Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care
The document provides information on nursing care of the mother during the postpartum period. Key points include:
- The postpartum period lasts approximately 6 weeks as the body returns to its pre-pregnant state.
- Physiologic changes include uterine involution over 10 days and lochia discharge over 3 weeks. Engorgement may occur between days 3-5.
- Nursing assessments include monitoring vital signs, bleeding, breast engorgement, and bonding with the infant. Interventions focus on preventing infection, reducing pain and fatigue, and promoting breastfeeding and self-care.
Fourth stage of labor: The hour or two after delivery when the tone of the uterus is reestablished as the uterus contracts again, expelling any remaining contents. These contractions are hastened by breastfeeding, which stimulates production of the hormone oxytocin.
This document provides an overview of preterm labor and abnormal uterine action. It begins by defining preterm labor as labor starting between 24-28 weeks and before 37 weeks of pregnancy. The prevalence of preterm labor is reported to range between 5-10%. Risk factors for preterm labor are then discussed, along with potential maternal and fetal complications. Diagnosis and management of preterm labor focuses on preventing onset, arresting labor if possible, and providing appropriate neonatal care. The document then discusses various types of abnormal uterine action including hypertonic, hypotonic, dyscoordinate, and tonic contractions. Causes, signs, and management are described for each type. Cervical dystocia is also reviewed, distinguishing between primary
This document discusses episiotomy, including its definition as a surgically planned incision made during childbirth, purposes such as facilitating delivery and reducing perineal tearing, types (median, mediolateral, lateral), indications, advantages, repair process, post-operative care, and potential complications. The repair process involves suturing the vaginal mucosa, perineal muscles, and skin in layers to restore anatomical structure while controlling bleeding and preventing infection.
Normal puerperium - Obstetrical and Gynecological NursingJaice Mary Joy
The word puerperium is originated from the Latin words ‘puer’ – child and ‘pams’ – bringing forth.
Also known as the post-partum, post-natal, or post-delivery period.
The mother during puerperium is termed as puerpera.
Shoulder dystocia occurs when the baby's shoulders become stuck after delivery of the head. It has a low incidence rate of 0.2-1% and risk factors include fetal macrosomia, obesity, diabetes and others. Diagnosis is made when normal maneuvers by the midwife fail to deliver the baby. Management involves calling for help, clearing the baby's airways, and performing maneuvers like McRoberts and Rubin's to rotate the shoulders and decrease their diameter in order to allow delivery. More invasive maneuvers like cleidotomy may be needed if these fail to deliver the anterior shoulder.
The document provides information on nursing care of the mother during the postpartum period. Key points include:
- The postpartum period lasts approximately 6 weeks as the body returns to its pre-pregnant state.
- Physiologic changes include uterine involution over 10 days and lochia discharge over 3 weeks. Engorgement may occur between days 3-5.
- Nursing assessments include monitoring vital signs, bleeding, breast engorgement, and bonding with the infant. Interventions focus on preventing infection, reducing pain and fatigue, and promoting breastfeeding and self-care.
Fourth stage of labor: The hour or two after delivery when the tone of the uterus is reestablished as the uterus contracts again, expelling any remaining contents. These contractions are hastened by breastfeeding, which stimulates production of the hormone oxytocin.
This document provides an overview of preterm labor and abnormal uterine action. It begins by defining preterm labor as labor starting between 24-28 weeks and before 37 weeks of pregnancy. The prevalence of preterm labor is reported to range between 5-10%. Risk factors for preterm labor are then discussed, along with potential maternal and fetal complications. Diagnosis and management of preterm labor focuses on preventing onset, arresting labor if possible, and providing appropriate neonatal care. The document then discusses various types of abnormal uterine action including hypertonic, hypotonic, dyscoordinate, and tonic contractions. Causes, signs, and management are described for each type. Cervical dystocia is also reviewed, distinguishing between primary
This document discusses episiotomy, including its definition as a surgically planned incision made during childbirth, purposes such as facilitating delivery and reducing perineal tearing, types (median, mediolateral, lateral), indications, advantages, repair process, post-operative care, and potential complications. The repair process involves suturing the vaginal mucosa, perineal muscles, and skin in layers to restore anatomical structure while controlling bleeding and preventing infection.
Normal puerperium - Obstetrical and Gynecological NursingJaice Mary Joy
The word puerperium is originated from the Latin words ‘puer’ – child and ‘pams’ – bringing forth.
Also known as the post-partum, post-natal, or post-delivery period.
The mother during puerperium is termed as puerpera.
Shoulder dystocia occurs when the baby's shoulders become stuck after delivery of the head. It has a low incidence rate of 0.2-1% and risk factors include fetal macrosomia, obesity, diabetes and others. Diagnosis is made when normal maneuvers by the midwife fail to deliver the baby. Management involves calling for help, clearing the baby's airways, and performing maneuvers like McRoberts and Rubin's to rotate the shoulders and decrease their diameter in order to allow delivery. More invasive maneuvers like cleidotomy may be needed if these fail to deliver the anterior shoulder.
The document discusses antenatal assessment, which involves the systematic supervision of a pregnant woman. It involves determining risk factors through a comprehensive history and physical exam. Regular checkups are recommended, starting with monthly visits until week 28, then twice monthly until week 36, and weekly during the last 4 weeks. The assessments monitor maternal and fetal health and wellbeing through tests, exams, ultrasounds and more. The goal is to promote a healthy pregnancy and delivery.
Puerperal infection is an infection of the genital tract that occurs after delivery. It is commonly caused by bacteria like Doderlein bacillus. Risk factors include prolonged rupture of membranes, traumatic delivery, and anemia. Symptoms range from local infection to sepsis. Diagnosis involves examinations, tests, and cultures to identify the site and cause of infection. Treatment involves antibiotics, surgery if needed to drain abscesses, and supportive care. Prevention focuses on clean delivery techniques, prompt repair of lacerations, and prophylactic antibiotics in high risk cases.
nurses/doctor will insert two lubricated, gloved fingers into your vagina with one hand, while the other hand presses gently on the outside of your lower abdomen. During this part of the exam, your doctor will check the size and shape of your uterus and ovaries, noting any tender areas or unusual growths.
This topic contains detailed description regarding Normal puerperium, it's definition, duration, phases, involution of uterus and other pelvic organs, lochia, general physiological changes of puerperium, lactation, management of normal puerperium, management of ailments and postnatal care.
Breast engorgement occurs when milk production causes swelling and hardness in the breasts. It is usually caused by a delay in breastfeeding after milk comes in around 3-4 days postpartum. Symptoms include pain, swelling, redness, and difficulty latching. Treatment involves frequent breastfeeding or milk expression, applying hot or cold compresses, wearing a supportive bra, and in severe cases medications like pain relievers or drugs to reduce milk production. Preventing engorgement requires initiating breastfeeding early and frequently to empty the breasts regularly.
Pathophysiology of Normal Labor:
A series of events that take place in female genital organs to expel the product of conception that are fetus, placenta, membranes) out of womb through the vagina into the outer world. We further describe pathogenesis and features of different stages of labor
The third stage of labor involves the separation and expulsion of the placenta after childbirth. The placenta separates from the uterine wall due to uterine contraction. The uterus then contracts further to aid the descent and expulsion of the placenta through the birth canal. Midwives monitor for signs of separation and use techniques like controlled cord traction or fundal pressure to deliver the placenta if needed. Oxytocic drugs may also be used to aid delivery or prevent hemorrhage. Care of both mother and newborn continues for at least an hour after completion of the third stage to ensure uterine contraction and monitor for complications.
This document provides an overview of the signs and symptoms of pregnancy presented by Nidhi Maurya. It begins with objectives to define pregnancy and explain signs and symptoms in each trimester. Common early signs include missed period, nausea, frequent urination and breast changes. Objective signs assessed include uterine size and fetal heart sound detectable after 18 weeks. Signs in the second trimester include quickening and skin changes. Third trimester brings prominent fetal movement and engagement of the presenting part. Fundal height increases throughout pregnancy.
The first stage of normal labour begins with the onset of true labour pains and ends with full dilatation of the cervix. For primi-gravida women this stage typically takes 12 hours, and for multi-gravida women it takes around 6 hours. Nursing care during this stage includes admission assessment, perineal care, monitoring contractions and vital signs, allowing rest and ambulation as tolerated, and shifting the patient to the delivery table once full dilatation is reached. Evidence shows that practices like ambulation during labour, support from a companion, and restricted vaginal exams and enemas can help make the first stage of labour safer and more comfortable.
This document discusses normal amniotic fluid levels at different gestational ages and the causes and effects of oligohydramnios, or low amniotic fluid. It notes that oligohydramnios can be caused by maternal or fetal conditions and presents risks to both mother and fetus. Management involves counseling, serial ultrasounds, amnioinfusion to increase fluid if needed, and close monitoring during labor due to risks of complications from reduced fluid levels like fetal distress, prolonged labor, and infection.
This document discusses induction of labor, including definitions, purposes, indications, contraindications, and methods. The key methods of medical induction discussed are prostaglandins like dinoprostone and misoprostol, oxytocin, and mifepristone. Prostaglandins work to ripen the cervix and stimulate contractions through local effects on cervical collagen and myometrium. Oxytocin stimulates contractions through receptor-mediated pathways. Mifepristone is a progesterone antagonist that blocks progesterone receptors to ripen the cervix. The document compares these methods and provides dosing and administration details.
The document discusses the process of puerperium, which is the period following childbirth where the body returns to its pre-pregnant state over approximately 6 weeks. Key changes include the uterus involuting from 1000g to 100g over this time, the return of ovarian function and menstruation between 8-12 weeks (or longer while breastfeeding), and the production and composition of colostrum and breastmilk. Proper breastfeeding and lactation is encouraged for infant health and development during this postpartum period of maternal physiological changes.
A placenta examination is performed after delivery to ensure the entire placenta and membranes have been expelled. It checks that the placenta is of normal size, shape, consistency and weight, and detects any abnormalities. The examination also evaluates the umbilical cord length and number of blood vessels. Key tools used include a bowl, weighing scale, and measuring tape. The placenta develops during pregnancy to support fetal growth and development through respiratory, alimentary, excretory and other vital functions.
