Maternal Care: The puerperium

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Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care

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Maternal Care: The puerperium

  1. 1. 12 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. 12-1 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: 12-2 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 • Assess a patient at the six-week after the six weeks have elapsed (e.g. the postnatal visit. ureters). Other organs never regain their pre- • Diagnose and manage the various pregnant state (e.g. the perineum). causes of puerperal pyrexia. It is important for the midwife or doctor • Recognise the puerperal psychiatric to assess whether the puerperal patient has disorders. returned, as closely as possible, to normal • Diagnose and manage secondary health and activity. postpartum haemorrhage. • Teach the patient the concept of ‘the The puerperium starts when the placenta is mother as a monitor’. delivered and lasts for six weeks. 12-3 Why is the puerperium important? 1. The patient recovers from her labour, which often leaves her tired, even
  2. 2. 230 MATERNAL 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 to12-4 What physical changes occur ravenous hunger.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 passing stoolimportant in the management of the normal when nearly fully dilated or during thepuerperium 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 the lead to complete urinary retention, or uterus and the normal diuresis (an retention with overflow incontinence. increased amount of urine passed), but A full bladder will interfere with also depends on whether the patient uterine contractions. 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 • Marked sweating may occur for some during pregnancy. Often stress days. incontinence becomes worse initially but tends to improve with time and with pelvic floor exercises.
  3. 3. THE PUERPERIUM 231 Pelvic floor exercises are also known as fingers. By the seventh day postpartum pinch or ‘knyp’ exercises. The muscles that the 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, ten times size of a 20-week pregnancy. By the end in succession on at least four occasions a of the first week it is about 12 weeks day. in size. At 14 days the fundus of the uterus should no longer be palpable NOTE Normal bladder function is likely to be above the symphysis pubis. After six temporarily impaired when a patient has been weeks it has decreased to the size of a given epidural analgesia. Complete retention normal multiparous uterus, which is of urine or retention with overflow may occur. slightly larger than a nulliparous one.6. Blood: This remarkable decrease in size is the • The haemoglobin concentration result of contraction and retraction becomes stable around the fourth day of the uterine muscle. The normally of the puerperium. involuting uterus should be firm and • The platelet count is raised and the non tender. The decidua of the uterus platelets become more sticky from necroses (dies), due to ischaemia, and is the fourth to tenth day after delivery. shed as the lochia. The average duration These and other changes in the clotting of red lochia is 24 days. Thereafter, the (coagulation) factors may cause lochia becomes straw coloured. Normal thrombo-embolism in the puerperium. lochia has a typical, non-offensive smell.7. Breasts: Offensive lochia is always abnormal. Marked changes occur during the puerperium with the production of milk.8. Genital tract: MANAGEMENT OF Very marked changes occur in the genital THE PUERPERIUM tract during the puerperium. • Vulva: The vulva is swollen and The management of the puerperium may be congested after delivery, but these divided into three stages: features rapidly disappear. Tears and/or an episiotomy usually heal easily. 1. The management of the first hour after • Vagina: Immediately after delivery delivery of the placenta (sometimes called the vagina is large, smooth walled, the fourth stage of labour). oedematous and congested. It rapidly 2. The management of the rest of the shrinks in size and rugae return by the puerperium. third week. The vaginal walls remain 3. The six week postnatal visit. laxer than before and some degree of vaginal prolapse (cystocoele and/or 12-5 How should you manage the first rectocoele) is common after a vaginal hour after the delivery of the placenta? delivery. Small vaginal tears, which are The two main objectives of managing the first very common, usually heal in seven to hour of the puerperium are: ten days. • Cervix: After the first vaginal delivery 1. To ensure that the patient is, and remains, the circular external os of the nullipara in a good condition. becomes slit-like. For the first few 2. The prevention of a postpartum days after delivery the cervix remains haemorrhage (PPH). partially open, admitting one or two To achieve these, you should:
  4. 4. 232 MATERNAL CARE1. Perform certain routine observations. 12-8 How can the patient help to prevent2. Care for the needs of the patient. postpartum haemorrhage during3. Get the patient’s co-operation in ensuring the first hour of the puerperium? that her uterus remains well contracted 1. The patient should be shown how to and that she reports any vaginal bleeding. observe:The correct management of the first hour of • The height of the uterine fundus inthe puerperium is most important as the risk relation to the umbilicus.of postpartum haemorrhage is greatest at this • The feel of a well-contracted uterus.time. • The amount of vaginal bleeding. 2. She should be shown how to ‘rub up’ the12-6 Which routine observations uterus.should you perform in the first hour 3. She should be told that if the uterineafter delivery of the placenta? fundus rises or the uterus relaxes or if vaginal bleeding increases, she must:1. Immediately after the delivery of the • Immediately call the midwife. placenta you should: • In the meantime rub up the uterus. • Assess whether the uterus is well contracted. These two important steps may help prevent a • Assess whether vaginal bleeding postpartum haemorrhage. appears more than normal. • Record the patient’s pulse rate, blood The patient can play a very important role in the pressure and temperature. prevention of postpartum haemorrhage.2. During the first hour after the delivery of the placenta, provided that the above observations are normal, you should: 12-9 When should a postpartum • Continuously assess whether the uterus patient be allowed to go home? is well contracted and that no excessive This will depend on: vaginal bleeding is present. • Repeat the measurement of the pulse 1. Whether the patient had a normal rate and blood pressure after one hour. pregnancy and delivery. • If the patient’s condition changes, 2. The circumstances of the hospital or clinic observations must be done more where the patient was delivered. frequently until the patient’s condition returns to normal. 12-10 When should a patient be allowed to go home following a normal pregnancy and delivery? Observations during the first hour of the puerperium are extremely important. A patient who has had a normal pregnancy and delivery may be allowed to go home about six hours after the birth of her infant, provided:12-7 How should you care for theneeds of the patient during the 1. The observations done on the mother andfirst hour of the puerperium? infant since delivery have been normal. 2. The mother and infant are normal onAfter the placenta has been delivered the examination, and the infant is sucking well.patient needs to be: 3. The patient is able to attend her nearest1. Washed. clinic on the day after delivery (day one)2. Given something to drink and maybe to eat. and then again on days three and five3. Allowed to bond with her infant. after delivery for postnatal care, or be4. Allowed to rest for as long as she needs to. visited at home by a midwife on those
  5. 5. THE PUERPERIUM 233 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 12-12 How will the circumstances at a clinic any screening tests must have a rapid or hospital influence the time of discharge? syphilis test and a rapid Rhesus grouping. Counselling for HIV testing must also be 1. Some clinics have no space to done. accommodate patients for longer than six5. A postnatal card needs to be completed hours after delivery. Therefore, patients who for the mother on discharge as this is the cannot be discharged safely at six hours will only means of communication between the have to be transferred to a hospital. delivery site and the clinic where she will 2. Some hospitals manage patients who live receive postnatal care. in remote areas where follow-up is not possible. These patients will have to be keptA patient should only be discharged home after in hospital longer before discharge.delivery if no abnormalities are found whenthe following examinations are performed: 12-13 What postnatal care should be1. A general examination, paying particular given during the puerperium after the attention to the: patient has left the hospital or clinic? • Pulse rate. The following observations must be done on • Blood pressure. the mother: • Temperature. • Haemoglobin concentration. 1. Assess the patient’s general condition.2. An abdominal examination, paying 2. Observe the pulse rate, blood pressure and particular attention to the state of temperature. contraction and tenderness of the uterus. 3. Determine the height of the uterine fundus3. An inspection of the episiotomy site. and assess whether any uterine tenderness4. The amount, colour, and odour of the is present. lochia. 4. Assess the amount, colour, and odour of5. A postnatal examination was completed the lochia. for the mother and infant. 5. Check whether the episiotomy is healing satisfactorily.12-11 When should a patient be 6. Ask if the patient passes urine normallydischarged from hospital following a and enquire about any urinary symptoms.complicated pregnancy and delivery? Reassure the patient if she has not passed a stool by day five.This will depend on the nature of the 7. Measure the haemoglobin concentration ifcomplication and the method of delivery. the patient appears pale.For example: 8. Assess the condition of the patient’s breasts1. A patient with pre-eclampsia should and nipples. Determine whether successful be kept in hospital until her blood breastfeeding has been established. pressure has returned to normal or is well The following observations must be done on controlled with oral drugs. the infant:2. A patient who has had a Caesarean section will usually stay in hospital for three days 1. Assess whether the infant appears well. or longer. 2. Check whether the infant is jaundiced.3. A patient who has had a postpartum 3. Examine the umbilical stump for signs of haemorrhage must be kept in hospital for infection.
