Puerperium

PUERPERIUM PUERPERIUM
Prepared by: Prepared by:

Charmi Jobelle S. Roca Charmi Jobelle S. Roca- - Napalit, Napalit,
RN, RM, MN, US RN, RM, MN, US- -RN RN
Definition of Terms Definition of Terms
. Puerperium/ Postpartum - refers to the
six- week period after delivery of the
baby
B. nvolution- return of the reproductive
organs to their prepregnant state
PrincipIes of Postpartum care PrincipIes of Postpartum care
1. Promote heaIing and invoIution of different
parts of the body
A. VascuIar changes
a.1 30%-50% increase in total cardiac volume
during pregnancy will be reabsorbed into the
general circulation within 5-10 mins after
placental delivery
a.2 WBC= 20,000- 30,000/ mm3
a.3extensive activation of clotting factors
- ambulation is done early
- Exercises
PrincipIes of Postpartum Care PrincipIes of Postpartum Care
a. Postpartum Day 1- KegeI's exercise
and abdominaI breathing
b. Postpartum Day 2- chin-to-chest: to
tighten and firm up abdominal muscles
c. When perineum has healed- knee-
to-abdomen: to strengthen abdominal
and gluteal muscles
W B. GenitaI Changes
b.1 uterine involution is assessed by
measuring the fundus by fingerbreadth
(= 1 cm)
- PPD1: fundus is 1 fingerbreadth below
the umbilicus
- PPD2: fundus is 2 fingerbreadths
below the umbilicus
- PPD10: cannot be palpated because it
is behind the symphysis pubis
b.2 Knee-chest position/ prone: to allow
uterus to go back to is usual position
b.3 fterpains/ afterbirth pains: give
analgesics
b.4 Lochia- uterine discharge consisting of
blood, decidua, WBC, mucus and some
bacteria
RUBR- 3 days post-op
SEROS- next 4-9 days
LB- from 10
th
up to 3-6 weeks
postpartum
Note: it should have any offensive odor;
same fleshy odor; lochia has same pattern
and amount whether CS or NSVD
b.5 Pain in perineal region may be relieved
by: Sim's position and warm sitz bath/
perineal heat lamp
b.6 sexual activity: may be resumed 3
rd
or
4
th
week postpartum
b.7 return of menstruation: expected after 8
weeks post delivery; if breastfeeding: 3-4
months
W b.8 postpartum check-up: should be done
after 6
th
week postpartum to assess
involution
C. Urinary changes
c.1 marked diuresis within 12 hours to
eliminate excess tissue fluid accumulation
during pregnancy
c.2 changes in urination
- others may complain of frequent
urination (d/t urination retention with
overfIow)
- others may have difficulty voiding (d/t
trauma to the trigone of the bladder)
D. Gastro-intestinal changes delayed
bowel evacuation postpartally
E. Vital signs
e.1 temperature may increase: d/t
dehydrating effects of labor
e.2: bradycardia (heart rate of 50-70 bpm)
is common for 6-8 days
. Weight- immediate weight loss of 10-12
pounds
2. Provide emotional support
Psychological phases during the post-
partum:
a. Taking-in phase: first 1-2 days
postpartum when the mother is passive
and relies on others regarding the recent
delivery for her newborn
b. taking-hoId phase: begins to take
actions and decisions; Post-partum blues
c. Letting Go
- nterdependent phase
- Redefines goals, new roles as
parents
- May extend till the child grows
3. Prevent post-partum compIications
a. Hemorrhage
b. Infection
4. EstabIish successfuI Iactation
Physiology of breastmilk production
Estrogen and progesterone levels after placental
delivery
Stimulates PG to produce Prolactin
cts on acinar cells to produce foremilk
W Stored in collecting tubules
When infant sucks
PPG is stimulated to produce oxytocin
Causes contraction of smooth muscles of
collecting tubules
Milk ejected forward let-down or
Milk ejection reflex
milk is produced
dvantages of breastfeeding (mother):
a. economical in terms of time, money
and effort
b. more rapid involution
c. less incidence of cancer of the breast
dvantages of breastfeeding (baby):
a. close mother-infant relationship
b. contains antibodies that protect
against common illnesses
c. less incidence of G diseases
d. always available at the right
temperature
4.1 Hygiene
- wash breasts daily with water ( soap
and alcohol should not be used)
