Coplications of Puerperium

8/2/2019 Coplications of Puerperium

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Seminar oncomplications

ofPuerperium.

Submitted To: Submitted By:

Mrs. K.P. Sunandha, Ms.Mercy Parneetha. K.A

Asst. Professor, M.Sc (N) II year

Obstetric and gynaecological OBG Nursing,

Nursing Department, J.M.J College of Nursing.

J.M.J College of Nursing.


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Name of the Guide : Mrs. K.P. Sunandha

Name of the Student : Ms. Mercy Parneetha. K.A.

Class : M.sc. (Nursing) II Year

Subject : Obstetrics and gynaecological nursing

Unit : IV

Name of the topic : Complication

Of Puerperium.

Group : M.Sc (N) Students

Place : M.Sc (N) Class room

Date : 27.02.2012

Time : 2:00pm to 4:00pm.

Method of Teaching : Lecture cum Discussion.

A. V aids : Black Board, Transparency, Power point, Pull chart,

Strip tease, Bulletin Board.


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General Objectives:

By the end of the class, the students acquire in-depth knowledge

regarding the complications of puerperium, appreciate the physical and

physiological changes in puerperium and develop skills in taking care of the

mother with any of the complications.

Specific Objectives:

By the end of the class, the students will be able to

define puerperium.

describe the postpartum complications principles.

enumerate the most postpartum complications.

explain the postpartum complications.

Perineal Rupture

Uterine and Vaginal Rupture

Post Parturient Uterine Atony

Post Parturient straining Bacterial Puerperal Infection

Postpartum Haemorrhage

Postpartum Endometritis

Postpartum Cardiomyopathy

Postpartum thyroiditis

Postpartum Depression.


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Introduction:

The Postpartum period, also known as the puerperium, begins with the

delivery of the baby and placenta. The end of the Postpartum period is less well

defined, but is often considered the 6-8 weeks after delivery because the effectsof pregnancy on many systems have resolved by this time and these systems

have largely returned to their pre- pregnant state.

Health care providers should be aware of the medical and psychological

needs of the postpartum mothers and sensitive to cultural differences that

surround child birth.

Definition:

Puerperium- a period from the expulsion of the placenta until 6-8 weeksafter birth, during which time the uterus and other organs and systems

return to their pre pregnant state and lactation is initiated. Many changes take place within the first 10-14 days. Role changes.

(or)

Period of confinement during and just after birth

includes 6 subsequent weeks postpartum during which normal pregnancy

involution occurs.

(or)

Involution is the process whereby the genital organs revert backapproximately to the state as they were before pregnancy.

Duration:

Puerperium begins as soon as the placenta is expelled and lasts for

approximately 6 weeks when the uterus becomes regressed almost to the non-

pregnant size.The period is arbitrarily divided into-

a) immediately within 7 daysb) early upto 6 weeksc) remote- upto 6 weeks.


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Postpartum Complications: Principles

The most frequent cause of postpartum hemorrhage is uterine atony.

Anything that over distends the uterus causes it to contract poorly or

overworks the uterus is a set-up for uterine atony.

Postpartum Complications

Most important postpartum complications

1. Perineal rupture

2. Retained placenta

3. Uterine prolapse

4. Uterine and vaginal rupture5. Post parturient paraplegia

6. Post parturient uterine atony

7. Post parturient straining

8. Bacterial puerperal diseases9. Puerperal intoxication

10. Puerperal infection

11. Septic metritis

12. Puerperal tetani

13. Puerperal vaginitis and vulvitis

1. Perineal Rupture

Causes :1. Spontaneous, during the second stage of labor (vigorous straining)

2. Extreme traction of an oversized fetus

3. Predisposition include a hypoplastic vulva


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Surgical correction:

1. Cleaning the perineal region

2. Light epidural anesthesia

3.Exposure the operative area by placing tension suture in the perineal skin

4. The free edge of the shelf is incised to a depth of 3 cm and extended laterally

and caudally on each side

5. Synthetic non-absorbable suture and a No. 2 or 3 half circle cutting edge

needle are used in the modified vertical suture pattern, starting at the deepest

part.

6. The two ends of each suture are left long (8 cm) and are tied together at their

ends to aid in identification of each knot during removal.

