancy, based on
identifying woman’s fertile days. For all natural methods, abstinence during thefertile days
is what prevents pregnancy.
- Basal body temperature (BBT): it refers to baseline reading or tracking of the body’s
temperature. During ovulation, the temperature rises (0.4 degree)
- Cervical mucous method/Ovulation method : observing the estrogen induced changes in
the cervical mucous during ovulation. The day of ovulation corresponds closely to the day
of peak mucous
- Symtothermic method : this method utilizes at least two indicators to identify the fertile
period, usually BBT and cervical mucous methods. BBT is recorded with any
thermometer before getting out of bed. Prior to ovulation the temperature is usually below
the normal body temperature, and it rises after ovulation in response to increasing levels of
progesterone.

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  Breast feeding: nature’s most effective form of contraception. Excess production of
prolactin during breast feeding supress the follicular stimulating hormone and thereby
preventing ovulation. Menstruation may occur without ovulation.
Permanent/Terminal methods
It is a one time method and provides most effective protection against pregnancy
1. Vasectomy: It is the removal of a piece of male vas deference (at least 1 cm after
clamping). It is comparatively simple operation, can be performed even in PHCs under
local anaesthesia. The ends are ligated and then folded back on themselves and sutured
into position so that the cut ends face away from each other.
2. Tubectomy: it is one of the most effective methods of contraception. There are two
procedures.
o Laparoscopy: It is done through abdominal approach with laparoscope. The
abdomen is infiltrated with carbon dioxide, nitrous oxide or air to visualize the
tube. Once the tubes are accessible, the fallopian rings/clips are applied to occlude
the tubes. The operation time is short, scar is small and hospital stay is shorter.
o Mini lap operation: a smaller abdominal incision of 2.5-3 cm, conducted under
local anaesthesia, performed 48 hrs after delivery. Cutting and tying the fallopian
tube as like that of vasectomy.

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