Complications of peuperium

Puerperium is the period following childbirth
during which the body tissues, specially the
pelvic organs revert back approximately to
the prepregnant state both anatomically
and physiologically.

Puerperium is defined as the time from the
delivery of the placenta through the first few
weeks after the delivery. This period is
usually considered to be 6weeks in duration
6 weeks after delivery, most of the changes
of pregnancy, labor, and delivery have
resolved and the body has reverted to the
nonpregnant state.

ANATOMY AND PHYSIOLOGY IN THE
POSTPARTUM PERIOD

COMPLICATIONS OF
PUERPERIUM HEAMORRHAG
E

 Postpartum hemorrhage is defined as
excessive blood loss during or after the third
stage of labor. The average blood loss is 500
mL at vaginal delivery and 1000mL at cesarean
delivery. Objectively, postpartum hemorrhage is
defined as a 10% change in hematocrit level
between admission and the postpartum period
or the need for transfusion after delivery
secondary to blood loss

 Early postpartum hemorrhage
 Is described as that occurring within the first
24 hours after delivery.
 Late postpartum hemorrhage
 Most frequently occurs 1-2 weeks after
delivery but may occur up to
6weeks of postpartum.

 Early postpartum hemorrhageMay result
from
 Uterine atony
 Retained products of conception
 Uterine rupture
 Uterine inversion
 Placenta accreta

 Lower genital tract lacerations
 Coagulopathy, and hematoma
 Late postpartum hemorrhage
 Infection
 Subinvolution of placental site

 Coagulopathy.
 Uterine atony and lower genital tract
lacerations are the most common causes
of postpartum hemorrhage.
 Factors Predisposing to Uterine Atony
Include

 Over distension of the uterus secondary to
multiple gestations, polyhydramnios,
macrosomia,
 Rapid or prolonged labor, grand multiparity,
oxytocin administration, intra-amniotic
infection, and use of uterine-relaxing agents
such as terbutaline, magnesium sulfate,
halogenated anesthetics, or nitroglycerin.

 uterine atony, lack of closure of the spiral
arteries and venous sinuses coupled with the
increased blood flow to the pregnant uterus
causes excessive bleeding

 Active management of the third stage of
labor with administration of uterotonics
before the placenta is delivered (oxytocin still
being the agent of choice), early clamping
and cutting of the umbilical cord, and traction
on the umbilical cord have proven to reduce
blood loss and decrease the rate
of postpartum hemorrhage.

 Including cervical and vaginal lacerations
(eg, sulcal tears), are the result of obstetrical
trauma and are more common with operative
vaginal deliveries, such aswith forceps or
vacuum extraction
 Other predisposing factors include
macrosomia, precipitous delivery, and
episiotomy.

INCIDENCE
 Vaginal delivery is associated with a 3.9%
incidence of post partum hemorrhage.
Cesarean delivery is associated with a 6.4%
incidence of post partum hemorrhage.
Delayed postpartum hemorrhage occurs in
1-2% of patients.

MORBIDITY AND MORTALITY
 In the United States, postpartum
hemorrhage is responsible for 5%
of maternal deaths. Other causes of
morbidity include the need for blood
transfusions or surgical intervention that may
lead to future infertility.

 Initial therapy includes
 Provide oxygen delivery,
 Bimanual massage,
 Removal of any blood clots from the uterus,
 Empty the bladder and the routine
administration of dilute oxytocin infusion (10-
40 U in 1000mL of lactated Ringer solution
[LRS] or isotonic sodium chloride solution).

 If retained products of conception are noted,
perform manual removal or uterine curettage.
 If oxytocin is ineffective, carboprost in an
intramuscularly administered doseof 0.25 mg
can be administered every 15 minutes, not to
exceed 3 doses.
 Misoprostol has been used clinically for the
treatment of postpartumhemorrhage. However,
further research is needed to determine
theeffectiveness, optimal dosage, and route of
administration.

 W hen postpartum hemorrhage is not
responsive to pharmacological therapy
and no vaginal or cervical lacerations have
been identified, consider the following more
invasive treatment methods:
 Uterine packing is now considered safe and
effective therapy for thetreatment of
postpartum hemorrhage.

