SEMINAR ON MINOR AILMENTS AND COMPLICATIONS OF PUERPERIUM

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Name of The Subject Name of the Topic Date Time Duration Group Venue Method of Teaching A.V.Aids

: : : : : : : : :

obstetric and gynaecological nursing Minor ailments & complications of puerperium 27-4-2011 2pm ± 4pm 2 hrs M.Sc (N) I year Students M.Sc (N) Class Room Lecture cum Discussion Black Board, LCD,Charts, Transparencies, hand outs, Flash cards, flip chart

Guided by

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Mrs.B.Valli,Asst professor Governament College Of Nursing Hyderabad

Submitted by

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Ms. G. Vanaja, M.Sc (N) I Year, Governament College Of Nursing, Hyderabad.

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OBJECTIVES: General Objectives: At the end of the seminar the group will be able to gain
indepth knowledge regarding Minor ailments & complications of puerperium

Specific Objectives:At the end of the seminar group will be able to 
Describe the minor ailments of puerperium  List out the complications of puerperium.  Describe the puerperal pyrexia  Explain the puerperal sepsis  Discuss the subinvolution  Describe the urinary complications in puerperium  Explain the breast complications  Explain the puerperal venous thrombosis and pulmonary embolism  List out puerperal emergencies  Discuss the psychiatric disordered during pregnancy.

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NO 1 2 3 4 5 6 7 8 9 Introduction Definition of puerperium Anatomy and physiology Minor ailments of puerperium and its relief measures.INDEX SL. Complications of puerperium Research studies Summary Conclusion Bibliography TOPIC PAGE NO 5 5 6 10-14 14-65 66-70 70 71 71-72 4 .

DEFINITION OF PUERPERIUM Puerperium is the period following childbirth during which the body tissues.INTRODUCTION Following the birth of the baby and expulsion the placenta. However recent research into the morbidity experienced by the women in the weeks after child birth suggests that some women continue to experience problems related to childbirth that extend well beyond the 6 week period defined as the puerperium complications. 5 . starts immediately after the delivery of the placenta and membranes and continues for 6 weeks. From a medical and physilogical view point this period is called the puerperium. The overall expectation is that by 6 week after the birth all the systems in the women¶s body will have recovered from the effects of pregnancy and return to their nonpregnant state. The quality of the mothers care at this time is important to ensure her immediate and future health. Postpartum does not occur as an isolated period and is significantly influenced by the process that have preceeded it. Changes in the body image and assumption of new roles often influence the outcome and ultimate adoptation to childbearing. The relationship between these factors has historically been the topic of some debate. The exact rationale for 6 week or 42 days period is unclear but appears to relate to a range of cultural customs and traditions in addition to the physiological processes that occur over this time. specially the pelvic organs revert back approximately to the prepregnant state both anatomically and physilogically. the mother enters a period of physical and psychological recuperation.

fluids. Myles By 6 weeks after delivery. UTERUS The pregnant term uterus (not including baby. the uterine fundus is palpable at or near the level of the maternal umbilicus. so that by the seventh day endometrial glands are already evident. most of the changes of pregnancy. except at the placental site. Over the next several weeks. The endometrial lining rapidly regenerates. most of the reduction in size and weight occurs in the first 2 weeks.DC. the uterus slowly returns to its nonpregnant state. In the 6 weeks following delivery. Immediately postpartum. This period is usually considered to be 6 weeks in duration. and delivery have resolved and the body has reverted to the nonpregnant state. at which time the uterus has shrunk enough to return to the true pelvis. An overview of the relevant anatomy and physiology in the postpartum period as follows. the uterus recedes to a weight of 50-100 g. Dutta Puerperium is defined as the time from the delivery of the placenta through the first few weeks after the delivery. the endometrium is restored throughout the uterus. etc) weighs approximately 1000 g. labor. although the overall uterine size remains larger than prior to gestation. Thereafter. By the 16th day. 6 . placenta.

and the changes in the placental bed result in the quantity and quality of the lochia that is experienced. The red discharge progressively changes to brownish red. with a more watery consistency (lochia serosa). Immediately after delivery. Over a period of weeks. VAGINA 7 . is variable. The size of the placental bed decreases by half. although it averages approximately 5 weeks.The placental site undergoes a series of changes in the postpartum period. The amount of flow and color of the lochia can vary considerably. By the end of the first week. known as lochia rubra. the volume of vaginal discharge (lochia) rapidly decreases. the contractions of the arterial smooth muscle and compression of the vessels by contraction of the myometrium ("physiologic ligatures") result in hemostasis. the external os closes such that a finger cannot be easily introduced. the discharge continues to decrease in amount and color and eventually changes to yellow (lochia alba). The period of time the lochia can last varies. CERVIX The cervix also begins to rapidly revert to a nonpregnant state. The duration of this discharge. but it never returns to the nulliparous state. This is the classic time for delayed postpartum hemorrhages to occur. Immediately after delivery. women experience an increase in the amount of bleeding at 7-14 days secondary to the sloughing of the eschar on the placental site. Thereafter. Fifteen percent of women have continue to have lochia 6 weeks or more postpartum. Often. a large amount of red blood flows from the uterus until the contraction phase occurs.

with more improvement over the following few months. the vaginal epithelium appears atrophic on smear. the mean time to first menses is 7-9 weeks. The woman who breastfeeds her infant has a longer period of amenorrhea and anovulation than the mother who chooses to bottle-feed. however. and sometimes torn or cut. 8 . The mother who does not breastfeed may ovulate as early as 27 days after delivery. PERINEUM The perineum has been stretched and traumatized. Most women have a menstrual period by 12 weeks. nerve. The return to a prepregnant state depends greatly on maternal exercise. This is restored by weeks 6-10.The vagina also regresses but it does not completely return to its prepregnant size. during the process of labor and delivery. The muscle tone may or may not return to normal. OVARIES The resumption of normal function by the ovaries is highly variable and is greatly influenced by breastfeeding the infant. The swollen and engorged vulva rapidly resolves within 1-2 weeks. and the rugae of the vagina begin to reappear in women who are not breastfeeding. and connecting tissues. ABDOMINAL WALL The abdominal wall remains soft and poorly toned for many weeks. it is further delayed in breastfeeding mothers because of persistently decreased estrogen levels. depending on the extent of injury to muscle. Resolution of the increased vascularity and edema occurs by 3 weeks. At this time. Most of the muscle tone is regained by 6 weeks.

High in protein content. 9 . the resumption of menses is highly variable and depends on a number of factors. which results in falling levels of estrogen and progesterone. If the mother is not breastfeeding.In the breastfeeding woman. BREASTS The changes to the breasts that prepare the body for breastfeeding occur throughout pregnancy. the removal of milk from the breast stimulates more milk production. and suckling by the newborn triggers its release. lactation can be established as early as 16 weeks' gestation. with the continued presence of prolactin. switches to an autocrine process. including how much and how often the baby is fed and whether the baby's food is supplemented with formula. the milk matures and contains all necessary nutrients in the neonatal period. Half to three fourths of women who breastfeed return to periods within 36 weeks of delivery. The colostrum is the liquid that is initially released by the breasts during the first 2-4 days after delivery. Over the first 7 days. is already present in the breasts. which the baby receives in the first few days postpartum. The milk continues to change throughout the period of breastfeeding to meet the changing demands of the baby. the prolactin levels decrease and return to normal within 2-3 weeks. The colostrum. this liquid is protective for the newborn. If delivery ensues. The delay in the return to normal ovarian function in the lactating mother is caused by the suppression of ovulation due to the elevation in prolactin. which begins as an endocrine process. The process. Lactogenesis is initially triggered by the delivery of the placenta.

RELIEVING MEASURES. Administer analgesics (ibuprofen) and antispasmodics. PAIN IN PERINEUM: Some degree of pain is felt in the stitches. Abnormal pain should be investigated to diagnose vulvo-vaginal hematoma or infection is developing.MINOR AILMENTS OF PUERPERIUM AND ITS RELIEF MEASURES. It is often felt more frequently while breast-feeding. 10 .  After pains  Pain on the perineum  Breast engorgement  Postnatal diuresis  Constipation  lactation supression AFTER PAINS It is the spasmodic. intermittent pain felt in the back and lower abdomen after delivery for a variable period of 2-4 days. MANGEMENT: Massage the uterus with expulsion of the clot. Presence of blood clots or bits of the after the birth leads to spasmodic hypertonic contractions of the uterus in an attempt to expel them out.

