Manual for converting raw scores to transformed scores.
\r\n\tIn this book the amperometry principles, instrumentation, cells (including flow cells), and functional materials used in amperometric sensors are presented together with the numerous applications of the amperometric (bio)sensors and the amperometric titrations in the environmental, food, and clinical analysis.
",isbn:null,printIsbn:null,pdfIsbn:null,doi:null,price:0,priceEur:null,priceUsd:null,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"502756538d952207e98c5b53b0f8c6ed",bookSignature:"Dr. Margarita Stoytcheva and Dr. Roumen Zlatev",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/8638.jpg",keywords:"Voltammetry, Direct Amperometry, Pulse Amperometry, Amperometric Sensors, Functional Materials, Amperometric Biosensors, Electrode Modification, Cells, Flow Cells, Amperometric titration, Amperometric Detection, Application",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"August 16th 2018",dateEndSecondStepPublish:"September 6th 2018",dateEndThirdStepPublish:"November 5th 2018",dateEndFourthStepPublish:"January 24th 2019",dateEndFifthStepPublish:"March 25th 2019",remainingDaysToSecondStep:"3 years",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:null,coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"170080",title:"Dr.",name:"Margarita",middleName:null,surname:"Stoytcheva",slug:"margarita-stoytcheva",fullName:"Margarita Stoytcheva",profilePictureURL:"https://mts.intechopen.com/storage/users/170080/images/system/170080.jpg",biography:"Prof. Margarita Stoytcheva has graduated from the University of Chemical Technologies and Metallurgy of Sofia, Bulgaria with titles of Chemical Engineer and Master of Electrochemical technologies. She obtained PhD and DSc degrees in Chemistry and Technical Sciences. She has participated in research and teaching in several universities in Bulgaria, Algeria, and France. From 2006 to the present, she has participated in activities of scientific research, technological development, and teaching at the Autonomous University of Baja California (Mexicali, Mexico) as a full-time researcher. Since 2008, she has been a member of the National System of Researches of Mexico, and since 2011 she has been a regular member of the Mexican Academy of Sciences. 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He was a fulltime researcher in the Bulgarian Academy of Sciences and a part-time professor at Sofia University before accepting the position of full-time senior researcher in UABC in 2005. Dr. Zlatev is a member of the Mexican National System of Researchers and a regular member of the Mexican Academy of Sciences. He participates in research projects in France, Germany, and Mexico. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"67643",title:"Psychosocial and Health-Related Quality of Life (HRQoL) Aspect of Oral and Maxillofacial Trauma",doi:"10.5772/intechopen.86875",slug:"psychosocial-and-health-related-quality-of-life-hrqol-aspect-of-oral-and-maxillofacial-trauma",body:'Following maxillofacial trauma, the psychosomatic requirements of patients are distinctive and very important. Studies have shown that individuals with maxillofacial trauma often presents with signs of depression/sadness, worry/anxiety and aggression/hostility over 1 year period after such traumatic conditions as compared to equaled control group [1]. Similarly, several authors have documented that 10–70% of maxillofacial trauma patients showed signs of sadness and worry [1]. Often, these patients have other psychosocial troubles such as joblessness, illiteracy and poor societal support [2]. Many times these symptoms are sub-threshold and might not meet the diagnostic benchmarks for a psychiatric condition. Subsequently, these subthreshold symptoms often lead to problem-solving dilemmas, deprived management of the condition and poor interventions. Other symptoms that may complicate the dilemma include normative reactions to sadness, anguish over the losses in such trauma, complications from medications and exhaustion from treatment.
Depression puts the individual at more danger of suicidal tendencies, reduced treatment compliance, and poor convalescence aftermath. In such cases, quality of life and recovery from the maxillofacial trauma are often compromised [3, 4].
Although maxillofacial fractures are one of the more common types of injuries, studies frequently publish epidemiology of maxillofacial injuries and management protocol. Such studies only from surgical management tend to disregard salient symptoms that can impact health aftermaths.
Throughout the preceding decade, the efforts of some investigators [5, 6, 7] have increasingly sensitized the surgical community to the hidden social and psychological factors that adversely influence treatment response and increase the risk of re-injury. Through the efforts of these investigators, maxillofacial injuries are now seen and managed both surgically and psychologically [8]. Although, efficient surgical repair is a critical aspect of recuperation, meeting the psycho-social needs that may put them at specific risk for poor psychological adjustment is equally important after the traumatic incident.
When these emotional and behavioral disorders, including depression and antisocial behavior remains untreated, it leads to deprived social performance, job-related fiasco, drug and substance abuse that upsurges the peril of violence and re-injury [5]. Based on these facts, the current mode of management should be a multidisciplinary approach wherein surgeons and other specialists (psychologists, psychotherapists and psychiatrists) will formulate a treatment plan that would addresses the surgical and psychosocial needs following maxillofacial trauma [5, 9].
Depression and anxiety related with maxillofacial injuries are often linked with concerns regarding recovery and stretch of the treatment course [10]. Disfigurement often associated with maxillofacial trauma also affects the social image of the individual with such injuries [11]. Social withdrawal and isolation is major sequelae that may ensue following the facial disfigurement with feeling inferior and social stigmatization [12, 13]. Many times recovery from maxillofacial injuries is often protracted with multiple surgeries and complex postoperative management to restore function. This protracted course may add to patient’s frustration [14].
Injuries to vital regions of the face such as the eyes, ears, and dental hard tissue injuries often increase exposure to stress and hinder recovery [15]. Substantial difficulties in returning to premorbid levels of work-related functioning have also been noted in these cases [16]. Maxillofacial trauma patients also report higher rates of somatoform symptoms, drug abuse, PTSD symptoms, body aura issues, stigmatization, lesser quality of life, and lower overall contentment with life [17]. Also, maxillofacial trauma patients report snags in marital, work-related, and social functioning [18, 19].
In psychology, self-esteem is a term used to echo a person’s overall emotional evaluation of his or her own worth. Self-esteem is the level, to which one respects, values, accepts, admires, and likes oneself [20]. During the mid-1960s, Rosenberg, a social learning theorist, defined self-esteem as a personal worth or worthiness [20].
The significance of self-esteem lies in the fact that it concerns one’s self, the way we are and the sense of our personal worth. Thus, self-esteem affects the way we are, the way we act in the world, and the way we relate with everyone else [21]. Furthermore, the way individuals reflect, feels, decides, and act is swayed by self-esteem. Low self-esteem is having a generally damaging overall outlook of oneself, judging or evaluating oneself negatively, and placing a general deleterious value on oneself as a person [21]. Low self-esteem can also have an impact on many aspects of a person’s life. It can affect a person’s functioning at work or at school. People with low self-esteem might not participate in many relaxation or entertaining activities, as they might believe that they do not justify any pleasure or fun [21]. Individual self-care could also be affected and might drink alcohol heavily and also abuse drugs and substances [21].
In everyday life, facial appearance plays an important function and roles. The appearance and “attractiveness” of an individual to one another is partially contributed by the person’s face [22]. Following maxillofacial trauma, the individual may suffer facial defacement, chronic facial pain, anosmia, dysosmia, speech, dental, and ocular infirmities. Often times, concern is dedicated on the apparent physical aspect of maxillofacial trauma while the impact on the patient’s psychological makeup and quality of life (QoL) is relegated to the background or even ignored. Most of the studies on psychological consequences and QoL in patients following maxillofacial injuries have been conducted in Western countries. Such studies in Sub-Saharan Africa and Middle East are rare [23].
