UNIT 5 NORMAL PUERPERIUM AND

NURSING MANAGEMENT
Structure
5.0 Objectives
5.1 Introduction
5.2 Normal Puerperium
5.2.1 Physiological Changes in Reproductive System
5.2.2 Physiological Changes in Other Systems of Body
5.2.3 Psychological Adjustments in Puerperium
5.3 Management of Normal Puerperium
5.3.1 Care of Mother
5.4 Role of Nurse-midwife in Post-natal Care
5.5 Let Us Sum Up
5.6 Answers to Check Your Progress

5.0 OBJECTIVES
After going through this unit, you should be able to:

l define the normal puerperium;

l discuss the physical, physiological adaptations taking place in puerperium;
l describe major physiological changes including lactation during post-partum recovery
period;
l recognize expected physiological responses of the new mothers and identify
deviations from the normal;
l explain appropriate nursing care to mother and baby during puerperium and lactation;
l identify the minor ailments and plan nursing interventions for mother and baby;
l plan teaching advices for self-care during puerperium and lactation at home; and
l state the role of nurse-midwife in the post-natal period;

5.1 INTRODUCTION
This unit will present the process of physical, physiological and psychological adjustments
that take place after delivery to puerperium and beyond. It will also discuss about the
management of woman and baby after birth. Many women may take months to become
really confident in their mothering role. Therefore, the nurses working in the hospital and
community have a unique opportunity to assist the mothers and families in this adjustment
process by competence, skills and sensitivity according to their needs and expectations.

5.2 NORMAL PUERPERIUM

We will tell you the definition and meaning of puerperium and about the physiological
changes that take place in the reproductive system during puerperium. Then we will tell
you the physiological changes that take place in other system of body and lactation in
details. At the end of this section we will acquaint you about psychological adjustment in
puerperium.

Definition

Puerperium is the period following child birth. This is characterized by the following
features:
113
Maternal Health and Nursing l The generative organs return back approximately to their pregravid state both
Intervention anatomically and physiologically.
l Lactation is initiated.
l Recuperation from the physical, hormonal and emotional experience of parturition.
This period is also known as post-partum, post-natal, post-delivery period.
Puerperium begins as soon as placenta is expelled and lasts for six weeks through the
process of involution.

5.2.1 Physiological Changes in Reproductive System

Now let us discuss the physical adaptations which takes place after the third stage of labour
is completed. There is involution of reproductive organs specially in uterus.
i) Involution of Uterus
Involution is the process whereby the pelvic reproductive organs returns to their pre-
pregnant size and position and the placental site of endometrium heals. Failure to complete
this process is known as sub-involution.
After the delivery uterus becomes firm and retracted with alternate hardening and
softening. The uterus measures about 20×12×7.5 cms(length, breadth and thickness) and
weighs about 1000 gms. At the end of 6 weeks it return to pregravid size of 7.5×5×2.5 cm
and weighs 60 gms. This reduction in weight and size is not in the number of cells but also
size of the same cells through the process autolysis of the muscle fibres and ischaemia of
the uterus. The contraction and reduction of the uterine muscles fibres compress the blood-
vessels and reduce the uterine blood supply.
Reduction of the size: After labour, fundus is 5 cms below umbilicus or 12 cms above the
symphysis pubis.
After 24 hrs at the level of umbilicus.
After 1 week 7.5 cms above the symphysis pubis and 12 days after labour the fundus is not
usually palpable. The placental site is 7.5 cms and at the end of 6 weeks measures 1.5 cms.
Position of the uterus: Immediately after delivery the uterus lies midway between the
symphysis pubis and the umbilicus. Within 12 hrs, it rises to the level of umbilicus or
slightly above it. Uterus begins to descent into the pelvic cavity at a rate of about 1 cm a
day until the 10th day, when it may be palpated at or below the level of symphysis pubis.
Consistency of the uterus: The strong frequent myometrial contractions that control blood
flow to the uterus cause it to become hard. Its consistency can be assessed by palpating the
uterus. It should feel firm and round. If the fundus is soft, it is called as boggy uterus,
indicates that contractions are inadequate allowing blood loss to continue.
Endometrium: It also undergoes involution after placenta is delivered. The major part of
decidua is cast off along with the placenta and membranes, more that the placental sites,
only the basal portion of the decidual remains. The superficial part containing the
degenerative decidua, blood cells and bits of foetal membrane become necrotic and is cast
off in lochia.
Regeneration occurs from ipithelium of the uterine gland mouths and interglandular
stromal cells. It is completed by 10 day and entire endometrium is restored during the 3rd
week except at the placental site where it takes about 6 weeks.
Clinical assessment of involution: Rate of involution of uterus can be assessed by taking
fundal height in relation to symphysis pubis with the measuring tape. Measurement to be
taken at the fixed time everyday. Bladder and bowel must be emptied, as they may raise
the level of fundus.
Following delivery fundus lies about 13.5 cms about the symphysis pubis. First 24 hours
uterus remains constant and then steady decrease in height by 1.25 cms (1/2") in 24 hrs. and
by the end of second week uterus becomes a pelvic organ and by six week becomes almost
normal in size.
ii) Cervix
After delivery the lower uterine segment and cervix remain loose, thin and stretched. It
114 may also appear odemetous and bruised from the delivery and may have small tears or
lacerations. It may take few weeks to revert back to normal shape and size of the isthmus. Normal Puerperium and
By the first post-partum day cervix has sufficiently narrowed and regained its normal Nursing Management

