Stage of Vigilance: Immediate postpartum period.

Assessment:
1. Vital Signs
BP is taken every 15 minutes
• Transient change are secondary to decreased blood volume after delivery
• Excitement may elevate the BP
• Low reading is often late sign of blood loss
Pulse checked every 15 minutes
• Bradycardia may occur to compensate for decreased of vascular bed and decreased intra abdominal
pressure.
• Tachycardia may indicate an increase in blood loss or a temperature elevation
● Temperature - slight elevation is normal (37.8 °C) due to dehydration and fatigue of labour

2. Fundal Check made every 15 minutes

Fundus is firm and well-contracted
• Fundus is midway between umbilicus and symphysis after delivery of the placenta
• Fundus rises slowly to the level of the umbilicus during the first hour of placental delivery.

3. Lochia estimation performed every 15 minutes

-Bloody discharge from the uterus during puerperium.
• Nature of flow (intermittent, trickle, clots)
• Amount of flow greater than 500 ml indicates postpartum hemorrhage
• Character and odor

4. Perineal inspection
• Episiotomy, laceration, or both (hematoma, redness, edema)

5. Psychosocial
• Joy: sense of peace and excitement
• Excitement: wide awake, talkative, hungry, and thirsty
Attachment process begins when:
1. Mother inspect the newborn
2. Mother wants to cuddle the infant and begin
breastfeeding
3. Mother feels the need to "let the world know"

POSTPARTUM PERIOD (PUERPERIUM)

• This period encompasses the time from the delivery of the placenta and membrane, to the return of the
woman's reproductive system to its non-pregnant condition.
• Puerperium usually last for 6-8 weeks after delivery.

ASSESSMENT PARAMETER
1. UTERUS
Involution - return 48 normal condition after delivery.
• Fundal height is approximately between symphysis and umbilicus in midline
• After pains (contractions) are common especially for multiparas and breast feeding mothers
• 1 hour postpartum, consistency is firm contracted
• Fundal height decreases by 1 cm/day and is no longer palpable in the abdomen after 10 davs Pain
decreases in fSequency after the 1st few days and is and are usually associated with breastfeeding,
multiparity, multiple fetus, and conditions producing over distension of the uterus
• Postpartum hemorrhage is the leading cause of maternal morbidity & mortality
2. LOCHIA
Composition:
a. endometrial tissue
b. blood
c. lymph

STAGES OF LOCHIA:
1. Rubra - 1 to 3 days, red in color
- Scant: if less than 2.5 cm (1 in) on menstrual pad in 1 hour
- Light: if less than 10 cm (4 in) on menstrual pad in 1 hour
-Light: if less than 10 cm (4 in) on menstrual pad in 1 hour
Moderate: less than 15 cm (6 in) on
'Amenstrual pad in 1 hour
-Heavy: if menstrual pad saturated in 1 hour
-Excessive: if menstrual pad is saturated in 15 minutes.

2. Serosa - pink, brown tinged 4 to 10 days

3. Alba - yellowish white: 10 to 14 days but can last for 3 to 6 weeks and remain normal.
• A danger sign it the reappearance of bright red blood after red lochia has stopped
• Odor is normally that of menstrual flow; foul odor may indicate infection
• Amount of lochia may be less after cesarean operation, but stages remain unchanged
• Amount night increase temporarily on standing due to pooling in the uterus and vagina
• Average amount of lochial discharge is 240 to
270ml

3. RETURN OF THE MENSTRUAL CYCLE

1. Non-lactating woman: 50% of the 1° few cycles ate anovulatory
At 6-8 weeks (40-45%)
At 12 weeks (75%)
Wthin 6 months (100%)
2. Lactating woman: 80% of the first few cycles are anovulatory
• Some women will not resume menstruation until after 18 months

Physiological Status:
Menstruation
● First menstrual cycle maybe unovulatory
● Non Nursing-ovulation=4-6weeks / 6-8 wks.menstruation begins
> Nursing/Lactation
• An ovulatory period
• No menstruation up to 6 mos.

