MINOR DISCOMFORT AND COMPLICATIONS OF PUERPERIUM AND ITS MANAGEMENT

INTRODUCTION:
The postpartum period or postnatal period is the period beginning immediately after the birth of a child and
extending for about 6 weeks. The minor ailments of puerperium are the minor discomforts faced by the
women during puerperium. There are the number of discomforts of the puerperium. While they are
considered normal, there is no reason for a woman to have to suffer with them.

DEFINITION:

Puerperium is the period following childbirth during which the body tissues, especially the pelvic organs
revert back approximately to the prepregnant state both anatomically and physiologically .The retrogressive
changes are mostly confined to the reproductive organs with the exception of the mammary glands which in
fact show features of activity.

Involution is the process whereby the genital organs revert back approximately to the state as they were
before pregnancy. The woman is termed as a puerpera.

DURATION:
Puererium begins as soon as the placenta is expelled and lasts for approximately 6 weeks when the uterus
becomes regressed almost to the nonpregnant size.

The period is arbitrarily divided into —

(a) immediate – within 24 hours,
(b) early – up to 7 days and
(c) remote – up to 6 weeks.
Similar changes occur following abortion but takes a shorter period for the involution to complete. Fourth
trimester is the time from delivery until complete physiologic involution and psychological.

MANAGEMENT OF AILMENTS

AFTER PAIN —

It 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 of after births lead to hypertonic contractions of the uterus in an attempt to
expel them out. This is commonly met in primipara. Pain may also be due to vigorous uterine contraction
especially in multipara. The mechanism of pain is similar to cardiac anginal pain induced by ischemia. Both
the types are excited during breastfeeding.With increased parity, there is decrease in uterine muscle tone,
which causes the uterus to relax thereby subject it to recontraction. In the instance of breastfeeding women,
the suckling of the baby stimulates the production of oxytocin by the posterior pituitary. The release of
oxytocin not only triggers the let-down reflex in the breasts but also causes the uterus to contract; even the
well- contracted uterus of a primipara will contract even more.

MANAGEMENT

 The treatment includes massaging the uterus with expulsion of the clot followed by administration of
analgesics (Ibuprofen) and antispasmodics.
 The key to effective relief from afterbirth pains is an empty bladder. The reason for this is the fact
that a full bladder displaces the uterus from its normal and proper position. When the uterus is so
displaced, it is unable to contract as it should and tends to relax, thus prohibiting relief from after
pains. Sometimes afterbirth pains are totally relieved just by the act of emptying the bladder.
 Once the bladder is empty, the woman may lie prone with a pillow under her lower abdomen. The
prone position places constant pressure against her uterus (the pillow creates even greater pressure),
which keeps it contracted and thus eliminates afterbirth pains, since there is no uterine relaxation.
The woman needs to be forewarned that when she first lies on stomach, she will have severe cramps
or pain for about 5 minutes before she experiences complete and total relief.
 Analgesia can be effective for afterbirth pains, but not for very long if the woman's bladder is not
emptied.
 For non-breast feeders, generally analgesia is not needed because the prone position usually
alleviates the discomfort even in multipara. It is important to remember that the let-down essential to
breastfeeding is inhibited by pain.

Excessive Perspiration

Excessive perspiration is due to the body's using this route as well as diuresis to get rid itself of the excess
interstitial fluid that resulted from the hormonal effect during pregnancy.

MANAGEMENT:

Keeping the mother clean and dry will provide comfort. The woman may want to change her gown
frequently. Bed sheets should be changed as necessary. Care must be taken to assure that the woman is
hydrated. Drinking glass of water or any fluid of her liking during each hour she is awake, will assure this.
Correction of anemia:

Majority of the women remain in an anemic state following delivery. Supplementary iron therapy (ferrous
sulfate 200 mg) is to be given daily for a minimum period of 4–6 weeks.

Hypertension is to be treated until it comes to a normal limit. Physician should be consulted if proteinuria
persists.

Breast Engorgement

It is thought that engorgement of the breasts is due to a combination of milk accumulation and stasis, and
increased vascularity and congestion. It occurs on approximately the 3rd postpartal day in both breastfeeding
and non-breastfeeding mothers and lasts approximately 24-48 hours.

Signs and symptoms of engorgement include the following, which are experienced to a greater or lesser
degree by individual woman:

Sense of increasing breast heaviness or filling on the day prior to engorgement

Enlargement of breasts from distention
Skin becomes tight, shining and reddened
Breasts are warm to touch
Veins become visible
Breasts are tender, throbbing and painful
Breasts feel firm, full and hard.
Because this is not an inflammatory process, there is no temperature elevation caused by breast engorgement.

MANAGEMENT:

Relief measures for a woman, who is nonbreastfeed is geared toward relief of discomfort and cessation of
lactation.

Relief for a breastfeeding woman aims for relief of discomfort and continuation of lactation.
Treatment of breast engorgement is important to the breastfeeding mother as unrelieved breast engorgement
suppresses the milk supply. With the current short hospital stay, many women will be home before breast
engorgement occurs and need to be instructed about what to do when it happens.

RELIEF MEASURE FOR NON BREASTFEEDER

1. Give the breasts good support. A breast binder should be used to provide upward and inward thrust and
support. If a binder is not available, one may be prepared using a pillowcase or towel,which will go around
the woman and two shorter strips to be used as shoulder straps. The binder has to be secured with safety pins
to fit each woman. A tuck is to be given beneath each breast to provide support and the ends are overlapped
and fitted in front. Applied this way a breast binder is extremely comfortable for the woman, because it
imparts support and prevents painful movement.

2. Apply ice bags or packs to the breasts. Ice relieves discomfort, has a certain numbing effect and does not
encourage milk flow.

3. Take analgesics such as Aspirin or paracetamol to relieve pain.

4. Avoid massaging the breasts in an effort to get the milk out. Such actions will only extend the length of
time of breast engorgement. Any emptying of the breasts by any means stimulates the breasts to further
lactation.

5. Do not apply heat to breasts, as heat dilates the blood vessels and ductile system causing the milk to flow.
This causes partial emptying and stimulates the breasts to further lactation.

Relief Measures for Breastfeeding Mothers

Relief measures for the breastfeeding woman are designed to get the milk flow and empty the breasts. This
also alleviates the mother's discomforts.

The following are the relief measures:

1. Carry out breast massage, manual expression and nipple rolling.
2. Nurse the baby every 2 - 3 hours without missing any feeding orusing any of the supplements.
3. Use both breasts at each feeding. Start on the breast, which is used last during the previous feeding. The
baby should be on each breast for 5-10 minutes to start with and then build-up to complete emptying of one
breast, which may take about 20 minutes before switching to the other to finish the feeding. Sucking for
shorter period initially helps to accustom the nipples to the baby's sucking and minimizes soreness.
Many breastfeeding mothers, who had antenatal breast preparation, begin breast feeding within an hour of
delivery, feed frequently thereafter and use both breasts to avoid undue breast engorgement:

1. Apply warmth to the breasts, prior to each breastfeeding to promote milk flow. This can be
accomplished with warm washcloth on breasts or warm shower.
2. Manually express the milk if there is engorging of the areola, to soften the area prior to nursing the
baby. This will help the baby latch on to the nipple properly and easily.
3. Use manual expression of milk to empty the breasts after the baby has nursed if they are still
uncomfortably full and engorged.
4. Maintain good support to the breasts without any pressure points. A nursing brassiere may be worn
for this purpose.
5. Ice bags may be used between feedings to reduce swelling and pain.
6. Analgesics may be used if needed.

