Complications during post partum period

1. Hemorrhagic complications
a. Retained placenta
b. Uterine atony
c. Inversion of the uterus
d. Subinvolution of the uterus
e. Laceration of the birth canal
2. Maternal infections

HEMORRHAGIC COMPLICATIONS
Obstetrical hemorrhage along with hypertension and infection forms the triad of the most common
cause of maternal death both in developed and underdeveloped countries. Postpartum hemorrhage
describes an event rather than a diagnosis, and when encountered, its etiology must be determined.
Common causes include bleeding from the placental implantation site, trauma to the genital tract and
adjacent structures, or both.

Definition: Traditionally, postpartum hemorrhage has been defined as the loss of 500 mL of blood or
more after completion of the third stage of labor. There are, however, some problems with this
Definition:
 Estimates of blood loss are notoriously low, often half the actual loss. Blood is mixed with
amniotic fluid and sometimes with urine. It is dispersed on sponges, towels and linens, in
buckets and on the floor.
 The importance of a given volume of blood loss varies with the woman’s hemoglobin level. A
woman with a normal hemoglobin level will tolerate blood loss that would be fatal for an
anemic woman.
 Bleeding may occur at a slow rate over several hours; the condition may not be recognized until
the woman suddenly enters shock. Even healthy, non-anemic women can have catastrophic
Blood loss.

The blood volume of a pregnant woman with normal pregnancy-induced hypervolemia usually increases
by 30 to 60 percent. This amounts to 1500 to 2000 mL for an average-sized woman. A normal pregnant
woman tolerates, without any remarkable decrease in postpartum hematocrit, a blood loss at delivery
that approaches the volume of blood that she added during pregnancy. Thus, if blood loss is less than
the amount added by pregnancy, the hematocrit stays the same acutely and during the first several
days. It eventually increases as normal plasma volume shrinks postpartum

Hemostasis at the Placental Site: Near term, it is estimated that at least 600 mL/min of blood flows
through the intervillous space. With separation of the placenta, these vessels are avulsed. Hemostasis
at the placental implantation site is achieved first by contraction of the myometrium that compresses
this formidable number of relatively large vessels. This is followed by subsequent clotting and
obliteration of their lumens. Thus, adhered pieces of placenta or large blood clots that prevent effective
myometrial contraction can impair hemostasis at the implantation site.

Predisposing Conditions: Hemorrhage can be caused by a number of factors. There are also a myriad
of circumstances which increases the risk for obstetrical hemorrhage. The table below will show that
hemorrhage can occur anytime throughout pregnancy, delivery and peurperium.
 Predisposing Factors and Causes of Postpartum Hemorrhage and
Vulnerable Patients
Abnormal Placentation
Placenta previa
Placental abruption
Placenta accrete/ increta/ percreta
Ectopic Pregnancy
Hydatidiform mole
Injuries to the Birth Canal
Episiotomy and Laceration
Forceps and Vacuum delivery
Cesarean delivery or hysterectomy
Uterine rupture
Previously scarred uterus High parity
Hyperstimulation Obstructed labor
Intrauterine manipulation midforceps rotation
Breech extraction
Obstetrical Factors
Obesity
Previous postpartum hemorrhage
Early preterm pregnancy
Sepsis syndrome
Uterine Atony
Uterine overdistention
Large Fetus Multiple fetuses
Hydramnios Retained clots
Labor induction
Anesthesia or analgesia
Labor abnormalities
Rapid labor Prolonged labor
Augmented labor Chorioamnionits
Previous Uterine surgery
Coagulation Defects – Intensify other causes
Massive transfusion Placental Abruption
Sepsis syndrome Severe Preeclampsia syndrome
Acute Fatty liver Anticoagulation treatment
Congenital coagulopathies Amniotic fluid Embolism
Prolonged retention of dead fetus Saline-induced abortion
Vulnerable Patients
Preeclampsia/eclampsia
Chronic renal insufficiency
Constitutionally small size

Blood Loss Estimation: Estimation is usually inaccurate. Postpartum bleeding may begin before or after
placental separation. Instead of sudden massive hemorrhage, there usually is steady bleeding. At any
given instant, it appears to be only moderate, but may persist until serious hypovolemia develops. After
placental delivery, constant seepage can lead to enormous blood loss. The effects of hemorrhage will
depend to a considerable degree on the nonpregnant blood volume and the corresponding magnitude
of pregnancy-induced hypervolemia. In some women after delivery, blood may not escape vaginally but
instead may collect within the uterine cavity, which can become distended by 1000 mL or more of
blood. It is then important to monitor the uterus immediately postpartum.

