MIDWIFERY CARE IN

POSTPARTUM
AND LACTATION
GROUP 4
Shofiyatil Laily

011511223003

Emma Anastya P. 011511223005

Siti Azerina H.

011511223008

Winda Marantika 011511223009

Aisha Amalia

011511223018

Erina Novita Dewi

011511223021

Resti Mutya Y.

011511223026

Bahriyatul H.

011511223045

CHAPTER 1
After childbirth, women go through the puerperium,
the period to restore the body in normal conditions.
This period is also called post-natal or post-partum.
Breastfeeding to the newborn is an important thing
because it has great benefits for both mother and baby.
In a survey of 15,341 adolescents ages 9 to 14 (8,186
girls and 7,155 boys) found that those who were fed
predominantly breastmilk in the first six months of life
were 22% less likely to be overweight 9-14 years later.

CHAPTER 2

MIDWIFERY CARE
IN POST PARTUM

LACTATION

MIDWIFERY
CARE IN POST
PARTUM
Post-Natal Period
The post-natal period is the
time which the body returns to
normal. Post-natal lasts for about
six weeks.

Post-Partum Care
There are also routine cares that
should be done by midwife to
mother, namely:
Vital Sign

Bladder

Breasts

Fundus of
uterus

lochia

Perinatal
care

mobilizati
on

Advice

 Normal temperature is 36,5 - 37oC (British Columbia Healthlink

BC, 2015). Rise in temperature is very often due to infection. If
fever occurs, examine breasts and lochia and note any complaints of

Vital Sign

pain.
Check the blood pressure for the first two days. If normal, check
again at the end of the post-partum period unless otherwise
indicated.

Put the baby to the breast soon after delivery. Make

Breasts

sure the breast are empty after each feeding,

expressing by hand if necessary.
The uterus decreases daily until it can no longer be palpated after

Fundus of
uterus

about 10 days. The level of the fundus should be checked daily (or on
each visit). The day after delivery, it is about one finger each
succeeding day. It should always be measured after the bladder has

Some
mothers have difficulty passing urine after delivery
been
emptied.
either because of a loss of the sensation of fullness or

Bladder

because they are frightened that passing urine will be

painful, and must be encouraged to pass urine within eight
hours of delivery

The lochia, or vaginal discharge after birth, is red

lochia

for about three days. For about another six days it

is pinkish-brown and noticeably less, then becomes
whitish in color. Normally, it stops within three
weeks.
Mother must be encouraged to keep her perineal

Perinatal
care

area clean, particularly after passing urine or feces.

Bathing once or twice per day, washing the
perineum once or twice per day, by using a bidet or
simply sitting over a bowl, will keep the perineum
clean.

mobilizati
on

Mother should be encouraged to walk in a few hours of

delivery. However, mother should be assisted the first
time she gets out of bed to go to the bath or shower as
she may feel weak and faint.

Advice To Mother
DIET

EXERCISES

PREVENTING
INFECTION

REST

Post Partum Mental Health

Baby blues

OCD

Postpartu
m anxiety

Postpartu
m
depression
(PPD)

Postpartu
m
psichosis
(PPP)

Baby blues refers to commonly occurring mood swings or mild

Baby blues

feelings

of

sadness

after

childbirth.

Also

called

postpartum

reactivity, these feelings usually peak approximately three to five

days postpartum and disappear within a couple of weeks after the
baby is born.

Postpartu
m
depression
(PPD)

Postpartum depression, a more serious disorder, usually develops

within the first three months postpartum but may develop any time
during the first year and includes symptoms such as low mood,
sleep disturbance, and poor functioning.PPD affects up to 20
percent of postpartum women.

Postpartu
m
psichosis
(PPP)

Potential for the development of postpartum psychosis is

highest within the first few weeks after childbirth. Onset is
sudden and characterized by hallucinations, delusions, agitation,
and other psychotic symptoms. Incidence is estimated at one to
three per 1,000 postpartum women.

Postpartum anxiety is less well-recognized disorder and may occur

on its own or in conjunction with depression. Anxiety affects 5 to 20

Postpartu
m anxiety

percent of new mothers; onset can be sudden or gradual.The

woman may worry excessively or feel anxious, have a short
temper, feel irritable and sad, or experience unusual symptoms of
anxiety.
OCD is also less well-recognized disorder and may occur on its

OCD

own or in conjunction with depression.Roughly 3 to 5 percent of

postpartum women experience obsessive symptomsintrusive,
repetitive, and persistent thoughts or mental pictures (often
about harming their baby), as well as behaviors targeted to
reducing anxiety.
Hormonal changes are theorized to be a causative factor in
postpartum mood disorders, and such changes may affect
women predisposed to the development of mood disorders
most.The stress of dealing with a newborn, lack of sleep, and
nutritional deficiencies may exacerbate the problem.

