Normal Puerperium PDF

# Normal Puerperium By the end of this lecture, the student will be able to achieve the following objectives: ## Domain 1: Professional and Ethical Practice: - Define the puerperium, lochia & involution. - Identify factors that slow & rapid uterine involution. - Differentiate between the types of...

# Normal Puerperium By the end of this lecture, the student will be able to achieve the following objectives: ## Domain 1: Professional and Ethical Practice: - Define the puerperium, lochia & involution. - Identify factors that slow & rapid uterine involution. - Differentiate between the types of lochia. - Enumerate the physiological changes during puerperium. - Discuss the psychological changes during puerperium. - Demonstrate understanding of the ethical principles and legal frameworks that guide nursing practice during the postpartum period. ## Domain 2: Holistic Patient-Centered Care: - Conduct a comprehensive assessment of women in the postpartum period. - Provide patient education on postpartum recovery, breastfeeding, newborn care, and self-care practices. - Promote comfort and support for women in the postpartum period. ## Domain 3: Manage people, work environment and quality: - Describe the causes for changes during puerperium. - Identify different minor discomforts during puerperium. - Analyze etiology of minor discomforts. ## Definitions of Postpartum Period (p.p.p): The period is also known as postnatal period, or puerperium. This is the period during which the maternal organs, particularly the reproductive organs return to the non-pregnant state which is characterized by breast feeding and the presence of lochia, and lasts for approximately 6 weeks. ## Physiological changes during puerperium 1. **Genital Changes:** a) Uterine Involution: It is the process whereby the pelvic reproductive organs return to their pre-pregnant size and position and the placental site of endometrium heals. | **Weight** | **Time** | |---|---| | 900-1000gm | After delivery | | 450-500gm | After 1 wk | | 200-250gm | After 2 wk | | 60 gm | At the end of 6 wks | **Level of Fundus:** | **Time** | **Location** | |---|---| | After delivery | At umbilicus | | After 1 wk | Midway between umbilicus and symphysis pubis | | After 2 wk | At symphysis pubis level | - **Sub involution**: Incomplete or delayed return of the uterus to its pre-gravid size during the puerperium. It usually due to retained products of conception and infection. - **Hyper involution**: It is the process by which the general organs return back to normal within short time. **Factors that enhance involution include:** - 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. b) **Lochia:** It is a uterine discharge coming through the vagina during the first 3-6 wks postpartum. It is alkaline in reaction and contains decidual fragments, blood, cervical mucus, vaginal epithelial cells and bacteria. **Types:** - **Lochia rubra (1st 5 days):** Red in color, consists mainly of blood and decidua. - **Lochia serosa (2nd 5 days):** Yellow in color, consists mainly of leucocytes, lasts for 5 days. - **Lochia alba (10-15 days):** White in color, consists mainly of leucocytes and mucus, lasts for 5 days. **N.B:** - Offensive lochia means infection. - Persistence of red Lochia means sub involution of the uterus (caused by retained part of the placenta). c) **The cervix:** Closed at 2-3 wks after delivery. d) **Perineum:** May be intact or have an episiotomy/tearing with suture. **Perineal discomfort caused by:** Presenting part pressure on the soft tissue that is between the anus and the vagina. e) **Menses:** Onset of 1st menstrual period following delivery is very variable and depends on lactation. It starts within 6-8 wks after delivery if the mother is not lactating. In lactating mother, it reappears not earlier than 3-4 months and it may be suspended until the baby stops breast feeding. 2. **Breast Changes:** - **Colostrum** is secreted in 1st 3 days. - **Milk secretion** starting at the 3-4th day, the breasts become engorged, larger, painful, tender. - **Suckling stimulates prolactin secretion** which causes milk production and oxytocin release which stimulates milk ejection. - **Cracked nipple which caused by** 1. Problems with the baby's latch 2. Not finding the optimal position 3. Not finding the ideal technique 4. Using a breast pump, particularly if the pump flange is too small - **Breast engorgement is the result of increased blood flow to breasts after the delivery due to:** - Missing a feeding. - Increased milk production than baby's needs. - Supplementing with formula between nursing sessions. - Weaning too quickly. - Nursing a baby that's ill. - Difficulty with latching and sucking. 3. **General Changes:** a) **Temperature:** Normal but reactionary pyrexia may occur but it doesn't exceed 38°C and drops within 24 hrs due to maternal exhaustion. A slight transient rise may occur at the 3rd day due to milk secretion &/or engorgement of the breasts. b) **Pulse:** Normal but rise (tachycardia) if there is hemorrhage or infection in early puerperium increasing with suckling due to oxytocin release. c) **After pains:** It is painful uterine contractions occur in early puerperium, which helps the uterus to return back to its non-pregnant size. - Increasing with suckling due to oxytocin release. - The multiparous women experience after pains more than primiparous women due to laxity of their uterine and abdominal muscles (over distended abdomen/uterus). d) **Urine:** Diuresis occurs to excrete the retained water in the body and lasting for 3-4 days. e) **Bowel:** 1- Constipation which caused by: - Changes in sleep patterns. - Stress - Dehydration and diet - Delay ambulation. - Side effect of some medications. 2- Hemorrhoids (Piles) A hemorrhoid is a painful swelling of a vein in the rectum. Which caused by Bearing down especially during a vaginal delivery f) **Loss of weight due to** - Evacuation of the uterine contents. - Fluid loss in urine and sweat. g) **Blood:** - **Increased coagulability** of the blood continues during the 1st two weeks to protect against bleeding. - **Hemoglobin concentration:** Tends to fall in the 1st 2-3 days. ## Psychological changes during postpartum: Emotional changes in the mother during the postpartum period through three phases: 1- **Taking-in phase** 2- **Taking-hold phase** 3- **Letting-go phase.** 1- **Taking-in phase (turning in):** It takes 2-3 days, during this time the mother's first concern is with her own needs (sleep and food). 2- **Taking - Hold phase:** It starts the 3 rd day postpartum. Women taking responsibility as a mother. 3- **Letting - go phase:** This generally occurs when the mother returns home.