Puerperal Sepsis: History, Causes and Interventions

Puerperal Sepsis: History, Causes and Interventions What is Puerperal Sepsis? Why is Puerperal Sepsis less prevalent now than 1900’s? Lynda Williams Abstract The purpose of the report is to understand what puerperal sepsis is and to raise awareness of the condition to expectant mothers, women that have miscarried, families and physicians. To understand the risks that is linked with the condition and to be able to spot signs and symptoms, as well as how to prevent further cases through aseptic techniques and principles and hand hygiene. The information that will be included is background information on the condition: what is it, how it came about, what treatment was used and what caused it. The report will include information on what are the symptoms, what causes it, who is at risk, how it can be diagnosed, how to treat it, what are the complications and how to prevent further cases from occurring. The report will focus on national statistics for the UK. This will include statistics to show how the prevalence of puerperal sepsis within the UK has decreased from 1900’s to today through medical advances and research. The research used will be secondary: books, journals, and internet. Primary research will not be used as the report is based on facts and information that is already available through reports and medical advice. Contents Background/Historypage 4 Causespage 5 Symptomspage 5 Who is at Risk?Page 6 Diagnosispage 6 Treatmentpage 6 Complications page 7 Preventionpage 7 Analysis of Statisticspage 8 Conclusionpage 8 Recommendationpage 8 Referencespage 9 Bibliographypage 10-11 Glossarypage 12 Appendixespage 13 Background/History Puerperal sepsis is a term giving to an infection that affect expectant mothers and those who have recently delivered. Infections within pregnancy can be severe as the genital tract has an increased surface area. (Knight, M. 2015). (Awori, N. et al. 1999). The infection can affect the cavity and walls of the uterus, which can lead to pelvic abscesses. The pus can spread high into the pelvis or into the lower abdomen. Infection tends to spreads after long labour or severe bleeding due to haemorrhaging which can cause peritonitis, septicaemia or death. (Awori, N. et al. 1999). Puerperal Sepsis formerly known as childbed fever or puerperal fever was a mystery; it killed those at the cruellest of moments. It was understood that wherever physicians went the disease became more prevalent, especially within hospitals. During the 1700’s it was believed women were delivered from the peril of childbirth, not deliver a child into the world. Physicians believed sepsis occurred when there was a failure to urinate, it then became known as ‘milk metastasis’ as the internal organs of those that had died looked like they were covered in milk, it was later identified as pus. (Burch, D. 2009). It was believed that puerperal fever was caused by various environmental factors: sewage, poor ventilation, cold, mists, vague ‘putrid tendencies,’ not bacterium and infection control. During the late 1700’s, Alexander Gordon leading obstetrician studied childbed fever and came to the conclusion that the disease was spread by physicians, it was related to skin infections and the only treatment was bloodletting. Bloodletting was widely accepted as a cure, however physicians understood more needed to be done to stop the spread of sepsis. (Burch, D. 2009). Causes Puerperal sepsis is caused by bacterium being introduced into the genital tract and women that are in labour or giving birth are more susceptible due to large genital tract surface area. The genital and urinary tracts have warm, moist environments that bacteria need to multiple. The bacterium can enter the body through pelvic exams, trauma during labour or prolonged labour. During pelvic exams the bacterium is introduced into the genital tract by unclean hands during examinations or through the use of non-sterile instruments. (Nall, R. 2014). Bacteria that are known to cause a puerperal sepsis include: Chlamydia Clostridium tetani Clostridium welchii Escherichia coli (E.coli) Gonococci Staphylococci Streptococci (Nall, R. 2014). Other causes of puerperal sepsis are mastitis, pyelonephritis, ruptured membranes, respiratory complication, first