- wash hands before and after feeding
- insert clean OS or piece of cloth in the
brassiere to absorb moisture when there is
considerable breast discharge
4.2 Method
- stimulate the baby to open mouth to
grasp nipples by means of ROOTING
refIex
- infant should grasp the whole areola
- to prevent nipples from becoming
sore and cracked infant should be
introduced to the breast gradually
- for continuous milk production, at
each feeding, the infant should be placed
first on the breast he fed last in the
previous feeding
- feed as often as the baby is hungry
- COLOSTRUM (contains gamma
globulins or antibodies)
4.3 ssociated problems:
a. engorgement: feeling of tension in
the breasts during the third postpartum
day often accompanied by increased in
temperature (miIk fever).
a.1. firm- fitting brassiere
a.2 CoId compress: if mother
does not intend to breastfeed
- Warm compress: if will breastfeed
b. Sore nippIes- NOT contraindication
to breastfeeding
- expose nipples to air by leaving
bra unsnapped for 10-15 mins after
feeding
- if normal air drying is not
effective, expose to 20-watt bulb
placed 12-18 inches away (cause
vasodilation and promote healing)
c. Mastitis- inflammation of the breasts
S/S: -localized pain, swelling and
redness in breast tissues
- lumps in the breasts
- milk becomes scanty
Mgt: 1. antibiotics as ordered
2. ice compress
3. discontinue breastfeeding in affected
breast
4.4 Contraindications to lactation
a. drugs- oral contraceptives,
tetracyclines, anticoagulants
b. certain disease conditions- TB
5. Motivate use of famiIy pIanning methods
I. ArtificiaI methods
a. OraI contraceptive: inhibits ovulation
S/E: headache and weight gain,
breast tenderness, dizziness,
N/V
C/: breastfeeding,
thromboembolism, DM &
liver disease, migraine, smokers
b. Intra-uterine device: prevents
implantation by setting up a non-specific cell
inflammatory reaction to the device
- inserted during menstruation to
ensure that the woman is not pregnant
c. diaphragm- a circular rubber disc that fits
over the cervix and forms a barrier against the
entrance of sperms
- can stay within 6 hours, but not more
than 24 hours
d. Condom- sperms are deposited at the tip
of the rubber sheath
e. Chemical methods: spermicides, jellies,
creams, suppositories
f. Surgical method:
1) tubal ligation- fallopian tubes are
ligated
b. vasectomy: vas deferens is cut and
tied, blocking the passage of sperms
. Natural Method
a. Rhythm/ calendar method
b. Cervical mucus/ Billing's method
c. Symptothermal method
d. Withdrawal/ coitus interruptus/
abstinence
RISK CONDITIONS RISK CONDITIONS
I. INFECTIONS:
A. SyphiIis (Treponema paIIidum)
Mgt: Penicillin M for 10 days
S/S of the newborn w/ syphilis:
- jaundice
- anemia and
hepatosplenomegaly
"snuffles (persistent rhinorrhea)
B. RubeIIa/ german measIes-
rubella virus slows down division of
infected cells during organogenesis
thus causing congenital defects
C. Postpartum infection
c.1 endogenous:
c.2 exogenous
Types of infection:
a. Infection of the perineum
S/S: pain, heat and feeling of
pressure in the perineum,
inflammation of the suture line
Mgt: Hot sitz bath
Doctor removes sutures to
drain area and resuture
b. endometritis- inflammation/
infection of the lining of the
uterus
S/S: abdominal tenderness,
uncontracted uterus
c. ThrombophIebitis- infection of the
lining of a blood vessel with formation of
clots
S/S: pain, stiffness and redness in the
affected part of the leg, milk leg
(phIegmasia aIba doIens), + homan's
sign
Mgt: 1. Bed rest with affected leg
elevated
2. anticoagulant (heparin)
S/E: hematuria, increased lochia
d. mastitis- inflammation of breast
tissue
II. BIeeding/ Hemorrhage
1. FIRST TRIMESTER BLEEDING
. Abortion termination of labor
before age of viability
Types:
a. SPONTANEOUS
K miscarriage
Causes
W Chromosomal aberrations due to advanced
maternal age
W Blighted ovum/ germ plasma defect
Natures way of expelling defective babies
CIassifications :
W Threatened
pregnancy is jeopardized by
bleeding and cramping but the
cervix is close and can be saved.