consistency to admit two fingers and by the end of first week narrows down to admit the tip
of a finger only.

Involution may continue for 3-4 months since the cervix sustained trauma, the parous
cervix will never again look like the non-parvous cervix. The external os which previously
resumbled a dimple, now a slit and laceration may leave scar tissue.

iii) Vaginal Canal

The vaginal canal appears swollen and smooth after delivery, gradually becomes smaller
and firm, never regains pre-pregnancy size, rugae partially reappears at third week but
never to the same degree as in pregnant size. The introitus remains permanently larger than
the vaginal state. The hymen is lacerated and is represented by nodular tags. Occasionally
a hematoma may develolp as a result of descent and delivery at external vaginal orifice,
vaginal wall at ischial spines and episiotomy site.

iv) Perineum

Muscle of the floor of perineum are stretched, swollen bruised. Even an intact perineum
can be edematous, erythematous and uncomfortable. A scar may be present if episiotomy
was performed.

v) Ovaries

The ovaries are inactive during the last two trimesters of pregnancy, because of the drop in
placental hormones level and gradually resumes the pre-pregnancy cycle.

vi) Lochia

It is the vaginal discharge for the first fortnight during puerperium. It orginates from the
uterine body, cervix and vagina.

It contains blood, decidual tissue, epithelial cells from the vagina mucus, bacteria and on
occasion, fragments of membranes and small clots. Its odour is fleshy but not offensive.
Various types of lochia are:
Lochia Rubra: The first phase of lochia when discharge is red and bloody called lochia rubra
means ‘red’. Lasts from 1-4 days, may contain few small blood clots.
Lochia Serosa: Occurs next 5-9 days, the colour is yellowish pink or pale brownish.
Lochia-Alba: Pale white because of the presence of leukocytes, lasts from 10-14 days.
The colour of lochia indicates the healing stage of the placental site.
The average amount of discharge for the first 5-6 days is about 250 ml.

Importance of Inspecting Lochia

l It gives information about the puerperal state of the mother – pads to be inspected
daily.
l Odour: If offensive – infection, retained cotton piece or plugs to be kept in mind.
l Amount: Scanty or absent – infection.
l Colour: Persistence red – subinvolution retained bits of conception.
l Duration: Lochia alba beyond three weeks suggestive of local lesions.

vii) Breasts and Lactation

a) Breasts

Already developed throughout pregnancy in response to hormonal stimulus. For the first
few days both breast feeding and non-feeding breasts of women secrete colostrum, a
creamy yellow precursor to milk, but the breasts remain soft and non-tender. Three days
after delivery in response to increased prolactin level breasts become firm and tender and
milk supply is initiated. They rapidly become distended, hard and warm because of
increased flow, venous and lymphatic congestion called physiological engorgement, lasts
about 24-48 hours and will resolve spontaneously, suckling by the baby stimulates ongoing 115
Maternal Health and Nursing milk production. The breast will remain firm, full and somewhat tender until emptied by
Intervention nursing.

b) Lactation

Lactation is under the control of numerous exocrine glands, particularly the pituitary
hormones prolactin and oxytocin. It is influenced by the sucking process and by maternal
emotions. Lactation, the process of breasts feeding results from interplay of hormones,
instinctive reflexes and learned behaviour of the mother and newborn. The establishment
and maintenance of lactation is determined by three factors:

1) The anatomical structure of the mammary gland and development of alveoli, ducts
and nipples (already studied in Unit on Anatony of Physiology of Breasts).
2) The initiation and maintenance of milk secretion, and
3) Milk ejection or propulsion of milk from the alveoli to the nipple.