 Use prophylactic antibiotics andconcomitant
oxytocin with this technique. The timing of
removal of the packing is controversial, but
most physicians favor 24-36 hours.
Thistreatment is successful in half of
patients. If unsuccessful, it still providestime
in which the patient can be stabilized before
other surgical techniquesare employed

 Foley catheter with a large bulb(24F) can be
used as an alternative touterine packing.This
technique can be highly effective, is
inexpensive, requires no special training,
and may prevent the need for surgery.

 Uterine artery embolization, which is
performed under local anesthesia, is a
minimally invasive technique. The success
rate is greater than 90%.This procedure is
believed to preserve fertility.

 Complications are rare (6-7%) and include
fever, infection, and non target embolization.
In patients at high risk for postpartum
hemorrhage, such as those with placenta
previa placenta accreta, coagulopathy, or
cervical pregnancy, the catheter can be
placed prophylactically.

 A suture is passed through the anterior uterine
wall in the lower uterine segment approximately
3 cm medial to the lateral edge of the uterus.
 The suture is wrapped over the fundus 3±4 cm
medial to the cornual and inserted into the
posterior uterine wall again in the lower uterine
segment approximately 3 cm medial to the
lateral edge of the uterus and brought out3 cm
medial to the other edge of the uterus.

 The suture is wrapped over the fundus and
directed into and out of the anterior uterine
wall parallel to the previous anterior sutures.
The uterus is compressed in an accordion
like fashion and the suture is tied across the
lower uterine segment.

 The B-Lynch suture technique and other
compression suture techniques areoperative
approaches to postpartum hemorrhage that
have proven to preservefertility.
 As practitioners become proficient in this
technique, it may be considered before
uterine artery or hypo gastric artery ligation
and hysterectomy.

 When conservative therapy fails, the next
step is surgery with either bilateral uterine
artery ligation or hypogastric artery
ligation.
 Uterine artery ligation is thought to be
successful in 80-95% of patients.

 If this therapy fails, hypogastric artery
ligation is an option. However, this approach
is technically difficult and is only successful
in 42-50% of patients.
 Instead, stepwise devascularization of the
uterus is now thought to be the next best
approach, with possible ligation of the utero-
ovarian and In fundibulo pelvic vessels
When all other therapies fail,

 Emergency hysterectomy is often a
necessaryand lifesaving procedure.

 ASSESSMENT
 Take complete history: of past and present
obstetrical history and also identify the risk
factors of hemorrhage.
 Physical examination especially the vital signs
signs of blood loss to be assessed.
 Assess the amount of blood loss its nature,
consistency, abdominal pain
 Assess for signs of shock.


 Decreased cardiac output related
to hypovolemia
 Fluid volume deficit related to excessive blood
loss
 Altered tissue perfusion related to hypovolemia
 Pain related to procedures and treatment
 Anxiety related to separation from newborn long
term impact on self careand infant care, need
for blood transfusion.

 Risk for injury related to changes in cerebral
tissue perfusion.
 Risk for altered parent/infant attachment
related to to complication and needfor
separation from newborn during treatment.

 Administer IV fluids as quickly as possible
 Administer oxytocics to help contract the
uterus
 Administer oxygen therapy
 Place the client in a trundle burg position to
increase venous return to the heart.
 Monitor vital signs every 5-10min,, and
observe the clients color, oxygen
saturation by pulse

 oxymetry, skin temperature and sensorium.
 Palpate the fundus for firmness and
massage to restore the tone.
 Evaluate the vaginal bleeding, extent of
perineal pad saturation, colour. Consistency
of bleeding clots and pooling on the under
pad.
 Prepare for blood transfusions and
administer blood transfusions.

 Reassure the mother and family.
 Allow the family members to involve in the
care.
 Explain the physiological process of
hemorrhage and interpret medical
treatments and procedures.

 Once the bleeding controlled assist the
mother and family what happened to
understand and why to anticipate what
impact this complication will have on the post
partum while care taking and self care
activities and to plan for special needs at
home.



 A rise of temperature reaching 100 degree
F(38 degree C) or more(measured orally on
2 separate occasions at 24 hrs apart
(excluding first 24 hrs)within first 10 days
following delivery is called puerperal pyrexia.

