Transcript post partum pp

Normal Postparutm Period
Lecturer: Eman Abu-Alfawaris
Objectives
• By the end of this session, the student
should be able to:
• Define postpartum period.
• Enumerate characteristics of PPP.
• Describe physiological changes during PPP.
• Explain psychological changes during PPP.
• Assess woman for uterine involution, lochia,
perineum, uterine consistency.
 Definition of puerperium:
• The first 6 weeks "40 days" following the
birth of an infant are known as the post
partum period or puerperium, in which
maternal body in general and genital
organs in particular return to nearly prepregnancy state.
• Puerperium is divided into immediate
postpartum (first 24 hours), early
postpartum (first week), and late
postpartum "from second week till end
of six weeks".
Characteristics of PPP:
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Involution: of the reproductive organs
or regressive changed.
Lactation: is initiated.
Recovery: from physiological effort &
emotional symptoms “Recuperation”.
 Post Partum Physiological Changes:
Endometrial regeneration is completed by about 3 weeks
except for the placental site, where regeneration is not
complete until 6 weeks.
• A. Reproductive system:
Involution rate:
1. Involution
of the
the size
uterus:Immediately• following
delivery,
of uterus as large
grapefruit and
can be palpated
between that
the
• Involution
refersmidway
to the changes
symphysis pubis
and umbilicus,
reproductive
organs, especially the
uterus, under go after childbirth to
Within an hour, the fundus rises to the level above the
return to their nearly pre-pregnancy size
umbilicus and should remain at this level for about 24
andnow
condition.
hours the uterus
weighs approximately 1000 gm.
• The involution occurs by two processes:
After 24 hours, the fundus begins to descend by
approximately 1cm, or one fingerbreadth, per day, so that
by the 10th day it is in the pelvic cavity and cannot be
palpated abdominally.
Objectives
Factors
that enhance involution
Characteristics
ofinclude:
PPP:
•Uncomplicated labor and birth.
•Breast-feeding.
•Early, frequent ambulation.
Factors that slow uterine involution include:
•Prolonged labor.
•Incomplete separation and expulsion of placenta.
•Previous labors.
•Distended (full) bladder.
•Anesthesia.
Assessment of involution of
uterus after childbirth– 2
days after childbirth
Assessment of involution
of uterus after childbirth–
4 days after childbirth
• Lochia:
• It is the uterine discharge coming through the
vagina during the first 3-4 weeks or the post
partum.
• It is alkaline in reaction; the amount is more
than the menstrual flow, with fleshy odor.
• It contains blood, fibrin, leucocytes, dead
decidual tissue, vaginal cells, peptone,
cholesterol, and numerous nonpathogenic
bacteria.
• types of Lochia
Type
Dases
Colors
Componants
Lochia rubra:
Lasts from the 1st post
partum days, to the
4th day
Red in color
fair amount of blood
shreds of the deciduas
amount of chorion,
aminiotic fluid, lanugo
hair, vernix caseosa
fatty epithelial cells,
leukocyte
Lochia serosa:
4-9 days
Pinkish yellow
discharge
containing less blood
and more serum
leukocyte ,
microorganism
Lochia alba:
10th day until 2-6
weeks postpartum .
Creamy or white
colored
leucocytes and mucus ,
epithelial cells,
microorganism .lochia
serosa has strong odor
• according to the amount the lochia classify to
– scant lochia: less than 2-5 cm blood on the
perineal pad
– light or mild lochia: less than 10cm blood on the
perineal pad\hrs
– moderate lochia: less than 15cm stain perineal
pad\hrs
– heavy lochia: 1 saturated pad\hrs
– sever lochia : more than 1 saturated pad \hrs
2. Cervix:
• Small tears or lacerations may be present, and the cervix is often
edematous. Rapid healing takes place, and the end of the first
week the cervix feels firm and the external so is the width of a
pencil.
• The internal os closes as nearly before pregnancy, but the shape
of the external os is permanently changed. It remains slightly
open and appears slit-like rather than round, as in the nulliparous
women.
• Complete cervical involution may take 3-4 months and child
birth result in a permanent change in an cervical OS from round
to elongated.