Breech presentation refers to when the fetus is in a longitudinal lie with its buttocks as the lowest part. The document discusses the different types of breech presentations as well as their incidence, classifications, positions, etiology, diagnosis, and management both during pregnancy and delivery. Management during pregnancy includes attempting external cephalic version after 36 weeks to convert the fetus to head-first position. Management during delivery depends on factors such as gestational age and fetal/maternal conditions, and may involve vaginal delivery with assistance, total breech extraction, or cesarean section to avoid risks to the mother and fetus.
A retained placenta occurs when the placenta is not expelled from the uterus within 30 minutes of childbirth. Risk factors include previous retained placentas, uterine injuries or surgeries, preterm births, induced labor, and multiple pregnancies. Causes can include failure of the placenta to separate fully from the uterine wall or abnormal placenta attachments like placenta accreta. Treatment involves controlled cord traction, manual removal in the operating room if needed, or hysterectomy for deeply embedded placentas. Complications can be life-threatening bleeding, infections, or shock if not properly managed.
This document discusses the first stage of labor and its management. The main events of the first stage are dilatation of the cervix and effacement of the cervix. It describes the processes involved like softening and thinning of the cervix. Management of the first stage focuses on monitoring the mother and fetus, providing comfort, and assessing progress. Complications that may arise include maternal distress, fetal distress, cephalopelvic disproportion, and prolonged labor.
This document discusses the diagnosis of pregnancy through various signs and tests. It outlines the signs and tests used to diagnose pregnancy in each trimester. In the first trimester, common signs include missed period, morning sickness, frequent urination and breast tenderness. Tests include examining the breasts, abdomen, pelvis and cervix. Immunological urine and blood tests detect human chorionic gonadotropin (hCG) produced during pregnancy. The document then discusses signs and tests in the second and third trimesters, which involve monitoring fetal growth, movement and position through physical exam, ultrasound and other tests. Differential diagnoses are also mentioned.
Cardiotocography (CTG) involves continuous electronic monitoring of the fetal heart rate and uterine contractions. It is done externally via ultrasound transducers on the mother's abdomen or internally via an electrode attached to the fetal scalp. CTG is used to evaluate the fetal heart rate patterns including baseline rate, variability, accelerations, and decelerations which can indicate fetal well-being or distress. Abnormal patterns may necessitate changes to labor management or delivery.
This document discusses abnormal labor and its management. It defines normal labor and describes abnormal labor as a difficult labor pattern that deviates from typical progression. Abnormal labor can be caused by issues with the cervix, uterus, maternal pelvis, or fetus. It further outlines the stages of labor and describes factors that can contribute to prolonged latent phase, dysfunctional labor, and dystocia. The management of abnormal labor may include amniotomy, oxytocin administration, operative vaginal delivery, or cesarean section depending on the specific issues present and labor progression. Close monitoring of labor and timely interventions are important to properly manage abnormal labor.
This presentation aims to explain the anatomical features and clinical implications of the lower uterine segment (LUS). The LUS is the part of the uterus between the attachment of the peritoneum superiorly and the internal cervical os inferiorly. It contains less muscle fibers and blood vessels than the upper segment. During pregnancy, the LUS stretches to form the lower part of the uterine cavity in the third trimester. Placental attachment to the LUS can lead to bleeding risks as the area thins in preparation for labor. The LUS is the site of incision for caesarean sections due to its weaker muscles and blood supply.
The document discusses various psychological changes and disorders that can occur during the postpartum period. It describes common changes like adjustment to new roles, postpartum blues, cultural influences on attachment. It also discusses postpartum disorders like depression, anxiety, stress reactions and trauma from delivery, postpartum OCD, PTSD and psychosis. Nursing interventions are focused on early detection and referral for treatment of any psychological issues and supporting positive parenting behaviors.
The document discusses antenatal assessment, which involves the systematic supervision of a pregnant woman. It involves determining risk factors through a comprehensive history and physical exam. Regular checkups are recommended, starting with monthly visits until week 28, then twice monthly until week 36, and weekly during the last 4 weeks. The assessments monitor maternal and fetal health and wellbeing through tests, exams, ultrasounds and more. The goal is to promote a healthy pregnancy and delivery.
Puerperal infection is an infection of the genital tract that occurs after delivery. It is commonly caused by bacteria like Doderlein bacillus. Risk factors include prolonged rupture of membranes, traumatic delivery, and anemia. Symptoms range from local infection to sepsis. Diagnosis involves examinations, tests, and cultures to identify the site and cause of infection. Treatment involves antibiotics, surgery if needed to drain abscesses, and supportive care. Prevention focuses on clean delivery techniques, prompt repair of lacerations, and prophylactic antibiotics in high risk cases.
nurses/doctor will insert two lubricated, gloved fingers into your vagina with one hand, while the other hand presses gently on the outside of your lower abdomen. During this part of the exam, your doctor will check the size and shape of your uterus and ovaries, noting any tender areas or unusual growths.
This topic contains detailed description regarding Normal puerperium, it's definition, duration, phases, involution of uterus and other pelvic organs, lochia, general physiological changes of puerperium, lactation, management of normal puerperium, management of ailments and postnatal care.
Breast engorgement occurs when milk production causes swelling and hardness in the breasts. It is usually caused by a delay in breastfeeding after milk comes in around 3-4 days postpartum. Symptoms include pain, swelling, redness, and difficulty latching. Treatment involves frequent breastfeeding or milk expression, applying hot or cold compresses, wearing a supportive bra, and in severe cases medications like pain relievers or drugs to reduce milk production. Preventing engorgement requires initiating breastfeeding early and frequently to empty the breasts regularly.
Pathophysiology of Normal Labor:
A series of events that take place in female genital organs to expel the product of conception that are fetus, placenta, membranes) out of womb through the vagina into the outer world. We further describe pathogenesis and features of different stages of labor
The third stage of labor involves the separation and expulsion of the placenta after childbirth. The placenta separates from the uterine wall due to uterine contraction. The uterus then contracts further to aid the descent and expulsion of the placenta through the birth canal. Midwives monitor for signs of separation and use techniques like controlled cord traction or fundal pressure to deliver the placenta if needed. Oxytocic drugs may also be used to aid delivery or prevent hemorrhage. Care of both mother and newborn continues for at least an hour after completion of the third stage to ensure uterine contraction and monitor for complications.
This document provides an overview of the signs and symptoms of pregnancy presented by Nidhi Maurya. It begins with objectives to define pregnancy and explain signs and symptoms in each trimester. Common early signs include missed period, nausea, frequent urination and breast changes. Objective signs assessed include uterine size and fetal heart sound detectable after 18 weeks. Signs in the second trimester include quickening and skin changes. Third trimester brings prominent fetal movement and engagement of the presenting part. Fundal height increases throughout pregnancy.
The first stage of normal labour begins with the onset of true labour pains and ends with full dilatation of the cervix. For primi-gravida women this stage typically takes 12 hours, and for multi-gravida women it takes around 6 hours. Nursing care during this stage includes admission assessment, perineal care, monitoring contractions and vital signs, allowing rest and ambulation as tolerated, and shifting the patient to the delivery table once full dilatation is reached. Evidence shows that practices like ambulation during labour, support from a companion, and restricted vaginal exams and enemas can help make the first stage of labour safer and more comfortable.
This document discusses normal amniotic fluid levels at different gestational ages and the causes and effects of oligohydramnios, or low amniotic fluid. It notes that oligohydramnios can be caused by maternal or fetal conditions and presents risks to both mother and fetus. Management involves counseling, serial ultrasounds, amnioinfusion to increase fluid if needed, and close monitoring during labor due to risks of complications from reduced fluid levels like fetal distress, prolonged labor, and infection.
This document discusses induction of labor, including definitions, purposes, indications, contraindications, and methods. The key methods of medical induction discussed are prostaglandins like dinoprostone and misoprostol, oxytocin, and mifepristone. Prostaglandins work to ripen the cervix and stimulate contractions through local effects on cervical collagen and myometrium. Oxytocin stimulates contractions through receptor-mediated pathways. Mifepristone is a progesterone antagonist that blocks progesterone receptors to ripen the cervix. The document compares these methods and provides dosing and administration details.
The document discusses the process of puerperium, which is the period following childbirth where the body returns to its pre-pregnant state over approximately 6 weeks. Key changes include the uterus involuting from 1000g to 100g over this time, the return of ovarian function and menstruation between 8-12 weeks (or longer while breastfeeding), and the production and composition of colostrum and breastmilk. Proper breastfeeding and lactation is encouraged for infant health and development during this postpartum period of maternal physiological changes.
A placenta examination is performed after delivery to ensure the entire placenta and membranes have been expelled. It checks that the placenta is of normal size, shape, consistency and weight, and detects any abnormalities. The examination also evaluates the umbilical cord length and number of blood vessels. Key tools used include a bowl, weighing scale, and measuring tape. The placenta develops during pregnancy to support fetal growth and development through respiratory, alimentary, excretory and other vital functions.
Breech presentation refers to when the fetus is in a longitudinal lie with its buttocks as the lowest part. The document discusses the different types of breech presentations as well as their incidence, classifications, positions, etiology, diagnosis, and management both during pregnancy and delivery. Management during pregnancy includes attempting external cephalic version after 36 weeks to convert the fetus to head-first position. Management during delivery depends on factors such as gestational age and fetal/maternal conditions, and may involve vaginal delivery with assistance, total breech extraction, or cesarean section to avoid risks to the mother and fetus.
A retained placenta occurs when the placenta is not expelled from the uterus within 30 minutes of childbirth. Risk factors include previous retained placentas, uterine injuries or surgeries, preterm births, induced labor, and multiple pregnancies. Causes can include failure of the placenta to separate fully from the uterine wall or abnormal placenta attachments like placenta accreta. Treatment involves controlled cord traction, manual removal in the operating room if needed, or hysterectomy for deeply embedded placentas. Complications can be life-threatening bleeding, infections, or shock if not properly managed.
This document discusses the first stage of labor and its management. The main events of the first stage are dilatation of the cervix and effacement of the cervix. It describes the processes involved like softening and thinning of the cervix. Management of the first stage focuses on monitoring the mother and fetus, providing comfort, and assessing progress. Complications that may arise include maternal distress, fetal distress, cephalopelvic disproportion, and prolonged labor.