Perineal (Stitch) Pain

Before any measures are instituted, it is essential to examine the perineum to ascertain, if the woman is
experiencing normal pain or if a complication, such as hematoma or infection, is developing.

Perineal comfort measures are as following:

1. Ice pack, ice bags or rubber gloves filled with crushed ice or ice chips can be applied. Ice bags or
packs should be wrapped in sterile towel or any clean disposable soft material. These are most useful
in reducing the swelling and numbing the area in the immediate postpartum period especially if the
woman had a third or fourth degree laceration.
2. Explain the care of engorged breast & cracked nipples.
3. Topical anesthetic spray or ointment may be used as ordered. If an ointment is to be used the woman
should be instructed to wash her hands before applying it.
4. Sitz bath two to three times a day. Many women consider the sitz bath most soothing of all the
measures.
5. A modification of the same idea is to pour warm water over the perineum. This can be a part of
routine perineal care after voiding and defecation. The warmth of the water increases circulation and
promotes healing. The warmth and motion of the water are soothing.

Constipation
Stool softeners or mild laxatives are usually ordered for women with third or fourth degree repair of
perineum. Multiparas with lax abdominal wall may also require measures to avoid constipation.
Haemorrhoids
If the woman has haemorrhoids, they may be quite painful for a few days. Relief measures include the
following:
Ice bags or packs
Medicated compresses
Analgesic or anaesthetic spray or ointment
Heat lamp
Warm water compresses
Stool softeners
Rectal suppositories
Replacement of external haemorrhoids inside the rectum.

BREASTFEEDING DIFFICULTIES AND MANAGEMENT

A mother who is breastfeeding for the first time is in a vulnerable position and requires support,
encouragement and knowledgeable assistance. She has to make the transition from being insecure, anxious
and self-doubt to being self-assured and confident in herself and her abilities.

Preparation for Mother

The mother should be prepared for each breastfeeding and helped with the following measures:
1. Assume a comfortable position, which also allows proper positioning of the baby. Side-lying, reclining or
sitting position with generous use of pillows for support and comfort.
2. Her bladder should be empty and should have received comfort measures for any after pains or perineal
discomfort prior to breastfeeding time.
3. Assure of available help as necessary.
4. Rested and relaxed.
5. Hands should be washed and nipples cleansed by gently wiping them off with plain water.

Preparation for Baby

1. The baby's immediate preparation includes having a clean diaper and if absolutely necessary to be
swaddle wrapped.
2. Position the baby so that he or she will not be doubled up or have a twisted neck when sucking and the
head and body are supported.
Positioning
In bringing the baby and breast together, the following steps are helpful:

1. Let the baby find the breast and grasp the nipple. Do not thrust the breast in the baby's face.

2. Help the mother to hold the breast beyond the areolar area, so her fingers will not interfere with proper
positioning of the baby's mouth and gums on the nipple.

3. Touch the baby's cheek with the nipple, so the baby will turn toward the breast (use the rooting reflex).

4. Express a few drops of colostrum, so they are on the surface of the nipple. This provides the baby with
instant gratification and reinforces learning.

5. As the baby grasps the nipple, the mother must make sure that the baby has enough of it for proper
positioning in the mouth. The baby must grasp more than just the end of the mother's nipple to compress the
lactiferous sinuses located beneath the areolae in order to obtain colostrum or milk

7. Once the baby mouth is properly positioned well on to the areola; the mother releases her grasp of her
breast. As the baby starts sucking and swallowing, she must provide breathing space for the baby, if needed,
by pressing with a finger on her breast where the baby's nose is. This is needed only during the learning
period and when the breast is engorged. Babies usually suck a bit, rest a bit (maintaining their hold on the
nipple while they rest) and then suck some more. The mother must be prepared for this.

6. Suction must be broken before trying to remove the baby the breast by slipping a finger into the corner of
the baby's mouth and between the baby's gums. Once the suction is broken, the baby is removed from the
breast without injury to the nipple. The baby is then burped and put to the other breast.

Establishing Lactation

Lactation is established by a combination of the following:

1. Starting breastfeeding as soon as pos sible after delivery.
2. Frequent feedings during the first few days, using both breasts.
3. No missed feedings.
4. No supplementary feedings. Rotation of breasts as the starting and ending to provide for complete
emptying of both breasts.
5. Tension free, painless, rested and relaxed mother during feeding times.
6. Baby properly positioned on the breast.
 7. Supportive spouse. After first few days, the baby will settle into his/her own pattern of feeding
frequency. A self-demand scheduling (i.e. feeding the baby when he/she is hungry) can be adopted
rather than a rigid scheduling.

BREAST CARE
The final factor in successful breastfeeding is effective breast care. Breast care and preparation for
breastfeeding begin in the antenatal period. Breast care while breastfeeding, is as follows:

1. Wash the nipples only with water. Soap, alcohol or any other drying agent can lead to cracking of the
nipples.
2. Expose the nipples to air for 15 - 30 minutes after a feeding.
3. While exposing the nipples to air, expose them also to sunlight and/or use dry heat from a 25-watt electric
bulb or sunshine.
4. Following exposure, rub a nipple cream, vitamin A and D ointment' or other pre scribed ointment. Provide
good support to the breasts.
5. If breasts become engorged, care for them.
6. If the nipple becomes tender:
a. Enhance the let-down before feeding with warmth, as discussed for care of the breast during
engorgement.
b. Nurse on the less sore nipple first until there is let-down, then switch the baby to the sorest nipple
to empty that breast, then switch back to the less sore nipple to finish the feeding.
c. Use a pacifier to meet the baby's sucking needs rather than the end of feedings on the nipple.
d. Breastfeed more frequently for shorter periods of time.
e. Be sure to use a combination of exposure to air and heat after each breast feeding, followed by
thorough application of nipple cream.
8. Be sure to break the suction, before removing the baby from the breast.
COMPLICATIONS OF PUERPERIUM

(1) HEAMORRHAGE

Postpartum hemorrhage is defined as excessive blood loss during or after the third stage of labor. The
average blood loss is 500 mL at vaginal delivery and 1000 mL at cesarean delivery.

Objectively, postpartum hemorrhage is defined as a 10% change in hematocrit level between admission and
the postpartum period or the need for transfusion after delivery secondary to blood loss.

 Early postpartum hemorrhage

Is described as that occurring within the first 24 hours after delivery.

 Late postpartum hemorrhage

Hemorrhage occurs beyond 24 hours and within puerperium, also called delayed or late puerperal
hemorrhage.

ETIOLOGY1

 Uterine atony

 Retained products of conception

 Uterine rupture

 Uterine inversion

 Placenta accreta

 Lower genital tract lacerations

 Coagulopathy, and hematoma

Late postpartum hemorrhage

 Retained products of conception

 Infection

 Sub involution of placental site

  Coagulopathy.

Uterine atony and lower genital tract lacerations are the most common causes of postpartum hemorrhage.

Factors Predisposing to Uterine Atony Include

 Over distension of the uterus secondary to multiple gestations

 Polyhydramnios

 Macrosomia,

 rapid or prolonged labor,

 grand multiparity

 oxytocin administration

 intra-amniotic infection

 Use of uterine-relaxing agents such as terbutaline, magnesium sulfate, halogenated anesthetics, or

nitroglycerin.