3. Vagina:
The vagina diminishes in size, but not as the pregravida state.
Rugea reappears in the third week. These are small skin folds
in the lower part, dark red in color.
The vagina and vaginal introitus are greatly stretched during
birth to allow passage of the fetus. Soon after childbirth, the
vaginal walls appear edematous, and multiple small
lacerations may be present.
The hymen is permanently torn and heals with small, irregular
tag of tissue visible at the vaginal introitus.
the site of placental attachment require 6-7
weeks to heal. In process called Exfoliation
4. Vulva:
Edema, minute or frank laceration may be seen
immediately after labor. Edema disappears
gradually in a few days while lacerations, if not
properly mended by sutures, may lead to the
formation of a post partum ulcer.
5. Perineum:
The appearance of the perineum will vary greatly,
depending on the type and extent of the episiotomy
or laceration.
Commonly the soft tissues of the perineum are
edematous and bruised. Ecchymosis due to rupture
of surface capillaries.
Resumption of Ovulation and Menstruation:
•Most non-nursing mothers resume
menstruation within 7 to 9 weeks after
childbirth.
•In lactating mothers, menstruation usually
reappears not earlier then 3-4 months, and
some times as late as 24 months.
•The first period is generally profuse and
prolonged.
•It should be mentioned that ovulation can
commence in the absence of menstruation,
and another pregnancy can occur.
 Body
weight:
Loss of weight is observed during the first l0 days
particularly in the non-lactating mothers. There is about a 4 –
5 kg loss of body weight (sometimes 8 kg) due to evacuation
of uterine contents and diuresis.
B. Cardiovascular System:
1. Cardiac out put:
•Despite the blood loss and transient increase in the maternal
cardiac output occurs following childbirth. This increase is
caused by Increased flow of blood back to the heart when
blood from the uteroplacental unit returns to central
circulation.
2. Blood volume:
Following delivery, despite 300 to 500 ml of blood loss during
normal vaginal delivery, and 500-1000 ml is lost in cesarean
births, excess blood volume, which was necessary during
pregnancy, remains in the intravascular compartment and in
interstitial spaces.
The body rids itself of the excess fluids by two
methods
1.Diuresis: “increased excretion of urine” is facilitated by a
decline in the adrenal hormone aldosterone, which is
increased during pregnancy to counteract the salt-wasting
effect of progesterone.
• urinary output of 3000 ml per day is not common for the first
few days of the post partum period.
2. Diaphoresis “profuse perspiration” also rids the
body of excess fluids through skin "sweating often
occurs at night"
3. Coagulation:
During pregnancy, plasma fibrinogen necessary for
coagulation increased as a protection against post
partum hemorrhage. As a result, the mother’s body
has a great ability to form clots and thus prevent
excessive bleeding.
4. Blood values:
The white blood cells count increasing 10.000/mm up to
20.000 or even 30.000/mm during postpartum
A moderate increase in the fibrinogen and sedimentation rate
occurs during the first postpartum period, and then gradually
gets back to normal values.
•HB% also diminishes, but not proportionately, decrease in
the homatocrit occurs during the plasma increases and thus
dilutes the concentration of blood cells and other substance
carried by the plasma.
•In the absence of complications and with proper diet and
hygiene, RBC count and content, and the blood constituents
usually return to the non-pregnant levels in 4-6 weeks.
•If the patient is Rh negative, evaluate her need for RhO(D)
immune globulin (RhoGAM). If indicated, administer the
RhoGAM within 72 hours of delivery
5. Vital signs:
at least twice daily and more frequently if indicated:
temperature : may increase in the first 24 hrs reach to
38 c after delivery ,because of the dehydration during
labor so encourage fluid intake .
pulse : decrease pulse rate during the 1st week to 6070 beat\mint(24-48 hrs), if increase you should think
of hemorrhage, anxiety, excitement.pain, visitor
Blood pressure : should be unchanged , if BP
>140\90mmhg may indicate postpartum hemorrhage.
Respiratory rate: unchanged . Respiratory function
Returns to normal by approximately 6 to 8 weeks
postpartum
C. Gastrointestinal System:
•Thirst is present due to the marked fluid
loss through sweat and urine.