After Pains
Constipation
Hemorrhoids
Swollen
Breasts
Cracked
Nipples

Min
or
Dis
ord
ers
Of
Post
part
um
Mot
her

Mastitis

Puerperal Sepsis

Complicatio
ns
Thrombophebiti
s

Secondary
Hemorrhage

The midwife should suspect an infection when there is a rise in

PUERPERALIS
SEPSIS

MASTITIS

THROMBOPHEBITIS

temperature and pulse rate, accompanied by any or several of

the following signs and symptoms.
The uterus is not steadily decreasing in size and may feel
Mastitis is an inflammation of the breasts due to
spongy.
infection or engorged breasts. Infection results from
The lochia is more than normal, less than normal, foul-smelling
cracked nipples. The mother will have a rise in
or still red or brown after 10 days.
temperature and pulse rate and may complain of
There is marked pallor, vomiting and restlessness.
The shivering
midwife and
should
treat seriously
headache,
painalways
and tenderness
in the any
There is severe headache.
complaint of tingling sensations, cramp-like pains or
breasts
Severe pain and tenderness in the lower abdomen.
swelling in the legs. Thrombophlebitis is an infection of
There is uncontrollable shivering.
the veins of the legs and is frequently associated with
varicose veins. There is a rise in temperature and
pulse rate, and pain and swelling in the affected leg. In

SECONDARY
HAEMORRHAGE

a more severe form the leg is pale and extremely

Bleeding from the vagina any time from six hours after
swollen.
the delivery to the end of postpartum (6 weeks) is called
secondary hemorrhage. It is caused by the retention of parts
of the placenta or membranes.

LACTATION

BREASTFEEDING

Exclusive Breastfeeding :
Practice of only giving an infant
breast-milk for the first six
months of life.
Human Milk Composition

Colostrum
present in the breast
during pregnancy
and for about the
first 2 to 4 days after
birth. Though small
in quantity during
the first 24 hours

Transitional Milk

Approximately
7 to 10 days
after delivery

Mature Milk

By 14 days milk
is considered
mature

Componets of Matur Milk

1.

Waters,. Water is the major constituent of human milk, which is 87%.

2.

Lipids,
About 50% of the calories in human milk come from lipids. Human milk contains
omega-3 fatty acids, including docosahexaenoic acid (DHA), important for brain and
retinal development and function. Cholesterol, important to the development of
membranes

3.

Proteins
The total protein content of human milk, 0.9%, milk protein can be divided into two
major components, whey and casein. Milk curd, which forms from the casein when the
milk pH drops below 5.0, is an insoluble calcium caseinate-calcium phosphate
complex.

4.

Carbohydrates,
Lactose, synthesized in the breast, is a disaccharide consisting of
galactose and glucose. At concentration levels of 7.2 g/dl, it is the major carbohydrate
in human milk and is essential as a source of glucose.

5.

Minerals, all minerals needed for newborn and infant growth are present in, and well

Componets of Matur Milk

6.

Vitamins, a major source of vitamin A, betacarotene, and vitamin E.

7.

Enyzmes, over 20 bioactive enzymes have been identified in human

milk.

8.

Other important components,

Human milk contains numerous peptide and nonpeptide bioactive
hormones: thyroxine, prolactin, erythropoetin, epidermal growth
factor, insulin, leptin and gastrin. Prostaglandins, also present,
influence gastrointestinal motility.

9.

Cellular components . It contains about 4000 cells per cubic mm

including neutrophils, macrophages, and lymphocytes

10. Enteromammary Pathway. Maternal lymphocytes, both T and B

cells, synthesize immunoglobulins and are thought to originate in

ANATOMY AND PSYCHOPHYSIOLOGY OF LACTATION

Mammary
Development
Lactogenesis and
Psychological
Influences
Oxytocin

Galactorrhea

Newborn
Oral
Developmen
t
Mother

Infant

Suckling

Breathing
and Suckling

Mammary Development

Birt
h
Puberty

Development starts from 4th weeks of

Gestation
Childhood is limited to general growth
Complete development of mammary function
is on pregnancy

Pregnancy

Lactation

32-42 week > increases 4x its original mass,

nipple and aerolla develop futher + pigmented
Est + prog & expulsion of the placenta >>
begins prod milk
Several hormones coupled with stimulation
let down reflex direct the development of
lactation

Mammary Development
Tabel 2. Hormonal Influences During Pregnancy

Hormone

Function

Prolactin

a.During pregnancy, prolactin has an important role in increasing breast mass.

b.controlled by the hypothalamus
c.There is no relationship between the degree of postpartum breast engogerment and the level of circulating
prolactin(West, 1979).
d.delays the return of ovulation by inhibiting ovarian responses to follicel-stimulating hormone.

