Beruflich Dokumente
Kultur Dokumente
By:Varsha Sharma
SUBINVOLUTION
DEFINITION:
When the involution is impaired or retarded it is called
subinvolution. The uterus is the most common organ affected
by subinvolution. As it is the most accessible organ to be
measured per abdomen, the uterine involution is considered
clinically as an index to assess sub involution.
CAUSES
Predisposing factors are
Grand multiparity,
Over distension of uterus as in twins and hydramnios
Maternal ill health
Caesarean section
Prolapse of the uterus
Retroversion after the uterus becomes pelvic organ
uterine fibroid
SYMPTOMS
The condition may be asymptomatic. The
predominant symptoms are:
Abnormal lochial discharge either excessive or
prolonged
Irregular or at times excessive uterine bleeding
Irregular cramp like pain is cases of retained
products or rise of temperature in sepsis
SIGNS
MANAGEMENT
Antibiotics in endometritis
Exploration of the uterus in retained products
Ergometrine so often prescribed to enhance
the involution process by reducing the blood
flow of the uterus is of no value in
prophylaxis.
NURSING MANAGEMENT
URINARY
COMPLICATIONS IN
PUERPERIUM
1.
2.
3.
4.
MANAGEMENT
Antibiotics
RETENTION OF URINE
CAUSES ARE
Bruising & edema of the bladder neck
Reflex from perineal injury
Unaccustomed position
INCONTINENCE OF URINE
Overflow incontinence
Stress incontinence: Usually manifests in late
puerperium
NURSING MANAGEMENT
Encourage urination early in the postnatal period.
Encourage to void every 2-4 hrs
Assist the mother to the bathroom or at bed side on bed pan.
Monitor intake and output
Monitor for frequency and volume of urine
If the mother is unable to void catheterize her
Monitor for any signs of infection of urinary tract if, any
report immediately.
SUPPRESSION OF URINE
BREAST
COMPLICATIONS
1 Breast engorgement
2 Cracked and retracted nipple leading
to difficulty in breast feeding
3 Mastitis and breast abscess
4 Lactation failure.
Breast Engorgement
Engorgement is defined as an uncomfortable swelling of the breast associated
with increased milk secretion and usually occurs from the second to fourth day
post natal.
There may be lymphatic and vascular congestion and possible interstitial
edema, causing swelling and tenderness. This exacerbates the tension of milk in
the ducts and may cause stasis of the milk, resulting in inability of the milk to
flow. This swelling and hardness may make it difficult for the baby to attach to
the nipple and problems can be further aggravated by nipple soreness.
the primiparous patient and the patient with inelastic breasts are likely to be
involved .
Engorgement is an indication that the baby is not in step with the stage of
lactation .
SYMPTOMS
Considerable pain and feeling of tenseness or heaviness in the
both breasts.
Generalized malaise
Rise of temperature
Painful breast feeding
PREVENTION
Avoid prelacteal feeds
Initiate breast feeding early and
unrestricted
Exclusive breast feeding on demand
Feeding in correct position.
Cracked nipple:
It is caused by
PROPHYLAXIS
Includes
TREATMENT
Correct attachment will provide immediate relief from pain and rapid healing.
Purified Lanolin with mothers milk is applied 3 or 4 times a day to hasten healing
when it is severe mother should use a breast pump and infant is fed the expressed
milk.
MASTITIS
TWO TYPES
Mammary cellulitis : inflammation of the connective
tissue between lobes in the breast
Mammary adentitis: infection in the lobes and ducts of
the breast
ETIOLOGY
Staphylococcus aureus
Staphylococcus epidermidis,
saprophyticus,
Streptococcus viridans,
E coli.
MODE OF INFECTION
ONSET
CLINICAL FEATURES
Generalized
Fever, chills
Myalgias,
Erythema, warmth, swelling, and breast tenderness.
Presence of toxic features
Presence of wedge shaped swelling on the breast with its apex at the
nipple.
The overlying skin is red, hot and flushed and feels tense and tender.
DIAGNOSIS
TREATMENT
Prophylaxis:
Encourage mother to wash her hands before each feed
Encourage to clean the nipples before and after each feed Reduce the nosocomial infection rates.
Curative management
Provide breast support
Encourage to take plenty of oral fluids
Encourage the mother to continue the breast feeding with good attachment
Nursing is established first on the unaffected side to establish let down.
The infected side is emptied manually with each feed
Flucloxacillin (pencillin) is the drug of choice. Erythromycin is the alternative drug of choice who are allergic
to penicillin.
Antibiotic therapy is continued for at least 7 days
Analgesics are given for pain
BREAST ABSCESS
Features are
Flushed breasts not responding to antibiotics
promptly
Browny edema of the overlying skin
Marked tenderness with fluctuation
Swinging temperature.
MANAGEMENT
BREAST PAIN
Risk factors
Diabetes mellitus
Oral thrush of infant
TREATMENT
Use of Miconazole oral lotion or gel into both the
nipples after each feed and into the infants mouth
thrice daily for 2 weeks.
CAUSES are
Infrequent suckling
Depression or anxiety state in the puerperium
Reluctance or apprehension to nursing
Ill development of nipples
Painful breast lesion
Endogenous suppression of Prolactin (retained placental bits)
Prolactin inhibition
TREATMENT
Antenatal:
Council the mother regarding the advantages of nursing her baby with breast milk
Take care of any breast abnormality specially a retracted nipple and to maintain
adequate breast hygiene especially in the last 2 months of pregnancy.
