Faculty: -Health Science /Department ---Midwifery

Postnatal Care
Study Units:

1. INTRODUCTION TO POSTNATAL CARE

2. THE NORMAL PUERPERIUM

3. Breast Feeding and Weaning

4. Nutrition for the Postpartum Mother

5. Family Planning service

6. Post natal exercises

7. Immunization Sche

8. ABNORMAL PUERPERIUM

9. Post-partum Hemorrhage (PPH)

10.Postpartum psychological promblems

11.Postpartum eclapmsia

12.Neonatal problems

INTRODUCTION TO POSTNATAL CARE

Chapter one
Introduction

The postpartum (or postnatal) period begins immediately after childbirth as the
mother's body, including hormone levels and uterus size, returns to a non-pregnant
state.

The terms puerperium, puerperal period, or immediate postpartum period are

commonly used to refer to the first six weeks following childbirth.

Cont.…
 • Majority of maternal and neonatal deaths occur during childbirth and
postnatal period.

Definition

The postpartum period is defined as one hour following the delivery of the placenta
through the first six weeks of an infant’s life.

Postpartum care encompasses management of the mother, newborn, and infant

during the postpartum period.

• WHO stated that PNC as a care given to the mother and her newborn baby
immediately after the birth of the placenta and for the first 42 days of life.

Classification of postpartum period

The postpartum period can be divided into three distinct stages:

the initial or acute phase, 6–12 hours after childbirth

subacute postpartum period, which lasts two to six weeks

the delayed postpartum period, which can last up to six months.

Aims of Care in the Postpartum Period

Support of the mother and her family in the transition to a new family
constellation, and response to their needs

Prevention, early diagnosis and treatment of complications of mother and infant,

including the prevention of vertical transmission of diseases from mother to infant

Referral of mother and infant for specialist care when necessary

Counseling on baby care

Support of breastfeeding

Counseling on maternal nutrition, and supplementation if necessary

Counseling and service provision for contraception, birth spacing and the
resumption of sexual activity

Immunization of the infant

Care and Service Provision in the Postpartum Period

The First 24 Hours After Birth (The Mother ):

Check for completeness of placenta and membranes

Assess general maternal well-being (blood pressure, body temperature)

Identify and respond to/refer immediate postpartum problems such as excessive

bleeding, fever, elevated blood pressure

The First 24 Hours After Birth (The Mother )

Check for pallor (conjunctiva and palms)

Check perineum for tears, inflammation, discharge

Check for uterine contraction and fundal height. Feel if uterus is hard and round

Encourage mother to empty bladder

Encourage mother to eat balanced diet with plenty of fluids

Initiate early (within one hour) and frequent, exclusive breastfeeding and assist the
mother to adopt correct breastfeeding practices

Advise on maternal/newborn reporting to health facility any danger signs

Advise on when to return for next postpartum check-up

The First 24 Hours After Birth
(The Newborn )

Wipe baby with wet cloth and dry (Do not bathe)

Monitor baby for breathing: listen for grunting, count breaths, look for chest
indrawing. Respond immediately if problems identified.

Ensure thermal protection—provide a warm environment, keep newborn in skin-to

skin contact with the mother

Weigh the baby

Provide cord care

Provide eye care

Assess general well-being (movements, muscle tone, swelling/bruises at the

presenting part, malformations)

Identify complications (e.g., birth asphyxia) or danger signs and respond

immediately or refer

The First Week Postpartum

The current norm for duration of stay in a health facility for delivery is 24-48 hours
in an uncomplicated vaginal delivery. Therefore, whether the birth took place in a
health facility or at home, there is need for some form of follow-up postpartum
care.

Consultations with mother and baby should be early in the first week (at least once
at day three) and followed-up as required.

The First Week Postpartum

The Mother
Check for general well-being of the mother (temperature, pallor, blood pressure)
Check uterus—is it hard and well contracted?

Check for distended bladder—ask about problems with passing urine

Check for, and respond to problems (Fever, Elevated blood pressure)

Re-enforce breastfeeding

Give iron folate supplementation for women who are anemic and counsel on
compliance.

Counsel and advise on the following and refer as necessary: hygiene,

Breastfeeding, Nutrition, Birth spacing and family planning , Immunization.

The First Week Postpartum

The neonate
Care in the first week postpartum includes a routine neonatal examination

Identify the following danger signs and respond/refer promptly: Poor sucking or
not sucking at all , Inactivity or lethargy, Fever or hypothermia

Immunization

If the mother and baby are healthy, frequent support by a caregiver is no longer
necessary after the first week. Traditionally, the mother is asked to come back for a
check-up 6 weeks after birth, with the baby.

Advice and Counseling

Postpartum Care and Hygiene

Breastfeeding

Nutrition

Birth Spacing and Family Planning

Immunization of mother and newborn

Common postnatal problems

Most common postnatal problems are include:
Postpartum infectious ( include uterine, bladder )

Excessive bleeding after deliver

Pain in the perineal area

Vaginal discharge Breast problems, such as swollen breasts, infection and clogged
ducts

Normal Puerperium
Chapter two

puerperium

Definition - Puerperium is period from the expulsion of the placenta to the

time the reproductive organs returns to pregravid state lasts 6–12 weeks after
delivery.

Puerperium is characterized by the following features:

 The reproductive organs return to the non pregnant state.

Other physiological changes occurred during pregnancy are reversed

(Involution).

 Lactation is initiated

 Recuperation of the mother from the stress of pregnancy and delivery

and assume responsibility for the care & nurture of her infant.

Normal puerperium manifestations

1. fever (24 hours)

2. Pain (uterine contraction)

3. sweat

4. lochia
Physiology of Puerperium
There are two major physiological events that occur during the puerperium.

The first is the establishment of lactation and the second is the return of the
physiological changes of pregnancy to the non-pregnant state.

During the first 2 weeks after childbirth, the changes in the organs are quite
rapid but some take 6–12 weeks to complete.

Changes in genital tract

 Involution of the uterus

 Lochia

 Involution of other pelvic organs

 Menstruation

Involution of the uterus

 Definition: the uterus returns to its normal site, tone & position of non
pregnant state

A. Immediately after delivery; the fundus of the uterus is easily palpable

halfway between the pubic symphysis and the umbilicus

B. 10-14 days later; at the level of the symphysis pubis

C. 6 weeks postpartum non pregnant.

Involution of the uterus

Mechanism:

1. Ischemia: After the birth of the baby & placenta, the uterine muscle &
blood vessels contracts so the blood circulation decreases.

2. Autolysis: muscle fibers are digested by proteolytic enzyme, waste product

then pass in to the blood stream and are eliminated by the kidneys.
3. endometrial lining rapidly regenerated (16 days).

Progress of change in the uterus after delivery

Cervix Weight of uterus Diameter of placental site

End of labour 900Gms 12.5cms Soft,

End of 1 WK 450gms 7.5cms 2cms

End of 2 WKS 200gms 5cms 1cm

End of 6 WKS 60gms 2.5cm

Lochia

o Lochia- discharge from the uterus during puerperium.

o Amount – varies with each woman

o Odor- heavy and unpleasant but not offensive

o The lochia undergo sequential change as involution progresses.

o The subsequent discharge, is fairly heavy at first and rapidly decreases

in amount over the first 2 to 3 days postpartum, although it may last for
several weeks.

Classification of Lochia
Lochia Rubra –Red in color consists of blood, chorion, decidua, amniotic
fluid, lanugo and meconium lasts in the first several days .

Lochia serosa – purple, contains less blood more serum as well as leukocytes
& organisms in the next few days.

Lochia alba – creamish pale discharge may persist for several weeks.

N:B: It is important that midwife/nurse realize the danger of retained

products which is indicated persistent red lochia.

Involution of other pelvic organs

  cervix

It never returns to the nulliparous state

The external os is closed to the extent that finger could not be easily
introduced

 vagina

Shrinks to nonpregnant state

 perineum

Swelling and engorgement are completely gone within 1-2 weeks.

Involution of ovarian function

Return of menstruation

 Non-Nursing mothers:

• Menstruation returns by 6-8 weeks

• The average time to ovulation is 45 days in nonlactating women

 Nursing Mothers:

May develop lactating amenorrhea.

Changes in other body system

Urinary tract: revived from pressure .

Alimentary canal:- Heart burn improves due to hormonal fall , Constipation

presents for few days painful perineum inhibits defecation

Circulatory system: blood volume decreases to pregravid level.

Respiratory system- full ventilation because lungs are no longer compressed

by the enlarged uterus.

Changes in other body system

Renal System
Glomerular filtration rate represents renal function and remains elevated in
the first few weeks postpartum, then returns to normal, therefore, drugs with
renal excretion should be given in increased doses during this time.ureter and
renal pelvis dilation regress by 6 to 8 weeks.

