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Hand-outs for Changes and Nursing Care during Postpartum and Puerperium

Postpartum Period - it is a time of transition, during which a couple gives up concepts

such as childless or parents of one and moves not only trying out their new role but
also determining whether they fit the new role.

Three phases of Puerperium Period

Taking-in phase - largely a time of reflection. A woman is largely passive. She prefers
having a nurse to attend her needs and make decisions for her, rather than do these things
herself. She wants to talk about her pregnancy, especially her labor and birth.
Encouraging her to talk about the birth is an important way to help the mother to integrate
the experience into her total life experiences.
Taking-Hold phase - starts a woman to initiate action. She begins to take a stronger
interest in her infant and begins maternal role behavior. It is usually best to give a woman
a brief demonstration of baby care and then allow her to care for her child herself with
watchful guidance as she enters this phase.
Letting-Go phase - a woman finally redefines her new role. She gives up fantasized
image of her child and accepts the real one; she gives up her of role of being childless or
the mother of only one or two. This process requires some grief work and readjustment of
relationships, similar to what occurred during pregnancy.

Development of Parental Attachment, Bonding, and Positive Family Relationships

When a woman enters into a relationship with her newborn, there are qualms and
conflicts must be addressed before the relationship can be meaningful. This is because
parental love is only partly instinctive.

When a woman has successfully linked with her newborn, it is termed attachment or
bonding. Looking directly at her newborns face with direct eye contact termed as en face
position is a sign a woman is beginning an effective attachment. Meanwhile, the action
that alerts caregivers to how actively the father, as well as the mothers beginning
bonding often called as engrossment.
The more time a woman has to spend with her baby is called rooming-in. It makes her
better acquainted with her child, feel more confident in her ability to care for her baby,
and more likely form a sound mother-child relationship.
When it comes to the siblings of the newborn and to the mother, separation from children
is often as painful for her a mother as it is for her children. A chance to visit the hospital
and see the new baby and their mother reduces feelings that their mother cares more
about the new baby than about them.
There are some feels that they were abandoned. Meaning after all, they were the center of
attention, with everyone asking about their health and well-being. Now, suddenly the
baby is everyones chief interest. You can help the woman move on these past feelings by
verbalizing the problem. This could also happen to the father because he feels resentful of
the time the mother spends with the infant. Making infant care a shared responsibility can
help alleviate these feelings and make both partners and feel equally involved in the
babys care.
Disappointment could also happen. All during pregnancy, they pictured a chubbycheeked, curly-haired, smiling girl or boy. They have instead a skinny baby, without any
hair, who seems to cry constantly. This can make it difficult to feel positive immediately
toward a child who does not meet their expectations. It can cause parents to remember
their adolescence, when they felt gangly and unattractive, or to experience feelings of
inadequacy. Comment on the childs good points, such as long fingers, lovely eyes, and
healthy appetite. Be aware, however, that, culturalyl, some groups are fearful for the baby
if these types of comments are made because they could draw evil influences toward the
Postpartum Blues - a woman experience some feelings of overwhelming sadness or
baby blues. This is because of the hormonal changes, particularly the decrease in
estrogen and progesterone that occurred with delivery of the placenta. Encouraging the
woman to talk about their postpartal feelings helps to differentiate between problems that
can be handled best with discussion and concerned understanding and those that should
be referred to a social service department or a community health agency for additional

