Needs And Care Of Mother During Puerperium

1. Needs And Care Of Mother
During Puerperium

2. INDRODUCTION
• Puerperium is the period following childbirth
up to the end of 6weeks during which the
reproductive organs and all the system of the
body return to their normal condition.
• Also known as postpartum/postnatal period
or puerperium.
• The postpartum period covers a critical
transitional time for a women,her newborn
and her family, on a physiological, emotional
and social level.

3. Cont..
• In both developing and developed countries
women’s need during this period have been
too often eclipsed by the attention given
during pregnancy and childbirth.
• Such an eclipse ignores the fact that majority
of maternal deaths and disabilities occur
during postpartum period.
• In Nepal, 62 mothers suffered death during
postnatal period.( DOHS,Annual Health Report
2015- 2016)

4. Major maternal health challenges in
postpartum period
Postpartum haemorrhage :
 most important single cause of maternal
death in the world.
 It is estimated 1,50,000 maternal deaths occur
in developing countries; majority of deaths
88% occur within 4hrs of delivery.
 In context of Nepal, 4034 women had PPH in
the fiscal year 2015- 16.

5. Challenges continue……
Pre-eclamsia/ eclampsia
 Third most important cause of maternal
mortality worldwide.
 In developing countries, it is estimated to
occur in about 1 in 100-1700 deliveries.
 In context of Nepal, 1192 mother had pre-
eclampsia and 753 mother suffered from
eclampsia in fiscial year 2015-16.

6. continue…
 Puerperial genital infection:
 Today puerperal infections are still a major
cause of maternal mortality in developing
countries.
 In nepal , 649 mothers had puerperial related
infections.

7. Continue….
Thromboembolic disease:
 In developed countries, thromboembolic
disease is the major cause of maternal
mortality.
 In the puerperium ,the incidence of clinically
diagnosed DVT is 0.19%.
 The incidence is lowest with uncomplicated
vaginal delivery(0.12%).
 Incidence increases gradually with
instrumental delivery 0.35%,MRP 0.65% and
C/S 4.1%

8. Continue….
Complications of the Urinary Tract:
 Retention of urine
 Incontinence of urine
 Urinary tract infections
Complaints about the perineum and the vulva
Puerperial mastitis
Psychological problems
 Postpartum blues(30-70%)
 Postpartum depression(10-15%)
 Puerperal psychosis(1-2:1000 deliveries)

9. Postnatal care
• Care of the mother and newborn after delivery
up to 6 weeks .
• It includes systematic examination of the mother
and the baby and appropriate advice given to
mother during that period.
• The national health care service package for
Nepal recommends three postnatal visits for all
women whether delivered at home or in a
facility:
a. 1st visit within 24hours
b. 2nd visit within 3 days
c. 3rd visit within 7 days

10. Information related to postnatal care
• % of Institutional delivery -55.11%
• % of birth attented by skilled birth
attendents(SBA) -53.72
• % of birth attented by a health worker other than
SBA -5.06
• % of normal deliveries -82.53
• % of assisted deliveries( vaccum or forceps) -2.34
• % of delivery by caesarean section(C/S) -15.13
• % of postpartum women who received a PNC
checkups within 24hrs of delivery -54.49

11. Cont..
• % of postpartum women who received a PNC
checkups within 24hrs of delivery -54.49
• % of postpartum women who had 3 PNC
checkups as per protocal -18.42
• % of postpartum women who received a 45 days
supplementation of iron folic acid(IFA) -43.94
• % of postpartum women who received vitamin A
supplementation -50.99

12. Objectives of postnatal care
• To observe the general condition of the
mother and baby.
• To find out postnatal problems and manage
them.
• To provide necessary health teaching to the
mother and family.
• To improve physical and mental health of the
mother.

13. Aims of postnatal care
• Timely detection and treatment of life-threatening
complications to save mother and newborn.
• Provide information and care to achieve healthy
outcomes for both mother and baby.
Principles
 To give all out attention to restore the health
status of the mother.
 To prevent infection.
 To take care of breasts ,including promotion of
lactation and nursing of the child.
 To motivate the mother for contraceptive
acceptance.