In uterine atony, lack of closure of the spiral arteries and venous sinuses coupled with the increased
blood flow to the pregnant uterus causes excessive bleeding.

Active management of the third stage of labor with administration of uterotonics before the placenta is
delivered (oxytocin still being the agent of choice), early clamping and cutting of the umbilical cord, and
traction on the umbilical cord have proven to reduce blood loss and decrease the rate of postpartum
haemorrhage.

Lower genital tract lacerations

Including cervical and vaginal lacerations (eg, sulcal tears), are the result of obstetrical trauma and more
common with operative vaginal deliveries, such as with forceps or vacuum extraction.

Other predisposing factors include macrosomia, precipitous delivery, and episiotomy.

INCIDENCE

 Vaginal delivery is associated with a 3.9% incidence of postpartum hemorrhage.

 Cesarean delivery associated with a 6.4% incidence of postpartum hemorrhage.
 Delayed postpartum hemorrhage occurs in 1-2% of patients.

MORBIDITY AND MORTALITY

In the United States, postpartum hemorrhage is responsible for 5% of maternal deaths. Other causes of
morbidity include the need for blood transfusions or surgical intervention that may lead to future infertility.

HISTORY

 The antepartum or early intrapartum identification of risk factors for postpartum hemorrhage allows
for advanced preparation and possible avoidance of severe sequelae.

 Every patient must be interviewed upon admission to the labor floor. Request information about
parity, multiple gestation, polyhydramnios, previous episodes of postpartum hemorrhage, history of
bleeding disorders, and desire for future fertility.

 Note the use of prolonged oxytocin administration, as well as the use of magnesium sulfate during
the patient's labor course.

PHYSICAL

 Physical examination is performed simultaneously with resuscitative measures. Perform a vigorous

bimanual examination, which may reveal a retained placenta or a hematoma of the perineum or
pelvis, and which also allows for uterine massage.

 Closely inspect the lower genital tract in order to identify lacerations. Closely examine the placenta
to determine if any fragments are missing.

DIAGNOSIS
  The onset of postpartum hemorrhage is acute, intervention is immediate, and resolution is generally
within minutes; consequently, laboratory studies or imaging in the management of the immediate
course of this process has little role.

 However, it is important to check a patient's CBC count and prothrombin time/activated partial
thromboplastin time (PT/aPTT) to exclude resulting anemia or coagulopathy, which may require
further treatment.

 Upon admission of each patient to the labor ward, obtain ABO and RH blood type determinations,
and acquire adequate intravenous access.

TREATMENT

 Initial therapy includes

 Provide oxygen delivery,

 Bimanual massage,

 Removal of any blood clots from the uterus,

 Empty the bladder,

 And the routine administration of dilute oxytocin infusion (10-40 U in 1000 mL of lactated Ringer
solution [LRS] or isotonic sodium chloride solution). If retained products of conception are noted,
perform manual removal or uterine curettage.

 If oxytocin is ineffective, carboprost in an intramuscularly administered dose of 0.25 mg can be

administered every 15 minutes, not to exceed 3 doses.

 Misoprostol has been used clinically for the treatment of postpartum hemorrhage. However, further
research is needed to determine the effectiveness, optimal dosage, and route of administration.

When postpartum hemorrhage is not responsive to pharmacological therapy and no vaginal or

cervical lacerations have been identified, consider the following more invasive treatment methods:
Uterine packing is now considered safe and effective therapy for the treatment of postpartum hemorrhage.
Use prophylactic antibiotics and concomitant oxytocin with this technique. The timing of removal of the
packing is controversial, but most physicians favor 24-36 hours. This treatment is successful in half of
patients. If unsuccessful, it still provides time in which the patient can be stabilized before other surgical
techniques are employed.

A Foley catheter with a large bulb (24F) can be used as an alternative to uterine packing. This technique can
be highly effective, is inexpensive, requires no special training, and may prevent the need for surgery.

Uterine artery embolization, which is performed under local anesthesia, is a minimally invasive technique.
The success rate is greater than 90%. This procedure is believed to preserve fertility. Complications are rare
(6-7%) and include fever, infection, and non-target embolization. In patients at high risk for postpartum
hemorrhage, such as those with placenta previa, placenta accreta, coagulopathy, or cervical pregnancy, the
catheter can be placed prophylactically.

The B-Lynch suture technique: A suture is passed through the anterior uterine wall in the lower uterine
segment approximately 3 cm medial to the lateral edge of the uterus. The suture is wrapped over the fundus
3-4 cm medial to the comual and inserted into the posterior uterine wall again in the lower uterine segment
approximately 3 cm medial to the lateral edge of the uterus and brought out 3 cm medial to the other edge of
the uterus. The suture is wrapped over the fundus and directed into and out of the anterior uterine wall
parallel to the previous anterior sutures. The uterus is compressed in an accordion like fashion and the suture
is tied across the lower uterine segment. The B-Lynch suture technique and other compression suture
techniques are operative approaches to postpartum hemorrhage that have proven to preserve fertility.

SURGICAL MANAGEMENT

 When conservative therapy fails, the next step is surgery with either bilateral uterine artery ligation
or hypogastric artery ligation.

 Uterine artery ligation is thought to be successful in 80-95% of patients. If this therapy fails,
hypogastric artery ligation is an option.
  However, this approach is technically difficult and is only successful in 42-50% of patients. Instead,
stepwise devascularization of the uterus is now thought to be the next best approach, with possible
ligation of the utero-ovarian and infundibulopelvic vessels

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

NURSING MANAGEMENT

Assessment

 Take complete history: of past and present obstetrical history and also identify the risk factors of
hemorrhage.

 Physical examination especially the vital signs of blood loss to be assessed.

 Assess the amount of blood loss its nature, consistency, abdominal pain.

 Assess for signs of shock.

NURSING DIAGNOSIS

 Decreased cardiac output related to hypovolemia

 Fluid volume deficit related to excessive blood loss

 Altered tissue perfusion related to hypovolemia

 Pain related to procedures and treatment

 Anxiety related to separation from newborn, long term impact on self-care and infant care, need for
blood transfusion.

 Risk for injury related to changes in cerebral tissue perfusion.

 Risk for altered parent/infant attachment related to complication and need for separation from
newborn during treatment.

INTERVENTIONS

 Administer IV fluids as quickly as possible

 Administer oxytocin to help contract the uterus

 Administer oxygen therapy

  Place the client in a trendelenburg position to increase venous return to the heart.

 Monitor vital signs every 5-10min and observe the clients color, oxygen saturation by pulse
oxymetry, skin temperature and sensorium.

 Palpate the fundus for firmness and massage to restore the tone.

 Evaluate the vaginal bleeding, extent of perineal pad saturation, color, consistency of bleeding clots
and pooling on the under pad.

 Prepare for blood transfusions and administer blood transfusions.

 Reassure the mother and family.

 Allow the family members to involve in the care. Explain the physiological process of hemorrhage
and interpret medical treatments and procedures

 Once the bleeding controlled assist the mother and family what happened to understand and why to
anticipate what impact this complication will have on the postpartum while care taking and self-care
activities and to plan for special needs at home.