7. The suture must not penetrate the rectal mucosa.

8. The perineal skin is closed with vertical mattress suture.

2. Uterine and vaginal Rupture:Causes

1. Prolonged dystocia with fetal emphysema2. Uterine torsion

3. Improper manipulation and traction of the fetus

4. Forced traction of the fetus in abnormal p.p.p.

5. Fatigue of the operator

6. Poorly dilated cervix7. Administration of oxytocin while the cervix is closed.

TreatmentIn small uterine rupture

Repeated doses of oxytocin

Parental and intrauterine AntibioticFluid therapy

Close observation of the client.

In large uterine rupture

o Suturing the uterus through the birth wayo Prolapsing the ruptured uterus and suturing ito Suturing the uterus through laparotomy


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3. Postparturient Uterine Atony

The uterus is abnormally large, roomy, flabby and without contraction directly

after birth

Causes: Uterine inertia (primary and secondary) Over-thinning of the uterus (twins, hydropsy) Rupture of the uterus or cervix Hypocalcaemia

Clinical findings:

In rectal examination, the uterus found descended in the abdominalcavity, the uterus lack any contraction and filled with lochia.

The cervix is dilated with small amount of lochia discharged from thevulva.

Secondary retention of placenta

Treatment:Oxytocin: 50-100 IU, within 24h after birth

Methergin: 5-10 mg i.m.

Calcium gluconate

Local and systemic antibiotic

4. Postparturient Straining

There is a persistent strong uterine birth pains for one or more day after birth

Causes:

There is irritant to the vagina or vulva Long standing dystocia

Bleeding from the genital tract

Symptoms The pains may persist for 4-7 days after birthContinuous or intermittent straining, arched back, sunken eyes and

depression.

Frequent defection, diarrhea. There is great tendency for prolapse of the vagina or rectum. Uterine contractions are stronger


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Treatment

General sedativeEpidural anesthesia

Local antibiotic within the uterusTreat the original cause

5. Bacterial puerperal Infection

Disease:Puerperal bacterial intoxication

Cause: Saprophytic bacteria

Pathogenesis: Putrifaction of the uterine contents produces toxins which

absorbed through the uterine endometrium to circulate in the blood with

general intoxication.Symptom: Fever, indigestion, exhaustion, little edema in the genital tract,

abnormal lochiaTreatment: Local antibiotic, Oxytocin, Siphoning the uterus, Supportive

treatment, Antihistaminic, Calcium gluconate, Systemic antibiotic, Epidural

Anesthesia.

Disease: Puerperal bacterial infection

Cause: Saprophytic bacteria

Pathogenesis: Bacterial activities are intensive. Bacteria tend to act locally

in the uterusSymptom: Fever, Depression, edema of the soft birth way, abdomen is tenseTreatment: same treatment

Disease: Septic metritis

Cause: Coliform , Streptococci and Micrococcus

Pathogenesis: The difficult form of the non-specific Puerperal infectionSymptom: Fever, reddish watery vulval discharge, peritonitis, arthritis.Treatment: same treatment.

Disease:Puerperal necrosisCause: NechrophorumPathogenesis: Necrotic bacteria get entrance to the uterus from the cervix.

Symptom: General health disturbances, liver painful no palpation, the

mucus membrane is yellowish.Treatment: Local and systemic Antibiotic, supportive treatment


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Disease:Puerperal tetanusCause: Cl. tetaniPathogenesis: m.o. enter the uterus through injury in the endometrium.Symptom: Muscular cramps and stiffness.

Treatment: Anti-tetanic serum, supportive treatment.

Disease: vaginitis and vulvitis

Cause: Saprophytic Bacteria, Nechrophorum.Pathogenesis: Narrow birth way result in trauma and laceration + m.o.Symptom: Swollen vulva and vagina.

Treatment: Oily bland antiseptic Antibiotic, Epidural

Anesthesia.

6.

Postpartum Hemorrhage

Obstetrical emergency that can follow vaginal or cesarean deliveryIncidence3% of births

3rd

most common cause of maternal death in US

Definition Excessive bleeding that makes the patient symptomatic

(lightheaded, syncope) and/or results in signs of hypovolemia(hypotension, tachycardia, oliguria)

(or)

A blood loss that exceeds 500 ml after a vaginal birth or 1,000mlafter a cesarean birth.

Early Postpartum Hemorrhage blood loss in the first 24 hrs afterchildbirth.

Late Postpartum Hemorrhageoccurs after the first 24 hrs.