Sitz bath Encourage the mother to sit in a tub with 2-3 inches of warm water for about 15 minutes.After using the bathroom. Care of perineal stitches Clean and dress the perineal area daily and cover with sterile pad. It is due to exaggerated normal venous and lymphatic engorgement of the breasts which precedes lactation. Swabbing should be done from above downwards. making sure to start at the front and end at the back to avoid spreading germs from the rectum to the vagina. generalized malaise and painful breast feeding. Encourage mother to pat the area dry. ‡ Do not directly apply the ice. MANAGEMENT:  Encourage the mother to consume lots of fluids. To reduce the swelling Apply Ice packs ‡ Wrap the ice pack in a washcloth or other soft or absorbent material. spray or pour warm water over the entire vaginal area. Advice the mother to use topical anaesthetic spray or ointment according to the prescription. 11 . BREAST ENGORGEMENT May occur about the third day postpartum and is often regarded by mothers as the result of the milk coming in. The mother approaches with pain and tense feeling of the breasts.

By the above mechanisms the body rids itself of excess fluid in the body MANAGEMENT  Keep the mother clean and dry  Change her dress frequently  Change the bed sheets frequently  Care must be taken to ensure that the mother is well hydrated. The profuse diaphoresis occurs especially at night for the first 2-3 days after childbirth. CONSTIPATION 12 . CAUSES Decreased estrogen levels Removal of increased venous pressure in the lower extremities Loss of the remaining pregnancy induced increase in bloodvolume. Support the breasts with a binder or brassiere.  Express the milk manually.  Analgesics may also be prescribed to relieve pain POSTNATAL DIURESIS Within 12hrs of the birth the women begins to lose excess tissue fluid accumulated during pregnancy.  The baby should be put to breast regularly after the expression of milk.  Apply hot bags on breast before nursing and ice bags after.

after giving birth. The average blood loss is 500 mL at vaginal delivery and 1000 mL at cesarean delivery. LACTATION SUPRESSION this is necessary when the women has decided not to breast feed or incase of neonatal death. MANAGEMENT  Advice the mother to wear well fitted supportive brassier or breast binder continuously atleast the first 72 hrs. postpartum hemorrhage is defined as a 10% change in hematocrit level between admission and the postpartum period or the need for transfusion after delivery secondary to blood loss. 13 . COMPLICATIONS OF PUERPERIUM HEAMORRHAGE Postpartum hemorrhage is defined as excessive blood loss during or after the third stage of labor. If necessary mild laxative such as Igol 2 tea spoons may be adviced at bed time.  Avoid breast stimulation.The priblem is much less because of early ambulation and liberalisation of dietary intake. But recent days it is not practiced much as it causes the seizures. newborn sucking or pumping of the breasts  Bromocriptine was often prescribed in olden days. Eg: Running warm water over the breasts. Encourage the mother to take a diet containing sufficient amount of roughage and fluids is enough to move the bowel. Objectively. strokes and MI.

Late postpartum hemorrhage Most frequently occurs 1-2 weeks after delivery but may occur up to 6 weeks of postpartum. Uterine atony and lower genital tract lacerations are the most common causes of postpartum hemorrhage. and hematoma  Late postpartum hemorrhage  Retained products of conception  Infection  Subinvolution of placental site  Coagulopathy. 14 . ETIOLOGY Early postpartum hemorrhage May result from  Uterine atony  Retained products of conception  Uterine rupture  Uterine inversion  Placenta accreta  Lower genital tract lacerations  Coagulopathy.Early postpartum hemorrhage Is described as that occurring within the first 24 hours after delivery.

15 . such as with forceps or vacuum extraction. precipitous delivery.grand multiparity. are the result of obstetrical trauma and are more common with operative vaginal deliveries. lack of closure of the spiral arteries and venous sinuses coupled with the increased blood flow to the pregnant uterus causes excessive bleeding. magnesium sulfate. LOWER GENITAL TRACT LACERATIONS Including cervical and vaginal lacerations (eg. sulcal tears). or nitroglycerin.oxytocin administration. rapid or prolonged labor. halogenated anesthetics. In uterine atony. Active management of the third stage of labor with administration of uterotonics before the placenta is delivered (oxytocin still being the agent of choice). macrosomia. Other predisposing factors include macrosomia. early clamping and cutting of the umbilical cord. polyhydramnios.Factors Predisposing to Uterine Atony Include Overdistension of the uterus secondary to multiple gestations. and use of uterine-relaxing agents such as terbutaline. and traction on the umbilical cord have proven to reduce blood loss and decrease the rate of postpartum hemorrhage. and episiotomy. intra-amniotic infection.

Delayed postpartum hemorrhage occurs in 1-2% of patients. postpartum hemorrhage is responsible for 5% of maternal deaths. MORBIDITY AND MORTALITY In the United States. PHYSICAL 16 . Other causes of morbidity include the need for blood transfusions or surgical intervention that may lead to future infertility. polyhydramnios. HISTORY The antepartum or early intrapartum identification of risk factors for postpartum hemorrhage allows for advanced preparation and possible avoidance of severe sequelae.INCIDENCE Vaginal delivery is associated with a 3. as well as the use of magnesium sulfate during the patient's labor course.4% incidence of postpartum hemorrhage. multiple gestation. and desire for future fertility. history of bleeding disorders. Cesarean delivery is associated with a 6. Note the use of prolonged oxytocin administration. previous episodes of postpartum hemorrhage.9% incidence of postpartum hemorrhage. Request information about parity. Every patient must be interviewed upon admission to the labor floor.

consequently. Perform a vigorous bimanual examination. it is important to check a patient's CBC count and prothrombin time/activated partial thromboplastin time (PT/aPTT) to exclude resulting anemia or coagulopathy.  Bimanual massage. which may reveal a retained placenta or a hematoma of the perineum or pelvis. Closely examine the placenta to determine if any fragments are missing. 17 . Closely inspect the lower genital tract in order to identify lacerations. Upon admission of each patient to the labor ward.  Empty the bladder. which may require further treatment.Physical examination is performed simultaneously with resuscitative measures. However. and resolution is generally within minutes. laboratory studies or imaging in the management of the immediate course of this process has little role. obtain ABO and D blood type determinations. intervention is immediate.  Removal of any blood clots from the uterus. DIAGNOSIS The onset of postpartum hemorrhage is acute. and acquire adequate intravenous access. TREATMENT Initial therapy includes  Provide oxygen delivery. and which also allows for uterine massage.

is inexpensive. The timing of removal of the packing is controversial. is a minimally invasive technique. which is performed under local anesthesia. 18 . This technique can be highly effective. y Uterine artery embolization.25 mg can be administered every 15 minutes. and route of administration. When postpartum hemorrhage is not responsive to pharmacological therapy and no vaginal or cervical lacerations have been identified. not to exceed 3 doses. further research is needed to determine the effectiveness. optimal dosage.The success rate is greater than 90%. If unsuccessful. requires no special training. carboprost in an intramuscularly administered dose of 0. Use prophylactic antibiotics and concomitant oxytocin with this technique. y A Foley catheter with a large bulb (24F) can be used as an alternative to uterine packing. but most physicians favor 24-36 hours. However. This treatment is successful in half of patients. it still provides time in which the patient can be stabilized before other surgical techniques are employed. perform manual removal or uterine curettage. consider the following more invasive treatment methods: y Uterine packing is now considered safe and effective therapy for the treatment of postpartum hemorrhage. And the routine administration of dilute oxytocin infusion (10-40 U in 1000 mL of lactated Ringer solution [LRS] or isotonic sodium chloride solution). and may prevent the need for surgery.This procedure is believed to preserve fertility.  If retained products of conception are noted.  If oxytocin is ineffective.  Misoprostol has been used clinically for the treatment of postpartum hemorrhage.

it may be considered before uterine artery or hypo gastric artery ligation and hysterectomy.  Uterine artery ligation is thought to be successful in 80-95% of patients. In patients at high risk for postpartum hemorrhage. and nontarget embolization. y The suture is wrapped over the fundus and directed into and out of the anterior uterine wall parallel to the previous anterior sutures. SURGICAL MANAGEMENT  When conservative therapy fails. y As practitioners become proficient in this technique. y The B-Lynch suture technique:A suture is passed through the anterior uterine wall in the lower uterine segment approximately 3 cm medial to the lateral edge of the uterus. or cervical pregnancy. coagulopathy. y The suture is wrapped over the fundus 3±4 cm medial to the cornual and inserted into the posterior uterine wall again in the lower uterine segment approximately 3 cm medial to the lateral edge of the uterus and brought out 3 cm medial to the other edge of the uterus. such as those with placenta previa. 19 . placenta accreta. infection.Complications are rare (6-7%) and include fever. the catheter can be placed prophylactically. y The B-Lynch suture technique and other compression suture techniques are operative approaches to postpartum hemorrhage that have proven to preserve fertility. the next step is surgery with either bilateral uterine artery ligation or hypogastric artery ligation. The uterus is compressed in an accordion like fashion and the suture is tied across the lower uterine segment.