•Tendency to atony of the gastrointestinal
tract, with flatulence and constipation.
•Constipation may be present as a result
of:
Intestinal atony.
Anorexia after labor.
Loss of body fluids.
Laxity of the abdominal wall.
Hemorrhoids, perineal trauma and
episiotomy.
• Normal bowel function returns approximately
2 to 3 days postpartum
• Gall bladder contractility increases to normal,
allowing for expulsion of small gallstones.
• -After cesarean section, bowel tone returns in
few days and flatulence causes abdominal
discomfort
system
of the postpartum woman has an increased capacity and has lost some of its muscle
birth the urethra, bladder, and tissue around the urinary meatus may become edemato
ults in diminish sensitivity to fluid pressure, and many mothers have no sensation of
der is distended.
tion and over distention of the bladder may cause two complications:
ct infection.
2. Post partum hemorrhage.
Changes in composition of urine:•Mild proteinuria may occur as a result of the
breakdown of uterine cells. common for 1 to 2 days
after delivery in 50% of postpartum women.
•The urine may also test positive for acetone /
ketonuria resulting from dehydration during a
prolonged labor.
•Lactoseuria may occur in breast-feeding woman as
a result of the lactation process.
•Bladder tone returns between 5 and 7 days
E.
Musculoskeletal system:
Muscles and joints:
•During the first few days, levels of the
hormone relaxin gradually subside.
Ligaments and cartilage of the pelvis
begin to return to their pre-pregnancy
position. This can cause hip or joint pain
that interferes with ambulation and
exercise.
•Good body mechanics and correct
posture are important during this time to
prevent low back pain and injury to the
joint
• Abdominal wall:
• During pregnancy, the abdominal walls stretch
to accommodate the growing of the fetus and
muscle tone diminished.
• Many women, expecting that the abdominal
muscles will return to the pre-pregnancy
condition after labor, are dismayed to find the
abdominal muscles weak, soft, and Flabby.
• The longitudinal muscles of the abdomen may
also separate (diastasis recti) during
pregnancy. The separation may be minimal or
sever.
• F. Integumentary system:
• After birth, the skin gradually reverts back to pre-pregnancy
state.
• The melanocyte-stimulating hormone (MSH) levels, which
caused hyperpigmentation during pregnancy decreases
rapidly after childbirth that result in disappear of chloasma
and linea nigra by 6 week.
• Skin erythema, which may develop during pregnancy as a
result of increased estrogen level, gradually disappear.
• Steria gnavidarum which develop on the abdomen, thighs,
and breasts, gradually become silvery lines and less
noticeable, but don’t disappear completely
• Hair loss can increase for the first 4 to 20 weeks postpartum
and then re-growth will occur, although the hair may not be
as thick as it was before pregnancy.
G. Endocrine system:
•Following expulsion of the placenta, a fairly rapid
decline occurs in placental hormones such as
estrogen, progesterone, human placental lactogen,
and human chronic gonadotrophin.
•Adrenal hormones, such as aldosterone, return to
pre-pregnancy levels.
•FSH remains low for about 12 days then begin to
rise to initiate new menstrual cycle, first cycle is
frequently an ovulatorty.
Neurological function:
• Discomfort and fatigue are common.
• Frontal and bilateral headaches are common
and are caused by fluid shifts in the first week
postpartum.
Physiology of lactation:
Lactation consists of two distinct processes:
1. "Milk production After labor, sudden fall of estrogen
and progesterone levels leads to marked rise of
prolactin level. This hormone stimulates the alveolar
cells leading to milk secretion.
2. Milk ejection:Stimulation of the nipple and areola (by
suckling), leads to increased production of oxytocin
from posterior pituitary. This hormone acts on the
myoepithelial cells which line the ducts causing its
contraction. Milk is ejected into the lactiferous ducts
and cysternae, where it is readily available to the
suckling infant (Let down reflex" ) .
• "Nipple erection reflex" results also from
stimulation of the nipple by suckling or tactile
stimulation of the nipple. This is of great help
to the baby during suckling.
