2. Puerperium – Physiological Changes During Puerperium
Definition
Puerperium is the period following childbirth.
When the endocrine influences of the placenta 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 experience of
parturition.
This Period is Also Known AS Post-Partum, Post-Natal, Post-Delivery Period.
Puerperium begins as soon as placenta is expelled and lasts for six weeks
through the process of involution.
3. Physiological Changes in Reproductive System
Involution of Reproductive Organs Specially in Uterus
1) Involution of Uterus
Involution is the process whereby the pelvic reproductive organs returns to the
prepregnant size and position and the placental site of endometrial heals.
After the delivery uterus becomes firm and retracted with alternate hardening
and softening.
The uterus measures about 20 × 12 x7.5 cm (Length, Breadth and Thickness)
and weigh about 1000 gms.
At the end of 6 weeks it return to pregravid size of 7.5x5x2.5 cm and weigh 60
gms.
4. Reduction of the Size:
• After Labor, fundus is 5 cms below
umbilicus or 12 cms above the symphysis
pubis.
• After 24 hrs at the level of umbilicus.
• After 1 Week 7.5 cms above the
symphysis pubis and 12 Days after labor
the fundus Is not usually palpable
• The placental site is 7.5 cms and at the
end of 6 weeks measures 1.5 cms.
5. Position of the uterus :
Immediately after delivery the uterus lies midway between the symphysis
pubis and the umbilicus. Within 12 hrs, it rises to the level of umbilicus or
slightly above it.
Uterus begins to descend into the pelvic cavity at a rate of about 1 cm a
day until the 10th day, when it may be palpated at or below the level of
symphysis pubis.
6. Consistency of the uterus:
The strong frequent myometrial contractions that
control blood flow to the uterus cause it to become
hard. Its consistency can be assessed by palpating
the uterus.
It should feel firm and round. If the fundus is soft, it
is called as boggy uterus, indicates that
contractions are inadequate allowing blood loss to
continue.
7. Endometrium :
It also undergoes involution after placenta is delivered.
The major part of decidua is cast off along with the placenta and
membranes, more than the placental sites, only the basal
portion of the decidual remains.
The superficial part containing the degenerative decidua, blood
cells and bits of fetal membrane become necrotic and is cast off
in lochia.
Regeneration occurs from epithelium of the uterine gland
mouths and interglandular stromal cells.
It is completed by 10 days and the entire endometrium is
restored during the 3rd week except at the placental site where
it takes about 6 weeks
8. Ii) Cervix
After delivery the lower uterine segment and cervix remain loose, thin
and stretched.
It may also appear odemetous and bruised from the delivery and may
have small tears or lacerations.
It may take a few weeks to revert back to normal shape and size of the
isthmus.
By the first post-partum day cervix has sufficiently narrowed and
regained its normal consistency to admit two fingers and by the end of
the first week narrows down to admit the type of a finger only.
Involution may continue for 3-4 months since the cervix sustained
trauma, the parous cervix will never again look like the non-parous
cervix.
The external os which previously resembled a dimple, now a slit and
laceration may leave scar tissue.
9. iii) Vaginal Canal
The vaginal canal appears swollen and smooth after delivery, gradually
becomes smaller and firm, never regains pre-pregnancy size, rugae partially
reappears at third week but never to the same degree as in prepregnant size.
The introitus remains permanently larger than the vaginal state. The hymen is
lacerated and is represented by nodular tags
iv) Perineum
Muscle of the floor of perineum are stretched, swollen bruised. Even an intact
perineum can be edematous, erythematous and uncomfortable. A scar may be
present if episiotomy was performed.
v) Ovaries
The ovaries are inactive during the last two trimesters of pregnancy, because of
the drop in placental hormones level and gradually resumes the pre-pregnancy
cycle
10. vi) Lochia
It is the vaginal discharge for the first fortnight during
puerperium. It originates from the uterine body, cervix
and vagina. It contains blood, decidual tissue,
epithelial cells from the vagina mucus, bacteria and on
occasion, fragments of membranes and small clots. Its
odor is fleshy but not offensive
Various types of lochia are :
Lochia Rubra:
The first phase of lochia when discharge is red and
bloody called lochia rubra means 'red'. Lasts from 1-4
days, may contain few small blood clots.