Timing of Hemorrhage
1. Antepartum Hemorrhage – bleeding during various times in gestation may give a clue as to its
cause. Bleeding during the first half of pregnancy maybe due to abortion or ectopic pregnancy.
Slight vaginal bleeding during active labor (bloody show) is the consequence of effacement and
dilatation of the cervix. Uterine bleeding coming from the cervix may be due to placenta previa,
abruption placenta or rarely, vasa previa.
2. Post-partum hemorrhage – frequently due to uterine atony or bleeding from genital tract
trauma.

Types of Postpartum Hemorrhage:

1. Immediate PPH – increased vaginal bleeding within the first 24 hours after childbirth
2. Delayed PPH or Late PPH – vaginal bleeding following the first 24 hours after childbirth

Diagnosis of PPH
Except possibly when intrauterine and intravaginal accumulation of blood is not recognized, or in some
instances of uterine rupture with intraperitoneal bleeding, the diagnosis of postpartum hemorrhage
should be obvious. The differentiation between bleeding from uterine atony and that from genital tract
lacerations is tentatively determined by predisposing risk factors and the condition of the uterus. If
bleeding persists despite a firm, well-contracted uterus, the cause of the hemorrhage most likely is from
lacerations. Bright red blood also suggests arterial blood from lacerations. To confirm that lacerations
are a cause of bleeding, careful inspection of the vagina, cervix, and uterus is essential.
Sometimes bleeding may be caused by both atony and trauma, especially after major operative delivery.
Inspection of the cervix and vagina should be performed after every delivery to identify hemorrhage
from lacerations.

Prevention of PPH
1. Immediate oxytocin – 10 units oxytocin IM within 1 minute of delivery of the baby, if not
available, give ergometrine 0.2mg IM
2. Controlled cord traction – place the other hand just above the woman’s pubic bone and stabilize
the uterus by applying counter traction during controlled cord traction to prevent inversion of
the uterus.
3. Early latching on – the newborn is placed skin-to-skin contact onto the mother’s chest and
allowed to latch within the first 30 minutes to one hour of life. This triggers an oxytocin surge
which stimulates both uterine cramping and the letdown reflex.
4. Uterine massage – immediately massage the fundus of the uterus through the woman’s
abdomen until the uterus is contracted.

COMMON CAUSES OF PPH

1. RETAINED PLACENTA

Definition: In a term pregnancy, the normal third stage of labor lasts 10-15minutes. Retained placenta
is used when the placenta has not been delivered within one hour after the birth of the baby. Between
30-45 minutes following birth, spontaneous delivery of the placenta can be expected in 20%-30% of
cases. In a minority of cases, the placenta will deliver between 45-60minutes of the delivery. Beyond 60
minutes, spontaneous placental delivery is highly unlikely. Active management of the third stage of
labor (AMTSL) will shorten the usual length of the third stage of labor.
Retained placenta is a potentially life-threatening complication of the third stage of labor. If
untreated, as may happen after home delivery, there is a high risk of maternal death due to hemorrhage
or infection. The current standard management is manual removal of the placenta. This is done by
passing a hand through the vagina into the cavity of the uterus, and usually requires general anesthesia

Assessment: If the placenta has not delivered within 30 minutes after birth, ensure that the woman’s
bladder is empty. Ask the mother to urinate or catheterize the bladder is necessary. If the placenta still
has not delivered:
1. Performing a visual inspection of the introitus may reveal the placenta sitting just inside the
vagina. If you can see the placenta, ask the woman to push it.
2. If the placenta is not immediately visible, a vaginal examination may reveal the placenta sitting
in the upper vaginal vault. In that case, if the uterus is well contracted, you may be able to
deliver the placenta using controlled cord traction while applying suprapubic counter-pressure
on the uterus with the other hand. This will usually result in delivery of the placenta. Avoid
forceful cord traction and fundal pressure as they may cause uterine inversion.
3. If placenta still not expelled, give oxytocin 10 units IM if not already done. Do NOT give ergot
alkaloids because they cause tonic uterine contraction which may delay expulsion of the
placenta.

