1. Normal and abnormal
puerperium

2. Normal puerperium (Postpartum care)

3. Normal Puerperium Definition
It is the period of adjustment after pregnancy and delivery when anatomical and physiological changes of pregnancy are reversed and the body returns to the normal non pregnant state.. (reproductive tract returns to its normal, non-pregnancy state)
6 weeks in duration. (periods after birth )

4. Stages of Puerperium The post partum period has been divide into:
The immediate puerperium, the first 24 hours after parturition; when acute post anesthetic or post delivery complications may occur.
The early puerperium, which extends until the first week post partum.
The remote puererium, which includes the period of time required for involution of the genital organs through the sixth weeks postpartum.

5. Anatomical and Physiological changes
Immediately after labor, the woman is in a state of physical fatigue in many cases, slight shivering, muscular tremors and chattering of teeth occur for about 10 – 15 minutes.

6. Temperature:
Fever It is normal but usually there is a slight rise during the first day which is known as (reactionary rise), not exceed 38oC and drops within 24 hours and not accompanied by increased pulse rate, if it is more than 38oc or for more than 24 hours, it is called puerperal pyrexia).

7. Involution of the uterus be at normal size by 6 weeks
return to the pelvis by about 2 weeks
be at normal size by 6 weeks
the weight changes of uterus
1000g immediately after birth (excluding the fetus,
placenta, membrane and amniotic fluid.
500g 1 weeks after birth
300g 2 weeks after birth
50g 6 weeks after birth
The endometrial lining rapidly regenerates (16 days)
The placental site undergoes a series of changes in the postpartum period
Its fundus level approximates that of a 20 week pregnancy at the level of umbilicus, at the end first post partum week it is palpable at the symphysis pubic

8. discharge comes from the placental site and maintains for 4-6 weeks
Decidua
discharge comes from the placental site and maintains for 4-6 weeks
Lochia rubra
Red in color for the first 3-4 days
Lochia serosa
Pink in color, maintains for 2 weeks
Lochia alba
White in color, maintains for 2-3 weeks

9. After Pain Characteristic of after pain:
After expulsion of fetus and placenta the uterus contracts to regain its normal size, weight and site, this called involution of uterus. Oxytocin is released from posterior lobe of the pituitary gland in response to the sucking, which facilitate uterine contraction.
Characteristic of after pain:
Occur during the 1st 2-3 days of puerperium
Abdominal pains (like cramps) and back pain.
Strong, regular, and coordinated.
The intensity, frequency and regularity of contraction decrease after the 1st postpartum day.

10. Constipation
It is common in the first few days of puerperium and is due to many factors. The woman‘s food intake is interrupted, there may be dehydration during labor, the abdominal muscles are lax and perineal lacerations make defecation painful.

11. Cervix
it never returns to the nulli-parous state.
the external os is closed to the extent that a finger could not be easily introduced.
It return to its normal state at 4 weeks after birth
Vagina
shrinks to a non-pregnant state
resolution of the increased vascularity and edema occurs by 3 weeks
the vaginal epithelium appears atrophic. This is restored by weeks 6-10.

12. Perineum Swelling completely gone within 1-2 weeks
The muscle tone may or may not return to normal, depending on the extent of injury.

13. The muscular walls of the pelvic organs
The voluntary muscles of the pelvic floor and pelvic supports gradually regain their tone during the puerperium. Tearing or overstretching of the musculature or fascia at the time of delivery predispose to genital hernias. Over distention of the abdominal wall during pregnancy may result in rupture of the elastic fibers, persistent striae, and diastases of the recti muscles. Involution of the abdominal musculature may require 6-7 weeks and vigorous exercises are not recommended until after that time.

14. Preparation for lactation
Lactation can occur by 16 weeks' gestation.
Lacto genesis is initially triggered by the delivery of the placenta (E↓P↓and prolactin).
the prolactin levels decrease and return to normal within 2-3 weeks (not breastfeeding)
The colostrums (the first 2-4 days)
The milk continues to change throughout the period of breastfeeding to meet the changing demands of the baby.

15. Psychological changes.
Mild degree of depression and emotional liability. (normal)
Puerperal psychosis, confusion with disorientation in time, space and a complete loss of interest in the child (abnormal)

16. Systemic change Cardiovascular system Hematologic changes
Blood volume returns to non-pregnant levels by the tenth days of puerperium
Cardiac output ↑(immediately after delivery) → slowly declines→ reach late pregnancy levels 2 days postpartum→ normal 2-6 weeks.
Hematologic changes
Hemoglobin concentration↑on the first postpartum days
Several clotting factors (fibrinogen) ↑on the first days

17. Is slightly lost during the first 10 days.
Micturation;
There is diuresis in the first two days of puerperium. Retention of urine may occur either due to the sphincter or reflexly from perineal trauma.
Skin;
There is a tendency to sweating.
Body weight:
Is slightly lost during the first 10 days.

18. Abnormal puerperium

19. Abnormal puerperium Post natal problems: Post partum hemorrhage.
Puerperal Sepsis
Retained placenta (the placenta still in the uterus for more than one hour after birth of the baby)
Painful perineum. (laceration of the perineum)
Circulatory problems: (Varicose veins, Deep venous thrombosis (DVT) or superficial venous thrombosis (SVT)).
After pain:

20. Management of painful perineum
Cold baths
Electrotherapy (TENS)
Pelvic floor exercises (contract relax technique
Teach the mother the correct defecation technique
Use of an appropriate cushion when sitting.

21. Deep venous thrombosis
Venous thrombosis occurs most commonly in the superficial and deep veins of the lower extremities.
Deep thrombi are most likely to develop in soleos muscle of the calf muscle.

22. Management of Varicose veins
Avoid prolonged standing and prolonged sitting.
Apply well-fitted below knee support stocking before ambulating in the morning.
Ask mother to elevate her leg on pillow while taking supine lying position.
Intermittent compression.
Bandaging.
Burgerיs Exercises.
Not to sit with leg crossed or knee flexed.

23. Management of DVT or SVT
Prophylactic treatment:
Early ambulation.
Avoidance of pressure on the thighs and calves.
Sitting position with knee flexed.
Encouragement of:
Circulatory ex., leg and deep breathing ex.

24. Management of After Pain
Analgesics.
TENS.
Frequent urination every 2 hours.
Heat application.
Relaxation on face.
Prone lying position with tow pillows under the pelvis (to keep the back from hollowing and to stretch the abdominal muscles, small pillow under feet, the upper limbs extended beside the trunk, head turned to one side, or the upper limbs crossed with the forehead rested on the crossed upper limbs

25. Values of relaxation on face:
It is a relaxed position.
Help involution of uterus.
Help discharge of blood colts and lochia.
Guard against retroversion flexion
Relief after pain

26. Diastasis of recti abdominal muscles
It means separation of the rectus abdominal muscles from med-line at linea alba. It is not hernia.
It is a gap between the recti muscles 25mm(2.5 fingers)
Palpated just superior to the umbilicus.
It may occur during pregnancy after 20 weeks of pregnancy
or expulsive stage of labour due to weakness and increases tension
of abdominal muscles.

27. Management of diastases of recti abdominal muscles
Static abdominal exercises.
Graduated dynamic abdominal exercises.
Neuromuscular electrical stimulation:
Using:
asymmetrical square current,
frequency 80 pulse/second,
Pulse duration 0.1→0.5 ms for ½ hour daily.

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