Abnormal puerperium

This topic contains detail information about all abnormalities during puerperium like puerperial pyrexia, sepsis, subinvolution, breast complications, urinary complications, puerperal venous thrombosis, pulmonary embolism, obstetric palsies, puerperal emergencies, psychiatric disroders, perinatal management

1. BY, MS.PRIYANKA
GOHIL
M.Sc. (N) OBG
Nursing Tutor, MBNC

2. NORMAL PUERPERIUM

3. ABNORMALITIES OF THE PUERPERIUMABNORMALITIES OF THE PUERPERIUM
Puerperal Pyrexia
Puerperal Sepsis
Subinvolution
Urinary complications: UTI, Urinary
Retention, Urinary Incontinence, Urinary
Suppression
Breast Complications: Breast Engorgement,
Cracked & Retracted Nipple, Acute Mastitis
Puerperal Venous Thrombosis & Pulmonary
Embolism
Puerperal Emergencies, Obstetric palsies,
Psychiatric Disorders during puerperium

4. PUERPERAL PYREXIA

5. PUERPERAL PYREXIA
“ A rise of temperature reaching 100.4
degree F or more (Measured orally) on
two seperate occassions at 24 hours
apart (excluding first 24 hours) within
first 10 days following delivery is called
Puerperal pyrexia”
In some countries postabortal fever is
also included.

6. CAUSES:-
Infection:
LSCS
wound
Pulmonary
infection

7. PUERPERAL SEPSIS
“An infection of the genital tract which
occurs as a complication of delivery is
termed puerperal sepsis.”
Puerperal pyrexia is considered to be
due to genital tract infection unless
proved otherwise.

8. INCEDENCE
There had been marked decline in
puerperal sepsis during the past few years
due to:-
Improved obstetric care
Availability of wider range of antibiotics

9. CAUSES:-
Combination of
all called as
Pelvic Cellulitis

10. PREDISPOSING FACTORS
Damage of Cervicovaginal mucous
membrane
Large placental wound surface area
Blood clots presents at placental site
ANTEPARTUM FACTORS:
Malnutrition and anemia
Preterm labour
PROM
Chronic illness
Prolonged rupture of membrane >18 hours

11. INTRAPARTUM FACTORS:
Repeated vaginal examinations
Prolonged rupture of membranes
Dehydration and keto- acidosis during
labour
Traumatic operative delivery
Hemorrhage
Retained bits of placenta or membranes
Placenta previa
Cesarean Section delivery

12. MICRO-ORGANISMS RESPONSIBLE
FOR PUERPERL SEPSIS

13. AEROBIC:-
Streptococcus hemolytic group- A
Streptococcus hemolytic group - B
Others: Streptococcus pyogenus, aureus,
E coli, Pseudomonas, chlamydia
ANAEROBIC:-
Streptococcus, peptococcus, bacteriodes

14. MODE OF INFECTION
Puerperal sepsis is essentially a wound
infection
Placental site, lacerations of the genital
tract or cesarean section wounds
It may get infected by ENDOGENOUS
or EXOGENOUS organisms.

15. CLINICAL FEATURES:-

16. 1. LOCAL INFECTION
Slight temperature rise
Generalized malaise
Headache
Redness and swelling to local wound
Pus formation

17. 2. UTERINE INFECTION
MILD:-
Rise in temperature and pulse rate
Offensive and copious lochial discharge
Subinvoluted and tender uterus
SEVERE:-
Acute onset with high grade temperature
with chills and rigor
Rapid pulse rate
Scanty and orderless lochia

18. 3. SPREADING INFECTION
Parametritis
Pelvic pritonitis
General peritonitis
Thrombophlebitis
Septicemia

19. INVESTIGATION
High vaginal endocervical swab
Blood examination
History, Clinical examination
Pelvic ultrasound
CT scan, MRI

20. PROPHYLAXIS
ANTENATAL:
Improvement of nutritional status
Eradication of any septic status
INTRANATAL:
Full surgical asepsis during labour
Prophylactic antibiotics: Cefriaxone 1g IV
immediate after cord clamping and second
dose: after 8 hour is recommended