  6. 6. 234 MATERNAL CARE4. Examine the eyes for conjunctivitis. 12-16 When should a patient be seen again5. Ask whether the infant has passed urine after postnatal care has been completed? and stool. The postnatal visit is usually held six weeks6. Assess whether the infant is feeding well after delivery. By this time almost all the organ and is satisfied after a feed. changes which occurred during pregnancy should have disappeared. The successful establishment of breastfeeding is one of the most important goals of patient care during the puerperium. THE SIX WEEK POSTNATAL VISIT12-14 How can you help to establishsuccessful breastfeeding? 12-17 Which patients need to attendBy providing patient education and a six week postnatal clinic?motivation. This should preferably startbefore pregnancy and continue throughout Patients with specific problems that need to bethe antenatal period and after pregnancy. followed up six weeks postpartum, e.g. patientsEncouragement and support are very who were discharged with hypertension needimportant during the first weeks after delivery. to come back to have their blood pressureThe important role of breastfeeding in measured. Patients who are healthy may belowering infant mortality in poor communities referred directly to the mother-and-childmust be remembered. health clinics.12-15 Which topics should you 12-18 What are the objectives ofinclude under patient education the six week postnatal visit?in the puerperium? It is important to determine whether:Patient education regarding herself, her 1. The patient is healthy and has returned toinfant, and her family should not start during her normal activities.the puerperium, but should be part of any 2. The infant is well and growing normally.woman’s general education, starting at school. 3. Breastfeeding has been satisfactorilyTopics which should be emphasised in patient established.education in the puerperium include: 4. Contraception has been arranged to the1. Personal and infant care. patient’s satisfaction.2. Offensive lochia must be reported 5. The patient has been referred to a mother- immediately. and-child health clinic for further care.3. The ‘puerperal blues’. 6. The patient has any questions about4. Family planning. herself, her infant, or her family.5. Any special arrangements for the next pregnancy and delivery. 12-19 How should the six week6. When to start coitus again. Usually postnatal visit be conducted? coitus can be started three to four weeks 1. The patient is asked how she and her infant postpartum when the episiotomy or tears have been since they were discharged from have healed. the hospital or clinic. 2. The patient is then examined. On Patient education is an important and often examination pay particular attention neglected part of postnatal care. to the blood pressure and breasts, and look for signs of anaemia. An abdominal
  7. 7. THE PUERPERIUM 235 examination is followed by a speculum Puerperal pyrexia may be caused by a serious examination to check whether the complication of the puerperium. episiotomy, vulval, or vaginal tears have healed. A cytology smear of the cervix should be taken if the patient is 30 years 12-22 What are the causes or older and has not previously had a of puerperal pyrexia? normal cervical smear. A cervical smear 1. Genital tract infection. should also be taken on any woman 2. Urinary tract infection. who has previously had an abnormal 3. Mastitis or breast abscess. smear. A bimanual examination is then 4. Thrombophlebitis (superficial vein done to assess the size of the uterus. The thrombosis). haemoglobin is measured and the urine 5. Respiratory tract infection. tested for glucose and protein. 6. Other infections.3. Attention must be given to any specific reason why the patient is being followed up, e.g. arrangements for the management 12-23 What is the cause of of patients who remain hypertensive after genital tract infection? delivery. Genital tract infection (or puerperal sepsis)4. The patient is given health education as is caused by bacterial infection of the raw set out in section 12-15. It should again be placental site or lacerations of the cervix, remembered to ask her whether she has vagina or perineum. any questions she would like to ask. NOTE Genital tract infection is usually causedIf the patient and her infant are both well, they by the group A or group B Streptococcus,are referred to their local mother-and-child Staphylococcus aureus or anaerobic bacteria.health clinic for further follow-up. 12-24 How should you diagnose A patient and her infant should only be discharged genital tract infection? if they are both well and have been referred to 1. History the local mother-and-child health clinic, and the If one or more of the following is present: patient has received contraceptive counselling. • Preterm or prelabour rupture of the membranes, a long labour, operative delivery, or incomplete delivery ofPUERPERAL PYREXIA the placenta or membranes may have occurred. • The patient will feel generally unwell.12-20 When is puerperal pyrexia present? • Lower abdominal pain.A patient has puerperal pyrexia if her oral 2. Examinationtemperature rises to 38 °C or higher during the • Pyrexia, usually developing within thepuerperium. first 24 hours after delivery. Rigors may occur.12-21 Why is puerperal pyrexia important? • Marked tachycardia. • Lower abdominal tenderness.Because it may be caused by serious • Offensive lochia.complications of the puerperium. • The episiotomy wound or perineal orBreastfeeding may be interfered with. The vaginal tears may be infected.patient may become very ill or even die. NOTE If possible, an endocervical swab should be taken for microscopy, culture, and sensitivity tests.