Factors Affecting Milk
Production
1- Regular complete
breastfeeding.
2- Suckling abilities of newborn.
3- Maternal health, and Nutrition.
4- Psychological factors.
5-Hormones : Prolactin, Oxytocin,
Thyroxin, Growth hormone, in
addition to Progesterone and
estrogen. Normal levels of these
hormones are essential for
initiation & maintenance of
lactation.
• Composition of Breast Milk:
• There is a higher fat content at midday for
example and in the hind milk white the fore
milk always contains more water protein. BM
is alkaline hued, bluish white in color. Average
sample for 24hr is said to contain protein 1.5%
fat 3.5% mineral salts 0.2% water 87.8%
vitamins as in colostrums calorific value 80 kilo
joules per 30ml.
• Post Partum Psychological Changes:
• After delivery, the woman may progress through
Rubin's stages of taking in, taking hold, and letting
go.
Dependent or “ Taking –in phase. :It takes 2-3 days,
Woman exhibits passive, dependent behavior.
the mother's first concern is with her own needs
Dependent – independent or “ Taking- hold “ phase.
It starts the 3rd day postpartum & lasts about 10 days
Openness to teaching on care of self and neonate.
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• Interdependent or “ letting – go “ phase:
Mothering functions become more established
there are two separations that the mother must
accomplish.
One is to realize and accept physical separation from
the infant
Second is to relinquish her former role as a childless
person and accept the enormous implications and
responsibilities other new situation. She must adjust
her life to the relative dependency and helplessness
other child.
Management of Postpartum Period
• Early needs of the mother:
1- Observation and recording to:
Vital signs
Check vital signs 2 times daily "morning and evening".
Observe for symptoms of hypovolemic shock and hemorrhage.
A temperature of 38c or above, for two consecutive days
after the first24hrs.is considered an early sign of puerperal
infection
 Bradycardia is a normal physiological phenomenon
Uterus
•Palpate the uterus daily to assess firmness
level of fundus, and the rate of involution of
the uterus.
•It should be well contracted, central and
involutes gradually at the rate of about 1cm
daily during the first seven to ten days of the
puerperium.
• Breast:
• The breasts are examined to note their tension and
consistency, and the signs of infection.
• In breast-feeding mothers, the amount and flow of
milk and the condition of the nipples and areola
should be observed.
• Perineum
• Observe perineum and suture line if present, for
redness, ecchymosis, and edema or gapping. Check
healing and cleanliness
• During the examination haemorrids may be noted
and appropriate treatment advised.
Lochia
Check lochia for
color, amount,
odor, consistency
and blood clots.
Urine out put
The urine out put is usually recorded for the first
24 hours after delivery to ensure that the woman is
passing and adequate amount of urine.
Legs
The midwife examines the patient's leg for pain
and edema
Emotional state
Phases of developing maternal role.
Post partum blues.
2. Rest and sleep:
Provide for sufficient periods of rest and sleep to
maintain physical and mental health, as to promote
lactation (8hrs nighttime sleep and 2hrs after noon-nap
are needed).
3.
Diet:
Provide diet high in proteins and calories
to restore tissues.
A daily requirement of 3000-3500 cal/day
is needed in the form of a well balanced
diet rich in 1st class proteins, calcium,
iron, vitamins, thiamine, riboflavin and
ascorbic acid
Liberal amounts of fluids are required "the
daily fluid intake should be 2.5-3 liters"
(e.g. milk, juice ….ect."
4. Hygiene:
•The women should be taken shower daily.
•The vulva and perineal care include washing or swabbing
with warm water and antiseptic solution, the area must be
kept clean and dry and free from infection.
•The perineum must be inspected daily if there are sutures
to see that healing is taking place. Non-absorbable sutures
are removed on the fifth or sixth day.
•Breast care should be done before and after feeding. The
nurse teaches the mother the technique of breast care and
encourages her to initiate breast-feeding.
5. Breast-feeding
Advantages of Breast Feeding
For baby:
Immunological properties help prevent infections.
Provides nutritional needs.
Easily digested.
Less sodium and protein than in cow's milk; puts less
stress on newborn's kidneys.
