Puerperal infection, also known as childbed fever, is an infection that occurs after childbirth. It is a leading cause of maternal death worldwide, accounting for up to 16% of maternal mortality cases. Puerperal infection causes at least 75,000 maternal deaths per year globally, most occurring in developing countries. The infection is usually caused by bacteria that normally inhabit the birth canal and lower intestines.

1. MS.Y.NATHALINA DEEPIKA.,MSC (N).,
LECTURER,
OBSTETRICS AND GYNECOLOGICAL NURSING
GANGA INSTITUTE OF HEALTH SCIENCES,
COIMBATORE.

2. PUERPERAL INFECTION

3. • Puerperal infection (also known as childbed fever) is a
disease that occurs shortly after childbirth.
• It is a leading cause of maternal death, accounting for
up to 16% of cases of mortality.
• It causes at least 75,000 maternal deaths worldwide per
year, most of which occur in developing
countries. Postpartum urinary retention occurs in 10-15
% of women (Yip et al. 1998; Lee et al. 1999)

4. • “Puerperium is the period following the child birth
during which the body tissues especially the pelvic
organ reverts back approximately to the pre-pregnant
state both anatomically and physiologically”.
• Puerperium begins as soon as the placenta is expelled
and last for approximately 6 weeks.

5. • The uterus begins its descent in to the pelvic cavity
on the first postpartum day.
• It diminishes rapidly in size, weight and position until
the tenth day, when it may be palpated at or below the
level of symphysis pubis.
• The physiological process of involution is most
marked in the body of the uterus.

6. • Following the delivery, the major part of the decidua
is cast off with the expulsion of the placenta and the
membranes, more at the placental site.
• The Endometrium left behind varies in thickness
from 2-4mm.

7. • The superficial part containing the degenerated
decidua, blood cells and bits of fetal membranes
becomes necrotic and is cast off in the lochia.
• Regeneration occurs from the epithelium of the
uterine gland mouths and interglandular stromal cells.

8. • Regeneration of epithelium is completed by 10th day
and entire Endometrium is restored by the day 16,
except at the placental site where it takes about
6weeks.

9. • Puerperal infections is a term used to describe any
infections of the reproductive tract during the first six
weeks of postpartum.

11. Definition
• Puerperal infection/ puerperal pyrexia is a
bacterial infection that occurs following childbirth.
The diagnostic criteria require that the childbearing
woman have a temperature elevated over 100.4°F
(38°C) on any two of the first 10 post-partum days
after day one, or over 101.5°F (38.6°C) during the
first 24 hours.

12. Causes
The causes of pyrexia are;
• Puerperal sepsis
• Urinary tract infection
• Mastitis
• Infection of caesarean wound
• Pulmonary infection
• Septic pelvic thrombophlebitis
• Malaria or pulmonary tuberculosis
• Unknown origin

13. Organisms
• Those organisms recognized as the common
causative agents are normally seen in the lower bowel
and lower genital tract.
(1) Anaerobic staphylococci.
(2) Anaerobic streptococci.
(3) Clostridium perfringens.
(4) Neisseria gonorrhea.

14. Pathology
 When the third stage of labor is completed, the
placental attachment site is raw, elevated, and dark red.
 The surface is nodular, owing to the numerous veins,
and offers an excellent portal of entry for
microorganisms.
 The uterine decidua is very thin and has many small
openings that offer a portal for pathogens.

15. • In addition, small cervical, vaginal and perineal
lacerations, as well as the episiotomy site, provide
entry ports for pathogens.
• The resultant inflammation and infection can remain
localized or can extend via blood or lymph vessels to
other tissues.

16. General risk factors
– History of cesarean delivery
– Premature rupture of membranes
– Frequent cervical examination (Sterile gloves
should be used in examinations. Other than a
history of cesarean delivery, this risk factor is most
important in postpartum infection.)