PUERPERAL PYREXIA
DEFINITION: A rise of temperature reaching 100.4°F (38°C) or more on two separate occasions at
24 hours apart (excluding first 24 hours) within first 10 days following delivery is called puerperal
pyrexia.

PUERPERAL SEPSIS
(Syn: Puerperal infection)

DEFINITION: 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.
There has been marked decline in puerperal sepsis during the past few years due to:
(1) Improved obstetric care,
(2) Availability of wider range of antibiotics.
Puerperal sepsis is commonly due to—
(i) Endometritis,
(ii) Endomyometritis, or
(iii) Endoparametritis
Or a combination of all these when it is called pelvic cellulitis.
Vaginal flora: The vaginal flora in late pregnancy and at the onset of labour consists of the following
organisms:
(1) Doderlein’s bacillus (60–70%),
(2) Yeast-like fungus with increased prevalence of Candida albicans (25%),
(3) Staphylococcus albus or aureus,
(4) Streptococcus—anaerobic common; beta-hemolytic rare,
(5) Escherichia coli and Bacteroides group,
(6) Clostridium welchii on occasion. These organisms remain dormant and are harmless during normal
delivery conducted in aseptic condition.

PREDISPOSING FACTORS OF PUERPERAL SEPSIS:

The pathogenicity of the vaginal flora may be influenced by certain factors:

(1) The cervico-vaginal mucous membrane is damaged even in normal delivery,
(2) The uterine surface too, especially the placental site, is converted into an open wound by the cleavage of
the decidua which takes place during the third stage of labor, and
(3) The blood clots present at the placental site are excellent media for the growth of the bacteria.

Antepartum risk factors:

(1) Malnutrition and anaemia,
(2) Preterm labour,
(3) Premature rupture of the membranes,
(4) Immunocompromised (HIV),
(5) Prolonged rupture of membrane more than 18 hours,
(6) Diabetes.

Intrapartum risk factors:

(1) Repeated vaginal examinations,
(2) Dehydration and ketoacidosis during labour,
(3) Traumatic vaginal delivery,
(4) Haemorrhage—antepartum or postpartum,
(5) Retained bits of placental tissue or membranes,
(6) Prolonged labour,
(7) Obstructed labour,
(8) Caesarean delivery.
Due to the factors mentioned above, the organisms gain foothold either in the traumatized tissues of the
uterovaginal canal or in the raw decidua left behind or in the blood clots, especially at the placental site.

MODE OF INFECTION:
Puerperal sepsis is essentially a wound infection. Placental site (being a raw surface), lacerations of the
genital tract or cesarean section wounds may be infected in the following ways:
 Sources of infection may be endogenous where organisms are present in the genital tract before
delivery. Anaerobic Streptococcusis the predominant pathogen.
 Infection may be autogenous where organisms present elsewhere (skin, throat) in the body and
migrate to the genital organs by bloodstream or by the patient herself. Beta-hemolytic Streptococcus,
E. coli, Staphylococcus are important.
 Infection may be exogenous where infection is contracted from sources outside the patient (from
hospital or attendants). Beta-hemolytic Streptococcus, Staphylococcus and E. coli are important.

PATHOLOGY
The primary sites of infection are:
(1) Perineum,
(2) Vagina,
(3) Cervix,
(4) Uterus.

CLINICAL FEATURES
Local infection
Uterine infection
Spreading infection

LOCAL INFECTION (WOUND INFECTION):

(1) There is slight rise of temperature, generalized malaise or headache,

(2) The local wound becomes red and swollen,
(3) Pus may form which leads to disruption of the wound. When severe (acute), there is high rise of
temperature with chills and rigor.

UTERINE INFECTION

Mild—
(1) There is rise in temperature (>100.4°F) and pulse rate (>90),
(2) Lochial discharge becomes offensive and copious,
(3) The uterus is subinvoluted and tender.

Severe—
(1) The onset is acute with high rise of temperature, often with chills and rigor,
(2) Pulse rate is rapid, out of proportion to temperature,
(3) Often there is breathlessness, coughs, abdominal pain and dysuria,
(4) Lochia may be scanty and odorless,
(5) Uterus may be subinvoluted, tender and softer.
There may be associated wound infection (perineum, vagina or the cervix).

SPREADING INFECTION (EXTRAUTERINE SPREAD) is evident by presence of pelvic tenderness

(pelvic peritonitis), tenderness on the fornix (parametritis), bulging fluctuant mass in the pouch of
Douglas (pelvic abscess).

INVESTIGATION OF PUERPERAL PYREXIA

The underlying principles in investigations are:
(1) To locate the site of infection,
(2) To identify the organisms,
(3) To assess the severity of the disease.
A case of puerperal pyrexia is considered to be due to genital sepsis unless proved otherwise.
The investigations should also be directed to find out any extragenital source of infection to account for
the fever as well.

Investigations of Puerperal Pyrexia

History: Antenatal, intranatal and postnatal history of any high risk factor for infection like anemia,
prolonged rupture of membranes or prolonged labor are to be taken.

Clinical examination includes thorough general, physical and systemic examinations. Abdominal
and pelvic examinations are done to note the involution of genital organs and locate the specific site of
infection. Legs should be examined for thrombophlebitis or thrombosis.

Investigations include:

(1) High vaginal and endocervical swabs for culture in aerobic and anaerobic media and sensitivity test to
antibiotics.
(2) “Clean catch” midstream specimen of urine for analysis and culture including sensitivity test.
(3) Blood for total and differential white cell count, hemoglobin estimation. A low platelet count may
indicate septicemia or DIC. Thick blood film should be examined for malarial parasites.
(4) Blood culture, if fever is associated with chills and rigor. Other specific investigations as per the clinical
condition are needed.
(5) Pelvic ultrasound is helpful—to detect any retained bits of conception within the uterus, to locate any
abscess within the pelvis, to collect samples (pus or fluid) from the pelvis for culture and sensitivity, and for
color flow Doppler study to detect venous thrombosis.
(6)Use of CT and MRI is needed especially when diagnosis is in doubt or there is pelvic vein thrombosis.
(7) X-ray chest (CXR) should be taken in cases with suspected pulmonary Koch’s lesion and also to detect
any lung pathology like collapse and atelectasis (following inhalation anesthesia).
(8) Blood urea and electrolytes may be done in a selected case to have a baseline record in the event that
renal failure develops later in the course of the disease or laparotomy is needed.

DIFFERENTIAL DIAGNOSIS

Any fever during puerperium is assumed to be due to puerperal sepsis unless otherwise proved. Infection
may occur in other parts of body connected to reproductive process or it can be incidental. They are:

a. Breast infections

b. Urinary tract infections

c. Incidental d. Tuberculosis

c. Typhoid

f. Malaria

h. Meningitis
i. AIDS related infections

PROPHYLAXIS
Puerperal sepsis is to a great extent preventable provided certain measures are undertaken before,
during, and following labor.

Antenatal prophylaxis includes improvement of nutritional status (to raise hemoglobin level) of the
pregnant woman and eradication of any septic focus (skin, throat, tonsils) in the body.

Intranatal prophylaxis includes—

(a) Full surgical asepsis during delivery,
(b) Screening for Group B Streptococcus in a high risk patient. Prophylactic use of antibiotic is not
recommended as a routine,
(c) Prophylactic use of antibiotic at the time of cesarean section has significantly reduced the incidence of
wound infection, endometritis, urinary tract infection and other serious infections.