Physiologic Changes of the Postpartum Period

Involution - the reproductive organs return to their nonpregnant state.
It involves two process. First, the area where the placenta was implanted is sealed off to
prevent bleeding. Second, the organ is reduced to its approximate pregestational size. The
sealing of the placenta site is accomplished by rapid contraction of the uterus
immediately after delivery of the placenta. Thrombi form within the uterine sinuses and
permanently seal the area. Endometrial tissue undermines the site and obliterates the
organized thrombi.
The uterus weighs about 1000 g after birth. At the end of the first week, it weighs 500 g.
By the time of involution, it weighs approximately 50 g, similar to its prepregnancy
weight. The uterus of a breastfeeding mother may contract even more quickly, because
oxytocin, which is released with breastfeeding stimulates uterine contractions. The
fundus is normally located in the midline of the abdomen. It can be felt slightly to the
right, because the bulk of the sigmoid colon forced it to that side during pregnancy and it
tends to remain in that position. We should assess fundal height shortly after a woman has
emptied her bladder for most accurate results, because a full bladder can keep the uterus
from contracting, pushing it upward and increasing the risk of excess bleeding and blood
clot formation in the uterus.
The first hour after birth is potentially the most dangerous time for a woman. If her uterus
should become relaxed during this time, it is called uterine atony. She will lose blood
very rapidly because no permanent thrombi have yet formed at the placental site. In some
women, contraction of the uterus after birth causes intermittent cramping termed
Lochia - this flow, consisting of blood, fragments of decidua, white blood cells, mucus,
and some bacteria. For the first 3 days after birth, a lochia discharge consists almost
entirely blood, with only small particles of decidua and mucus. It is mainly red color and
it is called lochia rubra. As the amount of blood involved in the cast-off tissue decreases
(about the fourth day) and leukocytes begin to invade the area, as they do with any
healing surface, the flow becomes pink or brownish and it is called lochia serosa. On the
10th day, the amount of the flow decreases and becomes colorless and white with streaks
of brownish mucus called lochia alba.
When it comes to the cervix, a uterine cervix feels soft and malleable to palpation. By the
end of 7 days, the external os has narrowed to the size of a pencil opening; the cervix
feels firm and nongravid again.

The vagina feels soft, with few rugae, and its diameter is considerably greater than
normal. The hymen is permanently torn and heals with small, separate tags of tissue. It
takes the entire postpartal period for the vagina to involute (by contraction, as with the
uterus) until it gradually returns to its approximate pregnancy state. If a woman practices
Kegel exercises, the strength and tone of the vagina will increase more rapidly.
The perineum is edematous and tender immediately after birth. Ecchymosis patches from
ruptured capillaries may show on the surface. The labia majora and labia minora typically
remain atrophic and softened after birth, never returning to their prepregnancy state.

Systemic Changes
Hormonal System
Pregnancy hormones begins to decrease as soon as the placenta is no longer present.
Levels of hCG and hPL are almost negligible by 24 hrs. By week 1, progestin, estrone,
and estradiol are all at prepregnancy levels. FSH remains low for about 12 days and then
begin to rise as a a new menstrual cycle is initiated.
Urinary System
2000 to 3000 ml of excess fluid accumulates in the body so extensive diaphoresis and
diuresis begin almost immediately after birth to rid the body of this fluid. This easily
increases the daily urine output of a postpartum woman from a normal level of 1500 ml
to 3000 ml per day during the 2 nd and 5th after birth. Hydronephrosis or increased size of
ureters remains present for about 4 weeks.

Circulatory System
The usual blood loss with a vaginal birth is 300 to 500 ml. With a cesarean birth, it is 500
to 1000 ml. Women usually continue to have the same high level of plasma fibrinogen
during the first postpartum weeks as they did during pregnancy.
Gastrointestinal System
Digestion and absorption begin to be active again soon after unless a woman had a
cesarean birth. Hemorrhoids that have been pushed out of the rectum because of the effort
of pelvic-stage pushing often are present. Bowel sounds are active.

Integumentary System
Stretch marks on a womans abdomen still appear reddened and may be even more
prominent during than during pregnancy, when they were tightly stretched.

Retrogressive Changes
A woman has sleep hunger meaning for the last several months, she probably
experienced difficulty in sleeping. All during labor, she worked hard with little or no
sleep. She lacks sleep.
Weight Loss
Rapid and diuresis and diaphoresis usually result in weight loss.

Progressive Changes
A woman starts to produce breast milk. Engorgement is the feeling of tension in the
breasts on the third or fourth day after birth.
Menstrual Flow
The resulting decrease in hormone concentrations cause a rise in production of FSH by
the pituitary, which leads with only slight delay to return to ovulation. This initiates the
return of normal menstrual cycles. A woman whos not breastfeeding can expect her
menstrual flow to return in 6 to 10 weeks after birth. If shes breastfeeding, it will return
in 3 or 4 months. It is called lactational amenorrhea.

Nursing Care
During the first 24 hrs after birth, we start first with the assessment which includes
history, physical examination and analysis of laboratory findings. We also include the
health history, her family profile, pregnancy history, labor and birth history, infant data,
and postpartum course.