Other interesting and possible sequelae of trauma are post-traumatic stress disorder (PTSD). This disorder starts with an initial event of the trauma, which causes the person to feel intense fear, helplessness, and horror. The event is re-experienced either during the daytime in the form of distressing flashbacks or at night as terrifying dreams. This again causes fear, dread and a heightened state of psychological arousal in which patient tends to restrict activities and constrict thoughts and emotions in an effort to avoid re-experiencing the trauma. This disorder significantly distresses the individual and is highly associated with marital, occupational, financial and health problems [24, 25, 26, 27]. Several investigators have reported PTSD rates of between 27 and 41% after maxillofacial injuries majorly caused by assault and interpersonal violence [1, 28], however, a preliminary Nigerian study reported a rate of 17.4% after maxillofacial trauma majorly caused by motorcycle accidents [23].
When managing patients with maxillofacial injuries, the psychosocial aspect of the management must follow some general principles and must be kept in mind during reconstructive surgeries [29]. All efforts must be geared toward creating some realistic expectations for both patients and their families regarding surgical upshot. The duration to complete reconstruction, possible total number of surgeries, and degree of life disruptions and pain that may likely occur should be clearly explained to both patients and relatives [29]. One of the most significant roles that the handling surgeon can make is to take time to thoroughly listen to the victims and relatives’ unique worries concerning the surgery, its sequel, and their capability living with defacement [30].
While many surgical team will satisfactorily respond to the psychological wants of their patients, many will require little additional psychosocial care like creating extra time, devotion and encouragement [31]. However, if the surgical team felt the patient and family may be assisted further by interrelating with psychiatrist or psychologists, such consultation should be expedited immediately by the surgical team.
Over the years, there has been some advancement made in focusing on the specific psychosocial worries of persons with maxillofacial disfigurement, including addressing the need for social skills improvement. Application of cognitive-behavioral forms which have been proven to very valuable will assist patients to cope with persistent negative social response following disfigurement from trauma. Furthermore, developing and spreading effective psycho-educational materials will also address specific concerns for those living with facial disfigurement [32].
The authors carried out a research to investigate the psychological and health-related quality of life among maxillofacial injured patients in Sub-Saharan Africa (Nigeria). This was a prospective repeated measure designed to evaluate psychological characteristics and health-related quality of life in subjects with maxillofacial trauma who presented at the Oral/Maxillofacial Surgery Unit or Accident & Emergency Unit, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria.
The study population was consecutive subjects with maxillofacial injuries attending the Accident and Emergency Unit or Oral/Maxillofacial Surgery Unit of the Obafemi Awolowo University Teaching Hospital Complex Ile-Ife Nigeria. Participants were recruited over a period of 12 months after approval from the hospital’s Ethics and Research Committee. Adult subjects above 18 years irrespective of sex, race and type of injury were recruited after informed consent for the study was given. Additionally, they satisfied all the specified inclusion criteria. Head injured patients were excluded. Baseline interview was conducted within 1 week of arrival in the hospital (Time 1). Follow-up interviews were conducted at intervals of 4–8 weeks after initial contact (Time 2) and 10–12 weeks thereafter (Time 3).
Data such as age, sex, level of education, occupation, and marital status was stored with questionnaire specially designed for such. The clinical data retrieved included cause of injury, location of injury, category of injury, and whether treatment was open reduction with internal fixation or closed reduction. Information about use of alcohol, drugs and other psychoactive substances were also obtained and recorded.
This is a 14-item self-reporting tool with anxiety and depression subscales [33]. Each detail is rated on a four-point gradation, with each subscale having a range of 0–21. The HADS data collection instrument has been authorized in Nigerian hospitals and community samples [34]. The endorsed cut-off mark of seven for this region was adopted for this study [34].
This is a screening instrument for self-esteem [20]. The scale is a 10 item statement. Retrieved scores were calculated as follows:
For questions 1, 2, 4, 6 and 7: They are rated as follows: strongly agree = 3, agree = 2, disagree = 1, strongly disagree = 0.
For items 3, 5, 8, 9 and 10 (which are upturned in valence): They are rated as follows: strongly agree = 0, agree = 1, disagree = 2, strongly disagree = 3.
The scale ranged from 0 to 30. Marks between 15 and 25 are within normal range while marks below 15 insinuate low self-esteem. The Rosenberg self-esteem scale has been used in earlier research in Nigeria [35].
World Health Organization QoL assessment instrument 26-item (WHO QoL-Bref) was used in assessing the QoL of individuals with maxillofacial injuries. This brief version QoL is a generic measure designed for use within a broad range of psychological and physical disorders [36]. It is a multidimensional tool, and was established for cross-cultural use; it assesses personal QoL. It comprises 26 queries and uses a five-point interval Likert response scale. For our study, the four domain model was applied. The four domains are those of physical health, psychological health, social relationships, and environment. Scores for domains were transformed on a scale of 4–20, with 20 being the highest and four being the lowest (see Table 1 for steps in checking, cleaning data and computing domain scores for WHO QoL-Bref and also manual for converting raw scores to transformed scores). Scores were scaled in a positive direction. Higher scores denote high QoL and low scores shows low QoL. The WHO QoL-Bref has been widely used in Nigeria [37].
Manual for converting raw scores to transformed scores.
The Trauma Screening Questionnaire [38] (TSQ) is a brief 10-item self-report measure devised to screen for posttraumatic stress disorder (PTSD). Each item is copied from the DSM-IV [25] criteria and describes either a re-experiencing symptom of PTSD (items 1–5) or a provocation symptom of PTSD (items 6–10). Evading and numbing symptoms, though also listed in the DSM-IV criteria, were not included in the TSQ in keeping with the authors’ goal of creating a useful screening tool that was “short and contained the least amount of items essential for precise case identification” [38]. The TSQ has been able to predict excellent levels of PTSD following preliminary psychometric data [38] from two samples (rail crash survivors and crime victims). The principal author states that “what the TSQ gains in simplicity and clarity more than compensates for the absence of symptoms that may be difficult to understand and judgments that may be difficult to make” [39]. The authors have suggested administering the TSQ at least 3 weeks after the traumatic event “to allow for natural recovery processes.” An ideal cut-off point was found to be a YES response to
Data was analyzed with SPSS version 16 (SPSS 16 Inc., Chicago, IL, USA). Results were calculated as frequencies (%), means and standard deviations (SD) for normally distributed variables.
The study population consisted of 80 participants. There were 64 (80.0%) males and 16 (20.0%) females. The mean age of the sample was 33.2 ± 12.5, range 18–70 years. Road traffic accidents were responsible for a sizeable proportion of injuries in the facial injured (68 (85%)). The socio-demographic characteristics of the study population are shown in Tables 2 and 3. Only 21 patients where admitted and most of them were discharged home within 1 week of hospital stay (16 (76.2%)) as shown in Table 4.
Facial injury (%) | |
---|---|
Male | 64 (80.0) |
Female | 16 (20.0) |
Young adult (18–35) | 60 (75.0) |
Middle age (36–44) | 10 (12.5) |
Elderly (45–70) | 10 (12.5) |
Married | 47 (58.8) |
Single | 33 (41.2) |
Divorced | 0 (0.0) |
No education | 2 (2.5) |
Primary | 13 (16.2) |
Secondary | 41 (51.3) |
Tertiary | 24 (30) |
Unemployed | 21 (26.3) |
Unskilled | 30 (37.5) |
Skilled | 14 (17.5) |
Professional | 12 (15.0) |
#Others | 3 (3.7) |
Personal | 15 (18.8) |
Rented | 64 (80.0) |
No house | 1 (1.2) |
Yes | 21 (26.3) |
No | 59 (73.7) |
Socio-demographic characteristics.
