What is Normal and Abnormal Puerperium, Maternal Care?

Definition of Normal Puerperium

Puerperium is Defined as the period following childbirth till 6 weeks. Puerperium is the period that follows the complete 3^rd stage of labor and continues within 6weeks. The puerperium period involves the involution of the reproductive organs.

Stages of Puerperium

Immediate puerperium – Within 24 hours
Early puerperium – Within 2^nd -7^th Days
Remote puerperium – 2^nd – 6^thWeeks

Benifites of Puerperium

Puerperium plays a major role in the Involution of the Organ after delivery.
Lochia
Contraception
Lactation
To prevent sepsis

What is Involution of the uterus?

Involution is a process in which reproductive organs revert back approximately to the pre-pregnant state.

Puerperium term Denote – Period
Puerperium term Denote – Women
Involution term Denote – Process

Involution – Reproductive organs revert back pre-pregnant state.

Changes in the Uterus after delivery

Soon after Delivery uterus changes are –>

Uterus shape – Globular
Uterus size – 20×12cm²
Soon after Delivery uterus weight – 900-1000gm
At the end of 1^st week uterus weight – 500gm
End of 2^nd week uterus weight – 300gm
End of 6^th week uterus weight – 80-100gm

Soon after Delivery uterus is located just below the umbilicus.

1^st 24 hours uterus Does not Descent But from 2^nd Day uterus’s Descent rate is 1.25 cm/day.

Uterus completely Descent in the pelvis at 10^th -12^th days (< 2 weeks).

Oxytocin continuously releases and stimulates the uterine contraction and helps to descend the uterus.

Changes in Placenta Soon after delivery

Soon after Delivery placenta wound – 7.5cm
At the end of 6week placenta wound -1.5cm

Changes in uterus Endometrium after the delivery

Endometrium regeneration start – 6^th – 7^th Day of delivery
Endometrium regeneration end – 16^th Day of Delivery

changes in uterine Epithelium after the delivery

Regeneration starts – on the 6^th -7^th Day of delivery.
Regeneration End – 10^th Day of delivery.

What is uterine Subinvolution?

Subinvolution is the Failure of the uterus to return to the nonpregnant state. The most common causes of subinvolution are retained placenta and infection.

Veginal changes in Puerperium

Vaginal involution takes approximately 4-8 weeks.
Vaginal rugae (mucosal fold) reappear in 3-4 weeks.
The vagina regains tone but does not regain full stretching.

Cervix changes in Puerperium

Cervix contracts slowly
Soon after delivery cervix is 2-3 fingers open
2 fingers opening of the cervix remain for a few Days
At the end of 1^st week, the cervix is completely closed
Nulliparous women’s cervix is round and the goal
Multiparous / Parous women cervix is transverse

The pelvic floor and pelvic fascia take a long time to involute

What is Lochia?

Lochia is Defined as the per vaginal Discharge, occurs after birth for the first fortnight (14night) during puerperium. Lochia is following birth and remains 1-5 days (14nights/weeks)

Origin of lochia is – Placental site and wound,Retain placenta,Episiotomy wound,Vaginal and cervix. injury

Amount of normal lochia is 250ml in first 5-6 Days
Lochia smell (Odour) – Fishy smell
Lochia PH – Initially alkaline and become acidic by the end of lochia

Classification of lochia

Lochia rubra – 1-4 Days
Lochia serosa – 4-10 Days
Lochia Alba – 10-15 Days

Lochia	Color	Composition of lochia
Lochia Rubra	Red color Discharge	Blood, Shields of Fetal membrane and Decidua vernix, Lanugo, and meconium
Lochia Serosa	Yellowish and Brownish Discharge	WBC, wound, Exudation, Mucous
Lochia Alba	Pale white Discharge	Mucous, epithelium cell, Desidual cell, WBC

Abnormalities in Lochia

Abnormalities On the basis lochia amount

Increase lochia amount Due to – Atony of the uterus

-Macrosomia

– Twin pregnancy

– Lesions in genital tracts

– Infection

– Incision

– Polyhydramnios

– Enlarged episiotomy

Decrease the amount of lochia Due to – Infection

-Premature labor

– Small fetus

– Lochometritis (Collection of lochia into the uterus)

Abnormalities in lochia On the basis of odor

Infection
Retained placenta
Blood collects
Lochometritis

On the basis of Duration – The duration of lochia is the increase in the case of genital lessons.
Persistent red color – Subinvolution.

Physiological changes in mother body During puerperium

Pulse – After normal Delivery, the pulse rate increases for a few hours, which settles Down to normal on 2^nd Day.
Temperature – Temperature should not be above 99 Degrees F in the first 24 hours but on 3^rd Day temp. slightly increase Due to breath engorgement. Temp. rise use to genitourinary tract infection

Physiological changes in mothers Weight

5-6kg weight loss after Delivery
Weight loss Due to the expulsion of Fetus, Placenta, Membrane, and fluid.