NURSING MANAGEMENT ASSESSMENT o Take complete history: of past and present obstetrical history and also identify the risk factors of hemorrhage. emergency hysterectomy is often a necessary and lifesaving procedure. 20 . this approach is technically difficult and is only successful in 4250% of patients. stepwise devascularization of the uterus is now thought to be the next best approach.  Assess the amount of blood loss its nature. hypogastric artery ligation is an option. Instead. with possible ligation of the utero-ovarian and infundibulopelvic vessels When all other therapies fail. abdominal pain  Assess for signs of shock. consistency. need for blood transfusion.  Risk for injury related to changes in cerebral tissue perfusion. If this therapy fails. NURSING DIAGNOSIS  Decreased cardiac output related to hypovolemia  Fluid volume deficit related to excessive blood loss  Altered tissue perfusion related to hypovolemia  Pain related to procedures and treatment  Anxiety related to separation from newborn long term impact on self care and infant care. However.  Physical examination especially the vital signs signs of blood loss to be assessed.

 Monitor vital signs every 5-10min. Consistency of bleeding clots and pooling on the under pad. Risk for altered parent/infant attachment related to to complication and need for separation from newborn during treatment. INTERVENTIONS:  Administer IV fluids as quickly as possible  Administer oxytocics to help contract the uterus  Administer oxygen therapy  Place the client in a trndlenburg position to increase venous return to the heart.  Prepare for blood transfusions and administer blood transfusions. oxygen saturation by pulse oxymetry.  Evaluate the vaginal bleeding..  Allow the family members to involve in the care.  Explain the physiological process of hemorrhage and interpret medical treatments and procedures. 21 . skin temperature and sensorium.  Reassure the mother and family. and observe the clients color. extent of perineal pad saturation.  Once the bleeding controlled assist the mother and family what happened to understand and why to anticipate what impact this complication will have on the post partum while care taking and self care activities and to plan for special needs at home.  Palpate the fundus for firmness and massage to restore the tone. colour.

There has been marked decline in puerperal sepsis during the fast few decades.PUERPERAL PYREXIA: Definition: a rise of temperature reaching 100 degree F(38 degree C) or more (measured orally on 2 separate occasions at 24 hrs apart (excluding first 24 hrs) within first 10 days following delivery is called puerperal pyrexia. Puerperal sepsis 2. Septic pelvic thrombophlebitis 7. Urinary tract infection 3. Unknown origin PUERPERAL SEPSIS An infection of the genital tract which occurs as a complication of delivery is termed as puerperal sepsis. CAUSES The causes of pyrexia are 1. The reasons are:  Better obstetric care 22 . Mastitis 4. A recrudescence of malaria or pulmonary tuberculosis 8. Infection of caesarean section wound 5. Pulmonary infection 6.

coli  Cl.welchi These organisms remain dormant and harmless during pregnancy and even delivery conducted in aseptic conditions otherwise leads to infection PREDISPOSING FACTORS OF PUERPERAL SEPSIS The pathigenesity of the vaginal flora may be influenced by certain factors Conditions lowering the host resistance : general or local  Multiplication of organisms in the devitalised tissue usually starts after the first two days of following  Introduction of organisms from out side 23 . Vaginal flora in late pregnancy and at the onset of labour consists of the following organisms  Doderlein¶s bacillus (60-70%)  Yeast like fungus  Staphylococcus albus or aureus  Streptococcus  E. Improved health status and there by increased general resistance to combat infection.  Availability of wider range of antibiotics sensitive to the responsible organisisms  Declined virulence of streptococcus beta hemolyticus.

or no immunization with tetanus toxoid  Diabetes. packing into the birth canal  Inadequate. RISK FACTORS  Chronic debilitating disease  Poor standards of hygiene These include as follows:  Pre term labour  Poor aseptic techniques o Manipulations high in the birth canal o Presence of dead tissue in the birth canal (due to prolonged retension of dead fetus  Retained fragments of placenta or membranes  Shedding of dead tissue from vaginal wall following  Obstructed labour) o Insertion of unclean hand or non-sterile instrument. Increased prevalence of organisms resistant to antibiotics. o Pre-existing anaemia and malnutrition  Prolonged/obstructed labour o Prolonged rupture of membranes > 18 hrs o Dehydration and ketoacidosis during labour  Frequent vaginal examinations o Caesarean section and other operative 24 .

deliveries o Unrepaired cervical lacerations. inability to pay for treatment 4. danger signs of infection or lack of birth and emergency preparation plan. Cultural factors which lead to delay in seeking medical care 6. Lack of transportation and resources needed for taking the women to a referral facility with an adequate management of such complications 2. Lack of knowledge about symptoms and signs of puerperal sepsis 7. Low socioeconomic status. Poor level of general education 5. Health service risk factors : These include:  Inaccessibility of appropriate health facilities  inadequate toilet and washing facilities  poor standards of cleanliness in the health facility  unacceptable delays in providing care at 25 . or large vaginal lacerations  Pre-existing sexually transmitted infections  Postpartum haemorrhage Community risk factors 1. Great distance from a woman¶s home to a health facility 3. Lack of health education.

including inappropriate use of antibiotics y Shortage of safe blood for transfusion. or more specifically Streptococcus agalactiae) usually causes less severe maternal disease. Other types (B. Clostridium welchii. Group B Streptococcus (abbreviated to GBS. Mycoplasma and very rarely. equipment. THE MICRO ORGANISMS RESPONIBLE FOR PUERPERAL SEPSIS The most common causative agents in inflammation of the inner lining of the uterus (endometritis) are Staphylococcus aureus and Streptococcus Group A Streptococcus (abbreviated to GAS. MODE OF INFECTION Puerperal sepsis is essentially a wound infection. and G) may also cause infection. or more specifically the Streptococcus pyogenes) is a form of Streptococcus bacteria responsible for most cases of severe hemolytic streptococcal illness.health facility  lack of necessary resources. C. D. Placental site. e.g. coli form bacteria. drugs (most effective antibiotics)  poor basic training of staff and inadequate continuing education  inadequate standards of care in labor and in the early postnatal period  failure to recognize the onset of infection  inadequate and/or delayed bacteriological investigations  inadequate response to signs of infection. lacerations 26 . Chlamydia. anaerobic bacteria. staff. in order of prevalence. Other causal organisms. include staphylococci.

Autogenous: Here the organisms are present elsewhere in the body (throat. The source of infection can be midwife. Exogenous: These comes from sources outside the body and are transmitted by another person. E. doctor and other patients or visitors. staphylococcus. Air and dust also cause infection to the patient. These are responsible for the infection. Coli etc. PERENEUM 27 . Skin) and migrate to the genital tract by blood stream Eg: streptococcus beta hemolyticus. Anaerobic streptococci and clostridium welchi which are found in the vagina. PATHOLOGY The primary sites of infection are  Perineum  Vagina  Cervix  Uterus. SOURCES OF INFECTION  Endogenous  Exogenous  Autogenous Endogenous: In this type the causative organisms are Streptococcus fecalis that lives in the anus and in the perineum.of the genital tract or caesarean section wounds may be infected in the following ways..

