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

:

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

Submitted by

:

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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INDEX SL.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. Complications of puerperium Research studies Summary Conclusion Bibliography

TOPIC

PAGE NO
5 5 6 10-14 14-65 66-70 70 71 71-72

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INTRODUCTION Following the birth of the baby and expulsion the placenta, the mother enters a period of physical and psychological recuperation. From a medical and physilogical view point this period is called the puerperium, starts immediately after the delivery of the placenta and membranes and continues for 6 weeks. 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. The relationship between these factors has historically been the topic of some debate. 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. 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. 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 quality of the mothers care at this time is important to ensure her immediate and future health.

DEFINITION OF PUERPERIUM
Puerperium is the period following childbirth during which the body tissues, specially the pelvic organs revert back approximately to the prepregnant state both anatomically and physilogically.
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DC. Dutta Puerperium is defined as the time from the delivery of the placenta through the first few weeks after the delivery. This period is usually considered to be 6 weeks in duration. Myles By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery have resolved and the body has reverted to the nonpregnant state. An overview of the relevant anatomy and physiology in the postpartum period as follows.

UTERUS
The pregnant term uterus (not including baby, placenta, fluids, etc) weighs approximately 1000 g. In the 6 weeks following delivery, the uterus recedes to a weight of 50-100 g. Immediately postpartum, the uterine fundus is palpable at or near the level of the maternal umbilicus. Thereafter, most of the reduction in size and weight occurs in the first 2 weeks, at which time the uterus has shrunk enough to return to the true pelvis. Over the next several weeks, the uterus slowly returns to its nonpregnant state, although the overall uterine size remains larger than prior to gestation. The endometrial lining rapidly regenerates, so that by the seventh day endometrial glands are already evident. By the 16th day, the endometrium is restored throughout the uterus, except at the placental site.
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The placental site undergoes a series of changes in the postpartum period. Immediately after delivery, the contractions of the arterial smooth muscle and compression of the vessels by contraction of the myometrium ("physiologic ligatures") result in hemostasis. The size of the placental bed decreases by half, and the changes in the placental bed result in the quantity and quality of the lochia that is experienced. Immediately after delivery, a large amount of red blood flows from the uterus until the contraction phase occurs. Thereafter, the volume of vaginal discharge (lochia) rapidly decreases. The duration of this discharge, known as lochia rubra, is variable. The red discharge progressively changes to brownish red, with a more watery consistency (lochia serosa). Over a period of weeks, 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, although it averages approximately 5 weeks. The amount of flow and color of the lochia can vary considerably. Fifteen percent of women have continue to have lochia 6 weeks or more postpartum. Often, women experience an increase in the amount of bleeding at 7-14 days secondary to the sloughing of the eschar on the placental site. This is the classic time for delayed postpartum hemorrhages to occur.

CERVIX
The cervix also begins to rapidly revert to a nonpregnant state, but it never returns to the nulliparous state. By the end of the first week, the external os closes such that a finger cannot be easily introduced.

VAGINA
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The vagina also regresses but it does not completely return to its prepregnant size. Resolution of the increased vascularity and edema occurs by 3 weeks, and the rugae of the vagina begin to reappear in women who are not breastfeeding. At this time, the vaginal epithelium appears atrophic on smear. This is restored by weeks 6-10; however, it is further delayed in breastfeeding mothers because of persistently decreased estrogen levels.

PERINEUM
The perineum has been stretched and traumatized, and sometimes torn or cut, during the process of labor and delivery. The swollen and engorged vulva rapidly resolves within 1-2 weeks. Most of the muscle tone is regained by 6 weeks, with more improvement over the following few months. The muscle tone may or may not return to normal, depending on the extent of injury to muscle, nerve, and connecting tissues. ABDOMINAL WALL The abdominal wall remains soft and poorly toned for many weeks. The return to a prepregnant state depends greatly on maternal exercise.

OVARIES
The resumption of normal function by the ovaries is highly variable and is greatly influenced by breastfeeding the infant. The woman who breastfeeds her infant has a longer period of amenorrhea and anovulation than the mother who chooses to bottle-feed. The mother who does not breastfeed may ovulate as early as 27 days after delivery. Most women have a menstrual period by 12 weeks; the mean time to first menses is 7-9 weeks.
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In the breastfeeding woman, the resumption of menses is highly variable and depends on a number of factors, including how much and how often the baby is fed and whether the baby's food is supplemented with formula. 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. Half to three fourths of women who breastfeed return to periods within 36 weeks of delivery.

BREASTS
The changes to the breasts that prepare the body for breastfeeding occur throughout pregnancy. If delivery ensues, lactation can be established as early as 16 weeks' gestation. Lactogenesis is initially triggered by the delivery of the placenta, which results in falling levels of estrogen and progesterone, with the continued presence of prolactin. If the mother is not breastfeeding, the prolactin levels decrease and return to normal within 2-3 weeks. The colostrum is the liquid that is initially released by the breasts during the first 2-4 days after delivery. High in protein content, this liquid is protective for the newborn. The colostrum, which the baby receives in the first few days postpartum, is already present in the breasts, and suckling by the newborn triggers its release. The process, which begins as an endocrine process, switches to an autocrine process; the removal of milk from the breast stimulates more milk production. Over the first 7 days, the milk matures and contains all necessary nutrients in the neonatal period. The milk continues to change throughout the period of breastfeeding to meet the changing demands of the baby.

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MINOR AILMENTS OF PUERPERIUM AND ITS RELIEF MEASURES. 
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. It is often felt more frequently while breast-feeding. 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.

MANGEMENT:
Massage the uterus with expulsion of the clot. 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.

