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The document discusses various complications during the puerperium, including puerperal pyrexia, sepsis, urinary issues, and breast complications. It details causes, symptoms, and management strategies for each complication, emphasizing the importance of proper care to prevent and treat these conditions. Additionally, it highlights the significance of antibiotic use, surgical interventions, and the necessity of monitoring to ensure maternal health during the postpartum period.

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BY: SAVITA S H
NORMAL PUERPERIUM
ABNORMALITIES OF THE PUERPERIUM ABNORMALITIES OF THE PUERPERIUM  Puerperal Pyrexia  Puerperal Sepsis  Subinvolution  Urinary complications: UTI, Urinary Retention, Urinary Incontinence, Urinary Suppression  Breast Complications: Breast Engorgement, Cracked & Retracted Nipple, Acute Mastitis  Puerperal Venous Thrombosis & Pulmonary Embolism  Puerperal Emergencies, Obstetric palsies, Psychiatric Disorders during puerperium
PUERPERAL PYREXIA
PUERPERAL PYREXIA “ A rise of temperature reaching 100.4 degree F or more (Measured orally) on two seperate occassions at 24 hours apart (excluding first 24 hours) within first 10 days following delivery is called Puerperal pyrexia” In some countries postabortal fever is also included.
CAUSES:- Infection: LSCS wound Pulmonary infection
PUERPERAL SEPSIS “An infection of the genital tract which occurs as a complication of delivery is termed puerperal sepsis.” Puerperal pyrexia is considered to be due to genital tract infection unless proved otherwise.
INCEDENCE There had been marked decline in puerperal sepsis during the past few years due to:- Improved obstetric care Availability of wider range of antibiotics
CAUSES:- Combination of all called as Pelvic Cellulitis
PREDISPOSING FACTORS Damage of Cervicovaginal mucous membrane Large placental wound surface area Blood clots presents at placental site ANTEPARTUM FACTORS: Malnutrition and anemia Preterm labour PROM Chronic illness Prolonged rupture of membrane >18 hours
INTRAPARTUM FACTORS: Repeated vaginal examinations Prolonged rupture of membranes Dehydration and keto- acidosis during labour Traumatic operative delivery Hemorrhage Retained bits of placenta or membranes Placenta previa Cesarean Section delivery
MICRO-ORGANISMS RESPONSIBLE FOR PUERPERL SEPSIS
AEROBIC:- Streptococcus hemolytic group- A Streptococcus hemolytic group - B Others: Streptococcus pyogenus, aureus, E coli, Pseudomonas, chlamydia ANAEROBIC:- Streptococcus, peptococcus, bacteriodes
MODE OF INFECTION Puerperal sepsis is essentially a wound infection Placental site, lacerations of the genital tract or cesarean section wounds It may get infected by ENDOGENOUS or EXOGENOUS organisms.
CLINICAL FEATURES:-
1. LOCAL INFECTION Slight temperature rise Generalized malaise Headache Redness and swelling to local wound Pus formation
2. UTERINE INFECTION MILD:- Rise in temperature and pulse rate Offensive and copious lochial discharge Subinvoluted and tender uterus SEVERE:- Acute onset with high grade temperature with chills and rigor Rapid pulse rate Scanty and orderless lochia
3. SPREADING INFECTION Parametritis Pelvic pritonitis General peritonitis Thrombophlebitis Septicemia
INVESTIGATION High vaginal endocervical swab Blood examination History, Clinical examination Pelvic ultrasound CT scan, MRI
PROPHYLAXIS ANTENATAL: Improvement of nutritional status Eradication of any septic status INTRANATAL: Full surgical asepsis during labour Prophylactic antibiotics: Cefriaxone 1g IV immediate after cord clamping and second dose: after 8 hour is recommended
POSTNATAL: Aseptic precautions atleast one week following delivery Too many visitors are restricted Sterilized senitory pads are to be used Infected babies and mothers should be in isolated room
GENERAL CARE:- Isolation of the patient Adequate fluid and calorie (IV) Anemia is to be corrected Progress chart should be maintained TREATMENT
ANTIBIOTICS
ANTIBIOTICS  Gentamicin, 2 mg/kg IV loading dose followed by 1.5 mg/kg IV every 8 hours  Ampicillin, 1g IV every 6 hours  Clindamycin 900 mg, IV every 8 hours  Cefotaxime 1 g, 8 hourly IV is an alternative  Metrinidazole 0.5 g IV, 8 hourly continue atleast 7-8 days
SURGICAL TREATMENT
PERINEAL WOUND:- Stiches of perineal wound may have to be removed to facilitate drainage of pus and relieve pain Wound has to be cleaned with sitz bath several times per day and dressed with antiseptic ointment or powder After the infection is controlled, secondary suture may be given on later date SURGICAL TREATMENT
RETAINED UTERINE PRODUCTS:- With diameter of 3 cm or less may be disregarded or left alone Otherwise surgical evacuation after antibiotic coverage for 24 hours should be done to avoid risk of septicemia SEPTIC THROMBOPHLEBITIS:- IV Heparin for 7-10 days
PELVIC ABCESS:- Drainage by colpotomy under ultrasound guidance WOUND DEHISCENCE: Dehiscence of episiotomy or abdominal wound following cesarean section:- Scrubbing the wound Debridement of all necrotic tissues Secondary suture
LAPROTOMY: Has got limited indications IV fluids and antibiotics usually controls the peritonitis When the peritonitis is unresponsible to antibiotics laprotomy is indicated HYSTERECTOMY: In case of uterine rupture or perforation Multiple abcess, gangrenous uterus Ruptured tubo-ovarian abcess