Management:
1. Umbilical vein injection with oxytocin is an inexpensive and simple intervention.
2. If in spite of controlled cord traction, administration of uterotonics and umbilical vein injection,
the placenta is not delivered; manual extraction should be offered as the definitive
management.
3. Prophylactic antibiotic (ampicillin and Metronidazole) should be given after manual delivery of
the placenta

Normal placental delivery:

.
Manual removal of the placenta: This is a life saving procedure. It is an invasive procedure associated
with increased risk of infection, perforation of the uterine wall, or genital tract trauma. For this reason,
it should NOT be done routinely or prophylactically. The procedure is painful hence appropriate
analgesia should be used.
1. Wearing sterile gloves insert your dominant hand into the vagina and follow the umbilical cord
up into the uterus.
2. At the same time, place your second hand up over the abdomen in order to support the fundus
of the uterus. This provides counter-traction during exploration and prevents inversion of the
uterus.
3. Gently palpate (feel around) the inside of the uterine cavity to ensure that all placental tissue
has been delivered.
4. If placental fragments are found, explore the entire cavity of the uterus until a line of cleavage is
identified between the placenta and the uterine wall.
5. To detach the placenta, placental lobes or fragments from the implantation site, keep your
fingers tightly together and use the edge of the hand to gradually make a space between the
placenta and the uterine wall.
6. Proceed slowly all around the placental bed until the whole placenta, placental lobe or
fragments feel as if they have been peeled or detached from the uterine wall.
7. Slowly withdraw your hand from the uterus while holding the placental lobe or fragments.
8. At the same time, use your other hand to provide counter-pressure to the fundus by pushing it
in the opposite direction of the hand that you are withdrawing.
9. Following removal, inspect the placenta if it is complete.

If you have difficulty separating the placenta from the uterine wall, suspect accreta and refer the woman
to a higher facility for laparotomy.
Introducing one hand into the vagina along the cord supporting the fundus while detaching the placenta

2. UTERINE ATONY

Definition: This is the most frequent cause of obstetrical hemorrhage. Uterine atony is defined as
failure of the uterus to contract adequately following delivery. This results in a soft and boggy uterus
leading to postpartum bleeding. Recognition of such trigger a series of interventions to achieve tone for
the uterus

Risk Factors:
1. Factors associated with uterine overdistention
 Multiple pregnancy
 Polyhydramnios
  Fetal macrosomia
2. Labor-related factors
 Induction of labor
 Prolonged labor
 Precipitate labor
 Oxytocin augmentation
 Manual removal of the placenta
3. Use of uterine relaxants
 Deep anesthesia
 Magnesium sulfate
4. Intrinsic factors
 Previous post-partum hemorrhage
 Placental abruptio or previa
 Obesity
 Age >35 yrs old

Prevention of uterine atony

 Active management of the third stage of labor is the best practice for the prevention of uterine
atony with the use of uterotonics being its most important component.
 AMTSL: use of uterotonics, controlled cord traction, delayed cord clamping
 All women giving birth should receive uterotonics during the third stage of labor. OXYTOCIN is
the uterotonic drug of choice.
 The preferred route of administration of oxytocin is intravenous. Intramuscular administration
gives the advantage of ease of administration and requires relatively less skill.
 In the absence of oxytocin, other injectable uterotonics that can be used.
 Delayed cord clamping (1 to 3 minutes) is recommended for all births while initiating
simultaneous newborn care more for the benefit of the newborn and not for prevention of PPH.
 Controlled cord traction is recommended in both vaginal and cesarean deliveries.

Other intervention:
*Bimanual uterine compression *External aortic compression
*Intrauterine balloon tamponade * compression sutures

*hypogastric artery ligation *uterine artery embolization

3. UTERINE INVERSION -

Definition: Peurperal inversion of the uterus is considered to be one of the classic hemorrhagic
disasters encountered in obstetrics. Unless promptly recognized and managed appropriately, associated
bleeding often is massive. Risk factors include alone or in combination:
1. Fundal placental implantation
2. Delayed-onset or inadequate uterine contractility after delivery of the fetus, that is
uterine atony
3. Cord traction applied before placental separation
4. Abnormally adhered placentation such as with the accrete syndrome