It is commonly polymicrobial(GroupAor B streptococci. On occasions . VAGINA The vaginal lacerations are infected directly or by extension from perinea! infection The rnucosa is swollen and hyperemic . chorioamnionitis.whether repaired or not .Lacerations on the perineum . prolonged rupture of membranes . 28 . infection is quite common as the cervix is commonly it is also the common site for the pathogenic organisms to UTERUS ENDOMYPMETRITIS The incidence varies from 1-3% following vaginal delivery and about 10%foliowing cesarean delivery . The wound edges become red and swollen There may be collection of sangopurulent discharge or pus which results in complete disruption of the wound. The risk factors for endometritis are retained products of conception cesarean section.are likely to be infected by organisms of low virulence like staphylococcus aureus or anaerobic streptococcus. and repeated vaginal examinations in labour.resulting in necrosis and sloughing.a retained and forgotten cotton plug may be left inside the vagina leading to offensive vaginal discharge. CERVIX The cervical lacerated and harbor. Clostridia)The decidua specially over the placental site is primarily affected.preterm labour.

due to lymphatic spread.The necrosed decidua sloughs off The discharge is offensive . and emboli may occlude the micro circulation of the vital organs like lungs or kidney.A zone of leucocytic barrier prevents the infection to the deeper myometrium. Endosalpingitis is un common. meningitis. uterine veins. Septicemia may cause lung abscess. The anaerobic pathogens are commonly involved. pericarditis. Severe infection is rare in now a days. SALPINGITIS May be interstitial.At times. The infection causes exudation and formation of an indurate mass usually confined to one side of the uterus. SEPTICEMIA AND SEPTIC SHOCK May be due to hemolytic streptococci or anaerobic streptococci.The infected thrombus may undergo complete resolution and suppuration . endocarditis or multiorgan failure. pelvic veins and rarely the inferior venacava . Death occurs in about 30%of cases. 29 . The uterus in that case is pushed to the contra lateral side. SEPTIC THROMBOPHLEBITIS May involve the ovarian veins. or perisalpingitis following pelvic peritonitis. Pelvic abscess following pelvic peritonitis may be due to spread of infection. PELVIC CELLUIITIS(PARAMETRITIS) Is due to spread of infection to the pelvic cellular tissues by direct or lymphatic or by haematogenous routes.

CLINICAL FEATURES  Local infection  Uterine infection  Spreading infection LOCAL INFECTION: ( WOUND INFECTION)  There is slight rise of temperature  Generalized malaise or headache  The local wound becomes red and swollen  Pus may form which leads to disruption of the wound  When severe there is high rise of temperature with chills and rigor UTERINE INFECTION : MILD  There is rise in temperature and pulse rate  Local discharge becomes offensive and copious  The uterus is subinvoluted and tender SEVERE  The onset is acute with high rise of temperature. often with chills and rigor  Pulse rate is rapid 30 .

tenderness of fornix (parametritis). Lochia may be scanty and odourless  Uterus may be sub involuted and tender and softer. diarrhea. bulging fluctuant mass in the pouch of doughlas ( pelvic abscess) PARAMETRITIS: The onset is about 7-10 th day of puerperium Constant pelvic pain Tenderness on the either side of the hypogastrium Vaginal examination reveals an unilateral tender indurate mass pushing the uterus to the contra lateral side PELVIC PERITONITIS: y Pyrexia with increase in pulse rate y Lower abdominal pain and tenderness y Vaginal examination reveals tenderness on the fornix and with the movement of cervix y Collection of the pus in the pouch of Douglas is evident by swinging temperature. 31 . and a bulging fluctuant mass felt through the posterior fornix. There may be associated wound infection SPREADING INFECTION (EXTRA UTERINE SPREAD) Is evident by presence of pelvis tenderness (pelvic peritonitis).

32 . BACTEREMIA. ENDOTOXIC OR SEPTIC SHOCK Is due to release of bacterial endotoxin causing circulatory inadequacy and tissue hypo perfusion. oliguria and adult respiratory distress syndrome.GENERAL PERITONITIS High fever with rapid pulse Vomiting Generalized abdominal pain Patient looks very ill and dehydrated Abdomen is tender and distended Rebound tenderness is often present THROMBOPHLEBITIS The clinical features are similar to those of uterine infection SEPTICAEMIA There is high rise of temperature associated with rigor Pulse rate is usually rapid even after the temperature settles down to normal Blood culture is positive Symptoms and signs of metastatic infection in the lungs. It is manifested by hypotension. meninges or joints may appear.

ante partum hemorrhage. Post natal details of the nature of fever.IN V E S T IG A T I O N S The underlying principles in investigations are To locate the site of infection To identify the organisms To assess the severity of the disease. like heart disease. tubercuiosis and urinary tract infections or malaria should be enquired . Abdominal examination to note involution of uterus. H IS T O R Y Antenatal history of anemia. o The study of pulse and temperature chart. duration of labour. Intranatal history regarding Preterm labour.any debilitating disease. diabetes. Clinical examination include.heart.spleen. nature of intrauterine manipulations if any. neck stiffness. and gums and tonsiis. presence of septic foci in teeth.lungs. duration of rupture of membranes. 33 . associated symptoms related with the site of lesion .breasts.liver.and legs. method of delivery. number of vaginal examinations outside and inside hospstal. Systemic examination include Throat. tenderness and presence of any feature of pelvic peritonitis and pelvic abscess.

Internal examination to note the character of lochia, condition of the perineal wound, Legs are examined to find to detect the thrombophlebitis and thrombosis,

INVESTIGATIONS INCLUDE 
High vaginal and endocervical swabs for culture and sensitivity test to antibiotics.  ³CLEAN CATCH´ mid stream specimen of urine for analysis and culture including sensitivity test.  Blood for Hemoglobin, total and differential leukocyte count.  Thick blood film for malaria parasite o Blood urea, serum creatinine o Serum electrolytes o Pelvic ultra sound: to detect any retained bits of conception within the uterus o To locate any abscess with the pelvis o Collecting samples from the pelvis for culture and sensitivity o Color flow doppler study to detect venous thrombosis. o CT AND MRI specially when there is doubt  x-ray chest  Hence for the above investigations and monitoring, infections spreading beyond uterus are sent to referral hospitals.

DIFFERENTIAL DIAGNOSIS

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Any fever during puerperium is assumed to be due to puerperal sepsis unless otherwise proved. Infection may occur in other parts of body connected to reproductive process or it can be incidental. They are: a. Breast infections b. Urinary tract infections c. Incidental d. Tuberculosis e. Typhoid f. Malaria g. Chest infection (pneumonia, bronchitis, tuberculosis) h. Meningitis AIDS related infections,

MANAGEMENT
(1) Preventive (2) Curative.

PREVENTIVE
Preventive measures are taken during antenatal, intranatal and postnatal period against puerperal sepsis

Antenatal
1. Improvement of nutritional status of the pregnant women and eradication of any septic focus (skin, throat, tonsils) in the body
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2. Preventing tetanus by immunization against tetanus 3. Diagnosis and treatment of conditions such as o Malnutrition o Anemia o Urinary tract infection o Diabetes mellitus o Syphilis o STDS 4. Preventing prolonged and obstructed labor by diagnosis of CPD and abnormal presentations, 5. Health education for institutional delivery or by trained personnel, 6. Training of Dais in aseptic delivery (observing 5 clean) and supplying them delivery kits. In tra n a ta l  All deliveries to be conducted using aseptic techniques  Personnel with septic focus are not allowed in the delivery room or postnatal ward  Unnecessary vaginal examinations are to be avoided  Unnecessary catheterization is to be avoided,  Avoid trauma to perineum by using correct technique to deliver the head, o Avoid unnecessary induction of labor by ARM o Suture perineal vagina! and cervical tears and episiotomy as early as possible taking all aseptic precautions
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Foot end to be raised to facilitate drainage  In mild cases. Postnatal a) Proper perineal care in woman with perineal wounds b) Maintain good personal hygiene c) Less the visitors d) Look out for early signs of infection CURATIVE Except mild cases of puerperal sepsis. General Care o Isolation and barrier nursing in hospital set up  Bed rest. temperature. respiration. 37 . lochial discharge fluids intake and output. prolonged labor. Prophylactic antibiotics is to be given in woman with premature rupture of membranes. all Other cases are managed in referral hospitals. IV fluids ringer lactate and dextrose saline are given  Blood transfusion may be required to correct anemia  Pain is relieved by adequate analgesia.  A chart is maintained by recording pulse. plenty of fluids orally and light diet is advised  In severe cases. instrumental deliveries and intrauterine manipulations and mothers who are undergoing caesarean section.  An indwelling catheter is used to relieve any urine retention.