Stages of Lactation

Lactogenesis (milk initiation): It begins during the later part of pregnancy. Colostrum is
secreted as a result of stimulation of the mammary alveolar cells by placental lactogen, a
prolactin-like substance. It continues after birth as an automatic process. The continued
secretion of milk is related to:

i) Sufficient production of pituitary hormone prolactin.

ii) Maternal nutrition.

Milk secretion occurs by the process of extrusion from the cells.

Movement of milk from alveoli to the mouth of infant is an active process within the breast
called “let down reflex” or “milks ejection reflex”. This reflex is a response to an infant’s
sucking on the breast. The sucking stimulates the post-pituitary gland to secret oxytocin.
Under the influence of oxytocin, the cells surrounding the alveoli contract propelling the
milk through the ductal system into the infant’s mouth.

Colostrum: A yellow, premilk substance, high in protein and contains antibodies. Its
production decreases gradually after childbirth and production of true milk begins. The
bluish white true milk usually comes in between 3rd and 5th post-partum day. The milk at
the beginning of the feeding is known as fore milk which contains less fat and flows at a
faster rate than at the end of the feeding, the hind milk. Hind milk is white and contains
more fat, calories and is believed to satisfy the infant and signal that the feeding should
come to an end.

The last stage of human lactation is ingestion of milk by the suckling baby. The full term
healthy new born baby possesses three instintive reflexes needed for successful breast
feeding:

l The rooting reflex,

l The sucking reflex, and
l The swallowing reflex.

Maternal Breast Feeding Reflexes

There are three major maternal reflexes involved in breast feeding which are:

i) Secretion of prolactin,
ii) Nipple erection, and
iii) The let down reflex.

Prolactin: It is considered as the key lactogenic hormone initiating and maintaining milk
secretion. Its production by the non-pituitary is mainly the result of the prolactin reflex
resulting from the infant’s suckling at the breasts. The sucking stimulus provided by the
baby sends a message to the hypothalamus. Hypothalamus stimulates the anterior pituitary
to release prolactin, the hormone that promotes milk production in the alveolar cells of the
mammary gland. The amount of prolactin secreted and hence the milk produced is related
116 to the amount of sucking stimulus, that is the frequency, intensity and duration with which
 CMYK

the baby is breast fed. Stimulation of breast nipple by infant’s mouth leads to nipple Normal Puerperium and
erection and prominence. The nipple erection reflex assists in the propulsion of milk Nursing Management

through the lactiferous sinuses to the nipple pores.

The ejection of milk from the alveoli and milk ducts occurs as a results of the milk-
ejection of let down reflex which is regulated in part by the CNS. The suckling stimulus
arrives at the hypothalamus, which promotes release of oxytocin from the post-pituitary.
Oxytocin stimulates contraction of the myoepithelial cells around the alveoli in the
mammary glands. Contraction of these muscle-like cells causes milk to be propelled
through the duct system and into the lactiferous sinuses where it becomes available to the
breast feeding infant.

Fig. 5.1: Let down reflex

The let down reflex appears to be sensitive to small differences in circulatory oxytocin
levels. Signs of let down reflex is easily recognized by mothers. It is characterized by a
tingling sensation that progresses to a feeling of pulling or of being squeezed from the
inside. Many women will feel this reflex by simply thinking about their baby or cry of
their baby. It seems to be somewhat consciously controlled. Sign includes milk dribbling
from the breast opposite to the one being used and uterine cramping during feeding caused
by the action of oxytocin on the uterus. Minor emotional and psychological disturbances
may influence the ease with which breast milk is released to the baby. The attitude of
mother towards breast feeding whether positive, doubtful or negative is a powerful factor in
achieving successful lactation, influencing milk production and facilitating the art of breast
feeding.

Cultural Aspects of Lactation

The nurse should also consider the cultural background of the client to provide proper
assistance to a new mother from a different culture and should become aware of that
culture’s practice.

Milk production: In the first post-partum week, the total amount of milk secreted in 24
hours is calculated to be 60 × No. of post-partum day and is expected in terms of
milliliters. The milk yield on 4th day is about 60×4=240 ml and by the end of second week
the milk yield is 120-180 ml per feeding.

Stimulation of lactation: Following methods can be adopted to improve adequate milk yield:

During pregnancy:

1) To improve the maternal instinct to nurse the baby, explaining the advantages of breast
feeding to the mother.
2) Care and preparation of nipples.
3) Teaching the mother how to express out the colostrums and take care of crust formed on
the nipples.
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CMYK
Maternal Health and Nursing Following delivery:
Intervention
1) To allow the baby to put to the breast at 4-6 hours interval for 3-5 minutes from the first
day.
2) Plenty of fluids to drink.
3) To avoid engorgement and trapping of milk, manual expression prior to nursing.

