COMPLICATIONS OF PUERPERIUM

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.
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 non pregnant state.

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 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.
1. Early postpartum hemorrhage: Is described as that occurring within the first 24 hours after
delivery.
2. Late postpartum hemorrhage: Most frequently occurs 1-2 weeks after delivery but may occur
up to 6 weeks of postpartum.
ETIOLOGY
 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.
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

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 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.
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.
TREATMENT
Initial therapy includes

Provide oxygen delivery,

Bimanual massage,

Removal of any blood clots from the uterus,

Empty the bladder,

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:


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.
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
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.


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.
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.

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.

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.


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.

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


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.
 If this therapy fails, hypogastric artery ligation is an option.

However, this approach is technically difficult and is only successful in 42-50% 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

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 When all other therapies fail, emergency hysterectomy is often a necessary and lifesaving
procedure.
NURSING MANAGEMENT
ASSESSMENT
 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.
 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
 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

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 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
 Increased prevalence of organisms resistant to antibiotics.

RISK FACTORS

Chronic debilitating disease

Poor standards of hygiene
These include as follows: Preterm labour

Poor aseptic techniques

Manipulations high in the birth canal
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)
Insertion of unclean hand or non-sterile instrument, packing into the
birth canal

Inadequate, or no immunization with tetanus toxoid

Diabetes.
Pre-existing anaemia and malnutrition

Prolonged/obstructed labour
Prolonged rupture of membranes > 18 hrs
Dehydration and ketoacidosis during labour

Frequent vaginal examinations

Caesarean section and other operative deliveries

Unrepaired cervical lacerations, or large vaginal lacerations

Pre-existing sexually transmitted infections

Postpartum haemorrhage

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 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
o Great distance from a woman’s home to a health facility

o Low socioeconomic status; inability to pay for treatment

o Poor level of general education

o Cultural factors which lead to delay in seeking medical care

o Lack of knowledge about symptoms and signs of puerperal sepsis

o Lack of health education, danger signs of infection or lack of birth

o 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 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
 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.

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MODE OF INFECTION
Puerperal sepsis is essentially a wound infection. Placental site, lacerations 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

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.

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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 infection is quite common as the cervix is commonly lacerated and it is
also the common site for the pathogenic organisms to harbor,

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.

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

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 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.

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

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 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
 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 7-10th 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:

 Pyrexia with increase in pulse rate

 Lower abdominal pain and tenderness
 Vaginal examination reveals tenderness on the fornix and with the movement of cervix
 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.

GENERAL PERITONITIS

High fever with rapid pulse

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 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.

INVESTIGATIONS

The underlying principles in investigations are

 To locate the site of infection

 To identify the organisms

 To assess the severity of the disease.

HISTORY

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 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.
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.
 “CLEAN 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.

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DIFFERENTIAL DIAGNOSIS

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

2. Preventing tetanus by immunization against tetanus

3. Diagnosis and treatment of conditions such as

o Malnutrition
o Anemia
o Urinary tract infection
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 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.

Intranatal

 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
 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

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 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.

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
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

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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,
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

18
 subinvolution.The uterus is the most common organ affected 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:

 Retained products of conception

 Uterine sepsis, endometritis

Factors that may cause sub involution

 Persistent lochia /fresh bleeding

 Long labor, anesthesia, full bladder, difficult delivery, retained placenta, infection

SYMPTOMS

The condition may be asymptomatic. The predominant symptoms are:

 Abnormal lochial discharge either excessive or prolonged

 Irregular or at times excessive uterine bleeding

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 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

 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

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

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 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

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.

21
 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 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:

22
 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 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
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.

23
 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
 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.
24
 MODE OF INFECTION:

There are two types of mastitis depending upon the site of infection

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.

MORBIDITYAND 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.
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.
25
 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:

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
26
 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:

 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

 Explain about the breast care and breast feeding techniques

27
 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
Acquired are due to the presence lupus anticoagulant and antiphospholipid antibodies.
Other acquired risk factors for thrombosis are — (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.

28
 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 — 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:

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 PYREXIA continues for more than a week in spite of antibiotic therapy.

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.

29
(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.

(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:

(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.

30
 (4) Anticoagulants — (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 — 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.

(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

31
 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 :

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.

32
MANAGEMENT :

Prophylaxis (as mentioned in venous thromboembolism)

Active treatment includes:

(1) Resuscitation — 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.

(2) I.V. fluid support is continued and blood pressure is maintained if needed by dopamine or
adrenaline.

(3) Thrombolytic therapy — 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.

33
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.

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 — hypovolaemic, endotoxic or idiopathic

(3) Postpartum eclampsia

(4) Pulmonary embolism — liquor amnii or air

(5) Inversion.

Early (within one week)

(1) Acute retention of urine

(2) Urinary tract infection

(3) Puerperal sepsis

34
 (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 — 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

 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 — 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.
35
 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)

 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 RESPONSE TO PERINATAL DEATHS AND 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

36
hysterectomy, birth of a malformed or a critically ill infant. Physician, nurse and attending staff must
understand the patient's reaction.

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 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

37
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

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.
38
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 VERSUS CONTINUOUS BLADDER

CATHETERIZATION ON LABOR DURATION AND POSTPARTUM URINARY
RETENTION AND INFECTION: A RANDOMIZED TRIAL.
Evron S, Dimitrochenko V, Khazin V, Sherman A, Sadan O, Boaz M, Ezri T.

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 patient-controlled
epidural analgesia for labor.

39
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).

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

CONCLUSION

40
 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

 Boback M Irene & Jenson Margaret “ Maternity & Gynaecologic Care, mosby company (5 th
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