POSTPARTUM COMPLICATIONS

Puerperal Infection “Puerperal Sepsis”

Any clinical infection of the genital canal and breasts that occurs within 28 days after abortion or delivery.

Postpartum infection of genital tract usually of the endometrium that may remain localized or may extend to various parts of the body.

Infections may result from bacteria commonly found in the vagina (endogenous) or from the induction of pathogens from outside the vagina (exogenous).

The most common microorganisms are Streptococci, E. coli, Staphylococci, Sexually Transmitted Diseases (STDs), Anaerobic microorganisms as Tetanus and gas gangrene.

Puerperal infection may occur anywhere in the pelvis or birth canal as endometritis, vaginitis, vulvitis.

Predisposing Factors1. Prolonged labor

2. Postpartum hemorrhage.

3. PROM.

4. Infection elsewhere in the body.

5. Intrauterine manipulation.

6. Anemia.

7. Retention of placental fragments.

8. Malnutrition. Clinical Findings: Symptoms may be mild to sever Any fever with a temperature of 38 ºC or more on 2

successive days (not counting the first 24 hours after delivery) must be considered to be caused by puerperal infection in the absence of another cause.

Endometritis Endometritis is the most

common puerperal infection and it occurs 24-48 hours after delivery.

Uterus usually larger than expected for postpartum day.

Lochia may be profuse, bloody and has a foul smelling.

Chills, fever, anorexia and general malaise.

Risk factors Cesarean birth Prolonged rupture of

the membranes Multiple vaginal

examinations Internal electronic FHR

monitoring

Diabetes Prior genital infection Inadequate aseptic

technique Anemia Smoking Nulliparity Operative vaginal

delivery Poor postpartum

perineal care

Puerperal Infection “Puerperal Sepsis” Endometritis usually occurs at the

placental site. Localized infection may be followed by

salpingitis, peritonitis & pelvic abscess formation, & septicemia may develop.

Secondary abscesses may arise in distant sites such as the lungs or liver. Pulmonary embolism or septic shock with DIC from any serious genital infection may prove fatal.

Parametritis Pelvic Cellulitis Infection of the pelvic connective tissue. Chills, fever, tachycardia, severe unilateral or

bilateral pain in the lower abdomen and tenderness on vaginal examination usually occur about the 4th postpartum day.

May result from infected wound in the cervix, vagina, peritoneum or lower uterine segment.

Uterus may be longer than expected. Pelvis area warm with an extremely sensitive spot

due to an abscess formation underneath. Incision and drainage is performed if an abscess

forms, antibiotics.

Thrombophlebitis Inflammation of venous wall with clot formation. Pelvic Thrombophlebitis:

Infection of veins supplying uterine wall and broad ligament.

Symptoms usually begin during the 2nd week following delivery.

The women may have severe chills and intermittent high fever (40 ºC), ? redness, increase skin temperature,

Blood cultures are taken to isolate the organisms. Femoral Thrombophlebitis:

Pain, tenderness, redness, hotness, edema of the calf or thigh.

Puerperal Infection “Puerperal Sepsis” Diagnostic Evaluation:

Clinical history.Physical examination.Leukocytosis, high neutrophils.Culture and sensitivity for discharge and blood

for both aerobic and anaerobic organisms.Lung scan, chest X-ray.

Management and Nursing Interventions:The most effective and cheapest treatment of

puerperal infection is prevention.

Preventive measures include

Good prenatal nutrition. Treatment of anemia. Control of intranatal hemorrhage. Good hygiene. Prolonged labor should be avoided. Traumatic vaginal delivery should be

avoided. Best aseptic techniques by medical

personnel.

Determine source of woman’s anxiety regarding complications. Explain prescribed treatment regimen. Correct misinformation. Monitor the woman’s condition: Continue monitoring of temperature, pulse and respiration. Isolate the woman with infection from other postpartum women. Maintain fluids and electrolytes. Blood may be necessary to combat severe anemia. Antibiotic therapy as prescribed. Monitor site of infection for manifestations. Provide diet with increased calories, protein and vitamins to promote

healing. Institute comfort measures: Good skin care. Soothing sponge bath. Frequent change of perineal pads. Analgesics as prescribed Assist the woman/family in planning for child care required by

prolonged hospitalization.

Mastitis Mastitis is inflammation of breast tissue It may involve formation of sub-areolar abscess in

the underlying milk glands or connective tissue and fat around the lobes and lobules.

Is unilateral, and develops

well after the flow of milk has

been established. Cause: Usually due to

Staphylococcus aureus

derived from the nursing

infant’s nose and throat into

a fissure in the nipple.

Clinical Manifestations

Symptoms may occur at the end of the 1st postpartum week but usually occur in the 3rd to the 4th week postpartum.