Human
Placental a. made by the placental
Lactogen (HPL)
b. is actively secreted into maternal circulation starting in the second month of pregnancy.
c. As yet, the role of HPL in lactogenesis is not clear, because it is produced in such large amounts, it may have a
lactogenis effect.
Glucocorticoids

a. hormones secreted by the adrenal glands

b. help to regulate water transport accors the cell membranes during lactation.
c. Cortisol, a main glucocorticoids, has little effect on the mammary system unless prolactin is present.

Thyroid
Stimulating a. hormones a promote mammary growth and lactation through a permissive rather than a regulatory role.
Hormone (TSH)
b. play a general role in the health of the mother by regulating metabolic processes. Because the thyroid gland is an
integral part of the complex endocrine system, a thyroid deficiency in the lactating mother can decrease the milk
supply.
Prolactin
inhibitting a.PIF, a hypothalamic substance, etiher dopamine itself or medicated by dopamine, inhibits prolactin secretions.
factor (PIF)
b.Nipple stimulation suppresses PIF and dopamine, causing prolactin levels to rise and the breast to produce milk.
c.Some drugs, such as phenothiazines and reserpine derivatives, increase breastmilk because they also inhibit PIF.
Thyrotropin-releasing
hormone(TRH)

TRH has been thought to increase TSH and prolactin levels. Therefore, TRH is thought to play a role in the control of
prolactin secretion. Recently, however some scientists were unable to conclude that TRH played any role in the release of
prolactin when they measured plasma prolactin and TSH responses to breastfeeding during the first month postparum.

Lactogenesis and
Psychological Influences
Milk comes in or rapidly increases in volume with breast
fullness 24 to 48 hrs after birth, lactation shifts from
endocrin to autocrin control
Quantity and Quality suckling or milk removal that governs
breast milk, not maternal hormones

Suckling

Stimulates

Afferent Impules

Posterior Pitutitary Hormones

Oxytocyn

Let-down Reflex

Nervous Systems

Oxytocin

Oxytovin levels in blood rise within 1 min of breast stimulation,

remain elevator during the stimulation and return to baseline
levels within 6 min, after stimulation of the nipple ends
Can contract mothers uterus > help control postpartum
bleeding + involution of uterin.
Contract during breastfeeding, but, continues to contract
rhymically as long as 20 min after the feeding
Deppresed + noraderinaline can shut down the milk ejection
reflex
While oxytocin appears to be keyed more closely to milk
ejcetion, without prolactin, milk is not made.

Galactorrhea

Galactorrhea is the spontaneous secretion of milk from

the breast under nonphysiological circumstances. Small
amounts of milk or serous fluid are commonly expressed for
weeks or months from woman who have previously been
pregnant and/or lactating. Abnormal milk secretion can be
used by several drugs, for example reserpone, methyldopa,
and phenothiazine.

Newborn Oral Development

During gestation,
11 weeks swallowing fluid
24 weeks suck reflex
32 weeks rooting responses link age
37 weeks combination sucking, swallowing, and
breathing
Epiglotis plays an important role by closing off the
pathway to the lungs when the infant swallows. This ensure
that the milk will travel into the esphagus, rahter than into
the trachea

has pads of fat on both cheeks to assist with suckling fat

enclosed within its own capsule of fibrous connective tissue,

provide stablity for suckling and reduce the likelihood of
collapsing of the cheeks and buccinator muscles between the
gums. Collapsing of the cheeks is more likely a premature baby
who lacks of the layer of fat (including that in the cheeks) that
gives

the

appearance.

full-term

infant

his

characteristic

plump

facial

Suckling

The nipple and its surrounding areola and underlying breast tissue is
drawn deeply into the infants mouth; then the infants lips and
cheeks from a seal. The infants lips are flanged out-ward around
the mothers breast and are minimally involved

The tip of the infants tongue is maintained behind the lower lip and
over the lower gum while the rest of the anterior tongue cups the
areola of the breast.