Management options:
1. Immediate treatment of hemorrhagic shock
2. Replacement of the uterus
Replacement of the uterus
1. Manually by pushing the uterus back through the cervical ring
2. Hydrostatic pressure – a bag of warmed fluid is hung on a pole used for intravenous
fluids above the level of the patient and allowed to flow, via tubing, into the vagina. The
pressure of the water results in correction of the inversion.
3. Administer smooth muscle relaxants such as terbutaline a beta-adrenergic agonist,
nitroglycerin or magnesium sulfate may facilitate replacement of the uterus.
4. Adequate analgesia is required through intravenous sedation or general anesthesia.
5. Uterotonic drugs should be given immediately after repositioning of the uterus

 Hysterectomy is regarded the last resort of management after repositioning the uterus
and medical treatment failed.
 Antibiotic prophylaxis is advisable

4.UTERINE SUBINVOLUTION
Definition: Uterine involution is the shrinking process of the uterus. It is the process by which the
puerperal uterus is normally restored to its nonpregnant state of the uterus. The fundus of the uterus is
noted at or just below the umbilicus immediately postpartum. By ten days, the postpartum uterus is not
palpable. Delayed or absent involution of the uterus during postpartum period is called uterine
subinvolution. The causes of subinvolution are numerous factors that interfere with complete
contraction of the myometrium. Among the important causes include retained placental fragments,
uterine fibromyomas and infection.

Diagnosis: Regardless of the cause of the condition, it is characterized by longer and heavier bleeding
after childbirth and, on pelvic examination, a larger and softer uterus than would be expected at that
time.

Treatment: includes oral ergonovine for 2-3 days, and if infection is present, antibiotic. The
hemoglobin/hematocrit is also evaluated and iron is given if necessary. Retained placental fragment is
best managed by prompt curettage.

5.GENITAL TRACT TRAUMA

A. Lacerations of the birth canal
B. Genital tract hematoma

 Genital tract trauma is the second most common cause of postpartum bleeding with an
approximate incidence of 20%. It involves laceration to the perinuem, vagina, or cervix; large
episiotomy including extensions; ruptured uterus; and uterine inversion
 Bleeding from genital injury is a major cause of morbidity and mortality in several disorders
involving the female reproductive tract. Such morbidity associated with childbirth may have
immediate and long-term effects on the physical, psychological, and social well-being of the
woman after delivery.
A. GENITAL TRACT LACERATIONS:
 Perineal trauma may occur spontaneously or arise from episiotomy during vaginal delivery.
There are several classifications of spontaneous perineal trauma. It can be classified according
to location or depth of the perineal tissue involved.

 Classification based on location:

a. Anterior perineal trauma – injury involving the labia, anterior vagina, urethra or clitoris
b. Posterior perineal trauma – injury to the posterior vaginal wall, perineal muscles or anal
sphincters and may extend to the rectum.
 Classification according to the degree or depth of the laceration:
o First degree - involves the fourchette, perineal skin, and vaginal mucosa but not the
underlying fascia and muscle
o Second degree – aside from the skin and mucous membrane, the fascia and muscles of
the perineal body are involved
o Third degree- lacerations extend through the skin, mucous membrane, perineal body
and anal sphincter
i. 3a: less than 50% of external anal sphincter thickness torn
ii. 3b: more than 50% of the external anal sphincter thickness torn
iii. 3c: both external and internal anal sphincter torn
c. Fourth degree – injury to the perineum involving the anal sphincter complex (external
and internal anal sphincter) and anal epithelium (rectal mucosa)
 Cervical lacerations:
d. Intrapartum cervical laceration have an overall incidence of 25-90% and most cases are
symptomatic. On the other hand, the clinically significant cervical lacerations
complicate 0.2% to 4.8% of all vaginal deliveries. Minor cervical lacerations are most
often undetected since most of these would be less than 0.5cm. Cervical tears may
extend to the upper third of the vagina.
e. Any cervical tear which is actively bleeding and or 2cm in length or longer should be
sutured.
3. It has been reported that women who had episiotomies or spontaneous perineal lacerations
have greater perineal pain or discomfort, decreased sexual satisfaction postnatally, and delayed
return of sexual activity than those who had intact perineum after delivery. This may disrupt
breastfeeding, family life and sexual relations depending on the severity of perineal trauma and
effectiveness of treatment.
4. Genital tract lacerations can be suspected when bleeding persists despite a well-contracted
uterus and administration of multiple uterotonics.
5. Restricting the use of episiotomy can reduce the incidence of severe perineal trauma.
6. Minimizing the use of operative vaginal delivery (vacuum or forceps) can decrease the incidence
of severe perineal trauma
7. Principles of perineal laceration repair:
a. Absorbable synthetic material (polyglycolic acid and polyglactin 910) to repair perineal
trauma. This is associated with less perineal pain, analgesic use, dehiscence and
resuturing.
b. Use polyglycolic acid 2-0 or PDS 3-0 absorbable suture with tapered needle to repair
cervical laceration
c. Continuous subcuticular suture for repair of perineal skin, and loose continuous non-
locking suturing technique to appose vaginal tissue, and perineal muscles
d. Only experienced health provider should repair difficult trauma under regional or
general anesthesia done in the operating room
e. Always perform vaginal and rectal examination postoperatively to check for bleeding,
hematoma, and ensure that the suture material has not been accidentally inserted
through the rectal mucosa
8. Resume sexual intercourse at 3-6 months after repair of laceration