NECROTYSING FACITIS: Wound scrubbing Debridement of all necrotic tissues Use of effective antimicrobial agents BACTEREMIC OR SEPTIC SHOCK: Fluid and electrolyte balance Respiratory supports Circulatory support (dopamine/ dobutamine) Infection control
SUBINVOLUTION
DEFINITION “When the involution is impaired or retarded it is called subinvolution” The uterus is the most common organ
CAUSES PREDISPOSING FACTORS: Grand multipara Over distention of uterus Maternal ill health Cesarean section Prolapse of the uterus Retroversion Uterine fibroid
CAUSES AGGREAVATING FACTORS:- Retained products of conception Uterine sepsis (Endometritis)
SYMPTOMS  May be asymptomatic sometimes  Abnormal Lochial Discharge : Excessive or prolonged  Irregular at times Excessive Uterine Bleeding  Irregular Cramp like Pain (Retained bits)  Rise of Temperature in case of Sepsis
SIGNS Fundal height Greater than Postnatal Day Uterus feels Boggy and Softer Displaced Bladder or Loaded Rectum
MANAGEMENT Antibiotics in case of infection Exploration of uterus for retained products Pessary in prolapse or retroversion Methargin to enhance involution process
URINARY COMPLICATIONS IN PUERPERIUM
URINARY TRACT INFECTION Most common cause of puerperal pyrexia Incedence 1-5 % May be because of consequences of: Reccurence of previous cystitis or pyelitis, asymptomatic bacteriuria First time because of: Frequent catheterization, stasis of urine
ORGANISMS RESPONSIBLE:- Strepto coccal aureus
CLINICAL FETURES: Fever Pus, blood clots in urine Acute pain Burning miturition
MANAGEMENT: IV fluids
RETENTION OF URINE Common complication in early puerperium. CAUSES: Bruising Edema of bladder neck Reflex from the perineal injury Anaccustamized position
TREATMENT Indwelling catheter for 48 hours Following removal catheter recidual urine is to be measured If it is more than 100 ml drainage is resumed Appropriate urinary antiseptics up to 5- 7 days
INCONTENENCE OF URINE Not a common symptom following birth It may be:- Stress incontenence (late puerperium) overflow incontenence ( following retention of urine) True incontenence (soon following labour)
SUPRESSION OF URINE “If the 24 hours urine excretion is less than 400 ml or less, supression of urine is dagnosed.” The cause is to be sought for and appropriate management is instituted.
BREAST COMPLICATIONS
COMMON COMPLICATIONS Mastitis and breast abcess Lactation failure Cracked and inverted nipple Breast engorgement
BREAST ENGORGEMENT Breast engorgement is due to exaggerated normal venous and lymphatic engorgement of the breasts which precedes lactation. This in turn prevents escape of milk from the lacteal system
The primiparous patient and the patient with inelastic breasts are more likely develop breast engorgement Engorgement is an indication that the baby is not in step with stage of lactation ONSET: • It usually manifests after the milk secretion starts ( 3rd and 4th day postpartm)
SYMPTOMS: Considerable pain and feeling of tendernes or heaviness Generalized malaise Painful breast feeding Rise of temperature
PREVENTION: Avoid prelecteal feeds Initiate early breast feeding Exclusive breast feeding on demand Feeding in correct position
TREATMENT: Support with the binders Mannual expression of milk Administer analgesics for pain Frequently and regular feeding the baby In severe cases gentle use of breast pump Hot application
CRACKED AND RETRACTED NIPPLE The nipple may become painful due to:
CAUSES:-
SYMPTOMS Condition may remain asymptomatic Sometimes painful when feeding the baby When infected, the infection may spread to the deeper tissue proceding mastitis
PROPHYLAXIS Local cleanliness during pregnancy and puerperium Clean the crusts before and after feeding Application of lotion to soothen the epithelium
TREATMENT Correct attachement during feeding Purified lanonin with mother's milk applied 3 or 4 times a day for healing In severe cases expression of milk by breast pump
For inflammed nipple and areola miconazole lotion is applied Apply nipple shields If persistant... biopsy is needed
RETRACTED AND FLAT NIPPLE Commonly seen in primiparous mother Manual expression of milk is initiated Correction of retracted nipple
ACUTE MASTITIS Incidence of mastitis is 2-5 % in lactating Less than 1% in nonlactating mother Organisms involved are...  Streptococcus aureus,  S. epidermidis and  Streptococci viridans
Mode of infection:- Two different types of mastitis based on location of infection. 1.Infection that involves the breast paranchymal tissues leading to cellulitis. (lacteal system remains unaffected) 2.Infection up to lactefarous ducts...lead to development of primary mammary adenitis
Source of infection : infant's nose/mouth Noninfected mastitis is due to milk stasis. Feeding from the affected breast can solve the problem ONSET: In superficial cellulitis, onset is acute during first 2-4 weeks postpartum However it may occurs after several weeks also
CLINICAL FEATURES SYMPTOMS INCLUDE: Generalized malaise and headache Fever ( 102 degree F) Severe pain and tender swelling
CLINICAL FEATURES SIGNS INCLUDE: Presence of toxic features Redness of overlying skin and swelling Warm and flushy
COMPLICATION Due to variable distruction of breast tissues, it leads to the formation of a breast abcess.