14. Components of postnatal care
• Examination of mother and newborn for
prevention ,early detection and treatment of
complications.
• Counseling regarding breast feeding ,birth
spacing ,prevention of infection and availability
and provision of appropriate services.
• Education on danger signs in mother and
newborn.
• Education on maternal nutrition.
• Supplement of vitamin A and iron.
• Immunization of newborn.
• Referral and transport for emergencies for
appropriate management.

15. Needs of mother and postnatal care
Immediately after labour within 1hour
• Blood pressure and rate atleast every 15
mins.
• Monitor amount of vaginal bleeding.
• Palpate uterus to ensure uterus is
contracted(if relaxed massage to enhance
oxytocin release).
• She may be given a drink to her likings or
something to eat if she is hungry.

16. Needs and Care Continued..
1st several hours
a. Rest and sleep:
• Most of the women feel tired and fatigue after
delivery from sleep disturbance, delivery
exhaustion and baby’s needs.
• The mother is in need of rest ,both physically
and mentally.
• Provide quite and undisturbed environment.
• Provide opportunity to disscuss her feelings and
provide extra help with the baby.
• Check Hb labels to exclude presence of anaemia.

17. Continue…
• Provide analgesics for episiotomy pain and
after pain.
• The mother is advised to have 8-10hours of
sleep at night and 2hours at afternoon till
40-60 days of delivery.
• Avoid strenuous work especially heavy lifting,
straining and pushing for at least 6weeks as it
predisposes to uterine prolapse.
• The mother should be advised to start usual
work gradually and avoid over exertion.

18. Continue…
b. Ambulation
• Ambulation should be encouraged as soon as
possible after delivery.
• For normal delivery, ambulation should be done
within 6-12 hrs and for C/s it should be delayed 24
hours.
• However early ambulation doesnot mean return
to normal activities which should be restricted for
at least 6 -8weeks.
• Early ambulation provides a sense of well being;
facilitates uterine drainage and hastens involution of
uterus; reduces bladder and bowel complications;
increases muscle tone and lessens chances of deep
vein thrombosis and embolic phenomenon.

19. c. Care of vulva and episiotomy wound
• Keep the vulva and vaginal area clean and
dry.
• Wash the hands before and after washing the
vagina.
• Wash/wipe genital area from front to back
with soap and water after each urination and
deafecation.
• Ice pack can be applied for several hours to
reduce edema and pain.

20. Care of vulva continue…
• At 24 hour postpartum –moist heat can decrease
local discomfort.
• Daily inspection of the site for signs of infection
and healing process.
• Change perineal pads or cloths at least 6times
per day during 1st week and atleast twice a day
thereafter.
• Wear loose fitting cotton underpants.
• Avoid douching ,having sex, inserting tampoons
or anything else in the vagina.
• Episiotomy incision is typically well healed and
asymptomatic by 3weeks.

21. d .Bladder function
• Ensure that the mother has voided within
6-8hours after delivery and thereafter at 4-6
hours interval.
• The mother fails to pass urine because of
lack of privacy, unaccustomed position
and reflux from perineal injuries.
• Catheterization may also be needed in
some cases.

22. e. Breast feeding and breast care guidelines:
• The mother should be counselled about the
importance of exclusive breastfeeding for baby for 1st
6months.
• Provide support to mother regarding techniques,
position, frequency ,importance of breast feeding.
• Encourage mother for nutritious diet and plenty of
liquids.
• Breastfeeding atleast every 2-3 hours to prevent breast
engorgement.
• Wear supportive cotton brassier or breast binder.
• Clean breasts and nipple with clean cloth and warm
water only before each feeding.

23. f. Maternal Infant bonding( Rooming in or
bedding in)
• There is no need for mother n baby to lie
seperately after a normal delivery.
• The baby should be kept in her bed or in a cot
besides her bed.
• Maternal –infant bonding is established by
holding, kissing, cuddling and gazing at the infant.
• It not establishes mother-child relationship but
also the mother is conversant with the art of
baby care which aids in full care of baby at home.