Elevated temperature (usually not above 39.3 ºC). Tachycardia Breast pain. Breast hardening and redness. Inflammatory edema, enlarged axillary lymph

nodes. Breast engorgement with obstruction of milk flow.

Management and Nursing intervention Acute mastitis can be avoided by:

Proper nursing technique, to prevent cracked nipple.Avoid missed feedings, waiting too long between

feedings.Maintain cleanliness and personal hygiene of both

mother and newborn. Implement plan of care:

Use comfort measures- breast support, tight binder or brassier.

Analgesics as prescribed.Application of heat to affected breast if suppuration is

present.

Suitable antibiotic for Staphylococcus aureus as Cephalosporines.

If breast milk is contaminated, breast feeding on affected side may be discontinued, empty breast on affected side with breast pump and discard milk until infection is controlled.

If abscess forms, incision and drainage may be necessary. Correct misinformation regarding condition and

complication. Keep the woman/family informed of changes in physiologic

status and treatment plan. empty the breasts every 2 to 4 hours by breast feeding,

manual expression, or breast pump.

Postpartum UTI Causes:

Bladder trauma during delivery.Urinary retention due to anesthesia, venous

congestion causing over distention of the bladder.

Frequent catheterization. Clinical Manifestations:

Elevated temperature and chills.Urinary frequency.Pain on urination.Flank pain.

Management and Nursing Interventions

Explain and implement plan of care:Monitor vital signs, degree and site of pain.Instruct the woman to increase fluid intake.Instruct the woman to empty her bladder

completely each time she urinates.Administer suitable antibiotics, analgesics, and

antispasmodics as prescribed.Encourage the woman to rest.

Describe complications and general treatment regimen.

Correct misinformation regarding condition and complications,

Subinvolution Is the slowing or failure of normal postpartum return of

reproductive organs to their pre-pregnancy state. (is the failure of the uterus to return to the nonpregnant state).

Causes:

1. Pelvic infection.

2. Retention of placental fragments.

3. Fibroid tumor.

4. Any other factors that interferes with myometrium contractions.

Clinical Manifestations:

1. Uterus larger or softer than expected for postpartum date.

2. Prolonged lochia discharge (after one month or more).

3. Irregular uterine bleeding.

4. Backache or sensation of weight in pelvis.

Management and Nursing Interventions

Explain and implement plan of care. Administration of oxytocin and methergine as

prescribed to increase uterine contractility. Prepare the woman for uterine curettage if

placental fragments have been retained. Administer suitable antibiotics for infection as

prescribed. Describe complications and usual treatment

regimen. Correct misinformation regarding condition

and complications.

Postpartum Hemorrhage

Is defined as a loss of blood excess of 500 ml in the 1st 24 hours following vaginal delivery and 1000 mL or more after a cesarean birth.

It occurs more frequently in the 1st hour following delivery. Approximately 5% of all women who give birth vaginally

experience a postpartum hemorrhage. According to The WHO, 25% of all pregnancy related

deaths result from postpartum hemorrhage. Postpartum hemorrhage could be early or late:

An early hemorrhage occurs within the first 24 hours after birth (mostly within the first 4 postpartum hours).

A late hemorrhage occurs more than 24 hours but less than 6 weeks postpartum.

Causes:

1. Uterine atony “Relaxation of the uterine muscles” Is a failure of the uterine myometrium to contract and

retract following birth. It occurs secondary to:

Multiple pregnancies that causes over distention of uterus and larger placental site.

High parity.Prolonged labor with maternal exhaustion.Deep anesthesia: provide uterine relaxation.Fibromyomata: prevents uterus from contracting.Retained placental fragments.Polyhydramnios.Macrosomia.

Causes 2. Laceration of the vagina, cervix or perineum

secondary to:Forceps delivery.Large infant.Multiple pregnancies.

3. Retained placental fragments:These fragments are the major cause of late postpartum

hemorrhage.Mostly occurs at 2-4 weeks after delivery.Results from placenta accreta (placenta with abnormally

firm attachments to the uterine wall) or manual removal of placenta.

4. Retained placenta:Hemorrhage may occur after the delivery of baby and

before delivery of the placenta.

Clinical Manifestations Uterine atony:

Uterus is soft, often difficult to palpate and will not remain contracted.

Bleeding is steady and slow rather than sudden and massive.

Blood pressure and pulse may not change until blood loss is significant.

Lacerations:Fundus is firm, bleeding is bright red.On examination, lacerations are found.

Retained placental fragments:Hemorrhage usually occurs about the 10th postpartum

day.Excessive blood loss: pallor, restlessness, dyspnea,

thready pulse, hypotension, chills and air hunger.