THE POSTPARTAL FAMILY

Postpartal Period
• Puerperium- "puer" child, "parere"-to bring
forth
• 6 weeks period after childbirth
• Retrogressive- involution of the uterus and vagina
• Progressive- production of milk for lactation, restoration of the normal menstrual cyde,' and beginning of
a parenting role

Psychological changes of the postpartal period

PHASES OF PUERPERIUM

1.) Taking-In Phase

• 2- to 3-day period, a woman is largely passive
• woman usually wants to talk about her pregnancy, especially about her labor and birth
• ***Main nursing is to listen and help the mother interpret events of the delivery to make them more
meaningful and clarify and misconceptions

2.) Taking-Hold Phase

- Occurs during day 1 - 3 following delivery
- Marked by a period of being dependent and passive behavior
Mother's primary needs are her own food and sleep
- Mother is talkative about her labor and delivery experience
***It is the best time for teaching!

3.) Letting-Go Phase

• woman finally redefines her new role
• She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being
childless or the mother of only one or two.

Development of Parental Love and Positive Family Relationship

1. En Face position - eye-to-eye contact
2. Explore with finger tips
3. Hand and Palmar contact
4. Whole arms enfolds whole baby dose to body

DPLPFR
• Claiming or Bonding
The Claiming Process: Includes the identification of the baby's specific Features, relating them To other
family members
"Those long toes are just like his Dad's"

Rooming-In
• Infant stays in the room rather than in the nursery.
• She can become better acquainted with her child and begin to feel more confident in her ability to care

Postpartal Blues
• 50% of women experience some feeling of overwhelming sadness for which they cannot account
• Hormonal changes- dec progesterone and estrogen
• Response to dependence and low self esteem caused by exhaustion, being away from home, physical
discomfort and tension
• Fearfulness, feeling of inadequacy, mood lability, anorexia and sleep disturbance
• Assurance and support
Physiologic Changes of the Postpartal Period

Involution
- Reproductive organs return to their normal state
• Uterus
•2 process
1.The area where the placenta is sealed off
- Accomplished by rapid contraction of the uterus after the delivery of the placenta
- Muscle fibers become shorter controlling the bleeding by compressing and sealing off blood vessels
2. The organ is reduced to its pregestational size through
- Autolytic process
• Few cells of the uterine wall are broken down into their protein component which is then absorbed in the
blood stream and excreted in the urine.
- Contraction
Immediately after birth - 1000g
• At the end of 15 wk- 500g
•6wks - 50g
-After placental delivery the uterus may be palpated through the abdominal wall halfway bet the umbilicus
and the symphysis pubis
• 1hr after- level of umbilicus
• Decrease 1 fingerbreath per day

Assessment of the Uterus

● Placement and Size (location)
● Tone
● Lochia

FETAL SKULL
● Contains the delicate brain which may be
subjected to great pressure as the head passes through the birth canal,
● The head is the most delicate part of deliver whether delivered first or last.
● An understanding of fetal skull enables the midwife to recognize normal presentations of the fetal
position

Bones of the vault

1. The Occipital bone - lies at the back of the head and forms the region of the occiput . Part of it
contributes to the base of the skull as it contains the / foremen magnum, which protects the spinal cord. At
the center is the occipital protuberance.
2. The (2) Two Parietal bones - lie on either side of the skull. The ossification center is called the parietal
eminence.
3. Two (2) Frontal bones - from the foreheads or the sinciput . At the center of each is frontal eminence.
The frontal bones fuse into a single bone by 8 years of age.