  8. 8. 236 MATERNAL CARE12-25 How should you manage 12-26 How must a patient withgenital tract infection? offensive lochia be managed?1. Prevention 1. If the patient has pyrexia she must be • Strict asepsis during delivery. admitted to hospital. • Reduction in the number of vaginal 2. If the involution of the patient’s uterus is examinations during labour to a slower than expected and the cervical os minimum. remains open, retained placental products • Prevention of unnecessary trauma are present. An evacuation of the uterus during labour. under general anaesthesia must be done. • Isolation of infected patients. 3. If the patient has a normal temperature2. Treatment and normal involution of her uterus, she • Admit the patient to hospital. can be managed as an outpatient with oral • Bring down the patient’s temperature, ampicillin and metronidazole (Flagyl). e.g. by tepid sponging. • Give the patient analgesia, e.g. paracetamol (Panado) 1 g (two adult Offensive lochia is an important sign of genital tablets) orally six-hourly. tract infection. • Adequate fluid intake with strict intake and output measurement. 12-27 How should you diagnose • Broad spectrum antibiotics, e.g. a urinary tract infection? intravenous ampicillin and oral 1. History metronidazole (Flagyl). If the patient • The patient may have been catheterised is to be referred, antibiotic treatment during labour or in the puerperium. must be started before transfer. • The patient complains of rigors • The haemoglobin concentration must (shivering) and lower abdominal pain be measured. A blood transfusion and/or pain in the lower back over one must be given if the haemoglobin or both the kidneys (the loins). concentration is below 8 g/dl. • Dysuria and frequency. However, these • Removal of all stitches if the wound is are not reliable symptoms of urinary infected. tract infection. • Drainage of any abscess. 2. Examination • If there is subinvolution of the • Pyrexia, often with rigors (shivering). uterus, an evacuation under general • Tachycardia. anaesthetic must be done. • Suprapubic tenderness and/or NOTE 24 hours after starting this treatment tenderness, especially to percussion, the patient’s condition should have improved over the kidneys (punch tenderness in considerably and the temperature should by the renal angles). then be normal. If this is not the case, evacuation 3. Side-room and special investigations of the uterus is required and gentamicin must • Microscopy of a midstream or catheter be added to the antibiotics. A laporotomy specimen of urine usually shows large and possibly a hysterectomy is indicated, if numbers of pus cells and bacteria. peritonitis and subinvolution of the uterus • Culture and sensitivity tests of the are present, and there is no response to the measures detailed above. Transfer the patient to urine must be done if the facilities are the appropriate level of care for this purpose. available. The presence of pyrexia and punch tenderness in the renal angles indicate an upper renal
  9. 9. THE PUERPERIUM 237tract infection and a diagnosis of acute • Tachycardia.pyelonephritis must be made. • Presence of a localised area of the forearm or leg which is swollen, red12-28 How should you manage a and tender.patient with a urinary tract infection? 12-31 How should you manage a patient1. Prevention with superficial vein thrombophlebitis? • Avoid catheterisation whenever possible. If catheterisation is essential, 1. Give analgesia, e.g. aspirin 300 mg (one it must be done with strict aseptic adult tablet) six-hourly. precautions. 