Postpartum Care

Postpartum Care

 The postnatal period is defined as not less than ten and not more than 28 days after the end of labour, during which the continued attendance of a midwife on the mother and baby is requisite

The role of the midwife during the post natal period is to provide care and support at a level determined in partnership with the woman the care of mothers and babies based upon four main principles like promoting physical and psychological well being identification of deviation from normal encouraging infant care promoter to develop effective parent infant relationship and strengthening the women and her partner conference to facilitate their parent role

Puerperium:

Definition of perineum: 

Puerperium starts immediately after the delivery of the placenta and associated membranes and continues for 6 weeks, characterised by 3       features,

The generative organs return to their pregravida state, lactation is initiated, and recuperation from the physical, hormonal and emotional experience of parturition takes place

Physiological changes Reproductive system:

Involution of t he uterius:

–          Immediately after placenta expulsion, the fundus of the uterus is slightly (5 cms) below the umbilicus or 12 cms above the symphysis pubis

–          The uterus begins to shrink so that within two weeks, the fundus descends below the symphysis pubis

–          By the end of 6 weeks uterus remains in its non-pregnant size

–          The process by which the postpartum uterus returns almost to its pre-pregnancy state is known as involution

–          During involution, autolysis of the muscle fibres and ischaemia of the uterus occur by the proteolytic enzymes with the liberation of peptones, which enter the bloodstream

Reduction in the size of the uterus:

	Weight of the uterus	Diameter of the placenta site	Cervix
End of labour End of 1 week End of 2 weeks End of 6 weeks	900 gms 450 gms 200 gms 60 gms	12.5 cm 7.5 cm 5.0 cm 2.5 cm	Soft flabby 2.5 cm 1 cm A slite

 

Changes in the cervix and vagina:

– Cervix is very flaccid after delivery

–          Cervical os opens gradually contracts, and for the first few days admits 2 fingers

      By 2 -3 weeks internal os is closed

      Vagina gradually diminishes in size and partially reappears at the third week

      The introitus remains permanently larger than the virginal state hymen is lacerated and is represented by nodular tags

    

Lochia:

–          It is the  vaginal discharge for the first 2 -3 weeks during puerperium

–          It is comprised of blood and necrotic decidua

–          Lochia have an alkaline reaction in which organisms can  flourish more rapidly than in the normally acidic secretions of the vagina

–          After delivering the remaining deci duous becomes differentiated into 2 layers

–          The superficial layer becomes necrotic and itt is sloughed off in the lochia

–          The basal layer remains and is the source of new endometrial

Types of lochia:

1. Lochia rubric – first 4 days
2. a)Red colour lochia
3. b)Consisting of blood from the placental site debris arising from the decidua and chorion
4. Lochia serosa from 5^th– 9^th day
5. a)Lochia becomes pale
6. b)Contains still some  red cells and more serum, predominantly leukocytes and necrotic deciduous tissue
7. Lochia alba after 10th-15th day
8. Lochia yellowish white colour
9. Consists of serous fluids and leukocytes, cervical mucus and debris from healing issues

Postpartum General Physiological Changes:

Urinary System:

Urinary tract:

–          Bladder is over-distended, and incomplete emptying is common

–          The insensitivity  of the bladder is due to trauma sustained by the nerve plexus during delivery

–          Stagnation of uterine predisposes to those implications and to ascending infection of the uterine tract

–          Diuresis occurs between the 2^nd and 5^th day

–          Dilated ureters  and renal pelvis return to the pre-pregnant state within 8 weeks

Gastrointestinal tract:

Increased thirst is due to loss of fluid during labour in the lpchoa dwrisis and prerspiration. Slight intestinal paralysis leads to constipation

CVS:

Blood:

–          Cardiac output rises soon after the delivery and remains elevated for 48 hours postpartum

–          By the 2^nd week, these changes have returned to non-pregnant values

–          Fibrinogen level remains elevated in the second week of puerperium

–          The hypercoagulable state persists until about 6 weeks

Return of the menstruation and ovulation:

–          The onset of the first menstrual period following delivery is variable and depends on the lactation

– A mother who does not breastfeed has an early resumption if menstruation by 6 -8 weeks

Physiology of the postnatal woman:

Women react during the postpartum period in different ways. The majority are happy and contented. The temperament of the woman has an important bearing on her reaction. The happy woman of average intelligence is usually a successful  mother

A process of adjustment:

The woman with her first baby goes through a process of adjustment that, for the well-balanced woman, presents no problem;

The immature may tend to reject the responsibilities involved in parenthood

Postpartum tears: (fourth day blues):

This condition may be due to a temporary endocruic imbalance following childbirth. A few may have short periods of mild depression and mood swings

During the first week of the puerperium, the woman should not be subjected to worry or excitement. Family support is needed to build confidence in  the mother

Postnatal care:

Care of the mother after delivery is known as postnatal or postpartal care. Broadly, this care falls into two areas: care of the mother, which is primarily the responsibility of the midwife and obstetrician and care of the newborn, which is the combined responsibility of the obstetrician and a paediatrician

Postnatal care includes a systematic examination of the mother and the baby, and appropriate advice given to the mother

Objectives of postnatal care:

–          To prevent complications of the postnatal period

–          To provide care for the rapid restoration of the mother to optimum                 health

–          To check the adequacy of breastfeeding

–          To provide family planning services

–          To provide basic health education to mothers or families

Complications of the postnatal period:

Certain complications may arise during the postpartum period, which should be recognised early and dealt with promptly.