This document discusses the diagnosis of pregnancy through various signs and tests. It outlines the signs and tests used to diagnose pregnancy in each trimester. In the first trimester, common signs include missed period, morning sickness, frequent urination and breast tenderness. Tests include examining the breasts, abdomen, pelvis and cervix. Immunological urine and blood tests detect human chorionic gonadotropin (hCG) produced during pregnancy. The document then discusses signs and tests in the second and third trimesters, which involve monitoring fetal growth, movement and position through physical exam, ultrasound and other tests. Differential diagnoses are also mentioned.
Cardiotocography (CTG) involves continuous electronic monitoring of the fetal heart rate and uterine contractions. It is done externally via ultrasound transducers on the mother's abdomen or internally via an electrode attached to the fetal scalp. CTG is used to evaluate the fetal heart rate patterns including baseline rate, variability, accelerations, and decelerations which can indicate fetal well-being or distress. Abnormal patterns may necessitate changes to labor management or delivery.
This document discusses abnormal labor and its management. It defines normal labor and describes abnormal labor as a difficult labor pattern that deviates from typical progression. Abnormal labor can be caused by issues with the cervix, uterus, maternal pelvis, or fetus. It further outlines the stages of labor and describes factors that can contribute to prolonged latent phase, dysfunctional labor, and dystocia. The management of abnormal labor may include amniotomy, oxytocin administration, operative vaginal delivery, or cesarean section depending on the specific issues present and labor progression. Close monitoring of labor and timely interventions are important to properly manage abnormal labor.
This presentation aims to explain the anatomical features and clinical implications of the lower uterine segment (LUS). The LUS is the part of the uterus between the attachment of the peritoneum superiorly and the internal cervical os inferiorly. It contains less muscle fibers and blood vessels than the upper segment. During pregnancy, the LUS stretches to form the lower part of the uterine cavity in the third trimester. Placental attachment to the LUS can lead to bleeding risks as the area thins in preparation for labor. The LUS is the site of incision for caesarean sections due to its weaker muscles and blood supply.
The document discusses various psychological changes and disorders that can occur during the postpartum period. It describes common changes like adjustment to new roles, postpartum blues, cultural influences on attachment. It also discusses postpartum disorders like depression, anxiety, stress reactions and trauma from delivery, postpartum OCD, PTSD and psychosis. Nursing interventions are focused on early detection and referral for treatment of any psychological issues and supporting positive parenting behaviors.
The puerperium is defined as the 6-week period following childbirth when the body recovers from pregnancy and returns to the non-pregnant state. This involves the involution of the uterus and other reproductive organs. The puerperium involves 3 stages - the immediate (first 24 hours), early (first week), and remote (weeks 2-6) periods. During this time the uterus decreases in size, the breasts produce milk, the vagina and perineum heal, and other systems such as the cardiovascular and respiratory systems return to normal. Proper care, rest, perineal exercises, and breastfeeding can help support the mother's recovery.
The document defines the puerperium period as the 6 weeks following childbirth when the body reverts from its pregnant state. It has 3 stages: immediate (24 hours), early (up to 7 days), and remote (up to 6 weeks). During this time, the uterus involutes from 1000g to 60g, the cervix regains its shape by 6 weeks, and other pelvic structures like the vagina and ligaments take longer to revert due to stretching during birth. Women experience lochia discharge, breast and lactation changes, as well as general physiological changes like increased urination and weight loss. Proper management focuses on rest, hygiene and infection prevention. Abnormalities can include puer
This document summarizes the differences between breastfeeding and artificial feeding, as well as the types and benefits of different milks. It discusses how breastfeeding is recommended for infants within one hour of birth and exclusively for six months. The benefits of breastfeeding for infants include reduced risks of various infections, SIDS, diabetes, mental health issues, and allergies. Benefits for mothers include stronger bonding, hormone release assisting weight loss and recovery, and long-term reduced risks of various cancers and diseases. It also outlines the composition differences between human milk, cow's milk, and buffalo's milk, as well as the unique composition and benefits of colostrum for newborn immunity and development.
The document summarizes the development and anatomy of the human placenta. It begins by defining the placenta and outlining its objectives. It then describes the development of the placenta from the chorion and decidua, the structures of the mature placenta including the chorionic plate, basal plate, intervillous space and villi, and the maternal and fetal circulations that occur through it. Finally, it discusses placental aging and the degenerative changes that occur over the course of a pregnancy.
Primary Maternal Care: The puerperium and family planningSaide OER Africa
Primary Maternal Care addresses the needs of healthcare workers in level 1 district hospitals and clinics who provide antenatal and postnatal care, but do not conduct deliveries. It is adapted from theory chapters and skills workshops from Maternal Care. This book complements the national protocol of antenatal care in South Africa. It covers: booking for antenatal care, assesing fetal growth and wellbeing, hypertensive disorders of pregnancy, antepartum haemorrhage, preterm labour, important medical conditions
The third stage of labor involves the delivery of the placenta, umbilical cord, and membranes. It typically lasts 15 minutes for first-time mothers and 5 minutes for others, not exceeding 30 minutes. There are two methods of placental separation - the Schultz method where it separates from the center and the Matthew Duncan method where it separates from the periphery. Controlled cord traction is used to deliver the placenta by applying gentle traction on the umbilical cord after signs of separation are present. The provider then checks the placenta and membranes for completeness.
006 management of the third stage of laborHummd Mdhum
The third stage of labor involves the period from delivery of the baby to delivery of the placenta. It normally takes 5-10 minutes and is divided into four phases: latent phase, contraction phase, detachment phase, and expulsion phase. The major risk is postpartum hemorrhage. Active management, including a uterotonic drug before delivery of the placenta and controlled cord traction, reduces blood loss and risk of retained placenta compared to expectant management. Complete placental separation is confirmed when the cord stops pulsing and cannot be pulled into the uterus.
The document discusses lactation and breastfeeding. It defines lactation as the production and secretion of breast milk after delivery. It describes the five stages of lactation: mammogenesis, lactogenesis, galactokinesis, galactopoiesis, and involution. Mammogenesis involves the development of the breasts. Lactogenesis involves the initiation and maintenance of milk synthesis. Galactokinesis is the ejection of milk from the breasts. Galactopoiesis maintains lactation. Involution is the regression of the breasts after lactation. The document also discusses the composition of breast milk, factors affecting lactation, and medications that can increase or decrease milk production.
The third stage of labour involves the delivery of the placenta and membranes after childbirth. It normally lasts 5-15 minutes but can take up to 30 minutes without significant bleeding. The main risks include postpartum hemorrhage from uterine atony, retained placenta, or genital tract trauma. Active management with controlled cord traction and uterotonics after delivery reduces the risk of PPH compared to expectant management. Complications are treated by uterine massage, additional uterotonics, exploration for trauma, or surgery in severe cases of hemorrhage.
The document discusses active management of the third stage of labor to minimize complications. It outlines the key components of active management, which include the use of oxytocics like oxytocin, controlled cord traction to deliver the placenta, uterine massage after delivery, and examination of the birth canal and placenta. The benefits of active management are highlighted as enhancing placental separation, safe placental delivery, and minimizing bleeding to reduce risks like postpartum hemorrhage.
Physiological and psychological changes during pregnancyHI HI
The document discusses various physiological changes that occur during pregnancy across multiple body systems. It describes changes in the endocrine, reproductive, cardiovascular, respiratory, gastrointestinal, renal, integumentary, and skeletal systems. Major hormonal changes driven by the placenta cause physical adaptations in many organs to support the developing fetus. Organs like the uterus, breasts, and cardiovascular system undergo significant changes to accommodate pregnancy.
The document describes the physiological changes that occur during the postpartum period. It discusses the involution of the uterus, which returns to its non-pregnant size within 6 weeks. It also covers changes in other systems like the endocrine, cardiovascular, respiratory and urinary systems. The postpartum period allows the body to recover from pregnancy and birth by returning the organs to their pre-pregnancy state through processes like autolysis and homeostasis over a period of 6 weeks.
This document discusses the emotional and physical changes that occur during pregnancy for both mothers and fathers. It covers the three trimesters of pregnancy and common feelings in each stage like anxiety, depression, and concern over weight gain or the baby's sex. Fetal development from embryo to fetus is outlined week by week. The importance of emotional support from family as well as understanding the psychological changes of pregnancy for better coping is also emphasized.
The document outlines the benefits of breastfeeding for both mother and baby, stating that breastfeeding provides babies with easy to digest milk containing antibodies that boost immunity, while also aiding weight loss and reducing cancer risks for mothers. Key facts presented include that breastfeeding lowers healthcare costs and misses less work for mothers due to healthier babies. The gold standard is exclusively breastfeeding for six months and continued breastfeeding for up to two years or beyond with appropriate complementary foods.
Puerperium is the period following childbirth during which the body tissues, specially the pelvic organs revert back approximately to the pre-pregnant state both anatomically and physiologically. puerperium begins as soon as the placenta is expelled and lasts for approximately 6 weeks when the uterus becomes regressed almost to the non-pregnant size.
The document discusses the physiology of lactation, including:
1. The anatomy of the breast and changes during pregnancy like increased size and vascularity.
2. The components of colostrum, which is higher in protein and vitamins than milk.
3. The four phases of lactation - preparation of breasts during pregnancy, milk synthesis after delivery stimulated by hormones like prolactin, ejection of milk, and maintenance of lactation.
The document provides information on managing the normal postpartum period, or puerperium. It defines the puerperium as lasting 6 weeks after delivery of the placenta. During this time, the mother's body returns to its non-pregnant state through physical changes in organs like the uterus, breasts, cardiovascular and gastrointestinal systems. Proper management of the first hour after delivery and routine observations are important to prevent postpartum hemorrhage. With no complications, patients can typically be discharged 6 hours after a normal vaginal delivery or after 3 days for a Cesarean section. Follow-up postnatal care is also required during the 6-week period.
The document discusses the normal puerperium period following childbirth. It defines puerperium as the period of approximately 6 weeks postpartum where the body reverts back to its pre-pregnant state anatomically and physiologically. It describes the anatomical changes like uterine involution and the physiological changes in various body systems. It also discusses lactation, nursing management including care of the mother and newborn, management of minor ailments, and checkups before discharge.
