Coplications of Puerperium
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Transcript of Coplications of Puerperium
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Seminar oncomplications
ofPuerperium.
Submitted To: Submitted By:
Mrs. K.P. Sunandha, Ms.Mercy Parneetha. K.A
Asst. Professor, M.Sc (N) II year
Obstetric and gynaecological OBG Nursing,
Nursing Department, J.M.J College of Nursing.
J.M.J College of Nursing.
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Name of the Guide : Mrs. K.P. Sunandha
Name of the Student : Ms. Mercy Parneetha. K.A.
Class : M.sc. (Nursing) II Year
Subject : Obstetrics and gynaecological nursing
Unit : IV
Name of the topic : Complication
Of Puerperium.
Group : M.Sc (N) Students
Place : M.Sc (N) Class room
Date : 27.02.2012
Time : 2:00pm to 4:00pm.
Method of Teaching : Lecture cum Discussion.
A. V aids : Black Board, Transparency, Power point, Pull chart,
Strip tease, Bulletin Board.
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General Objectives:
By the end of the class, the students acquire in-depth knowledge
regarding the complications of puerperium, appreciate the physical and
physiological changes in puerperium and develop skills in taking care of the
mother with any of the complications.
Specific Objectives:
By the end of the class, the students will be able to
define puerperium.
describe the postpartum complications principles.
enumerate the most postpartum complications.
explain the postpartum complications.
Perineal Rupture
Uterine and Vaginal Rupture
Post Parturient Uterine Atony
Post Parturient straining Bacterial Puerperal Infection
Postpartum Haemorrhage
Postpartum Endometritis
Postpartum Cardiomyopathy
Postpartum thyroiditis
Postpartum Depression.
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Introduction:
The Postpartum period, also known as the puerperium, begins with the
delivery of the baby and placenta. The end of the Postpartum period is less well
defined, but is often considered the 6-8 weeks after delivery because the effectsof pregnancy on many systems have resolved by this time and these systems
have largely returned to their pre- pregnant state.
Health care providers should be aware of the medical and psychological
needs of the postpartum mothers and sensitive to cultural differences that
surround child birth.
Definition:
Puerperium- a period from the expulsion of the placenta until 6-8 weeksafter birth, during which time the uterus and other organs and systems
return to their pre pregnant state and lactation is initiated. Many changes take place within the first 10-14 days. Role changes.
(or)
Period of confinement during and just after birth
includes 6 subsequent weeks postpartum during which normal pregnancy
involution occurs.
(or)
Involution is the process whereby the genital organs revert backapproximately to the state as they were before pregnancy.
Duration:
Puerperium begins as soon as the placenta is expelled and lasts for
approximately 6 weeks when the uterus becomes regressed almost to the non-
pregnant size.The period is arbitrarily divided into-
a) immediately within 7 daysb) early upto 6 weeksc) remote- upto 6 weeks.
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Postpartum Complications: Principles
The most frequent cause of postpartum hemorrhage is uterine atony.
Anything that over distends the uterus causes it to contract poorly or
overworks the uterus is a set-up for uterine atony.
Postpartum Complications
Most important postpartum complications
1. Perineal rupture
2. Retained placenta
3. Uterine prolapse
4. Uterine and vaginal rupture5. Post parturient paraplegia
6. Post parturient uterine atony
7. Post parturient straining
8. Bacterial puerperal diseases9. Puerperal intoxication
10. Puerperal infection
11. Septic metritis
12. Puerperal tetani
13. Puerperal vaginitis and vulvitis
1. Perineal Rupture
Causes :1. Spontaneous, during the second stage of labor (vigorous straining)
2. Extreme traction of an oversized fetus
3. Predisposition include a hypoplastic vulva
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Surgical correction:
1. Cleaning the perineal region
2. Light epidural anesthesia
3.Exposure the operative area by placing tension suture in the perineal skin
4. The free edge of the shelf is incised to a depth of 3 cm and extended laterally
and caudally on each side
5. Synthetic non-absorbable suture and a No. 2 or 3 half circle cutting edge
needle are used in the modified vertical suture pattern, starting at the deepest
part.
6. The two ends of each suture are left long (8 cm) and are tied together at their
ends to aid in identification of each knot during removal.