2. Support the leg with an elastic bandage.2. Treatment 3. Encourage the patient to walk around. • Admit the patient to hospital. • Take measures to bring down the temperature. RESPIRATORY TRACT • Analgesia, e.g. paracetamol (Panado) INFECTION 1 g orally six-hourly. • Adequate fluid intake. • Intravenous cefuroxime (Zinecef) 12-32 How should you diagnose a 750 mg eight-hourly. lower respiratory tract infection? NOTE Organisms causing acute pyelonephritis A lower respiratory tract infection, such as are often resistant to ampicillin, therefore acute bronchitis or pneumonia, is diagnosed intravenous cefuroxime (Zinacef ) must be used. as follows: 1. History Antibiotics should not be given to a patient • The patient may have had general with puerperal pyrexia until she has been fully anaesthesia with endotracheal investigated. intubation, e.g. for a Caesarean section. • Cough, which may be productive. • Pain in the chest. • A recent upper respiratory tractTHROMBOPHLEBITIS infection. 2. Examination • Pyrexia.12-29 What is superficial vein • Tachypnoea (breathing rapidly).thrombophlebitis? • Tachycardia.This is a non-infective inflammation and 3. Special investigationsthrombosis of the superficial veins of the • A chest X-ray is useful in diagnosingleg or forearm where an infusion was given. pneumonia.Thrombophlebitis commonly occurs duringthe puerperium, especially in varicose veins. NOTE Examination of the chest may reveal basal dullness due to collapse, increased breath sounds or crepitations due to pneumonia,12-30 How should you diagnose or bilateral rhonchi due to bronchitis.superficial leg vein thrombophlebitis?1. History 12-33 How should you manage a patient • Painful swelling of the leg or forearm. with a lower respiratory tract infection. • Presence of varicose veins. 1. Prevention2. Examination • Skilled anaesthesia. • Pyrexia.
  10. 10. 238 MATERNAL CARE • Proper care of the patient during • Genital tract. induction and recovery from • Legs, especially the calves. anaesthesia. 4. Perform the necessary special • Encourage deep breathing and coughing investigations, but always send off a: following a general anaesthetic to • Endocervical swab. prevent lower lobe collapse. • Midstream or catheter specimen of2. Treatment urine. • Admit the patient to hospital, unless 5. Start the appropriate treatment. the infection is very mild. • Oxygen, if required. • Ampicillin orally or intravenously If a patient presents with puerperal pyrexia depending on the severity of the the cause of the pyrexia must be found and infection. appropriately treated. • Analgesia, e.g. paracetamol (Panado) 1 g six-hourly. • Physiotherapy. PUERPERAL PSYCHIATRIC3. Special investigations • Send a sample of sputum for DISORDERS microscopy, culture, and sensitivity testing if possible. 12-36 Which are the puerperal psychiatric disorders?12-34 Which other infections maycause puerperal pyrexia? 1. The ‘puerperal blues’. 2. Temporary postnatal depression.Tonsillitis, influenza and any other acute 3. Puerperal psychosis.infection, e.g. acute appendicitis. 12-37 Why is it important to recognise the12-35 What should you do if a patient various puerperal psychiatric disorders?presents with puerperal pyrexia? 1. The ‘puerperal blues’ are very common in1. Ask the patient what she thinks is wrong the first week after delivery, especially on with her. day three. The patient feels miserable and2. Specifically ask for symptoms which cries easily. Although the patient may be point to: very distressed, all that is required is an • An infection of the throat or ears. explanation, reassurance, and a caring, • Mastitis or breast abscess. sympathetic attitude and emotional support. • A chest infection. The condition improves within a few days. • A urinary tract infection. 2. Postnatal depression is much commoner • An infected abdominal wound if the than is generally realised. It may last for patient had a Caesarean section or a months or even years and patients may puerperal sterilisation. need to be referred to a psychiatrist. • Genital tract infection. Patients with postnatal depression usually • Superficial leg vein thrombophlebitis. present with a depressed mood that cannot3. Examine the patient systematically, be relieved, a lack of interest in their including the: surroundings, a poor or excessive appetite, • Throat and ears. sleeping difficulties, feelings of inadequacy, • Breasts. guilt and helplessness, and sometimes • Chest. suicidal thoughts. • Abdominal wound, if present. • Urinary tract.