Postpartum prophylaxis includes aseptic precautions for at least 1 week, following delivery until the open
wounds in the uterus, perineum, vagina are healed up. Too many visitors are restricted. Sterilized
sanitary pads are to be used. Infected babies and mothers should be in isolated room.

TREATMENT
General care:
(i) Isolation of the patient is preferred especially when hemolytic Streptococcus is obtained on
culture,
(ii) Adequate fluid and calorie are maintained by intravenous infusion (IV),
(iii) Anemia is corrected by oral iron or if needed by blood transfusion,
(iv) An indwelling catheter is used to relieve any urine retention due to pelvic abscess. It also helps
to record urinary output,
(v) A chart is maintained by recording pulse, respiration, temperature, lochial discharge, and fluid
intake and output.
(vi) Antibiotics: Ideal antibiotic regimen should depend on the culture and sensitivity report.

 Pending the report, gentamicin (2 mg/kg IV loading dose, followed by 1.5 mg/kg IV every 8 hours)
and clindamycin (900 mg IV every 8 hours) should be started.
  Metronidazole 0.5 g IV is given at 8 hours interval to control the anaerobic group. The treatment is
continued until the infection is controlled for at least 7–10 days.
 Antibiotic Regimens: Severe sepsis. A combination of either piperacillin-tazobactam or carbapenem
plus clindamycin has broadest range of antimicrobial coverage. Women with MRSA infection should
be treated with vancomycin or teicoplanin.

Surgical treatment: There is little role of major surgery in the treatment of puerperal sepsis.

Perineal wound—
To stitches of the perineal wound may have to be removed to facilitate drainage of pus and relieve pain. To
wound is to be cleaned with sitz bath several times a day and is dressed with an antiseptic ointment or
powder. After the infection is controlled, secondary suture may be given.

Retained uterine products with a diameter of 3 cm or less may be disregarded and left alone. Otherwise
surgical evacuation after antibiotic coverage for 24 hours should be done to avoid the risk of septicaemia.
Cases with septic pelvic thrombophlebitis are treated with IV heparin for 7–10 days.

Pelvic abscess should be drained by colpotomy under ultrasound guidance.

Wound dehiscence:
Dehiscence of episiotomy or abdominal wound following cesarean section is managed by scrubbing the
wound twice daily, debridement of all necrotic tissue and then closing the wound with secondary suture.
Appropriate antimicrobials are used following culture and sensitivity.

Laparotomy has got limited indications.

Maintenance of electrolyte balance by intravenous fluids along with appropriate antibiotic therapy usually
controls the peritonitis. However, in unresponsive peritonitis, laparotomy is indicated. Even if no palpable
pathology is found, drainage of pus may be efective. Hysterectomy is indicated in cases with rupture or
perforation, having multiple abscesses, gangrenous uterus or gas gangrene infection. Ruptured tubo-ovarian
abscess should be removed.

Necrotizing fasciitis is rare but fatal complication of wound infection (abdominal, perineal, and vaginal),
involving muscle and fascia. Risk factors are diabetes, obesity and hypertension. Infection is caused by
Group A beta-hemolytic Streptococcus and often it is polymicrobial. Tissue necrosis is the significant
pathology. Treatment includes: Rehydration, wound scrubbing, debridement of all necrotic tissues, and use
of high dose broad-spectrum (IV) antibiotics.
NURSING MANAGEMENT

Assessment

Postpartum nursing assessment focus on identifying the signs and symptoms of infections early, monitoring
progress and physiologic functions, including uterine involution, noting needs for comfort and education,
and identifying emotional reactions and needs.

Nursing planning and intervention

 The nurse plays a role in carrying out medical treatment such as Antibiotic therapy.

 Monitor vital signs

 Assess for signs and symptoms and disease progression Provide comfort measures for pain relief.

 Promote healing and wellbeing through nutrition and fluid intake. Encourage mother and neonate
bonding

 Provide information regarding newborn care and encourage for visits to the nursery

 Explain about infectious process and its expected course and treatment.

 Involve the family members in the care

 Provide the support and encouragement for the client or family.

SUBINVOLUTION

DEFINITION:
When the involution is impaired or retarded, it is called subinvolution. The uterus is the most common
organ affected in subinvolution. As it is the most accessible organ to be measured per abdomen, the uterine
involution is considered clinically as an index to assess subinvolution.

CAUSES:

Predisposing factors are—

(1) Grand multiparty,
(2) Over distension of uterus as in twins and hydramnios,
(3) Maternal ill-health,
(4) Caesarean section,
(5) Prolapse of the uterus,
(6) Retroversion after the uterus becomes pelvic organ,
(7) Uterine fibroid.

Aggravating factors are:

(1) Retained products of conception,
(2) Uterine sepsis (endometritis).

SYMPTOMS: The condition may be asymptomatic. The predominant symptoms are:

(1) abnormal lochial discharge, either excessive or prolonged,
(2) irregular or at times excessive uterine bleeding,
(3) irregular cramp-like pain in cases of retained products or rise of temperature in sepsis.

SIGNS:
(1) The uterine height is greater than the normal for the particular day of puerperium.
(2) Normal puerperal uterus may be displaced by a full bladder or a loaded rectum.
(3) It feels boggy and softer.

MANAGEMENT:
Here size of the uterus is not important and provided there is absence of features, such as excessive lochia or
irregular bleeding or sepsis, the size of the uterus can be safely ignored.
Appropriate therapy is to be instituted only when subinvolution is found to be a mere sign of some
local pathology:
(1) Antibiotics in endometritis,
(2) Exploration of the uterus in retained products,
(3) Pessary in prolapse or retroversion.
(4)Methergine, so often prescribed to enhance the involution process by reducing blood flow of the uterus, is
of little value in prophylaxis.

NURSING MANAGEMENT

 Encourage early ambulation in postnatal period

 Daily evaluation of fundal height and documentation.

URINARY COMPLICATIONS IN PUERPERIUM

1. Urinary tract infection

2. Retension of urine

3. Incontinence of urine

4. Suppression of urine

URINARY TRACT INFECTION:

It is one of the common causes of puerperal pyrexia, the incidence being 1–5% of all deliveries. The
infection may be the consequence of any of the following:

(1) Recurrence of previous cystitis or pyelitis,

(2) Asymptomatic bacteriuria becomes overt,
(3) Infection contracted for the first time during puerperium is due to—
(a) Effect of frequent catheterization, either during labor or in early puerperium to relieve retention
of urine,
(b) Stasis of urine during early puerperium due to lack of bladder tone and less desire to pass urine.

The organisms responsible are—E. coli, Klebsiella, Proteus and S. aureus.

MANAGEMENT:
Antibiotic

RETENTION OF URINE:

This is a common complication in early puerperium.

The causes are—
(1) Bruising and edema of the bladder neck,
(2) Reflex from the perineal injury,
(3) Unaccustomed position.

Treatment:
If simple measure fails to initiate micturition, an indwelling catheter is to be kept in situ for about 48 hours.
This not only empties the bladder but helps in regaining the normal bladder tone and sensation of fullness.
Following removal of catheter, the amount of residual urine is to be measured. If it is found to be more than
100 mL, continuous drainage is resumed. Appropriate urinary antiseptics should be administered for about
5–7 days.

