Rugae Are Never Again as Prominent as in a Nulliparous Woman

12 The puerperium

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Contents

• Objectives
• The normal puerperium
• Management of the puerperium
• The half dozen calendar week postnatal visit
• Puerperal pyrexia
• Genital tract infection
• Urinary tract infections
• Thrombophlebitis
• Respiratory tract infection
• Puerperal psychiatric disorders
• Secondary postpartum bleeding
• Self-monitoring
• HIV positive mothers
• Case studies

Objectives

When you have completed this affiliate you should be able to:

1. Define the puerperium.
2. Listing the physical changes which occur during the puerperium.
3. Manage the normal puerperium.
4. Appraise a patient at the half-dozen-week postnatal visit.
5. Diagnose and manage the various causes of puerperal pyrexia.
6. Recognise the puerperal psychiatric disorders.
7. Diagnose and manage secondary postpartum bleeding.
8. Teach the patient the concept of 'the female parent equally a monitor'.

The normal puerperium

12-i What is the puerperium?

The puerperium is the period from the end of the third stage of labour until most of the patient's organs have returned to their pre-pregnant state.

12-2 How long does the puerperium terminal?

The puerperium starts when the placenta is delivered and lasts for half dozen weeks (42 days). However, some organs may only return to their pre-pregnant state weeks or even months later the 6 weeks take elapsed (due east.g. the ureters). Other organs never regain their pre-significant state (e.thou. the perineum).

Information technology is of import for the midwife or doc to assess whether the puerperal patient has returned, as closely as possible, to normal health and activity.

The puerperium starts when the placenta is delivered and lasts for 6 weeks.

12-3 Why is the puerperium important?

1. The patient recovers from her labour, which often leaves her tired, even exhausted. There is, still, a feeling of great relief and happiness.
2. The patient undergoes what is probably the most of import psychological experience of her life, as she realises that she is responsible for some other human being, her baby.
3. Breastfeeding should be established.
4. The patient should decide, with the guidance of a midwife or doctor, on an appropriate contraceptive method.

12-4 What concrete changes occur in the puerperium?

Almost every organ undergoes modify in the puerperium. These adjustments range from mild to marked. Only those changes which are important in the management of the normal puerperium will be described here:

1. General condition:
   • Some women experience shivering presently later on commitment, without a change in body temperature.
   • The pulse rate may be dull, normal or fast, only should not be above 100 beats per infinitesimal.
   • The blood force per unit area may also vary and may be slightly elevated in an otherwise healthy patient. It should, yet, exist less than 140/xc mm Hg.
   • There is an firsthand drop in weight of near 8 kg after delivery. Further weight loss follows involution of the uterus and the normal diuresis (an increased corporeality of urine passed), but also depends on whether the patient breastfeeds her infant.
2. Skin:
   • The increased pigmentation of the face up, abdominal wall and vulva lightens merely the areolae may remain darker than they were earlier pregnancy.
   • With the onset of diuresis the general puffiness and whatsoever oedema disappear in a few days.
   • Marked sweating may occur for some days.
3. Intestinal wall:
   • The intestinal wall is flaccid (loose and wrinkled) and some separation (divarication) of the abdominal muscles occurs.
   • Pregnancy marks (striae gravidarum), where present, exercise not disappear, merely do tend to go less cherry in time.
4. Gastrointestinal tract:
   • Thirst is common.
   • The appetite varies from anorexia to ravenous hunger.
   • At that place may be flatulence (excess current of air).
   • Many patients are constipated equally a result of decreased tone of the bowel during pregnancy, decreased nutrient intake during labour and passing stool when virtually fully dilated or during the 2nd stage of labour. Constipation is common in the presence of an episiotomy or painful haemorrhoids.
   • The routine administration of enemas when patients are admitted in labour is unnecessary and is not beneficial to patients. It also causes constipation during the puerperium.
5. Urinary tract:
   • Retention of urine is common and may result from decreased tone of the bladder in pregnancy and oedema of the urethra following delivery. Dysuria and difficulty in passing urine may lead to consummate urinary retentivity, or retention with overflow incontinence. A full bladder will interfere with uterine contractions.
   • A diuresis usually occurs on the second or third day of the puerperium. In oedematous patients information technology may offset immediately after commitment.
   • Stress incontinence (a leak of urine) is mutual when the patient laughs or coughs. It may commencement be noted in the puerperium or follow stress incontinence which was nowadays during pregnancy. Often stress incontinence is worse initially simply tends to improve with time and with pelvic floor exercises.
   • Pelvic floor exercises are also known as compression or 'knyp' exercises. The muscles that are exercised are those used to suddenly terminate a stream of urine midway through micturition. These muscles should be tightened, as strongly as possible, 10 times in succession on at least four occasions a mean solar day.

   Note

   Normal bladder function is likely to be temporarily impaired when a patient has been given epidural analgesia. Complete retentivity of urine or retentivity with overflow may occur.