Lochia Serosa:
Occurs next 5-9 days, the color is yellowish pink or
pale brownish.
Pale white because of the presence of leukocytes,
lasts from 10-14 days. The color of lochia indicates the
healing stage of the placental site. The average
amount of discharge for the first 5-6 days is about 250
ml
11. .
Importance of Inspecting Lochia
It gives information about the puerperal state of the mother pads to be inspected
daily.
Odour: If offensive – Infection, retained cotton piece plugs to be kept in
mind.
Amount: Scanty or absent = Infection.
Colour: Persistence red - Subinvolution retained bits of conception.
Duration : Lochia alba beyond three weeks suggestive of local lesions.
12. vii) Breasts and Lactation
a) Breasts
Already developed throughout pregnancy in response
to hormonal stimulus.
For the first few days both breast feeding and non-
feeding breasts of women secrete colostrum, a
creamy yellow precursor to milk, but the breasts
remain soft and non-tender.
Three days after delivery in response to increased
prolactin level breasts become firm and tender and
milk supply is initiated.
They rapidly become distended, hard and warm
because of increased flow, venous and lymphatic
congestion called physiological engorgement, lasts
about 24-48 hours and will resolve spontaneously,
suckling by the baby stimulates ongoing milk
production.
The breast will remain firm, full and somewhat tender
until emptied by nursing.
13. b) Lactation
Lactation is under the control of numerous exocrine glands, particularly the pituitary
hormones prolactin and oxytocin. It is influenced by the sucking process and by
maternal emotions.
Lactation, the process of breast feeding results from interplay of hormones, instinctive
reflexes and learned behavior of the mother and newborn.
The establishment and maintenance of lactation is determined by three factors:
1) The anatomical structure of the mammary gland and development of alveoli, ducts
and nipples
2) The initiation and maintenance of milk secretion, and
3) Milk ejection or propulsion of milk from the alveoli to the nipple.
14. Stages of Lactation
The physiology of lactation depends upon 4 processes.
They are as follows:-
a. Preparation of breast (Mammogenesis)
b. Synthesis and secretion from the breast alveoli
(Lactogenesis)
c. Ejection of Milk (Galactokinesis)
d. Maintenance of Lactation (Galactopoiesis)
15. a. Preparation of breast (Mammogenesis)
Pregnancy is associated with a remarkable growth of both ductal and lobuloalveolar systems. An
intact nerve supply is not essential for the growth of the mammary glands during pregnancy.
b. Synthesis and secretion from the breast alveoli (Lactogenesis).
Lactogenesis begins during the later part of pregnancy. The colostrum is secreted as a result of
stimulation of the mammary alveolar cells by placental lactogen, after birth as an automatic process as
long as milk is removed from the breast. The milk secretion actually starts on the 3rd or 4th of
postpartum day. Around this the breast become engorged, tense, tender and feels warm.
The continuing secretion of milk is mainly related -:
Sufficient production of the anterior pituitary hormone prolactin.
Efficient removal of milk.
Maternal nutrition and fluid intake are contributing factors to the quantity and quality of milk
16. c. Ejection of Milk (Galactokinesis)
Movement of milk from the alveoli where it is secreted by a process of extrusion from the cells to the
mouth of the infant is an active process within the breast.
The milk ejection reflex is initiated by suckling which stimulates the release of oxytocin from the
posterior pituitary. Oxytocin contracts the myoepithelial cells surrounding the alveoli and the
lactiferous ducts therapy aiding expulsion of milk. This is recognized by the mother as the milk let
down.
This process is dependent on the let-down, or milk ejection, reflex. Sucking stimulates the posterior
pituitary gland to secrete oxytocin. Under the influence of oxytocin, the cells surrounding the alveoli
contract, propelling the milk through the ductal system into the infant's mouth.
The milk ejection reflex is inhibited by emotional stress, breast pain, engorgement and this may
explain why maternal anxiety leads to failure of lactation. The ejection reflex may be deficient for
several days following initiation of milk secretion and results in breast engorgement
17. d. Maintenance of Lactation (Galactopoiesis)
Prolactin appears to be the single most important galactopoietic hormone. For maintenance of
effective and continuous lactation, suckling is essential. It is not only essential for the removal of milk
from the glands, but it is also causes the release of prolactin. Secretion is a continuous process unless
suppressed by congestion or emotional disturbance. Milk pressure reduces the rate of production and
hence periodic breast feed.ng is necessary to relieve the pressure which in turn maintains the
secretion.