21. POSTNATAL:
Aseptic precautions atleast one week
following delivery
Too many visitors are restricted
Sterilized senitory pads are to be used
Infected babies and mothers should be
in isolated room

22. GENERAL CARE:-
Isolation of the patient
Adequate fluid and calorie (IV)
Anemia is to be corrected
Progress chart should be maintained
TREATMENT

23. ANTIBIOTICS

24. ANTIBIOTICS
Gentamicin, 2 mg/kg IV loading dose
followed by 1.5 mg/kg IV every 8 hours
Ampicillin, 1g IV every 6 hours
Clindamycin 900 mg, IV every 8 hours
Cefotaxime 1 g, 8 hourly IV is an alternative
Metrinidazole 0.5 g IV, 8 hourly
 continue atleast 7-8 days

25. SURGICAL TREATMENT

26. PERINEAL WOUND:-
Stiches of perineal wound may have to
be removed to facilitate drainage of pus
and relieve pain
Wound has to be cleaned with sitz bath
several times per day and dressed with
antiseptic ointment or powder
After the infection is controlled,
secondary suture may be given on later
date
SURGICAL TREATMENT

27. RETAINED UTERINE PRODUCTS:-
With diameter of 3 cm or less may be
disregarded or left alone
Otherwise surgical evacuation after
antibiotic coverage for 24 hours should be
done to avoid risk of septicemia
SEPTIC THROMBOPHLEBITIS:-
IV Heparin for 7-10 days

28. PELVIC ABCESS:-
Drainage by colpotomy under ultrasound
guidance
WOUND DEHISCENCE:
Dehiscence of episiotomy or abdominal wound
following cesarean section:-
Scrubbing the wound
Debridement of all necrotic tissues
Secondary suture

29. LAPROTOMY:
Has got limited indications
IV fluids and antibiotics usually controls
the peritonitis
When the peritonitis is unresponsible to
antibiotics laprotomy is indicated
HYSTERECTOMY:
In case of uterine rupture or perforation
Multiple abcess, gangrenous uterus
Ruptured tubo-ovarian abcess

30. NECROTYSING FACITIS:
Wound scrubbing
Debridement of all necrotic tissues
Use of effective antimicrobial agents
BACTEREMIC OR SEPTIC SHOCK:
Fluid and electrolyte balance
Respiratory supports
Circulatory support (dopamine/ dobutamine)
Infection control

31. SUBINVOLUTION

32. DEFINITION
“When the involution is impaired or
retarded it is called subinvolution”
The uterus is the most common organ

33. CAUSES
PREDISPOSING FACTORS:
Grand multipara
Over distention of uterus
Maternal ill health
Cesarean section
Prolapse of the uterus
Retroversion
Uterine fibroid

34. CAUSES
AGGREAVATING FACTORS:-
Retained products of conception
Uterine sepsis (Endometritis)

35. SYMPTOMS
May be asymptomatic sometimes
Abnormal Lochial Discharge : Excessive or
prolonged
Irregular at times Excessive Uterine Bleeding
Irregular Cramp like Pain (Retained bits)
Rise of Temperature in case of Sepsis

36. SIGNS
Fundal
height
Greater than
Postnatal
Day
Uterus feels
Boggy and
Softer
Displaced
Bladder or
Loaded
Rectum

37. MANAGEMENT
Antibiotics in case of infection
Exploration of uterus for retained
products
Pessary in prolapse or retroversion
Methargin to enhance involution
process

38. URINARY
COMPLICATIONS IN
PUERPERIUM

39. URINARY TRACT INFECTION
Most common cause of puerperal
pyrexia
Incedence 1-5 %
May be because of consequences of:
Reccurence of previous cystitis or
pyelitis, asymptomatic bacteriuria
First time because of: Frequent
catheterization, stasis of urine