Physiological changes in puerperium normal puerperium.pptxNeharikaKumari5
The document summarizes the anatomical and physiological changes that occur during the postpartum period known as the puerperium. Key points include: the puerperium lasts around 6 weeks as the reproductive organs return to their non-pregnant state (involution); the uterus decreases rapidly in size from 1000g immediately after delivery to 50g by 6 weeks; lactation is initiated by withdrawal of progesterone and estrogen allowing prolactin to stimulate milk production; oxytocin triggers milk ejection in response to suckling.
This document discusses the puerperium period following childbirth. It defines puerperium as the time period when the body returns to its pre-pregnant state, which normally lasts 6 weeks. The document outlines the anatomical and physiological changes during this period, including uterine involution and lochia discharge. It also discusses management of normal puerperium, including postnatal care, exercise, treatment of common issues, and health education.
Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning
NURSING MANAGEMENT DURINGTHE POSTPARTUM PERIOD 2021.pdfssuser873e5a1
The document discusses nursing management of the postpartum period, including assessing the physical and emotional changes a woman experiences, monitoring for complications, and providing education on self-care and infant care. It outlines the assessments nurses should perform, including vital signs, a head-to-toe examination checking systems like breasts, uterus, bladder, and lochia, and ensuring the woman's needs are addressed during recovery. The goal of postpartum care is to help the woman and family adapt to the newborn while assisting recovery and identifying any deviations from normal postpartum progression.
The document summarizes the birth process, which consists of three stages: early labor, active labor, pushing and delivery, and delivery of the placenta. Contractions become stronger and more frequent during early and active labor as the cervix dilates. Transition occurs when the cervix is fully dilated and pushing begins. The baby's head emerges during crowning and delivery. Shortly after, the placenta detaches and is delivered.
This document discusses minor ailments and complications that can occur during the postpartum period known as the puerperium. It begins with an introduction to the puerperium and what occurs anatomically and physiologically during the normal postpartum recovery process. Some of the minor ailments discussed include after pains, postpartum hematomas, constipation, and painful perineum. Postpartum hematomas are localized blood collections that can form beneath the skin or vaginal mucosa due to trauma during delivery and cause pain, swelling and difficulty voiding if large. Nursing care involves applying ice, monitoring for signs of infection or increased size, and evacuating large hematomas surgically if needed.
Labour is considered prolonged if it lasts more than 12 hours. It can be caused by issues with the passageway (pelvis), passenger (baby), powers (contractions), or psyche (mental state). Prolonged labour risks maternal and fetal complications if neglected. Close monitoring is needed to detect obstruction early. Treatment depends on fetal viability but may include resuscitating the mother, controlling infection, relieving obstruction via c-section, and post-delivery care like antibiotics and bladder drainage. Abnormal uterine contractions can also prolong labour and are treated with oxytocin.
The postpartum period lasts 6 weeks after childbirth. During this time, the body undergoes both retrogressive and progressive changes. Psychologically, most women experience the taking-in, taking-hold, and letting-go phases as they adjust to their new role as parents. Nursing care focuses on assessment and support of the physiological changes like uterine involution and lactation. Pain management, nutrition, and ensuring adequate rest are also priorities in the postpartum period.
Normal labor progresses through four stages: first stage of dilation, second stage of baby delivery, third stage of placenta delivery, and fourth stage of recovery. The first stage has latent and active phases where the cervix dilates from 0-10 cm. Abnormal labor can occur if there are issues like large baby size, fast or slow progression, or medical complications. Some types of abnormal labor include shoulder dystocia, uterine rupture, precipitous labor, and postpartum hemorrhage. Preterm labor is when labor starts before 37 weeks of pregnancy.
Postpartum slides finals for the studentsBea Galang
The document discusses postpartum care and the postpartum period, which refers to the six weeks following childbirth. The key principles of postpartum care are to promote healing of the body, provide emotional support, establish successful lactation, and prevent complications. Genital changes include involution of the uterus and vagina. Lochia is present and changes color and consistency over time. Vital signs and weight change in the postpartum period. Establishing breastfeeding involves understanding milk production and providing instructions to the mother. The document also discusses newborn care including maintaining temperature and airway, assessment, identification, and nursery care procedures.
The document discusses postpartum care and the postpartum period, which refers to the six weeks following childbirth. The key principles of postpartum care are to promote healing of the body, provide emotional support, establish successful lactation, and prevent complications. Genital changes include involution of the uterus and vagina. Lochia is present and changes color and consistency over time. Vital signs like temperature may fluctuate in the postpartum period. Newborn care focuses on establishing breathing, maintaining temperature, assessing the newborn, identifying the newborn, and providing nursery care like feeding and assessments.
This document provides an overview of abnormal labour, including definitions, causes, signs and symptoms, diagnosis, management, and specific types such as prolonged labour and maternal injuries. Abnormal labour is defined as labour that does not meet normal time limits and milestones. It can be caused by issues with uterine contractions, pelvic abnormalities, large babies, or psychological factors. Prolonged labour increases risks for both mother and baby. Management may include accelerating labour through drugs or proceeding with c-section if needed. Maternal injuries from labour include perineal tears, vaginal tears, cervical tears, and vulval hematoma, which require repair or drainage. The document also describes different types of abnormal uterine action.
The postpartum period, also known as the puerperium, lasts around 6 weeks as the body returns to its pre-pregnant state. During this time, the uterus involutes from 1000g back to 60g, the cervix narrows, and the vagina regains tone. Lochia is discharged for 1-3 weeks as the endometrium regenerates. Physiological changes include temperature regulation returning to normal and increased risk of urinary tract issues as the bladder adapts. Nursing care focuses on monitoring involution and managing any complications.
The normal puerperium period begins after childbirth and lasts approximately 6 weeks as the body reverts back to the pre-pregnant state. Involution is the process by which the genital organs return to their pre-pregnant size and shape. Lochia is the vaginal discharge present for the first 2 weeks, providing information about the mother's health. Proper management includes rest, ambulation, bladder care, treatment of any complications, and promotion of breastfeeding.
The document summarizes the stages and changes that occur during the puerperium period, which is defined as the time from delivery of the placenta through the first 6 weeks postpartum. During this period, the uterus, cervix, vagina, perineum, abdominal wall, ovaries, and breasts all revert back to a nonpregnant state. Most of the reduction in size of the uterus occurs within the first 2 weeks as it recedes to its normal size of 50-100 grams from 1000 grams during pregnancy. The puerperium period is broken down into immediate (first 24 hours), early (first week), and remote (weeks 2-6) stages.
It is a chapter in obstetrics. it is important to know what happens after pregnancy. it includes definition, involution of the uterus,lochia, general physiological changes , lactation, physiology of lactation etc. it is very knowledgeable ppt. please read this vey carefully.
Physiology of puerperium,management of mother during puerperium,postnatal exe...preetishukla38
physiological changes during puerperium is very important to bsc nursing students to understand that what are exactly changes occure in mother during post natal periods.
Assessment and management of woman during postnatal periodHARSH786249
The document summarizes the normal physiological changes that occur during the postnatal period. Key points include:
- The postnatal period, also called the puerperium, lasts 6 weeks as the body returns to its pre-pregnant state. Involution of the uterus and other organs occurs through this period.
- Vital signs like temperature and pulse are monitored to check for issues like hemorrhage and infection. The uterus normally decreases in size steadily in the first weeks after delivery. Lochia discharge indicates the progress of involution.
Asp openly licensed stories for early reading in africa mar 2015 slideshareSaide OER Africa
A recent presentation made by Tessa Welch, the African Storybook Project leader, to University of Pretoria Education students on the project and on openly licensed stories for early reading in Africa.
Quality Considerations in eLearning in South Africa. Presentation at the eLearning Summit, Indaba Hotel, 16 October 2014. Looks the the quality review process and quality criteria.
African Storybook: The First 18 Months of the ProjectSaide OER Africa
Presentation by African Storybook Initiative Leader, Tessa Welch, on the first 18 months of the initiative. Presented on 26 June at the African Storybook Summit at the University of British Columbia.
Digital Storytelling for Multilingual Literacy Development: Implications for ...Saide OER Africa
Digital Storytelling for Multilingual Literacy Development: Implications for Teachers - Presentation by Tessa Welch at the South African Basic Education Conference 31 March - 1 April 2014. Presentation explains Saide's African Storybook Initiative. Overview: Requirements for effective literacy development of young children in African countries; obstacles to achieving this goal; multi-pronged approach to overcoming obstacles; examples of digital storytelling in a school community; implications for teachers.
This document provides an overview of technology trends and outlook for African higher education. It discusses key drivers and constraints to integrating technology, including motivators like access to resources and constraints like low digital fluency of faculty. Current trends include growing social media usage, blended learning, and data-driven assessment. The document outlines different modes of educational provision from fully offline to fully online. It provides an outlook on emerging technologies like flipped classrooms, learning analytics, and 3D printing and their potential impact on higher education in both the short and long term. The talk concludes by emphasizing that technology should support, not replace, good teaching practices.
eLearning or eKnowledge - What are we offering students?Saide OER Africa
eLearning or eKnowledge - What are we offering students? A look at the convergence of elearning and eknowledge, looking at the purpose of the design - informational or instructional? Presented at the Unisa Cambridge Open and Distance eLearning Conference, Stellenbosch.
Presentation given at the Online and eLearining Conference organised by Knowledge Resources at the Forum, Bryanston, Johannesburg 28-29 August 2013. Created by Greig Krull, Sheila Drew and Brenda Mallinson.
Understand school leadership and governance in the South African context (PDF)Saide OER Africa
This module gives an overview of what management and leadership is about in a school setting. As an aspiring principal it begins a process of developing understanding about the challenges that face principals on a daily basis and allows you to also explore your own realities and decide on new and better action. In addition, you will look at some of the international trends in management and leadership and will compare what is happening in the South Africa scene to others.
Toolkit: Unit 8 - Developing a school-based care and support plan.Saide OER Africa
The document provides guidance to school management teams on developing a school-based care and support plan. It includes tools to help schools analyze the needs of vulnerable learners, create a vision statement, conduct a SWOT analysis, and identify strategic goals. The tools would help schools understand the challenges they face in supporting vulnerable students, develop a plan to address these challenges, and establish goals and objectives in key areas like nutrition, aftercare, counseling, and HIV/AIDS education.