Calcium is better absorbed.
Least allergenic food for infant.
Promotes development of facial muscles, jaw, and teeth.
Less likely to be overfed; less obesity.
Has natural laxative effects.
Fulfilling psychological needs.
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For the mother:
Oxytocin release aids uterine involution.
Strong mother-infant relationship.
Convenient; always available; no preparation.
Cost effective.
Less incidence of cancer breast.
Natural contraception.
• Breast feeding technique:
• Clean the breast before and after feeding.
• Mother Clothes should not be tight over
breast & clean.
• Wash hand before nursing her infant.
• The infant should be hungry, dry and warm.
• The mother should be in comfortable. Position
either lying on her side or sitting up position.
• Nursing role for promotion of breast-feeding:
1- Inform all pregnant women about the
benefits and management of breast-feeding.
2- Help the mothers to initiate the breastfeeding within half-hour of birth.
3- Emphasize to mother the benefits of breastfeeding.
4- Teach mother the correct technique for
.successful feeding.
5- Support them & their babies to adapt to new
situation.
• 6- Give advice to proper diet, exercise, rest, and fluid intake,
care of the breast, clothing and bathing.
• 7- Emphasize the role of father in sharing the rearing
responsibility & providing support for the mother.
• 8- Raising awareness of the importance of child spacing for
maternal & child health.
• 9- Arrange for close contact of mothers with their premature
babies through encourage them to handle, or touch them.
• 10- Teach mothers how to express their milk with most
hygiene for their pre-term baby.
• 11- Instruct mother about breast self examination & breast
care.
• 12- The nurse should advice all mothers about the practice
that help successful breast-feeding.
• 13- Instruct mothers about the contraceptive effect of breastfeeding.
14- The maternal child health care educator must help parents
learn how to identity breast-feeding problems and how to
manage it.
15- Practice rooming in-allow mothers and babies to remain
together 24 hours a day
6. Proper positioning:
•During the first 8hrs.after labor, the mother is allowed to sleep in
any comfortable position.
•After that, prone position or either lateral positions should be
encouraged in order to facilitate involution and to help drainage of
lochia.
•Sitting position is also recommended since it promotes
contraction of the abdominal muscles, aids pelvic circulation, and
helps drainage of lochia
•Knee-chest position is indicated in certain conditions because it
prevents RVF of the uterus and hastens its involution
•Both supine and semi-sitting positions should be avoided.
Side-lying
Football Position
C Position
Cradle Position
• 7. Ambulation:
• Encourage early ambulation to prevent blood stasis
and deep venous thrombosis.
• Heavy activities are avoided to prevent
complications.
• 8. Promote bladder and bowel function:
• Bladder
• Voiding should be encouraged within 6-8hrs after
labor.
• If no urine is passed after 12 hrs. Initiate simple
nursing measure to induce voiding.
• If failed, catheterization, under complete a septic
technique is performed.
• Bowel
• There may be no bowel action for a couple of
days because the bowel has probably been
emptied during labor.
• Glycerin suppository may be used to relieve
constipation.
• 8. Post natal exercise:
• Encourage post partum exercise which promotes circulation.
• Lessen the possibility of venous thrombosis and restore the
muscle tone of the abdominal wall and pelvic floor.
• Postnatal exercises help to give the patient a sense of well
being.
• Certain patients, such as those suffering from heart lesions,
should not be allowed to perform all the exercises, though
even they may be encouraged, on medical advice to take
gentle exercise.
• Deep breathing and free movements in the bed should be
encouraged from the day of the delivery. On the second day
the following exercises may be done provided the labor has
been normal and the patient is in health. In prescribing
exercises discretion must be used and the exercises must be
adapted to the individual. In hospital the exercises will
probably be directed by a physiotherapist.
• Breathing exercises:
• Deep-breathing exercises should be
performed as described for antenatal period,
with the patient lying flat in be stretch, stiffen
and reflex the muscles of the right and let leg
alternately.
• Pelvic floor tone. Several exercises may be performed:
• Lie flat on the back with body relaxed. Tighten the anus for ten seconds as
though trying to control a loose motion or retain an enema. Repeat six
times, and then rest for one minute. Carry out the same procedure eight
times.