The breast should be able to produce enough milk or full or partial feeding of the baby for nine months
postpartum.
In order to achieve this, the following factors are necessary:- Maternal good health:-A mother should
be physically and mentally well and she should be free from anxiety. Stimulation of the breast by
sucking reflex of the breast. The baby should suckle at the breast at a regular interval. Adequate
employing of the breast by the baby sucking on them or by manual expression of the breasts
18. Lactogenesis (milk initiation):
It begins during the later part of pregnancy. Colostrum is secreted as a result of stimulation of the mammary
alveolar cells by placental lactogen, a prolactin-like substance. It continues after birth as an automatic
process.
The continued secretion of milk is related to:
i) Sufficient production of pituitary hormone prolactìn.
ii) Maternal nutrition.
Colostrum:
A yellow, premilk substance, high in protein and contains antibodies. Its production decreases gradually
after childbirth and production of true milk begins. The bluish white true milk usually comes in between 3rd
and 5th post-partum day. The milk at the beginning of the feeding is known as fore milk which contains less
fat and flows at a faster rate than at the end of the feeding, the hind milk. Hind milk is white and contains
more fat, calories and is believed to satisfy the infant and signal that the feeding should come to an end.
The last stage of human lactation is ingestion of milk by the suckling baby. The full term healthy new born
baby possesses three instinctive reflexes needed for successful breast feeding:
1. The rooting reflex,
2. The sucking reflex, and
3. The swallowing reflex
19. Maternal Breast Feeding Reflexes
There are three major maternal reflexes involved in breast feeding which are:
i) Secretion of prolactin,
ii) Nipple erection,
iii) The let down reflex.
i) Prolactin Reflex
It is considered as the key lactogenic hormone initiating and maintaining milk secretion. Its production by the
non-pituitary is mainly the result of the prolactin reflex resulting from the infant's suckling at the breasts. The
sucking stimulus provided by the baby sends a message to the hypothalamus.
Hypothalamus stimulates the anterior pituitary to release prolactin, the hormone that promotes milk
production in the alveolar cells of the mammary gland. The amount of prolactin secreted and hence the milk
produced is related to the amount of sucking stimulus, that is the frequency, intensity and duration with which
the baby is breast fed. Stimulation of breast nipple by infant's mouth leads to nipple erection and
prominence.
20. ii) The nipple erection reflex assists in the propulsion of milk through the lactiferous sinuses to
the nipple pores.
iii) The ejection of milk from the alveoli and milk ducts occurs as a result of the milk ejection
of let down reflex which is regulated in part by the CNS. The suckling stimulus arrives at the
hypothalamus ,which promotes release of oxytocin from the post-pituitary.
Oxytocin stimulates contraction of the myoepithelial cells around the alveoli in the mammary
glands. Contraction of these muscle-like cells causes milk to be propelled through the duct
system and into the lactiferous sinuses where it becomes available to the breast feeding
infant.
21. The let down reflex appears to be sensitive to
small differences in circulatory oxytocin
levels. Signs of let down reflex is easily
recognized by mothers.
It is characterized by a tingling sensation that
progresses to a feeling of pulling or of being
squeezed from the inside. Many women will feel
this reflex by simply thinking about their baby or
crying about their baby. It seems to be somewhat
consciously controlled.
Sign includes milk dribbling from the breast
opposite to the one being used and uterine
cramping during feeding caused by the action of
oxytocin on the uterus. Minor emotional and
psychological disturbances may influence the
ease with which breast milk is released to the
baby. The attitude of mother towards breast
feeding whether positive, doubtful or negative is a
powerful factor in achieving successful lactation,
influencing milk production and facilitating the art
of breast feeding.
22.
23. Physiological Changes in Other Systems of Body
i) Cardiovascular Function
Volume adjustment:
In the puerperium dramatic changes occur in cardiovascular system. During pregnancy blood
increased by 30% to 50%.
During vaginal birth and placental delivery woman loses about 500 ml of blood, 1000 ml during
cesarean birth, this depletes a portion of the additional fluid but shift in fluids that are redirected
from the placenta compensate and increase the circulatory volume.
