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MS.SASIKALA .N, MSC (N),
OBSTETRICS & GYNECOLOGICAL NURSING
LECTURER
GANGA COLLEGE OF NURSING
COIMBATORE
Normal Puerperium
Content Overview
• Puerperium : Definition
• Duration
• Anatomical Changes
• Physiological changes
• Lactation
• Nursing Management
• Management Of Minor Ailments
• Records
• Check up And Advice On Discharge.
Introduction
 Postpartum period is the period beginning
immediately after the birth of a child and
extending for about six weeks
 The WHO describes the Postnatal period as the
most critical and yet the most neglected phase in
the lives of mothers and babies; most death occurs
during the Postnatal period.
Definition – Puerperium
• Puerperium is the period following the childbirth
during which the body tissues, specially the pelvic
organs revert back approximately to the pre
pregnant state both Anatomically and
Physiologically
• Involution is the process whereby the genital
organs revert back approximately to the state as
they were before pregnancy.
The women is termed as Puerpera.
Duration
• Puerperium begins as soon as the placenta
expelled and last for approximately 6 weeks when
Maternal system return to pregnant state.
Immediate : within 24 hours
Early : up to 7days
Remote : up to 6weeks.
Anatomical changes during Puerperium
1. Involution of uterus :
Uterus :
• Becomes firm and retracted with hardening and
softening.
• Measures about 20x12x7.5cm(Length x Breadth x
Thickness) and weighs about 1000gm
• At the end of 6 weeks become non pregnant state
weight about 60gm.
Cont..
Lower uterine segment :
● Immediately following delivery, the
Lower segment becomes a Thin, Flabby,
Collapsed structure.
● It takes few weeks to get revert back to pre-
pregnant state.
Cont…
Cont…
Clinical assessmentof Involutionofuterus
• Funduslies13.5cm forthe 1st24hrs following delivery
• Steady decrease by1.25cminnext24hrs
• At Day14(2ndweek)-notpalpable-pelvicorgan
Cervix contracts slowly,
• External os : for few days can admit 2 fingers.by
the end of 1st week narrow down can admit tip of
finger only.
• Cervix never return back to nulliparous state.
• Internal os : closes as before
Physiological changes
 Muscles:
myometrial
autolysis cellsizereduced
Inc.
steroid collagenase
hormones andproteolyticenzyme
Endophlebitis Thrombosis
Fibrinoid endarteritis Hyalinisation
BloodVessels
Cont…
 Endometrium
 Regenerationstartson day 10
 Endometrium arises from proliferation of
endometrial glandular and stroma of the inter
glandular
• By the 10th day : regeneration of epithelium
completed.
• By the 16th day : the endometrium is restored.
• At about 6 weeks : the endometrium of placental
site is restored
Placental site involution
Other pelvic structure
4-8weeks;
It regain its tone. but
Does not revert to
originalstate.
Hymen is lacerated and it
is like a nodular tag.
Vagina
Long time
d/t
stretching
during
parturition
Pelvicfloor&Fascia
Lochia
• Vaginal discharge for the 1stfortnight during
puerperium
● Odor: Offensive fishysmell
● Reaction :Alkaline reaction
Colour and Composition of Lochia
 Lochia Rubra : 1-4days
• Blood
• Fetal membrane & decidua
 Lochia serosa : 5-9days
• Less RBC
• Leucocytes, Microorganisms
• Shreds, Lanugo, Meconium
 LochiaAlba : 10-15days
• Leukocytes, Micro organism,
• Cholestrin crystals & Decidual cells
Measurement of discharge
• If it is excessive the number of pad changes can be
measured in every 15mins
• Weighing measures : 1 gram = 1 ml of blood
• By inch tape :
• Scanty = <1 inch stain
• Small = <4 inch
• Moderate = < 6 inch
• Heavy = > 6 inch
• Excessive : pad saturation with in 15mins
Clinical Importance
•Puerperal Sepsis,
•E.Coli, retained tissues.
•Infection
•Lochiometra
•Infection
•Sub involution
•Retainedconceptus
•Causes secondaryPPH
•Local genitalinfection
Malodorous
Scanty/absent
Excessive
Red colorpersist
Lochia Alba
beyond 3weeks
General physiological changes
 Pulse:
 Raises following delivery but settles down to
normal on 2nd day
 Temperature:
 It should not exceed 99 degree Fahrenheit.
Any raise above suggestive of infection of
Genito-urinarytract
 GIT:
 Increased thirstduetoexcessivebloodloss
 Constipation due to intestinal paresis
 Reduced abdominal muscle tone.
cont…
 UrinaryTract:
 Pronounced Diuresison 2nd -3rdday
 Overdistension
 Presence of residualurine
 High riskofinfection
 Weight Loss:
 5-6kgexpulsionof fetusplacenta, liqour,
blood
 2kg-during puerperium dt diuresis
 Continued up to 6monthsof delivery
Cont..
