KASTURBA NURSING COLLEGE, SEWAGRAM

CASE
PRESENTATION

POSTNATAL CASE
IDENTIFICATION DATA:

1. Name of patient: Mrs. Meena Sunil Kadu

2. Age : 26yrs.
3. Education: 10th pass
4. Religion: Hindu
5. Marital staus: married
6. Address: wardha
7. CR.NO: 2016035025389
8. Date of admission: 15/09/16
9. Time of admission: 10.45 am
10. Diagnosis: Peurperial sepsis .

SPOUSE PARTICULARS:

1. Husband name : Mr. Sunil S.Kadu

2. Age: 30yrs
3. Education: 12th pass
4. Occupation: labor
5. Income: 8,000/month
PRESENT COMPLAINT:

The client Mrs. Meena admitted in hospital on 15/09/16 with the complaint of pain at vagina,
headache and fever. After examination & investigation doctor diagnosed as peurperial sepsis.

HISTORY OF ILLNESS:

CHIF COMPLAINT:

The chief complaint of patient is pain at vagina,fever,pain in abdomen, insomnia, , anorexia,

anxiety and fatigue.

MENSTRUAL HISTORY:

1. Age of menarche: 15yrs.

2. Duration of menstrual cycle: 28 days
3. Duration of cycle in a day: 4 days
4. Regularity: regualr
5. Amount of flow: normal

CONTRACEPTIVE HISTORY:

Mrs. Meena taken oral contraceptive in previous year.

OBSTETRIC HISTORY:

HISTORY OF PREVIOUS PREGNANCY:

Mrs. Meena has one time conceived previously .she has one male child.

 Period of pregnancy: 9 month

 Type of labour/ delivary: vaginal delivary
 Birth weight : 3 kg

PRESENT PREGNANCY:

 Number of ANC visits: she has done 4 ANC visits.

 Minor ailments: she has a problem of minor sickness, breast discomfort in first 8
week.she has also a problem of backache & leg cramp.
PAST MEDICAL HISTORY:

There was no history of medical illness in during this period.

PAST SURGICAL HISTORY:

There was no significant history of surgery.

FAMILY HISTORY:

Mrs. Meena belongated to nuclear family. There is no history of any hereditary , communicable
disease .

Family tree:

Family compositon:

SR. NAME OF AGE/SEX RELATION EDUCATIO OCCUPATION HEALTH

NO MEMBERS WITH N STATUS
PATIENT

1. Mr. Shriram 63/male Father in 4th std Farmer Healthy

law
2. Mrs . Sandhya 60/female Mother in 4th std House wife Healthy
law
3. Mr. Sunil 30/male Husband 12th std labor Healthy

4. Mrs. Meena 26/female Self 10th std Housewife Unhealth

y

Healthy

5 Male child 5 days/ Son ----- -----

male

DIETARY HISTORY:
Mrs. Meena is vegetarian. She takes 2 times meal in a day. She likes green leafy vegetables &
fruits. She have no allergy of any food.

SOCIOECONOMIC HISTORY:

Mrs. Meena is belongated to middle class family. Her husband is breadwinner of the family.he is
Labor earning 7,000/ month. Her relationship with family friends,& relatives is good.

PERSONAL HISTORY:

Mrs. Meena is housewife, she like to do cooking work. Her mode of sleeping is normal &
urinary pattern was also normal.

PHYSICAL ASSESSMENT

1. General appearance:
 Body built: Average
 Nutrition: good
 Height: 5 foot 6 inch
 Appearance : dull
 Weight: 48 kg
2. Mental status:
 Level of consciousness: conscious
 Appearance: anxious & worried
3. Head & Face:
 Scalp: no dandruff & pediculi in scalp
4. Eyes : no any infection or stye in eyes.
5. Neck : no enlargement of thyroid gland and lymph node.
6. Breast: no crackled nipple. Areola become pigmented.
7. Extrimities:
 Upper extremities: normal movement of upper extremities.
 Lower extremities: pitting edema on ankle.
8. Genitals:
 Vagina: lochia discharge.

OBSTETRICAL EXAMINATION:
 1. Inspection: linea nigra & striae gravid is seen in lower abdomen.
2. Palpation: fundal height is decreased.
3. Auscultation: normal bowel sound heard.

NEONATAL ASSESSMENT:

GENERAL OBSERVATION:

 Colour: pink
 Skin : lanougo is absent
 Vernix caseousa: present
 Cyanosis: absent
 Rashes: no any rashes on the skin
 Birth mark : baby have no birth mark.
 Head: anterior fontanel: no any deviation.
Posterior fontanel: no any abnormality.
 Eyes: no discharge, no infectin
 Lips: no cleft lip
 Genitalias: both testis is present on scrotal sac.