Voluntary workers.
Facial injury (%) | |
---|---|
Assault | 6 (7.5) |
Road traffic accident | 68 (85.0) |
Others (fall and occupational injury) | 6 (7.5) |
Motorcycle | 52 (76.6) |
Car | 9 (13.2) |
Truck | 1 (1.4) |
Bus | 6 (8.8) |
Combined | 0 (0.0) |
Intercity | 26 (37.7) |
Intracity | 43 (62.3) |
Driver | 43 (64.2) |
Passenger | 24 (35.8) |
Pedestrian | 0 (0.0) |
Burst tyre | 9 (25.0) |
Failed brakes | 0 (0.0) |
Unknown | 27 (75.0) |
Over speeding | 30 (68.2) |
Drunk | 2 (4.5) |
Slept off | 0 (0.0) |
Unknown | 12 (27.3) |
Sociodemographic characteristics (continued).
Duration of hospital stay (week) | Facial injury ( |
---|---|
<1 | 16 (76.2) |
4–8 | 5 (23.8) |
10–12 | — |
>12 | — |
Total | 21 (100) |
Distribution of duration of hospital stay and injury.
Mandibular fracture was the most frequently fractured facial bone (
Type | Right (%) | Left (%) | #Combined (%) | Total (%) |
---|---|---|---|---|
Mandible | 12 (26.1) | 16 (34.8) | 18 (39.1) | 46 (100) |
Maxilla | 4 (36.4) | 1 (9.1) | 6 (54.5) | 11 (100) |
Zygomatic bone | 7 (100) | 0 | 0 | 7 (100) |
Mandible + maxilla | 3 (21.4) | 3 (21.4) | 8 (57.2) | 14 (100) |
Maxilla + zygomatic | 0 | 0 | 2 (100) | 2 (100) |
Total | 80 (100) |
Distribution of facial bone fracture.
Combined (both right and left).
Bar chart showing distribution of maxillofacial bone fractures.
Sixty-seven subjects (83.8%) were managed with closed reduction of the fractured bone, 13 (16.2%) were treated with open reduction and rigid internal fixation (Table 6).
Type of treatment | Facial injury (%) |
---|---|
Closed reduction | 67 (83.8) |
Open reduction | 13 (16.2) |
Total | 80 (100) |
Distribution of types of treatment received by the facial fracture.
The Hospital anxiety and Depression scale (HADS) detected 56 (70.0%) had anxiety at baseline, 32 (42.1%) at Time 2 and only 9 (11.8%) had anxiety at Time 3. There was reduction in anxiety levels with time with only 9 (11.8%) having anxiety after 10–12 weeks post trauma (Table 7).
The Hospital anxiety and Depression scale (HADS) detected 42 (52.5%) cases of depression at baseline, 36 (47.4%) cases at Time 2 and 14 (18.4%) cases at Time 3 (These are subjects that scored above the cut-off point of 7 on the Depression scale of the HADS). There was reduction in depression levels with time (Table 8).
Thirty-three (41.3%) participants in the facial injured subjects scored between 0 and 14 at Time 1. At Time 2, 39 (51.3%) subjects scored between 0 and 14, while at Time 3, 7 (9.2%) scored between 0 and 14. Subjects with facial injuries consistently had lower self-esteem (Table 9).
Time | Facial injury |
---|---|
Time 1 (within 1 week of injury) | ( |
#Score 0–14 | 33 (41.3%) |
¶Score 15–30 | 47 (58.7%) |
Time 2 (4–8 weeks) | ( |
#Score 0–14 | 39 (51.3%) |
¶Score 15–30 | 37 (48.7%) |
Time 3 (10–12 weeks) | ( |
#Score 0–14 | 7 (9.2%) |
¶Score 15–30 | 69 (90.8%) |
Changes in proportion of subjects with low and normal self-esteem with time.
Low self-esteem.
Normal self-esteem.
Throughout the review periods, the psychological domains of the WHO QoL-Bref were constantly lower than other domains. This was followed closely by the social relationship domain at Time 1 review period (Table 10).
Domains at Times 1, 2, and 3 | Facial injury |
---|---|
Physical health | 11.0 (±1.8) |
Psychological health | 9.3 (±1.8) |
Social relationship | 10.5 (±2.6) |
Environment | 11.4 (±2.3) |
Physical health | 12.5 (±1.5) |
Psychological health | 11.4 (±1.8) |
Social relationship | 13.1 (±2.5) |
Environment | 12.9 (±1.6) |
Physical health | 13.5 (±1.3) |
Psychological health | 12.9 (±1.8) |
Social relationship | 15.8 (±6.7) |
Environment | 14.3 (±2.5) |
Change in mean WHO (HRQoL-Bref) score according to domains at Times 1, 2, and 3.
The PTSD was evaluated only at Times 2 and 3 consistent with the commencement of evaluation after 3 weeks of injury. Seventy-six patients were screened out of the 80 participants at Times 1 and 2. Nineteen patients had symptoms of PTSD at Time 1 and 20 patients at Time 2 with a prevalence rates of 25.0 and 26.3% respectively (Figure 2).
Bar chart showing distribution of number of maxillofacial injured having potential for post-traumatic stress disorder (PTSD) at Times 1 and 2.
The management of maxillofacial is largely driven by the obvious clinical manifestations of the physical injury, while the less evident psychosocial sequelae are rarely considered [40]. Documented possible symptoms of these psychological sequelae following facial trauma include increase in levels of depression, anxiety, phobic anxiety, and obsessive compulsive tendencies [40]. The appearance and “attractiveness” of a person to other people is partly contributed by the person’s face. As a result of maxillofacial trauma, the patient may suffer facial disfigurement.
Previous reports [23, 41, 42, 43] have supported these new findings where 84% of injuries resulted from road traffic accidents. Road traffic accident continue to account for the most common reason of maxillofacial injury because of insufficient vehicular maintenance, lack of traffic laws enforcement, and poor levels of educational status of drivers [44]. In United Kingdom, United States of America and other parts of the world, the mandatory uses of seat belts, crash helmets, traffic law enforcement, and increase in use of vehicles with airbags have reduced the incidence of maxillofacial injuries due to road traffic accident [45, 46].
Majority of the road traffic accident were motorcycle related, 76.6% in facial injured subjects. This is because motorcycle is still a major means of transportation in Sub-Saharan Africa and riders do not often wear protective helmets making them more prone to head and facial injuries. Frequent traffic congestion because of poor road maintenance/network has made this mode of transportation attractive in most communities because motorcycles can navigate through narrow ways [44]. Whereas motorcycle-related facial trauma has been on the increase in Nigeria, a study in Europe however showed a decline in the incidence of such injuries in motorcycle-related accident [47]. Enforcement and use of appropriate crash helmets, increasing vehicle ownership due to increase in wealth were the reasons given for this decrease.
Assault-related maxillofacial injuries remain the main cause of maxillofacial trauma in industrialized nations [28, 48, 49]. This was not observed in this study as assault accounted for only 6 (7.5%) cases of facial trauma.
The present study recorded male preponderance. The reason for this observation is that motorcycle operators were predominantly males [34]. This pattern is in agreement with previous findings were male preponderance was reported [42, 43, 48].
The overall mean age for the study population was 33.2 (SD ± 12.5) years. This finding is also in agreement with previous studies where young adults are frequently involved in road traffic accidents [43, 50]. This age group is the period of high activity and individuals in this age group are more likely to take part in dangerous and risky exercises and sports, drive motor vehicle and motorcycles carelessly and are likely to be involved in violence [51]. More than half of the subjects who sustained injuries were either unemployed or involved in unskilled jobs. These findings echoed previous findings that patients with maxillofacial injuries have psychosocial problems like anxiety and depression, low self-esteem, unemployment, lower educational level and poor social support [2].
The maxillofacial injured subjects were anxious from this study. This is comparable to previous reports of high rate of psychosocial complication following maxillofacial trauma [1, 28]. This present findings contrast those of previous study in south west Nigeria [23] where researchers stated that 11.8% of individuals sustaining maxillofacial injuries faced extreme anxiety levels immediately after injury, 3.0% during 4–8 weeks and 13.0% at 10–12 weeks follow-up times. While both studies were carried out in a comparable setting, the reason for the disparity could not be described; however, the authors opined that higher attrition rate in the earlier study might be responsible.
This study has shown high levels of depression in maxillofacial injured subjects. The findings are similar to those of previous researches investigating psychosocial complications of traumatic injury [1, 23, 28, 52]. A comparable finding in an erstwhile Nigerian study stated that 41.2% of patients had depression at Time 1 (within 10 days of injury), 47.1% at Time 2 (6–8 weeks after injury), and 21.7% at Time 3 (10–12 weeks after injury) [23]. This similarity was because both studies were carried out in similar study population and environment. The etiology of injury was also similar. Higher proportion of maxillofacial facial injured patients were depressed at Times 2 and 3 (47.4 and 18.4%, respectively) from previous study. This pattern is possibly as 52 (65%) patients of the maxillofacial injured sustained concomitant maxillofacial soft tissue wounds with the additional enduring scarring that could not be masked. This long-lasting scarring may alter their form and personality leading to social retraction and loss of self-esteem [16]. In addition, disfiguring might be the etiology of constant depression and be a continuous reminder of the mishap or act of violence where the injury occurred [53]. Though, the anxiety and depression levels were decreasing over the review times, it did not totally cease. Lento et al. [40] have described comparable outcomes whereby notwithstanding the decline in signs of psychological grief over time, additional psychological snags were still reported in injured group than the comparison cohort.
Other reports [40, 54] have opined that post-traumatic symptomatology may be an extension of earlier psychosocial problems and these individuals may be inadequately equipped psychologically to endure the pressures of the injury and recovery. Prior psychological status of persons in the third world nations is not a usual practice, therefore background psychological position of our patients were unavailable.
Extensive literature search yielded only two published data on risks of anxiety and depression following maxillofacial trauma from Sub-Saharan Africa [23, 55]. Additionally, our outcomes reverberated the need for reconstructive surgeons and other healthcare professionals to identify these psychosocial agonies together with the physical injuries sustained by these patients. Also, trauma care givers must be informed and trained in offering brief psychologic evaluations.
The human face is the central point of identity of a person, and the existence of scar may alter a person’s identity, which could lead to seclusion and loss of self-esteem. Additionally, when such injuries affect functions like speech and feeding, a maxillofacial injured subject may develop psychosocial problems [15, 56, 57]. Studies has also acknowledged the fact that nice-looking persons are more likely to have better self-esteem, accomplish higher levels of educational and job-related satisfaction, have more satisfying sexual encounters, and will generally have a better quality of life [58]. Consequently, it is rational to resolve that living with a maxillofacial defacement puts the person at an increased peril of undergoing a drastically reduced low quality of life and low self-esteem [2].
Psychological interventions are needed in the near aftermath of trauma in maxillofacial injured, as esteem needs of victims are frequently compromised. In this study, patients who screened positive for low self-esteem were referred to the psychiatry unit of the hospital for further follow-up. The strongest deficits in self-esteem were seen in the 1st week after injury and again from 6 to 8 weeks during recovery. This showed that maxillofacial injured consistently had low self-esteem throughout the review periods [59].
Lower HRQoL after physical trauma has been reported in other studies [60]. In addition, it is probable that the physical dysfunction caused by these injuries may adversely affect the patients’ ability to undertake their daily activities like tooth brushing, eating which will lower their mood and sense of self-esteem [60]. From the study, it will be observed that throughout the review periods, the psychological domains of the WHO QoL-Bref were constantly lower than other domains. This shows that maxillofacial injured are psychologically affected apart from the physical injuries they sustained. Similarly, the social relationship domain at Time 1 review period was also lower than other domains. Social relationships after maxillofacial injuries was also affected whereby patient may abstain from social interactions due to presence of scars on the face or inability to speak especially following inter-maxillary fixation [61].
Maxillofacial trauma may occur in life-threatening situations and as a result of accidents or industrial mishaps [62]. This may often herald the onset of PTSD. The principal symptoms of PTSD comprise (i) re-experiencing of the incidence (e.g., having unpleasant and upsetting thoughts and/or distressing images and dreams); (ii) evasion of thoughts, emotions or situations linked to the incidence; and (iii) autonomic nervous system hyperarousal, including struggles with sleeping, having an exaggerated disconcert response and undergoing increased irritability and nervousness [63].
From the current study, 19 patients had symptoms of PTSD at Time 1 and 20 patients at Time 2 with a prevalence rates of 25.0% and 26.3% respectively. This shows that in African population, there is high risk of patients with maxillofacial injuries to developing PTSD. A previous preliminary Nigerian study have reported a rate of 17.4% after maxillofacial trauma majorly caused by motorcycle accidents [23]. The current study showed a higher prevalence rate probably due to lower attrition rate as compared to previous study which reported a high attrition rate.
Studies have shown that there is the proof of PTSD signs and symptoms in adult acquired maxillofacial trauma patients [1, 28]. Similarly, it is likely that a significant lot of patients might experience sub-clinical forms of PTSD (i.e., not meeting the full diagnostic benchmarks) that can greatly affect quality of life [64]. Patients with maxillofacial injuries who recounted PTSD symptoms were more likely to also report pre-injury psychological troubles, amplified levels of stress and deprived social support [65].
Furthermore, such patients are also likely to be elder female that experience more injury-related pain [66]. Identification of PTSD signs and symptoms can lead to additional exploration and uncovering of earlier unrecognized psychological symptoms like depression and anxiety disorders [67].
Injured patients are typically unemployed, socially disadvantaged, mostly males from their mid-twenties to their mid-thirties [48]. They had likely been exposed to prior traumatic events, though they typically did not currently have PTSD from these events at the time of the orofacial injury [48].
With the astronomical rates of unidentified and untreated psychosocial problems in patients suffering from maxillofacial trauma, using the emergency care as a chance to screen for psychosocial troubles will likely increase the discovery of more patients with behavioral disorders that might have precipitated the injury and interfere with a complete recovery. Evidence has shown that psychological assessment of trauma patients followed by referral to mental health services for those identified may result in better aftermath.
Since the acute trauma is frequently the only contact the patients who are healthy young adults have with the hospital, this hospital visit, may offer chances to ascertain psychosocial hitches such as alcohol, drug and substance abuse that may lead to subsequent re-injury and poor treatment outcome. While a substantial subgroup of maxillofacial injuries are associated with alcohol and substance abuse [68], there is potential for integrating brief screening and behavioral interventions into the care of these folks.
Physical scarring and psychological wounds may develop over time, and even become chronic [63]. It is likely that these negative sequelae are going to be even more prevalent in persons who already are experiencing difficulties with substance use, anxiety, depression, hostility, small social networks, limited social support and financial resources, and unmet social service need when they are injured. While surgical treatment may repair the broken bones, many of these patients remain to be at danger for re-injury or deprived psychological outcomes because they may lack the social and personal resources required to make the sustained positive behavior changes. A standard of widespread participation created on the ethics of collective care, wherein medical practitioners from multiple disciplines work together to develop and implement an integrated treatment plan to address the concurrent social and psychologic needs of maxillofacial injury patients is very essential and long overdue [69].
