1 The Postpartum Period Puerperium = fourth trimester of pregnancy - the 6-week interval between the...

1

The Postpartum Period

• Puerperium = fourth trimester of pregnancy - the 6-week interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state

2

Uterine Involution

• Uterine Involution: – return of the uterus to its pre-pregnancy

size and condition, which begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle

• Uterine fundal descent: – immediately after birth uterus is in the

midline approximately 2 cm below the level of the umbilicus, size of grapefruit (like 16 weeks of gestation), weighs approximately 1000 g.

– Within 12 hours the fundus may be approximately 1 cm above the umbilicus

– During next few days the fundus descends 1 to 2 cm (fingerbreadth) every 24 hours.

– By the sixth postpartum day the fundus is normally located halfway between the umbilicus and the symphysis pubis.

– A week after birth the uterus once again lies in the true pelvis.

– After the ninth postpartum day the uterus should not be palpable abdominally.

3

Uterine Involution

• Increased estrogen and progesterone levels are responsible for stimulating the massive growth of the uterus during pregnancy. Prenatal uterine growth results from both hyperplasia, an increase in the number of muscle cells, and from hypertrophy, an enlargement of the existing cells. Postpartally, the decrease in these hormones causes autolysis, the self-destruction of excess hypertrophied tissue. The additional cells laid down during pregnancy remain and account for the slight increase in uterine size after each pregnancy.

• Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection.

4

Lochia Assessment• Lochia–vaginal discharge after childbirth.• It takes 6 weeks for the vagina to regain its pre-pregnancy contour.• For the first 2 hours after birth the amount of uterine discharge should

be approximately that of a heavy menstrual period. After that time, the lochia flow should steadily decrease.

• Lochia: rubra, serosa or alba• Assessment of lochia includes noting color, presence and size of clots

and foul odor.

• Day 1- 3 - lochia rubra (blood with small pieces of decidua and mucus)

• Day 4-10-22-27 – lochia serosa (pink or pinkish brown serous exudate with old blood, cervical mucus, erythrocytes and leukocytes, tissue debris)

• Day 11- 21 - lochia alba (yellowish white discharge with leucocytes, decidua, epithelian cells, mucus, serum, bacteria)

• The amount of lochia is usually less after cesarean births. Flow of lochia usually increases with ambulation and breastfeeding and receives an oxytocin medication

5

LOCHIAL AND NONLOCHIAL BLEEDINGLOCHIAL

BLEEDINGNONLOCHIAL BLEEDINGLochia

• Lochia usually trickles from the vaginal opening. The steady flow is greater as the uterus contracts

• A gush of lochia may result as the uterus is massaged. If it is dark in color, it has been pooled in the relaxed vagina, and the amount soon lessens to a trickle of bright red lochia (in the early puerperium).

Bleeding • If the bloody discharge

spurts from the vagina, there may be cervical or vaginal tears in addition to the normal lochia.

• If the amount of bleeding continues to be excessive and bright red, a tear may be the source.

6

Cervix

• The cervix is soft immediately after birth. • By 18 hours postpartum it has shortened, become firm, and regained its

form. • The cervix up to the lower uterine segment remains edematous, thin,

and fragile for several days after birth. • The ectocervix (portion of the cervix that protrudes into the vagina)

appears bruised and has some small lacerations—optimal conditions for the development of infection.

• The cervical os, which dilated to 10 cm during labor, closes gradually. • Two fingers may still be introduced into the cervical os for the first 4 to 6

days postpartum; however, only the smallest curette can be introduced by the end of 2 weeks.

• The external cervical os never regains its prepregnant appearance; it is no longer shaped like a circle but appears as a jagged slit that is often described as a "fishmouth."

• Lactation delays the production of cervical and other estrogen-influenced mucus and mucosal characteristics.

7

VAGINA AND PERINEUM• Vagina

– vaginal mucosa is thin, atrophic, with decrease amount of lubrication and without rugae as a result of estrogen deprivation which lead to coital discomfort (dyspareunia) until ovarian function returns and menstruation resumes.

– – The greatly distended, smooth-walled vagina gradually returns to its

prepregnancy size by 6 to 8 weeks after childbirth. Rugae reappear by approximately the fourth week, but they are never as prominent as they are in the nulliparous woman. Most rugae are permanently flattened.

• Perineum– the introitus is erythematous and edematous, especially in the area of the

episiotomy or laceration repair. It is barely distinguishable from that of a nulliparous woman

– Episiotomy. Most episiotomies are visible only if the woman is lying on her side with her upper buttock raised or if she is placed in the lithotomy position.