ANTHROPOMETRIC ASSESSMENT:

 Head circumference: 32cm

 Chest circumference: 30 cm
 Mid arm circumference: 12 cm
 Weight: 3 kg
 Length: 50 cm

REFLEXES:

 Sucking reflex: sucking movement is present . baby suck the milk properly.
 Rooting reflex: head turn toward the stimulation.
 Gagging reflex: immediate return of undigested food.
 Grasp reflex: grasping the object by closing finger around it.

CRY OF BABY: normal

FIRST FEED GIVEN: after 3 hours.

INVESTIGATION:
  HAEMATOLOGY REPORT

SR.NO TEST PATIENT VALUE NORMAL VALUE

1. Haemoglobin 10 gm % 12 – 16 gm %

2. TLC 11,400/ cumm 4000-11000/ cumm

3. DLC- Neutrophils 45% 40-75%

Lymphocyte 35% 20-45%
Monocyte 4% 2-10%
Eosinophil 3% 1-6 %

4. Blood group O rh positive

TRETMENT

SR NAME OF DOSE ROUTE ACTION SIDE- NURSES

NO DRUG EFFECTS RESPONSIBILITY
1.Check the
1. Cap. Autrin 1.5 mg Oral Haematinics GI discomfort medication
(iron Anoroxia properly.
supplement) Nausea 2.Check the expiry
Vomiting date of medication.
Cnstipation 3. before giving the
medication check
2. Inj. 5 mg IM Antibiotics Peripheral the pation name age
amikacin edema , diagnosis & bed
Hypotension no.
Dizziness 4.give the medicine
250 Nausea at right time & by
3. mg Oral antiemetics right route.
Tab. Diarrhea 5.Check patient for
phenargan Headache any side effect.
Hepatic 6. record & report
dysfunction the given
medication.
ANATOMY & PHYSIOLOGY
DISEASE ASPECT
 NORMAL
PEURPERIUM
 NORMAL PUERPERIUM

DEFINITION:

Puerperium is the period following childbirth during which the body tissue ,specially the pelvic
organ revert back approximately to the pre- pregnant state both anatomically and
physiologically.

DURATION:

Puerperium begins as soon as the placenta is expelled and lasts for approximate ly 6 week when
the uterus become regressed almost to the non- pregnant size. The period arbitrarily divided into-
a) immediate- within 24 hours; b) early – upto 7 days; c) remote – upto 6 week.

INVOLUTION OF THE UTERUS:

ANATOMICAL CONSIDERATION:

UTERUS:

Immediately following delivary , the uterus become firm and retract with alternate hardening and
softening . the uterus measure about 20x 12x 7.5 cm. and weighs about 1000gm . at the end of 6
week , its measurement is almost similar to that of the non- pregnant state and weighs about 60
gm.

LOWER UTERINE SEGMENT:

Immediately following delivary , the lower segment become a thin ,flabby, collapsed structure. It
take a few weeks to revert back to the normal shape and the size of the isthmus.

CERVIX: the cervix contracts slowly the external OS admits two finger for a few days but by
the end of first week narrow down to admit the tip of finger only.

PHYSIOLOGICAL CONSIDERATION:

MUSCLE : there is marked hypertrophy and hyperplasia of muscle fibre during pregnancy and
the individual muscle fibers enlarges to the extent of 10 times in length and 5 times in breadth .

BLOOD VESSEL:the changes of blood vessel are pronounced at the placental site.The arteries
are constricted by contraction of its wall and thickening of the intima followed by thrombosis.

ENDOMETRIUM: following delivery the major part of the deciduas is caste of with the
expulsion of placenta and the membrane more at placental site.Regeneration starts by 7th day it
occurs from the epithelium of the uterine gland mouth and interglandular stroma cells.
INVOLUTION OF OTHER PELVIC STRUCTURE:

VAGINA: The distensible vagina, noticed soon after birth take a along time to involute . It
regain its tone but never to the vaginal state.The mucosa remain delegate for first few weeks.
Hymen is lacerated and is represented by nodular tags.

LOCHIA: It is the vaginal discharge for the first fortnight during puerperium.

ODOUR AND REACTION

It has got a peculiar offensive fishy smell. Its reaction is alkaline tending to become acid toward
the end.

COLOUR :Depending upon the variation of the colour of the discharge it is named as

1.Lochia Rubra:1-4 days

2.Lochia Serosa:5-9 days

3.Lochia alba:10-15 days

COMPOSITION:Lochia Rubra : consist of blood , shreds of fetal membrane and deciduas ,

vernix caseosa and meconium.