RELIEVING MEASURES;

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After using the bathroom, spray or pour warm water over the entire vaginal area. Encourage mother to pat the area dry, making sure to start at the front and end at the back to avoid spreading germs from the rectum to the vagina. To reduce the swelling Apply Ice packs ‡ Wrap the ice pack in a washcloth or other soft or absorbent material. ‡ Do not directly apply the ice. Sitz bath Encourage the mother to sit in a tub with 2-3 inches of warm water for about 15 minutes. Care of perineal stitches Clean and dress the perineal area daily and cover with sterile pad. Swabbing should be done from above downwards. Advice the mother to use topical anaesthetic spray or ointment according to the prescription.

BREAST ENGORGEMENT
May occur about the third day postpartum and is often regarded by mothers as the result of the milk coming in. It is due to exaggerated normal venous and lymphatic engorgement of the breasts which precedes lactation. The mother approaches with pain and tense feeling of the breasts, generalized malaise and painful breast feeding.

MANAGEMENT: 
Encourage the mother to consume lots of fluids.
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Support the breasts with a binder or brassiere.  Apply hot bags on breast before nursing and ice bags after.  Express the milk manually.  The baby should be put to breast regularly after the expression of milk.  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 profuse diaphoresis occurs especially at night for the first 2-3 days after childbirth.

CAUSES
Decreased estrogen levels Removal of increased venous pressure in the lower extremities Loss of the remaining pregnancy induced increase in bloodvolume. 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.

CONSTIPATION
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The priblem is much less because of early ambulation and liberalisation of dietary intake. Encourage the mother to take a diet containing sufficient amount of roughage and fluids is enough to move the bowel. If necessary mild laxative such as Igol 2 tea spoons may be adviced at bed time.

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.after giving birth.  Avoid breast stimulation. Eg: Running warm water over the breasts, newborn sucking or pumping of the breasts  Bromocriptine was often prescribed in olden days. But recent days it is not practiced much as it causes the seizures, strokes and MI.

COMPLICATIONS OF PUERPERIUM HEAMORRHAGE
Postpartum hemorrhage is defined as excessive blood loss during or after the third stage of labor. The average blood loss is 500 mL at vaginal delivery and 1000 mL at cesarean delivery. Objectively, 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.
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Early postpartum hemorrhage Is described as that occurring within the first 24 hours after delivery. Late postpartum hemorrhage Most frequently occurs 1-2 weeks after delivery but may occur up to 6 weeks of postpartum.

ETIOLOGY
Early postpartum hemorrhage May result from  Uterine atony  Retained products of conception  Uterine rupture  Uterine inversion  Placenta accreta  Lower genital tract lacerations  Coagulopathy, and hematoma  Late postpartum hemorrhage  Retained products of conception  Infection  Subinvolution of placental site  Coagulopathy. Uterine atony and lower genital tract lacerations are the most common causes of postpartum hemorrhage.
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Factors Predisposing to Uterine Atony Include Overdistension of the uterus secondary to multiple gestations, polyhydramnios, macrosomia, rapid or prolonged labor,grand multiparity,oxytocin

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

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INCIDENCE
Vaginal delivery is associated with a 3.9% incidence of postpartum hemorrhage. Cesarean delivery is associated with a 6.4% incidence of postpartum hemorrhage. Delayed postpartum hemorrhage occurs in 1-2% of patients.

MORBIDITY AND MORTALITY
In the United States, postpartum hemorrhage is responsible for 5% of maternal deaths. Other causes of morbidity include the need for blood transfusions or surgical intervention that may lead to future infertility.

HISTORY
The antepartum or early intrapartum identification of risk factors for postpartum hemorrhage allows for advanced preparation and possible avoidance of severe sequelae. Every patient must be interviewed upon admission to the labor floor. Request information about parity, multiple gestation, polyhydramnios, previous episodes of postpartum hemorrhage, history of bleeding disorders, and desire for future fertility. Note the use of prolonged oxytocin administration, as well as the use of magnesium sulfate during the patient's labor course.

PHYSICAL

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Physical examination is performed simultaneously with resuscitative measures. Perform a vigorous bimanual examination, which may reveal a retained placenta or a hematoma of the perineum or pelvis, and which also allows for uterine massage. Closely inspect the lower genital tract in order to identify lacerations. Closely examine the placenta to determine if any fragments are missing.

DIAGNOSIS
The onset of postpartum hemorrhage is acute, intervention is immediate, and resolution is generally within minutes; consequently, laboratory studies or imaging in the management of the immediate course of this process has little role. However, 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, which may require further treatment. Upon admission of each patient to the labor ward, obtain ABO and D blood type determinations, and acquire adequate intravenous access.

TREATMENT
Initial therapy includes  Provide oxygen delivery,  Bimanual massage,  Removal of any blood clots from the uterus,  Empty the bladder,
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And the routine administration of dilute oxytocin infusion (10-40 U in 1000 mL of lactated Ringer solution [LRS] or isotonic sodium chloride solution).  If retained products of conception are noted, perform manual removal or uterine curettage.  If oxytocin is ineffective, carboprost in an intramuscularly administered dose of 0.25 mg can be administered every 15 minutes, not to exceed 3 doses.  Misoprostol has been used clinically for the treatment of postpartum hemorrhage. However, further research is needed to determine the effectiveness, optimal dosage, and route of administration. When postpartum hemorrhage is not responsive to pharmacological therapy and no vaginal or cervical lacerations have been identified, consider the following more invasive treatment methods:
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Uterine packing is now considered safe and effective therapy for the treatment of postpartum hemorrhage. Use prophylactic antibiotics and concomitant oxytocin with this technique. The timing of removal of the packing is controversial, but most physicians favor 24-36 hours. This treatment is successful in half of patients. If unsuccessful, it still provides time in which the patient can be stabilized before other surgical techniques are employed.

y

A Foley catheter with a large bulb (24F) can be used as an alternative to uterine packing. This technique can be highly effective, is inexpensive, requires no special training, and may prevent the need for surgery.

y

Uterine artery embolization, which is performed under local anesthesia, is a minimally invasive technique.The success rate is greater than 90%.This procedure is believed to preserve fertility.