6. Blood:
   • The haemoglobin concentration becomes stable around the fourth solar day of the puerperium.
   • The platelet count is raised and the platelets go stickier from the fourth to 10th day later on delivery. These and other changes in the clotting (coagulation) factors may crusade thromboembolism in the puerperium.

7. Breasts:

   Marked changes occur during the puerperium with the production of milk.

8. Genital tract:

   Very marked changes occur in the genital tract during the puerperium.

   • Vulva: The vulva is swollen and congested after commitment, only these features rapidly disappear. Tears and/or an episiotomy commonly heal easily.
   • Vagina: Immediately after delivery the vagina is large, polish walled, oedematous and congested. It speedily shrinks in size and rugae return by the third calendar week. The vaginal walls remain laxer than before and some degree of vaginal prolapse (cystocoele and/or rectocoele) is common later on a vaginal commitment. Modest vaginal tears, which are very common, usually heal in vii to 10 days.
   • Cervix: After the first vaginal delivery the circular external os of the nullipara becomes slit-like. For the commencement few days after delivery the cervix remains partially open up, admitting 1 or 2 fingers. Past the seventh day postpartum the cervical os will have closed.
   • Uterus: The nigh important change occurring in the uterus is involution. After delivery the uterus is about the size of a 20-calendar week pregnancy. By the end of the starting time calendar week it is about 12 weeks in size. At 14 days the fundus of the uterus should no longer be palpable above the symphysis pubis. After 6 weeks it has decreased to the size of a normal multiparous uterus, which is slightly larger than a nulliparous 1. This remarkable decrease in size is the issue of wrinkle and retraction of the uterine musculus. The normally involuting uterus should exist firm and non tender. The decidua of the uterus necroses (dies), due to ischaemia, and is shed equally the lochia. The average duration of red lochia is 24 days. Thereafter, the lochia becomes harbinger coloured. Normal lochia has a typical, non-offensive smell. Offensive lochia is e'er abnormal.

Direction of the puerperium

The management of the puerperium may be divided into three stages:

1. The management of the commencement hour afterwards commitment of the placenta (sometimes called the fourth stage of labour).
2. The management of the residue of the puerperium.
3. The 6 week postnatal visit.

12-5 How should you manage the first two hours after the delivery of the placenta?

The two master objectives of managing the kickoff 60 minutes of the puerperium are:

1. To ensure that the patient is, and remains, in a good status.
2. The prevention of a postpartum haemorrhage (PPH).

To achieve these, you should:

1. Perform sure routine observations.
2. Care for the needs of the patient.
3. Go the patient's co-operation in ensuring that her uterus remains well contracted and that she reports any vaginal haemorrhage.

The correct management of the showtime 2 hours of the puerperium is most important every bit the risk of postpartum haemorrhage is greatest at this time.

12-6 Which routine observations should yous perform in the first two hours after delivery of the placenta?

1. Immediately afterward the delivery of the placenta you should:
   • Assess whether the uterus is well contracted.
   • Assess whether vaginal bleeding appears more than normal.
   • Record the patient'due south pulse rate, blood pressure and temperature.
2. During the first hour afterwards the delivery of the placenta, provided that the higher up observations are normal, you should:
   • Continuously appraise whether the uterus is well contracted and that no excessive vaginal haemorrhage is nowadays.
   • Repeat the measurement of the pulse charge per unit and blood force per unit area every 15 minutes for the 1^st hr and every thirty minutes for the 2^nd hr.
   • If the patient'due south condition changes, observations must exist done more frequently until the patient'southward condition returns to normal.

Observations during the first hr of the puerperium are extremely of import.

12-7 How should yous care for the needs of the patient during the first hour of the puerperium?

After the placenta has been delivered the patient needs to be:

1. Done.
2. Given something to beverage and maybe to eat.
3. Allowed to bail with her babe.
4. Allowed to rest for as long as she needs to.

12-8 How can the patient help to prevent postpartum haemorrhage during the starting time 60 minutes of the puerperium?

1. The patient should be shown how to observe:
   • The meridian of the uterine fundus in relation to the umbilicus.
   • The feel of a well-contracted uterus.
   • The amount of vaginal haemorrhage.
2. She should exist shown how to 'rub up' the uterus.
3. She should exist told that if the uterine fundus rises or the uterus relaxes or if vaginal haemorrhage increases, she must:
   • Immediately call the midwife.
   • In the meantime rub up the uterus.

These two important steps may assist forbid a postpartum bleeding.

The patient tin play a very important function in the prevention of postpartum haemorrhage.

12-ix When should a postpartum patient exist allowed to go home?

This will depend on:

1. Whether the patient had a normal pregnancy and commitment.
2. The circumstances of the hospital or clinic where the patient was delivered.

12-x When should a patient be immune to get domicile following a normal pregnancy and delivery?