Puerperium:
Encourage adequate fluid intake
Nurse the baby regularly
Treat the painful local lesions
Metaclopromide and sulpride have been found to increase milk production.
NURSING DIAGNOSIS
Altered comfort (pain) related to infection and
inflammation in the breast
Anxiety related to clients inability to continue breast
feeding
Altered parenting related to clients inability to
continue breast feeding.
Knowledge deficit related to care of the breast, breast
feeding techniques.
PUERPERAL VENOUS
THROMBOSIS
ETIOPATHOGENESIS
Symptoms include
Pain in the calf muscles,
Edema legs
Rise in skin temperature.
On examination a symmetric leg edema (difference in circumference between the
affected and the normal leg more than 1cm) is significant.
A positive homans sign pain in the calf on dorsiflexion of the foot may be present.
INVESTIGATIONS
PELVIC THROMBOPHLEBITIS
Postpartum thrombophlebitis originates in the thrombosed veins at
the placental site by organisms such as anaerobic Streptococci or
Bacteroides (fragilis).
When localized in the pelvis, it is called pelvic thrombophlebitis
There is no specific clinical feature of pelvic thrombophlebitis, but it
should be suspected in cases where PYREXIA continues for more than
a week inspite of antibiotic therapy
CLINICAL FEATURES
(1) It usually develops on the second week of puerperium.
(2) Mild pyrexia At times the fever may be high with chills and
rigor.
(3) Evidences of constitutional disturbances such as headache,
malaise, and rising pulse rate.
(4) The affected leg swollen, painful, white and cold. The pain is
due to arterial spasm as a result of irritation from the nearby
thrombosed vein.
(5) Blood count shows polymorph nuclear leucocytosis.
DIAGNOSIS
Women at risk of venous thromboembolism during pregnancy have been grouped into
different categories depending on the presence of risk factors. Thrombo prophylaxis
to such a woman depends on the specific risk factor and the category
(1) A low risk woman has no personal or family history of VTE and are heterozygous
for factor V Leiden mutation. Such a woman needs no thrombo prophylaxis. (2) A high
risk woman is one who has previous VTE or VTE in present pregnancy, or
Antithrombin-in deficiency. Such a woman needs low molecular weight heparin
prophylaxis throughout pregnancy and post partum 6weeks. Women with
antithrombin-III deficiency can be treated with antithrombin-III concentrate
prophylacticaly
MANAGEMENT
(1)The patient is put to bed rest with the foot end raised above
the heart level.
(2) Pain on the affected area may be relieved with analgesics.
(3) Appropriate antibiotics are to be administered.
(4) Anticoagulants
The anticoagulant therapy should be continued till all evidences of the disease have
disappeared which generally take 3-6 months. Neither anticoagulant should prevent the
mother from breast-feeding.
(5) As soon as the pain subsides, gentle movement is allowed on bed by the end of
first week.
High quality elastic stockings are fitted on the affected leg before mobilization.
(6) Vena cava fillers are used for patients with recurrent pulmonary embolism or
where anticoagulant therapy is contraindicated.
(7) Fibrinolytic agents like streptokinase produce rapid resolution of pulmonary
emboli.
(8) Venous thrombectomy is needed for massive illio femoral vein thrombosis or for
massive pulmonary embolus.
PULMONARY
EMBOLISM
DIAGNOSIS
: X-ray of the chest shows diminished vascular marking in areas of infarction,elevation of the
dome of the diaphragm and often pleural effusion. It is useful to ruleout pneumonia and
atelectasis.
ECG : tachycardia, right axis shift.
ARterial blood gas : POa > 85 mm Hg on room air is reassuring but does not ruleout PE. Oxygen
saturation < 95% on room air needs further investigation.
Doppler ultrasound
can identify a DVT. When the test is positive for DVT, anticoagulation therapy should be started.
Lung scans : (Ventilation /Perfusion scan) Perfusion scan will detect areas of diminished blood
flow whereas a reduction in perfusion with maintenance of ventilation indicates pulmonary
embolism. Magnetic Resonance Imaging (MRI) can be used in pregnancy as the risk of ionizing
radiation is absent.
Pulmonary angiography: is considered to be the most accuratemethod of diagnosis.
MANAGEMENT
Prophylaxis (as mentioned in venous thromboembolism)
Active treatment includes:
(1)Resuscitation : cardiac massage, oxygen therapy, intravenous heparin bolus dose of 5,000 IU and morphine
15 mg (I.V.) are started. Heparin therapy is to be continued upto 40,000 IU per day so as to maintain the
clotting time to over 12minutes for the first 48 hours. Heparin level is maintained at 0.2 to 0.4 units/ml or the
activated partial thromboplastin time (APTT) about twice the normal.
(2) I.V. fluid support is continued and blood pressure is maintained if needed bydopamine or adrenaline.
(3)Thrombolytic therapy
Streptokinase with a loading dose of 600,000 IU can be given and continued with 100,000 IU per hour. It does
not cross the placentawhen used during pregnancy.
(4) Tachycardia is counteracted by digitalis
.(5) Recurrent attacks of pulmonary embolism necessitate surgical treatment like embolectomy, placement of
vena caval filter or ligation of inferior vena cava andovarian veins.
Surgical treatment is done following pulmonary arteriography.