Presentation on

Postpartum
Complications

Submitted To, Submitted By,

Mrs.K Sampoorna, Miss. Dasari. Beulah,
Lecturer, MSc(N) 1st year,
Government College of Nursing, Government College of Nursing.
Name of the subject : Obstetrical and Gynaecological Nursing

Name of the topic : Postpartum Complications

Group : MSc Nursing 2nd year’s

Medium of instruction : English

Method of presentation : Lecture cum Discussion

Date and time : 23/03/2019 – 8 am to 10 am

Duration : 2 hours

Place : Government College of Nursing

Name of the student : Miss. Dasari Beulah

 PUERPERAL INFECTION

Introduction

Puerperal infection (also known as child bed fever) is a disease that occurs shortly
after childbirth. It is a leading cause of maternal death, accounting for up to 16% of
cases of mortality. It causes at least 75,000 maternal deaths worldwide per year, most of
which occur in developing countries. Postpartum urinary retention occurs in 10-15 % of
women (Yip et al. 1998; Lee et al. 1999)
“Puerperium is the period following the child birth during which the body tissues
especially the pelvic organ reverts back approximately to the pre-pregnant state both
anatomically and physiologically”. Puerperium begins as soon as the placenta is
expelled and last for approximately 6 weeks. Immediately following the delivery, the
uterus becomes firm and retracted with alternate hardening and softening. At delivery,
women’s uterus weighs approximately 1000g (2.2pounds) and by the end of Puerperium,
weight will be 60g (2 ounce). The uterus measures about 20x12x75cm (length, breadth,
thickness). The placental site contracts rapidly presenting a raised surface with measures
about 7.5cm and remains elevated even at 6 weeks when it measures about 1.5cm.
Immediately after delivery, the uterus lies midway between the symphysis pubis and
umbilicus. Within hours of delivery, it rises to the level of umbilicus or slightly above it.
The uterus begins its descent in to the pelvic cavity on the first postpartum day. It
diminishes rapidly in size, weight and position until the tenth day, when it may be
palpated at or below the level of symphysis pubis. The physiological process of
involution is most marked in the body of the uterus. Following the delivery, the major
part of the decidua is cast off with the expulsion of the placenta and the membranes,
more at the placental site. The Endometrium left behind varies in thickness from 2-4mm.
The superficial part containing the degenerated decidua, blood cells and bits of fetal
membranes becomes necrotic and is cast off in the lochia. Regeneration occurs from the
epithelium of the uterine gland mouths and interglandular stromal cells. Regeneration of
epithelium is completed by 10th day and entire Endometrium is restored by the day 16,
except at the placental site where it takes about 6weeks.

Definition
Puerperal infection/ puerperal pyrexia is a bacterial infection that occurs
following childbirth. The diagnostic criteria require that the childbearing woman have a
temperature elevated over 100.4°F (38°C) on any two of the first 10 post-partum days
after day one, or over 101.5°F (38.6°C) during the first 24 hours.

Causes
The causes of pyrexia are;
‫ ڃ‬Puerperal sepsis
‫ ڃ‬Urinary tract infection
‫ ڃ‬Mastitis
‫ ڃ‬Infection of caesarean wound
‫ ڃ‬Pulmonary infection
‫ ڃ‬Septic pelvic thrombophlebitis
‫ ڃ‬Malaria or pulmonary tuberculosis
‫ ڃ‬Unknown origin

Organisms
Those organisms recognized as the common causative agents are normally seen in
the lower bowel and lower genital tract.
(1) Anaerobic staphylococci.
(2) Anaerobic streptococci.
(3) Clostridium perfringens.
(4) Neisseria gonorrhea.
Pathology
 When the third stage of labor is completed, the placental attachment site is raw,
elevated, and dark red. The surface is nodular, owing to the numerous veins, and
offers an excellent portal of entry for microorganisms. The uterine decidua is very
thin and has many small openings that offer a portal for pathogens.
 In addition, small cervical, vaginal and perineal lacerations, as well as the
episiotomy site, provide entry ports for pathogens. The resultant inflammation and
infection can remain localized or can extend via blood or lymph vessels to other
tissues.