A patient who has had a normal pregnancy and commitment may be allowed to go dwelling house nearly 6 hours after the nascency of her infant, provided:

1. The observations washed on the female parent and infant since commitment have been normal.
2. The female parent and infant are normal on exam, and the infant is sucking well.
3. The patient is able to nourish her nearest dispensary on 24-hour interval 3 to 6 afterward delivery (mean solar day 1) for postnatal care, or be visited at home by a midwife.
4. Patients who received no antenatal care and are delivered without having had any screening tests must accept rapid tests for syphilis, Rhesus grouping and HIV.
5. A postnatal card needs to be completed for the mother on belch as this is the only means of communication between the delivery site and the dispensary where she volition receive postnatal care.

A patient should only exist discharged home after delivery if no abnormalities are establish when the post-obit examinations are performed:

1. A full general exam, paying particular attention to the:
   • Pulse rate.
   • Claret pressure.
   • Temperature.
   • Haemoglobin concentration.
2. An abdominal examination, paying particular attention to the state of contraction and tenderness of the uterus.
3. An inspection of the episiotomy site.
4. The corporeality, colour, and odour of the lochia.
5. A postnatal test was completed for the mother and infant.

It is important to arrange for suitable contraception before the patient is discharged home.

The Essential Postnatal Obstetric Care (EPOC) card with the mother and infant'due south discharge data could now exist completed. If any of the shaded blocks are ticked, treatment is required or the mother needs to exist referred to the side by side level of intendance. The checklist will again be used during the day 3 to half dozen visit to check that all the important tasks have been completed (i.e. equally a quality control tool).

12-11 When should a patient exist discharged from hospital post-obit a complicated pregnancy and delivery?

This will depend on the nature of the complexity and the method of commitment. For example:

1. A patient with pre-eclampsia should be kept in hospital until her claret pressure level has returned to normal or is well controlled with oral drugs.
2. A patient who has had a Caesarean section volition normally stay in infirmary for ii to three days or longer.
3. A patient who has had a postpartum bleeding must be kept in hospital for at least 24 hours to ensure that her uterus is well contracted and that in that location is no further bleeding.
4. Patients who received no antenatal care and are delivered without having had any screening tests must take rapid tests for syphilis, Rhesus grouping and HIV.

Information technology is important to suit for suitable contraception before the patient is discharged home.

The Essential Postnatal Obstetric Intendance (EPOC) card with the mother and infant's belch data could now be completed. If whatsoever of the shaded blocks are ticked, treatment is required or the female parent needs to be referred to the next level of intendance. The checklist will again exist used during the day 3 to 6 visit to cheque that all the of import tasks have been completed (i.e. as a quality control tool).

12-12 How volition the circumstances at a clinic or hospital influence the fourth dimension of discharge?

1. Some clinics take no space to arrange patients for longer than 6 hours afterwards delivery. Therefore, patients who cannot be discharged safely at half-dozen hours will accept to be transferred to a hospital.
2. Some hospitals manage patients who live in remote areas where follow-upwards is non possible. These patients will have to be kept in infirmary longer before discharge.

12-xiii What postnatal care should be given during the puerperium after the patient has left the hospital or clinic?

The following observations must be done on the mother:

1. Assess the patient's general status.
2. Ask about mood changes and problems with animate and coughing.
3. Notice the pulse rate, blood pressure and temperature.
4. Determine the height of the uterine fundus and assess whether any uterine tenderness is present.
5. Assess whether the amount of vaginal bleeding is more than normal.
6. Bank check whether the episiotomy is healing satisfactorily.
7. Enquire if the patient passes urine normally and enquire about whatsoever urinary symptoms. Reassure the patient if she has not passed a stool by 24-hour interval five.
8. Measure the haemoglobin concentration if the patient appears pale.
9. Assess the status of the patient's breasts and nipples. Determine whether breastfeeding has been successfully established.
10. Examine the calves for tenderness and swelling (show of deep vein thrombosis).

The following observations must exist washed on the infant:

1. Appraise whether the infant appears well.
2. Check whether the baby is jaundiced.
3. Examine the umbilical stump for signs of infection.
4. Examine the eyes for conjunctivitis.
5. Enquire whether the baby has passed urine and stool.
6. Appraise whether the baby is feeding well and is satisfied later a feed.

The PCR results of babies of mothers living with HIV need to be obtained. The barcode of the laboratory asking will exist attached to the Road to Health booklet.

The successful establishment of breastfeeding is one of the most of import goals of patient intendance during the puerperium.

The EPOC card (Figure 12-1) for the day seven visit could at present be completed. The checklist will once more exist used during the 6 weeks visit.

Figure 12-i: EPOC card

12-xiv How can you aid to constitute successful breastfeeding?

By providing patient education and motivation. This should preferably start earlier pregnancy and proceed throughout the antenatal flow and after pregnancy. Encouragement and back up are very important during the first weeks afterwards delivery. The important role of breastfeeding in lowering baby mortality in poor communities must be remembered.