– Hemorrhoids (anal varicosities) are commonly seen. Internal hemorrhoids may evert while the woman is pushing during birth. Women often experience associated symptoms such as itching, discomfort, and bright red bleeding with defecation. Hemorrhoids usually decrease in size within 6 weeks of childbirth.

8

Endocrine System

• Placental hormones (human chorionic somatomammotropin, estrogens, cortisol, and the placental enzyme insulinase)– dramatically decrease and reverse the diabetogenic effects of

pregnancy, resulting in significantly lower blood sugar levels in the immediate puerperium.

– Estrogen and progesterone levels drop markedly after expulsion of the placenta and reach their lowest levels 1 week postpartum. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy.

– In nonlactating women, estrogen levels begin to rise by 2 weeks after birth and by postpartum day 17 are higher than in women who breastfeed

– β-Human chorionic gonadotropin disappears from maternal circulation in 14 days

9

Endocrine System• Pituitary hormones and ovarian function

– The persistence of elevated serum prolactin levels in breastfeeding women appears to be responsible for suppressing ovulation. Because levels of follicle-stimulating hormone (FSH) have been shown to be identical in lactating and nonlactating women, it is thought that the ovulation is suppressed in lactating women because the ovary does not respond to FSH stimulation when increased prolactin levels are present

– Prolactin levels in blood rise progressively throughout pregnancy. – In nonlactating women, prolactin levels decline after birth and reach the prepregnant

range in 4 to 6 weeks – In breastfeeding woman prolactin levels remain elevated into the sixth week after birth,

and influence by the frequency of breastfeeding, the duration of each feeding, and the degree to which supplementary feedings are used.

– Ovulation occurs as early as 27 days after birth in nonlactating women, with a mean time of 70 to 75 days. Approximately 70% of nonbreastfeeding women resume menstruating by 3 months after birth.

– In women who breastfeed, the mean length of time to initial ovulation is 17 weeks. In lactating women, both resumption of ovulation and return of menses are determined in large part by breastfeeding patterns. Many women ovulate before their first postpartum menstrual period occurs; thus there is need to discuss contraceptive options early in the puerperium.

– The first menstrual flow after childbirth is usually heavier than normal. Within three to four cycles the amount of menstrual flow returns to the woman's prepregnancy volume

10

BREASTS

• Promptly after birth, there is a decrease in the concentrations of hormones (i.e., estrogen, progesterone, hCG, prolactin, cortisol, and insulin) that stimulated breast development during pregnancy. The time it takes for these hormones to return to prepregnancy levels is determined in part by whether the mother breastfeeds her infant.

• BREASTFEEDING MOTHERS• As lactation is established, a mass (lump) may be felt in the breast. Unlike the lumps associated with

fibrocystic breast disease or cancer (which may be consistently palpated in the same location), a filled milk sac shifts position from day to day. Before lactation begins, the breasts feel soft and a yellowish fluid, colostrum, can be expressed from the nipples. After lactation begins, the breasts feel warm and firm. Tenderness may persist for approximately 48 hours after the start of lactation. Bluish-white milk with a skim-milk appearance (true milk) can be expressed from the nipples. The nipples are examined for erectility and signs of irritation such as cracks, blisters, or reddening.

• NONBREASTFEEDING MOTHERS• The breasts generally feel nodular in contrast to the granular feel of breasts in nonpregnant women.

The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. Colostrum is present for the first few days after childbirth. Palpation of the breast on the second or third day, as milk production begins, may reveal tissue tenderness in some women. On the third or fourth postpartum day, engorgement may occur. The breasts are distended (swollen), firm, tender, and warm to the touch (because of vasocongestion). Breast distention is caused primarily by the temporary congestion of veins and lymphatics rather than by an accumulation of milk. Milk is present but should not be expressed. Axillary breast tissue (the tail of Spence) and any accessory breast or nipple tissue along the milk line may be involved. Engorgement resolves spontaneously, and discomfort decreases usually within 24 to 36 hours. A breast binder or tight bra, ice packs, or mild analgesics may be used to relieve discomfort. Nipple stimulation is avoided. If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.

11

Fourth Stage of Labor

• Goal of nursing care is to assist woman and their partners during their initial transition to parenting

• Nursing's role is to monitor the recovery of the new mother and infant, to identify and manage promptly any deviations from the normal processes that may occur, and to promote and support parent-infant attachment

12

Fourth Stage of Labor

• First 1 to 2 hours after birth– During this time, maternal organs undergo their

initial readjustment to the nonpregnant state and the functions of body systems begin to stabilize.

