Definition of Post-partum Period
The postpartum period (puerperium) is referred to from the end of birth until the genital
tract has returned to normal. The average duration of the postpartum period is 42 days.
(6 weeks) and comprise the (Puerperal Period Postnatal Period Post-partum period)
The postpartum period covers a period of 6 weeks
What are factors affect the mother's physiological and psychological adaptation to this
period ?
---The energy level of the mother
¬Mother's comfort
¬Newborn health
¬The quality of health care and
¬Support system
It's crucial to establish the mother-baby relationship.
What are the Phases of post-partum? ( 6 weeks)
Early Post-partum and Late Post-partum Period Period
Phases of post-partum
1- Early Post-partum Phases
The early postpartum stage starts after the birth is completed and lasts up to 48 hours.
The mother is passive and tired because of the stress of labor, the primary need of the
mother is to ensure pain relief, sleeping, and eating are provided. At this phase it's
essential to teach breastfeeding, perineal care, and newborn care because mothers are
willing to converse at this period.( In the early post-partum period, rapid physical and
psychological changes occur. Therefore, it is a very critical period. 60% of maternal deaths
occur during this period due to PPH. For this reason, it is the dominant idea to monitor
the mother and infant in the hospital during this phase)
1- Late Post-partum Period
The late postpartum period starts 48 hours after birth and is completed until the genital
tract has returned to normal.
Non-risky puerperant women spend this period at their homes. Therefore, postpartum
home visits are necessary and important and they also adapt to the role of motherhood by
shifting their interest to the baby and the risk factor of puerperium decreases day by day.
Physiologic Changes of the Postpartum Period
Maternal changes occurring during pregnancy are expected to return to normal during
the puerperium. All organs return to their previous state (retrogressive changes), while ,
progressive changes occur only in the breasts.
Changes in the puerperium process are divided into two groups.
1) Retrogressive (All reproductive organs; Other systems)
2) (Breasts’ Change) Progressive II
Retrogressive Postpartum Changes
1- Involution
¬Involution is the process by which all organs are transformed from a pregnant to a non-
pregnant state.
¬Especially in the first 3-4 days after birth, very significant changes are observed.
What is a delay in involution called? SUB-INVOLUTION
CHANGES THAT OCCUR.
1)Uterus Involu/on
Immediately after the birth of the placenta, the involution of the uterus begins. The uterus
is felt between the umbilicus and symphysis pubis and felt stiff, as large as a grapefruit,
and weighs 1000 grams.
Approximately at the end of the 6th week, the uterus gradually shrinks to 50-80 g and
bleeding also disappears after the 6th week of the postpartum period.
At the end of this period, the endometrium is re-prepared for normal reproductive
function.
On the 10th day after birth, the uterus is no longer felt in the abdomen. If it is felt by
palpation, it should be thought that there is a slowdown in the involution process.
During this process, the uterus should continue to gradually shrink.
FACTORS ACCELERATING INVOLUTION
Why Involution in primiparas is much faster than multiparas? Because primipara
women have stronger uterine muscles
breastfeeding can cause increasing oxytocin levels thus accelerating passive uterine
contractions. What does this contraction do? These contractions allow the uterus to return
to its former size quickly and also prevent hemorrhage.
Nurses should encourage the mother to walk early because this prevents blood from
accumulating in the uterus and accelerates the uterine involution in addition an empty
bladder accelerates involution, Involution occurs more quickly in women who are well
nourished and ambulate early after birth. Because the body heals faster in women who are
well-nourished.
Keywords - Primiparity, breastfeeding, ambulating early after birth, healthy mother
FACTORS SLOWING DOWN UTERINE INVOLUTION
--DIFFICULT AND LONG LABOR
¬ANESTHETIC SUBSTANCES
¬PARTIAL DISPOSAL OF PLACENTA AND MEMBRANES
¬INFECTION
¬INTRAUTERINE EXCESSIVE BLEEDING
¬CONDITIONS WHERE THE UTERUS IS OVERSTRETCHED (POLYHYDRAMNIOS,
MULTIPLE PREGNANCY, LARGE SIZE BABY)
¬ELDERLY MULTIPAROUS (SINCE THE UTERINE MUSCLES ARE WEAK,
SUFFICIENT CONTRACTION AND INVOLUTION ARE DELAYED.)
¬FULL BLADDER (A FULL BLADDER CAN DELAY INVOLUTION BY PREVENTING
THE DISCHARGE OF ACCUMULATED BLOOD IN THE UTERUS.)
THESE FACTORS DON'T LET THE UTERINE FIBERS TO SUFFICIENTLY
CONTRACT. THEREFORE, THE INVOLUTION PROCESS GET
PROLONGED AND LIFE-THREATENING CONDITION
2- LOCHIA (CHANGES THAT OCCUR)
A discharge from the uterus and vagina following delivery is called lochia.
¬Lochia includes blood, small pieces of decidua, mucus, vernix caseose, lanugo.
and meconium (6).
¬After birth, the characteristics of lochia gradually change and turn into lochia rubra,
lochia serosa, and finally lochia alba.
LOCHIA RUBRA
Lochia rubra occurs between 1 to 3 days after birth.