12-15 Which topics should yous include under patient educational activity in the puerperium?

Patient instruction regarding herself, her infant, and her family should not outset during the puerperium, but should be function of any woman'due south general education, starting at school. Topics which should be emphasised in patient education in the puerperium include:

1. Personal and infant care.
2. Offensive lochia must be reported immediately.
3. The 'puerperal dejection'.
4. Family planning.
5. Whatsoever special arrangements for the next pregnancy and delivery.
6. When to start coitus again. Unremarkably coitus tin can exist started 3 to 4 weeks postpartum when the episiotomy or tears take healed.

Patient education is an of import and oft neglected part of postnatal care.

12-16 When should a patient be seen again after postnatal intendance has been completed?

The postnatal visit is usually held 6 weeks after commitment. By this time near all the organ changes which occurred during pregnancy should take disappeared.

The half-dozen week postnatal visit

12-17 Which patients need to attend a half dozen week postnatal dispensary?

Patients with specific issues that need to exist followed upward 6 weeks postpartum, e.g. patients who were discharged with hypertension need to come back to have their blood force per unit area measured. Patients who are healthy may be referred direct to the mother-and-kid health clinics.

12-18 What are the objectives of the 6 week postnatal visit?

It is important to determine whether:

1. The patient is healthy and has returned to her normal activities.
2. The infant is well and growing normally.
3. Breastfeeding has been satisfactorily established.
4. Contraception has been arranged to the patient'southward satisfaction.
5. The patient has been referred to a mother-and-kid wellness clinic for farther care.
6. The patient has any questions nearly herself, her baby, or her family.

12-19 How should the half dozen calendar week postnatal visit be conducted?

1. The patient is asked how she and her babe have been since the last postnatal care visit.
2. The patient is so examined. On exam pay particular attention to the blood pressure and breasts, and look for signs of anaemia. An abdominal exam is followed by a speculum exam to check whether the episiotomy, vulval or vaginal tears accept healed.
3. A cytology smear of the cervix should exist taken if the patient is thirty years or older and has not previously had a normal cervical smear. A cervical smear should also exist taken on whatever adult female who has previously had an abnormal smear.
4. The haemoglobin is measured and the urine tested for glucose and poly peptide.
5. Attention must be given to whatever specific reason why the patient is beingness followed up, e.thousand. arrangements for the direction of patients who remain hypertensive after delivery.
6. The patient is given health didactics. It should again be remembered to ask her whether she has any questions she would like to ask.

If the patient and her infant are both well, they are referred to their local mother-and-kid health clinic for farther follow-upward.

A patient and her infant should just be discharged if they are both well and have been referred to the local mother-and-child health clinic, and the patient has received contraceptive counselling.

Puerperal pyrexia

12-20 When is puerperal pyrexia present?

A patient has puerperal pyrexia if her oral temperature rises to 38 °C or college during the puerperium.

12-21 Why is puerperal pyrexia of import?

Because information technology may be caused by serious complications of the puerperium. It may interfere with breastfeeding. The patient may become very sick or even die.

Puerperal pyrexia may be caused by a serious complication of the puerperium.

12-22 What are the causes of puerperal pyrexia?

1. Genital tract infection.
2. Urinary tract infection.
3. Mastitis or breast abscess.
4. Thrombophlebitis (superficial vein thrombosis).
5. Respiratory tract infection.
6. Other infections.

Genital tract infection

12-23 What is the cause of genital tract infection?

Genital tract infection (or puerperal sepsis) is acquired past bacterial infection of the raw placental site or lacerations of the cervix, vagina or perineum.

Note

Genital tract infection is usually caused by the group A or group B Streptococcus, Staphylococcus aureus or anaerobic bacteria.

12-24 How should you diagnose genital tract infection?

1. History

   If one or more of the post-obit is present:

   • Preterm or prelabour rupture of the membranes, a long labour, operative delivery, or incomplete delivery of the placenta or membranes may take occurred.
   • The patient volition experience generally unwell.
   • Lower abdominal hurting.

2. Examination

   • Pyrexia, unremarkably developing inside the outset 24 hours subsequently delivery. Rigors may occur.
   • Marked tachycardia.
   • Lower intestinal tenderness.
   • Offensive lochia.
   • The episiotomy wound or perineal or vaginal tears may be infected.

Notation

An endocervical swab should be taken for microscopy, culture, and sensitivity tests.

12-25 How should you manage genital tract infection?

1. Prevention
   • Strict asepsis during delivery.
   • Reduction in the number of vaginal examinations during labour to a minimum.
   • Prevention of unnecessary trauma during labour.
   • Isolation of infected patients.
2. Handling
   • Admit the patient to hospital.
   • Bring down the patient's temperature, e.g. by tepid sponging.
   • Give the patient analgesia, e.one thousand. paracetamol (Panado) i thousand (two adult tablets) orally half dozen-hourly.
   • Acceptable fluid intake with strict intake and output measurement.
   • Broad spectrum antibiotics, e.g. intravenous ampicillin and oral metronidazole (Flagyl). If the patient is to be referred, antibiotic handling must be started before transfer.
   • The haemoglobin concentration must be measured. A blood transfusion must be given if the haemoglobin concentration is beneath 8 yard/dl.
   • Removal of all stitches if the wound is infected.
   • Drainage of whatsoever abscess.
   • If at that place is subinvolution of the uterus, an evacuation under general anaesthetic must exist done.

Note

24 hours after starting this treatment the patient's condition should take improved considerably and the temperature should by and then be normal. If this is not the case, evacuation of the uterus is required and gentamicin must be added to the antibiotics. A laparotomy and possibly a hysterectomy is indicated, if peritonitis and subinvolution of the uterus are nowadays, and there is no response to the measures detailed above. Transfer the patient to the appropriate level of care for this purpose.

12-26 How must a patient with offensive lochia be managed?

1. If the patient has pyrexia she must be admitted to infirmary.
2. If the involution of the patient's uterus is slower than expected and the cervical os remains open, retained placental products are present. An evacuation of the uterus nether general anaesthesia must be washed.
3. If the patient has a normal temperature and normal involution of her uterus, she can be managed as an outpatient with oral amoxicillin and metronidazole (Flagyl).

Offensive lochia is an important sign of genital tract infection.

Urinary tract infections

12-27 How should you lot diagnose a urinary tract infection?

1. History
   • The patient may take been catheterised during labour or in the puerperium.
   • The patient complains of rigors (shivering) and lower abdominal pain and/or hurting in the lower dorsum over one or both the kidneys (the loins).
   • Dysuria and frequency. Notwithstanding, these are not reliable symptoms of upper urinary tract infection.
2. Examination
   • Pyrexia, ofttimes with rigors (shivering).
   • Tachycardia.
   • Suprapubic tenderness and/or tenderness, especially to percussion, over the kidneys (punch tenderness in the renal angles).
3. Side-room and special investigations
   • Microscopy of a midstream or catheter specimen of urine usually shows large numbers of pus cells and bacteria.
   • Civilisation and sensitivity tests of the urine must exist washed if the facilities are available.

The presence of pyrexia and dial tenderness in the renal angles indicate an upper renal tract infection and a diagnosis of acute pyelonephritis must be made.

12-28 How should you manage a patient with a urinary tract infection?

1. Prevention
   • Avoid catheterisation whenever possible. If catheterisation is essential, it must be done with strict hygienic precautions.
2. Treatment
   • Admit patients with upper urinary tract infections to hospital.
   • Take measures to bring down the temperature.
   • Analgesia, e.g. paracetamol (Panado) 1 chiliad orally 6-hourly.
   • Adequate fluid intake.
   • Intravenous cefuroxime (Zinacef) 750 mg eight-hourly.

Annotation

Organisms causing acute pyelonephritis are frequently resistant to ampicillin, therefore intravenous cefuroxime (Zinacef) must be used.

Antibiotics should not be given to a patient with puerperal pyrexia until she has been fully investigated.

Thrombophlebitis

12-29 What is superficial vein thrombophlebitis?

This is a non-infective inflammation and thrombosis of the superficial veins of the leg or forearm where an infusion was given. Thrombophlebitis usually occurs during the puerperium, particularly in varicose veins.

12-30 How should you diagnose superficial leg vein thrombophlebitis?

1. History
   • Painful swelling of the leg or forearm.
   • Presence of varicose veins.
2. Examination
   • Pyrexia.
   • Tachycardia.
   • Presence of a localised surface area of the forearm or leg which is swollen, scarlet and tender.

12-31 How should you manage a patient with superficial vein thrombophlebitis?

1. Give analgesia, east.one thousand. Aspirin 300 mg (1 adult tablet) 6-hourly.
2. Back up the leg with an rubberband cast.
3. Encourage the patient to walk around.

Respiratory tract infection

12-32 How should you diagnose a lower respiratory tract infection?

A lower respiratory tract infection, such every bit acute bronchitis or pneumonia, is diagnosed as follows:

1. History
   • The patient may have had general anaesthesia with endotracheal intubation, e.g. for a Caesarean section.
   • Coughing, which may exist productive.
   • Pain in the chest.
   • A recent upper respiratory tract infection.
2. Examination
   • Pyrexia.
   • Tachypnoea (breathing apace).
   • Tachycardia.
3. Special investigations
   • A chest Ten-ray is useful in diagnosing pneumonia.

Note

Examination of the chest may reveal basal dullness due to collapse, increased breath sounds or crepitations due to pneumonia, or bilateral rhonchi due to bronchitis.

12-33 How should you manage a patient with a lower respiratory tract infection.

1. Prevention
   • Skilled amazement.
   • Proper care of the patient during induction and recovery from anaesthesia.
   • Encourage deep breathing and coughing following a general anaesthetic to prevent lower lobe collapse.
2. Treatment
   • Acknowledge the patient to hospital, unless the infection is very balmy.
   • Oxygen, if required.
   • Amoxicillin orally or ampicillin intravenously depending on the severity of the infection.
   • Analgesia, east.g. paracetamol (Panado) ane g 6-hourly.
   • Physiotherapy.
3. Special investigations
   • Send a sample of sputum for microscopy, civilization, and sensitivity testing if possible.

12-34 Which other infections may cause puerperal pyrexia?

Tonsillitis, influenza and any other acute infection, e.g. acute appendicitis.

12-35 What should you do if a patient presents with puerperal pyrexia?

1. Ask the patient what she thinks is wrong with her.
2. Specifically enquire for symptoms which point to:
   • An infection of the throat or ears.
   • Mastitis or chest abscess.
   • A chest infection.
   • A urinary tract infection.
   • An infected abdominal wound if the patient had a Caesarean department or a puerperal sterilisation.
   • Genital tract infection.
   • Superficial leg vein thrombophlebitis.
3. Examine the patient systematically, including the:
   • Pharynx and ears.
   • The drip site on the arm.
   • Breasts.
   • Breast.
   • Abdominal wound, if present.
   • Urinary tract.
   • Genital tract.
   • Legs, peculiarly the calves.
4. Perform the necessary special investigations, but always send off a:
   • Endocervical swab.
   • Midstream or catheter specimen of urine.
5. Start the advisable handling.

If a patient presents with puerperal pyrexia the cause of the pyrexia must exist plant and appropriately treated.

Puerperal psychiatric disorders

12-36 Which are the puerperal psychiatric disorders?

1. The 'puerperal blues'.
2. Temporary postnatal depression.
3. Puerperal psychosis.

12-37 Why is it important to recognise the diverse puerperal psychiatric disorders?

1. The 'puerperal dejection' are very mutual in the start week after delivery, especially on days three to 5. The patient feels miserable and cries hands. Although the patient may exist very distressed, all that is required is an explanation, reassurance, and a caring, sympathetic mental attitude and emotional support. The condition improves within a few days.
2. Postnatal low is much commoner than is by and large realised. It may last for months or even years and patients may need to be referred to a psychiatrist. Patients with postnatal low usually present with a depressed mood that cannot be relieved, a lack of interest in their surroundings, a poor or excessive appetite, sleeping difficulties, feelings of inadequacy, guilt and helplessness, and sometimes suicidal thoughts.
3. Puerperal psychosis is an uncommon just very of import condition. The onset is commonly astute and an observant attendant volition notice the sudden and marked change in the patient's behaviour. She may rapidly pose a threat to her infant, the staff, and herself. Such a patient must be referred urgently to a psychiatrist and will usually need admission to a psychiatric unit.

Note

Patients with puerperal psychosis are unable to care for themselves or their infants. They are often disorientated and paranoid and may have hallucinations. They may also be severely depressed or manic.

Secondary postpartum haemorrhage

12-38 What is secondary postpartum haemorrhage?

This is any amount of vaginal bleeding, other than the normal amount of lochia, occurring after the first 24 hours postpartum until the cease of the puerperium. It normally occurs between the fifth and 15th days after delivery.

12-39 Why is secondary postpartum haemorrhage of import?

1. A secondary postpartum haemorrhage may exist and so severe that it causes shock.
2. Unless the crusade of the secondary postpartum haemorrhage is treated, the vaginal haemorrhage will continue.

12-40 What are the causes of secondary postpartum haemorrhage?

1. Genital tract infection with or without retention of a slice of placenta or part of the membranes. This is the commonest cause.
2. Separation of an infected slough in a cervical or vaginal laceration.
3. Breakdown (dehiscence) of a Caesarean section wound of the uterus.

However, the crusade is unknown in up to half of these patients.

Notation

Gestational trophoblastic disease (hydatidiform mole or choriocarcinoma) and a disorder of claret coagulation may also crusade secondary postpartum haemorrhage.

12-41 What clinical features should alert y'all to the possibility of the patient developing secondary postpartum haemorrhage?

1. A history of incomplete commitment of the placenta and/or membranes.
2. Unexplained puerperal pyrexia.
3. Delayed involution of the uterus.
4. Offensive and/or persistently red lochia.

12-42 How should yous manage a patient with secondary postpartum haemorrhage?

1. Prevention
   • Aseptic technique throughout labour, the delivery and the puerperium.
   • Careful examination later delivery to make up one's mind whether the placenta and membranes are consummate.
   • Proper repair of vaginal and perineal lacerations.
2. Handling
   • Admission of the patient to hospital is indicated, except in very mild cases of secondary postpartum haemorrhage.
   • Review of the clinical notes with regard to completeness of the placenta and membranes.
   • Obtain an endocervical swab for bacteriology.
   • Give ampicillin intravenously and metronidazole (Flagyl) orally.
   • Give xx units oxytocin in an intravenous infusion if excessive haemorrhage is nowadays.
   • Claret transfusion, if the haemoglobin concentration drops beneath 8 thou/dl.
   • Removal of retained placental products under spinal or full general anaesthesia.