 The causes of pyrexia are
 Puerperal sepsis
 Urinary tract infection.
 Mastitis.
 Infection of caesarean section wound.
 Pulmonary infection.
 Septic pelvic thrombophlebitis.
 A recrudescence of malaria or pulmonary
tuberculosis.
 Unknown origin

 An infection of the genital tract which occurs
as a complication of delivery is termed as
puerperal sepsis. There has been marked
decline in puerperal sepsis during the fast
few decades.

 Better obstetric care
Improved health status and there by increased
general resistance to combat infection.
 Availability of wider range of antibiotics sensitive
to the responsible organisisms
 Declined virulence of streptococcus
beta hemolyticus.Vaginal flora in late pregnancy
and at the onset of labour consists of the
following organisms

 Doderlein’s bacillus (60-70%)
 Yeast like fungus
 Staphylococcus albus or aureus
 Streptococcus
 E.coli

 Cl.welchi
 These organisms remain dormant and
harmless during pregnancy and even
delivery conducted in aseptic conditions
otherwise leads to infection

 The pathigenesity of the vaginal flora may be
influenced by certain factors
 Conditions lowering the host resistance:
 General or local
 Multiplication of organisms in the devitalized
tissue usually starts after the first two days
of following
 Introduction of organisms from out side
 Increased prevalence of organisms resistant
to antibiotics.


RISK FACTORS:
 These include as follows:
 Chronic debilitating disease
 Poor standards of hygiene
 Pre term labour

 Poor aseptic techniques
 Manipulations high in the birth canal
 Presence of dead tissue in the birth canal
(dueto prolonged retension of dead fetus

 Retained fragments of placenta or
membranes.
 Shedding of dead tissue from vaginal wall
following;
 Obstructed labour
 Insertion of unclean hand or non-sterile
instrument, packing into the birth canal
 Inadequate, or no immunization with tetanus
toxoid

 Diabetes.
 Pre-existing anaemia and malnutrition
 Prolonged/obstructed labour
 Prolonged rupture of membranes > 18 hrs
 Dehydration and ketoacidosis during labour
 Frequent vaginal examinations

 Caesarean section and other operative
deliveries
 Unrepaired cervical lacerations, or large
vaginal lacerations
 Pre-existing sexually transmitted infections
 Postpartum haemorrhage

 1. Lack of transportation and resources
needed for taking the women to are feral
facility with an adequate management of
such complications
 2. Great distance from a woman’s home to
a health facility
 3. Low socioeconomic status; inability to pay
for treatment
 4. Poor level of general education

 . Cultural factors which lead to delay in
seeking medical care
 6. Lack of knowledge about symptoms and
signs of puerperal sepsis
 7. Lack of health education, danger signs of
infection or lack of birth and emergency
preparation plan.

 Health service risk
factors: These include:
 Inaccessibility of appropriate health facilities
 Inadequate toilet and washing facilities poor
standards of cleanliness in the health facility
 Unacceptable delays in providing care at
health facility

 Lack of necessary resources, e.g. staff,
equipment, drugs (most effective antibiotics)
 Poor basic training of staff and inadequate
continuing education
 Inadequate standards of care in labor and in
the early postnatal period

 Failure to recognize the onset of infection
 Inadequate and/or delayed bacteriological
investigations
 Inadequate response to signs of infection,
including inappropriate use of antibiotic
 Shortage of safe blood for transfusion.

 THE MICROORGANISMS RESPONIBLE
FOR PUERPERAL SEPSIS
 The most common causative agents in
inflammation of the inner lining of the uterus
(endometritis) are
 Staphylococcus aureus and Streptococcus
Group A
 Streptococcus (abbreviated to GAS, or more
specifically the Streptococcus pyogenes) is a
form of Streptococcus bacteria responsible for
most cases of severe hemolytic streptococcal
illness.

 Other types (B, C, D, and G) may also cause
infection. Group B Streptococcus
(abbreviated to GBS, or more specifically
Streptococcus agalactiae) usually causes
less severe maternal disease.
 Other causal organisms, in order of
prevalence, include staphylococci, coli form
bacteria, anaerobic bacteria, Chlamydia,
Mycoplasma and very rarely, Clostridium
welchii.

 SOURCES OF INFECTION:
 Endogenous
 Exogenous
 Autogenous

PATHOLOGY:
 The primary sites of infection are
 Perineum
 Vagina
 Cervix
 Uterus.