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Complications are rare (6-7%) and include fever, infection, and nontarget embolization. In patients at high risk for postpartum hemorrhage, such as those with placenta previa, placenta accreta, coagulopathy, or cervical pregnancy, the catheter can be placed prophylactically.
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.

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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.

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The suture is wrapped over the fundus and directed into and out of the anterior uterine wall parallel to the previous anterior sutures. The uterus is compressed in an accordion like fashion and the suture is tied across the lower uterine segment.

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The B-Lynch suture technique and other compression suture techniques are operative approaches to postpartum hemorrhage that have proven to preserve fertility.

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As practitioners become proficient in this technique, it may be considered before uterine artery or hypo gastric artery ligation and hysterectomy.

SURGICAL MANAGEMENT 
When conservative therapy fails, the next step is surgery with either bilateral uterine artery ligation or hypogastric artery ligation.  Uterine artery ligation is thought to be successful in 80-95% of patients.
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If this therapy fails, hypogastric artery ligation is an option. However, this approach is technically difficult and is only successful in 4250% of patients. Instead, stepwise devascularization of the uterus is now thought to be the next best approach, with possible ligation of the utero-ovarian and infundibulopelvic vessels When all other therapies fail, emergency hysterectomy is often a necessary and lifesaving procedure.

NURSING MANAGEMENT ASSESSMENT
o Take complete history: of past and present obstetrical history and also identify the risk factors of hemorrhage.  Physical examination especially the vital signs signs of blood loss to be assessed.  Assess the amount of blood loss its nature, consistency, abdominal pain  Assess for signs of shock.

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, need for blood transfusion.  Risk for injury related to changes in cerebral tissue perfusion.
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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.  Monitor vital signs every 5-10min,, and observe the clients color, oxygen saturation by pulse oxymetry, skin temperature and sensorium.  Palpate the fundus for firmness and massage to restore the tone.  Evaluate the vaginal bleeding, extent of perineal pad saturation, colour. Consistency of bleeding clots and pooling on the under pad.  Prepare for blood transfusions and administer blood transfusions.  Reassure the mother and family.  Allow the family members to involve in the care.  Explain the physiological process of hemorrhage and interpret medical treatments and procedures.  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.

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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.

CAUSES
The causes of pyrexia are 1. Puerperal sepsis 2. Urinary tract infection 3. Mastitis 4. Infection of caesarean section wound 5. Pulmonary infection 6. Septic pelvic thrombophlebitis 7. A recrudescence of malaria or pulmonary tuberculosis 8. Unknown origin

PUERPERAL SEPSIS
An infection of the genital tract which occurs as a complication of delivery is termed as puerperal sepsis. There has been marked decline in puerperal sepsis during the fast few decades. The reasons are:  Better obstetric care
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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. 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.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

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Increased prevalence of organisms resistant to antibiotics.

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, packing into the birth canal  Inadequate, or no immunization with tetanus toxoid  Diabetes. 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

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deliveries o Unrepaired cervical lacerations, or large vaginal lacerations  Pre-existing sexually transmitted infections  Postpartum haemorrhage Community risk factors

1. Lack of transportation and resources needed for taking the women to a referral facility with an adequate management of such complications 2. Great distance from a woman¶s home to a health facility 3. Low socioeconomic status; inability to pay for treatment 4. Poor level of general education 5. Cultural factors which lead to delay in seeking medical care 6. Lack of knowledge about symptoms and signs of puerperal sepsis 7. Lack of health education, danger signs of infection or lack of birth and emergency preparation plan.

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
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health facility  lack of necessary resources, e.g. staff, equipment, 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, including inappropriate use of antibiotics y Shortage of safe blood for transfusion.

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, or more specifically the Streptococcus pyogenes) is a form of Streptococcus bacteria responsible for most cases of severe hemolytic streptococcal illness. Other types (B, C, D, and G) may also cause infection. Group B Streptococcus (abbreviated to GBS, or more specifically Streptococcus agalactiae) usually causes less severe maternal disease. Other causal organisms, in order of prevalence, include staphylococci, coli form bacteria, anaerobic bacteria, Chlamydia, Mycoplasma and very rarely, Clostridium welchii.

MODE OF INFECTION
Puerperal sepsis is essentially a wound infection. Placental site, lacerations
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of the genital tract or caesarean section wounds may be infected in the following ways.

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. Anaerobic streptococci and clostridium welchi which are found in the vagina. These are responsible for the infection.

Exogenous:
These comes from sources outside the body and are transmitted by another person. The source of infection can be midwife, doctor and other patients or visitors. Air and dust also cause infection to the patient.

Autogenous:
Here the organisms are present elsewhere in the body (throat, Skin) and migrate to the genital tract by blood stream Eg: streptococcus beta hemolyticus, staphylococcus, E. Coli etc,.

PATHOLOGY
The primary sites of infection are  Perineum  Vagina  Cervix  Uterus.

PERENEUM
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Lacerations on the perineum ,whether repaired or not ,are likely to be infected by organisms of low virulence like staphylococcus aureus or anaerobic streptococcus. The wound edges become red and swollen There may be collection of sangopurulent discharge or pus which results in complete disruption of the wound.

VAGINA
The vaginal lacerations are infected directly or by extension from perinea! infection The rnucosa is swollen and hyperemic ,resulting in necrosis and sloughing. On occasions ,a retained and forgotten cotton plug may be left inside the vagina leading to offensive vaginal discharge.