The complications are puerperal sepsis, thrombophlebitis, secondary haemorrhage, and other complications, such as Urinary tract infection and mastitis.

It is extremely important to look for these complications in the post-partum period and prevent or treat them promptly

Restoration of the mother to optimum health:

The objective of postpartum care is to provide care whereby the woman can recuperate physically and emotionally from her experience of delivery

Physical:

1. Postnatal examination, soon after delivery, the health checkups must be frequent, i.e twice a day during the first 3 days and subsequently once a day till the umbilical cord drops off. Postnatal examination includes a head-to-toe assessment, vital signs

 

To be recorded 4^th only to identify any source of infection, breasts should be examined daily for any areas of redness, heat, hardness or pain

1. Anaemia: Routine haemoglobin examination should be done during postnatal visits and when anaemia is discovered,
2. It should be treated in some cases; it may continue for a year or more
3. Nutrition: Through a malnutrition mother can secrete as much breast milk as well nourished one, the nutritional needs of the mother are adequately met
4. Postnatal exercises: Postnatal exercises are necessary to bring the stretched abdominal and pelvic muscles back and normal as quickly as possible

Psychological;

The next big area of postnatal care involves a consideration of the Psychological factors, particularly for the recently delivered woman. One of the Psychological problems is fear and insecurity may be eliminated by proper prenatal instruction

Breastfeeding:

Postnatal care offers an excellent opportunity to find out how the mother is getting along with her baby particularly about feeding in some societies lactation  continues to make an important contribution to the childs nutritions for 18 months or longer for many children breast milk provides the main sources of nourishment in the 1^st year of life a great asset in India is  that an average Indian mother although poor I nutritional status has a remarkable ability to feed  her infant for prolonged periods some times extending to nearly 2 years

Family planning:

It has alrwady been stressed that family planning is related to every phase of maternity cycle post partum sterilization is generally recommended on the 2^nd day after   delivery although lactation confers some protection against conception contraceptives must therefore be used that will not affect lactation in the early post partun period “PILLS” should be avoided in a lactating mother a s they do suppress lactation

Basic health education:

Health education during the postnatal period should cover the following broad areas

–          Personal and environmental hygiene

–          Feeding for mother and infant

–          Pregnancy spacing

–          Importance of a health check-up

–          Birth registration

Postnatal care and needs:

The first 4 weeks after the birth are referred to as post postnatal or post partum period, which is not less than 10 and not more than 28 days after the end of labour, during which the attitude of a midwife on the mother and baby is requisite

The intricate relationships between physiological and psychological adjustments and social factors are encompassed in the result of postnatal care

Midwifery postpartum visits:

–          The nature and purpose of the  visits by the midwife may vary according to this cultural background

–          10 10-day period following the birth recognised as a period within which statutory visits are made to have insight into low women’s views on the timing of these visits it aims to assist the mother and her baby towards attaining an optimum health state

Physiological observations:

The  birth at home as in a home birth setting, the midwife primarily focuses on the observation of the result of postpartum mother and the new baby

–          Assessment of the observations contained within the examination

–          Records provide a tool to use if there is a concern about a woman who is feeling unwell and provide a comprehensive picture of the woman’s state of health, but may be less useful in the case of a healthy postpartum woman

–          Assess for potential aspects of morbidity, women’s feelings of unwell reporting different from her previous experiences

The Uterus:

After birth, oxytocin is secreted from the posterior pituitary gland to act upon the uterine muscles and the separation of the placenta. After which the uterine cavity collapses into a belt at this point, it still retains its potential

Abdominal palpation is done to assess the uterus with regular observation of the fundus height

Report keeping appropriate use:

Clear and accurate records of any observation that has been undertaken are essential tools of competent practice

Postpartum vaginal blood loss:

–          Assess the variability of vaginal floss from menstruation, identify colours and consistency

–          Ask about the previous history

–          Assessed for any clots passed

Perineal tears:

–          Assess the degree of pain and discomfort

–          Observe the progress of healing from any transverse

–          Appropriate care immediately after the birth or suturing after birth to reduce oedema and précising

–          Collect information about urinary symptoms, such as any dribbling of urine

–          Soaking in a bath may provide relief from the Pain

Observation of Pulse temperature, respiratory and blood pressure:

–          Make note of pulse rate for one full minute

–          Check the signs of well-being, including respiratory rate

– Overall body temperature, any untoward body odour colour, and complexion

–          If the client is  feeling unwell, check vitals as there may be an infection

–          After the birth of the baby, a  baseline recording of the woman’s blood pressure will be made

–          Routine B.P. checking daily is necessary

Circulation:

The body has to reabsorb a quantity of excess fluid following the birth majority of women, resulting in passing large amounts of urine

–          Assess the oedema of ankles and feet, urinary output

–          Avoid long periods of standing and elevate feet and legs when sitting

 

Skin and nutrition:

–           Maintain balanced fluid intake and a diet that has a greater proportion of fresh food in it

–          Improve gastrointestinal activity and absorption of iron and minerals

Care of the  bladder:

The mother is encouraged to pass urine 6 – 8  hours following delivery if a patient fails to pass urine, catherization

Care of bowel:

A diet containing sufficient roughage and fluids is enough to move the bowel

Rest and sleep:

For 8 – 12 hours is necessary

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