The incidence varies from 1-3% following
vaginal delivery and about10%foliowing
cesarean delivery .It is commonly
polymicrobial (GroupA or B streptococci,
Clostridia) The decidua specially over the
placental site is primarily affected.

 The risk factors for endometritis
 Rretained products of conceptioncesarean
section
 Chorioamnionitis
 prolonged rupture of membranes
 pretermlabour
 repeated vaginal examinations in labour.

 The necrosed decidua sloughs off
 The discharge is offensive .
 A zone of leucocytic barrier prevents the
infection to the deeper myometrium.
 Severeinfection is rare in now a days.

PE LV IC CELLUIITIS(PARAMETRITI )
 Is due to spread of infection to the pelvic
cellular tissues by direct or lymphatic or by
haematogenous routes. The infection causes
exudation andformation of an indurate mass
usually confined to one side of the uterus.
Theuterus in that case is pushed to the
contra lateral side.

SALPINGITIS:
 May be interstitial, due to lymphatic spread,
or perisalpingitis following pelvic peritonitis.
Endosalpingitis is un common. Pelvic
abscess following pelvic peritonitis may be
due to spread of infection.

SEPTIC THROMBOPH LEBITIS :
 May involve the ovarian veins, uterine veins,
pelvic veins and rarely the inferior venacava
.The infected thrombus may undergo
complete resolution nand suppuration ,At
times, and emboli may occlude the micro
circulation of the vital organs like lungs or
kidney. The anaerobic pathogens are
commonly involved.

SEPTICEMIA AND SEPTIC SHOCK :
 May be due to hemolytic streptococci or
anaerobic streptococci. Septicemia may
cause lung abscess, meningitis, pericarditis,
endocarditis or multiorgan failure. Death
occurs in about 30%of cases.

CLINICAL FEATURES:
 Local infection
 Uterine infection
 Spreading infection

LOC AL INFECTION: ( WOUND INFECTION)
 There is slight rise of temperature
 Generalized malaise or headache
 The local wound becomes red and swollen
 Pus may form which leads to disruption of
the wound
 When severe there is high rise of
temperature with chills and rigor

MI LD
 There is rise in temperature and pulse rate
 Local discharge becomes offensive and
copious
 The uterus is subinvoluted and tender

SEVERE
 The onset is acute with high rise of
temperature, often with chills andrigor
 Pulse rate is rapid
 Lochia may be scanty and odourless
 Uterus may be sub involuted and tender and
softer. There may beassociated wound
infection

SPREA DING INFECTION
(EXTRA UTERINE SPREAD)
 Is evident by presence of pelvis tenderness
(pelvic peritonitis),tenderness of fornix
(parametritis), bulging fluctuant mass in the
pouch of doughlas ( pelvic abscess)

P ARAMETRITIS:
 The onset is about 7-10th day of Puerperium
Constant pelvic pain Tenderness on the
either side of the hypogastrium Vaginal
examination reveals an unilateral tender
indurate mass pushing the uterus to the
contra lateral side

PE LV IC PERITONITIS :
 Pyrexia with increase in pulse rate
 Lower abdominal pain and tenderness

 Vaginal examination reveals tenderness on
the fornix and with themovement of cervix
 Collection of the pus in the pouch of Douglas
is evident by swinging temperature, diarrhea,
and a bulging fluctuant mass felt through
the posterior fornix.

GENEAL PERITONITIS :
 High fever with rapid pulse Vomiting
Generalized abdominal pain Patient looks
very ill and dehydrated Abdomen is tender
and distended Rebound tenderness is often
present

THROMBOPHLEBITIS:
 The clinical features are similar to those of
uterine infection

SEPTICAMIA:
 There is high rise of temperature associated
with rigor Pulse rate is usually rapid even
after the temperature settles down to normal
Blood culture is positive Symptoms and
signs of metastatic infection in the lungs,
meninges or joints may appear.

BACTEREMIA, ENDOTOXICOR
SEPTIC SHOCK:
 Is due to release of bacterial endotoxin
causing circulatory inadequacy and tissue
hypo perfusion. It is manifested by
hypotension, oliguria and adult respiratory
distress syndrome.