CERVIX
The cervical lacerated and harbor, 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 .It is commonly polymicrobial(GroupAor B streptococci, Clostridia)The decidua specially over the placental site is primarily affected. The risk factors for endometritis are retained products of conception cesarean section, chorioamnionitis, prolonged rupture of membranes ,preterm labour, and repeated vaginal examinations in labour.
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The necrosed decidua sloughs off The discharge is offensive .A zone of leucocytic barrier prevents the infection to the deeper myometrium. Severe infection is rare in now a days.

PELVIC CELLUIITIS(PARAMETRITIS)
Is due to spread of infection to the pelvic cellular tissues by direct or lymphatic or by haematogenous routes. The infection causes exudation and formation of an indurate mass usually confined to one side of the uterus. The uterus in that case is pushed to the contra lateral side.

SALPINGITIS
May be interstitial, due to lymphatic spread, or perisalpingitis following pelvic peritonitis. Endosalpingitis is un common. Pelvic abscess following pelvic peritonitis may be due to spread of infection.

SEPTIC THROMBOPHLEBITIS
May involve the ovarian veins, uterine veins, pelvic veins and rarely the inferior venacava .The infected thrombus may undergo complete resolution and suppuration ,At times, and emboli may occlude the micro circulation of the vital organs like lungs or kidney. The anaerobic pathogens are commonly involved.

SEPTICEMIA AND SEPTIC SHOCK
May be due to hemolytic streptococci or anaerobic streptococci. Septicemia may cause lung abscess, meningitis, pericarditis, endocarditis or multiorgan failure. Death occurs in about 30%of cases.

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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
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Lochia may be scanty and odourless  Uterus may be sub involuted and tender and softer. There may be associated wound infection

SPREADING INFECTION (EXTRA UTERINE SPREAD)
Is evident by presence of pelvis tenderness (pelvic peritonitis), tenderness of fornix (parametritis), 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, diarrhea, and a bulging fluctuant mass felt through the posterior fornix.
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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, meninges or joints may appear.

BACTEREMIA, ENDOTOXIC OR SEPTIC SHOCK
Is due to release of bacterial endotoxin causing circulatory inadequacy and tissue hypo perfusion. It is manifested by hypotension, oliguria and adult respiratory distress syndrome.
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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.

H IS T O R Y
Antenatal history of anemia, ante partum hemorrhage, presence of septic foci in teeth, and gums and tonsiis,any debilitating disease, like heart disease, diabetes, tubercuiosis and urinary tract infections or malaria should be enquired . Intranatal history regarding Preterm labour, duration of rupture of membranes, number of vaginal examinations outside and inside hospstal, duration of labour, method of delivery, nature of intrauterine manipulations if any. Post natal details of the nature of fever, associated symptoms related with the site of lesion , Clinical examination include, o The study of pulse and temperature chart, neck stiffness, Systemic examination include Throat,breasts,lungs,heart,liver,spleen,and legs. Abdominal examination to note involution of uterus, tenderness and presence of any feature of pelvic peritonitis and pelvic abscess.
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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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Prophylactic antibiotics is to be given in woman with premature rupture of membranes, prolonged labor, instrumental deliveries and intrauterine manipulations and mothers who are undergoing caesarean section. 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, all Other cases are managed in referral hospitals. General Care o Isolation and barrier nursing in hospital set up  Bed rest. Foot end to be raised to facilitate drainage  In mild cases, plenty of fluids orally and light diet is advised  In severe cases, IV fluids ringer lactate and dextrose saline are given  Blood transfusion may be required to correct anemia  Pain is relieved by adequate analgesia.  An indwelling catheter is used to relieve any urine retention.  A chart is maintained by recording pulse, respiration, temperature, lochial discharge fluids intake and output.
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ANTIBIOTICS: Ideal antibiotic regime should depend on the culture and sensitivity report Pending the report gentamicin (2mg/kg IV loading dose followed by1.5 mg/kg IV every8 hours) or Ampicillin (1gr IV every 6 hours) should be started. Intravenous administration of cefotaxime 1 gr 8 hourly is another alternative. Metronidazole 0.5 gr, IV is given at 8 hrs interval is also another alternative. The treatment is is continued until the infection is controlled for at least 7-10 days. SURGICAL TREATMENT There is very little role of major surgery in the treatment of puerperal sepsis. PERINEAL WOUND: The stitches of perineal wound may have to be removed to facilitate drainage of pus and relieve pain. The wound Is to be dressed with hot compress with mild antiseptic solution followed by application of antiseptic ointment or powder. After the infection is controlled secondary suture may be given at a later date. Retained bits of uterine products with a diameter of 3 cm or less may be disregarded and left alone. Otherwise surgical evacuation after antibiotic coverage for 24 hrs

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Cases with pelvic thrombophlebitis are treated with heparin for 7-10 days Pelvic abscess should be drained by colpotomy under ultrasound guidance. Laparotomy has got limited indications. Unresponsive peritonitis or any other possible pathology. HYSTERECTOMY In cases with rupture or perforation having multiple abscesses, gangrenous uterus or gas gangrene infection hysterectomy is performed.

NURSING MANAGEMENT
Assessment Post partum nursing assessment focus on identifying the signs and symptoms of infections early, monitoring progress and physioiogic functions, including uterine involution, noting needs for comfort and education , and identifying emotional reactions and needs. Nursing diagnoses pain related to infection site, procedures or treatments Risk for injury related to child birth and physiologic stressors, spread of infection, Risk for infection related to exposure to others and equipment lack of knowledge of infection transmission. Anxiety related to interference with recovery. Risk for altered parenting related to limited contact, pain, or inabitityto focus attention on neonate,
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Risk for altered parent/infant attachment related to client¶s inability to bond with neonate. Situational low self esteem related to infection and interference with caretaking responsibilities. Knowledge deficit related to infectious process, treatment

regimen, and implications for care of self and neonate.