Changes in other body system,cont…

Musculoskeletal system:- The softened pelvic joints and ligaments of

pregnancy gradually return to normal over a period of about 3months.

Endocrine system – Oxytocin – is secreted by posterior pituitary gland and

acts up on uterine muscles & upon breast tissue.

POSTPARTAM CARE

The morbidity associated with the puerperium is shows that after childbirth
mothers have high levels of post-partum problems.

In the absence of complications, the postpartum hospital stay ranges from 48

hours after a vaginal delivery to 96 hours after a cesarean delivery, excluding
day of delivery.
 Chapter three
Breast Feeding and weaning
 Breastfeeding

 Breastfeeding: is the feeding for an infant or young child with breast milk
directly from the female human breast not by baby bottle or other container.

 Breast milk contains the right balance of nutrients to help the infant to grow
into a strong and healthy toddler.

 Some of the nutrients in breast milk also help protect for infant against some
common childhood illnesses and infections.

 It may also help the mothers health, Certain types of cancer may occur less
often in mothers who have breastfed their babies.

 Types of Breast Milk

 Colostrum: from birth to the 5th day of life

 Transient milk: from 5th day to 21th day

 Mature milk: after the 21th day

 Colostrums v/s mature milk

Breast milk composition

 The composition of human milk is the biologic norm for infant nutrition.

 Human milk also contains many hundreds to thousands of distinct bioactive

molecules that protect against infection and inflammation and contribute to
immune maturation, and organ development.

 Breast milk composition of Nutrients

 Breast milk contains all the nutrients the infant needs for proper growth and
development.

 These nutrients include:

 Free water

 Proteins

 Fats

 Carbohydrates

 Minerals, vitamins

 Breast milk composition of Bioactive Factors

 Immunoglobulins–Predominant Secretory IgA in breast milk

 Bioactive cytokines – Including transforming growth factor-b (TGF-b)1 and

2.

 Others– leukocytes, oligosaccharides, epidermal growth factor (EGF) and

insulin-like growth factor (IGF)-1.

 Advantage of Breastfeeding for the Infant

Is a whole food for the infant, contains balanced proportions and sufficient
quantity of all the needed nutrients for the first 6 months.

Is easy to digest. Nutrients are well absorbed.

Promotes adequate growth and development, thus preventing stunting.

Is always clean, ready and at the right temperature.

 Advantage of Breastfeeding for the Infant, cont…

Contains antibodies that protect against diseases, especially against diarrhea

and respiratory infections.

Contains enough water for the baby’s needs (87% of water and minerals).
 Protects against allergies.

Helps jaw and teeth development; suckling develops facial muscles.

 Advantage of Breastfeeding for the Infant, cont…

Frequent skin-to-skin contact between mother and infant lead to better

psychomotor, affective and social development of the infant.

The infant benefits from the colostrum, which protects him/her from
diseases. The amount is perfect for newborn stomach size.

Promotes brain development; increased IQ scores.

Advantage of Breastfeeding for the mother

Reduces risks of postpartum hemorrhage

Exclusive breastfeeding 98% effective as a contraceptive method and

amenorrhea persists.

Reduces the mother’s workload.

Stimulates bond between mother and baby.

Reduces risks of breast and ovarian cancer.

Program of breastfeeding
1. Maternal instructions:

 Nipple care to avoid retracted nipples

 Suckling should be initiated ASAP

 No extra fluids

2. Technique of nursing

 Mother sit comfortable

 Baby held semi setting

 Both breast are given

  Nipple and hands are cleaned

 Breast held with nipple fitting in baby mouth.

 Program of breastfeeding, cont…

3. interval between feeds:

 A. two hourly feeding for:

 1st 2weeks of life

 Premature

 Scanty milk flow

 4 hotly feeding for :

 After the 4th month

 Overweight and strong sucking

 Liberal milk flow

 Program of breastfeeding, cont…

4. adequacy of breastfeeding:

 Adequate feeding: adequate weight gain

 Under feeding: poor weight gain

 Over feeding: excessive weight gain

Challenges in breast feeding Among mother

 Scanty milk supply

 Milk engorgement

 Retracted nipples

 Painful nipples
 Acute mastitis and breast abscess

 Large pendulous breast

 Work and lactation

 Contraception and lactation

 Pregnancy and lactation

 Challenges in breast feeding

among Infant

 Congenital anomalies

 Painful mouth

 Weak sucking

 Nasal obstruction

 Dyspneic condition

 Contraindications of breast feeding

1. Maternal causes:

 Temporary:

 Bilateral nipple fissuring

 Bilateral acute mastitis and abscess

 Acute maternal disease

 Post-partum illness

 Herpes simplex of nipples

 Mother receiving some drugs

 Contraindications of breast feeding, Maternal causes cont…

 Permanent
  Debilitating chronic diseases e.g uncontrolled DM

 Malignancy

 Active maternal CMV infection

 Local breast causes e.g. breast cancer.

 Contraindications of breast feeding, infant causes

 Temporary:

 Respiratory distress

 Very low birth weight

 Permanent

 Milk protein allergy

 Lactose intolerance

 galactosemia

WEANING
 Process of introducing semi-liquid to semi-solid foods other than breast
milk.

 The transition of food pattern has to keep pace with the child’s growth who
triples his birth weight and 1 ½ times his birth length by the end of one year
- Time of introduction of food type.

Consistency, frequency of food, calorie density and nutrient density need to be

monitored closely, also the Hygiene.

Reasons for starting weaning at 4-6 months

 Breast milk sufficient for the growth of the baby only till 6 months of age.

 Breast milk output starts to decline thereafter but baby’s physical + mental
development continues at a very fast pace till the end of 2 years.
 Reasons for starting weaning at 4-6 months

 Enzymes necessary to digest the complex structure of solid food are

developed.

 Weaning latest by 6 months - failing which will lead to malnutrition.

 How to initiate weaning and progress

 Consistency:

 Breast feeds (0-6 months)

 Semi-liquid (after 5-6 months) Easy to digest, smooth and gentle on baby’s
stomach.

 Semi-solid (after 8-9 months) Baby now needs food with taste and texture.

 Semi solid (after 10 months) Baby now needs food that satisfy his urge to
chew-complex taste and texture

 Solid diet including variety of food items (1-.2 yrs).


How to initiate weaning and progress, Frequency:
 Till 5-6 months - child is given breast feeds on demand i.e. 9-10 times over
24 hours.

 From 6- 8 months - As the child grows, his requirements increase and he

starts to accept larger volume and thicker consistency at a time - feed him
7-8 times/d

 From 9- 12 months - child normally eats 6-7 times per day and each time.

 By 12 - 15 months - child eats at least 6 times per day.

 By 18 months - child’s eating schedule of 5-6 times /day gets fixed.

 Optimal infant and young child feeding recommendations

Safe and appropriate infant and young child feeding.

 Interventions targeted at young infants (0–6 months)

 Early initiation of breastfeeding.

 Exclusive breastfeeding.

 Counseling and support for appropriate feeding of low-birth-weight

infants.

Early initiation of breastfeeding

 WHO RECOMMENDATION

 Place babies in skin-to-skin contact with their mothers immediately

following birth for at least an hour and encourage mothers to recognize
when their babies are ready to breastfeed, offering help if needed.

 WHAT IS COLOSTRUM?

 First milk produced.

 Higher nutrient density than mature milk.

 Protein, fat, vitamin A.

 Rich in antibodies, growth factors.

 Amount of colostrum produced matches the newborn’s stomach.

Benefits of early initiation

Colostrum is rich in immune and non-immune components that fight
infection and accelerate intestinal maturation.

Promotion of warmth and protection may reduce risk of death from

hypothermia.

The alternative, pre-lacteal feeding, may disrupt normal physiologic gut

priming.

Exclusive breastfeeding
0-<6 months
  Only breast milk, no other liquids or solids, not even water,
with the exception of necessary vitamins, mineral supplements
or medicines.

WHO RECOMMENDATION

 As a global public health recommendation, infants should be exclusively

breastfed for the first six months of life to achieve optimal growth,
development and health. …… .”

 Exclusive breastfeeding

Earlier onset of ample milk production.

Longer duration of breastfeeding.

Improved mother/infant bonding.

Decreased infant distress.

Stronger uterine contractions that prevent uterine bleeding.

Artificial feeding is always risky

 Why artificial feeding is always risky?

 Artificial feeding

1. Complementary feeding: ( breast feeds are completed by bottle feeds)

2. Supplementary feeding: (some breast feeds are replaced by bottle feeds)

3. Substitutive feeding: (all breast feeds are replaced by bottle feeds)

 Faulty feeding and malnutrition

Feeding on artificial milk formulas -reconstituting wrongly.