General risk factors

◦ History of cesarean delivery
◦ Premature rupture of membranes
◦ Frequent cervical examination (Sterile gloves should be used in
examinations. Other than a history of cesarean delivery, this risk factor is
most important in postpartum infection.)
◦ Internal fetal monitoring
◦ Preexisting pelvic infection including bacterial vaginosis
◦ Diabetes
◦ Nutritional status
◦ Obesity

Predisposing Factors
(1) Prolonged rupture of uterine membranes provides increased opportunity for
infection to develop prior to delivery.
(2) Retained placental fragments-provides additional medium for infectious growth.
 (3) Postpartal hemorrhage-causes decreased resistance to pathogens
(4) Preexisting anemia-low resistance to infection.
(5) A prolonged and difficult labor, especially with the involvement of instruments
(forceps).
(6) Intrauterine manipulations for fetal delivery or manual expulsion of placenta.

Preventive measures
(1) Restrict personnel with respiratory infections from working with patients.
(2) Use caps, mask, gowns, and gloves when working in delivery rooms.
(3) Use sterilized equipment within control dates.
(4) Wash hands meticulously (staff).
(5) Correct breaks in sterile techniques immediately.
(6) Instruct the patient on hand washing and cleansing her perineum from front to
back.
(7) Limit unnecessary vaginal exams during labor which increases the chances of
introducing organisms from the rectum and vagina into the uterus.

Kinds of Postpartal Infections

(1) Endometritis-invasion of microorganisms into the placental site of the uterine
wall.
(2) Pelvic cellulitis (parametritis)-infection that has spread beyond the endometrium
into the surrounding pelvic structures including the broad ligament.
(3) Peritonitis-an infection of the peritoneum, either generalized or localized.
(4) Salpingitis-an infection of the fallopian tubes following childbirth.
 PUERPERAL SEPSIS

Definition
An infection of the genital tract which occurs as a complication of delivery is
termed puerperal sepsis.
There has been a marked decline in puerperal sepsis during the past few decades. The
reasons are;
 Better obstetric care
 Improved health status and thereby increased general resistance to combat
infection
 Availability of wider range of antibiotics sensitive to the responsible organisms
 Declined virulence of streptococcus beta heamolyticus
Vaginal flora
The vaginal flora during pregnancy and labor includes;
 Doderlein bacillus (60-70%)
 Yeast like fungus with the increased prevalence of Candida albicans (25%)
 Staphylococcus albus or aureus
 Streptococcus
 Ecoli and cl. Welchi
The organisms remain dormant and are harmless during normal delivery conducted in
aseptic condition.
Predisposing factors of puerperal sepsis
The pathogenicity of the vaginal flora may be influenced by certain factors;
 Condition lowering the host resistance- general or local
 Multiplication of organism in the devitalized tissue(acid media) usually starts after
the two days following delivery
 Introduction of organism from outside
 Increased prevalence of organisms resistant to antibiotics
 Antepartum factors: malnutrition and anaemia, preterm labor, premature rupture
of membrane, chronic debilitating illness and prolonged rupture of membrane >18
hours.
 Intrapartum factors: repeated vaginal examinations, prolonged rupture of
membranes >18 hours, dehydration and ketoacidosis during labour, traumatic operative
delivery, haemorrhage- antepartum or postpartum, retained bits of placental tissue or
membranes, placenta praevia and caesarean delivery.
The organisms grow inside the traumatized tissues of the utero vaginal canal or in the
raw decidua left behind or in the blood clots especially in the placental site.
Microorganism responsible for puerperal sepsis and the pathology
 Aerobic- streptococcus heamolyticus group A (GAS) - toxic shock syndrome,
necrotizing fasciitis in episiotomy or caesarean section wound. Streptococcus
heamolyticus group B is a significant cause of neonatal septicemia, respiratory disease
and meningitis. Maternal risks are also high.
 Anaerobic- anaerobic streptococcus, bacteroides (fagilis, bivius, fusobacteria) and
clostridia.