birth, poor socioeconomic status, caesarean delivery and superficial or deep-vein thrombosis. (Baring, N. 2013). Symptoms Symptoms for puerperal sepsis normally appear between 24 hours to 10 days after infection begins. If one or more symptoms are present, action should be taken and treat as appropriate. Women should be monitored closely for any of the following symptoms: Fever – higher that 38à ¢Ã‚ Ã‚ °C or 100.4à ¢Ã‚ Ã‚ °F Shivering and chills Uterus does not return to normal size Pain and discomfort in lower abdomen Tenderness and pain in the uterus Malaise Discharge from the vagina – foul-smelling and containing pus Pale and discoloured skin Short of breath Fatigued, difficult to rouse Altered mental state Edema Flu like symptoms (Nall, R. 2014) (Sepsis Alliance 2015). Who is at Risk? Any woman that is pregnant, has miscarried, aborted or delivered are at risk of sepsis but certain factors increase that risk. Women that are more susceptible are those that have liver disease, lupus a condition of the immune system, diabetes, congestive heart failure, are obese, first pregnancy, women that are under 25 or women that are over 40. Women over 40 are at risk of sepsis from infections due to placenta praevia and placenta abruption. Women that are underwent invasive procedures to become pregnant or invasive tests during pregnancy are more prone to infections that can lead to sepsis. (Sepsis Alliance 2015) Diagnosis Abnormal changes in the patient temperature, heart and breathing rate can indicate infection. The vagina and uterus will be checked for swelling and tenderness by abdominal and internal exams. Broad-spectrum antibiotics will be prescribed if sepsis is suspected to prevent the infection from spreading, long term damage to the body and death. Further tests will be carried out to determine the type of infection, where it is located and if bodily functions have been affected. These tests can include: Blood and urine test Wound swabs Blood pressure checks Ultrasound scan, X-rays or computerised tomography (CT) scan Organ function tests – liver, kidney, heart Lumbar puncture Stool samples (NHS Choices. 2014) (Nall, R. 2014) Treatment If sepsis is suspected broad-spectrum antibiotics will be given orally or intravenously to prevent infection spreading. When results from further testing have been received then a focused antibiotic is used to kill the bacterium. Anti-fever medication and cold compresses may be used to keep the fever under control. Oxygen may be given as levels in the blood can become low due to the body demand for oxygen. Intravenous fluids may be given to prevent dehydration and kidney failure, normally given within the first 48 hours after hospital admission. Sepsis can cause the blood pressure to drop; medication called vasopressors will be given to increase blood pressure allowing the patient condition to improve. Infection sites need to be keep clean and dry; pus to be drained away allowing infected tissue to repair and to prevent bacteria from entering. (Nall, R. 2014) (NHS Choices. 2014) Complications Sepsis can lead to serious complications and the damage can be irreversible. Complications for the women include: Septicaemia Septic shock Peritonitis Haemorrhaging Pyelonephritis Mastitis Pulmonary embolism Disseminated intravascular coagulation Abscesses Death Compromise fertility The foetus can be affected causing depressed Apgar scores, neonatal septicaemia, pneumonia and death. (Dharmaraj, D. Patriquin, G. 2012) Willacy (2012) wrote that severe sepsis can cause acute organ dysfunction and has a mortality rate of 20-40%. If septic shock develops the mortality rate rises to around 60%. Prevention Following aseptic techniques and principles is very important. Correct cleaning practice of hospital and home environments need to be followed and use of sterile packs and equipment must be used to prevent contamination; these must only be used once then deposed of. (Johnson, R. Taylor, W. 2011. p. 80). Physicians must exercise the correct hand hygiene techniques (appendixes A) and use antiseptic soap, washes, alcohol-based rubs and sterile gloves. By doing this it reduces the risk of introducing bacterium into a sterile environment. (Johnson, R. Taylor, W. 2011. pp. 73-77). Protective clothing: aprons, shoes covers must be worn to prevent