Professional Documents
Culture Documents
Postpartum Complication
Postpartum Complication
• Management
• - Principles
• • Resuscitation of the mother
• • Identification of the specific cause of PPH
• • Call for help (Obstetrician, Anesthetist, midwife…)
• • Management is done following the figure below
• Treatment approaches for PPH
• Called for help
• Uterine massage
• Empty the bladder
• Bi-manual compression
• Inspect for obvious laceration
• Predisposing factors
• Grand multiparity
• Over distension of uterus as in twins and hydramnios
• Maternal ill health
• Cesarean section
• Prolapse of the uterus
• Uterine fibroid (leiomyomas)
• No sucking of the baby
• Aggravating factors
• Retained products of conception
• Uterine sepsis
• Retention of lochia (lochiametra)
• Clinical features
• Excessive or prolonged discharge of lochia
• Irregular or excessive uterine bleeding
• Irregular cramp like pain
• Uterine height more than normal for the particular day of postpartum
Cont..
• Prevention of sub-involution
• Make sure the placenta and membranes are complete expelled
• Give ergo or oxytocin after birth
• Keep uterus well contracted after birth
• Put the baby on breast
• Advice the mother on hygiene
• Treatment
• 1. Oral administration of methyl Ergometrine 0.2mg Q 10 hours to improve uterine time
and complete involution.
• 2. An oral antibiotic if the uterus is tender on palpation and analgesics
• 3. Exploration of the uterus for retained products
• 4. Pessary in prolapse or retroversion
• N.B. Be certain that women know at discharge from a health care facility the normal
process of involution and lochial discharge
Puerperal infection
• Puerperal pyrexia
• An elevation of temperature to 38c°(100.4F°) or more occurring on two separate occasions at 24hrs
apart( excluding the first 24hrs) within the first 10days following delivery is called puerperal pyrexia
• Causes
• Puerperal sepsis
• Urinary tract infection: cystitis, pyelonephritis
• Breast infection
• Infection of laparotomy wound (cesarean section)
• Intercurrent infection: acute bronchitis, pneumonia, influenza, acute appendicitis and enteric fever
• Thrombophlebitis
• Deep vein thrombosis
• Flaring up of tuberculosis
• Puerperal Sepsis
• Infection of the genital tract that occurs at any time between the rupture of membranes in labour
and 42 day following delivery or abortion
• Cause
• a. Endogenous bacteria
• b. Exogenous bacteria
• Symptoms
• - Pelvic pain
• - Fever 38.50C or more
• - Abnormal smell, foul dour of vaginal discharge
• - Delay in the rate of reduction of the size of the
uterus. (Sub-involution)
Risk factors for puerperal sepsis
•Poor hygiene
•Poor aseptic technique
•Manipulations in birth canal
•Presence of dead tissue in the birth canal due to IUFD
•Retained fragments of placenta or membranes shedding of dead tissue from vaginal wall
following obstructed labour.
•Insertion of unsterile hand, instrument or packing / traditional practices should also be
examined/
•Pre existing anemia and malnutrition
• Prolonged of obstructed labour
•Prolonged rupture of membrane
• Frequent vaginal examinations
•Caesarean section and other operative deliveries
• Unrepaired vaginal or cervical lacerations
• Preexisting sexually transmitted disease
•Post partum hemorrhage
•Not being immunized against tetanus
•diabetes
• Site of infection
• 1. Placental site
• 2. Perineum
• 3. Vagina
• 4. Cervix
• 5. Uterus
• Women are vulnerable to infection in the proportion
because the placental site is large, warm, dark moist,
rich to grow very quickly.
• During delivery traumatized tissue of tear in the vagina
or perineal area is susceptible to infection.
•Managing Puerperal sepsis
•1. Isolation and Barrier nursing of the woman Nurse the woman in a separate room,
use gloves only when attending her keep one set of equipment, dishes and other
utensils for the use of this woman, wash hands carefully before & after attending this
woman.
•2. Administration of high doses of antibiotics / Broad spectrum/
•3. Give plenty of fluids:- the aim of this is to correct or prevent dehydration and help
to lower the fever.
• In severe cases it is necessary to give IV fluids at first.