W InevitabIe
moderate bleeding, cramping,
tissue protrudes from the cervix
and the cervix is open.
Types :
W CompIete
all products of conception are
expelled.
Mgt : emotional support
W IncompIete
placenta and membranes retained.
Mgt : D&C
b. HABITUAL
3 or more consecutive pregnancies result in
abortion usually related to incompetent cervix.
Management (suture of cervix)
W McDonaId procedure
W Shirodkar
CS delivery
c. MISSED
fetus dies; product of conception remain in
uterus 4 weeks or longer
signs of pregnancy cease
W (-) pregnancy test
W Dark brown
W Scanty bleeding
Mgt : induction of labor/ vacuum extraction
d. INDUCED
Therapeutic abortion principle of 2 fold
effect
W Done when mother has class 4 heart
disease
B. Ectopic Pregnancy
occurs when gestation is located outside the
uterine cavity
Common site : mpulla or Tubal
Dangerous site: nterstitial
UNRUPTURED
W Missed period
W bdominal pain within
3- 5wks of missed
period (maybe
generalized of one
sided)
W Scant, dark brown
vaginal bleeding
W Vague discomfort
RUPTURED
W sudden, sharp severe
unilateral pain, knife
like
W shoulder pain
W (+) CuIIen's sign
bluish tinged
umbilicus
W syncope/fainting
2. SECOND TRIMESTER BIeeding
A. Hydatidiform MoIe / "bunch of grapes"
W Gestational Trophoblastic Disease progressive
degeneration of Chorionic Villi
W gestational anomaly of the placenta consisting of
a bunch of clear vesicles.
S/S:
W rape-sized vesicles passed thru
the vagina
W Hyperemesis gravidarum due to
HCG
W undal height
W Vaginal bleeding (scant or profuse)
W high levels of HCG
W Pre ecclampsia at about 12wks
W Vesicles look like a "snowstorm on
sonogram
W B. Incompetent Cervix
W McDonaId procedure
temporary circlage of incompetent cervix.
Delivery : NSVD
SE: infection
W Shirodkar procedure
permanent procedure.
Delivery : caesarian section required.
3. THIRD TRIMESTER BLEEDING
A. PIacenta Previa
W it occurs when the placenta is improperly
implanted in the lower uterine segment,
sometime covering the cervical os.
W ssessment
Outstanding sign : frank, bright red,
painIess bIeeding
enlargement (usually has not occurred)
fetal distress
abnormal presentation
B. Abruptio PIacenta
W it is the premature separation of the
placenta from the implantation site.
W t usually occurs after the twentieth week
of pregnancy
W Cause:
Cocaine user
Severe PH
ccident
W ssessment:
Outstanding sign : dark red & painfuI
bIeeding
couveIaire uterus (caused by bleeding into
the myometrium) (-) contraction
rigid boardlike abdomen
severe abdominal pain
dropping coagulation factor (a potential for
DC)
sx : bleeding to any part of the body.
