S.

No DATE ACTIVITY

1. 27.05.2019 Greeted the staff and informed about selecting a mother for my care study.
Introduced myself to the mother and explained the procedure and care. Vital
signs checked and recorded. She got admitted at 12.25 am with C/o pain in
lower abdomen and back. No complaints of drained PV. History collection
done. Physical assessment done. Physical preparation done and shifted to
labour room. She delivered at 9.52 am. Male baby alive and healthy, no
congenital anomaly. Passed meconium. No undue bleeding PV stable. Had a
glass of coffee. Shifted to the postnatal ward at 4 pm. Routine medication
given. Vital signs checked stable.
2. 28.05.2019 Vital signs checked stable. Bp 110/90mm of Hg. Baby sucking well and active
passed meconium and urine. Mother has no undue bleeding hydrated. Passed
motion and urine. On soft solid diet. Taking cap. Amoxicillin 500mgtds. T
paracetamol 1 tds T. metronidazole 400mg tds BCT 1 od, FST 1 od and
T-vitamin C 1 od.

3. 29.05.2019 Vital signs checked stable. Bp 110/90mm of Hg. Baby sucking well and active
passed meconium and urine. Mother has no undue bleeding hydrated. Passed
motion and urine. On soft solid diet. Taking cap. Amoxicillin 500mgtds. T
paracetamol 1 tds T. metronidazole 400mg tds BCT 1 od, FST 1 od and
T-vitamin C 1 od. Episiotomy wound healthy

4. 30.05.2019 Vital signs checked stable. Bp 110/90mm of Hg. Baby sucking well and active
passed meconium and urine. Mother has no undue bleeding hydrated. Passed
motion and urine. On soft solid diet. Taking cap. Amoxicillin 500mgtds. T
paracetamol 1 tds T. metronidazole 400mg tds BCT 1 od, FST 1 od and
T-vitamin C 1 od. Episiotomy wound healthy

5. 31.05.2019 Vital signs checked stable. Bp 110/90mm of Hg. Baby sucking well and active
passed meconium and urine. Mother has no undue bleeding hydrated. Passed
motion and urine. On soft solid diet. Taking cap. Amoxicillin 500mgtds. T
paracetamol 1 tds T. metronidazole 400mg tds BCT 1 od, FST 1 od and
T-vitamin C 1 od. Episiotomy wound healthy

TIME PLAN
S.NO DATE ACTIVITY

6. 1.06.2019 Vital signs checked stable. Bp 110/90mm of Hg. Baby sucking well and active
passed meconium and urine. Mother has no undue bleeding hydrated. Passed
motion and urine. On soft solid diet. Taking cap. Amoxicillin 500mgtds. T
paracetamol 1 tds T. metronidazole 400mg tds BCT 1 od, FST 1 od and
T-vitamin C 1 od. Episiotomy wound healthy
7. 3.06.2019 Vital signs checked stable. Bp 110/90mm of Hg. Baby sucking well and active
passed meconium and urine. Mother has no undue bleeding hydrated. Passed
motion and urine. On soft solid diet. Taking cap. Amoxicillin 500mgtds. T
paracetamol 1 tds T. metronidazole 400mg tds BCT 1 od, FST 1 od and
T-vitamin C 1 od. Episiotomy wound healthy
INTRODUCTION

People move through several predictable stages during transition first is the act of ending old ways
of thinking or believing next. There is a neutral zone during fortable and finally ,there is new beninning
during which new ideas and concepts are put into action.

The postparturm period is a time of trantion during which a people gives up concepts such as
childless or parents of one and moves of the beginning of new parenthood.the immediate postnatal
period is netural time during which a couple tries out the new role and attempts to fit their exepection
for their role.the nurses can help couples acknowledge the extend of the change. So that they can gain
closure on their process life style opening,chennels for communication ,anticipating new needs and high
lighting potential gain that will occur becauses by changes are important action.

AIM AND OBJECTIVES:

1) To asses the health status of the mother. Medical disorder like diabetes , hypertention should
be reassessed.
2) To detect and treat at the earliest any gynecological condition arising out of obstetric legacy.
3) To note the progress of the baby including the immunization schedule for the infant.
4) To impart family planning guidance ( discussed above).
I.DEMOGRAPHIC DATE:

Name of the mother: Mrs.Vijaya lakshmi.