• Lie flat on the bed and forcely abduct the thighs against resistance (the
nurse attempts to hold the thighs together while the patient pushes them
apart. Repeat slowly six times. Later the same exercise may be carried out,
but with the nurse holding the patient’s Knees together instead of the
thighs.
• Lie flat upon the back with the hands upon the hips and elevate the feet
alternately, counting one to six, up, and one to four, down.
• Lie flat with the hands resting lightly on the abdominal wall. Then slowly
raise the head and shoulders. The patient must not push the chin forwards
or the abdominal wall will be pushed outwards instead of contracting, nor
must any weight be rested on the elbows.
• Sit up in bed with the hands clasped round the flexed knees and endeavor
to touch the knees with the chain. The nearer the head and knees
approach the greater the contraction of the abdominal muscles.
• Strengthening the muscles generally:
• The patient, sitting up in bed and bedding
forward with legs outstretched places her
hands on her ankles. The trunk is then
stretched backwards and the arms drawn up
and bent to imitate rowing, the knees are
slightly flexed at the same time.
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Late needs of the mother
Health education and counseling
The midwife nurse plays an important role as
health educator and counseling which
should provide the woman health education
and counseling about:
Breast feeding, definite, technique and
position.
Resumption of sexual relations. Include
information about when to expect
menstruation.
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Post natal exercise, hygiene, rest, sleep and nutrition.
The care of the baby which includes hygiene, prevention of
infection, feeding and giving him love and sense of security
feel her about the advantages of rooming in.
Family planning methods for spacing of pregnancy.
Stress the importance of post partum examination. Visits
and follow up to assess involution, general health and well
being of the mother before discharge.
•  Care of the newborn infant:
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Observing the general condition.
• Checking the cord.
• Checking the infant's physical needs.
• Cleanliness, feeding, warmth, sleep, protection from unsuitable
environment.
• Checking psychological needs: bonding and attachment.
• Carry out partial or complete bath to ensure cleanliness and comfort.
• Use proper clothing to keep the infant warm.
• Perform cord dressing.
• Encourage early breast-feeding.
• Ensure adequate hours of sleep.
• Protect from environmental hazards.
• Discuss infant care with mother.
• Cleanliness, handling, clothing, cord care, feeding, bonding, diapering,
circumcision of male infant, immunization, weaning, and community
resources.
• Encourage early skin to skin contact, bonding and attachment.
• Postpartum visits
• The first visit :
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The visit is carried out 3-4 weeks after
labor in order to assess the degree of
involution of the body in general and of the
genital tract in particular. General and local
examination is performed. The client
condition is evaluated through various
medical and nursing activities that include:
• Measuring and recording of blood pressure.
• Estimation of the hemoglobin percentage, and
aggressive treatment of anemia, if present.
• Urine analysis for sugar and albumen.
• Thorough examination of breasts and nipples for
early detection and treatment of abnormalities.
• Examination of abdominal muscles, perineum,
perineal wounds and nature of lochia to asses the
degree of involution of these parts, and to exclude
the presence of infection.
• Careful and thorough examination of: size of the
uterus, its position, tenderness, the condition of the
cervix (such as laceration or erosions) as well as the
condition of the pelvic floor. Management of any
lesion should readily start.
• The second visit:
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The visit is done at the end of the 6th
postpartum week. It is carried out along the same
lines as the postnatal visit with the institution of
more active treatment for certain lesions:
• If retroversion flexion (RVF)is still present a pessary
must be inserted
• Cervical erosion may call for cauterization.
• Subinovlution calls for more energetic treatment.
• Health teaching items at this time include advice in
relation to:
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Sexual intercourse, which should be prohibited during the
six postpartum weeks.
Spacing of pregnancies and counseling about the
appropriate contraceptive method, which should be
prescribed and may be started at once?
If the prolapsed of genital tract is present, it should be
treated by pelvic floor muscle exercises and / or the
insertion of a ring pessary. The patient should be advised to
abstain from bearing down. Chronic cough and constipation
should be treated for this purpose, however, operative
treatment is not considered before the lapse of six months
when total involution of the genital tract is established.