Intravenous administration of cefotaxime 1 gr 8 hourly is another alternative. SURGICAL TREATMENT There is very little role of major surgery in the treatment of puerperal sepsis. IV is given at 8 hrs interval is also another alternative. PERINEAL WOUND: The stitches of perineal wound may have to be removed to facilitate drainage of pus and relieve pain. The treatment is is continued until the infection is controlled for at least 7-10 days. The wound Is to be dressed with hot compress with mild antiseptic solution followed by application of antiseptic ointment or powder. Retained bits of uterine products with a diameter of 3 cm or less may be disregarded and left alone.ANTIBIOTICS: Ideal antibiotic regime should depend on the culture and sensitivity report Pending the report gentamicin (2mg/kg IV loading dose followed by1. Metronidazole 0. After the infection is controlled secondary suture may be given at a later date.5 mg/kg IV every8 hours) or Ampicillin (1gr IV every 6 hours) should be started. Otherwise surgical evacuation after antibiotic coverage for 24 hrs 38 .5 gr.

monitoring progress and physioiogic functions. spread of infection. gangrenous uterus or gas gangrene infection hysterectomy is performed. HYSTERECTOMY In cases with rupture or perforation having multiple abscesses. and identifying emotional reactions and needs. Laparotomy has got limited indications. Risk for altered parenting related to limited contact. noting needs for comfort and education . including uterine involution. pain. Anxiety related to interference with recovery. procedures or treatments Risk for injury related to child birth and physiologic stressors. Risk for infection related to exposure to others and equipment lack of knowledge of infection transmission. NURSING MANAGEMENT Assessment Post partum nursing assessment focus on identifying the signs and symptoms of infections early. 39 . Unresponsive peritonitis or any other possible pathology. Nursing diagnoses pain related to infection site. or inabitityto focus attention on neonate.Cases with pelvic thrombophlebitis are treated with heparin for 7-10 days Pelvic abscess should be drained by colpotomy under ultrasound guidance.

treatment regimen. Definition When the involution is impaired or retarded it is called subinvolution. Promote healing and wellbeing through nutrition and fluid intake. Monitor vital signs Assess for signs and symptoms and disease progression Provide comfort measures for pain relief. and implications for care of self and neonate. the uterus does not return to its normal size. SUBINVOLUTION Sub involution is a medical condition in which after childbirth. Situational low self esteem related to infection and interference with caretaking responsibilities. Involve the family members in the care Provide the support and encouragement for the client or family. Nursing planning and intervention o The nurse plays a role in carrying out medical treatment such as Antibiotic therapy. Encourage mother and neonate bonding Provide information regarding newborn care and encourage for visits to the nursery Explain about infectious process and its expected course and treatment. Knowledge deficit related to infectious process.The uterus is the most common organ affected 40 .Risk for altered parent/infant attachment related to client¶s inability to bond with neonate.

anesthesia. Prolapse of the uterus f. Retroversion after the uterus becomes pelvic organ g. d. Grand multiparity. endometritis Factors that may cause sub involution y y Persistent lochia /fresh bleeding Long labor. b. Uterine fibroid Aggravating factors are: y y Retained products of conception Uterine sepsis. infection SYMPTOMS 41 . retained placenta.by subinvolution. Maternal ill health. As it is the most accessible organ to be measured per abdomen .the uterine involution is considered clinically as an index to assess sub involution. difficult delivery. Overdistension of uterus as in twins and hydramnios c. CAUSES Predisposing factors are a. full bladder. Caesarean section e.

The predominant symptoms are: y y y Abnormal lochial discharge either excessive or prolonged Irregular or at times excessive uterine bleeding Irregular cramp like pain is cases of retained products or rise of temperature in sepsis SIGNS The uterine height is greater than the normal for the particular day of puerperium. Normal puerperal uterus may be displaced by a full bladder or a loaded rectum. It feels boggy and sifter MANAGEMENT y y y Antibiotics in endometritis Exploration of the uterus in retained products Ergometrine so often prescribed to enhance the involution process by reducing the blood flow of the uterus is of no value in prophylaxis. NURSING MANAGEMENT:  Encourage early ambulation in postnatal period  Daily evaluation of fundal height and documentation.The condition may be asymptomatic. Urinary tract infection 42 . URINARY COMPLICATIONS IN PUERPERIUM 1.

coli .E.2.Staph. Aureus MANAGEMENT 43 . Infection Contracted for the first time during puerperium is due to a) Effect of frequent catheterization either during labor Or in early puerperium to relieve retention of urine. Recurrence of previous cystitis or pyelitis 2. Asymptomatic becomes overt 3. b) Stasis of urine during early puerperium due to lack of bladder tone and less desire to pass urine Organisms responsible are: . Incontinence of urine 4. Suppression of urine URINARY TRACT INFECTION: Is most common cause of puerperal pyrexia Incidence: 1-5% of all deliveries The infection may be the consequence of any of the following 1.Proteus . Pretension of urine 3.Klebsiella .

Stress 44 . Incontinence may be 1 Overflow incontinence 2 Stress incontinence: Usually manifests in late puerperium 3 True incontinence: In the form of genito urinary fistula usually appears soon following Delivery or within 1st week of puerperium.  This not only empties the bladder but helps in regaining the normal bladder tone and sensation of fullness. Incontinence of urine: This is not a common symptom following birth.Antibiotics RETENSION OF URINE: This is a common complication in early puerperium Causes are : 1.  Appropriate urinary antiseptics should be administered for about 5-7 days. Unaccustomed position Treatment of retention of urine:  If simple measure fails to initiate micturation. Bruising & edema of the bladder neck 2. an indwelling catheter is to be kept in situ for about 48 hours. Reflex from perineal injury 3.

any report immediately. causing swelling and tenderness. Brest Engorgement: Engorgement is defined as an uncomfortable swelling of the breasts associated with increased milk secretion and usually occurs from the second to fourth day post natal.  Encourage to void every 2-4 hrs  Assist the mother to the bathroom or at bed side on bed pan.incontinence is established by noting the escape of urine through the urethral opening during stress. There may be lymphatic and vascular congestion and possible interstitial edema.  Monitor intake and output  Monitor for frequency and volume of urine  If the mother is unable to void catheterize her  Monitor for any signs of infection of urinary tract if. This exacerbates the 45 . BREAST COMPLICATIONS : 1 Breast engorgement 2 Cracked and retracted nipple leading to difficulty in breast feeding 3 Mastitis and breast abscess 4 Lactation failure. Nursing management  Encourage urination early in the postnatal period. The exact nature of urinary fistula is established by noting the fistula site by examining the patient in Sims position using Sims speculum or by three swab test if the fistula is tiny.

 Generalized malaise  Rise of temperature  Painful breast feeding  Prevention  Avoid prelacteal feeds  Initiate breast feeding early and unrestricted  Exclusive breast feeding on demand  Feeding in correct position. This swelling and hardness may make it difficult for the baby to attach to the nipple and problems can be further aggravated by nipple soreness. Due to a fissure situated either at the tip or base of the nipple 46 . SYMPTOMS  Considerable pain and feeling of tenseness or heaviness in the both breasts. Elevate the breasts by supporting brassieres. resulting in inability of the milk to flow. The baby should be put to breast at regular intervals 3. In severe cases the breasts are emptied by expressing them manually or by a breast pump. 5.tension of milk in the ducts and may cause stasis of the milk. CRACKED AND RETRACTED NIPPLE Cracked nipple: The nipple may become painful due to Loss of surface epithelium the formation of a raw area on the nipple. Manual expression of any remaining milk after each feed 4. Management of breast engorgement 1. Administer analgesics to relieve pain 2.

 Miconazole lotion is applied over the nipple as well as in the baby¶s mouth if there is oral thrush. TREATMENT :  Correct attachment will provide immediate relief from pain and rapid healing.  Purified Lanolin with mother¶s milk is applied 3 or 4 times a day to hasten  healing when it is severe mother should use a breast pump and infant is fed the expressed milk. rest is given to the affected nipple using a breast pump while the nipples heal. RETRACTED AND FLAT NIPPLE 47 .  The persistence of a nipple ulcer in spite of therapy mentioned. Inflamed nipple areola may be due to thrush also. Prophylaxis Includes  Local cleanliness during pregnancy &puerperium before and after each breast feeding to prevent crust formation over the nipple .It is caused by  Unclean hygiene resulting in formation of a crust over the nipple  Retracted nipple  Trauma from baby¶s mouth due to incorrect attachment to the breast.  The condition may be asymptomatic but becomes painful when the infant sucks. needs biopsy to exclude malignancy.  If it fails to heal up.

MASTITIS Mastitis is defined as inflammation of the mammary gland.  saprophyticus.  E coli. INCIDENCE: 2-5% in lactating and less than 1% in non lactating women. The most common causative organisms include  Staphylococcus aureus  Staphylococcus epidermidis. so that feeding is possible.  Babies are able to attach to the breast correctly and are able to suck adequately.  Mastitis is also associated with primiparity. manual expression of milk cn initiates lactation. ETIOLOGY  Milk stasis and cracked nipples.  Streptococcus viridans.  It is usually acquired. which contribute to the influx of skin flora. It is commonly met in primigravidae. In difficult cases.  Gradually breast tissue becomes soft and more protractile. are the underlying factors associated with the development of mastitis. and improper nursing technique. MODE OF INFECTION: There are two types of mastitis depending upon the site of infection 48 . incomplete emptying of the breast.