spread of infection and contamination from one situation to another, these to be deposed of after one use. Use of non-touch technique is important by ensuring sterile equipment does not touch with anything unsterile to prevent contamination and potential for infection. The use of an assistant to open packs and equipment can reduced the risk of cros s contamination as it prevents touching anything non-sterile with sterile gloved hands. (Johnson, R. Taylor, W. 2011. pp. 80-82). Analysis of Statistics During the early 1900’s, just under 1.5% in 1000 births within the UK died from sepsis, greatly decreased on early years. Advances in medicine meant physicians were discovering asepsis was paramount in infection control. The introduction of carbolic spray in operating room, hand washing and rubber gloves were used to minimise contamination. Then in 1920, face masks were introduced into obstetrics to prevent contamination through body fluids. (Chamberlain, G. 2006). In the last hundred years there has been a significant drop in puerperal sepsis. In 2003-5 0.85% of maternal deaths per 100,000 births were a direct cause of sepsis, which means asepsis was tackling infection. However in 2006-8 there was a rise to 1.13%, through lack of knowledge, not seeking advice when unwell and through infection control. Sepsis is now the leading cause of maternal death within UK above hypertension, thromboembolic disease and haemorrhage, where there has been a reduction in these. It has been noted that over recent years that it has been hard to achieve a reduction in the number of deaths within the UK due to bacterial infections, more needs to be done in order to prevent maternal deaths and these statistics rising further. (Sriskandan, S. 2011). Conclusion Puerperal sepsis is now the leading cause of maternal death, which means more medical research need to be undertaken in order to reduce the number of cases. Sepsis through pelvic exams, trauma during labour or prolonged labour needs to be evaluated and assessed on how using aseptic techniques and principles can reduce the risk of cross contamination and introducing bacterium into the genital tracts. Over the last hundred years puerperal sepsis has declined significantly, however over recent years it has increased from lack of knowledge and infection control. The UK is a developed country and should have infection control and aseptic techniques and principles at the forefront of medical practice. Recommendations After miscarriages, during last trimester and during delivery broad-spectrum antibiotic should be given orally or intravenously to expectant mothers to provide the body with a barrier towards infections, this could reduce the number of cases sepsis. More training and awareness of sepsis and aseptic principles should be provided to physicians, to ensure understanding and they are being diligent in regards to infection control. Expectant mother and families should receive education through antenatal classes to learn the signs and symptoms of sepsis and what to do if they suspect it. Symptoms can be confused with flu like symptoms and education should be given to seek help and advice off midwives, health visitors and other physicians. References Awori, N. Bayley, A. Beasley, A. Boland, J. Crawford, M. Driessen, F. Foster, A. Graham, W. Hancock, B. Hancock, B. Hankins, G. Harrison, N. Kennedy, I. Kyambi, J. Nundy, S. Sheperd, J. Stewart, J. Warren, G. Wood, M. (1999) ‘Puerperal Sepsis,’ Primary Surgery, 1 [Online]. Available at: http://www.meb.uni-bonn.de/dtc/primsurg/docbook/html/x1831.html (Accessed: 20/04/2015). Baring, N. (2013) OBSTETRICS Puerperal Infection. Available at: http://www.slideshare.net/nianbaring/obstetrics-puerperal-infection (Accessed: 23/04/2015). Burch, D. (2009) When Childbirth Was Natural, and Deadly. Available at: http://www.livescience.com/3210-childbirth-natural-deadly.html (Accessed: 23/04/2015). Chamberlain, G. (2006) ‘British maternal mortality in the 19th and early 20th centuries’ Journal of the Royal Society of Medicine. 99(11). 559-563. [Online]. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1633559/ (Accessed: 20/04/2015). Dharmaraj, D. Patriquin, G. (2012) Puerperal Infection. Available at: http://www.sharinginhealth.ca/conditions_and_diseases/puerperal_infection.html (Accessed: 25/04/2015). Johnson, R. Taylor, W. (2011) Skills for Midwifery Practice. 