Postnatal complications

Postnatal complications

1. COMPLICATIONS & MINOR AILMENTS OF PUERPERIUM Mrs. U SREEVIDYA, Msc . NURSING, Associate Professor, Apollo college of nursing, CHITTOOR

2. INT R O D U CTION Puerperium, the period of adjustment after childbirth during which the mother’s reproductive system returns to its normal prepregnant state. triggered by a sharp drop in the levels of estrogen and progesterone produced by the placenta during pregnancy . The uterus shrinks back to its normal size and resumes its prebirth position by the sixth week.

3. CONTENTS NORMAL PUERPERIUM MINOR AILMENTS OF PUERPERIUM AFTER PAINS POSTPARTUM HAEMATOMAS CONSTIPATION PAINFUL PERINEUM BACK PAIN HAEMORRHOIDS SYMPHYSIS PUBIS PAIN HEADACHES MATERNAL FATIGUE TRUE INCONTINENCE URINARY RETENTION FECAL INCONTINENCE POSTPARTUM COMPLICATIONS PUERPERAL PYREXIA PUERPERAL SEPSIS UTIs THROMBO-EMBOLIC DISORDERS ENDOCRINE DISORDERS SUB-INVOLUTION OF UTERUS PSYCHIATRIC DISORDERS BREAST COMPLICATIONS OBSTETRIC PALSIES

4. Normal Puerperium

5. DE F I N I T ION It is the period following child birth during which all the body tissue especially pelvic organs revert back to their pre pregnant stage both anatomically and physiologically. It has 3 types: Immediate- within 24 hrs Recent- within 7 days Remote- up to the end of 6 weeks

6. By 6 weeks after delivery, most of the changes of pregnancy resolved and the body has regained the non-pregnant state.

7. A na t o m i c a l an d P h y s i o l ogic al changes Immediately after labor, the woman is in a state of physical fatigue in many cases, slight shivering, muscular tremors and chattering of teeth occur for about 10 – 15 minutes.

8. Temperature It is normal that a slight rise in the temperature during the first day , which is known as (reactionary rise), not exceed 38oC and drops within 24 hours and not accompanied by increased pulse rate, if it is more than 38oc or for more than 24 hours, it is called puerperal pyrexia).

9. Involution of the uterus return to the pelvis by about 2 week s - be at normal size by 6 weeks T he weight changes of uterus 1000g immediately after birth (excluding the fetus, placenta, membrane and amniotic fluid. 500g 1 week after birth 300g 2 weeks after birth 50g 6 weeks after birth  The endometrial lining rapidly regenerates (16 days)  The placental site undergoes a series of changes in the postpartum period

10. Uterus Immediate PP 6 weeks 50-100 gms 1000 gms

11. Immediate PP Umbili c us 2 weeks Pelvic cavity Near normal size 6 weeks Post partum uterus

12. Decidua discharge comes from the placental site and maintains for 4-6 weeks • • Lochia rubra Red in color for the first 3-4 days Lochia serosa Pink in color, maintains for 2 weeks Lochia alba White in color, maintains for 2-3 weeks

13. Immediately after delivery Lochia Lochia alba Cease Blee d ing Lochia rubra Lochia serosa Uterine contraction Yellow /white Brownish red 5 - 6week Pink ish red

14.  The cervix also begins to rapidly revert to a nonpregnant state .  It never returns to the nulliparous state.  By the end of the first week, the external os closes The external os is closed to the extent that a finger could not be easily introduced. Cervix

15. Vagina By 3 weeks  increased vascularity and edema At the end of puerperium  Shrinks to a nonpregnant state by 6-10 weeks  The vaginal epithelium appears atrophic on smear and the normal epithelium will be restored. Who deliver vaginally  taught her to perform kegel exercises

16. Vagina VASCULARI T Y EDEMA FLA TT ENED ATROPHIC Decreased estrogen levels

17.  Perineum Swelling completely gone within 1-2 weeks The muscle tone may or may not return to normal, depending on the extent of injury.

18. Perineum SWOLLEN & ENGORGED VULVA Resolves within 1-2 weeks

19. Ovarian function Greatly influenced by breastfeeding Caused by the suppression of ovulation due to the elevation in prolactin.

20.  The mother who does not breastfeed may ovulate as early as 27 days after delivery.  Most women have a menstrual period by 12 weeks; the mean time to first menses is 7-9 weeks. Ovaries ( continue )

21.  The abdominal wall remains soft and poorly toned for many weeks.  The return to a pre - pregnant state depends greatly on maternal exercise . Abdominal wall

22.  The changes to the breasts that prepare the body for breastfeeding occur throughout pregnancy.  If delivery ensu r es, lactation can be established as early as 16 weeks' gestation. Breasts

23. Preparation for lactation Lactation can occur by 16 weeks' gestation. Lacto genesis is initially triggered by the delivery of the placenta ( E↓P↓and prolactin). T he prolactin levels decrease and return to normal within 2-3 weeks (not breastfeeding) The colostrum s ecrets in the first 2- 3 days The milk continues to change throughout the period of breastfeeding to meet the changing demands of the baby.

24. In non nursing women  The prolactin levels decrease and return to normal within 2-3 weeks Colostrum secreted for 2 days  contain protein , fat , minerals , IgA and IgG After 3-6 days  replaced by milk (protein , lactose , water and fat )

25. 1) Cardiovascular system C a rd i a c o u t p ut ↑ ( i mm ed i a te l y a f t e r d e l i v e r y ) → s l ow l y declines → reach normal 2-6 weeks. Blood volume returns to nonpregnant levels by the 10th day of puerperium 2) Hematologic changes : Hemoglobin & hematocrit ↑ after delivery Coagulation factors remain elevated in early puerperium 8-12 weeks return to non pregnant level Systemic changes

26. M i ctura ti on ; There is diuresis in the first two days of puerperium. Retention of urine may occur either due to the sphincter or reflexly from perineal trauma. Skin; There is a tendency to sweating. Body weight: Is slightly lost during the first 10 days.

27. The immediate postpartum period most often occurs in the hospital setting, where the majority of women remain for approximately 2 days after a vaginal delivery and 3-5 days after a cesarean delivery . Routine Postpartum Care

28.  During this time, women are recovering from their delivery and are beginning to care for the newborn.  This period is used to make sure the mother is stable and to educate her in the care of her baby (especially the first-time mother). Routine Postpartum Care (continue)

29.  While still in the hospital, the mother is monitored for  Blood loss,  Signs of infection,  Abnormal blood pressure,  Contraction of the uterus,  Ability to void. Routine Postpartum Care (continue)

30.  Routine practices include a check of the baby's blood type and administration of the RhoGAM vaccine to the Rh-negative mother if her baby has an Rh- positive blood type.  At minimum, the mother's hematocrit level is checked on the first postpartum day.  Women are encouraged to ambulate and to eat a regular diet. Routine Postpartum Care (continue)

31.  After a vaginal delivery, most women experience swelling of the perineum and consequent pain. This is intensified if the woman has had an episiotomy or a laceration.  Routine care of this area includes ice applied to the perineum to reduce the swelling and to help with pain relief . Vaginal delivery