Feeding on diluted fresh milk

Breast feeding for a long time

Delayed weaning
 Feeding via dirty feeding bottles.

Chapter four
Nutrition for the Postpartum Mother
 Special Concerns of the Postpartum Mother

 Restocking nutritional stores

 Providing good quality milk for her breastfed baby

 Losing weight gradually

 Restocking Nutritional Stores

 Eat according to MyPyramid

 Continue to take a daily multiple vitamin and mineral supplement as
prescribed by health care provider

 Continue to take an iron supplement each day as prescribed by health care

provider

 Eat the MyPyramid Way

 Grains

 Vegetables

 Fruits

 Milk

 Meat and Beans

 Food Guide Pyramid

Grains

 1 slice bread

 1 tortilla

 ½ cup rice, pasta, or cereal

 1-ounce ready-to-eat whole-grain cereal

 ½ hamburger bun, bagel or English muffin

 3 4 plain crackers

 Vegetables

 ½ cup chopped raw or cooked vegetable

 1 cup raw, leafy vegetables

 ¾ cup vegetable juice

 ½ cup scalloped potatoes

 Fruits
 1 piece fruit or melon wedge

 ¾ cup fruit juice

 ½ cup chopped, cooked or canned fruit

 ¼ cup dried fruit

 Milk

 1 cup milk or yogurt

 1-½ ounces natural cheese

 2 ounces process cheese

 Meat and Beans

1 ounce cooked lean beef, pork, lamb, veal,

poultry, or fish

 ¼ cup cooked dry beans

 1 egg

 2 tablespoons peanut butter

 ½ ounce of nuts or seeds

 Fats, Sugars, and Salt (Sodium)

 Make most of your fat sources from fish, nuts, and vegetable oils

 Limit solid fats and foods containing solid fats

 Choose food and beverages low in added sugars and sodium

 Special Concerns of the Breastfeeding Mom

 Protein

 Fat

 Vitamin B12
 Vitamin D

 Vitamin K

 Folic Acid

 Calcium

 Cont..

 Chromium

 Iron

 Selenium

 Zinc

 Fluids

 Adequate Calories

 Protein

 Protein needs are higher during breastfeeding than at any other time in life

 While breastfeeding, can get enough protein from a nutritious diet

 Fat

 Composition of fats in breast milk is determined

by the mothers diet

 Breast milk contains docosahexaenoic acid (DHA)

 DHA is important for baby's visual and brain

development

 Include one serving of fish in diet each week

 Best sources of DHA are fatty fish, such as

salmon

 Vitamin B12
 Vitamin B12 is found only in foods from animal sources

 Meat, poultry, fish, eggs, and dairy products are excellent sources

 Some vegetarians may need a vitamin B12

supplement

 Vitamin D

 Breast milk is low in Vitamin D

 Food sources include Vitamin D-fortified cows milk and soy milk

 Yogurt, cheese, and other dairy products are not usually fortified with
Vitamin D

 Sunlight helps the body produce Vitamin D

 Some vegetarians may need a Vitamin D supplement

 Vitamin K

 Vitamin K is produced in the small intestine

 The newborn infant has a sterile intestine for several days after birth

 Breast milk may be low in Vitamin K

 prescribe a Vitamin K supplement for the infant

 Folic Acid

 Leafy vegetables, citrus fruits, legumes, and

nuts are excellent sources of folic acid

 Grain products like breads, cereals, pasta and rice are enriched with folic
acid

 Make sure you get enough folic acid, especially if planning another
pregnancy in the near future

 Calcium
 Main mineral in bones and teeth

 Important mineral in nerve transmission and muscle contraction

 A breastfeeding mother loses 200 300 mg of calcium in breast milk each day

 Inadequate intake The body draws from calcium reserves in the mothers
bones

 Calcium-rich Foods

 The postpartum mother should consume at least three servings of milk each
day

 Nonfat and low-fat milk and milk products are excellent sources of calcium

 Some vegetables and fish with edible bones are also good sources of calcium

 Chromium

 Helps produce high quality milk in breast-feeding mothers

 Low intake of chromium can increase the mothers risk for developing high
blood sugar and heart disease

 Iron

 An important component of blood

 Iron concentrations in most women are depleted after pregnancy

 Most women should continue to eat iron-rich foods and take iron
supplements

 The body absorbs iron best from foods from animal sources

 Selenium

 Selenium helps both mother and baby maintain a strong immune system

 It also aids in cell growth

 Nursing baby's selenium status is directly
affected by what the mother eats

 Food sources include seafood, extra-lean meat, cooked dried beans and peas,
and chicken

 Zinc

 Essential for baby's growth and development

 Breastfeeding increases the demand for this

nutrient

 Many women don't consume enough zinc

 The body uses zinc from foods of animal origin best

 Fluids

 Nursing mother loses about 23 ounces of fluid each day

 feel thirsty, are already dehydrated

 Drink at least six glasses of water in addition

to other fluids daily

 Drink a glass of milk, juice, or water at each

meal and each time the baby nurses

 Low fluid intake could result in constipation and fatigue

 Practices Incompatible with Breastfeeding

 Avoid

 Alcohol

 Illicit Drugs

 Cigarette Smoking

 Caution
 Medicinal Drugs

 Herbal Supplements

 Caffeine

 Getting Back to Pre-pregnancy Weight

 Excessive weight gain during pregnancy is an important factor in postpartum

weight retention

 Avoid fad diets!

 Breastfeeding speeds up the weight loss process

 Success Strategies for Weight Loss

 Lose weight gradually 1 to 2 pounds per week

 Reduce fat intake and eat more fruits,

vegetables, whole-grains, and nonfat/low-fat milk and milk products, and
lean meat products

 If breastfeeding, don't attempt weight loss for

the first six weeks postpartum, then aim for a
weight loss of no more than a 2 pound weight loss per month

 Success Strategies for Weight Loss (cont.)

 Eat regular meals and snacks

 Watch portion sizes

 Include high protein foods in your meals (e.g., chicken breast, water packed
tuna, grilled salmon)

 Begin to exercise as soon as health care provider gives the okay

 Chapter five
Family Planning service
Definition

A program to control the number of children in a family through the practice of

contraception or other methods of birth control.

Family planning allows individuals to attain their desired number of children and
the spacing and timing of their births.

Family planning programs provide services that help people achieve:

The number of children they desire

Reduce the number of unwanted pregnancies

Reduce the risk of sexually transmitted infection

(especially condom)

Improve the health of women and children by spacing birth.

Purpose of Family Planning

The purpose of family planning is to help women and their patterns protect
themselves from unwanted pregnancies and identify conditions that may affect
reproductive health

Planning for pregnancy ensures that the parent or parents are best prepared
mentally physically, and emotionally to care for a child.

Benefits of using family planning

 Benefits to the mother

The mother’s body will recover, hence she regains her immunity

The mother has more time to pay attention to the children

Control number of children

Prevents teenage pregnancies

Prevents of anemia as a results of the mother not conceiving frequently

 Benefits to the baby

The baby can breast feed for long period since the mother is healthy

The baby is happy and the healthier

Strong immune system

Family Planning methods

There are different of methods of contraception including:

 natural method
 mechanical method or barrier method
 surgical or permanent method
 chemical method or hormonal method

Natural method
Natural methods of birth control do not involve medications or devices to prevent
pregnancy but rather rely on behavioral practices and/or making observations
about women’s ability and menstrual cycle

 Breast Feeding method:

continuous breast feeding is a form of contraception that can postpones ovulation
for up to 6month after giving birth.

It works because the hormone required to stimulate milk production prevents the
release of hormone that triggers ovulation.

No side effects
Many other advantages.

99% Effective contraception with correct and consistent use.

 Two-day Method:
Women track their fertile periods by observing presence of cervical mucus (if any
type color or consistency).

Prevents pregnancy by avoiding unprotected vaginal sex during most fertile days.

96% effective contraception with correct and consistent use.

 Calendar method or rhythm method:

Women monitor their pattern of menstrual cycle over 6 months, subtracts 18 from
shortest cycle length (estimated 1st fertile day) and subtracts 11 from longest cycle
length (estimated last fertile day).

avoiding unprotected vaginal sex during the 1st and last estimated fertile days, by
abstaining or using a condom.

91% with correct and consistent use.

 Basal Body Temperature (BBT) Method:

Woman takes her body temperature at the same time each morning before getting
out of bed observing for an increase of 0.2 to 0.5 degrees C.

Prevents pregnancy by avoiding unprotected vaginal sex during fertile days.

99% effective with correct and consistent use.

 Withdrawal (coitus interrupts):

Man withdraws his penis from his partner's vagina, and ejaculates outside the
vagina, keeping semen away from her external genitalia.