Suppression of lactation: In case baby is born dead, dies in the neonatal period or when the
mother does not like to breast feed her baby or it is contraindicated. This can be effective,
either by using hormones or by mechanical means.

Hormones: Use of hormones is effective if started soon after delivery. It suppresses

lactation through inhibition of pituitary hormone. The drugs used are Tab ethynyl oestradiol
0.05 mg thrice daily for 5 days or combination of testosterones and oestrogen preparations
etc. as prescribed.

The risk of these oestrogenic preparations to the puerperal mothers should be kept in mind
and patient to be observe for thromboembolic manifestation or late post-partum blood loss.

Mechanical: This is effective where the lactation is to be suppressed after the esablishment
of milk secretion:

1) Patient should stop breast feeding.

2) Should not express or pump out the milk from the breast.
3) A tight compression bandage or binder on breasts for 2-3 days.
4) Analgesic tablets containing aspirin and may be given to relieve pain.

5.2.2 Physiological Changes in Other Systems of Body

i) Cardiovascular Function

Volume adjustment: In the puerperium dramatic changes occur in cardiovascular system.

During pregnancy blood increased by 30% to 50%. During vaginal birth and placental
delivery woman loses about 500 ml of blood, 1000 ml during cesarean birth, this depletes a
portion of the additional fluid but shift in fluids that are redirected from the placenta
compensate and increase the circulatory volume. Without the extra blood vessels of the
uterus and placenta, blood is returned to the central circulation. Vena caval compression
from the large uterus is relieved and blood from the pelvic region returns unimpeded to the
general circulation, along with extra vascular fluid accumulated during pregnancy.

Cardiac output increase 25% to 80% depending on the type of delivery with resultant
increase in stroke volume (SV). This required special attention in woman with cardiac
problem.

Heart rate: During pregnancy heart rate increases to 15 beats per minute and the SV is also
increased, thus improving cardiac output (CO) to effectively circulate a larger blood
volume in the expanded uterine and placental vascular bed. After delivery, body attempts to
compensate for increase central venous load, slowing the heart rate to as low as 40-60 beats
per minute to control CO and prevent systematic overload and hypertension.
Bradycardia is normal post-portum adaptation. An increase in pulse rate may indicate
haemorrhage infection, thrombosis, anxiety, pain or excitement related to delivery and
should be explored.
Blood pressure: Blood pressure may decrease in the early recovery period in response to
anesthesia, blood pressure etc., orthostatic hypotension may occur because of fluid shift
and decreased intra-abdominal pressure. It returns to normal within first week after delivery
unless the women experience complications such as pregnancy induced hypertension.
Hemoglobin and Hematocrit: During the initial period of post-partum diuresis the
increased volume of RBCs during pregnancy will now decrease because of loss of extra
body fluids. Hematocrit may rise in the first 3-7 days gradually return to normal levels by
4-5 weeks as old cells die out and fewer new ones form. Non-pregnant levels are reached
by 5-8 weeks.
White blood counts: Normal adult WBC count is between 5000 and 10000/mm3. Count rise
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during pregnancy and labour up to the level of 15,000 to 20,000/mm3. According to experts
load is acceptable upto 40,000/mm3 for the first 24 hours to 48 hours post-partum. It falls to Normal Puerperium and
normal in 4-7 days. Persistent elavation indicates infection. Nursing Management