During the feeding, the mothers nipple and areola elongates into a
teat by suction created within the babys mouth.

The jaw moves the tongue up, compressing the maternal aerola against the infants alveolar ridge
which causes milk to be expressed from the lactiferous sinuses into the infants mouth.
As the anterior portion of the tongue is raised, the posterior tongue is depressed and retracted in
undulating or peristaltic motions, forming a groove that channels the milk to the back of the oral cavity
where it stimulates receptors that initiate the swallowing reflex. This backward movement produces a
negative pressure, similar to withdrawing a piston in an airtight syringe.

Suckling

If the volume of milk takes is sufficient to trigger

swallowing, the back of the tongue elevates and
presses against the posterior pharyngeal wall. The soft
planes rises and closes off the nasal passageways.
The larynx then moves up and forward to close the
trachea, propelling the milk into the esophagus.
Afterwards the larynx returns to its previous position.

The infant lowers his jaw, the lactiferous sinuses refill and a new cycle
begins. A rhythm is created by this sequence of vertical jaw movements
and the depression and elevation of the posterior tongue. Each suck
sequence is followed by a swallow. The rapid jaw movement and the
infants tongue and lips stimulate tactile nerve endings in the mothers
aerola, initiating the release of oxytocin from her pituitary gland.

Breathing and Suckling

In a normal, coordinated, nutritive suckling cycle,

swallowing does not inhibit respiration, and breathing
appears to continue throughout the suckling cycle.
almost always recovers spontaneously, and often
continues to suck and swallow despite cyanosis.
Unless hypoxic, the newborn is an obligated nose
breather. This is due in part to the positioning of the soft
palate, and to the lack of space in the mouth for air to be
travelling in and out.
While it it true that babies have ventilator problems
when the nasal passages are occluded, an infant is
capable of breathing through the mouth when it it
necessary

THE RIGHT POSITION OF BREASTFEEDING

Cleanse her hands with soap and raise
them.
Find the most comfortable posisition
Work with the mother at her eye level
Help to position the babys head so
that it is snuggled securely in the
mothers arms and rotated toward her.
Ask the mother to support her breast
with her hand, keeping her thumb well
above the areola and the rest of her
fingers below and under the breast.

Help the mother position her baby so that his nose is at

the level of the mothers nipple.

Explain that for these early feedings, her infant should

be offered both breasts at each feeding to stimulate the
need-supply response.

If the mother elects to end a feeding before her baby

has slipped off the breast or pushed the nipple out of
his mouth,

Common Challenges

1. Sore
Nipples

4. Not Enough Milk

2. Engorgement

5. Plugged Duct

3. Mastitis

6. Fungal Infections

7. Inverted, Flat, or Very Large Nipples

CHAPTER 3
The post-natal period is the time during which the body returns to normal. It last
about six weeks. WHO describes that post-natal period is as the most critical yet the
most neglected phase in the lives of mothers and babies, most death occurs during this
period. Therefore, post-partum care is needed during this period.
Breast milk is a complete food for the new baby. The nutritional profile of breast
milk in terms of calories, vitamins, and minerals is the best for the new baby. Because it
has the perfect propotion of them all. One of the most important skills that a baby and
mother have to learn together is how to position and attach baby to the breast.

REFERENCES
Morris,

SE. 1982. The normal acquisition of oral feeding skills: Implications for
assessment and treatment. New York: Therapeutic Media.
Wesson, Nicky. 1995. Alternative Health Alternative Maternity. Optima
Riordan, J. & Aurberch, Kathleen G. 1993.Breastfeeding and Human Lactation. Jones
and Bartlett Publishers
Cox, Helen. 1971. Midwifery Manual A Guide for Auxiliary Midwives. McGraw-Hill Inc
College of Midwives of Manitoba (CMM) Postpartum Care of Mother and Infant. Dec
2004
Training modules ; Essential Antenatal, Perinatal and Postpartum Care. World Health
Organization 2003
WHO recommendations on Postnatal care of the mother and newborn. October
2013
WHO.http://who.int/globaltargets_breastfeeding_policybrief . accessed on October
17th 2015
http://www.womanshealth.gov/Breastfeeding . accessed on October 18th 2015
http://www.wellstart.org/Lactation-Management-Self-Study-Modules . accessed on
October 18th 2015
www.arhp.org/guide. A Quick Reference Guide for CliniciansPostpartum
Counseling . July 2013

THANK YOU