 The underlying principles in investigations
are
 To locate the site of infection
 To identify the organisms
 To assess the severity of the disease

 Antenatal history of anemia, ante partum
hemorrhage, presence of septic foci in teeth,
and gums and tonsiis,any debilitating
disease, like heart disease, diabetes,
tubercuiosis and urinary tract infections or
malaria should be enquired

Intranatal history
 Regarding Preterm labour, duration of
rupture of membranes, number of vaginal
examinations outside and inside hospital,
duration of labour, method of delivery, nature
of intrauterine manipulations if any.

 Post natal details
 Of the nature of fever, associated symptoms
related with the site of lesion ,

Clinical examination include,
 The study of pulse and temperature chart,
neck stiffness, Systemic examination include
Throat, breasts, lungs, heart, liver, spleen,
and legs.
 Abdominal examination to note involution of
uterus, tenderness and presence of
any feature of pelvic peritonitis and pelvic
abscess.

 Internal examination to note the character of
lochia, condition of the perineal wound ,Legs
are examined to find to detect the
thrombophlebitis andthrombosis

 High vaginal and endocervical swabs for
culture and sensitivity test to antibiotics.
 CLEAN CATCH´ mid stream specimen of
urine for analysis and culture including
sensitivity test.
 Blood for Hemoglobin, total and differential
leukocyte count.
 Thick blood film for malaria parasite
 Blood urea, serum creatinine

 Serum electrolytes
 Pelvic ultra sound: to detect any retained bits
of conception within the uterus
 To locate any abscess with the pelvis
 Collecting samples from the pelvis for culture
and sensitivity
 Color flow doppler study to detect venous
thrombosis.

 CT AND MRI specially when there is doubt
 x-ray chest
 Hence for the above investigations and
monitoring, infections spreading beyond
uterus are sent to referral hospitals.

 Any fever during puerperium is assumed to
be due to puerperal sepsis unless otherwise
proved. Infection may occur in other parts of
body connected to reproductive process or it
can be incidental. They are.
 Breast infections .
 Urinary tract infections
 Incidental

 Tuberculosis.
 Typhoid
 Malaria
 Chest infection (pneumonia,
bronchitis, tuberculosis)
 Meningitis AIDS related infections,

1. PREVENTIVE: Preventive measures are
taken during antenatal, intranatal and
postnatal period against puerperal sepsis

Antenatal
 Improvement of nutritional status of
the pregnant women and eradicationof any
septic focus (skin, throat, tonsils) in the body
 Preventing tetanus by immunization against
tetanus
 Diagnosis and treatment of conditions such
as
 Malnutrition

 Anemia
 Urinary tract infection
 Diabetes mellitus
 Syphilis
 STDS.
 Preventing prolonged and obstructed labor
by diagnosis of CPD and abnormal
presentations,

 Health education for institutional delivery or
by trained personnel.
 Training of Dais in aseptic delivery
(observing 5 clean) and supplyingthem
delivery kits.

Intranatal
 All deliveries to be conducted using aseptic
techniques
 Personnel with septic focus are not allowed
in the deliveryroom or postnatal ward
 Unnecessary vaginal examinations are to be
avoided

 Unnecessary catheterization is to be
avoided,
 Avoid trauma to perineum by using correct
technique todeliver the head,
 Avoid unnecessary induction of labor by
ARM

 Suture perineal vagina! and cervical tears
and episiotomy as early as possible taking
all aseptic precautions
 Prophylactic antibiotics is to be given in
woman with premature rupture of
membranes, prolonged labor, instrumental
deliveries and intrauterine manipulations and
mothers who are undergoing caesarean
section.

2. CURATIVE:
 Except mild cases of puerperal sepsis, all
Other cases are managed inreferral
hospitals.
 GENERAL CARE:
 ANTIBIOTICS :

 PERINEAL WOUND
 HYSTERECTOMY

ASSESSMENT;
 NURSIN NURSING PLANNING AND
INTERVENTION:
 DIAGNOSES:

 Predisposing factors are;
 Grand multiparity.
 Overdistension of uterus as in twins
and hydramnios.
 Maternal ill health,
 Caesarean sectione.
 Prolapse of the uterus

 Retroversion after the uterus becomes pelvic
organg.
 Uterine fibroid
 Aggravating factors are
 Uterine sepsis
 Endometritis

 Factors that may cause sub involution
 Persistent lochia/fresh bleeding
 Long labor, anesthesia, full bladder, difficult
delivery, retained placenta,infection

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

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
loadedrectum.It feels boggy and sifter

MANAGEMENT:
 Antibiotics in endometritis
 Exploration of the uterus in retained products
 Ergometrine so often prescribed to enhance
the involution process by reducing the blood
flow of the uterus is of no value in
prophylaxis.