40. ORGANISMS RESPONSIBLE:-
Strepto
coccal
aureus

41. CLINICAL FETURES:
Fever
Pus,
blood
clots in
urine
Acute
pain
Burning
miturition

42. MANAGEMENT:
IV
fluids

43. RETENTION OF URINE
Common complication in early
puerperium.
CAUSES:
Bruising
Edema of bladder neck
Reflex from the perineal injury
Anaccustamized position

44. TREATMENT
Indwelling catheter for 48 hours
Following removal catheter recidual
urine is to be measured
If it is more than 100 ml drainage is
resumed
Appropriate urinary antiseptics up to 5-
7 days

45. INCONTENENCE OF URINE
Not a common symptom following birth
It may be:-
Stress incontenence (late puerperium)
overflow incontenence ( following
retention of urine)
True incontenence (soon following
labour)

46. SUPRESSION OF URINE
“If the 24 hours urine excretion is less
than 400 ml or less, supression of urine
is dagnosed.”
The cause is to be sought for and
appropriate management is instituted.

47. BREAST
COMPLICATIONS

48. COMMON COMPLICATIONS
Mastitis and breast abcess
Lactation failure
Cracked and inverted nipple
Breast engorgement

49. BREAST ENGORGEMENT
Breast engorgement is due to
exaggerated normal venous and
lymphatic engorgement of the breasts
which precedes lactation.
This in turn prevents escape of milk
from the lacteal system

50. The primiparous patient and the patient
with inelastic breasts are more likely
develop breast engorgement
Engorgement is an indication that the
baby is not in step with stage of
lactation
ONSET:
•It usually manifests after the milk
secretion starts ( 3
rd
and 4
th
day
postpartm)

51. SYMPTOMS:
Considerable
pain and
feeling of
tendernes or
heaviness
Generalized
malaise
Painful
breast
feeding
Rise of
temperature

52. PREVENTION:
Avoid prelecteal feeds
Initiate early breast feeding
Exclusive breast feeding on demand
Feeding in correct position

53. TREATMENT:
Support with the binders
Mannual expression of milk
Administer analgesics for pain
Frequently and regular feeding the
baby
In severe cases gentle use of breast
pump
Hot application

54. CRACKED AND RETRACTED
NIPPLE
The nipple may become painful due to:

55. CAUSES:-

56. SYMPTOMS
Condition may remain asymptomatic
Sometimes painful when feeding the
baby
When infected, the infection may
spread to the deeper tissue proceding
mastitis

57. PROPHYLAXIS
Local cleanliness during pregnancy
and puerperium
Clean the crusts before and after
feeding
Application of lotion to soothen the
epithelium

58. TREATMENT
Correct attachement during feeding
Purified lanonin with mother's milk
applied 3 or 4 times a day for healing
In severe
cases
expression of
milk by breast
pump

59. For inflammed
nipple and areola
miconazole lotion
is applied
Apply nipple
shields
If persistant...
biopsy is needed

60. RETRACTED AND FLAT NIPPLE
Commonly seen in primiparous mother
Manual expression of milk is initiated
Correction of retracted nipple

62. ACUTE MASTITIS
Incidence of mastitis is 2-5 % in
lactating
Less than 1% in nonlactating mother
Organisms involved are...
Streptococcus aureus,
S. epidermidis and
Streptococci viridans

64. Mode of infection:-
Two different types of mastitis based on
location of infection.
1.Infection that involves the breast
paranchymal tissues leading to cellulitis.
(lacteal system remains unaffected)
2.Infection up to lactefarous ducts...lead
to development of primary mammary
adenitis

65. Source of infection : infant's nose/mouth
Noninfected mastitis is due to milk
stasis.
Feeding from the affected breast can
solve the problem
ONSET:
In superficial cellulitis, onset is acute
during first 2-4 weeks postpartum
However it may occurs after several
weeks also

66. CLINICAL FEATURES
SYMPTOMS
INCLUDE:
Generalized
malaise and
headache
Fever ( 102
degree F)
Severe pain and
tender swelling

