COMPLICATIONS OF POSTNATAL

DEFINITION OF PUERPERIUM
Puerperium is the period following childbirth during which the body tissues, specially
the pelvic organs revert back approximately to the prepregnant state both anatomically and
physilogically.
COMPLICATIONS OF PUERPERIUM
LIST OUT THE COMPLICATIONS OF PUERPERIUM-
 Hemorrhage
 Puerperal pyrexia
 Puerperal sepsis
 Subinvolution
 Urinary complications
 Breast complications
 Puerperal venous thrombosis & pulmonary embolism
 Puerperaal emergency
 Psychiatric disorders during puerperium
HEAMORRHAGE

DEFINITION

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.

TYPES: -
 Primary postpartum hemorrhage: - is the hemorrhage occurring during the third stage
of labor and within 24 hours of delivery.
1. Third stage hemorrhage: - Bleeding occurs before expulsion of placenta.
2. True postpartum haemorrhage-Bleeding occurs subsequent to expulsion of placenta
(majority).
 Secondary postpartum hemorrhage: - Hemorrhage occurring after 24hours of delivery
and within 6weeks of delivery. It is also referred to as puerperal hemorrhage.
CAUSES:
1. Atonic uterus (70%)
2 Traumatic (20%)
3.Tissue (10%)
4. Mixed
5. Blood coagulopathies (1%)

MANAGEMENT OF TRUE POSTPARTUM HAEMORRHAGE

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SECONDARY POSTPARTUM HEMORRHAGE
Secondary postpartum hemorrhage is bleeding from the genital tract more than 24 hours after
delivery of the placenta and may occur up to 6 weeks after delivery. It is most likely to occur
between 8th and 14th day after delivery.
CAUSES
 Retained bits of cotyledons, membranes or a large uterine blood clot.
 Separation of slough over a deep cervicovaginal laceration.
CLINICAL FEATURES
 The lochia is heavier than normal and will consist of a bright red loss
 The lochia may be offensive, if infection is a contributing factor.
MANAGEMENT
Supportive Therapy
 Resuscitative measures including blood transfusion, if the bleeding is heavy
 Ergometrine 0.5 mg intramuscularly, if the bleeding is uterine in origin
 Antibiotics as a routine.
Conservative Therapy
Bedrest and observation for 24 hours, if the bleeding is mild.
Active Management
 Exploration of the uterus under general anesthesia, if retained bits of placenta or
membranes is the cause.
 Gentle curettage is done and the materials removed are to be sent for histopathological
examination
 Ergometrine 0.5 mg is given intramuscularly. Secondary bleeding following cesarean
section may at times require laparotomy for applying hemostatic sutures. Rarely,
ligation of internal iliac artery or hysterectomy may become necessary.
NURSING CONSIDERATIONS
 If the uterus is still palpable, massaging the uterus and expressing the clots may help
 The mother must be encouraged to empty her bladder
 All the pads and linen must be assessed for the volume of blood lost
 Vital signs and general condition must be monitored.
 Hemoglobin estimation, iron treatment and teaching about iron-rich foods
 Help to breastfeeding mothers to save the milk for the baby.
PUERPERAL PYREXIA
DEFINITION-
"This is rise of temperature to 100.4°F, that is 38°C or more, within 14 days after
confinement or abortion."
CAUSES-
1. Puerperal sepsis
2. Urinary tract infection
3. Mastitis
PURPERAL SEPSIS

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DEFINITION-
"An infection of the genital tract which occurs as a complication of delivery is termed as
puerperal sepsis."
PREDISPOSING FACTORS-
These are:
1. Conditions lowering the resistance-general or local.
2. Conditions favoring multiplication and increased virulence of the organisms.
3. Introduction of organisms from outside.
ORGANISMS
The organisms responsible for puerperal sepsis are:
1. Aerobic: These include:
a. Staphylococcus pyogenes
b. E. Coli
c. Klebsiella
2. Anaerobic: These include:
a. Anaerobic streptococcus
MODE OF INFECTION-
Puerperal sepsis is essentially a wound infection. In this, the placental site, laceration of
genital tract or caesarean section wounds may be infected in the following ways:
 Endogenous
 Exogenous
 Autogenous
CLINICAL MANIFESTATIONS
1. Local infection (wound infection)
2. Uterine infection
3. Spreading infection (extra-uterine spread)
INVESTIGATIONS OF PUERPERAL PYREXIA
1. History taking including Antenatal, Intranatal and Postnatal history.
2. Imaging studies.
3. Pelvic CT scan
4. MRI (Magnetic Resonance Imaging).
NURSING MANAGEMENT OF PUERPERAL SEPSIS
The management includes:
1. Prophylaxis-Antenatal, Intranatal, Postnatal treatment.
2. General treatment.
3. Antibiotics therapy.
4. Surgical treatment.
SUBINVOLUTION