Health education to puerperal women at this time should
also include instructions related to the possibility of
encountering menstrual irregularities during the following
months. This irregularities range from complete
amenorrhea to oligomenorrhea, hypomenorrhea or
polymenorrhea. Bleeding is expected at the end of 6th
puerperal week in the majority of patients. in non lactating
mothers, however , menstruation usually appears after 6-8
weeks .
• The third visit:
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This is performed at the end of 3 months by
which time complete involution of the genital tract
has occurred. General and local examinations are
carried out, and any discovered lesion should be
dealt with:
• Cervical erosions must be cauterized.
• Persistent RVF and / or prolapsed should be
managed properly.
• If lactation amenorrhea is present, the client should
be instructed that this is not a bar against another
pregnancy, and suitable contraceptive measures
should be instituted.
•  Minor Discomforts during the Postpartum
Period
• They are minor complaints felt by the
parturient during postpartum period. Simple
nursing measures (interventions) are needed
to alleviate these complaints.
•  After-pains:
• It is a spasmodic colicky pain in the lower abdomen
during the early postpartum, days due to vigorous
contractions of the uterus. It is more common and
more severe in multiparous due to weak muscle
tone. Conditions with increased intra-abdominal
pressure e.g. polyhydraminios, multiple pregnancy,
large size infant.
• Predisposing factors:
• Presence of blood clots, piece of membranes or
placental tissue.
• Breastfeeding increases after-pain.
• Nursing management:
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Simple uterine Massage.
Reassurance and simple explanation of the cause.
Proper positioning (prone, sitting).
Offering warm drinks,
Mild sedatives on doctor's orders (before feeding).
Avoid full bladder.
Encourage abdominal muscle exercises and pelvic
floor muscle exercises. After-pains:
•  Urinary Retention
• It is the inability to excrete urine, i.e. urine is
accumulated within the urinary bladder. A common
complaint during the first few days after labor.
• Causes:
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• Laxity of the abdominal muscles.
• Inability to micturate in the recumbent position.
• Reflex inhibition due to stitched perineum or bruised
urethra.
• Atony of the bladder.
• Compression of the urethra by edema or
haematoma.
• Nursing management:
• Urine should be passed approximately 8-12 hrs after
delivery. If not, the following measures should be
attempted:
• Perineal care with warm water.
• Privacy and reassurance,
• Warm bedpan.
• listening to the sound of running water
• Hot-water bottle over the symphysis pubis
• If these measures fail, catheterization should be
performed using complete aseptic technique.
•  Constipation
• An abnormal infrequent and difficult evacuation of
feces may occur during the first few days
postpartum.
• Nursing management:
• Health teaching should consider the following:
• Diet rich in roughage.
• Increase fluid intake.
• Milk before bedtime.
• Exercises.
• After 72 hrs a glycerin suppository, or mild laxative,
may be administered as ordered.
•  Engorged Breast
• It is an accumulation of increased amounts of blood and other
body fluids as well as milk in the breasts. This condition occurs
frequently about the 3rd day postpartum, especially in
primipara. It is due to lymphatic and venous engorgement,
and is relieved when milk comes out.
• Causes:
• Inadequate and/or infrequent breast-feeding.
• Inhibited milk ejection reflex.
• Signs and symptoms:
• Breasts are firm, heavy (due to blocked ducts), swollen,
tender and hot (37.8"C).
• Pain may be present leading to irritability and insomnia. The
mother may refuse to nurse the infant.
• Nursing management:
• Apply moist warm packs to the involved breast 2-3
minutes before each feeding
• Massage and manual expression of milk to relieve
areola engorgement before feeding. This facilitates
attachment.
• Cold application after feeding.
• A well-fitting bra should be used to provide support
and comfort.
• Mild analgesics may be ordered. Syntocinon
inhalation may be prescribed. In severe cases,
administration of 2 doses of diuretic (as Lasix 40 mg)
is effective
•  Cracked Nipple
• Fissured nipple occurs in about half of the nursing mothers at one time or
another. Nipple tenderness and soreness are usually the result of trauma
and irritation.