17. – Internal fetal monitoring
– Preexisting pelvic infection including bacterial
vaginosis
– Diabetes
– Nutritional status
– Obesity

18. Predisposing Factors
1) Prolonged rupture of uterine membranes provides
increased opportunity for infection to develop prior
to delivery.
2) Retained placental fragments-provides additional
medium for infectious growth.
3) Postpartal hemorrhage-causes decreased resistance
to pathogens

19. (4) Preexisting anemia-low resistance to infection.
(5) A prolonged and difficult labor, especially with the
involvement of instruments (forceps).
(6) Intrauterine manipulations for fetal delivery or
manual expulsion of placenta.

20. Preventive measures
(1) Restrict personnel with respiratory infections from
working with patients.
(2) Use caps, mask, gowns, and gloves when working
in delivery rooms.
(3) Use sterilized equipment within control dates.
(4) Wash hands meticulously (staff).

21. (5) Correct breaks in sterile techniques immediately.
(6) Instruct the patient on hand washing and cleansing
her perineum from front to back.
(7) Limit unnecessary vaginal exams during labor which
increases the chances of introducing organisms from
the rectum and vagina into the uterus.

22. Kinds of Postpartal Infections
(1) Endometritis-invasion of microorganisms into the
placental site of the uterine wall.
(2) Pelvic cellulitis (parametritis)-infection that has
spread beyond the endometrium into the surrounding
pelvic structures including the broad ligament.

23. (3) Peritonitis-an infection of the peritoneum, either
generalized or localized.
(4) Salpingitis-an infection of the fallopian tubes
following childbirth.

24. PUERPERAL SEPSIS

25. DEFINITION

26. PREDISPOSING FACTORS
• The pathogenicity of the vaginal flora may be
influenced by certain factors;
• Condition lowering the host resistance- general or local
• Multiplication of organism in the devitalized tissue
usually starts after the two days following delivery
• Introduction of organism from outside
• Increased prevalence of organisms resistant to
antibiotics

27. Antepartum factors:
• malnutrition and anaemia
• preterm labor
• premature rupture of membrane
• chronic debilitating illness
• prolonged rupture of membrane >18 hours.

28. Intrapartum factors:
• repeated vaginal examinations
• prolonged rupture of membranes >18 hours
• dehydration and ketoacidosis during labour
• traumatic operative delivery
• Haemorrhage- antepartum or postpartum
• retained bits of placental tissue or membranes,
• caesarean delivery.

29. Microorganism responsible for puerperal sepsis and
the pathology
• Aerobic- streptococcus heamolyticus group A (GAS)
• Streptococcus heamolyticus group B
• Anaerobic- anaerobic streptococcus,
• bacteroides (fagilis, bivius, fusobacteria)
• clostridia.

30. MODE OF INFECTION
 Puerperal sepsis is essentially a wound infection.
 Placental site, lacerations of genital tract or caesarean
section wounds may be infected in the many ways
 The source of infection may be endogenous where
organisms are present in the genital tract before
delivery

31. • Autogenous, where organism present elsewhere in the
body and migrate it to the genital organs by blood
streams or by the patient herself.
• Exogenous: where the infection is contracted from
sources outside the patient (from hospital or
attendants).

32. PATHOLOGY
The primary sites of infection are;
• Perineum
• Vagina
• Cervix
• Uterus

33. • The infection is either localized to the site or spread
to distant sites.
• The lacerations on the perineum, vagina and cervix
are often infected by the organism due to the presence
of blood clots or dead space.

34. • The wounds become red, swollen and associated
sangopurulent discharge.
• There may be disruption of the wound if repaired
before control of infection.
• Diabetes, obesity, low nutritional statuses are the
other high risk factors for wound infection.

35. SPREAD OF INFECTION
• Pelvic cellulitis (parametritis) is due to spread of
infection to the pelvic cellular tissues
• The infection causes exudation and formation of an
indurated mass
• Salpingitis: may be interstitial or perisalpingitis.
Pelvic abscess may be there

36. • Septic pelvic thrombophlebitis: may involve the
ovarian veins, uterine veins, pelvic vein and rarely
inferior venacava
• Septicemia and septic shock may be due to hemolytic
streptococci or anaerobic streptococci.
• Septicemia may cause lung abscess, meningitis,
pericarditis, endocarditis or multi organ failure.
• Death occurs in about 30% cases.