Road traffic accident remained the main cause of injury of subject and majorities were males. Most of the patients were young adults. There were significant differences in depression and anxiety level in the maxillofacial injured subjects at baseline (Time 1), Time 2 (4–8 weeks) and Time 3 (10–12 weeks) with the recording of higher levels of depression and anxiety. Similarly, lower self-esteem was observed subjects at Time 1 (within 1 week), Time 2 (4–8 weeks) and Time 3 (10–12) weeks post injury. The psychological domains of the WHO QoL-Bref was constantly lower than other domains. This shows that maxillofacial injured are psychologically affected apart from the physical injuries they sustained.
In addition to providing surgical care, the team must be able to address social needs (homelessness, joblessness) and psychological needs (PTSD, depression, anxiety, and substance use).
Innovative cost-effective programs which can integrate medical and psychological care are especially necessary in hospitals taking care of trauma patients.
Interventions like motivational interviewing which is a brief form of counseling created to assist patients gather personal resources to promote positive behavior change. This can be presented to patients within days of maxillofacial injury and principally important in refining long-term outcomes.
Educating surgeons on behavioral issues and offering easily assessable guides for swift screening of psychosocial problems is essential.
Developing collaborative bonds with mental health professionals and social health workers are critical first steps regarding incorporating mental health assistances into the full care of maxillofacial injured patients.
Studies on psychological aspect of maxillofacial trauma in other continents like Middle East, Asia and African nations should be encouraged for data comparison.
My supervisors late professor V.I. Ugboko, Dr. D.I. Ukpong, professor K.C Ndukwe for supervising the project, making several corrections, modifications and suggestions. Many thanks to professor (Mrs) A.O. Fatusi and Dr. S.B. Aregbesola for reading and making corrections. Many thanks also to late professor Olusile and professor F.J. Owotade for their contributions and advice.
Finally, the logistic support provided by the management of Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria, is gratefully acknowledged.
The authors declare no conflict of interest.
I want to dedicate this work to the following:
To Almighty God, the Beneficent and most Merciful.
To my wife, Engr. (Dr) Mrs. Maryam Niyilola Braimah for her unflinching support and encouragement at all times and my children, Aishah, Aliyah, and Amilah.
And finally to my parents, in-laws, and siblings.
Puerperium is the time following delivery during which pregnancy-induced maternal anatomical and physiological changes return to the nonpregnant state. Its duration is understandably inexact, but is considered to range between 4 and 6 weeks. By popular use, however, the meaning usually includes the six subsequent weeks of delivery.
The word puerperium is derived from Latin—puer- child andparus bringing forth.
The postpartum period is associated with much tradition and superstition because the health of a new infant is very important to the survival of any family. Puerperium begins as soon as the placenta is expelled and lasts for approximately 6 weeks when the uterus regress almost to the non pregnant size.
Puerperium can be divided into:
immediate – within 24 hours.
early – up to 7 days.
remote – up to 6 weeks.
The uterus weighs approximately 1000 gm and has a volume of 5 L immediately after delivery, compared with its non pregnant weight of approximately 70 g m and 5–10 ml.
Just after delivery, the height of the uterine fundus is halfway between the pubic symphysis and the umbilicus. It happens because of the delivery of the fetus, placenta and amniotic fluid. Also there is loss of hormonal stimulation.
The height of the fundus just after delivery is 13.5 cm above the symphysis pubis. The level remains constantfor first 24 hours. After that, there is a steady decrease in height by 1.25 cm in 24 hours, resulting in uterus so that by the end of 2nd week the uterus becomes a pelvic organ. The rate of involution thereafter slows down getting back the uterus to normal size in 6 weeks. Just after delivery, due to the rapidly decreasing endometrial surface that is attached to the placenta, placenta gets sheared from the decidual layer. The average diameter of the placenta attached to the deciduas is 18 cm; which goes down to 9 cm in the immediate postpartum period.
For the first 3 days after delivery, the placental site is infiltrated with granulocytes and mononuclear cells. It is a reactionary change that extends into the endometrium and superficial myometrium as well.
By the 7th day, the regeneration of endometrial glands is evident, and they often appear atypical with irregular chromatin patterns, enlarged nuclei, pleomorphism and increased cytoplasm.
By the end ofthe first week, regeneration of the endometrial stroma is also evident, and mitotic figures are noted in gland epithelium. By postpartum day 16, the endometrium gets fully restored.
Just after birth, hemostasis is achieved by arterial smooth muscle contraction and compression of vessels by the involuting uterine muscle. In the first 8 days, vessels in the placental site are characterized by thrombosis, hyalinization. Endophlebitis in the veins and hyalinization and obliterativefibrinoid endarteritis in the arteries are notable findings.
The postpartum uterine discharge, or lochia, begins as a flow of blood that lasts several hours, then rapidly diminishes to a reddish brown discharge through the third or fourth day postpartum.
The post partum discharge is termed lochia and it contains erythrocytes, shredded decidua, epithelial cells and bacteria. For the first few days after delivery, it is known as lochia rubra. After 3 or 4 days, lochia becomes progressively pale in color and is known as lochia serosa. Then at around 10th day, because of an admixture of leukocytes and reduced fluid content, lochia assumes a white or yellow-white color known as lochia alba. The average duration of puerperial lochial discharge is from 24 to 36 days [1].
Breastfeeding or the use of oral contraceptive agents does not affect the duration of lochia. The cervical os contracts slowly, and for a few days just after labor, it readily admits two fingers. Gradually, this opening narrows and the cervix thickens with reformation of endocervical canal in a week. The external os never resumes its pre gravid appearance. It remains somewhat wider with the ectocervical depressions getting permanent at the site of lacerations.
The vagina and the introitus gradually reduce in size but hardly regain the nulliparous size and shape. Rugae start appearing by the third week but are less prominent. The hymen is represented by several small tissue tags of tissue that form the myrtiform caruncles.
After delivery, the vaginal epithelium reflects the hypoestrogenic state, and it stops proliferating until 4 to 6 weeks. Some damage to the pelvic floor may be inevitable, and parturition predisposes to urinary incontinence and pelvic organ prolapse.
Ovulation starts as early as 27 days after childbirth. It can start after about 70 to 75 days in non lactating women. But for breastfeeding women, the mean time to ovulation can be about 6 months.
Menstruation usually resumes by 12 weeks postpartum in 70% of non lactating women. The mean time to the first menses after childbirth is 7 to 9 weeks.
In a woman exclusively breastfeeding, the likelihood of ovulation within the first 6 months postpartum is 1% to 5%.
The persistent elevation of serum prolactin in lactating women is the basis for ovulation suppression in lactating women. Prolactin levels get back to the normal range by 3 weeks after delivery in nonlactating women but remains elevated till the 6th week in lactating women.
The broad and round ligaments require considerable time to recover from stretching and loosening during pregnancy.
After cesarean delivery, a 6-week interval to allow fascia to heal and abdominal soreness to diminish is reasonable.
Silvery abdominal striae commonly develop as striaegravidarum.
Marked separation of the rectus abdominis muscles—diastasis recti—may result.
