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Intrapartum Care: The puerperium


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Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning

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Intrapartum Care: The puerperium

  1. 1. 7 The puerperiumBefore you begin this unit, please take the THE NORMALcorresponding test at the end of the book toassess your knowledge of the subject matter. You PUERPERIUMshould redo the test after you’ve worked throughthe unit, to evaluate what you have learned. 7-1 What is the puerperium? The puerperium is the period from the end Objectives of the third stage of labour until most of the patient’s organs have returned to their pre- pregnant state. When you have completed this unit you should be able to: 7-2 How long does the puerperium last? • Define the puerperium. • List the physical changes which occur The puerperium starts when the placenta is delivered and lasts for six weeks (42 days). during the puerperium. However, some organs may only return to • Manage the normal puerperium. their pre-pregnant state weeks or even months • Diagnose and manage the various after the six weeks have elapsed (e.g. the causes of puerperal pyrexia. ureters). Other organs never regain their pre- • Recognise the puerperal psychiatric pregnant state (e.g. the perineum). disorders. It is important for the midwife or doctor • Diagnose and manage secondary to assess whether the puerperal patient has postpartum haemorrhage. returned, as closely as possible, to normal • Teach the patient the concept of ‘the health and activity. mother as a monitor’. The puerperium starts when the placenta is delivered and lasts for six weeks. 7-3 Why is the puerperium important? 1. The patient recovers from her labour, which often leaves her tired and even
  2. 2. 116 INTRAPAR TUM CARE exhausted. There is, nevertheless, a feeling 3. Abdominal wall: of great relief and happiness. • The abdominal wall is flaccid (loose2. The patient undergoes what is probably the and wrinkled) and some separation most important psychological experience of (divarication) of the abdominal her life, as she realises that she is responsible muscles occurs. for another human being, her infant. • Pregnancy marks (striae gravidarum),3. Breastfeeding should be established. where present, do not disappear but do4. The patient should decide, with the tend to become less red in time. guidance of a midwife or doctor, on an 4. Gastrointestinal tract: appropriate contraceptive method. • Thirst is common. • The appetite varies from anorexia to7-4 What physical changes ravenous hunger.occur in the puerperium? • There may be flatulence (excess wind). • Many patients are constipated as aAlmost every organ undergoes change in the result of decreased tone of the bowelpuerperium. These adjustments range from during pregnancy, decreased foodmild to marked. Only those changes which are intake during labour and passingimportant in the management of the normal stool during the late first stage andpuerperium will be described here. second stage of labour. Constipation1. General condition: is common in the presence of an • Some women experience shivering episiotomy or painful haemorrhoids. soon after delivery, without a change in The routine administration of enemas body temperature. when patients are admitted in labour • The pulse rate may be slow, normal or is unnecessary and is not beneficial to fast, but should not be above 100 beats patients. It also causes constipation during per minute. the puerperium. • The blood pressure may also vary and 5. Urinary tract: may be slightly elevated in an otherwise • Retention of urine is common and healthy patient. It should, however, be may result from decreased tone of the less than 140/90 mm Hg. bladder in pregnancy and oedema of • There is an immediate drop in weight the urethra following delivery. Dysuria of about 8 kg after delivery. Further and difficulty in passing urine may weight loss follows involution of lead to complete urinary retention, or the uterus and the normal diuresis retention with overflow incontinence. (increased amount of urine passed), but A full bladder will interfere with also depends on whether the patient uterine contraction. breastfeeds her infant. • A diuresis usually occurs on the2. Skin: second or third day of the puerperium. • The increased pigmentation of the face, In oedematous patients it may start abdominal wall and vulva lightens but immediately after delivery. the areolae may remain darker than • Stress incontinence (a leak of urine) they were before pregnancy. is common when the patient laughs • With the onset of diuresis the general or coughs. It may first be noted in puffiness and any oedema disappear in the puerperium or follow stress a few days. incontinence which was present during • Marked sweating may occur for some pregnancy. Often stress incontinence days. becomes worse initially but tends to improve with time and with pelvic floor exercises.