Mode of infection
Puerperal sepsis is essentially a wound infection. Placental site, lacerations of
genital tract or caesarean section wounds may be infected in the following ways;
 The source of infection may be endogenous where organisms are present in the
genital tract before delivery; anaerobic streptococcus is the predominant pathogen.
 Infection may be autogenous, where organism present elsewhere in the body and
migrate it to the genital organs by blood streams or by the patient herself. Streptococcus
beta heamolyticus, e.coli, staphylococcus are important
 Exogenous: where the infection is contracted from sources outside the patient
(from hospital or attendants). Streptococcus beta heamolyticus, staphylococcus and e.
coli are important.
Pathology
The primary sites of infection are;
 Perineum
 Vagina
 Cervix
 Uterus
The infection is either localized to the site or spread to distant sites. The lacerations on
the perineum, vagina and cervix are often infected by the organism due to the presence
of blood clots or dead space. The wounds become red, swollen and associated
sangopurulent discharge. There may be disruption of the wound if repaired before
control of infection. Diabetes, obesity, low nutritional statuses are the other high risk
factors for wound infection.

 Perineum: lacerations on the perineum, whether repaired or not, are likely to be

infected by organism of low virulence like staphylococcus aureus or anaerobic
streptococcus. The wound edge becomes red and swollen. There may be collection of
sangopurulent discharge or pus which results in complete disruption of wound.
 Vagina: the vaginal infections are infected directly or by extension from the
perineal infection. The mucosa is swollen and hyperemic, resulting in necrosis and
sloughing. A retained and forgotten cotton plug may be left inside the vagina leading to
offensive vaginal discharge.
 Cervix: the cervical infection is quiet common as the cervix is commonly
lacerated and it is also the common site, for the pathogenic organism to harbor.
 Uterus: Endometritis; the incidence is 1-3% following vaginal delivery and about
10% following caesarean delivery. The decidua especially over the placental site is
primarily affected. The risk factors of Endometritis are retained products of conception,
caesarean section, chorioamnionitis, prolonged rupture of membrane, preterm labor and
repeated vaginal examinations in labor. The necrosed decidua sloughs off. The discharge
is offensive.

Spread of Infection
 Pelvic cellulitis (parametritis) is due to spread of infection to the pelvic cellular
tissues by direct or lymphatic or by haemotogenous routes. The infection causes
exudation and formation of an indurated mass usually confined to one side of the uterus.
the uterus in that case is pushed to the contralateral side.
 Salpingitis: may be interstitial or perisalpingitis. Endosalpingitis (tubal mucosa) is
uncommon. Pelvic abscess may be there
 Septic pelvic thrombophlebitis: may involve the ovarian veins, uterine veins,
pelvic vein and rarely inferior venacava. The infected thrombus may undergo complete
resolution or suppuration. The emboli may occlude the micro-circulation of the vital
organs like kidney or lungs.
 Septicemia and septic shock may be due to hemolytic streptococci or anaerobic
streptococci. Septicemia may cause lung abscess, meningitis, pericarditis, endocarditis
or multi organ failure. Death occurs in about 30% cases.

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 become 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, lochial discharge becomes
offensive and copious, the uterus is subinvoluted and tender.
Severe: the onset is acute with high rise in temperature, often with chills and rigor,
pulse rate is rapid, out of proportion to temperature, lochia may be scanty and odorless,
uterus may be subinvoluted, tender and softer. There may be associated wound
infections.
Spreading infection (extra uterine spread): is evidenced by the presence of pelvic
tenderness (pelvic peritonitis), tenderness on fornix (parametritis), bulging fluctuant
mass in the pouch of Douglas (pelvic abscess).

Investigations of puerperal sepsis

The underlying principles of investigations are;
 To locate the site of infection
 To identify the organism
 To assess the severity of the disease
 History: antenatal history of anemia, antepartum haemorrhage, presence of septic
foci in teeth, gums and tonsils, any debilitating diseases like heart diseases, diabetes,
tuberculosis, urinary tract infections or malaria
Intranatal history of preterm labour, duration of rupture of membranes, number of
internal examinations done outside and inside the hospital, duration of labor, method of
delivery and nature of intrauterine manipulation if any.
Postnatal details of the nature of fever and the associated symptoms related with the site
of lesion, if present are helpful.
 Clinical examination: includes the study of pulse and temperature chart, neck
stiffness, systematic examination includes breast, lungs, heart, liver, spleen and legs,
abdominal examinations to note involution of the uterus, whether the uterus is tender or
not, presence of peritonitis or pelvic abscess, internal examination to note the character
of lochia, condition of perineal wound, pelvic abscess, and bimanual examination to find
out any pelvic cellulitis or abscess, limbs are examined to detect thrombophlebitis or
thrombosis.
 Investigations include:
 High vaginal an endocervical swabs for culture in aerobic and anaerobic media
and sensitivity test to antibiotics
 Clean catch midstream specimen of urine for analysis and culture including
sensitivity test
 Blood for total and differential white cell count, haemoglobin estimation. Thick
blood film should be examined for malaria parasite.
 Blood culture, if fever is associated with chills and rigor
 Pelvic ultrasound to detect any retained bits of conception within the uterus, to
locate any abscess with the pelvis, collecting samples from the pelvis for culture and
sensitivity, color flow Doppler study to detect venous thrombosis
 C T and MRI
 X-ray chest to know the lung pathology
 Blood urea and electrolytes to know the renal pathology