It is dark red in color.
There is intense bleeding in Lochia rubra.
(Similar to the early days of menstruation)
Lochia rubra content; erythrocytes, leucocytes, bacteria, decidua fragments, fetal
meconium, lanugo, and vernix caseous.
Lochia Serosa
¬Lochia serosa occurs approximately between the 4th and 10th days of birth.
¬Lochia serosa has brownish to pinkish discharge and the amount of blood and tissue
decreases in the lochia serosa.
¬Lochia serosa content; erythrocytes, leucocytes, bacteria, decidua fragments. But fetal
meconium, lanugo or vernix caseosa can not see any more in the lochia serosa.
Lochia Alba
Lochia alba appears on the tenth day and the discharge decreases and almost looks
colorless or whitish.
¬It may last until the third week after birth.
¬Normally lochia alba consists of only mucus.
¬Should not have an offensive odor
¬Should not be excessive in amount. Initially, the amount of lochia is
Characteristics of
high but it should gradually decrease. The total amount of lochia
Lochia
varies between 150-400 cc all during the postpartum period.
¬Lochia should not be too much in quantity.
¬Should not contain large pieces of tissue or blood clots. Large pieces
may be a sign that pieces of placenta remain in the uterus.
¬Should proceed from rubra -- serosa – alba. Even if the duration of
lochia rubra and alba changes, the order should never change.
3) THE CERVIX
¬The cervix is soft immediately after birth, but once contraction of the cervix takes place
it also returns to its prepregnant state.
¬Women who have not given birth or who have only a c-section have a dimple appearance
in the middle of the cervical opening. With the postpartum tear, this dimple turns into a
straight line.
CHANGES IN OTHER REPRODUCTIVE SYSTEM ORGANS
VAGINA
The vagina may be edematous and tissue damage appear.
¬ Vaginal rugae begin to appear when ovarian function returns.
¬The vagina returns to its pre-pregnant state after the end of the postpartum period but
remains slightly loose than before.
EXTERNAL GENITAL ORGANS
¬The labia minora and majora are still atrophic and soft after birth and would never
return to its pre-pregnant state. ¬The perineum is edematous and tender immediately
after birth. ¬Also, may have tears, lacerations, or an episiotomy.
HORMONAL SYSTEM
• As soon as the placenta is removed, pregnancy hormones start to decrease (HPL, HCG)
• Progestin, estrone, and estradiol return to their pre-pregnancy levels a week after birth.
• FSH remains low for 12 days and then starts to increase to signal the start of a new
menstrual cycle.
• For her lactation, the prolactin level rises compared to the gestational period.
• About half of women who are not breastfeeding start see menstrual bleeding 6-8 weeks
after birth. But due to the prolactin hormone ovulation is suppressed in breastfeeding
mothers and menstruation starts later.
URINARY SYSTEM ***
• Because of progesterone withdrawal the amount of urine increases. On the 2nd to 5th
day after birth, the urinary output of the woman increases to as much as 3000 mL per
day.
• The woman’s abdomen must be assessed frequently during the postpartum period to
prevent damage to the bladder due to overdistention.
• Urine may contain more nitrogen because of the increased activity of the woman
during labor.
CIRCULATORY SYSTEM.
• Blood volume returns to its prepregnancy level by the first or second week of birth.
• Hematocrit levels reach its normal prepregnancy level 6 weeks after birth.
• An increase in leukocytes and plasma fibrinogen occurs in the first postpartum weeks
as a defense mechanism against infection and hemorrhage.
INTEGUMENTARY CHANGES
• Skin pigment changes will begin to disappear • Striae never disappear but the color of
the striae changes from red to white.
1. Body Temperature
• Fever due to dehydration in the first 24 hours in the postpartum period is normal
to rise to 38 degrees.
• After the first 24 hours, with the onset of lactation, the temperature may be around
38 degrees.
• However, if high fever persists after the first day, infection should be suspected.
•
• 2. Blood Pressure
• • Blood Pressure: low blood pressure due to the decrease in pressure in the pelvis
may occur. This is a normal physiological condition.
• • The independently developed blood pressure elevation should be carefully
evaluated.
3. Heart Beat:
Bradycardia is common in 6-12 days postpartum.
Tachycardia is less common and is associated with more blood loss, difficult and
prolonged labor.
¬Taking the paCent's history
¬Asssesment of vital signs
¬AuscultaCon of lung
¬Assesment of breasts
Physical EvaluaCon
¬Assesment of abdomen, uterus and fundus
¬Assesment of lochia
¬Assesment of perineum
¬Assesment of lower Extremity
Asssesment of vital signs
¬In the first hour after the birth ........... every 15 minutes ¬In the second hour after the
birth................ every 30 minutes ¬In the next 2 hours after the birth..............every hourly
¬Then ............... every 8 hours
Assesment of breasts
¬Nipple status
¬Swelling and tenderness in the breasts
Assesment of abdomen, uterus and fundus
The placement and size of the uterus should be evaluated.
The uterus should be level with the umbilicus after delivery. The uterus then should
decrease 1 FB per day. Should also be midline and the size of a grapefruit.