Physiological changes in Urinary tract after pregnancy

Retention of urine is common in perperium period

Common urinary problems in Puerperium is occur –

Overdistension
Incomplete emptying
Residual urine
Risk of urinary tract infection

Problems in GI tracts in Puerperium

Thirst increase
Constipation Due to delayed gastrointestinal motility
Anal incontinence

Body Fluid Changes in Puerperium

During 1^st Week – 2-liter fluid loss
Next 5 weeks – 1.5-liter fluid loss
Fluid loss Depends on – Retain fluid During pregnancy
Dehydration
Blood loss During Delivery.
Blood volume Decrease after Delivery.

Return to the pre-pregnant level by the 2^nd week.

Changes in Menstruation & Ovulation

In non-lactating Mother	In lactating Mother
Menstrual return early 6^th -12^th week	Menstrual return early 12^th week
Ovulation as early 4^th Week after Delivery	ovulation as early 10^th week after Delivery
Contraception are use start at 3^rd postpartum week	Contraception start at 3^rd post partum mouth
Common contraception is OCP.	Common contraception is DMPA

Lactation in Puerperium period – Lactation is a process of milk production, and secrete by the mammary glands after delivery. 1^st Breast milk is colostrums after Delivery

Colostrum – colostrum is yellow, serous fluid, Alkaline in nature

Colostrum has high specific gravity.
Colostrum involves more vit. A, protein, Vit.A , Na⁺ Cl^-.
Colostrum involves low carbohydrate, fat, and Potassium.

Abnormal Puerperium

Two major Abnormalities in puerperium. these are puerperal pyrexa and other one is purpureal sepsis.

Puerperal pyrexia
Purpureal sepsis

What is Puerperal pyrexia

Puerperal pyrexia is Increased body temperature = 38⁰c (100.4⁰f) following in the first 10 days after the delivery.

Purpureal sepsis

Purpureal sepsis is a postpartum infection, an infection of the female genital treated as a complication of delivery.

Predisposing factors for purpureal sepsis

Antenatal factor – preterm labor

Premature rupture of membrane
Anemia and malnutrition
Prolonged rupture of membrane

Intrapartum factor – Repeated per vaginal examination

Trauma during delivery
Instrumental trauma
Refrained placenta
Cesarean delivery
Hemorrhage.

The most common site of puerperal sepsis is = Placental site

The most common route of puerperal sepsis is = Direct

The most common microorganism involved in puerperal sepsis is = streptococci

The most common manifestation of puerperal sepsis = Endometritis

Sign and Symptom of Purpureal sepsis

Increased body temperature
Generalize headache, rapid pulse
Redness and swelling of the vulva
Offensive lochia occur
Tender and soft uterus of subinvolution of the uterus
Pus formation of the wound
Prematurity’s
Construct pelvis pain and leukocytosis
Lower abdominal pain and tenderness
Pus collection in the pouch of Douglas

Diagnosis of Purpureal sepsis

History collection and physical examination
Blood test and smear test
Vaginal and cervical swab test
Urine test (Routine and microscopic)
Complete blood count
Ultra-sonography
X-ray

Nursing role in preventing puerperal sepsis

1. Take the history and physical examination done

2. Collect the vital sign assessment

3. To maintain the hygiene – Wear gloves

Clean the perineal area with the help of an antiseptic solution
Clear anterior to posterior direction.

Ask the client to change the sanitary napkin frequently
Educate the client about the use of sterile sanitary napkins.
Ask the client to wash his hands before and after changing the sanitary napkin and wear gloves.
Ask the client to take a bath daily or to change the undergarments daily.
Maintain ventilation in the room to prevent the infarction site bath twice a day.

Explain to the client about the proper method of breastfeeding, the importance of breastfeeding, and breast self-examination.
Nurse on courage to client for intake high calory and high protein diet.

E.g.:- for lactating mother + 600 kcal/day (2200+600= 2800 kcal/day)

:- protein = +25 gm /day

Prepare the lochia chart for 2 weeks of delivery.
Assess the level of hemoglobulin.

Eg:- If hb decrease = <10 gm/dl – indicate slow involution.

If hb Increase = > 11 gm/ dl – Indicate rapid involution: slow involution Increase the change of postpartum infection

Educate the client about sexual intercourse, sex avoidance within 6 weeks after delivery.
Make the symphysis fundal height chart
Bowel and bladder care.
Prevent constipation – provide a high fiber diet.
Maintain the fluid intake and urine output chart
Provide rest and Immunization.
Provide proper sleep patterns.
Minimize the number of visitors in the roomof delivery.
Post-partum exercise – Kegel exercise.

Kegel exercises help in stretching pelvic and bladder muscles.

Educate the client about Importance of contraception and method of contraception.

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