Prophylaxis
Puerperal sepsis is to a great extent preventable provided certain measures are
under taken before, during and following labour.
o Antenatal prophylaxis: improvement of nutritional status, and eradication of any
septic focus (skin, throat and tonsils) in the body
o Intranatal prophylaxis: full surgical asepsis during delivery, screening for group B
streptococcus in high risk patients, prophylactic use of antibiotics during caesarean
section, ceftriaxone 1gm IV immediately after cord clamping and second dose after 8 hrs
is recommended.
o Postpartum prophylaxis: includes aseptic precautions for atleast 1 week following
delivery until the open wounds in the uterus, perineum and vagina are healed up. Too
many visitors are restricted. Sterilized sanitary pads are to be used. Infected baby and
mother should be in isolated room.

Treatment
 General care: isolation of the patient is preferred specially when hemolytic
streptococcus is obtained on culture
 Adequate fluid and calorie is supplied if needed by intravenous infusion
 Anaemia is corrected by oral iron and if needed by blood transfusion
 Pain is relieved by adequate analgesia
 An indwelling catheter is used to relieve any urine retention due to pelvic abscess.
 Vital chart should be maintained including pulse, respiration, temperature, lochial
discharge, and fluid intake-output.

 Antibiotics: ideal antibiotic regime should depend on the culture and sensitivity
report. Pending the report, Gentamycin 2mg/kg IV loading dose followed by 1.5mg/kg
IV every 8 hrs and ampicillin 1gm IV every 6 hrs or clindamycin 900 mg IV every 8 hrs
should be started. Intravenous administration of cefotaxime 1gm 8 hrly is another
alternative. Metronidazole 0.5gm IV is given at 8 hours interval to control the anaerobic
group. The treatment is continued until the infection is controlled at least 7-10 days.

 Surgical treatment:
 Perineal wound: the stitches the perineal wound may have to be removed to
facilitate drainage the 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 uterine product: with a diameter of 3cm or less may be disregarded
and left alone. Surgical evacuation after antibiotic coverage for 24 hrs should be done to
avoid the risk of septicemia. Cases with septic pelvic thrombophlebitis are treated with
IV heparin for 7-10 days.
 Pelvic abscess: should be drained by colpotomy under ultrasound guidance.
 Abscess: pointing above the poupart’s ligament should be incised and pus is
drained.
 Laprotomy: for unresponsive peritonitis, Laprotomy is indicated. Hysterectomy
in case with rupture or perforation, abscess and gas gangrene infection
 Management of bacteraemic or septic shock: monitor fluid and electrolyte
balance (to monitor CVP), respiratory and circulatory support, infection control.
 URINARY COMPLICATIONS

URINARY TRACT INFECTION

It is one of the most common causes of puerperal pyrexia. The infection may be
the consequence of the following;
 Recurrence of previous cystitis/pyelitis
 Asymptomatic bacteriuria becomes overt
Infection contracted for the first time during puerperium is due to;
 Effect of frequent catheterization either during labour or during puerperium
 Stasis ofurine during early puerperium due to lack of bladder tone and less desire
to pass urine