9. Episiotomy should not be performed routinely. Routine episiotomies are no longer standard or
recommended practice, but there are instances when a midwife may need to perform the
procedure.
10. Review for indications.
• Allow more space for operative or manipulative vaginal delivery (breech, shoulder dystocia,
forceps, vacuum extraction);
 Prevent damage of the fetus during face or breech presentation or during instrumental
delivery.
• accommodate issues associated with scarring from female genital cutting or poorly healed
third or fourth degree tears;
• shorten the second stage of labor for fetal distress or maternal condition
 Aid the delivery of the presenting part when the perineum is tight and causing poor progress
in the second stage of labor.
11. Steps in performing an episiotomy:
1. Apply antiseptic solution to the perineal area.
2. Use local infiltration with lidocaine. Make sure there are no known allergies to lidocaine.
Infiltrate beneath the vaginal mucosa, beneath the skin of the perineum and deeply into the
perineal muscle using about 10 mL 0.5% lidocaine solution.
Note: Aspirate (pull back on the plunger) to be sure that no vessel has been penetrated. If blood
is aspirated, remove the needle. Recheck the position carefully and try again. Never inject if
blood is aspirated. The woman can suffer convulsions and death if IV injection of lidocaine
occurs.
*Anaesthetize early to provide sufficient time for effect.
3. Wait to perform episiotomy until the perineum is thinned out; and 3–4 cm of the baby’s head is
visible during a contraction. Timing is important. If the procedure is undertaken too early, the
presenting part will not be pressing on the perineum, and therefore complications associated
with increased bleeding may occur.
4. After sufficient time for the anesthesia to take effect, the incision should be made. Wearing
high-level disinfected or sterile gloves, place two fingers between the baby’s head and the
perineum. Use scissors to cut perinuem about 3-4cm in the Mediolateral direction. Ideally, the
incision is made during a contraction, when there is a clear view due to stretched tissue and a
reduced likelihood of severe bleeding.
5. Immediately after the incision, controlled birth of the head should occur, ensuring there is no
extension of the episiotomy incision.
6. Carefully examine for extensions and other tears and repair.
12. Repair of episiotomy:
1. Apply antiseptic solution to the area around the episiotomy
2. Close the vaginal mucosa using continuous 2-0 suture
a. Start the repair about 1 cm above the apex (top) of the episiotomy. Continue the suture
to the level of the vaginal opening;
b. At the opening of the vagina, bring together the cut edges of the vaginal opening;
c. Bring the needle under the vaginal opening and out through the incision and tie.
d. Close the perineal muscle using interrupted 2-0 sutures.
e. Close the skin using interrupted or subcuticular 2-0 sutures
3. Do rectal examinations after repair
Complications:
1. If a hematoma occurs, open and drain. If there are no signs of infection and bleeding has
stopped, reclose the episiotomy.
2. If there are signs of infection, open and drain the wound. Remove infected sutures and debride
the wound:
a. If the infection is mild, antibiotics are not required;
b. If the infection is severe but does not involve deep tissues, give a combination of
antibiotics (Ampicillin plus Metronidazole)
3. If the infection is deep, involves muscles and is causing necrosis (necrotizing fasciitis), give a
combination of antibiotics until necrotic tissue has been removed and the woman is fever-free
for 48 hours.

B. Genital tract Hematoma

 The pregnant uterus, vagina and vulva have rich vascular supplies that are at risk of trauma
during the birth process, and the trauma may result in formation of a hematoma. Peurperal
genital hematomas are relatively uncommon but can be a cause of serious morbidity and
even maternal death. Hematomas occur in 1:3000to 1:5000 deliveries, and rarely, is
potentially life-threatening complication of childbirth.