67. CLINICAL FEATURES
SIGNS INCLUDE:
Presence of toxic features
Redness of overlying skin and swelling
Warm and flushy

68. COMPLICATION
Due to variable distruction of breast
tissues, it leads to the formation of a
breast abcess.

69. PROPHYLAXIS
Hand washing before and after each
feed, maintaing hygiene, keep the breast
and nipple dry

70. MANAGEMENT
Support by binders
Plenty of oral fluids
Good attachment when feeding the
baby
Initiate feeding from uninfected breast
first to establish let down
The infected site is emptied manually
with each feed
Dicloxacilin is the drug of choice. 500
mg 6 hourly. erythromycin is
alternative

71. •Antibiotic therapy is to continue up to 7
days
•Analgesics
•Milk flow is maintained by feeding the
baby
•It will prevent proloferation of
staphylococcus in the stagnant milk
•The ingested staphylococcus will
digested without any harm

72. BREAST ABCESS
FEATURES ARE:
Flushed breasts not responding to
antibiotics
Browny edema on the overlying skin
Marked tenderness with fluctuation
Swinging temperature

73. MANAGEMENT
Incision and drainage under general
anesthesia
Deep radial incision extending from
near the areolar margin to prevent
injury of the lacteferous ducts
Incision perpendicular to the
lactiferous duct can increase the risk of
fistula formation and ductal occlusion

74. Finger exploration has to be done to
break the walls of loculi.
The cavilty is loosely packed with
gause which should be replaced after
24 hoursby a smaller pack
Continue till it heals up
Abcess can also be drained by serial
percutaneous niddle aspiration under
ultrasound guidance
Surgical draiange is commonly done

75. Breast feeding is contonued at
uninvolved side
The infected side is mechanically
expressed by pump every two hourly
and with every let down
Reccurence risk is about 10 %
Once cellulitis resolved breast feeding
from the involved side may be resumed

76. BREAST PAIN
May be due to....
Engorgement
Infection ( candida albicans)
Nipple trauma
Mastitis
Occasionally on letching-on or let
down reflex

77. MANAGEMENT
Appropriate nursing technique
Positioning
Breast care
Use of myconazole oral lotion or gel on
the nipples and in infant's mouth thrice
daily for two weeks are helpful

78. LACTATION FAILURE
CAUSES ARE:
Infrequent suckling
Depression or anxiety state in puerperium
Unwilling to nursing
Ill development of nipples
Endogenous supression of prolactin
Prolactin inhibition

79. MANAGEMENT
ANTENATAL:
Counsell mother regading benefits of
nursing her baby
To take care of any breast abnormality..
breast engorgement
Maintaining adequate breast hygiene
specially in last two months of
pregnancy

80. PUERPERIUM:
Encourage adequate fluid intake
To nurse the baby regularly
Treat the painfull local lesions to
prevent nursing phobia
Metoclopramide 10 g thrice daily,
intranasal oxytocin and sulpiride
( selective dopamine intagonist) has
been found to increase milk production.
They act by stimulating prolactin
secretion

81. PULMONARY VENOUS
THROMBOSIS

82. PREVALENCE
Thrombosis of leg Thrombosis of leg
vein and pelvic vein vein and pelvic vein
is most commonis most common
However, the
prevalence is less

83. RISK FACTORS
Vascular stasis
Hypercoagulopathy of blood
Vascular endothelial trauma
Other pregnancy related factors
Venous thrombo-embolic disease like..
deep vein thrombosis, thrombophlebitis,
pulmonary embolism

84. This stasis causes damage to the
endothelial cells
Thrombophilias are hypercoaguable states
in pregnancy that increase the risk of
venous thrombosis (inheritate/ acquired)

85. OTHER ACQUIRED RISK FACTORS
Advanced age and
parity
Operative delivery
Obesity
Anemia
Heart disease
Infection- pevic celluitis
Trauma to the venous
wall
Immobility and smoking

