An introduction to postpartum care of mother and newborn; associated complications of delivery and management

1. NORMAL PUERPERIUM AND
POSTNATAL CARE
Dr Adu Appiah-Kubi
Consultant, Gynaecologic Oncologist
Snr lecturer, SoM, Uhas
HO

3. Introduction
The work of the obstetrician still continues even after delivery of the
fetus
The puerperium or postnatal period is important:
 The foundations of bonding between mother and baby are laid
 Establishment of lactation
 Psychological changes take place
 Reversal of the physiological changes that occurred during
pregnancy

4. Puerperium

5. The puerperium
the period following delivery where the reproductive organs return to
their normal pre-pregnant state
It spans from delivery of the placenta till 6 weeks thereafter
Synonymous with the Postnatal period
Divided into:
Immediate puerperium: 24hours after delivery
Early puerperium: between the 2nd
to 7th
day after delivery
Late puerperium: from the 2nd
week through to the 6th
week after delivery

6. Anatomical and physiological changes
After delivery of placenta levels of the ff hormones fall rapidly
Estrogen
Progesterone
 hCG
hPL
Fall in the levels of these hormones result in reversal of the
physiological changes of pregnancy

7. Uterus
Undergoes involution:
 the process by which the postpartum uterus, weighing about 1kg
returns to its pre-pregnancy state of less than 100g
After the 3rd
stage of labour,
the uterine fundus is at the level of the umbilicus
(20 -22weeks of gestation)
2 weeks after delivery,
uterine fundus is at pubic symphysis
At 6 weeks,
it is not palpable abdominally

8. • Involution is accelerated by the release of oxytocin
• The rate of involution is much slower after a CS
• The uterus regains its pre-pregnant size at about 4 weeks after
delivery
• The cervix regains its consistency within 3 days and by 10 days the os
is about 1cm wide

10. Uterine sub-involution
Definition
 Arrest or retardation of the postpartum involution of the uterus
Features:
 Prolongation of lochia discharge
 Irregular or excessive uterine bleeding which sometimes may be
profuse
 Uterus is larger and softer
Causes: retention of placental fragments and puerperal sepsis

11. The lochia
Definition
Blood-stained uterine discharge comprising blood and necrotic
decidua which discharge after delivery
Only the superficial layer of the decidua becomes necrotic and
sloughs off
The basal layer adjacent to the myometrium is left intact and is
subsequently involved in the regeneration of new endometrium and
this is complete by the 3rd
week.

12. Lochial changes
First few days after delivery:
 lochia is red (lochia rubra); consists of blood and decidual debris
 The colour then becomes pink when it contains mainly WBCs,
decidual debris and some red cells. (Lochia serosa)
By end of the first week:
 it is yellowish-white in colour, consisting mainly of serous fluid and WBCs.
(Lochia alba)
Persistent red lochia suggests delayed involution

14. Endometrial regeneration
2-3 days after delivery the remaining decidua becomes differentiated
into 2 layers
Superficial layer: becomes necrotic and is sloughed off in the lochia
Basal layer: adjacent to the myometrium, remains intact, source of new
endometrium
The endometrium regenerates: from proliferation of the endometrial
glandular remnants and the stroma of the inter-glandular connective
tissue
Regeneration is rapid, except at the placental site
Entire endometrium is restored by the third week

15. Ovarian activity
Breastfeeding induces a reduction in GnRH, LH and FSH
This results in amenorrhoea
menses (before 6 months) are mostly anovulatory
Fertility remains low
On average, HCG becomes negative 2 weeks after delivery

16. The vulva, vagina and pelvic floor
Early puerperium:
vagina and its outlet form a capacious smooth-walled passage that gradually diminishes in
size
Rarely returns to nulliparous dimensions
Day 4:
Re-absorption of excess fluid in these tissues
Third week
Vaginal rugae reappear
The torn hymen shows several small tags of tissue which after healing are converted into the
carunculae myrtiformes
Changes in the pelvic support during parturition predispose to uterine prolapse and to
urinary stress incontinence

17. Cardiovascular and haematological changes
Following delivery:
First 4 days:
transient rise in both DBP and SBP
Then a progressive fall in BP
6 weeks:
BP reaches pre-pregnancy pressures in majority of women
Progressive fall in blood volume after delivery
Results in initial rise in haemoglobin concentration on first day after
delivery
Followed by a sharp fall to a minimum level on 4th
and 5th
days