Organisms
 E coli, klebsiella, proteus, staph. Aureus

Treatment
 The antimicrobial agents should be appropriate for mother and fetus.
Any one of the drugs include;
Ж Ampicillin 500 mg qid
Ж Nitrofurantoin 100 mg qid
Ж Cephalexin 500 mg tid
Ж Amoxicillin-clavulanic acid 375 mg tid
 A course of 7-10 days will cure 70-100%
 Single dose of nitrofurantoin 0.2 gm or amoxicillin 3 gm has been found effective
Nitrofurantoin
Uses: This medication is used to treat or prevent certain urinary tract infections.
This medication is an antibiotic that works by stopping the growth of bacteria. It will not
work for viral infections. This medication is usually taken four times daily to treat an
infection or once daily at bedtime to prevent infections. Side effects: Nausea, vomiting,
loss of appetite, headache, dizziness, or drowsiness may occur. Take this medication
with food to help minimize nausea.
Cephalexin
Drug class and mechanism: Cephalexin belongs to a class of antibiotics called
cephalosporins. They are similar to penicillin in action and side effects. They stop or
slow the growth of bacterial cells by preventing bacteria from forming the cell wall that
surrounds each cell. The cell wall protects bacteria from the external environment and
keeps the contents of the cell together.

Dosing: The dose of cephalexin for adults is 1 to 4 grams in divided doses.

Children are treated with 25-100 mg/kg/day in divided doses. The dosing interval may
be every 6 or 12 hours depending on the infection.

Pregnancy: There are no good studies of cephalexin in pregnant women.

Cephalexin should only be used during pregnancy if there are no other safe alternatives.

Side effects: The most common side effects of cephalexin are diarrhea, nausea,
abdominal pain, vomiting, headaches, dizziness, skin rash, fever, abnormal liver tests
and vaginitis. Individuals who are allergic to penicillin may also be allergic to
cephalexin
RETENTION OF URINE
Common complication in early puerperium.

Causes
o Bruising and edema of the bladder neck
o Reflex from perineal injury
o Unaccustomed position
Treatment
 If simple measures fails to initiate micturition, an indwelling catheter is to be kept
in situ for about 48 hours.
 Following the removal of catheter, the amount of residual urine is to be measured.
It is found to be more than 100 ml, continuous drainage is resumed.
 Appropriate urinary antiseptics should be administered for about 5-7 days.

INCONTINENCE OF URINE
Not a common symptom following delivery. The incontinence may;
1. Overflow incontinence
2. Stress incontinence
3. True incontinence
Overflow incontinence following retention of urine should first be excluded before
proceeding to differentiate between the other two. Stress incontinence usually manifest
in late puerperium; whereas the true incontinence in the form of genitor urinary fistula
usually appears soon following the delivery or within first week.

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

SUPRESSION OF URINE
One should differentiate suppression from retention of urine. If 24 hours excretion is less
than 400 ml, suppression of urine is diagnosed.

Medical Treatment
(1) Antibiotics to which the causative organisms are sensitive, analgesics, and sedatives.
(a) Initial antibiotics are given by IV until the fever resolves.
(b) May possibly switch from IV and give oral medication if fever remains normal for
48 to 72 hours.
(c) May use a course of triple antibiotics until all cultures are obtained.
Clindamycin and gentamicin may be used as initial therapy, as they are broad-spectrum
antibiotics; that is, covering more than one organism. Ampicillin may be added if
symptoms persist.
(2) Incision and drainage (I&D) of any abscesses formed.

Nursing Care
(1) Isolation, if possible, the removal of the patient from the maternity ward.
(2) Meticulous hand washing.
(3) Patient placed in Fowler's position to facilitate drainage.
(4) Re education of the patient on hand washing and perineal care.
(5) Emotional support since the patient may be prevented from rooming in with her
infant while her temperature is elevated.

Prevention
 Identification of such risk factors as premature rupture of membranes
  The use of prophylactic antibiotics at the time of an emergent cesarean section
will lower the incidence of puerperal infection.
 The fundamental practice of strict aseptic technique is the first line of prevention.

Prognosis
 With access to appropriate antibiotics, the prognosis of rapid recovery from
puerperal infection is excellent.

Health care team roles

Physicians and nurses are involved in the prevention, diagnosis, and treatment of
puerperal infection.
Good prenatal care is essential for avoiding the risk of infection after childbirth.
Post-partum nurses assess patients for signs and symptoms of infection and
educate patients about these signs and symptoms prior to discharge.
Emergency physicians are seeing an increasing number of post-partum patients
presenting with a fever or evidence of infection due to earlier discharge from the
hospital after childbirth.
Home health nurses making follow-up visits assess patients for signs and symptoms of
infection.

Special considerations and prevention tips of Puerperal infection:

1. Monitor vital signs every 4 hours (more frequently if peritonitis has developed),
intake, and output. Enforce strict bed rest.