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Causes of Postpartum Hemorrhage

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Risk Factors

Prolonged 3rd stage of labor

Fibroids, placenta previa Previous PPH Over distended uterus Episiotomy Use of magnesium sulfate, preeclampsia Induction or augmentation of labor


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Management

Swift execution of a sequence of interventions with prompt assessment of

response

Initial steps Fundal massage ABCs, O2, IV access with 16g catheters

Infuse crystalloid; transfuse blood products as needed Examine genital tract, inspect placenta, observe clotting Give uterotonic drugs

Oxytocin 20 IU per L of NS

Methylergonovine (Methergine) 0.2mg IM q2-4h

Misoprostol 800 or 1000mg PR

Secondary steps Will likely require regional or general anesthesia Evaluate vagina and cervix for lacerations Manually explore uterus

Treatment options

Repair lacerations with running locked absorbable suture Tamponade Arterial embolization Laparotomy

uterine vessel ligation Hysterectomy


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Bimanual uterine compression massage is performed by placing one hand

in the vagina and pushing against the body of the uterus while the other

hand compresses the fundus from above through the abdominal wall. The

posterior aspect of the uterus is massaged with the abdominal hand and

the anterior aspect with the vaginal hand.

Preventive Measures

correcting anemia prior to delivery.

episiotomies only if necessary.

active management of third stage.

assess patient after completion of paper work to detect slow steady

bleeds.


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Management of Postpartum Hemorrhage

7. Postpartum Endometritis

Infection of the deciduas (pregnancy endometrium)

Incidence


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Fevermost common sign Uterine tenderness Foul lochia Leukocytosis

Bacteremiain 10-20%, usually a single organism

Workup CBC Blood cultures Urine culture DNA probe / Chlamydia Imaging studies if no response to adequate in 48-72h

CT scan abd/pelvis

US abd/pelvis

Treatment Broad spectrum IV

Clindamycin 900mg IV q8h and

Gentamycin 1.5mg/kg IV q8h Treat until afebrile for 24-48h and clinically improved; oral therapy

not necessary Add ampicillin 2g IV q4h to regimen when not improving to cover

resistant enterococci

Prevention prophylaxis for women undergoing C-section

Cefazolin 1-2g IV as single dose

8. Postpartum Thyroiditis

A variant form of Hashimotos thyroiditis occurring within 1 year after

parturition

Incidence3-16% of postpartum women

Up to 25% in women with Type 1 DMThyroid inflammation damages follicles proteolysis of thyroglobulin release of T3 + T4 TSH suppression.


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Clinical manifestations 20-30%

Hyperthyroidism 2-4 mos pp, lasting 2-8 wks, followed by

hypothyroidism, lasting 2-8 wks, then recovery

20-40%Hyperthyroidism only 40-50%

Hypothyroidism only, beginning 2-6 mos pp

Symptoms and signs, when present, are mild

HyperthyroidismAnxiety, weakness, irritability, palpitations, tachycardia,

tremor Hypothyroidism

Lack of energy, sluggishness, dry skin

Diagnosis Small, diffuse, nontender goiter or normal exam High or high normal T3 + T4, low TSH, low radioiodine uptake

(hyper phase) Low or low normal T4, high TSH (hypo phase)

65-85% have high antithyroidTreatment Most need no treatment.

Hyper: atenolol or propanolol

Avoid in nursing womenHypo: levothyroxine 50-100 mcg qd for 8-12 wks.

Educate patient on sex, increased risk of developing

hypothyroidism or goiter, likely recurrence with subsequentpregnancies

9. Postpartum Depression

Most common complication

Occurs in 13% (1 in 8) of women after pregnancy Recurs in 1 in 4 with prior depression Begins within 4 weeks after delivery

Multifactorial etiology

Rapid decline in hormones, genetic susceptibility, life stressorsRisk Factors

Prior h/o depression, family h/o mood disorders, stressful lifeevents

Pattern of sex are similar to other episodes of depression

Depressed mood, anxiety, loss of appetite, sleep disturbance,fatigue, guilt, decreased concentration


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Must be present most of the day nearly every day for 2 wks.Screening

Edinburgh Postnatal Depression Scale + screen with score >/= 10

Check for anemia and thyroid diseaseDifferential Diagnosis Baby Bluescommon, transient mood disturbance