PROPHYLAXIS Hand washing before and after each feed, maintaing hygiene, keep the breast and nipple dry
MANAGEMENT Support by binders Plenty of oral fluids Good attachment when feeding the baby Initiate feeding from uninfected breast first to establish let down The infected site is emptied manually with each feed Dicloxacilin is the drug of choice. 500 mg 6 hourly. erythromycin is alternative
• Antibiotic therapy is to continue up to 7 days • Analgesics • Milk flow is maintained by feeding the baby • It will prevent proloferation of staphylococcus in the stagnant milk • The ingested staphylococcus will digested without any harm
BREAST ABCESS FEATURES ARE: Flushed breasts not responding to antibiotics Browny edema on the overlying skin Marked tenderness with fluctuation Swinging temperature
MANAGEMENT Incision and drainage under general anesthesia Deep radial incision extending from near the areolar margin to prevent injury of the lacteferous ducts Incision perpendicular to the lactiferous duct can increase the risk of fistula formation and ductal occlusion
Finger exploration has to be done to break the walls of loculi. The cavilty is loosely packed with gause which should be replaced after 24 hoursby a smaller pack Continue till it heals up Abcess can also be drained by serial percutaneous niddle aspiration under ultrasound guidance Surgical draiange is commonly done
Breast feeding is contonued at uninvolved side The infected side is mechanically expressed by pump every two hourly and with every let down Reccurence risk is about 10 % Once cellulitis resolved breast feeding from the involved side may be resumed
BREAST PAIN May be due to.... Engorgement Infection ( candida albicans) Nipple trauma Mastitis Occasionally on letching-on or let down reflex
MANAGEMENT Appropriate nursing technique Positioning Breast care Use of myconazole oral lotion or gel on the nipples and in infant's mouth thrice daily for two weeks are helpful
LACTATION FAILURE CAUSES ARE: Infrequent suckling Depression or anxiety state in puerperium Unwilling to nursing Ill development of nipples Endogenous supression of prolactin Prolactin inhibition
MANAGEMENT ANTENATAL: Counsell mother regading benefits of nursing her baby To take care of any breast abnormality.. breast engorgement Maintaining adequate breast hygiene specially in last two months of pregnancy
PUERPERIUM: Encourage adequate fluid intake To nurse the baby regularly Treat the painfull local lesions to prevent nursing phobia Metoclopramide 10 g thrice daily, intranasal oxytocin and sulpiride ( selective dopamine intagonist) has been found to increase milk production. They act by stimulating prolactin secretion
PULMONARY VENOUS THROMBOSIS
PREVALENCE Thrombosis of leg Thrombosis of leg vein and pelvic vein vein and pelvic vein is most common is most common However, the prevalence is less
RISK FACTORS Vascular stasis Hypercoagulopathy of blood Vascular endothelial trauma Other pregnancy related factors Venous thrombo-embolic disease like.. deep vein thrombosis, thrombophlebitis, pulmonary embolism
This stasis causes damage to the endothelial cells Thrombophilias are hypercoaguable states in pregnancy that increase the risk of venous thrombosis (inheritate/ acquired)
OTHER ACQUIRED RISK FACTORS Advanced age and parity Operative delivery Obesity Anemia Heart disease Infection- pevic celluitis Trauma to the venous wall Immobility and smoking
DEEP VEIN THROMBOSIS Clinical diagnosis is unreliable. In majority it remains asymptomatic SYMPTOMS INCLUDE: Pain in the caff muscles On examination asymmentric leg edema A positive Homan's sign
INVESTIGATIONS  Doppler utrasound  VUS- venous utrasonography  Venography  MRI
PELVIC THROMBOPHLEBITIS Originates in the thrombosed veins at placental site by organism such as an anaerobic streptococci or bacteriosides When localised in the pelvis called pelvic thrombophlebitis. There is specific features but it is suspected when there is constatnt fever instead of antibiotics administration
EXTRA PELVIC SPREAD Through the right ovarian vein to inferior vana cava and hence to the lungs Through left ovarian vein to left renal vein and hence to the left kidney Retrograde extension to iliofemoral veins to produce the clinical pathological entity called “phlegmasia alba dolens” ( adjacent cellulitis in femoral vein)
CLINICAL FEATURES: Usually develops in second week of puerperium Mild pyrexia High grade fever with chills and rigor Constitutional disturbances like... headache, malaise, rising pulse rate Swelling, pain, white , cold over affected leg
PROPHYLAXIS PREVENTIVE MEASURES: Prevention of trauma, sepsis, anemia, dehydration Use of elastic compression stocking Leg exercise, Early ambulation
MANAGEMENT Bed rest with foot end kept higher to heart level Pain management Antibiotics Anticoagulants- Heparin- 15000 units IV followed by 10,000 units 6-8 hourly for 4 to 6 injections. up to 7 to 10 days Administartion of fibrinolytic agents Venous thrombectomy
PULMONARY EMBOLISM Most leading cause of maternal deaths Classical symptoms of massive pulmonary embolism are... Sudden collapse Acute chest pain Air hunger Death usually occurs within short time from shock and vagal inhibition
Important signs...  Tachypnea  Dyspnea  Pleuritis- chest pain  Cough  Tachycardia  Hemoptysis  Rise in temperature
DIAGNOSIS ECG Arterial blood gas D-Dimer: value (More than 500 ng/ mL) Doppler utrasound Lung scans Pulmonary angiography Spital CT MRA: Magnetic resonance angiography
MANAGEMENT Prophylactic measures Active treatment: Resuscitation: cardiac massage, oxygen therapy, heparin bolus IVof 5000 units and morphine 15 mg IV fluids Incase of recurrent .. embolectomy, placement of caval filters, ligation of inferior vana cava and ovarian veins
OBSTETRIC PALSIES (Syn.POSTPARTUM TRAUMATIC NEURITIS) The commonest form of obstetric palsy encountered in puerperium is... “FOOT DROP” Usually unilateral Appears shortly after delivery/ first day postpartum
It is due to stretching of the lumbosacral trunk by the prolapsed intervertebral disc between L5 and S1 Backward rotation of the sacrum during labour may also be a contributory factor Direct pressure either by fetal head or forcep blade on the lumbosacral cord or sacral plexus
Condition is usually mild May passed unnoticed Neurological examination reveals lower motor neurone type of lesions with placcidity and wasting of muscles in areas supplied by femoral nerve or lumbosacral plexus Secondary loss is always present
Management of damaged lumbosacral nerve roots is same as that of the proplapsed intervertebral disc in consultation with an orthopedist Paraplegia due to epidural hematoma or abcess is rare.