32.  Pain medications are helpful both systemically as nonsteroidal anti- inflammatory drugs (NSAIDs) or narcotics and as local anesthetic spray to the perineum Vaginal delivery (continue)

33.  The woman who has had a cesarean delivery usually does not experience pain and discomfort from her perineum but rather from her abdominal incision.  This, too, can be treated with ice to the incision and with the use of systemic pain medication.  Women who have had a cesarean delivery are often slower to begin ambulating, eating, and voiding; however, encourage them to quickly resume these and other normal activities . Cesarean delivery

34.  Substantial education takes place during the hospital stay, especially for the first-time mother.  The mother (and often the father) is taught routine care of the baby, including feeding, diapering, and bathing, as well as what can be expected from the baby in terms of sleep, urination, bowel movements, and eating. Patient education

35.  In women who choose not to breastfeed, the care of the breasts is quite different.  Care should be taken not to stimulate the breasts in any way in order to prevent milk production. Women who choose not to breastfeed  Ice packs are applied to the breasts and the use of a tight brassiere or a binder can also help to prevent breast engorgement.  Acetaminophen or NSAIDs can alleviate the symptoms of breast engorgement (eg, tenderness, swelling, fever) if it occurs.  Bromocriptine was formerly administered to suppress milk production; however, its use has diminished because it requires 2 weeks of administration, does not always work, and can produce adverse reactions.

36.  The most important information is who and where to call if she has problems or questions.  She also needs details about resuming her normal activity.  Instructions vary, depending on whether the mother has had a vaginal or a cesarean delivery. Discharge instructions

37.  The woman who has had a vaginal delivery may resume all physical activity, including using stairs, riding or driving in a car, and performing muscle- toning exercises, as long as she experiences no pain or discomfort.  The key to resuming normal activity is not to overdo it on one day to the point that the mother is completely exhausted the next day. Resuming normal activity

38.  Pregnancy, labor, delivery, and care of the newborn are strenuous and stressful, and the mother needs sufficient rest to recover.  The woman who has had a cesarean delivery must be more careful about resuming some of her activities.  She must avoid overuse of her abdomen until her incision is well healed in order to prevent an early dehiscence or a hernia later on. Resuming normal activity. ( continue)

39.  Women typically return for their postpartum visit at approximately 6 weeks after delivery.  No sound reason for this exists; the time has probably become the standard so that women who are returning to work can be medically cleared to return. Return for postpartum visit

40. MINOR AILMENTS OF PUERPERIUM

41. MINOR AILMENETS O F PUERPERIUM 1. AFTER PAIN S :- I t is infrequent, spasmodic pain felt in the lower abdomen after delivery for a variable period of 2-4 days. presence of blood clots or bits after birth leads to hypertonic contraction of the uterus in an attempt to expel them out.

42.  After expulsion of fetus and placenta , the uterus contracts to regain its normal size, weight and site, this called involution of uterus. Oxytocin is released from posterior lobe of the pituitary gland in response to the sucking, which facilitate uterine contraction.  Characteristic of after pain: Occur during the 1 st 2-3 days of puerperium Abdominal pains (like cramps) and back pain. Strong, regular, and coordinated. The intensity, frequency and regularity of contraction decrease after the 1 st postpartum day.

43. NURSING MANAGEMENT I t includes in massaging the uterus with expulsion of clots followed by administration of analgesics & antispasmodics. Effective relief from pain by emptying bladder. Provide a prone position with pillow under her lower abdomen.( it provides a constant pressure against her uterus ,which keeps it contracted thus eliminates after birth pains)

44. QUESTIONS HOW MANY ANIMALS ARE THERE IN PICTURE? WHAT IS THE SECOND OBJECT IN THE LAST ROW FROM LEFT SIDE? IS THERE A PEN IN THE PICTURE OR NOT? TOTAL HOWMANY OBJECTS ARE THERE? HOWMANY BALOONS ARE THERE? WHAT ARE THE COLOURS OF THOSE? WHAT’S WRITTEN ON THE BLACK BOARD?

45. ANSWERS TWO TRUMPET NO, IT’S A PENCIL 25 3 – LIGHT GREEN, DARK GREEN AND PURPLE THERE IS NO BLACK BOARD. ONLY WHITE BOARD AND IT IS EMPTY.

46. 2. POSTPARTUM HEMATOMAS Postpartum hematomas are localized collections of blood in loose connective tissue beneath the skin that covers the external genitalia, beneath the vaginal mucosa, or in the broad ligaments.

47. Perineal hematoma

48. PAIN ON THE PERINEUM Never forget to examine the perineum when analgesic is given to relieve pain. Early detection of vulvo- vaginal h ae m a toma can thus be made .

49. Pathophysiology/Etiology Trauma during spontaneous labor Trauma during forceps application or delivery Inadequate suturing of an episiotomy

50. Clinical Manifestations Complaints of pressure and pain, often noting that the pain is excruciating ( Severe, sharp perineal pain. ) Discolored skin that is tight, painful to touch Possible decrease in blood pressure, tachycardia

51. 4. Appearance of a tense, sensitive mass of varying size covered by discolored skin. 5. Swelling in the perineal wall. 6. Often seen on the opposite side of the episiotomy. 7. Inability to void due to pressure/edema on or around the urethra. 8. Complaint of fullness or pressure in the vagina. Clinical Manifestations cont …

52. Complications Hypovolemia and shock from extreme blood loss Anemia, infection Increased length of postpartum recovery period

53. Management Small hematomas are left to resolve on their own - ice packs may be applied. Large hematomas may require evacuation of the blood and ligation of the bleeding vessel. Analgesics and antibiotics may be ordered (due to increased chance of infection).

54. Medical Treatment . This consists of analgesics given for discomfort, opening the hematoma so blood clots can be evacuated and the bleeders can be ligated, and packing for pressure

55. Nursing Interventions . Apply ice to area of hematoma. Observe for evidence of enlarged hematoma. Sitz baths (hot or cold ) can give additional relief.

56. Nursing Interventions/Patient Education Inspect perineal and vulva l area s for signs of a hematoma when woman complains of pain or pressure after delivery. Inspect the vaginal area for signs of a hematoma if woman is unable to void after anesthesia has worn off. Monitor vital signs at least every 10 to 15 minutes and evaluate for signs of shock. Relieve pain of a hematoma by applying an ice bag to perineal area, medicating with mild analgesics, and positioning for comfort to decrease pressure on the affected area.

57. Nursing Interventions/Patient Education 5. Help to relieve voiding problems by assisting to bathroom to void if able to ambulate. 6. If she is unable to void, catheterize. 7. Teach the woman the importance of eating a balanced diet and to include food high in iron. 8. Encourage the woman to take vitamin supplements and to take medications as ordered.

58. It is common in the first few days of puerperium and is due to many factors. The woman‘s food intake is interrupted, there may be dehydration during labor . T he abdominal muscles are lax and perineal lacerations make defecation painful. 3. CONSTIPATION

59. 4. PAINFUL PERINEUM: This is a result of trauma during childbirth, due to an episiotomy, a spontaneous tear or a combination of both. Classification of Laceration of the Perineum: 1 st degree : Involves the fourchette, the perineal skin and the posterior vaginal wall. 2nd degree: Involves the above structure as well as the muscle of the perineal body. 1 st and 2 nd degrees are called incomplete tears. 3rd degree: (Complete perineal tear): Involves the above structures as well as the external anal sphincter and it may include the anterior wall of the anal canal or rectum.