Nursing planning and intervention o The nurse plays a role in carrying out medical treatment such as Antibiotic therapy. Monitor vital signs Assess for signs and symptoms and disease progression Provide comfort measures for pain relief. Promote healing and wellbeing through nutrition and fluid intake. 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. Involve the family members in the care Provide the support and encouragement for the client or family.

SUBINVOLUTION
Sub involution is a medical condition in which after childbirth, the uterus does not return to its normal size. Definition When the involution is impaired or retarded it is called subinvolution.The uterus is the most common organ affected

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by subinvolution. 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.

CAUSES
Predisposing factors are a. Grand multiparity, b. Overdistension of uterus as in twins and hydramnios c. Maternal ill health, d. Caesarean section e. Prolapse of the uterus f. Retroversion after the uterus becomes pelvic organ g. Uterine fibroid Aggravating factors are:
y y

Retained products of conception Uterine sepsis, endometritis

Factors that may cause sub involution
y y

Persistent lochia /fresh bleeding Long labor, anesthesia, full bladder, difficult delivery, retained placenta, infection

SYMPTOMS
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The condition may be asymptomatic. 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.

URINARY COMPLICATIONS IN PUERPERIUM
1. Urinary tract infection
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2. Pretension of urine 3. 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. Recurrence of previous cystitis or pyelitis 2. Asymptomatic becomes overt 3. 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. b) Stasis of urine during early puerperium due to lack of bladder tone and less desire to pass urine

Organisms responsible are:
- E.coli - Klebsiella - Proteus - Staph. Aureus

MANAGEMENT
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Antibiotics

RETENSION OF URINE:
This is a common complication in early puerperium

Causes are :
1. Bruising & edema of the bladder neck 2. Reflex from perineal injury 3. Unaccustomed position

Treatment of retention of urine: 
If simple measure fails to initiate micturation, an indwelling catheter is to be kept in situ for about 48 hours.  This not only empties the bladder but helps in regaining the normal bladder tone and sensation of fullness.  Appropriate urinary antiseptics should be administered for about 5-7 days.

Incontinence of urine:
This is not a common symptom following birth.

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. Stress
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incontinence is established by noting the escape of urine through the urethral opening during stress. 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.

Nursing management 
Encourage urination early in the postnatal period.  Encourage to void every 2-4 hrs  Assist the mother to the bathroom or at bed side on bed pan.  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, any report immediately.

BREAST COMPLICATIONS :
1 Breast engorgement 2 Cracked and retracted nipple leading to difficulty in breast feeding 3 Mastitis and breast abscess 4 Lactation failure.

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. There may be lymphatic and vascular congestion and possible interstitial edema, causing swelling and tenderness. This exacerbates the
45

tension of milk in the ducts and may cause stasis of the milk, resulting in inability of the milk to flow. 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.

SYMPTOMS 
Considerable pain and feeling of tenseness or heaviness in the both breasts.  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.

Management of breast engorgement
1. Administer analgesics to relieve pain 2. The baby should be put to breast at regular intervals 3. Manual expression of any remaining milk after each feed 4. In severe cases the breasts are emptied by expressing them manually or by a breast pump. 5. Elevate the breasts by supporting brassieres.

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. Due to a fissure situated either at the tip or base of the nipple
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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.

Prophylaxis
Includes  Local cleanliness during pregnancy &puerperium before and after each breast feeding to prevent crust formation over the nipple .

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. Inflamed nipple areola may be due to thrush also.  Miconazole lotion is applied over the nipple as well as in the baby¶s mouth if there is oral thrush.  If it fails to heal up, rest is given to the affected nipple using a breast pump while the nipples heal.  The persistence of a nipple ulcer in spite of therapy mentioned, needs biopsy to exclude malignancy.

RETRACTED AND FLAT NIPPLE
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It is commonly met in primigravidae.  It is usually acquired.  Babies are able to attach to the breast correctly and are able to suck adequately. In difficult cases, manual expression of milk cn initiates lactation.  Gradually breast tissue becomes soft and more protractile, so that feeding is possible.

MASTITIS
Mastitis is defined as inflammation of the mammary gland.

INCIDENCE: 2-5% in lactating and less than 1% in non lactating women. ETIOLOGY 
Milk stasis and cracked nipples, which contribute to the influx of skin flora, are the underlying factors associated with the development of mastitis.  Mastitis is also associated with primiparity, incomplete emptying of the breast, and improper nursing technique. The most common causative organisms include  Staphylococcus aureus  Staphylococcus epidermidis,  saprophyticus,  Streptococcus viridans,  E coli.

MODE OF INFECTION:
There are two types of mastitis depending upon the site of infection

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1. Infection that involves the breast parenchyma tissues leading to cellulitis. The lacteal system remains unaffected. 2. Infection gains access through the lactiferous duct leading to development of primary mammary adenitis. Non Infective Mastitis may be due to milk stasis. Feeding from the affected breast solves the problem

Onset: The onset is acute during late first week of puerperium. Where as in
mammary adenitis, the onset is insidious and usually occurs near the end of the first week.

CLINICAL FEATURES 
Generalized malaise and headache  Fever, chills  Myalgias,  Erythema, warmth, swelling, and breast tenderness.  Presence of toxic features  Presence of wedge shaped swelling on the breast with its apex at the nipple.  The overlying skin is red, hot and flushed and feels tense and tender.

MORBIDITY AND MORTALITY
Neglected, resistant, or recurrent infections can lead to the development of an abscess, requiring parenteral antibiotics and surgical drainage. Abscess development complicates 5-11% of the cases of postpartum mastitis sand should be suspected when antibiotic therapy fails. Mastitis and breast abscess also increase the risk of viral transmission from mother to infant. The diagnosis of mastitis is solely based on the clinical picture.
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Physical examination focus on vital signs, review of systems, and a complete examination to look for other sources of infection. Typical findings include an area of the breast that is warm, red, and tender. When the exam reveals a tender, hard, possibly fluctuant mass with overlying ery thema, a breast abscess should be considered.

