PERINEAL HEMATOMAS

 A perineal hematoma is a collection of blood in the subcutaneous layer of tissue of the

perineum. The overlying skin, as a rule, is intact with no noticeable trauma.
 Such blood collections can be caused by injury to blood vessels in the perineum during
birth.
 Occur after rapid, spontaneous births and in women who have perineal varicosities
 It appears as an area of purplish discoloration with obvious swelling
 The area is tender to palpation
Therapeutic Management
 Mild analgesic
 Ice pack
 Site maybe incised and the bleeding vessel ligated under local anesthesia
o If an episiotomy incision line is opened to drain a hematoma, it may be left open
and packed with gauze rather than resutured
o Packing is usually removed within 24 to 48 hour
o Keeping it clean and dry & using a sitz bath once or twice a day

PUERPERAL INFECTION
 Infection of the reproductive tract is another leading cause of maternal mortality
 Theoretically, the uterus is sterile during pregnancy and until the membranes rupture.
 A puerperal infection is always potentially serious, because, although it usually begins as
only a local infection, it can spread to involve the peritoneum (peritonitis) or the
circulatory system (septicemia)
 group B streptococci, Escherichia coli, Staphylococcal infections are common

ENDOMETRITIS
 Endometritis is an infection of the endometrium, the lining of the
uterus
 Bacteria gain access to the uterus through the vagina and enter the
uterus either at the time of birth or during the postpartal period
Assessment:
 Fever in 3rd-4th portpartal day
  WBC result is not used to determine since there is an increase
WBC after birth
 Temp 0f 38 C for 2 consecutive days (except the frst 24hr after birth)
suggestion infection
 Depending on the severity of the infection, a woman may have accompanying chills,
loss of appetite, and general malaise.

Therapeutic Management
 Administration of an appropriate antibiotic, such as clindamycin
 Oxytocic agent such as methylergonovine, may be prescribed to encourage uterine
contraction
 Sitting in a Fowler’s position or walking encourages lochia drainage by gravity
 Assess normal color, quantity, and odor of lochia discharge and the size, consistency, and
tenderness of a normal postpartal uterus

INFECTION OF THE PERINEUM

 If a woman has a suture line on her perineum from an episiotomy or a laceration repair,
a portal of entry exists for bacterial invasion
 Pain, heat, and a feeling of pressure in the suture line
 May have fever or none
 Suture line reveals the inflammation. One or two stitches may be sloughed
away, or an area of the suture line may be open with purulent drainage present


Therapeutic Management
 remove perineal sutures- to open and drain
 Packing gauze can be used for drain iage
 Systemic or topical antibiotic
 Analgesic
 Sitz baths, moist warm compresses
 change perineal pads frequently
 proper perineal washing
 Encourage the woman to ambulate

PERITONITIS
 infection of the peritoneal cavity, usually occurs as an extension of endometritis
  It is one of the gravest complications of childbearing and is a major cause of
death from puerperal infection
 The infection spreads through the lymphatic system or directly through the
fallopian tubes or uterine wall to the peritoneal cavity
 An abscess may form in the cul-de-sac of Douglas, because this is the lowest point of the
peritoneal cavity and gravity causes infected material to localize there
 Rigid abdomen, abdominal pain, high fever, rapid pulse, vomiting,
and the appearance of being acutely ill

Therapeutic Management
 Peritonitis is often accompanied by paralytic ileus (blockage of inflamed intestines)
 This requires insertion of a nasogastric tube to prevent vomiting and rest the bowel
 Analgesics for pain relief

THROMBOPHLEBITIS
 inflammation of the lining of a blood vessel with the formation of blood clots
 When thrombophlebitis occurs in the postpartal period, it is usually an extension of
an endometrial infection
 Thrombophlebitis is classified as superficial vein disease (SVD) or deep
vein thrombosis (DVT)
It tends to occur because:
 A woman’s fibrinogen level is still elevated from pregnancy, leading to
increased blood clotting.
 Dilatation of lower extremity veins is still present as a result of pressure of
the fetal head during pregnancy and birth.
 The relative inactivity of the period or a prolonged time spent in delivery or birthing
room stirrups leads to pooling, stasis, and clotting of blood in the lower
extremities.
 Obesity from increased weight before pregnany and pregnancy weight gain can lead to
relative inactivity and lack of exercise.
 The woman smokes cigarettes.
 Ambulation and limiting the time a woman remains in obstetric
stirrups encourages circulation in the lower extremities,
promotes venous return, and decreases the possibility of clot
formation, also helping to prevent thrombophlebitis.
  stirrups of examining or delivery table should be well padded, to prevent any sharp
pressure against the calves of the legs.
 wearing support stockings for the first 2 weeks after birth can help increase venous
circulation and prevent stasis
o put them on before she rises in the morning
o remove the support stockings twice daily and assess her skin underneath for
mottling or inflammation that would suggest inflammation of her veins
o Beginning such activities as walking can also be important. An exercise program
will also be important in helping women lose their pregnancy weight

FEMORAL THROMBOPHLEBITIS
 the femoral, saphenous, or popliteal veins are involved
 decreased circulation, along with edema, gives the leg a white or drained appearance
 If femoral thrombophlebitis develops, a woman notices an
elevated temperature, chills, pain, and redness in the affected
leg about 10 days after birth
 Homans’ sign (pain in the calf of the leg on dorsiflexion of the
foot) may be positive
 Doppler ultrasound or contrast venography usually is ordered to confirm the diagnosis.

Therapeutic Management
 Treatment consists of bed rest with the affected leg elevated
 administration of anticoagulants: heparin and warfarin/comadine
 strict bed rest can be enforced
 Provide good back, buttocks, and heel care
 Check for bed wrinkles so that a woman does not develop the secondary problem of a
pressure ulcer while on bed rest
 Never massage the skin over the clot; this could loosen the clot,
causing a pulmonary or cerebral embolism
 Heat supplied by a moist, warm compress can help decrease inflammation
 Always cover wet, warm dressings with a plastic pad to hold in heat and moisture
 Analgesic
 Heparin therapy: can be given subcutaneously
o Protamine sulfate: antidote
o Check PTT
o Safe for BF
 Warfarin Therapy:
 o antidote to warfarin is vitamin K
o discontinue breastfeeding
 Lochia usually increases in amount in a woman who is receiving an anticoagulant
 Assess for other possible signs of bleeding for anti-coagulant therapy such as easy
bruising, ecchymosis,