Toolkit: Unit 7 - Counselling support for vulnerable learners.Saide OER Africa
The purpose of this toolkit is to conduct a situational analysis or assessment that will help you to understand the size of the challenge and the current capacity of your school to set up a counselling service. To assist you to decide on the most suitable options for implementing counselling support in your school context.
The purpose of this toolkit is to use a brainstorming technique to come up with creative ideas respond to the challenge of providing aftercare support for vulnerable learners. To use the ideas from the brainstorming session to inform the development of a draft set of ideas for an aftercare strategy.
There are different ways of combating discrimination and creating a safe and nonthreatening environment at school. An important contribution can be made by implementing an Anti-Bullying Policy
The guidelines and the five priority areas identified by Department of Education offer a framework that supports the development of a school HIV and AIDS policy. The guidelines and priorities can also be used to review your school's existing HIV and AIDS policy and determine how adequate it is and what changes may be necessary
Toolkit: Unit 1 - How responsive are schools to the socio-economic challenges...Saide OER Africa
The purpose of this toolkit is to understand what threatens the quality of education in your school so that you can take informed action to remedy the situation.
Reading: Understanding Intrapersonal Characteristics (Word)Saide OER Africa
Here are a few key points about Joseph based on the description:
- He struggles to focus, follow instructions, and complete work. This suggests difficulties with attention, executive functioning, and/or self-regulation.
- He is easily distracted and fidgety. This could indicate an attention issue like ADHD.
- He has quick temper outbursts. This points to potential difficulties with emotional regulation.
- The water spill incident triggered an extreme reaction, rather than a calm response like Martha's. This reinforces the idea of challenges with emotional control.
Overall, Joseph seems to exhibit signs of difficulties with attention, self-control, and emotional regulation - all of which could interfere with his ability to function
Reading: Understanding Intrapersonal Characteristics (pdf)Saide OER Africa
The impact of intrapersonal characteristics on school performance and learner development - A reading to accompany Unit Six of the module: Teaching and Learning Mathematics in Diverse Classrooms. This reading is useful because it summaraizes the various theoretical perspectives for understanding inclusive education, and because it uses case studies of typical learners to illustrate how teaching and learning activities need to be adapted to ensure that all children, no matter what their background or intrapersonal characteristics do learn mathematics.
Reading: Guidelines for Inclusive Learning Programmes (word)Saide OER Africa
A reading to accompany Unit Six of the module: Teaching and Learning Mathematics in Diverse Classrooms. This Reading consists of two extracts from a document "Guidelines for Inclusive Education Learning Programmes" produced by the Department of Education in June 2005.
Reading: Guidelines for Inclusive Learning Programmes (pdf)Saide OER Africa
A reading to accompany Unit Six of the module: Teaching and Learning Mathematics in Diverse Classrooms. This Reading consists of two extracts from a document "Guidelines for Inclusive Education Learning Programmes" produced by the Department of Education in June 2005.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
How to Add Chatter in the odoo 17 ERP ModuleCeline George
In Odoo, the chatter is like a chat tool that helps you work together on records. You can leave notes and track things, making it easier to talk with your team and partners. Inside chatter, all communication history, activity, and changes will be displayed.
The simplified electron and muon model, Oscillating Spacetime: The Foundation...RitikBhardwaj56
Discover the Simplified Electron and Muon Model: A New Wave-Based Approach to Understanding Particles delves into a groundbreaking theory that presents electrons and muons as rotating soliton waves within oscillating spacetime. Geared towards students, researchers, and science buffs, this book breaks down complex ideas into simple explanations. It covers topics such as electron waves, temporal dynamics, and the implications of this model on particle physics. With clear illustrations and easy-to-follow explanations, readers will gain a new outlook on the universe's fundamental nature.
ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...PECB
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
Certified as an ISO/IEC 27001: Information Security Management Systems (ISMS) Lead Implementer, Data Protection Officer, and Cyber Risks Analyst, Denis brings a heightened focus on data security, privacy, and cyber resilience to every endeavor.
His expertise extends across a diverse spectrum of reporting, database, and web development applications, underpinned by an exceptional grasp of data storage and virtualization technologies. His proficiency in application testing, database administration, and data cleansing ensures seamless execution of complex projects.
What sets Denis apart is his comprehensive understanding of Business and Systems Analysis technologies, honed through involvement in all phases of the Software Development Lifecycle (SDLC). From meticulous requirements gathering to precise analysis, innovative design, rigorous development, thorough testing, and successful implementation, he has consistently delivered exceptional results.
Throughout his career, he has taken on multifaceted roles, from leading technical project management teams to owning solutions that drive operational excellence. His conscientious and proactive approach is unwavering, whether he is working independently or collaboratively within a team. His ability to connect with colleagues on a personal level underscores his commitment to fostering a harmonious and productive workplace environment.
Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
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A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
বাংলাদেশের অর্থনৈতিক সমীক্ষা ২০২৪ [Bangladesh Economic Review 2024 Bangla.pdf] কম্পিউটার , ট্যাব ও স্মার্ট ফোন ভার্সন সহ সম্পূর্ণ বাংলা ই-বুক বা pdf বই " সুচিপত্র ...বুকমার্ক মেনু 🔖 ও হাইপার লিংক মেনু 📝👆 যুক্ত ..
আমাদের সবার জন্য খুব খুব গুরুত্বপূর্ণ একটি বই ..বিসিএস, ব্যাংক, ইউনিভার্সিটি ভর্তি ও যে কোন প্রতিযোগিতা মূলক পরীক্ষার জন্য এর খুব ইম্পরট্যান্ট একটি বিষয় ...তাছাড়া বাংলাদেশের সাম্প্রতিক যে কোন ডাটা বা তথ্য এই বইতে পাবেন ...
তাই একজন নাগরিক হিসাবে এই তথ্য গুলো আপনার জানা প্রয়োজন ...।
বিসিএস ও ব্যাংক এর লিখিত পরীক্ষা ...+এছাড়া মাধ্যমিক ও উচ্চমাধ্যমিকের স্টুডেন্টদের জন্য অনেক কাজে আসবে ...
This presentation was provided by Steph Pollock of The American Psychological Association’s Journals Program, and Damita Snow, of The American Society of Civil Engineers (ASCE), for the initial session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session One: 'Setting Expectations: a DEIA Primer,' was held June 6, 2024.
Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
Executive Directors Chat Leveraging AI for Diversity, Equity, and InclusionTechSoup
Let’s explore the intersection of technology and equity in the final session of our DEI series. Discover how AI tools, like ChatGPT, can be used to support and enhance your nonprofit's DEI initiatives. Participants will gain insights into practical AI applications and get tips for leveraging technology to advance their DEI goals.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
Main Java[All of the Base Concepts}.docxadhitya5119
This is part 1 of my Java Learning Journey. This Contains Custom methods, classes, constructors, packages, multithreading , try- catch block, finally block and more.
1. 12
The
puerperium
Before you begin this unit, please take the THE NORMAL
corresponding test at the end of the book to
assess your knowledge of the subject matter. You PUERPERIUM
should redo the test after you’ve worked through
the unit, to evaluate what you have learned.
12-1 What is the puerperium?
The puerperium is the period from the end
Objectives of the third stage of labour until most of the
patient’s organs have returned to their pre-
pregnant state.
When you have completed this unit you
should be able to:
12-2 How long does the puerperium last?
• Define the puerperium.
• List the physical changes which occur The puerperium starts when the placenta is
delivered and lasts for six weeks (42 days).
during the puerperium.
However, some organs may only return to
• Manage the normal puerperium. their pre-pregnant state weeks or even months
• Assess a patient at the six-week after the six weeks have elapsed (e.g. the
postnatal visit. ureters). Other organs never regain their pre-
• Diagnose and manage the various pregnant state (e.g. the perineum).
causes of puerperal pyrexia. It is important for the midwife or doctor
• Recognise the puerperal psychiatric to assess whether the puerperal patient has
disorders. returned, as closely as possible, to normal
• Diagnose and manage secondary health and activity.
postpartum haemorrhage.
• Teach the patient the concept of ‘the The puerperium starts when the placenta is
mother as a monitor’. delivered and lasts for six weeks.
12-3 Why is the puerperium important?
1. The patient recovers from her labour,
which often leaves her tired, even
2. 230 MATERNAL CARE
exhausted. There is, nevertheless, a feeling 3. Abdominal wall:
of great relief and happiness. • The abdominal wall is flaccid (loose
2. The patient undergoes what is probably the and wrinkled) and some separation
most important psychological experience of (divarication) of the abdominal
her life, as she realises that she is responsible muscles occurs.
for another human being, her infant. • Pregnancy marks (striae gravidarum),
3. Breastfeeding should be established. where present, do not disappear, but do
4. The patient should decide, with the tend to become less red in time.
guidance of a midwife or doctor, on an 4. Gastrointestinal tract:
appropriate contraceptive method. • Thirst is common.
• The appetite varies from anorexia to
12-4 What physical changes occur ravenous hunger.
in the puerperium? • There may be flatulence (excess wind).
• Many patients are constipated as a
Almost every organ undergoes change in the result of decreased tone of the bowel
puerperium. These adjustments range from during pregnancy, decreased food
mild to marked. Only those changes which are intake during labour and passing stool
important in the management of the normal when nearly fully dilated or during the
puerperium will be described here: second stage of labour. Constipation
1. General condition: is common in the presence of an
• Some women experience shivering episiotomy or painful haemorrhoids.
soon after delivery, without a change in The routine administration of enemas
body temperature. when patients are admitted in labour
• The pulse rate may be slow, normal or is unnecessary and is not beneficial to
fast, but should not be above 100 beats patients. It also causes constipation during
per minute. the puerperium.
