Postpartum complications-postpartum psychiatric complications, breast complications

1. Postpartum complications
Monisha U
Lecturer
Amrita College of Nursing,AIMS,Kochi

2. Postpartum psychiatric
disorders

3. • In the first 3 months after
delivery,incidence of mental
illness is high
• Overall incidence is 15-20%

4. Etology
• Changes in hormones levels
• History of depression
• Emotional factors
• Fatigue
• Life style factors

5. Risk factors of postpartum
mental illness
• Past history-psychiatric
illness,puerperial psychiatric illness
• Family history-major psychiatric
illness,marital conflit,poor social
situation
• Present pregnancy-young
age,CS,difficuilt labor,neonatal
complications
• Unmet expectations

6. D
Postpartum Mood Disorders
Postpartum Blues/Baby blues
Postpartum Depression (PPD)
Postpartum Psychosis (PPP)

7. Postpartum Blues
• Observed on 4-5 days of delivery and
last for few days
• Nearly 50% suffer from this problem
• Symptoms resolve within 2 weeks

8. Postpartum Blues-“baby blues”
Characteristics:
• Mild mood swings ,depression
• Irritability ,helplessness
• Anxiety ,negative feeling towards
infant
• Decreased concentration
• Insomnia
• Tearfulness
• Crying spells

9. Treatment
• Reassurance
• Psychological support by family
members

10. Postpartum depression
• Obseved in 10-20% mothers
• Gradual in onset over the first 4 months
following delivery or abortion
• Manifestations-loss of energy and
appetite,insomnia,social
withdrawal,irritability,suiciadal attitude
• Risk of recurrence is high

11. Treatment
• Fluoxetine or paroxetine is effective,safe
for breast feeding also
• Oestrogen patch has been used
• General supportive meaures
• Overall prognosis is good

12. Postpartum
psychosis(schizophrenia)
• Observed in 0.14%-0.26% of mothers
• Commondly seen in women with past
history of psychosis or with positive
family history
• Onset is sudden within 4 days of delivery
• Risk of recurrence in subsequent
pregnancy is 20-25%

13. Manifestations
• Fear
• Restlessness
• Confusion followed by
hallucianations,delusions and
disorientation(usually mainc or
depressive)
• Suicidal,infanticidal impulses

14. Management
• Psychiatric consultation
• Hospitalization
• Chlorpromazine 150mg stat and 50-150mg
tds/day
• Sublingual estradiol 1mg thrice daily
• ECT is considered in depressive psychosis
• Lithium is indicated in manic depressive
psychosis(breast feeding is contraindicated)

15. Postpartum breast complications
1.Breast engorgement
2.Cracked nipple
3.Retracted nipple
4.Mastitis
5.Breast abscess
6.Lactation failure

16. Breast engorgement
• Painful overfilling of breast with milk
• Onset-3rd or 4th postpartum
• The three basic components of breast
engorgement are
1.congestion/increased vascularization
2.accumulation of milk
3. edema caused by the congestion and
obstruction of lymphatic drainage.

17. • milk retention in the alveoli alveolar
distension duct compression ® milk
flow obstruction deterioration of
alveolar distension increased
obstruction.

18. Symptoms
• Pain
• Feeling heaviness
• Generalised malaise
• Rise in temperature
• Painfull breast feeding

19. Prevention
– start nursing as soon as possible;
– breastfeed on demand;
– use a proper breastfeeding
technique;
– avoid the use of supplements.

20. Treatment
– if the areola is engorged, manually
express some milk before breastfeeding, so
that the areola gets soft enough for the baby
to grasp it properly;
– breastfeed on demand on a regular basis;
– massage the breasts gently – this is
important to fluidify the viscous milk and
to stimulate the let-down reflex;

21. – use systemic analgesics/anti-inflammatory
drugs.
Ibuprofen is regarded as most efficient, and it
also helps to reduce inflammation and edema.
Paracetamol can be used as an alternative

22. • apply cold compresses after or between
breastfeeding to reduce edema, vascularization
and pain
• apply warm compresses to help the ejection of
the milk;

23. Cracked nipple
• caused by improper positioning and
inappropriate latch-on.

24. Prevention
• use a proper breastfeeding technique;
• keep the nipples dry by exposing them to
air or sunlight and change the nursing
pads used to prevent milk flow, on a
regular basis;
• avoid products that remove the natural
protection of nipples, such as soaps,
alcohol or any drying agent;

25. • breastfeed on demand
• – manually express milk from the areola
before breastfeeding if it is engorged

26. • – if a feeding has to be discontinued, slip
the index or little finger into the infant's
mouth between his/her gums to break
suction before the infant is taken off of
the breast;
• – avoid the use of nipple shields.