Age : 23 Years

Educational level : 12th standard

Name of Husband : Mr.Gnanavel

Age : 29 years

Education leavel : B.Sc

Religion : Hindu

Occupation : Private employee.

Income : RS 10,000/-

Admitted on : 27.05.2019 At 6.10 pm

I.P.No : 35083

Ward :Postnatal ward

Unit : V unit

Address : Eliz Nagar,Madurai.

LMP : 6.9.2018

EDD : 13.6.2019

Diagnosis score : Labour natural with episiotomy

Obestetriccal score : primi.

Weeks of gestation : 38 weeks.

Date of delivery : 27.05.2019 at 9.52 am

Type of delivery : Labour natural with episiotomy

Sex of baby : Male

 Postnatal day : 2nd

Date of assessment : 29.06.2019

Care started : 27.06.2019

Care end : 3.06.2019

Informant : Mother and her mother -in law

Reason for hospitalization: safe confinement.

II.REASON FOR HOSPITALIZATION /NEED FOR SEEKING HEALTH CARE:

The mother got admitted for safe confinement and able to perceive fetal movements
history of lower abdominal pain. No history of draning from vagina.
III.PERSONAL HISTORY:

Nutrition : Non vegetarian

Frequency of meals : 3 times a day
Food fade : She is not having food fade
Food allergy : She is having allergy to mutton

Habits

There is no habit of Alcohol, Smoking, Chewing pan, Using snuff etc.,

Drugs

She is taking drugs on prescription. Not having allergic reaction to any other drugs.
Sleep
She is sleeping 8 hours at night time and 1 hour during the day. She has intermittent
Sleep. No disturbances.

Rest
She takes 1 hour rest at day time and is adequate.

Hygiene
Takes bath daily and she is clean and neat. Maintains personal hygiene.

Exercises
She is doing household works.

Urinary pattern
Normal urinary pattern. There is no burning sensation during voiding

Bowel pattern
Normal bowel pattern present. No constipation.

Menstrual history
She attained menarche at the age of 13 years
Irregular menstrual cycle
No pain during menstruration

Marital history
She got married at the age of 21 years
No history of consanguineous marriage
IV. SOCIO ECONOMIC STATUS

Moderate socio economic status.

Her husband is the bread winner of the family. He is a private employee.

Rs. 10000 / month.

Own concrete house with adequate ventilation , electricity and closed drainage system.

Bore water supply

No kitchen garden and pet animals

Having 2 cows in their home

V. FAMILY HISTORY

Nuclear family

There is no history of multiple pregnancies

There is no history of genetic disorders, hypertension, diabetes mellitus, heart disease and
seizure disorder in her family

VI. MEDICAL HISTORY

Childhood illness : Nil

Previous illness : Nil

Surgeries : Nil

Any other : Nil

VII.OBSTETRICAL HISTORY

a. Present obstetrical history

LMP : 6.9.2018
EDD : 13.6.2019
 b. Past obstetrical history

Year of Antenata Intranatal Postnatal New Birth Breast Remarks

delivery l period period period born weight feeding
sex

Primi -- -- -- -- -- -- --

VIII. PHYSICAL EXAMINATION :

General appearance

Conscious, oriented to time, place and person.

Moderately built, well groomed, pallor

Skin

Brownish complexion of skin

Skin turgor is reduced in abdominal region

Afebrile, no inflammation, redness or itching.

Hair and scalp

Hair is black in color, equal distribution of hair is present

Scalp is clean, No dandruff and pediculosis.

Eyes

Normal vision in both eyes

Conjunctiva is pink, sclera is white

Eyes are clear and No signs of inflammation

Nose

Nostrils are patent and clean. Olfaction is normal

No nasal septal deviation . No discharge. Stuffiness present.

Ears

Symmetrical ear , hearing ability is good in both ears

Auditory canal is clean

No accumulation of wax and No discharge

MOUTH AND THROAT

Lips

Lips are moist and pink in colour

No angular stomatitis

Tongue

Pinks in colour, mildly coated

Oral hygiene is good and No halitosis

Movement of tongue is normal

Teeth

Dental alignment is normal

All 32 teeth is present

No dental carries

Gums and oral mucosa

Intact no signs of inflammation and gum bleeding

Throat

No signs of inflammation

Neck

Carotid pulse is felt on both sides

Range of motion is normal

No swelling of neck and lymph denopathy

Chest

Symmetrical and bilateral air entry present

Breathing movement are symmetrical

Normal breath sounds heard

Breast

Inspection

Symmetrical, enlarged, tensed.