  3. 3. THE PUERPERIUM 117 Pelvic floor exercises are also known as fingers. By the 7th day postpartum the pinch or ‘knyp’ exercises. The muscles that cervical os will have closed. are exercised are those used to suddenly • Uterus: The most important change stop a stream of urine midway through occurring in the uterus is involution. micturition. These muscles should be After delivery the uterus is about the tightened, as strongly as possible, 10 times in size of a 20 week pregnancy. By the end succession on at least four occasions a day. of the first week it is about 12 weeks Normal bladder function is likely to be in size. At 14 days the fundus of the temporarily impaired when a patient has uterus should no longer be palpable been given epidural analgesia. Complete above the symphysis pubis. After six retention of urine or retention with weeks it has decreased to the size of a overflow may occur. normal multiparous uterus, which is6. Blood: slightly larger than a nulliparous one. • The haemoglobin concentration This remarkable decrease in size is the becomes stable around the 4th day of result of contraction and retraction the puerperium. of the uterine muscle. The normally • The platelet count is raised and the involuting uterus should be firm and platelets become more sticky from the non tender. The decidua of the uterus 4th to 10th day after delivery. These necroses (dies), due to ischaemia, and is and other changes in the clotting shed as the lochia. The average duration (coagulation) factors may cause of red lochia is 24 days. Thereafter, the thrombo-embolism in the puerperium. lochia becomes straw coloured. Normal7. Breasts: lochia has a typical, non-offensive smell. Marked changes occur during the Offensive lochia is always abnormal. puerperium with the production of milk.8. Genital tract: Very marked changes occur in the genital MANAGEMENT OF tract during the puerperium: THE PUERPERIUM • Vulva: The vulva is swollen and congested after delivery, but these The management of the puerperium may be features rapidly disappear. Tears or an divided into three stages: episiotomy usually heal easily. • Vagina: Immediately after delivery 1. The management of the first hour after the vagina is large, smooth walled, delivery of the placenta (sometimes called oedematous and congested. It rapidly the fourth stage of labour). shrinks in size and rugae return by the 2. The management of the rest of the third week. The vaginal walls remain puerperium. laxer than before and some degree of 3. The six week postnatal visit. vaginal prolapse (cystocoele and/or rectocoele) is common after a vaginal 7-5 How should you manage the delivery. Small vaginal tears, which are patient during the first hour after very common, usually heal in seven to the delivery of the placenta? 10 days. The two main objectives of managing the first • Cervix: After the first vaginal delivery hour of the puerperium are: the circular external os of the nullipara becomes slit-like. For the first few 1. To ensure that the patient is, and remains, days after delivery the cervix remains in a good condition. partially open, admitting one or two 2. The prevention of a postpartum haemorrhage (PPH).
  4. 4. 118 INTRAPAR TUM CARETo achieve these, you should: 3. Allowed to bond with her infant. 4. Allowed to rest for as long as she needs to.1. Perform certain routine observations.2. Care for the needs of the patient.3. Get the patient’s co-operation in ensuring 7-8 How can the patient help to prevent that her uterus remains well contracted postpartum haemorrhage during and that she reports any vaginal bleeding. the first hour of the puerperium?The correct management of the first hour of 1. The patient should be shown how tothe puerperium is most important as the risk observe:of postpartum haemorrhage is greatest at this • The height of the uterine fundus intime. relation to the umbilicus. • The feel of a well-contracted uterus. • The amount of vaginal bleeding.7-6 Which routine observations 2. She should be shown how to ‘rub up’ theshould you perform in the first hour uterus.after delivery of the placenta? 3. She should be told that if the uterine1. Immediately after the delivery of the fundus rises or the uterus relaxes or if placenta you should: vaginal bleeding increases, she must: • Assess whether the uterus is well • Immediately call the midwife. contracted. • In the meantime rub up the uterus. • Assess whether vaginal bleeding These two important steps may help prevent a appears more than normal. postpartum haemorrhage. • Record the patient’s pulse rate, blood pressure and temperature.2. During the first hour after the delivery The patient can play a very important role in the of the placenta, provided that the above prevention of postpartum haemorrhage. observations are normal, you should: • Continuously assess whether the uterus is well contracted and that no excessive 7-9 When should a postpartum vaginal bleeding is present. patient be allowed to go home? • Repeat the measurement of the pulse This will depend on: rate and blood pressure after one hour. • If the patient’s condition changes, 1. Whether the patient had a normal observations must be done more pregnancy and delivery. frequently until the patient’s condition 2. The circumstances of the hospital or clinic returns to normal. where the patient was delivered. 7-10 When should a patient be Observations during the first hour of the allowed to go home following a puerperium are extremely important. normal pregnancy and delivery? A patient who has had a normal pregnancy7-7 How should you care for the and delivery may be allowed to go homeneeds of the patient during the about six hours after the birth of her infant,first hour of the puerperium? provided:After the placenta has been delivered the 1. The observations done on the mother andpatient needs to be: infant since delivery have been normal.1. Washed. 2. The mother and infant are normal on2. Given something to drink and maybe to eat. examination, and the infant is sucking well.
