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Care of the PostpartumCare of the PostpartumClientClient
Romamea MagdayaoRomamea Magdayao
Ana Marie LopezAna Marie Lopez
Rowena Jenniesa LabordoRowena Jenniesa Labordo
Hanna Mae MagtolesHanna Mae Magtoles
BSN2BSN2--CC
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Postpartum Physical AdaptationsPostpartum Physical Adaptations(pg. 906(pg. 906--929)929)
Uterine InvolutionUterine Involution Fundal positionFundal position
changes: Boggychanges: Boggy Lochia: Rubra, Serosa,Lochia: Rubra, Serosa,
AlbaAlba Cervical changesCervical changes Vaginal changesVaginal changes Perineal changesPerineal changes Recurrence ofRecurrence of
ovulation andovulation andmenustrationmenustration
LactationLactation
GastrointestinalGastrointestinalSystemSystem
Urinary tractUrinary tract
Vital signsVital signs
Weight lossWeight loss
Postpartum chillPostpartum chill
Postpartal diaphoresisPostpartal diaphoresis
Afterpains or AfterbirthAfterpains or Afterbirthpainspains
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Uterine InvolutionUterine Involution
The rapid reduction in size ofThe rapid reduction in size ofthe uterus and its return to athe uterus and its return to acondition similar to its precondition similar to its pre--pregnancy state.pregnancy state.
The uterus remains slightlyThe uterus remains slightlylarger than it was before thelarger than it was before thefirst pregnancy.first pregnancy.
Process is complete at 3 weeksProcess is complete at 3 weeks
except at the placental site (6except at the placental site (6to 7 weeks)to 7 weeks)
SubinvolutionSubinvolution may be causedmay be causedby an infection or retainedby an infection or retained
placenta fragments.placenta fragments.
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WEIGHT OF THE UTERUSWEIGHT OF THE UTERUS
Right after delivery: 1000Right after delivery: 1000gramsgrams
1 week after1 week after :500:500gramsgrams
2 weeks after2 weeks after : 300 grams: 300 grams
6 weeks after6 weeks after : 50: 50 6060
gramsgrams
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Fundal Position ChangesFundal Position Changes
After birth :After birth :
1st day: one fingerbreadth below1st day: one fingerbreadth below
umbilicusumbilicus 2nd day: two fingerbreadths below2nd day: two fingerbreadths below
umbilicusumbilicus
9th to 10th day: cannot be palpated9th to 10th day: cannot be palpated
abdominallyThe first postpartum day it isabdominallyThe first postpartum day it islocated 1 cm or fingerbreadth below thelocated 1 cm or fingerbreadth below theumbilicus.umbilicus.
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Fundal Position ChangesFundal Position Changes
May be displaced to the left or rightMay be displaced to the left or rightby a distended bladder.by a distended bladder.
Becomes boggy with uterine atonyBecomes boggy with uterine atony
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Boggy Uterus Boggy Uterus
Massage the uterusMassage the uterus
Place infant on mothers breastPlace infant on mothers breast
Administer oxytocinAdminister oxytocin Check BPCheck BP
Do not give if BP > 140/90Do not give if BP > 140/90
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UTERINE CONTRACTIONSUTERINE CONTRACTIONS
Prevent bleedingPrevent bleeding
AfterpainsAfterpains uncomfortable crampsuncomfortable cramps
Common in multiparaCommon in multipara Oxytocin treatedOxytocin treated
Breastfeeding mothersBreastfeeding mothers
22 3 days3 days
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NURSING MEASURESNURSING MEASURES
Explain the cause and purpose ofExplain the cause and purpose ofafterpainsafterpains
Keep bladder emptyKeep bladder empty Prone position to lessen discomfortProne position to lessen discomfort
Gentle massageGentle massage
Administer analgesicsAdminister analgesics
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VAGINAL DISCHARGEVAGINAL DISCHARGE
LOCHIALOCHIA
Uterine discharge after deliveryUterine discharge after delivery
Blood, mucus, epithelial cells, leukocytesBlood, mucus, epithelial cells, leukocytesand bacteriaand bacteria
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COLOR AND PATTERNCOLOR AND PATTERN
Rubra:Rubra: dark red in colordark red in color
present the first 2present the first 2--3 days3 dayspostpartumpostpartum
few small clotsfew small clots Serosa:Serosa:
pinkish to brownishpinkish to brownish
44thth to the 10th dayto the 10th day
Alba:Alba: creamy or yellowishcreamy or yellowish
persists for a week or two afterpersists for a week or two after
serosa, may be later inserosa, may be later in
breastfeeding clients.breastfeeding clients.