Without the extra blood vessels of the uterus and placenta, blood is returned to the central
circulation.
Vena caval compression from the large uterus is relieved and blood from the pelvic region returns
unimpeded to the general circulation, along with extra vascular fluid accumulated during
pregnancy.
Cardiac output increase 25% to 80% depending on the type of delivery with resulting increase in
stroke volume (SV). This required special attention in women with cardiac problems.
.
24. Heart rate :
During pregnancy heart rate increases to 15 beats per minute and the SV is also increased,
thus improving cardiac output (CO) to effectively circulate a larger blood volume in the expanded
uterine and placental vascular bed.
After delivery, body attempts to compensate for increased central venous load, slowing the heart
rate to as low as 40-60 beats per minute to control CO and prevent systematic overload and
hypertension.
Bradycardia is normal post-partum adaptation. An increase in pulse rate may indicate
haemorrhage infection, thrombosis, anxiety, pain or excitement related to delivery and should be
explored.
Blood pressure :
Blood pressure may decrease in the early recovery period in response to anesthesia, blood
pressure etc., orthostatic hypotension may occur because of fluid shift and decreased intra-
abdominal pressure.
It returns to normal within the first week after delivery unless the women experience
complications such as pregnancy induced hypertension.
25. Hemoglobin and Hematocrit :
During the initial period of post-partum diuresis the increased yolume of
RBCS during pregnancy will now decrease because of loss of extra body fluids.
Hematocrit may rise in the first 3-7 days gradually return to normal levels by 4-5
weeks as old cells die out and fewer new ones form.
Non-pregnant levels are reached by 5-8 weeks.
26. White blood counts:
Normal adult WBC count is between 5000 and 10000/mm3. Count rise during
pregnancy and labor up to the level of 15,000 to 20,000/mm3.
According to experts load is acceptable up to 40,000/ mm3 for the first 24 hours
to 48 hours post-partum. It falls to normal in 4-7 days. Persistent elevation
indicates infection.
Coagulation Factor:
Clotting Factor Increase Near Term and Remain High in Immediate Postpartum
Period. Platelet, Fibrin and Fibrinogen Levels Are Elevated During Recovery.
Their function Is to protect against bleeding caused by Delivery of Foetus and
placenta. But they also contribute to thrombus if the woman is immobile. All
Levels Return to Normal In 3-4 Weeks
27. II) Respiratory Function
After Delivery with the decrease in Abdominal Pressure, the diaphragm decends to sits normal position
permitting better lung expansion and ventilation but the respiratory rate does not noticebly change.
iii) Excretory Function
Body water In the extra-vascular spaces and excess plasma volume from the pregnancy are rapidly
eliminated. But the second the second-partum day diuresis and polyurea occur, upto 3 liter / day .
Urine is passed for few days and within one week returns to normal voiding pattern. Bladder Sits capacity,
filling upto 1000 or 1500 ml of urine without discomfort.
Retention of Urine may result because of stretching of Perineal Floor, bruising and edema of the trigone and
urethral meatus. Regional or General Anesthesia may temporary inhibit natural function, diminishing urinary
sensations from the Bladder.
Urinary Retention follows putting the woman at risk for hemorrhage from a poorly contracting uterus.
Stasis Also Predisposes to urinary tract infections. Increased membrane permeability persists for first week,
proteinurea of upto 1+, glucose passed in the form of galactose, urinary ketones may be present.
Dilatation of the Uterus and Renal Pelvis requires about 6 Weeks to return to Pre-Pregnancy State In
Urinary Stasis, microorganisms can easily travel upwards causing Kidney Infection
28. iv) Gastrointestinal Function
Increased thirst in early puerperium is due to loss of fluid during labour,
lochia, diuresis and perspiration.
Slight intestinal paresis leads to constipation.
Lack of tone of the perineal and abdominal muscles and reflex pain in the
perineal region are contributing factors for constipation.
Ambulation, progression of diet, anti-fluctuants or enemas generally make
the woman more comfortable.
During delivery the straining and pressure on the lower bowel causes the
extrusion of internal hemorrhoids.
After delivery these reduce in size and can be manually re-inserted in the
rectum
29. v) Integumentary Function
After delivery the skin changes caused by pregnancy begin to recede.
As the melanocyte stimulating hormone that caused pigmentational changes is
eliminated, melasama disappears, unless excessive pigmentation has occurred.