PUERPERAL EMERGENCIES
There are many acute complications Majority of them are alarming complications Arises immediately after delivery Except pulmonary embolism
Common complications are.....  IMMEDIATE: –Postpartum hemorrhage –Shock –Postpartum eclapmsia –Pulmonary embolism –Inversion
 EARLY (WITHIN A WEEK): –Acute retention of urine –Urinary tract infection –Puerperal sepsis –Breast engorgement –Mastitis and breast abcess –Pulmonary infection –Anuria following abruptio placenta, mismatched boold transfusion or eclampsia
 DELAYED: –Secondary postpartum hemorrhage –Thrombo-embolic manifestation –Psychosis –Postpartum cardiopathy –Postpartum hemolytic uremic syndrome
PSYCHIATRIC DISORDERS DURING PUERPERIUM
INTRODUCTION In the first 3 months after delivery, the incidence of mental illness is high. Overall incidence is about 15-20%. Sleep deprivation, hormone elevation near the end of gestation and massive postpartum withdrawal contribute to the high risk
HIGH RISK FACTORS PAST HISTORY: Psychiatric illness Puerperal psychiatric illness FAMILY HISTORY: Major psychiatric illness Marital conflicts Poor social situation
PRESENT PREGNANCY: Young age Cesarean delivery Difficult labour Neonatal complications OTHERS: Unmet expectations
PUERPERAL BLUES It is transient state of mental illness observed 4-5 days after delivery Lasts for few days Incidence is 50 %
MANIFESTATIONS ARE:  Depression  Anxiety  Tearfullness  Insomnia  Helplessness  Negative feelings towards the infant  No specific metabolic or endocrine abnormalities detected  But lowered troptophan (neurotransmitor serotonin) level is observed. it indicats altered neurotransmitter function
TREATMENT: Reassurance Psychological support by the family members
POSTPARTUM DEPRESSION Observed in 10-20 % of mothers More gradual in onset over the first 4-6 months following delivery or abortion Changes in the hypothelamo-pitutary- adrenal axis may be a cause
MANIFESTED BY: Loss of energy Loss of appetite Insomnia Social withdrawal Irritability Suicidal attitude Risk of reccurence is 50-100% in subsequence pregnancies
TREATMENT: Is started early Fluoxentine or paroxetine (serotonin uptake inhibitors) General supportive measures
POSTPARTUM PSYCHOSIS Observed in 0.14-0.26 % of mothers Commonly seen in women with past history and family history Onset is relatively sudden Lasts for 4 days
MANIFESTED BY: Fear Restlessness Confusion followed by hallucination, delusion and disorientation Suicidal, infanticidal impulses Temporary seperation and clinical supervision is needed Risk foe reccurence 20-25%
MANAGEMENT: A psychiatrist must be consulted urgently Hospitalization is needed Chlopramazine 150 mg stat and 50-150 mg three time /day is started Sublingual estradiol 1 mg TDS in significant improvement Electro convulsive therapy if remains unresponsive or in depressive psychosis Lithium in manic depressive psychosis Breast feeding is restricted in case of lithium administration
PSYCHOLOGICAL RESPONSES TO THE PERINATAL DEATHS AND MANAGEMENT Most perinatal events are joyful But when a fetal /neonatal death occurs, social attention must be given to grieving parents and family It may be because of unexcpected hysterectomy, birth of malformed or chronically ill infant Prolonged seperation from chronically ill infant can also cause grief
Physician, nurse and attending staff must understand patient's reaction The common maternal somatic symptoms are... Insomnnia Fatigue Sighing respiration Feeling of guilt Anger Hostility ( feeling of opposition)
MANAGEMENT OF PERINATAL GRIEVING Facilitating grieving process with consolation (comfort), support, sympathy Others are: 1. supporting the couple in seeing/ holding/ taking photographs of infant 2. Autopsy requests 3. Planning investigations 4. Follow up visits 5. Plan for subsequent pregnancy
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abnormalpuerperium.pptSSSSSSSSSSSSSSSSSSS

  • 1.
  • 2.
  • 3.
