Postnatal complications

1. COMPLICATIONS & MINOR
AILMENTS OF
PUERPERIUM
Mrs. U SREEVIDYA,
Msc. NURSING,
Associate Professor,
Apollo college of nursing,
CHITTOOR

2. INTRODUCTIO
N
� Puerperium, the period of adjustment after
childbirth during which the mother’s reproductive
system returns to its normal prepregnant state.
triggered by a sharp drop in the levels of
estrogen and progesterone produced by the
placenta during pregnancy. The uterus shrinks
back to its normal size and resumes its prebirth
position by the sixth week.

3. CONTENTS
✣ NORMAL PUERPERIUM
✣ MINOR AILMENTS OF
PUERPERIUM
⨳ AFTER PAINS
⨳ POSTPARTUM
HAEMATOMAS
⨳ CONSTIPATION
⨳ PAINFUL PERINEUM
⨳ BACK PAIN
⨳ HAEMORRHOIDS
⨳ SYMPHYSIS PUBIS PAIN
⨳ HEADACHES
⨳ MATERNAL FATIGUE
⨳ TRUE INCONTINENCE
⨳ URINARY RETENTION
⨳ FECAL INCONTINENCE
✣ POSTPARTUM
COMPLICATIONS
⨳ PUERPERAL PYREXIA
⨳ PUERPERAL SEPSIS
⨳ UTIs
⨳ THROMBO-EMBOLIC
DISORDERS
⨳ ENDOCRINE DISORDERS
⨳ SUB-INVOLUTION OF
UTERUS
⨳ PSYCHIATRIC DISORDERS
⨳ BREAST COMPLICATIONS

4. Normal
Puerperium

5. DEFINITION
� It is the period following child birth during which all the
body tissue especially pelvic organs revert back to their
pre pregnant stage both anatomically and
physiologically.
It has 3 types:
� Immediate- within 24 hrs
� Recent- within 7 days
� Remote- up to the end of 6 weeks

6. By 6 weeks after delivery, most of the
changes of pregnancy resolved and the
body has regained the non-pregnant
state.

7. Anatomical and Physiological
changes
• Immediately after labor, the woman is in a
state of physical fatigue in many cases,
slight shivering, muscular tremors and
chattering of teeth occur for about 10 – 15
minutes.

8. Temperature
It is normal that a slight rise in the temperature during
the first day, which is known as (reactionary rise), not
exceed 38oC and drops within 24 hours and not
accompanied by increased pulse rate, if it is more
than 38oc or for more than 24 hours, it is called
puerperal pyrexia).

9. Involution of the uterus
• return to the pelvis by about 2 weeks
- be at normal size by 6 weeks
The weight changes of uterus
• 1000g immediately after birth (excluding the fetus, placenta,
membrane and amniotic fluid.
• 500g 1 week after birth
• 300g 2 weeks after birth
• 50g 6 weeks after birth
The endometrial lining rapidly regenerates (16 days)
The placental site undergoes a series of changes in
the postpartum period

10. Uterus
Immediate PP
6 weeks50-100 gms
1000 gms

11. Immediate PPUmbilicus
2 weeks
Pelvic cavity
Near normal size
6 weeks
Post partum uterus

13. Decidua
discharge comes from the placental site and
maintains for 4-6 weeks
•
•
• Lochia rubra
Red in color for the first 3-4 days
Lochia serosa
Pink in color, maintains for 2 weeks
Lochia alba
White in color, maintains for 2-3 weeks

14. Immediately after
delivery
Lochia
Lochia alba
Cease
Bleeding
Lochia rubra
Lochia serosa
Uterine contraction
Yellow/white
Brownish red
5-6week
Pinkish red

15. The cervix also begins to rapidly revert to a
nonpregnant state.
It never returns to the nulliparous state.
By the end of the first week, the external os
closes
• The external os is closed to the extent that a
finger could not be easily introduced.
Cervix

17. Vagina
- By 3 weeks increased vascularity and edema
- At the end of puerperium Shrinks to a nonpregnant
state
- by 6-10 weeks The vaginal epithelium appears
atrophic on smear and the normal epithelium will be
restored.
Who deliver vaginally taught her to
perform kegel exercises

18. Vagina
VASCULARITY
EDEMA
FLATTENED
ATROPHIC
Decreased estrogen levels

19. Perineum
✣ Swelling completely gone within 1-2
weeks
✣ The muscle tone may or may not
return to normal, depending on the
extent of injury.

20. Perineum
SWOLLEN & ENGORGED VULVA
Resolves within 1-2 weeks

21. Ovarian function
• Greatly influenced by breastfeeding
• Caused by the suppression of ovulation
due to the elevation in prolactin.

22. ✣ The mother who does not breastfeed may
ovulate as early as 27 days after delivery.
✣ Most women have a menstrual period by 12
weeks; the mean time to first menses is 7-9
weeks.
Ovaries(continue)

23. ✣ The abdominal wall remains soft and poorly
toned for many weeks.
✣ The return to a pre-pregnant state depends
greatly on maternal exercise.
Abdominal wall

24. ✣ The changes to the breasts that prepare the
body for breastfeeding occur throughout
pregnancy.
✣ If delivery ensures, lactation can be
established as early as 16 weeks' gestation.
Breasts

25. Preparation for lactation
Lactation can occur by 16 weeks'
gestation.
• Lacto genesis is initially triggered by the
delivery of the placenta (E↓P↓and prolactin).
• The prolactin levels decrease and return to
normal within 2-3 weeks (not breastfeeding)
• The colostrum secrets in the first 2-3 days
• The milk continues to change throughout the
period of breastfeeding to meet the changing
demands of the baby.

26. - In non nursing women The prolactin levels decrease
and return to normal within 2-3 weeks
Colostrum secreted for 2 days contain protein , fat , minerals , IgA and
IgG
After 3-6 days replaced by milk (protein , lactose , water and fat )

27. 1) Cardiovascular system
• Cardiac output ↑(immediately after delivery) →
slowly declines→ reach normal 2-6 weeks.
• Blood volume returns to nonpregnant levels by the 10th day
of puerperium
2) Hematologic changes :
• Hemoglobin & hematocrit ↑ after delivery
• Coagulation factors remain elevated in early puerperium
8-12 weeks return to non pregnant level
Systemic changes

28. Micturation;
• There is diuresis in the first two days of puerperium.
Retention of urine may occur either due to the
sphincter or reflexly from perineal trauma.
Skin;
There is a tendency to sweating.
Body weight:
Is slightly lost during the first 10 days.

30. ✣ The immediate postpartum period most often
occurs in the hospital setting, where the majority
of women remain for approximately 2 days after
a vaginal delivery and 3-5 days after a cesarean
delivery.
Routine Postpartum Care

31. ✣ During this time, women are recovering from
their delivery and are beginning to care for the
newborn.
✣ This period is used to make sure the mother
is stable and to educate her in the care of her
baby (especially the first-time mother).
Routine Postpartum Care
(continue)

32. While still in the hospital, the mother
is monitored for
Blood loss,
Signs of infection,
Abnormal blood pressure,
Contraction of the uterus,
Ability to void.
Routine Postpartum Care
(continue)

33. Routine practices include a check of the baby's blood
type and administration of the RhoGAM vaccine to
the Rh-negative mother if her baby has an Rh-
positive blood type.
At minimum, the mother's hematocrit level is checked
on the first postpartum day.
Women are encouraged to ambulate and to eat a
regular diet.
Routine Postpartum Care
(continue)

34. After a vaginal delivery, most women experience
swelling of the perineum and consequent pain.
This is intensified if the woman has had an
episiotomy or a laceration.
Routine care of this area includes ice applied to the
perineum to reduce the swelling and to help with
pain relief.
Vaginal delivery

35. Pain medications are helpful both
systemically as nonsteroidal anti-
inflammatory drugs (NSAIDs) or narcotics
and as local anesthetic spray to the
perineum
Vaginal delivery(continue)

36. The woman who has had a cesarean delivery usually
does not experience pain and discomfort from her
perineum but rather from her abdominal incision.
This, too, can be treated with ice to the incision and
with the use of systemic pain medication.
Women who have had a cesarean delivery are often
slower to begin ambulating, eating, and voiding;
however, encourage them to quickly resume these
and other normal activities.
Cesarean
delivery

37. ✣ Substantial education takes place during the hospital
stay, especially for the first-time mother.
✣ The mother (and often the father) is taught routine care
of the baby, including feeding, diapering, and bathing, as
well as what can be expected from the baby in terms of
sleep, urination, bowel movements, and eating.
Patient education

38. In women who choose not to breastfeed, the care of
the breasts is quite different.
Care should be taken not to stimulate the breasts in
any way in order to prevent milk production.
Women who choose not to breastfeed
Ice packs are applied to the breasts and the use of a
tight brassiere or a binder can also help to prevent
breast engorgement.
Acetaminophen or NSAIDs can alleviate the
symptoms of breast engorgement (eg,
tenderness, swelling, fever) if it occurs.
Bromocriptine was formerly administered to suppress milk
production; however, its use has diminished because it
requires 2 weeks of administration, does not always work,
and can produce adverse reactions.

39. The most important information is who and where
to call if she has problems or questions.
She also needs details about resuming her normal
activity.
Instructions vary, depending on whether the
mother has had a vaginal or a cesarean delivery.
Discharge instructions

40. The woman who has had a vaginal delivery may
resume all physical activity, including using
stairs, riding or driving in a car, and performing
muscle-toning exercises, as long as she
experiences no pain or discomfort.
The key to resuming normal activity is not to
overdo it on one day to the point that the mother
is completely exhausted the next day.
Resuming normal activity

41. Pregnancy, labor, delivery, and care of the newborn
are strenuous and stressful, and the mother needs
sufficient rest to recover.
The woman who has had a cesarean delivery must be
more careful about resuming some of her activities.
She must avoid overuse of her abdomen until her
incision is well healed in order to prevent an early
dehiscence or a hernia later on.
Resuming normal activity.
(continue)

42. ✣ Women typically return for their postpartum visit at
approximately 6 weeks after delivery.
✣ No sound reason for this exists; the time has probably
become the standard so that women who are returning
to work can be medically cleared to return.
Return for postpartum visit

43. MINOR AILMENTS
OF PUERPERIUM

44. MINOR AILMENETS OF
PUERPERIUM
• 1. AFTER PAINS:-
It is infrequent, spasmodic pain felt in
the lower abdomen after delivery for a
variable period of 2-4 days.
presence of blood clots or bits after
birth leads to hypertonic contraction of
the uterus in an attempt to expel them
out.

45. After expulsion of fetus and placenta, the uterus contracts to
regain its normal size, weight and site, this called involution of
uterus.
• Oxytocin is released from posterior lobe of the pituitary gland in
response to the sucking, which facilitate uterine contraction.
Characteristic of after pain:
 Occur during the 1st 2-3 days of puerperium
 Abdominal pains (like cramps) and back pain.
 Strong, regular, and coordinated.
 The intensity, frequency and regularity of contraction decrease
after the 1stpostpartum day.

46. NURSING MANAGEMENT
• It includes in massaging the uterus with
expulsion of clots followed by administration of
analgesics & antispasmodics.
• Effective relief from pain by emptying bladder.
• Provide a prone position with pillow under her
lower abdomen.( it provides a constant pressure
against her uterus ,which keeps it contracted
thus eliminates after birth pains)

48. QUESTIONS
✣ HOW MANY ANIMALS ARE THERE IN PICTURE?
✣ WHAT IS THE SECOND OBJECT IN THE LAST
ROW FROM LEFT SIDE?
✣ IS THERE A PEN IN THE PICTURE OR NOT?
✣ TOTAL HOWMANY OBJECTS ARE THERE?
✣ HOWMANY BALOONS ARE THERE? WHAT ARE
THE COLOURS OF THOSE?
✣ WHAT’S WRITTEN ON THE BLACK BOARD?

49. ANSWERS
✣ TWO
✣ TRUMPET
✣ NO, IT’S A PENCIL
✣ 25
✣ 3 – LIGHT GREEN, DARK GREEN AND
PURPLE
✣ THERE IS NO BLACK BOARD. ONLY WHITE
BOARD AND IT IS EMPTY.

50. 2. POSTPARTUM HEMATOMAS
• Postpartum hematomas are localized
collections of blood in loose connective
tissue beneath the skin that covers the
external genitalia, beneath the vaginal
mucosa, or in the broad ligaments.

51. Perineal hematoma

52. • PAIN ON THE PERINEUM
• Never forget to examine the perineum
when analgesic is given to relieve
pain.
• Early detection of vulvo- vaginal
haematoma can thus be made.

53. Pathophysiology/Etiology
1. Trauma during spontaneous labor
2.Trauma during forceps application or
delivery
3. Inadequate suturing of an episiotomy

54. Clinical Manifestations
1.Complaints of pressure and pain, often
noting that the pain is excruciating
(Severe, sharp perineal pain.)
2.Discolored skin that is tight, painful to
touch
3.Possible decrease in blood pressure,
tachycardia

55. 4. Appearance of a tense, sensitive mass of
varying size covered by discolored skin.
5. Swelling in the perineal wall.
6. Often seen on the opposite side of the
episiotomy.
7. Inability to void due to pressure/edema
on or around the urethra.
8. Complaint of fullness or pressure in the
vagina.
Clinical Manifestations cont…

56. Complications
1.Hypovolemia and shock from extreme
blood loss
2. Anemia, infection
3.Increased length of postpartum recovery
period

57. Management
1.Small hematomas are left to resolve on
their own - ice packs may be applied.
2.Large hematomas may require evacuation
of the blood and ligation of the bleeding
vessel.
3.Analgesics and antibiotics may be
ordered (due to increased chance of
infection).

58. Medical Treatment. This consists of
analgesics given for discomfort,
opening the hematoma so blood clots
can be evacuated and the bleeders
can be ligated, and packing for
pressure

59. Nursing Interventions.
• Apply ice to area of hematoma.
• Observe for evidence of enlarged
hematoma.
• Sitz baths (hot or cold ) can give
additional relief.

60. Nursing Interventions/Patient
Education
1. Inspect perineal and vulval areas for signs of a hematoma
when woman complains of pain or pressure after delivery.
2.Inspect the vaginal area for signs of a hematoma if woman is
unable to void after anesthesia has worn off.
3. Monitor vital signs at least every 10 to 15 minutes and
evaluate for signs of shock.
4. Relieve pain of a hematoma by applying an ice bag to perineal
area, medicating with mild analgesics, and positioning for
comfort to decrease pressure on the affected area.

61. Nursing Interventions/Patient
Education
5. Help to relieve voiding problems by assisting to bathroom to
void if able to ambulate.
6. If she is unable to void, catheterize.
7. Teach the woman the importance of eating a balanced
diet and to include food high in iron.
8. Encourage the woman to take vitamin supplements and
to take medications as ordered.

62. • It is common in the first few days of puerperium
and is due to many factors.
• The woman‘s food intake is interrupted, there
may be dehydration during labor.
• The abdominal muscles are lax and perineal
lacerations make defecation painful.
3. CONSTIPATION

63. 4. PAINFUL PERINEUM:
✣ This is a result of trauma during childbirth, due to
an episiotomy, a spontaneous tear or a
combination of both.
✣ Classification of Laceration of the Perineum:
✣ 1st degree: Involves the fourchette, the perineal skin and
the posterior vaginal wall.
✣ 2nd degree: Involves the above structure as well as the
muscle of the perineal body.
1st and 2nd degrees are called incomplete tears.
✣ 3rd degree: (Complete perineal tear): Involves the above
structures as well as the external anal sphincter and it may
include the anterior wall of the anal canal or rectum.

64. Submucous or hidden perineal
tear:
✣ The levator ani may be injured without apparent tear in the
vaginal mucosa leading to subsequent prolapse.
✣ The swelling and bruising which follow an episiotomy and
repair or a tear produce a degree of pain.
✣ A haematoma may develop and cause very intense perineal
pain. Other causes of perineal pain may include wound
breakdown, excessively tight sutures and infection.

66. Management:
1. Cold baths are more effective than warm baths as warm
baths tend to increase oedema and sensitivity to pain. Ice
and local analgesics are the most helpful modalities.
2. Epifoam (1% hyclrocortisone and 1% local analgesia).
3. Electrotherapy.
4. Pelvic floor exercises; using a contract-relax technique
as an efficient pump mechanism to increase circulation
and decrease oedema.
5. Teach the mother the correct defecation technique by
using of pressure pad held against the wound during
evacuation.
6. Use of an appropriate cushion when sitting.

67. 5. Back pain
✣ Back pain is a very common postnatal complaint. The pain
is most frequently located in the posterior pelvic and lumbar
areas, also cervical and thoracic pain following delivery and
in the immediate post delivery period.
✣ Hormones released in pregnancy lead to ligamentous laxity
which affects the biomechanics of the pelvic girdle and the
vertebral column.
✣ The laxity of these ligaments may remain for some time
after delivery despite the decrease in hormonal levels at
birth.
✣ Relaxin levels return to its normal values three days post
partum, but the effects of relaxin take up to three months to
return to normal.

68. Causes of postnatal back pain:
✣ Altered physiological and biomechanical state due to
pregnancy.
✣ Trauma during labour and delivery.
✣ Lack of postural control and stability during the early post
partum days.
✣ Back pain can also be experienced due to post delivery
uterine contractions during breast feeding.
✣ Urinary tract infection will refer pain to the back.
Treatment:
✣ Gentle mobilization if restricted joint movement.
✣ Strengthening exercises for the abdominal and back
muscles.
✣ Postural correction advices and exercises.
✣ Electrotherapy.

69. Hemorrhoids are another postpartum issue likely
to affect women who have vaginal deliveries.
Symptomatic relief is the best treatment during
this immediate postpartum period because
hemorrhoids often resolve as the perineum
recovers.
This can be achieved by the use of corticosteroid
creams, witch hazel compresses, and local
anesthetic spray to the perineum.
6. Hemorrhoids

70. 7. Symphysis pubis pain
It is a pain in the symphysis pubis which occurs during
pregnancy and continuous after delivery. Also, it is resulted
from birth.
Treatment
✣ Stabilization of the pelvic joints by using trochanteric belt or a
full pelvic bender.
✣ Static abdominal exercise is encouraged before movement
around the bed.
✣ A pillow may be placed between knees to make rolling over
more comfortable.
✣ Reduction of pain by electrotherapy.

71. 8. Headaches
Spinal Headaches:
✣ The accidental puncture of the dura and the resultant leaking of the
cerebrospinal fluid into the epidural space can give rise to severe
headache. Symptoms aggravated by the upright position and relieved
when the patient lies down. A mother who experiences a spinal
headache is very distressed by this condition, as it has a spontaneous
onset and she is unable to respond immediately to her baby's needs.
Physiotherapy Treatment:
✣ Decrease the risk of deep venous thrombosis and pulmonary
complications due to enforced bed rest, by circulatory, leg and
breathing exercises.
✣ Keep her physically comfortable by strengthening program while the
mother lies in supine position.

72. 9. Maternal Fatigue:
✣ The demands on an inexperienced mother give rise to
nervous tension and fatigue. Labour and delivery can
also be an exhausting experience.
Management:
✣ - Relaxation to alleviate the tension.
✣ - Massage sessions

73. 10. True
incontinence
✣ It is a rare complication and is usually
associated with a vesico-vaginal fistula resulting
from pressure necrosis during obstructed labour
or following direct injury to the bladder.
✣ After repair physiotherapy program is applied for
such cases aiming to strength pelvic floor
muscles as in cases of incontinence.

74. 11. Urinary retention
✣ It is a common problem in the immediate puerperium and may
result in overflow incontinence. The major cause of retention is
pain from the perineum and partially due to the sudden decrease
in intra abdominal pressure; the bladder has responds less
readily to the stretch reflex caused by its filling.
Traditional methods of encouraging micturition include;
✣ Early ambulation.
✣ Hot baths.
✣ Relief of perineal pain by analgesic drugs and electrotherapy.

75. 12. Faecal
incontinence
✣ May occur following a third degree perineal
tear where a recto-vaginal fistula is present.
Some faecal incontinence may occur where
the external anal sphincter is damaged.
✣ Surgical closure is necessary which is followed
by physiotherapy program to strengthen pelvic
floor muscles.

80. A-Postpartum Hemorrhage
(PPH) B-Puerperal fever and
sepsis-Endometritis
-Wound
Infections
- Mastiti
s
- UTIsC-Septic Pelvic
Thrombophlebitis D-
Endocrine Disorders
- Postpartum depression
(PPD)
-Postpartum thyroiditis
E-Psychiatric
Disorders
-Postpartum blues
-Postpartum psychosis
F- UTERINE
SUBINVOLUTION
POSTNATAL
COMPLICATIONS

81. Sequence of events in
abnormal
puerperium
• At 2nd OR 3rd day Endometritis
• At 4th day Mastitis OR Wound
infection
• At 7th day Thrombophlebitis

82. +
Postpartum fever
(PUERPERAL PYREXIA)

83. +
Definition
Postpartum fever is defined as a temperature
of 38.7 degrees C (101.6 degrees F) or
greater for the first 24 hours or greater than
38.0 degrees C (100.4 degrees F) on any two
of the first 10 days postpartum.
If fever is present, a physical examination
should be performed to identify the source of
infection and direct optimal therapy.

84. +
Differential
Diagnosis
• Urinary tract infection
• Mastitis or breast abscess
• Atelectasis
• Wound infection (episiotomy or other
surgical site infection)
• Endometritis or deep surgical infection
• Septic pelvic thrombophlebitis
• Drug reaction
• Complications related to anesthesia

85. CAUSES
• Puerperal sepsis
• Urinary tract infection: cystitis, pyelonephritis.
• Breast infection
• Infection of laparotomy wound (caesarean
section)
• Intercurrent infection : acute bronchitis,
pneumonia, influenza, acute appendicitis &
enteric fever

86. NURSING MANAGEMENT
• Isolation and proper hand washing.
• Patient placed in Fowler's position to
facilitate drainage.
• Administer antipyretics.
• Education of the patient on handwashing and
perineal-care.
• Emotional support
• Check the vital signs.
• Maintain the fluid intake and output.
• Sufficient rest is enforced by analgesics and
sedatives
• Identify the cause and treat accordingly.

90. IN THE UTERUS..
• Puerperal infection is a postpartum
infection of the genital tract, usually of the
endometrium, that may remain localized or
may extend to various parts of the body.

91. PREDISPOSING FACTORS
ANTEPARTUM FACTORS:-
Malnutrition & anemia
Pre-eclampsia
Pre mature rupture of
membranes
Chronic debilitating illness
Sexual intercourse

92. INTRAPARTUM FACTORS
• Sepsis during internal
examination
• Dehydration & keto-acidosis
• Traumatic operative delivery
• Hemorrhage
• Placenta praevia

93. Pathophysiology/Etiology
• Bacterial organisms either are introduced from
external sources or are normally present in the genital
tract and are carried to the uterus.
COMMON FACTORS include:
1.Prolonged labor or rupture of membranes (PROM)
2.Number of vaginal examinations
3.Infection elsewhere in the body
4.Anemia, malnutrition
5.Size and number of perineal lacerations
6.Intrauterine manipulation
7.Retained placental fragments of membranes
8.Lapse in aseptic technique
9.Poor perineal hygiene
10.Cesarean section

94. Clinical Manifestations
• Diagnosis is made by sustained fever of
38°C (100.4°F) or higher occurring on any
two of the first 10 days postpartum,
excluding the first 24 hours.
• Symptoms depend on site and extension
of infection.

95. Puerperal fever

96. A. Endometritis
A. Endometritis Postpartum infection involving
the endometrium
1.Uterus usually larger than expected for
postdelivery day.
2.Lochia may be profuse, bloody, and foul
smelling.
3.Chills and fever occur if lochial discharge is
obstructed by clots.
4.Infection may spread to myometrium,
parametrium, uterine (fallopian) tubes,
peritoneum, and blood.

97. B. Parametritis
• B. Parametritis (Pelvic Cellulitis) Infection of the pelvic
connective tissue spread by the lymphatic system within the
uterine wall. Often a result of an infected wound in the cervix,
vagina, perineum, or lower uterine segment
1. Chills, fever (38.8°-40.0°C; 102°-104°F), tachycardia
2. Severe unilateral or bilateral pain in lower abdomen
3. Enlarged and tender uterus
4. Uterine position may become fixed as it is displaced by the
exudate along the broad ligament.

98. Parametritis & peritonitis

99. C) Wound
Infection
Include infections of the perineum developing at
the site of an episiotomy or laceration, as well
as abdominal incision after a cesarean birth.
Diagnosis based on presence of erythema,
induration, warmth, tenderness, and purulent
drainage from the incision site, with or without
fever.

100. Cont. (Wound Infection)
Perineal infections are rare appears on
the third or fourth postpartum day.
• Risk factors include infected lochia, fecal
contamination of the wound, and poor
hygiene.
Abdominal wound infections
S aureus, is isolated in 25% of these
infections.
Treatment :
Abscesses must be drained, and broad-

101. UTIs
- The most common pathogen is E coli. In pregnancy
- Risk factors Cesarean delivery, forceps delivery,
vaccum delivery, induction of labor, maternal renal
disease, preeclampsia, eclampsia, epidural
anesthesia, bladder catheterization, length of
hospital stay, and previous UTI during pregnancy.
Diagnosis
History (frequency, urgency, dysuria, hematuria)
Physical examination (febrile patient, Suprapubic
tenderness) Laboratory tests (urinalysis, urine culture and
CBC) Treatment
Antibiotic regimen for 3-7 Days

102. INVESTIGATIONS
Collect the history
Clinical examination
Investigations include-
Urine culture
Blood culture
Vaginal swabs for culture

103. Management
1. Aseptic technique, avoid cross infection
Hand wash medical personnel.
2. Antibiotic therapy is instituted after cultures are
obtained and causative agent identified.
3. Supportive therapy is used to control pain and to
maintain hydration and nutritional status.
4. Drainage is indicated for abscess development.

104. MEDICAL TREATMENT:
•Ampicillin 500 mg,I/M
3-5 mg/kg body•Gentamycin
weight,
•Cefuroxime 750 mg,I/V
•Metronidazole 0.5 gm,I/V

105. PROPHYLACTIC NURSING MANAGEMENT
Certain measures are undertaken before
delivery, during delivery and in
postpartum period.
Antenatal period-
To detect and eradicate the septic focus.
To maintain or improve the health status
like hemoglobin level, prevent
preeclampsia.
Should take care about personal hygiene.

106. Contd…..
INTRANATAL PERIOD
The delivery should be conducted
taking full surgical asepsis.
The patient is instructed not to touch
the vulva during labour.
Excessive blood loss should be
replaced promptly.
Prophylactic antibiotics.

107. CONT…
•Use caps, mask, gowns, and gloves when
working in delivery rooms.
• Use sterilized equipment within control dates.
•Wash hands meticulously (staff).
•Limit unnecessary vaginal exams during
labor which increases the chances of introducing
organisms from the rectum and vagina into the uterus

108. POSTPARTUM PERIOD
• Aseptic precautions should be taken during
perineal care.
• Too many visitors should not be allowed.
• Sterilized pads should be used and changed.
• Instruct the patient on hand washing and
cleansing her perineum from front to back.
• Restrict personnel with respiratory infections
from working with patients.
• Early ambulation in postpartum.
• Daily evaluation of fundal height to
document involution

109. Nursing Care of Puerperal Infection.
• Isolation, if possible, the removal of
the patient from the maternity ward.
• Meticulous hand washing.
• Patient is placed in Fowler's
position to facilitate drainage.
• Educate the patient on
handwashing and perineal-care.

110. • Emotional support since the patient may be
prevented from rooming in with her infant while
her temperature is elevated.
• Check the vital signs.
• Maintain the fluid intake and output.
• Anemia should be corrected by blood
transfusion.
• Sufficient rest is enforced by analgesics and
sedatives.

111. Complications
• Thrombophlebitis may result from puerperal infection spread
along the veins.
1. Femoral thrombophlebitis—appears 10 to 20 days after
delivery as pain in calf, positive Homan's sign, fever, edema
2. Pelvic thrombophlebitis
a. Infection of the veins of uterine wall and broad ligament
usually caused by anaerobic streptococci
b.Severe repeated chills and wide range of temperature
changes occur about 2 weeks after delivery.
1. Strict bed rest, anticoagulants, and antibiotics are indicated.

112. URINARY TRACT
INFECTIONS

113. A urinary tract infection (UTI) is defined as a bacterial
inflammation of the bladder or urethra.
>100,000 colony-forming units from a clean-catch
urine specimen
>10,000 colony-forming units on a catheterized
specimen
Urinary Tract Infections

114. Risk factors for
postpartum UTI
Cesarean delivery
Forceps delivery
Vacuum delivery
Induction of labor
Maternal renal disease
Etiology
Preeclampsia
Eclampsia
Epidural anesthesia
Bladdercatheterization
Length of hospital stay
Previous UTI during
pregnancy

115. The most common pathogen is E coli.
In pregnancy, group B streptococci are
the major pathogen.
Other causative organisms include
Staphylococcus saprophyticus, E faecalis,
Proteus, and K pneumoniae.

116. Postpartum bacteruria occurs in 3-34% of
patients, resulting in a symptomatic
infection in approximately 2% of these
patients.
Incidence

117. A patient may report frequency, urgency,
dysuria, hematuria, suprapubic or lower
abdominal pain, or no symptoms at all.
History

118. On examination, vital signs are stable and
the patient is afebrile.
• Suprapubic tenderness may be elicited on
abdominal examination.
Physical examination

119. Acute cystitis
Acute pyelonephritis
Differential diagnosis

120. Ultrasound Abdomen
Urine culture from a clean-catch / catheterized
specimen
CBC
Investigation
s

121. Treatment is started empirically in
uncomplicated infection.
Treatment is with a 3- or 7-day
antibiotic regimen.
Treatment

122. Commonly used antibiotics include
trimethoprim/sulfamethoxazole, ciprofloxacin,
and norfloxacin.
Amoxicillin is often still used, but it has lower
cure rates secondary to increasing resistance of E
coli.
The quinolones are very effective but should not
be used in breastfeeding mothers.

123. PUERPERAL
THROMBO-EMBOLIC
DISORDERS

124. Puerperal
Thrombosis
Leg vein & pelvic vein is one of the
complication in western countries.
However the prevalence is low in Asians &
Africans.
Etiopathogenesis
In normal pregnancy there is rise in
concentration of coagulation factors 1, 2,
7, 8, 9, 10, 12. plasma fibrinolytic inhibitors
produced by placenta.
Alteration in blood constituents- increased
number of platelet & their adhesiveness.

125. Venous stasis is increased due to compression
of gravid uterus to IVC & iliac veins. This stasis
cause damage to endothelial cells.
Thrombophilias are the genetic condition
associated with deficiencies of antithrombin3
protein C .
Acquired thrombophilias are due to
presence of lupus anticoagulant &
antiphospholipids antibodies.

126. Risk
factors:
Advanced age & parity
Operative delivery
Obesity
Anemia & heart disease.
Trauma to venous vessel wall.
Infections
DVT
C/F: Asymptomatic, pain in calf muscle,
edema of leg, rise skin temperature.
• Homan’s sign positive.

128. Deep vein thrombosis & Homan’s sign

129. Investigations:
Doppler ultrasound.
Realtime ultrasonography.
Venography.
Pelvic Thrombophlibits
C/F: usually develop after 2nd week of
puerperium.
 Fever with chills & rigors.
Feature of toxemia i.e. headache, malaise &
rising pulse.
Affected leg is painful, swollen & cold.

130. PELVIC THROMBOPHLEBITIS
Originates in the thrombosed veins at placental site by
organism such as an anaerobic streptococci or
bacterioides.
When localised in the pelvis called pelvic
thrombophlebitis.
There is no specific features but it is suspected when
there is constant fever inspite of antibiotics
administration.

131. EXTRA PELVIC SPREAD
Through the right ovarian vein to inferior vana
cava and hence to the lungs
Through left ovarian vein to left renal vein and
hence to the left kidney
Retrograde extension to iliofemoral veins to
produce the clinical pathological entity called
“phlegmasia alba dolens” ( adjacent cellulitis in
femoral vein)

132. CLINICAL FEATURES:
Usually develops in second week of puerperium
Mild pyrexia
High grade fever with chills andrigor
Constitutional disturbances like... headache, malaise,
rising pulse rate
Swelling, pain, white , cold over affected leg

133. PROPHYLAXIS
PREVENTIVE MEASURES:
Prevention of trauma, sepsis, anemia,
dehydration
Use of elastic compressionstocking
Leg exercise, Earlyambulation

134. MANAGEMENT
Bed rest with foot end kept higherto heart level
Pain management
Antibiotics
Anticoagulants- Heparin- 15000 units IV followed by 10,000
units 6-8 hourly for 4 to 6 injections. up to 7 to 10 days
Administartion of fibrinolytic agents
Venous thrombectomy

135. Septic Pelvic Thrombophlebitis
(SPT)
- It is a venous inflammation with thrombus formation
in association with fevers unresponsive to antibiotic
therapy.
- Bacterial infection of the endometrium seeds
organisms into the venous circulation, which damages
the vascular endothelium and in turn results in
thrombus formation.
- The thrombus acts as a suitable medium for
proliferation of anaerobic bacteria.

136. Cont.
(SPT)
Diagnosis
A. History
• It usually accompanies endometritis
• Pts with OVT may describe lower abdominal pain, with
or
without radiation to the flank, groin, or upper
abdomen.
B. Physical Examination
- Should focus on looking for other sources of infection.
- Fever, tachycardia
- On abdominal examination, 50-70% of pts with ovarian
vein thrombosis have a tender, palpable, ropelike mass.
C. CT and MRI are the studies of choice

137. Cont.
(SPT)
Treatment
• IV heparin for 7-10 days.
• Antibiotic therapy is most commonly
with gentamicin and clindamycin

138. PULMONARY EMBOLISM
Most leading cause of maternal deaths
Classical symptoms of massive
pulmonary embolism are...
Sudden collapse
Acute chest pain
Air hunger
Death usually occurs within short time from
shock and vagal inhibition

139. Important signs...
Tachypnea
Dyspnea
Pleuritis- chest pain
Cough
Tachycardia
Hemoptysis
Rise in temperature

140. DIAGNOSIS
ECG
Arterial blood gas
Doppler utrasound
Lung scans
Pulmonary angiography
MRA: Magnetic resonance angiography

141. MANAGEMENT
Prophylactic measures
Active treatment:
Resuscitation: cardiac massage, oxygen
therapy, heparin bolus IVof 5000 units and
morphine 15 mg
IV fluids
Incase of recurrent .. embolectomy,
placement of caval filters, ligation of inferior
vana cava and ovarian veins

142. Prophylaxis for VTE
Preventive measures:
exclude the cause and treat
accordingly f o r low & high risk
woman.
Management:
 bed rest & foot is raised.
 Analgesics
 Anticoagulants
 Gentle movements of the leg after relief of pain.
 Vena caval fillers
 Fibrinolytic agents
 Venous thrombectomy.

143. ENDOCRINE
DISORDERS

144. Endocrine Disorders
Clinical or laboratory dysfunction occurs in 5-
10% of postpartum women
Caused by
A. Primary disorders of the thyroid, such as
1) Postpartum thyroiditis (PPT)
2) Graves disease,
B. Secondary disorders of the
hypothalamic- pituitary axis, such as
1) Sheehan syndrome
2) Lymphocytic hypophysitis.
(pituitary enlargement+Hypopitutarism ↓TSH)

145. PostPartum Thyroiditis
(PPT)
- It is a transient autoimmune
destructive lymphocytic thyroiditis.
- Can occur any time in the 1st postpartum
year.
It has 2 phases
1) 1-4 mo PP thyrotoxicosis (↓TSH)
2) 4-8 mo PP hypothyroidism (↑TSH)

146. +
Postpartum thyroiditis cont..
Postpartum thyroiditis is a destructive thyroiditis
induced by an autoimmune mechanism within one
year after parturition.
It usually presents in one of three ways:
1. Transient hyperthyroidism alone
2. Transient hypothyroidism alone
3. Transient hyperthyroidism followed by
hypothyroidism and then recovery

147. +
Prevalence
The reported prevalence of postpartum
thyroiditis varies globally and ranges from 1 to
17 percent.
Higher rates, up to 25 percent, have been
reported in women with type 1 diabetes mellitus,
and among women with a prior history of
postpartum thyroiditis

148. +
Pathogenesis
It is considered a variant form of chronic
autoimmune thyroiditis (Hashimoto's
thyroiditis).
Women destined to develop postpartum
thyroiditis usually have high serum antithyroid
peroxidase antibody concentrations early in
pregnancy, which decline later and then rise
again after delivery.

149. +
Clinical features
The symptoms and signs of hyperthyroidism,
when present, are typically mild and consist
mainly of fatigue, weight loss, palpitations,
heat intolerance, anxiety, irritability,
tachycardia, and tremor.
Similarly, hypothyroidism is also usually
mild, leading to lack of energy, cold
intolerance, constipation, sluggishness, and
dry skin. [8]

150. Serum antithyroid peroxidase antibody
concentrations are high in 60 to 85
percent of women with postpartum
thyroiditis.
It is highest during the hypothyroid phase.
+
Laboratory findings

151. +
Screening
There is insufficient evidence to support a
recommendation for screening all pregnant
women for postpartum thyroiditis.
However, women at highest risk for developing
postpartum thyroiditis should have a serum TSH
measurement at three and six months
postpartum.

152. +
Management
The majority of women with postpartum
thyroiditis need no treatment during either the
hyperthyroid or the hypothyroid phases of
their illness.
• Thyroid Function Tests should be monitored every
four to eight weeks to confirm resolution of
biochemical abnormalities or to detect the
development of more severe hypothyroidism,
indicating possible permanent hypothyroidism.

153. • Women who have bothersome symptoms of
hyperthyroidism can be treated with 40 to 120
mg propranolol or 25 to 50 mg atenolol daily
until their serum T3 and serum free T4
concentrations are normal.
• Women with symptomatic hypothyroidism
should be treated with levothyroxine (T4)
irrespective of the degree of TSH elevation.

154. Sub
involutio
n of
uterus

155. Definition
• Sub involution of uterus is impaired and
deficient involution of the uterus following
delivery.
• when the uterus is not reverted back to
the pre-pregnant state both anatomically
& physiologically it is considered as
subinvolution of uterus.

157. Predisposing factors
•
•
Grand multiparity
over-distention of uterus as in twins &
hydromnios
• Maternal ill health
• Cesarean section
• Prolapse of the uterus
• Uterine fibroids
• No sucking of the
baby

158. Clinical features
• Excessive or prolonged discharge of lochia
• Irregular or excessive uterine bleeding
• Irregular cramp like pain
• Uterine height more than normal for the
particular day of post partum

159. Cont. (Uterine Subinvolution )
Treatment:
1- Administration of oxytocic medication
to improve uterine muscle tone,
includes:
(a) Methergine - a drug of choice (PO)
(b) Pitocin.
(c) Ergotrate.
2 Dilation and curettage (D&C) to remove
any placental fragments.
3 Antimicrobial therapy for endometritis

160. Nursing Management
• Sub involution is managed by treating the
causes.
•
•
Antibiotics for sepsis.
Exploration of the uterus for retained
products.
• pessary in prolapse or retroversion.
• Early ambulation postpartum.
• Daily evaluation of fundal height to
document involution.

161. PSYCHIATRIC
DISORDERS

162. Psychiatric Disorders
1 Postpartum blues - 50-70%
• Mild, self limited, arises during the first 2 weeks PP
• TTT: Support & education
2 Postpartum depression (PPD) - 10-
15%.
• More prolonged (3-6 months)
• TTT: Supportive care and reassurance, SSRI
3 Postpartum psychosis- 0.14-0.26%.
• Generally lasts only 2-3 months. Need psychiatrist.
• Better prognosis than nonpuerperal psychosis.

163. • postparum blues : a normal developmental crisis
related to the adjustments that are being made
relative to the new role of parent, along with the
added responsibilities, fatigue, and excitement that
go with the birth.
• If a woman is unable to work through her feelings
within about 2 weeks, and the symptoms continue,
a more serious depression is indicated.
• postpartum depression; social, cultural,
physiologic and psychological factors experienced
may contribute to postpartum
• Postpartum psychosis; a severe form of
depression that occurs in a small percentage of
women giving birth.

164. Any prolonged episodes
of depression during or
after pregnancy should
receive urgent
attention.

165. +
Postpartum blues and
depression
Pregnant women and
their friends, families,
and clinicians expect
the postpartum period
to be a happy time,
characterized by the
joyful homecoming of
the newborn.
Unfortunately, this is
not the case in many
mothers.

166. +
Postpartum
blues
Postpartum blues refer to a transient condition
characterized by mood swings from elation to
sadness, irritability, anxiety, decreased
concentration, insomnia, tearfulness, and crying
spells.
Forty to 80 percent of postpartum women develop
these mood changes, generally within two to three
days of delivery.
Symptoms typically peak on the fifth postpartum
day and resolve within two weeks

168. +
Etiology
Although there are no conclusive data
regarding the etiology of postpartum blues,
multiple factors are probably involved.
Although all women experience hormonal
fluctuations postpartum, some women may
be more sensitive to these changes than
others.

169. +
Women at high risk
Major risk factors for postpartum blues
include…
•
•
•
•
•
✣ History of depression
✣ Depressive symptoms during
pregnancy
✣ Family history of depression
✣ Premenstrual or oral contraceptive associated
mood changes
✣ Stress around child care
✣ Psychosocial impairment in the areas of
work, relationships, and leisure
activities.

170. Case Study: Postpartum Depression
Sheela was a 30 year-old mother of four children who had been married for
eight years. She lived with her husband and in-laws in a small village. She had given
birth to her fourth child three months previously. Her pregnancy and labor had been
uneventful, and an untrained traditional midwife helped conduct the home delivery.
Because pregnancy was viewed in her village as a normal occurrence that did not
require any medical attention, Sheela did not receive any antenatal or postnatal
care.
For a month after the birth, Sheela felt normal, but then she began to
exhibit unusual behavior. She became reclusive and stopped speaking to anyone at
home, losing interest in her daily activities and ceasing to care for her children. The
rest of the people in her family, however, were busy with their own lives and seemed
indifferent to her condition.
One day, when all of her family members had gone to the fields to work,
Sheela set herself on fire and walked out of the house covered in flames. Some
neighboring men saw her and smothered the flames with blankets, and one of them
ran to get her family from the fields. They called an auto rickshaw to take her to the
hospital, where Sheela was admitted to the burns unit. She had sustained 63%
superficial and deep burns. Eight days after admission, she died of shock and
septicemias.

171. What were the social, economic, and
medical factors that contributed to
Sheela’s death?
What could have been done to prevent
it?

172. What went wrong?
· Home delivery by untrained attendant
· No antenatal or postnatal care
· No high risk identification
·Symptoms of depression not detected
· Indifferent attitude of family members

173. POSTPARTUM DEPRESSION
• Postpartum depression may occur in the first
2 weeks after delivery
Etiology: unknown, but..
- Hormonal theory– decrease estrogen level
As like as menstrual period, menopause
- Psychosocial aspect; lack of support system,
unwanted baby
- Cultural aspect; male dominant, favorable
sex baby

174. Clinical Manifestations
1.Exaggerated and prolonged periods of
irritability, moodiness, hostility, fatigue
2. Ineffective coping
3.Withdrawal and inappropriate response to
the infant or family
4. Loss of interest in activities
5. Insomnia

176. Management
• Signs and symptoms may be overlooked,
making the diagnosis of depression difficult.
• Counseling with a mental health professional,
medication, and continuous support from family
and friends may be helpful in managing the
depressed patient.
• If untreated, the woman may not fully recover
and possibly harm the infant or others.
• refer to psychologist.

177. 1. Listen to the woman regarding her adjustment to role
of mother and observe for any clinical manifestations
suggesting depression.
2. Ask the woman about the infant's behavior. Negative
statements about the infant may suggest that the
woman is having difficulty coping.
3. Provide support and encourage husband, family and
friends to support and assist with the infant and mother.
4. Physical support as well as emotional support may be
indicated.
5. Educate the woman that treatment may help alleviate her
symptoms and allow her to better care for herself and
infant.
Nursing Interventions/Patient
Education

178. POSTPARTUM
PSYCHOSIS

179. PSYCHOSIS
(SCHIZOPHRENIA)
About 1 in 500-1000 mothers.
 Seen in woman with past H/O psychosis or with
positive family H/o.
 Relatively sudden in onset with in 4 days after
delivery.
 Manifestations:
 Fear, restless, confusion followed by
hallucination, delusion and disorientation.
 Suicidal, infanticidal impulse may be present.
 Risk of recurrence in subsequent pregnancy is
2-20%.

181. Treatment
Psychiatrist consulted urgently.
Admission needed.
Chlorpromazine 150mg stat & 50-150mg
thrice daily.
ECT: needed if unresponsive case.
Lithium is indicated in manic depressive
psychosis & breast feeding
contraindicated.

182. Case study- Discussion
Sheela had several children, and the intervals between
the births were quite short. Because she did not receive
antenatal or postnatal care, her symptoms of depression were
not detected.
The tragic outcome in Sheela’s case could have been
avoided by her husband and relatives been more caring and
supportive. Psychological support and counseling with
antidepressant drugs could have also helped prevent the
tragedy.

183. CONCLUSION:
Postpartum depression is a condition faced by millions of women
each year.
• In fact, about 10-15% of all mothers suffer some form of this depression
between a month and a year after childbirth.
• Postpartum depression is thought to be caused by shifts in hormone levels
during and immediately after pregnancy.
• Symptoms often include feelings of restlessness, anxiety, and depression;
loss of energy, sleep difficulties, and weight loss or gain.
• In much rarer cases (less than 1% of postpartum women) new mothers
may experience postpartum psychosis, symptoms of which include refusal
to eat, paranoia, and irrational thoughts.
• Although postpartum depression is common, it can be successfully treated
with medicine and therapy.

184. Psychological
response to perinatal
death.

185. Psychological response to perinatal
death.
Most perinatal events are joyful.
But when perinatal death occurs special
attention must given to grieving patient & her
family.
Perinatal grieving may also be due to
unexpected hysterectomy, birth
malformed, critically ill infant.
Obstetrician, nurse & attending staff must
understand the patient reaction.

186. Management.
Facilitating the grieving process, support &
sympathy.
Supporting the couple in holding or taking
photograph of the infant .
Requesting for autopsy .
Follow up visits & plan for subsequent
pregnancy.

187. BREAST COMPLICATIONS
IN PUERPERIUM

188. CLASSIFICATION OF
BREAST DISORDERS
NIPPLE
DISORDERS
BREST
INFECTIONS

189. NIPPLE DISORDERS
CLASSIFICATION
INVERTED/
RETRACTED
NIPPLE
CRACKED
NIPPLES

190. INVERTED
NIPPLES
DEFINITION-
It is a condition in
which nipple
instead of pointing
outwards get
retracted into the
breast.

191. METHODS-
• Use of breast pump.
• Hospital grade electric pump.
• Use of nipple shield.
• Frequent stimulation

192. Breast pump

193. Nipple shield

194. Cont..
✣ OTHER METHODS-
• Plastic surgery
• Nipple piercing
• Regular stimulation
• Suction cups or clamps
• Homemade nipple protractor.

195. Suction cups

196. Clamp, piercing, shells…

197. CRACKED
NIPPLES
DEFINITION- it is a condition in which there is loss
of surface epithelium with the formation of raw
area on the nipple along with fissure situated
either at the tip or of the base of nipple
CAUSE-
• improper hygiene resulting in crust
formation,
• Retracted
nipples,
• Trauma Due to
incorrect breast
feeding.

198. Cont…

199. Cont…
SYMPTOMS- painful breast feeding, it may
progress to mastitis.
PROPHYLAXIS-maintaining hygiene.
TREATMENT-correct attachment of infant,
• purified lanonin application(3-4
times),
• usage of breast pump and shields(if
severe),
• application of miconazole lotion,
• biopsy.

200. BREAST INFECTIONS
CLASSIFICATION
MASTITIS
SUBAREOLAR
ABCESS

201. MASTITIS
DEFINITION- It is the inflammation of parenchyma
of the mammary gland
TYPES-
PATHOGENS-staphylococcus, streptococcus,
gram negative bacilli such as escherichia coli,
salmonella, mycobacterium, candida,
cryptococcus (rarely)
PUERPERAL MASTITIS
NON PUERPERAL MASTITIS

202. Mastitis

203. Cont…
CAUSES-
PUERPERAL MASTITIS
 Blocked milk ducts
 Milk excess
 Cracked nipples
 Tight clothing
 Microorganism
transference by
patient and infant.
CAUSES-
NON PUERPERAL
MASTITIS
 Hyperprolactinemia
 Thyroid disorders
 Breast trauma,
surgery
 Nipple piercing
 Medications .

204. Cont…
✣ SYMPTOMS
✣ NON
PUERPERAL
MASTITIS
✣ Redness,
swelling
✣ Diffused
tenderness, pain
✣ Abscess
✣ Nipple
discharge.
SYMPTOMS
PUERPERAL
MASTITIS
Tough,
doughy
texture
Dull to severe
pain
Flu-like symptoms
Abscess (rare)

205. TREATMENT
✣ PUERPERAL
MASTITIS
 Breast feeding.
 Use of suction
devices
 Heat application (prior
to feeding)
 Cold compresses
(severe)
 Antibiotics
TREATMENT
NON PUERPERAL
MASTITIS
Symptomatic
management
Broad spectrum
antibiotics.

206. BREAST ABSCESS
Breast abscess is a painful build-up of pus in the
breast caused by an infection.
• It mainly affects women who are breastfeeding.
• It is a localised collection of pus in the breast tissue.
Signs and Symptoms: The signs and symptoms of breast abscesses
are:
 a tender swelling or lump in an area of the breast;
 pain in the affected breast;
 redness, warmth, swelling, and tenderness in an area of the breast;
 fever;
 muscles aches; and
 feeling generally unwell.

207. CAUSES: Breast abscesses are usually caused by a bacterial
infection, which often occurs when a woman is breast feeding.
OTHER CAUSES:
Breast abscesses can also develop in women who
are not breast feeding. Risk factors can include:
•injury to the breast;
•cracked nipples;
•having diabetes or problems with immune system;
•nipple piercing; and
•breast implant surgery.

208. Treatment :
 US guided needle aspiration for abscesses < 3 cm
 Analgesia and antibiotics
 General anaesthesia for larger periareolar or
retroareolar abscess.
 Surgery for large abscess with complications.
Investigations : clinical breast examination
 Ultrasound
 Needle biopsy

209. BREAST
ENGORGEMENT
DEFINITION-it is a condition which occurs
in mammary glands by expanding viens
and the pressure of new breast milk
contained with in them.
CAUSE- It is due to exaggerated normal
venous and lymphatic engorgement of
breasts which precedes lactation. It
involves primiparous women and women
with inelastic breast.

210. Breast engorgement

211. Cont….
SYMPTOMS-Pain, feeling of heaviness,
generalized malaise, transient rise of
temperature, painful breast feeding.
PREVENTION-
• to avoid prelacteal feeds(Any food provided to a
newborn before the initiation of mother's breastfeeding is
considered to be a prelacteal feed.),
• to initiate early and unrestricted breast
feeding,
• exclusive breast feeding on demand,
• feeding in correct position.

212. Cont…
MANAGEMENT
-To support the breast with brassiere
-Mannual expression of any remainaing milk
after each feed
-To administer analgesics for pain
-Put baby on breast feed regularly and at
frequent intervals
-Gentle use of breast pump (if severe)

213. FAILING LACTATION
CAUSES:-
• Debilitating state of the mother
• Early primigravidae
• Failure to suckle the baby regularly
• Depression or anxiety state in the
puerperium
• Apprehension to nursing
• Premature baby, who is too weak to suck
• Painful breast lesions

214. MANAGEMENT
ANTENATAL
• Education regarding the advantages of
breast feeding
• Correction of abnormalities like retracted
nipples
• Breast hygiene
• Improving the general health status of
mother

215. Cont…
POSTNATAL
• Encourage adequate fluid intake
• Nurse the baby regularly
• Treat painful lesions promptly
• Express residual milk after each feeding
• Drugs like thyroid extract or prolactin are
useful.

216. OBSTETRIC
PALSIES

217. OBSTETRIC PALSIES
(Syn.POSTPARTUM TRAUMATIC
NEURITIS)
The commonest form of obstetric palsy
encountered in puerperium is...
“FOOT DROP”
Usually unilateral
Appears shortly after delivery/ first day
postpartum

219. It is due to stretching of the lumbosacral
trunk by the prolapsed intervertebral disc
between L5and S1
Backward rotation of the sacrum during
labour may also be a contributory factor
Direct pressure either by fetal head or forceps
blade on the lumbosacral cord or sacral
plexus

221. Condition is usually mild
May passed unnoticed
Neurological examination reveals lower motor
neurone type of lesions with flaccidity and
wasting of muscles in areas supplied by femoral
nerve or lumbosacral plexus.
Sensory loss is often present

222. Management of damaged lumbosacral
nerve roots is same as that of the
proplapsed intervertebral disc in
consultation with an orthopedist.
Paraplegia due to epidural hematoma
or abcess is rare.

223. NURSING
MANAGEMENT

224. NURSING MANAGEMENT OF
PUERPERAL INFECTIONS & OTHER
COMPLICATIONS
✣ The nursing management of clients with
puerperal infection includes preventing the
control spread of infection, promoting healing,
and improving the attachment/bonding of parent
and infant.

225. 1. Risk For Infection
Nursing Diagnosis
•Risk for Infection
Risk Factors:
•Presence of infection, broken skin and/or traumatized tissues.
•high vascularity of involved area.
•Invasive procedures and/or increased environmental exposure.
•Chronic disease (e.g., diabetes), anemia, malnutrition.
•Immunosuppression and/or untoward effect of medication (e.g.,
opportunistic/secondary infections)
Desired Outcomes
•Patient will verbalize understanding of individual causative risk factors.
•Patient will initiate behaviors to limit the spread of infection, as
appropriate, and reduce the risk of complications.
•Patient will achieve timely healing, free of additional complications.

226. Nursing Interventions Rationale
Review prenatal, intrapartal, and postpartal record.
Identifies factors that place client in high-risk
category for development/spread of postpartal infection.
Demonstrate and maintain a strict hand-washing policy
for staff, client, and visitors.
Helps prevent cross-contamination.
Instruct the proper disposal of contaminated linens,
dressings, and peripads. Maintain isolation, if indicated.
Prevents spread of infection.
Demonstrate correct perineal cleaning after voiding and
defecation, and frequent changing of peripads.
Cleaning removes urinary/fecal contaminants. Changing
pad removes moist medium that favors bacterial growth.
Demonstrate proper fundal massage. Review importance
and timing of the procedure.
Enhances uterine contractility; promotes involution and
passage of any retained placental fragments.
Monitor temperature, pulse, and respirations.
Note presence of chills or reports of anorexia or malaise.
Elevations in vital signs accompany
infection; fluctuations, or changes in symptoms, suggest
alterations in client status. Note:
Persistent fever unresponsive to antibiotic therapy may
indicate pelvic thrombophlebitis.
Observe perineum/incision for other signs of infection
(e.g., redness, edema, ecchymosis, discharge and
approximation [REEDA scale]). Note subinvolution of
uterus, extreme uterine tenderness.
Allows early identification and treatment; promotes
resolution of infection. Note: Although localized infections
are usually not severe, occasional progression to
necrotizing fasculitis can be life-threatening.

228. Nursing Interventions Rationale
Monitor oral/parenteral intake, stressing the need for at
least 2000 ml fluid per day. Note urine output, degree of
hydration, and presence of nausea, vomiting, or diarrhea.
Increased intake replaces losses and
enhances circulating volume,
preventing dehydration and aiding in fever reduction.
Encourage semi-Fowler’s position. Enhances flow of lochia and uterine/pelvic drainage.
Promote early ambulation, balanced with adequate rest.
Advance activity as appropriate.
Increases circulation; promotes clearing of respiratory
secretions and lochial drainage; enhances healing and
general well-being. Note: Presence of
pelvic/femoral thrombophlebitis may require strict bed
rest.
Investigate reports of leg or chest pain. Note
pallor, swelling, or stiffness of lower extremity.
These signs and symptoms are suggestive of
septic thrombus formation. Note: Embolic
sequelae, especially pulmonary embolism, may be initial
indicator of thrombophlebitis.
Recommend that breastfeeding mother periodically check
infant’s mouth for presence of white patches.
Oral thrush in the newborn is a common side effect of
maternal antibiotic therapy.
Encourage client/couple to prioritize
postdischarge responsibilities (e.g., homemaking tasks,
child care)
Client will require additional rest to
facilitate recuperation/healing. Household duties need to
be reassigned or delayed as appropriate.
Instruct in proper medication use (e.g., with or without
meals,take entire course of antibiotic, as prescribed).
Oral antibiotics may be continued after discharge. Failure
to complete medication may lead to relapse.

229. 2. Acute Pain
Nursing Diagnosis
•Acute Pain
May be related to
•Body response to infective agent, properties of infection (e.g., skin/tissue
edema, erythema)
Possibly evidenced by
•Verbalizations, restlessness, guarding behavior, self-focusing.
•Autonomic responses
Desired Outcomes
•Patient will identify/use individually appropriate comfort measures.
•Patient will report decreased level of pain/discomfort.

230. Nursing Interventions Rationale
Assess location and nature of discomfort or pain, rate
pain on a 0–10 scale.
Helps in the differential diagnosis of tissue involvement
in the infectious process.
Assess for non-verbal pain cues.
Non-verbal cues such as crying, grimacing, or withdrawn
behavior may indicate pain.
Provide instruction regarding, and assist
with, maintenance of cleanliness and warmth.
Promotes sense of general well-being and enhances
healing. Alleviates discomfort associated with chills.
Instruct client in relaxation techniques;
provide diversionary activities such as radio, television,
or reading.
Refocuses client’s attention, promotes positive attitude,
and enhances comfort.
Encourage continuation of breastfeeding as client’s
condition permits. Otherwise suggest and provide
instruction in the use of manual or electric breast pump.
Prevents discomfort of engorgement;
promotes adequacy of milk supply in breastfeeding
client.
Change client’s position frequently. Provide comfort
measures; e.g., back rubs, linen changes.
Reduces muscle fatigue, promotes relaxation
and comfort.
Encourage the woman to ask for pain medications
before the pain becomes severe/intolerable.
Pain is a lot easier to control before it becomes severe.
Apply local heat using heat lamp or sitz bath as
indicated.
Heat promotes vasodilation, increasing circulation to the
affected area and promoting localized comfort.
Administer analgesics or antipyretics. Reduces associated discomforts of infection.

231. 3. Risk For Altered Parent-Infant Attachment
Nursing Diagnosis
•Risk for Altered Parent-Infant Attachment
Risk Factors
•Interruption in bonding process.
•Physical illness.
•Perceived threat to own survival.
Desired Outcomes
•Patient will exhibit ongoing attachment behaviors during parent-infant
interactions.
•Patient will maintain/assume responsibility for physical and emotional
care of the newborn, as able.
•Patient will express comfort with parenting role.

232. Nursing Interventions Rationale
Monitor client’s emotional responses to illness and
separation from infant, such as depression and anger.
Encourage client to verbalize feelings and reinforce
normalcy as appropriate.
Normal expectations are of an uncomplicated postpartal
period with the family unit intact. Illness due to infection
alters the situation and may result in separation of client
from family or newborn, which can contribute to feelings
of isolation and depression.
Observe maternal-infant interactions
Provides information regarding status of bonding
process and client needs.
Provide opportunities for maternal-infant contact
whenever possible. Place pictures of infant at client’s
bedside (especially if nature of infection/client’s condition
or hospital policy requires separation of infant from
mother during febrile period).
Facilitates attachment, prevents client from engaging in
self-preoccupation to the exclusion of the infant.
Encourage father or other family members to care and
interact with the infant.
May be encouraging to mother to know that family is
caring for the infant and providing emotional support.
Note: Unexpected/prolonged hospital stay may reduce
father’s ability to spend time with newborn because of
other responsibilities, including care of siblings. Father
may require additional support during this stressful time.
Discuss availability or effectiveness of support systems
in home setting.
Client requires additional support to
accomplish homemaker tasks, allowing client to obtain
adequate rest and spend time with infant/other children.
Identify individual support systems. Refer
to visiting nurse services, home care agencies, as
indicated.
Client may require assistance with home maintenance
and activities of daily living while following discharge
instructions for rest and recuperation.

233. 4. Imbalanced Nutrition: Less Than Body Requirements
Nursing Diagnosis
•Imbalanced Nutrition: Less Than Body Requirements
May be related to
•Intake insufficient to meet metabolic demands (anorexia, nausea/vomiting,
medical restrictions).
Possibly evidenced by
•Aversion to eating.
•Decreased oral intake or lack of oral intake.
•Unanticipated weight loss
Desired Outcomes
•Patient will meet nutritional needs, as evidenced by timely wound healing,
appropriate energy level, and Hb/Hct within normal postpartal
expectations.

234. Nursing Interventions Rationale
Discuss eating habits including, food preferences and
intolerances.
To appeal to client what she likes/desires.
Note total daily intake. Maintain diary of calorie intake,
patterns and times of eating.
To reveal changes that should be made in client’s
dietary intake.
Promote intake of at least 2000 ml/day of juices, soups,
and other nutritious fluids.
Provides calories and other nutrients to meet metabolic
needs and replaces fluid losses, thereby increasing
circulating fluid volume.
Encourage choice of foods high in protein, iron, and
vitamin C when oral intake permitted.
Protein helps promote healing and regeneration of new
tissue. Iron is necessary for Hb synthesis. Vitamin C
facilitates iron absorption and is necessary for cell wall
synthesis.
Encourage adequate sleep/rest.
Reduces metabolic rate, allowing nutrients and oxygen
to be used for the healing process.
Assist with placement of nasogastric (NG) or Miller-
Abbott tube.
May be necessary for gastrointestinal decompression in
presence of abdominal distension or peritonitis.
Administer parenteral fluids/nutrition, as indicated.
May be necessary to combat dehydration, replace fluid
losses, and provide necessary nutrients when oral intake
is limited/restricted.
Administer iron preparations and/or vitamins, as
indicated.
Useful in correcting anemia or deficiencies when
present.

235. SUMMARY & CONCLUSION
Puerperal
complications
•Breastfeeding difficulties
• Low milk supply
• Cracked nipples
•Breast engorgement
•Postpartum bleeding
•Postpartum depression
•Postpartum psychosis
•Postpartum thyroiditis
•Puerperal fever
•Puerperal mastitis

236. Any Question ?