37. CLINICAL FEATURES
• Local infection
• Uterine infection
• Spreading infection

38. INVESTIGATIONS OF PUERPERAL
SEPSIS
• History
• Clinical examination: includes the study of pulse and
temperature chart, neck stiffness
• systematic examination includes breast, lungs, heart,
liver, spleen and legs
• abdominal examinations to note involution of the
uterus, whether the uterus is tender or not, presence
of peritonitis or pelvic abscess

39. • internal examination to note the character of lochia,
condition of perineal wound, pelvic abscess
• bimanual examination to find out any pelvic cellulitis
or abscess,
• limbs are examined to detect thrombophlebitis or
thrombosis.

40. • High vaginal an endocervical swabs for culture in
aerobic and anaerobic media and sensitivity test to
antibiotics
• Clean catch midstream specimen of urine for analysis
and culture including sensitivity test
• Blood for total and differential white cell count,
haemoglobin estimation.
• Thick blood film should be examined for malaria
parasite.

41. • Pelvic ultrasound to detect any retained bits of
conception within the uterus,
• color flow Doppler study to detect venous thrombosis
• C T and MRI
• X-ray chest to know the lung pathology
• Blood urea and electrolytes to know the renal
pathology

42. PROPHYLAXIS
Antenatal prophylaxis:
• improvement of nutritional status
• eradication of any septic focus (skin, throat and
tonsils) in the body

43. Intranatal prophylaxis:
• full surgical asepsis during delivery
• screening for group B streptococcus in high risk
patients
• prophylactic use of antibiotics during caesarean
section
• ceftriaxone 1gm IV immediately after cord clamping
and second dose after 8 hrs is recommended.

44. Postpartum prophylaxis:
• Includes aseptic precautions for at least 1 week
following delivery until the open wounds in the
uterus, perineum and vagina are healed up.
• Too many visitors are restricted.
• Sterilized sanitary pads are to be used.
• Infected baby and mother should be in isolated room.

45. TREATMENT
• General care: isolation of the patient is preferred
specially when hemolytic streptococcus is obtained
on culture
• Adequate fluid and calorie is supplied if needed by
intravenous infusion
• Anaemia is corrected by oral iron and if needed by
blood transfusion
• Pain is relieved by adequate analgesia

46. • An indwelling catheter is used to relieve any urine retention
due to pelvic abscess.
• Vital chart should be maintained
Antibiotics:
• Gentamycin 2mg/kg IV loading dose followed by 1.5mg/kg
IV every 8 hrs and ampicillin 1gm IV every 6 hrs
• clindamycin 900 mg IV every 8 hrs should be started.
Intravenous administration of cefotaxime 1gm 8 hrly is

47. • Metronidazole 0.5gm IV is given at 8 hours interval
to control the anaerobic group.
• The treatment is continued until the infection is
controlled at least 7-10 days.

48. Surgical treatment:
Perineal wound:
• the stitches the perineal wound may have to be
removed
• The wound is to be dressed with hot compress with
mild antiseptic solution followed by application of
antiseptic ointment or powder.
• After the infection is controlled, secondary suture
may be given at a later date.

49. • Retained uterine product: Surgical evacuation after
antibiotic coverage for 24 hrs should be done
• Cases with septic pelvic thrombophlebitis are treated
with IV heparin for 7-10 days.
• Pelvic abscess: should be drained by colpotomy
under ultrasound guidance.
• Abscess: above the poupart’s ligament should be
incised and pus is drained.