  11. 11. THE PUERPERIUM 2393. Puerperal psychosis is an uncommon but However, the cause is unknown in up to half of very important condition. The onset is these patients. usually acute and an observant attendant will notice the sudden and marked change NOTE Gestational trophoblastic disease in the patient’s behaviour. She may rapidly (hydatidiform mole or choriocarcinoma) and pose a threat to her infant, the staff, and a disorder of blood coagulation may also cause secondary postpartum haemorrhage. herself. Such a patient must be referred urgently to a psychiatrist and will usually need admission to a psychiatric unit. 12-41 What clinical features should alert you to the possibility of the patient developing NOTE Patients with puerperal psychosis are secondary postpartum haemorrhage? unable to care for themselves or their infants. 1. A history of incomplete delivery of the They are often disorientated and paranoid and may have hallucinations. They may placenta and/or membranes. also be severely depressed or manic. 2. Unexplained puerperal pyrexia. 3. Delayed involution of the uterus. 4. Offensive and/or persistently red lochia.SECONDARY POSTPARTUM 12-42 How should you manage a patientHAEMORRHAGE with secondary postpartum haemorrhage? 1. Prevention12-38 What is secondary • Aseptic technique throughout labour,postpartum haemorrhage? the delivery and the puerperium. • Careful examination after delivery toThis is any amount of vaginal bleeding, other determine whether the placenta andthan the normal amount of lochia, occurring membranes are complete.after the first 24 hours postpartum until the • Proper repair of vaginal and perinealend of the puerperium. It commonly occurs lacerations.between the fifth and 15th days after delivery. 2. Treatment • Admission of the patient to hospital is12-39 Why is secondary postpartum indicated, except in very mild cases ofhaemorrhage important? secondary postpartum haemorrhage.1. A secondary postpartum haemorrhage • Review of the clinical notes with regard may be so severe that it causes shock. to completeness of the placenta and2. Unless the cause of the secondary membranes. postpartum haemorrhage is treated, the • Obtain an endocervical swab for vaginal bleeding will continue. bacteriology. • Give ampicillin and metronidazole (Flagyl) orally.12-40 What are the causes of secondary • Give 20 units oxytocin in anpostpartum haemorrhage? intravenous infusion if excessive1. Genital tract infection with or without bleeding is present. retention of a piece of placenta or part of the • Blood transfusion, if the haemoglobin membranes. This is the commonest cause. concentration drops below 8 g/dl.2. Separation of an infected slough in a • Removal of retained placental products cervical or vaginal laceration. under general anaesthesia.3. Breakdown (dehiscence) of a Caesarean section wound of the uterus.
  12. 12. 240 MATERNAL CARE12-43 What may you find on physical • Conjunctivitis.examination to suggest that retained • Infection of the umbilical cord stump.pieces of placenta or membranesare the cause of a secondary Each patient must be taught to monitor her ownpostpartum haemorrhage? wellbeing, as well as that of her fetus or infant.1. The uterus will be involuting slower than usual.2. Even though the patient may be more than seven days postpartum, the cervical os CASE STUDY 1 will have remained open (a finger can be passed through the cervix). Following a spontaneous vertex delivery in a clinic, you have delivered the placenta and membranes completely. The maternal and fetalSELF-MONITORING conditions are good and there is no abnormal vaginal bleeding. You are the only staff member in the clinic. You are called away and12-44 What is meant by the concept will have to leave the patient alone for a while.of ‘the mother as a monitor’?This is a concept where the patient is made 1. How can you get the patient’s help inaware of the many ways in which she can preventing a postpartum haemorrhage?monitor her own, as well as her fetus’ or infant’s The patient should be shown how to observe:wellbeing, during pregnancy, in labour, and inthe puerperium. This has two major advantages: 1. The height of the uterine fundus. 2. Whether the uterus is well contracted.1. The patient becomes much more involved 3. The amount of vaginal bleeding. in her own perinatal care. 4. She should also be asked to empty her2. Possible complications will be reported by bladder frequently. the patient at the earliest opportunity. 2. What should the patient do if12-45 How can the patient act as she notices that her uterus relaxesa monitor in the puerperium? and/or there is vaginal bleeding?The patient must be encouraged to report She should rub up the uterus and call youthe following complications as soon as she immediately.becomes aware of them:1. Maternal complications 3. What should you check on • Symptoms of puerperal pyrexia. before leaving the patient? • Breakdown of an episiotomy. You should make sure that: • Breastfeeding problems. • Excessive or offensive lochia. 1. The patient and her infant’s observations are • Recurrence of vaginal bleeding, i.e. normal and both their conditions are stable. secondary postpartum haemorrhage. 2. The patient understands what she has to do. • Prolonged postnatal depression. 3. You will be able to hear the patient, if she2. Complications in the infant calls you. • Poor feeding or other feeding problems. • Lethargy. • Jaundice.