    ABNORMALITIES OF THEPUERPERIUM ABNORMALITIES OF THE PUERPERIUM  Puerperal Pyrexia  Puerperal Sepsis  Subinvolution  Urinary complications: UTI, Urinary Retention, Urinary Incontinence, Urinary Suppression  Breast Complications: Breast Engorgement, Cracked & Retracted Nipple, Acute Mastitis  Puerperal Venous Thrombosis & Pulmonary Embolism  Puerperal Emergencies, Obstetric palsies, Psychiatric Disorders during puerperium
  • 4.
  • 5.
    PUERPERAL PYREXIA “ Arise of temperature reaching 100.4 degree F or more (Measured orally) on two seperate occassions at 24 hours apart (excluding first 24 hours) within first 10 days following delivery is called Puerperal pyrexia” In some countries postabortal fever is also included.
  • 6.
  • 7.
    PUERPERAL SEPSIS “An infectionof the genital tract which occurs as a complication of delivery is termed puerperal sepsis.” Puerperal pyrexia is considered to be due to genital tract infection unless proved otherwise.
  • 8.
    INCEDENCE There had beenmarked decline in puerperal sepsis during the past few years due to:- Improved obstetric care Availability of wider range of antibiotics
  • 9.
  • 10.
    PREDISPOSING FACTORS Damage ofCervicovaginal mucous membrane Large placental wound surface area Blood clots presents at placental site ANTEPARTUM FACTORS: Malnutrition and anemia Preterm labour PROM Chronic illness Prolonged rupture of membrane >18 hours
  • 11.
    INTRAPARTUM FACTORS: Repeated vaginalexaminations Prolonged rupture of membranes Dehydration and keto- acidosis during labour Traumatic operative delivery Hemorrhage Retained bits of placenta or membranes Placenta previa Cesarean Section delivery
  • 12.
  • 13.
    AEROBIC:- Streptococcus hemolytic group-A Streptococcus hemolytic group - B Others: Streptococcus pyogenus, aureus, E coli, Pseudomonas, chlamydia ANAEROBIC:- Streptococcus, peptococcus, bacteriodes
  • 14.
    MODE OF INFECTION Puerperalsepsis is essentially a wound infection Placental site, lacerations of the genital tract or cesarean section wounds It may get infected by ENDOGENOUS or EXOGENOUS organisms.
  • 15.
  • 16.
    1. LOCAL INFECTION Slighttemperature rise Generalized malaise Headache Redness and swelling to local wound Pus formation
  • 17.
    2. UTERINE INFECTION MILD:- Risein temperature and pulse rate Offensive and copious lochial discharge Subinvoluted and tender uterus SEVERE:- Acute onset with high grade temperature with chills and rigor Rapid pulse rate Scanty and orderless lochia
  • 18.
    3. SPREADING INFECTION Parametritis Pelvicpritonitis General peritonitis Thrombophlebitis Septicemia
  • 19.
    INVESTIGATION High vaginal endocervicalswab Blood examination History, Clinical examination Pelvic ultrasound CT scan, MRI
  • 20.
    PROPHYLAXIS ANTENATAL: Improvement of nutritionalstatus Eradication of any septic status INTRANATAL: Full surgical asepsis during labour Prophylactic antibiotics: Cefriaxone 1g IV immediate after cord clamping and second dose: after 8 hour is recommended
  • 21.
    POSTNATAL: Aseptic precautions atleastone week following delivery Too many visitors are restricted Sterilized senitory pads are to be used Infected babies and mothers should be in isolated room
  • 22.
    GENERAL CARE:- Isolation ofthe patient Adequate fluid and calorie (IV) Anemia is to be corrected Progress chart should be maintained TREATMENT
  • 23.
  • 24.
    ANTIBIOTICS  Gentamicin, 2 mg/kgIV loading dose followed by 1.5 mg/kg IV every 8 hours  Ampicillin, 1g IV every 6 hours  Clindamycin 900 mg, IV every 8 hours  Cefotaxime 1 g, 8 hourly IV is an alternative  Metrinidazole 0.5 g IV, 8 hourly continue atleast 7-8 days
  • 25.
  • 26.
    PERINEAL WOUND:- Stiches ofperineal wound may have to be removed to facilitate drainage of pus and relieve pain Wound has to be cleaned with sitz bath several times per day and dressed with antiseptic ointment or powder After the infection is controlled, secondary suture may be given on later date SURGICAL TREATMENT
  • 27.
    RETAINED UTERINE PRODUCTS:- Withdiameter of 3 cm or less may be disregarded or left alone Otherwise surgical evacuation after antibiotic coverage for 24 hours should be done to avoid risk of septicemia SEPTIC THROMBOPHLEBITIS:- IV Heparin for 7-10 days
  • 28.
    PELVIC ABCESS:- Drainage bycolpotomy under ultrasound guidance WOUND DEHISCENCE: Dehiscence of episiotomy or abdominal wound following cesarean section:- Scrubbing the wound Debridement of all necrotic tissues Secondary suture
  • 29.
    LAPROTOMY: Has got limitedindications IV fluids and antibiotics usually controls the peritonitis When the peritonitis is unresponsible to antibiotics laprotomy is indicated HYSTERECTOMY: In case of uterine rupture or perforation Multiple abcess, gangrenous uterus Ruptured tubo-ovarian abcess
  • 30.
    NECROTYSING FACITIS: Wound scrubbing Debridementof all necrotic tissues Use of effective antimicrobial agents BACTEREMIC OR SEPTIC SHOCK: Fluid and electrolyte balance Respiratory supports Circulatory support (dopamine/ dobutamine) Infection control
  • 31.
  • 32.