Striae gravidarum may fade to a silvery color in light skinned women but they
remain deeper on darker skin.
The linea nigra and darkened areola fade, but in some women faint traces will
persist. In a few months hair and nail growth will return to pre-pregnant pattern.
30. vi) Musculo-skeletal Function
Women may be fatigued or exhausted after labour.
The labor position and pushing technique may leave arms, neck, shoulders
and perineal muscle sore and aching.
Abdominal muscles:
Uterine ligaments remain loose and relaxed, abdominal muscles have less
tone, resulting in soft, flabby abdomen. Exercise may help but restoration of
the muscles may be prolonged.
Joints:
Under the influence of relaxation, the pelvis joints particularly the symphysis
pubis may separate slightly during labour, causing pain and discomfort,
becomes stabilized by 6-8 weeks.
31. vii) Endocrine Functions
Menstruation and Ovulation
The exact mechanism responsible for resumption of the menstrual cycle is not
known and time of resumption is unique for each individual. Cycles can begin in
lactating mothers as early as 8 weeks after delivery or as late as 18 months. 40%
of the lactating mothers may have their first menstrual period as early as 4 to 6
weeks after delivery and 90% by 24 weeks.
It is because prolactin levels interfere with the development of the graffian
follicle. Since prolactin level is influenced by the strength of infant sucking, the
frequency of feedings, therefore, breast feeding is unreliable as a method of
contraception.
32. viii) Immunologic Function
Infection
Puerperal women are at special risk for wound infection and infections of uterus, urinary
tract, respiratory tract or breast.
Predisposing factors such as diabetes, chronic respiratory problems, anemia, malnutrition
and substance abuse, etc. alert the nurse as in cases of prolonged labor, difficult delivery,
multiple pregnancy, lacerations, hematoma or cesarean delivery.
Puerperal sepsis is the most common post-partum infection of the genital tract in the post
partum period appearing before the 10th day after delivery.
An elevated temperature in the first 24 hours after delivery may be caused by dehydration,
fatigue, chilling and blood loss. The temperature may be as high as 380 c is considered
within normal limits.
low grade fever is related to engorgement of the breast
33. POST NATAL CARE
Post natal care includes systematic examination of the mother and the baby appropriate
advice given to the mother during postpartum period.
The first postnatal examination is done and the advice is given on discharge of the patient
from the hospital. The second routine postnatal care is conducted at the end of 6th week
postpartum.
Postnatal Check Up
Detection of risk at earlier stage & its management
Management of Normal puerperium
Treatment of Minor Ailments
Treatment of anaemia
Health & nutrition education
Postnatal Exercise
34. Postnatal Check Up
General health check up
Monitoring of involution process
For satisfactory establishment of lactation
For examination of newborn
Management of Normal Puerperium
First hour - important for PPH Early ambulation
Avoid strenuous activities for 6 weeks
8-10 hours sleep
Needs 500 - 700 calories more
Care of Episiotomy stitches (REEDA)
35. Care of Mother
The management of Puerperium consists of providing the means whereby the woman can
recover physically and emotionally and gain supervised experience in the care of her infant, This
consists of the following principles:
1) To restore the health status of mother.
2) To prevent infection.
3) To take care of breasts including promotion of breast feeding.
4) To provide for care of the baby.
5) To motivate and guide for family planning.
6) To give need-based health education.
36. Immediate Care
The first hour after delivery does not end the recovery process.
The clinical phase of recovery continues throughout hospitalization and weeks after discharge.
During this time accurate observations, nursing history and physical assessment allow formation of
appropriate nursing diagnosis and effective plan of care.
These may be as follows:
Initial observations
Childbirth recovery
Her general appearance of her presence of pain, her color of her reflects circulation and
perfusion.
Observe her from her for pallor, flusting or cynosis.
Note whether she is very fatigued, quiet, excited or anxious,comfortable or in distress
Assess the I/V line in place, amount of fluid and medication etc.
Whether she had surgery:the Folley's catheter is in place
Check whether she is concerned about the baby or herself
37. Physical Assessment
It should be provided in the following order:
Vital signs: Take pulse, respiration and blood pressure. Temperature is taken to ensure that
woman is not dehydrated and to rule out infection. Postpartum checks include vital signs
every 15 minutes for one hour, then 30 minutes in the second hour and then every 4 hours for
24 hours.