DIAGNOSIS
No laboratory tests are required. Expressed milk can be sent for analysis, 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. 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.  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.  Antibiotic therapy is continued for at least 7 days  Analgesics are given for pain

BREAST ABSCESS:
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Features are  Flushed breasts not responding to antibiotics proptly  Brawny edema of the overlying skin  Marked tenderness with fluctuation  Swinging temperature.

MANAGEMENT 
Drain the abscess under general anesthesia  Encourage the breast feeding on the unaffected side.  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.

BREAST PAIN
Candida albicans is a common cause of breast pain.

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.

LACTATION FAILURE: (INADEQUATE MILK PRODUCTION) CAUSES are:
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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. Puerperium:  Encourage adequate fluid intake  Nurse the baby regularly  Treat the painful local lesions  Metaclopromide and sulpride have been found to increase milk production.

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, breast feeding techniques.

Planning and Interventions
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Explain about the breast care and breast feeding techniques  Instruct the mother on the signs and symptoms of infection and need for prompt treatment.  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- embolic diseases include Deep vein thrombosis Thrombophlebitis Septic pelvic thrombophlebitis Pulmonary embolus. ETIOPATHOGENESIS: Alteration in blood constituents Venous stasis is increased due to compression of gravid uterus to the inferior vena cava and iliac veins. This stasis causes damage to cells. Thrombophilias are hypercoagulable states in pregnancy that increase the risk of venous thrombosis. It may be inherited or acquired. Inherited Thrombophilias are the genetic conditions associated with the deficiencies of anti antithrombin III, Protein C, and protein S. Others are factor V Leiden mutation

53

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

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Postpartum thrombophlebitis originates in the thrombosed veins at the placental site by organisms such as anaerobic Streptococci or Bacteroides (fragilis). When localized in the pelvis, it is called pelvic thrombophlebitis There is no specific clinical feature of pelvic thrombophlebitis, but it should be suspected in cases where antibiotic therapy.
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. Through the left ovarian vein to the left renal vein and then to the left kidney. 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 femoral vein may be directly affected from adjacent cellulitis. The condition is seldom met now-a-days. Clinical features: (1) It usually develops on the second week of puerperium. (2) Mild pyrexia At times the fever may be high with chills and rigor. (3) Evidences of constitutional disturbances such as headache, malaise, and rising pulse rate. (4) The affected leg swollen, painful, white and cold. The pain is due to arterial spasm as a result of irritation from the nearby thrombosed vein.
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(5) Blood count shows polymorph nuclear leucocytosis. Diagnosis may be made by ultrasound, computed tomography (CT) scan or by magnetic resonance imaging (MRI) PROPHYLAXIS FOR VENOUS THROMBOEMBOLISM in PREGNANCY AND PUERPERIUM Preventive measures include: ‡ Prevention of trauma, sepsis, anemia in pregnancy and labor. Dehydration during delivery should be avoided. ‡ Use of elastic compression stocking and intermittent pneumatic compression devices during surgery. ‡ Leg exercises, early ambulation are encouraged following operative delivery. . Women at risk of venous thromboembolism during pregnancy have been grouped into different categories depending on the presence of risk factors. Thrombo prophylaxis to such a woman depends on the specific risk factor and the category, (1) A low risk woman has no personal or family history of VTE and are heterozygous for factor V Leiden mutation. Such a woman needs no thromboprophylaxis. (2) A high risk woman is one who has previous VTE or VTE in present pregnancy, or Antithrombin-in deficiency. Such a woman needs low molecular weight heparin prophylaxis throughout pregnancy and post partum 6 weeks. Women with antithrombin-III deficiency can be treated with antithrombin-III concentrate prophylacticaly

MANAGEMENT:
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(1) The patient is put to bed rest with the foot end raised above the heart level. (2) Pain on the affected area may be relieved with analgesics. (3) Appropriate antibiotics are to be administered. (4) Anticoagulants ² (a) Heparin 15,000 units are administered intravenously followed by 10,000 units, 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. if thrombosis is severe. Prolongation of activated partial thromboplastin time (APTT) to 1.5-2.5

times indicates effective and safe anti coagulation. Low molecular weight heparin (LMWH), can be used safely in pregnancy. Enoxaparin 40 mg daily is given. It does not cross the placenta, (b) A drug of coumarin series ² warfarin is commonly used orally with an overlap of at least three days with heparin. The initial daily single dose of 7 mg for 2 days is adequate for induction. Subsequent maintenance dose depends upon international normalized ratio (1NR) which should be within the range of 2.0 - 3.0. The daily maintenance dose of warfarin is usually 5 to 9 mg to be taken at the same time each day. The anticoagulant therapy should be continued till all evidences of the disease have disappeared which generally take 3-6 months. Neither anticoagulant should prevent the mother from breast-feeding. (5) As soon as the pain subsides, gentle movement is allowed on bed by the end of first week. High quality elastic stockings are fitted on the affected leg before mobilization.
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(6) Vena cava fillers are used for patients with recurrent pulmonary embolism or where anticoagulant therapy is contraindicated. (7) Fibrinolytic agents like streptokinase produce rapid resolution of pulmonary emboli. (8) Venous thrombectomy is needed for massive illiofemoral vein thrombosis or for massive pulmonary embolus.