    DEFINITION “When the involutionis impaired or retarded it is called subinvolution” The uterus is the most common organ
  • 33.
    CAUSES PREDISPOSING FACTORS: Grand multipara Overdistention of uterus Maternal ill health Cesarean section Prolapse of the uterus Retroversion Uterine fibroid
  • 34.
    CAUSES AGGREAVATING FACTORS:- Retained productsof conception Uterine sepsis (Endometritis)
  • 35.
    SYMPTOMS  May beasymptomatic sometimes  Abnormal Lochial Discharge : Excessive or prolonged  Irregular at times Excessive Uterine Bleeding  Irregular Cramp like Pain (Retained bits)  Rise of Temperature in case of Sepsis
  • 36.
    SIGNS Fundal height Greater than Postnatal Day Uterus feels Boggyand Softer Displaced Bladder or Loaded Rectum
  • 37.
    MANAGEMENT Antibiotics in caseof infection Exploration of uterus for retained products Pessary in prolapse or retroversion Methargin to enhance involution process
  • 38.
  • 39.
    URINARY TRACT INFECTION Mostcommon cause of puerperal pyrexia Incedence 1-5 % May be because of consequences of: Reccurence of previous cystitis or pyelitis, asymptomatic bacteriuria First time because of: Frequent catheterization, stasis of urine
  • 40.
  • 41.
  • 42.
  • 43.
    RETENTION OF URINE Commoncomplication in early puerperium. CAUSES: Bruising Edema of bladder neck Reflex from the perineal injury Anaccustamized position
  • 44.
    TREATMENT Indwelling catheter for48 hours Following removal catheter recidual urine is to be measured If it is more than 100 ml drainage is resumed Appropriate urinary antiseptics up to 5- 7 days
  • 45.
    INCONTENENCE OF URINE Nota common symptom following birth It may be:- Stress incontenence (late puerperium) overflow incontenence ( following retention of urine) True incontenence (soon following labour)
  • 46.
    SUPRESSION OF URINE “Ifthe 24 hours urine excretion is less than 400 ml or less, supression of urine is dagnosed.” The cause is to be sought for and appropriate management is instituted.
  • 47.
  • 48.
    COMMON COMPLICATIONS Mastitis andbreast abcess Lactation failure Cracked and inverted nipple Breast engorgement
  • 49.
    BREAST ENGORGEMENT Breast engorgementis due to exaggerated normal venous and lymphatic engorgement of the breasts which precedes lactation. This in turn prevents escape of milk from the lacteal system
  • 50.
    The primiparous patientand the patient with inelastic breasts are more likely develop breast engorgement Engorgement is an indication that the baby is not in step with stage of lactation ONSET: • It usually manifests after the milk secretion starts ( 3rd and 4th day postpartm)
  • 51.
    SYMPTOMS: Considerable pain and feeling of tendernesor heaviness Generalized malaise Painful breast feeding Rise of temperature
  • 52.
    PREVENTION: Avoid prelecteal feeds Initiateearly breast feeding Exclusive breast feeding on demand Feeding in correct position
  • 53.
    TREATMENT: Support with thebinders Mannual expression of milk Administer analgesics for pain Frequently and regular feeding the baby In severe cases gentle use of breast pump Hot application
  • 54.
    CRACKED AND RETRACTED NIPPLE Thenipple may become painful due to:
  • 55.
  • 56.
    SYMPTOMS Condition may remainasymptomatic Sometimes painful when feeding the baby When infected, the infection may spread to the deeper tissue proceding mastitis
  • 57.
    PROPHYLAXIS Local cleanliness duringpregnancy and puerperium Clean the crusts before and after feeding Application of lotion to soothen the epithelium
  • 58.
    TREATMENT Correct attachement duringfeeding Purified lanonin with mother's milk applied 3 or 4 times a day for healing In severe cases expression of milk by breast pump
  • 59.
    For inflammed nipple andareola miconazole lotion is applied Apply nipple shields If persistant... biopsy is needed
  • 60.
    RETRACTED AND FLATNIPPLE Commonly seen in primiparous mother Manual expression of milk is initiated Correction of retracted nipple
  • 62.
    ACUTE MASTITIS Incidence ofmastitis is 2-5 % in lactating Less than 1% in nonlactating mother Organisms involved are...  Streptococcus aureus,  S. epidermidis and  Streptococci viridans
  • 64.
    Mode of infection:- Twodifferent types of mastitis based on location of infection. 1.Infection that involves the breast paranchymal tissues leading to cellulitis. (lacteal system remains unaffected) 2.Infection up to lactefarous ducts...lead to development of primary mammary adenitis
  • 65.
    Source of infection: infant's nose/mouth Noninfected mastitis is due to milk stasis. Feeding from the affected breast can solve the problem ONSET: In superficial cellulitis, onset is acute during first 2-4 weeks postpartum However it may occurs after several weeks also
  • 66.
  • 67.
    CLINICAL FEATURES SIGNS INCLUDE: Presenceof toxic features Redness of overlying skin and swelling Warm and flushy
  • 68.
    COMPLICATION Due to variabledistruction of breast tissues, it leads to the formation of a breast abcess.
  • 69.
    PROPHYLAXIS Hand washing beforeand after each feed, maintaing hygiene, keep the breast and nipple dry
  • 70.
    MANAGEMENT Support by binders Plentyof oral fluids Good attachment when feeding the baby Initiate feeding from uninfected breast first to establish let down The infected site is emptied manually with each feed Dicloxacilin is the drug of choice. 500 mg 6 hourly. erythromycin is alternative
  • 71.