Marked leukocytosis and thrombocytosis may occur during and after labor. The greatest level of coagulability is observed immediately after delivery and remains for the following 48 hours. Fibrinogen concentrations gradually diminish over the first 2 weeks postpartum. Increased fibrinolytic activity is seen in the initial 4 days following delivery. The fibrinolytic activity is back to normal in a week and is shown by plasminogen activation inhibitor 1levels. D-dimer levels are more than pregnancy levels, but are a poor marker of thrombus formation. Protein-S levels and activated protein-C resistance are less for around 6 weeks in puerperium. The changes in the coagulation system, together with vessel trauma and immobility, account for the increased risk for thromboembolism noted in the puerperium, especially when an operative delivery has occurred.
Plasma volume is diminished by about 1000 mL just after delivery and that is due to blood loss during delivery.
Due to the shift of extracellular fluid into the vascular space. The plasma volume is replenished by the 3rd day of puerperium. Also, the total blood volume declines by 16% of the pre delivery value, and that manifests as transient anemia.
By 8 weeks of puerperium, the red cell mass rebounds and the hematocrit becomes normal in most women. Since, the blood volume becomes normal, venous tone also gets to baseline. Pulse rate increases throughout gestation, like stroke volume and cardiac output. Just after delivery, these remain elevated or may rise even higher for initial 30 to 60 minutes. Following delivery, a transient rise of about 5% occurs in both diastolic and systolic blood pressures and that continues for the first 4 days postpartum.
Thyroid volume increases to about 30% during pregnancy and then gets back to normal in a 12-week period in puerperium. Both thyroxine and triiodothyronine increase throughout pregnancy and becomes normal within 4 weeks post delivery. For women on thyroid medications, it is advisable to check thyroid profile at 6 weeks postpartum to titrate the dosage. Sometimes, during the postpartum period, there is an increased risk for the development of a transient autoimmune thyroiditis that may later evolve into permanent hypothyroidism.
The immune system gets compromised during pregnancy—particularly cellular-mediated immunity. The rebound of cellular mediated immunity after delivery leads to “flare-ups” of autoimmune diseases and subclinical infections with inflammatory reactions. Autoimmune thyroiditis, multiple sclerosis, and lupus erythematosus are examples of auto immune diseases that show flare ups in the first few months of puerperium.
Normal pregnancy-induced glomerular hyperfiltration persists during the puerperium but returns to prepregnancy baseline by 2 weeks [2].
Dilated ureters and renal pelves return to their prepregnant state by 2 to 8 weeks postpartum.
Postpartum, the bladder has an increased capacity and a relative insensitivity to intravesical pressure. Thus, over distention, incomplete emptying, and excessive residual urine are frequent in puerperium [3, 4].
Breasts begin to secrete colostrum after delivery. It is a dark yellow liquid and usually can be expressed from the nipples by the second postpartum day. In comparison to mature milk, colostrum is rich in both immunological components and minerals and amino acids [5]. It also has more protein, mostly globulin, but contains less sugar and fat.
Colostrum secretion continues for 5 days to 2 weeks post partum, with later conversion from “transitional” to mature milk in next 4 to 6 weeks.
For most parturients, the immediate puerperium is spent in the hospital or birthing center.
In the 1950s, the lying-in period after delivery used to be around 8 to 14 days. Now, most women stay in the hospital only for 24 to 48 hours after a vaginal birth. For patients with an uncomplicated postoperative course after caesarean delivery, the post partum stay is only 2 to 4 days. During the hospital stay, the focus should be on preparation of the mother for newborn care, infant feeding including the special issues involved with breastfeeding, and also the required newborn laboratory testing.
There are no dietary restrictions for women who have been delivered vaginally. Two hours after uncomplicated vaginal delivery, a woman is allowed to eat.
Infection commonly occurs in approximately 5% of post partum patients and significant immediate postpartum hemorrhage in approximately 1% of patients. Just after the delivery of the placenta, the uterus is palpated bimanually to ascertain its tonicity. Uterine palpation is very important and is repeated frequently during the immediate postpartum period to prevent and identify uterine atony promptly. In only 1% of cases, bleeding persists or is excessive and is called delayed postpartum hemorrhage. If the bleeding is heavy or the uterus is believed to contain blood clots, uterus should be massaged until it contracts and the clots expressed. The physician may be notified, and on order an oxytocin preparation such as syntocinon 1 ml given intramuscularly orIV infusion with 5% glucose is administered. When the general condition of the mother is satisfactory, the mother and baby should be transferred to the ward. As soon as the post natal ward is notified that the newly delivered mother and her baby is to be transferred to the ward, the mid wife should arrange for a bed to be prepared in a single room or in a quite area of a ward so that the mother will be able to sleep following her efforts during delivery.
On arrival, we should note the following:
Consistency of the uterus
Blood loss
Pulse
BP
Temperature
General condition of the mother-tired –feeling weak
Parity and age
Blood group and Rh factor
Events of labour and delivery including the amount of blood loss
The baby’s condition at birth and his birth weight
Mother’s chosen method of infant feeding
What examinations and tests have already been carried out and plan for those which must be done during the next few days.
Every morning the mother should be seen and asked as to how she is feeling. The midwife should particularly note if the mother complains of feeling unduly tired. Any woman who is anaemic or who is developing an infection will not feel well. Temperature, pulse and Blood pressure should be measured. The temperature and pulse rate may be recorded at least twice a day for the few days and then once daily until the 10th days of the puerperium. If the temperature exceeds 37.3 degree Celsius or 99 degree Fahrenheit, the physician is to be notified. The pulse rate is normally 80 or below per minute. Any rise in the pulse rate above 90 beats per minute should be reported to the physician irrespective of whether it is accompanied by rise in temperature or not. Any rise in temperature may be indicative of excessive bleeding or of a developing puerperal infection. Tachycardia which is due to excessive bleeding will be accompanied by hypotension. When a nurse notices a rising pulse rate and fall in blood pressure she must check the state of the uterus and lochia in order to identify post partumhaemorrhage. The blood pressure is checked during the first 24 hours following a normal delivery and for a longer period of time, if there has been any history of bleeding, hypertension during pregnancy, or if the mother has had a Caesarean section or has required any other surgical intervention.
The breasts should be examined daily and noted whether the breasts are soft and are free from lumps, redness and soreness.
Abnormal nipples: Inverted and flat nipples.
The complications of breast feeding are engorgement of breasts. In breasts feeding mothers breast engorgement occurs around the third and fourth post partum day. The breasts arehard, painful and sometimes flushed. The mother may develop pyrexia along with that. Engorgement results from an increased amount of blood and edema in the breasts and indicates that the baby is not ready to take the full quantity. Warm compresses to the breasts and removal of excess milk at the end of each feeding will relieve the condition. Even tight brassieres help.
The bowels tends to be sluggish during the puerperium for the following reasons.
The woman is losing fluid from her body in quantities of urine, in perspiration and breastmilk.
The anus maybe insensitive to stimulation having been forcibly dilated by the pressure of baby’s head.
It is good to give some mild laxative for the first 36 hrs after delivery such as liquid paraffin or milk of magnesia. When diet contains sufficient roughage and fluid, the bowel needs less artificial stimulation. If the bowels do not move 48 hrs after delivery, glycerine or dulcolex suppository is usually given.
The nursing mother needs a liberal nourishing diet to build up her strength and enable her to produce sufficient breast milk. Good whole food is essential containing sufficient proteins, minerals and vitamins. As so many women are anaemic at this time the nurse must ensure that food rich in iron are included in the diet. The haemoglobin is estimated on 8th or 9th day. Iron supplements are usually prescribed for one month. As the woman is losing calcium when she breastfeeds, she should take adequate dietary calcium. Fruit and vegetables should be served at every meal.