3rd edn. London: Churchill Livingstone Elsevier. Knight, M. (2015) What is a life threatening complication in pregnancy and childbirth? Available at: http://ww.healthtalk.org/peoples-experiences/pregnancy-children/conditions-threaten-womens-lives-childbirth-pregnancy/what-life-threatening-complication-pregnancy-and-childbirth (Accessed: 12/04/2015). Nall, R. (2014) Puerperal Infection. Available at: http://www.healthline.com/health/puerperal-infection (Accessed: 23/04/2015). NHS Choices (2014) Sepsis – Diagnosis. Available at: http://www.nhs.uk/Conditions/Blood-poisoning/Pages/Diagnosis.aspx (Accessed: 25/04/2015). Sepsis Alliance (2015) Sepsis. Available at: http://www.sepsisalliance.org/sepsis/symptoms/ (Accessed: 24/04/2015). Sriskandan, S. (2011) ‘Severe peripartum sepsis’ Royal College of Physicians of Edinburgh, 41 339–46. [Online]. Available at: www.rcpe.ac.uk/sites/default/files/sriskandan.pdf (Accessed: 26/04/2015) Willacy, H. (2012) Puerperal Pyrexia. Available at: http://www.patient.co.uk/doctor/Puerperal-Pyrexia.htm (Accessed: 25/04/2015). World Health Organizations (2015) Clean Care is Safer Care. Available at: http://www.who.int/gpsc/clean_hands_protection/en/ (Accessed: 26/04/2015). Bibliography Awori, N. Bayley, A. Beasley, A. Boland, J. Crawford, M. Driessen, F. Foster, A. Graham, W. Hancock, B. Hancock, B. Hankins, G. Harrison, N. Kennedy, I. Kyambi, J. Nundy, S. Sheperd, J. Stewart, J. Warren, G. Wood, M. (1999) ‘Puerperal Sepsis,’ Primary Surgery, 1 [Online]. Available at: http://www.meb.uni-bonn.de/dtc/primsurg/docbook/html/x1831.html (Accessed: 20/04/2015). Baring, N. (2013) OBSTETRICS Puerperal Infection. Available at: http://www.slideshare.net/nianbaring/obstetrics-puerperal-infection (Accessed: 23/04/2015). Burch, D. (2009) When Childbirth Was Natural, and Deadly. Available at: http://www.livescience.com/3210-childbirth-natural-deadly.html (Accessed: 23/04/2015). Chamberlain, G. (2006) ‘British maternal mortality in the 19th and early 20th centuries’ Journal of the Royal Society of Medicine. 99(11). 559-563. [Online]. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1633559/ (Accessed: 20/04/2015). Colebrook, L. (1936) ‘The Prevention of Puerperal Sepsis.’ BJOG: An International Journal of Obstetrics Gynaecology, 43 691–714. [Online]. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2210245/?page=1 (Accessed: 26/04/2015). Dharmaraj, D. Patriquin, G. (2012) Puerperal Infection. Available at: http://www.sharinginhealth.ca/conditions_and_diseases/puerperal_infection.html (Accessed: 25/04/2015). Encyclopaedia Britannica (2015) Puerperal fever. Available at: http://www.britannica.com/EBchecked/topic/482821/puerperal-fever (Accessed: 23/04/2015). Jessica Trust (2015) Childbed fever: the facts. Available at: http://www.jessicastrust.org.uk/childbed-fever/information-for-parents/ (Accessed: 24/04/2015) Johnson, R. Taylor, W. (2011) Skills for Midwifery Practice. 3rd edn. London: Churchill Livingstone Elsevier. Johnstone, W. (1938) ‘Prevention and Control of Puerperal Sepsis.’ British Medical Journal, 2(4049) 331-335. [Online]. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2210245/?page=1 (Accessed: 26/04/2015). Khaskheli, M. Baloch, S. Sheeba, A. (2013) ‘Risk factors and complications of puerperal sepsis at a tertiary healthcare centre.’ Pakistan Journal of Medical Science, 29(4) 972-976. [Online]. Available at: http://www.pjms.com.pk/index.php/pjms/article/view/3389 (Accessed: 26/04/2015). Knight, M. (2015) What is a life threatening complication in pregnancy and childbirth? Available at: http://ww.healthtalk.org/peoples-experiences/pregnancy-children/conditions-threaten-womens-lives-childbirth-pregnancy/what-life-threatening-complication-pregnancy-and-childbirth (Accessed: 12/04/2015). Macdonald, S. Magill-Cuerden, J. (2011) Mayes’ Midwifery. 