  5. 5. THE PUERPERIUM 1193. The patient is able to attend her nearest 2. A patient who has had a Caesarean section clinic on the day after delivery (day one) will usually stay in hospital for three days and then again on days three and five or longer. after delivery for postnatal care, or be 3. A patient who has had a postpartum visited at home by a midwife on those haemorrhage must be kept in hospital for days. Primigravidas should be seen again at least 24 hours to ensure that her uterus on day seven, especially to ensure that is well contracted and that there is no breastfeeding is well established. further bleeding.4. Patients who received no antenatal care and are delivered without having had any 7-12 How will the circumstances at a clinic screening tests must have a rapid syphilis test or hospital influence the time of discharge? and a rapid Rhesus grouping. Counselling for HIV testing must also be done. 1. Some clinics have no space to5. A postnatal card needs to be completed accommodate patients for longer than six for the mother on discharge as this is the hours after delivery. Therefore, patients who only means of communication between the cannot be discharged safely at six hours will delivery site and the clinic where she will have to be transferred to a hospital. receive postnatal care (figure 7-1). 2. Some hospitals manage patients who live in remote areas where follow up is notA patient should only be discharged home after possible. These patients will have to be keptdelivery if no abnormalities are found when in hospital longer before discharge.the following examinations are performed:1. A general examination, paying particular 7-13 What postnatal care should be attention to the: given during the puerperium after the • Pulse rate. patient has left the hospital or clinic? • Blood pressure. The following observations must be done on • Temperature. the mother: • Haemoglobin concentration.2. An abdominal examination, paying 1. Assess the patient’s general condition. particular attention to the state of 2. Observe the pulse rate, blood pressure and contraction and tenderness of the uterus. temperature.3. An inspection of the episiotomy site. 3. Determine the height of the uterine fundus4. The amount, colour and odour of the lochia. and assess whether any uterine tenderness5. A postnatal was completed for the mother is present. and infant. 4. Assess the amount, colour and odour of the lochia.7-11 When should a patient be 5. Check whether the episiotomy is healingdischarged from hospital following a satisfactorily.complicated pregnancy and delivery? 6. Ask if the patient passes urine normally and enquire about any urinary symptoms.This will depend on the nature of the Reassure the patient if she has not passed acomplication and the method of delivery. For stool by day 5.example: 7. Measure the haemoglobin concentration if1. A patient with pre-eclampsia should the patient appears pale. be kept in hospital until her blood 8. Assess the condition of the patient’s breasts pressure has returned to normal or is well and nipples. Determine whether successful controlled with oral drugs. breastfeeding has been established. The following observations must be done on the infant:
  6. 6. 120 INTRAPAR TUM CARE1. Assess whether the infant appears well. 7-15 Which topics should you2. Check whether the infant is jaundiced. include under patient education3. Examine the umbilical stump for signs of in the puerperium? infection. Patient education regarding herself, her4. Examine the eyes for conjunctivitis. infant and her family should not start during5. Ask whether the infant has passed urine the puerperium, but should be part of any and stool. woman’s general education, starting at school.6. Assess whether the infant is feeding well Topics which should be emphasised in patient and is satisfied after a feed. education in the puerperium include: 1. Personal and infant care. The successful establishment of breastfeeding is 2. Offensive lochia must be reported one of the most important goals of patient care immediately. during the puerperium. 3. The ‘puerperal blues’. 