Nipple, is erect, moist, not cracked.

Primary areola and secondary areola is present

Montgomery tubercle is present

No signs of inflammation

Breast feed initiated immediately after birth.

Abdomen

Bowel sounds heard. Previous scar present

Involuted uterus is palpated per abdomen.

Uterus is contracted and hard

Height of the fundus is 18 cm

Genitalia

Fishy smell present

Lochia rubra is present

The amount of lochia is 100 ml

No vulval edema

Episiotomy

Redness : Redness is present

Edema : Edema is not present

Ecchymosis : Not present

Discharge : No discharge from the episiotomy wound

Approximation of edges : Approximated well

Micturition : There is normal micturition pattern.

Bowel movement : Normal bowel movement present

Extremities : Range of motion is normal

No pedal edema

No redness or pain in the leg

Homan sign is negative

Back and spine

Lordosis of spine is present

No ulcer or scar

REVIEW OF SYSTEM

Central nervous system

Conscious, oriented and in a very happy mood

Respiratory system

Bilateral air entry present. No creptus or rhonchi/ pleural rub.

Cardiovasular system

S1 S2 heard, No murmur or gallop

Gastro intestinal system

Bowel sounds heard. No constipation

Musculo skeletal system

Spinal curvature is normal

IX. LAB INVESTIGATION/DIAGNOSTIC PROCEDURE:

Date Name Client Value Normal Value Remarks

RFT

15.06.2019 Sr. sugar 89g/dl 80 – 120 mg/dl Normal

Sr. urea 29mg/dl 20 – 40 mg/dl Normal

Sr. creatinine 1.1mg/dl 0.7 – 1.4 mg/dl Normal

Sr. Bilirubin 0.7mgs/dl < 1 mg/dl Normal

Blood Hb 15.8g/dl 12 – 16 g/ dl Normal

Platelets 3.06 ls/cu.mm 2 – 4lakhs / cu.mm Normal

Urine

Albumin Nil Nil Normal

Sugar Nil Nil Normal

Deposits 0 – 2 pus / cells 0-6 pus / cells Normal

Blood group O positive

HIV Negative Negative Normal

HbsAg Negative Negative Normal

Anti - HCV Negative Negative Normal

 ASSESSMENT OF NEWBORN

Demographic Data:

Name : B/o Vijaya Lakshmi

Mother’s name : Mrs. Vijaya Lakshmi

Father’s name : Mr . Gnanavel.

Address : Eliz Nagar,

Madurai

Date of Birth : 27.05.2019

Sex : Male

I . P. No : 35083

Ward : postnatal ward

Unit : V OG

Condition at birth : Baby cried immediately after birth

Apgar score : 1 minute – 8/10, 5 minute 9/10

Birth order : 1

OBSTETRICAL HISTORY :

Past Obstetrical History

Year of Antenatal Intranatal Postnatal New born Birth Breast remarks

delivery period period period sex weight feeding

-- -- -- -- -- -- -- --
Present Obstetrical History :

History of present labour / delivery : Labour Natural with Episiotomy

Characteristic of Amniotic fluid : Clear liquor

Drugs and anesthesia used : Inj. Xylocaine used for episitomy suture

GENERAL EXAMINATION :

Vital Signs :

Temperature : 98.6 F

Heart rate : 144 beats / minute

Respiration : 48 breaths / minute

Weight : 3.3 kg

Length : 50 cm

Skin : Pink in colour, there is no central and peripheral cyanosis

Turgor : Normal skin turgor

Vernixcaseosa : Present

Nails : Soft and clean

Lanugo : Present

Milina : Present in the nose

Mangolian spots : Present in the buttocks

Head : There is no caput succedaneum, cephal hematoma or birth injury

Fontanelles/Sutures : Diamond shaped anterior fontanels and triangular shaped posterior fontanels

Present/sutures are normally present.

Eyes : Eyes are symmetrical, there is no congential cataract discharge squint.

Mouth : There is no cleft palate and oral thrush

Lips : Pinks in colour, cleft lip not present, there is no drooling of saliva.