60. Submucous or hidden perineal tear: The levator ani may be injured without apparent tear in the vaginal mucosa leading to subsequent prolapse. The swelling and bruising which follow an episiotomy and repair or a tear produce a degree of pain. A haematoma may develop and cause very intense perineal pain. Other causes of perineal pain may include wound breakdown , excessively tight sutures and infection.

61. Management: 1. Cold baths are more effective than warm baths as warm baths tend to increase oedema and sensitivity to pain. Ice and local analgesics are the most helpful modalities. 2. Epifoam (1% hyclrocortisone and 1% local analgesia). 3. Electrotherapy . 4. Pelvic floor exercises; using a contract-relax technique as an efficient pump mechanism to increase circulation and decrease oedema. 5. Teach the mother the correct defecation technique by using of pressure pad held against the wound during evacuation. 6. Use of an appropriate cushion when sitting .

62. 5. Back pain Back pain is a very common postnatal complaint. The pain is most frequently located in the posterior pelvic and lumbar areas, also cervical and thoracic pain following delivery and in the immediate post delivery period. Hormones released in pregnancy lead to ligamentous laxity which affects the biomechanics of the pelvic girdle and the vertebral column. The laxity of these ligaments may remain for some time after delivery despite the decrease in hormonal levels at birth. Relaxin levels return to its normal values three days post partum, but the effects of relaxin take up to three months to return to normal.

63. Causes of postnatal back pain: Altered physiological and biomechanical state due to pregnancy. Trauma during labour and delivery. Lack of postural control and stability during the early post partum days. Back pain can also be experienced due to post delivery uterine contractions during breast feeding. Urinary tract infection will refer pain to the back. Treatment: Gentle mobilization if restricted joint movement. Strengthening exercises for the abdominal and back muscles. Postural correction advices and exercises. Electrotherapy.

64.  Hemorrhoids are another postpartum issue likely to affect women who have vaginal deliveries.  Symptomatic relief is the best treatment during this immediate postpartum period because hemorrhoids often resolve as the perineum recovers.  This can be achieved by the use of corticosteroid creams, witch hazel compresses, and local anesthetic spray to the perineum . 6. Hemorrhoids

65. 7. Symphysis pubis pain It is a pain in the symphysis pubis which occurs during pregnancy and continuous after delivery. Also, it is resulted from birth. Treatment Stabilization of the pelvic joints by using trochanteric belt or a full pelvic bender. Static abdominal exercise is encouraged before movement around the bed. A pillow may be placed between knees to make rolling over more comfortable. Reduction of pain by electrotherapy.

66. 8. Headaches Spinal Headaches: The accidental puncture of the dura and the resultant leaking of the cerebrospinal fluid into the epidural space can give rise to severe headache. Symptoms aggravated by the upright position and relieved when the patient lies down. A mother who experiences a spinal headache is very distressed by this condition, as it has a spontaneous onset and she is unable to respond immediately to her baby's needs. Physiotherapy Treatment: Decrease the risk of deep venous thrombosis and pulmonary complications due to enforced bed rest, by circulatory, leg and breathing exercises. Keep her physically comfortable by strengthening program while the mother lies in supine position.

67. 9. Maternal Fatigue: The demands on an inexperienced mother give rise to nervous tension and fatigue. Labour and delivery can also be an exhausting experience. Management: - Relaxation to alleviate the tension. - Massage sessions

68. 10. True incontinence It i s a rare complication and is usually associated with a vesico -vaginal fistula resulting from pressure necrosis during obstructed labour or following direct injury to the bladder. After repair physiotherapy program is applied for such cases aiming to strength pelvic floor muscles as in cases of incontinence .

69. 11. Urinary retention It is a common problem in the immediate puerperium and may result in overflow incontinence. The major cause of retention is pain from the perineum and partially due to the sudden decrease in intra abdominal pressure; the bladder has responds less readily to the stretch reflex caused by its filling. Traditional methods of encouraging micturition include; Early ambulation. Hot baths. Relief of perineal pain by analgesic drugs and electrotherapy.

70. 12. Faecal incontinence May occur following a third degree perineal tear where a recto-vaginal fistula is present. Some faecal incontinence may occur where the external anal sphincter is damaged. Surgical closure is necessary which is followed by physiotherapy program to strengthen pelvic floor muscles.

71. A-Postpartum Hemorrhage (PPH) B-Puerperal fever and sepsis -Endometritis -Wound Infections M a st i t i s UTIs C-Septic Pelvic Thrombophlebitis D-Endocrine Disorders - Postpartum depression (PPD) -Postpartum thyroiditis E-Psychiatric Disorders -Postpartum blues -Postpartum psychosis F- UTERINE SUBINVOLUTION POSTNATAL COMPLICATIONS

72. Sequence of events in abnormal puerperium At 2nd OR 3rd day  Endometritis At 4th day  Mastitis OR Wound infection At 7th day  Thrombophlebitis

73. + Postpartum fever (PUERPERAL PYREXIA)

74. + Definition  Postpartum fever is defined as a temperature of 38.7 degrees C (101.6 degrees F) or greater for the first 24 hours or greater than 38.0 degrees C (100.4 degrees F) on any two of the first 10 days postpartum.  If fever is present, a physical examination should be performed to identify the source of infection and direct optimal therapy.

75. + Differential Diagnosis Urinary tract infection Mastitis or breast abscess Atelectasis Wound infection (episiotomy or other surgical site infection) Endometritis or deep surgical infection Septic pelvic thrombophlebitis Drug reaction Complications related to anesthesia

76. CAU S ES Puerperal sepsis Urinary tract infection: cystitis, pyelonephritis. Breast infection Infection of laparotomy wound (caesarean section) Intercurrent infection : acute bronchitis, pneumonia, influenza, acute appendicitis & enteric fever

77. NURSING MANAGEMENT Isolation and proper hand washing. Patient placed in Fowler's position to facilitate drainage. Administer antipyretics. E ducation of the patient on handwashing and peri neal -care. Emotional support Check the vital signs. Maintain the fluid intake and output. Sufficient rest is enforced by analgesics and sedatives Identify the cause and treat accordingly.

78. IN THE UTERUS.. Puerperal infection is a postpartum infection of the genital tract, usually of the endometrium, that may remain localized or may extend to various parts of the body.

79. P R EDI S P OS I N G FA CT OR S ANTEPARTUM FACTORS:- Malnutrition & anemia Pre-eclampsia Pre mature rupture of membranes Chronic debilitating illness Sexual intercourse

80. INTRAPARTUM FACTORS Sepsis during internal examination Dehydration & keto-acidosis Traumatic operative delivery Hemorrhage Placenta praevia

81. Pathophysiology/Etiology Bacterial organisms either are introduced from external sources or are normally present in the genital tract and are carried to the uterus. COMMON FACTORS include: Prolonged labor or rupture of membranes (PROM) Number of vaginal examinations Infection elsewhere in the body Anemia, malnutrition Size and number of perineal lacerations Intrauterine manipulation Retained placental fragments of membranes Lapse in aseptic technique Poor perineal hygiene Cesarean section

82. Clinical Manifestations Diagnosis is made by sustained fever of 38°C (100.4°F) or higher occurring on any two of the first 10 days postpartum, excluding the first 24 hours. Symptoms depend on site and extension of infection.