4. Family planning.7-14 How often should a patient be 5. Any special arrangements for the nextseen at the nearest clinic to her home pregnancy and delivery.following discharge from the hosital 6. When to start coitus again. Usuallyor clinic where she was delivered? coitus can be started three to four weeks postpartum when the episiotomy or tearsThis will depend on the availability of clinics have healed.and the distance the patient stays from aclinics. Ideally she must be seen on day one,three and five. However, if this is not feasible Patient education is an important and oftena single visit on day three is most valuable to neglected part of postnatal care.identify complications that may occur duringthe puerperium and to provide treatment that 7-16 When should a patient be seen againwill prevent severe complications. A system after postnatal care has been completed?by which clinics are informed about patientsin their drainage area that were discharged The postnatal visit is usually held six weeksfrom hospital following a delivery will be of after delivery. By this time almost all the organgreat value. changes which occurred during pregnancy should have disappeared.7-14 How can you help to establishsuccessful breastfeeding? A patient and her infant should only be dischargedBy providing patient education and motivation. if they are both well and have been referred toThis should preferably start before pregnancy the local maternal and child health clinic, and theand continue throughout the antenatal period patient has received contraceptive counselling.and after pregnancy. Encouragement andsupport are very important during the firstweeks after delivery. The important role ofbreastfeeding in lowering infant mortality in PUERPERAL PYREXIApoor communities must be remembered. 7-20 When is puerperal pyrexia present? A patient has puerperal pyrexia if her oral temperature rises to 38 °C or higher during the puerperium.
  7. 7. THE PUERPERIUM 1217-21 Why is puerperal pyrexia important? • Lower abdominal tenderness. • Offensive lochia.Because it may be caused by serious • The episiotomy wound or perineal orcomplications of the puerperium. vaginal tears may be infected.Breastfeeding may be interfered with. Thepatient may become very ill or even die. If possible, an endocervical swab should be taken for microscopy, culture and sensitivity tests. Puerperal pyrexia may be caused by a serious complication of the puerperium. 7-25 How should you manage genital tract infection?7-22 What are the causes of 1. Prevention:puerperal pyrexia? • Strict asepsis during delivery.1. Genital tract infection. • Reduction in the number of vaginal2. Urinary tract infection. examinations during labour to a3. Mastitis or breast abscess. minimum.4. Thrombophlebitis (superficial vein • Prevention of unnecessary trauma thrombosis). during labour.5. Respiratory tract infection. • Isolation of infected patients.6. Other infections. 2. Treatment: • Admit the patient to hospital.7-23 What is the cause of • Measures to bring down thegenital tract infection? temperature, e.g. tepid sponging. • Analgesia, e.g. paracetamol (Panado)Genital tract infection (or puerperal sepsis) 1 g (two adult tablets) orally caused by bacterial infection of the raw • Intravenous fluids with strict intakeplacental site or lacerations of the cervix, and output measurement.vagina or perineum. • Broad-spectrum antibiotics, e.g.Genital tract infection is usually caused intravenous ampicillin and oralby the group A or group B Streptococcus, metronidazole (Flagyl). If the patientStaphylococcus aureus or anaerobic bacteria. is to be referred, antibiotic treatment must be started before transfer.7-24 How should you diagnose • The haemoglobin concentration mustgenital tract infection? be measured. A blood transfusion must be given if the haemoglobin1. History: concentration is below 8 g/dl. If one or more of the following is present: • Removal of all stitches if the wound is • Preterm or prelabour rupture of the infected. membranes, a long labour, operative • Drainage of any abscess. delivery or incomplete delivery of • If there is subinvolution of the the placenta or membranes may have uterus, an evacuation under general occurred. anaesthetic must be done. • The patient will feel generally unwell. • Lower abdominal pain. 24 hours after starting this treatment the2. Examination: patient’s condition should have improved • Pyrexia, usually developing within the considerably and the temperature should first 24 hours after delivery. Rigors may by then be normal. If this is not the case, occur. evacuation of the uterus is required and • Marked tachycardia. gentamicin must be added to the antibiotics.
