Postnatal care

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Postnatal care
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Puerperium

• The 6 week period following birth during which
  time the various changes that occurred during
  Pregnancy revert to the non-pregnant state.

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Physiological changes during Puerperium
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Cardiovascular system

• Reverts to normal during the first 2 weeks. The
  extra load on the heart from extra volume of
  blood disappears by the second week.

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Vagina, perineum

• vaginal wall is initially swollen, bluish and
  remains fragile for 1-2 weeks.
• Perineal oedema may persist for some days.

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Uterus

• After delivery of placenta, the uterus is at size
  of 20-week pregnancy,
• Reduces in size on abdominal examination by 1
  finger-breadth each day such that on the 12th day
  it cannot be palpated.
• By end of puerperium it is only slightly larger
  than pre-pregnancy.

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Lochia

• for first 3-4 days, lochia comprises mainly blood
  and remnants of trophoblastic tissue.
• During days 3-12 the colour is reddish-brown but
  then changes to yellow.
• By the 24th day it becomes colorless

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Minor complaints during puerperium
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Serious puerperal problems
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Postnatal psychosis

• Affects 1-3/1000 women and usually appears as
  mania or depression and sometimes as
  schizophrenia.
• Usually begins suddenly at 5-15 days with
  confusion, anxiety, restlessness and sadness.
• There is rapid development of
• Delusions, e.g. baby has died or is deformed
• Hallucinations with deepening melancholia.
• The women must be admitted to hospital,
  preferably with her baby.

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Postpartum hemorrhage

• Primary postpartum haemorrhage
• is defined as loss of more than 500 ml of blood
  during first 24 hours.
• 80 of cases are associated with either an atonic
  uterus or placental remnants.
• Rest of cases are associated with laceration of
  the genital tract, rarely uterine rupture or
  blood coagulation defect.

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Postpartum hemorrhage (2)

• Secondary postpartum haemorrhage
• is abnormal bleeding after 24 hours up until 6
  weeks postpartum.
• Usual causes are
• Poor epithelialisation of placental site (80
  cases)
• Retained placental fragment and/or blood clots
  (usually detected by ultrasound)
• Uterus is often found to be bulky and tender with
  cervix open.
• Initially treated with ergometrine IM plus
  antibiotics. Curettage is only necessary if
  bleeding persists despite this.

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Puerperal pyrexia

• Defined as
• Temperature 38C or above during the first 14
  days after delivery.
• Now occurs in only 1-3 of all births.
• Most cases are due to
• anaerobic streptococci that normally inhabit the
  vagina. Initially, infect placental bed and then
  spread either into parametrium or via uterine
  cavity to Fallopian tubes.
• Alternatively may be breast infection or UTI, or
  non-infective cause such as thrombophlebitis or
  deep vein thrombosis

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Thromboembolism

• Now occurs in lt1/1000 births and more common in
• overweight,
• over the age of 35 or
• Caesarean section
• Deep vein thrombosis indicated by
• low-grade fever,
• raised pulse rate.
• Calf muscles are tender and painful.
• Clinical signs are unreliable and need
  confirmation with colour Doppler ultrasound.
• Pulmonary embolus
• dyspnoea and pleural pain and
• cyanosis may develop later.
• women may die within 2-4 hours.

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Post-Natal care
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Aims of Postnatal care
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Postnatal care visit

• The immediate postpartum care during the first
  6-24 hours after delivery needs to be viewed as
  part of care during delivery.
• The recommended visits at the 2nd, 4th, 6th,
  14th, 21st, and 40th day after delivery.
• The least number of visits is 3 visits at
  6hours, 6days and 6 weeks to meet the needs of
  the mother and newborn.

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Components of post-natal care
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1- History

• a) Any complications during pregnancy or labour.
• b) Any abnormal symptoms or signs of
  complications,(hemorrhage, infections and
  eclampsia)
• Vaginal bleeding, normally it is blood in the few
  days after delivery, later it becomes brownish
  then pink, and it becomes colorless only by 24th
  day.
• Bad smelling vaginal discharge.
• Pain or tenderness in the abdomen or breast.
• Fever.
• c) Diet What she is eating.

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2- physical examination

• The Mother
• Measuring temperature, blood pressure
• Abdomen for swelling, distended bladder, for
  cesarean incision and for determining the size
  and firmness (involution) of the uterus.
• Perineum for swelling, discharge, tears
  episiotomies.
• NB No vaginal examination
  should be performed early in
• puerperium except when it is
  absolutely indicated.
• breast for cracked nipples, engorgement or
  abscess.
• Leg for thrombosis.
• Checking for signs of anemia.
• The newborn for vital signs, umbilical stump,
  suckling power, respiratory
• distress (cyanosis), tremors, convulsion and
  jaundice. Ask about
• vomiting, constipation or anuria.

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3- Give the proper treatment if needed, give 200
000 IU of vitamin A orally iron

• 4- Refer the post-partum cases requiring special
  treatment.

5- Record the finding on the maternal card.
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6- Health education.

• The key messages that should be covered are the
  followings
• 1- Avoid puerperal infection
• Personal hygiene particularly that after
  urination and defecation
• No person with any upper respiratory tract
  infection or hand infection should be attending
  during exposure of the genitalia.
• 2- Care for the episiotomy or first degree
  perineal tear
• The woman has to be trained to clean the wound
  daily in the morning and each time after she
  passes any urine or stools using warm water and
  soap.
• 3- Sleep and rest
• The mother should have periods of rest
• Gradual return to household duties is advisable
  starting by the end of the fist week. She should
  avoid any strenuous activity for about 4 weeks.
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• 4- Diet
• She should be aware that all her nutritional
  needs are increased during the first six months
  of lactation together with fluid intake iron
  supplementation.
• 5- Advice and counseling on breastfeeding
• The woman should be instructed about
• Advantages of breast feeding
• Importance of early initiation of breast feeding
  (within ½ -1 hr)
• Encourage breast feeding on demands.
• Personal hygiene after feeding. Only water is
  recommended for washing
• nipples and allowed to dry in air after
  feeding and then covered with
• clean pads. Drying agents as boric acid
  alcohol must be avoided.

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• 6- Psychological changes
• The postpartum woman may show normally minor
  psychological instability as mood swing, and body
  image changes. It is important for the woman and
  her husband to understand these changes
• 7- Postnatal exercises
• These exercises should be continued for a minimum
  of six weeks to help normal involution of
  muscles, organs and sphincters. These include
  respiratory exercises, ankle muscle exercises,
  pelvic muscle strengthening and squatting

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7- Immunization

• The Rh -ve woman who did not produce anti Rh
  antibodies during pregnancy and whose baby is Rh
  ve is given 300 mg of Rh-immune globulin within
  24-48 hours of labour.
• Women who are not already immune to rubella are
  excellent candidates for vaccination.