Chest : Bilateral air entry normal, chest movement normal. Chest retraction

Not present

Heart : Heart present in the normal position. There is no murmur sound heard.

Abdomen : Soft.No abdominal distension, bowel sound present, No organomegaly

Umbilicus : Umbilicus healthy. No other discharges

Urinary flow : Normal flow

No of Times : 10 – 12 times

Rectum : Patent.

Bowel movement : Present

Meconium : Passed

Transitional stools : Light yellow in colour, normal consistency

Extremities : There is no syndactyl, polydactyl, simian crease, Tallipes Equino

Varus and hip dislocation .

REFLEXES

Feeding reflex : Sucking Elicited

Swallowing : Elicited

Rooting : Elicited

Gag : Elicited
PROTECTIVE REFLEXES :

Blinking : Elicited

Cough and Sneezing : Elicited

Yawn : Elicited

OTHERS

Tonic neck reflex : Elicited

Babinski’s : Elicited

Doll’s eye : Elicited

Steeping : Elicited

Moro reflex : Elicited

EEFEEDING PATTERN:

Breasting feeding

Time of initiation : Within 30 mins

No of feeds per day : Demand feeding given by mother

Parental bonding : Elicited by rooming in

PARENTAL BONDING

Eye contact : Maintained

Sleep : 18 hours/day

Respond to stimuli : Respond to auditory and tactile stimuli

REVIEW OF ANATOMY AND PHYSIOLOGY

THE UTERUS

The uterus is a hollow pyriform muscular organ situated in the pelvis between the bladder in front
and rectum behind.

POSITION

Its normal position is one of the anteversion and anteflexion. The uterus inclines to the right so
that the cervix is directed to the left and comes in close relation with the left ureter.

MEASREMENT AND PARTS

The uterus measures about 8 cm long, 5 cm wide at the fundus and its walls are about 1.25 cm

Thick. Its weight varies from 50 – 80 g.

PARTS

1. Body or corpus
2. Isthumus
3. Cervix

Body or corpus : the body is further divided into fundus- the part which lies above the openings of the
uterine tubes. The body properly is triangular and lies between the openings of the tubes and the
isthumus.

Isthumus

Its is a constricted part measuring about 0.5 cm situated between the body and te cervix.

Cervix -- neck of the uterus.

LAYERS

1. ENDOMETRIUM

It is the inner epithelial layer along with its mucous membrane of the mammalian uterus. During

Pregnancy the uterine glands and blood vessels in the endometrium further increase in size and
number . it has the basal layer and a functional layer thickens and then is sloughed during the
menstrual cycle.
 2. MYOMETRIUM

The uterus mostly consists of smooth muscle known as myometrium. The inner most layer of
myometrium is known as junctional zone which becomes thickened in adenomyosis.

3. PERIMETRIUM

Serous layer of visceral peritoneum. It covers the outer surface of the uterus.

BLOOD SUPPLY

The uterus is supplied by arterial blood both from the uterine artery and the ovarian artery.

PHYSIOLOGICAL CHANGES DURING PUERPERIUM

INTRODUCTION

The postpartum period or puerperium is the time of major adjustments and adaptation not
just for the mother , but for members of the family. It is during this time that parenting and
relationship between the mother and newborn begins. Loving apposite, relationship between
parents and their newborn promotes the emotional well being of all.

DEFINITION: Puerperium is the period following childbirth during which the body tissuses, especially
the pelvic organs revert back approximately to the prepregnant state both anatomically and
physiologically. The retrogressive changes are mostly confined to the reproductive organs with
exception of the mammary glands which in fact show features of activity.

D.C.DUTTA

INVOLUTION OF THE UTERUS

ANATOMICAL CONSIDERATION

Immediately following delivery, the uterus becomes firm and retract with alternate hardening
and softening . the uterus measures about 20 x 12 x 7.5 cm3 ( length , breadth and thickness) and
weighs about, 1,000 g At the end of 6 weeks , its measurement is almost similar to that of the non-
pregnant state and weighs about 60g .the decrease in size of the uterus and cervix has been shown with
serial MRI. The placental site contract rapidly presenting a raised surface which measures about 7.5 cm
and remains elevated even at 6 weeks when it measures about 1.5 cm.
 WEIGHT OF THE UTERUS AFTER DELIVERY

TIME SIZE (g)

After delivery 1000

End of first week 300-350

End of second week 100

End of sixth week 50

Lower uterine segement:i

Immediiated following delivery,the lower segement becomes a thin, flabby and collapsed structure. It
takes a few weeks to revert back to the normal shape and size of the isthmus ,i.e. the between the body
of the uterus and internal os of the cervix.