  8. 8. 122 INTRAPAR TUM CAREA laporotomy and possibly a hysterectomy 3. Side room and special investigations:are indicated, if peritonitis and subinvolution • Microscopy of a midstream or catheterof the uterus are present, and there is no specimen of urine usually shows largeresponse to the measures detailed above. numbers of pus cells and bacteria.Transfer the patient to the appropriate level • Culture and sensitivity tests of theof care for this purpose. urine must be done if the facilities are available.7-26 How must a patient with The presence of pyrexia and punch tendernessoffensive lochia be managed? in the renal angles indicate an upper renal1. If the patient has pyrexia she must be tract infection and a diagnosis of acute admitted to hospital and be treated as pyelonephritis must be made. explained in section 7-25.2. If the involution of the patient’s uterus is 7-28 How should you manage a patient slower than expected and the cervical os with a urinary tract infection? remains open, retained placental products 1. Prevention: are present. An evacuation of the uterus • Avoid catheterisation whenever under general anaesthesia must be done. possible. If catheterisation is essential, Further treatment is as explained in it must be done with strict aseptic section 7-25. precautions.3. If the patient has a normal temperature 2. Treatment: and normal involution of her uterus, she • Admit the patient to hospital. can be managed as an out patient with oral • Measures to bring down the ampicillin and metronidazole (Flagyl). temperature. • Analgesia, e.g. paracetamol (Panado) Offensive lochia is an important sign of genital 1 g orally six-hourly. tract infection. • Intravenous fluids. • Intravenous ampicillin 1 g and clavulanic acid 200 mg (Augmentin)7-27 How should you diagnose immediately and eight-hourly ora upper urinary tract infection cefuroxime (Zinacef) 750 mg eight-(acute pyelonephritis)? hourly.1. History: Organisms causing acute pyelonephritis are • The patient may have been catheterised often resistant to ampicillin, either intravenous during labour or in the puerperium. ampicillin and clavulanic acid (Augmentin) or • The patient complains of rigors cefuroxime (Zinacef) must be used. (shivering) and lower abdominal pain and/or pain in the lower back over one or both the kidneys (the loins). Antibiotics should not be given to a patient • Dysuria and frequency. However, these with puerperal pyrexia until she has been fully are not reliable symptoms of urinary investigated. tract infection.2. Examination: • Pyrexia, often with rigors (shivering). • Tachycardia. • Suprapubic tenderness and/or tenderness, especially to percussion, over the kidneys (punch tenderness in the renal angles).
  9. 9. THE PUERPERIUM 123THROMBOEMBOLISM 1. History: • The patient may have had general anaesthesia with endotracheal7-29 What is superficial vein intubation, e.g. for a Caesarean section.thrombophlebitis? • Cough, which may be productive. • Pain in the chest.This is a non-infective inflammation and • A recent upper respiratory tractthrombosis of the forearm where an infusion infection.was given or superficial veins of the leg. 2. Examination:Thrombophlebitis commonly occurs during • Pyrexia.the puerperium, especially in varicose veins. • Tachypnoea (breathing rapidly). • Tachycardia.7-30 How should you diagnose 3. Special investigations:superficial leg vein thrombophlebitis? • A chest X-ray is useful in diagnosing1. History: pneumonia. • Painful swelling of the leg or forearm. Examination of the chest may reveal basal • Presence of varicose veins. dullness due to collapse, increased breath2. Examination: sounds or crepitations due to pneumonia, or • Pyrexia. bilateral rhonchi due to bronchitis. • Tachycardia. • Presence of a localised area of the leg 7-33 How should you manage a patient or forearm which is swollen, red and with a lower respiratory tract infection. tender. 1. Prevention:7-31 How should you manage a patient • Skilled anaesthesia.with superficial vein thrombophlebitis? • Proper care of the patient during induction and recovery from1. Give analgesia, e.g. aspirin 300 mg (one anaesthesia. adult tablet) six-hourly. • Encourage deep breathing and coughing2. Support the leg with an elastic bandage. following a general anaesthetic to3. Encourage the patient to walk around. prevent lower lobe collapse.There is no indication for anticoagulant 2. Treatment:therapy unless there is deep vein thrombosis. • Admit the patient to hospital unless theHowever, if there are signs of infection of infection is very mild.the drip site a course of antibiotics should • Oxygen if prescribed. The skin around the drip site • Ampicillin orally or intravenouslywould be swollen (indurated), tender, warm depending on the severity of theand red. Prescribe a course of oral amoxacillin. infection. • Analgesia, e.g. paracetamol (Panado) 1g six-hourly.7-32 How should you diagnose a • Physiotherapy.lower respiratory tract infection? 3. Special investigations:A lower respiratory tract infection, such as • Send a sample of sputum foracute bronchitis or pneumonia, is diagnosed microscopy, culture and sensitivityas follows: testing if possible.