83. Puerperal fever

84. A. Endometritis A. Endometritis Postpartum infection involving the endometrium Uterus usually larger than expected for postdelivery day. Lochia may be profuse, bloody, and foul smelling. Chills and fever occur if lochial discharge is obstructed by clots. Infection may spread to myometrium, parametrium, uterine (fallopian) tubes, peritoneum, and blood.

85. B. Parametritis B. Parametritis (Pelvic Cellulitis) Infection of the pelvic connective tissue spread by the lymphatic system within the uterine wall. Often a result of an infected wound in the cervix, vagina, perineum, or lower uterine segment 1. Chills, fever (38.8°-40.0°C; 102°-104°F), tachycardia Severe unilateral or bilateral pain in lower abdomen Enlarged and tender uterus Uterine position may become fixed as it is displaced by the exudate along the broad ligament.

86. Parametritis & peritonitis

87. C ) Wound Infection Include infections of the perineum developing at the site of an episiotomy or laceration, as well as abdominal incision after a cesarean birth . Diagnosis based on presence of erythema, induration, warmth, tenderness, and purulent drainage from the incision site , with or without fever.

88. Cont. (Wound Infection) Perineal infections are rare appears on the third or fourth postpartum day. Risk factors include infected lochia, fecal contamination of the wound, and poor hygiene. Abdominal wound infections S aureus, is isolated in 25% of these infections. Treatment : Abscesses must be drained, and broad-spectrum antibiotics may be initiated .

89. D ) UTIs The most common pathogen is E coli. In pregnancy Risk factors Cesarean delivery, forceps delivery, vac c um delivery, induction of labor, maternal renal disease, preeclampsia, eclampsia, epidural anesthesia, bladder catheterization, length of hospital stay, and previous UTI during pregnancy. Diagnosis History (frequency, urgency, dysuria, hematuria) Physical examination (febrile patient, Suprapubic tenderness) Laboratory tests (urinalysis, urine culture and CBC) Treatment Antibiotic regimen for 3-7 Days

90. INVESTIGATIONS Collect the history Clinical examination Investigations include- Urine culture Blood culture Vaginal swabs for culture

91. Management Aseptic technique, avoid cross infection Hand wash medical person ne l. Antibiotic therapy is instituted after cultures are obtained and causative agent identified. Supportive therapy is used to control pain and to maintain hydration and nutritional status. Drainage is indicated for abscess development.

92. MEDICAL TREATMENT: Ampicillin 500 mg,I/M 3 - 5 m g /kg body G e nt a m y cin weight, Cefuroxime 750 mg,I/V Metronidazole 0.5 gm,I/V

93. PROPHYLA CTIC NURSING MANAGEMENT Certain measures are undertaken before delivery , during delivery and in postpartum period. Antenatal period- To detect and eradicate the septic focus. To maintain or improve the health status like hemoglobin level, prevent preeclampsia. Should take care about personal hygiene.

94. Contd….. INTRANATAL PERIOD The delivery should be conducted taking full surgical asepsis. The patient is instructed not to touch the vulva during labour. Excessive blood loss should be replaced promptly. Prophylactic antibiotics.

95. CONT… Use caps, mask, gowns, and gloves when working in delivery rooms. Use sterilized equipment within control dates. Wash hands meticulously (staff). Limit unnecessary vaginal exams during labor which increases the chances of introducing organisms from the rectum and vagina into the uterus

96. POSTPARTUM PERIOD Aseptic precautions should be taken during perineal care. Too many visitors should not be allowed. Sterilized pads should be used and changed. Instruct the patient on hand washing and cleansing her perineum from front to back. Restrict personnel with respiratory infections from working with patients. Early ambulation in postpartum. Daily evaluation of fundal height to document involution

97. Nursing Care of Puerperal Infection . Isolation, if possible, the removal of the patient from the maternity ward. Meticulous hand washing. Patient is placed in Fowler's position to facilitate drainage. E ducat e the patient on handwashing and peri neal -care.

98. Emotional support since the patient may be prevented from rooming in with her infant while her temperature is elevated . Check the vital signs. Maintain the fluid intake and output. A n e mi a shoul d be corre cte d by b l ood transfusion. Su ff i c i e nt r e s t i s en f or c e d by a nalg e s i c s a nd sedatives.

99. Complications Thrombophlebitis may result from puerperal infection spread along the veins. Femoral thrombophlebitis —appears 10 to 20 days after delivery as pain in calf, positive Homan's sign, fever, edema Pelvic thrombophlebitis Infection of the veins of uterine wall and broad ligament usually caused by anaerobic streptococci Severe repeated chills and wide range of temperature changes occur about 2 weeks after delivery. Strict bed rest, anticoagulants, and antibiotics are indicated.

100. URINARY TRACT INFECTIONS

101.  A urinary tract infection (UTI) is defined as a bacterial inflammation of the bladder or urethra.  >100,000 colony-forming units from a clean-catch urine specimen  >10,000 colony-forming units on a catheterized specimen Urinary Tract Infections

102.  Risk factors for postpartum UTI  Cesarean delivery  Forceps delivery  Vacuum delivery  Induction of labor  Maternal renal disease E t iology  Preeclampsia  Eclampsia  Epidural anesthesia  Bladder catheterization  Length of hospital stay  Previous UTI during pregnancy

103.  The most common pathogen is E coli.  In pregnancy, group B streptococci are the major pathogen.  Other causative organisms include Staphylococcus saprophyticus, E faecalis, Proteus, and K pneumoniae.

104.  Postpartum bacteruria occurs in 3-34% of patients, resulting in a symptomatic infection in approximately 2% of these patients. Incidence

105.  A patient may report frequency, urgency, dysuria, hematuria, suprapubic or lower abdominal pain, or no symptoms at all . History

106.  On examination, vital signs are stable and the patient is afebrile. Suprapubic tenderness may be elicited on abdominal examination. Physical examination

107.  Acute cystitis  Acute pyelonephritis Differential diagnosis

108.  U ltrasound A bdomen  Urine culture from a clean-catch / catheterized specimen  CBC Investigations

109.  Treatment is started empirically in uncomplicated infection.  Treatment is with a 3- or 7-day antibiotic regimen. Treatment

110.  Commonly used antibiotics include trimethoprim/sulfamethoxazole, ciprofloxacin, and norfloxacin.  Amoxicillin is often still used, but it has lower cure rates secondary to increasing resistance of E coli.  The quinolones are very effective but should not be used in breastfeeding mothers.

111. PUERPERAL THRO M B O-EMBOLIC DISORDERS

112. Puerperal Thrombosis  Leg vein & pelvic vein is one of the complication in western countries.  However the prevalence is low in Asians & Africans. Etiopathogenesis  In normal pregnancy there is rise in concentration of coagulation factors 1, 2, 7, 8, 9, 10, 12. plasma fibrinolytic inhibitors produced by placenta.  Alteration in blood constituents- increased number of platelet & their adhesiveness.