– Meanwhile, the newborn continues the transition from intrauterine to extrauterine existence

– Excellent time to begin Breastfeeding • Encouraging of the mother• Colostrum prompting elimination of meconium

13

Care in the Immediate Postpartum Period

• Assessment– During first hour every 15 minutes– During second hours every 30 minutes

• VS (Ps, BP, T) • fundal height and firmness• bladder distension• amount of lochia• presence of edema• status of perineum,

• Postanesthesia recovery (every 15 min)– Activity– Respiration– BP– Level of cosciousness– Color– general anesthesia

• Awake, alert, orient to time, place, and person, respiratory rate, oxygen saturation levels at least 95%, as measured by a pulse oximeter– epidural or spinal anesthesia

• should be able to raise her legs, extended at the knees, off the bed, or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed. The numb or tingling, prickly sensation should be entirely gone from her legs. Often, it takes 1.5 to 2 hours for these anesthetic effects to disappear.

• Providing comfort measures• Analgesics• Promoting bladder elimination• Providing fluid and food

14

Slide 14

Nursing Care After Cesarean Birth

• Same as with normal vaginal delivery except– Postanesthesia recovery– Monitoring of abdominal dressing– Urinary catheter– Respiratory care– Prevention of thrombophlebitis– Interventions for pain

15

Postpartum Physical Assessment

• B - breast• U - uterus• B - bowels• B - bladder• L - lochia• E - episiotomy

16

General Assessment

• Enter the room quietly, speak quietly.

• Wash hands and provide for privacy.

• Inform patient before turning on lights.

• Note LOC, activity level, position, color, general demeanor.

• Take note of the total environment:– Safety/patient considerations– Note equipment and medical devices

17

Breast Assessment

• Breasts: Soft, engorged, filling, swelling, redness, tenderness.

• Nipples: Inverted, everted, cracked, bleeding, bruised, presence of colostrum or breastmilk.

• Colostrum–yellowish fluid rich in antibodies and high in protein.

• Engorgement occurs by day 3 or 4. Due to vasoconstriction as milk production begins

• Lactation ceases within a week if breastfeeding is never begun or is stopped.

18

• Nipple soreness is a portal of entry for bacteria - breast infection (Mastitis).

• Maternal after pains: may be due to breastfeeding and multiparity

• Always stay with the client when getting out of bed for the first time – hypotension effect and excess bleeding

• When assessing fundal height, if you notice any discrepancies in fundal height have patient void and then reassess.

19

Assessing Uterine Fundus

• Location in relation to umbilicus

• Degree of firmness• Is it at Midline or deviated to

one side?• Bladder Full?• A boggy uterus may indicate

uterine atony or retained placental fragments.

• Boggy refers to being inadequately contracted and having a spongy rather than firm feeling.

20

Massaging the Fundus• Every 15 mins during the 1st hr,

every 30 mins during the next hr, and then, every hr until the patient is ready for transfer.

• Document fundal height.

• Evaluate from the umbilicus using fingerbreadths.

• This is recorded as 2 fingers below the umbilicus (U/2), one finger above the umbilicus (1/U), and so forth.

• The fundus should remain in the midline. If it deviates from the middle- distended bladder.

21

Uterine Atony

• Lack of muscle tone in the cervix.

• Uterus feels soft and boggy

• The bladder has increased capacity and decreased muscle tone.

• This leads to over-distension of the bladder, incomplete emptying of bladder, retention of residual urine and increased risk of UTI and postpartum hemorrhage.

22

Bowels & Bladder

• When was the patients last bowel movement?• Is she passing flatus? (gas)• Assess for bowel sounds• Voiding pattern - without difficulty/pain, urine may

be blood tinged from lochia• Nursing interventions: Assist to the bathroom. Use

measures to encourage voiding (privacy). Encourage use of peri-bottle with warm water, fluids, fiber, frequent ambulation, stool softeners; teach effects of pain medication.

23

Slide 23

Urinary System

• A full bladder can displace the uterus and lead to postpartum hemorrhage

• In the woman who voids frequently, small amounts of urine may have increased residual urine because her bladder does not empty completely

• Residual urine in the bladder may promote the growth of microorganisms

24

Lochia: Pad Count 1. Scant: 1-inch stain on pad in 1 hour

2. Light/small: 4 inches in 1 hour

3. Moderate: 6 inches in 1 hour

4. Heavy/large: Pad saturated in 1 hour• Excessive: Pad saturated in 15 min• Can estimate blood loss by weighing pads:• 500 mL = 1 lb. or 454 g

25

Episiotomy/Perineal Assessment• Patient in lateral Sims (side lying) position.• Use the acronym REEDA

– Redness, Edema, Ecchymosis, Discharge, Approximation of suture lines “edges of episiotomy”) to guide assessment.