  10. 10. 124 INTRAPAR TUM CARE7-34 Which other infections may PUERPERAL PSYCHIATRICcause puerperal pyrexia? DISORDERSTonsillitis, influenza and any other acuteinfection, e.g. acute appendicitis. 7-36 Which are the puerperal7-35 What should you do if a patient psychiatric disorders?presents with puerperal pyrexia? 1. The ‘puerperal blues’.1. Ask the patient what she thinks is wrong 2. Temporary postnatal depression. with her. 3. Puerperal psychosis.2. Specifically ask for symptoms which point to: 7-37 Why is it important to recognise the • An infection of the throat or ears. various puerperal psychiatric disorders? • Mastitis or breast abscess. • A chest infection. 1. The ‘puerperal blues’ are very common • A urinary tract infection. in the first week after delivery, especially • An infected abdominal wound if the on day 3. The patient feels miserable and patient had a Caesarean section or a cries easily. Although the patient may be puerperal sterilisation. very distressed, all that is required is an • Genital tract infection. explanation, reassurance, and a caring, • Superficial leg vein thrombophlebitis. sympathetic attitude and emotional support.3. Examine the patient systematically, The condition improves within a few days. including the: 2. Postnatal depression is much commoner • Throat and ears. than is generally realised. It may last for • Breasts. months or even years and patients may • Chest. need to be referred to a psychiatrist. • Abdominal wound, if present. Patients with postnatal depression usually • Urinary tract. present with a depressed mood that • Genital tract. cannot be relieved, a lack of interest in • Legs, especially the calves. their surroundings, a poor or excessive4. Perform the necessary special appetite, sleeping difficulties, feelings of investigations, but always send off a: inadequacy, guilt and helplessness, and • Endocervical swab. sometimes suicidal thoughts. • Midstream or catheter specimen of 3. Puerperal psychosis is an uncommon but urine. very important condition. The onset is5. Start the appropriate treatment. usually acute and an observant attendant will notice the sudden and marked change in the patient’s behaviour. She may rapidly If a patient presents with puerperal pyrexia pose a threat to her infant, the staff and the cause of the pyrexia must be found and herself. Such a patient must be referred appropriately treated. urgently to a psychiatrist and will usually need admission to a psychiatric unit. Patients with puerperal psychosis are unable to care for themselves or their infants. They are often disorientated and paranoid and may have hallucinations. They may also be severely depressed or manic.