27. Treatment
• offer the least affected breast first;
• – express enough milk before breastfeeding
to stimulate the let-down reflex, thus
preventing the infant from sucking too
vigorously on the breast;
• – alternate between different positions,
reducing the pressure on sore areas or on
damaged tissues;
• – use oral systemic analgesics, if necessary.

28. Mastitis
• Mastitis is an inflammatory process of
one or more breast segments (the upper
left quadrant is most commonly affected)
that may or may not progress into
bacterial infection. It usually occurs in
the second and third weeks after delivery,
and very rarely, after the twelfth week

29. Treatment
• Proper emptying of the breast
• Antibiotic therapy is indicated in the presence
of the following criteria: (1) cell and colony
count and milk culture indicating infection; (2)
severe symptoms right from the beginning; (3)
visible nipple crack; and (4) persistence of
symptoms after 12 to 24 hours of the effective
removal of the accumulated milk.

30. • Amoxicillin, cephalosporins, clindamycin
or erythromycin) are the antibiotics of
choice, for 10 to 14 days.
• Besides antibiotic therapy and complete
emptying of the affected breast
• maternal rest (preferably in bed),
• analgesics or non-steroidal anti-
inflammatory drugs such as ibuprofen,
• abundant intake of fluids.

31. Breast abscess
• Breast abscess is caused by untreated
mastitis or results from late or inefficient
treatment.

32. • Warm compresses before feedings can
help drain the milk, whereas cold
compresses after feedings or short
intervals help relieve the symptoms.
• If no improvement is obtained within 48
hours, the presence of breast abscess
should be investigated.

33. Retracted nipple
• A retracted nipple is a nipple that turns
inward instead of outward, except when
stimulated. This type of nippleis
sometimes referred to as an
inverted nipple.

34. Lactation failure
• Causes-infrequent sucking
• Depression or anxiety in puerperium
• Reluctance or apprehension to nursing
• Ill development of nipple
• Painful breast lesion
• Endogenous suppression of prolactin

35. Treatment
• Antenatal-council the mother reagarding
advantages of breast feeding,take care of any
breast abnormality specially retracted nipple
• Puerperium-adequate fluid intake,nurse the
baby regularly,painful local lesion to be treated
• Metoclopramaide 10mg TID,intranasl
oxytocin,sulpiride(selective dopamine
antagonist) can use

36. Subinvolution
• When involution is impared or retracted
is called subinvolution.
• Causes
• Predisposing factors-
grandmultiparity,overdistention of uterus
as in twins,maternal ill
health,LSCS,prolapse of
uterus,reteroversion after the uterus
become pelvic organ,uterine fibroid

37. • Aggravating factors-retained products
of conception,uterine sepsis.
• Symptoms-abnormal lochial
discharge,irregular excessive
bleeding,irregular cramps like pain,rise in
temperature as in sepsis.

38. • Signs-Uterine height is greater than
normal,feels soft and boggy
• Management-Antibiotics in
endometritis,exploration of uterus in
retained products,pessary in prolapse or
retroversion

39. Puerperal pyrexia
• A rise in temperature reaching 100.4
F(38C) or more(measured orally) on 2
seprate occasions at 24 hours
apart(excluding first 24 hours)with in
first 10 days following delivery called
puerperal pyrexia.

40. Causes
• Puerperal sepsis
• UTI(cystitis,pyelonephritis)
• Mastitis
• Infection of CS wound
• Pulmonary infection
• Septic pelvic thrombophlebitis
• Unknown origin

41. Puerperal sepsis/infection
• Infection of the genital tract which occurs
as a complication of delivery called
puerperal sepsis.

42. Predisposing factors
• Cervicomucus membrane damaged in
normal delivery
• Placental surface injury
• Blood clots present at placental site
• Antepartum factors-malnutrition and
anemia,preterm labour,PROM,chronic
debiliatating illness,prolonged rupture of
membrane >18 hours.