24. Needs and care continue…
1st few days
a) Diet :
• Most essential need especially for lactating
mother.
• Permitted to eat normal diet of choice if
uncomplicated vaginal delivery.
• Clear liquids ,soft diet and finally regular diet as
tolerated if uncomplicated C/s.
• Eat atleast 2 additional servings of staple food to
supply extra 500kcal/day.
• Eat atleast 3 additional servings of calcium rich
foods.
• .

25. Diet continue…
• Drink atleast 8glasses of water(2litres) each
day, drink a cup of fluid each time she
breastfeeds.
• Include of variety of liquids such as milk,
juice, soup, water etc for drink.
• Take micronutrient supplement ,as directed.
• Eat smaller, more frequent meals.
• Avoid alcohol ,tobacco and smoking.
• Reassure the mother that she can eat any
normal foods.

26. Discomfort and pain
• NSAIDs, such as ibuprofen 400 mg po q 4 to 6
h, work effectively on both perineal
discomfort and uterine cramping.
• Acetaminophen 500 to 1000 mg po q 4 to 6 h
can also be used.
• After surgery or repair of significant
laceration, women may require opioids to
relieve discomfort.
• If pain is significantly worsening, women
should be evaluated for complications such as
vulvar hematoma.

27. Bowel Function:
• The mild ileus that follows delivery ,together
with perineal discomfort, poor intake and
postpartum fluid losses predisposes to
constipation.
• Mother are encouraged to defecate before
leaving the hospital.
• Encourage sufficient fluids and culturally
appropriate food to prevent constipation.
• Encourage for early ambulation following
delivery.

28. Bowel continue…
• Encourage for early ambulation following
delivery.
• If defecation has not occurred within 3 days, a
mild cathartic (eg, psyllium, docusate,
bisacodyl) can be given.
• Avoiding constipation can prevent or help
relieve existing hemorrhoids, which can also
be treated with warm sitz baths.
• Women with an extensive perineal laceration
repair involving the rectum or anal sphincter
can be given stool softeners (eg, docusate).

29. Vaccination and Rh desensitization
• Women who are susceptible for rubella should be
vaccinated against rubella on the day of discharge.
• If women have not yet received tetanus-diphtheria-
acellular pertussis (Tdap) vaccination (ideally given
between wk 27 and 36 of each pregnancy) and have
not had a tetanus and diphtheria toxoids (Td) booster
in ≥ 2 yr, they should be given Tdap before discharge
from the hospital or birthing center, regardless of their
breastfeeding status.
• If women with Rh-negative blood have an infant with
Rh-positive blood but are not sensitized, they should
be given Rh0(D) immune globulin 300 mcg IM within 72
hours of delivery to prevent sensitization.

30. Medications for postnatal mother
• Iron /folate(40mg/400mcg) to prevent anaemia after
food for 3months.
• Tab calcium 400mg for 6 weeks after delivery.
• Single dose of vit A 2,00,000IU as soon as possible
after delivery up to 8weeks.
• If the woman is living in hookworm endemic area
and has not received treatment within 6months or
there is positive laboratory test:
Give Mebendazole 100mg BD for 3days OR
Give Albendazole 400mg stat.
• If in endemic area ,provide an additional dose after
12weeks.

31. Safer relation and safer sex
• After 6weeks, coitus may be resumed based on
patient’s desire and comfort.
• Intercourse should be avoided if there is vaginal
bleeding, perineal pain ,foul smelling discharge.
• Patient should be counselled about the dangers
of premature intercourse.
• Counsel the woman that she is more susceptible
to STIs.
• Practice safe sexual relations.
• Consistent use of condom even during
lactational amenorrhea.

32. HIV counselling
• If the woman does not know about her HIV
status or has not been tested, provide HIV
counseling covering these points:
– Individual risk factors for HIV/AIDS.
– How the virus is transmitted.
– Myths and rumuors regarding HIV.
– HIV testing and results.