The tone of the uterus should be firm /stiff.
Physical Evaluation
4. Assessment technique of the uterus
¬The nurse should stand on the side of the bed with her face towards the mother.
The fundus should be checked between the umbilicus and symphysis pubis.
¬If the uterus is found boggy or con not felt uterine massage is necessary.
¬When the uterus becomes stiff after the massage, the massage should be stopped
immediately. Because excessive massage can cause the uterus to relax or boggy again.
Assessment criteria of Lochia
¬The color, content, quantity, and odor of the lochia should be evaluated.
¬The mother should be taught how to follow lochia in color and quantity.
¬Also, In case of overflowing bleeding onto the bedding or when 2 or more pads become
contaminated per hour, the doctor should be informed about PPH.
REMEMBER EVERY MINUTE/HOUR EVALUATION
Assessment Procedure of Perineum
The nurse should turn the patient to a side-lying / sims position. Then gently spread
buttocks apart and inspect with a penlight.
¬During assessment episiotomy/ lacerations/ edema/ hematoma/ hemorrhoids should be
observed
Assessment of lower Extremity
¬ Thrombophlebitis and embolism are the most important complications that can be seen
in the postpartum period. Therefore, lower extremity control should be performed.
¬The condition of varicose veins and edema should be evaluated.
¬In addition, it should be checked whether the temperature of the legs is equal by
palpation of both
legs at the same time.
COMMON POSTPARTUM CHANGES
Postpartum Care
1. Control of Postpartum Bleeding
Postpartum hemorrhage (PPH) is defined as blood loss of 500ml or more within 24 hours after
birth.
Approximately 3% to 5% of obstetric patients will experience postpartum hemorrhage.
Annually, these preventable events are the cause of one‐ fourth of maternal deaths worldwide.
Postpartum Care
Risk Factors for Postpartum Hemorrhage
• Antepartum hemorrhage
• Prolonged labor
• Preeclampsia
• Chorioamnionitis
• Fetal macrosomia
• Maternal anemia
• Maternal obesity
• Multifetal gestation
Complications of Postpartum Hemorrhage
• Anemia • Postpartum depression • Blood transfusion • Orthostatic hypotension • Dilutional
coagulopathy • Fatigue
• Myocardial ischemia • Mortality.
Postpartum Care
1. Control of postpartum bleeding
Medical and physical interventions are used to control postpartum hemorrhage
Oxytocin (Pitocin)
Methylergonovine (Methergine) Misoprostol (Cytotec)
Postpartum Care
1- EXTERNAL UTERINE MASSAGE
First, the fullness of the bladder should be evaluated. If necessary, the bladder is emptied.
Then lochia is evaluated.
During the external uterine massage one hand is placed on the symphysis pubis and the
other hand compresses the fundus from above through the abdominal wall. In this
position, a moderate circular massage is applied to the FUNDUS. Fu
2- Internal Uterine massage
¬Massage is performed by placing one hand in the vagina
and pushing against the body of the uterus while the other
hand compresses the fundus from above through the
abdominal wall.
¬The uterus is kept over the abdomen. Massage should be in
the form of hard circles
VİDEO- Uterine Massage Technique
https://www.youtube.com/watch?v=kRav3hBejrw
https://www.youtube.com/watch?v=O06-6sGnn1k
https://www.youtube.com/watch?v=onyPC943cWs
https://www.youtube.com/watch?v=vAQvwAWqx4o
2. Perineum Care
¬After each urination and defecation (elimination) perineal care should
be done.
Postpartum ¬Ice pack can be used in the first 24 hours after birth to reduce
Care discomfort in the perineum.
¬Warm sitting bath is useful after 24 hours
¬Local Anesthetic agents can be used
¬Pads should be change frequently
Video- perineal care
https://www.youtube.com/watch?v=Edz9o56EgD0
48
3. Bladder Care
¬The mother is expected to urinate in 2-4 hours.
Postpartum Care ¬In case of spontaneous mother can not urine; listening of
water sound or drinking hot drinks, immersing hands in hot
water or pouring hot water on the vulva can be useful.
¬If the mother cannot urinate despite everything, the urine
should be evocated with a urinary catheter at the 6th hour after
birth by the nurse.
3. Patient education
In addition, the following subjects must be included in every education;
¬Nutrition,
¬Hygiene, ¬ Postpartum
education is
the most
¬Perineal care, important
element of
care. If
Postpartum
In addition, the following subjects must be included in every training;
Care
¬Bleeding control, possible, training should be given to
Drug use, both mother and family before
¬Family planning methods discharge.
¬Nurses should determine the needs
of the mothers first of all when
planning the education.
¬Breastfeeding ¬Baby care
¬Date of medical visits for mother and baby ¬Hazard symptoms of
postpartum period
Hazard Symptoms of Postpartum Period
Heavy bleeding
Increasing pain
Fever
Abnormal Discharge and lochia Pain when urinating.
Chest pain.
Postpartum Danger Symptoms
Breast pain, redness, and swelling,
Swelling in one or two legs, redness and
increased temperature
Persistent perineal pain
Anxiety, sadness, and fear that lasts longer than a few weeks.
