1. Unit Eleven Postpartum Complications
Puerperal Infection “Puerperal Sepsis”
Is any clinical infection of the genital canal and breasts that occurs within 28 days after abortion or delivery.
Postpartum infection of genital tract usually of the endometrium that may remain localized or may extend to various parts of the body.
Infections may result from bacteria commonly found in the vagina (endogenous) or from the induction of pathogens from outside the vagina (exogenous).
The most common microorganisms are Streptococci, E. coli, Staphylococci, Sexually Transmitted Diseases (STDs), Anaerobic microorganisms as Tetanus and gas gangrene.
Puerperal infection may occur anywhere in the pelvis or birth canal as endometritis, vaginitis, vulvitis.
Dr. Areefa SM Albahri
PhD in MCH
Dr. Areefa SM Albahri
PhD in MCH

2. Predisposing Factors:
1. Prolonged labor
2. Postpartum hemorrhage.
3. PROM.
4. Infection elsewhere in the body.
5. Intrauterine manipulation.
6. Anemia.
7. Retention of placental fragments.
8. Malnutrition.
Endometritis usually occurs at the placental site.
Secondary abscesses may arise in distant sites such as the lungs or liver. Pulmonary embolism or septic shock with DIC from any serious genital infection may prove fatal.

3. Clinical Findings:
Symptoms may be mild or fulminating
Any fever with a temperature of 38 ºC or more on 2 successive days (not counting the first 24 hours after delivery) must be considered to be caused by puerperal infection in the absence of another cause.
1. Endometritis
Endometritis is the most common puriperal infection and it occurs hours after delivery.
Uterus usually larger than expected for postpartum day. Lochia may be profuse, bloody and has a foul smelling.
Chills, fever, anorexia and general malaise.

4. Risk factors for endometritis
Cesarean birth
Prolonged rupture of the membranes
Multiple vaginal examinations
Internal electronic FHR monitoring
Low socio-economic status
Poor nutrition, young age
Diabetes
Prior genital infection
Inadequate aseptic technique
Anemia
Smoking
Operative vaginal delivery
Poor postpartum perineal care

5. Parametritis Pelvic Cellulitis
Infection of the pelvic connective tissue.
Chills, fever, tachycardia, severe unilateral or bilateral pain in the lower abdomen and tenderness on vaginal examination usually occur about the 4th postpartum day. May result from infected wound in the cervix, vagina, peritoneum or lower uterine segment.
Uterus may be longer than expected.
Pelvis area warm with an extremely sensitive spot due to an abscess formation underneath.
Incision and drainage is performed if an abscess forms, antibiotics.

6. Thrombophlebitis
Inflammation of venous wall with clot formation.
• Pelvic Thrombophlebitis:
Infection of veins supplying uterine wall and broad ligament.
Symptoms usually begin during in the 2nd week following delivery.
The women may have severe chills and intermittent high fever (40 ºC), ? redness, increase skin temperature,
Blood cultures are taken to isolate the organisms.
• Femoral Thrombophlebitis:
- Pain, tenderness, redness, hotness, edema of the calf or thigh.

7. Bacteremia
Presence of bacteria in the blood stream.
Chills, fever, tachypnea, pale skin, cyanosis of the lips and fingers, increase lochial secretions with foul odor.
5. Peritonitis
Inflarnmation of the peritoneurn.
Chills, high fever, tachycardia, vomiting, severe abdominal pain.

8. Diagnostic Evaluation:
Clinical history.
Physical examination.
Leukocytosis, high neutrophils.
Culture and sensitivity for discharge and blood for both aerobic and anaerobic organisms.
Lung scan, chest X-ray.
Management and Nursing Interventions:
The most effective and cheapest treatment of puerperal infection is prevention.

9. Preventive measures include:
Good prenatal nutrition.
Treatment of anemia.
Control of intranatal hemorrhage.
Good inratranal hygiene.
Prolonged labor should be avoided.
Traumatic vaginal delivery should be avoided.
Best aseptic techniques by medical personnel.
Explain prescribed treatment regimen.
Correct misinformation.

10. Monitor the woman’s condition:
Continue monitoring of temperature, pulse and respiration.
Isolate the woman with infection from other postpartum women.
Maintain fluids and electrolytes.
Blood may be necessary to combat severe anemia.
Antibiotic therapy as prescribed.
Monitor site of infection for manifestations.
Provide diet with increased calories, protein and vitamins to promote healing.

11. Mastitis
Mastitis is inflammation of breast tissue
It may involve formation of subareolar abscess in the underlying milk glands or connective tissue and fat around the lobes and lobules.
Is unilateral, and develops well after the flow of milk has been established.

13. Cause:
Usually due to Staphylococcus aureus derived from the nursing infant’s nose and throat into a fissure in the nipple.
Clinical Manifestations:
Symptoms may occur at the end of the 1st postpartum week but usually occur in the 3rd to the 4th week postpartum.
Elevated temperature (usually not above 39.3 ºC).
Tachycardia
Breast pain.
Breast hardening and redness.
Inflammatory edema, enlarged axillary lymph nodes.
Breast engorgement with obstruction of milk flow.

