PSYCHOLOGICAL CHANGES OF THE POST PARTAL PERIOD

PUERPERIUM
• Refers to the 1st six weeks after delivery. At this time, the woman undergoes psychologic & physiologic
adaptations as she returns to a nonpregnant state.
Post Partum Care
• should respond to the special needs of the mother & baby & should include:
• Prevention & early detection & treatment of complications & disease
• Provision of advice & services on breastfeeding, birth spacing, immunization & maternal nutrition.

Psychological Adaptations after Delivery

1. Rubin’s Post Partum Phase:
a. Taking – In Phase
b. Taking – Hold Phase/TransitionPhase
c. Letting – Go Phase

Development of Parental Love & Positive Family Relationships

1. Rooming In
• The more time a woman has to spend w/ her baby, the sooner she may feel competent in her childcare.
• Development of Parental Love & Positive Family Relationships
Types of Rooming In:
a. Complete
b. Partial
• Development of Parental Love & Positive Family Relationships
2. Sibling Visitation
• Separation is painful to both mother & child
• Listening to telephone reports is different than seeing the baby (eating well could be imagine by the child as
sitting on a dining table, using spoon & fork)
Maternal Concerns & Feelings in the Postpartal Period
1. Abandonment
2. Disappointment
3. Postpartal blues
– Will be discussed later as we go along

Psychological Adaptations after Delivery

2. Some women may experience euphoria in the first few days after delivery and set unrealistic goals for activities after
discharge from the birthing place.
3. Many women may experience temporary mood swings during this period because of the discomfort, fatigue, and
exhaustion following labor and delivery, and because of hormonal changes after delivery.
• Psychological Adaptations after Delivery
4. Some mothers may experience postpartum blues at approximately the third postpartum day and may exhibit
irritability, poor appetite, insomnia, tearfulness, or crying.
• Psychological Adaptations after Delivery
5. Research findings indicate that new mothers commonly identify postpartum needs such as coping with:
– The physical changes and discomforts of the puerperium, including a need to regain their prepregnancy
figure.
– Changing family relationships and meeting the needs of family members, including the infant.
– Fatigue, emotional stress, feelings of isolation, and being tied down.
– A lack of time for personal needs and interests.

PHYSIOLOGIC ADAPTATIONS OR CHANGES AFTER DELIVERY

Involution
• A process whereby the reproductive organs return to their nonpregnant state.
Important guidelines: (BUBBLE HE)
Breast (engorgement)
• With loss of the placenta, circulating levels of estrogen and progesterone decrease and levels of prolactin
increase, thus initiating lactation in the postpartum woman.
Uterus (contraction, position, size)
1. Uterine involution refers to the return of the uterus to its prepregnant size, shape and function.
2. The diminution of uterine size is due to a decrease in size of myometrial cells not a decrease in their number.

Uterus (contraction, position, size)

3. In the surface of the uterus within a few days after delivery, the remaining deciduas differentiates in two layers.
– The outer superficial (glandular layer) goes necrosis & is eventually sloughed off.
– The next layer, the basal layer, regenerates & gives rise to the new endometrium.

Uterus (contraction, position, size)

4. The uterus does not return to its original prepregnant condition, uterine size is slightly increased after each
pregnancy.
5. Breastfeeding promote involution because stimulation of the nipple when the infant suckles in the release of oxytocin.

Uterus (contraction, position, size)

6. Weight of the Uterus:
– Right after delivery: 1000 grams
– One week after delivery: 500 grams
– Two weeks after delivery: 300 grams
– Six weeks after delivery: 50-60 grams
Fundus
1. The fundus is assessed frequently for firmness, position & height.
2. Palpation of Fundus: …

If on palpation the uterus feels boggy:

– Massage it gently in circular motion, this is the 1st action to take
– Place the infant on the mother’s breast to stimulate uterine contractions by the release of oxytocin
– Administer oxytocin (as ordered) or increase infusion, do not administer ergot products if BP is above
140/90 mmhg
3. Height of Fundus:
– Measure the position or height of fundus by using umbilicus as a landmark.
– Place fingers on the abdomen of the woman just below the umbilicus & count the number of
fingerbreadths that fit between the top of the fundus & umbilicus.
Uterine Contractions and Afterpains
1. Uterine contractions during the postpartum period prevent bleeding by sealing off maternal vessels that were
torn during placental separation.
2. Afterpains are more common to multiparas, women treated with oxytocin, breastfeeding mothers & women
whose uterus was overdistended.
3. Afterpains are present for 2 to 3 days after childbirth.
4. Measures:
– Explain to the woman the cause & purpose of afterpains
– Keep bladder empty by regular voiding because a distended bladder increases afterpains
– Instruct woman to assume prone position to lessen discomfort of afterpains
•