Sadness, weeping, irritability, anxiety, and confusion

Occurs in 40 - 80% of postpartum women. Postpartum psychosis

Psychiatric emergency due to risk of infanticide or suicide

Bizarre behavior, disorganization of thought, hallucinations,

delusions

usually occurs in first 2 weeks of pp

TreatmentInitiate at half the usual starting dose

Treat for at least 612 months after full remission to

prevent relapse

Sertraline or paroxetine for breast-feeding mothers May also respond to psychotherapy Hormonal therapy

Patient resources

National Womens Health Info Center(www.4woman.gov) www.depressionafterdelivery.com

Blues:

Most common perinatal mood disturbance Prevalence: 30-75% Onset day 3 or 4 Mild, transient lasting hours to days Resolve within 2 weeks

No treatment necessary

Postpartum Psychosis

Most rare and severe form of postpartum mood disorder Prevalence: 0.01-0.02% Onset: rapid, within 72 hours of birth, 95% of cases within 2 weeks Treatment: Psychiatric Emergency, Psychiatristtreatment with

medication.
http://www.4woman.gov/http://www.4woman.gov/http://www.4woman.gov/http://www.depressionafterdelivery.com/http://www.depressionafterdelivery.com/http://www.depressionafterdelivery.com/http://www.4woman.gov/


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Postpartum Psychiatric Disorders

Disorder Prevalence Onset Duration Treatment

Blues 30-75% Day 3 or 4 Several days None

Postpartum

Depression

10 15% Within weeks Weeks

Months

Treatment by GP or psychiatrist

Postpartum Psychosis 0.01

0.02%

Within 2

weeks

Weeks

months

Psychiatric emergency

Hospitalization required


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Subinvolution of uterus:

Description Incomplete involution or failure of the uterus to return to its normal

size and conditionCause

InfectionRetained placenta fragments

Assessment Uterine pain on palpation Uterus is larger than expected Fundus is higher in the abdomen Greater than normal vaginal bleeding Lochia does not follow normal pattern i.e.:

RUBRASEROSA -- RUBRA Backache

Leucorrhea if infection (white, creamy discharge)

TreatmentMethergin 0.2 mg Q3-4H PO for 24-48 hours Antibiotics Possibly D&C

Nursing interventionsMedications as ordered Assessment of fundus Safety and comfort needs

Mastitis:

Description Inflammation of the breast as a result of infection Primarily seen in breast-feeding mothers 2 to 4 weeks after

delivery

Cause Staph aureus Hemolytic strep How it is transmitted:

Babys nose and throatMothers or health care providers hands Cracked nipples


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Assessment Localized heat and swelling Pain: redness, warmth and firm to touch with areas of lumpiness Elevated temperature and chills

Tachycardia Headache Complaints of flu-like symptoms

Intervention: Promote comfort of the client Instruct mother in good hand-washing and breast hygiene Apply heat to enhance inflammatory process (kill microbes)Maintain lactation in breast-feeding mothers Encourage manual expression of breast milk or use of breast pump

every 4 hoursREMEMBER, during EARLY stages of mastitis, the mother is

encouraged to breast-feed DIRECTLY Encourage mother to support breasts with supportive bra Administer analgesics as prescribed Administer antibiotics as prescribed Possibly I&D

Conclusion:

During pregnancy and Postpartum, changes occur in the circulating blood

volume, peripheral vascular compliance and resistance, myocardial function,heart rate and the neuro hormonal system. These changes allow the

cardiovascular system to meet the increased metabolic changes demands of

pregnancy.


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BIBLIOGRAPY:

Lowdermilk,perry and Bobak, maternity &womens health care, 6 thedition, 1997, mosby, inc., st. Louis, missori, pg no: 358-367.

Donna L.Wong &Shannon E. Perry, maternal & child nursing care,1998,Mosby, Inc, St.Louis,pg no546-574.James DK, PJ steer & etal, High Risk pregnancy management, 2nd

edition.2001, WB Saun ders, China, pg no. 667-687.D.C Dutta, Text book of obstetrics including perinatology &

contraception, 6th

edition, New central book agency, Pg no. 543-567.

Kamini Rao, Textbook of midwifery & obstetrics for nurses, 1st edition,New Delhi,pg no.276-297.

Diane M. Fraber, Myles Text book for Midwives, 15 the edition, Elsevier, pg no. 98-130.

www.encyclopedia.com

www.wikepedia.com

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