Management and Nursing interventions

Monitor changes in physiologic status: Monitor vital signs frequently.Describe number and saturation of perineal pads

used per hour.Describe character and amount of vaginal bleeding.Evaluate uterine firmness, height and position.

Restore fluid/blood volume:Administer IV Fluids as prescribed to restore fluid

volume.Administer blood as prescribed.When cause has been determined, prepare the

woman for further treatment.

Management and Nursing interventions

Uterine atony:Vigorous massage is instituted.Oxytocics such as Methylergonovin (Methergin) and

Oxytocin (Pitocin) may be given.Laceration:

Prepare the woman to return to the delivery room for inspection and repair.

Retained placental fragments:Prepare the woman for curettage of the uterus.

Retained placenta:The physician manually removes the placenta by

inserting a gloved hand into the uterus and placing the other hand externally on the fundus.

Management and Nursing interventions

O2 at 4-7 L/min is given by facemask.Help reduce anxiety:

Determine major cause of mother’s anxiety.Explain current status and prescribed treatment

regimen.Correct misinformation regarding states or

potential complications.Keep the woman/family informed of changes in

physiologic status or treatment plan with emphasis on improvement condition.

Results from placenta accreta or manual removal of placenta.

Breast feeding Human breast milk is the ideal infant food choice. It

is bacteriologically safe, fresh, readily available and balanced to meet the infant’s needs.

“human milk is species-specific, and all substitute feeding preparations differ markedly from it, making human milk uniquely superior for infant feeding”

The World Health Organization and the American Academy of Pediatrics recommend human milk as the exclusive nutrient source for the first 6 months of life, and indicates that breastfeeding be continued at least through the first 12 months of life, and thereafter as long as mother and baby mutually desire.

Breast feeding Although the composition of infant formula is

similar to that of breast milk, breast milk is still considered to be the best option for optimal health promotion and disease prevention in the newborn. Research provides good evidence that breastfeeding decreases the rate of postneonatal infant mortality (21%), and reduces the incidence of a wide range of infectious diseases including bacterial meningitis, bacteremia, diarrhea, respiratory tract infection, necrotizing enterocolitis, otitis media, urinary tract infection, and late-onset sepsis rates in preterm infants.

Contraindications for breastfeeding

Infants with galactosemia (due to an inability to digest the lactose in the milk)

Mothers with active tuberculosis or HIV infection

Mothers with active herpes lesions on the nipples

Mothers who are receiving certain medications, such as lithium or methotrexate

Mothers who are exposed to radioactive isotopes (e.g., during diagnostic testing)

The neonate is most alert during the first 1 to 2 hours after an unmedicated birth, and this is the ideal time to put the infant to the breast.

Cesarean deliveries and medicated births, including those with epidural anesthesia, may require more mother–infant skin to skin contact before a successful latch-on occurs.

To feed effectively, the infant must awaken and let his mother know that he wants to eat.

An optimal breastfeeding experience begins with the mother’s prompt response to her infant’s feeding readiness cues.

The mother should hold the baby so that his nose is aligned with the nipple and watch for an open mouth gape.

Feedings that last less than 10 minutes or continue for longer than 40 minutes are not satisfactory and require consultation.

POSITIONS FOR BREASTFEEDINGCradle hold position

POSITIONS FOR BREASTFEEDING Football position

POSITIONS FOR BREASTFEEDING Side-lying position

BREASTFEEDING Frequent feeding (at least every 2 to 3 hours) is To minimize the stasis of milk, it is advised that the infant

is fed at each breast at least 15 to 20 minutes until at least one breast softens after the feeding, otherwise, it will cause breast engorgement.

To help reduce the swelling and enhance milk flow, the nurse should instruct the mother to use warm compresses and perform hand expression before nursing. This action softens the areola, initiates the let-down reflex, and

allows the infant to more easily grasp the areola. Massaging the breasts during feedings, taking a warm

shower, and hand-expressing some milk before nursing will help to enhance milk flow and help facilitate infant latch-on.

Birth–1 month Breast every 2–3 hours----Bottle every 3–4 hours

2–3 oz. per feeding

2–4 months Breast or bottle every 3–4 hours

3–4 oz. per feeding

4-6 months Breast or bottle 4-6 times per day

4-5 oz. per feeding

6–8 months Iron-fortified, rich cereal

Breast or bottle 4 times per day

6–8 oz. per feeding

8–10 months Finger foods

Chopped or mashed foods

Sippy cup with formula, breast milk, juice or water

Breast or bottle 4 times per day

6–8 oz. per feeding

10–12 months Self-feeds with fi ngers and spoon

Most table foods are allowed

Breast or bottle 4 times per day

6–8 oz. per feeding