• The blood pressure may also vary and 5. Urinary tract:
may be slightly elevated in an otherwise • Retention of urine is common and
healthy patient. It should, however, be may result from decreased tone of the
less than 140/90 mm Hg. bladder in pregnancy and oedema of
• There is an immediate drop in weight the urethra following delivery. Dysuria
of about 8 kg after delivery. Further and difficulty in passing urine may
weight loss follows involution of the lead to complete urinary retention, or
uterus and the normal diuresis (an retention with overflow incontinence.
increased amount of urine passed), but A full bladder will interfere with
also depends on whether the patient uterine contractions.
breastfeeds her infant. • A diuresis usually occurs on the
2. Skin: second or third day of the puerperium.
• The increased pigmentation of the face, In oedematous patients it may start
abdominal wall and vulva lightens but immediately after delivery.
the areolae may remain darker than • Stress incontinence (a leak of urine)
they were before pregnancy. is common when the patient laughs
• With the onset of diuresis the general or coughs. It may first be noted in
puffiness and any oedema disappear in the puerperium or follow stress
a few days. incontinence which was present
• Marked sweating may occur for some during pregnancy. Often stress
days. incontinence becomes worse initially
but tends to improve with time and
with pelvic floor exercises.
3. THE PUERPERIUM 231
Pelvic floor exercises are also known as fingers. By the seventh day postpartum
pinch or ‘knyp’ exercises. The muscles that the cervical os will have closed.
are exercised are those used to suddenly • Uterus: The most important change
stop a stream of urine midway through occurring in the uterus is involution.
micturition. These muscles should be After delivery the uterus is about the
tightened, as strongly as possible, ten times size of a 20-week pregnancy. By the end
in succession on at least four occasions a of the first week it is about 12 weeks
day. in size. At 14 days the fundus of the
uterus should no longer be palpable
NOTE Normal bladder function is likely to be above the symphysis pubis. After six
temporarily impaired when a patient has been weeks it has decreased to the size of a
given epidural analgesia. Complete retention normal multiparous uterus, which is
of urine or retention with overflow may occur.
slightly larger than a nulliparous one.
6. Blood: This remarkable decrease in size is the
• The haemoglobin concentration result of contraction and retraction
becomes stable around the fourth day of the uterine muscle. The normally
of the puerperium. involuting uterus should be firm and
• The platelet count is raised and the non tender. The decidua of the uterus
platelets become more sticky from necroses (dies), due to ischaemia, and is
the fourth to tenth day after delivery. shed as the lochia. The average duration
These and other changes in the clotting of red lochia is 24 days. Thereafter, the
(coagulation) factors may cause lochia becomes straw coloured. Normal
thrombo-embolism in the puerperium. lochia has a typical, non-offensive smell.
7. Breasts: Offensive lochia is always abnormal.
Marked changes occur during the
puerperium with the production of milk.
8. Genital tract: MANAGEMENT OF
Very marked changes occur in the genital THE PUERPERIUM
tract during the puerperium.
• Vulva: The vulva is swollen and The management of the puerperium may be
congested after delivery, but these divided into three stages:
features rapidly disappear. Tears and/or
an episiotomy usually heal easily. 1. The management of the first hour after
• Vagina: Immediately after delivery delivery of the placenta (sometimes called
the vagina is large, smooth walled, the fourth stage of labour).
oedematous and congested. It rapidly 2. The management of the rest of the
shrinks in size and rugae return by the puerperium.
third week. The vaginal walls remain 3. The six week postnatal visit.
laxer than before and some degree of
vaginal prolapse (cystocoele and/or 12-5 How should you manage the first
rectocoele) is common after a vaginal hour after the delivery of the placenta?
delivery. Small vaginal tears, which are
The two main objectives of managing the first
very common, usually heal in seven to
hour of the puerperium are:
ten days.
• Cervix: After the first vaginal delivery 1. To ensure that the patient is, and remains,
the circular external os of the nullipara in a good condition.
becomes slit-like. For the first few 2. The prevention of a postpartum
days after delivery the cervix remains haemorrhage (PPH).
partially open, admitting one or two To achieve these, you should:
4. 232 MATERNAL CARE
1. Perform certain routine observations. 12-8 How can the patient help to prevent
2. Care for the needs of the patient. postpartum haemorrhage during
3. Get the patient’s co-operation in ensuring the first hour of the puerperium?
that her uterus remains well contracted
1. The patient should be shown how to
and that she reports any vaginal bleeding.
observe:
The correct management of the first hour of • The height of the uterine fundus in
the puerperium is most important as the risk relation to the umbilicus.
of postpartum haemorrhage is greatest at this • The feel of a well-contracted uterus.
time. • The amount of vaginal bleeding.
2. She should be shown how to ‘rub up’ the
12-6 Which routine observations uterus.
should you perform in the first hour 3. She should be told that if the uterine
after delivery of the placenta? fundus rises or the uterus relaxes or if
vaginal bleeding increases, she must:
1. Immediately after the delivery of the • Immediately call the midwife.
placenta you should: • In the meantime rub up the uterus.
• Assess whether the uterus is well
contracted. These two important steps may help prevent a
• Assess whether vaginal bleeding postpartum haemorrhage.
appears more than normal.
• Record the patient’s pulse rate, blood The patient can play a very important role in the
pressure and temperature.
prevention of postpartum haemorrhage.
2. During the first hour after the delivery
of the placenta, provided that the above
observations are normal, you should: 12-9 When should a postpartum
• Continuously assess whether the uterus patient be allowed to go home?
is well contracted and that no excessive This will depend on:
vaginal bleeding is present.
• Repeat the measurement of the pulse 1. Whether the patient had a normal
rate and blood pressure after one hour. pregnancy and delivery.
• If the patient’s condition changes, 2. The circumstances of the hospital or clinic
observations must be done more where the patient was delivered.
frequently until the patient’s condition
returns to normal. 12-10 When should a patient be
allowed to go home following a
normal pregnancy and delivery?
Observations during the first hour of the
puerperium are extremely important. A patient who has had a normal pregnancy
and delivery may be allowed to go home about
six hours after the birth of her infant, provided:
12-7 How should you care for the
needs of the patient during the 1. The observations done on the mother and
first hour of the puerperium? infant since delivery have been normal.
2. The mother and infant are normal on
After the placenta has been delivered the
examination, and the infant is sucking well.
patient needs to be:
3. The patient is able to attend her nearest
1. Washed. clinic on the day after delivery (day one)
2. Given something to drink and maybe to eat. and then again on days three and five
3. Allowed to bond with her infant. after delivery for postnatal care, or be
4. Allowed to rest for as long as she needs to. visited at home by a midwife on those
5. THE PUERPERIUM 233
days. Primigravidas should be seen again at least 24 hours to ensure that her uterus
on day seven, especially to ensure that is well contracted and that there is no
breastfeeding is well established. further bleeding.
4. Patients who received no antenatal care
and are delivered without having had 12-12 How will the circumstances at a clinic
any screening tests must have a rapid or hospital influence the time of discharge?
syphilis test and a rapid Rhesus grouping.
Counselling for HIV testing must also be 1. Some clinics have no space to
done. accommodate patients for longer than six
5. A postnatal card needs to be completed hours after delivery. Therefore, patients who
for the mother on discharge as this is the cannot be discharged safely at six hours will
only means of communication between the have to be transferred to a hospital.
delivery site and the clinic where she will 2. Some hospitals manage patients who live
receive postnatal care. in remote areas where follow-up is not
possible. These patients will have to be kept
A patient should only be discharged home after in hospital longer before discharge.
delivery if no abnormalities are found when
the following examinations are performed: 12-13 What postnatal care should be
1. A general examination, paying particular given during the puerperium after the
attention to the: patient has left the hospital or clinic?
• Pulse rate. The following observations must be done on
• Blood pressure. the mother:
• Temperature.
• Haemoglobin concentration. 1. Assess the patient’s general condition.
2. An abdominal examination, paying 2. Observe the pulse rate, blood pressure and
particular attention to the state of temperature.
contraction and tenderness of the uterus. 3. Determine the height of the uterine fundus
3. An inspection of the episiotomy site. and assess whether any uterine tenderness
4. The amount, colour, and odour of the is present.
lochia. 4. Assess the amount, colour, and odour of
5. A postnatal examination was completed the lochia.
for the mother and infant. 5. Check whether the episiotomy is healing
satisfactorily.
12-11 When should a patient be 6. Ask if the patient passes urine normally
discharged from hospital following a and enquire about any urinary symptoms.
complicated pregnancy and delivery? Reassure the patient if she has not passed a
stool by day five.
This will depend on the nature of the 7. Measure the haemoglobin concentration if
complication and the method of delivery. the patient appears pale.
For example: 8. Assess the condition of the patient’s breasts
1. A patient with pre-eclampsia should and nipples. Determine whether successful
be kept in hospital until her blood breastfeeding has been established.
pressure has returned to normal or is well The following observations must be done on
controlled with oral drugs. the infant:
2. A patient who has had a Caesarean section
will usually stay in hospital for three days 1. Assess whether the infant appears well.
or longer. 2. Check whether the infant is jaundiced.
3. A patient who has had a postpartum 3. Examine the umbilical stump for signs of
haemorrhage must be kept in hospital for infection.
6. 234 MATERNAL CARE
4. Examine the eyes for conjunctivitis. 12-16 When should a patient be seen again
5. Ask whether the infant has passed urine after postnatal care has been completed?
and stool.
The postnatal visit is usually held six weeks
6. Assess whether the infant is feeding well
after delivery. By this time almost all the organ
and is satisfied after a feed.
changes which occurred during pregnancy
should have disappeared.
The successful establishment of breastfeeding is
one of the most important goals of patient care
during the puerperium. THE SIX WEEK
POSTNATAL VISIT
12-14 How can you help to establish
successful breastfeeding?
12-17 Which patients need to attend
By providing patient education and a six week postnatal clinic?
motivation. This should preferably start
before pregnancy and continue throughout Patients with specific problems that need to be
the antenatal period and after pregnancy. followed up six weeks postpartum, e.g. patients
Encouragement and support are very who were discharged with hypertension need
important during the first weeks after delivery. to come back to have their blood pressure
The important role of breastfeeding in measured. Patients who are healthy may be
lowering infant mortality in poor communities referred directly to the mother-and-child
must be remembered. health clinics.
12-15 Which topics should you 12-18 What are the objectives of
include under patient education the six week postnatal visit?
in the puerperium? It is important to determine whether:
Patient education regarding herself, her 1. The patient is healthy and has returned to
infant, and her family should not start during her normal activities.
the puerperium, but should be part of any 2. The infant is well and growing normally.
woman’s general education, starting at school. 3. Breastfeeding has been satisfactorily
Topics which should be emphasised in patient established.
education in the puerperium include: 4. Contraception has been arranged to the
1. Personal and infant care. patient’s satisfaction.
2. Offensive lochia must be reported 5. The patient has been referred to a mother-
immediately. and-child health clinic for further care.