43. • Intrapartum factors-repeated vaginla
examinations,prolonged rupture of
membranes>18 hrs,dehydration,traumatic
operative delivery,hemorrhage-
antepartum/postpartum,retained bits of
placenta or membranes,placenta
praevia,LSCS

44. Microorganisms responsible
• Aerobic-Streptococcus haeemolyticus Group
A,Staphylococcus aureus,E-
coli,Klebsiella,Pseudomonas,Chlamydia,Staph
ylococcus pyogenes.
• Anaerobic-
Streptococcus,Peptococcus,Bacteroids,Clostri
dia.

45. Clinical features
• Local infection-
• slight raise in temperature, generalized
malaise and headache.
• Redness and the swelling of the local wound
• Pus formation and disruption of wound
• Uterine infection-
• Pyrexia of variable degree and tachycardia.
• Red, copius and offensive lochia.
• Subinvoluted, tender and soft uterus.

46. • Sever infection-
• Fever with chills and rigor
• Rapid pulse
• Scanty, odorless lochia
• Involuted uterus

47. • Parametritis-
• Sustained rise in temperature (7th to 10th day)
• Constant pelvic pain
• Tenderness on either side of the hypogastrium
• Unilateral, tender mass felt on vaginal
examination
• leukocytosis

48. • Pelvic peritonitis:-
• Pyrexia with increased pulse rate
• Lower abdominal pain and tenderness
• Collection of the pus in pouch of douglas

49. • Generalised peritonitis:-
• High fever with rapid pulse
• Vomiting
• Abdominal pain
• Tender and distended abdomen
• Thrombophelebitis –
• swinging fever with chills and rigor
• Features of pyemia

50. • Septicemia-
• High temperature with rigor
• Rapid pulse
• Headache, insomnia or mental confusion
• Positive blood culture
• Sign/symptoms of infection in the lungs,
• meninges or joint

51. Investigations
• Bacteriological study-
• Smear
• Culture and antibiotic sensitivity of
purulent material
• High vaginal and cervial swabs
• Peritoneal fluids
• Blood culture

52. • Urine :-
• Routine and microscopic examination
• Culture if infection is suspected
• Complete blood count-
• Ultrasonography-
• For diagnosis of pelvic masses
• Pelvic abscess
• Pelvic peritonitis
• Retained bits of placenta and/ or
membrane

53. Prevention
• Antenatal
• Improvement of general condition
• Treatment of septic cocci
• Abstinence from sexual intercourse in the last
two months
• Care about personal hygiene – bathing in dirty
water to be avoided
• Avoiding contact with people having infection,
such as cold, boils.
• Avoiding unnecessary vaginal examinations in
the later months.

54. • Intrapartum
• Staff attending on labor client should be
free of infections.
• Full surgical asepsis to be taken while
conducting delivery
• Women having respiratory tract infection
or skin infection should be admitted in
single room or separate ward

55. • Membranes should be kept intact as long
as possible and vaginal examination
should be restricted to minimum
• Traumatic vaginal delivery and
intrauterine manipulation should be
preferably avoided. If required should be
done using fresh (sterile) gloves with
liberal use of strong antiseptic solution.
• Laceration of the genital tract should be
repaired promptly and meticulously with
perfect homeostasis

56. • Excessive blood loss during delivery
should be replaced promptly by
transfusion to improve the general body
resistance
• Prophylactic antibiotic must be
administered in cases of premature
rupture of membranes, prolonged labor or
following traumatic delivery.

57. • Postpartum
• Take aseptic precautions while dressing
the perineal wound
• Restriction of the visitor in the
postpartum ward
• Mothers to be instructed to use sterile
sanitary pads and to change them
frequently

58. • Vulva and perineum to be cleaned with
mild antiseptic solution following
urination and defecation
• Infected mothers and babies are to be
isolated
• To keep the floor of the inpatient ward
dust free by frequent mopping.

59. Treatment
• The woman should be placed in sterile
room/ward with adequate light and
ventilation
• Complete rest is to be given in head high
position which help in drainage of lochia
and localization of infection to the pelvis
if there is pelvic peritonitis
• Analgesics and sedatives are
administered to enforce rest

60. • Broad spectrum antibiotics are given IV
until antibiotic sensitivity report are
available,followed by specific antibiotics.
• Stool softeners are administered to keep
the keep the bowel open
• Anemia to be corrected by blood
transfusion

61. • Infected wound of perineum vulva and vagina
are laid open for drainage, cleaned and
dressed with antiseptic preparation.