Uterus: For vaginal delivery, check the fundus for consistency, height and
descent. Measurement of abdominal girth after LSCS.
LSCS: Check the dressing for the presence of bleeding.
Perineal area : Check perineal pad for amount, color of lochia, odor, clots, intact sutures,
odema, pain and anus for any repaired lacerations or haemorrhoids.
38. Rest and ambulation:
For most of the woman 8-12 hours of rest is enough following delivery.
She is able to feed the baby, move out of bed and go to the toilet.
Now-a-days early embulation is followed because of the following advantages:
1) Provides a sense of well being.
2) Reduces bladder and bowel complications.
3) Facilitate uterine drainage and involution.
4) Reduces puerperal venous thrombosis and embolic phenomenon
5) Early Ambulation does not mean return to normal activities.
These should be restricted for at least 6 weeks.
.
39. Diet:
The Woman Should Be Given Light Diet on the First Day and Normal Diet from The Second Day.
The Lactating Mother Should Be Given High Calories, Adequate Proteins, Fats, Mineral, Vitamins
and Plenty Of Fluids, and Green Leafy Vegetables.
The Mother Must consume Iron, Folic Acid and Calcium Also.
In a Non-Lactating Mother Normal Diet is Enough.
40. CARE OF BLADDER:
The woman is encouraged to pass urine within 6-8 Hours following delivery and
then after 4-6 Hours Interval.
Many times woman do not pass urine because of the following reasons:
Lack of Privacy and Unaccustomed Position.
Reflex from Perineal Injuries.
Privacy to be Provided.
Patient May Be Allowed to use the toilet.
If fails to pass urine,catheterization should be done.
It can be done in incomplete emptying of the Bladder because of residual Urine
More Than 60 ml.
Continuous Drainage is kept until the bladder tone is regained to prevent Infection
and Cystitis.
41. Care to Bowel:
Abdomen Should Be Visually Inspected for distension, palpated For firmness Or Rigidity and
auscultated for the presence of Bowel Sound Specially After Surgical Delivery. Ask the woman if
she Is able to pass Flatus and Feel Urge Office.
Care of Breast:
Breast and Nipples To Be Washed and Cleaned With Water, And Soap To Be Applied While Taking
Bath. Supporting Brassiero of Right Size To Be Worn for Proper Support. If Proper Care has not
been taken during antenatal period ,dried scales formed by the Breast secretions may become
firmly adherent closing the duct openings.
Need for Rooming In:
In This System Baby Remain at The Mother's Bedside for Most of the Time Of The Day and
Treaty AS A Unit. It provides Psychological and Physical Advantage to Both Mother and Baby and
Minimizes the Cross Infection When The Baby Is In Nursery. It helps to feed the Baby On Demand
and Relief Workload of Nursery Staff.
42. Immunologic Needs
Immunization:
Delivery of the Fetus and placenta increases the chances of Fetal Blood
Entering Maternal Circulation for RH Negative Mother with the Rh Positive Infant
predisposes to the formulation of antibodies that can endanger future
pregnancies.
Prevention of isoimmunization is possible if Rh- Immunoglubulin is administered
within 72 hours after delivery.
Administration of Anti-D Gamma Globulin to Unimmunized RH-Negative Mother
With Rh positive Baby Within 72 Hours Of Delivery.
43. Sleep:
The amount of energy spend during Labor and Birth leaves the Mother in
need of rest both physical and Mental.
She should be protected against worries and fatigues.
If there is some discomforts such as afterpains, engorged breast should be
dealt with adequate analgesics as necessary.
Child Care Should be planned so that Mother can rest while other members
of family to be encouraged helping her rest.
Visitor should be limited because fatigue adversely affects Milk Production,
interferes with learning, can precipitate depression and lower the Self
esteem.
44. Care of The Vulva and Episiotomy Wound:
After Delivery Vulva and Buttocks Are Washed With Saline, Lotion Or Soap
and Water.
Antiseptic Ointment or Lotion Applied Over the Episiotomy Sterile Pad Given.
This should be done atleast 3-4 times a day with the each act of micturation
and defecation.
This will also relieve pain.
Cold Compresses are applied for the First 24 Hours to prevent and decrease
odema and diminish local sensation.
