B y Bharati saikia, msc nursing CON,JIPMER

1. SEMINAR ON
MANAGEMENT OF PUERPERIALSEPSIS,
SORE,CRACKLEDNIPPLES,
cOunselling ANTENATALmothers
Presented by:
Bharati saikia
MSc Nursing 1st Year
College of Nursing
JIPMER

2. Introduction
 The puerperium is indeed a time of great
importance for both the mother and her
baby, and yet it is an aspect of maternity
care that has received relatively far less
attention than pregnancy and delivery.
 Puerperal sepsis is an infective condition
in the mother following childbirth.
 It is the third most common cause of
maternal death worldwide as a result of
child birth after haemorrhage and
abortion.
PUERPERAL
SEPSIS

3. NORMAL PUERPERIUM- DEFINITION
• The puerperium refers to the six week period, which
follows child birth.
• During this time the pelvic organs return to the nongravid
state, the physiological changes of pregnancy are reversed
and lactation is established.

5. Puerperal sepsis was defined as infection of the genital
tract occurring at any time between the onset of rupture of
membranes or labour, and the 42nd day postpartum in which
two or more of the following are present:
 Fever (oral temperature 38.5°C/101.3°F or higher on any occasion).
 Pelvic pain.
 Abnormal vaginal discharge, e.g. presence of pus.
 Abnormal smell/foul odour of discharge.
 Delay in the rate of reduction of the size of the uterus
(involution).

7. Primary sites of infection are
1. perineum
2. vagina
3. cervix
4. uterus

10. Magnitude of Puerperal Sepsis
 According to World Health Organization (WHO) estimates
puerperal sepsis accounts for 15% of the 500000
maternal deaths annually.
 In low and middle income countries puerperal infections
are the sixth leading cause of disease burden in women
during their reproductive years.
 Puerperal sepsis can cause long-term health problems
such as chronic pelvic inflammatory disease (PID) and
infertility in females.

11. CONT…
 Sample Registration System (SRS), India estimated that 16% and 11%
maternal deaths in the year 1998 (survey of causes of death) and 2001-
03(special survey of deaths) respectively were due to puerperal sepsis.
 In a population based study in rural Maharashtra puerperal sepsis was the
second major cause of maternal mortality (13.2%) after postpartum
haemorrhage.

12. PREDISPOSING FACTORS
 Conditions lowering the resistance- general or local
 Conditions favoring multiplication and increased virulence
of the organism.
 Introduction of organisms from outside.
 Increased prevalence of organisms resistant to antibiotics
and chemotherapy.

13. ANTEPARTUM FACTORS
 Malnutrition and anemia.
 Pre-eclampsia.
 Preterm labor
 Premature rupture of membranes.
 Chronic debilitating illness.
 Sexual intercourse during late pregnancy’s
 Immunocompromised eg AIDS
 Organism of normal vaginal floraie. Candida
albicans,staphylococcus aureaus,e.coli

14. INTRAPARTUM
FACTORS
 Introduction of sepsis in to the upper
genital tract during internal examination
especially after rupture of the membranes
or during manipulative delivery.
 Dehydration and keto acidosis during
labor.
 Traumatic operative delivery.
 Hemorrhage- antepartum or postpartum.
 Retained bits of placental tissue or
membranes.
 Placenta- previa- placental site lying close
to the vagina.
 Obstructed labor or cs section

15. ORGANISMS
• Aerobic: staphylococcus pyogens, e- coli, Klebsiella/
Pseudomonas/ non-hemolytic streptococcus /
staphylococcus auerus.
• Anaerobic: anaerobic Streptococus .bacteroides,
Cl.welchi, Cl.tetani.

16. MODE OF INFECTION
Puerperial sepsis is essentially a wound infection . placental
site, laceration of the genital tract or caeserian section
wounds may be infected in the following ways;
 Endogenous:
• when the organisms are present in the genital tract
before delivery and become pathogenic .
• Anaerobic Streptococus is the predominant one.

17. CONT…
 Autogenous:
• The organisms , present elsewhere in the body,
migrate to the genital organs either through blood
stream or by droplet infection or are conveyed to the
site by the patient herself or her attendants.
• Streptococcus beta haemolyticus , E. coli, Cl. welchi
and stephylococus are thus migrated from septic
throat, faeces and skin infection.

18. CONT…
 Exogenous:
• infection is contracted from some others sources
outside the patient.
• The organisms are introduced by the attendants
usually from the respiratory tract of the doctors or
nurses.

19. CONT…
 Exogenous:
• The infection may be dust borne or as droplet;may
occur during internal examination , or from
contaminated linen or blanket.
• Streptococcus beta hemolyticus and stephylococus
pyogenes are common; while E. coli, Cl. Welchi or
tetani are rarer ones.

20. SIGNS AND SYMPTOMS
 fever (temperature >38 °C)
 lower abdominal pain
 abnormal and foul-smelling lochia
 Chills & rigor
 burning micturition
 If the general condition of the woman is poor, i.e. if the
body temperature of the woman is

21. CONT…
 >38 °C, and any of the following conditions is present:
• weakness
• abdominal tenderness
• foul-smelling lochia
• profuse lochia
• severe lower abdominal pain
• h/o heavy vaginal bleeding
• burning micturition, with or without flank pain
• Subinvolunted uterus,tender
• lochiametra

23. INVESTIGATIONS
HISTORY:
• Antenatal history of anemia
• Pre-eclampsia
• Antepartum hemorrhage
• Presence of septic foci in teeth , gums and tonsils
• Debilitating disease like heart disease, diabetes,
tuberculosis, chronic nephritis and urinary tract infection
or malaria

24. Intranatal history regarding:
• Time of rupture of the membranes
• Number of internal examinations done outside and inside
the hospital.
• Duration of labour
• Method of delivery
• Nature of intra uterine manipulation
• Any trauma to the genital tract

25. CONT…
 Postnatal details:
• Nature of fever and associated symptoms
Investigations:
 High vaginal and endocervical swabs for culture
 “clean catch” mid stream collection of urine for C/S test.
 Blood investigations –WBC, Hb,platelet
 Blood C/S
 Others-
 Usg, MRI,CT CXRAY

26. PROPHYLAXIS
ANTENATAL:
 To detect and eradicate the septic focus especially located
in the teeth, gums, tonsils , middle ears or skin
 To maintain or improve the health status of the patient
 Vaginal examination during pregnancy especially in the
last month should be kept to a minimum and should be
carried out with strict surgical asepsis.

27. CONT…
 Similarly douching during pregnancy is to be avoided
 Intercourse should be avoided during the last two months
to prevent introduction of organisms like streptococcus.
 The patient should avoid contact with persons suffering
from infectious disease.
 The patient should take care about personal hygiene.

28. CONT…
INTRANATAL:
• All staff attending the labour cases should have nasal and
throat swabs taken before attending to their duties.
• The delivery should be conducted taking full surgical
asepsis.
• Patient having respiratory tract or skin infection should
have swabs taken for C/S

29. CONT…
• The patient is instructed not to touch the vulva during labour or
thereafter
• Vaginal examinations should be restricted as minimum.
• Traumatic vaginal delivery should preferably be avoided.
• Lacerations of the genital tract should be repaired promptly.
• Prophylactic antibiotics
• Start IV fluids
• Give the first dose of antibiotics(i.e. ampicillin 1g orally,
metronidazole 400mg orally,& gentamycin 80mg IM stat.
• Refer the women urgetly to the PHC.

30. POSTPARTUM PERIOD:
• Aseptic precautions should be taken.
• Too many visitors should not be allowed
• Sterilized sanitary pad should be used and changed
frequently

31. TREATMENT
General
 The patient should be placed in separate ward
 Adequate fluid and electrolyte balance must be maintained
 Correct anemia
 Sufficient rest is enforced by analgesics and sedatives.
 Anemia should be corrected by blood transfusion
 Temperature, pulse, respiration and BP , intake and output should be
maintained.
 Antibiotic treatment should be continued atleast 10 days.
 Wound should be cleaned
 Dehiscence of episiotomy /abd wound

32. SURGICAL TREATMENT
 Perineal wound: the stitches of the perineal wound may
have to be removed to facilitate drainage of pus and
relieve pain.
 The wound is to be dressed with hot compress with mild
antiseptic solution followed by application of antiseptic
ointment or powder.

33. CONT…
 After the infection is controlled, secondary suture may be
given at a later date.
 Infected retained products: should be removed as early
as possible under cover of antibiotics by digital
exploration of the uterine cavity.
 Pelvic abscess should be drained by colpotomy.

34. COMPLICATIONS
• Peritonitis
• Pelvic thrombophlebitis
• Pulmonary embolism
• Pelvic abscess
• Sepsis or septic shock

35. SORE AND CRACKLED NIPPLES
Introduction:
“ A newborn has only three demands. They are warmth in the
arms of its mother , food from her breasts and security in the
knowledge of her presence. Breast feeding satisfies all three.’

36. DEFINITIONS
Sore nipples:
Sore nipples are any persistent pain in the nipples that lasts
throughout the entire breastfeeding or hurts between
feedings.

37. DEFINITIONS
Crackled nipples:
The nipple may become painful due to:
 Loss of surface epithelium with the formation of raw area
on the nipple
 Fissure either at the tip or the base of the nipple.

38. CAUSES
 Some studies indicate that cracked nipples are caused by poor
latch.
 Yet other causes could be poor positioning, use of a feeding
bottle, breast engorgement, inexperience, semi-protruding
nipples, use of breast pumps and light pigmentation of the
nipples.
 Tongue tie
 Small mouth
 Short frenulum
 High palate

39. CONT…
 Breast engorgement is also a main factor in altering the
ability of the infant to latch-on.
 Engorgement changes the shape and curvature of the
nipple region by making the breast inflexible, flat, hard,
and swollen.
 The nipples on an engorged breast are flat.

40. SIGNS AND SYMPTOMS
 Cracked nipples are most often associated with
breastfeeding and appear as cracks or small lacerations or
breaks in the skin of the nipple.
 In some instances an ulcer will form.
 Cracked nipples are trauma to the nipple and can be
quite painful.

41. CONT…
 Cracked nipples typically appear three to seven days
after the birth.
 If the nipples appears to be wedge-shaped, white and
flattened, this may indicate that the latch is not good
and there is a potential of developing cracked nipples.

42. PREVENTION
Cracked nipples may be able to be prevented by:
Avoid soaps and harsh washing or drying of the breasts and
nipples. This can cause dryness and cracking.
Rubbing a little breast milk on the nipple after feeding to
protect it.
Keeping the nipples dry to prevent cracking and infection.

43. MANAGEMENT
 Ask the mother to breastfeed the child in your presence.
 Check for the proper attachment of the baby to the breast. Proper
attachment means:
• The baby’s mouth is wide open.
• The nipple and the maximum part of the areola is in the baby’s mouth.
• Lower lip of baby is everted
• Swallowing movements of the jaw are visible & occasionally swallowing
sounds are heard too
• If properly attatched advise her to heal craked nipple & continue breast
feeding otherwise it will be engorged
 If the breasts are engorged, and the baby is unable to take the areola and
nipple in and suckle, advice the mother to express a little milk before
feeding.

44. CONT…
 This will decrease the size of the breasts, and make them
softer, and thus easier for the baby to suckle.
 Feed the baby from each breast alternately.
 If despite regular feeding there is engorgement, the
mother may be advised to express breast milk and empty
her breasts at regular intervals.
 Applying hind milk (the milk which comes out during the
latter part of a breastfeeding session) to sore and cracked
nipples has a healing effect.

45. TREATMENT
• Cracked nipples can be treated with 100% lanolin.
• Glycerin nipple pads can be chilled and placed
over the nipples to help soothe and heal cracked
or painful nipples.
• If the cause of cracked nipples is from thrush,
treatment is usually begun with nystatin.
• Continuing to breastfeed will actually help the
nipples heal.
• A little breast milk or purified lanolin cream or
ointment helps the healing process.

46. BreastEngorgement
• Breast engorgement is the painful overfilling of the breasts with
milk.
• This is usually caused by an imbalance between milk supply and
infant demand.
• This condition is a common reason that mothers stop breast-
feeding sooner than they had planned.

47. CAUSES
• Waiting too long to begin breast-feeding your newborn.
• Not feeding often enough.
• Small feedings that do not empty the breast well.
• If you and your baby suddenly stop breast-feeding.
• Babies who are fed formula or water are less likely to
breast-feed well.
• Severe engorgement can make it difficult for your baby to
latch on to the breast properly and feed well. This can
make the problem worse.

48. What are common symptoms of breast
engorgement?
Engorged breasts:
 Are swollen, firm, and painful. If severely engorged,
they are very swollen, hard, shiny, warm, and slightly
lumpy to the touch.
 May have flattened-out nipples. The dark area around
the nipple, called the areola, may be very hard. This
makes it difficult for your baby to latch on.
 Can cause a slight fever of around 37.8°C (100°F).
 Can cause slightly swollen and tender lymph nodes in
your armpits.

49. PREVENTING ENGORGEMENT
 Feed the baby frequently, atleast 8-12 times in 24
hours.
 As breasts fill with milk, feed every 1 ½ to 2 ½ hours
during the day and 3 hours at night to lessen the
chance that breasts will become severely engorged .
 Do not use a pacifier
 Do not time or limit feeds. Allow the baby to end the
feed himself when he is done.
 Applying ice to breasts as “milk comes in” (after feeds
for 15 to 20 minutes) will reduce the swelling caused
by edema

50. CONT…
 A bag of frozen peas or corn works well.
 Use gentle massage to help milk flow.
 If baby still unable to latch, then hand express
or pump your breasts, just enough to soften
them.
 Take Ibuprofen to reduce inflammation and
pain.
 Continue to apply ice for 15 minutes after
breastfeeds.
 Seek medical help if fever(above 101 F) or flu
like symptoms.

51. COUNSELLING ANTENATAL MOTHER
Introduction
Effective counseling in language that the women in
your community can understand will enable them to know
when to get help quickly from you or from a health facility.

52. General principles of counselling the pregnant woman
Counselling the pregnant woman is a process of two-
way interpersonal communication in which you help her to
know about possible problems that she may encounter
during pregnancy, and make her own decisions about how to
respond.

53. Skills and attitudes for effective two-way communication
• Welcome the woman and ask her to sit near you and
facing you.
• Smile and make good eye contact with her.
• Reassure her that you will always maintain her privacy and
confidentiality.
• Without her permission, do not include a third person in
the meeting.

54. CONT…
• Use simple non-medical language and terminologies
throughout that she can understand, and check frequently
that she has really understood.
• Actively listen to her, using gestures and verbal
communication to show her that you are paying attention
to what she says.
• Encourage her to ask questions, express her needs and
concerns, and seek clarification of any information that
she does not understand.

55. Counselling has succeeded when the pregnant woman:
• Feels she got the help she wanted
• Understands the common danger symptoms
• Knows what to do and feels confident that she can come
soon if she develops one of the danger symptoms
• Feels respected, listened to and appreciated
• Comes back when she needs your help

56. In all visits before 20 weeks In all visits after 20 weeks
Persistent vomiting
Vaginal bleeding
No change in abdominal growth
Fever
Vomiting
Headache
Burning epigastric pain (see
Figure 15.4)
Blurred vision
Vaginal bleeding
Leakage of fluid
No change in abdominal growth
Persistent vomiting
Danger symptoms - all pregnant women should know.

57. Diet and rest
• The woman should be advised to eat more than her
normal diet throughout her pregnancy.
• Remember, a pregnant woman needs about 300 extra kcal
per day compared to her usual diet.
• The woman should be advised to refrain from taking
alcohol or smoking during pregnancy.
• The woman should be advised NOT to take any
medication unless prescribed by a qualified health
practitioner.

58. CONT…
• Some of the recommended dietary items are cereals, milk and milk
products such as curd, green leafy vegetables and other vegetables, pulses,
eggs and meat, including fish and poultry (if the woman is a non-
vegetarian), nuts (especially groundnuts), jaggery, fruits, etc. Give examples
of the types of food, suggested preparations, if possible, and how much to
eat.
• The woman should be advised to sleep for 8 hours at night and rest for
another 2 hours during the day.
• She should be told refrain from doing heavy work, especially lifting heavy
weights, as it can adversely affect the birth weight of the baby

59. Infant and young child feeding
• Pregnancy is the ideal time to counsel the
mother regarding the benefits of breastfeeding
her baby.
Initiation of breastfeeding:
• Counsel the mother that breastfeeding should
ideally be initiated within half-an-hour of a
normal delivery (or within two hours of a
caesarean section, or as soon as the mother
regains consciousness, in case she undergoes a
caesarean section).

60. Exclusive breastfeeding for 6 months:
• It should be emphasized to the mother that only breast
milk and nothing but breast milk should be given to the
baby for the first 6 months, not even water.
• The mother should be assured that breast milk has
enough water to quench the baby’s thirst

61. Demand feeding:
• This refers to the practice of breastfeeding the
child whenever he/she demands. it, as can be
made out by the child crying.
• The practice of feeding the child by the clock
should be actively discouraged.
• After a few days of birth, most children will
develop their own hunger cycle and will feed
every 2-4 hours.

62. Rooming in:
• This refers to the practice of keeping the mother and baby
in the same room and preferably on the same bed. This is
usually practised in the Indian setting.
• This practice should be encouraged as it has certain
advantages.

63. Sex during pregnancy
• It is safe to have sex throughout the pregnancy, as long as
the pregnancy is normal.
• Sex should be avoided during pregnancy if there is a risk of
abortion (history of previous recurrent spontaneous
abortions), or a risk of preterm delivery (history of
previous preterm labour).

64. Referralforcomplicationsduringpregnancy,labouranddelivery,and
thepostpartumperiod.Keepthefollowingpointsinmindwhile
referringthewomantoahighercentre
• After appropriate management of the emergency, discuss the
decision to refer with the womanand her relatives, especially the
people who are decision-makers in the family.
• Quickly organize transport and possible financial aid.
• Inform the referral centre by phone, if possible.
• Accompany the woman, if possible; otherwise send another health
worker trained in maternal health care.
• Also send along a relative who can donate blood should the need
arise.
• If the referral is being made after delivery, as far as possible, send
the baby with the mother.
• Send the emergency drugs and supplies in the transporting vehicle.
• Write a referral note to the health personnel at the referral centre.
The note should contain salient points about the history main
clinical findings medication given (dose, route and time of
administration) other interventions done, if any.

65. During the journey:
• watch the IV infusion.
• if the journey is long, give appropriate treatment on the way.
• keep a record of all the IV fluids and medications given,
including the time of administration and the condition of the
woman from time to time.

66. COUNSELLING AND
SUPPORTIVE ENVIRONMEN
• Supportive care during an emergency/complication
• Emotional and psychological reactions of the woman and her family
• The reaction of various members of the family to an emergency situation depends
on the social, cultural and religious situations, the personalities of the people
involved and the gravity of the problem.
• Common reactions of people to obstetric emergencies or maternal death include:
• Denial (feelings of .it can.t be true.);
• Guilt regarding possible responsibility
• Anger (frequently directed towards the health care staff but often masking anger
that patients direct at themselves for .failure.);
• Depression and loss of self-esteem, which may be long-lasting;
• Disorientation.
• General principles of communication and support
• While each emergency situation is unique, the following general principles offer
guidance on how to handle emergencies. Communication and genuine empathy are
probably the most important keys to effective care in such situations.

67. At the time of the event
• Listen to those who are distressed. The family/woman will need to discuss their hurt and sorrow.
• Do not change the subject or move on to easier or less painful topics of conversation. Show
empathy.
• Tell the family/woman as much as you can and as much as they can understand about what is
• happening. Understanding the situation and its management can reduce their anxiety and prepare
them for what happens next.
• Be honest. Do not hesitate to admit what you do not know. Maintaining trust matters more than
appearing knowledgeable.
• If language/dialect is a barrier to communication identify someone to translate for you.
After the event
• Give practical assistance, information and emotional support.
• Respect traditional beliefs and customs and accommodate the family.s needs as far as possible.
• Explain the problem to help reduce anxiety and guilt. Repeat information several times and give
written information, if possible. People going through an emergency will not remember much of
what is said to them.
• Many families and women blame themselves for what has happened. Provide counselling to the
family and woman and allow them to reflect on the event.
• Listen and express understanding and acceptance of the woman.s feelings. Non-verbal
communication may speak louder than words: a squeeze of the hand or a look of concern can say an
enormous amount.
• You yourself may feel anger, guilt, sorrow, pain and frustration in the face of obstetric emergencies
that may lead you to avoid talking to the family/woman. Remember, expressing your emotions is not
a weakness.

68. ANTENATAL EXERCISES
USES OF ANTENATAL EXERCISE
• Muscles of good tone are more elastic and will regain their
farther strength more efficiently and more quickly after
being stretched than muscles of poor tone.
• Exercising abdominal muscles antenatally will ensure a
speedy return to normal.

69. CONT…
• Postnatally effective pushing in labor as the Lessing of
backache in pregnancy.
• The ligaments around the pelvis stretch and no longer give
such firm support to the joints, the muscles become the
second line of defense helping to prevent an exaggerated
pelvic tilt and the unnecessary stress on the pelvic
ligaments.

70. 1.EXERCISE -HEAD LIFT WITH PELVIC TILT
STEPS:
•The arms are closed over the diastases and pulled towards midline.
•Slowly lift the head off the floor while performing a posterior pelvic tilt, slowly
lower the head and relax
•All abdominal contractions should be performed with an exhalation so that
intra abdominal pressure is minimized.

71. 2. EXERCISE – LEG SLIDING
STEPS:
•Hook lying with pelvis in a posterior tilt.
•Instruct the woman to hold the pelvic tilt as she first
slides one foot along the floor until the leg is straight
•She stops sliding at a point at which she can no longer
hold the pelvic tilt. Slowly tilt the leg and bring back to the
starting position

72. CONT…
•Repeat with other leg breathing should be coordinated
with the exercise, so that abdominal contractions occur
with inhalations.

73. 3. EXERCISE – PELVIC TILT EXERCISE
STEPS :
1. Quadruped (on hands and knees) instruct the mother to
perform a posterior pelvic tilt while keeping her back
straight, have her draw in and tighten the abdomen and
hold, then relax and perform an anterior tilt through partial
range.

74. EXERCISE – PELVIC EXERCISE
STEPS :
•Ask women lie flat on her back with her knees bent and her
feet flat on the floor.
•Slowly the woman decreases the lumbar: curve by
tilting the pelvis to press the small of her back against
the floor while simultaneously tighten her abdominal
and buttock muscles.

75. EXERCISE-ABDOMINAL TIGHTENING
STEPS:
• Sit comfortably or kneel on four.
• Breath in and out then pull in the lower part of the abdomen
below the umbilicus while continuing to breath normally.
• Hold for up to 10 seconds. Repeat up to 10 times. This tones
the deep transverse abdominal muscles which are the main
postural support of the spine and will help to prevent back
ache in future.

76. EXERCISE – FOOT AND LEG EXERCISE
The circulation during pregnancy particularly the venous return, is
sluggish and this can lead to problems such as cramps, varicose
veins and oedema. To prevent following exercises can be done.
STEPS :
•Sit or half lie with legs supported.
•Bend and stretch the ankles at least 12 times circles both feet at
the ankle at least 20 times in each direction.
•Brace both knees, hold for a count of four, then release. Repeat
12 times.

77. Advantages of husband/partner involvement in antenatal
counselling
Helps the partner/husband to become aware of the danger
symptoms the woman may encounter during the
pregnancy.
Will make him more caring and more concerned.
Helps him to take action (early reporting) when danger
symptoms appear.

78. CONT…
Alerts him to save money for possible emergencies, e.g.
transport to the health facility.
Alerts the family to decide on their preferred place of
delivery.
Helps the family get prepared for caring for the mother and
her baby after the birth.
Is a further entry point to increase general public awareness
of the potential risks during pregnancy.