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SIGNS OF ABNORMAL LOCHIASIGNS OF ABNORMAL LOCHIA
SIGNSSIGNS POSSIBLE CAUSEPOSSIBLE CAUSE
FOUL SMELLFOUL SMELL INFECTIONINFECTION
LARGE CLOTSLARGE CLOTS RETAINED FRAGMENTSRETAINED FRAGMENTS
EXCESSIVEEXCESSIVEAMOUNTAMOUNT
LACERATION OF BIRTHLACERATION OF BIRTHCANALCANAL
RETURN TORETURN TO
RUBRIA AFTERRUBRIA AFTERSEROSA OR ALBASEROSA OR ALBA
RETAINED FRAGMENTSRETAINED FRAGMENTS
INFECTIONINFECTION
BLEEDING AFTERBLEEDING AFTER
6 WEEKS6 WEEKS
SUBINVOLUTION OFSUBINVOLUTION OF
THE UTERUSTHE UTERUS
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CERVICAL CHANGESCERVICAL CHANGES
Spongy, flabby, formless andSpongy, flabby, formless andbruised.bruised.
Original form is regained in a fewOriginal form is regained in a fewhourshours
The shape is permanently changed byThe shape is permanently changed bythe first childbearing.the first childbearing.
Goes from dimple like to a lateral slitGoes from dimple like to a lateral slit(fish mouth)(fish mouth)
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VAGINAL CHANGESVAGINAL CHANGES
Edematous and bruisedEdematous and bruised
Small superficial lacerations may beSmall superficial lacerations may be
presentpresent Laceration and episiotomy heals afterLaceration and episiotomy heals after
2 weeks2 weeks
Size and rugae return to preSize and rugae return to prepregnancy in 3 weekspregnancy in 3 weeks
By 6 weeks appears normalBy 6 weeks appears normal
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PERINEAL CHANGESPERINEAL CHANGES
edematous with some bruisingedematous with some bruising
Episiotomy edges should beEpisiotomy edges should be
approximatedapproximated Ecchymosis may occur and delayEcchymosis may occur and delay
healinghealing
Suture: 7 to 10 daysSuture: 7 to 10 days Perineal muscle tone regained : 6Perineal muscle tone regained : 6thth
weeksweeks
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PERINEAL CAREPERINEAL CARE
Flush with warm waterFlush with warm water
Pat dry from front to backPat dry from front to back
Change pad frequentlyChange pad frequently
Observe signs of infectionObserve signs of infection
Reduce hemorrhoidsReduce hemorrhoids
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PERINEAL CAREPERINEAL CARE
ICE PACKSICE PACKS
SITZ BATHSITZ BATH
PROMOTE CIRCULATIONPROMOTE CIRCULATION 20 MINUTES20 MINUTES
PERINEAL LAMPPERINEAL LAMP Promote vasodilationPromote vasodilation
25 to 40 watts light25 to 40 watts light 1212 --18 inches away18 inches away
20 minutes 3x a day20 minutes 3x a day
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Recurrence of Ovulation andRecurrence of Ovulation andMenustrationMenustration
VariableVariable
Generally returns to nonGenerally returns to non--nursing mothersnursing mothersbetween 7 and 9 weeks after birthbetween 7 and 9 weeks after birth
The first cycle is nonThe first cycle is non--ovulatoryovulatory
Breastfeeding clients may experienceBreastfeeding clients may experiencemenstruation and ovulation based on themenstruation and ovulation based on the
amount of time nursingmay occur fromamount of time nursingmay occur from2nd to 18th month2nd to 18th month
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LACTATIONLACTATION
During pregnancy, the breastsDuring pregnancy, the breastsdevelop in preparation for lactation asdevelop in preparation for lactation as
a result of both estrogen anda result of both estrogen andprogesterone. After birth, theprogesterone. After birth, theinterplay of maternal hormones leadsinterplay of maternal hormones leadsto the establishment of milkto the establishment of milk
production.production.