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DEFINITION
"When the involution is impaired or retarded it is called subinvolution".
CAUSES
Anything interfering with proper contraction of the uterus, e.g., full bladder, rectum and
retained products.
PREDISPOSING FACTORS –
1. Grand multiparity.
2. Overdistension of uterus as in twins and hydramnios.
AGGRAVATING FACTORS
1. Retained products of conception.
2. Uterine sepsis.
3. retention of lochia
SYMPTOMS-
1. Excessive or prolonged discharge of lochia
2. Irregular or excessive uterine bleeding
3. Irregular cramp-like pain
SIGNS
1.Uterine height more than normal for the particular day of postpartum.

2. Normal puerperal uterus may be displaced by a full bladder or a loaded rectum.

3.It feels boggy and sifter

MANAGEMENT-
 antibiotic for sepsis
 exploration of the uterus for retained products

NURSING MANAGEMENT:

 Encourage early ambulation in postnatal period

 Daily evaluation of fundal height and documentation.

URINARY COMPLICATIONS IN PUERPERIUM

1. Urinary tract infection

2. Retention of urine
3. Incontinence of urine
4. Suppression of urine

URINARY TRACT INFECTION:

Is most common cause of puerperal pyrexia

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Incidence: 1-5% of all deliveries
Organisms responsible are:
- E. coli
- Klebsiella
Management
Antibiotics
RETENTION OF URINE
This is a common complication in early puerperium
Causes
1. Oedema of bladder neck.
2. 2 Reflex from perineal injury.
Treatment
1. Indwelling catheter should be kept in bladder for 48 hours.
2 Urinary antiseptics should be administered for 7 days.
INCONTINENCE OF URINE
1. It is not common following childbirth.
2. It may be due to:
a. Overflow incontinence
b. Stress incontinence
c. True incontinence
3.. Stress incontinence appears in late puerperium.
4. True incontinence appears within first week of puerperium in the from of fistula.
SUPPRESSION OF URINE
Definition
It is said to be suppression when urine excretion is less than 400 ml in 24 hours.
Causes
It may be due to:
1. Massive blood loss
2. Severe dehydration
3. Septic abortion
4. Hypovolemia
5. DIC (Disseminated Intravascular Coagulopathy)
6. Spasm of intrarenal arteries
Treatment
It is treated by:
1. Controlling fluid imbalance
2. Maintaining caloric requirement

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3. Supportive therapy
3. Prevention of complications
Nursing management
 Encourage urination early in the postnatal period.
 Encourage to void every 2-4 hrs
COMMON BREAST COMPLICATIONS IN PUERPERIUM
The common breast complications in puerperium are:
1. Breast engorgement.
2. Coked and retracted nipple leading to difficulty in breast feeding.
3. Mastitis and breast abscess.
4. Failing lactation.
BREAST ENGORGEMENT
Definition
"Breast engorgement is a venous congestion of the breasts occurring from the 3rd day of the
puerperium."
Cause
Breast engorgement is due to exaggerated normal venous and lymphatic engorgement of the
breasts which precedes lactation.
Onset
It’s usually shows its manifestations after the milk secretion starts on 3rd or 4th postpartum
day.
Symptoms
1. Pain in both the breasts
2. Tenderness /heaviness in both breasts.
3. Generalized malaises.
Management of breast engorgement
1. Administer analgesics to relieve pain
2. The baby should be put to breast at regular intervals
CRACKED AND RETRACTED NIPPLE
DEFINITION
"Cracked nipple means raw area on nipple which may cause pain.”
CAUSES
1. Unclean hygiene resulting in formation of a crust over the nipple
2. Retracted nipple.
3. Vigorous suckling in engorged breasts cases having inadequate milk flow.
SIGNS AND SYMPTOMS