 Genital tract hematomas are classified according to their anatomical location. The most
common locations for puerperal hematomas are the vulva, vaginal/paravaginal area, and
retroperitoneum/subperitoneal.

 Vulvar hematomas are limited to the vulvar tissues superficial to the anterior urogenital
diaphragm, while vulvovaginal hematomas may extend to the paravaginal area. These types
of hematoma arise from injury to the branches of the pudendal artery including the inferior
rectal, transverse perineal, or posterior labial branches, as a result of episiotomy or perineal
laceration

Risk factors include: nulliparity, prolonged second stage of labor, instrumental delivery, big baby
(greater than 4000g), genital tract varicosities, maternal age more than 29years, preeclampsia,
multiple pregnancy and clotting disorder.

Signs and symptoms: excessive perineal pain is a hallmark symptom of puerperal hematoma. A
change in vital signs disproportionate to the amount of blood loss should also prompt a gentle pelvic
examination.

Management: large hematomas (>3cm) are best managed with surgical evacuation, primary closure
and compression for 12-24 hours. Small, non-expanding hematomas (<3cm) can be managed
conservatively.
 MATERNAL INFECTIONS
Definition:
Puerperal infection is a general term used to describe any bacterial infection of the genital tract after
delivery. Along with preeclampsia and obstetrical hemorrhage, puerperal infection formed the lethal
triad of causes of maternal deaths for many decades of the 20th century.

Puerperal Fever
A number of factors can cause fever—a temperature of 38.0°C (100.4°F) or higher—in the puerperium.
Most persistent fevers after childbirth are caused by genital tract infection. Other common causes of
puerperal fever are breast engorgement and pyelonephritis or occasionally respiratory complications
after cesarean delivery.
 About 15 percent of women who do not breast feed develop postpartum fever from breast
engorgement. Acute pyelonephritis has a variable clinical picture, and postpartum, the first sign
of renal infection may be fever, followed later by costovertebral angle tenderness, nausea, and
vomiting. Atelectasis is caused by hypoventilation and is best prevented by coughing and deep
breathing on a fixed schedule following surgery. Fever associated with atelectasis is thought to
follow infection by normal flora that proliferates distal to obstructing mucous plugs. Minor
temperature elevations in the puerperium may also occasionally be caused by superficial or
deep-venous thrombosis of the legs.

 General management:
1. Encourage bed rest
2. Ensure adequate hydration (oral or IV)
3. Tepid sponge bath to help decrease temperature
4. If shock is suspected or develops, immediately begin treatment