Lochia serosa : Consists of less RBC but more leucocytes, wound exceduates and mucus from
cervix.

Lochia alba : Contains plenty of decidual cell , leucocytes, mucus and granular epithelial cells.

AMMOUNT: The average amount of discharge for the first five to six days is estimated to be
250 ml.

GENERAL PHYSIOLOGICAL CHANGES:

PULSE: For a few hours after normal delivery the pulse rate is likely to be raised which settle
down to the normal during the second day.

TEMPERATURE: The temperature should not above 37.2c within the first 24 hours. There
may be slight reactionary rise following delivery by 0.5 f but comes down to normal within 12
hours.

URINARY TRACT: The bladder mucosa becomes oedematous and hyperemic and often shows
evidence of submucus extravasation of blood. The bladder capacity is increased.

GASTRO INTESTINAL TRACT: Increased thirst in early puerperium is due to loss of fluid
during labour , in the lochia , dieresis and perspiration. Constipation is a common problem due to
delayed GI motility.
WEIGHT LOSS: In addition to the weight loss as consequence of expulsion of the fetus ,
placenta, liquor and blood loss , a further loss of about 2 kg occurs during pueperium chiefly
caused by dieresis.

FLUID LOSS: There is a net fluid loss atleast 2 liters during first week and an additional 1.5
liters during the next 5 weeks

MENSTRUATION AND OVULATION ; The onset of the first menstrual period following
delivery is very variable and depends on lactation. The menstruation returns 6th week following
delivery in about 40% and by 12th week in80% of cases.
DEFINATION :-

An infection of the genital tract which occurs as a complication of delivery is termed puerperal
infection.

INCIDENCE :-

 puerperal infection affect 2 to 10 % of patient

 It is 5 to 10 times higher in ceserian section

PREDISPOSING FACTORS OF PUERPERAL INFECTION

Antepartum factors

 1.Malnutrition and anemia

 2.Pre –eclapmsia

 3.Premature rupture

 4.Chronic debilitating illness

 5.Sexual intercours during late pregnancy

Intrapartum factor

 1.Vaginal examination

 2.Dehydraton and ketoacidosis during labour

 3.Traumatic operative delivery

 4. Haemorrhage- aph or pph

 5. Retained bits of placental tissue or membrane

 6. Placenta previa.

MODE OF INFECTION:

 Endogenous: organism present in the genital tract before delivery become pathogenic

 Autogenous: organism present elsewhere in the body migrate to the genital organs either
through blood stream or by droplet infection
  Exogenous: infection is contracted from source outside the client.the organism are
introduced by the attendants,usually from the respiratory tract of physcians or nurses.

CLINICAL FEATURES

 Local infection

1.Slight rise of temprature.headache

2.Redness and swelling of the wound

3.Pus formation

 Uterine infection

1.Pyrexia and tachycardia.

2.Red, copious and offensive lochia.

3.Subinvoluted, tender and soft uterus.

4.Fever with chills and rigor

5. Rapid pulse.

6.Scanty, odorless lochia.

7.Involuted uterus.

 Parametritis

1.Sustained rise of temperature(7th to 10th day)

2. Constant pelvic pain.

3.Tenderness on either side of the hypogastrium.

4.unilateral, tender mass felt on vaginal examination

Pelvic peritonitis

1. Pyrexia with increased pulse rate

2. Lower abdominal pain tenderness

 3. On vaginal examination, tenderness of the fornix

General peritonitis

1. High fever with rapid pulse.

2. vomiting.

3. 3. Generalised abdominal pain.

4. 4. Tender and distended abdomen.

5. Thrombophlebitis

6. 1.Swinging temperature with chills ad rigor

7. Septicemia

8. 1.High temperature associated with rigor.

9. 2.rapid pulse.

10. 3.Headache, insomnia or mental confusion.

11. 4.Positive blood culture.

12. 5.Metastatic infection in the lungs, meninges or joints

INVESTIGATIONS

1.Bacteriological study:

 Smear

 Culture and antibiotic sensitivity of purulent material

 High vaginal and cervical swabs

 Peritoneal fluid

 Blood culture as appropriate

 . Urine Routine and microscopic examination

 Culture if infection is suspected

 3. Complete blood count

  4. Ultrasonography : For diagnosis of pelvic masses, pelvic abscess, pelvic peritonitis,
retained bits of placenta and /or membranes.

 5. Other specific investigations as per clinical condition such as chest X- ray or blood for
malaria parasites

PREVANTION AND TREATMENT OF PUERPERAL INFECTION

Antenatal

1. Improvement of general condition

2. Treatment of septic focei

3. Abstinence from sexual intercourse in the last two months

4. Care about personal hygiene- bathing in dirty water to be avoided

5. Avoiding contact with people having infection, such as cold, boils

6. Avoiding contact with people having infection, such as cold, boils

7. 6. Avoiding unnecessary vaginal examinations and douches in the later months.

Intrapartum

8. 1.Staff (physicians and nurses) attending on labor clients should be free of infections.

9. 2.Full surgical asepsis to be taken while conducting delivery.

10. 3.Women having respiratory tract infection or skin infection should be admitted in single
room or separate ward.

11. 4.Membranes should be kept intact as long as possible and vaginal examination should be
restricted to minimum.

12. Traumatic vaginal delivery and intrauterine manipulation should be preferably avoided. If
required, should be done using fresh (sterile) gloves with liberal use of strong antiseptic
solutions.

13. 6. Lacerations of the genital tract should be repaired promptly and meticulously with
perfect haemostasis.

14. Excessive blood loss during delivery should be replaced promptly and meticulously by
transfusion to improve the general body resistance
 15. 8. Prophylactic antibiotics must be administered tn cases of premature rupture of
membranes, prolonged labor or following traumatic delivery

Postpartum

16. 1.Nurses to take aseptic precautions while dressing the perineal wound.

17. 2.Restriction of visitors in the postpartum ward.

18. 3.Mothers to be instructed to use sterile sanitary pads and to change them frequently

19. . Vulva and perineum to be washed/cleaned with mild antiseptic solution following
urination and defecation.

20. 5. Infected mothers and babies are to be isolated

21. 6. To keep the floor of the in-patient ward dust free by frequent mopping (wet swabbing)

TREATMENT

 The woman should be placed in a separate room/ward with adequate light and ventilation.

 Complete rest is to be given in head high position, which helps in drainage of lochia and
localization of infection to the pelvis if there is pelvic peritonitis

 Analgesics and sedatives are administered to enforce rest.

 Broad-spectrum antibiotics are given intravenously until antibiotics sensitivity reports are
available, followed by specific antibiotics.

 Stool softeners are administered (milk of magnesia at bed –item ) to keep the bowels
open.

 Anemia to be corrected by blood transfusion

 Infected wounds of perineum, vulva and vagina are laid poen for drainage, cleaned and
dressed with antiseptic preparations.

 SURGICAL TREATMENT

 The stitches of the perineal wound may have to be removed to facilitate drainage of pus
and relieve pain.

 After the infection is controlled, secondary sutures may be given later.

 Infected retained products should be removed as early as possible under cover of

antibiotics by digital exploration of the uterine cavity.
  Pelvic abscess should be drained by colpotomy.

 Abscess above the Poupart’s ligaments should be incised and the pus drained.

NURSING DIAGNOSIS

1. Pain related to peurperial sepsis

2. Hyperthermia related to infectious process.
3. Imbalance nutrition related to inadequate intake of food.
4. Disturbed sleeping pattern related to hospitalization.
5. Fluid volume deficite related to nausea & vomiting.
6. Anxiety related to fear of ina bility to manage disease process.
7. Knowledge deficit related to treatment regimen.
 HEALTH EDUCATION

 DIET:
 Advice patient to increase calorie intake in diet.
 Advice patient to eat egg, meat & fish etc.
 Advice patient to eat citrous fruit & green leafy vegetable .
 Advice patient to eat fruit like apple to meet the demand of iron.
 POSTNATAL HYGIENE:
 Rest & sleep: adviced patient to take rest at least 8-10 hours.
 Bowel : advice patient to take plenty of fluid to avoid constipation.
 Bathing: advice patient to take daily bath but be carefull against slipping in the
bathroom due to imbalance.
 Breast care: advice patient to take care of her breast & check for any retracted
nipple or breast engorgement.
 IMMUNIZATION:
 Advice patient to follow the immunization schedule.
 DRUG:
 Adviced patient to take medicine properly at right time prescribed by physician.
 BREAST FEEDING:
 Advice mother to feed the baby as per his demand.
 PERINEAL CARE:
 Ask mother to keep the perineal area clean prevent to the infection.
 FOLLOW – UP:
 Advice patient to visit the hospital for postnatal check- up.

BIBLIOGRAPHY

1. D.C.Dutta’s , textbook of obstrtrics, seventh edition, published by new central agency,

page no. 219- 229.
2. Annamma Jacob, ‘ textbook of midwefery’, first edition, published by Jaypee, page no.
294-296.
3. Ross and Wilson, ‘ textbook of anatomy and physiology, tenth edition, published by
Elsevier, page no. 80-84, 89-90.
4. K.D. Tripathi,’ textbook of medical pharmacology’ sixth edition , published by Jaypee,
page no. 539-540.
5. www.google.com