Coagulation factor : Clotting factor increase near term and remain high in immediate post-
partum period. Platelet, fibrin and fibrinogen levels are elevated during recovery. Their
function is to protect against bleeding caused by delivery of foetus and placenta. But they
also contribute to thrombus if the woman is immobile. All levels return to normal in 3-4
weeks.
ii) Respiratory Function
After delivery with the decrease in abdominal pressure, the diaphragm descents to its
normal position permitting better lung expansion and ventilation but the respiratory rate
does not noticeably change.
iii) Excretory Function
Body water in the extra-vascular spaces and excess plasma volume from the pregnancy are
rapidly eliminated. But the second post-partum day diuresis and polyurea occur, upto 3
litre/day urine is passed for few days and within one week returns to normal voiding
pattern. Bladder increases its capacity, filling upto 1000 or 1500 ml of urine without
discomfort. Retention of urine may result because of stretching of perineal floor, bruising
and edema of the trigone and urethral meatus.
Regional or general anesthesia may temporarily inhibit natural function, diminishing
urinary sensations from the bladder. Urinary retention follows putting the woman at risk for
hemorrhage from a poorly contracting uterus. Stasis also predisposes to urinary tract
infections.
Increased membrane permeability persists for first week, proteinurea of upto 1+, glucose
passed in the form of galactose, urinary ketones may be present.
Dilatation of the uterus and renal pelvis requires about 6 weeks to return to pre-pregnancy
state. In urinary stasis, microorganisms can easily travel upwards causing kidney infection.
iv) Gastrointestinal Function
Increased thirst in early puerperium is due to loss of fluid during labour, lochia, diuresis
and perspiration. Slight intestinal paresis leads to constipation. Lack of tone of the perineal
and abdominal muscles and reflex pain in the perineal region are contributing factors for
constipation. Ambulation, progression of diet, anti-fluctuants or enemas generally make the
woman more comfortable.
During delivery the straining and pressure on the lower bowel causes the extrusion of internal
hemorrhoids. After delivery these reduce in size and can be manually re-inserted in the rectum.
Hemorrhoids present during pregnancy also shrink and rarely requires surgical reduction.
The speed with which bowels becomes regulated depends on the daily activity, diet and fluids,
exercises and mild laxatives may be ordered by doctor to facilitate emptying the bowel.
v) Integumentary Function
After delivery the skin changes caused by pregnancy begin to recede. As the melanocyte
stimulating hormone that caused pigmentational changes is eliminated, melasama
disappears, unless excessive pigmentation has occurred.
Striae gravidarum may fade to a silvery colour in light skinned women but they remain
deeper on darker skin. The linea nigra and darkened areola fade, but in some women faint
traces will persist. In few months hair and nail growth will return to pre-pregnant pattern.
vi) Musculo-skeletal Function
Women may be fatigued or exhausted after labour. The labour position and pushing
technique may leave arms, neck, shoulders and perineal muscle sore and aching.
Abdominal muscles: Uterine ligaments remain loose and relaxed, abdominal muscles have
less tone, resulting in soft, flabby abdomen. Exercise may help but restoration of the
muscles may be prolonged.
Joints: Under the influence of relaxation, the pelvis joints particularly the symphysis pubis
may separate slightly during labour, causing pain and discomfort, becomes stabilized by
6-8 weeks. 119
Maternal Health and Nursing vii) Endocrine Functions
Intervention
Menstruation and Ovulation

The exact mechanism responsible for resumption of the menstrual cycle is not known and
time of resumption is unique for each individual. Cycles can begin in lactating mothers as
early as 8 weeks after delivery or as late as 18 months. 40% of the lactating mothers may
have their first menstrual period as early as 4 to 6 weeks after delivery and 90% by 24
weeks. It is because prolactin levels interfere with the development of the graffian follicle.
Since prolactin level is influenced by the strength of infant sucking, the frequency of
feedings, therefore, breast feeding is unreliable as a method of contraception.

viii) Immunologic Function

Infection

Puerpral women are at special risk for wound infection and infections of uterus, urinary
tract, respiratory tract or breast. So nurses can recognize them and teach all the women how
to prevent and report the symptoms of post-partum infections. Predisposing factors such as
diabetes, chronic respiratory problems, anemia, malnutrition and substance abuse etc. alert
the nurse as in cases of prolonged labour, difficult delivery, multiple pregnancy, laceratives,
hematoma or cesarean delivery.

Once the women at risk is identified the plan of nursing care can be formulated to decrease
the additional risks. The woman must be taught to recognize the warning signs and seek
medical care.

Puerperal sepsis is the most common post-partum infection of the genital tract in the post-
partum period appearing before the 10th day after delivery.

An elevated temperature in the first 24 hours after delivery may be caused by dehydration
fatigue, chilling and blood loss. The temperature may be as high as 38o c is considered
within normal limits. If temperature remains high after the first day, cause must be found
and treated especially if there is history of premature rupture of membranes, long or
traumatic labour and delivery.

If low grade fever related to engorgement of breast is there, do not isolate the baby from
mother because the infant and mother usually have the same bacterial and viral agents and
nothing is gained by isolating.

Check Your Progress 1

1) Enumerate the characteristic features of normal puerperium.

..........................................................................................................................................
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..........................................................................................................................................

2) Explain the term involution.

..........................................................................................................................................
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..........................................................................................................................................

3) Write a short note on Lochia.

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..........................................................................................................................................
..........................................................................................................................................

4) Fill in the blanks:

a) The size of uterus after six weeks of delivery is approximately .............................

in length ........................... in breadth and ........................... in thickness.
b) Weight of the uterus after puerperium is reduced to ........................... .
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 c) Coagulation factor in blood remains ........................... in immediate post-partum Normal Puerperium and
period. Nursing Management

d) Haemmorhoids present during pregnancy ........................... during puerperium.

e) Ovulation of menstrual cycle can begin in lactating mothers as early as
....................... weeks after delivery or as late as ........................... months.
f) A creamy, yellow precursor to milk is called ........................... .