Diagnosis of fever after childbirth

Presenting Symptom and Other Symptoms and Signs Probable Diagnosis

Symptoms and Signs Typically Sometimes Present
Present
• Fever/chills • Light vaginal bleeding Metritis
• Lower abdominal pain • Shock
• Purulent, foul-smelling lochia
• Tender uterus
• Lower abdominal pain and • Poor response to antibiotics Pelvic abscess
distension • Swelling in adnexa or pouch of
• Persistent spiking fever/chills Douglas
• Tender uterus • Pus obtained upon culdocentesis
• Low-grade fever/chills • Rebound tenderness Peritonitis
• Lower abdominal pain • Abdominal distension
• Absent bowel sounds • Anorexia
• Nausea/vomiting
• Shock
• Breast pain and tenderness • Hard enlarged breasts Breast engorgement
• 3–5 days after delivery • Both breasts affected
• Breast pain and tenderness • Inflammation preceded by Mastitis
• Reddened, wedge-shaped area engorgement
on breast • Usually only one breast affected
• 3–4 weeks after delivery
• Firm, very tender breast • Fluctuant swelling in breast Breast abscess
• Overlying erythema • Draining pus
• Unusually tender wound with • Slight erythema extending Wound abscess, wound
bloody or serous discharge beyond edge of incision seroma or wound
hematoma
• Painful and tender wound • Hardened wound Wound cellulitis
• Erythema and edema beyond • Purulent discharge
edge of incision • Reddened area around wound
• Dysuria • Retropubic/suprapubic pain Cystitis
• Increased frequency and • Abdominal pain
urgency of urination
 Dysuria • Retropubic/suprapubic pain Acute pyelonephritis
• Spiking fever/chills • Loin pain/tenderness
• Increased frequency and • Tenderness in rib cage
urgency of urination • Anorexia
• Abdominal pain • Nausea/vomiting
 Spiking fever despite antibiotics • Calf muscle tenderness Deep vein thrombosis
• Fever • Consolidation Pneumonia
• Difficulty in breathing • Congested throat
• Cough with expectoration • Rapid breathing
• Chest pain • Rhonchi/rales
• Fever • Typically occurs postoperative Atelectasis
• Decreased breath sounds
• Fever • Enlarged spleen Uncomplicated malaria
• Chills/rigors
• Headache
• Muscle/joint pain
• Symptoms and signs of • Convulsions Severe/complicated
uncomplicated malaria • Jaundice Malaria
• Coma
• Anemia
• Fever • Confusion Typhoid
• Headache • Stupor
• Dry cough
• Malaise
• Anorexia
• Enlarged spleen
• Fever • Muscle/joint pain Hepatitis
• Malaise • Urticaria
• Anorexia • Enlarged spleen
• Nausea
• Dark urine and pale stool
• Jaundice
• Enlarged liver
1.Uterine Infection: METRITIS
 Postpartum uterine infection has been called variously endometritis, endomyometritis, and
endoparametritis.
 Predisposing Factors:
1. The route of delivery is the single most significant risk factor for the development of uterine
infection. Nearly 25-fold increased infection-related mortality rate is seen with cesarean versus
vaginal delivery.
2. Prelabor membrane rupture
3. Multiple cervical examinations
4. Cesarean Delivery- Single-dose perioperative antimicrobial prophylaxis is given almost
universally at cesarean delivery. This decreased the incidence and severity of postcesarean
delivery infections than any other practice in the past 30 years.
5. Lower socioeconomic status.
6. Cesarean delivery for multifetal gestation,
7. young maternal age
8. nulliparity
9. prolonged labor induction
10. Obesity
11. meconium-stained amnionic fluid

 Common Pathogens: Infections are polymicrobial. Although the cervix and vagina routinely
harbor such bacteria, the uterine cavity is usually sterile before rupture of the amnionic sac. As
the consequence of labor and delivery and associated manipulations, the amnionic fluid and
uterus commonly become contaminated with anaerobic and aerobic

NORMAL FLORA
CERVICOVAGINAL FLORA
*Cervical examinations
*internal monitoring
*prolonged labor
*uterine incision

INOCULATION OF UTERINE INCISION

ANEROBIC CONDITIONS
*Surgical trauma
*sutures
*devitalized tissue
*blood and serum

BACTERIAL PROLIFERATION
CLINICAL INFECTION
 Bacteria Commonly Responsible for Female Genital Infections
Aerobes
Gram-positive cocci—group A, B, and D streptococci, enterococcus, Staphylococcus aureus,
Staphylococcus epidermidis
Gram-negative bacteria—Escherichia coli, Klebsiella,Proteus species
Gram-variable—Gardnerella vaginalis
Others
Mycoplasma and Chlamydia species, Neisseria gonorrhoeae
Anaerobes
Cocci—Peptostreptococcus and Peptococcus species
Others—Clostridium and Fusobacterium species Mobiluncus species

 Diagnosis: Fever is the most important criterion for the diagnosis of postpartum metritis.
Temperatures commonly are 38 to 39°C. Chills that accompany fever suggest bacteremia.
Women usually complain of abdominal pain, and parametrial tenderness is elicited on
abdominal and bimanual examination. Although an offensive odor may develop, many women
have foul-smelling lochia without evidence for infection.
 Treatment: If mild metritis develops after a woman has been discharged following vaginal
delivery, outpatient treatment with an oral antimicrobial agent is usually sufficient. For
moderate to severe infections, however, intravenous therapy with a broad-spectrum
antimicrobial regimen is indicated. Improvement follows in 48 to 72 hours in nearly 90 percent
of women treated with one of several regimens. Persistent fever after this interval mandates a
careful search for causes of refractory pelvic infection. The woman may be discharged home
after she has been afebrile for at least 24 hours.
 If retained placental fragments are suspected, perform a digital exploration of the uterus to
remove clots and large pieces. Use ovum forceps or a wide curette if required.
 If there is no improvement with conservative measures and there are signs of general peritonitis
(fever, rebound tenderness, abdominal pain), perform a laparotomy to drain the pus.
 If the uterus is necrotic and septic, perform subtotal hysterectomy


PELVIC ABSCESS
Management: Give a combination of antibiotics before draining the abscess and continue until the
woman is fever-free for 48 hours. For spinking fever, perform a laparotomy.