•4. Ruling out Retained placental fragments:- suspect this if the uterus is soft and bulky,
if lochia are excessive and contain blood clots, it can be a sign of puerperal sepsis.
•The woman should be referred to a facility that has the equipment and health care
personnel trained to perform curettage.
•5. Providing skilled nursing care:- Careful attention to the comfort of the woman.
•It is important for the woman to rest, monitor uterine size, measure intake and
output, keep accurate recurs; prevent spread of infection and cross infection.
•Accurate observation, recording and reporting
• Prevention
• improvement of general hygiene
• Take aseptic precaution while dressing Perineal wound
• Restriction of visitors in the postpartum ward
• Vulva and perineum to be washed/cleaned with mild
antiseptic solution following urination and defecation
• Abstinence from sexual intercourse in the last two
months
• Avoid unnecessary vaginal examination and douches in
the later month
• Breast complications
• The common breast complications in puerperium are breast engorgement, cracked and retracted nipple,
mastitis, breast abscess and failing lactation
•
• Breast engorgement
• Breast engorgement may occur due to excessive production of milk, obstruction to outflow of milk or poor
removal of milk by the baby.
• It usually manifests after the milk secretion starts (3rd or 4th postpartum day)
• Symptoms
• Both breasts feel tender, tense and firm
• Nipples become edematous and flushed
• The veins over the breasts become engorged and prominent
• Generalized malaise and rise of temperature
• Painful breastfeeding
• Preventive measures
• To initiate breastfeeding early and feeding at frequent intervals
• Exclusive breastfeeding on demand
• Feeding in correct position
• Management
• Support the breasts with a binder or brassier
• Manual expression of any milk after each
feeding and keeping the intervals short
between feeds
• Analgesics for pain
• The cause of poor sucking by the newborn
should be corrected
• Cracked and retracted nipples
• The nipples may become painful due to loss of surface epithelium with the formation of raw
area of the nipple or due to a fissure situated at the tip or the base of the nipple
• These two conditions often co-exist, which are referred to as the cracked nipple
• Cracked nipple is sore nipples are any persistent pain in the nipples that lasts throughout the
entire breastfeeding or hurts between feeding
• Causes
• Inadequate hygiene resulting in the formation of a crust over the nipple
• Retracted nipple
• Vigorous sucking and an inadequate milk flow
• The women experiences soreness and pain at the site of the fissure, the fissure may become
infected, when infected, the infection may spread to the deeper tissue producing mastitis and
hence, it should be treated
• Prevention
• Local cleanliness during pregnancy, and in the puerperium before and after each
breastfeeding t prevent crust formation over the nipple
• Treatment
• Application of tincture on benzoic after the night feeding and the fissure is likely to be healed in
8 to 12 hours
• The nipple is to be kept dry and exposed to air
• Breast milk should be removed by manual expression or pump
• If infected, an antiseptic cream is applied locally
• If it fails to heal, breastfeeding from the affected breast is stopped for 24 hours
• Retracted nipple (inverted nipple)
• An inverted nipple is a condition in which the nipple is pulled inward into the breast instead of
pointing outward.
• This condition can also called nipple inversion, nipple retracted or invaginated nipple and its
common in Primigravida.
• Manually pulling out the retracted nipple during the last two months of pregnancy is useful to
rectify the defect
• After delivery, the nipple is pulled out by the suction action of the disposable syringes
• The procedure may have to be repeated for few days
• Acute Puerperal Mastitis
• Is inflammation of the breast and externally painful and may lead to abscess formation.
• The most common infectious organism is staphylococcus aureus.
• The most likely source of the infection is the baby and out breaks of skin and eye infections
among babies are frequently due to staphylococcus aureus.
• Organisms are transmitted by cross infection and can easily affect a whole part.
•
•
• Sign and symptoms
• - Occurs after the 8th postnatal day
• - The onset is rapid with a sharp rise in temperature which can reach as high as 40C.
• - Rapid pulse
• - Throbbing pain and tenderness in the affected breast.
