Complicated Midwifery II - BMP 311

LECTURE NOTE ON COMPLICATED MIDWIFERY II

• This lecture note details abnormal puerperium and is part of BMP 311.
• The target audience is third-year, first-semester basic midwives.
• The document covers the 2019 set of Basic Midwives curriculum.

INTRODUCTION

• The course aims to equip students to identify conditions deviating from normal puerperium.
• It emphasizes the role of midwives in early diagnosis, appropriate intervention, and referrals.
• The course also highlights their role in emergency and operative interventions.

OBJECTIVES

• Students will demonstrate competence in early diagnosis and appropriate intervention, and referral for puerperium complications.

COURSE CONTENT (UNIT I)

• Breast Complications:
  • Sub-involution
  • Breast abscess and hematoma
• Postpartum Hemorrhage:
  • Primary and secondary
• Puerperal Pyrexia:
  • Infection leading to fever during puerperium
• Puerperal Sepsis:
  • Infection following childbirth
• Pelvic Abscess:
  • Infection in the pelvic area
• Endometritis:
  • Inflammation of the uterine lining
• Deep Venous Thrombosis (DVT)/Thrombophlebitis:
  • Blood clot in a deep vein
• Severe Anemia:
  • Low red blood cell count
• Thrombophlebitis:
  • Inflammation and clot formation in a vein
• Puerperal Psychosis/Depression:
  • Mental health conditions
• Shock:
  • Life-threatening condition
• Amniotic fluid embolism (AFE):
  • Fluid from the amniotic sac entering the bloodstream
• Disseminated intravascular coagulation (DIC):
  • Abnormality of blood clotting
• Eclampsia:
  • High blood pressure during pregnancy
• Retained placenta/product of conception:
  • Placenta or membranes not completely expelled

BREAST COMPLICATIONS (Page 3, 4)

• Acute Puerperal Mastitis:
  • Breast inflammation
  • Common cause: Staphylococcus aureus
  • Symptoms: Rapid onset, fever, throbbing pain, indurated area
• Breast Engorgement:
  • Breast swelling and hardness
  • Causes: Inefficient feeding, delayed breastfeeding
  • Treatments: Warm compresses, gently expressing milk, support with binder or brassiere
• Breast Abscess:
  • Collection of pus in the breast
  • Causes: Untreated mastitis, nipple cracks.
  • Treatment: Surgical incision and drainage with antibiotics.

COMPLICATIONS OF PUERPERIUM (Page 3)

• Usually, women recover well but existing health problems or infection can affect the patient's status.
• There are complications encountered during pregnancy that can happen more often Post-partum.

BREAST ABSCESS (Page 6)

• Accumulation of pus in the breast
• Most common in lactating women
• Causes: Mastitis, untreated infection from the breast or baby, cracked nipples in lactating and non-lactating women
• Symptoms: Pain, redness, swelling, warm skin, pus discharge, fever
• Diagnosis: History and physical examination

ACUTE PUERPERAL MASTITIS (Page 4)

• Inflammation of the breast
• Symptoms: Fever, rapid pulse, sharp pain/tenderness
• Treatment: Antibiotic and analgesic if pus is present.
• Prevention: Proper feeding, supportive care

HAEMATOMA (Page 10)

• Blood accumulation in the uterus
• Types: Subchorionic, retroplacental
• Causes: Placental separation and cord insertion, large subchorionic hematomas.

POST-PARTUM HAEMORRHAGE (Page 10)

• Blood loss of >500ml within 24 hours of delivery
• Causes: Uterine atony, retained placental fragments, uterine trauma, coagulopathies
• Risk Factors: Maternal profile, over-distension, induction labour, placental abnormalities
• Management: Measures for uterine tone, prevention of retained tissue, management of trauma.

PRIMARY POST-PARTUM HAEMORRHAGE (Page 10)

• Blood loss >500ml vaginally within 24 hours of delivery
• Classification: Minor (500–1000 ml) and major (>1000ml)
• Causes: Uterine atony, retained tissue, trauma, thrombopathy

SECONDARY POST-PARTUM HAEMORRHAGE (Page 14)

• Blood loss 24 hours after delivery to 12 weeks postpartum.
• Causes: Retained placental fragments, infection (endometritis), placental site abnormality

ABORTION (Page 17-28, 29-30)

• Common reasons for induced abortion include:
  • Non-usage of family planning methods,
  • Failure of contraception.
  • Lack of access to contraceptives.
  • Unwanted pregnancy due to financial difficulties
  • Fear of parent's reaction to pregnancy
  • Unwanted pregnancy for other social or personal reasons
• Methods: Use of drugs, vaginal interference. These are unsafe.
• Unsafe abortions commonly result in medical or mental health problems.
• Complications: Infection (septic abortion), injuries.
• Management: Antibiotics, surgical procedures.
• Prevention: Family planning counseling

PUERPERAL PSYCHOSIS (Page 49)

• Rare mental health disorder in postpartum period
• Symptoms: Bizarre behavior, hallucinations, inability to sleep, harm to baby.
• Treatment: Psychiatric hospital admission under consultant care.

OBSTETRIC SHOCK (Page 49)

• Life-threatening condition due to insufficient blood flow to organs.
• Causes: Haemorrhage, infection, hypersensitivity reactions.
• Symptoms: Decreased blood pressure, rapid pulse, cold/clammy skin, restlessness

ANEMIA IN PREGNANCY (Page 66)

• Low red blood cell count during pregnancy
• Symptoms: Weakness, dizziness, shortness of breath, and pale skin

THROMBOPHLEBITIS (Page 47)

• Inflammation of a vein with a blood clot
• Causes: Blood clotting disorders, prolonged immobility, pregnancy, high estrogen levels.
• Symptoms: Pain, swelling, redness along the vein, tenderness
• Management: Rest, elevation of the affected limb, compression, anti-coagulants

PUERPERAL PYREXIA (Page 53)

• Fever during the postpartum period (within 6 weeks post-delivery).
• Causes: UTI, mastitis, retained placental tissue complications.
• Management: Identification of the cause, treatment (antibiotics as appropriate).

PELVIC ABSCESS (Page 37)

• Localized collection of pus in the pelvic cavity.
• Causes: Operative procedures, infection.
• Symptoms: Fever, lower abdominal pain, vaginal discharge, vaginal bleeding.
• Management: Surgical drainage, antibiotics, supportive care.

PUERPERAL SEPSIS (Page 36-37)

• Infection of the genital tract after childbirth.
• Causes: Infection, retention of placental fragments, trauma or retained products
• Symptoms: Fever, abdominal pain, foul vaginal discharge, tachycardia, etc
• Management: Antibiotics (IV), supportive care , monitor vital signs

Other Topics

• Miscellaneous topics are included as part of the lecture notes and some are mentioned above with specific details, as a guide for the learners.