Some women feel more comfortable with warm water Sitz Bath.
45. Postnatal exercises
DEFINITION
• A series of physical exercises that are performed by the postnatal mother to
bring about optimal functioning of all systems and prevent complications
PURPOSES
1. • To improve the tone of muscles which are stretched during pregnancy
and labour specially the abdominal and perineal muscles
2. • To educate about correct posture and body
3. To minimize the risk of puerperal venous thrombosis by promoting
circulation and preventing venous stasis
4. • To prevent back ache
5. • To prevent genital prolapse
6. • To prevent stress incontinence of urine.
46. PROCEDURE
1. • Explain the procedure to patient
2. • Provide privacy and demonstrate the procedure
TYPES OF EXERCISES
• ABDOMINAL EXERCISES
• CIRCULATORY EXERCISES
• PELVIC FLOOR EXERCISE
• CHEST EXERCISES
47. I.ABDOMINAL EXERCISES
ABDOMINAL BREATHING
• Instruct the women to assume a supine
position with knees bent
• Instruct her to inhale through the nose,
the ribcage, as stationary as possible,
and allow the abdomen to expand and
then contract the abdominal muscle as
she exhales slowly through the mouth
• Instruct her to place one hand on the
chest and one on the abdomen when
inhaling. The hand on abdomen should
rise and the hand on the chest should
remain stationary
• Repeat the exercises five times
48. HEAD LIFT
• Instruct the mother to lie
supine with knees bent and
arms out stretched at her side
• Instruct her inhale deeply at
first and then exhale while lifting
the head slowly to hold the
position for few seconds and
relax
Benefits:
Strengthens abdominal
muscles
49. HEAD AND SHOULDER
RAISING
1. • On the second postpartum
day instruct women to
2. • Lie flat without pillow and
raise head until the chin
touches the chest
3. • On the 3rd postpartum day
instruct: To raise the both
head and shoulder off the bed
and lower them slowly
4. • Gradually increase the
number of repetitions until she
is able to do this for 10 times
50. LEG EXERCISES
• It begins on the 7th postpartum
day
• Lie down on the floor with no
pillows under the head point toe
and slowly raise one leg keeping
the knee straight
• Lower the leg slowly
• Gradually increase to ten times
each leg
51. 1. PELVIC FITTING OR ROCKING
2. • Lie flat on the floor with knees
bent and feet flat, inhale and
while exhaling flatten the back
hand against the floor
3. • Repeat up to 10 times
4. 20. PELVIC FITTING
52. KNEE AND LEG ROLLING
Lie flat on her back with
knee bent and feet flat on
the floors or bed
• Keep the shoulders and
feet stationary and the
knees to side to touch one
side of the bed, then other
• Maintain a smooth motion
as the exercise is repeated
five times
53. HIP HITCHING
• Lie on her back with one
knee bent on the other knee
straight
• Slide the heel of the
straight leg downwards thus
lengthening
• Shorten the same leg by
drawing the hip upwards to
ribs on the same side
• Repeat up to 10 times
54. ABDOMINAL TIGHTENING
• Sit comfortably or kneel
on breath in and out,
then pull in the lower part
of the abdomen below
the umbilicus
• While continuing to
breath normally hold up
of 10 minutes and repeat
up to 10 minutes
55. II.CIRCULATORY EXERCISES
FLOOR AND LEG EXERCISES
1. • Sit or half lie with legs
supported
2. • Bend and stretch the ankles at
least 12 times
3. • Circle both feet at the ankles at
least 20 times in each direction
4. • Repeat for 12 times
56. III.PELVIC FLOOR
EXERCISE
• Sit, stand or half lie with
legs slightly apart close and
draw up around the anal
passage as through
preventing a bowel action
. • Hold the contractions for
10 seconds.
• Repeat up to 10 times
57. . IV.CHEST EXERCISES
• Lie flat with arms extended straight out to the side,
bring both hands together above the chest while
keeping the arms straight hold for a few seconds and
return to the straight position
CHEST EXERCISE WITH DUMBBELL
• Repeat the exercises five times initially and follow
the advice of the health care providers for increasing
the number of repetitions
• Instruct the mother to bend her elbows, clasp her
hands together above her chest and press her hands
together for a few seconds.
• Repeat this at least five times