7. The suture must not penetrate the rectal mucosa.
8. The perineal skin is closed with vertical mattress suture.
2. Uterine and vaginal Rupture:Causes
1. Prolonged dystocia with fetal emphysema2. Uterine torsion
3. Improper manipulation and traction of the fetus
4. Forced traction of the fetus in abnormal p.p.p.
5. Fatigue of the operator
6. Poorly dilated cervix7. Administration of oxytocin while the cervix is closed.
TreatmentIn small uterine rupture
Repeated doses of oxytocin
Parental and intrauterine AntibioticFluid therapy
Close observation of the client.
In large uterine rupture
o Suturing the uterus through the birth wayo Prolapsing the ruptured uterus and suturing ito Suturing the uterus through laparotomy
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3. Postparturient Uterine Atony
The uterus is abnormally large, roomy, flabby and without contraction directly
after birth
Causes: Uterine inertia (primary and secondary) Over-thinning of the uterus (twins, hydropsy) Rupture of the uterus or cervix Hypocalcaemia
Clinical findings:
In rectal examination, the uterus found descended in the abdominalcavity, the uterus lack any contraction and filled with lochia.
The cervix is dilated with small amount of lochia discharged from thevulva.
Secondary retention of placenta
Treatment:Oxytocin: 50-100 IU, within 24h after birth
Methergin: 5-10 mg i.m.
Calcium gluconate
Local and systemic antibiotic
4. Postparturient Straining
There is a persistent strong uterine birth pains for one or more day after birth
Causes:
There is irritant to the vagina or vulva Long standing dystocia
Bleeding from the genital tract
Symptoms The pains may persist for 4-7 days after birthContinuous or intermittent straining, arched back, sunken eyes and
depression.
Frequent defection, diarrhea. There is great tendency for prolapse of the vagina or rectum. Uterine contractions are stronger
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Treatment
General sedativeEpidural anesthesia
Local antibiotic within the uterusTreat the original cause
5. Bacterial puerperal Infection
Disease:Puerperal bacterial intoxication
Cause: Saprophytic bacteria
Pathogenesis: Putrifaction of the uterine contents produces toxins which
absorbed through the uterine endometrium to circulate in the blood with
general intoxication.Symptom: Fever, indigestion, exhaustion, little edema in the genital tract,
abnormal lochiaTreatment: Local antibiotic, Oxytocin, Siphoning the uterus, Supportive
treatment, Antihistaminic, Calcium gluconate, Systemic antibiotic, Epidural
Anesthesia.
Disease: Puerperal bacterial infection
Cause: Saprophytic bacteria
Pathogenesis: Bacterial activities are intensive. Bacteria tend to act locally
in the uterusSymptom: Fever, Depression, edema of the soft birth way, abdomen is tenseTreatment: same treatment
Disease: Septic metritis
Cause: Coliform , Streptococci and Micrococcus
Pathogenesis: The difficult form of the non-specific Puerperal infectionSymptom: Fever, reddish watery vulval discharge, peritonitis, arthritis.Treatment: same treatment.
Disease:Puerperal necrosisCause: NechrophorumPathogenesis: Necrotic bacteria get entrance to the uterus from the cervix.
Symptom: General health disturbances, liver painful no palpation, the
mucus membrane is yellowish.Treatment: Local and systemic Antibiotic, supportive treatment
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Disease:Puerperal tetanusCause: Cl. tetaniPathogenesis: m.o. enter the uterus through injury in the endometrium.Symptom: Muscular cramps and stiffness.
Treatment: Anti-tetanic serum, supportive treatment.
Disease: vaginitis and vulvitis
Cause: Saprophytic Bacteria, Nechrophorum.Pathogenesis: Narrow birth way result in trauma and laceration + m.o.Symptom: Swollen vulva and vagina.
Treatment: Oily bland antiseptic Antibiotic, Epidural
Anesthesia.
6.
Postpartum Hemorrhage
Obstetrical emergency that can follow vaginal or cesarean deliveryIncidence3% of births
3rd
most common cause of maternal death in US
Definition Excessive bleeding that makes the patient symptomatic
(lightheaded, syncope) and/or results in signs of hypovolemia(hypotension, tachycardia, oliguria)
(or)
A blood loss that exceeds 500 ml after a vaginal birth or 1,000mlafter a cesarean birth.
Early Postpartum Hemorrhage blood loss in the first 24 hrs afterchildbirth.
Late Postpartum Hemorrhageoccurs after the first 24 hrs.
