1) The document discusses the management of the normal postpartum period, including rest, diet, care of the perineum and breasts, bonding with the infant, immunizations, and advice upon discharge. 2) Common postpartum ailments like afterpains are also covered, along with their treatment, and exercises to improve muscle tone are described. 3) The mother is encouraged to ambulate early, eat a nutritious diet, and take care of personal hygiene during recovery from delivery.

1. NORMAL PUERPERIUM
1. MANAGEMENT OF NORMAL
PUERPERIUM
2. MANAGEMENT OF AILMENTS
ASSOCIATED WITH PUERPERIUM

2. MANAGEMENT OF NORMAL
PUERPERIUM
 The Principles of management are:
1) To restore the health care of mother.
2) To prevent infection
3) To take care of the breasts, including promotion of
breast feeding.
4) To motivate mother for contraception.

3. COMPONENTS OF
MANAGEMENT

4. IMMEDIATE ATTENTION
Following delivery patient should be closely observed (under
guidelines for management of third stage of labor).
She may be given a drink of her choice or something to eat, if
she is hungry.
EMOTIONAL SUPPORT IS ESSENTIAL
Usually the first feeling of the mother is a sense of relief or
happiness, but their might be postpartum blues or stress due to
illness or newborn’s prematurity , congenital malformations or
death.

5. REST AND AMBULANCE :
Early ambulation after delivery is beneficial an is
encouraged.
Advantages
1) Provides a sense of well being
2) Bladder complications and constipation are less
3) Facilitates uterine drainage and hastens involution of
uterus
4) Lessens puerperal venous thrombosis and embolism

6. HOSPITAL STAY
Early discharge from the hospital is a universal procedure.
Adequate supervision by trained health providers, encourage
early discharge.
Most patients a discharged within 2 days following
spontaneous vaginal delivery with proper education and
instructions.
Some might need prolonged hospitalization due to morbidities
(infections of urinary tract, or perineal wound, pain or
breastfeeding problems)

7. DIET
Normal diet of her choice
If lactating,
1) high calories
2)adequate proteins and fat
3)plenty of fluids,vitamins and minerals
If non lactating , diet is enough as in a non- pregnant
women.

8. CARE OF THE BLADDER
The patient is encouraged to pass urine following delivery as
soon as convenient.
At times patient fails to pass urine, reasons:
1) Unaccustomed position
2) Reflex pain from perineal injuries(forceps delivery or difficult
labor)
If patient still fails to pass urine, catheterization is done.
Catheterization is indicated in case of incomplete emptying of
bladder , i.e. >60ml residual urine .
Continuous drainage, until bladder tone is regained.
Infection and cystitis are to be avoided.

10. CARE OF THE BOWEL
Constipation is much less due to early ambulation and
liberalization of dietary intake.
Diet containing sufficient roughage and fluids is enough to
move the bowel.
Mild laxative such as isabgol husk two teaspoons may be
given at bedtime, if necessary.

11. SLEEP
The patient is in need of rest, both physical and
mental.
She should be protected against undue fatigue
and worries.

12. CARE OF VULVA AND EPISIOTOMY
WOUND
i. Shortly, after delivery, the vulva and buttocks are washed
with soap water down over the anus and a sterile pad is
applied.
ii. Personal hygiene is advised.
iii. Perineal wound should be dressed with spirit and antiseptic
powder after each act of micturition and defecation or atleast
twice a day.
iv. Nurse should use sterile gloves during dressing.
v. Cold (ice)sitz baths relieve pain and edema by
vasoconstriction.
vi. If pain is persistent, a vaginal or rectal examination is done
to detect any hematoma ,wound gaping or infection.

13. CARE OF BREASTS
Nipple should be washed with sterile water before feeding and
should be kept clean and dry after feeding is over.
NIPPLE SORENESS is avoided by frequent short feedings
rather than prolonged feeding, keeping the nipples clean and
dry. Candida infection can be another cause.
NIPPLE CONFUSION is a situation where the infant accepts
artificial nipple but refuses mother’s nipple , can be avoided by
making nipple more protractile and not offering supplemental
fluids to the infant.

14. MATERNAL -INFANT BONDING
Rooming -in
It starts from first few moments after birth, manifested by
bonding,kissing,cuddling and gazing at the infant.
Baby should be kept in the bed or in a cot besides the mother.
This establishes a relationship an d mother takes full care of the
baby while home and is conversant in the art of baby care.
Baby friendly hospital initiative, promotes the rooming in, infant
parent bonding and breastfeeding.