• Causes:
• Improper antenatal care.
• Improper technique of breastfeeding.
• Unnecessary prolonged lactation.
• Flat or large size nipple--- excoriation.
• The use of irritating substances e.g. soaps, lotions.
• Conditions as candidiasis, and contact dermatitis.
• Engorgement of the breast.
• Signs and symptoms:
• Irritation of the nipple in the form of minute blisters or petechial spots.
• Persistent pain and tenderness.
• Bleeding.
• Inflammation signs.
• Nursing management:
• Proper technique of breast-feeding should be
followed.
• Apply moist heat and massage before feeding (3-5
min).
• Frequent, short feedings.
• Air/sun exposure.
• Avoid engorged breast.
• Avoid irritating materials.
• Use supportive bra.
• Mild analgesic and panthenol ointment may be used.
• Treatment of candidiasis and dermatitis.
• Insufficient milk supply:
• Physiological variations in milk secretion are often perceived
as milk insufficiency.
• Nursing management:
• Encourage the mother to follow frequent breast-feeding.
• Mother should drink more fluids.
• Reduce outside activities that are strenuous.
• Avoid supplementary hour feeds.
• Nurse the baby every hour if necessary.
• Nurse in a relaxed position.
• Try to avoid distracting or up setting situation while breastfeeding.
• Breast-feed just as the baby wakes up before he can begin
crying from hunger.
• Have a warm or cool drink each time the baby is breast-fed.
•  Leaking of breast milk:
• Women who have active ejection reflexes
often find that breasts leak milk during the
first few weeks after delivery.
• Nursing management:
• The mother should put clean pieces of gauze
or cloth inside the bra to soak up the milk.
• Change the clothes frequently.
• Breast care frequently.
 Mastitis: Is an infection of the parenchyma of the
mammary gland usually occurring within the
first 2-3 weeks of postpartum. It may
progresses to cause breast Abscess.
• Nursing management:
• Instruct the mother about self-administration of
antibiotics, analgesics and antipyretic.
• Instruct the mother about personal hygiene.
• Breast care with water not using soap.
• Intermittent exposure of the nipples to air and
changing of breast pads when wet.
• Breast feeding should be continued or pumped
emptying the affected side to relieve engorgement.
• If abscess develops drain it.
• If feeding is too painful, maintain lactation through
expression and offering the baby milk by spoon and
cup.
•  Perineal Discomfort
• It usually occurs due to presence of tears, lacerations,
episiotomy and edema.
• Nursing management:
• Frequent perineal care under aseptic technique, (the area
should be kept clean and dry).
• Soaks of magnesium sulphate compresses in case of edema.
• Expose to dry heat (electric lamp) will help the healing
process.
• Health education that includes:
• Perineal self care.
– Position (lateral with a pillow between thighs).
– Diet: rich in protein.
– Sources of strain such as coughing, constipation and carrying heavy
objects should be avoided.
– Encourage pelvic floor muscle exercises.
– Avoid infection.
– The use of cotton underwear.
•  Postpartum Blues (Depression)
• Rev a Rubin defined postpartum blues as "the gap
between the ideal and reality: the new mother's
expectations may exceed her capabilities, resulting in
cyclic feelings of
• Depression". This condition is usually temporary and
may occur in the hospital. The condition is partly due
to hormonal changes, and partly due to the ego
adjustment that
• Accompanies role transition.
• Signs and symptoms:
–
–
–
–
Disturbed appetite and sleeping patterns.
Discomfort, fatigue and exhaustion.
Episodes of crying for no apparent cause.
The mother may experience a let down feeling
accompanied by irritability and tears which often relieves
the tension.
– Guilt feeling at being depressed.
• Predisposing factors:
–
–
–
–
–
–
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The first pregnancy or pregnancy in late childbearing age.
Social isolation.
Ambivalence toward the woman's own mother.
Prolonged, hard labor.
Anxiety regarding finances.
Marital disharmony.
Crisis in the family.
• Nursing management:
– Reassurance, understanding, and anticipatory
guidance will help the parents become aware that
these feelings are a normal accompaniment to this
role transition.