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The signs and symptoms are:
1. Soreness and pain at the site of fissure.
2. Fissure may be infected and infection can spread to deeper tissues leading to mastitis.
3. Pain and tenderness on suckling by the baby.
Prophylaxis
Includes
 Local cleanliness during pregnancy &puerperium before and after each breast
feeding to prevent crust formation over the nipple.
 to exclude malignancy.
RETRACTED AND FLAT NIPPLE
 It is commonly met in primigravidae.
 It is usually acquired.
ACUTE MASTITIS
Mastitis is defined as inflammation of the mammary gland.
INCIDENCE:
2-5% in lactating and less than 1% in non-lactating women.
ETIOLOGY
Milk stasis and cracked nipples, which contribute to the influx of skin flora, are the
underlying factors associated with the development of mastitis.
The most common causative organisms include
 Staphylococcus aureus
 Staphylococcus epidermidis,
 saprophyticus,
 Streptococcus viridians,
 E coli. 
CLINICAL FEATURES

 Generalized malaise and headache

 Fever, chills
 Myalgias,
DIAGNOSIS

 No laboratory tests are required. Expressed milk can be sent for analysis, but the accuracy
and reliability of these results are controversial and aid little in the diagnosis and treatment of
mastitis.
TREATMENT
Curative management

 Provide breast support

 Encourage to take plenty of oral fluids
 Encourage the mother to continue the breast feeding with good attachment
 Nursing is established first on the unaffected side to establish let down.
BREAST ABSCESS:
Definition

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"It is the formation of abscess/pus in the breast which makes the mother look ill and the
breast is more painful, enlarged and oedematous".
Clinical Features
 Flushed breasts not responding to antibiotics promptly
 Brawny edema of the overlying skin
 Marked tenderness with fluctuation
 Swinging temperature.
Management
 Drain the abscess under general anesthesia
 Encourage the breast feeding on the unaffected side.
 The infected breast is pumped every 2 hrs and with every let down
 Once cellulites is resolved breast feeding from the involved side may be resumed.
BREAST PAIN
Candida albicans is a common cause of breast pain.
Risk Factors
 Diabetes mellitus
 Oral thrush of infant
Treatment:
Use of Miconazole oral lotion or gel into both the nipples after each feed and into the infant’s
mouth thrice daily for 2 weeks.
LACTATION FAILURE: (INADEQUATE MILK PRODUCTION)
Causes are:

 Infrequent suckling
 Depression or anxiety state in the puerperium
 Reluctance or apprehension to nursing
 Ill development of nipples
 Painful breast lesion
 Endogenous suppression of Prolactin (retained placental bits)
 Prolactin inhibition
Treatment:
Antenatal:

 Council the mother regarding the advantages of nursing her baby with breast milk
 Take care of any breast abnormality specially a retracted nipple and to maintain
adequate breast hygiene especially in the last 2 months of pregnancy.
Puerperium:

 Encourage adequate fluid intake

 Nurse the baby regularly
 Treat the painful local lesions
 Metoclopramide and sulpride have been found to increase milk production.
PUERPERAL VENOUS THROMBOSIS

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  "Puerperal venous thrombosis is the most important complication in puerperium”
 Thrombosis of the leg veins is one of the common and important complications in puerperium
especially in the western countries
 Venous thrombo- embolic diseases include-
Deep vein thrombosis
Thrombophlebitis
Septic pelvic thrombophlebitis
Pulmonary embolus.
DEEPVEIN THROMBOSIS
Diagnosis:

 Clinical diagnosis is unreliable.

 In majority it remains asymptomatic.
Symptoms- include
 Pain in the calf muscles,
 Edema legs
 Rise in skin temperature.
 On examination-
 a symmetric leg edema (difference in circumference between the affected and the
normal leg more than 1 cm) is significant.
 A positive human’s SIGN — pain in the calf on dorsiflexion of the foot may be present.
Investigations: The following biophysical tests are employed to confirm the diagnosis:
1. Doppler ultrasound to detect changes in the velocity of blood flow in the femoral vein.
2. Venography by injecting non-ionic water-soluble radio-opaque dye to note the filling
defect in the venous lumen is
PELVIC THROMBOPHLEBITIS:
Postpartum thrombophlebitis originates in the thrombosed veins at the placental site by
organisms such as anaerobic Streptococci or Bacteroides (fragilis). When localized in the
pelvis, it is called pelvic thrombophlebitis
Diagnosis may be made by ultrasound, computed tomography (CT) scan or by magnetic
resonance imaging (MRI)
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
PULMONARY EMBOLISM

