POST NATAL CARE.

DR. MAHESWARI JAIKUMAR.

DEF : Post Natal period or PUERPERIUM begins after the third stage of labor till first 6 wks following the delivery.

POST NATAL VISIT.

ADVICE THE MOTHER AS FOLLOWS.

At least two post natal visit are must.

First visit – within two days of delivery

First visit – within two days of delivery.

Second visit – six wks of delivery.

AIMS OF FIRST VISIT.

OBTAIN HISTORY ON :

Delivery.

Bowel & Bladder functions.

Sleep.

Lactation.

Any ailment.

GENERAL EXAMINATIOIN --- FIRST VISIT.

FOR,

Fever.

Anemia.

Breast.

Uterus.

Lochia.

TPR,Bp, Pallor on examination.

SPECIFIC EXAMINATION.NOTE THE SIZE OF THE UTERUS & RECORD AS FOLLOWS.

N Wk/day Involution Y N Sig

1 Immediately following the delivery

At 20 wks of preg.

2 24 hrs In the same position.

3 2-3 days Comes below at the rate of 1 inch/day

4 3-6 days Comes at the rate of ½ an inch /day.

5 7-10 days Descends beneath symphysis pubis & enters pelvic cavity

6 Within 6 wks.

Ut remains its original size.

INFERENCE.

NORMAL INVOLUTION/ SUB INVOLUTION.

Note the colour & smell of Lochia.

Examine Episiotomy for healing process.

Look for s/s of fever, tachycardia, breast complaints, pain abdomen, fullness of abdomen, foul smelling discharge, sub involution of the uterus & manage appropriately.

AIMS OF SECOND POST NATAL VISIT.

Study the involution of the uterus.

Assess Hb levels.

Screen for fitness of contraception.

MANAGEMENT OF NORMAL PUERPERIUM.

Encourage the mother to ambulate.

Avoid strenuous activities.

Educate the mother on the following.

Maintenance of personal & perineal hygiene.

Advice light diet on the first day & subsequently can take normal diet

The mother should consume 300 Kcal more than the non lactating woman.

Advise roughage diet.

Encourage the mother to pass urine frequently. (4-6 hrly ).

Episiotomy wound / stitches should be cleaned daily & dressed with antiseptic powder & covered with sterile pad.

Educate the mother to change her diaper every 4-6 hrly.

Educate the mother to wash her hand each time before feeding her baby.

Administer IFA tablets 6 Mo post partum.

Advice abstinence for 6 wks.

Offer contraceptive advice following 6 wks.

Consume 550 Kcal extra during lactating period.

Educate on child care.

POST PARTUM MINOR AILMENTS & MANAGEMENT.

Sl.No Minor Ailment Management

1.

2.

3.

4.

5

After Pain (For 2-4 days)

Retention of Urine

Pain (Episiotomy site)

Engorgement of breast

Constipation

Re-assurance

Mild Analgesics

Hot/ Cold water application on supra Public region.

Tab / Ibuprofen 400 mg. 8 hrly x3-4 days

Hot water formentation Light massage from periphery to nipple. 5 units of syntocinon IM, may be given following manual expression of milk

Roughage rich diet

POSTPARTUMPROBLEMS/COMPLICATIONS & MANAGEMENT.

PUERPERAL PYREXIA.

PUERPERAL SEPSIS.

UTI.

CRACKED NIPPLE.

ACUTE MASTITIS.

BREAST ABCESS.

PUERPERAL VENOUS THROMBOSIS.

PUERPERAL PSYCHOSIS.

POST PARTUM HAEMORRHAGE.

PUERPERAL SEPSIS.

PUERPERAL PYREXIA.Def : Temp 100 & 100.4 F within 14 days of delivery.

Causes : Puerperal sepsis.

UTI.

Breast engorgement.

Infection.

Deep vein thrombosis.

Investigation : Hb %.

TLC.DLC.

Urine for pus cells.

MANAGEMENT.

PROPHYLACTIC.

AN PERIOD. : Improve health & nutrition.

Abstinence in the last 6 wks.

Personal hygiene.

Avoidance of infection.

INTRA PARTUM. : Observe principles of cleanliness.

Avoid unnecessary PV examinations.

Treat injury of birth canal appropriately.

Prescribe prophylactic antibiotics.

ANTIBIOTICS. : Ampicillin 500 mg 6 hrly & Metronidazole 400 mg 8 hrly.

Administer to promote uterine contraction.

POST PARTUM.

Advice personal hygiene.

Avoidance of too many visitors.

TREATMENT.

Bed rest with head end raised to facilitate uterine discharge.

Advice plenty of oral fluids.

Prescribe appropriate antibiotics.

PUERPERAL SEPSIS.

DEF : INFECTION OF THE GENITAL TRACT BETWEEN THE ONSET OF RAPTURE OF MEMBRANES, LABOUR & WITH IN 6 WKS FOLLOWING DELIVERY.

INVESTIGATIONS. :

TLC.

High polymorph levels.

Low Hb levels. Vaginal discharge for C/S.

SIGNS & SYMPTOMS.Fever with malaise.

Temp > 38.C.

Abnormal vaginal discharge.

Pelvic pain

Sub involution of uterus.

Vomiting.