 BloodValues:
 Immediate-reduced blood volume;Normalin
2weeks
 Riseincardiacoutput; Normal in1week
 Leukocytosis dt stress
 Plateletcountreduced;normalstatewithin2wks.
 Menstruation:
 Ifnot breastfeeding- resumesin6wks in
40% cases and by 12th week in 80%
cases.
 If breast fed her baby then, the
menstruation occur until the baby stops
breast fed.
Cont..
 Ovulation:
 Non-lactating mother- 4wks
 Lactating mother- 10weeks
 Exclusive Breastfeeding- 98%contraception
up6months
Lactation
• Colostrum : First secretion from the beast milk is
called colostrum
Lactation reflex arc and the role of prolactin and
oxytocin
Changes in Breast and Lactation
• Mammary duct-
gland growth and
development
• Initiation of milk
secretion in alveoli
• Maintenance of
lactation
• Removal of milk
from gland
Physiology of lactation
Cont…
Composition of colostrum
 Deep yellow serous fluid
 High specific gravity
 High protein
 High vitamin A and chloride content
 Low carbohydrate fat and sodium content
Advantages :
 The Ab( IgA, IgG and IgM) and humoral factors
(lactoferrin) provide immunological defense to the
newborn
 It has laxative action on the baby because of large
fat globules
Nursing care of mother during
puerperium (immediate care)
Principles :
• To give all out attention to restore the health status
of the mother
• To prevent infection
• To take care of the breast, to promote lactation and
to take care of the child
• To motivate the mother for contraception
1.Rest and ambulance
• Good rest to feel fresh and can breast feed the
baby.
• Good sleep is in need for both physical and mental
health
Early ambulation :
• To provide sense of wellbeing.
• Bladder complications and constipation are
reduced
• Facilitates uterine drainage and hastens involution
of the uterus
• Lessens puerperal venous thrombosis and
2.Diet
Normal diet :
• High calories, adequate protein, fat, plenty of
fluids, minerals and vitamins
3.Care of bowel and bladder
• The mother is encouraged to pass urine following
delivery as soon as convenient
• A diet containing sufficient roughage and fluids is
enough to move the bowel
4. Care of vulva and episiotomy wound
• After delivery vulva and buttocks are washed with
soap and water down over the anus and a sterile
pad is applied.
• Personal cleanliness of the vulval region.
• The perineal wound should be dressed with spirit
and antiseptic powder after micturition and
defecation.
• Change sanitary pads atleast every 2-4hours
• Encourage sitz bath 20mnts thrice a day.
• Educate mother to take well balanced diet(rich
protein and vitamin)
Cont..
• Avoid from scratching or touching the wound site
unnecessarily.
• Educate the mother regarding signs of
infection(swelling, redness etc.)
• Early ambulation to help healing process of
episiotomy wound.
• Kegel exercise to strengthen the pelvis and lessen
perineal pain.
5.Call doctor or health care provider if
mother has
• Repeated clots the size of a quarter or larger passing
from the vagina.
• Heavy or gushing bleeding from the vagina.
• Discharge that has a bad odor.
• Severe pain in the abdomen or increased pain near
your stitches.
• Fever or chill.
• No bowel movement within one week after the birth
of your baby.
• Pain or urgency with urination or inability to urinate.
6.Care of breast
• The Nipple should be washed with water before
each feeding.
• It should be kept dry after the feeding is over
• Support he breast with brassiere.
• Avoid Nipple soreness.
7.Maternal infant bonding-rooming in
• It starts from first few moments after birth.
• The baby should be kept in her bed or in a cot
besides her bed.
• Rooming in promotes parent infant bonding.
• Initiate breast feeding.
Positions and attachment
8.Asepsis and antiseptics
• Maintain asepsis during perineal wound dressing
• Use clean bed linen and clothing
• Clean surroundings
• Limited number of visitors to prevent infection
9.Management of ailments
After pain :
• Abdominal pain due to presence of placental bits
or blood clots
Nursing care:
• Massaging the uterus
• Check for expulsion of the clots
• Administer analgesics and antispasmodics
• If there is a pain in the perineum check for vulval
hematoma
Nursing care :
• Sitz bath with hot or cold water
Records
• Vital signs : record twice a day
• Measurement of height of the uterus above the
symphysis pubis once a day same time(check for
involution of the uterus)
• Character of lochia
• Bowel and bladder movement
For new born:
• Vital signs
• Weight
• Nutrition(sucking well)
• Bowel and bladder
Check up and advice on discharge
• Continuance of supplementary iron therapy
• Postnatal exercise
• Return back to routine physical activity
• Breast feeding and care of the New born
• Avoidance of intercourse 4-6weeks until
lacerations or episiotomy wound healing
• Family planning advice and guidance
• Postnatal check up after 6weeks.