  11. 11. THE PUERPERIUM 125SECONDARY POSTPARTUM 7-42 How should you manage a patient with secondary postpartum haemorrhage?HAEMORRHAGE 1. Prevention: • Aseptic technique throughout labour,7-38 What is secondary the delivery and the puerperium.postpartum haemorrhage? • Careful examination after delivery to determine whether the placenta andThis is any amount of vaginal bleeding, other membranes are complete.than the normal amount of lochia, occurring • Proper repair of vaginal and perinealafter the first 24 hours postpartum until the lacerations.end of the puerperium. It commonly occurs 2. Treatment:between the fifth and fifteenth days after • Admission of the patient to hospital isdelivery. indicated, except in very mild cases of secondary postpartum haemorrhage.7-39 Why is secondary postpartum • Review of the clinical notes with regardhaemorrhage important? to completeness of the placenta and1. A secondary postpartum haemorrhage membranes. may be so severe that it causes shock. • Obtain an endocervical swab for2. Unless the cause of the secondary bacteriology. postpartum haemorrhage is treated, the • Give ampicillin and metronidazole vaginal bleeding will continue. (Flagyl) orally. • Give Syntometrine 1 ml intramuscularly or 20 units oxytocin in7-40 What are the causes of secondary an intravenous infusion.postpartum haemorrhage? • Blood transfusion, if the haemoglobin1. Genital tract infection with or without concentration drops below 8 g/dl. retention of a piece of placenta or part of the • Removal of retained placental products membranes. This is the commonest cause. under general anaesthesia.2. Separation of an infected slough in a cervical or vaginal laceration. 7-43 What may you find on physical3. Breakdown (dehiscence) of a Caesarean examination to suggest that retained section wound of the uterus. pieces of placenta or membranesHowever, the cause is unknown in up to half of are the cause of a secondarythese patients. postpartum haemorrhage?Gestational trophoblastic disease 1. The uterus will be involuting slower than(hydatidiform mole or choriocarcinoma) and usual.a disorder of blood coagulation may also cause 2. Even though the patient may be more thansecondary postpartum haemorrhage. seven days postpartum, the cervical os will have remained open.7-41 What clinical features should alert youto the possibility of the patient developing SELF-MONITORINGsecondary postpartum haemorrhage?1. A history of incomplete delivery of the placenta and/or membranes. 7-44 What is meant by the concept2. Unexplained puerperal pyrexia. of ‘the mother as a monitor’?3. Delayed involution of the uterus. This is a concept where the patient is made4. Offensive and/or persistently red lochia. aware of the many ways in which she can
  12. 12. 126 INTRAPAR TUM CAREmonitor her own, as well as her fetus’ or infant’s 1. How can you get the patient’s help inwellbeing, during pregnancy, in labour and in preventing a postpartum haemorrhage?the puerperium. This has two major advantages: The patient should be shown how to observe:1. The patient becomes much more involved 1. The height of the uterine fundus. in her own perinatal care. 2. Whether the uterus is well-contracted.2. Possible complications will be reported by 3. The amount of vaginal bleeding. the patient at the earliest opportunity. 4. She should also be asked to empty her bladder frequently.7-45 How can the patient act as amonitor in the puerperium? 2. What should the patient do ifThe patient must be encouraged to report she notices that her uterus relaxesthe following complications as soon as she and/or there is vaginal bleeding?becomes aware of them: She should rub up the uterus and call you1. Maternal complications: immediately. • Symptoms of puerperal pyrexia. • Breakdown of an episiotomy. 3. What should you check on • Breastfeeding problems. before leaving the patient? • Excessive or offensive lochia. • Recurrence of vaginal bleeding, i.e. You should make sure that: secondary postpartum haemorrhage. 1. The patient and her infant’s observations are • Prolonged postnatal depression. normal and both their conditions are stable.2. Complications in the infant: 2. The patient understands what she has to do. • Poor feeding or other feeding 3. You will be able to hear the patient, if she problems. calls you. • Lethargy. • Jaundice. • Conjunctivitis. CASE STUDY 2 • Infection of the umbilical cord stump. A patient is day three following an uncomplicated Caesarean section for Each patient must be taught to monitor her own cephalopelvic disproportion. She complains wellbeing, as well as that of her fetus or infant. of leaking urine when coughing or laughing, and she is also worried that she has not passed a stool since the delivery. She starts to cry andCASE STUDY 1 says that she should not have fallen pregnant. Her infant takes the breast well and sleeps wellFollowing a spontaneous vertex delivery in after each feed. On examination the patienta district hospital, you have delivered the appears well, her observations are normal, theplacenta and membranes completely. The uterus is the size of a 16-week pregnant uterus,maternal and fetal conditions are good and the abdominal wound appears normal and thethere is no abnormal vaginal bleeding. You lochia is red and not offensive.are also responsible for the casualty unit andare called. You will have to leave the patient 1. Is her puerperium progressing normally?alone for a while. Yes. The patient appears healthy with normal observations, and the involution of her uterus is satisfactory.
