ABNORMAL PUEPERIUM:

Class objectives:
1) Define abnormal pueperium.
2) Identify thromboembolic disorders in abnormal
pueperium.
3) Discuss the complications, treatment and their
management.
4) Describe the puerperal sepsis and pueperium
pyrexia.
5) Psychiatric disorder in pregnancy
Definitions:
Definitions:
 Abnormal Pueperium: a condition manifested by the
signs of high temperature ,and abnormal vaginal
discharge during the 6 weeks postpartum period.
Common complications during
pueperium:
Thrombus: a blood clot formed within a blood vessels
and remaining attached to its place of origin.
Thrombosis: The formation of a thrombus in a blood
vessel.
Embolus: An abnormal particle eg an air bubble or part
of clot) circulating in the blood.
Embolism:
Occlusion of blood vessels by an embolus.
1. Thromboembolism:
 Thromboembolis:
Is a blood clot formed within a blood vessels
and remaining attached to its place of
origin.
Predisposing factors:

 A past or family history of thrombosis

 Immobility due to disablement, epidural
anaesthesia,paralysis or medical condition.
 Postoperatively in particularly following emergency
caesarian section.
 Congenital deficiency of ant thrombin III.
 Obesity , age >35yrs and parity >4.
 Severe varicose veins.
 Current other infections or illnesses.
Types of thrombosis:
1) Superficial thrombo-phlebitis
2) Deep vein thrombosis.
Superficial thrombo-phlebitis
Superficial thrombo-phlebitis: It affects the super visual
vein of the legs .
The signs and symptoms like:
Swelling,
hardness of the area,
slight pyrexia 4th to 10th day.
Cont:superficial thromboflebitis
It does not lead to pulmonary embolism
More common in women who are overweight.
There is possibility for these women to develop deep
venous thrombosis.
Midwife should examine the legs carefully to exclude
signs of deeper thrombosis and inform doctor.
Cont:superficial thromboflebitis;
Give reassurance and supportive bandage is helpful.
Encourage exercises.
Avoid crossing legs and they should be elevated when
woman is sitting.
Deep vein thrombosis (DVT):
Thrombosis of the deep veins of the calf, thigh or
pelvis may predispose to pulmonary embolism.
This is suspected only with the following signs:
Tenderness to the leg
Pain on walking or when the deep veins in leg are
pressed.
Swelling of the area(2-3 cm>than non affected area,
temperature may be raised).
Deep vein thrombosis (DVT):
If the vein is obstructed the clinical signs are more
marked but if no obstruction there will be no clinical
signs.
DVT is manifested during the first 2weeks after
delivery.
Take blood sample for full screening including
prothrombin time.
Management and treatment of
DVT:
Mobilization may be restricted to:
Reduce the risk of detachment of the thrombus until
the prothrombin time has shown signs of
improvement and any swelling has subsided.
Treatment is usually by anticoagulant therapy therapy
(heparin 4000u IV per day for 5-10)
Oral warfarin may be given to maintain the activated
thromboplastin time until the end of pueperium.
Management and treatment of
DVT:
The use of anticoagulant must be carefully
controlled.
There is a potential danger of hemorrhage
occurring from the placenta site and of formation
of hematomas'.
If this occurs stop anticoagulant.
The effect of heparin can be reversed by an
intravenous of protamine sulphate.
Management and treatment of
DVT:
The midwife should advise the woman to report any
vaginal bleeding or vulva pain.
Give every explanation and important information to
the mother as reassurance.
2. Pulmonary embolism:
 This occurs when part of the clot breaks away from a
vessel wall and enters the system circulation.
 It causes an obstruction once it reaches a vessel
with a lumen smaller than itself, usually a
pulmonary artery.
Cont:pulmonary embolism:
Signs and symptoms of small pulmonary emboli:
 Chest pain
 Dyspnoea
 Coughing
 Slight haemoptysis.
 Pyrexia
 Tachycardia
Management and treatment of
pulmonary embolism:
 Emergency medical aid must be summoned.
 Oxygen must be given and IV heparin administered as
soon as possible and continued by infusion.
 Pain may be relieved by IV morphine and the woman’s
condition will usually improve within a few hours.
 Treatment should then continue as for DVT.
Cont: management:
 However the woman does not respond to this therapy
the advise of a vascular specialist should be sought.
 It should be remembered that events such as
embolism and hemorrhage may act as triggers to the
development of DIC.
PSYCHIATRIC DISORDERS OF PUERPERIUM:
 Introduction
With rapid physiological and psychological change
occurring during the first week of puerperium. It is not
surprising to find that many women experience
emotional ability during the first 3-4 days.
The preceding events of pregnancy, labour and
delivery together with the peak experience of giving
birth all contribute to a mixture of emotional
reactions.
Cont’
There are two district types of psychiatric
disorder associated with the
puerperium :
 puerperal psychosis.
 Postnatal depression.
Puerperal psychosis:
Puerperal psychosis is more common in :
Primigravida.
Those who have suffered previous major
psychiatric illness.
Those with family history of mental illness
and probably unmarried mothers.
 Cont’
The onset of puerperal psychosis is usually rapid,
occuring within the first few days of delivery and rarely
beyond the first 2-3 weeks.
Puerperal psychosis may have an acute onset or it may
develop more gradually .
Acutely or gradually, these become more profound
with extreme mood swings during which feelings of
guilt or anxiety may be expressed
 Sign and symptoms