• - A wedge shaped, indurate and reddened area of the breast is seen on examination
• Investigation
• - A sample of breast milk is sent for bacteriological examination
• Treatment
• Prophylactic:
• Antenatal care to nipple, prevention of engorgement and isolation of the
infected baby
• Curative
• Isolation of the mother and baby
• Suspension of breastfeeding on the affected side until the infection is
controlled
• Manual expression of milk to relieve engorgement
• Suppression of lactation by bromocriptine (parlodel) 2.5mg orally for 14 days
• Antibiotic therapy for at least 10days
• Analgesics and sedatives as required
• Breast Abscess
• Acute puerperal mastitis may lead to abscess formation. If this occurs the
affected breast is extremely painful, edema is usually present and the breast
becomes tense and red.
• The axially glands become tender and enlarged.
• The abscess must be incised and drained to prevent spread into other areas of
breast which would cause damage.
• Prevention
• The best method of treatment lies in prevention.
• Attention to hand washing and hygiene will both lower the incidence of
infection among babies and reduce risk of breast infection in mothers.
• Nurses, midwives and doctors must maintain cleanliness and wash their hands
before attending to a mother or a baby
Failing lactation
• Causes
• Debilitating state of the mother
• Elderly Primigravida
• Failure to suckle the baby regularly
• Depression or anxiety state in the puerperium
• Premature baby, who is too weak to suck
• Ill development of breasts
• Painful breast lesion
• Treatment
• Antenatal
• Education regarding the advantages of breastfeeding
• Correction of abnormalities like retracted nipple
• Maintenance of adequate breast hygiene especially in the last two months of pregnancy
• Improvement the general health status of the mother
• Postnatal
• Encourage adequate fluid intake
• Treat painful lesions promptly
• Express residual milk after each feeding
• Drugs like prolactin is useful
Perineal wound
• Definition:
• DVT is the formation of blood clots within the deep veins, most commonly in the lower extremities or pelvis.
• PE is thrombosis or showers of emboli in the pulmonary vessels
• Risk factors
• - Advanced maternal age
• - Increased parity
• - Multiple gestations
• - Surgery (C/S, episiotomy, and lacerations)
• - Prolonged immobility, as with bed rest
• - Dehydration
• - Prior DVT or PE
• - Lupus anticoagulant
• - Pre-eclampsia
Signs and symptoms
• Introduction
• This severe form of mental illness affects approximately one or two mothers in every 1000.
• The onset is rapid and usually occurs within the first few days after delivery.
• The symptoms are those of depressive psychosis, manic illness or in some cases schizophrenia.
This illness most often affects primipara.
• Definition:
• Puerperal psychosis: is a depressive disorder occurring within 6 months after delivery
Causes/Risks factors
• Previous depression
• Family history of depression
• History premenstrual syndrome
• Current history of abuse
• Unwanted pregnancy
• Alcohol or substance abuse
• Vulnerability to hormonal change
• Environmental stressors
• Signs and symptoms
• Five signs of the following, most of the day, every day, for two weeks
• Depressed or irritable mood
• Inability to enjoy (anhedonia) –
• Changes in sleep: (cannot sleep when the baby is sleep)
• Changes in appetite
• Guilt
• Thought of death
• Investigations
• Thyroid test to rule out hypothyroidism
• CT scan to rule out cerebral tumor
•
• Management
• The illness must be treated promptly by admission to a psychiatry unit under
the care of a consultant.
• Medication and psychotherapy
• In most cases the baby will be able to accompany his mother into hospital and
this should be encouraged if at all possible prompt psychiatric case is vital and
skilled psychiatric nursing care is required including medical treatments.
• With prompt treatment the prognosis is good but, unfortunately, it is likely that
further episodes of the illness will occur throughout the woman’s life around
there is a high risk of recurrence in subsequent pregnancies.
• Complications
• Suicide
• Infanticide
• Recommendations
• If any signs/symptoms of depression alert health facility
• Encourage breastfeeding
• Role of the midwife
• The community midwife should continue to visit both mother and baby to
undertake the nonpsychiatric aspects of postnatal care.
• Family support also needs consideration
• Midwife needs to offer advice and support to women during subsequent
pregnancies and to alert the physician regarding psychiatric care when
appropriate, in order to initiate prompt referral, should it become necessary.
• The community midwife should be able to help the mother reestablish the
mother-baby relationship and rebuild self-esteem by encouraging care of the
baby within a safe environment