Cervix: The cervix contracts slowly; the exeternal os admits two fingers for a few days but by the end of
1 st week, narrows down to admit the tip of a finger only. The contour of the cervix takes a longer time
to region (6 weeks) and the exeternal os neverts back to the nulli-parous state.

PHYSIOLOGICAL CONSIDERATION:

The physiological process of involution is most marked in the body of the

uterus.changes occurs in the following components:

1)Muscles

2)Blood vessels

3)Endometrium.
Muscles:

There is marked hypertrophy and hyperplasia of muscles fibers during pregnancy and the
individual muscle fiber enlarges to the extent of 10 times in length and 5 times in breadth. During
puerperium , the number of muscles fibers is not decreased , but there is substantial reduction of the
myometrial cell size.withdrawal of the steroid hormones, estrogen and progesterone , may lead to
increase in the activity of the release of proteolytic enzyme.

Autolysis of the protoplasm occurs by the proteolytic enzyme with liberation of peptones
which enter the bloodstream.These are excreted through the kidneys as urea and creatine. This explains
the increased excretion of the products in the puerperal urine. The connective tissues also undergo the
type of degeneration.

The condition which favour involution are-

a) Efficacy of the enzymatic action

b) Relative anoxia induced by effective contraction and retraction of the uterus.

Blood vessels:

The changes of the blood vessels are pronounced at the placental site.the arteries are
constricted by contraction of its wall and thickenking of the intima followed by thrombosis.during
the1st week,arteries undergo thrombosis,hyalinization and fibrinoid end arteritis.veins are obliterated
by thrombosis,hyalinization and endophlebitis.new blood vessels grow inside the thrombi.

Endometrium:

Following delivery , the major part of the decidua is cast off with the expulsion of the placenta
and membrances,more at the placental site.the endometrium left behind varies in thickness from 2mm
to 5mm.the superficial part containing the degenerated deciduas,blood cells and bits of fetal
memberances becomes necrotic and is cast off in the lochia.

Regeneration starts by 7th day.It occurs from the epithelium of the uterine gland mouths and
interglandular stromal cells.Regeneration of the epithelium is completed by 10 th
day and the entire endometrium is restored by day 16,except at the placental site where it takes about 6
weeks.

CLINICAL ASSESSMENT OF INVOLUTION:

The rate of involution of the uterus can be assessed clinically by noting the height of the uterus
in relation to the symphysis pubis. The measurement should be taken carefully at a fixed time every
day, preferably the bowel too, as the same observer. Bladder must be emptied level of the fundus of
the uterus. The uterus is to be centralized and with a measuring tape, the fundal height is measured
above the symphysis pubis.

Following delivery, the fundus lies about 13.5 cm ( 5 1/2 “) above the symphysis pubis. During the
first 24 hours, the level remains constant; thereafter, there is a steady decrease in height by 1.25 cm
(0.5”) in 24 hours, so that by the end of 2nd week the uterus becomes a pelvic organ. The rate of
involution thereafter slows down until by 6 weeks, the uterus becomes almost normal in size.

The involution may be affected adversely and is called sub-involution. Sometimes, the involution may be
continued in women who are lactating so that the uterus may be smaller in size super_involution. The
uterus, however, returns to normal size if the lactation is withheld.

INVOLUTION OF OTHER PELVIC STRUCTURES

Vagina : The distensible vagina, noticed soon after birth takes a long time ( 6 – 10 weeks ) to involute.
It regains its tone but never to the virginal state. The mucosa remains delicate for the first few weeks
and submucous venous congestion persists even longer. It is the reason to withhold surgery on
puerperal vagina. Rugae partially reappear at 3rd week but never to the same degree as in pre-pregnant
state. Introitus remains permanently larger than the virginal state.

Hymen is lacerated and is represented by nodular tags—the carunculae myrtiformes.

Broad ligaments and round ligaments require considerable time to recover from the stretching and
laxation . pelvic floor and pelvic fascia take a long time to involute from the stretching effect parturition.