5.2.3 Psychological Adjustments in Puerperium

You have learnt about the physiological changes which the women undergo after delivery
to the puerperium. Now let us discuss the psychological adaptations or adjustment which
takes place during the peurperium. These are as follows :

Attachment: Puerperium period is a time of transition from non-parenthood to parenthood.

Parent-infant attachment leads to bonding depending on infant’s responsiveness. This
encourages them to continue interaction. Bond formation is an outgrowth of reciprocal
attachment stimulus-response and affectional ties that help form a constructive social
relationship. Example of this behaviour is kissing of infant, bonding and cuddling and
maintaining eye to eye contact.

Maternal Development Tasks: The stages through which the new mother goes through
are taking in, taking hold and letting go. After delivery the mother is exhausted and needs
rest and sleep and during the first and second day she will be taking in all the experiences
of labour and delivery and asking many question. Her physical needs and deficits of
nourishment and needs of her infant should be met.

Taking hold means the period when the mother attends to infant’s needs and her own needs.
She is usually eager to learn how to care for the child and herself.

During the later recovery, the mother must let go and view the child as a separate person.
Those women who have difficulty letting others assist with the care of her child may
develop psychological problems. The nurse must try to identify this unresolved problem.

Potential for Mood Changes: The first few days, even to 10-14 days would be considered
a period of “normal” crisis and disequilibrium especially for the first time mothers.

The Blues: Many mothers may experience mood swings known as the “Post-Partum
Blues” episodes of unexpected crying, sensitivity and sadness generally 3-7 days after
delivery due to fatigue and hormonal shifts and last for 1-2 weeks. The reason is drop in the
level of hormone estrogen and progesterone.

Post-partum Depression: Beginning 2 weeks after delivery more severe symptoms

characterize post-partum depression may be due to lack of sleep, additional responsibilities
and discomforts if infection or pain. The severe form of post-partum depression is post-
partum psychosis or puerperal psychosis.

Check Your Progress 2

1) Enumerate the factors that determine the establishment and maintenance of lactation.
.................................................................................................................................
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.................................................................................................................................

2) Explain the role of prolactin in milk secretion.

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.................................................................................................................................

3) List the psychological adjustments that the puerperal mother may face after delivery.
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Maternal Health and Nursing
Intervention 5.3 MANAGEMENT OF NORMAL PEURPERIUM
In this section you will come to know about nursing management of normal puerperium
which includes immediate care, initial observation, physical assessment, diet, personal
hygiene and postnatal exercises. We have also included care of new born in brief but
described in details in Block 2 Unit 5.

It is needless to mention over here that the care of a post natal mother is incomplete unless
the new born baby is also totally looked after by the nurse. The mother’s anxiety and stress
for her new born’s welfare and care should be understood fully by the nurse and proper
attention should always be given to the complaints and queries of the mother regarding her
newborn.

5.3.1 Care of Mother

The management of puerperium consists of providing the means whereby the woman can
recuperate physically and emotionally and gain supervised experience in the care of her
infant. This consists of the following principles:

1) To restore the health status of mother.

2) To prevent infection.

3) To take care of breasts including promotion of breast feeding.

4) To provide for care of the baby.

5) To motivate and guide for family planning.

6) To give need based health education.

Immediate Care
The first hour after delivery does not end the recovery process. The clinical phase of
recovery continues throughout hospitalization and weeks after discharge. During this time
accurate observations, nursing history and physical assessment allow formation of
appropriate nursing diagnosis and effective plan of care. These may be as follows:

Initial observations
First impression of woman provide an overview of how she is recovering of childbirth. Her
general appearance and presence of pain, her colour reflects circulation and perfusion.
Observe her for pallor, flusting or cynosis. Note whether she is very fatigue, quiet, excited
or anxious. Is she looking comfortable or in distress. Assess the I/V line in place, amount of
fluid and medication etc. If she had surgery? Whether the Folley’s catheter is in place? Is
she concerned about the baby and herself?