18. Hormonal changes
By 72hrs:
 fall in levels of sex steroids (progesterone, estradiol) to pre-
pregnancy levels
By 24hrs following delivery:
 serum HPL reaches undetectable levels (half life of HPL is 20mins)
By 7 days:
 HCG levels fall below 100mIU/ml (half life of 9hrs)
Pituitary hormones: FSH, LH remain at their low pre-pregnancy levels for
first 10 days

19. Management of normal
puerperium
.

20. Management during first hour
• Prevention and control of post-partum haemorrhage (PPH)
• Repair of any perineal trauma
• Initiation of bonding
• Careful and complete examination of neonate
• Check vital signs: temperature, Pulse, BP, respiration
• Check fundal height; ensure uterus is well contracted
• Observe for any bleeding PV
• Oxytocin drip may be run for up to 4-6hrs after delivery when risk of
PPH is high

21. Management of subsequent 23hrs
Haemorrhage:
 ensure uterus remain well
contracted and that there is no
abnormal bleeding PV
Adequate analgesia:
 esp.
if she had CS,
 repair of episiotomy/perineal tear
and
having postpartum contractions
(after pains)
Adequate rest:
 esp. if labour was prolonged
Urinary tract:
 ensure regular bladder
emptying to avoid urinary
retention
Maternal nutrition:
 counsel on intake of adequate
amounts of calories and fluids
Breastfeeding:
 mother is taught how to put the
baby to the breast and
encouraged to establish lactation

22. Management over the next 6 days
Detection and prevention of sepsis
Establishment of breastfeeding
Prevention of DVT
Ensure adequate rest for mother esp. if baby is restless at night or
mother is being plagued by visitors
Psychological support
Physiotherapy, pelvic floor exercises (Kegel’s)
Contraceptive advice (given before discharge from hospital)

23. POSTNATAL CARE

24. Definition:
• Health care and education given both mother and baby during the
puerperium

25. Objectives of PNC
To maintain the physical and psychological well-being of both mother
and baby
To detect and treat/refer complications in both mother and baby
To provide education on nutrition, infant feeding and immunization
• To counsel and provide family planning services

26. Activities
Management of normal puerperium
Identification and management of complications
Micronutrient supplementation
Birth registration
Immunization of both mother and baby
HIV counselling and testing (if not done during ANC)
Counselling on safe sex practices and STI prevention
Family planning counselling and services

27. Conduct of PNC
Traditionally 2 visits are required
At 7-10 days and at 6 weeks
Currently WHO recommends:
1st
visit: within 24-72hrs (esp. for women who deliver outside a health
facility)
2nd
visit: at 7-10 days
3rd
visit: at 6 weeks
Other visits may be scheduled as necessary

28. First visit
For the mother:
Review delivery notes if available
Obtain complaints
Review lab results (Hb, urinalysis)
Perform a general examination
Check for pallor, BP and Pulse, extremities for oedema
Specific examinations
Breast: engorgement, warmth/tenderness, cracked/sore nipples, milk
flow

29. Abdomen
Distension
Tenderness
Operation wound
healing (if any)
Uterine size
Any other masses:
ovarian enlargement
Perineum
General hygiene
Lochia: colour, odour,
amount
Tears/episiotomy
healing
Any swellings:
haematoma

30. Client education
Personal hygiene
Nutritional requirements
Infant feeding (exclusive breastfeeding)
Baby’s immunization
Birth registration
HIV counselling and testing
Counselling on safe sex practices and STI prevention
Counsel on family planning counselling and services
Danger signs of the puerperium

31. Danger signs of the puerperium
FEVER
SEVERE LOWER ABDOMINAL PAIN
OFFENSIVE/EXCESSIVE LOCHIA
EXCESSIVE BLEEDING
SEVERE HEADACHES

32. For the baby
Review delivery findings
Obtain any complaints: feeding well, crying well, passage of stools
Perform a general examination: check for hydration (fontanelles),
pallor, jaundice, umbilicus
Discuss danger signs in the newborn

33. Danger signs in the newborn
No passage of stools since birth
Pustular skin rash
Discharging eyes
Inflamed/ discharging umbilical stump
Jaundice
Swollen abdomen

34. Subsequent Visits
Obtain complaints
Review any laboratory tests
Repeat physical examinations on both mother and baby
Check baby’s immunization schedule
Counsel of family planning and help client make an informed choice

35. Conclusion
Discussed puerperium and postnatal care
Attention must be paid to both mother and the neonate
Proper postnatal care is needed to enable a subsequent
pregnancy better

36. Thank you