12-43 What may y'all notice on physical examination to suggest that retained pieces of placenta or membranes are the cause of a secondary postpartum haemorrhage?

1. The uterus will be involuting slower than usual.
2. Even though the patient may be more than vii days postpartum, the cervical bone will have remained open (a finger can be passed through the neck).

Self-monitoring

12-44 What is meant by the concept of 'the mother equally a monitor'?

This is a concept where the patient is fabricated aware of the many ways in which she can monitor her own, as well as her fetus' or infant's wellbeing, during pregnancy, in labour, and in the puerperium. This has two major advantages:

1. The patient becomes much more involved in her ain perinatal care.
2. Possible complications will be reported past the patient at the primeval opportunity.

12-45 How can the patient act as a monitor in the puerperium?

The patient must be encouraged to study the post-obit complications equally presently as she becomes aware of them:

1. Maternal complications
   • Symptoms of puerperal pyrexia.
   • Breakdown of an episiotomy.
   • Breastfeeding problems.
   • Excessive or offensive lochia.
   • Recurrence of vaginal bleeding, i.east. secondary postpartum haemorrhage.
   • A depressed mood or other symptoms of postnatal depression.
2. Complications in the infant
   • Poor feeding or other feeding problems.
   • Sluggishness.
   • Jaundice.
   • Conjunctivitis.
   • Infection of the umbilical string stump.

Each patient must be taught to monitor her ain wellbeing, too as that of her fetus or infant.

HIV positive mothers

12-46 How should HIV positive mothers and their newborn infants be managed during the puerperium?

Women who are on ARV treatment should continue their TLD or FDC for life.

At 6 weeks after delivery women on ARV treatment should be reassessed.

Infants of all HIV positive women should receive a dose of nevirapine at birth and and then daily until 6 weeks of age. If the female parent is on ARV handling the daily dose of nevirapine to the infant can be stopped at vi weeks. If an HIV positive woman is breastfeeding and not on ARV treatment, the daily nevirapine to the infant should be continued until a calendar week subsequently the last breastfeed.

A mother newly diagnosed with HIV and those that defaulted treatment and are known to have had a viral load lower than detectable should exist commenced on TLD. Women that defaulted handling whose viral load was not suppressed or with an unknown viral load must be commenced on AZT, 3TC and TLD. AZT syrup for 6 weeks must be added to the nevirapine given to these infants every bit they are at high risk for HIV transmission during labour. The NVP must continue until the viral load is less than 1000 copies/ml.

A PCR HIV test must be done on the infant soon after nativity and the result followed upward. If positive, the infant must commence HAART as soon as possible.

The HIV status and HIV treatment of the mother also equally the method of infant feeding must be entered on the infant's Road to Health booklet.

The importance of attention a good for you baby clinic at vi weeks must exist emphasised. At 10 weeks and once more six weeks following weening an HIV exam (HIV Deoxyribonucleic acid PCR test) will be washed to determine whether the baby is HIV infected or not. Infants infected with HIV must be commenced on HAART as soon as possible.

12-47 What is the nevirapine and AZT dose for infants?

Most term infants will need 1.five ml NVP from birth to six weeks. Thereafter the amount of NVP will increase as the infant gains weight. Run into table 12-1 for dosing guidelines.

Table 12-1: Nevirapine dosing guidelines for newborns: NVP syrup 10 mg/ml

Nascence weight	Daily dosage	Quantity
Less than 2.0 kg	First 2 weeks:2 mg/kg	0.2 ml/kg
	Next iv weeks:four mg/kg	0.4 ml/kg
two.0 – 2.5 kg	Nascency to half-dozen weeks:1 0mg	one.0 ml
More than ii.5 kg	Birth to half-dozen weeks:15 mg	1.five ml

The dose of AZT for infants weighing 2.v kg or more is one.5 ml twice daily. If the babe weighs less than two.5 kg, the dose is 1 ml twice daily.

Example study i

Post-obit a spontaneous vertex delivery in a dispensary, you have delivered the placenta and membranes completely. The maternal and fetal conditions are good and there is no abnormal vaginal haemorrhage. You are the merely staff member in the clinic. You are called away and will have to go out the patient alone for a while.

1. How can y'all go the patient'southward help in preventing a postpartum bleeding?

The patient should be shown how to observe:

1. The height of the uterine fundus.
2. Whether the uterus is well contracted.
3. The corporeality of vaginal haemorrhage.
4. She should also be asked to empty her bladder frequently.

ii. What should the patient do if she notices that her uterus relaxes and/or there is vaginal bleeding?

She should rub upwards the uterus and phone call you immediately.

3. What should you cheque on before leaving the patient?

You should make sure that:

1. The patient and her infant'southward observations are normal and both their conditions are stable.
2. The patient understands what she has to do.
3. Y'all will be able to hear the patient, if she calls yous.

Case written report two

A patient returns to a clinic for a visit three days afterward a normal first pregnancy and delivery. She complains of leaking urine when coughing or laughing, and she is also worried that she has not passed a stool since the delivery. She starts to cry and says that she should not take fallen significant. Her baby takes the breast well and sleeps well later each feed. On examination the patient appears well, her observations are normal, the uterus is the size of a xvi-week significant uterus, and the lochia is red and not offensive.

i. Is her puerperium progressing normally?

Aye. The patient appears salubrious with normal observations, and the involution of her uterus is satisfactory.

2. What should be done most the patient'southward complaints?

Stress incontinence is common during the puerperium. Therefore, the patient must exist reassured that it will improve over time. Nevertheless, pelvic floor exercises must exist explained to her as they will hasten improvement of her incontinence. She demand not be worried near not having passed a stool as this is normal during the first few days of the puerperium.

3. Why is the patient regretting her pregnancy and crying for no apparent reason?

She probably has the 'puerperal blues' which are common in the puerperium. Heed sympathetically to the patient's complaints and reassure her that she is managing well as a female parent. Also explain that her feelings are normal and are experienced by most mothers.

four. What educational topics must be discussed with the patient during this visit?

1. The care and feeding of her babe, stressing the importance of breastfeeding.
2. Family unit size and when she plans to take her next infant.
3. Which contraceptive method she should apply and how to use it correctly.
4. The care and feeding of her infant, stressing the importance of breastfeeding.
5. The time that coitus tin can be resumed.

Besides enquire about and discuss any other uncertainties which the patient may have.

Case study three

Following a prolonged kickoff stage of labour due to an occipito-posterior position, a patient has a spontaneous vertex delivery. The placenta and membranes are complete. At that place is no excessive postpartum blood loss and the patient is discharged home after 6 hours. Within 24 hours of delivery the patient is brought to a dispensary. She has a temperature of 39 °C, a pulse charge per unit of 110 beats per infinitesimal and complains of a headache and lower abdominal hurting. The uterus is tender to palpation and the lochia offensive.

1. What does the patient present with?

Puerperal pyrexia.

ii. What is the most likely cause of the puerperal pyrexia?

Genital tract infection, i.e. puerperal sepsis. This diagnosis is suggested past the full general signs of infection and the uterine tenderness and offensive lochia. The patient had a prolonged kickoff stage of labour, which is commonly accompanied by a greater than usual number of vaginal examinations and, therefore, predisposes her to genital tract infection.

3. Was the early postnatal management of this patient right?

No. The patient should not take been discharged domicile so early on as she had a prolonged beginning stage of labour which places her at a higher adventure of infection. She should accept been observed for at least 24 hours.

4. How should you manage this patient further in the clinic?

She must exist fabricated comfortable. Paracetamol (Panado) ane grand orally may exist given for the headache. If necessary, she should be given a tepid sponging. An intravenous infusion should exist started and she must and so exist referred to hospital. The infant must accompany the patient to hospital. The need to get-go antibiotic treatment, such as intravenous ampicillin and oral metronidazole (Flagyl), before transfer must exist discussed with the doctor.

Case study 4

A patient is seen at a clinic on twenty-four hours 5 following a normal pregnancy, labour and delivery. She complains of rigors and lower abdominal hurting. She has a temperature of 38.5 °C, tenderness over both kidneys (loins) and tenderness to percussion over both renal angles. A diagnosis of puerperal pyrexia is made and the patient is given oral amoxicillin. She is asked to come back to the clinic on mean solar day vii.

1. Are you satisfied with the diagnosis of puerperal pyrexia?

No. Puerperal pyrexia is a clinical sign and non a diagnosis. The cause of the pyrexia must exist establish by taking a history, doing a physical test and, if indicated, completing special investigations.

ii. What is the about likely crusade of the patient'southward pyrexia?

An upper urinary tract infection as suggested by the pyrexia, rigors, lower intestinal pain and tenderness over the kidneys.

3. Do you concord with the management given to the patient?

No. An upper urinary tract infection that causes puerperal pyrexia is an indication for admitting the patient to infirmary. Intravenous cefuroxime (Zinacef) must be given, equally this will lead to a rapid recovery and prevent serious complications.

iv. Why is a puerperal patient at chance of a urinary tract infection and how may this be prevented?

Catheterisation is frequently required and this increases the risk of a urinary tract infection. Catheterisation must but exist carried out when necessary and must always exist washed as an aseptic procedure. Screening and treating asymptomatic bacteriuria at the antenatal dispensary will reduce acute pyelonephritis during the puerperium.

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Source: https://bettercare.co.za/learn/maternal-care/text/12.html

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