Physical Assessment
It should be provided in the following order:
Vital signs: Take pulse, respiration and blood pressure. Temperature is taken to ensure that
woman is not dehydrated and to rule out infection.
Post-partum checks include vital signs every 15 minutes for one hour, then 30 minutes in
the second hour and then every 4 hours for 24 hours.
Uterus: For vaginal delivery, check the fundus for consistency, height and descent.
Measurement of abdominal girth after LSCS.
LSCS: check the dressing for presence of bleeding.
Perineal area: Check perineal pad for amount, colour of lochia, odor, clots, intact sutures,
odema, pain and anus for any repaired lacerations or haemorrhoids.
Rest and ambulation: For most of the woman 8-12 hours of rest is enough following
delivery. She is able to feed the baby, move out of bed and go to toilet. Now-a-days early
embulation is followed because of the following advantages:
1) Provides a sense of well being.
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2) Reduces bladder and bowel complications. Normal Puerperium and
Nursing Management
3) Facilitate uterine drainage and involution.
4) Reduces puerperal venous thrombosis and embolic phenomenon.
5) Early ambulation does not mean return to normal activities. These should be
restricted for at least 6 weeks. During this period she should take as much rest as
possible, avoid strenuous work like lifting, staining and pushing heavy things. If
normal delivery lies down for sometime in prone position to help in anteversion of
uterus. Take at least 2 hours of rest after midday meals.
Diet: The woman should be given light diet on the first day and normal diet from the
second day. The lactating mother should be given high calories, adequate proteins, fats,
mineral, vitamins and plenty of fluids, and green leafy vegetables. The mother must
consume iron, folic acid and calcium also. In a non-lactating mother normal diet is enough.
Care of bladder: The woman is encouraged to pass urine within 6-8 hours following
delivery and then after 4-6 hours interval. Many times woman do not pass urine because of
the following reasons:
l Lack of privacy and unaccustomed position.
l Reflex from perineal injuries.
Privacy to be provided. Patient may be allowed to use the toilet. If fails to pass urine
catheterization should be done.
It can be done in incomplete emptying of the bladder because of residual urine more than
60 ml. Continuous drainage is kept until the bladder tone is regained to prevent infection
and cystitis.
Care to bowel: Abdomen should be visually inspected for distension, palpated for firmness
or rigidity and auscultated for the presence of bowel sound specially after surgical delivery.
Ask the woman if she is able to pass flatus and feel urge defecate.
Care of breast: Breast and nipples to be washed and cleaned with water, and soap to be
applied while taking bath. Supporting brassiere of right size to be worn for proper support.
If proper care has not been taken during antenatal period dried scales formed by the breast
secretions may become firmly adherent closing the duct openings.
Need for rooming in: In this system baby remain at the mother’s bedside for most of the
time of the day and treated as a unit. It provides psychological and physical advantage to
both mother and baby and minimizes the cross infection when the baby is in nursery. It
helps to feed the baby on demand and relieves workload of nursery staff.
Immunologic Needs
Immunization: Delivery of the fetus and placenta increases the chances of fetal blood
entering maternal circulation for Rh negative mother with the Rh positive infant
predisposes to the formulation of antibodies that can endanger future pregnancies.
Prevention of isoimmunization is possible if Rh-immunoglubulin is administered within 72
hours after delivery.
Administration of anti-D gamma globulin to unimmunized Rh-negative mother with Rh-
positive baby within 72 hours of delivery.
Sleep: The amount of energy spend during labour and birth leaves the mother in need of
rest both physical and mental. She should be protected against worries and fatigues. If there
is some discomfort such as afterpains, engorged breast should be dealt with adequate
analgesics as necessary. Child care should be planned so that mother can rest while other
members of family to be encouraged helping her rest. Visitor should be limited. Because
fatigue adversely affects milk production, interferes with learning, can precipitate
depression and lower the self esteem.
Care of the vulva and episiotomy wound: After delivery vulva and buttocks are washed
with saline, lotion or soap and water. Antiseptic ointment or lotion applied over the
episiotomy sterile pad given. This should be done at least 3-4 times a day with the each act
of micturation and defecation. This will also relieve pain. Cold compresses are applied for
the first 24 hours to prevent and decrease odema and diminish local sensation. Some
women feel more comfortable with warm water sitz bath. 123
Maternal Health and Nursing Postnatal Exercises
Intervention
The objectives of post-partum exercises are:

1) To improve the muscle tone which have stretched during pregnancy and delivery, the
abdominal and perineal muscles.
2) To teach about the correct posture to be maintained while getting up from the bed and
practice correct principles of lifting and working during daily activities. (Refer to the
unit on post-natal exercises)

Health Checkup and Advices on Discharge

Health Checkup

l Thorough health checkup of mother and baby prior to discharge.

l Examination includes checkup of vitals, anaemia, breast condition, progress of
involution and lochial discharge.
l Inspection of perineal wound if present.
l Complete checkup of the body – general condition, weight, feeding of the baby,
immunization status and any congenital abnormalities to be treated.