3. The ‘puerperal blues’. 6. The patient has any questions about
4. Family planning. herself, her infant, or her family.
5. Any special arrangements for the next
pregnancy and delivery. 12-19 How should the six week
6. When to start coitus again. Usually postnatal visit be conducted?
coitus can be started three to four weeks
1. The patient is asked how she and her infant
postpartum when the episiotomy or tears
have been since they were discharged from
have healed.
the hospital or clinic.
2. The patient is then examined. On
Patient education is an important and often examination pay particular attention
neglected part of postnatal care. to the blood pressure and breasts, and
look for signs of anaemia. An abdominal
7. THE PUERPERIUM 235
examination is followed by a speculum
Puerperal pyrexia may be caused by a serious
examination to check whether the
complication of the puerperium.
episiotomy, vulval, or vaginal tears have
healed. A cytology smear of the cervix
should be taken if the patient is 30 years 12-22 What are the causes
or older and has not previously had a of puerperal pyrexia?
normal cervical smear. A cervical smear
1. Genital tract infection.
should also be taken on any woman
2. Urinary tract infection.
who has previously had an abnormal
3. Mastitis or breast abscess.
smear. A bimanual examination is then
4. Thrombophlebitis (superficial vein
done to assess the size of the uterus. The
thrombosis).
haemoglobin is measured and the urine
5. Respiratory tract infection.
tested for glucose and protein.
6. Other infections.
3. Attention must be given to any specific
reason why the patient is being followed
up, e.g. arrangements for the management 12-23 What is the cause of
of patients who remain hypertensive after genital tract infection?
delivery. Genital tract infection (or puerperal sepsis)
4. The patient is given health education as is caused by bacterial infection of the raw
set out in section 12-15. It should again be placental site or lacerations of the cervix,
remembered to ask her whether she has vagina or perineum.
any questions she would like to ask.
NOTE Genital tract infection is usually caused
If the patient and her infant are both well, they by the group A or group B Streptococcus,
are referred to their local mother-and-child Staphylococcus aureus or anaerobic bacteria.
health clinic for further follow-up.
12-24 How should you diagnose
A patient and her infant should only be discharged genital tract infection?
if they are both well and have been referred to
1. History
the local mother-and-child health clinic, and the If one or more of the following is present:
patient has received contraceptive counselling. • Preterm or prelabour rupture of the
membranes, a long labour, operative
delivery, or incomplete delivery of
PUERPERAL PYREXIA the placenta or membranes may have
occurred.
• The patient will feel generally unwell.
12-20 When is puerperal pyrexia present? • Lower abdominal pain.
A patient has puerperal pyrexia if her oral 2. Examination
temperature rises to 38 °C or higher during the • Pyrexia, usually developing within the
puerperium. first 24 hours after delivery. Rigors may
occur.
12-21 Why is puerperal pyrexia important? • Marked tachycardia.
• Lower abdominal tenderness.
Because it may be caused by serious • Offensive lochia.
complications of the puerperium. • The episiotomy wound or perineal or
Breastfeeding may be interfered with. The vaginal tears may be infected.
patient may become very ill or even die.
NOTE If possible, an endocervical swab should be
taken for microscopy, culture, and sensitivity tests.
8. 236 MATERNAL CARE
12-25 How should you manage 12-26 How must a patient with
genital tract infection? offensive lochia be managed?
1. Prevention 1. If the patient has pyrexia she must be
• Strict asepsis during delivery. admitted to hospital.
• Reduction in the number of vaginal 2. If the involution of the patient’s uterus is
examinations during labour to a slower than expected and the cervical os
minimum. remains open, retained placental products
• Prevention of unnecessary trauma are present. An evacuation of the uterus
during labour. under general anaesthesia must be done.
• Isolation of infected patients. 3. If the patient has a normal temperature
2. Treatment and normal involution of her uterus, she
• Admit the patient to hospital. can be managed as an outpatient with oral
• Bring down the patient’s temperature, ampicillin and metronidazole (Flagyl).
e.g. by tepid sponging.
• Give the patient analgesia, e.g.
paracetamol (Panado) 1 g (two adult
Offensive lochia is an important sign of genital
tablets) orally six-hourly. tract infection.
• Adequate fluid intake with strict intake
and output measurement. 12-27 How should you diagnose
• Broad spectrum antibiotics, e.g. a urinary tract infection?
intravenous ampicillin and oral
1. History
metronidazole (Flagyl). If the patient
• The patient may have been catheterised
is to be referred, antibiotic treatment
during labour or in the puerperium.
must be started before transfer.
• The patient complains of rigors
• The haemoglobin concentration must
(shivering) and lower abdominal pain
be measured. A blood transfusion
and/or pain in the lower back over one
must be given if the haemoglobin
or both the kidneys (the loins).
concentration is below 8 g/dl.
• Dysuria and frequency. However, these
• Removal of all stitches if the wound is
are not reliable symptoms of urinary
infected.
tract infection.
• Drainage of any abscess.
2. Examination
• If there is subinvolution of the
• Pyrexia, often with rigors (shivering).
uterus, an evacuation under general
• Tachycardia.
anaesthetic must be done.
• Suprapubic tenderness and/or
NOTE 24 hours after starting this treatment
tenderness, especially to percussion,
the patient’s condition should have improved over the kidneys (punch tenderness in
considerably and the temperature should by the renal angles).
then be normal. If this is not the case, evacuation 3. Side-room and special investigations
of the uterus is required and gentamicin must • Microscopy of a midstream or catheter
be added to the antibiotics. A laporotomy specimen of urine usually shows large
and possibly a hysterectomy is indicated, if numbers of pus cells and bacteria.
peritonitis and subinvolution of the uterus
• Culture and sensitivity tests of the
are present, and there is no response to the
measures detailed above. Transfer the patient to
urine must be done if the facilities are
the appropriate level of care for this purpose. available.
The presence of pyrexia and punch tenderness
in the renal angles indicate an upper renal
9. THE PUERPERIUM 237
tract infection and a diagnosis of acute • Tachycardia.
pyelonephritis must be made. • Presence of a localised area of the
forearm or leg which is swollen, red
12-28 How should you manage a and tender.
patient with a urinary tract infection?
12-31 How should you manage a patient
1. Prevention
with superficial vein thrombophlebitis?
• Avoid catheterisation whenever
possible. If catheterisation is essential, 1. Give analgesia, e.g. aspirin 300 mg (one
it must be done with strict aseptic adult tablet) six-hourly.
precautions. 2. Support the leg with an elastic bandage.
2. Treatment 3. Encourage the patient to walk around.
• Admit the patient to hospital.
• Take measures to bring down the
temperature. RESPIRATORY TRACT
• Analgesia, e.g. paracetamol (Panado) INFECTION
1 g orally six-hourly.
• Adequate fluid intake.
• Intravenous cefuroxime (Zinecef) 12-32 How should you diagnose a
750 mg eight-hourly. lower respiratory tract infection?
NOTE Organisms causing acute pyelonephritis
A lower respiratory tract infection, such as
are often resistant to ampicillin, therefore acute bronchitis or pneumonia, is diagnosed
intravenous cefuroxime (Zinacef ) must be used. as follows:
1. History
Antibiotics should not be given to a patient • The patient may have had general
with puerperal pyrexia until she has been fully anaesthesia with endotracheal
investigated. intubation, e.g. for a Caesarean section.
• Cough, which may be productive.
• Pain in the chest.
• A recent upper respiratory tract
THROMBOPHLEBITIS infection.
2. Examination
• Pyrexia.
12-29 What is superficial vein • Tachypnoea (breathing rapidly).
thrombophlebitis? • Tachycardia.
This is a non-infective inflammation and 3. Special investigations
thrombosis of the superficial veins of the • A chest X-ray is useful in diagnosing
leg or forearm where an infusion was given. pneumonia.
Thrombophlebitis commonly occurs during
the puerperium, especially in varicose veins. NOTE Examination of the chest may reveal basal
dullness due to collapse, increased breath
sounds or crepitations due to pneumonia,
12-30 How should you diagnose or bilateral rhonchi due to bronchitis.
superficial leg vein thrombophlebitis?
1. History 12-33 How should you manage a patient
• Painful swelling of the leg or forearm. with a lower respiratory tract infection.
• Presence of varicose veins. 1. Prevention
2. Examination • Skilled anaesthesia.
• Pyrexia.
10. 238 MATERNAL CARE
• Proper care of the patient during • Genital tract.
induction and recovery from • Legs, especially the calves.
anaesthesia. 4. Perform the necessary special
• Encourage deep breathing and coughing investigations, but always send off a:
following a general anaesthetic to • Endocervical swab.
prevent lower lobe collapse. • Midstream or catheter specimen of
2. Treatment urine.
• Admit the patient to hospital, unless 5. Start the appropriate treatment.
the infection is very mild.
• Oxygen, if required.
• Ampicillin orally or intravenously
If a patient presents with puerperal pyrexia
depending on the severity of the the cause of the pyrexia must be found and
infection. appropriately treated.
• Analgesia, e.g. paracetamol (Panado)
1 g six-hourly.
• Physiotherapy. PUERPERAL PSYCHIATRIC
3. Special investigations
• Send a sample of sputum for DISORDERS
microscopy, culture, and sensitivity
testing if possible.
12-36 Which are the puerperal
psychiatric disorders?
12-34 Which other infections may
cause puerperal pyrexia? 1. The ‘puerperal blues’.
2. Temporary postnatal depression.
Tonsillitis, influenza and any other acute 3. Puerperal psychosis.
infection, e.g. acute appendicitis.
12-37 Why is it important to recognise the
12-35 What should you do if a patient various puerperal psychiatric disorders?
presents with puerperal pyrexia?
1. The ‘puerperal blues’ are very common in
1. Ask the patient what she thinks is wrong the first week after delivery, especially on
with her. day three. The patient feels miserable and
2. Specifically ask for symptoms which cries easily. Although the patient may be
point to: very distressed, all that is required is an
• An infection of the throat or ears. explanation, reassurance, and a caring,
• Mastitis or breast abscess. sympathetic attitude and emotional support.