62. Surgical management
• The stitches of the perineal wound may
have to be removed to facilitate drainage
of pus and relieve pain.
• After the infection is controlled,
secondary sutures may be given later.
• Infected retained product should be
removed as early as possible under cover
of antibiotics .

63. UTI
• It is an infection of the urinary organs
such as kidney, ureter, urinary bladder
and urethra

64. Causative organisms
• E. coli
• Klebsiella
• Proteus
• Staphylococcus aureus

65. Other causes
• Recurrence of previous cystitis and
pyelitis
• Infection contracted for the first time
during pregnancy is due to :-
• Effect of frequent catheterization either
during labor or in early puerperium to
relative retention of urine.

66. • Stasis of urine during early puerperium due to
lack of bladder tone and less desire to pass
urine.

67. Incidence
• It is one of the common cause of
puerperal pyrexia, the incidence being 1-
5 % of all deliveries

68. Clinical features
• Raised temperature ( pyrexia)
• Costovertebral angle pain
• Supra pubic discomfort
• Frequent and often painful micturation
• Nausea and vomiting

69. Diagnosis
• UTI is confirmed by examination of an
uncontaminated midstream clean catch
sample for urinalysis and culture and
antibiotic sensitivity test.

70. Management
• High fluid intake
• Adequate drainage of urine
• Appropriate antimicrobial therapy.

71. Postpartum hemorrhage
• PPH is a condition in which excessive
bleeding from the genital tract at any time
following the baby’s birth up to 6 weeks after
delivery.
• Hemorrhage may occur before, during, or after
delivery of the placenta.
• • The average blood loss following vaginal
delivery,cesarean delivery and cesarean
hysterectomy is 500 ml, 1000 ml and 1500 ml
respectively.

72. Definition
• Any amount of bleeding from or into the
genital tract following birth of the baby
up to the end of the puerperium, which
adversely affects the general condition of
the mother, evidenced by increase in
pulse rate and falling blood pressure is
called postpartum hemorrhage”

75. Venous thrombo embolism(VTE)
during puerperium
• Last trimester and immediate postpartum
were considered the highest risk periods
for deep vein thrombosis (DVT) and
pulmonary embolism (PE) and
thrombophlebitis(superficial and deep)

76. DVT
• Symptoms
• Pain on calf muscles
• Edema legs
• Rise in skin temperature
• On examination asymmetric leg edema
• Positive Homans sign

77. Investigations
• Doppler USG
• Venography
• MRI

78. Prevention
• Prevention of trauma,sepsis and anemia
• Dehydration during labor to be avoided
• Use of elastic compression
stockings,intermittent compression
devices
• Leg exercises,early ambulation

79. Management-Goals
• Arrest of the growth of the thrombus
• prevention of pulmonary embolization

80. Management
• To put the patient to bedrest with the foot
end raised above heart level
• Pain on affected area may be relieved by
analgesics
• Appropriate antibiotics to be
administered
• Anticoagulants-Heparin 15000units
administerd IV followed by 10000
units,4-6 hourly for 4-6 injections.

81. • Heparin is continued for at least 7-10
days or even longer if thrombosis is
severe.

82. Pulmonary embolism
• Classical symptoms-sudden collapse
with acute chest pain and air hunger,
death occurs with in short time from
shock and vagal inhibition
• Important symptoms-
tachypnea,dysponea,pleuritic chest
pain,cough,tachycardia,hemoptysis,rise in
temperature

83. Diagnosis
• X ray
• ECG
• ABG
• D-dimer
• Doppler USG
• Lung scans
• Pulmonary angiography
• Spiral CT pulmonary angiography
• MRA

84. Treatment
• Active treatment
• 1.Resusciation-cardiac massage,oxygen
therapy,IV heparin bolus dose of 5000IU
and morphine 15mg IV started.Heparin
therapy to be continued up to
40000IU/day so as to maintain the
clotting time to over 12 minutes for the
first 48 hours.

85. • 2.IV fluid support-is continued and BP
is maintained if needed by dopamine and
adrenaline
• 3.Tachycardia treated by digitalis
• Recurrent attacks of pulmonary
embolism needs surgical treatment like
embolectomy,placement of caval
filter,ligation of inferior venacava