Advices on Discharge

l Measures to improve general health of the mother, continuation of supplementary therapy.

l Breast care, personal hygiene.
l Post-natal exercises to be done at least for 6 weeks.
l Breast feeding demand/schedule, exclusive till 6 months.
l Care of newborn baby vaccinations to be done.
l Abstinence for intercourse for 6 weeks.
l Family planning advice and guidance to prevent accidental pregnancy.
l Post-natal checkup after 6 weeks.

5.4 ROLE OF NURSE-MIDWIFE IN POSTNATAL CARE

The role of nurse midwife during postnatal period is to provide care and support to the mother
and baby based on the following principles :

1) Promoting physical and psychological well-being of the mother, her baby and the family
unit.
2) Identification of deviation from normal physiological or psychological progress and
make prompt referral as required.
3) Encourage sound methods of infant care and feeding and prompt development of effective
parent-infant relationship.
4) Support and strengthen woman, her husband and family’s confidence within their family
and culture environment.
5) Monitor progress of mother and child according to the needs, expectations and attitudes
of a particular mother and baby.
6) Promotion of a relaxed environment conducive to establish effective communication
between mother and her family.
7) Provide non-judgemental approach, offer guidance, advise whenever necessary. Not to
make decisions on behalf of the woman or convey disapproval of her decision.
8) Promote breast feeding whenever possible. Respect individual choice and support the
mother concerning method of feeding. In case of artificial feeding advise about
preparation and sterilization equipment.
9) Follow these important elements of maternity nursing care :
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 a) Use universal precautions and gloves when there is contact with blood or other Normal Puerperium and
body fluids. Nursing Management

b) Obtain clients consent before any procedure or treatment and explain the findings
after a procedure is completed.
c) Provide individualize care by determining clients’ needs for nursing interventions.
d) Encourage and teach self care during every contact with client.
e) Provide privacy respecting cultural needs.
f) Support patient-infant and sibling-infant interaction during hospital stay.

10) Maintain proper records and reports.

5.5 LET US SUM UP

In this unit you have learnt that puerperium is the period following child birth during which
the body tissues specially the pelvic organs revert back approximately to the pregravid state
anatomically and physiologically. It has also been discussed the physiological changes which
have taken place in various systems of the body, involution of uterus, lochia and its
characteristics, the establishment of lactation. The unit also includes the psychological responses
of the mother to its child.

You have also learnt the management of normal puerperium, the immediate care to be given
to the mother and child, the care of breast, care of episiotomy and the post-natal exercises etc.

5.6 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1

1) Characteristics features of puerperium are:

l The secrative organs return back approximately to their pre-gravid state both
anatomically and physiologically.
l Lactation is initiated.
l Recuperation from physical, hormonal and emotional experience of parturition.
2) Involution is the process by which the pelvic organs returns to their pre-pregnant size
and position and the placental site of endometrium heals.
3) Lochia is the vaginal discharge for the first fortnight during peurperium. The discharges
originates from the uterine body, cervix and vagina. It contains blood, decidual tissues,
epithelial cells, bacteria and at times fragments of membranes, and small blood clots. It
has a fleshy odour which is not offensive. The types of Lochia are Lochia Rubra meaning
‘Red’, occurring during the first 1-4 days after delivery and may contain small blood
clots. Lochia Serosa occurs next 5-9 days, the colour is yellowish pink or pale brownish.
Lochia Alba lasts for next 10-15 days, is pale white in colour due to presense of
leuckocytes. The colour of Lochia indicates the healing stage of placental site and is
also an indication of proper involution of the uterus. The average amount of discharge
for the first 5-6 days is about 250 ml.
4) a) 7.5 cm, 5 cm and 2.5 cm
b) 60 gm
c) high
d) shrink
e) 8 weeks, 18 months
f) colostrum

Check Your Progress 2

1) Factors that determine the establishment and maintenance of lactation are:

a) The anatomical structure of the mammary glands and development of alveoli, ducts
and nipples.
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Maternal Health and Nursing b) The initiation and maintenance of milk secretion.
Intervention
c) Milk ejection or propulsion of milk from the alveoli to the nipple.
2) Prolactin is the most important lactogenic hormone initiating and maintaining milk
secretion. The hormone is produced by the anterior pituitary gland and is mainly the
result of the prolactin reflex resulting from the infants sucking at the breasts. The suckling
stimulus provided by the baby sends a message to the Hypothalamus which in turn
stimulates the anterior pituitary to release prolactin hormone, to promote the production
of milk in the aleveolar cells of the mammary gland. The frequency, intensity and duration
of the breast feeding influences the amount of prolactin secreted and milk produced.
3) a) Attachment
b) Natural development tasks
c) Mood changes
d) Post-partum blues
e) Post-partum depression.

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