33. Prevention of infection
• Asepsis must be maintained specially during
the first weeks of puerperium.
• The uterus provides an ideal environment for
growth of microorganisms.
• The general resistance is also lowered
following childbirth.
• Liberal use of local antibiotics and aseptic
measures during perineal wound dressing.

34. Prevention of infection continue…
• Use of clean bed linen and clothing.
• Keep the room clean and free from dust.
• Emphasize the importance of handwashing.
• Restriction of visitors to a minimum.
• General cleaniness should be maintained by
bathing, brushing teeth ,self perineal care,
changing clothes dailyetc

35. Hospital stay
• Early discharge from the hospital is an almost
universal procedure.
• If normal delivery,discharge is done after 24
hours.
• In case of C/S without complications after 3-4
days after delivery.

36. Uterus and involution
• The uterine fundus should be carefully
palpated each day to ensure adequate
involution.
• Emptying the bladder prior to palpation is
necessary.
• The uterus should feel evenly contracted,
smooth, firm and shouldnot be palpable.
• Specific daily measurement of fundal height is
done to indentify subinvolution of uterus.

37. Complication readiness
• Counsel the mother and family about the
danger signs of both mother and baby and
return to health facility if these signs develop
Mother
i. heavy vaginal bleeding more than 2pads
soaked in 30mins
ii. Convulsions ,loss of consciousness
iii. Severe headache ,blurred vision
iv. Foul smelling vaginal disharge

38. • Haematoma formation
• Swelling and pain in perineum
• Pain in calf
• Severe abdominal pain
• Fever
• Verbalization/ behaviour that indicates she
may hurt the baby and herself.

39. Baby
• Feeding difficulties(poor sucking ,refusal to feed.
• Lethargy or poor cry
• Breathing difficulties
• Stiffness of body and difficulty opening mouth
• Blue lips and tongue
• Feeling abnormally hot or cold
• Persistent vomitting or abdominal distension
• Swelling ,redness pus or foul smell around cord
• Yellow body within 48hours of birth
• Large abscess or multiple pustules on the skin

40. Family planning
• Introduce the concept of family planning and
birth spacing including postpartum IUD.
• Counsel to space for atleast 3years in between
two pregnancies
• Counsel for exclussive breastfeeding to
activate LAM.
• Don’t wait until 1st menstruation to begin
contraception-ovulation may occur before 1st
menstruation.
• Discuss the benefits and limitations of
different FP methods.

41. Follow up visit
The woman should be regularly followed up as
follows:
i. 1st visit- within 72hours of delivery
ii. 2nd visit-within 4-7 days after delivery
iii. 3rd visit-within 42days after delivery
After that the woman should follow up for
baby’s immunization according to national
immunization schedule.

42. Immunization
• The woman and her family should be
counseled about immunization to child.
• The nurse must give detail information about
the name, timing, dose, the disease prevented
by such vaccine and the need of complete
dose of vaccination to their child.

43. National immunization programme

44. Postnatal and pelvic floor exercises
• Exercises should be started as soon as possible
after delivery in order to:
a. improve blood circulation
b. help in involution of reproductive organs.
c. prevent thrombosis and thrombophlebitis.
d. promote wellbeing of mother.
e. Restore tone of the abdominal and pelvic
muscles.
f. Facilitate proper drainage of lochia

45. • A woman with uncomplicated vaginal delivery
can resume postpartum exercises soon after
birth.
• The woman should be encouraged to start
with simple exercises and gradually progress
to more strenuous ones.
• No exercise immediately after meal.
• No exercise of the abdomen to the ceasarean
section mother.

46. exercise continue..
Types of postnatal exercise
 Deep breathing exercise
 Limb exercise
 Abdominal exercise
 Perineal and pelvic floor exercise

47. 1 .Deep Breathing Exercise
It can be started from the 1st day of
delivery.
Done to prevent chest complications.
It can be done 3-4 times a day.
The mother lies down on her back with arm
extended.
Breathe slowly and deeply by using abdominal
muscles 5-10times.

48. Limbs exercise
It can be done from the first day of
delivery.
Prevents thrombosis, thrombophlebitis and
minimizes engorgement of breast.
It also increases blood circulation and proper
drainage of lochia.
It includes extension, flexion, adduction of
hands and legs.