14th edn. London: Churchill Livingstone Elsevier. MedicineNet.com (2012) Definition of Fever, puerperal. Available at: http://www.medicinenet.com/script/main/art.asp?articlekey=7921 (Accessed: 24/04/2015). Nall, R. (2014) Puerperal Infection. Available at: http://www.healthline.com/health/puerperal-infection (Accessed: 23/04/2015). NHS Choices. (2015) Peritonitis. Available at: http://www.nhs.uk/Conditions/Peritonitis/Pages/Introduction.aspx (Accessed: 23/04/2015). NHS Choices (2014) Sepsis – Diagnosis. Available at: http://www.nhs.uk/Conditions/Blood-poisoning/Pages/Diagnosis.aspx (Accessed: 25/04/2015). O’Connell, K. (2012) What is septicaemia? Available at: http://www.healthline.com/health/septicemia#Overview1 (Accessed: 23/04/2015). Royal College of Obstetricians Gynaecologists (2012) Sepsis following Pregnancy, Bacterial. Available at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg64b/ (Accessed: 26/04/2015). Sepsis Alliance (2015) Sepsis. Available at: http://www.sepsisalliance.org/sepsis/symptoms/ (Accessed: 24/04/2015). Sriskandan, S. (2011) ‘Severe peripartum sepsis’ Royal College of Physicians of Edinburgh, 41 339–46. [Online]. Available at: www.rcpe.ac.uk/sites/default/files/sriskandan.pdf (Accessed: 26/04/2015) Willacy, H. (2012) Puerperal Pyrexia. Available at: http://www.patient.co.uk/doctor/Puerperal-Pyrexia.htm (Accessed: 25/04/2015). World Health Organizations (2015) Clean Care is Safer Care. Available at: http://www.who.int/gpsc/clean_hands_protection/en/ (Accessed: 26/04/2015). World Health Organizations (2015) Managing puerperal sepsis. Available at: http://www.who.int/maternal_child_adolescent/documents/4_9241546662/en/ (Accessed: 20/04/2015). Glossary Apgar scores designed to quickly evaluate a newborns physical condition. Asepsis the absence of sepsis or infection. Disseminated intravascular coagulation (DIC) is a serious disorder in which the proteins that control blood clotting becomeover active. Malaise is a feeling of general discomfort or uneasiness; normally first indication of infection of other disease. Mastitis is the inflammation of breast tissue. Peritonitis is the inflammation of the thin layer of tissue that lines the inside of the abdomen called the peritoneum. Placenta abruption part of the placenta comes away from the uterus wall), Placenta praevia – all or part of the placenta covers the cervix. Pulmonary embolism is a blockage in the artery that transports blood to the lungs. Pyelonephritis inflammation of the substance of the kidney as a result of bacterial infection. Septicemia is known as bacteremia or blood poisoning. Septicemia occurs when a bacterial infection enters the bloodstream. Appendixes Appendixes A – Hand washing techniques (WHO. 2015) 1 | Page Seamus Heaneys North Collection | Postcolonial analysis Seamus Heaneys North Collection | Postcolonial analysis Introduction The field of postcolonial theory is of increasing primacy within critical theory and literary theory. Postcolonial studies emphasise the re-emergence of cultural strengths and identities, personal, racial, national and the like. However, the term itself, and the existence of a field of critical theory and studies related to it, is still contested and debated. Situating a discussion or literary analysis within such a field could, therefore, be inherently problematic, although this author will attempt to justify why Heaney can be viewed as a post-colonial poet by dint of his work, not just the happenstance of his temporal and national placement. This essay will attempt to discuss and analyse the thematic and stylistic characteristics of Seamus Heaneys work, focusing on his North collection. The particular themes and dimensions of these poems are significant in relation to postcolonial theory because they so strongly related to aspects of his cultural and racial identity and heritage, as well as to his personal history and experience. Reference will be made within the essay to different critical views upon his work, and to the underlying and associated political dimensions of the context within which the works were produced. Discussion Ashcroft et al (1989: 2) state that the term post-colonial can be used to cover all the culture affected by the imperial process from the moment of colonization to the present day. It is a literature which emerges following the decline of the Empire (Cudden, 145). What each of these literatures have in common beyond their special and distinctive regional characteristics is that they emerged in their present form out of the experience of colonization and asserted themselves by foregrounding the tension with the imperial power, and by emphasizing their differences from the assumptions of the imperial