50. • Laparotomy: for unresponsive peritonitis, Laparotomy is
indicated
• Hysterectomy in case with rupture or perforation, abscess
and gas gangrene infection
Management of bacteraemic or septic shock: monitor
fluid and electrolyte balance
• respiratory and circulatory support
• infection control

52. UTERINE SUBINVOLUTION

53. • Subinvolution is a medical condition in which after
childbirth, the uterus does not return to its normal
size.
• Definition: When the involution is impaired or
retarded it is called subinvolution

54. • The uterus is the most common organ affected by
subinvolution.
• As it is the most accessible organ to be measured per
abdomen ,the uterine involution is considered
clinically as an index to assess subinvolution.
• Uterine subinvolution is a slowing of the process of
involution or shrinking of the uterus.

55. Causes
Predisposing factors are
A. Grand multiparty
B. Over distension of uterus as in twins and hydramnios
C. Maternal ill health
D. Caesarean section
E. Pelvic infection

56. E. Prolapse of the uterus
F. Retroversion after the uterus becomes pelvic organ
G. Uterine fibroid

57. Aggravating factors are:
• Retained products of conception
• Uterine sepsis
• Endometritis

58. Symptoms
The condition may be asymptomatic. The predominant
symptoms are:
 Abnormal lochial discharge either excessive or
prolonged
 Irregular or at times excessive uterine bleeding
 Irregular cramp like pain is cases of retained products
or rise of temperature in sepsis

59. Signs
• The uterine height is greater than the normal for the
particular day of puerperium.
• Normal puerperal uterus may be displaced by a full
bladder or a loaded rectum.
• It feels boggy and sifter.

60. Medical Treatment
(1) Administration of oxytocic medication to improve
uterine muscle tone. Oxytocic medication includes
(a) Methergine-a drug of choice since it can be given by
mouth.
(b) Pitocin.
(c) Ergotrate.

61. (2) Dilation and curettage (D&C) to remove any
placental fragments.
(3) Antimicrobial therapy for endometritis.
• Pessary in prolapse or retroversion

62. • Methergine (Methylergonovine maleate) is a semi-
synthetic ergot alkaloid used for the prevention and
control of postpartum hemorrhage.
• Methergine is available in sterile ampoules of 1 mL,
containing 0.2 mg methylergonovine maleate for
intramuscular or intravenous injection

63. Indications and usage
• For routine management after delivery of the placenta;
postpartum atony and hemorrhage, subinvolution. Under full
obstetric supervision, it may be given in the second stage of
labor following delivery of the anterior shoulder.
Contraindications
• Hypertension; toxemia; pregnancy; and hypersensitivity.

64. Warnings
 This drug should not be administered I.V. routinely because
of the possibility of inducing sudden hypertensive and
cerebrovascular accidents.
 If I.V. administration is considered essential as a lifesaving
measure, Methergine (methylergonovine maleate) should be
given slowly over a period of no less than 60 seconds with
careful monitoring of blood pressure. Intra-arterial or
periarterial injection should be strictly avoided.

65. Precautions
• Caution should be exercised in the presence of sepsis,
obliterative vascular disease, hepatic or renal involvement.
Also use with caution during the second stage of labor.
• The necessity for manual removal of a retained placenta
should occur only rarely with proper technique and adequate
allowance of time for its spontaneous separation.

66. Adverse reactions
• The most common adverse reaction is hypertension
associated in several cases with seizure and/or
headache.
• Hypotension has also been reported. Nausea and
vomiting have occurred occasionally.

67. • Rarely observed reactions have included: acute
myocardial infarction, transient chest pains, arterial
spasm (coronary and peripheral), bradycardia,
tachycardia, dyspnea, hematuria, thrombophlebitis,
water intoxication, hallucinations, leg cramps,
dizziness, tinnitus, nasal congestion, diarrhea,
diaphoresis, palpitation, rash, and foul taste

68. Pitocin
 Warning: This medication is recommended to be used only
in pregnancies that have a medical reason for inducing labor
(e.g., eclampsia).
 Uses: Oxytocin is a hormone used during the late stage of
pregnancy to induce labor (contractions).
 It is often used to induce labor in difficult pregnancies or
pregnancies at risk for complications (e.g., preeclampsia,
eclampsia, diabetes).27

69.  Other uses: This drug may also be used during
pregnancy to test the heartbeat of the fetus; and to
remove the placenta and control bleeding of the uterus
after childbirth.
 How to use: Follow all instructions for proper mixing
and dilution with the correct IV fluids. This drug
should be mixed in a saline, dextrose, or Lactated
Ringers solution.