LOCHIA

It is the vaginal discharge for the first fortnight during puerperium. The discharge originates from the
uterine body, cervix and vagina.

Odor and reaction:

It has got a peculiar offensive fishy smell. Its reaction is alkaline, tending to become acid toward the end.

Color : Depending upon the variation of the color of the discharge, it is named as:

( 1 ) lochia rubra - 1—4 days, (red)

Composition : Lochia rubra consists of blood, shreds of fetal membranes and deciduas, vernix
caseosa, lanugo and meconium.

( 2 ) lochia serosa - ( 5—9 days )- yellowish or pink or pale brownish

Composition : lochia serosa consists of less RBS but more leukocytes, wound exudates, mucus from the
cervix and microorganisms (anaerobic streptococci and staphylococci). The presence of bacteria is not
pathognomonic unless associated with clinical signs of sepsis.

( 3 ) lochia alba - 10—15 days, ( pale white )

Composition:

Lochia alba contains plenty of decidual cells, leukocytes, mucus, cholester in crystals, fatty and granular
epithelial cells and microorganisms.

Amount : the average amount of discharge for the first 5—6 days is estimated to be 250 ml..
Normal duration :

The normal duration may extend up to 3 weeks. The red lochia may persist for longer duration
especially in women who get up from the bed for the first time in later period. The discharge may be
scanty , especially following premature labours or may be excessive in twin delivery or hydramnios.

Clinical importance : the character of the lochial discharge discharge gives useful information about the
abnormal puerperal state.

The vulval pads are to be inspected daily to get information of:

Odor : if malodorous—indicates infection. Retained plug or cotton piece inside the vagina should be kept
in mind.

Amount : scanty or absent—signifies infection or lochiometra

If excessive—indicates infection.

Color : Persistence of red color beyond the normal limit signifies subinvolutionor retained bits of
conceptus.

Duration : duration of the lochia alba beyond 3 weeks suggests local genital lesion.

GENERAL PHYSIOLOGICAL CHANGES

PULSE

For a few hours after normal delivery , the pulse rate is likely to be raised , which settles down to
normal during the second day. However , the pulse rate often rises with after-pain or excitement

TEMPERATURE

The temperature should not be above 37.2°C ( 99°F ) within the first 24 hours. There may be slight
reactionary rise following delivery by 0.5°F but comes down to normal within 12 hours. On the 3 rd day,
there may be slight rise of temperature due to breast engorgement which should
Not last for more than 24 hours.However , genitourinary tract infection should be excluded if there is
rise of temperature.

URINARY TRACT

The bladder mucosa becomes edematous and hyperaemic and often shows evidences of
submucous extravasation of blood. The bladder capacity is increased .The bladder may be over
distended without any desire to pass urine.

The common urinary problems are:

Over distention .

Incomplete emptying and presence ofresidual urine.

Urinary stasis is seen in more than 50 % of women .

The risk of urinary track infection is , therefore, high.

Dilated ureters and renal pelvis return to normal size within 8 weeks. There only “clean catch”
sample of urine should be collected and sent for examination and contamination with lochia should be
avoided. Is pronounced dieresis on the 2 nd or 3rd day of the puerperium.

GASTROINTESTINAL TRACK:

Increased thirst in early puerperium is due to loss of fluid during labor, in india, in lochia, dieresis and
perspiration.

Constipation is a common problem for the following reasons:

Delayed gastrointestinal motility

Mild ileus following delivery

Perineal discomfort.

WEIGHT LOSS

In addition to the weight loss ( 5—6 ) as a consequence of the expulsion of the fetus,
Placentae, liquor and blood loss, a further loss of about 2 kg ( 4.4 lb) occurs during puerperium chiefly
caused by dieresis. This weight loss may continue up to 6 month of delivery.

URINARY TRACK AND RENAL FUNCTION

In relation to changes pregnancy persistence of urinary stasis in the ureters and bladder is observed
even up to 12 weeks postpartum. Glomerular filtration return to normal by 8 weeks postpartum.

FLUID LOSS

There is a net fluid loss of at least 2 liters during the 1 st week and an additional 1.5 liters during the next
5 weeks. The amount of loss depends on the amount retained during pregnancy, dehydration during
labor and blood loss during delivery. The loss of salt and water are larger in women with preeclamsia
and eclampsia.