centre. (Ashcroft et al, 2). Green and Lebihan (37) suggest that post colonial writing may be engaged in rewriting a particular version of history, or in challenging a forceful commonplace view of politics. Loomba (103) however, suggests that the issue is complicated because the use of the prefix post leads to the implication of a discrete era or discipline which is associated with an aftermath, one that is temporal, as in coming after, an ideological, as in supplanting. In the case of Heaney, one could view his writing as being a product of colonial heritage, because his style is so strongly related to traditional poetic forms, particularly lyric poetry, and because the evidence of that colonial heritage, in a post-colonial backlash, is all around him. The North collection was first published 1975, almost a year after the break down of the Sunningdale Agreement, which was followed by an IRA backlash? and a 15 day strike by loyalist workers which ended up in the disbanding of the Faulkner-led government. The years 1974 and 1975 have been described as some of the worst moments of the troubles, and it is no surprise, therefore, that Heaneys work should refer not only these occurrences, but to his ambiguous position in relation to them. The theme of violence is evident in the North poems in a variety of guises. those hacked and glinting/in the gravel of thawed streams /were ocean-deafened voices warning me, lifted again/in violence and epiphany. (from North in North, 1975) The consequences of violence death, decay and associated conditions, are also prevalent within these works. I can see her drowned body in the bog, the weighting stone, the floating rods and boughs. (from Punishment in North, 1975) This corpse is viewed by Heaney as a reflection of the Catholic women who, during the troubles in Northern Ireland, were publicly punished (tarred and chained to their houses) for dating and associating with British soliders. Violence as a cultural representation, violence as a theme, and the products and representations of violence, seem to dominate many of Heaneys works (Lunday, 111). The land and the violence associated with the people of the land seem to be inextricably linked. In terms of style, this extract shows while Heaney embraces simple, poetic beauty of language, it is this very beauty which starkly contrasts with his subject. The way in which Heany sets out to depict adultery and the tribal consequences of this shows a connection to both present and past. Yet this is no romanticised past, no idealised heritage to generate a strong sense of nationalism. I almost love you / but would have cast, I know, / the stones of silence. I am the artful voyeur / your brains exposed and darkened combs (from Punishment in North, 1975) Johnson (2005) suggests that this poem serves to articulate and present the tragedy of a people in a place, the Catholics of Northern Ireland. The responses of the speaker to the adultery are very much linked with the context, and with an awareness that, within this context, no act that could be construed as impacting upon or connecting with the politics of the time is without consequences. Therefore, Heaneys postcolonial nature is traversing his roots in Northern Irish rural life, which allow him to make use of myth and certain unique aspects of the Irish experience, whilst also commenting on the contemporary context and the political conflict that forms the backdrop to the publication of these works. . The theme of death and bodies relates to his heritage and history in real ways. It could be argued that one of the central motifs in this collection is the bog, wild lands which carry the history of millions of years. This setting allows for the exploration of the past, and is how Heaney connects his political and ideological present with his past. Thus it is important linguistically and emblematically. . The themes of Heaneys North collection of poems can be viewed in relation to his heritage as an Irishman, and as the son of a farming family, and as someone who has a strongly emotive connection with the land of his birth (Johnson, 2005). These poems are specifically connected to the landscapes and the history of his life and heritage. Spirituality and religion is smaller, less obvious theme of these poems, and there are significant