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Causes of Postpartum Hemorrhage
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TToonnee AAttoonniicc uutteerruuss 7700
TTrraauummaa
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2200
TTiissssuuee
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1100
TThhrroommbbiinn CCooaagguullooppaatthhyy 11
Risk Factors
Prolonged 3rd stage of labor
Fibroids, placenta previa Previous PPH Over distended uterus Episiotomy Use of magnesium sulfate, preeclampsia Induction or augmentation of labor
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Management
Swift execution of a sequence of interventions with prompt assessment of
response
Initial steps Fundal massage ABCs, O2, IV access with 16g catheters
Infuse crystalloid; transfuse blood products as needed Examine genital tract, inspect placenta, observe clotting Give uterotonic drugs
Oxytocin 20 IU per L of NS
Methylergonovine (Methergine) 0.2mg IM q2-4h
Misoprostol 800 or 1000mg PR
Secondary steps Will likely require regional or general anesthesia Evaluate vagina and cervix for lacerations Manually explore uterus
Treatment options
Repair lacerations with running locked absorbable suture Tamponade Arterial embolization Laparotomy
uterine vessel ligation Hysterectomy
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Bimanual uterine compression massage is performed by placing one hand
in the vagina and pushing against the body of the uterus while the other
hand compresses the fundus from above through the abdominal wall. The
posterior aspect of the uterus is massaged with the abdominal hand and
the anterior aspect with the vaginal hand.
Preventive Measures
correcting anemia prior to delivery.
episiotomies only if necessary.
active management of third stage.
assess patient after completion of paper work to detect slow steady
bleeds.
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Management of Postpartum Hemorrhage
7. Postpartum Endometritis
Infection of the deciduas (pregnancy endometrium)
Incidence
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Fevermost common sign Uterine tenderness Foul lochia Leukocytosis
Bacteremiain 10-20%, usually a single organism
Workup CBC Blood cultures Urine culture DNA probe / Chlamydia Imaging studies if no response to adequate in 48-72h
CT scan abd/pelvis
US abd/pelvis
Treatment Broad spectrum IV
Clindamycin 900mg IV q8h and
Gentamycin 1.5mg/kg IV q8h Treat until afebrile for 24-48h and clinically improved; oral therapy
not necessary Add ampicillin 2g IV q4h to regimen when not improving to cover
resistant enterococci
Prevention prophylaxis for women undergoing C-section
Cefazolin 1-2g IV as single dose
8. Postpartum Thyroiditis
A variant form of Hashimotos thyroiditis occurring within 1 year after
parturition
Incidence3-16% of postpartum women
Up to 25% in women with Type 1 DMThyroid inflammation damages follicles proteolysis of thyroglobulin release of T3 + T4 TSH suppression.
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Clinical manifestations 20-30%
Hyperthyroidism 2-4 mos pp, lasting 2-8 wks, followed by
hypothyroidism, lasting 2-8 wks, then recovery
20-40%Hyperthyroidism only 40-50%
Hypothyroidism only, beginning 2-6 mos pp
Symptoms and signs, when present, are mild
HyperthyroidismAnxiety, weakness, irritability, palpitations, tachycardia,
tremor Hypothyroidism
Lack of energy, sluggishness, dry skin
Diagnosis Small, diffuse, nontender goiter or normal exam High or high normal T3 + T4, low TSH, low radioiodine uptake
(hyper phase) Low or low normal T4, high TSH (hypo phase)
65-85% have high antithyroidTreatment Most need no treatment.
Hyper: atenolol or propanolol
Avoid in nursing womenHypo: levothyroxine 50-100 mcg qd for 8-12 wks.