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, hypertension and sepsis. While deep venous thrombosis in the leg or in the pelvis is most likely the cause of pulmonary embolism, but in about 80-90%, it occurs without any previous clinical manifestations of deep vein thrombosis. The predisposing factors are those already mentioned in venous thrombosis. The clinical features depend on the size of the embolus and on the preceding health status of the patient. The classic symptoms of massive pulmonary embolism are Sudden collapse with acute chest pain and air hunger. Death usually occurs within short time from shock and vagal inhibition. The important signs and symptoms of pulmonary embolism are : Tachypnoea, dyspnoea, pleuritic chest pain, cough, tachycardia, haemoptysis and rise in temperature > 37°c. DIAGNOSIS :
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X-ray of the chest shows diminished vascular marking in areas of infarction, elevation of the dome of the diaphragm and often pleural effusion. It is useful to rule out pneumonia and atelectasis. ECG: tachycardia, right axis shift. Arterial blood gas: POa > 85 mm Hg on room air is reassuring but does not rule out PE. Oxygen saturation < 95% on room air needs further investigation. Doppler ultrasound can identify a DVT. When the test is positive for DVT, anti coagulation therapy should be started. 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. Magnetic Resonance Imaging (MRI) can be used in pregnancy as the risk of ionizing radiation is absent. Pulmonary angiography is considered to be the most accurate method of diagnosis.

MANAGEMENT :
Prophylaxis (as mentioned in venous thromboembolism) Active treatment includes: (1) Resuscitation ² cardiac massage, oxygen therapy, intravenous heparin bolus dose of 5,000 IU and morphine 15 mg (I.V.) are started. Heparin therapy is to be continued upto 40,000 IU per day so as to maintain the clotting time to over 12 minutes for the first 48 hours. Heparin level is maintained at 0.2 to 0.4 units/ml or the activated partial thromboplastin time (APTT) about twice the normal.

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(2) I.V. fluid support is continued and blood pressure is maintained if needed by dopamine or adrenaline. (3) Thrombolytic therapy ² Streptokinase with a loading dose of 600,000 IU can be given and continued with 100,000 IU per hour. It does not cross the placenta when used during pregnancy. (4) Tachycardia is counteracted by digitalis. (5) Recurrent attacks of pulmonary embolism necessitate surgical treatment like embolectomy, placement of vena caval filter or ligation of inferior vena cava and ovarian veins. Surgical treatment is done following pulmonary arteriography.

OBSTETRIC PALSIES
(Post partum traumatic mastitis) The commonest form of obstetric palsy encountered in puerperium is foot drop. It is usually unilateral and appears shortly after delivery or during first day postpartum or so. It is thought to be due to stretching of the lumbosacral trunk by the prolapsed intervertebral disc between L5 and S1. Backward rotation of the sacrum during labor may also be a contributing factor. The condition is usually mild and may pass unnoticed, unless there is disability. 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. Sensory loss is often present.
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MANAGEMENT
(1) Rest in bed for about 6 weeks on a suitable mattress supported by hard board. (2) A splint is applied to prevent damage of over-stretched paralyzed muscles. (3) Massage and electrical stimulation of the muscles as early as possible. (4) Active exercise is encouraged.

PUERPERAL EMERGENCIES
There are many acute complications that may occur during the puerperium. The majority of the alarming complications, however, arise immediately following delivery and except pulmonary embolism as a consequence of thromboembolism phenomenon, the late complications are relatively less risky. The complications are: Immediate (1) Postpartum hemorrhage (2) Shock ² hypovolaemic, endotoxic or idiopathic (3) Postpartum eclampsia (4) Pulmonary embolism ² liquor amnii or air (5) Inversion. Early (within one week) (1) Acute retention of urine (2) Urinary tract infection (3) Puerperal sepsis
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(4) Breast engorgement (5) Mastitis and breast abscess (6) Pulmonary infection (atelectasis) (7) Anuria following abruption placenta, mismatched blood transfusion or eclampsia. Delayed (I) Secondary postpartum hemorrhage (2) Thromboembolism manifestation ² pulmonary embolism, thrombophlebitis (3) Psychosis (4) Postpartum cardiomyopathy (5) Postpartum hemolytic uremic syndrome Psychiatric disorders during puerperium In the first three months after delivery, the incidence of mental illness is high. Overall incidence is about 15-20%. HIGH RISK FACTORS FOR POST PARTUM MENTAL ILLNESS: Past history: Psychiatric illness, Puerperal psychiatric illness. Family history: Major psychiatric illness, marital conflict. Present pregnancy: Caesarean delivery, difficult labor, Neonatal complications. Others: Unmet expectations. PUERPERAL BLUES

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It is a transient state of mental illness observed 4-5 days after delivery and it lasts for few days.  Nearly 50% of the post partum women suffer from the problem.  Manifestations are ² depression, anxiety, tearfulness, insomnia, helplessness and negative feelings towards the infant.  No specific metabolic or endocrine abnormalities have been detected. But lowered tryptophan level is observed. It suggests altered neuro transmitter function.  Treatment is reassurance and psychological support by the family members.

POST PARTUM DEPRESSION 
It is observed in 10-20% of mothers.  It is more gradual in onset over the first 4-6 months following delivery or abortion.  Changes in the hypothalamo-pituitary-adrenal axis may be a cause.  Manifestations loss of energy and appetite, insomnia, social withdrawal, irritability and even suicidal attitude.  Risk of recurrence is high (50-100%) in subsequent pregnancies.