acute restlessness.
Insomnia (unassociated with disturbance by her
baby).
Bizarre behavior (delusions or hallucinations)
becomes detached from her the reality of her
situation.
 Cont’
 She may avoid her baby.
 She may do or say inappropriate things.
 React out of character.
 At times she may appear depressed.
 She may take longer than expected to do simple tasks
such as nappy changing.
Cont:Puerperal psychosis:
She may forget when her baby was last fed.
The woman may experience suicidal
impulses or desires to harm her baby.
She may appear confused at times with
periods of hyperactivity.
Severely depressed patients may have
delusions that her baby is malformed,
abnormal or evil.
Management and treatment:
Keep woman under constant observation till
appropriate help is obtained.
Early intervention with antipsychotic drugs
is helpful.
Treatment is done under care of psychotic
team.
Introduce the mother and baby as soon as it
is considered appropriate and safe to do so.
(joint-admision)
 Cont’
The advantages of joint-admissions are:
Re-establishment of maternal –infant
relationship.
Observation of the interaction between
mother and baby & exploration of feelings.
To rebuilt self-esteem by encouraging care
of the baby in a safe environment.
 Cont’
The midwife should continue to visit both
mother and baby for postnatal care.
Complete recovery is often achieved but there’s
a possibility for further episodes of the illness
in subsequent pregnancies.
 The midwifes needs to be able to offer advice
and support to women during subsequent
pregnancies.
She should also contact the psychiatric team
when appropriate for a promport referral when
necessary
Postnatal depression:
Postnatal depression
Postnatal depression tends to be gradual.
It develops after the second postnatal week.
The conditions may last for 3-6 months and in some
cases it will persist throughout the 1st year of baby’s
life.
Such causes considerable disruption of family life and
maternal child relationships.
Causes of postnatal depression:
 It Appears to be more prevalent in women who have
experienced other stress –inducing life events around the
time of birth, such as
 Moving house
 Problems in relationship
 Low self-esteem
 Lack of close support networks.
 Stress associated with certain aspects of postnatal care.
 The dramatic change in the circulating hormones
progesterone and estrogen following expulsion of the
placenta are causative.
 Sign and symptoms
 During the pueperium, however, the woman may complain
of numerous indefinable physical symptoms.
 May appear overanxious about her baby in spite of evidence
that the infant is well and thriving.
 Tendency to experience difficulty failing asleep.
 Once asleep the woman may sleep for a long periods.
 They often feel well in the morning but deteriorate as the
day goes on.
 In most other depression, early walking is reported with
symptoms more acute in the morning but improving as the
day goes on.
 Cont’
The depressed woman may feel constantly tired in
spite of adequate periods of rest.
She feels unable to cope with the needs of her baby
and other family members.
She is likely to feel a failure as a mother hence afraid to
admit her feelings.
Awareness of body language and knowledge of the
individual woman may help the midwife to identify
potential risk.
Management and treatment:
 Early and initiation of appropriate treatment brings the
best treatment.
 Provide mild sedation and antidepressant in less severe
depression.
 Counseling in early stage.
 Involve the husband or partner and family members within
care is helpful.
 Admission in psychiatric ward when depression is
advanced.
 It should be remembered that untreated ,undiagnosed
clinical depression can evolve into psychotic illness.
 Cont’
Information about depression should be recorded in the
woman’s obstetric notes.
This is to ensure :
 the opportunity for planning increased
support.
 Early alleviation of symptoms in any
subsequent pregnancy.
 Prevention
Progesterone is thought to prevent recurrence of
postnatal depression.
Most women can be treated effectively by brief
supportive or problem-solving treatments.
A small proportion may benefit from antidepressant
medication.
Puerperal pyrexia and puerperal sepsis
Puerperal Fever/Pyrexia
Body temp. 38 degree C or more
recorded twice in the first 10 days after
delivery.
Causes of Puerperal fever