  13. 13. THE PUERPERIUM 241CASE STUDY 2 2. Which contraceptive method she should use and how to use it correctly. 3. The care and feeding of her infant,A patient returns to a clinic for a visit three stressing the importance of breastfeeding.days after a normal first pregnancy and 4. The time that coitus can be resumed.delivery. She complains of leaking urinewhen coughing or laughing, and she is also Also ask about, and discuss, any otherworried that she has not passed a stool since uncertainties which the patient may have.the delivery. She starts to cry and says that sheshould not have fallen pregnant. Her infanttakes the breast well and sleeps well after each CASE STUDY 3feed. On examination the patient appears well,her observations are normal, the uterus is the Following a prolonged first stage of labour duesize of a 16-week pregnant uterus, and the to an occipito-posterior position, a patient haslochia is red and not offensive. a spontaneous vertex delivery. The placenta and membranes are complete. There is no excessive1. Is her puerperium progressing normally? postpartum blood loss and the patient isYes. The patient appears healthy with normal discharged home after six hours. Within 24observations, and the involution of her uterus hours of delivery the patient is brought backis satisfactory. to the clinic. She has a temperature of 39 °C, a pulse rate of 110 beats per minute and complains of a headache and lower abdominal2. What should be done about pain. The uterus is tender to palpation.the patient’s complaints?Stress incontinence is common during 1. What does the patient present with?the puerperium. Therefore, the patientmust be reassured that it will improve over Puerperal pyrexia.time. However, pelvic floor exercises mustbe explained to her as they will hasten 2. What is the most likely causeimprovement of her incontinence. She need of the puerperal pyrexia?not be worried about not having passed a stool Genital tract infection, i.e. puerperal sepsis.as this is normal during the first few days of This diagnosis is suggested by the generalthe puerperium. signs of infection and the uterine tenderness. The patient had a prolonged first stage of3. Why is the patient regretting labour, which is usually accompanied byher pregnancy and crying for a greater than usual number of vaginalno apparent reason? examinations and, therefore, predisposes herShe probably has the ‘puerperal blues’ which 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 are No. The patient should not have beennormal and are experienced by most mothers. discharged home so early as she had a prolonged first stage of labour which places4. What educational topics must be her at a higher risk of infection. She shoulddiscussed with the patient during this visit? have been observed for at least 24 hours.1. Family size and when she plans to have her next infant.
  14. 14. 242 MATERNAL CARE4. How should you manage this 2. What is the most likely causepatient further in the clinic? of the patient’s pyrexia?She must be made comfortable. Paracetamol An upper urinary tract infection as suggested(Panado) 1 g orally may be given for the by the pyrexia, rigors, lower abdominal painheadache. If necessary, she should be given and tenderness over the kidneys.a tepid sponging. An intravenous infusionshould be started and she must then be 3. Do you agree with the managementreferred to hospital. If at all possible, the infant given to the patient?must accompany the patient to hospital. Theneed to start antibiotic treatment, such as No. A urinary tract infection that causesintravenous ampicillin and oral metronidazole puerperal pyrexia is an indication for(Flagyl), before transfer must be discussed admitting the patient to hospital. Intravenouswith the doctor. cefuroxime (Zinecef) must be given, as this will lead to a rapid recovery and prevent serious complications.CASE STUDY 4 4. Why is a puerperal patient at risk of a urinary tract infection andA patient is seen at a clinic on day five following how may this be prevented?a normal pregnancy, labour and delivery. Shecomplains of rigors and lower abdominal pain. Catheterisation is often required and thisShe has a temperature of 38.5 °C, tenderness increases the risk of a urinary tract infection.over both kidneys (loins) and tenderness to Catheterisation must only be carried outpercussion over both renal angles. A diagnosis when necessary and must always be done asof puerperal pyrexia is made and the patient is an aseptic procedure. Screening and treatinggiven oral ampicillin. She is asked to come back asymptomatic bacteriuria at the antenatalto the clinic on day seven. clinic will reduce acute pyelonephritis during the puerperium.1. Are you satisfied with thediagnosis of puerperal pyrexia?No. Puerperal pyrexia is a clinical sign andnot a diagnosis. The cause of the pyrexia mustbe found by taking a history, doing a physicalexamination and, if indicated, completingspecial investigations.

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