70. • Side effects: Nausea, vomiting, cramping, and
stomach pain may occur. If any of these effects
persist or worsen, notify the doctor promptly.
• irregular heartbeat, dizziness, lightheadedness,
swelling, severe bleeding (after childbirth), seizures,
headache, blurred vision, one-sided weakness.

71. Nursing Interventions.
(1) Early ambulation postpartum.
(2) Daily evaluation of fundal height to document
involution.

72. POSTPARTUM HAEMORRHAGE

73. DEFINITION
• Any amount of bleeding from or into the genital
tract following the birth of the baby up to the end
of puerperium which adversely affects the general
condition of the patient evidenced by rise in pulse
rate and falling blood pressure is called
postpartum haemorrhage

74. TYPES OF POSTPARTUM
HAEMORRHAGE
• Primary
• Secondary

75. PRIMARY POSTPARTUM
HAEMORRHAGE
Two types
• Third stage haemorrhage
• True postpartum haemorrhage

76. CAUSES OF PRIMARY
POSTPARTUM HAEMORRHAGE
Four causes;
• Atonic
• Traumatic
• Mixed
• Blood coagulopathy

77. Atonic
• Grand multipara: inadequate retraction and frequent
adherent placenta
• Over distension of the uterus
• Malnutrition and anaemia
• Antepartum haemorrhage
• Prolonged labour
• Anaesthesia
• Initiation or augmentation of delivery by oxytocin

78. • Persistent uterine distension: retention of partially
separated placenta or bits of placenta or blood clots
• Malformation of uterus
• Uterine fibroid
• Constriction ring
• Precipitate labour: in rapid delivery

79. Mismanaged third stage of labour
• Too rapid delivery of the baby
• Premature attempt to deliver the placenta before it is
separated
• Kneading and fiddling of the uterus
• Pulling the cord
• Manual separation of the placenta increases blood
loss during caesarean delivery

80. Traumatic (20%)
• Trauma to the genital tract
• Trauma involves usually the cervix, vagina, perineum
(episiotomy wound and lacerations), para urethral
region and rarely the rupture of uterus occurs.
Mixed: combination of atonic and traumatic causes

81. Blood coagulation disorders, acquired or congenital:
• less common, the blood coagulopathy may be due to
diminished procoagulant or increased fibrinolytic
activity.

82. DIAGNOSIS AND CLINICAL
EFFECTS
The effect of blood loss depends on
• Pre delivery hemoglobin level
• Degree of pregnancy induced hypervolaemia
• Speed at which blood loss occurs

83. • State of uterus, as felt per abdomen, gives a reliable
clue as regards the cause of bleeding.
• In traumatic haemorrhage, the uterus is found well
contracted.
• In atonic haemorrhage, the uterus is found flabby and
massive blood loss from the injuries, a state of low
general condition can make the uterus atonic.

84. PROGNOSIS
• Post partum haemorrhage is one of the life
threatening emergencies.
• It is responsible for maternal deaths in about
10%.

85. PREVENTION
Antenatal
• Improvement of the health status
• keep the haemoglobin level normal(>10gm/dl)
• High risk patients (twins, hydramnios, and grand
multipara) are to be screened and delivered in well
equipped hospitals.
• Blood grouping should be done

86. Intranatal
• Slow delivery of the baby
• Expert obstetrics anesthetist is needed when the
delivery is conducted under general anaesthesia
• During caesarean section spontaneous separation and
delivery of placenta
• Active management of third stage

87. • Temptation of fiddling or kneading with the uterus or
pulling the cord should be avoided
• Examination of placenta and membranes
• Oxytocin infusion should be continued for at least
one hour after delivery
• Exploration of utero vaginal canal
• Observe the patient for about two hours

89. MANAGEMENT OF THIRD STAGE
BLEEDING
Placental site bleeding
• Palpate the fundus and massage the uterus to make it
hard

90. • Sedation may be given with morphine 15mg intra
muscularly
• Expression of placenta is to be done it is separated
• If placenta is not separated, manual removal of
placenta under general anaesthesia is to be done.