86. DEEP VEIN THROMBOSIS
Clinical diagnosis is unreliable.
In majority it remains asymptomatic
SYMPTOMS INCLUDE:
Pain in the caff muscles
On examination asymmentric leg
edema
A positive Homan's sign

87. INVESTIGATIONS
Doppler utrasound
VUS- venous utrasonography
Venography
MRI

88. PELVIC THROMBOPHLEBITIS
Originates in the thrombosed veins at
placental site by organism such as an
anaerobic streptococci or
bacteriosides
When localised in the pelvis called
pelvic thrombophlebitis.
There is specific features but it is
suspected when there is constatnt
fever instead of antibiotics
administration

89. EXTRA PELVIC SPREAD
Through the right ovarian vein to
inferior vana cava and hence to the
lungs
Through left ovarian vein to left renal
vein and hence to the left kidney
Retrograde extension to iliofemoral
veins to produce the clinical
pathological entity called “phlegmasia
alba dolens” ( adjacent cellulitis in
femoral vein)

90. CLINICAL FEATURES:
Usually develops in second week of
puerperium
Mild pyrexia
High grade fever with chills and rigor
Constitutional disturbances like...
headache, malaise, rising pulse rate
Swelling, pain, white , cold over
affected leg

91. PROPHYLAXIS
PREVENTIVE MEASURES:
Prevention of trauma, sepsis, anemia,
dehydration
Use of elastic compression stocking
Leg exercise, Early ambulation

92. MANAGEMENT
Bed rest with foot end kept higher to
heart level
Pain management
Antibiotics
Anticoagulants- Heparin- 15000 units IV
followed by 10,000 units 6-8 hourly for
4 to 6 injections. up to 7 to 10 days
Administartion of fibrinolytic agents
Venous thrombectomy

93. PULMONARY EMBOLISM
Most leading cause of maternal deaths
Classical symptoms of massive
pulmonary embolism are...
Sudden collapse
Acute chest pain
Air hunger
Death usually occurs within short time
from shock and vagal inhibition

94. Important signs...
Tachypnea
Dyspnea
Pleuritis- chest pain
Cough
Tachycardia
Hemoptysis
Rise in temperature

95. DIAGNOSIS
ECG
Arterial blood gas
D-Dimer: value (More than 500 ng/ mL)
Doppler utrasound
Lung scans
Pulmonary angiography
Spital CT
MRA: Magnetic resonance angiography

96. MANAGEMENT
Prophylactic measures
Active treatment:
Resuscitation: cardiac massage, oxygen
therapy, heparin bolus IVof 5000 units and
morphine 15 mg
IV fluids
Incase of recurrent .. embolectomy,
placement of caval filters, ligation of inferior
vana cava and ovarian veins

97. OBSTETRIC PALSIES
(Syn.POSTPARTUM TRAUMATIC NEURITIS)
The commonest form of obstetric palsy
encountered in puerperium is...
“FOOT DROP”
Usually unilateral
Appears shortly after delivery/ first day
postpartum

98. It is due to stretching of the
lumbosacral trunk by the prolapsed
intervertebral disc between L
5
and S
1
Backward rotation of the sacrum
during labour may also be a
contributory factor
Direct pressure either by fetal head or
forcep blade on the lumbosacral cord
or sacral plexus

100. Condition is usually mild
May passed unnoticed
Neurological examination reveals lower
motor neurone type of lesions with
placcidity and wasting of muscles in
areas supplied by femoral nerve or
lumbosacral plexus
Secondary loss is always present

101. Management of damaged lumbosacral
nerve roots is same as that of the
proplapsed intervertebral disc in
consultation with an orthopedist
Paraplegia due to epidural hematoma
or abcess is rare.