113.  Venous stasis is increased due to compression of gravid uterus to IVC & iliac veins. This stasis cause damage to endothelial cells.  Thrombophilias are the genetic condition associated with deficiencies of antithrombin3 protein C .  Acquired thrombophilias are due to presence of lup u s anticoagulant & antiphospholipids antibodies.

114. Risk factors:  Advanced age & parity  Operative delivery  Obesity  Anemia & heart disease.  Trauma to venous vessel wall.  I n f e c t i on s DVT C/F: Asymptomatic, pain in calf muscle, edema of leg, rise skin temperature. Homan’s sign positive.

115. Deep vein thrombosis & Homan’s sign

116. Investigations :  Doppler ultrasound.  Realtime ultrasonography .  Venography. Pelvic Thrombophlibits C/F: usually develop after 2 nd week of puerperium. Fever with chills & rigors.  Feature of toxemia i.e. headache, malaise & rising pulse.  Affected leg is painful, swollen & cold.

117. PELVIC THROMBOPHLEBITIS  Originates in the thrombosed veins at placental site by organism such as an anaerobic streptococci or bacterioides .  When localised in the pelvis called pelvic thrombophlebitis .  There is no specific features but it is suspected when there is constant fever ins pite of antibiotics administration .

118. 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)

119. 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

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

121. 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

122. Septic Pelvic Thrombophlebitis (SPT) It is a venous inflammation with thrombus formation in association with fevers unresponsive to antibiotic therapy. Bacterial infection of the endometrium seeds organisms into the venous circulation, which damages the vascular endothelium and in turn results in thrombus formation. The thrombus acts as a suitable medium for proliferation of anaerobic bacteria.

123. Cont. (SPT) Diagnosis History It usually accompanies endometritis Pts with OVT may describe lower abdominal pain, with or without radiation to the flank, groin, or upper abdomen. Physical Examination Should focus on looking for other sources of infection . Fever , tachycardia On abdominal examination, 50-70% of pts with ovarian vein thrombosis have a tender , palpable , ropelike mass. C. CT and MRI are the studies of choice

124. Cont. (SPT) Treatment IV heparin for 7-10 days . Antibiotic therapy is most commonly with gentamicin and clindamycin

125. 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

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

127. DIAGNO S IS  ECG  Arterial blood gas  Doppler utrasound  Lung scans  Pulmonary angiography  MRA: Magnetic resonance angiography

128. 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

129. Prophylaxis for VTE Preventive measures :  exclude the cause and treat accordingly for low & high risk woman. Management : bed rest & foot is raised. Analgesics Anticoagulants Gentle movements of the leg after relief of pain. Vena caval fillers Fibrinolytic agents Venous thrombectomy.

130. ENDOCRINE DISORDERS

131. Endocrine Disorders Clinical or laboratory dysfunction occurs in 5-10% of postpartum women Caused by Primary disorders of the thyroid , such as Postpartum thyroiditis (PPT) Graves disease, Secondary disorders of the hypothalamic- pituitary axis , such as Sheehan syndrome Lymphocytic hypophysitis. ( pituitary enlargement+Hypopitutarism  ↓ TSH )

132. PostPartum Thyroiditis (PPT) It is a transient autoimmune destructive lymphocytic thyroiditis. Can occur any time in the 1 st postpartum year. It has 2 phases 1-4 mo PP  thyrotoxicosis ( ↓ TSH) 4-8 mo PP  hypothyroidism ( ↑ TSH)

133. + Postpartum thyroiditis cont..  Postpartum thyroiditis is a destructive thyroiditis induced by an autoimmune mechanism within one year after parturition.  It usually presents in one of three ways: Transient hyperthyroidism alone Transient hypothyroidism alone Transient hyperthyroidism followed by hypothyroidism and then recovery

134. + Prevalence  The reported prevalence of postpartum thyroiditis varies globally and ranges from 1 to 17 percent.  Higher rates, up to 25 percent, have been reported in women with type 1 diabetes mellitus, and among women with a prior history of postpartum thyroiditis

135. + Pathogenesis  It is considered a variant form of chronic autoimmune thyroiditis (Hashimoto's thyroiditis).  Women destined to develop postpartum thyroiditis usually have high serum antithyroid peroxidase antibody concentrations early in pregnancy, which decline later and then rise again after delivery.

136. + Clinical features  The symptoms and signs of hyperthyroidism, when present, are typically mild and consist mainly of fatigue, weight loss, palpitations, heat intolerance, anxiety, irritability, tachycardia, and tremor.  Similarly, hypothyroidism is also usually mild, leading to lack of energy, cold intolerance, constipation, sluggishness, and dry skin. [8]

137.  Serum antithyroid peroxidase antibody concentrations are high in 60 to 85 percent of women with postpartum thyroiditis.  It is highest during the hypothyroid phase. + Laboratory findings

138. + Screening  There is insufficient evidence to support a recommendation for screening all pregnant women for postpartum thyroiditis.  However, women at highest risk for developing postpartum thyroiditis should have a serum TSH measurement at three and six months postpartum.

139. + Management  The majority of women with postpartum thyroiditis need no treatment during either the hyperthyroid or the hypothyroid phases of their illness. T hyroid F unction T est s should be monitored every four to eight weeks to confirm resolution of biochemical abnormalities or to detect the development of more severe hypothyroidism, indicating possible permanent hypothyroidism.

140. Women who have bothersome symptoms of hyperthyroidism can be treated with 40 to 120 mg propranolol or 25 to 50 mg atenolol daily until their serum T3 and serum free T4 concentrations are normal. Women with symptomatic hypothyroidism should be treated with levothyroxine (T4) irrespective of the degree of TSH elevation.

141. Sub involution of uterus

142. Definition Sub involution of uterus is impaired and deficient involution of the uterus following delivery . when the uterus is not reverted back to the pre-pregnant state both anatomically & physiolog ically it is considered as subinvolution of uterus.

143. Pr edisposing factors • • Grand multiparity over-distention of uterus as in twins & hydromnios Maternal ill health Cesarean section Prolapse of the uterus Uterine fibroids No sucking of the baby

144. Clinical features Excessive or prolonged discharge of lochia Irregular or excessive uterine bleeding Irregular cramp like pain Uterine height more than normal for the particular day of post partum

145. Cont. (Uterine Subinvolution ) Treatment: 1- Administration of oxytocic medication to improve uterine muscle tone, includes: Methergine - a drug of choice ( PO ) Pitocin . Ergotrate . Dilation and curettage ( D&C ) to remove any placental fragments. Antimicrobial therapy for endometritis

146. Nursing Management Sub involution is managed by treating the causes. • • Antibiotics for sepsis. Exploration of the uterus for retained products. pessary in prolapse or retroversion. Early ambulation postpartum. Daily evaluation of fundal height to document involution.