Educate patient on sex, increased risk of developing
hypothyroidism or goiter, likely recurrence with subsequentpregnancies
9. Postpartum Depression
Most common complication
Occurs in 13% (1 in 8) of women after pregnancy Recurs in 1 in 4 with prior depression Begins within 4 weeks after delivery
Multifactorial etiology
Rapid decline in hormones, genetic susceptibility, life stressorsRisk Factors
Prior h/o depression, family h/o mood disorders, stressful lifeevents
Pattern of sex are similar to other episodes of depression
Depressed mood, anxiety, loss of appetite, sleep disturbance,fatigue, guilt, decreased concentration
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Must be present most of the day nearly every day for 2 wks.Screening
Edinburgh Postnatal Depression Scale + screen with score >/= 10
Check for anemia and thyroid diseaseDifferential Diagnosis Baby Bluescommon, transient mood disturbance
Sadness, weeping, irritability, anxiety, and confusion
Occurs in 40 - 80% of postpartum women. Postpartum psychosis
Psychiatric emergency due to risk of infanticide or suicide
Bizarre behavior, disorganization of thought, hallucinations,
delusions
usually occurs in first 2 weeks of pp
TreatmentInitiate at half the usual starting dose
Treat for at least 612 months after full remission to
prevent relapse
Sertraline or paroxetine for breast-feeding mothers May also respond to psychotherapy Hormonal therapy
Patient resources
National Womens Health Info Center(www.4woman.gov) www.depressionafterdelivery.com
Blues:
Most common perinatal mood disturbance Prevalence: 30-75% Onset day 3 or 4 Mild, transient lasting hours to days Resolve within 2 weeks
No treatment necessary
Postpartum Psychosis
Most rare and severe form of postpartum mood disorder Prevalence: 0.01-0.02% Onset: rapid, within 72 hours of birth, 95% of cases within 2 weeks Treatment: Psychiatric Emergency, Psychiatristtreatment with
medication.
http://www.4woman.gov/http://www.4woman.gov/http://www.4woman.gov/http://www.depressionafterdelivery.com/http://www.depressionafterdelivery.com/http://www.depressionafterdelivery.com/http://www.4woman.gov/ -
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Postpartum Psychiatric Disorders
Disorder Prevalence Onset Duration Treatment
Blues 30-75% Day 3 or 4 Several days None
Postpartum
Depression
10 15% Within weeks Weeks
Months
Treatment by GP or psychiatrist
Postpartum Psychosis 0.01
0.02%
Within 2
weeks
Weeks
months
Psychiatric emergency
Hospitalization required
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Subinvolution of uterus:
Description Incomplete involution or failure of the uterus to return to its normal
size and conditionCause
InfectionRetained placenta fragments
Assessment Uterine pain on palpation Uterus is larger than expected Fundus is higher in the abdomen Greater than normal vaginal bleeding Lochia does not follow normal pattern i.e.:
RUBRASEROSA -- RUBRA Backache
Leucorrhea if infection (white, creamy discharge)
TreatmentMethergin 0.2 mg Q3-4H PO for 24-48 hours Antibiotics Possibly D&C
Nursing interventionsMedications as ordered Assessment of fundus Safety and comfort needs
Mastitis:
Description Inflammation of the breast as a result of infection Primarily seen in breast-feeding mothers 2 to 4 weeks after
delivery
Cause Staph aureus Hemolytic strep How it is transmitted:
Babys nose and throatMothers or health care providers hands Cracked nipples
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Assessment Localized heat and swelling Pain: redness, warmth and firm to touch with areas of lumpiness Elevated temperature and chills
Tachycardia Headache Complaints of flu-like symptoms
Intervention: Promote comfort of the client Instruct mother in good hand-washing and breast hygiene Apply heat to enhance inflammatory process (kill microbes)Maintain lactation in breast-feeding mothers Encourage manual expression of breast milk or use of breast pump
every 4 hoursREMEMBER, during EARLY stages of mastitis, the mother is
encouraged to breast-feed DIRECTLY Encourage mother to support breasts with supportive bra Administer analgesics as prescribed Administer antibiotics as prescribed Possibly I&D
Conclusion:
During pregnancy and Postpartum, changes occur in the circulating blood
volume, peripheral vascular compliance and resistance, myocardial function,heart rate and the neuro hormonal system. These changes allow the
cardiovascular system to meet the increased metabolic changes demands of
pregnancy.
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BIBLIOGRAPY:
Lowdermilk,perry and Bobak, maternity &womens health care, 6 thedition, 1997, mosby, inc., st. Louis, missori, pg no: 358-367.
Donna L.Wong &Shannon E. Perry, maternal & child nursing care,1998,Mosby, Inc, St.Louis,pg no546-574.James DK, PJ steer & etal, High Risk pregnancy management, 2nd
edition.2001, WB Saun ders, China, pg no. 667-687.D.C Dutta, Text book of obstetrics including perinatology &
contraception, 6th
edition, New central book agency, Pg no. 543-567.
Kamini Rao, Textbook of midwifery & obstetrics for nurses, 1st edition,New Delhi,pg no.276-297.
Diane M. Fraber, Myles Text book for Midwives, 15 the edition, Elsevier, pg no. 98-130.
www.encyclopedia.com
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