INCONTINENCE OF URINE:
This is not a common symptom following birth. The incontinence may be:
(1) overflow incontinence,
(2) stress incontinence,
(3) true incontinence.

Overflow incontinence following retention of urine should first be excluded before proceeding to
differentiate between the other two. Stress incontinence usually manifests in late puerperium whereas,
True incontinence in the form of genitourinary fistula usually appears soon following delivery or within
first week of puerperium.

Diagnosis of stress incontinence is established by noting the escape of urine through the urethral opening
during stress. The exact nature of urinary fistula is established by noting the fistula site by examining the
patient in Sims’ position, using Sims’ speculum or by three swab test, if the fistula is tiny.

SUPPRESSION OF URINE:

One should differentiate suppression from retention of urine. If the 24 hours urine excretion is less than
400 mL or less, suppression of urine is diagnosed; the cause is to be sought for and appropriate
management is instituted.

Nursing management

 Encourage urination early in the postnatal period.

  Encourage to void every 2-4 hrs. Assist the mother to the bathroom or at bed side on bed pan.

 Monitor intake and output.

 Monitor for frequency and volume of urine If the mother is unable to void catheterize her

 Monitor for any signs of infection of urinary tract if, any report immediately.

BREAST COMPLICATIONS

The common breast complications in puerperium are:

(1) breast engorgement,
(2) cracked and retracted nipple leading to difficulty in breastfeeding,
(3) mastitis and breast abscess,
(4) lactation failure.
Breast engorgement and infection are responsible for puerperal pyrexia.

BREAST ENGORGEMENT

Cause:
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. The primiparous patient and
the patient with inelastic breasts are likely to be involved. Engorgement is an indication that the baby is not
in step with the stage of lactation.

Onset:
It usually manifests after the milk secretion starts (third or fourth day postpartum).

Symptoms include—
(a) Considerable pain and feeling of tenseness or heaviness in both the breasts,
(b) Generalized malaise or even transient rise of temperature and
(c) Painful breastfeeding.

Prevention includes—
(i) To avoid prelacteal feeds,
(ii) To initiate breastfeeding early and unrestricted,
 (iii) Exclusive breastfeeding on demand,
(iv) Feeding in correct position,
(v) Correct latch on.

Treatment:
(1) To support the breasts with a binder or brassiere,
(2) Frequent suckling
(3) Manual expression of any remaining milk after each feed,
(4) To administer analgesics for pain,
(5) The baby should be put to the breast regularly at frequent intervals,
(6) In a severe case, gentle use of a breast pump may be helpful. This will reduce the tension in the breast
without causing excess milk production.

CRACKED AND RETRACTED NIPPLE

Cracked nipple:
The nipple may become painful due to—
(1) Loss of surface epithelium with the formation of a raw area on the nipple, or
(2) Due to a fissure situated either at the tip or the base of the nipple. These two conditions frequently
coexist and are referred to as cracked nipple. It is caused by—
(a) Unclean hygiene resulting in formation of a crust over the nipple,
(b) Retracted nipple, and
(c) Trauma from baby’s mouth due to incorrect attachment to the breast,
(d) Infection with Candida albicans and S. aureus is often present. The condition may remain
asymptomatic but becomes painful when the infant. sucks. When infected, the infection may spread
to the deeper tissue producing mastitis.

Prophylaxis includes local cleanliness during pregnancy and in the puerperium before and after each
breastfeeding to prevent crust formation over the nipple.

Treatment:

 Correct attachment (latch on) will provide immediate relief from pain and rapid healing. Fresh
human milk and saliva have got healing properties.
 Purified lanolin with the mother’s milk is applied three or four times a day to hasten healing.
 When it is severe, mother should use a breast pump and the infant is fed with the expressed milk.
 Inflamed nipple and areola may be due to thrush also. Miconazole lotion is applied over the nipple as
well as in the baby’s mouth if there is oral thrush.
  If it fails to heal up, rest is given to the affected nipple using a breast pump while the nipples heal.
Nipple shields (thin latex) can be used. The persistence of a nipple ulcer, in spite of therapy
mentioned, needs biopsy to exclude malignancy.

Retracted and flat nipple:

 It is commonly met in primigravidae.
 It is usually acquired.
 Babies are able to attach to the breast correctly and are able to suck adequately.
 In difficult cases, manual expression of milk can initiate lactation.
 Gradually breast tissue becomes soft and more protractile, so that feeding is possible.

ACUTE MASTITIS
 Mastitis is the inflammation of the mammary gland.
 The incidence of mastitis is 2–5% in lactating and less than 1% in non-lactating women.
 The common organisms involved are S. aureus, Staphylococcus epidermidis and Streptococci
viridans.
 Risk factors for mastitis are poor nursing, maternal fatigue and cracked nipple.

Mode of infection—
There are two different types of mastitis depending upon the site of infection.
(1) Infection that involves the breast parenchymal tissues leading to cellulitis. The lacteal system remains
unaffected.
(2) Infection gains access through the lactiferous duct leading to development of primary mammary adenitis.
The source of organisms is the infant’s nose and throat.

Noninfective mastitis may be due to milk stasis. Feeding from the affected breast solves the problem.

Clinical features:
Symptoms include—
(a) Generalized malaise and headache, nausea, vomiting,
(b) Fever (102°F or more) with chills, and
(c) Severe pain and tender swelling in one quadrant of the breast.

Signs include—
(a) Presence of toxic features, and
(b) Presence of a swelling on the breast. The overlying skin is red, hot and flushed and feels tense and tender.

Diagnosis:
Microscopic examination of breast milk, showing leucocytes more than 106 /mL and bacterial count more
than 103 /mL, supports the diagnosis of mastitis.

Complications:
Due to variable destruction of breast tissues, it leads to the formation of a breast abscess.

PROPHYLAXIS:
Thorough hand washing before each feed, cleaning the nipples before and after each feed, and keeping them
dry, reduce the nosocomial infection rates.

Management—
(a) Breast support,
(b) Plenty of oral fluids,
(c) Breastfeeding is continued with good attachment. Nursing is initiated on the uninfected side first to
establish let down,
(d) The infected side is emptied manually with each feed,
(e) Dicloxacillin (penicillinase-resistant penicillin) is the drug of choice. A dose of 500 mg every 6 hours
orally is started till the sensitivity report available. Erythromycin is an alternative to patients who are allergic
to penicillin. Antibiotic therapy is continued for at least 7 days.
(f) Analgesics (ibuprofen) are given for pain.
(g) Milk flow is maintained by breastfeeding the infant. This prevents proliferation of Staphylococcus in the
stagnant milk. The ingested Staphylococcus will be digested without any harm.

BREAST ABSCESS:
Features are—
(1) Flushed breasts not responding to antibiotics promptly,
(2) Brawny edema of the overlying skin,
(3) Marked tenderness with fluctuation,
(4) Swinging temperature.

Treatment
  If an abscess is formed, it is to be drained under general anesthesia
 Breastfeeding is continued in the uninvolved side.
 The infected breast is mechanically pumped every 2 hours and with every let down.
 Recurrence risk is about 10%.
 Once cellulitis has resolved, breastfeeding from the involved side may be resumed.
 Antibiotics to be continued depending upon the culture report of pus.

BREAST PAIN

Breast pain may be due to engorgement, infection (C. albicans), nipple trauma, mastitis or occasionally
with latching on or let down reflex.