147. PSYCHIATRIC DISORDERS

148. Psychiatric Disorders Postpartum blues - 50-70% Mild, self limited, arises during the first 2 weeks PP TTT: Support & education Postpartum depression (PPD) - 10-15%. More prolonged (3-6 months) TTT: Supportive care and reassurance , SSRI Postpartum psychosis- 0.14-0.26%. Generally lasts only 2-3 months . Need psychiatrist. Better prognosis than nonpuerperal psychosis.

149. postparum blue s : a normal developmental crisis related to the adjustments that are being made relative to the new role of parent, along with the added responsibilities, fatigue, and excitement that go with the birth. If a woman is unable to work through her feelings within about 2 weeks, and the symptoms continue, a more serious depression is indicated. postpartum depression ; social, cultural, physiologic and psychological factors experienced may contribute to postpartum Postpartum psychosis ; a severe form of depression that occurs in a small percentage of women giving birth.

150. Any prolonged episodes of depression during or after pregnancy should receive urgent attention .

151. + Postpartum blues and depression  Pregnant women and their friends, families, and clinicians expect the postpartum period to be a happy time, characterized by the joyful homecoming of the newborn. Unfortunately, this is not the case in many mothers.

152. + Postpartum blues  Postpartum blues refer to a transient condition characterized by mood swings from elation to sadness, irritability, anxiety, decreased concentration, insomnia, tearfulness, and crying spells.  Forty to 80 percent of postpartum women develop these mood changes, generally within two to three days of delivery.  Symptoms typically peak on the fifth postpartum day and resolve within two weeks

153. + Etiology  Although there are no conclusive data regarding the etiology of postpartum blues, multiple factors are probably involved.  Although all women experience hormonal fluctuations postpartum, some women may be more sensitive to these changes than others.

154. + Women at high risk  Major risk factors for postpartum blues include … • • • • • History of depression Depressive symptoms during pregnancy Family history of depression Premenstrual or oral contraceptive associated mood changes Stress around child care Psychosocial impairment in the areas of work, relationships, and leisure activities.

155. Case Study: Postpartum Depression Sheela was a 30 year-old mother of four children who had been married for eight years. She lived with her husband and in-laws in a small village. She had given birth to her fourth child three months previously. Her pregnancy and labor had been uneventful, and an untrained traditional midwife helped conduct the home delivery. Because pregnancy was viewed in her village as a normal occurrence that did not require any medical attention, Sheela did not receive any antenatal or postnatal care. For a month after the birth, Sheela felt normal, but then she began to exhibit unusual behavior. She became reclusive and stopped speaking to anyone at home, losing interest in her daily activities and ceasing to care for her children. The rest of the people in her family, however, were busy with their own lives and seemed indifferent to her condition. One day, when all of her family members had gone to the fields to work, Sheela set herself on fire and walked out of the house covered in flames. Some neighboring men saw her and smothered the flames with blankets, and one of them ran to get her family from the fields. They called an auto rickshaw to take her to the hospital, where Sheela was admitted to the burns unit. She had sustained 63% superficial and deep burns. Eight days after admission, she died of shock and septicemias.

156. What were the social, economic, and medical factors that contributed to Sheela’s death? What could have been done to prevent it?

157. What went wrong? · Home delivery by untrained attendant · No antenatal or postnatal care · No high risk identification ·Symptoms of depression not detected · Indifferent attitude of family members

158. POSTPARTUM DEPRESSION Postpartum depression may occur in the first 2 weeks after delivery Etiology: unknown, but.. Hormonal theory – decrease estrogen level As like as menstrual period, menopause Psychosocial aspect; lack of support system, unwanted baby - Cu ltu r al aspect; male dominant, favorable sex baby

159. Clinical Manifestations Exaggerated and prolonged periods of irritability, moodiness, hostility, fatigue Ineffective coping Withdrawal and inappropriate response to the infant or family Loss of interest in activities Insomnia

160. Mana g ement Signs and symptoms may be overlooked, making the diagnosis of depression difficult. Counseling with a mental health professional, medication, and continuous support from family and friends may be helpful in managing the depressed patient. If untreated, the woman may not fully recover and possibly harm the infant or others.  refer to psychologist .

161. Listen to the woman regarding her adjustment to role of mother and observ e for any clinical manifestations suggesting depression. Ask the woman about the infant's behavior. Negative statements about the infant may suggest that the woman is having difficulty coping . Provide support and encourage husband, family and friends to support and assist with the infant and mother. Physical support as well as emotional support may be indicated. Educate the woman that treatment may help alleviate her symptoms and allow her to better care for herself and infant. Nursing Interventions/Patient Education

162. POSTPARTUM PSYCHOSIS

163. PUERPERAL PSYCHOSIS ( SCHIZOPHRENIA )  About 1 in 500-1000 mothers. Seen in woman with past H/O psychosis or with positive family H/o. Relatively sudden in onset with in 4 days after delivery. Manifestation s : Fear, restless, confusion followed by hallucination, delusion and disorientation. Suicidal, infanticidal impulse may be present. Risk of recurrence in subsequent pregnancy is 2-20%.

164. T re a t ment  Psychiatrist consulted urgently.  Admission needed.  Chlorpromazine 150mg stat & 50-150mg thrice daily.  ECT: needed if unresponsive case.  Lithium is indicated in manic depressive psychosis & breast feeding contraindicated.

165. Case study- Discussion Sheela had several children, and the intervals between the births were quite short. Because she did not receive antenatal or postnatal care, her symptoms of depression were not detected. The tragic outcome in Sheela’s case could have been avoided by her husband and relatives been more caring and supportive. Psychological support and counseling with antidepressant drugs could have also helped prevent the tragedy.

166. CONCLUSION: Postpartum depression is a condition faced by millions of women each year. In fact, about 10-15% of all mothers suffer some form of this depression between a month and a year after childbirth. Postpartum depression is thought to be caused by shifts in hormone levels during and immediately after pregnancy. Symptoms often include feelings of restlessness, anxiety, and depression; loss of energy, sleep difficulties, and weight loss or gain. In much rarer cases (less than 1% of postpartum women) new mothers may experience postpartum psychosis, symptoms of which include refusal to eat, paranoia, and irrational thoughts. Although postpartum depression is common, it can be successfully treated with medicine and therapy.

167. Psychological response to perinatal death.

168. Psyc h o l o g i c a l r e s pon se to perinatal death.  Most perinatal events are joyful.  But when perinatal death occurs special attention must given to grieving patient & her family.  Perinatal grieving may also be due to unexpected hysterectomy, birth malformed, critically ill infant.  Obstetrician, nurse & attending staff must understand the patient reaction.

169.  Management.  Facilitating the grieving process, support & sympathy.  Supporting the couple in holding or taking photograph of the infant .  Requesting for autopsy .  Follow up visits & plan for subsequent pregnancy.

170. BREAST COMPLICATIONS IN PUERPERIUM

171. CLASSIFICATION OF BREAST DISORDERS NIPPLE D IS O R D E R S BREST I N FEC T I O NS

172. NIPPLE DISORDERS CLASSIFICATION IN V E RT E D / R E TRACT E D NIPPLE CRACKED NIPPLES

173. INVERTED NIPPLES DEFINITION- It is a condition in which nipple instead of pointing outwards get retracted into the breast.