Uterine Contractions and Afterpains

4. Healthcare measures:
– Massage uterus gently, forceful massage causes too much pain by stimulating very strong uterine
contractions
– Never apply heat to abdomen, heat causes uterine relaxation which can result to hemorrhage
– Administer analgesics as ordered
Placental Site
1. The placental site heals in 6 weeks
2. Bleeding maternal vessels in the placental site are sealed off by thromboses & uterine contractions.
Cervix
1. The cervix is soft, edematous & relaxed right after delivery.
2. It regains its prepregnancy firmness after the 1 st week postpartum but the external os does not return to its original
prepregnant conditions as it is lacerated during delivery.
3. By the end of the 1st week, the external os is closed & will not admit a finger.
Vagina
1. Right after childbirth, the vagina is a smooth & swollen passage.
2. Lacerations & episiotomy are usually healed after 2 weeks.
3. After 3 to 4 weeks, rugae reappear, but not as numerous as before pregnancy.
4. The vagina returns to its prepregnant condition after 6 to 8 weeks but does not regain its original virginal state.
Vagina
5. The hymen is converted to myrtiformes caruncles.
6. Resolution of the vagina to its preparegnant condition is delayed in women who are breastfeeding because of the
persistent low estrogen levels.

Perineum
1. The perineum is likewise traumatized. It is often swollen, discolored & painful after delivery, often with lacerations &
episiotomy.
2. The perineum is observed for signs infection (edema, redness, purulent discharge, gaping at suture line) and trauma.
Perineum
3. The discomfort of episiotomy does not last for more than one week because perineal area heals rapidly.
• Episiotomy
4. Most of the perineal muscle tone is regained by 6 weeks. However, the muscle tone may or may not return to normal,
depending on the extent of injury.
5. Perineal care: Perineal cleaning is done to prevent infection, to ease the woman & eliminate odor.
Provide the following instructions:
• Flush with warm water after each voiding & defecation from front to back
• Pat dry from front to back to back not in reverse order toprevent contamination of perineal area
• Change her perineal pad each time she uses the toilet. Apply peri pad front to back

Provide the following instructions:

• Observe incision for signs of infection (for example: redness, swelling, unusual discharge)
• Apply topical agents to relieve perineal pain after Sitz bath such as Witch Hazel compress, Epifoam, Nupercainal
Ointment
• Teach patient to digitally reduce hemorrhoids
• Tighten buttocks before sitting
6. Ice Packs:
• Ice packs are applied to the perineum during the 1 st 24 & lessen discomfort by providing anesthesia.

7. Sitz Bath: Application of heat to the perineum is done after the 1 st 24 hours following delivery to promote circulation
by vasodilation, thereby, promoting healing.
•

8. Perineal Lamp: The peri-light is used to promote vasodilation and perineal healing.
 • Place woman in dorsal recumbent position, drape thighs and place lamp between the legs
• Peri light
• Sitz Bath

Bladder (distention)
URINARY SYSTEM
1. Diuresis begins 12 hour after delivery & extends up to 5 th day as the body gets rid of extracellular fluid
accumulated during pregnancy.
2. Acetone in the urine after labor & lactosuria during the 1 st week is normal.

URINARY SYSTEM
3. The bladder & urethra are traumatized by the pressure exerted by the fetal head as it passess through the birth canal.

URINARY SYSTEM
4. Generally bladder tone is regained after one week & normal kidney function, after one month.
5. To avoid distention, the bladder is assessed every time fundus is checked.

URINARY SYSTEM
6. Effects of bladder distention:
• Hemorrhage
• Infection
• Increase discomfort to the woman

URINARY SYSTEM
Atony of bladder wall:
– If bladder distention is allowed to continue for a long period of time, it can damage bladder & cause
atony of bladder wall
• Overflow incontinence:
– The bladder can contain only a certain amount of urine, when this capacity is reached, the sphincter of
the bladder relaxes & urine flowsout.
– This flow of urine is not within the voluntary control of the woman

URINARY SYSTEM
7. Signs of full bladder:
– Suprapubic swelling
– High fundus
– Increase lochia

URINARY SYSTEM
8. Measures to induce voiding: The woman is expected to void within 6 to 8 hours after delivery. After the initial voiding,
encourage the woman to void every 4 hours.
• Provide privacy
• Open faucet & let woman listen to running water
• Pour warm water over the perineum