Normal Puerperium

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Normal Puerperium

  • 1. MS.SASIKALA .N, MSC (N), OBSTETRICS & GYNECOLOGICAL NURSING LECTURER GANGA COLLEGE OF NURSING COIMBATORE
  • 3. Content Overview • Puerperium : Definition • Duration • Anatomical Changes • Physiological changes • Lactation • Nursing Management • Management Of Minor Ailments • Records • Check up And Advice On Discharge.
  • 4. Introduction  Postpartum period is the period beginning immediately after the birth of a child and extending for about six weeks  The WHO describes the Postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most death occurs during the Postnatal period.
  • 5. Definition – Puerperium • Puerperium is the period following the childbirth during which the body tissues, specially the pelvic organs revert back approximately to the pre pregnant state both Anatomically and Physiologically • Involution is the process whereby the genital organs revert back approximately to the state as they were before pregnancy. The women is termed as Puerpera.
  • 6. Duration • Puerperium begins as soon as the placenta expelled and last for approximately 6 weeks when Maternal system return to pregnant state. Immediate : within 24 hours Early : up to 7days Remote : up to 6weeks.
  • 7. Anatomical changes during Puerperium 1. Involution of uterus : Uterus : • Becomes firm and retracted with hardening and softening. • Measures about 20x12x7.5cm(Length x Breadth x Thickness) and weighs about 1000gm • At the end of 6 weeks become non pregnant state weight about 60gm.
  • 8. Cont.. Lower uterine segment : ● Immediately following delivery, the Lower segment becomes a Thin, Flabby, Collapsed structure. ● It takes few weeks to get revert back to pre- pregnant state.
  • 10. Cont… Clinical assessmentof Involutionofuterus • Funduslies13.5cm forthe 1st24hrs following delivery • Steady decrease by1.25cminnext24hrs • At Day14(2ndweek)-notpalpable-pelvicorgan Cervix contracts slowly, • External os : for few days can admit 2 fingers.by the end of 1st week narrow down can admit tip of finger only. • Cervix never return back to nulliparous state. • Internal os : closes as before
  • 11. Physiological changes  Muscles: myometrial autolysis cellsizereduced Inc. steroid collagenase hormones andproteolyticenzyme Endophlebitis Thrombosis Fibrinoid endarteritis Hyalinisation BloodVessels
  • 12. Cont…  Endometrium  Regenerationstartson day 10  Endometrium arises from proliferation of endometrial glandular and stroma of the inter glandular • By the 10th day : regeneration of epithelium completed. • By the 16th day : the endometrium is restored. • At about 6 weeks : the endometrium of placental site is restored
  • 14. Other pelvic structure 4-8weeks; It regain its tone. but Does not revert to originalstate. Hymen is lacerated and it is like a nodular tag. Vagina Long time d/t stretching during parturition Pelvicfloor&Fascia
  • 15. Lochia • Vaginal discharge for the 1stfortnight during puerperium ● Odor: Offensive fishysmell ● Reaction :Alkaline reaction
  • 16. Colour and Composition of Lochia  Lochia Rubra : 1-4days • Blood • Fetal membrane & decidua  Lochia serosa : 5-9days • Less RBC • Leucocytes, Microorganisms • Shreds, Lanugo, Meconium  LochiaAlba : 10-15days • Leukocytes, Micro organism, • Cholestrin crystals & Decidual cells
  • 17. Measurement of discharge • If it is excessive the number of pad changes can be measured in every 15mins • Weighing measures : 1 gram = 1 ml of blood • By inch tape : • Scanty = <1 inch stain • Small = <4 inch • Moderate = < 6 inch • Heavy = > 6 inch • Excessive : pad saturation with in 15mins
  • 18. Clinical Importance •Puerperal Sepsis, •E.Coli, retained tissues. •Infection •Lochiometra •Infection •Sub involution •Retainedconceptus •Causes secondaryPPH •Local genitalinfection Malodorous Scanty/absent Excessive Red colorpersist Lochia Alba beyond 3weeks
  • 19. General physiological changes  Pulse:  Raises following delivery but settles down to normal on 2nd day  Temperature:  It should not exceed 99 degree Fahrenheit. Any raise above suggestive of infection of Genito-urinarytract  GIT:  Increased thirstduetoexcessivebloodloss  Constipation due to intestinal paresis  Reduced abdominal muscle tone.