NURSING MANAGEMENT:
 Encourage early ambulation in postnatal
period
 Daily evaluation of fundal height and
documentation.

URINAR Y COMPLICATIONS IN
PUERPERIUM

 Retention of urine.
 Incontinence of urine
 Suppression of urine

 Breast engorgement
 Cracked and retracted nipple leading to
difficulty in breast feeding
 Mastitis
 Breast abscess
 Lactation failure

 Thrombosis of the leg veins is one of the
common and important complications in
Puerperium especially in the western
countries Venous thrombo- embolic diseases
include
 Deep vein thrombosis Thrombo phlebitis
Septic pelvic thrombo phlebitis Pulmonary
embolus.

 Acquired are due to the presence lupus
anticoagulant and
antiphospholipidantibodies.
 Other acquired risk factors for
thrombosis are;
 Advanced age and parity
 Operative delivery (10 times more)

 Obesity
 Anemia.
 Heart disease
 Infection-pelvic cellulites
 Trauma to the venous wall.

SYMPTOMS:
 Pain in the calf muscles,
 Edema legs
 Rise in skin temperature.

 On examination a symmetric leg edema
(difference in circumference between the
affected and the normal leg more than1cm)
is significant.
 A positive human’s sign pain in the calf on
dorsiflexion of the foot may be present.

DIAGNOSIS:
 Clinical diagnosis is unreliable. In majority it
remains asymptomatic.

INVESTIGATIONS:
 The following biophysical tests are
employed to confirm the diagnosis:
 Doppler ultrasound to detect changes in the
velocity of blood flow in the femoral vein.
 Venography by injecting non-ionic water
soluble radio-opaque dye to note the filling
defect in the venous lumen

 Postpartum thrombophlebitis originates in
the thrombosed veins at the placental site by
organisms such as anaerobic Streptococci or
Bacteroides (fragilis). When localized in the
pelvis, it is called pelvic thrombophlebitis
There is no specific clinical feature of pelvic
thrombophlebitis, but it should be suspected
in cases.

CLINICAL FEATURES:
 It usually develops on the second week of puerperium.
 Mild pyrexiaAt times the fever may be high with chills and
rigor.
 Evidences of constitutional disturbances such as
headache, malaise, and rising pulse rate.
 The affected leg swollen, painful, white and cold. The pain
is due to arterial spasm as a result of irritation from the
nearby thrombosed vein.
 Blood count shows polymorph nuclear leucocytosis.

DIAGNOSIS: May be made by;
 Ultrasound
 Computed tomography (CT) scan
 Magnetic resonance imaging (MRI)

 Preventive measures include:
 Prevention of trauma, sepsis, anemia in
pregnancy and labor.
 Dehydration during delivery should be avoided.
 Use of elastic compression stocking and
intermittent pneumatic compression devices
during surgery.
 Leg exercises, early ambulation are
encouraged following operative delivery.

MANAGEMENT:
 Anticoagulants

CLINICAL FEATURES; Depend on the size of
the embolus and on the preceding health
status of the patient.

CLASSIC SYMPTOMS; of massive
pulmonary embolism are
 Sudden collapse with acute chest pain and
air hunger.
 Death usually occurs within short time from
shock and vagal inhibition.
 The important signs and symptoms of
pulmonary embolism are:
 Tachypnoea

 Dyspnoe
 Pleuritic chest pain
 cough
 tachycardia
 Haemoptysis
 Rise in temperature > 37°c.

DIAGNOSIS:
 X-ray
 ECG:
 Arterial blood gas:
 Doppler ultrasound
 Lung scans:
 Pulmonary angiography

 Prophylaxis
 Active treatment includes:
 Resuscitation cardiac massage, oxygen
therapy, intravenous heparin bolus dose of
5,000 IU and morphine 15 mg (I.V.) are
started

 I.V.fluid support
 Thrombolytic therapy

 surgical treatment like embolectomy,
placement of vena caval filter or ligation of
inferior vena cava and ovarian
veins. Surgical treatment is done
following pulmonary arteriography.