BREAST ENGORGEMENT
Definition: This is an exaggeration of the lymphatic and venous engorgement that occurs before
lactation. It is not the result of over distention of the breast with milk. This is commonly seen in women
who do not breastfeed. It peaks 3-5 days after delivery.

Management:
1. Breastfeeding women:
  If the woman is breastfeeding and the baby is not able to suckle, encourage the woman to
express milk by hand or with a pump.
o If the woman is breastfeeding and the baby is able to suckle:
o Encourage the woman to breastfeed more frequently, using both breasts at each
feeding;
o Show the woman how to hold the baby and help it attach;
o Relief measures before feeding may include:
- Apply warm compresses to the breasts just before breastfeeding, or encourage the
woman to take a warm shower;
- Massage the woman’s neck and back;
- Have the woman express some milk manually before breastfeeding and wet the nipple
area to help the baby latch on properly and easily;
o Relief measures after feeding may include:
- Support breasts with a binder or brassiere;
- Apply cold compress to the breasts between feedings to reduce swelling and pain;
- Give paracetamol 500 mg by mouth as needed;
- Follow up in three days to ensure response.
2. Not breastfeeding:
 if the woman is not breastfeeding:
o support breasts with a binder or well-fitting brassiere;
o apply cold compress to the breast to reduce swelling and pain;
o avoid massaging or applying heat to the breasts;
o avoid stimulating the nipples;
o give paracetamol 500 mg by mouth as needed;
o Follow-up in three days to ensure response.

BREAST INFECTION
1. MASTITIS
Definition: Parenchymatous infection of the mammary gland. Almost always unilateral and
marked engorgement usually precedes inflammation. Symptoms include chills or actual rigor,
which are soon followed by fever and tachycardia. The breast becomes hard and reddened, and
there is severe pain. About 10 percent of women with mastitis develop an abscess. Detection of
fluctuation may be difficult, and sonography may be helpful to detect an abscess.
Staphylococcus aureus is the most commonly isolated organism.

Treatment: Treat with antibiotics.

o Encourage the woman to breastfeed and support breasts with a binder or brassiere
o Apply cold compress to the breasts between feedings to reduce swelling and pain
o Give paracetamol as needed

2. BREAST ABSCESS
Abscess should be suspected when fever is not resolving within 48-72 hours of mastitis
treatment or when a mass is palpable.

Treatment:
o Drain the abscess
 o Encourage the woman to continue breastfeeding even when there is collection of pus,
support breasts with a binder or brassiere and apply cold compress to the breasts
between feeding to reduce pain and swelling
o Give paracetamol as needed

INFECTION OF PERINEAL AND ABDOMINAL WOUNDS

1. WOUND ABSCESS, WOUND SEROMA AND WOUND HEMATOMA
 If there is pus or fluid, open and drain the wound.
 Remove infected skin or subcutaneous sutures and debride the wound
 If there is an abscess, treat with antibiotics
 Advise woman good hygiene and wear clean pads or cloth

2. WOUND CELLULITIS AND NECROTIZING FASCIITIS

 If there is fluid or pus, open and drain the wound.
 Remove infected skin or subcutaneous sutures and debride the wound.
 Do not remove fascial sutures.
 If infection is superficial and does not involve deep tissues, monitor for development of an
abscess and give a combination of antibiotics
- ampicillin 500 mg by mouth four times per day for five days;
- PLUS metronidazole 400 mg by mouth three times per day for five days.
 If the infection is deep, involves muscles and is causing necrosis (necrotizing fasciitis), give
a combination of antibiotics until necrotictissue has been removed and the woman is fever-free
for 48 hours
- penicillin G 2 million units IV every six hours;
- PLUS gentamicin 5 mg/kg body weight IV every 24 hours;
- PLUS metronidazole 500 mg IV every eight hours;
- Once the woman is fever-free for 48 hours, give:
- ampicillin 500 mg by mouth four times per day for five days;
- PLUS metronidazole 400 mg by mouth three times per day for five days.

Note: Necrotizing fasciitis requires wide surgical debridement. Perform delayed primary closure two to
four weeks later, depending on resolution of infection.
• If the woman has a severe infection or necrotizing fasciitis, admit her to the hospital for
management and change wound dressing twice daily.