post partum care & complications

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    POSTPARTUM CARE& COMPLICATIONS

    Dr. Baran Palanimuthu , MDDepartment Of Obstetrics & Gynaecology

    Sultan Abdul Halim General Hospital

    Sg.Petani

    Kedah Darul Aman

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    The postpartum period

    (puerperium) is from the

    end of labour until the

    genital tract has returned to

    normal. It usually last for

    42 days.

    INTRODUCTION

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    The Aims of Postpartum Care:

    Support mother and family

    Prevention, early diagnosis and treatment of

    complications

    Referral

    counselling

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    The Aims of Postpartum Care:

    Support of breastfeeding

    Educate on nutrition, and supplementation

    Counselling contraception and the resumption of

    sexual activity

    Immunization of infant

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    Is to increase the awareness of warning

    signal and appropriate intervention at all

    level.

    About 2/3 of the maternal deaths occur

    during the postnatal period

    RATIONALE

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    NEEDS OF WOMEN AND NEWBORN

    1.Information/counselling on:

    Herself-Health

    Self care

    Sexual life

    Nutrition

    Contraception

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    NEEDS OF NEWBORN

    Information/counselling

    Care of the baby

    *Special Needs referto Neonatal Care

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    NEEDS OF NEWBORN

    Information/counselling

    Breastfeeding

    *Special Needs refer to Neonatal Care

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    Postpartum care: What to expect after a vaginal

    delivery

    Vaginal soreness

    - Keep the wound clean-Rinse the perineum after using the toilet.

    - Sit down carefully. If sitting is uncomfortable, sit on a pillow or padded ring.

    Vaginal discharge

    - Lochia after delivery. Expect a bright red, heavy flow of blood for first fewdays.-Will gradually taper off- changing from pink or brown to yellow or white.

    - To reduce the risk of infection, use sanitary napkins rather than tampons.

    Contractions- Few days after delivery- contractions often resemble menstrual cramps , help

    prevent excessive bleeding by compressing the blood vessels in the uterus.

    - Carefull when a fever rise or abdomen is tender to the touch

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    Hemorrhoids and bowel movements

    - Foods high in fiber and drink plenty of water.

    - RX: e.g Bisacodyl

    - Fecal incontinence due to long labor. Frequent Kegel exercise

    Sore breasts and leaking milk

    - Known as engorgement- Nurse baby (Practise good lactation method)

    - Apply cold washcloths or ice packs on breasts

    Mood changes

    - Mood swings, irritability, sadness and anxiety are common

    - Share feelings, and ask your partner, loved ones or friends for help

    Urination problems

    - Watch out for s/sx of UTI

    - Pregnancy stretch connective tissue @ base bladder cause nerve + muscle damageto bladder or urethra. Problem-Dysuria,Urgency,frequency usually improves within 3months.

    - Adviced for Kegelsexcercise

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    Postpartum care: What to expect after a C-

    section

    Treat C-section incision with care:

    - It takes about four to 6 weeks for a C-section incision to heal

    - Have a good posture -stand and walk & sudden movements-coughing, sneezing

    /laughing.

    - Complete medications-especially antibiotics

    - Empty bladder frequently -reduce risk of UTI

    Look for signs of infection

    - The incision is red, swollen or leaking discharge

    - Fever > 38 degree celcius

    - Increasing pain around incision

    - OTHERS = Vaginal Delivery

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    Post Partum Complications

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    Post Partum Haemorrhage (PPH)

    Defination:

    - Excessive bleeding after childbirth; traditionally defined as a loss of 500 ml

    or more after a vaginal birth and 1000 ml or more after a cesarean birth

    - Primary Haemorrhage:

    Bleeding 24 hours but within puerperium

    Causes are:

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    1.Uterine Atony

    - The most common cause:- Uterus fail to contract following the delivery of placenta

    Predisposing conditions:- Multiparity

    - Prolonged labour

    - Conditions overdistends uterus-> Multiplepregnancy,macrosomia,polyhidramnios ,hydrops fetalis

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    2.Retained Placenta

    Occurs when only part of placenta been seperated

    Bleeding continues @ seperation site because uterus

    unable to contract down due to retained placenta

    Sometimes only small part of placenta retained butenough to cause PPH

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    3.Genital Tract Laceration

    Commonly follows assisted deliveries: e.gForceps/Ventouse

    Arises when inappropriate application of instruments/excessive force used to deliver the baby.

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    4.Abruptio Placenta

    Occurs because

    1.Patient may gone into DIVC on account consumtivecoagulopathy

    2.Extravasation of blood within the myometrium(Couveleire uterus)cause uterine atony

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    6.Acute inversion of the uterus

    Uterus is pulled inside out & fundus of the uterus

    presented @ the introitus.

    Often occurs when there is excessive traction used to

    deliver the placenta when it has not yet seperated fromthe fundus of uterus

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    Puerperal Infections

    Reproductive tract associated with childbirth Metritis, perineal or cesarean wound

    Causes of metritis Cesarean - Prolonged labor

    PROM - Multiple vaginal exams

    Scalp electrodes - Internal uterine monitor

    OB trauma - Instrument assisted birth

    Manual removal of placenta

    Prexisting infection

    Compromised health status

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    Puerperal Infections:Metritis

    Assessment

    Abd/Uterine pain

    Foul smelling

    vaginal dischargeFever 101-104 F

    Chills

    Malaise30% increase in

    WBC

    Interventions

    CBC

    Cultures

    Hygiene

    Abscess is drained

    IV antibiotics

    Antipyretics

    ICU hospitalization

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    Overdistention of the Bladder

    Cause Unable to empty bladder due to trauma or anesthesia

    Assessment Distended bladder

    Displaced uterus, increased vaginal bleeding, boggy uterus,backache, restless

    Intervention Encourage voiding

    Perineal ice packs Pour water over perineum

    Aseptic straight catheter X 1

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    Urinary Tract Infections

    Cause Retention of urine

    Bacteria from catheterization

    Cystitis Assessment Intervention

    Increase fluids >> Void frequently

    Empty bladder >> Urine culture and

    antibiotics Prevention

    Hygiene

    Void q 2-4 hrs

    Increase acidit in urine

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    Urinary Tract Infections

    Pyelonephritis Assessment

    UTI signs >> High fever

    Chills >> Flank pain

    N&V >> Acutely ill Management

    IV antibiotics >> Increase fluids

    Antipyretics >> AnalgesicFollow-up culture in 2 weeks

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    Mastitis Infection of breast tissue

    Causes Bacteria enters through cracks in nipple

    Milk stasis

    Poor hand washing

    Breast not dry or wet breast pad

    Incorrect placement of baby causes sore nipples

    Assessment Fever > 101 F and chills, acutely ill

    Flu-like symptoms, malasia, headache

    Painful, warm, red area of breast

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    Mastitis

    Intervention Bed rest - Increase fluids Supportive bra - Antibiotics Analgesic

    Breast feed frequently Warm compress before feeding Cold packs between feedings Drain abscess

    Prevention Early feedings and frequent feedings Change babys feeding positions Massage clogged duct Empty breast at each feeding

    Nipple care

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    Thromboembolic Disorders

    Blood clot formed from impeded blood flow Causes Hypercoagulability of blood Venous stasis

    Injury to epithelium of vessels Increased risk Prevention Avoid dehydration Avoid trauma to legs in stirrups Early postpartum ambulation Leg exercises to support venous return No smoking Antiembolism stockings

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    Thromboembolic Disorders

    Superficial thrombophelbitis 3 to 4thday after delivery

    Assessment

    Tenderness >> Localized heat

    Swelling >> RednessNo or low fever

    Intervention

    Elevate leg >> Bed rest

    Local moist heat >> Analgesia

    Support hose Little risk of pulmonary embolism

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    Thromboembolic Disorders

    Deep vein thrombosis Intervention

    Bed rest >> Elevate leg

    Analgesia >> Antibiotics

    Anticoagulant therapy

    IV heparin

    Coumadin for 2 to 6 months

    Monitor for pulmonary embolism

    Antiembolism stockings after symptoms:

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    Every visit to HC

    Mother

    Examination of

    vital signs

    breast

    abdomen

    Perineum

    These should be recorded in the Rekod KesihatanIbu KIK/1(a)/96 and KIK/1(b)/96 .

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    Every visit to HC

    Mother

    Health and well-being.

    Symptoms of abnormal lochia,

    Chest pain,

    Difficulty in breathing,

    Redness and inflammation of lower limbs

    Calf swelling and tenderness.

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    Ask Mother about Baby:

    Health and well-being.

    Feeding

    Bowel opening

    Passed urine

    Other concerns.

    Every visit

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    Assessment On Baby

    body weight body temperature eyes, skin

    umbilical cord.

    If the mother accompanies her baby in the ward, thepostnatal care should be continued for the mother bythe hospital staff as scheduled.

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    CHECK LIST TO IDENTIFY HIGH RISKS

    Senarai semak bagi mengesan factor risiko semasa postnatal digunakan oleh anggota jururawat/ pegawai

    perubatan ketika menjalankan jagaan postnatal.

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    Resumption of sexual activity post natally

    Some Studies shown

    By eight weeks postpartum 71% of respondentshad resumed intercourse, and by ten weeks 90%

    of the women who had partners had resumedintercourse (Glazener 1997).

    Another factor that influences sexual behaviorpost partum is pain related to perineal damage

    and sutures, caused by vaginal tears andepisiotomies (Glazener 1997).

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    Resumption of sexual activity cont..

    Mother and her partner should decide together Sexual intercourse may be resumed after mothers

    vaginal bleeding has stopped and stitches arehealed (usually within 4- 6 weeks)

    Be aware that sex first few times following birthmay be painful Advised for lubricants andcomfortable positioning.

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    COPING WITH DEATHS

    GRIEF:

    Emotional and somatic responses felt by an

    individual on the death of another individual.

    More intense if the death occurs in a person who is

    closely related.

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    NORMAL GRIEF REACTION

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    MORTALITY BEREAVEMENT

    Maternal Death

    Stillbirth

    Neonatal death

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