CLO 6
6.1 – 6.2
Definition and Duration
- Period after delivery of placenta lasting 6 weeks (puerperium)
- True postpartum period may extend 9-12 months for complete physical and psychological
adjustment
- Critical transition period for woman, newborn, and family
Reproductive System Changes
Uterine Changes
- Involution process returns uterus to non-pregnant size
- Weight reduces from 1000g post-birth to 60g by 6 weeks
- Factors promoting involution:
- Complete placental expulsion
- Uncomplicated labor
- Breastfeeding
- Early ambulation
Lochia Progression
1. Lochia rubra (first 3-4 days): deep red discharge
2. Lochia serosa (3-10 days): pinkish brown
3. Lochia alba (10-14 days to 6 weeks): creamy white/light brown
Cervical and Vaginal Changes
- Cervix returns to prepregnant state by week 6
- External os never returns to original appearance
- Vagina returns to approximate pre-pregnant size by 6-8 weeks
Systemic Adaptations
Cardiovascular Changes
- Blood volume normalizes within 4 weeks
- Bradycardia (40-60 bpm) common in first 2 weeks
- Blood pressure may slightly increase for first week
Urinary System
- Increased glomerular filtration rate
- Postpartum diuresis begins within 12 hours
- Common voiding difficulties due to:
- Perineal trauma
- Decreased bladder tone
- Regional anesthesia effects
Musculoskeletal Changes
- Joint changes mostly temporary except feet
- Common fatigue and reduced activity tolerance
- Decreased abdominal muscle tone
- Possible diastasis recti
Lactation
- Begins 4-5 days postpartum
- Regulated by prolactin and oxytocin
- Engorgement peaks 3-5 days postpartum
- Management includes frequent feeding, warm/cold compresses
Psychological Adaptation
Rubin's Three Phases
1. Taking-in phase: dependency and birth process focus
2. Taking-hold phase: mixed dependent/independent behavior
3. Letting-go phase: relationship reestablishment
Mood Disorders
- Baby blues: mild symptoms peaking days 4-5
- Postpartum depression: more severe, requires treatment
Nursing Assessment and Management
Assessment Framework (BUBBLE-HEE)
- Breasts
- Uterus
- Bladder
- Bowels
- Lochia
- Homan's sign
- Epidural site
- Emotional status
Vital Signs Monitoring
- Temperature: slight elevation normal first 24 hours
- Pulse: 40-80 bpm normal
- Blood pressure: monitor for changes indicating complications
- Pain assessment: goal 0-2 on pain scale
Discharge Criteria
- Stable vital signs
- Appropriate lochia
- Normal lab values
- Wound healing
- Demonstrated self-care ability
- Support system in place
- Understanding of complications
- Follow-up care arranged
Comfort and Safety Measures
- Pain management for episiotomy/lacerations
- Early ambulation with safety precautions
- Breast care education
- Perineal care
- Exercise guidance including Kegel exercises
- Nutritional support
- Family planning education
6.3
Overview
Family planning involves the intentional prevention of pregnancy during sexual intercourse. The
main purposes include:
- Improving maternal and child health
- Ensuring adequate resources (time, social, financial, environmental) for child-rearing
- Preventing STDs
Criteria for Ideal Contraceptive Methods
- Safety and freedom from side effects
- Reliability
- Ease of administration and convenience
- Cost-effectiveness
- Cultural feasibility and acceptability
Types of Contraceptive Methods
1. Natural Methods
Coitus Interruptus (Withdrawal)
- Penis withdrawn before ejaculation
- Advantages: No cost, no devices required
- Disadvantages: Requires self-control, risk of pregnancy from pre-ejaculatory fluid
Lactational Amenorrhea Method (LAM)
- Criteria:
- First six months post-delivery
- Exclusive breastfeeding
- No menstruation
Fertility Awareness Method (FAM)
- Based on identifying fertile periods
- Methods include:
- Calendar-based
- Symptom-based (Two-day method, Basal body temperature)
- Biological marker methods
- Advantages: No cost, no devices
- Disadvantages: Requires regular periods, self-control
2. Barrier Methods
Male Condom
- Thin rubber sheath for penis
- Advantages:
- Simple and effective
- Protects against STDs
- No medical supervision needed
- Disadvantages:
- Risk of tearing or slipping
- Possible latex allergies
