What is Normal and Abnormal Puerperium, Maternal Care

What is Normal and Abnormal Puerperium, Maternal Care?

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Definition of Normal Puerperium

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

Stages of Puerperium

  1. Immediate puerperium – Within 24 hours
  2. Early puerperium – Within 2nd -7th Days
  3. Remote puerperium – 2nd – 6th Weeks

Benifites of Puerperium

  1. Puerperium plays a major role in the Involution of the Organ after delivery.
  2. Lochia
  3. Contraception
  4. Lactation
  5. 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 1st week uterus weight – 500gm
  • End of 2nd week uterus weight – 300gm
  • End of 6th week uterus weight – 80-100gm

Soon after Delivery uterus is located just below the umbilicus.

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

Uterus completely Descent in the pelvis at 10th -12th 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 – 6th – 7th Day of delivery
  • Endometrium regeneration end – 16th Day of Delivery

changes in uterine Epithelium after the delivery

  • Regeneration starts – on the 6th -7th Day of delivery.
  • Regeneration End – 10th 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 1st 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

  1. Lochia rubra – 1-4 Days
  2. Lochia serosa – 4-10 Days
  3. 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
  1. On the basis of Duration   – The duration of lochia is the increase in the case of genital lessons.
  2. Persistent red color – Subinvolution.

Physiological changes in mother body During puerperium

  1. Pulse – After normal Delivery, the pulse rate increases for a few hours, which settles Down to normal on 2nd Day.
  2. Temperature – Temperature should not be above 99 Degrees F in the first 24 hours but on 3rd 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 1st 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 2nd week.

 Changes in Menstruation & Ovulation

 

              In non-lactating Mother                     In lactating Mother
  • Menstrual return early 6th -12th week
  • Menstrual return early 12th week
  • Ovulation as early 4th Week after Delivery
  • ovulation as early 10th week after Delivery
  • Contraception are use start at 3rd postpartum week
  • Contraception start at 3rd 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. 1st 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.

  1. Puerperal pyrexia
  2. Purpureal sepsis

What is Puerperal pyrexia

  • Puerperal pyrexia is Increased body temperature = 38c (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

  1. Antenatal factor – preterm labor
  • Premature rupture of membrane
  • Anemia and malnutrition
  • Prolonged rupture of membrane
  1. 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.
  1. Explain to the client about the proper method of breastfeeding, the importance of breastfeeding, and breast self-examination.
  2. 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

  1. Prepare the lochia chart for 2 weeks of delivery.
  2. 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

  1. Educate the client about sexual intercourse, sex avoidance within 6 weeks after delivery.
  2. Make the symphysis fundal height chart
  3. Bowel and bladder care.
  4. Prevent constipation – provide a high fiber diet.
  5. Maintain the fluid intake and urine output chart
  6. Provide rest and Immunization.
  7. Provide proper sleep patterns.
  8. Minimize the number of visitors in the roomof delivery.
  9. Post-partum exercise – Kegel exercise.
  • Kegel exercises help in stretching pelvic and bladder muscles.
  1. Educate the client about Importance of contraception and method of contraception.
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