URINARY SYSTEM
• Catheterization if this measure fails to initiate normal voiding. When catheterizing a postpartum patient with
urinary retention:
– Use straight catheter if one hour catheterization is ordered. Use foley if 24 hours catheterization is
ordered.
– Maintain aseptic technique
– Provide gentle touch as the area is area sore
9. Measures to prevent Infection:
• Flush perineum with warm water after each voiding, wipe with clean tissue from front to back
• Apply perineal pad from front to back
• Liberal fluid intake
• Decoction of guava leaves for perineal flushing promotes healing
• Perilight for 15-20 minutes promotes healing by promoting blood flow

Instruct about signs & symptoms of UTI that must be reported immediately to physician:
– Frequency of urination/urgency of urination
– Painful urination
– Suprapubic pain

Bowel (positive for bowel sounds for elimination)

GASTROINTESTINAL SYSTEM
1. Many women ate hungry after delivery because of foods & fluids restriction during labor, diaphoresis & the strenuous
labor they just went through.
•

Bowel (positive for bowel sounds for elimination)

2. Bowel movement may be delayed for days after delivery resulting in constipation. This is caused by:
– Decreased muscle tone during labor & puerperium
– Lack of food during labor
– Predelivery enema
– Dehydration
– Perineal pain caused by episiotomy, hemorrhage, laceration
•

Lochia (color, amount, consistency, number of pads consumed) –a change in reproductive system
1. Lochia is the uterine discharge after delivery consisting of blood, mucus, epithelial cells, leukocytes & bacteria.
2. Lochia is never absent irregardless of the method of delivery
•

Lochia
3. Color and pattern: The pattern of lochia is similar to menses & should not reverse.
– Lochia Rubra
– Lochia Serosa
– Lochia Alba
•

4. Amount: The amount of lochial flow should be similar to menstrual flow.

– Check the perineal pad & estimate amount of blood loss based on how much saturated it is:
• 1 inch stain after one hour: scant amount
• 2-4 inch stain after one hour: light amount
• 4-6 inch stain after 1 hour: moderate amount
• Fully saturated after 1 hour: heavy amount
 •

5. Presence of Clots:
– In the 1st few days after delivery, it is normal for lochia rubra to contain some small clots but never large
ones.
– The presence of large clots indicates retained placental fragments.
6. Smell:
– Lochia should smell like menstrual discharge.
– A foul smelling lochia is a sign of infection.
•

7. Signs of Abnormal Lochia:

•

Episiotomy (condition of wound healing, signs of infection)

• Assess incisions for signs of infection and healing.
• A good method to remember how to evaluate the episiotomy is the use of the acronym REEDA:
– R – Redness
– E – Edema
– E - Ecchymosis (purplish patch of blood flow)
– D – Discharge
– A - Approximation, or the closeness of the skin edges
•

REEDA is based on a 3-point scale.

• A score of 3 indicates an assessment of very poor wound healing.
• On the first postpartum day, the REEDA score may range from 0 to 3;
• by the second postpartum week, the score should be 0 to 1.
•

Homan’s sign (presence or absence)

Homan’s Sign
• Pain in the cals on dorsiflexion of the foot.
• Inspect legs for signs of thromboembolism, and assess Homans' sign.
•

Emotions (presence or absence of depression, coping mechanisms)

1. Abandonment
2. Disappointment
3. Postpartal Blues
•

CARDIOVASCULAR SYSTEM
Blood Volume
1. Blood loss in vaginal delivery is about 500 ml. & with caesarean delivery, it is between 500 to 1000 ml.
2. Blood loss & diuresis in the postpartum period contribute to reduction in blood volume.
 •

CARDIOVASCULAR SYSTEM
Blood Volume
3. The 40% increase in blood volume during pregnancy enters the maternal circulation within 5 to 10 minutes after
placental delivery
•

Blood Components
1. Hematocrit rises in the 1st 3 to 7 days due to hemaconcentration caused by excretion of large amounts of fluid in
the uterine (diuresis during the 1 st few days after delivery).
2. Leukocytosis of 20,000 to 30,000 (normal 5,000 to 10,000) during the 1 st 12 days characterized by increased
neutrophils & eosinophils & decrerased lymphocytes.
•

Blood Components
3. Fibrinogen & thromboplastin remains elevated until the 3 rd postpartum week.
4. Increased leukocyte sedimentation rate.
 