Suture and fontanelles- Suture are cranial joints and are formed.
• There are several sutures and fontanelles in the fetal skull:
● Lamboidal suture - separates the occipital bone from the two/parietal bones.
● Sagittal suture - lies between the two parietal bone passing from one temple to another.
● Coronal Suture - separates three frontal bones from the parietal passing from one temple to
another.
● Frontal Suture - runs between the two halves of the frontal bone.
● Posterior Fontanelle or Lambda - is situated at the junction of the lamboidal and sagittal sutures.
It is small, triangular in shape and normally closes by 6 weeks of age.
● Anterior Fontanelle or Lambda - is found at the junction of the sagittal coronal frontal sutures.
Region of Skull
1. Occiput - lies between the foramen magnum and the posterior fontanelle.
2. Vertex - is bounded by the posterior fontanelle, the two parietal and anterior fontanelles. Of the 95% of
the ROA babies born had first, 95% present by the vertex.
3. Sinciput or brow- extends from the anterior fontanelle and the suture to the orbital ridges
4. Face - is small in the newborn, extending from the orbital ridges and the root of the nose to the junction
of the chin and the neck. The point between the eyebrow is called the glabella. The chin termed the
mentum and is important landmark.

Attitude of the Fetal Head

● It is used to describe the degree of flexion or extension of the head and neck. The attitude L oxof
the head determines which diameter will present in labour and therefore influences the outcome

ATTITUDE OF THE PRESENTING ENGAGING DIAMETER EXTENT OF THE

HEAD DIAMETER ENGAGING DIAMETER

COMPLETE FLEXION VERTEX Sub-Occipitobregmatic Estimated from below

PRESENTATION 9.5 cm the occipital
protuberance to the
mid-point of the bregma.

HEAD IN MILITARY CROWN Occipitofrontal From occipital

ATTITUDE PRESENTATION 11.5 cm protuberance to the
midpoint of the frontal
suture.

HEAD PARTIALLY BROW Mentovertical From the chin to the

EXTENDED PRESENTATION 13.5 cm highest point on the
vertex.

HEAD FULLY FACE PRESENTATION Face Presentation From where the chin
EXTENDED joins the neck to the
bregma.
 (PICTURE)

● LIE - the lie of the fetus the relationship between the long axis of the fetus and the long axis of the
uterus.
● ATTITUDE - is the relationship of the fetal head and limbs to its trunk. The attitude should be one of
flexion.
 ● The fetus is curled up with chin and the chest and the arms and legs, are flexed, forming a snug,
compact mas which accommodates itself to the uterine cavity. Flexior of the fetal Cad enables the
smallest diameters to present the pelvis and results in east labor.

DENOMINATOR - is the name of the part of the presentation which is used when referring to fetal position.
Each presentation has a different denominator and these are as follows:
• In the vertex presentation, it is the occiput.
• In the breech presentation, it is the sacrum.
• In the face presentation, it is the mentum.

POSITION - is the relationship between the denominator of the presentation and six points on the pelvic
brim

Fetal Positions for Labor and Birth

1. The Left Occiput Anterior (LOA) position is the most common in labor. It general represents no
problems or additional pain during labor or birth. Here the back of the baby's head is slightly off
center in the pelvis with the back of the head towards the mother's left thigh.
2. Left Occiput Transverse (LOT) When the baby is facing out the mother's right thigh, the baby is
said to be Left Occiput Transverse (LOT). This position is half way between a posterior and anterior
position.
3. Left Occiput Posterior (LOP) When your baby is lying in the pelvis facing forward and slightly to
the left, so that the baby would be looking out the right thigh, it is said to be in the Left Occiput
Posterior (LOP) position. This presentation can lead to more back pain and a slower labor.
4. Right Occiput Transverse (ROT) When the baby is facing out the mother's left thigh, the baby is
said to be Right Occiput Transverse (ROT).
5. Right Occiput Posterior (ROP) When your baby is lying in the pelvis facing forward and slightly to
the right, so that the baby would be looking out the left thigh, it is said to be in the Right Occiput
Posterior (ROP) position. This presentation can lead to more back pain and a slower labor.