Abscess development complicates 5-11% of the cases of postpartum mastitis sand should be suspected when antibiotic therapy fails. 2. Infection gains access through the lactiferous duct leading to development of primary mammary adenitis. Feeding from the affected breast solves the problem Onset: The onset is acute during late first week of puerperium. chills  Myalgias. Where as in mammary adenitis. Mastitis and breast abscess also increase the risk of viral transmission from mother to infant. CLINICAL FEATURES  Generalized malaise and headache  Fever. 49 . MORBIDITY AND MORTALITY Neglected.  Erythema. The diagnosis of mastitis is solely based on the clinical picture.1.  The overlying skin is red.  Presence of toxic features  Presence of wedge shaped swelling on the breast with its apex at the nipple. requiring parenteral antibiotics and surgical drainage. hot and flushed and feels tense and tender. warmth. the onset is insidious and usually occurs near the end of the first week. resistant. The lacteal system remains unaffected. or recurrent infections can lead to the development of an abscess. Infection that involves the breast parenchyma tissues leading to cellulitis. Non Infective Mastitis may be due to milk stasis. and breast tenderness. swelling.

a breast abscess should be considered.Physical examination focus on vital signs. and tender.  The infected side is emptied manually with each feed  Flucloxacillin (pencillin) is the drug of choice. Erythromycin is the alternative drug of choice who are allergic to penicillin. When the exam reveals a tender. Expressed milk can be sent for analysis. red. DIAGNOSIS No laboratory tests are required. Curative management  Provide breast support  Encourage to take plenty of oral fluids  Encourage the mother to continue the breast feeding with good attachment  Nursing is established first on the unaffected side to establish let down. Typical findings include an area of the breast that is warm. hard. but the accuracy and reliability of these results are controversial and aid little in the diagnosis and treatment of mastitis. TREATMENT Prophylaxis: Encourage mother to wash her hands before each feed Encourage to clean the nipples before and after each feed Reduce the nosocomial infection rates. and a complete examination to look for other sources of infection.  Antibiotic therapy is continued for at least 7 days  Analgesics are given for pain BREAST ABSCESS: 50 . review of systems. possibly fluctuant mass with overlying ery thema.

LACTATION FAILURE: (INADEQUATE MILK PRODUCTION) CAUSES are: 51 .Features are  Flushed breasts not responding to antibiotics proptly  Brawny edema of the overlying skin  Marked tenderness with fluctuation  Swinging temperature.  The infected breast is pumped every 2 hrs and with every let down  Once cellulites is resolved breast feeding from the involved side may be resumed. Risk factors  Diabetes mellitus  Oral thrush of infant TREATMENT: Use of Miconazole oral lotion or gel into both the nipples after each feed and into the infant¶s mouth thrice daily for 2 weeks. MANAGEMENT  Drain the abscess under general anesthesia  Encourage the breast feeding on the unaffected side. BREAST PAIN Candida albicans is a common cause of breast pain.

Puerperium:  Encourage adequate fluid intake  Nurse the baby regularly  Treat the painful local lesions  Metaclopromide and sulpride have been found to increase milk production. Planning and Interventions 52 . Infrequent suckling  Depression or anxiety state in the puerperium  Reluctance or apprehension to nursing  Ill development of nipples  Painful breast lesion  Endogenous suppression of Prolactin (retained placental bits)  Prolactin inhibition TREATMENT: Antenatal: Council the mother regarding the advantages of nursing her baby with breast milk Take care of any breast abnormality specially a retracted nipple and to maintain adequate breast hygiene especially in the last 2 months of pregnancy. breast feeding techniques. NURSING DIAGNOSIS  Altered comfort (pain) related to infection and inflammation in the breast  Anxiety related to clients inability to continue breast feeding  Altered parenting related to client¶s inability to continue breast feeding.  Knowledge deficit related to care of the breast.

Protein C. It may be inherited or acquired. Explain about the breast care and breast feeding techniques  Instruct the mother on the signs and symptoms of infection and need for prompt treatment. Others are factor V Leiden mutation 53 . ETIOPATHOGENESIS: Alteration in blood constituents Venous stasis is increased due to compression of gravid uterus to the inferior vena cava and iliac veins. Inherited Thrombophilias are the genetic conditions associated with the deficiencies of anti antithrombin III. and protein S. Thrombophilias are hypercoagulable states in pregnancy that increase the risk of venous thrombosis.embolic diseases include Deep vein thrombosis Thrombophlebitis Septic pelvic thrombophlebitis Pulmonary embolus.  Inspect nipples for any cracks and soreness  Provide warm applications  Administer antibiotics PUERPERAL VENOUS THROMBOSIS Thrombosis of the leg veins is one of the common and important complications in puerperium especially in the western countries Venous thrombo. This stasis causes damage to cells.

Symptoms include  Pain in the calf muscles.  On examination a symmetric leg edema (difference in circumference between the affected and the normal leg more than 1 cm) is significant. (c) Obesity. (b) Operative delivery (10 times more).Acquired are due to the presence lupus anticoagulant and antiphospholipid antibodies. (d) Anemia. Investigations: The following biophysical tests are employed to confirm the diagnosis: 1. In majority it remains asymptomatic.  Edema legs  Rise in skin temperature. DEEPVEIN THROMBOSIS Diagnosis: Clinical diagnosis is unreliable. Other acquired risk factors for thrombosis are ² (a) Advanced age and parity. (C) Heart disease. Doppler ultrasound to detect changes in the velocity of blood flow in the femoral vein. Venography by injecting non-ionic water soluble radio-opaque dye to note the filling defect in the venous lumen is PELVIC THROMBOPHLEBITIS: 54 . (f) Infection-pelvic cellulites.  A positive homan¶s sign ² pain in the calf on dorsiflexion of the foot may be present. 2. (g) Trauma to the venous wall.

white and cold. 55 . Through the left ovarian vein to the left renal vein and then to the left kidney. painful.Postpartum thrombophlebitis originates in the thrombosed veins at the placental site by organisms such as anaerobic Streptococci or Bacteroides (fragilis). Retrograde extension to ilio-femoral veins to produce the clinico-pathological entity of "phlegmasia alba dolens"or white leg Phlegmasia alba dolens (Syn : White leg): It is a clinico-pathological condition usually caused by retrograde extension of pelvic thrombophlebitis to involve the ilio-femoral vein. The pain is due to arterial spasm as a result of irritation from the nearby thrombosed vein. it is called pelvic thrombophlebitis There is no specific clinical feature of pelvic thrombophlebitis. (4) The affected leg swollen. (2) Mild pyrexia At times the fever may be high with chills and rigor. malaise. PYREXIA continues for more than a week in spite of Extra pelvic spread: Through the right ovarian vein into inferior vena cava and then to the lungs. (3) Evidences of constitutional disturbances such as headache. but it should be suspected in cases where antibiotic therapy. When localized in the pelvis. The condition is seldom met now-a-days. and rising pulse rate. The femoral vein may be directly affected from adjacent cellulitis. Clinical features: (1) It usually develops on the second week of puerperium.

sepsis. (1) A low risk woman has no personal or family history of VTE and are heterozygous for factor V Leiden mutation. Thrombo prophylaxis to such a woman depends on the specific risk factor and the category.(5) Blood count shows polymorph nuclear leucocytosis. . Diagnosis may be made by ultrasound. early ambulation are encouraged following operative delivery. Women with antithrombin-III deficiency can be treated with antithrombin-III concentrate prophylacticaly MANAGEMENT: 56 . Such a woman needs low molecular weight heparin prophylaxis throughout pregnancy and post partum 6 weeks. anemia in pregnancy and labor. Dehydration during delivery should be avoided. (2) A high risk woman is one who has previous VTE or VTE in present pregnancy. Women at risk of venous thromboembolism during pregnancy have been grouped into different categories depending on the presence of risk factors. Such a woman needs no thromboprophylaxis. or Antithrombin-in deficiency. ‡ Use of elastic compression stocking and intermittent pneumatic compression devices during surgery. computed tomography (CT) scan or by magnetic resonance imaging (MRI) PROPHYLAXIS FOR VENOUS THROMBOEMBOLISM in PREGNANCY AND PUERPERIUM Preventive measures include: ‡ Prevention of trauma. ‡ Leg exercises.