  • 20. cont…  UrinaryTract:  Pronounced Diuresison 2nd -3rdday  Overdistension  Presence of residualurine  High riskofinfection  Weight Loss:  5-6kgexpulsionof fetusplacenta, liqour, blood  2kg-during puerperium dt diuresis  Continued up to 6monthsof delivery
  • 21. Cont..  BloodValues:  Immediate-reduced blood volume;Normalin 2weeks  Riseincardiacoutput; Normal in1week  Leukocytosis dt stress  Plateletcountreduced;normalstatewithin2wks.  Menstruation:  Ifnot breastfeeding- resumesin6wks in 40% cases and by 12th week in 80% cases.  If breast fed her baby then, the menstruation occur until the baby stops breast fed.
  • 22. Cont..  Ovulation:  Non-lactating mother- 4wks  Lactating mother- 10weeks  Exclusive Breastfeeding- 98%contraception up6months
  • 23. Lactation • Colostrum : First secretion from the beast milk is called colostrum
  • 24. Lactation reflex arc and the role of prolactin and oxytocin
  • 25. Changes in Breast and Lactation • Mammary duct- gland growth and development • Initiation of milk secretion in alveoli • Maintenance of lactation • Removal of milk from gland
  • 27. Cont… Composition of colostrum  Deep yellow serous fluid  High specific gravity  High protein  High vitamin A and chloride content  Low carbohydrate fat and sodium content Advantages :  The Ab( IgA, IgG and IgM) and humoral factors (lactoferrin) provide immunological defense to the newborn  It has laxative action on the baby because of large fat globules
  • 28. Nursing care of mother during puerperium (immediate care) Principles : • To give all out attention to restore the health status of the mother • To prevent infection • To take care of the breast, to promote lactation and to take care of the child • To motivate the mother for contraception
  • 29. 1.Rest and ambulance • Good rest to feel fresh and can breast feed the baby. • Good sleep is in need for both physical and mental health Early ambulation : • To provide sense of wellbeing. • Bladder complications and constipation are reduced • Facilitates uterine drainage and hastens involution of the uterus • Lessens puerperal venous thrombosis and
  • 30. 2.Diet Normal diet : • High calories, adequate protein, fat, plenty of fluids, minerals and vitamins
  • 31. 3.Care of bowel and bladder • The mother is encouraged to pass urine following delivery as soon as convenient • A diet containing sufficient roughage and fluids is enough to move the bowel
  • 32. 4. Care of vulva and episiotomy wound • After delivery vulva and buttocks are washed with soap and water down over the anus and a sterile pad is applied. • Personal cleanliness of the vulval region. • The perineal wound should be dressed with spirit and antiseptic powder after micturition and defecation. • Change sanitary pads atleast every 2-4hours • Encourage sitz bath 20mnts thrice a day. • Educate mother to take well balanced diet(rich protein and vitamin)
  • 33. Cont.. • Avoid from scratching or touching the wound site unnecessarily. • Educate the mother regarding signs of infection(swelling, redness etc.) • Early ambulation to help healing process of episiotomy wound. • Kegel exercise to strengthen the pelvis and lessen perineal pain.
  • 34. 5.Call doctor or health care provider if mother has • Repeated clots the size of a quarter or larger passing from the vagina. • Heavy or gushing bleeding from the vagina. • Discharge that has a bad odor. • Severe pain in the abdomen or increased pain near your stitches. • Fever or chill. • No bowel movement within one week after the birth of your baby. • Pain or urgency with urination or inability to urinate.
  • 35. 6.Care of breast • The Nipple should be washed with water before each feeding. • It should be kept dry after the feeding is over • Support he breast with brassiere. • Avoid Nipple soreness.
  • 36. 7.Maternal infant bonding-rooming in • It starts from first few moments after birth. • The baby should be kept in her bed or in a cot besides her bed. • Rooming in promotes parent infant bonding. • Initiate breast feeding.
  • 38. 8.Asepsis and antiseptics • Maintain asepsis during perineal wound dressing • Use clean bed linen and clothing • Clean surroundings • Limited number of visitors to prevent infection
  • 39. 9.Management of ailments After pain : • Abdominal pain due to presence of placental bits or blood clots Nursing care: • Massaging the uterus • Check for expulsion of the clots • Administer analgesics and antispasmodics • If there is a pain in the perineum check for vulval hematoma Nursing care : • Sitz bath with hot or cold water
  • 40. Records • Vital signs : record twice a day • Measurement of height of the uterus above the symphysis pubis once a day same time(check for involution of the uterus) • Character of lochia • Bowel and bladder movement For new born: • Vital signs • Weight • Nutrition(sucking well) • Bowel and bladder
  • 41. Check up and advice on discharge • Continuance of supplementary iron therapy • Postnatal exercise • Return back to routine physical activity • Breast feeding and care of the New born • Avoidance of intercourse 4-6weeks until lacerations or episiotomy wound healing • Family planning advice and guidance • Postnatal check up after 6weeks.