The woman needs adequate rest, quietness and sleep because of the hypersensitive state of her nervous system. If kept awake by some discomfort such as after pains, haemorrhoids, or engorged breasts, the nurse should treat the cause before giving analgesics. The ward should be closed morning and afternoon for 1 hour. The patient is requested to relax and keep silent if they cannot sleep. The persistent insomnia in absence of pain should be viewed as a warning sign of ensuing puerperal psychosis at times.
Asepsis must be maintained, especially during the first week of puerperium. The woman is particularly vulnerable to infection at this time for the following reasons:
The uterus provides an ideal environment for the growth and multiplication of the micro organisms.
The lacerated and bruised tissues of the vulva and vagina being devitalised are unable to resist the invasion of organism.
The vaginal orifice is gaping and micro organisms can readily enter.
The woman’s immunity is lowered because of depletion of energy, lack of sleep and food.
Blood loss may have been excessive.
The nurse must wear a mask when the vulva is exposed during the first week of puerperium.
The room and bed linen, the women skin and clothing should be clean. Adequate use of soap and water is the first requirement.
What to report to the physician.
Temperature and pulse.
Appetite and sleep
Bowel and bladder movements
Character of lochia
Condition of sutured perineum
Pain eg. In the breasts, abdomen, leg, head
Any peculiarity in behaviour.
In puerperium, the woman is advised to maintain hygiene and clean the vulva from anterior to posterior toward the anus. A cool pack may be applied to the perineum to bring down edema and pain during the first 24 hours, especially in perineal laceration or an episiotomy.
Uterine involution manifests as several clinical findings. In primiparas, the uterus usually remains tonically contracted after delivery. Whereas in multiparas, the uterus contracts vigorously at intervals and manifests as afterpains, which are almost like labor pains. These pains are more pronounced as parity increases and worsen when the newborn lactates, because of oxytocin release. By the 3rd day post partum, afterpains decrease in intensity and become mild. In women with postpartum uterine infections, there may be severe and persistent after pains. Aspirin can be given with food in those cases.
Severe perineal, vaginal or rectal pain always warrants careful inspection and palpation. Hemorrhoidal veins are often congested at term. Thrombosis is common and may be promoted by second-stage pushing. Treatment for the condition includes topically applied anesthetics, warm soaks, and stool-softening agents.
Stool softeners may be prescribed, especially if the patient has had a fourth degree perineal tear or a laceration involving the rectal mucosaduring delivery.
Hemorrhoids are varicosities of the hemorrhoidal veins and are commonly found in puerperium. Surgical treatment may be considered only after 6 months postpartum to allow for natural involution. Sitz baths, stool softeners, and local medicinal preparations are useful alongwith reassurance.
She goes to the toilet after 6 hours to pass urine Periurethral edema after vaginal delivery may cause transitory urinary retention.
Recumbent- posture and lack of privacy.
Stitches in perineum.
Bruises of bladder neck- bladder neck spasms.
Bladder atony.
Women go to toilet or sit on bedpan withscreen. Hot and cold water bottles are applied on hypogastrium. Plenty of oral fluid to be given. Catherization if she cannot pass urine. Patients’ urinary output should be monitored for the first 24 hours after delivery. If catheterization is required more than twice in the first 24 hours, placement of an indwelling catheter for 1 to 2 days is advisable. Prolonged catheterization needs to be avoided.
Mild analgesics containing codeine, aspirin, or acetaminophen, preferably in various combinations are given as frequently as every 4 hours during the first few days. It is fairly common for mother to exhibit some degree of depressed mood a few days after delivery termed postpartum blues. Post partum blues can be multi factorial. Mostly, anticipation, recognition, and reassurance works. This disorder is usually mild and self-limited to 2 to 3 days, but sometimes may last up to 10 days. Persistence or worsening of moods calls for evaluation for symptoms of major depression.
Postpartum patients should be encouraged to begin ambulation as soon as possible after delivery. Early ambulation helps avoid urinary retention and prevents puerperal venous thromboses and pulmonary embolism. Early ambulation is the key to faster recovery post delivery.
Nipples are cleansed with sterile water and cotton swab before and after feeding. They are covered with sterile bra. In non lactating women, breast engorgement occurs in the initial days of puerperium and gradually reduces over this period. Painful breasts should be supported with a well-fitting brassiere. Ice packs and analgesics may also help relieve breast discomfort and pain. Women who do not wish to breastfeed should be encouraged to avoid nipple stimulation and advised to avoid continued manual expression of milk. Mastitis, or infection of the breast tissue, most often occurs in lactating women and manifests as sudden-onset fever, localized pain and swelling in the breast. Mastitis is associated with infection by micro organisms like
Treatment includes continuation of breastfeeding or emptying the breast with a breast pump to avoid engorgement and also use of appropriate antibiotics.
Women who do not have antirubella antibody should be immunized during the immediate postpartum period [6]. Breastfeeding is not a contraindication for that.
If a patient has not received the tetanus-diphtheria acellular pertussis vaccine, or it has been at least 2 years since her last tetanus-diphtheria booster, she should be administered a dose before discharge from hospital.
If the woman is Rh-negative blood group, not isoimmunized and has given birth to a Rh-positive or weak-Rh-positive baby, 300 micrograms of anti-D immune globulin should be administered postpartum, ideally within 72 hours of delivery.
In sitting posture she feeds her baby for sometime daily, she lies in her face for three weeks.
Deep breathing and simple movement of limbs are encouraged. Some simple exercises are practised when she feels it for after a few days to tone up abdominal and pelvic floor muscles as:-.
Deep breathing.
Abdominal wall is tightened on deep inspiration and breatheholding followed by its relaxation. This is done 10 times on floor with knees pulled up.
Pelvic floor muscles- Bent knees press on a pillow followed by relaxation for a number of times. Encourage erect walks.
Sexual intercourse is permitted with use of contraceptive following first post natalcheck up at sixth week.
Postpartum care in the hospital should include discussion of contraception. Approximately 15% of non-nursing women are fertile at 6 weeks postpartum. Progestin preparations (oral norethindrone or depo-medroxyprogesterone acetate) have no effect or may slightly facilitate lactation. Women may consider initiating progesterone-only contraceptives at 6 weeks if breastfeeding exclusively or at 3 weeks if not exclusively.
Postpartum sterilization is performed at the time of cesarean delivery or after a vaginal delivery and should not extend the patient’s hospital stay.
Coitus may be resumed when the woman is pain free and comfortable. However, the risks of hemorrhage and infection are minimal at approximately 2 weeks postpartum. Women should be counseled, especially if breastfeeding, that coitus may initially be uncomfortable because of a dry vagina as a result of low estrogen levels. In such conditions, use of exogenous, water soluble lubrication is helpful.
By discharge, women who had an uncomplicated vaginal delivery can resume most activities, including bathing, driving, and household functions. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) recommend a postpartum visit between 4 and 6 weeks. This has proven quite satisfactory to identify abnormalities beyond the immediate puerperium and to initiate contraceptive practices.
Advice on discharge for home:
Exclusive breast feeding for 6 months
Care of the newborn
Total infant immunization for protection of infant from six killer diseases.
Oral rehydration for mild diarrhoea
The discharge carries the following:
Discharge slip- carrying details of the delivery and childbirth date.
Instruction to mother on food, iron folic acid laxative.
betadime cream is applied once daily on perineal wound at home for 7 days.
She is instructed to put on sterile pad forlochial discharge and to return on sixth week for post natalcheck up.