Mgt : for hysterectomy
POST- PARTUM HEMORRHAGE
EarIy PospartaI Hemorrhage
1. Uterine Atony
W boggy fundus
W profuse bleeding
W interventions
massage the uterus (first intervention)
cold compress
modified trendelenburg
fast drip V
breastfeeding to release oxytocin
W 2. Laceration
- well contracted uterus with profuse bleeding
W assess perenium for laceration
Degrees of Iaceration
1st degree vaginal skin and mucus
membrane
W 2nd degree 1st degree + muscles
W 3rd degree 2nd degree + external
sphincter of rectum
W 4th degree 3rd degree + mucus
membrane of rectum
3. Hematoma
W bluish discoloration of subQ tissues of
vagina or perenium
W Candidates
delivery of very large babies
pudendal block
excessive manipulation due to excessive E
4. DIC - disseminated intravascuIar
coaguIation
W ailure to coagulate
W Bleeding in the eyes, ears, nose
W Oozing blood
W Seen in cases with
bruptio placenta
Still birth / UD
Late Postpartum Hemorrhage
1. Retained pIacentaI fragments
W manual extraction of fragments is
done
W uterine massage
W Candidates of these disorders are
W Grand multiparous
W Post CS
3. NECTONS
a. Perineal infections
b. endometritis
. Pregnancy Induced Hypertension
W vascular disease of unknown cause which
occurs anytime after 24
th
week of gestation
W Types :
. GestationaI HPN
W HPN without edema & proteinuria.
W Mgt : monitor BP
B. Pre-ecIampsia triad
sx : HPN with edema, proteinuria or
albuminuria which cause is unknown or
idiopathic but multifactoral
W Sign of pre-eclampsia :
> 30mmHg systolic
> 15mmHg diastolic
RoII over test
W 10-15min side lying
W Then supine
W Then take BP
a. miId pre-eccIampsia
W 140/90mmHg, +1 or +2 proteinuria Early
signs : wt, inability to wear wedding ring
due to developing edema
b. Severe pre-eccIampsia
W 160/110, +3 or +4, proteinuria, visual
disturbances
W P promote bedrest
W Prevent convulsions by nursing
measures
Prepare the following at bedside
W tongue depressor, Suction machine &
O2 tank
E ensure high protein intake (1g/kg/day)
Na in moderation
A antihypertensive drug with hydralazine
C CNS depressant with Mg Sulfate for anti-
convulsion
E evaluate physical parameters for MgSO4
toxicity :
C. Eclampsia with seizure
BUN sign of glumerular damage
IV. Diabetes MeIIitus
W cause by absent & lack of nsulin
W ction of nsulin is to facilitate transfer of glucose
into the cell
W Dx test : 50gm 1hr Glucose Tolerance Test
130 hyperglycemia
70 hypoglycemia
80-120 euglycemia
if > 130mg/dl, the Mother needs to undergo a
3hr GTT
W Maternal Effects :
hypoglycemia during the 1st trimester
development of the brain
Hyperglycemia during the 2nd & 3rd trimester
W HPL effect Mgt : give insulin. OH are
teratogenic.
W 1st trimester - insulin, 2nd trimester -
insulin, post partum drop suddenly
W requent infections (eg. Moniliasis)
W etal Effects :
hypoglycemia during the 1st trimester and
Hyperglycemia during the 2nd & 3rd trimester
thru facilitated diffusion
Macrosomia/LG 4000gms
UGR due to prolonged DM
Preterm birth- promote still birth
W Newborn Effects :
Hyperinsulinism and Hypoglycemia
W 40mg/dl
W Normal : 45-55mg/dl
W Borderline : 40mg/dl
W Sx : pitched shrill cry, tremors, jitteriness
W Dx test : heel stick test to check glucose
levels
Hypocalcemia
W 7mg/dl
W Calcemic tetany
W Tx : Ca gluconate
V. Heart Disease
W Classification :
no limitation
Slight limitation, ordinary activity causes
fatigue
W good prognosis can deliver vaginally
W Mgt : sleep of 10hrs/day, rest 30mins after
meals
moderate limitation, less than ordinary
activity causes discomfort
W poor prognosis. Good for vaginal delivery
W Mgt : early hospitalization by 7-8mos
V marked limitation of physical activity for
even at rest there is fatigue
W poor prognosis. Good for vaginal delivery
only with regional anesthesia.