174. METHODS- Use of breast pump. Hospital grade electric pump. Use of nipple shield. Frequent stimulation

175. Breast pump

176. Nipple shield

177. Cont.. OTHER METHODS- Plastic surgery Nipple piercing Regular stimulation Suction cups or clamps Homemade nipple protractor.

178. Suction cups

179. Clamp, piercing, shells…

180. CRACKED NIPPLES DEFINITION- it is a condition in which there is loss of surface epithelium with the formation of raw area on the nipple along with fissure situated either at the tip or of the base of nipple CAUSE- improper hygiene resulting in crust formation, Retracted nipples, Trauma Due to incorrect breast feeding.

181. C o nt…

182. C o nt… SYMPTOMS- painful breast feeding, it may progress to mastitis. PROPHYLAXIS- maintaining hygiene. TREATMENT- correct attachment of infant, purified lanonin application(3-4 times), usage of breast pump and shields(if severe), application of miconazole lotion, biopsy.

183. BREAST INFECTIONS CLASSIFICATION MASTITIS SUB A R E O L A R ABCESS

184. MASTITIS DEFINITION- It is the inflammation of parenchyma of the mammary gland T Y P E S - PATHOGENS -staphylococcus, streptococcus, gram negative bacilli such as escherichia coli, salmonella, mycobacterium, candida, cryptococcus (rarely) PUERPERAL MASTITIS NON PUERPERAL MASTITIS

185. M a s t i t i s

186. C o nt… CAUSES- PUERPERAL MASTITIS Blocked milk ducts Milk excess Cracked nipples Tight clothing Microorganism transference by patient and infant. CAUSES- NON PUERPERAL MASTITIS Hyperprolactinemia Thyroid disorders Breast trauma, surgery Nipple piercing Medications .

187. C o nt… SYMPTOMS NON PUERPERAL MASTITIS  Redness, swelling  Diffused tenderness, pain  Abscess  Nipple discharge. SYMPTOMS P U E R PE R A L MASTITIS  Tough, doughy texture  Dull to severe pain  Flu-like symptoms  Abscess (rare)

188. T R E A T M E N T P U E R PE R A L MASTITIS Breast feeding. Use of suction devices Heat application (prior to feeding) Cold compresses (severe) Antibiotics TREATMENT NON PUERPERAL MASTITIS  S y m p t o m a t ic management  Broad spectrum antibiotics.

189. BREAST ABSCESS Breast abscess is a painful build-up of pus in the breast caused by an infection. It mainly affects women who are breastfeeding. It  is a localised collection of pus in the breast tissue. Signs and Sym p toms : The signs and symptoms of breast abscesses are: a tender swelling or lump in an area of the breast; pain in the affected breast; redness, warmth, swelling, and tenderness in an area of the breast; fever; muscles aches; and feeling generally unwell.

190. CAUSES: Breast abscesses are usually caused by a bacterial infection, which often occurs when a woman is breast feeding. OTHER CAUSES: Breast abscesses can also develop in women who are not breast feeding . Risk factors can include: injury to the breast; cracked nipples; having diabetes or problems with immune system; nipple piercing; and breast implant surgery.

191. Treatment : US guided needle aspiration for abscesses < 3 cm Analgesia and antibiotics General anaesthesia for larger periareolar or retroareolar abscess. Surgery for large abscess with complications. Investigations : clinical breast examination Ultrasound Needle biopsy

192. BREAST ENGORGEMENT DEFINITION- it is a condition which occurs in mammary glands by expanding viens and the pressure of new breast milk contained with in them. CAUSE- It is due to exaggerated normal venous and lymphatic engorgement of breasts which precedes lactation . I t involves primiparous women and women with inelastic breast.

193. Breast engorgement

194. C o n t …. SYMPTOMS- Pain, feeling of heaviness, generalized malaise, transient rise of temperature, painful breast feeding. PREVENTION- to avoid prelacteal feeds ( Any food provided to a newborn before the initiation of mother's breastfeeding is considered to be a  prelacteal  feed. ) , to initiate early and unrestricted breast feeding, exclusive breast feeding on demand, feeding in correct position.

195. C o nt… MANAGEMENT -To support the breast with brassiere -Mannual expression of any remainaing milk after each feed -To administer analgesics for pain -Put baby on breast feed regularly and at frequent intervals -Gentle use of breast pump (if severe)

196. FAILING LACTATION CAUSES:- Debilitating state of the mother Early primigravidae Failure to suckle the baby regularly Depression or anxiety state in the puerperium Apprehension to nursing Premature baby, who is too weak to suck Painful breast lesions

197. MANA G EMENT ANTENATAL Education regarding the advantages of breast feeding Correction of abnormalities like retracted nipples Breast hygiene Improving the general health status of mother

198. C o nt… POSTNATAL Encourage adequate fluid intake Nurse the baby regularly Treat painful lesions promptly Express residual milk after each feeding Drugs like thyroid extract or prolactin are useful.

199. OBSTETRIC PALSIES

200. 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

201.  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 s blade on the lumbosacral cord or sacral plexus

202.  Condition is usually mild  May passed unnoticed  Neurological examination reveals lower motor neurone type of lesions with f laccidity and wasting of muscles in areas supplied by femoral nerve or lumbosacral plexus .  Se nso ry loss is often present

203.  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.

204. NURSING MANAGEMENT

205. NURSING MANAGEMENT OF PUERPERAL INFECTIONS & OTHER COMPLICATIONS The nursing management of clients with puerperal infection includes preventing the control spread of infection, promoting healing, and improving the attachment/bonding of parent and infant.

206. 1. Risk For Infection Nursing Diagnosis Risk for Infection Risk Factors: Presence of infection, broken skin and/or traumatized tissues. high vascularity of involved area. Invasive procedures and/or increased environmental exposure. Chronic disease (e.g.,  diabetes ),  anemia , malnutrition. Immunosuppression and/or untoward effect of  medication  (e.g., opportunistic/secondary infections) Desired Outcomes Patient will verbalize understanding of individual causative risk factors. Patient will initiate behaviors to limit the spread of infection, as appropriate, and reduce the risk of complications. Patient will achieve timely healing, free of additional complications.

207. Nursing Interventions Rationale Review prenatal, intrapartal, and postpartal record. Identifies factors that place client in high-risk category for development/spread of postpartal infection. Demonstrate and maintain a strict hand-washing policy for staff, client, and visitors. Helps prevent cross-contamination. Instruct the proper disposal of contaminated linens, dressings, and  peripads . Maintain isolation, if indicated. Prevents spread of infection. Demonstrate correct perineal cleaning after voiding and defecation, and frequent changing of peripads. Cleaning removes urinary/fecal contaminants. Changing pad removes moist medium that favors bacterial growth. Demonstrate proper fundal massage. Review importance and timing of the procedure. Enhances uterine contractility; promotes  involution  and passage of any retained placental fragments. Monitor temperature, pulse, and respirations. Note presence of chills or reports of  anorexia  or malaise. Elevations in vital signs accompany infection; fluctuations, or changes in symptoms, suggest alterations in client status. Note: Persistent  fever  unresponsive to antibiotic therapy may indicate pelvic  thrombophlebitis . Observe perineum/incision for other signs of infection (e.g., redness, edema, ecchymosis, discharge and approximation [REEDA scale]). Note subinvolution of uterus, extreme uterine tenderness. Allows early identification and treatment; promotes resolution of infection. Note: Although localized infections are usually not severe, occasional progression to necrotizing fasculitis can be life-threatening.