connections between the religious conflicts with which he has been surrounded, and the language of the poems, particularly in the choice to differentiate between the sacred and the secular. and found only the secular/powers of the Atlantic thundering (from North in North, 1975). Heaney also associates religion with violence (see earlier theme) in violence and epiphany (from North in North, 1975). This is unsurprising, given the issue of the troubles and the context within which this writing has emerged. However, this is not a comfortable or easy asociation, for the reader in particular, because the connection between the images of violence used and what the writer (and reader) must know and understand about Irelands history (such as the civil war) and its contemporary political stuggles, can perhaps be said to manifest within this writing in Heaneys trademark lyrical yet uncompromising style. Historical violence may be a mirror for current violence, as in, for example The Tollund Man, where the man is not more than the obvious, a sacrifical offering to this rapacious earth mother (Johnson, 25): She tighened her torc on him/And opened her fen. He is also, as with Punishment, a symbol of more recent victims of violence, which surround him as concepts, and as images, perhaps images too disturbing for poetic expression. While The stockinged corpses/laid out in the farmyards are a reference to Catholics murdered by protestants during the civil war (Johnson, 2005), Heany used the Tollund Man as a symbol and representation of the history of these bodies. He is all of those, from past to present, murdered for an ideology, as are the other bog bodies Heaney addresses, in a number of his collections. Parker describes this mythologising of the present through the past as Heaney casting around, like his fellow Northern Irish poets, in searh of appropriate strategies for addre ssing the political crisis. (131). I first saw his twisted face In a photograph, A head and shoulder Out of the peat Bruised like a forceps babe But now he lies Perfected in my memory. (Heaney 1969 The Graubelle Man). Here, we see the stylistic nature of the work as beig paramount. The poets love of, or reverence for, language, is evident here, as he pursues what Johnson (27) describes as evocative similes, which serve a number of purposes. The past perfection alluded to here is poignant because of the imperfections of the present, as if past violence becomes less appalling and more symbolic than present violence. He is using language of the present to capture and describe something that is past and ancient, much as he does in his translation of Beowulf (McGuire, 80). This very much makes Heaneys work a product of his physical heritage (Parker, 19; Tuan 684), and he connects his feelings, history and the history of the politics and wars of past and present with the land upon which they have taken place (Evans, 54; Mitchell and Ryan, 8). Conclusion. The works of Seamus Heaney can be strongly argued to be post-colonial, because they are a clear product of a heritage which is profoundly marked and shaped by imperialism and colonialism. The history of his nation, and of his work, is to be found within the land, and within the words that he uses to evoke both. The stylistic features of Heaneys poems, especially the North collection, adhere to conventions of lyric poetrym and is amenable to traditional expectations about poetic form and launguage (Johnson 28). It is not surprising that thematically, and emblematically, violence, retribution, and religiosity, all find their way into these works. However, this author would also argue that these themes may be as much a product of the readers interpretation, based on a knowledge of the poet and his context and history, and this raises the question of whether the work of a poet can ever be divorced from what the reader knows about how and where the poetry is produced. The power of Heaneys words lie in his skill ful manipulation of language that adheres to familiar poetic forms but addresses powerful images and emblems. Overall, these works mimic the questions and concepts raised by the Irish troubles and show such issues played out linguistically, stylistically, and symbolically through petry that is at once stark and gentle, uncompromising and moderate.