• A chest infection. The condition improves within a few days.
• A urinary tract infection. 2. Postnatal depression is much commoner
• An infected abdominal wound if the than is generally realised. It may last for
patient had a Caesarean section or a months or even years and patients may
puerperal sterilisation. need to be referred to a psychiatrist.
• Genital tract infection. Patients with postnatal depression usually
• Superficial leg vein thrombophlebitis. present with a depressed mood that cannot
3. Examine the patient systematically, be relieved, a lack of interest in their
including the: surroundings, a poor or excessive appetite,
• Throat and ears. sleeping difficulties, feelings of inadequacy,
• Breasts. guilt and helplessness, and sometimes
• Chest. suicidal thoughts.
• Abdominal wound, if present.
• Urinary tract.
11. THE PUERPERIUM 239
3. Puerperal psychosis is an uncommon but However, the cause is unknown in up to half of
very important condition. The onset is these patients.
usually acute and an observant attendant
will notice the sudden and marked change NOTE Gestational trophoblastic disease
in the patient’s behaviour. She may rapidly (hydatidiform mole or choriocarcinoma) and
pose a threat to her infant, the staff, and a disorder of blood coagulation may also
cause secondary postpartum haemorrhage.
herself. Such a patient must be referred
urgently to a psychiatrist and will usually
need admission to a psychiatric unit. 12-41 What clinical features should alert you
to the possibility of the patient developing
NOTE Patients with puerperal psychosis are secondary postpartum haemorrhage?
unable to care for themselves or their infants.
1. A history of incomplete delivery of the
They are often disorientated and paranoid
and may have hallucinations. They may placenta and/or membranes.
also be severely depressed or manic. 2. Unexplained puerperal pyrexia.
3. Delayed involution of the uterus.
4. Offensive and/or persistently red lochia.
SECONDARY POSTPARTUM
12-42 How should you manage a patient
HAEMORRHAGE with secondary postpartum haemorrhage?
1. Prevention
12-38 What is secondary • Aseptic technique throughout labour,
postpartum haemorrhage? the delivery and the puerperium.
• Careful examination after delivery to
This is any amount of vaginal bleeding, other determine whether the placenta and
than the normal amount of lochia, occurring membranes are complete.
after the first 24 hours postpartum until the • Proper repair of vaginal and perineal
end of the puerperium. It commonly occurs lacerations.
between the fifth and 15th days after delivery. 2. Treatment
• Admission of the patient to hospital is
12-39 Why is secondary postpartum indicated, except in very mild cases of
haemorrhage important? secondary postpartum haemorrhage.
1. A secondary postpartum haemorrhage • Review of the clinical notes with regard
may be so severe that it causes shock. to completeness of the placenta and
2. Unless the cause of the secondary membranes.
postpartum haemorrhage is treated, the • Obtain an endocervical swab for
vaginal bleeding will continue. bacteriology.
• Give ampicillin and metronidazole
(Flagyl) orally.
12-40 What are the causes of secondary
• Give 20 units oxytocin in an
postpartum haemorrhage?
intravenous infusion if excessive
1. Genital tract infection with or without bleeding is present.
retention of a piece of placenta or part of the • Blood transfusion, if the haemoglobin
membranes. This is the commonest cause. concentration drops below 8 g/dl.
2. Separation of an infected slough in a • Removal of retained placental products
cervical or vaginal laceration. under general anaesthesia.
3. Breakdown (dehiscence) of a Caesarean
section wound of the uterus.
12. 240 MATERNAL CARE
12-43 What may you find on physical • Conjunctivitis.
examination to suggest that retained • Infection of the umbilical cord stump.
pieces of placenta or membranes
are the cause of a secondary
Each patient must be taught to monitor her own
postpartum haemorrhage?
wellbeing, as well as that of her fetus or infant.
1. The uterus will be involuting slower than
usual.
2. Even though the patient may be more than
seven days postpartum, the cervical os
CASE STUDY 1
will have remained open (a finger can be
passed through the cervix). Following a spontaneous vertex delivery in
a clinic, you have delivered the placenta and
membranes completely. The maternal and fetal
SELF-MONITORING conditions are good and there is no abnormal
vaginal bleeding. You are the only staff
member in the clinic. You are called away and
12-44 What is meant by the concept will have to leave the patient alone for a while.
of ‘the mother as a monitor’?
This is a concept where the patient is made 1. How can you get the patient’s help in
aware of the many ways in which she can preventing a postpartum haemorrhage?
monitor her own, as well as her fetus’ or infant’s The patient should be shown how to observe:
wellbeing, during pregnancy, in labour, and in
the puerperium. This has two major advantages: 1. The height of the uterine fundus.
2. Whether the uterus is well contracted.
1. The patient becomes much more involved 3. The amount of vaginal bleeding.
in her own perinatal care. 4. She should also be asked to empty her
2. Possible complications will be reported by bladder frequently.
the patient at the earliest opportunity.
2. What should the patient do if
12-45 How can the patient act as she notices that her uterus relaxes
a monitor in the puerperium? and/or there is vaginal bleeding?
The patient must be encouraged to report She should rub up the uterus and call you
the following complications as soon as she immediately.
becomes aware of them:
1. Maternal complications 3. What should you check on
• Symptoms of puerperal pyrexia. before leaving the patient?
• Breakdown of an episiotomy.
You should make sure that:
• Breastfeeding problems.
• Excessive or offensive lochia. 1. The patient and her infant’s observations are
• Recurrence of vaginal bleeding, i.e. normal and both their conditions are stable.
secondary postpartum haemorrhage. 2. The patient understands what she has to do.
• Prolonged postnatal depression. 3. You will be able to hear the patient, if she
2. Complications in the infant calls you.
• Poor feeding or other feeding
problems.
• Lethargy.
• Jaundice.
13. THE PUERPERIUM 241
CASE STUDY 2 2. Which contraceptive method she should
use and how to use it correctly.
3. The care and feeding of her infant,
A patient returns to a clinic for a visit three
stressing the importance of breastfeeding.
days after a normal first pregnancy and
4. The time that coitus can be resumed.
delivery. She complains of leaking urine
when coughing or laughing, and she is also Also ask about, and discuss, any other
worried that she has not passed a stool since uncertainties which the patient may have.
the delivery. She starts to cry and says that she
should not have fallen pregnant. Her infant
takes the breast well and sleeps well after each CASE STUDY 3
feed. On examination the patient appears well,
her observations are normal, the uterus is the Following a prolonged first stage of labour due
size of a 16-week pregnant uterus, and the to an occipito-posterior position, a patient has
lochia is red and not offensive. a spontaneous vertex delivery. The placenta and
membranes are complete. There is no excessive
1. Is her puerperium progressing normally? postpartum blood loss and the patient is
Yes. The patient appears healthy with normal discharged home after six hours. Within 24
observations, and the involution of her uterus hours of delivery the patient is brought back
is satisfactory. to the clinic. She has a temperature of 39 °C,
a pulse rate of 110 beats per minute and
complains of a headache and lower abdominal
2. What should be done about
pain. The uterus is tender to palpation.
the patient’s complaints?
Stress incontinence is common during 1. What does the patient present with?
the puerperium. Therefore, the patient
must be reassured that it will improve over Puerperal pyrexia.
time. However, pelvic floor exercises must
be explained to her as they will hasten 2. What is the most likely cause
improvement of her incontinence. She need of the puerperal pyrexia?
not be worried about not having passed a stool Genital tract infection, i.e. puerperal sepsis.
as this is normal during the first few days of This diagnosis is suggested by the general
the puerperium. signs of infection and the uterine tenderness.
The patient had a prolonged first stage of
3. Why is the patient regretting labour, which is usually accompanied by
her pregnancy and crying for a greater than usual number of vaginal
no apparent reason? examinations and, therefore, predisposes her
She probably has the ‘puerperal blues’ which to genital tract infection.
are common in the puerperium. Listen
sympathetically to the patient’s complaints 3. Was the early postnatal management
and reassure her that she is managing well as of this patient correct?
a mother. Also explain that her feelings are No. The patient should not have been
normal and are experienced by most mothers. discharged home so early as she had a
prolonged first stage of labour which places
4. What educational topics must be her at a higher risk of infection. She should
discussed with the patient during this visit? have been observed for at least 24 hours.
1. Family size and when she plans to have her
next infant.
14. 242 MATERNAL CARE
4. How should you manage this 2. What is the most likely cause
patient further in the clinic? of the patient’s pyrexia?
She must be made comfortable. Paracetamol An upper urinary tract infection as suggested
(Panado) 1 g orally may be given for the by the pyrexia, rigors, lower abdominal pain
headache. If necessary, she should be given and tenderness over the kidneys.
a tepid sponging. An intravenous infusion
should be started and she must then be 3. Do you agree with the management
referred to hospital. If at all possible, the infant given to the patient?
must accompany the patient to hospital. The
need to start antibiotic treatment, such as No. A urinary tract infection that causes
intravenous ampicillin and oral metronidazole puerperal pyrexia is an indication for
(Flagyl), before transfer must be discussed admitting the patient to hospital. Intravenous
with the doctor. cefuroxime (Zinecef) must be given, as this
will lead to a rapid recovery and prevent
serious complications.
CASE STUDY 4
4. Why is a puerperal patient at
risk of a urinary tract infection and
A patient is seen at a clinic on day five following
how may this be prevented?
a normal pregnancy, labour and delivery. She
complains of rigors and lower abdominal pain. Catheterisation is often required and this
She has a temperature of 38.5 °C, tenderness increases the risk of a urinary tract infection.
over both kidneys (loins) and tenderness to Catheterisation must only be carried out
percussion over both renal angles. A diagnosis when necessary and must always be done as
of puerperal pyrexia is made and the patient is an aseptic procedure. Screening and treating
given oral ampicillin. She is asked to come back asymptomatic bacteriuria at the antenatal
to the clinic on day seven. clinic will reduce acute pyelonephritis during
the puerperium.
1. Are you satisfied with the
diagnosis of puerperal pyrexia?
No. Puerperal pyrexia is a clinical sign and
not a diagnosis. The cause of the pyrexia must
be found by taking a history, doing a physical
examination and, if indicated, completing
special investigations.