Treatment
Treatment is started early. Fluoxetine or paroxetine (serotonin uptake inhibitors) is effective and has fewer side effects. It is safe for breast feeding also. Estrogen patch has also been used. General supportive measures are essential as in blues. If no prompt response with medication, psychiatric consultation is sought for. The overall prognosis is good. POST PARTUM PSYCHOSIS (SCHIZOPHRENIA)
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Observed in about one in 500 to 1000 mothers. Commonly seen in women with past history of psychosis or with a positive family history.  Onset is relatively sudden usually within 4 days of delivery.  Manifestations fear, restlessness, confusion followed by hallucinations, delusions and disorientation (usually manic or depressive). Suicidal, infanticide impulses may be present. In that case temporary separation and nursing supervision is needed.  Risk of recurrence in the subsequent pregnancy is 20-25% and there is increased risk of psychotic illness outside pregnancy also. Management:  A psychiatrist must be consulted urgently.  Admission is needed.  Chlorpromazine 150 mg stat and 50-150 mg three times a day is started.  Sublingual oestradiol (1 mg thrice daily) results in significant improvement. Electroconvulsive therapy is considered if it remains unresponsive or in depressive psychosis.  Lithium is indicated in manic depressive psychosis. In that case breast feeding is contraindicated. PSYCHOLOGICAL MANAGEMENT Most perinatal events are joyful. But when a fetal or neonatal death occurs special attention must be given to the grieving patient and her family. Perinatal grieving may also be due to unexpected hysterectomy, birth of a malformed or a critically ill infant. Physician, nurse and attending staff must understand the patient's reaction. RESPONSE TO PERINATAL DEATHS AND

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Management includes: Facilitating the grieving process, with support and sympathy. Others are : supporting the couple in seeing or holding or tacking photographs of the infant; autopsy requests, planning investigations, follow up visit and plan for subsequent pregnancy.

RESEARCH STUDIES
ADVANCED LIFE SUPPORT IN OBSTETRICS (ALSO) AND POST-PARTUM

HEMORRHAGE: A PROSPECTIVE INTERVENTION STUDY IN TANZANIA.

Sorensen BL, Rasch V, Massawe S, Nyakina J, Elsass P, Nielsen BB. Source Department of International Health, Immunology and Microbiology, Faculty of Health Sciences, University of Copenhagen Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark Muhimbili University of Health and Allied Sciences, Dar es-Salaam Kagera Regional Hospital, Bukoba Town, Tanzania Institute of Psychology, Faculty of Social Sciences, University of Copenhagen Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark. Abstract Objective. 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. Design. Prospective intervention study. Setting. A regional, referral hospital. Population. A total of 510 women delivered before and 505 after the intervention. Methods. All high- and mid-level providers
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involved in childbirth at the hospital attended a two-day ALSO provider course. Staff management was observed and post-partum bleeding assessed at all vaginal deliveries for seven weeks before and seven weeks after the training. Main Outcome Measures. PPH (blood loss •500ml), severe PPH (blood loss •1000ml) and staff performance to prevent, detect and manage PPH. Results. The incidence of PPH was significantly reduced from 32.9 to 18.2%[RR 0.55 (95%CI: 0.44-0.69)], severe PPH from 9.2 to 4.3%[RR 0.47 (95%CI: 0.29-0.77)]. The active management of the third stage of labor was also significantly improved. There was a significant decrease in episiotomies. By visual estimation, staff identified one in 25 of the PPH cases before the ALSO training and one in five after the training. A significantly higher proportion of women with PPH had continuous uterine massage, oxytocin infusion and bimanual compression of the uterus after the training. Conclusions. A two-day ALSO training course can significantly improve staff performance and reduce the incidence of PPH, at least as evaluated by short-term effects.

POSTPARTUM

OVARIAN

VEIN

THROMBOSIS

CAUSING

SEVERE

HYDRONEPHROSIS.

Holmström SW, Barrow BP. Source University of South Florida, Tampa, Florida, USA. sholmstr@health.usf.edu

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Abstract BACKGROUND: Ovarian vein thrombosis is a rare postpartum complication. The diagnosis is often delayed, given that the differential diagnosis is broad. This case illustrates an unusual presentation of postpartum ovarian vein thrombosis. 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. A computed tomographic scan demonstrated severe right

hydronephrosis and right pyelocalyceal rupture and was suggestive of a right ovarian vein thrombosis. She was admitted and treated with a right nephrostomy tube and anticoagulation. Four weeks after nephrostomy tube placement, she underwent right antegrade nephrostography, and free flow of contrast from her distal ureter to her bladder was seen without evidence of obstruction. 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.

Evron S, Dimitrochenko V, Khazin V, Sherman A, Sadan O, Boaz M, Ezri T.

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

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MEASUREMENTS: Duration of the second stage of labor, dose of local anesthetics given, and primary outcomes were compared by group using the t-test for independent samples. Main secondary outcomes were postpartum urinary retention and rate of postpartum urinary tract infection (UTI; asymptomatic bacteruria). MAIN RESULTS: Duration of the second stage of labor was longer in Group CC than Group IC: 105 +/- 72 vs. 75 +/- 52 min (P = 0.002). This finding was associated with increased local anesthetic dose requirement in Group CC during both stages of labor (73 +/25 mL vs. 63 +/- 26 mL; P = 0.005). The rate of UTI was similar (30%) in both study groups. CONCLUSION: Intermittent bladder catheterization was associated with shorter second-stage labor and less local anesthetic, but the same frequency of postpartum urinary retention and UTI was seen with both catheterization groups.

SUMMARY
Today we have discussed about the minor ailments of puerperium like after pains, breast engorgement, suppression of lactation, perineal stitch pain, suppression of lactation, constipation and complications of puerperium like puerperal pyrexia, puerperal sepsis, urinary tract complications, breast

complications, venous thrombosis, pulmonary embolism, puerperal emergencies, psychiatric disorders etc

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CONCLUSION
Following the birth of the baby and expulsion the placenta, the mother enters a period of physical and psychological recuperation. From a medical and physilogicak view point this period is called the puerperium, starts immediately after the delivery of the placenta and membranes and continues for 6 weeks.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,ensure the bonding between the mother and baby, and to prevent many complications.and to prevent such complications care must be taken not only at one particular stage, but through out the pregnancy,intranatal period and in postnatal period also.

BIBLIOGRAPHY 
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