Headache.

Tachcyardia.

Flushed face.

PV shows tender parametrium & uterus.

MANAGEMENT.

Bed rest.

Plenty of oral fluids.

Hydrotherapy.

Antibiotics.

Ref to FRU for further management.

UTI.

S/S. Fever pain in the renal angle.

History of painful micturation. (DYSURIA).

History of frequency of micturation.

Retention of urine.

INVESTIGATION. :

WBC count – increased.

Polymorphs- increased.

Pus cells in urine.

Urine for C/S – positive.

MANAGEMENT. Plenty of fluids.

Antibiotics according to the sensitivity.

BREAST ENGORGEMENT.

CONDITION.Due to exaggerated venous and lymphatic enlargement usually on the 3rd / 4th post partum day.

S/S : Tense & tender breast.

Knobby to feel.

Fever.

Pain.

MANAGEMENT.

Firm breast support.

Cold fomentation.

Pain killers.

Expression of milk.- manually or by using breast pump.

CRACKED NIPPLE.CONDITION. Raw or loss of surface epithelium

at the tip or base of the nipple.

CAUSES. Due to unhygienic resulting from formation of crust over the nipple by retracted nipple.

Vigorous sucking in engorged breast or improper way of breast feeding.

ACUTE MASTITIS.

CONDITION. Due to infection of cracked nipple.

CAUSE.Infection by Staphylococcus aureus.

Seen in first or second wk of of Puerperium.

Fever 102.F or more.

Chills.

Pain & swelling in one quadrant of the breast.

Over lying skin is hot & red.

If left may lead to breast abscess.

MANAGEMENT.

Treat using appropriate antibiotics.

Administer sedatives.

Avoid breast feeding on the affected side.

Manual expression of milk from opposite side during feeding will be helpful.

BREAST ABCESS.

CONDITION. : Exhibited by fever at the end of 1st wk.

S / S Pain in the breast.

Cracked nipple.

Temp – 102 F – 103 F.

Localized redness.

Swelling in the breast.

INVESTIGATION WBC and polymorph are high.

MANAGEMENT.Breast support.

Avoidance of breast feeding on the affected side.

Drainage of pus under general anesthesia.

Ref to FRU if required.

PUERPERAL VENOUS THROMBOSIS.

CONDITION. Superficial thrombophlebitis. & Deep vein thrombosis.

S / S THE PREDISPOSING FACTORS ARE

Anemia

Heart disease.

Trauma.

Local infection.

Caesarian section.

Use of estrogens to suppress lactation..

Immobilization.

INVESTIGATION. Affected area is painful tender & red.

The area is warm to touch & painful to touch. with rapid pulse.

Calf muscle pain.

Positive Homan’s sign.

MANAGEMENT Ref to FRU.

PUERPERAL PSYCHOSIS.

S /S

PRE DISPOSING FACTORS.

Severe eclampsia.

Difficult labour.

Puerperal fever.

The condition starts after 3-4 days of child birth as INSOMNIA, DELUSION.

INVESTIGATION & MANAGEMENT.

Refusal of foods.

Confusion.

Tendency to suicide.

Tendency to infanticide.

Ref to FRU.

Counsel the relatives.

POST PRTUM HAEMMORHAGE

S / S H/O of severe blood loss after delivery.

H/O of retained placenta.

H/O of instrumentation.

Manipulation during the delivery.

Hypovolumic shock.

Atonic uterus.

Tears in vagina, cervix on P/V examination.

MANAGEMENT.

PRIMARY MANAGEMENT.

Treatment of shock

Oxytocis.

Bimanual compression of uterus.

Suture of vaginal & cervical tears.

Vaginal packing.

Ref in left lat position..

REFER FOR

Blood transfusion.

Manual removal of placenta.

Repair of tears in vagina, cervix.

PUERPERAL SEPSIS.

S/S History of fever with any of the following.

H/O of foul smelling discharge.

Abdominal tenderness.

Pelvic or abdominal pain.

Sub involution of the uterus.

MANAGEMENT.

Antibiotics.

Ref for surgical intervention.

Drainage.

REFER FOR

Investigation for C/S.

Removal of retained products.

Treatment of septic shock.

Laprotomy if required.

DANGER SIGNS OF PERE NATAL PERIOD.

ANTE NATAL. Fits.

Passing fluid or discharge from vagina.

Head ache.

Visual disturbances.

Bleeding PV with or APH without pain.

Swelling of feet, face, hands.

Severe anemia.

Any other unusual complaints.

INTRA NATAL PERIOD.Fits.

Foetal distress.

Mal presentations.

No progress of labor for 12 hrs.

Sluggish pains/ no pains after rapture of membranes.

Good pains following ROM, but poor progress of labor.

Prolapse of the cord / hand.

Me conium stained liquor.

Slow , irregular, fast FHR.

Excessive show or bleeding.

Collapse during labor.

Placenta not separated within ½ an hour.

POST NATAL PERIOD.

Fits.

Excessive bleeding.

Fever,chills.

Foul smelling discharge.

Puerperal sepsis.

Thrombophlebitis.

UTI.

Mastitis.

PPH.

Maternal exhaustion.

Fever > 38 C.

S / S toxemia.

Rising pulse rate.