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 Pulmonary embolism is the leading cause of maternal deaths in many centers especially in the
developed countries after the sharp decline of maternal mortality due to hemorrhage, hypertension
and sepsis.
The predisposing factors are those already mentioned in venous thrombosis. The clinical
features depend on the size of the embolus and on the preceding health status of the patient.
The important signs and symptoms of pulmonary embolism are:
 Tachypnoea,
 dyspnea,
DIAGNOSIS:
X-ray of the chest
ECG
MANAGEMENT:
Prophylaxis (as mentioned in venous thromboembolism)

Active treatment includes:

(1) Resuscitation

(2) I.V. fluid support

(3) Thrombolytic therapy — Streptokinase with a loading dose of 600,000 IU can be given
and continued with 100,000 IU per hour. It does not cross the placenta when used during
pregnancy.

PUERPERAL EMERGENCIES
Immediate
(1) Postpartum hemorrhage
(2) Shock — hypovolaemic, endotoxic or idiopathic
(3) Postpartum eclampsia
(4) Pulmonary embolism — liquor amnii or air
(5) Inversion.
Early (within one week)
(1) Acute retention of urine
(2) Urinary tract infection
(3) Puerperal sepsis
(4) Breast engorgement
(5) Mastitis and breast abscess
(6) Pulmonary infection (atelectasis)

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 (7) Anuria following abruption placenta, mismatched blood transfusion or eclampsia.
Delayed
(1) Secondary postpartum hemorrhage
(2) Thromboembolism manifestation — pulmonary embolism, thrombophlebitis
(3) Psychosis
(4) Postpartum cardiomyopathy
(5) Postpartum homolytic uremic syndrome

PSYCHOLOGICAL DISTURBANCES IN THE PUERPERIUM-

INTRODUCTION –
 In the first 3 months after delivery, the incidence of mental illness is high.
 Overall incidence is about 15-20%.
 Sleep deprivation, hormone elevation near the end of gestation and massive
postpartum withdrawal contribute to the high riskPsychiatric disorders during
puerperium in the first three months after delivery, the incidence of mental illness is
high. Overall incidence is about 15-20%.
PUERPERIAL BLUES
The incidence of mental disorders is highest during the first 3 months after the delivery.
Definition
"It is a transient state of mental illness observed 4-5 days after the delivery. It usually lasts for
a few days. It affects nearly 50% of postpartum women".
Causes
The causes can be:
 A negative feeling towards the child
 Anxiety
 Depression
 Treatment
1. The mother is given psychological support.
2. Her fear anxiety is dealt with calm and quiet approach.
3. POST PARTUM DEPRESSION
 It is observed in 10-20% of mothers.
 It is more gradual in onset over the first 4-6 months following delivery or abortion.
 Changes in the hypothalamo-pituitary-adrenal axis may be a cause.
 Manifestations 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.

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  Fluoxetine or paroxetine (serotonin uptake inhibitors) is effective and has fewer side
effects. It is safe for breast feeding also.
POST PARTUM PSYCHOSIS (SCHIZOPHRENIA)

 Observed in about one in 500 to 1000 mothers. Commonly seen in women with past history of
psychosis or with a positive family history.
 Onset is relatively sudden usually within 4 days of delivery.
Manifestations by:
fear, restlessness, confusion followed by hallucinations, delusions and disorientation (usually
manic or depressive). Suicidal, infanticide impulses may be present. In that case temporary
separation and nursing supervision is needed.
Management:

 A psychiatrist must be consulted urgently.

 Admission is needed.
 Chlorpromazine 150 mg stat and 50-150 mg three times a day is started.
PSYCHOLOGICAL RESPONSE TO PERINATAL DEATHS AND MANAGEMENT

 Most perinatal events are joyful

 But when a fetal /neonatal death occurs, social attention must be given to grieving
parents and family
 It may be because of unexpected hysterectomy, birth of malformed or chronically ill
infant
 Prolonged separation from chronically ill infant can also cause grief
 Physician, nurse and attending staff must understand patient's reaction
 The common maternal somatic symptoms are...
 insomnia
 Fatigue

MANAGEMENT OF PERINATAL GRIEVING

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

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