if thrombosis is severe. Prolongation of activated partial thromboplastin time (APTT) to 1.(1) The patient is put to bed rest with the foot end raised above the heart level. Neither anticoagulant should prevent the mother from breast-feeding. (2) Pain on the affected area may be relieved with analgesics.3.0. It does not cross the placenta. (4) Anticoagulants ² (a) Heparin 15. can be used safely in pregnancy. (b) A drug of coumarin series ² warfarin is commonly used orally with an overlap of at least three days with heparin. (3) Appropriate antibiotics are to be administered. High quality elastic stockings are fitted on the affected leg before mobilization. The anticoagulant therapy should be continued till all evidences of the disease have disappeared which generally take 3-6 months. 4 to 6 hourly for four to six injections when the blood coagulation is likely to be depressed to the therapeutic level. Heparin is continued for at least 7 to 10 days or even longer. Low molecular weight heparin (LMWH). The daily maintenance dose of warfarin is usually 5 to 9 mg to be taken at the same time each day.0 . Enoxaparin 40 mg daily is given. Subsequent maintenance dose depends upon international normalized ratio (1NR) which should be within the range of 2.5 times indicates effective and safe anti coagulation.000 units are administered intravenously followed by 10.5-2. gentle movement is allowed on bed by the end of first week.000 units. The initial daily single dose of 7 mg for 2 days is adequate for induction. 57 . (5) As soon as the pain subsides.

The clinical features depend on the size of the embolus and on the preceding health status of the patient. DIAGNOSIS : 58 . it occurs without any previous clinical manifestations of deep vein thrombosis. The predisposing factors are those already mentioned in venous thrombosis. The classic symptoms of massive pulmonary embolism are Sudden collapse with acute chest pain and air hunger. tachycardia. pleuritic chest pain. Death usually occurs within short time from shock and vagal inhibition. The important signs and symptoms of pulmonary embolism are : Tachypnoea. haemoptysis and rise in temperature > 37°c. cough. hypertension and sepsis. (7) Fibrinolytic agents like streptokinase produce rapid resolution of pulmonary emboli. dyspnoea.(6) Vena cava fillers are used for patients with recurrent pulmonary embolism or where anticoagulant therapy is contraindicated. (8) Venous thrombectomy is needed for massive illiofemoral vein thrombosis or for massive pulmonary embolus. but in about 80-90%. While deep venous thrombosis in the leg or in the pelvis is most likely the cause of pulmonary embolism. PULMONARY EMBOLISM Pulmonary embolism is the leading cause of maternal deaths in many centres especially in the developed countries after the sharp decline of maternal mortality due to hemorrhage.

When the test is positive for DVT. Doppler ultrasound can identify a DVT.X-ray of the chest shows diminished vascular marking in areas of infarction. Pulmonary angiography is considered to be the most accurate method of diagnosis. Heparin therapy is to be continued upto 40. MANAGEMENT : Prophylaxis (as mentioned in venous thromboembolism) Active treatment includes: (1) Resuscitation ² cardiac massage. Oxygen saturation < 95% on room air needs further investigation. Magnetic Resonance Imaging (MRI) can be used in pregnancy as the risk of ionizing radiation is absent. oxygen therapy.) are started.000 IU and morphine 15 mg (I. 59 . ECG: tachycardia.4 units/ml or the activated partial thromboplastin time (APTT) about twice the normal. Heparin level is maintained at 0. It is useful to rule out pneumonia and atelectasis. Lung scans: (Ventilation /Perfusion scan) Perfusion scan will detect areas of diminished blood flow whereas a reduction in perfusion with maintenance of ventilation indicates pulmonary embolism.000 IU per day so as to maintain the clotting time to over 12 minutes for the first 48 hours.V. elevation of the dome of the diaphragm and often pleural effusion. intravenous heparin bolus dose of 5. right axis shift. anti coagulation therapy should be started. Arterial blood gas: POa > 85 mm Hg on room air is reassuring but does not rule out PE.2 to 0.

000 IU can be given and continued with 100. The condition is usually mild and may pass unnoticed. (3) Thrombolytic therapy ² Streptokinase with a loading dose of 600. placement of vena caval filter or ligation of inferior vena cava and ovarian veins. unless there is disability. 60 .V. Neurological examination reveals lower motor neuron type of lesion with flaccidity and wasting of the muscles in areas supplied by the femoral nerve or lumbosacral plexus.000 IU per hour. fluid support is continued and blood pressure is maintained if needed by dopamine or adrenaline. Backward rotation of the sacrum during labor may also be a contributing factor. Sensory loss is often present. It does not cross the placenta when used during pregnancy. Surgical treatment is done following pulmonary arteriography. It is thought to be due to stretching of the lumbosacral trunk by the prolapsed intervertebral disc between L5 and S1.(2) I. (5) Recurrent attacks of pulmonary embolism necessitate surgical treatment like embolectomy. (4) Tachycardia is counteracted by digitalis. It is usually unilateral and appears shortly after delivery or during first day postpartum or so. OBSTETRIC PALSIES (Post partum traumatic mastitis) The commonest form of obstetric palsy encountered in puerperium is foot drop.

(4) Active exercise is encouraged. (2) A splint is applied to prevent damage of over-stretched paralyzed muscles. Early (within one week) (1) Acute retention of urine (2) Urinary tract infection (3) Puerperal sepsis 61 . endotoxic or idiopathic (3) Postpartum eclampsia (4) Pulmonary embolism ² liquor amnii or air (5) Inversion. however. the late complications are relatively less risky. (3) Massage and electrical stimulation of the muscles as early as possible. The majority of the alarming complications. arise immediately following delivery and except pulmonary embolism as a consequence of thromboembolism phenomenon.MANAGEMENT (1) Rest in bed for about 6 weeks on a suitable mattress supported by hard board. PUERPERAL EMERGENCIES There are many acute complications that may occur during the puerperium. The complications are: Immediate (1) Postpartum hemorrhage (2) Shock ² hypovolaemic.

HIGH RISK FACTORS FOR POST PARTUM MENTAL ILLNESS: Past history: Psychiatric illness. mismatched blood transfusion or eclampsia. difficult labor. Present pregnancy: Caesarean delivery. PUERPERAL BLUES 62 . the incidence of mental illness is high. thrombophlebitis (3) Psychosis (4) Postpartum cardiomyopathy (5) Postpartum hemolytic uremic syndrome Psychiatric disorders during puerperium In the first three months after delivery. Others: Unmet expectations. Overall incidence is about 15-20%. Family history: Major psychiatric illness. marital conflict. Neonatal complications. Puerperal psychiatric illness.(4) Breast engorgement (5) Mastitis and breast abscess (6) Pulmonary infection (atelectasis) (7) Anuria following abruption placenta. Delayed (I) Secondary postpartum hemorrhage (2) Thromboembolism manifestation ² pulmonary embolism.

 It is a transient state of mental illness observed 4-5 days after delivery and it lasts for few days. Estrogen patch has also been used. But lowered tryptophan level is observed. It is safe for breast feeding also.  Manifestations are ² depression. It suggests altered neuro transmitter function. social withdrawal. POST PARTUM DEPRESSION  It is observed in 10-20% of mothers. irritability and even suicidal attitude.  Manifestations loss of energy and appetite.  Nearly 50% of the post partum women suffer from the problem. The overall prognosis is good. If no prompt response with medication. anxiety. insomnia. insomnia. POST PARTUM PSYCHOSIS (SCHIZOPHRENIA) 63 . General supportive measures are essential as in blues. tearfulness.  Risk of recurrence is high (50-100%) in subsequent pregnancies. helplessness and negative feelings towards the infant.  Treatment is reassurance and psychological support by the family members.  Changes in the hypothalamo-pituitary-adrenal axis may be a cause. Treatment Treatment is started early.  No specific metabolic or endocrine abnormalities have been detected.  It is more gradual in onset over the first 4-6 months following delivery or abortion. psychiatric consultation is sought for. Fluoxetine or paroxetine (serotonin uptake inhibitors) is effective and has fewer side effects.