 Uterine infection
 Breast infection
 Urinary infection
 Malaria
 Thrombophlebitis
 Other incidental infections
puerperal infection
• The term puerperal infection refers to a bacteria
infection following child birth or miscarriage.
• The infection may also be referred to as puerperal or
post partum fever.
• The genital tract particularly the uterus is the most
commonly infected site. In some cases infection can
spread to other parts of the body.
puerperal infection…..
Widespread infection or sepsis, is a rare, but potentially
fatal complication, Puerperal infection affects
estimated 1-8% of women in puerperal.
Puerperal infection may occur in the;
 genital tract
 breast
 urinary tract
 lungs
 blood vessels or any wound.
Common causes of postpartum infection
are:
 Caesarian section.
 Endometritis ; is associated with prolonged rupture of
membranes.
 Urinary tract infections.
 Infected wounds.
 Septic thrombophlebitis.
Common causes of postpartum
infection are……
 Mastitis.
 Difficult vaginal birth which involved the use of
forceps or vacuum extractor.
 Multiple vaginal examinations.
RISK FACTORS
 Prolonged labor
 Obstructed labor
 Prolonged PPROM
 Frequent vaginal examinations
 Operative delivery
RISK FACTORS…….
 Poor prenatal nutrition.
 Un-repaired tears
 Post partum hemorrhage (PPH)
 Obesity.
 Anemia.
PATHOPHYSIOLOGY
 Localized infection gives rise to infected wounds and
lacerations, and occasionally abscess form.
 Pelvic infection occurs as a result of ascending of
infection from the perineum, vagina or cervix to the
uterine cavity.
 Then it is spread to the fallopian tubes causing
salpingitis and possible blockage of the tubes. It may
also spread to the peritoneum.
PATHOPHYSIOLOGY CONT..
A patient who develops salpingitis or peritonitis
becomes severe ill, with a
 thread pulse,
pain on abdominal on palpation,
vomiting and diarrhea leading to rapid
dehydration.
Lateral spread invades the parametric and causes
pelvic cellulites. If Septicemia occur it can cause
rigor and persistent high fever, and the patient is
seriously ill.
SIGNS AND SYMPTOMS
CONT…..

 Fever that develops within the first 10 days after giving

birth
• A fever 38.50 C, fever of or above in the first 24 hours
after giving birth.
 Lochia may be offensive and suppuration of lacerations and
of the suture line may be visible. Lochia may be scanty only
for 24hours if caused by hemolytic streptococci.
 General body Malaise.
 Abdominal pain.
 Loss of appetite.
 Vomiting and diarrhea.
 The uterus is tender in palpation.
INVESTIGATIONS.
 Any pyrexia following birth or miscarriage which
persists for 24hours should be regarded as
infection of genital tract.
 A full general examination is made after delivery.
 High vaginal swab is taken to identify causative
organisms.
 Mid – stream specimen of urine, to establish the
source and cause of infection and sensitivity of the
causative organisms to various antibiotics.
 Blood culture of the organism
INVESTIGATIONS CONT ….
 Ultra sound examination or CT scan is done to locate
potential abscess or blood clots in the pelvic region.
 MRI may be used
 Chest X- ray also may be ordered if the lung infection
is suspected.
MEDICAL MANAGEMENT.