2. Frequently inspect the perineum. Assess the fundus, and palpate for tenderness
(subinvolution may indicate endometritis). Note the amount, color, and odor of vaginal
drainage, and document your observations.
3. Administer antibiotics and analgesics, as ordered. Assess and document the type.
degree, and location of pain as well as the patient's response to analgesics. Give the
patient an antiemetic to relieve nausea and vomiting, as necessary.

4. Provide sitz baths and a heat lamp for local lesions. Change bed linen, perineal pads,
and under pads frequently. Keep the patient warm.

5. Elevate the thrombophlebitic leg about 30 degrees. Don't rub or manipulate it or

compress it with bed linen. Provide warm soaks for the leg. Watch for signs of
pulmonary embolism, such as cyanosis, dyspnea, and chest pain.

6. Offer reassurance and emotional support. Thoroughly explain all procedures to the
patient and family.

7. If the mother is separated from her infant, provide her with frequent reassurance about
his progress. Encourage the father to reassure the mother about the infant's condition as
well.

8. Maintain aseptic technique when performing a vaginal examination. Limit the number
of vaginal examinations performed during labor. Take care to wash your hands
thoroughly after each patient contact.

9. Keep the episiotomy site clean.

10. Screen personnel and visitors to keep persons with active infections away from
maternity patients.
Instruct all pregnant patients to call the health care provider immediately when their
membranes rupture. Warn them to avoid intercourse after rupture or leak of the amniotic
sac. Teach the patient how to maintain good perineal hygiene following delivery.

NURSING CARE PLAN

1. Deficient Fluid Volume: Hypovolemia related to excessive loss.

Intervention Rationale
1. Assess the fluid status 1. To obtain the baseline data

2. Maintain Intake and output 2. To understand the fluid status of the

chart mother

3. Monitor for signs of 3. Deficient fluid volume can lead to

complications such as dehydration
dehydration
4. To improve the fluid volume
4. Administer IV fluids as
prescribed
 2. Risk for Infection related to the pregnancy and child birth as evidenced by rise in

temperature

Intervention Rationale
1. Assess the signs of infection 1. To obtain the baseline data

2. Monitor vital signs 2. Change in vital signs indicates

infection
3. Encourage mother to follow
hygienic measures. 3. Reduces chance of infection.

4. Administer antibiotics as 4. To reduce the risk of infection

prescribed

3. Acute Pain related to vasospasm as evidenced by facial expression.

Intervention Rationale
1. Assess the level of pain 1. To obtain the baseline data

2. Encourage comfortable 2. To reduce pain

position
3. Improves general condition.
3. Encourage mother to take
4. To reduce the pain
adequate rest

4. Administer analgesics as
prescribed
4. Ineffective Tissue Perfusion related to hypovolemia

Intervention Rationale
1. Assess the fluid status 1. To obtain the baseline data

2. Maintain Intake and output 2. To understand the fluid status of the

chart mother

3. Monitor for signs of 3. Deficient fluid volume can lead to

complications such as dehydration
dehydration
4. To improve the fluid volume
4. Administer IV fluids as
prescribed

5. Anxiety related to the threat of changes in health status.

Intervention Rationale
1. Assess the level of anxiety 1. To obtain the baseline data

2. Encourage the mother to ventilate her 2. To reduce the anxiety level

feelings
3. To relieve the anxiety
3. Clarify the doubts of the mother
4. To improve the knowledge
4. Health education of disease condition level of the mother
 6. Knowledge Deficit related to lack of information obtained.

Intervention Rationale
1. Assess the level of knowledge 1. To obtain the baseline data

2. Encourage the mother to ventilate her
feelings
3. Clarify the doubts of the mother
4. Health education of disease condition
2. To reduce the fear and anxiety
3. To relieve the anxiety and fear
4. To improve the knowledge
level of the mother

BIBLIOGRAPHY
1. B. T. Basavanthappa, “ Text book of Midwifery and Reproductive Health Nursing’,

Jaypee brothers medical publications, New Delhi, First edition

2. Wong, Hockenberry, Perry, Wilson, Lowdermilk, “ Maternal Child Nursing care”,

Elsevier Mosby publications, Missouri, 3rd edition, 2006

3. D C Dutta, “Text book of Obstetrics”, New central book publications, Culcutta, sixth

edition, 2004