14. Management and Nursing intervention:
Acute mastitis can be avoided by:
Proper nursing technique, to prevent cracked nipple.
Avoid missed feedings, waiting too long between feedings.
Maintain cleanliness and personal hygiene
Implement plan of care:
Use comfort measures- breast support, tight binder or brassier.
Analgesics as prescribed.
Application of heat to affected breast if suppuration is present.
Suitable antibiotic for Staphylococcus aureus as Cephalosporines
If breast milk is contaminated, breast feeding on affected side may be discontinued, empty breast on affected side 2-4 hr..
If abscess forms, incision and drainage may be necessary.

15. Postpartum UTI
Causes:
Bladder trauma during delivery.
Urinary retention due to anesthesia,
venous congestion causing over distention of the bladder.
Frequent catheterization.
Clinical Manifestations:
Elevated temperature and chills.
Urinary frequency.
Pain on urination.
Flank pain.

16. Explain and implement plan of care:
Management and Nursing Interventions:
Explain and implement plan of care:
Monitor vital signs, degree and site of pain.
Instruct the woman to increase fluid intake.
Instruct the woman to empty her bladder.
Administer suitable antibiotics, analgesics, and antispasmodics as prescribed.
Encourage the woman to rest.
Describe complications and general treatment regimen.
Correct misinformation regarding condition and complications,

17. Sub-involution
Is the slowing or halting of normal postpartum return of reproductive organs to their pre-pregnancy state. (is the failure of the uterus to return to the nonpregnant state).
Causes:
1. Pelvic infection.
2. Retention of placental fragments.
3. Fibroid tumor.
4. Any other factors that interferes with myometrium contractions.

18. Clinical Manifestations:
1. Uterus larger or softer than expected for postpartum date.
2. Prolonged lochia discharge (after one month or more).
3. Irregular uterine bleeding.
4. Backache or sensation of weight in pelvis.
Management and Nursing Interventions:
Administration of Ergonovine Maleate as prescribed to increase uterine contractility.
Prepare the woman for uterine curettage if placental fragments have been retained. Administer suitable antibiotics for infection as prescribed.
report signs of infection, vaginal bleeding or any tissue passed vaginally. Correct misinformation regarding condition and complications.

19. Postpartum Hemorrhage
Is defined as a loss of blood excess of 500 ml in the 1st 24 hours following vaginal delivery and 1000 mL or more after a cesarean birth.
It occurs more frequently in the 1st hour following delivery.
Approximately 5% of all women who give birth vaginally experience a postpartum hemorrhage.
According to The WHO, 25% of all pregnancy related deaths result from postpartum hemorrhage.
Postpartum hemorrhage could be early or late:

20. An early hemorrhage occurs within the first 24 hours after birth (mostly within the first 4 postpartum hours). During this time, the blood flow to the uterus is between 500 and 800 mL/minute, and the placental site contains multiple exposed venous areas and low resistance
A late hemorrhage occurs after more than 24 hours but less than 6 weeks postpartum.

21. Causes:
1. Uterine atony “Relaxation of the uterine muscles”.
Is a failure of the uterine myometrium to contract and retract following birth.
It occurs secondary to:
Multiple pregnancies that causes over distention of uterus and larger placental site.
High parity.
Prolonged labor with maternal exhaustion.
Deep anesthesia: provide uterine relaxation.
Fibromyomata: prevents uterus from contracting.
Retained placental fragments.
Polyhydramnios.
Macrosomia.

22. Laceration of the vagina, cervix or perineum secondary to:
Forceps delivery.
Large infant.
Multiple pregnancies.
3. Retained placental fragments:
These fragments are the major cause of late postpartum hemorrhage.
Mostly occurs at 2-4 weeks after delivery.
Results from placenta accreta or manual removal of placenta.
4. Retained placenta:
Hemorrhage may occur after the delivery of baby and before delivery of the placenta.

23. Clinical Manifestations:
Uterine atony:
Uterus is soft, often difficult to palpate and will not remain contracted.
Bleeding is steady and slow rather than sudden and massive.
Blood pressure and pulse may not change until blood loss is significant.
Lacerations:
Fundus is firm, bleeding is bright red.
On examination, lacerations are found.
Retained placental fragments:
Hemorrhage usually occurs about the 10th postpartum day.
Excessive blood loss: pallor, restlessness, dyspnea, thready pulse, hypotension, chills and air hunger.

24. Management and Nursing interventions:
Monitor changes in physiologic status:
Monitor vital signs frequently.
Describe number and saturation of perineal pads used per hour.
Describe character and amount of vaginal bleeding.
Evaluate uterine firmness, height and position.
Restore fluid/blood volume:
Administer IV Fluids as prescribed to restore fluid volume.
Administer blood as prescribed.
When cause has been determined, prepare the woman for further treatment.

25. Uterine atony: Vigorous massage is instituted. Oxytocics may be given.
Laceration:
Prepare the woman to return to the delivery room for inspection and repair.
Retained placental fragments :
Prepare the woman for curettage of the uterus.
Retained placenta:
The physician manually removes the placenta by inserting a gloved hand into the uterus and placing the other hand externally on the fundus.
O2 at 4-7 L/min is given by facemask.
Help reduce anxiety:
Determine major cause of mother’s anxiety.
Explain current status and prescribed treatment regimen.
Correct misinformation regarding states or potential complications.
Keep the woman/family informed of changes in physiologic status or treatment plan with emphasis on improvement condition.
Results from placenta accreta or manual removal of placenta.