She is also referred to infant immunization center for full immunization of infantsupto 10 months.
Post natal care:
First check up on discharge and second on sixth post partum week.
Mother: general health, pulse, BP, temperature breasts, uterine fundus is palpated per lower abdomen for normal involution.
Perineum is inspected and that of lochia.
Bladder and bowel functions are enquired.
Infant: weight, skin condition (jaundiced), eyes, condition of umbilical cord, feeding, stool, urination, any other problem are checked by referring to pediatric opd or paediatrician.
Second post natal check up on sixth week.
Mother and infant: duration of lochia, duration of first menses, sleep, bladder, bowel, perineal wound, breasts or bottle feeding.
Any problem of mother or baby is enquired.
Examination on mother: weight, BP, Pulse, anemia, breast, abdomen, perineum, pelvic organs.
Infants: weight, heart, lungs, umbilicus, Inj BCG are checked.
Advice on discharge: Food advices to mother, giving her a food chart and use of boiled water.
Rest, sleep, exercise and posture by mother.
Advice on contraceptives.
Breast feeding.
After delivery, the breasts start to secrete colostrum, which is a deep lemon yellow liquid usually by the second postpartum day. Compared with mature milk, colostrum is rich in immunological components and contains more minerals and amino acids, protein, much of which is globulin, but less sugar and fat. The colostrum content of immunoglobulin A (IgA) offers the newborn protection against enteric pathogens. Mature milk is a complex and dynamic biological fluid that consists of fat, proteins, carbohydrates, bioactive factors, minerals, vitamins, hormones and many other cellular products. The concentrations and contents of human milk change even during a single feed, but are affected by maternal diet and newborn age, health and needs.
A nursing mother usually produces 600 mL of milk daily. However, maternal gestational weight gain has little impact on the quantity or quality of milk. Milk is isotonic with plasma, and lactose alone accounts for half of the osmotic pressure. Essential amino acids in milk are derived from blood, and nonessential amino acids come from blood or synthesized in the mammary gland. Alpha-lactalbumin, beta-lactoglobulin and casein are some of the milk proteins. Fatty acids are synthesized in the breast alveoli from glucose and are secreted by an apocrine-like process. Though vitamins are found in human milk, but these are present in variable amounts. Vitamin K is virtually absent, and thus, an intramuscular dose is required to be given to the newborn [7].
Even the milk serum whey contains large amounts of interleukin-6. Human milk has a whey-to-casein ratio of 60:40 and that is considered ideal for absorption. Prolactin is also actively secreted into breast milk. Epidermal growth factor (EGF) found in milk is not destroyed by gastric proteolytic enzymes and hence may be absorbed to promote growth and maturation of newborn intestinal mucosa [8]. Lactoferrin, melatonin, oligosaccharides, and essential fatty acids are the other constituents of milk. The precise humoral and neural mechanisms involved in lactation are complex.
Progesterone, estrogen, and placental lactogen, as well as prolactin, cortisol, and insulin act in concert to stimulate the growth and development of the milk-secreting apparatus in lactating breasts [9]. With delivery, the maternal serum levels of progesterone and estrogen decline abruptly and significantly. The falling progesterone and estrogen levels remove the inhibitory influence on alpha-lactalbumin production and thus stimulates lactose synthase in milk. Progesterone withdrawal also allows prolactin to act unopposed and stimulates production of alpha-lactalbumin in milk. The intensity and duration of subsequent lactation are controlled, in large part, by the repetitive stimulus of nursing and emptying of milk from the breast. Prolactin is essential for lactation and women with extensive pituitary necrosis— Sheehan syndrome—does not lactate. Although after delivery, plasma prolactin levels drop to levels lower than during pregnancy, each act of suckling causes a rise in levels [10]. Suckling curtails the release of dopamine, also known as prolactin-inhibiting factor, from the hypothalamus. That in turn, also transiently induces prolactin secretion. Oxytocin is known to be secreted by the pituitary in pulsatile fashion. This oxytocin stimulates contraction of myoepithelial cells in the alveoli and small milk ducts and hence helps in milk expression. Milk ejection or letting down, is a reflex initiated especially by suckling, which stimulates the posterior pituitary to liberate oxytocin. The reflex may even be provoked by an infant cry and can be inhibited by maternal fright or stress.
Human milk is known ideal food for newborns for it provides age-specific nutrients, immunological factors, and antibacterial substances to the newborn. Milk also helps in promoting cellular growth and differentiation. For both mother and infant, the benefits of breastfeeding are long-term and unique. World Health Organization (2011) recommends exclusive breastfeeding for up to 6 months.
Nutritional
Immunological
Developmental
Psychological
Social
Economical
Environmental
Optimal growth and development
Decrease risks for acute and chronic diseases
The Baby Friendly Hospital Initiative is an international program to promote exclusive breastfeeding. It is based on the World Health Organization (1989) Ten Steps to Successful Breastfeeding. World wide, almost 20,000 hospitals are designated as “baby-friendly hospitals.
Ten Steps to Successful Breastfeeding (Baby Friendly Hospital Initiative):
Have a written breastfeeding policy that is regularly communicated to all Health-care staff.
Train all staff in skills necessary to implement this policy.
Inform all pregnant women about the benefits and management of breastfeeding.
Help mothers initiate breastfeeding within an hour of birth.
Show mothers how to breastfeed and how to sustain lactation, even if they should be separated from their infants.
Feed newborns nothing but breast milk, unless medically indicated, and under no circumstances provide breast milk substitutes, feeding bottles, or pacifiers free of charge or at low cost.
Practice rooming-in, which allows mothers and newborns to remain together 24 hours a day.
Encourage breastfeeding on demand.
Give no artificial pacifiers to breastfeeding newborns.
Help start breastfeeding support groups and refer mothers to them.
Nursing is contraindicated in some women who have intake of street drugs or alcohol abuse; have an infant with galactosemia; human immunodeficiency virus (HIV) infection; active, untreated tuberculosis; undergoing breast cancer treatment [11]. Breastfeeding has been recognized for some time as a mode of HIV transmission and is proscribed in developed countries in which adequate nutrition is otherwise available. Other viral infections do not contraindicate breastfeeding. Women with active herpes simplex virus may suckle their infants if there are no breast lesions and ifparticular care is directed to hand washing before nursing.
With inverted and depressed nipples, nursing is very difficult. Here, lactiferous ducts open directly into a depression at the center of the areola. If the depression is not deep, milk can sometimes be expressed with the help of a breast pump. During the last few months of pregnancy, daily attempts can be madeto draw or “tease” the nipple out with the fingers.
Extra breasts—polymastia, or extra nipples—polythelia, may develop along the milk line or the former embryonic mammary ridge In some women, rests of accessory breast tissue may also be found in the mons pubis or vulva. In the general population, the incidence of accessory breast tissue ranges from 0.22 to 6 percent [12]. These accessory breasts are very small and are mistaken to be pigmented moles, lymphadenopathy or lipoma. However, polymastia has no obstetrical significance. But, occasional enlargement of these accessory breasts during pregnancy or postpartum cause patient discomfort and anxiety.
Galactocele is another complication wherein a milk duct gets obstructed by inspissated milk secretions. The amount is ordinarily limited, but an excess may form a fluctuant mass—a galactocele. Galactocoele may cause pressure symptoms and also form an abscess. It might get resolved spontaneously or might require aspiration.
Among individuals, the volume of milk secreted varies markedly. This depends on breast glandular development rather than maternal health. Rarely, there is a condition with complete lack of mammary secretion—agalactia. Again, mammary secretion might be excessive—polygalactia.
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