BLOOD VALUES

Immediately following delivery , there is slight decrease of blood volume due to blood loss and
dehydration. Blood volume returns to non-pregnant level by the 2 nd week. Cardiac output rises soon
after delivery to about 80% above the pre-labor value but slowly returns to normal within 1 week.

RBC volume and hematocrit values returns to normal by 8 weeks postpartum after the hydremia
disappears.

Leukocytosis to the extent of 25000/mm3 occurs following delivery probably in response to stress of
labor. Platelet count decreases soon after the separation of the placenta but secondary elevation occurs,
with increase in platelet adhesiveness between 4 and 10 days.

Fibrinogen level remains high up to the 2 nd week of puerper. A hypercoagulable state persists for 48
hours postpartum and fibrinolytic activity is enhanced in first 4 days. The increase in fibrinolytic activity
after delivery acts as a protective mechanism.

OVARIAN FUNCTION ( MENSTRUTION AND OVULATION ):

The onset of the first menstrual period following delivery is very variable depends on lactation. If
woman does not breastfeed her baby, menstruation returns by 12 th week following delivery in 80% of
cases. The meantime for onset of first menstruation is 7—9 weeks.
In nonlactating mothers, ovulation may occur as early as 4 weeks and in lactating mothers about 10
weeks after delivery. Duration of anovulation depends upon the frequency (>8/24 hours), intensity and
duration of breastfeeding. The physiological basis of anovulation and amenorrhea is due to elevated
levels of serum prolactin associated with suckling. In lactating mothers the mechanism of amenorrhea
and anovulation are depicted schematically below

LACTATION : for the first 2 days following delivery , no further anatomic changes in the breasts occur.
The secretion from the breasts called colostrums, which starts during pregnancy becomes more
abundant during the period.

COMPOSITION OF THE COLOSTRUM

It is deep yellow serous fluid, alkaline in reaction. It has got a higher specific gravity; a high protein,
vitamin A , sodium and chloride content but has got lower carbohydrate, fat and potassium than the
breast milk. Colostrums and milk contains immunologic components such as immunoglobulin A (1gA ),
complements, macrophages, lymphocytes, lactoferrin and other enzymes ( lactoperoxidase).
Microscopically: it contains fat globules, colostrums corpuscles and acinar epithelial cells. The
colostrums corpuscles are large polynuclear leukocytes , oval or round in shape containing numerous fat
globules.

Percentage Composition of Colostrum and Breast Milk

Protein Fat Carbohydrate Water

Colostrums 8.6 2.3 3.2 86

Breast milk 1.2 3.2 7.5 87

Advantages :

( 1 ) The antibodies ( IgA, IgG, IgM ) and humoral factors ( lactoferrin ) provides immunogical defense
to the new born.
( 2 ) It has laxative action on the baby because of large fat globules.

PHYSIOLOGY OF LACTATION

Although lactation starts following delivery , the preparation for effective lactation starts during
pregnancy.

The physiological basis of lactation is divided into four phases:

(a) Preparation of breasts ( mammogenesis )

(b) Synthesis and secretion from the breastalveoli ( lactogenesis)
(c) Ejection of milk ( galactokinesis ).
(d) Maintenance of lactation ( galactopoiesis )

Mammogenesis :

Pregnancy is associated with remarkable growth of both ductal and lobuloalveolar systems.

An intact nerve supply is not essential for the growth of mammaryglands during pregnancy.

Lactogenesis:

The alveolar cells are the principal sites for production of milk. Though some secretory activity is evident
( colostrums ) during pregnancy and accelerated following delivery, milk secretion actually starts on 3 rd
or 4th postpartum day. Around this time , the breasts become engorged, tense, tender and feel warm.
Inspite of a high prolactin level during pregnancy, milk secretion is kept in abeyance. Probably, steroids –
estrogen and progesterone circulating during pregnancy make the breast tissues un responsive to
prolactin. When the estrogen and progesterone are withdrawn following delivery, prolactin begains its
milk secretory activity in previously fully developed mammary glands. Prolactin, insulin, growth
hormone and glucocorticoids are the important hormones in this stage. The secretory activity is also
enhanced directly or indirectly by growth hormone, thyroxine and insulin. For milk secretion to occur,
nursing effort is not essential.

Galactokinesis: