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LO4: Mange post-natal complications

Providing care for a mother with breast problem.
There are five common breast problems in the puerperium:
1-Breast engorgement
2 -Cracked & retracted nipple
3-Breast abscess
4-Failing lactation.
5- Mastitis
Breast engorgement
Definition:- Abnormal accumulation of milk in the breast due to excessive production of milk or
obstruction to out flow of milk or poor removal of milk by the baby.
This is where the ducts become blocked usually occur b/n 3rd& 5th day and the milk cannot pass
the lymphatic’s become engorged and the breast become edematous.
-It usually manifests after the milk secretion states (3rd or 4th postpartum day)
Symptoms - The breasts are full, hard and heavy due to venous and lymphatic engorgement and
edema
-Breast feels tender, tense & firm
-Nipple becomes edematous & flushed
-The veins over the breast becomes engorged & prominent
-Pain full breast feeding.
-Increased body Temperature.
Prevention: -
- Clean and dry nipples properly after each feed
- Don’t let the baby suck for a long period during the 1st two days after delivery.
- Make sure that the baby’s mouth is on the nipple properly
- Express the breast during pregnancy so that the colostrum comes out
- This is done from the 36th wks and it clears the ducts.
Treatment:-If the nipples are cracked and sore take the baby off the breast for 48hrs, until the
cracks are healed.
- Express the milk and feed the baby with a cup of spoon
- Apply heat to the nipples TID(three times a day) for 20 → will help healing
- Zinc benzoic ointment
- Keeps baby at breast feeds
- Decrease fluid intake
- A binder will help to support the breast
- Doctor may order diuretics (like lasix 20 -40 mg) usually a single dose.
Nursing/midwife care
-Support the breast with a binder or brassieres.
-Manual expression of any milk after each feeding & keeping the interval short b/n feeds.
-The cause of poor sucking by the baby should be corrected.
-Analgesics for pain.
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Puerperal mastitis: - is an inflammation of the breast which is not treated may proceed to
abscess formation
- Common organism: - staphylococcus aurous.
- It is usually caused by either cracked nipples or engorged breasts.
Source of infection -The baby
-Out breaks of skin
Predisposing factors: -
- Multiplication of organisms in engorgement
- Bruising of the breast tissue
- Cracked nipple which permits the inflammation:-introduction of organism sometimes
from the baby’s nose.
S/S: - A sharp rise in temperature 38.3oC – 40oC with chills
- Rapid pulse
- Throbbing pain and tenderness in the breast
- A diffuse or wedge shaped indurated reddened area
- Generalized malaise with head ache and shivering
- The over laying skin is hot & flushed feels tense & tender.
- Sever pain & swelling on the guardant of the breast with its apex at the nipple.
Mgt: – Avoid acute arrangement and cracked nipples cleanliness of breasts, hands Prompt,
recognition of the early sign and immediate administration of antibiotics
Prophylaxis
-Support the breast with binder
-ANC to nipple
-Prevention of engorgement
-Isolation of the infected baby
Curative-Isolation of mother & baby

- Cloxacillin is the drug of choice

- Crystalline penicillin 5,000,000IU stat then 500,000 ID IU 4-6hrs.
- Suspension of breast feeding until the infection is controlled on the affected side.
- Manual expression of milk to prevent engorgement.
- Suppression of lactation by - bromocriptine 2.5mg Po for 14days.
- Antibiotics - cloxacilline 500mg Po qid for 7-10days.
- Crystalline penicillin 5,000,000IU stat then 500,000 ID IU 4-6hrs.
- A procaine penicillin 900,000 IU or 3me is then given daily
- Analgesics to reduce pain & to induce sleep
E.g. Codeine, panadol
Prevention:-
 Treat cracked nipple & engorged breast
 Keeps the breast with good hygiene
Breast Abscess – is the pus formation in the breast
-The breast is usually recognized by a triangular red area& fluctuated when you press it
-caused by neglected mastitis.
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S/S -Pain, tenderness & indurations increases, the skin is red shiny and the breast much
enlarged
- Fluctuation and alteration in vital sign
- Raise in temperature and sweating
- Rapid pulse and brawny edema
- Rigors are common
- Axially gland becomes tender & enlarged and edema
Mgt: - Isolation
- Incision and drainage
- Bacteriological examination of the pus
- Appropriate antibiotics
- Large dressing after incision in firmly
- Antipain as needed
Prevention
-Treat acute mastitis properly

Retracted nipple

 -Is common in primigravida

-If left uncorrected it may lead to difficulty in breast feeding & predispose to cracked
nipple.
 Manually pulling out the retracted nipple during the last two month of pregnancy
is useful to rectify the defect.
 After delivery, the nipple is pulled out by the suction of disposable syringe.
 The procedure may have to be repeated for few days.

Cracked nipple
 The nipple may become painful due to loss of surface epithelium, with the
formation of a raw area on the nipple - called cracked nipple.
 This is when the nipple gets a cut in them caused by the baby while sucking and
predisposed to by lack of proper breast hygiene in prenatal time &which baby is feeding
Cause -In adequate hygiene resulting in the formation of a crust over the nipple
-Retracted nipple.
-Vigorous sucking & inadequate milk flow.
S/S -Soreness & pain at the site of fissure.
-If infected leads to mastitis.
 Prevention:-
- Rolling the nipple during pregnancy
- During puerperium not allowing baby to suck too long or to suck on empty breast
- warming breast before and after feeding to avoid crust which may cause cracking
- Local cleanliness during pregnancy & puerperium.

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Rx Take baby off breast baby must be spoon fed

-Keep the nipple dry & exposed to air.
-Breast milk should removed by manual expression or pump.
-If infected apply antiseptic cream locally.
-Apply analgesic tincture of benzoin after the night feeding.
-If it fails to heal, breast feeding from an affected breast is stopped for 24 hrs.
-Apply either Nupercaine cream which has an antibiotic
-Analgesic for pain.
Failing lactation
Causes - Debilitating state of mother
-Elderly primigravida
-Depression (anxiety) state of mother
-Premature baby who is too weak to suck.
-Painful breast lesion.
-Failure to feed (suck) the baby regularly.
Rx
Antenatal -Health education about the advantage of breast feeding.
-Correction of abnormalities like retracted nipple.
-Proper breast hygiene especially in the last two months of pregnancy.
-Improving the general health status of the mother.
Postnatal -Encourage adequate fluid intake
-Nurse the baby regularly.
-treat painful lesion
-Give drug like prolactin (thyroid extract)
Sub-involution
Definition-is incomplete return of an organ (Uterus) to its non pregnant size & shape during
puerperium.
It is a term applied when the uterus doesn’t contract properly to its normal size, the first day after
delivery. The fundus rises to the umbilicus then gradually shrinks about 1cm each day.
Causes: - Retained placenta
- Puerperal sepsis
- Prolonged labour
- Weak uterine muscle
- Grand- multiparty
- Endometritis
- Myoma - Interfering with the complete contraction of the ux.
Sign and symptoms: -
- Bulky and soft uterus
- Lochia is profuse and reddish brown
- The fundal height remains stationary for a few days
Prevention: - Make sure that the placenta is expelled & complete

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- Put the baby to the breast as soon as possible, if both mother and the baby are normal.
- Keep the uterus well rub bed up and contracted after delivery
- Get the mother out of the bed the first day after delivery, provided that she is normal
Rx: - If there is retained product, massage the uterus and evacuate and curettage will be
performed
Ergometrine 0.5mg tablets 1-2 times PO TID for a week or every 12 hrs to improve complete
involution of Uterus
-Antibiotics if the Uterus is tender on palpation.
-Ampicilline 500mg Po qid for 10-14 days.

Deep vein thrombosis (DVT)

Deep vein thrombosis (DVT)a blood clot, almost always is one of the deep veins in the legsis a
rare complication during the puerperium.
However, when it occurs it can be rapidly fatal if the clot breaks away from the vein in the leg
and travels to the heart, lungs or brain, blocking vital blood vessels.
The chance of developing a DVT is more common during pregnancy than in the non-pregnant
state, and the risk increases during the puerperium. Why deep veins in the legs develop clots
(thrombosis) is not exactly known.
However, the risk is much higher when the postnatal woman spends most of the time in bed and
doesn’t walk about much for several days after the birth.
In most parts of Ethiopia, the local custom is for postnatal women to remain in bed, with no
activity except a short walk to use the latrine. So it is important for you to identify the clinical
features of DVT, make a diagnosis and refer her to a hospital as early as possible. Pregnant
women are at increased risk of DVT b/c - hyper coagulable state of the blood. It is a condition
when a clot formation in the venous usually of the lower limbs
Clinical features of deep vein thrombosis (DVT)

-Pain in one leg only: usually sudden onset, persistent and aching type of pain.
-Tenderness: the area is painful when you touch it.
-Swelling: the affected leg is swollen with greater than 2 cm difference in
circumference compared to the other (healthy) leg. The swelling may be in the
calf or the thigh.
- Palpable cord: you may feel a cord-like structure deep in the swollen leg.
- Change in limb colour: the affected leg appears a little bit red.
- Calf pain: she will feel pain when you try to do extreme extension at the ankle
joint.
- Rarely bilateral and Fever
- Positive “Homan’s sign” - pain on dorsiflexion of the foot.
Rx -Immobilization of the leg & immediate referral.
-Anticoagulant – warfarin or Heparin

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Throbophlebitis: - is an inflammation 2nd to a clot that has formed in superficial veins or

varicose veins as a result of stasis & hyper-coagulability state of blood during pregnancy &
puerperium.
S/S- Reddened area over the vein is not due to infection but as a result of clot reaction
- Pain in the leg
- The area is firm on palpation from clotting lying in it

Mgt: - Bed rest

- Supportive bandage or elastic is warm
- Elevate the leg when sitting & exercise
- Analgesics e.g. Butazolidine
- Heparin or anticoagulant
Phelebothrombosis: - is a condition when a clot is formed in the deep vein of the calf of
femoral and some times in the iliac vein.
Causes: - After pelvic or abdominal operation
- Vein stasis (woman aged > 35years)
- High parity and - Obese
S/S pain and swelling
Danger: - Fragments can be detached and cause pulmonary embolus
- If the clots is large the artery is completely blocked and sudden death can occur
Mgt: - Anticoagulant e.g. Heparin
- Early ambulation or exercise
- Prevention of anemia
- Bed rest and anti-pain until pain disappears
- Bed should be elevated
Pulmonary embolism: - is caused by clots that blocks the artery being traveled from the
veins in the pelvis or legs
S/S: - Pt may collapses and dies without warning
- Acute chest pain due to ischemia of the lung
- Blood stained sputum
- Cyanosis and collapse
- Dyspnea and hypotension
- Marked distress and respiratory failer& cardiac arrest
Mgt: - Call the physician urgently
- Pt will be propped up with pillows and O2 is given
- Anticoagulant therapy
- Administration of IV morphine
- Resuscitation if necessary
- Investigation → Chest cardiography
→E C G

Information sheet 1 ABNORMAL PUERPRIUM

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1. PROVIDING CARE FOR A MOTHER WITH PURERPERAL SEPSIS

Puerperal sepsis is any bacterial infection of the genital tract which occurs after the birth of a
baby. It is usually more than 24 hours after delivery before the symptoms and signs appear. If,
however, the woman has had prolonged rupture of membranes or a prolonged labour without
prophylactic antibiotics, then the disease may become evident earlier. It is a temperature
elevation of 38 degree centigrade or more occurring at least twice after the first 24 hours
and before the 10 post partum day until 6 wks of delivery or abortion.
- Site of infection include: the endometrium, breast tissue, perineal or abdominal wounds
and the venous system.
Causative organisms
- Arises as a result of the invasion, incubation and multiplication of an organism.
- The infection in the uterus is usually due to retained products of conception where the
laws of sterility have not been observed.Induced abortion is the main cause
- Interference during delivery
- low sterility technique
- Prolonged labour
- Early rupture of the membrane
- Microrganisms
- Puerperal sepsis is more likely to occur in the following women in whom bacteria could
have been introduced in to the genital tract during delivery.
 Women who had premature rupture of membrane & delivery was delayed
 Women who had instrumental or operative delivery.
 Women whose resistance to infection has broken down e.g DM, anaemia,
 Women who got dehydrated during labour
 Women who had severe haemorrhage or shock
- Some of the most common bacteria are:
- streptococci
- staphylococci
- Escherichia coli (E.coli)
- Clostridium tetani
- clostridium welchii
- Chlamydia
- Gonococci (bacteria which cause sexually transmitted diseases).
- More than one type of bacteria may be involved when a woman develops puerperal
sepsis.
- Bacteria may be either endogenous or exogenous.
- Endogenous bacteria These are bacteria which normally live in the vagina and rectum
without causing harm (e.g. some types of streptococci and staphylococci, E.coli,
clostridium welchii).
- Even when a clean technique is used for delivery, infection can still occur from
endogenous bacteria.
- Endogenous bacteria can become harmful and cause infection if:

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- they are carried into the uterus, usually from the vagina, by the examining finger or by
instruments during pelvic examinations
- there is tissue damage, i.e. bruised, lacerated or dead tissue (e.g. after a traumatic delivery
or following obstructed labour)
- There is prolonged rupture of membranes because microorganisms can then enter the
uterus.
- Exogenous bacteria These are bacteria which are introduced into the vagina from the
outside (streptococci, staphylococci, clostridium tetani, etc.).
- Exogenous bacteria can be introduced into the vagina:
- By unclean hands and unsterile instruments
- By droplet infection (e.g. a health provider sneezing, coughing onto own hands
immediately prior to examination)
- by foreign substances that are inserted into the vagina (e.g. herbs, oil, cloth)
- By sexual activity.
- Students should be aware of the problem of postpartum tetanus and sexually
transmitted diseases which are both caused by exogenous bacteria.

Risk factors for puerperal sepsis

Most common complications of puerperium occurring in 1-3% of vaginal deliveries&
25-50% of c/s deliveries.
Route of deliveries
Prolonged rupture of membranes >12 hrs.
Prolonged labour
Multiple pelvic examinations
Chorioamnionitis
Intrauterine manipulations like manual removal
Remnants of placenta and genital lacerations
Systemic factor immune suppressive.
Some women are more vulnerable to puerperal sepsis, includingfor example those who
are anaemic and/or malnourished. For example, protracted labour, prolonged rupture of
the membranes, frequent vaginal examinations, a traumatic delivery, caesarean section
and retained placental fragments all predispose to puerperal infection.
Symptoms and signs of puerperal sepsis
The following symptoms and signs occur in puerperal sepsis:

- fever (temperature of 38°C or more)

- chills and general malaise
- lower abdominal pain and tender uterus
- Sub-involution of the uterus
- Purulent, foul-smelling lochia.
- Light vaginal bleeding and shock.
Types of puerperal sepsis
A. Localized: - involving the vulva and vagina (swabs or tampons left inside),
episiotomy or endometritis.

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B. Generalized: - Spreading to the tubes (salpingitis) cellulites.

- Spreading to the peritoneum → peritonitis
- Spreading to the blood stream → septicemia

S/S: - Cardinal signs

A. Early raised temperature persisting for 24hours > 37oC – Raised pulse rate 120/minute
B. late – Sub-involution
- Offensive lochia foul smelling
- increased WBC count
Investigations: - Physical examination to exclude all other infections like throat, Breast,
lungs, legs.
- High vaginal swab
- Blood (RBC), Hgb, WBC count and culture
1- Endomyometritis
.It is infection of the endometrium and myometrium
.It is the commonest form of puerperal sepsis
.If untreated it progresses to pelvic peritonitis and generalized peritonitis, pelvic
abscess, septicemia and thrombophlebitis.
Symptoms like fever, profuse or malodors lochia, lower abdominal pain.
.Temperature of >38oC, tachycardia, lower abdominal tenderness and uterine
tenderness with sub involution.
. Laboratory investigations reveal leukocytosis.
Management
- All cases should be admitted
- Start broad spectrum antibiotics and continued until the patient is fever free for 24-48
hours.
- If there is RPC the uterus should be evacuated.
- Resuscitation with IV fluids, anti-pyretic and bed rest.
- Isolate the patient as this infection spreads quickly
- Antibiotics usually ampcillin until culture is back. Cloxacillin usually the most effective
antibiotics.
- Analgesics and antipyretics
Midwifery Care
- Isolation of the pt
A clean and an infected patient should not be nursed at the same time
All the utensils should be separated
The room should be disinfected after discharge
- Antibiotics and analgesics according to the Dr’s order
- Iv fluid administration
- NGT and aspiration
- Input and output charge
- Care for pressure area
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- Mouth care
- Bed bath
- Bladder catheterization
- Bowels: - Supposition or enema if there is constipation
- Room should be clean
Observation
- Vital signs or To, RR, PR every 4hrs
- Report any rise in temperature

- Mental status
- Sleep and appetite
- Fluid balance sheet
Complications
- Pelvic and generalized peritonitis, pelvic abscess, thrombophlebitis, septic shock and late
complication infertility and ectopic pregnancy.
Preventions
- Aseptic technique during procedure
- Avoid traumatic delivery
- Avoiding repeated pelvic examinations
- Preventing prolonged labour
- Proper third stage management
- Treating systemic illness and nutritional deficiency.
2- Wound infection
It includes episiotomy site infections, infections of lower genital tract tears and abdominal
wound infections after c/s or laparotomy.
Episiotomy site infection present with persistent pain and offensive discharge from the site.
Abdominal wound infection includes persistent pain, over the wound and tender indurated,
swollen and reddened wound edges with fever.
Management
- Removal of sutures and drain abscess if any.
- Provision of local wound care with antiseptic solutions
- Antibiotics indicated only if there are systemic signs of infections
- Secondary closure may be needed after signs of infection have cleared.
Signs & symptoms
- Sub-involution offensive lochia(1st sign)
- uterus became bulky ,painful & tender
Later:-
 pyrexia over37oC (high sweating fever and occasionally rigrs & chills)
 pulse rate of 120 and over
 foul smelling lochia
 severe abdominal tenderness
 raised WBC count
Investigation:-
- History of labour
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- Physical examination
- High vaginal swab
- Blood WBC count.
Management
1-isolate pt this infection spreads quickly
2-antibiotics, usually Ampicilline, cloxacillne is also the most effective antibiotic.
3-Analgeric & antipyretic
The infection may be
1- localized involving the vulva, vagina, endometrium & episiotomy site
2- generalized by spreading to the uterus, peritoneum and old stream
If spread of infection occurs like Salpingitis, peritonitis, septicaemia,
- The is a very sick pt who needs good care and much kindness
- It is often seen in mothers who has been admitted to hospital with rusted(reddish) uterus
C/s after being many days in labour or after criminal abortion.
Nursing care:-
1-isolate the Patient
2- Antibiotic &analgesics
3-Intraventous fluid
4- Intake& output balance
5- Frequent change of position (prevent decubitus)
6- General patient hygiene
HOW PUERPERAL SEPSIS OCCURS
The uterine infection may start before the onset of labour i.e. in cases of pre-labour rupture of the
membranes, during labour, or in the early postnatal period before healing of lacerations in the
genital tract and the placental site have taken place.
In cases of pre-labour rupture of membranes, antibiotics should be given either to treat
amnionitis, if the woman has fever and foulsmelling vaginal discharge, or as a prophylactic
measure to reduce the risk of infection.
Following delivery, puerperal sepsis may be localized in the perineum, vagina, cervix or uterus.
Infection of the uterus can spread rapidly if due to virulent organisms, or if the mother’s
resistance is impaired. It can extend beyond the uterus to involve the fallopian tubes and ovaries,
to the pelvic cellular tissue causing Thrombophlebitis of the uterine veins can transport infected
clots to other organs. Severe infection can be further complicated by septic shock and
coagulation failure which gives rise to bleeding problems. Puerperal sepsis can be rapidly fatal.
Women are particularly vulnerable to infection in the postpartum period because of the following
factors:

1. The placental site is large, warm, dark and moist. This allows bacteria to grow
very quickly. It is an ideal medium to culture bacteria. In the laboratory, warm,
dark and moist conditions are produced artificially in order to help bacteria grow
and multiply.

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2. The placental site has a rich blood supply, with large blood vessels leading directly
into the main venous circulation. This allows bacteria in the placental site to move
very quickly into the bloodstream. This is called septicemia. Septicemia can lead
to death very quickly.
3. The placental site is accessible via the genital tract to both endogenous and
exogenous microorganisms. Only the vagina (7–10 cm long) separates the
entrance to the uterus from the vulva and perineum. Therefore, high standards of
vulval and perineal cleanliness during labour and after delivery are essential to
prevent harmful bacteria (e.g. E.coli from the rectum) from entering the uterus
and causing metritis.
4. p During the actual birth, women may have sustained tears in the cervix, vagina or
perineal area or have had an episiotomy. These areas of traumatized tissue are
susceptible to infection, especially if the aseptic technique during vaginal
examinations and at delivery was poor, and the situation is exacerbated by poor
standards of perineal and vulval cleanliness in the early postnatal period. Infection
is usually localized initially, but can spread to underlying and surrounding tissues
and into the bloodstream, causing septicemia.

OTHER CAUSES OF FEVER IN THE POSTPARTUM PERIOD

Fever in the puerperium can also be caused by:

- urinary tract infection (acute pyelonephritis)

- wound infection (e.g. scar of caesarean section)
- mastitis or breast abscess
- thrombo-embolic disorders, e.g. thrombophlebitis or deep vein thrombosis
- respiratory tract infections (pneumonia)
- other medical conditions, such as malaria and typhoid
- human immune deficiency virus (HIV)-related infections.
Puerperal pyrexia: - is a temperature of 38oC occurring within 14days of delivery or
abortion.
Causes: - Puerperal sepsis or genital tract infection

- Breast and urinary tract infection

- Thromboembolic disorders and wound infection (C/S)
- None infectious disorders e.g. breast engorgement
- Pyelitis: - Acute inflammation of the pelvis of the kidney, caused by bacterial infection.
- cystitis:- inflammation of the urinary bladder
- Mastitis or breast abscess
Puerperal eclampsia: - is the onset of convulsion during puerperium: Occurs 48-72hrs after
delivery
S/S – Elevated blood pressure
- edema of the legs, and feet, puffiness of the face
- Albumin urea
- Severe headache
- Epigastric pain and nausea

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- Convulsion and coma

- Rapid pulse and bounding
- Raised temperature
Treatment: - Prevent patient from injury
- Clear air way
- Mouth spatula to prevent the tongue from biting (before convulsion)
- Relieve vasoconstriction
- Promote diuresis
- Sedatives as ordered by physician
- If severe- tracheal intubation may be required
Nursing/midwife Care: - Similar with eclampsia under abnormal pregnancy
Postpartum tetanus: -is infection of the mother or baby caused by clostridium tetani. Tetanus
bacilli, which grow in the intestines of animals and humans, are particularly prevalent in rural
areas. They are found in soil and dust and are spread by animal and human faeces. The
organisms enter the body through a laceration or break in the skin. In the case of puerperal
sepsis, they may enter via lacerations of the genital tract or through the unhealed placental site.
In some countries, it is the practice to place herbs or other substances that may be infected into
the vagina during or after labour, in the mistaken belief that it will be helpful. In babies, the point
of entry is often the umbilical cord, especially if it is cut with a dirty instrument, or in some
cultures, herbs or cow dung are used to dress the cord.
Tetanus is an acute and often fatal disease, but it can be prevented by immunization. All women
in pregnancy should have their immunization status checked and be given a course of tetanus
toxoid, if not fully immunized. The schedule for immunization is as follows:

- First contact with women of childbearing age: Tetanus toxoid 1 (TT1)

- At least 4 weeks after TT1: Tetanus toxoid 2 (TT2)
- At least 6 months after TT2: Tetanus toxoid 3 (TT3)
- At least 1 year after TT3: Tetanus toxoid 4 (TT4)
- At least 1 year after TT4: Tetanus toxoid 5 (TT5)
In areas where sexually transmitted infections(STIs) (e.g. gonorrhea and chlamydial infection)
are common, they cause many uterine infections. If a woman develops a STI during pregnancy
and it remains untreated, the microorganisms causing the disease will stay in the genital tract and
may cause a uterine infection after delivery. Uterine infections caused by STIs can be prevented
by diagnosis of the condition and implementing the appropriate treatment during pregnancy.

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LO5: Psychiatric disorders

Psychiatric disorders in the postnatal period
Psychiatric disorders are relatively common after childbirth and may include postpartum ‘blues’,
postpartum depression (PPD), and postpartum psychosis.
-This is when the pt is mentally disturbed during the puerperium especially the first 2wks.
Puerperal and labour may place a great strain on the women and the result of this can have either
depression or mentally illness.
Postpartum ‘blues’ and postpartum depression
Hormone changes are thought to be the cause of postpartum blues, a mild, transient, self-limiting
disorder (it resolves on its own), which commonly arises during the first few days after delivery,
and lasts up to two weeks. It is characterized by signs of sadness, crying, anxiety, irritation,
restlessness, mood swings, headache, confusion, forgetfulness, and insomnia. It rarely has
much effect on the woman’s ability to function, or care for her baby.
Providing loving support, care and education has been shown to have a positive effect on
recovery. Loving support can help women to recover from postpartum ‘blues’.
But if women develops a serious postpartum depression (persistent sadness, low mood, difficulty
in finding motivation to do anything), it will greatly affect her ability to complete the normal
activities associated with daily living. Cases of depression need attention from trained mental
health professionals for supportive care and reassurance, so refer the woman as soon as you can.
The role of the patient’s family is also very important in the course of treatment. Women with
high levels of depression are less likely to initiate breastfeeding soon after the birth, and their
babies are more likely to have episodes of illness such as diarrhea.
■Can you suggest why the baby might be affected in this way?
□If breastfeeding is not commenced successfully the woman may bottle feed the baby with
formula milk, which carries a greater risk of infection to the baby from unclean bottles. A
depressed mother may also not take notice of health education messages about preventing
infection in her newborn.
If two or more of the following symptoms occur during the first two weeks of the puerperium,
refer the mother:

-
Inappropriate guilt or negative feelings towards herself
-
Cries easily
-
Decreased interest or pleasure
-
Feels tired and agitated all the time
-
Disturbed sleep, sleeping too much or sleeping too little
-
Diminished ability to think or concentrate, Marked loss of appetite.
-
There may also be episodes of postpartum psychosis, marked by delusions
(paranoid or irrational beliefs or hallucinations – seeing or believing (hearing)
things that are not real.
Early signs: - Persistent insomnia for no apparent reason

Post Natal care for Midwifery 2nd year students

Zekariyas M.
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-
The night duty should check if the mother sleeps at night, otherwise report to the
doctor.
Later sign: - Patient does not like nurse or Doctor or husband or all of them
- Becomes restless, refused, food, becomes emaciates
 Post partum blues or depression should not be mixed up with mental illness
Rx: - Reassurance, don’t leave her alone
- Remove her baby, she may harm him/her
- Remove everything that can harm her self
- Sedation according to Dr’s order
Depression or mental illness
Early sign:-
- persistent insomnia for no apparent reason
- it is the duty of the night nurse to check if the mother sleep at night and if not to report it
and give sedative ordered by doctor
Later signs
- pt does not like nurse or doctor or husband or all of them.
- She may become restless and have incorrect speech
- She refuses food and often become emaciated
Treatment:- Reassure her don’t leave her alone.

- Remove her baby (she may harm him)

- Remove anything that can harm herself
- Report to doctor who orders sedative
NB- “post partum depression” or” post partum blues” or “3rd day blue” must not be mixed up
with mental illness.

Postpartum Psychosis
Postpartum psychosis is the most severe form of postpartum psychiatric illness.

It is a rare event that occurs in approximately 1 to 2 per 1000 women after childbirth.

Its presentation is often dramatic, with onset of symptoms as early as the first 48 to 72 hours
after delivery. The majority of women with puerperal psychosis develop symptoms within the
first two postpartum weeks.

It appears that in most cases, postpartum psychosis represents an episode of bipolar illness; the
symptoms of puerperal psychosis most closely resemble those of a rapidly evolving manic (or
mixed) episode.

The earliest signs are restlessness, irritability, and insomnia. Women with this disorder exhibit a
rapidly shifting depressed or elated mood, disorientation or confusion, and erratic or
disorganized behavior. Delusional beliefs are common and often center on the infant. Auditory
hallucinations that instruct the mother to harm herself or her infant may also occur. Risk for
infanticide, as well as suicide, is significant in this population.
Post Natal care for Midwifery 2nd year students
Zekariyas M.