Vital signs
1. Physiologic bradycardia
2. Orthostatic hypotension
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INTEGUMENTARY SYSTEM
1. Chloasma, palmar erythema (flushing of the skin due to dilatation of blood capillaries in the dermis), linea negra &
other skin changes during pregnancy gradually disappears during the postpartumperiod.
2. Striae gravidarum do not disappear & assumes a silvery white appearance.
•

MENSTRUATION AND OVULATION

1. Although reestablishment of ovulation & menstruation is very variable in women who breastfeeds, nonlactating
women usually menstruate by 7 to 9 weeks & ovulate by 8-10 weeks after delivery.
2. If the woman breastfeeds for 6 months, ovulation usually begins after 28 weeks.
•

WEIGHT
1. The woman loss about 5 to 6 kg of weight after delivery and continue to loss weight until the end of the postpartum
period, primarily due to dieresis and diaphoresis.
2. The baseline weight that the woman usually attains after the postpartum period is higher than her weight before
pregnancy by about 3 lbs.
•

AMBULATION
1. Mothers who had normal spontaneous delivery are allowed to ambulate 4 to 8 hours after childbirth.
  Patients who received anesthesia are allowed to get out of bed after 8 hour when they are fully awake
& reflexes have returned.
•

AMBULATION
2. The woman may feel faint & dizzy the 1 st time she ambulates due to orthostatic hypotension.
•

4. Advantages of Early Ambulation

– Prevent constipation
– Prevent circulatory problems thrombophlebitis
– Prevent urinary problems
– Promote rapid recovery & return of woman’s strength
– Hasten drainage of lochia
– Improves gastrointestinal & urinary function
– Provide a sense of well being
•

Nutrition – Metabolic
– Provision of adequate nutrition through balance diet and plenty of liquids
1. The postpartum woman’s diet should be high in protein, iron and vitamins to promote healing.
2. Nonlactating women need about 2,200 to 2,300 calories daily. Lactating women need an additional 500-800 calories.
•

Nutrition – Metabolic
3. Daily intake of vitamin & iron supplement for
4 – 6 weeks postpartum is recommended for breastfeeding mothers to ensure nutritious milk supply to the
infant, overcome iron & vitamin deficiency & aid in tissue healing & regeneration.
•

EXERCISE

1. Purpose of post partum exercise:

– To prevent complications
– Promote psychological well being
– For rapid return of woman’s figure
– Strengthen muscles of the back, pelvic floor, abdomen
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EXERCISE

2. Post partum exercise:

– Abdominal breathing: Tighten abdominal muscles
– Kegel’s exercise: Tighten perineal muscle
– Chin to chest: Stregthen abdominal muscles
– Arm raising: Return of breast & abdominal muscle tone
– Leg raising: Tighten abdominal muscles
 – Sits up: Tighten abdominal muscles
•

EXERCISE

EXERCISE

RESUMPTION OF SEX

1. Sexual intercourse can be resumed 3 to 4 weeks after vaginal delivery if bleeding has stopped, perineum is healed & if
it does not cause pains to the woman.
2. Sexual intercourse is usually resumed after the 1 st postpartum check up in women who underwent CS.
•

REST AND SLEEP

1. The woman should rest & sleep as much as needed during the early postpartum period to overcome fatigue,
excitement, anxiety & discomfort associated with long & exhausting labor & delivery.
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REST AND SLEEP

2. Instruct the mother to avoid heavy lifting & strenuous activity after discharge.
3. The woman may resume light housekeeping on the 2 nd week & can go back to normal activities by 4 to 6 weeks.
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LACTATION SUPPRESSANT

1. Upon admission, it should be ascertained if the woman desires to breastfeed her baby or not.
 – If breastfeeding is not to be done, breastmilk production should be prevented immediately after birth.
•

LACTATION SUPPRESSANT

2. Two methods of breastmilk suppression:

a. Mechanical suppression: Involves the use of no pharmacologic techniques to prevent breastmilk production.
b. Pharmacologic suppression: Involves the use of drugs to inhibit breastmilk production.
– Hormonal agents: Dela dumone, Tace
– Bromocriptine (Parlodel): Nonestrogen medication that suppress secretion of prolactin. This drug is
taken twice daily for 14 days.
•

DISCHARGE

1. The newly delivered mother is ready to go out of the health care facility 24-48 hours after NSVD.
2. Primiparas may leave after 2 to 3 days and multiparas after 1 to 2 days if they are recovering normally.
3. After CS, a woman may be discharged on the 3 rd or 4th day.
•

DISCHARGE

4. Before leaving, she should be instructed regarding the schedule of her postpartum check-up/clinic visit & to report
immediately to her doctor if the following signs & symptoms appear:
– Heavy vaginal bleeding or bright red vaginal bleeding
– Fever
– Foul smelling lochia
– Swollen, tender, hot area on her leg
 – Burning sensation on urination or inability to void
– Persistent perineal pelvic pain
•

CLINIC VISITS

• The mother is instructed to come back to the hospital or her obstetrician 4 to 6 weeks after delivery for
examination and follow-up care.