208. Nursing Interventions Rationale Monitor oral/parenteral intake, stressing the need for at least 2000 ml fluid per day. Note  urine  output, degree of hydration, and presence of  nausea , vomiting, or  diarrhea . Increased intake replaces losses and enhances circulating volume, preventing  dehydration  and aiding in fever reduction. Encourage semi-Fowler’s position. Enhances flow of lochia and uterine/pelvic drainage. Promote early ambulation, balanced with adequate rest. Advance activity as appropriate. Increases circulation; promotes clearing of respiratory secretions and lochial drainage; enhances healing and general well-being. Note: Presence of pelvic/femoral  thrombophlebitis  may require strict bed rest. Investigate reports of leg or  chest pain . Note pallor, swelling, or stiffness of lower extremity. These signs and symptoms are suggestive of septic  thrombus  formation. Note: Embolic sequelae, especially  pulmonary embolism , may be initial indicator of thrombophlebitis. Recommend that  breastfeeding  mother periodically check infant’s  mouth  for presence of white patches. Oral thrush in the  newborn  is a common side effect of maternal antibiotic therapy. Encourage client/couple to prioritize postdischarge responsibilities (e.g., homemaking tasks, child care) Client will require additional rest to facilitate recuperation/healing. Household duties need to be reassigned or delayed as appropriate. Instruct in proper medication use (e.g., with or without meals,take entire course of antibiotic, as prescribed). Oral  antibiotics  may be continued after discharge. Failure to complete medication may lead to relapse.

209. 2. Acute Pain Nursing Diagnosis Acute Pain May be related to Body response to infective agent, properties of infection (e.g., skin/tissue edema, erythema) Possibly evidenced by Verbalizations, restlessness, guarding behavior, self-focusing. Autonomic responses Desired Outcomes Patient will identify/use individually appropriate comfort measures. Patient will report decreased level of pain/discomfort.

210. Nursing Interventions Rationale Assess location and nature of discomfort or pain, rate pain on a 0–10 scale. Helps in the differential diagnosis of tissue involvement in the infectious process. Assess for non-verbal pain cues. Non-verbal cues such as crying, grimacing, or withdrawn behavior may indicate pain. Provide instruction regarding, and assist with, maintenance of cleanliness and warmth. Promotes sense of general well-being and enhances healing. Alleviates discomfort associated with chills. Instruct client in  relaxation  techniques; provide diversionary activities such as radio, television, or reading. Refocuses client’s attention, promotes positive attitude, and enhances comfort. Encourage continuation of breastfeeding as client’s condition permits. Otherwise suggest and provide instruction in the use of manual or electric breast pump. Prevents discomfort of engorgement; promotes adequacy of milk supply in breastfeeding client. Change client’s position frequently. Provide comfort measures; e.g., back rubs, linen changes. Reduces  muscle   fatigue , promotes relaxation and comfort. Encourage the woman to ask for pain medications before the pain becomes severe/intolerable. Pain is a lot easier to control before it becomes severe. Apply local heat using heat lamp or sitz bath as indicated. Heat promotes vasodilation, increasing circulation to the affected area and promoting localized comfort. Administer analgesics or antipyretics. Reduces associated discomforts of infection.

211. 3. Risk For Altered Parent-Infant Attachment Nursing Diagnosis Risk for Altered Parent-Infant Attachment Risk Factors Interruption in bonding process. Physical illness. Perceived threat to own survival. Desired Outcomes Patient will exhibit ongoing attachment behaviors during parent-infant interactions. Patient will maintain/assume responsibility for physical and emotional care of the newborn, as able. Patient will express comfort with parenting role.

212. Nursing Interventions Rationale Monitor client’s emotional responses to illness and separation from infant, such as  depression  and anger. Encourage client to verbalize feelings and reinforce normalcy as appropriate. Normal expectations are of an uncomplicated postpartal period with the family unit intact. Illness due to infection alters the situation and may result in separation of client from family or newborn, which can contribute to feelings of isolation and depression. Observe maternal-infant interactions Provides information regarding status of bonding process and client needs. Provide opportunities for maternal-infant contact whenever possible. Place pictures of infant at client’s bedside (especially if nature of infection/client’s condition or hospital policy requires separation of infant from mother during febrile period). Facilitates attachment, prevents client from engaging in self-preoccupation to the exclusion of the infant. Encourage father or other family members to care and interact with the infant. May be encouraging to mother to know that family is caring for the infant and providing emotional support. Note: Unexpected/prolonged hospital stay may reduce father’s ability to spend time with newborn because of other responsibilities, including care of siblings. Father may require additional support during this stressful time. Discuss availability or effectiveness of support systems in home setting. Client requires additional support to accomplish homemaker tasks, allowing client to obtain adequate rest and spend time with infant/other children. Identify individual support systems. Refer to visiting  nurse  services, home care agencies, as indicated. Client may require assistance with home maintenance and activities of daily living while following discharge instructions for rest and recuperation.

213. 4. Imbalanced Nutrition: Less Than Body Requirements Nursing Diagnosis Imbalanced Nutrition : Less Than Body Requirements May be related to Intake insufficient to meet metabolic demands (anorexia, nausea/vomiting, medical restrictions). Possibly evidenced by Aversion to eating. Decreased oral intake or lack of oral intake. Unanticipated weight loss Desired Outcomes Patient will meet nutritional needs, as evidenced by timely wound healing, appropriate energy level, and Hb/ Hct  within normal postpartal expectations.

214. Nursing Interventions Rationale Discuss eating habits including, food preferences and intolerances. To appeal to client what she likes/desires. Note total daily intake. Maintain diary of calorie intake, patterns and times of eating. To reveal changes that should be made in client’s dietary intake. Promote intake of at least 2000 ml/day of juices, soups, and other nutritious fluids. Provides calories and other nutrients to meet metabolic needs and replaces fluid losses, thereby increasing circulating fluid volume. Encourage choice of foods high in protein, iron, and vitamin C when oral intake permitted. Protein helps promote healing and regeneration of new tissue. Iron is necessary for Hb synthesis. Vitamin C facilitates iron absorption and is necessary for cell wall synthesis. Encourage adequate  sleep /rest. Reduces metabolic rate, allowing nutrients and oxygen to be used for the healing process. Assist with placement of nasogastric (NG) or Miller- Abbott tube. May be necessary for gastrointestinal decompression in presence of abdominal distension or peritonitis. Administer parenteral fluids/nutrition, as indicated. May be necessary to combat  dehydration , replace fluid losses, and provide necessary nutrients when oral intake is limited/restricted. Administer iron preparations and/or vitamins, as indicated. Useful in correcting anemia or deficiencies when present.

215. SUMMARY & CONCLUSION Puerperal complications Breastfeeding difficulties   Low milk supply Cracked nipples Breast engorgement Postpartum bleeding Postpartum depression Postpartum psychosis Postpartum thyroiditis Puerperal fever Puerperal mastitis

216. Any Question ?