PUERPERIUM

Puerperium / Postpartum
6-week
period after
delivery of
the baby

Involution
The return
of the
reproductive
organs

PRINCIPLES OF POSTPARTUM CARE

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

1. VASCULAR CHANGES
A.30%-50% increase in total cardiac
volume during pregnancy will be
reabsorbed into the general
circulation within 5-10 minutes after
placental delivery.
Implications:
Crucial to gravidocardiacs = not
able to handle such workload

B. White blood cell counts increases to

20,000-30,000/mm3
Implications:
WBC cannot be used as
indicator of postpartum infection

C. There is an extensive activation of

the clotting factors, which encourage
thromboembolization.
Thats the reason why;
Ambulation is done early after 4-8
hours in normal vaginal delivery.

Exercises are recommended:

Kegels and
abdominal
breathing on
postpartum
day 1 (PPD 1)

Chin-to-chest
On 2nd day
tighten and
firm up
abdominal
muscles.

Knee-to-abdomen
When perineum
has healed, to
strengthen
abdominal and
gluteal muscles.

 Massage is contraindicated

D. All blood values are back to prenatal

levels by the 3rd-4th week postpartum.

2. GENITAL CHANGES
A. Uterine involution
is assessed by
measuring the
fundus by
fingerbreadths
(=1cm)/PPD

Subinvoluted uterus
A big uterus and vaginal bleeding
with clots.
Blood clots are good media for
bacteria
Therefore, sign of puerperal sepsis

B. To encourage return of the uterus to

its usual anteflexed position, prone and
knee-chest positions.

C. Afterpains/Afterbirth pains
Strong uterine
contractions felt
Multis
Delivered
macrosomias
and twins
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 aand
some bacteria

Pattern:
Rubra 1st 3 days PPD, red and
moderate in amount.
Serosa next 4-9 days; pink or
brownish and decrease in amount
Alba from the 10th day up to 3-6
weeks; colorless and minimal

Characteristics:

Pattern should not reverse.

It should approximate menstrual flow.
It should not have offensive odor.
It should not contain large clots.
It should never be absent, regardless
of method of delivery
CS & NSD same pattern and
amount

E. Pain in the perineal region maybe

relieved
Sims position minimizes strain on
the suture line
Perineal heat lamp / Warm sitz bath
vasodilation, increase blood supply,
therefore, promotes healing
Application of topical analgesics or
administration of oral analgesics, as
ordered

F. Sexual Activity
Maybe resumed by the 3rd to 4th week
postpartum, if bleeding has stopped
and episiorrhapy has healed
Decreased reactions to sexual
stimulation on the first 3 months
because of hormonal changes and
emotional factors

G. Menstruation
No
breastfeeding
menstrual flow
returns within 8
weeks after
delivery

Breastfeeding
after 3-4 months
Maybe ovulating
even without
mentrauation.

H. Postpartum check-up
Should be done
after the 6th week
postpartum to
assess involution

3. URINARY CHANGES
There is marked diuresis
within 12 hours postpartum
to eliminate excess tissue
fluid accumulation during
pregnancy
Some may complain of
small frequent urinations

4. GASTROINTESTINAL CHANGES
delayed bowel PPD due to:
a. Decreased muscle tone
b. Lack of food + enema during labor
c. Dehydration
d. Pain from perineal tenderness d/t
episiotomy , lacerations or
hemorrhoids.

5. VITAL SIGNS
A. Temperature increases because of
dehydration effects of labor
Implication:
Any increase in temperature
postpartum is not a sign of infection

B. Bradycardia
Heart rate of 50-70 per minute for
6-8 days postpartum
C. There is no change in respiratory
rate

6. WEIGHT
Immediate weight loss of 10-12 lbs.
representing the weight of the
Fetus
Placenta
Amniotic fluid
Blood
Weight loss will occur next days due to
diaphoresis.

B. Provide emotional support

The psychological
phases during the
postpartum period

1. Taking-in Phase
First 1-2 days PPD when mother is
passive and relies on others to take
care for her and her newborn.
She keeps on verbalizing her feelings
regarding the recent delivery to be
able to integrate the experience into
herself.

Taking-in Phase

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
d/t hormonal changes, fatigue,
feelings of inadequacy in taking care
of new baby.

C. Prevent Postpartum
Complications
1. HEMORRHAGE
Blood loss of >500 cc
Normal blood loss during labor and
delivery is 250-350
Leading cause of maternal
mortality rate

I.

EARLY POSTPARTUM
HEMORRHAGE
first 24 hours postpartum

A.UTERINE ATONY
Uterus is not well contracted,
relaxed or boggy

Predisposing factors:

1.Overdistention
2.Cesarean
section
3.Placental
accidents
4.Prolonged and
difficult labor

Management:

Massage
Ice compress
Oxytocin
administration
Emptying the
Bladder
Bimanual
Compression
Hysterectomy

B. LACERATIONS
Mediolateral and midline
C. HYPOFIRINOGENEMIA
Clotting defect

II. LATE POSTPARTUM

HEMORRHAGE
A. RETAINED
PLACENTAL
FRAGMENTS

Management:
Dilatation and
curettage

B. HEMATOMA
Due to injury of the blood vessels
during delivery
Commonly seen in precipitate
delivery and with perineal
varocosities

Treatment:
Ice compress during 1st 24
hours
Oral analgesics, as ordered
Site is incised and bleeding is
ligated

2. INFECTION
Sources:
Endogenous normal flora
becomes dangerous
Exogenous pathogens are
introduced from external resources

Anaerobic streptococci
organism most frequently responsible for
postpartum infections

Common exogenous sources:

Hospital personnel
Excessiveure obstetric
manipulation
Breaks in aseptic technique
Coitus in late pregnancy
Premature ruptue of membrane

General
Symptoms:
Malaise
Anorexia
Fever
Chills
Headache

Management:
Complete bed
rest
Proper nutrition
Increase fluid
intake
Antipyretics
Antibiotics
As oredered