W Low forceps delivery when unable to push
& to shorten the stage of labor
W Mgt :
V. MuItipIe preganncy
Classification:
a. Monozygotic/ identical- twins begin
with a single ovum and sperm, but in the
process of fusion or in one of the first cell
divisions, the zygote divides into two
identical but separate individuals
b. Dizygotic/ fraternal- two separate ova are
fertilized by two separate sperms;
actually siblings growing in the utero
Complications:
1. Toxemia 4. abruptio placenta
2. Polyhydramnios 5. prematurity
3. anemia 6. postpartal hemo
V. BIood incompatibiIity an antigen-
antibody reaction which causes excessive
destruction of fetal RBC
. Mother is Rh negative and the fetus is
RH +
B. Mother is blood type O and the fetus is
either blood type or B
VIII. Dystocia- difficult labor and delivery
A. Uterine inertia- sluggishness of
contractions
causes: inappropriate use of analgesics,
pelvic bone contraction, overdistention
(d/t multiparity, multiple pregnancy)
B. Precipitate deIivery- labor and delivery
that is completed in less than 3 hours after
the onset of true labor pains; may be due
to multiparity or following oxytocin
administration
Can lead to:
Extensive laceration, abruptio placenta,
hemorrhage Shock
C. ProIonged Iabor- in primis, labor lasting
for 18 hours, and in multis more than 12
hours
Can lead to:
Maternal exhaustion
Uterine atony
caput succedaneum
D. Uterine rupture- when the uterus
undergoes more straining than it is
capable of sustaining
S/S:
sudden severe pain
hemorrhage & signs of shock
Mgt: HYSTERECTOMY
E. Uterine inversion- fundus is forced
through the cervix so that the uterus is
turned inside out
Causes:- Strong fundal push
- attempts to deliver the placenta
before signs of placental separation
Mgt: HYSTERECTOMY
F. Amniotic fIuid emboIism- occurs when
amniotic fluid is forced into an open
maternal uterine blood sinus through some
defect in the membranes
S/S: inability to breathe
sharp chest pain
turns pale, then bluish-gray
G. TriaI Labor- if the woman has borderline
pelvic measurements but fetal position and
presentation is good
H. Premature Iabor and deIiver- uterine
contractions occur before 38
th
week of
gestation
- if there is no bleeding and cervical
dilatation and fetal heart sounds are good,
premature uterine contractions can be
stopped by the ff drugs:
Ritodrine- a muscle relaxant
Bricanyl
- f premature contraction is accompanied
by fetal descent and cervical dilatation,
premature deliver is inevitable:
- Pain meds are kept to a minimum
- STERODS (glucocorticoids) are given
to mother to help in the maturation of
fetaI Iungs
- CaudaI, spinaI anesth are preferred
- Cord is cut immediateIy
IX. Induced Labor- to bring about labor
either by amniotomy or drugs (oxytocin or
prostaglandin)
Prerequisites:
- no CPD
- fetus is viable
- single fetus is longitudinal lie
- ripe cervix
IX. InstrumentaI deIiveries
A. Forceps deIivery- use of metaI
instruments
W Complications:
- forceps marks (noticeable for 24-48
hours)
- bladder or rectal injury, facial
paralysis, seizures, epilepsy, cerebral
palsy
B. Cesarean section
ndications:
- CPD
- severe toxemia
Types:
. Low segment (LSCS)
B. Classic vertical incision

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