Tries to keep sperm out of the woman's body, preventing fertilization.

96% with correct and consistent use.

Artificial methods
 chemical method:
These methods use chemicals referred to as hormone to prevent conceptions.

They include hormones, taken orally, by injection, or implanted, to prevent

ovulation and special preparation put in the vagina to kill sperm locally the
chemical methods of various type;

a) Pills
The pills is one of the most popular contraceptive method there are many types of
pills and they are comes into two forms;

1- combined oral contraceptive pill

2- progesterone only contraceptive pill

Both are taken daily and are over 99% effective at preventing pregnancy when
taken correctly

Combined oral contraceptives (COCs) or “the pill”. Prevents from ovulation.

S. effects: DVT, HTN, CVA, weight gain, nausea, dizziness, headache.

Progestogen-only pills (POPs) or "the minipill

Thickens cervical mucous to block sperm and egg from meeting and prevents
ovulation.

S. effects: Irregular vaginal bleeding, Headache, Depression.

b)Depo Provera
Depo Provera is an injection given every 10-13 weeks in the arm or hip. It contains
no estrogen so it is safe for women unable to use estrogen products. Menses
become non-existent on Depo Provera and it is more than 99% effective.
Side effects include

Spotting, wt. gain, headaches, breast tenderness, dizziness, loss of libido and
depression

c) Nuva Ring or vaginal ring

The ring is a combination estrogen/progestin flexible ring, which is placed into the
vagina. It works the same as the patch and the pill in preventing pregnancy.

The ring is worn for 3 weeks and then left out for 1 week. It is more than 99%
effective if used correctly.

d) Implanon (implants)
The Implanon is a small, flexible rod that is implanted under the skin of the upper,
inner arm. The implant works by stopping ovulation

The Implanon is good for 3 years and is 99% effective.

Problems

Difficulty in removing

Side effects

Changes in menstrual bleeding, Headaches, wt. gain

Artificial methods
Long-acting reversible contraception
Long-acting reversible contraception (LARC) is a contraceptive that lasts for a
long time.

There are two types of long-acting reversible contraception (LARC)

An intrauterine device (IUD) that lasts five or

 more years

An implant under the skin that lasts either three Or five years.

Artificial methods
BARRIER METHODS:
Barrier methods stop sperm from entering the vagina.

There are three main barrier methods of contraception:

Male condoms

Female condoms

diaphragms.

Surgical methods
Permanent contraception is sterilization that permanently prevents pregnancy.

For Women

Tubal ligations

Cut and seal the fallopian tubes

Hysterectomy

Removal of the uterus

For Men

Vasectomy

Vas deferens are cut and sealed.

Counselling for family planning
Good counseling helps clients choose and use family planning method that suit
them.

Clients differ, their situations differ, and they need different kinds of help.

Counseling new clients about family planning needs a step-by-step process

The process includes learning, making choices, making decisions and it consists of
six steps which can be remembered with the acronyms GATHER.

The GATHER steps

G-Greet clients in an open, respectful manner. Assure the clients of confidentiality.

Give as Much time listening.

A-Ask clients about themselves.

Help clients talk about their family planning practices, intensions,

concerns, and wishes

T-Tell clients about choices depending on the clients need, tell the clients what
reproductive health choices she/he might take.

Focus on methods that interest the client. Also explain other services that the client
may want

H-Help clients make an informed choice.

Help the client think about the options.

Encourage the client to express opinions and ask questions.

Consider medical eligibility criteria for the family planning method that interest the
client.

In the end make sure that the client has made clear decision
R-Return visits should be welcome: Discuss and agree when the client will
return for follow up or more supplies if needed.

Always invite the client to return any time of any reason.

Chapter six
IMMUNIZATION
• Childhood immunization has reduced the impact of major infectious
diseases markedly.

• Active immunization is the process of inducing immunity by vaccination

with a vaccine or toxoid (inactivated toxin).

• Passive immunization includes transplacental transfer of maternal

antibodies and the administration of antibody, either as immunoglobulin or
monoclonal antibody.

Acquired Or Adaptive Immunity

I- Passive acquired immunity

a-Naturally passive acquired immunity

Antibodies are passed through placenta

to the fetus

b- Artificially passive acquired immunity

The injection of already prepared antibodies, such as gamma globulin (short-

term immunization)

II- Active acquired immunity

a-Natural active acquired immunity :

- Following clinical or subclinical infections

 - measles or mumps, in which immunity is

long lasting

b- Artificial active acquired immunity :

- Following vaccination with live or killed infectious agents or their products

• Vaccinations may be with live attenuated viruses (measles, mumps,

rubella, varicella), inactivated or killed viruses (polio, hepatitis A [HAV],
influenza), recombinant products (hepatitis B [HBV]), or immunogenic
components of bacteria (pertussis, Haemophilus influenzae type b [Hib],
and Streptococcus pneumoniae), including toxoids (diphtheria, tetanus).

• Many purified polysaccharides are T-independent antigens that initiate B

cell proliferation without involvement of CD4 T lymphocytes and are poor
immunogens in children younger than 2 years old.

• Conjugation of a polysaccharide to a protein carrier induces a T-dependent

response in infants and creates immunogenic vaccines for Hib, S.
pneumoniae, and Neisseria meningitidis.

Children in the Somalia routinely receive vaccines against 8 diseases: diphtheria,

tetanus, pertussis, Hib infection(Meningitis), HBV ( PENTA), poliomyelitis,
measles, TB (BCG).

• Most vaccines are administered by IM or SC injection.

• The preferred sites for administration are the anterolateral aspect of the
thigh in infants and the deltoid region in children and adults.

• Multiple vaccines can be administered simultaneously at anatomically

separate sites without diminishing the immune response.

• Measles, mumps, and rubella (MMR) and varicella vaccines should be

administered simultaneously or at least 30 days apart.
 • Administration of blood products and immunoglobulin can diminish the
response to live virus vaccines if administered before the recommended
interval.

• General contraindications to vaccination include serious allergic reaction

(anaphylaxis) after a previous vaccine dose or to a vaccine component,
immunocompromised states or pregnancy for live virus vaccines, and
moderate or severe acute illness with or without fever.

• History of anaphylactic-like reactions to eggs is a contraindication to

influenza and yellow fever vaccines, which are produced in embryonated
chicken eggs.

• Mild acute illness with or without fever, convalescent phase of illness, recent
exposure to infectious diseases, current antimicrobial therapy, breastfeeding,
mild to moderate local reaction or low-grade to moderate fever after
previous vaccination, and history of penicillin or other non vaccine allergy
or receiving allergen extract immunotherapy are not contraindications to
immunization.

• Severe immunosuppression resulting from congenital immunodeficiency,

HIV infection, leukemia, lymphoma, cancer therapy, or a prolonged course
of high-dose corticosteroids (≥2 mg/kg/day for >2 weeks) predisposes to
complications and is a contraindication for live virus vaccines.

• MMR vaccination is recommended at 12 months of age, with a second dose

1 month later rather than waiting until 4 to 6 years, for all HIV-infected
children who do not have evidence of severe immunosuppression.

• Varicella vaccine is contraindicated for persons with cellular

immunodeficiency, but is recommended for persons with impaired humoral
immunity (hypogammaglobulinemia or dysgammaglobulinemia) and at 12
months of age for HIV-infected children who do not have evidence of severe
immunosuppression, given as two doses 3 months apart.

PROPHYLAXIS
 • Prophylaxis is used in many situations, such as post-exposure, perinatal
exposure, and pre-exposure for persons at increased risk of infection.

• Primary prophylaxis is used to prevent infection before a first occurrence.

• Secondary prophylaxis is used to prevent recurrence of infection after a

first episode.

• Prophylaxis may include antibiotics, immunoglobulin or monoclonal

antibody, vaccine, or a combination.

Vaccination

• Vaccination is a method of giving antigen to stimulate the immune response

through active immunization.

• A vaccine is an immuno-biological substance designed to produce specific

protection against a given disease.

• A vaccine is “antigenic” but not “pathogenic”.

Immunizing agents

Immunoglobulins

There are 5 major classes: IgM, IgA, IgG, IgE, IgD.

Two types of immunoglobulin preparations are available for passive immunization:

Normal human immunoglobulin

Specific (hyper-immune) human immunoglobulin

Antisera or antitoxins

These are materials prepared in animals or non human sources such as horses.

Immunoglobulin and antiserum

Types of vaccines

Live vaccines
Attenuated live vaccines

Inactivated (killed vaccines)

Toxoids

Polysaccharide and polypeptide (cellular fraction) vaccines

Surface antigen (recombinant) vaccines.

Live vaccines

Live vaccines are made from live infectious agents without any amendment.

The live vaccine is “Variola” small pox vaccine, made of live vaccinia cow-pox
virus (not variola virus) which is not pathogenic but antigenic, giving cross
immunity for variola.

Live attenuated (avirulent) vaccines

Virulent pathogenic organisms are treated to become attenuated and avirulent but
antigenic. They have lost their capacity to induce full-blown disease but retain their
immunogenicity.

Live attenuated vaccines should not be administered to persons with suppressed

immune response due to:

Leukemia and lymphoma

Other malignancies

Receiving corticosteroids and anti-metabolic agents

Radiation

pregnancy

Inactivated (killed) vaccines

Organisms are killed or inactivated by heat or chemicals but remain antigenic.

They are usually safe but less effective than live attenuated vaccines.
The only absolute contraindication to their administration is a severe local or
general reaction to a previous dose.

Toxoids

• They are prepared by detoxifying the exotoxins of some bacteria rendering

them antigenic but not pathogenic.

• Adjuvant (e.g. alum precipitation) is used to increase the potency of vaccine.

• The antibodies produces in the body as a consequence of toxoid

administration neutralize the toxic moiety produced during infection rather
than act upon the organism itself.

• In general toxoids are highly efficacious and safe immunizing agents.

Polysaccharide and polypeptide (cellular fraction) vaccines

They are prepared from extracted cellular fractions e.g. meningococcal vaccine
from the polysaccharide antigen of the cell wall, the pneumococcal vaccine from
the polysaccharide contained in the capsule of the organism, and hepatitis B
polypeptide vaccine.

Their efficacy and safety appear to be high.

Surface antigen (recombinant) vaccines.

It is prepared by cloning HBsAg gene in yeast cells where it is expressed.

HBsAg produced is then used for vaccine preparations.

Their efficacy and safety also appear to be high.

Types of vaccines

Routes of administration

Deep subcutaneous or intramuscular route (most vaccines)

Oral route (sabine vaccine, oral BCG vaccine)

Intradermal route (BCG vaccine)

Scarification (small pox vaccine)

Intranasal route (live attenuated influenza vaccine)

Scheme of immunization

Primary vaccination

One dose vaccines (BCG, variola, measles, mumps, rubella, yellow fever)

Multiple dose vaccines (polio, DPT, hepatitis B)

Booster vaccination

To maintain immunity level after it declines after some time has elapsed (DT,
MMR).

Remember

Wait at least 4 weeks (one month) after previous dose of PENTA-OPV before
giving next dose.

If child comes after gap of more than 4 weeks for its next dose of PENTA-
OPV, give next dose of series. Do NOT repeat previous dose, as there is no
maximum interval between doses.

Remember

Remember

All due vaccines can be given at same time but in different limbs (sites)

Chapter seven
 Post natal exercises
Definition Post natal Period

It refers to the time from termination of pregnancy till 42 days. Exercises Is a

physical activity that is planned , structured and repetitive for the purpose of
conditioning any part of the body

Importance of Post-Natal Exercises

Improve circulation

Strengthen pelvic floor muscle

Prevent backache

Strengthen the tummy muscles

Benefits of Exercises

Reduces the risk of developing heart disease, diabetes, and cancer

Reduces high blood pressure, high cholesterol

Reduces body weight, depression, anxiety and improves psychological wellbeing

Builds and maintains healthy muscles, bones and joints

Important information to be consider when beginning Exercises

 Wear loose supportive clothing

 Environment-stable environment

 Nutrition-do not exercise on full stomach

 Safety-do not exercise alone in the dark

 Low impact exercise is preferable during postnatal period.

Principles of Exercises

Frequency
Intensity-mild to moderate exercise are recommended

Duration-30 minutes of exercise per day

Post Natal Exercises

 Deep breathing exercise

 Lie on bed with knees bent, with a pillow behind

 Breathe in deeply through nose. Sigh out.

 Repeat 5 times Breathing exercises help to improve your circulation

FOOT AND ANKLE EXERCISE

 Keep knees relaxed for both exercises.

 Bend and stretch ankles vigorously up and down for 30 seconds.

 Circle both feet 10 times in each direction.

 Repeat these exercises frequently

PELVIC FLOOR EXERCISE-KEGAL

 Pelvic floor muscles are stretched during pregnancy and childbirth.

 Strong pelvic floor muscles are essential to prevent leakage of urine when
sneeze or cough, for enjoyable sexual intercourse

 to give complete control of bowels.

 Strong muscles will also help prevent developing a prolapsed womb.

 can do this exercise standing, sitting or lying.

 Pull the area around vagina up and down

 The contraction should be held for 10 seconds(to a count of 6) and repeated

upto10 times

 The exercise should be continued for 2-3 months.

  This exercise is especially important if mother have stitches.

 It helps to improve the circulation and will help to heal quickly

PELVIC TILTING EXERCISE

Lie on a firm surface with knees bent and a comfortable pillow beneath the head

Pull in tummy(inhale, while exhale flatten the back)

Press the lower part of back down flat

Hold for several seconds and repeat.

ABDOMINAL BREATHING

This is to strengthen the diaphragm

Take a deep breath, raising her abdominal wall and exhale slowly.

To ensure correct method ask to keep one hand on chest and one on abdomen

while inhaling the hand on the abdomen should be raised and hand on the chest
should remain stationary.

Repeat the exercise five times

HEAD AND SHOULDER RAISING

On the 2ndpost partum day-Lie flat and raise head until the chin is touching the
chest.

On the 3 rd post partum day-raise both head and shoulder off the bed and lower
them slowly , increase gradually.

LEG RAISING

Begun on the 7th post partum day

Lying down on the floor with no pillows under the head

Point toe and slowly raise one leg keeping the knee straight

Lower the leg slowly.

KNEE ROLLING

This is to strengthen the oblique abdominal muscles.

In back lying with knees bent, pull in the abdomen and roll both knees to one side
as far is comfortable, keeping shoulders flat.

Return knees to upright position and relax the abdomen.

Pull in again and roll both knees to other side.

Perform 10 times

HIP HITCHING OR LEG SHORTENING

In back lying with one knee bent and the other knee straight.

Slide the heel of the straight leg down word thus lengthening the leg.

Shorten the same leg by drawing the hip up

towards the ribs on the same side.

Repeat up to 10 times

Change to the opposite side and repeat.

WARNING SIGNS

Increased fatigue

Muscle aches and pains

Changing the color of lochia –pink to red

Heavier lochia flow

Lochia starts flowing again after it had stopped

Chapter eight
 ABNORMAL PUERPERIUM

 Puerperal Pyrexia

 Definition:

a temperature of 38C or > lasts for 2 days

or > in the first 10 days postpartum,

exclusive of the first 24h.

Causes:

1. genital tract infection ( puerperal sepsis ).

2. milk engorgement ,mastitis & breast abscess

3. DVT & PE.

4. UTI.

5. chest infection.

6. CS delivery, wound infection & fasciites.

7. meningitis.

 Acute Puerperal Mastitis

 Definition: Is inflammation of the breast and externally painful and may

lead to abscess formation.

 The most common infectious organism is staphylococcus aureus.

 The most likely source of the infection is the baby and out breaks of skin and
eye infections among babies are frequently due to staphylococcus aureus.

 Acute Puerperal Mastitis, Cont.…

 Sign and symptoms

- Occurs after the 8th postnatal day

- temperature higher then 40C.

- Rapid pulse

- Throbbing pain and tenderness in the affected breast.

-reddened area of the breast is seen on examination.

 Investigation of Acute Puerperal Mastitis

 A sample of breast milk is sent for bacteriological examination and abroad

spectrium antibiotic is given until the causative organism is known.

 Management of acute mastitis in puerperium

 Breast support

 plenty of oral fluids

 antibiotic—cephalexin

 analgesic (ibuprofen) and

 breastfeeding to be continued.

 Breast feeding should be suspended if pus is found in the milk and the
pump or hand expression.

 Puerperal Sepsis

 Infection of the genital tract that occurs at any time between the rupture of
membranes in labour and 42 day following delivery or abortion with the
following symptoms.

- Pelvic pain

- Fever 38.5C or more

-Abnormal smell, foul odor of vaginal discharge

- sub involution.

- Vomiting,
 - Dry tongue and lips.

 Puerperal Sepsis cont….

Sites of infection:

 Wound: mainly the placental site and wounds of the perineum, vulva,
vagina or cervix.
Dead tissue: usually blood clots, and retained placental fragment.


Risk factors for puerperal sepsis

 - Poor hygiene

- Poor aseptic technique

- Manipulations in birth canal.

- Prolonged rupture of membrane

- Frequent vaginal examinations

-Unrepaired vaginal or cervical lacerations

 . Non obstetric :

.. Obesity.