    • Antibiotic therapyis to continue up to 7 days • Analgesics • Milk flow is maintained by feeding the baby • It will prevent proloferation of staphylococcus in the stagnant milk • The ingested staphylococcus will digested without any harm
  • 72.
    BREAST ABCESS FEATURES ARE: Flushedbreasts not responding to antibiotics Browny edema on the overlying skin Marked tenderness with fluctuation Swinging temperature
  • 73.
    MANAGEMENT Incision and drainageunder general anesthesia Deep radial incision extending from near the areolar margin to prevent injury of the lacteferous ducts Incision perpendicular to the lactiferous duct can increase the risk of fistula formation and ductal occlusion
  • 74.
    Finger exploration hasto be done to break the walls of loculi. The cavilty is loosely packed with gause which should be replaced after 24 hoursby a smaller pack Continue till it heals up Abcess can also be drained by serial percutaneous niddle aspiration under ultrasound guidance Surgical draiange is commonly done
  • 75.
    Breast feeding iscontonued at uninvolved side The infected side is mechanically expressed by pump every two hourly and with every let down Reccurence risk is about 10 % Once cellulitis resolved breast feeding from the involved side may be resumed
  • 76.
    BREAST PAIN May bedue to.... Engorgement Infection ( candida albicans) Nipple trauma Mastitis Occasionally on letching-on or let down reflex
  • 77.
    MANAGEMENT Appropriate nursing technique Positioning Breastcare Use of myconazole oral lotion or gel on the nipples and in infant's mouth thrice daily for two weeks are helpful
  • 78.
    LACTATION FAILURE CAUSES ARE: Infrequentsuckling Depression or anxiety state in puerperium Unwilling to nursing Ill development of nipples Endogenous supression of prolactin Prolactin inhibition
  • 79.
    MANAGEMENT ANTENATAL: Counsell mother regadingbenefits of nursing her baby To take care of any breast abnormality.. breast engorgement Maintaining adequate breast hygiene specially in last two months of pregnancy
  • 80.
    PUERPERIUM: Encourage adequate fluidintake To nurse the baby regularly Treat the painfull local lesions to prevent nursing phobia Metoclopramide 10 g thrice daily, intranasal oxytocin and sulpiride ( selective dopamine intagonist) has been found to increase milk production. They act by stimulating prolactin secretion
  • 81.
  • 82.
    PREVALENCE Thrombosis of leg Thrombosisof leg vein and pelvic vein vein and pelvic vein is most common is most common However, the prevalence is less
  • 83.
    RISK FACTORS Vascular stasis Hypercoagulopathyof blood Vascular endothelial trauma Other pregnancy related factors Venous thrombo-embolic disease like.. deep vein thrombosis, thrombophlebitis, pulmonary embolism
  • 84.
    This stasis causesdamage to the endothelial cells Thrombophilias are hypercoaguable states in pregnancy that increase the risk of venous thrombosis (inheritate/ acquired)
  • 85.
    OTHER ACQUIRED RISKFACTORS Advanced age and parity Operative delivery Obesity Anemia Heart disease Infection- pevic celluitis Trauma to the venous wall Immobility and smoking
  • 86.
    DEEP VEIN THROMBOSIS Clinicaldiagnosis is unreliable. In majority it remains asymptomatic SYMPTOMS INCLUDE: Pain in the caff muscles On examination asymmentric leg edema A positive Homan's sign
  • 87.
    INVESTIGATIONS  Doppler utrasound VUS- venous utrasonography  Venography  MRI
  • 88.
    PELVIC THROMBOPHLEBITIS Originates inthe thrombosed veins at placental site by organism such as an anaerobic streptococci or bacteriosides When localised in the pelvis called pelvic thrombophlebitis. There is specific features but it is suspected when there is constatnt fever instead of antibiotics administration
  • 89.
    EXTRA PELVIC SPREAD Throughthe right ovarian vein to inferior vana cava and hence to the lungs Through left ovarian vein to left renal vein and hence to the left kidney Retrograde extension to iliofemoral veins to produce the clinical pathological entity called “phlegmasia alba dolens” ( adjacent cellulitis in femoral vein)
  • 90.
    CLINICAL FEATURES: Usually developsin second week of puerperium Mild pyrexia High grade fever with chills and rigor Constitutional disturbances like... headache, malaise, rising pulse rate Swelling, pain, white , cold over affected leg
  • 91.
    PROPHYLAXIS PREVENTIVE MEASURES: Prevention oftrauma, sepsis, anemia, dehydration Use of elastic compression stocking Leg exercise, Early ambulation
  • 92.
    MANAGEMENT Bed rest withfoot end kept higher to heart level Pain management Antibiotics Anticoagulants- Heparin- 15000 units IV followed by 10,000 units 6-8 hourly for 4 to 6 injections. up to 7 to 10 days Administartion of fibrinolytic agents Venous thrombectomy
  • 93.
    PULMONARY EMBOLISM Most leadingcause of maternal deaths Classical symptoms of massive pulmonary embolism are... Sudden collapse Acute chest pain Air hunger Death usually occurs within short time from shock and vagal inhibition
  • 94.
    Important signs...  Tachypnea Dyspnea  Pleuritis- chest pain  Cough  Tachycardia  Hemoptysis  Rise in temperature
  • 95.