91. • If the patient is in shock, she is resuscitated first before
undertaking manual removal.
• If the patient is delivered under general anaesthasia,
quick manual removal of the placenta removes the
problem.
Traumatic bleeding
• The utero vaginal canal is to be explored under general
anaesthesia after the placenta is expelled
• haemostatic sutures are placed on the offending sites.

92. STEPS OF MANUAL REMOVAL OF
PLACENTA
• Step 1: operation is done under general
anaesthesia. Or deep sedation with 10mg
diazepam IV. Patient is placed in lithotomy
position. Catheterize the bladder with all aseptic
technique.

93. • Step 2: one hand is introduced in to the uterus after
smearing with the antiseptic solution in cone shaped
manner, following the cord, which is made taut by the
other hand.
• While introducing the hand, labia are separated by the
fingers of other hand.
• The fingers of the uterine hand should locate the
margin of the placenta.

94. • Step 3: counter pressure on the uterine fundus is
applied by the other hand placed over the abdomen.
• The abdominal hand should steady the fundus and
guide the movement of the fingers inside the uterine
cavity till the placenta is completely separated.

95. • Step 4: as soon as the placental margin is reached, the
fingers are insinuated between the placenta and the
uterine wall with the back of the hand in contact with
the uterine wall.
• The placenta is gradually separated with a sideways
slicing movement of the fingers, until whole placenta
is separated.

96. • Step 5: when the placenta is completely separated, it
is extracted by traction of the cord by the other hand.
• The uterine hand is still inside the uterus for
exploration of the cavity to be sure that nothing is left
behind.

97. • Step 6: IV ergometrine, 0.25 mg is given
• uterine hand is gradually removed while massaging
the uterus, by the external hand to make it hard.
• Inspection of the cervico-vaginal canal is to be done
to exclude any injury.
• Step 7: placenta and membranes are to be inspected
for completeness

98. COMPLICATIONS
• Hemorrhage due to incomplete removal
• Shock
• Injury to the uterus
• Infection

99. • Inversion
• Sub involution
• Thrombo phlebitis
• Embolism

100. MANAGEMENT OF TRUE
POSTPARTUM HAEMORRHAGE
Immediate measures: (If Blood loss is more than a
liter).
• Call for extra help
• Put in two large bore 14 gauge IV cannula
• Send blood for group and cross matching and ask
for two units of blood

102. • Infuse rapidly two liters of normal saline
(crystalloids) or plasma substitutes like haemaccel, a
urea linked gelatin, to re expand the vascular bed.
• Monitor pulse, blood pressure, type and amount of
fluids the patient has received, urea output, drugs;
type, dose and time and central venous pressure.

103. ACTUAL MANAGEMENT
Atonic uterus:
• Step 1: (a) massage the uterus to make it hard and
express the clot
(b) methergine 0.2mg is given IV
(c) morphine 15mg IM
(d) Inj.Oxytocin drip is started, 10 units in 500ml of NS at
the rate of 30-40 drops /min.

105. (e) empty the bladder
(f) examine the expelled placenta and membranes
If the uterus fails to contract, proceed to next step

106. Methargin
• USES: This medication is used after childbirth to help stop
bleeding from the uterus. Methylergonovine belongs to a
class of drugs known as ergot alkaloids. It works by
increasing the rate and strength of contractions and the
stiffness of the uterus muscles. These effects help to decrease
bleeding.
• SIDE EFFECTS: Headache, nausea, vomiting, or dizziness
may occur

107. • Step II: the uterus is to be explored under general
anaesthasia.
• Simultaneous inspection of the cervix, vagina
especially in the para urethral region
• In refractory cases: Inj. 15methyl PGF2  250µg IM
in the deltoid muscle every 1-2 hours up to maximum
5 doses or misoprostol PGE1 1000µg per rectum is
effective.