.. DM.

.. HIV.

 Investigations

 High vaginal swab/wound swab for culture and sensitivity

 Complete blood count

 Pelvic ultrasound: To detect any retained bits of tissue inside the uterus or to
detect pelvic abscess.

 Management of Puerperal sepsis

Treatment:

A. Mild and Moderate infections :

broad spectrum antibiotic as:

cephalosporin + metronidazole.

in the first 48h ,antibiotic should be given IV.

B. Severe infections :

septic/endotoxic shock

appropriate antibiotics should be aggressively

given ,any delay could be fatal.

Prevention:

1. awareness of general hygiene principles.

2. good surgical technique with proper hemostasis.

3. prophylactic antibiotics

especially in emergency CS.

a single intra operative dose of cephalosporin+metronidazole.

 Complications

1. Pelvic abscess

salpingo- ophoritis and pelvic peritonitis . This

could progress to a generalized peritonitis and

the development of pelvic absess.

2. Pelvic Peritonitis

metritis and parametitis.

3. Septic Thrombophlebitis
 spread to distant sites via lymphatics , bl.v to

the iliac vessels or directly via the ovarian

vessels.

 Other Puerperal problems

 Urinary Problems

• Retention

• Incontinence

• Infection

 Venous thrombosis

 Secondary Hemorrhage

 Puerperal psychosis

 Obstetric palsy

Chapter nine
Postpartum Hemorrhage
 Overview
 Postpartum hemorrhage (PPH) is an obstetrical emergency.

 It is a major cause of maternal morbidity, and one of the top three causes of
maternal mortality in both high and low per capita income countries.

 With timely diagnosis, appropriate resources, and appropriate management,

however, PPH may be the most preventable cause of maternal mortality.

 Post partum Hemorrhage

 Definition:- Post partum hemorrhage is bleeding from the genital tract

during the 3rd stage of labor, or with in 24 hours after delivery of the
placenta to the amount of 500ml or any amount that will change the patient’s
condition.

 Types of PPH:

 Primary Hemorrhage

 Secondary hemorrhage

 Primary Hemorrhage

 Primary hemorrhage occurs in 1st 24 hours, This is the commonest and most
dangerous type, Occurs in 4-6% of pregnancies.

 Caused by The Four T’s:

 Tone – atony (70% of all cases)

 Tissue – 10% retained Placenta, uterine inversion

 Trauma –20% cervical or vaginal laceration, uterine rupture

 Thrombin events – less then 1%defects in coagulation

Inherited or acquired.

 Secondary hemorrhage
  Secondary hemorrhage: abnormal or excessive bleeding from the birth
canal occurring between 24 hours and 12 weeks postnatally .

 Causes include:

- Chorioamnioitis

- Retained products

 Risk factors

 Previous PPH

 Retained placenta

 Anemia

 Uterine over-distension

 Antepartum hemorrhage

 Prolonged labor

 Induction of labour

 Hypertensive disorders.

 precipitate labour

 General Management of PPH

 Three basic principle are applied:

1. Call an obstetrician

2. Stop the bleeding

3. Resuscitate the mother

 Management becomes easier if considered in THREE areas:

A) Head

B) Arms
C) Uterus/pelvis

 MANAGEMENT: Area 1: HEAD

 Lie woman flat

 Check airway / check breathing / give oxygen

 Talk to patient Reassure.

 Note time of relevant EVENTS.

 MANAGEMENT: Area 2: ARMS

 Check PULSE and BP

 Establish LARGE BORE IV ACCESS x2

 X-MATCH 4-6 units Blood

 Start FLUID RESUSCITATION if required (x2L crystalloid)

 —Give DRUGS:

◦ERGOMETRINE 500microg IV/IM

◦SYNTOCINON IV INFUSION (10U/hour)

◦MISOPROSTOL 1000microg

 MANAGEMENT Area 3: UTERUS

 IF ATONY PERSISTS – APPLY BIMANUAL COMPRESSION or

AORTIC COMPRESSION

 REVIEW CAUSES – 4 „T‟s

 Commonest Type of PPH

1. Atonic postpartum hemorrhage

2. Traumatic postpartum hemorrhage

3. Hypofibrinogenemia
 Atonic Postpartum Hemorrhage (80% of PPH)

 This is bleeding from the placental site when the uterus is not well
contracted.

 This is a failure of a myometrium at the placental site to contract and retract

and to compress torn blood vessels and control blood loss by a living
ligature action.

 Causes of Atonic Postpartum Hemorrhage

 Incomplete separation of placenta

 Retained placenta, placental fragments or membranes

 Prolonged labour & obstructed labour resulting in uterine inertia.

 over striating of the uterus e.g. multiple pregnancy.

 Anteportum hemorrhage

 Precipitate labor

 Full bladder

 Mismanagement of the third state of labor

 Management of atonic PPH

 Massage uterus

 Give ergometrine

 Baby to breast

 Empty bladder

 Empty uterus

 Bimanual compression

 Performing a uterine massage

 Bimanual compression
 Wearing sterile gloves, insert a hand into the vagina and remove any blood
clots from the lower part of cervix.

 —Form a Fist and place into the anterior fornix and apply pressure against
the anterior wall of the uterus.

 —With the other hand, press deeply into the abdomen behind the uterus.

 —Maintain compression until bleeding is controlled and uterus contracts .

 Surgical Management

 Consider surgical management when uterotonic agents (± tamponade) don’t

work

 Exploratory laparotomy

 Hypogastric artery ligation

 Bilateral uterine artery ligation (O’Leary sutures)

 Hysterectomy

 Traumatic Post Partum Hemorrhage (20% of PPH)

 This is bleeding from a laceration of the cervix, vaginal wall, and perineum
episiotomy or even from ruptured uterus.

 Cause:

 Delivery through partially dilated cervix

 Instrumental delivery-bruised

 Difficult delivery- Face to pubes, after coming head of breech

 Management of traumatic PPH

 When bleeding is due to the tear, explore the area for the tear, clamp the
bleeding point and suture.

 If the laceration is sutured and bleeding stop make sure that the uterus is
well contacted.
  If bleeding is from bruised cervix place a pack against it for a few minutes to
an hour.

 If bleeding is from ruptured uterus, transfer to the hospital as soon as

possible; go with patient or send a full written report with date, time of
departure and Signature.

 Hypo Fibrinogenemia

 This is bleeding due to a clothing defect and the patient continuous to

bleeding in spite of treatment for the other types of postpartum hemorrhage.

 Causes:

 Placental abraptio

 Intrauterine death

 Amniotic fluid embolism

 Pre- eclampsia, eclampsia

 Intra uterine infection

 Hepatitis

 Management of hypofibrinogenemia (DIC)

 The best treatment is

 - Fresh blood transfusion

- Fibrinogen or triple strength plasma transfusion

- Give oxygen and resuscitate with IV dirp

- Drugs as prescribed

E.g Morphine for pain

- IV syntocinic if uterus is lax.

 Consequences of PPH
  Shock and collapse- death

 Puerperal anemia – weakness & low resistance to infection

 Fear of the further pregnancy

 Sheehan’s syndrome- due to anterior pituitary necrosis

 Infection

Chapter ten
Postpartum preeclampsia
Postpartum preeclampsia is a rare condition that occurs with high blood pressure
and excess protein urea soon after childbirth.
Preeclampsia is a similar condition that develops during pregnancy and typically
resolves with the birth of the baby.

Most cases of postpartum preeclampsia develop within 48 hours of childbirth.

However, postpartum preeclampsia sometimes develops up to six weeks or later
after childbirth. This is known as late postpartum preeclampsia.

Cont…

Postpartum preeclampsia requires prompt treatment. Left untreated, postpartum

preeclampsia can cause seizures and other serious complications.

Symptoms

Signs and symptoms of postpartum preeclampsia — which are typically the same
as symptoms of preeclampsia — might include:

High blood pressure (hypertension) — 140/90 mm Hg) or greater

Excess protein in the urine (proteinuria)

Severe headaches

blurred vision

Upper abdominal pain,

Decreased urination

CLASSIFICATION

 Preeclampsia

 Weight gain

 Increases protein in urine

 Relative hypertension 140/90

 Sever preeclampsia:

 Frontal headache
  Blurred vision

 Upper abdominal pain

 Altered mental status

 Eclampsia:

 1 or more generalized seizure or coma

 Seizure lasts 60-70 sec

Causes

The causes of postpartum preeclampsia and preeclampsia that occurs during

pregnancy aren't well-understood.

Risk factors

High blood pressure during most recent pregnancy.

Obesity.

multiples pregnancy

Chronic high blood pressure.

Diabetes

Complications

Complications of postpartum preeclampsia include:

 Postpartum eclampsia.

 Pulmonary edema.

 Stroke

 Thromboembolism

 HELLP syndrome.

Diagnosis
Postpartum preeclampsia is usually diagnosed with lab tests:

• Blood tests.

• LFT, RFT, number of platelets

• Urinalysis. protein

Management

Postpartum preeclampsia may be treated with medication, including:

Medication to lower high blood pressure. (antihypertensive medication).

 labetolol

 hydralazine

Medication to prevent seizures.

Magnesium sulfate

Magnesium sulfate is typically taken for 24 hours.

Chapter eleven
Psychological problems in the postpartum period
Although the days after birth are generally considered a period of intense
happiness, this period has its dark sides too.

During some of these days or even during several weeks many mothers do not feel
happy at all; the postpartum period should be considered as a vulnerable time for
the development of emotional and psychological disorders.

The last part of pregnancy and childbirth can be troublesome; the body goes
through rapid changes, especially hormonal. In the first days post partum the body
often feels painful and uncomfortable.

The regular care of the baby involves new tasks and uncertainties, and disturbs the
night's rest; the relationship to the partner changes, especially after the birth of a
first child. In many countries women have occupations outside their homes; with
the birth of her child the woman assumes her two- or even threefold duties:
motherhood, external occupation and household activities.

In the nuclear families of modern societies in developed countries these problems

may be different from those in developing countries, where support from family
and neighbours is more commonly available. However, the rapidly growing
phenomenon of urbanisation is changing the potential for postpartum support in
many places.

Three different types of postpartum psychological disorders have been described

(Pop 1991b).

Postpartum blues is characterised by mild mood disturbances, marked by

emotional instability (crying spells apparently without cause, insomnia,
exaggerated cheerfulness, anxious tension, headache, irritability, etc.). Usually the
complaints develop within the first week postpartum, continue for several hours to
a maximum of ten days and then disappear spontaneously. Because of their
frequency (30-70%) postpartum blues are sometimes considered a normal
physiological event. It is assumed that biological changes in the first week post
partum are responsible.

Postpartum depression, often also called postnatal depression is a more protracted

depressive mood with complaints of affective nature: the woman is gloomy,
depressed, irritable, sad. She may have complaints of cognitive and vital nature:
insomnia, lack of appetite, disturbance of concentration, loss of libido.

These complaints are not unique to the postpartum period, and postpartum
depression is not a special kind of depression. It is true that the postpartum period
is a vulnerable time for some women; circumstances associated with motherhood
play a role (availability of social support, changes in life style).

Postpartum thyroid dysfunction may contribute (Pop et al 1991a). The incidence of

severe postpartum depression has been reported as 6%, and the most vulnerable
period is between 8 and 20 weeks postpartum. Depression occurring later is more
protracted and more serious than in the early postpartum period. Depression has an
important influence on maternal-infant interaction during the first year, because the
infant experiences inadequate stimulation (Beck 1995).

There is no evidence that treatment with hormones (progesterone or its derivatives)

is effective, although such treatment has often been advocated, based on
uncontrolled studies. Nevertheless in severe cases treatment and support are
necessary.

Treatment may consist of psychotherapy and antidepressants, and is not different

from the treatment of depression in general.

The support from caregivers for distressed postpartum women/couples has been
investigated in two randomized trials (Forrest et al 1982, Holden et al 1989). This
support was associated with a decreased incidence of women's distress six months
later. It is not yet clear if such support is best provided by highly trained
caregivers, or if support by lay women or self-help groups is sufficient. For the
prevention of depression the labour environment also seems important: a
randomized trial of companionship during labour showed that depression and
anxiety ratings 6 weeks after delivery were lower in the group that received
support during labour (Wolman et al 1993).

Puerperal psychosis is a much more serious disturbance, that should be

distinguished from both other depressive mood disorders. It occurs in 0.1-0.2% of
all postpartum women; symptoms usually start at the end of the first week,
sometimes in the second week, seldom later. The woman is anxious, restless,
sometimes manic with paranoid thoughts or delusions. She reacts abnormally
towards her family members.

Gradually it becomes clear that a psychotic disturbance of her personality exists

that may become dangerous for herself and for the baby.

Admission to a psychiatric department or clinic is necessary; preferably with her

baby.

The psychotic disease as such cannot be distinguished from other psychoses,

nevertheless the moment the disease manifests itself is apparently not coincidental.
This can be concluded from the fact that the same woman after a subsequent
pregnancy has a clearly increased chance of recurrence of the puerperal psychosis.
These women also have an increased risk of psychotic disorder in other stressful
circumstances.

The task of the primary caregiver is to be watchful and to diagnose the disease in
time; a past history of psychotic illness should alert caregivers to potential
problems. Where there are clear signs of psychosis the patient should accompanied
to a hospital or clinic where she can receive appropriate treatment and support.

CHAPTER TWOELEVE

INFANT HEALTH CHALLENGES IN THE POSTNATAL PERIOD

5.1 General considerations

In this section a brief outline of infant morbidity will be given, from the standpoint
of the caregiver in primary care. Disabilities and diseases that can be treated only
in well-equipped hospitals will be mentioned, but the treatment will not be
discussed in detail. The emphasis will be laid on early diagnosis and prevention by
the caregiver, and on the indications for referral.

5.2 Life threatening infant morbidity

5.2.1 Preterm birth

Birth at a gestational age of <37 weeks occurs in 5-9% of all pregnancies, with
regional differences. In developed countries it is the main cause of perinatal
mortality; in these countries as many as 85% of neonatal deaths occurring in
structurally normal infants can be attributed to preterm birth (Rush et al 1976). It is
also an important cause of disability and handicap: of all infants born <32 weeks
and surviving the neonatal period 6-7% have a major handicap and another 8% a
minor handicap (Veen et al 1991).

Adequate treatment aimed at survival without handicap, especially of very preterm

infants (<32 weeks) requires care (preferably also birth in) at well-equipped
hospitals.

The rate in developing countries has been estimated to be higher due to different
reasons. Survival of preterm infants, especially very preterm, is lower too since
special care, that is required for their survival, is not available. Neonatal intensive
care units (NICUs) for the treatment of very preterm infants are extremely
expensive and require sophisticated technological equipment as well as skilled
personnel.

5.2.2 Smallness for gestational age

Low birth weight (LBW, <2500 g, as defined by WHO) may be due to preterm
delivery or smallness for gestational age (intra-uterine growth retardation), or to a
combination of both. A very high proportion of infants in less developed countries
are born with low birth weight.

There is no ideal definition that would identify newborns who are truly growth
retarded and at increased risk of increased morbidity and mortality and that would
exclude those who have reached growth potential and are not at increased risk.
Birth weight charts indicating birth weight centiles are all based on weights
recorded in developed countries, largely in infants of white Caucasian mothers.
Infants of African or Asian descent often have lower mean birth weights and a
higher percentage is <2500 g. Nevertheless, these infants may often be appropriate
for gestational age (AGA), and therefore not at substantially increased risk
(Doornbos et al 1991).

Small for gestational age (SGA) infants may be small from genetic causes, but the
majority is growth retarded because of maternal malnutrition and/or ill health,
maternal behaviour problems such as smoking and alcohol abuse and factors not
yet well understood. True intra-uterine fetal growth retardation is a major cause of
perinatal mortality, both intra-uterine and neonatal mortality.

Regardless of the cause all small newborns need frequent feeding, thermal
protection and growth monitoring.

5.2.3 Congenital anomalies

Congenital anomalies or malformations are an important cause of perinatal and

neonatal deaths. Among the most severe malformations are neural tube defects and
other defects of the central nervous system, chromosomal disorders, malformations
of the gastrointestinal tract, congenital heart disease, malformations of the
urogenital system like bilateral renal agenesis and musculoskeletal anomalies.
Some of the malformations may have been caused by infectious diseases acquired
during pregnancy (rubella, cytomegalovirus infection, toxoplasmosis). Nutritional
factors may sometimes be involved (iodine or folic acid deficiency).
Consanguinity, which prevails in numerous communities, is an important
predisposing factor.

In developed countries lethal malformations constitute 20-25% of total perinatal

mortality (Treffers 1995). In developing countries this percentage will be lower,
because more infants die by other causes. However, the incidence of
malformations in less developed countries is probably higher due to several
factors: deficiency of several micronutrients, advanced maternal age, infections
(rubella) and consanguinity in some parts.

Often therapy for the malformation is impossible, and sometimes care for the dying
is the only possible action. But always the care for the parents is important; the
birth of a severely malformed infant is a serious shock.

5.2.4 Severe bacterial infection

Infections are significant causes of mortality and morbidity in newborn infants,

both preterm and term. The two principal sources of neonatal infection are the
mother and the environment, including the delivery place, the nursery or home.
Infections manifesting in the first days of life are usually the result of exposure to
microorganisms of maternal origin, infections presenting later have more often an
environmental source though they could manifest around birth. However, poor
practices around birth should always be examined as a potential cause of
infections, as learned from the experience with neonatal tetanus and epidemics of
staphylococcal infections in nurseries.

The outcome of neonatal infection can be improved if the disease is recognized

early and treated promptly and appropriately.

In developed countries the incidence is between 1-10/1000 in term infants and

more frequent in preterm infants. It is estimated that the incidence in developing
countries in both groups is higher.

Causative organisms are primarily Escherichia coli, but other bacteria may also
play a role: in more developed countries group B streptococci, in Nigeria
salmonella and Streptococcus pneumoniae have been found (Barclay 1971),
elsewhere Listeria monocytogenes. Infections with Staphylococcus aureus are
mostly acquired from caregivers.

A task of the caregiver is to recognize early symptoms of neonatal sepsis and to

guard against nosocomial infection. Infection control in the newborn care is among
the most effective preventive measures for newborns.

The symptoms of the disease are non-specific. There may be no elevation of the
temperature, often the infant is hypothermic. It may be lethargic, cyanotic (blue
discolouration of the skin), and may have difficulty breathing.

The general condition of the infant can deteriorate rapidly. If during the first days
after birth an infant is suspected of having sepsis, it should be referred to a hospital
as soon as possible. Antibiotics will usually include penicillin or ampicillin, in
combination with an aminoglycoside.

5.2.5 Neonatal tetanus

This very serious infection only occurs in regions where basic hygienic measures
during and after delivery are neglected or unknown, and where the immunization
coverage of young women is still inadequate. The total global estimate of deaths
from neonatal tetanus is 550 000; more than 50% of these deaths occur in Africa
and South-Central Asia (WHO 1994d). The infected umbilical stump is usually the
point of entrance of the bacteria, especially if the umbilicus has been treated with
dung, which is sometimes done by traditional birth attendants. Symptoms of the
disease are cramps, especially in the facial muscles, suckling becomes impossible,
later convulsions occur with general spasms (opisthotonus).

The infant showing early signs of tetanus requires expert nursing care, although the
prognosis is extremely poor. Tetanus is often associated with sepsis. \

The main strategy in the fight against neonatal tetanus is clean delivery, together
with immunization of pregnant women and women of childbearing age, at least in
regions where adolescents are inadequately immunized (see section 9.2). The tasks
of skilled personnel are primarily to teach families and traditional birth attendants
principles of clean delivery and cord care, and also to recognize early symptoms of
neonatal tetanus.

5.2.6 Newborns suffering from birth trauma

Perinatal trauma (birth injuries) may be mechanical, by difficult deliveries. It

includes fractures, subcutaneous haematomas, damage to the central nervous
system like intracranial haemorrhage and spinal cord injuries, and damage to
peripheral nerves like brachial plexus injury.

The best prevention of birth injuries is appropriate management of labour and

delivery. Little treatment is available although the diagnosis is usually not difficult;
at least it will be evident that something serious occurred. After a major trauma the
infant needs referral to a centre where it can receive special care.

There is no agreed definition of birth asphyxia. It is defined simply as the failure to

initiate and sustain breathing at birth. Although birth asphyxia and trauma are often
combined, hypoxic injury can occur without visible trauma. A newborn that has
suffered asphyxia has difficulty to initiate breathing spontaneously, is hypotonic
after birth, may have convulsions.

The lifesaving procedure for newborn infants with asphyxia is resuscitation (WHO
1996b). Those who were successfully resuscitated at birth do not necessarily have
problems in their early neonatal period or later.
Severe asphyxia combined with poor or no resuscitation is the worst possible start
in life. There is little specific treatment available for those infants even with
unlimited resources besides loving care and continuous psycho-social stimulation.

5.3 Other serious infant morbidity

5.3.1 Disturbance of thermoregulation

A newborn infant is dependent on his/her environment for the maintenance of body

temperature, much more so than later in life.

Hypothermia is harmful to the newborn. The baby's body cools down rapidly,
unless measures are taken such as keeping them dry and in a warm environment. A
fall in body temperature can be reduced by skin-to-skin contact between baby and
mother. Hypothermia should be prevented, and if it occurs, it should be corrected
immediately by adequate measures. It should be kept in mind that hypothermia in a
newborn may be one of the first symptoms of (infectious) disease.

Hyperthermia is usually caused by a too warm environment, e.g. by exposure to

sun or hot-water bottles, especially if the baby is well swaddled. It can be harmful
and the environment should be adjusted adequately. Clinically hyperthermia
cannot be distinguished from fever and an infection should always be considered
and ruled out as a potential cause of increased body temperature.

5.3.2 Jaundice

It is both normal and common for healthy newborn infants to become jaundiced. In
term infants this occurs in about 15% and more frequently in preterm. Jaundice is a
sign not a disease as long as the level of bilirubin does not go over values
considered to be safe. The most common jaundice in term newborn infants is
physiological and it seldom reaches severity that might be harmful.

In a small proportion of infants jaundice is a sign of serious disease. In those cases

it usually appears early and/or it becomes severe. The most common causes of
severe jaundice are haemolytic diseases of different etiologies and infections. In
countries with no prevention of Rh-iso-immunization or with other specific
problems such as glucose-6-phosphate dehydrogenase deficiency severe forms of
jaundice are more frequent than elsewhere. Jaundice in preterm infants can be a
combination of the immature organism not being able to metabolize bilirubin, and
diseases. It should be considered a more serious problem than in term infants. Poor
clinical practices can contribute significantly to the level of jaundice.

Phototherapy is an effective treatment for most newborns with moderately severe

jaundice. Phototherapy is considered a safe intervention without known side-
effects. However, it usually involves hospital admission of the infant with
separation from the mother, and negative consequences for breastfeeding and
mother-infant relation. Interventions aimed at lowering serum bilirubin values are
performed too often in term infants (Newman & Maisels 1990, 1992).

When the values of bilirubin exceed levels considered safe exchange transfusion is
indicated - at what exact values will dependent on the age of the infant, gestational
age and other problems (Provisional committee for quality improvement and
subcommittee on hyperbilirubinaemia 1994). It has never been proven that
bilirubin values <340 ìmol/l are harmful for term infants not suffering from
haemolytic disease (Scheidt et al 1990, Newman & Klebanoff 1993, Seidman et al
1994).

5.3.3 Ophthalmia neonatorum

This is a purulent discharge from the eyes occurring within the first month of birth
(WHO 1994d). It is a common disease of the newborn. In countries where STDs
are prevalent, the most frequent cause of purulent conjunctivitis in the first month
of life is Chlamydia trachomatis. More dangerous is gonococcal conjunctivitis
which may lead to keratitis and blindness.

Treatment is by intramuscular antibiotics. Routine prophylaxis by applying an

antiseptic solution within 1 hour of birth is recommended in many countries; it
reduces the transmission rate from mother to newborn considerably. In some
developed countries where sexually transmitted diseases are rare the method has
been abandoned and replaced by frequent inspection of the eyes. In those countries
and regions, where prevalence of sexually transmitted diseases is higher eye
prophylaxis is still considered as a cost-effective intervention that will prevent
blindness (WHO 1994d).

5.3.4 Neonatal herpes infection

This is a serious but relatively rare infection of the newborn. In recent decades the
importance of the disease has been somewhat overestimated in scientific literature
and publicity in developed countries.

The reported incidence varies geographically: in the USA figures up to 28 per 100
000 are given (Sullivan-Bolyai et al 1983); in the Netherlands in a national survey
during 1981-1985 an incidence of about 5 cases per year was found, or about 3 per
100 000 live births (Van der Meijden & Dumas 1987).

The number of pregnant women with known chronic genital herpes is much larger,
which implies that the risk of neonatal herpes in infants of women with recurrent
genital herpes is relatively low (Prober et al 1987). Some of the cases of herpes
neonatorum are caused by herpes virus type I, which is the primary causative agent
of herpes labialis.

5.3.5 Hepatitis B

If the mother is a carrier of the hepatitis B virus (HBV), there is a high risk of
vertical transmission from the mother to the baby during and after birth. Affected
infants usually become asymptomatic chronic carriers, and will be at risk later in
life of chronic liver disease and hepatoma. Only occasionally does a newborn
develop fulminant hepatitis.

5.4 Conclusion

The health challenges faced by the newborn are impressive; their extent is greater
than in any other relatively short period of human life. This justifies a well-
organized care system, designed to check the health of the infant, to support the
parents in their task, and to take measures whenever necessary to prevent or
combat disease.