102. PUERPERAL
EMERGENCIES

103. There are many acute complications
Majority of them are alarming
complications
Arises immediately after delivery
Except pulmonary embolism

104. Common complications are.....
 IMMEDIATE:
–Postpartum hemorrhage
–Shock
–Postpartum eclapmsia
–Pulmonary embolism
–Inversion

105.  EARLY (WITHIN A WEEK):
–Acute retention of urine
–Urinary tract infection
–Puerperal sepsis
–Breast engorgement
–Mastitis and breast abcess
–Pulmonary infection
–Anuria following abruptio placenta,
mismatched boold transfusion or
eclampsia

106.  DELAYED:
–Secondary postpartum hemorrhage
–Thrombo-embolic manifestation
–Psychosis
–Postpartum cardiopathy
–Postpartum hemolytic uremic
syndrome

107. PSYCHIATRIC DISORDERS
DURING PUERPERIUM

108. INTRODUCTION
In the first 3 months after delivery, the
incidence of mental illness is high.
Overall incidence is about 15-20%.
Sleep deprivation, hormone elevation
near the end of gestation and massive
postpartum withdrawal contribute to
the high risk

109. HIGH RISK FACTORS
PAST HISTORY:
Psychiatric illness
Puerperal psychiatric illness
FAMILY HISTORY:
Major psychiatric illness
Marital conflicts
Poor social situation

110. PRESENT PREGNANCY:
Young age
Cesarean delivery
Difficult labour
Neonatal complications
OTHERS:
Unmet expectations

111. PUERPERAL BLUES
It is transient state of mental illness
observed 4-5 days after delivery
Lasts for few days
Incidence is 50 %

112. MANIFESTATIONS ARE:
Depression
Anxiety
Tearfullness
Insomnia
Helplessness
Negative feelings towards the infant
No specific metabolic or endocrine
abnormalities detected
But lowered troptophan (neurotransmitor
serotonin) level is observed. it indicats
altered neurotransmitter function

113. TREATMENT:
Reassurance
Psychological support by the family
members

114. POSTPARTUM DEPRESSION
Observed in 10-20 % of mothers
More gradual in onset over the first 4-6
months following delivery or abortion
Changes in the hypothelamo-pitutary-
adrenal axis may be a cause

115. MANIFESTED BY:
Loss of energy
Loss of appetite
Insomnia
Social withdrawal
Irritability
Suicidal attitude
Risk of reccurence is 50-100% in
subsequence pregnancies

116. TREATMENT:
Is started early
Fluoxentine or paroxetine (serotonin
uptake inhibitors)
General supportive measures

117. POSTPARTUM PSYCHOSIS
Observed in 0.14-0.26 % of mothers
Commonly seen in women with past
history and family history
Onset is relatively sudden
Lasts for 4 days

118. MANIFESTED BY:
Fear
Restlessness
Confusion followed by hallucination,
delusion and disorientation
Suicidal, infanticidal impulses
Temporary seperation and clinical
supervision is needed
Risk foe reccurence 20-25%

119. MANAGEMENT :
A psychiatrist must be consulted urgently
Hospitalization is needed
Chlopramazine 150 mg stat and 50-150 mg
three time /day is started
Sublingual estradiol 1 mg TDS in
significant improvement
Electro convulsive therapy if remains
unresponsive or in depressive psychosis
Lithium in manic depressive psychosis
Breast feeding is restricted in case of
lithium administration

120. PSYCHOLOGICAL RESPONSES TO THE
PERINATAL DEATHS AND MANAGEMENT
Most perinatal events are joyful
But when a fetal /neonatal death
occurs, social attention must be given
to grieving parents and family
It may be because of unexcpected
hysterectomy, birth of malformed or
chronically ill infant
Prolonged seperation from chronically
ill infant can also cause grief

121. Physician, nurse and attending staff
must understand patient's reaction
The common maternal somatic
symptoms are...
Insomnnia
Fatigue
Sighing respiration
Feeling of guilt
Anger
Hostility ( feeling of opposition)

122. MANAGEMENT OF PERINATAL GRIEVING
Facilitating grieving process with
consolation (comfort), support, sympathy
Others are:
1.supporting the couple in seeing/ holding/
taking photographs of infant
2.Autopsy requests
3.Planning investigations
4.Follow up visits
5.Plan for subsequent pregnancy