108. • Step III: uterine massage and bimanual compression
• Procedure: the whole hand is introduced in to the
vagina in a cone shaped fashion
• The vaginal hand is clenched in to fist with the back of
the hand directed posteriorly and knuckles in the anterior
fornix.
• The other hand is placed over the abdomen behind the
uterus
• The uterus is firmly squeezed between the two hands.

110. • Step IV: uterine tamponade: tight uterine packing
under GA.
• Procedure: a 5 meter long strip of gauze, 8cm wide
folded twice is required.
• The gauze should be soaked in antiseptic cream
before introduction.
• The gauze is high up and packed in to fundal area
while the uterus is steadied by the external hand.

111. • The rest of the cavity is packed so that no empty space is
left behind.
• A separate pack is used to fill the vagina.
• An abdominal binder is used.
• Antibiotics should be given and the plug should be
removed after 24 hours.
• Insertion of a Sengstaken Blakemore tube into the
uterine cavity and inflating the balloon with 200ml of NS
also can be done.

113. • Step V: surgical methods to control PPH
• Ligation of uterine arteries
• Ligation of the ovarian and uterine artery anastomosis
if the bleeding continues
• Ligation of anterior division of internal iliac artery
• B-Lynch brace suture and haemostatic suturing
• Angiographic arterial embolisation

115. • Step VI: Hysterectomy: If uterus fails to contract and
bleeding continues.
Traumatic PPH
• The trauma to the perineum, vagina and cervix is to
be searched under good light by speculum
examination and haemostasis is achieved by catgut
sutures.

117. SECONDARY POSTPARTUM
HAEMORRHAGE
Causes
• The bleeding occurs between 8th to 14th days of delivery.
The causes are;
• Retained bits of cotyledon or membranes
• Infection and separation of cervico vaginal laceration
• Endometritis and subinvolution of placental site due to
delayed healing process

118. Diagnosis
• The bleeding is bright red and of varying amount.
• Rarely it may be brisk.
• Varying degree of anemia and evidence of sepsis are
present.
• Internal examination reveals evidence of sepsis,
subinvolution of uterus
• Ultra sonography is useful in detecting the bits of
placenta inside the uterine cavity

119. MANAGEMENT
• Supportive therapy: blood transfusion if necessary,
to administer ergometrine 0.5mg IM if bleeding is
uterine in origin, to administer antibiotics as a routine
• Conservative: if the bleeding is slight and no
apparent cause is detected, a careful watch for a
period of 24hrs or so is done in the hospital

120. • Active treatment: explore the uterus under GA.
• The products are removed by ovum forceps.
• Curettage is done using flushing curette. Ergometrine
0.5mg is given IM.
• The material removed are to be sent for histological
examination

121. NURSING CARE PLAN
• Fluid volume deficit related to haemorrhage
• Monitor the fluid volume status
• Maintain intake output chart
• Monitor for the signs of complications such as
haemorrhage
• Administer IV fluids
• Blood transfusion if needed

122. Anxiety related to prognosis
• Assess the level of anxiety
• Encourage mother to ventilate her feelings
• Clarify the doubts asked
• Health education on antenatal care

123. Knowledge deficit related to the disease condition
• Assess the level of knowledge
• Encourage mother to ask doubts
• Educate the mother about the disease condition
• Give psychological reassurance on prognosis

124. Potential for complications related to haemorrhage
• Administer the medication as prescribed
• Assess for the signs of complications
• Monitor the factors alleviating the complication

125. Potential for infection related to postpartum
haemorrhage
• Assess for the signs of infection
• Monitor vital signs
• Encourage mother to follow hygienic measures
• Encourage the mother to take well balanced diet