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GASTROINTESTINALGASTROINTESTINAL
May have a regular dietMay have a regular diet High in protein, iron and vitaminsHigh in protein, iron and vitamins
Bowels tend to be sluggishBowels tend to be sluggish Episiotomy clients may delay bowelEpisiotomy clients may delay bowel
movement for fear of painmovement for fear of pain
Cesarean birth clients may receiveCesarean birth clients may receive
clear liquids and progress to a regularclear liquids and progress to a regulardietdiet
Stool softeners may be usedStool softeners may be used
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URINARY TRACTURINARY TRACT
increased bladder capacity, swelling and bruising ofincreased bladder capacity, swelling and bruising oftissue, decreased sensitivity to fluid pressure, andtissue, decreased sensitivity to fluid pressure, anddecreased sensation of bladder filling.decreased sensation of bladder filling.
At risk for overAt risk for over--distention, incomplete emptying, anddistention, incomplete emptying, and
buildup of residual urine.buildup of residual urine. Urinary output increases 1rst 24 hours post deliveryUrinary output increases 1rst 24 hours post delivery
((puerperal diuresispuerperal diuresis))
Urine specimens should be obtained as a catheterizedUrine specimens should be obtained as a catheterizedspecimen.specimen.
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CARDIOVACULARCARDIOVACULAR
Blood loss: NSD: 300 to 500 ml CS: 500 to 1000Blood loss: NSD: 300 to 500 ml CS: 500 to 1000mlml reduction in blood volumereduction in blood volume
40% increase of maternal blood volume after40% increase of maternal blood volume after
delivery of the placentadelivery of the placenta Return of cardiac output to pregnant state takesReturn of cardiac output to pregnant state takes
about 2about 2-- 3 weeks from delivery3 weeks from delivery
Hemoconcentration in the first 3 to 7 daysHemoconcentration in the first 3 to 7 days
Leukocytosis in the first 12 daysLeukocytosis in the first 12 days
Elevated fibrinogen levels up to the third weeksElevated fibrinogen levels up to the third weeks Physiologic bradycardia during the first 24 hoursPhysiologic bradycardia during the first 24 hours
Orthostatic hypotension in the first 24 hoursOrthostatic hypotension in the first 24 hours
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INTEGUMENTARYINTEGUMENTARY
Disappearance of skin changes (6Disappearance of skin changes (6weeks) except for striae and diastisisweeks) except for striae and diastisisrectirecti
Areolar hyperpigmentation may notAreolar hyperpigmentation may notdisappear completelydisappear completely
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Vital SignsVital Signs
afebrile after the first 24 hours.afebrile after the first 24 hours.
BP WNL,BP WNL, a decrease may occura decrease may occur. An. An
BP may indicate toxemia, PIH.BP may indicate toxemia, PIH. Pulse rate may decrease to 50Pulse rate may decrease to 50--70.70.
Tachycardia should alert the nurse toTachycardia should alert the nurse toblood loss/difficult birthblood loss/difficult birth..
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Blood ValuesBlood Values
Blood values should return to theBlood values should return to theprepregnant state by the end of theprepregnant state by the end of thepostpartum period.postpartum period.
Leukocytosis with white blood cell (WBC)Leukocytosis with white blood cell (WBC)counts up to 30,000 per mL may occurcounts up to 30,000 per mL may occurearly postpartum.early postpartum.
Convenient rule of thumb is a 2 point dropConvenient rule of thumb is a 2 point drop
in hematocrit equals a blood loss of 500in hematocrit equals a blood loss of 500mL.mL.
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Weight LossWeight Loss
An initial weight loss of 10 to 12 lbsAn initial weight loss of 10 to 12 lbsoccurs as a result of the birth of theoccurs as a result of the birth of the
infant, placenta and amniotic fluid.infant, placenta and amniotic fluid. Puerperal diuresis accounts for loss ofPuerperal diuresis accounts for loss of
an additional 5 lbs during the earlyan additional 5 lbs during the earlypostpartum period.postpartum period.
Normally return to preNormally return to pre--pregnantpregnantweight by 6 weeks postpartum.weight by 6 weeks postpartum.
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Postpartum Chill andPostpartum Chill andPostpartal DiaphoresisPostpartal Diaphoresis
Most clients experience a shaking chill orMost clients experience a shaking chill ortremor after delivery.tremor after delivery.
Warm blankets usually relieve this tremor orWarm blankets usually relieve this tremor or
chill.chill.
Chills and fever late in the postpartumChills and fever late in the postpartumperiod may indicate sepsis.period may indicate sepsis.
Diaphoretic episodes may occur at night, aDiaphoretic episodes may occur at night, a
normal occurrence as the body rids itself ofnormal occurrence as the body rids itself ofwaste products.waste products.
