Normal puerperium

(Postpartum care)
 Normal Puerperium
Definition
1. It is the period of adjustment after pregnancy and delivery when
anatomical and physiological changes of pregnancy are reversed and
the body returns to the normal non pregnant state.. (reproductive tract
returns to its normal, non-pregnancy state)

1. 6 weeks in duration. (periods after birth )

 Stages of Puerperium

• The post partum period has been divide into:

• The immediate puerperium, the first 24 hours after

parturition; when acute post anesthetic or post delivery
complications may occur.
• The early puerperium, which extends until the first
week post partum.
• The remote puererium, which includes the period of
time required for involution of the genital organs through
the sixth weeks postpartum.
 Anatomical and Physiological
changes

• Immediately after labor, the woman is in a

state of physical fatigue in many cases,
slight shivering, muscular tremors and
chattering of teeth occur for about 10 – 15
minutes.
 Temperature:
 Fever It is normal but usually there is a slight rise
during the first day which is known as (reactionary
rise), not exceed 38oC and drops within 24 hours
and not accompanied by increased pulse rate, if it
is more than 38oc or for more than 24 hours, it is
called puerperal pyrexia).
 Involution of the uterus
 return to the pelvis by about 2 weeks
 be at normal size by 6 weeks
 the weight changes of uterus
 1000g immediately after birth (excluding the fetus,
placenta, membrane and amniotic fluid.
 500g 1 weeks after birth
 300g 2 weeks after birth
 50g 6 weeks after birth

 The endometrial lining rapidly regenerates (16 days)

 The placental site undergoes a series of changes in the
postpartum period

Its fundus level approximates that of a 20 week pregnancy at the

level of umbilicus, at the end first post partum week it is palpable
at the symphysis pubic
Decidua
discharge comes from the placental site and
maintains for 4-6 weeks
• Lochia rubra
Red in color for the first 3-4 days
• Lochia serosa
Pink in color, maintains for 2 weeks
• Lochia alba
White in color, maintains for 2-3 weeks
 After Pain

 After expulsion of fetus and placenta the uterus contracts to

regain its normal size, weight and site, this called involution of
uterus. Oxytocin is released from posterior lobe of the pituitary
gland in response to the sucking, which facilitate uterine
contraction.
 Characteristic of after pain:
 Occur during the 1st 2-3 days of puerperium
 Abdominal pains (like cramps) and back pain.
 Strong, regular, and coordinated.
 The intensity, frequency and regularity of contraction decrease
after the 1st postpartum day.
 Constipation

• It is common in the first few days of

puerperium and is due to many factors.
The woman‘s food intake is interrupted,
there may be dehydration during labor, the
abdominal muscles are lax and perineal
lacerations make defecation painful.
 Cervix
 it never returns to the nulli-parous state.
 the external os is closed to the extent that a
finger could not be easily introduced.
 It return to its normal state at 4 weeks
after birth

 Vagina
 shrinks to a non-pregnant state
 resolution of the increased vascularity and
edema occurs by 3 weeks
 the vaginal epithelium appears atrophic.
This is restored by weeks 6-10.
 Perineum
 Swelling completely gone within 1-2
weeks
 The muscle tone may or may not
return to normal, depending on the
extent of injury.
 The muscular walls of the pelvic organs

• The voluntary muscles of the pelvic floor and

pelvic supports gradually regain their tone during
the puerperium. Tearing or overstretching of the
musculature or fascia at the time of delivery
predispose to genital hernias. Over distention of
the abdominal wall during pregnancy may result
in rupture of the elastic fibers, persistent striae,
and diastases of the recti muscles. Involution of
the abdominal musculature may require 6-7
weeks and vigorous exercises are not
recommended until after that time.
 Preparation for lactation
 Lactation can occur by 16 weeks' gestation.

 Lacto genesis is initially triggered by the delivery

of the placenta (E↓P↓and prolactin).

 the prolactin levels decrease and return to normal

within 2-3 weeks (not breastfeeding)

 The colostrums (the first 2-4 days)

 The milk continues to change throughout the

period of breastfeeding to meet the changing
demands of the baby.
 Psychological changes.

• Mild degree of depression and emotional

liability. (normal)
• Puerperal psychosis, confusion with
disorientation in time, space and a
complete loss of interest in the child
(abnormal)
 Systemic change
 Cardiovascular system
 Blood volume returns to non-pregnant levels by the
tenth days of puerperium
 Cardiac output ↑(immediately after delivery) →
slowly declines→ reach late pregnancy levels 2 days
postpartum→ normal 2-6 weeks.
 Hematologic changes
 Hemoglobin concentration↑on the first postpartum
days
 Several clotting factors (fibrinogen) ↑on the first days
Micturation;
There is diuresis in the first two days of puerperium.
Retention of urine may occur either due to the sphincter
or reflexly from perineal trauma.
Skin;
There is a tendency to sweating.
Body weight:
Is slightly lost during the first 10 days.
Post natal problems:
 Post partum hemorrhage.
 Puerperal Sepsis
 Retained placenta (the placenta still in the uterus for
more than one hour after birth of the baby)
 Painful perineum. (laceration of the perineum)
 Circulatory problems: (Varicose veins, Deep venous
thrombosis (DVT) or superficial venous thrombosis
(SVT)).
• After pain:
 Management of painful perineum

Cold baths
Electrotherapy (TENS)
Pelvic floor exercises (contract relax
technique
Teach the mother the correct defecation
technique
Use of an appropriate cushion when
sitting.
 Deep venous thrombosis

• Venous thrombosis occurs most commonly in the

superficial and deep veins of the lower extremities.

• Deep thrombi are most likely to develop in soleos muscle

of the calf muscle.
 Management of Varicose veins

 Avoid prolonged standing and prolonged sitting.

 Apply well-fitted below knee support stocking
before ambulating in the morning.
 Ask mother to elevate her leg on pillow while
taking supine lying position.
 Intermittent compression.
 Bandaging.
 Burger‫י‬s Exercises.
 Not to sit with leg crossed or knee flexed.
 Management of DVT or SVT

Prophylactic treatment:
Early ambulation.
Avoidance of pressure on the thighs and
calves.
Sitting position with knee flexed.
Encouragement of:
Circulatory ex., leg and deep breathing ex.
 Management of After Pain

1) Analgesics.
2) TENS.
3) Frequent urination every 2 hours.
4) Heat application.
5) Relaxation on face.
Prone lying position with tow pillows under the pelvis (to keep the back
from hollowing and to stretch the abdominal muscles, small pillow
under feet, the upper limbs extended beside the trunk, head
turned to one side, or the upper limbs crossed with the forehead
rested on the crossed upper limbs
Values of relaxation on face:
It is a relaxed position.
Help involution of uterus.
Help discharge of blood colts and lochia.
Guard against retroversion flexion
Relief after pain
Diastasis of recti abdominal muscles
• It means separation of the rectus abdominal muscles from med-line
at linea alba. It is not hernia.
• It is a gap between the recti muscles 25mm(2.5 fingers)
• Palpated just superior to the umbilicus.
• It may occur during pregnancy after 20 weeks of pregnancy
or expulsive stage of labour due to weakness and increases tension
of abdominal muscles.
 Management of diastases
of recti abdominal muscles

 Static abdominal exercises.

 Graduated dynamic abdominal exercises.
 Neuromuscular electrical stimulation:
Using:
 asymmetrical square current,
 frequency 80 pulse/second,
 Pulse duration 0.1→0.5 ms for ½ hour daily.