15. ASEPSIS AND ANTISEPTICS
Must be maintained during the 1st week of puerperium.
Liberal use of antiseptics and aseptic measures during
perineal wound dressing, use of clean linen and
clothings.
Clean surroundings and limited number of visitors
reduces nosocomial infections

16. IMMUNISATION
i. Administration of anti-D-gamma globulin to
unimmunized Rh-negative mother bearing Rh-positive
baby.
ii. Women who are susceptible to rubella can be
vaccinated safely with live attenuated rubella virus and
mandatory postponement of pregnancy for atleast 2
months following vaccination can be easily achieved.
iii. Booster dose of TT toxoid ,hepB, Tdap should be
given at time of discharge , if not given during
pregnancy.

17. MANAGEMENT OF
AILMENTS

18. AFTER PAIN

19. It is 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 after births lead to hypertonic
contractions of uterus in an attempt to expel them out.
 This is commonly seen in primipara.
 Pain can be due to vigorous uterine contractions especially in
multipara.
 Mechanism : Ischemia and is excited due to breastfeeding.

 Treatment : massaging the uterus with expulsion of blood
clots followed by administration of analgesics and
antispasmodics.

20.  PAIN ON PERINEUM
Never forget to examine the perineum when analgesic is
given to relieve the pain.
Early detection of vulvovaginal hematoma can be made
Sitz bath can give additional pain relief.
 CORRECTION OF ANAEMIA
Majority of women in tropics remain in anemic state following
delivery
Supplemental iron therapy(ferrous sulfate 200mg) is given
daily for a minimum period of 4-6 weeks
Hypertension is treated until it comes to a normal level.
Physician should be consulted if proteinuria persists

21. TO MAINTAIN A CHART
A progress chart is to be maintained noting the following
points:
1) Pulse, respiration and temperature recording every 6
hourly or atleast twice a day.
2) Measurement of height of uterus above pubic symphysis
once a day in a fixed time with prior evacuation of bladder
and bowel.
3) Character of lochia.
4) Urination and bowel movement.

23. POSTPARTUM EXERCISE

24.  Objectives:
1) To improve muscle tone, which are stretched during
pregnancy and labor especially the abdominal and
perineal muscles.
2) To educate about correct posture to be attained when the
patient is getting up from her bed
3) Correct principle of lifting and working positions during day
to day activities.
Advantages:
i. To minimize the risk of puerperal venous thrombosis
ii. Promoting arterial circulation and prevents venous stasis
iii. To prevent backache
iv. to prevent genital prolapse and stress incontinence of
urine

25. PROCEDURE
 Initially, she is taught breathing exercises and
leg movements lying in the bed.
 Then, she is instructed to tone up abdominal
and perineal muscles and to correct postural
defects by a trained physiotherapist.
 Should be continued atleast until 3 months

26. COMMON EXERCISES
a) To tone up the pelvic floor muscles: Patient is
asked to contract the pelvic muscles in a manner
to withhold the act of defecation or urination and
the relax.
b) To tone up the abdominal muscles: the patient
is to lie in the dorsal position with the knees bent
and feet flat on the bed. The abdominal muscles
are contracted the relaxed alternately.
c) To tone up the back muscles : the patient is to
lie on her face with the arms by her side. The
head and shoulders are slowly moved up and
down.

27.  Physical activity can be resumed without
delay.
 Sexual activity may be resumed (after 6
weeks) when the perineum is comfortable
and bleeding has stopped. Some women
may get ‘flaring response’ of some
autoimmune disorders due to rebound effect
of some immune suppression during
pregnancy.

28. CHECK UP OR ADVICE ON DISCHARGE
 A thorough check up of the mother and baby is mandatory
prior to discharge of the patient from the hospital.
 Discharge certificate should have all the important
information regarding mother and the baby.
Advice includes :
1) Measures to improve her general health. Continuance of
her supplemental iron therapy.
2) Postnatal exercises
3) Procedure for gradual return to day to day activities

29. 4) Avoidance of intercourse for a reasonable period of 4-6
weeks until lacerations or episiotomy wound are well healed.
5) Breastfeeding and care of newborn.
6)Family planning advice and guidance (contraception): non
lactating women should practice some form of contraception
after 3 weeks and lactating women after 3 months of delivery.

30. Methods of contraception:
I. Natural methods cannot be used until the menstrual cycles
are regular however exclusive breast feeding provided 98%
contraception for 6 months
II. Barrier methods may be used
III. Steroidal contraception : combined preparations are
suitable for lactating women and should be started 3
weeks after and in lactating women, avoided due to
suppressive effects
IV. Progestin only pills
V. Other progestins ( DMPA, Levonogestrol implants )
VI. IUDs
VII. PPIUCD
VIII. Sterilization

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