Female Condom
- Soft pouch inserted in vagina
- Can be inserted up to 8 hours before sex
- 79-95% effective
Diaphragm
- Inserted before intercourse
- Requires proper fitting and placement
3. Hormonal Methods
Oral Contraceptives
- Combined Pills (estrogen and progesterone)
- Progesterone-only Pills
- Advantages:
- Highly effective when taken regularly
- Reduces anemia risk
- Reduces risk of certain conditions
- Disadvantages:
- Side effects possible
- Must be taken regularly
- May affect breast milk production
Injectable Contraception (Depo-Provera)
- Given every three months
- 99.7% effective
- Side effects may include irregular bleeding, weight changes
Other Hormonal Methods
- Transdermal Patch
- Implants (99.95% effective)
4. Intrauterine Devices (IUD)
- T-shaped device placed in uterus
- Over 97% effective
- Advantages: Long-term protection, reversible
- Disadvantages: Risk of infection, uterine perforation
5. Sterilization
Tubal Ligation (Female)
- Surgical procedure
- Fallopian tubes cut or tied
- Failure rate: 0.8-3.7%
Vasectomy (Male)
- Vas deferens sealed or cut
- No-scalpel technique available
- Failure rate: 0.1%
Nurse's Role in Family Planning
1. Patient education about contraceptive methods
2. Counseling on pregnancy achievement
3. Assessment including:
- Medical history
- Family history
- OB/GYN history
- Personal history
4. Supporting client participation in decision-making
5. Addressing misconceptions
6. Education about method failure and backup options
6.4
Common Postpartum Disorders
1. Hemorrhage
2. Infection
3. Thromboembolic disease
4. Postpartum affective disorders
1. Postpartum Hemorrhage (PPH)
- Life-threatening complication after vaginal and cesarean births
- Leading cause of maternal death worldwide (358,000/year)
- Blood loss criteria: >500ml after vaginal birth, >1000ml after cesarean
- Types: Early (within 24 hours) and Late (24 hours to 6 weeks)
Causes (5 T's):
1. Tone
- Uterine atony (most common cause)
- Factors: multifetal gestation, fetal macrosomia, hydramnios
2. Tissue
- Retained placental fragments
- Can lead to subinvolution
- Treatment: uterine stimulants and antibiotics
3. Trauma
- Lacerations and hematomas
- Uterine inversion
- Cervical lacerations
- Common with forceps delivery
4. Thrombin
- Coagulation disorders
- Conditions include:
- Idiopathic thrombocytopenic purpura
- Von Willebrand disease
- Disseminated intravascular coagulation (DIC)
5. Traction
- Uterine inversion from excessive umbilical cord traction
- Treatment includes repositioning under anesthesia
2. Thromboembolic Conditions
- Types: Superficial thrombosis and Deep vein thrombosis
- Risk factors: oral contraceptive use, smoking, prolonged standing
- Symptoms: calf swelling, erythema, warmth, positive Homan's sign
- Management: NSAIDs, bed rest, anticoagulant therapy
3. Postpartum Infections
Types:
1. Metritis
- Infection of endometrium and adjacent tissues
- Common bacteria: E. coli, Klebsiella
2. Wound Infections
- Affects cesarean incisions and episiotomy sites
- Usually appears 24-48 hours post-discharge
3. Urinary Tract Infections
- Caused by bowel flora bacteria
- Related to catheterization and frequent examinations
4. Mastitis
- Breast inflammation within first 2 weeks
- Affects 2-33% of breastfeeding women
- Treatment: milk removal, antibiotics, warm/cold compresses
4. Postpartum Affective Disorders
Types and Characteristics:
1. Baby Blues
- Affects 50-90% of women
- Peaks days 4-5, resolves within 2 weeks
- Mild symptoms: anxiety, irritability, insomnia
2. Postpartum Depression (PPD)
- More severe than baby blues
- Lasts beyond 6 weeks
- Symptoms: restlessness, worthlessness, guilt, hopelessness
- Treatment: antidepressants, therapy
- Can affect fathers (paternal PPD)
3. Postpartum Psychosis
- Emergency psychiatric condition
- Occurs within 3 months of birth
- Symptoms: delusions, hallucinations, disorganized thinking
- Requires hospitalization and constant supervision
Nursing Management Across All Conditions
- Regular assessment of risk factors
- Monitoring vital signs and symptoms
- Patient education and support
- Infection prevention protocols
- Family support and counseling
- Appropriate referrals when needed