  13. 13. THE PUERPERIUM 1272. What should be done about 39 °C, a pulse rate of 110 beats per minute andthe patient’s complaints? complains of a headache and lower abdominal pain. The uterus is tender to palpation.Stress incontinence is common duringthe puerperium. Therefore, the patientmust be reassured that it will improve over 1. What does the patient present with?time. However, pelvic floor exercises must Puerperal explained to her as they will hastenimprovement of her incontinence. She need 2. What is the most likely causenot be worried about not having passed a stool of the puerperal pyrexia?as this is normal during the first few days ofthe puerperium. Genital tract infection, i.e. puerperal sepsis. This diagnosis is suggested by the general signs3. Why is the patient regretting of infection and the uterine tenderness. Theher pregnancy and crying for patient had a prolonged first stage of labour,no apparent reason? which is usually accompanied by a greater than usual number of vaginal examinations and,She probably has the ‘puerperal blues’ which therefore, predisposes to genital tract infection.are common in the puerperium. Listensympathetically to the patient’s complaints 3. Was the early postnatal managementand reassure her that she is managing well as of this patient correct?a mother. Also explain that her feelings arenormal and are experienced by most mothers. No. The patient should not have been discharged home so early as she had a4. What educational topics must prolonged first stage of labour which placesbe discussed with the patient her at a higher risk of infection. She shouldbefore discharging her home? have been observed for at least 24 hours.1. Family size and when she plans to have her 4. How should you manage this next infant. patient further in the clinic?2. Which contraceptive method she should use and how to use it correctly. She must be admitted. Paracetamol (Panado)3. The care and feeding of her infant, 1 g orally may be given for the headache. If stressing the importance of breastfeeding. necessary she should be given a tepid sponging.4. The time that coitus can be resumed. An intravenous infusion should be started and she must receive intravenous ampicillinAlso ask about, and discuss, any other and oral metronidazole (Flagyl). Twenty fouruncertainties which the patient may have. hours later the patient’s condition should have improved considerably and the temperature should by then be normal. If this is not theCASE STUDY 3 case, evacuation of the uterus is required and gentamicin must be added to the antibiotics..Following a prolonged first stage of labour dueto an occipito-posterior position, a patient hasa spontaneous vertex delivery. The placenta and CASE STUDY 4membranes are complete. There is no excessivepostpartum blood loss and the patient is A patient is seen at a district hospital on daydischarged home after six hours. Within 24 five following a normal pregnancy, labour andhours of delivery the patient is brought back to delivery. She complains of rigors and lowerthe district hospital. She has a temperature of abdominal pain. She has a temperature of
  14. 14. 128 INTRAPAR TUM CARE38.5 °C, tenderness over both kidneys (loins) 3. Do you agree with the managementand tenderness to percussion over both renal given to the patient?angles. A diagnosis of puerperal pyrexia is made No. A urinary tract infection that causesand the patient is given oral ampicillin. She is puerperal pyrexia is an indication forasked to come back to the clinic on day seven. admitting the patient to hospital. Intravenous ampicillin plus clavulanic acid (Augmentum)1. Are you satisfied with the must be given as this will lead to a rapiddiagnosis of puerperal pyrexia? recovery and prevent serious complications.No. Puerperal pyrexia is a clinical sign andnot a diagnosis. The cause of the pyrexia must 4. Why is a puerperal patient atbe found by taking a history, doing a physical risk of a urinary tract infection andexamination and, if indicated, completing how may this be prevented?special investigations. Catheterisation is often required and this increases the risk of a urinary tract infection.2. What is the most likely cause Catheterisation must only be carried outof the patient’s pyrexia? when necessary and must always be done asAn upper urinary tract infection (acute an aseptic procedure. Screening and treatingpyelonephritis) as suggested by the pyrexia, asymptomatic bacteriuria at the antenatalrigors, lower abdominal pain and tenderness clinic will reduce acute pyelonephritis duringover the kidneys. the puerperium.
  15. 15. THE PUERPERIUM 129Figure 7-1: A postnatal card for assessing a woman within the first week and again at 6 weeks after delivery