POSTPARTUM CARE & COMPLICATIONS

Dr. Baran Palanimuthu , MD Department Of Obstetrics & Gynaecology Sultan Abdul Halim General Hospital Sg.Petani Kedah Darul Aman

INTRODUCTION

The postpartum period

(puerperium) is from the

end of labour until the

genital tract has returned to normal. It usually last for 42 days.

The Aims of Postpartum Care:

Support mother and family Prevention, early diagnosis and treatment of

complications
Referral counselling

The Aims of Postpartum Care:

Support of breastfeeding Educate on nutrition, and supplementation

Counselling contraception and the resumption of

sexual activity
Immunization of infant

RATIONALE
Is to increase the awareness of warning

signal and appropriate intervention at all level.

About 2/3 of the maternal deaths occur

during the postnatal period

NEEDS OF WOMEN AND NEWBORN

1.Information/counselling on:

Herself-Health

Self care
Sexual life Nutrition Contraception

NEEDS OF NEWBORN
Information/counselling

Care of the baby

*Special Needs refer to Neonatal Care

NEEDS OF NEWBORN
Information/counselling

Breastfeeding

*Special Needs refer to Neonatal Care

Postpartum care: What to expect after a vaginal delivery

Vaginal soreness - Keep the wound clean-Rinse the perineum after using the toilet. - Sit down carefully. If sitting is uncomfortable, sit on a pillow or padded ring. Vaginal discharge

- Lochia after delivery. Expect a bright red, heavy flow of blood for first few
days.-Will gradually taper off- changing from pink or brown to yellow or white. - To reduce the risk of infection, use sanitary napkins rather than tampons.

Contractions - Few days after delivery- contractions often resemble menstrual cramps , help prevent excessive bleeding by compressing the blood vessels in the uterus.

- Carefull when a fever rise or abdomen is tender to the touch

 Hemorrhoids and bowel movements - Foods high in fiber and drink plenty of water. - RX: e.g Bisacodyl - Fecal incontinence due to long labor. Frequent Kegel exercise Sore breasts and leaking milk - Known as engorgement- Nurse baby (Practise good lactation method) - Apply cold washcloths or ice packs on breasts Mood changes - Mood swings, irritability, sadness and anxiety are common - Share feelings, and ask your partner, loved ones or friends for help Urination problems - Watch out for s/sx of UTI - Pregnancy stretch connective tissue @ base bladder cause nerve + muscle damage to bladder or urethra. Problem-Dysuria,Urgency,frequency usually improves within 3 months. - Adviced for Kegels excercise

Postpartum care: What to expect after a Csection

Treat C-section incision with care: - It takes about four to 6 weeks for a C-section incision to heal - Have a good posture -stand and walk & sudden movements-coughing, sneezing /laughing. - Complete medications-especially antibiotics - Empty bladder frequently -reduce risk of UTI Look for signs of infection - The incision is red, swollen or leaking discharge - Fever > 38 degree celcius - Increasing pain around incision - OTHERS = Vaginal Delivery

Post Partum Complications

Post Partum Haemorrhage (PPH)

Defination: - Excessive bleeding after childbirth; traditionally defined as a loss of 500 ml

or more after a vaginal birth and 1000 ml or more after a cesarean birth - Primary Haemorrhage: Bleeding <24 hours following delivery - Secondary Haemorrhage Bleeding > 24 hours but within puerperium
Causes are:

1.Uterine Atony
- The most common cause: - Uterus fail to contract following the delivery of placenta Predisposing conditions: - Multiparity - Prolonged labour - Conditions overdistends uterus-> Multiple pregnancy,macrosomia,polyhidramnios ,hydrops fetalis

2.Retained Placenta
Occurs when only part of placenta been seperated Bleeding continues @ seperation site because uterus

unable to contract down due to retained placenta Sometimes only small part of placenta retained but enough to cause PPH

3.Genital Tract Laceration

Commonly follows assisted deliveries: e.g

Forceps/Ventouse Arises when inappropriate application of instruments/ excessive force used to deliver the baby.

4.Abruptio Placenta
Occurs because

1.Patient may gone into DIVC on account consumtive coagulopathy

2.Extravasation of blood within the myometrium (Couveleire uterus) cause uterine atony

5.Placenta Preavia
Bleeding because the lower segment does not contract

effectively Because placenta have been attached there the placental surface of lower segment continue to bleed

6.Acute inversion of the uterus

Uterus is pulled inside out & fundus of the uterus

presented @ the introitus. Often occurs when there is excessive traction used to deliver the placenta when it has not yet seperated from the fundus of uterus

Puerperal Infections
Reproductive tract associated with childbirth

Metritis, perineal or cesarean wound

Causes of metritis

Cesarean - Prolonged labor PROM - Multiple vaginal exams Scalp electrodes - Internal uterine monitor OB trauma - Instrument assisted birth Manual removal of placenta Prexisting infection Compromised health status

Puerperal Infections: Metritis

Assessment
Abd/Uterine

Interventions
CBC Cultures Hygiene Abscess

pain Foul smelling vaginal discharge Fever 101-104 F Chills Malaise 30% increase in WBC

is drained IV antibiotics Antipyretics ICU hospitalization

Puerperal Infections: Perineal and Cesarean wounds

Perineal wound

Assessment

Cesarean wound

Assessment
Sutures removed Drain purulent material Antibiotics Analgesics Warm compress or sitz baths