Management:
 Appropriate nursing technique, positioning and breast care can reduce pain significantly when it is
due to nipple trauma, engorgement or mastitis.
 Use of miconazole oral lotion or gel into both the nipples and into infant’s mouth thrice daily for 2
weeks is helpful.

LACTATION FAILURE (INADEQUATE MILK PRODUCTION):

The causes are:

(1) Infrequent suckling,
(2) Depression or anxiety state in the puerperium,
(3) Reluctance or apprehension to nursing,
(4) Ill development of the nipples,
(5) Painful breast lesion,
(6) Endogenous suppression of prolactin (retained placental bits),
(7) Prolactin inhibition (ergot preparations, diuretics, pyridoxine).

Treatment:
For maintenance of effective lactation in an otherwise healthy individual, the following
Guidelines are helpful.

Antenatal:
(1) To counsel the mother regarding the advantages of nursing her baby with breast milk,
(2) To take care of any breast abnormality especially a retracted nipple and to maintain adequate breast
hygiene especially in the last 2 months of pregnancy.

Puerperium:
(1) To encourage adequate fuid intake,
(2) To nurse the baby regularly,
(3) Painful local lesion is to be treated to prevent development of nursing phobia,
(4) Metoclopramide, intranasal oxytocin and sulpiride (selective dopamine antagonist) have been found to
increase milk production. They act by stimulating prolactin secretion. Metoclopramide given in a dose of
10 mg thrice daily is found helpful.

PUERPERAL VENOUS THROMBOSIS AND PULMONARY EMBOLISM

Thrombosis of the leg veins and pelvic veins is one of the common and important complications in
puerperium especially in the Western countries. The prevalence is, however, low in Asian and African
countries.

Basic pathology for venous thrombosis are—

(i) Vascular stasis,
(ii) Hypercoagulability of blood (pregnancy), and
(iii) Vascular endothelial trauma (Virchow’s triad 1856).

Other pregnancy-specific risk factors are as mentioned below:

Venous thromboembolic diseases include:
Deep vein thrombosis (ilio femoral)
Thrombophlebitis (superficial and deep veins)
Pulmonary embolus

Risk factors for VTE—

(1) High risk: Previous VTE, thrombophilia;
(2) Intermediate risk:
(a) Heart disease,
(b) SLE,
(c) Surgical procedures (LSCS);
(3) Low risk: Presence of less than three 3 from any of these risk factors mentioned:
(a) Age >35 years,
(b) Obesity (BMI >35),
(c) Parity ≥3,
(d) Immobility,
(e) Dehydration,
(f) Hyperemesis,
(g) Multiple pregnancy
Risk Factors more than three 3 make the patient as intermediate risk.

DEEP VEIN THROMBOSIS—

Diagnosis: Clinical diagnosis is unreliable. In majority, it remains asymptomatic.

Symptoms include pain in the calf muscles, edema legs and rise in skin temperature.

On examination asymmetric leg edema (difference in circumference between the affected and the normal
leg more than 2 cm) is significant.
A positive Homan’s sign—pain in the calf on dorsiflexion of the foot may be present.

Investigations:
The following biophysical tests are employed to confirm the diagnosis:

(1) Doppler ultrasound

(2) Venography
(3) Magnetic resonance imaging (MRI)

PELVIC THROMBOPHLEBITIS:

Postpartum thrombophlebitis originates in the thrombosed veins at the placental site by organisms such as
anaerobic Streptococci or Bacteroides (fragilis). When localized in the pelvis, it is called pelvic
thrombophlebitis. There is no specific clinical feature of pelvic thrombophlebitis, but it should be
suspected in cases where the pyrexia continues for more than a week in spite of antibiotic therapy
Clinical features:
(1) It usually develops on the second week of puerperium.
(2) Mild pyrexia is common prior to the dramatic local manifestations. At times, the fever may be high with
chills and rigor.
(3) Evidences of constitutional disturbances such as headache, malaise and rising pulse rate or features of
toxemia may be present.
(4) The affected leg is swollen, painful, white and cold. The pain is due to arterial spasm as a result of
irritation from the nearby thrombosed vein.

PROPHYLAXIS AND MANAGEMENT FOR VENOUS THROMBOEMBOLISM (VTE)

IN PREGNANCY AND PUERPERIUM

Preventive measures include:

Prevention of trauma, sepsis, anemia in pregnancy and labor. Dehydration during delivery should be
avoided.
Use of elastic compression stocking and intermittent pneumatic compression devices during surgery.
Leg exercises, early ambulation are encouraged following operative delivery.

Thromboprophylaxis to such a woman depends on the specific risk factor and the category.

(1) A low risk woman has no personal or family history of VTE and is heterozygous for factor V Leiden
mutation. Such a woman needs no thromboprophylaxis, early mobilization and adequate hydration to be
maintained.
(2) A high risk woman needs low-molecular-weight heparin (LMWH) prophylaxis throughout pregnancy
and postpartum 6 weeks.
(3) Intermediate risk women with three or more risk factors are considered for antenatal prophylaxis with
LMWH up to 7 days of puerperium.

Management:
(1) The patient is put to bed rest with the foot end raised above the heart level.
(2) Pain on the affected area may be relieved with analgesics.
(3) Appropriate antibiotics are to be administered.
(4) Anticoagulants—
(a) Heparin 15,000 units are administered intravenously, followed by 10,000 units 4–6 hourly for 4–
6injections when the blood coagulation is likely to be depressed to the therapeutic level.
 LMWH can be used safely in pregnancy. Enoxaparin 20 mg (wt <50 kg) or 40 mg (wt 50–90 kg)
daily is given. It does not cross the placenta.
Fondaparinux a synthetic pentasaccharide can inhibit factor Xa but not thrombin. It has limited
transplacental passage. It can be used in cases with heparin-induced thrombocytopenia or heparin
allergies.

The anticoagulant (warfarin, LMWH or unfractionated heparin) is safe for breastfeeding.

PSYCHIATRIC DISORDERS DURING PUERPERIUM

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 risk.

HIGH RISK FACTORS FOR POSTPARTUM MENTAL ILLNESS:

‹ Past history: Psychiatric illness, puerperal psychiatric illness.
‹ Family history: Major psychiatric illness, marital conflict, poor social situation.
‹ Present pregnancy: Young age, caesarean delivery, difficult labour, neonatal complications.
‹ Others: Unmet expectations.

PUERPERAL BLUES

‹ It is a transient state of mental illness observed 4–5 days after delivery and it lasts for a few days.
‹ Nearly 50% of the postpartum women suffer from the problem.
‹ Manifestations are—depression, anxiety, tearfulness, insomnia, helplessness and negative feelings toward
the infant.
‹ No specific metabolic or endocrine abnormalities have been detected. But lowered tryptophan level is
observed. It suggests altered neurotransmitter function.

Treatment is reassurance and psychological support by the family members.

POSTPARTUM DEPRESSION

‹ It is observed in 10–20% of mothers.

‹ It is more gradual in onset over the frst 4–6 months following delivery or abortion.
‹ Changes in the hypothalamo–pituitary–adrenal axis may be a cause.
‹ Manifested by loss of energy and appetite, insomnia, social withdrawal, irritability and even suicidal
attitude.
‹ Risk of recurrence is high (50–100%) in subsequent pregnancies.