49. Procedure
-raise the hand slowly forward then back
to the position 4-5 times.
-raise hand slowly over the head and clap
the hand firmly for few second and being back
in position 3-4 times.
-The lower limb is also extended and flexed
5-10 times.

50. 3.Abdominal Exercises
• Abdominal exercises need to regain tone as
soon as possible after delivery in order to
protect the spine, prevent back problems
and help the mother regain her former figure.
• It includes:
Head and Shoulder Raising
Leg raising
Pelvic Tilting or Rocking
Knee Rolling
Hip Hitching

51. Head and Shoulder Raising
• On the second postpartum day, lie flat without
pillow and raise head until the chin is touching
the chest.
• On the third postpartum day raise both head
and shoulders off the bed and lower them
slowely.
• Increase gradually until able to do 10 times.

52. Pelvic Tilting or Rocking
• Lie flat on the floor with knees bent and feet
flat.
• Inhale, and while exhaling , flatten the back hard
against the floor so that there is no space
between the back and floor .
• While doing this, tighten abdominal muscles and
the muscles of the buttocks .
• Inhale normally, hold breath for up to 10sec, and
then relax.
• Repeat up to 10 mins.

53. Knee Rolling
• This exercise will strengthen the oblique
abdominal muscles.
• It is done in back lying position with knees bent,
pull in the abdomen and roll both knees to one
side as far as comfortable , keeping shoulders
flat.
• Return knees to and upright position and relax
the abdomen .
• Pull in again and roll both knees to the other
side.
• Repeat up to 10 mins.

54. Hip Hitching
• Hip hitching or leg shortening is performed in
back lying with one knee bent and the other
straight.
• Slide the heel of the straight leg downwards thus
lengthening the leg.
• Shorten the same leg by drawing the hip towards
the ribs on the same side .
• Repeat up to 10times, keeping the abdomen
pulled in.
• Change to the opposite side and repeat.

55. 4.Pelvic floor exercises
• This exercise is used to strengthen and tone
the muscles of the pelvic floor.
• The mother should be encouraged to exercise
as soon as possible to prevent gyanecological
problems.
- Lie or sit or stand with slightly apart and
draw up preventing flow of urine.
- Hold as long as posible.
- Then allow to relax.
- Repeat it for 3- 4 times a day.

56. Management of Psychological Needs
of mother
Maternal self-image
• An important assessment concerns the women’s
self concept ,body image and sexuality.
• How the mother feel about herself and her body
affects her behaviour and adaptation to
parenting.
• The mother may be reluctant to resume sexual
intercourse for fear of pain or worry that coitus
may damage healing perineal tissue.

57. Adaptation to parenthood and parent
infant interaction
• The psychosocial assessment also include
evaluating adaptation to parenthood.
• Successful adaptation begin to appear early in
the postbirth peroid as mother react positively
to the newborn infant and the process
continues.
• Mother’s adaptation to new role is exhibied on
her realistic perception, acceptance to the
newborn’s need and limited abilities, immature
social responses and helpnessness.

58. Continue….
• Examples of positive parent infant interaction
include taking pleasure in the infant and in the
tasks done for him or her, understanding the
infant ‘s emotional state and providing
comfort.
• The behavior like kissing infant, bonding and
cuddling infant and maintaining eye contact.
• If these behaviour are lacking the nurse need
to investigate the reasons and provide
appropriate support and counseling.

59. Potential for mood changes
• The first few days ,even 10-14 days would
be considered a period of crisis and
disequilibrium especially for the first time
mother.
• Many mother may experience mood swings
known as postpartum blues.
• The drop in the levels of hormone estrogen
and progesterone is responsible for this
behaviour.
• It spontaneously resolves in 1- 2weeks.

60. Family structure and functioning
• The mother’s adjustment to her role as
mother is affected by her relationship with
her partner, her mother and other relatives
and any other children.
• The nurse can help the new mother’s return
home by identifying possible conflicts among
family members and helping the mother plan
strategies for dealing with these problems.