Intervention

Overdistention of the Bladder

Cause

Unable to empty bladder due to trauma or anesthesia Distended bladder Displaced uterus, increased vaginal bleeding, boggy uterus, backache, restless Encourage voiding Perineal ice packs Pour water over perineum Aseptic straight catheter X 1

Assessment

Intervention

Urinary Tract Infections

Cause

Retention of urine Bacteria from catheterization

Assessment Intervention
Increase

Cystitis

fluids Empty bladder antibiotics

>> Void frequently >> Urine culture and

Prevention
Hygiene Void

q 2-4 hrs Increase acidity in urine

Urinary Tract Infections

Pyelonephritis

Assessment
UTI

signs Chills N&V

>> High fever >> Flank pain >> Acutely ill

Management
IV

antibiotics >> Increase fluids Antipyretics >> Analgesic Follow-up culture in 2 weeks

 Infection of breast tissue Causes

Mastitis

Bacteria enters through cracks in nipple Milk stasis Poor hand washing Breast not dry or wet breast pad Incorrect placement of baby causes sore nipples
Fever > 101 F and chills, acutely ill Flu-like symptoms, malasia, headache Painful, warm, red area of breast

Assessment

Mastitis
Intervention

Bed rest - Increase fluids Supportive bra - Antibiotics Analgesic Breast feed frequently Warm compress before feeding Cold packs between feedings Drain abscess Early feedings and frequent feedings Change babys feeding positions Massage clogged duct Empty breast at each feeding Nipple care

Prevention

Thromboembolic Disorders
Blood clot formed from impeded blood flow Causes

Hypercoagulability of blood Venous stasis Injury to epithelium of vessels

Increased risk Prevention

Avoid dehydration Avoid trauma to legs in stirrups Early postpartum ambulation Leg exercises to support venous return No smoking Antiembolism stockings

Thromboembolic Disorders
Superficial thrombophelbitis

3 to 4th day after delivery Assessment

Tenderness Swelling

>> Localized heat >> Redness

No or low Intervention
Elevate

fever

leg >> Bed rest Local moist heat >> Analgesia Support hose

Little risk of pulmonary embolism

Thromboembolic Disorders
Deep vein thrombosis

10 to 20 Assessment Swelling Pain

days after delivery

Erythema Heat Pedal

edema Low to high fever Positive Homans Sometimes decreased perfusion Chills

Thromboembolic Disorders
Deep vein thrombosis

Intervention
Bed

rest >> Elevate leg Analgesia >> Antibiotics Anticoagulant therapy IV heparin Coumadin for 2 to 6 months Monitor for pulmonary embolism Antiembolism stockings after symptoms:

Thromboembolic Disorders
Pulmonary embolism

Clot moves to pulmonary artery Assessment

Dyspnea Cough Cyanosis Tachypnea Treatment Alert

>> Chest pain >> Hemoptysis >> Hypotension >> Tachycardia

physician >> Elevate head of bed Oxygen >> Narcotics Anticoagulation with heparin

Every visit to HC
Mother

Examination of
vital signs breast

abdomen
Perineum

These should be recorded in the Rekod Kesihatan Ibu KIK/1(a)/96 and KIK/1(b)/96 .

Every visit to HC
Mother
Health and well-being.

Symptoms of abnormal lochia,

Chest pain, Difficulty in breathing,

Redness and inflammation of lower limbs

Calf swelling and tenderness.

Every visit

Ask Mother about Baby: Health and well-being. Feeding Bowel opening Passed urine Other concerns.

Assessment On Baby

body weight body temperature eyes, skin umbilical cord. If the mother accompanies her baby in the ward, the postnatal care should be continued for the mother by the hospital staff as scheduled.

When Necessary

Observe the feeding Help the mother to improve the technique of breast

feeding.

CHECK LIST TO IDENTIFY HIGH RISKS

Senarai semak bagi mengesan factor risiko semasa post natal digunakan oleh anggota jururawat/ pegawai perubatan ketika menjalankan jagaan postnatal.

NUTRITION
Mothers eat a healthy balanced diet vitamins minerals.

plan simple and healthy meals that include choices from all of the recommended groups from the food pyramid.

Resumption of sexual activity post natally

Some Studies shown By eight weeks postpartum 71% of respondents had resumed intercourse, and by ten weeks 90% of the women who had partners had resumed intercourse (Glazener 1997). Another factor that influences sexual behavior post partum is pain related to perineal damage and sutures, caused by vaginal tears and episiotomies (Glazener 1997).

Resumption of sexual activity cont..

Mother and her partner should decide together Sexual intercourse may be resumed after mothers

vaginal bleeding has stopped and stitches are healed (usually within 4- 6 weeks) Be aware that sex first few times following birth may be painful Advised for lubricants and comfortable positioning.

Contraception:
Counseling to all postnatal mothers regarding the risk of

next pregnancy. Should be started before any sexual activity.

 Offered to all Postnatal mothers especially those high

risk cases. Method as in MEC (Medical eligibility criteria for contraceptive use) - MOH 2006 All high risk mothers should be registered in both PPC (Pre-pregnancy care clinic) and FP (family practice Clinic.

COPING WITH DEATHS

GRIEF:
Emotional and somatic responses felt by an

individual on the death of another individual.

More intense if the death occurs in a person who is

closely related.

NORMAL GRIEF REACTION

MORTALITY BEREAVEMENT
Maternal Death Stillbirth Neonatal death

Thank You