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AMBULATIONAMBULATION
NSD : 4NSD : 4 8 hours8 hours
ANESTHESIA : 8 hoursANESTHESIA : 8 hours
ADVANTAGES:ADVANTAGES: Prevent constipationPrevent constipation
Prevent circulatory problems, urinaryPrevent circulatory problems, urinaryproblemsproblems
Promote recoveryPromote recovery
Hasten drainage of lochiaHasten drainage of lochia
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EXERCISEEXERCISE
PurposePurpose
Prevent complicationsPrevent complications
Psychological well beingPsychological well being
Strengthen muscles of back, pelvic floorStrengthen muscles of back, pelvic floorand abdomenand abdomen
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EXERCISEEXERCISE
POSTPARTUM EXERCISEPOSTPARTUM EXERCISE
Abdominal breathingAbdominal breathing
Kegel exercise: tighten perineal muscleKegel exercise: tighten perineal muscle
Arm RaisingArm Raising
Leg RaisingLeg Raising
SitSit--upsups
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REST AND SLEEPREST AND SLEEP
At least 8 hoursAt least 8 hours
Avoid heavy liftingAvoid heavy lifting
Light housekeeping: 2 weeksLight housekeeping: 2 weeks Normal activities: 4Normal activities: 4 6 weeks6 weeks
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RESUMPTION OF SEXRESUMPTION OF SEX
VAGINAL DELIVERY: 3VAGINAL DELIVERY: 3 4 WEEKS4 WEEKS
CS: 2 WEEKSCS: 2 WEEKS
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DischargeDischarge
Primiparas : 2 to 3 daysPrimiparas : 2 to 3 days Multipara: 1Multipara: 1to 2 daysto 2 days CS: 3 to 4 daysCS: 3 to 4 days
Discharge IE is done before leavingDischarge IE is done before leaving
Follow up: 4 to 6 weeks after deliveryFollow up: 4 to 6 weeks after delivery
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PostpartumPostpartumPsychologicalPsychological
AdaptationsAdaptations
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Postpartum PsychologicalPostpartum PsychologicalAdaptationsAdaptations
Postpartum bluesPostpartum blues
Development of ParentDevelopment of Parent--InfantInfant
attachmentattachment Initial attachment BehaviorInitial attachment Behavior
FatherFather--Infant InteractionsInfant Interactions
Cultural InfluencesCultural Influences
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RUBINS POSTPARTUM PHASERUBINS POSTPARTUM PHASE
TAKINGTAKING--IN PHASEIN PHASE
11stst 22-- 3 days postpartum3 days postpartum
Need for sleep and restNeed for sleep and rest
Dependence on otherDependence on other
TAKINGTAKING--HOLD PHASEHOLD PHASE
Transition phaseTransition phase
33rdrd day to 2 weeks postpartumday to 2 weeks postpartum
Control body functionControl body function
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TAKINGTAKING--HOLD PHASEHOLD PHASE
Ability to assume the mother roleAbility to assume the mother role
LETTINGLETTING--GO PHASEGO PHASE Realize that the infant is a separateRealize that the infant is a separate
individual and not a part of herselfindividual and not a part of herself
Feeling of lossFeeling of loss
Adjustment phaseAdjustment phase
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Postpartum bluesPostpartum blues
Transient period of depression : 1Transient period of depression : 1 -- 22weeks after birth.weeks after birth.
Manifested by mood swings, anger,Manifested by mood swings, anger,weepiness, anorexia, difficultyweepiness, anorexia, difficultysleeping, and a feeling of letdown.sleeping, and a feeling of letdown.
CAUSE: Hormonal changes andCAUSE: Hormonal changes and
psychological adjustmentspsychological adjustments
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Postpartum bluesPostpartum blues
Resolve naturally in 2 to 3Resolve naturally in 2 to 3weeks with support andweeks with support and
reassurance.reassurance.
If symptoms persist, theIf symptoms persist, the
client should be evaluatedclient should be evaluatedfor postpartum depression.for postpartum depression.
