Physical health problems and complications in the puerperium C H A P T E R 2 4 Physical health problems and complications in the puerperium

The chapter aim s to: discuss the role of midwifery care in the detection and management of life-threatening conditions and postpartum morbidity review best practice in the management of problems associated with trauma and pathology arising from pregnancy and childbirth review the role of the midwife (and family) where postpartum health is complicated by an instrumental or operative birth.

The need for women-focused and family-centered postpartum care will assist physical and psychological recovery ,What is important is to focus upon the needs of women as individuals The midwife needs to be familiar with the woman's antenatal and labour history assessing whether or not the woman's progress is following the expected postpartum recovery pattern

The role of the midwife identify whether a potentially life-threatening condition refer the woman for appropriate emergency investigations and care

Potentially life-threatening conditions and morbidity after the birth women still die postpartum. The discovery of penicillin and the provision of a blood transfusion were major contributions to saving women's lives over the past century

Thrombosis or thromboembolism and haemorrhage were major causes of direct maternal deaths Cardiac disease is the most common cause of indirect death the indirect maternal mortality rate has not changed sepsis is now the most common cause of direct maternal death

genital tract infection, community-acquired Group A streptococcal (GAS) infection maternal morbidity after childbirth was typically under-reported by women

The midwife has a duty to undertake midwifery care for at least the first 28 days, all women should receive essential core routine care in the first 6–8 weeks after birth. Midwife monitoring her recovery & offer her appropriate information and advice

Immediate untoward events for the mother following the birth of the baby Immediate (primary) postpartum haemorrhage (PPH) is a potentially life-threatening event which occurs at the point of or within 24 hours of expulsion of the placenta and membranes and presents as a sudden, and excessive vaginal blood loss Secondary, or delayed PPH is where there is excessive or prolonged vaginal loss from 24 hours after birth and for up to 6 weeks' postpartum primary PPH volume of blood loss (>500 ml) as part of its definition, there is no volume of blood specified for a secondary PPH and management differs according to apparent clinical need

it is most frequently the placental site that is the source. a cervical or deep vaginal wall tear or trauma to the perineum might be the cause Retained placental fragments or other products of conception are likely to inhibit the process of involution,

an urgent need for the routine use of a national modified early obstetric warning score (MEOWS) chart in all pregnant or postpartum women who become unwell and require either obstetric or gynecology services’. Usage of this score will help in providing timely recognition, treatment and referral of women who have or are developing a critical illness after birth and postnatal.

Maternal collapse within 24 hours of the birth without overt bleeding no signs of haemorrhage are apparent other causes need to be considered Management : ensuring the woman is in a safe environment until appropriate treatment can be administered by the most appropriate health professionals maintaining the woman's airway basic circulatory support as needed and providing oxygen. It is important to remember that, regardless of the apparent state of collapse, the woman may still be able to hear and so verbally reassuring the woman (and her partner or relatives if present) is an important aspect of the immediate emergency and ongoing care.

Postpartum complications and identifying deviations from the normal Following the birth of their baby, women feelings elation that they have experienced the birth and survived Women may experience symptoms that might be abnormal

During postpartum visit , the midwife is obtain a random collection of information Women will probably give information about events or symptoms that are the most worrying or most painful to them at that time. Assess signs of morbidity and determine whether these might indicate the need for referral.

Assess general state of illness including signs of infection. pyrexia as a mildly raised temperature may be related to normal physiological hormonal responses, for example the increasing production of breastmilk. infection and sepsis are important factors in postpartum maternal morbidity and mortality

a rise in temperature above 38 °C it is usual for this to be considered a deviation from normal and of clinical significance. If puerperal infection is suspected, the woman must be referred back to the obstetric services

community midwives, who may be the first to pick up any potentially abnormal signs during their routine postnatal observations for all women, not just those who have had a caesarean section (CS)

The pulse rate and respirations are also indicators . no evidence of vaginal haemorrhage, for example, a weak and rapid pulse rate (>100 bpm) in conjunction with a woman who is in a state of collapse with signs of shock and a low blood pressure (systolic <90 mmHg) may indicate the formation of a haematoma,

where there is an excessive leakage of blood from damaged blood vessels into the surrounding tissues. A rapid pulse rate in woman that she is anaemic ??indicate increased thyroid or other dysfunctional hormonal activity.

The uterus and vaginal loss following vaginal birth Midwifery assessment of uterine sub- involution at intervals done when: the woman is feeling generally unwell has abdominal pain a vaginal loss that is markedly brighter red or heavier than previously is passing clots reports her vaginal loss to be offensive

subinvolution of the uterus indication of postpartum infection, or the presence of retained products of the placenta or membranes, or both Signs & symptoms of uterine subinvolution the uterus fails to follow the expected progressive reduction in size, feels wide or ‘boggy’ on palpation less well contracted than expected.

Treatment: Antibiotics oxytocic drugs that act on the uterine muscle hormonal preparations evacuation of the uterus ,usually under a general anaesthesia

Vulnerability to infection, potential causes and prevention Infection is the invasion of tissues by pathogenic microorganisms the degree of illness relates to their virulence and number. Vulnerability is exist , enable the organism to thrive and reproduce and where there is access to and from entry points in the body. Organisms are transferred between sources and a potential host by hands, air currents and fomites (secretion )

(i.e. agents such as bed linen). Hosts are more vulnerable to infection when *poor immunity presented The body responds to the invading organisms by forming antibodies, which in turn produce inflammation initiating other physiological changes such as pain and an increase in body temperature.

Acquired of an infective organism can be endogenous, where the organisms are already present in or on the body – e.g. Streptococcus faecalis ,Clostridium welchii (both present in the vagina) or Escherichia coli (present in the bowel) or organisms in a state are reactivated, notably tuberculosis bacteria.

Other routes are exogenous, where the organisms are transferred from other people (or animal) body surfaces or the environment. Other transfer mechanisms include droplets – inhalations of respiratory pathogens on liquid particles (e.g. β-haemolytic streptococcus a n d Chlamydia trachomatis) , cross-infection and nosocomial (hospital-acquired) transfer from an infected person or place to an uninfected one (e.g. Staphylococcus aureus).

The bacteria responsible for the majority of puerperal infection arise from the streptococcal or staphylococcal species, with community acquired GAS infection causing most serious problems The Streptococcus bacterium has a chain-like formation and may be haemolytic or non-haemolytic, and aerobic or anaerobic; the most common species associated with puerperal sepsis is the β-haemolytic S. pyogenes

The Staphylococcus bacterium has a grape-like structure, of which the most important species is S. aureus or pyogenes. Staphylococci are the most frequent cause of wound infections; where these bacteria are coagulase-positive they form clots on the plasma which can lead to more widely spread systemic morbidity.

There is additional concern about their resistance to antibiotics and subsequent management to control spread of the infection. postpartum women and healthcare professionals should be aware of how infection can be acquired and should pay particular attention to effective hand- washing techniques.

adhere to the accepted practice for aseptic technique the use of gloves Avoiding the spread of infection ,when the woman or her family or close contacts have a sore throat or upper respiratory tract infection Educating women and their family about the basic principles of good hand hygiene

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