    DIAGNOSIS ECG Arterial blood gas D-Dimer:value (More than 500 ng/ mL) Doppler utrasound Lung scans Pulmonary angiography Spital CT MRA: Magnetic resonance angiography
  • 96.
    MANAGEMENT Prophylactic measures Active treatment: Resuscitation:cardiac massage, oxygen therapy, heparin bolus IVof 5000 units and morphine 15 mg IV fluids Incase of recurrent .. embolectomy, placement of caval filters, ligation of inferior vana cava and ovarian veins
  • 97.
    OBSTETRIC PALSIES (Syn.POSTPARTUM TRAUMATICNEURITIS) The commonest form of obstetric palsy encountered in puerperium is... “FOOT DROP” Usually unilateral Appears shortly after delivery/ first day postpartum
  • 98.
    It is dueto stretching of the lumbosacral trunk by the prolapsed intervertebral disc between L5 and S1 Backward rotation of the sacrum during labour may also be a contributory factor Direct pressure either by fetal head or forcep blade on the lumbosacral cord or sacral plexus
  • 100.
    Condition is usuallymild May passed unnoticed Neurological examination reveals lower motor neurone type of lesions with placcidity and wasting of muscles in areas supplied by femoral nerve or lumbosacral plexus Secondary loss is always present
  • 101.
    Management of damagedlumbosacral nerve roots is same as that of the proplapsed intervertebral disc in consultation with an orthopedist Paraplegia due to epidural hematoma or abcess is rare.
  • 102.
  • 103.
    There are manyacute complications Majority of them are alarming complications Arises immediately after delivery Except pulmonary embolism
  • 104.
    Common complications are..... IMMEDIATE: –Postpartum hemorrhage –Shock –Postpartum eclapmsia –Pulmonary embolism –Inversion
  • 105.
     EARLY (WITHINA WEEK): –Acute retention of urine –Urinary tract infection –Puerperal sepsis –Breast engorgement –Mastitis and breast abcess –Pulmonary infection –Anuria following abruptio placenta, mismatched boold transfusion or eclampsia
  • 106.
     DELAYED: –Secondary postpartumhemorrhage –Thrombo-embolic manifestation –Psychosis –Postpartum cardiopathy –Postpartum hemolytic uremic syndrome
  • 107.
  • 108.
    INTRODUCTION In the first3 months after delivery, the incidence of mental illness is high. Overall incidence is about 15-20%. Sleep deprivation, hormone elevation near the end of gestation and massive postpartum withdrawal contribute to the high risk
  • 109.
    HIGH RISK FACTORS PASTHISTORY: Psychiatric illness Puerperal psychiatric illness FAMILY HISTORY: Major psychiatric illness Marital conflicts Poor social situation
  • 110.
    PRESENT PREGNANCY: Young age Cesareandelivery Difficult labour Neonatal complications OTHERS: Unmet expectations
  • 111.
    PUERPERAL BLUES It istransient state of mental illness observed 4-5 days after delivery Lasts for few days Incidence is 50 %
  • 112.
    MANIFESTATIONS ARE:  Depression Anxiety  Tearfullness  Insomnia  Helplessness  Negative feelings towards the infant  No specific metabolic or endocrine abnormalities detected  But lowered troptophan (neurotransmitor serotonin) level is observed. it indicats altered neurotransmitter function
  • 113.
  • 114.
    POSTPARTUM DEPRESSION Observed in10-20 % of mothers More gradual in onset over the first 4-6 months following delivery or abortion Changes in the hypothelamo-pitutary- adrenal axis may be a cause
  • 115.
    MANIFESTED BY: Loss ofenergy Loss of appetite Insomnia Social withdrawal Irritability Suicidal attitude Risk of reccurence is 50-100% in subsequence pregnancies
  • 116.
    TREATMENT: Is started early Fluoxentineor paroxetine (serotonin uptake inhibitors) General supportive measures
  • 117.
    POSTPARTUM PSYCHOSIS Observed in0.14-0.26 % of mothers Commonly seen in women with past history and family history Onset is relatively sudden Lasts for 4 days
  • 118.
    MANIFESTED BY: Fear Restlessness Confusion followedby hallucination, delusion and disorientation Suicidal, infanticidal impulses Temporary seperation and clinical supervision is needed Risk foe reccurence 20-25%
  • 119.
    MANAGEMENT: A psychiatrist mustbe consulted urgently Hospitalization is needed Chlopramazine 150 mg stat and 50-150 mg three time /day is started Sublingual estradiol 1 mg TDS in significant improvement Electro convulsive therapy if remains unresponsive or in depressive psychosis Lithium in manic depressive psychosis Breast feeding is restricted in case of lithium administration
  • 120.
    PSYCHOLOGICAL RESPONSES TOTHE PERINATAL DEATHS AND MANAGEMENT Most perinatal events are joyful But when a fetal /neonatal death occurs, social attention must be given to grieving parents and family It may be because of unexcpected hysterectomy, birth of malformed or chronically ill infant Prolonged seperation from chronically ill infant can also cause grief
  • 121.
    Physician, nurse andattending staff must understand patient's reaction The common maternal somatic symptoms are... Insomnnia Fatigue Sighing respiration Feeling of guilt Anger Hostility ( feeling of opposition)
  • 122.
    MANAGEMENT OF PERINATALGRIEVING Facilitating grieving process with consolation (comfort), support, sympathy Others are: 1. supporting the couple in seeing/ holding/ taking photographs of infant 2. Autopsy requests 3. Planning investigations 4. Follow up visits 5. Plan for subsequent pregnancy