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Development of ParentDevelopment of Parent--InfantInfantattachmentattachment
Level of trustLevel of trust
Level of selfLevel of self--esteemesteem
Capacity for enjoying herselfCapacity for enjoying herself
Interest in and adequacy of knowledgeInterest in and adequacy of knowledgeabout childbearing and childrearingabout childbearing and childrearing
Clients prevailing mood or usual feelingClients prevailing mood or usual feeling
tonetone Reactions to the present pregnancyReactions to the present pregnancy
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Initial attachment BehaviorInitial attachment Behavior Progression of touching activitiesProgression of touching activities
En face position dominatesEn face position dominates
Relies heavily on senses of sight,Relies heavily on senses of sight,touch, hearing in getting to knowtouch, hearing in getting to knowthe babythe baby
Some negative feelings maySome negative feelings mayoccur; be understanding notoccur; be understanding notcondescendingcondescending
Reciprocity is an interactionalReciprocity is an interactional
cycle that occurs simultaneouslycycle that occurs simultaneouslybetween mother and infant.between mother and infant.(mutual cueing behaviors,(mutual cueing behaviors,expectancy, delight in each othersexpectancy, delight in each otherscompany when synchronous)company when synchronous)
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FatherFather--Infant InteractionsInfant Interactions
Primary role has been supportingPrimary role has been supportingrolerole
Engrossment (the characteristicEngrossment (the characteristicsense of absorption,sense of absorption,preoccupation, and interest inpreoccupation, and interest in
the infant demonstrated bythe infant demonstrated byfathers during early contact withfathers during early contact withthe newborn.the newborn.
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Cultural InfluencesCultural Influences
Postpartum care my be affected byPostpartum care my be affected bycultural beliefs: No shower, nocultural beliefs: No shower, nobreastfeeding for the first three days,breastfeeding for the first three days,
hot and cold foodshot and cold foods
Do not make generalizationsDo not make generalizations
Extended family may play anExtended family may play an
important role in careimportant role in care
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Postpartum AssessmentPostpartum Assessment
Vital signs: BP should remainVital signs: BP should remainconsistent with baseline BPconsistent with baseline BPduring pregnancy. Pulse 50during pregnancy. Pulse 50 --90,90,respirations 16respirations 16--24, temp 9824, temp 98--100.4100.4
Breasts: Smooth, evenBreasts: Smooth, evenpigmentation, soft, filling, full,pigmentation, soft, filling, full,engorgedengorged
Abdomen: soft, fundus firm,Abdomen: soft, fundus firm,
midline and at/or belowmidline and at/or belowumbilicus, may be tender onumbilicus, may be tender onpalpationpalpation
Lochia: rubra, scant toLochia: rubra, scant to
moderate, no clots, rubra tomoderate, no clots, rubra to
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Postpartum AssessmentPostpartum Assessment Perineum: Slight edema, noPerineum: Slight edema, no
bruising, episiotomy withoutbruising, episiotomy withoutredness, swelling or drainage,redness, swelling or drainage,hemorrhoids (none or small)hemorrhoids (none or small)
Lower extremities: No pain withLower extremities: No pain with
palpation, negative Homans signpalpation, negative Homans sign Elimination: voiding 4Elimination: voiding 4--6 hrs, no6 hrs, no
bladder distention noted, normalbladder distention noted, normalbowel movement by the 2bowel movement by the 2ndnd to 3to 3rdrd
day post deliveryday post delivery
Psychological adaptation: culturalPsychological adaptation: culturalassessment, bonding, holding enassessment, bonding, holding enface, attachment behaviorsface, attachment behaviors
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Postpartum AssessmentPostpartum Assessment
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Dysfunctions of the PostpartumDysfunctions of the PostpartumPeriodPeriod
Postpartal Uterine Infection: Endometritis, PelvicPostpartal Uterine Infection: Endometritis, PelvicCellulitisCellulitis
Perineal Wound InfectionPerineal Wound Infection
Cesarean Wound InfectionCesarean Wound Infection
Urinary Tract Infection (UTI)Urinary Tract Infection (UTI)
MastitisMastitis
Thromboembolitic Disease: Superficial Leg VeinThromboembolitic Disease: Superficial Leg VeinDisease, Deep Vein Thrombosis, Septic PelvicDisease, Deep Vein Thrombosis, Septic PelvicThrombophlebitisThrombophlebitis
Postpartum Psychiatric Disorder: baby blues,Postpartum Psychiatric Disorder: baby blues,Postpartum Psychosis, Postpartum Major MoodPostpartum Psychosis, Postpartum Major MoodDisorderDisorder
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Two methods of milk suppressionTwo methods of milk suppression
a. mechanical (tight bras, avoidinga. mechanical (tight bras, avoiding
nipple stimulation, ice packs)nipple stimulation, ice packs)b. pharmacologic (bromocriptine)b. pharmacologic (bromocriptine)