Treatment:
Treatment is started early. Fluoxetine or paroxetine (serotonin reuptake inhibitors) is effective and has fewer
side effects. It is safe for breastfeeding also. Estrogen patch has also been used. General supportive measures
are essential as in blues. If no prompt response with medication, psychiatric consultation is sought for. The
overall prognosis is good.

POSTPARTUM PSYCHOSIS (SCHIZOPHRENIA)

‹ Observed in about 0.14–0.26% of mothers. Commonly seen in women with past history of psychosis or
with a positive family history.
‹ Onset is relatively sudden usually within 4 days of delivery.
‹ Manifested by fear, restlessness, confusion followed by hallucinations, delusions and disorientation
(usually manic or depressive). Psychotic women may have delusions. Suicidal, infanticidal impulses may be
present. In that case temporary separation and nursing supervision are needed.
‹ Risk of recurrence in the subsequent pregnancy is 20–25% and there is increased risk of psychotic illness
outside pregnancy also.

Management:
A psychiatrist must be consulted urgently. Hospitalization is needed. Chlorpromazine 150 mg stat and 50–
150 mg three times a day is started. Sublingual estradiol (1 mg thrice daily) results in significant
improvement. Electroconvulsive therapy is considered if it remains unresponsive or in depressive psychosis.
Lithium is indicated in manic depressive psychosis. In that case breastfeeding is contraindicated.

PSYCHOLOGICAL RESPONSE TO PERINATAL DEATHS AND MANAGEMENT

Most perinatal events are joyful. But when a fetal or neonatal death occurs special attention must be given to
the grieving patient and her family. Perinatal grieving may also be due to unexpected hysterectomy, birth of
a malformed or a critically ill infant. Physician, nurse and attending staff must understand the patient's
reaction.

Management includes: Facilitating the grieving process, with support and sympathy.

Others are: supporting the couple in seeing or holding or tacking photographs of the infant; autopsy
requests, planning investigations, follow up visit and plan for subsequent pregnancy,
THEORY APPLICATION

Maternal Role Attainment Theory

As a head nurse in pediatrics and staff nurse in intrapartum, postpartum, and newborn nursery units, Ramona
Mercer had a great deal of experience in nursing care for mothers and infants. This gave her a strong
foundation for nursing.

Attainment Theory

The Maternal Role Attainment Theory was developed to serve as a framework for nurses to provide
appropriate health care interventions for non-traditional mothers in order for them to develop a strong
maternal identity. This mid-range theory can be used throughout pregnancy and postnatal care, but is also
beneficial for adoptive or foster mothers, or others who find themselves in the maternal role unexpectedly.
The process used in this nursing model helps the mother develop an attachment to the infant, which in turn
helps the infant form a bond with the mother. This helps develop the mother-child relationship as the infant
grows.

The primary concept of this theory is the developmental and interactional process, which occurs over a
period of time. In the process, the mother bonds with the infant, acquires competence in general caretaking
tasks, and then comes to express joy and pleasure in her role as a mother.

The nursing process in the Maternal Role Attainment Theory follows four stages of acquisition.

They are: anticipatory, formal, informal, and personal.

 The anticipatory stage is the social and psychological adaptation to the maternal role. This includes
learning expectations and can involve fantasizing about the role.

 The formal stage is the assumption of the maternal role at birth. In this stage, others in the mother's
social system or network, and relying on the advice of others in making decisions.

 The informal stage is when the mother develops her own methods of mothering which are not
conveyed by a social system. She finds what works for her and the child.
  The personal stage is the joy of motherhood. In this stage, the mother finds harmony, confidence,
and competence in the maternal role. In some cases, she may find herself ready for or looking
forward to another child.

JOURNAL STUDIES
Advanced life support in obstetrics (also) and post-partum hemorrhage: a prospective intervention
study in tanzania.

Sorensen BL. Rasch V. Massawe S. Nyakina J. Elsass P. Nielsen BD.

Abstract

Objective
To evaluate the impact of Advanced Life Support in Obstetrics (ALSO) training on staff performance and
the incidences of post-partum hemorrhage (PPH) at a regional hospital in Tanzania. Design. Prospective
intervention study. Setting. A regional, referral hospital. Population. A total of $10 women delivered before
and 505 after the intervention. Methods. All high- and mid-level providers involved in childbirth at the
hospital attended a two-day ALSO provider course. Staff management was observed and post-partum
bleeding assessed at all vaginal deliveries for seven weeks before and seven weeks after the training.

Main Outcome Measures

PPH (blood loss 2500ml), severe PPH (blood loss 21000ml) and staff performance to prevent, detect and
manage PPH. Results. The incidence of PPH was significantly reduced from 32.9 to 18.24RR 0.55 (95%CI:
0.44 - 0.69)] severe PPH from 9.2 to 4.3\%/RR 0.47 (95%CI: 0.29-0.77)]. The active management of the
third stage of labor was also significantly improved. There was a significant decrease in episiotomies. By
visual estimation, staff identified one in 25 of the PPH cases before the ALSO training and one in five after
the training. A significantly higher proportion of women with PPH had continuous uterine massage,
oxytocin infusion and bimanual compression of the uterus after the training.

Conclusion

A two-day ALSO training course can significantly improve staff performance and reduce the incidence of
PPH, at least as evaluated by short-term effects.

SUMMARY
Today we have discussed about the minor ailments of puerperium like after pains, breast engorgement,
suppression of lactation, perineal stitch pain, suppression of lactation, constipation and complications of
puerperium like puerperal pyrexia, puerperal sepsis, urinary tract complications, breast complications,
psychiatric disorders etc...and their respective managements.

CONCLUSION

Following the birth of the baby and expulsion the placenta, the mother enters a period of physical and
psychological recuperation. From a medical and physilogicak view point this period is called the puerperium,
starts immediately after the delivery of the placenta and membranes and continues for 6 weeks this period is
the crucial period where the mother and the baby also has to be cared effectively to improve the health of the
mother, ensure the bonding between the mother and baby, and to prevent many complications.and to prevent
such complications care must be taken not only at one particular stage, but through out the
pregnancy,intranatal period and in postnatal period also.

24

Hon

BIBLIOGRAPHY

1. Dutta P. Pediatric Nursing, 3 ^ n ed. New Delhi, JAYPEE Brothers Medical Publishers (P) Ltd; 2014

2. Hockenberry M, Rodgers C, Wilson D. Essentials of Pediatric Nursing. 10" ed. London. Elsevier

Publishing House; 2016.

3. Dutta D.C.Textbook of Obstetrics.7 7 ^ a ed. London.New Central Book Agency(P) Ltd:2011.121-139,

4. Elizabeth M.Midwifery for 2 ^ (nd) ed.New Delhi CBS Publishers and Distributors Pvt Ltd; 2013.

5. Seth.S.S.Essential of Obstetrics 2 ed. Jaypee Brothers Medical Publishers(P)Ltd:2011:

6. Cooper.M.Fraser.D.Textbokk for Midwives. 15 ed. New York. Churchill Livingstone Elsevier, 2009,
7. Swan D. Obstetrics Nursing Procedure Manual. New Delhi. The Health Science Publishers.2017.

8. Anamma J. A comprehensive textbook of midwifery. 2d ed. JAYPEE Brothers Medical Publishers. 2008

9. Mudaliar A L. Clinical obstetrics. 10 ^ 8 ed. University's press India Pvt.Ltd. 2008.