 Antibiotic therapy is the backbone of puerperal

infection treatment.
 Initial antibiotic therapy may consist of
clindamycin and gentamicin, which fight a broad
array of bacteria types. If the fever and other
symptoms do not respond to these antibiotics, a
third, such as
ampicillin, is added.
 Other antibiotics may be used depending on the
identity of the infective bacteria and the possibility of
an allergic reaction to certain antibiotics
MEDICAL MANAGEMENT CONT..
 Analgesics may be given to relieve pain and fever
e.g. paracetamol.
 Intravenous infusion may be necessary if there are
signs of dehydration.
 Blood Transfusion in case of anemia. .
 If an abscess has been diagnosed,
surgical drainage may be required.
In the presence of thrombophlebitis,
heparin therapy will be needed to provide
anticoagulation.
NURSING MANAGEMENT

 Good prenatal care is essential for avoiding the risk

of infection after childbirth.
 Post-partum nurses assess patients for signs and
symptoms of infection and educate patients about
these signs and symptoms prior to discharge
 Encourage regular bathing to increase comfort and
maintain personal hygiene.
 Change vulvae pads frequently to prevent ascending
infections.
 Encourage to eat light nourishing diet to improve
health and immunity.
 Check vital signs. Temperature, Pulse rate, respiration
and blood pressure to evaluate patient progress.
 Record or monitor intake and output chart.
NURSING MANAGEMENT CONT…
 Collect all investigations as prescribed e.g.
hemoglobin estimation.
 Protect the mother from unnecessary stress and
over tiredness, to promote psychological
wellbeing.
 Take care of the baby at the Mother’s bed side do
not move the baby unless is severely ill
POSSIBLE COMPLICATION
 Septicemia
 Haemolytic anemia
 Jaundice.
CONCLUSION

Careful attention to antiseptic procedures during

childbirth is the basic underpinning of preventing
infection. With some procedures, such as cesarean
section, a doctor may administer prophylactic
antibiotics as a prevemptive strike against infectious
bacteria.
Breast Problems
 Retracted / cracked nipples
 Breast engorgement
 Mastitis
 Breast abscess
 Failure of lactation
Common breastfeeding problems
 Engorgement
 Condition where by the breast become swollen and
painful with poor flow of milk
 It is caused by too much milk and tissue fluid collecting in the
breast
 Normally occur few days after delivery mostly due to delay in
breastfeeding
 Unrestricted breastfeeding soon after delivery and baby
suckling in good condition usually prevent the problem
 To treat engorgement, it is essential to remove the milk
 Warm the breasts and express the milk
 Mother should continue to breastfeed the child as per
demand
 Blocked duct
 This a tender swelling that forms in one part of a
breast
 This is due to that the milk is not getting out of that part
of the breast
 Advice the mother to feed the baby frequently on the
side with swelling
 While the baby is suckling, the mother can gently
massage the swelling toward the nipple
 Express the milk while massaging the swollen part
 Mastitis
 Untreated engorgement or blocked duct can be infected
and result to mastitis or an abscess
 The breast become very tender and the mother fill
unwell and has fever
 Express the milk
 Continue breastfeeding
 Refer the mother to the doctor
 Mother need to rest
 Sore nipples
 These are cracks and/or fissures, on the nipple skin
 Caused by suckling in poor position
 A drop of hindmilk can help to heal the nipple
 Dry the nipple in dry air
 The pain usually stops as soon as the suckling position
improves
 Sore nipples which continue for a long time or sharp
pain which goes deep into the breast may be due to
infection
 The baby may have white patches of thrush in her
mouth, then send them for medication
 Flat nipples
 Shape of the nipple is not an issue, the issue is whether
the nipple can be stretched out easily
 If the nipple does not stretch easily it is important to
help the child so that she can take enough breast into
her mouth form a nipple
Cultural beliefs and attitudes
affecting breastfeeding
 Colostrum is not good for baby
 The baby need more than a breast milk
 Breast milk may go bad
 Babies should not breastfed if the mother is pregnant
 Babies should not breastfeed if they are sick or if the
mother is sick
Cultural beliefs and attitudes
affecting breastfeeding
 Bottle feeds make a baby fatter and healthier
 Following fashion
 Fear of becoming attractive to men
 Fear of being too occupied with baby
 Shyness about feeding in public
References:
1) Fraser M.D ,Cooper A,M(2003) Myles Textbook for
Midwives. 14th edition,churchil Livingistone.
2) Gelder M,Mayou.P,Coven.P (2001) Shorter oxford
Textbook or Psychiatry 4th edition .oxford university
press.delhi.