OBSTETRIC PALSIES (POST
PARTUM TRAUMATIC
MASTITIS)

 Rest in bed for about 6 weeks on a suitable
mattress supported by hard board.
 A splint is applied to prevent damage of
over-stretched paralyzed muscles.
 Massage and electrical stimulation of the
muscles as early as possible.
 Active exercise is encouraged.

PUERPERAL EMERGENCIES
 There are many acute complications that may
occur during the puerperium. The majority of
the alarming complications, however, arise
immediately following delivery and except
pulmonary embolism as a consequence of
thromboembolism phenomenon, the late
complications are relatively less risky.
The complications are:

Immediate
 Postpartum hemorrhage
 Shock hypovolaemic, endotoxic or idiopathic
 Postpartum eclampsia
 Pulmonary embolism liquor amnii or air
 Inversion.

Early (within one week )
 Acute retention of urine
 Puerperal sepsis
 Breast engorgement

 Mastitis and breast abscess
 Pulmonary infection (atelectasis)
 Anuria following abruption placenta,
mismatched blood transfusion or eclampsia

Delayed
 Secondary postpartum hemorrhage
 Thromboembolism manifestation pulmonary
embolism, thrombophlebitis
 Psychosis
 Postpartum cardiomyopathy
 Postpartum hemolytic uremic syndromePsychiatric
disorders during puerperium In the first three
months after delivery, theincidence of mental illness
is high. Overall incidence is about 15-20%.


HIGH RISK FACTORS FOR POST PARTUM
MENTAL ILLNESS::
 Past history: Psychiatric illness, Puerperal
psychiatric illness.
 Family history: Major psychiatric illness,
marital conflict.
 Present pregnancy: Caesarean delivery,
difficult labor, Neonatal complications.
 Others: Unmet expectations.

PUERPERAL BLUES
 It is a transient state of mental illness
observed 4-5 days after delivery and it lasts
for few days.
 Nearly 50% of the post partum women
suffer from the problem.


MANIFESTATIONS:
 Depression
 Anxiety
 Tearfulness
 Insomnia
 Helplessness and negative feelings towards
the infant.

 No specific metabolic or endocrine
abnormalities have been detected. But
lowered tryptophan level is observed. It
suggests altered neurotransmitter function.
 Treatment is reassurance and psychological
support by the family members.

POST PARTUM DEPRESSION
 It is observed in 10-20% of mothers
 It is more gradual in onset over the first 4-6
months following delivery or abortion.
 Changes in the hypothalamo-pituitary-
adrenal axis may be a cause.

 Manifestations
 Loss of energy and appetite, insomnia,
social withdrawal, irritability and even
suicidal attitude.
 Risk of recurrence is high (50-100%) in
subsequent pregnancies.

TREATMENT :
 Treatment is started early.
 Fluoxetine or paroxetine (serotonin uptake
inhibitors) is effective and has fewer side
effects. It is safe for breast feeding also.
Estrogen patch has also been used. General
supportive measures are essential as in blues.
If no prompt response with medication,
psychiatric consultation is sought for. The
overall prognosis is good

POST PARTUM PSYCHOSIS
(SCHIZOPHRENIA)

MANAGEMENT :
 A psychiatrist must be consulted urgently.
 Admission is needed.
 Chlorpromazine 150 mg stat and 50-150 mg
three times a day is started.

 Sublingual oestradiol (1 mg thrice daily)
results in significant improvement
.Electroconvulsive therapy is considered if it
remains unresponsive or indepressive
psychosis.
 Lithium is indicated in manic depressive
psychosis. In that case breast feeding
iscontraindicated.

 Most perinatal events are joyful. But when a
fetal or neonatal death occurs special
attention must be given to the grieving
patient and her family. Perinatal grieving may
also be due to unexpected hysterectomy,
birth of a malformed or a critically ill infant.
Physician, nurse and attending staff must
understand the patient's reaction.

MANAGEMENT:
 Facilitating the grieving process, with support
and sympathy.
 Others are: Supporting the couple in seeing
or holding or tacking photographs of the
infant; autopsy requests, planning
investigations, follow up visit and plan
for subsequent pregnancy.

Complications of peuperium

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Complications of peuperium

Similar to Complications of peuperium (20)

More from sakshi rana

More from sakshi rana (19)

Recently uploaded

Recently uploaded (20)

Complications of peuperium