 Observed in about one in 500 to 1000 mothers.  Chlorpromazine 150 mg stat and 50-150 mg three times a day is started.  Onset is relatively sudden usually within 4 days of delivery. nurse and attending staff must understand the patient's reaction. Electroconvulsive therapy is considered if it remains unresponsive or in depressive psychosis. Perinatal grieving may also be due to unexpected hysterectomy. PSYCHOLOGICAL MANAGEMENT Most perinatal events are joyful.  Manifestations fear. confusion followed by hallucinations. infanticide impulses may be present. Commonly seen in women with past history of psychosis or with a positive family history.  Admission is needed.  Risk of recurrence in the subsequent pregnancy is 20-25% and there is increased risk of psychotic illness outside pregnancy also. In that case breast feeding is contraindicated. RESPONSE TO PERINATAL DEATHS AND 64 . But when a fetal or neonatal death occurs special attention must be given to the grieving patient and her family. Suicidal. Management:  A psychiatrist must be consulted urgently.  Sublingual oestradiol (1 mg thrice daily) results in significant improvement. In that case temporary separation and nursing supervision is needed.  Lithium is indicated in manic depressive psychosis. delusions and disorientation (usually manic or depressive). birth of a malformed or a critically ill infant. restlessness. Physician.

Source Department of International Health. Immunology and Microbiology. To evaluate the impact of Advanced Life Support in Obstetrics (ALSO) training on staff performance and the incidences of post-partum hemorrhage (PPH) at a regional hospital in Tanzania. A total of 510 women delivered before and 505 after the intervention. All high. Nyakina J. Massawe S. University of Copenhagen Department of Gynecology and Obstetrics. with support and sympathy. Setting. Population. Tanzania Institute of Psychology. Dar es-Salaam Kagera Regional Hospital. planning investigations. Sorensen BL. Abstract Objective. Odense University Hospital. Faculty of Health Sciences. Denmark. Nielsen BB.Management includes: Facilitating the grieving process. Elsass P. Prospective intervention study. Faculty of Social Sciences. Bukoba Town. RESEARCH STUDIES ADVANCED LIFE SUPPORT IN OBSTETRICS (ALSO) AND POST-PARTUM HEMORRHAGE: A PROSPECTIVE INTERVENTION STUDY IN TANZANIA. Odense.and mid-level providers 65 . Methods. referral hospital. University of Copenhagen Department of Obstetrics and Gynecology. autopsy requests. Denmark Muhimbili University of Health and Allied Sciences. Design. Rasch V. follow up visit and plan for subsequent pregnancy. Others are : supporting the couple in seeing or holding or tacking photographs of the infant. A regional. Aarhus University Hospital. Aarhus.

oxytocin infusion and bimanual compression of the uterus after the training. POSTPARTUM OVARIAN VEIN THROMBOSIS CAUSING SEVERE HYDRONEPHROSIS.3%[RR 0.9 to 18.involved in childbirth at the hospital attended a two-day ALSO provider course.55 (95%CI: 0. PPH (blood loss •500ml).edu 66 . USA.69)]. There was a significant decrease in episiotomies. By visual estimation. severe PPH from 9.29-0. Staff management was observed and post-partum bleeding assessed at all vaginal deliveries for seven weeks before and seven weeks after the training. The incidence of PPH was significantly reduced from 32.47 (95%CI: 0. sholmstr@health.usf.44-0. Holmström SW. Main Outcome Measures. The active management of the third stage of labor was also significantly improved. A significantly higher proportion of women with PPH had continuous uterine massage. Results. at least as evaluated by short-term effects. Barrow BP.77)]. severe PPH (blood loss •1000ml) and staff performance to prevent. detect and manage PPH.2 to 4.2%[RR 0. Source University of South Florida. Tampa. staff identified one in 25 of the PPH cases before the ALSO training and one in five after the training. Florida. A two-day ALSO training course can significantly improve staff performance and reduce the incidence of PPH. Conclusions.

67 . A computed tomographic scan demonstrated severe right hydronephrosis and right pyelocalyceal rupture and was suggestive of a right ovarian vein thrombosis. Sadan O. CASE: A young woman presented on postpartum day 3 after an uncomplicated vaginal delivery with severe right lower quadrant abdominal pain and right thigh numbness. The diagnosis is often delayed. CONCLUSION: Ovarian vein thrombosis should be considered in the differential diagnosis of any woman in the puerperium presenting with pelvic or abdominal pain. THE EFFECT OF INTERMITTENT ON LABOR VERSUS AND CONTINUOUS POSTPARTUM BLADDER URINARY CATHETERIZATION DURATION RETENTION AND INFECTION: A RANDOMIZED TRIAL. This case illustrates an unusual presentation of postpartum ovarian vein thrombosis. and free flow of contrast from her distal ureter to her bladder was seen without evidence of obstruction. Four weeks after nephrostomy tube placement. she underwent right antegrade nephrostography. Ezri T. Evron S. Sherman A. Boaz M. Khazin V.Abstract BACKGROUND: Ovarian vein thrombosis is a rare postpartum complication. Dimitrochenko V. given that the differential diagnosis is broad. She was admitted and treated with a right nephrostomy tube and anticoagulation.

primiparous parturients who received patientcontrolled epidural analgesia for labor. INTERVENTIONS: Patients were randomly allocated to either the intermittent bladder catheterization group (Group IC. DESIGN: Randomized. n = 109) or the continuous catheterization group (Group CC. PATIENTS: 209 ASA physical status I and II.Source Obstetric Anesthesia Unit. SETTING: University-affiliated hospital. the Edith Wolfson Medical Center. controlled. 68 . prospective. Department of Anesthesia. Israel. Abstract STUDY OBJECTIVE: To assess the effect of intermittent versus continuous bladder catheterization on labor duration and local anesthetic consumption. n = 100). Holon. single-blind trial.

suppression of lactation. dose of local anesthetics given. CONCLUSION: Intermittent bladder catheterization was associated with shorter second-stage labor and less local anesthetic. breast complications. 75 +/. The rate of UTI was similar (30%) in both study groups. urinary tract complications. asymptomatic bacteruria). This finding was associated with increased local anesthetic dose requirement in Group CC during both stages of labor (73 +/25 mL vs.MEASUREMENTS: Duration of the second stage of labor. SUMMARY Today we have discussed about the minor ailments of puerperium like after pains. venous thrombosis. P = 0. MAIN RESULTS: Duration of the second stage of labor was longer in Group CC than Group IC: 105 +/. 63 +/. perineal stitch pain. Main secondary outcomes were postpartum urinary retention and rate of postpartum urinary tract infection (UTI. psychiatric disorders etc 69 . puerperal emergencies.26 mL. but the same frequency of postpartum urinary retention and UTI was seen with both catheterization groups. breast engorgement.72 vs.52 min (P = 0. puerperal sepsis. and primary outcomes were compared by group using the t-test for independent samples. constipation and complications of puerperium like puerperal pyrexia. pulmonary embolism. suppression of lactation.005).002).

BIBLIOGRAPHY  Boback M Irene & Jenson Margaret ³ Maternity & Gynaecologic Care. what can be achieved in the next decade. new central book agency page no: 433-444. From a medical and physilogicak view point this period is called the puerperium.this period is the crucial period where the mother and the baby also has to be cared effectively to improve the health of the mother. starts immediately after the delivery of the placenta and membranes and continues for 6 weeks. the mother enters a period of physical and psychological recuperation. Philadelphia. Int J Gynaecol Obstet 2000. page no:625-653  WHO. but through out the pregnancy.CONCLUSION Following the birth of the baby and expulsion the placenta. and to prevent many complications.  Myles (2003) ³ text book for midwives´ (14th edition). <PubMed> 70 . The prevention and management of puerperal infections  The Authors Acta Obstetricia et Gynecologica Scandinavica© 2011 Nordic Federation of Societies of Obstetrics and Gynecology.and to prevent such complications care must be taken not only at one particular stage.964-971  DC Dutta (2004) ³ text book of obstetrics´ ( 6 th edition) India:. Maternal survival in developing countries: what has been done.ensure the bonding between the mother and baby. Churchill livingstone publishers. 70(1): 89-97. mosby company (5th edition) page no.  Oxford Textbook of Medicine  Donnay F.intranatal period and in postnatal period also.

healthline. and Paul D. Ghassan. British Journal of Psychiatry 172: 521-526  BJOG: An International Journal of Obstetrics & Gynaecology  Volume 74.com  www.scribd. 11:12 (18 April 2011)  Journal-obgyn-india.wikipedia." American Family Physician 52.com  www. Terp I M. Cindy Dedmon.com  The Internet Journal of Gynecology and ObstetricsŒ ISSN: 1528-8439  http://www. Mortensen P B (1998) Post-partum psychoses: clinical diagnoses and relative risk of admission after parturition.journal-obgyn-india.com  www. 2 (August 1995): 531.com/  www. pages 294±298. April 1967  Hamadeh. Mozley. no. "Postpartum Fever.com 71 . Issue 2.pubmed.  Journal of BMC Women's Health 2011.

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