• Even if there is no episiotomy, the perineum should still be assessed. – Nursing care and patient teaching

• Cold packs• Topical and systemic medications• Nonpharmacologic pain relief methods

• Unusual perineal discomfort may be a symptom of impending infection or hematoma.Hemorrhoids ?

26

Episiotomy Pain Relief

• Instruct Mother:

• Tighten her buttocks and perineum before sitting to prevent pulling on the episiotomy and perineal area and to release tightening after being seated.

• Rest several times a day with feet elevated.

• Practice Kegel exercise many times a day to increase circulation to the perineal area and to strengthen the perineal muscles.

27

Postpartum Physical Assessment

• B - breast• U - uterus• B - bowels• B - bladder• L - lochia• E - episiotomy

28

Routine care for the postpartum woman: Educate about danger signs (1)

Vaginal bleeding:

• More than 2 or 3 pads soaked in 20-30 minutes after delivery, OR

• Bleeding increases rather than decreases after delivery

29

Severe abdominal pain

Fever and too weak to get out of bed


30

• Fast or difficult breathing

• Severe headache, blurred vision

• Convulsions


31

• Pain in the perineum or draining pus

• Foul-smelling lochia

Dribbling of urine or pain on micturition


32

The woman doesn’t feel well.

Breasts swollen, red or tender breasts, or sore nipples


33

Postpartum Hemorrhage Postpartum Hemorrhage ((PPHPPH))

• Definition and incidenceDefinition and incidence– PPH traditionally defined as loss of more PPH traditionally defined as loss of more

than:than:• 500 ml of blood after vaginal birth500 ml of blood after vaginal birth• 1000 ml after cesarean birth1000 ml after cesarean birth

– Cause of maternal morbidity and mortalityCause of maternal morbidity and mortality– Life-threatening with little warning Life-threatening with little warning – Often unrecognized until profound symptoms Often unrecognized until profound symptoms

34

The causes of postpartum hemorrhage can

be thought of as the four Ts:

Etiology of PPH

tone,

tissue,

trauma,

thrombin

35

35 of 34

Postpartum Hemorrhage Postpartum Hemorrhage Etiology and risk factors (1)Etiology and risk factors (1)

– UterineUterine atony atony• Marked hypotonia of uterus Marked hypotonia of uterus • Leading cause of PPH, Leading cause of PPH,

complicating approximately complicating approximately 1 in 20 births1 in 20 births

• Brisk venous bleeding with Brisk venous bleeding with impaired coagulation until impaired coagulation until the uterine muscle the uterine muscle contractscontracts

36

Uterine atonyUterine atony

Multiple gestation,

high parity,

prolonged labor

chorioamnionitis,

augmented labor,

tocolytic agents


37

• Explore the uterine cavity.

• Inspect vagina and cervix for lacerations.

• If the cavity is empty, Massage and give methylergonovine 0.2 mg, the dose can be repeated every 2 to 4 hours.

• Rectal 800mcg. Misoprostol is beneficial.

Management of uterine atony

38

During the administration of uterotonic agents, bimanual compression may control hemorrhage. The physician places his or her fist in the vagina and presses on the anterior surface of the uterus while an abdominal hand placed above the fundus presses on the posterior wall. This while the Blood for transfusion made available.

Management of uterine atony

39

Complications of Puerperium

• Uterine Atony (Cont’d)• Treatment

– Uterine compression– Oxytocics

» Early suckling causes endogenous release of oxytocin

» Oxytocin IV/IM 10 units» Methylergonovine» Methyl prostoglandin F

40


Lacerations of genital tractLacerations of genital tract• Should be suspected if bleeding continues with a Should be suspected if bleeding continues with a

firm, contracted fundusfirm, contracted fundus• Includes perineal and cervical lacerations as well as Includes perineal and cervical lacerations as well as

pelvic hematomaspelvic hematomas

40 of 34

41

Lacerations and traumaLacerations and trauma

Planned

•Cesarean section,

•episiotomy

Unplanned

•Vaginal/cervical tear,

•surgical trauma


42

Postpartum Hemorrhage Postpartum Hemorrhage

Genital tract lacerations Management

Genital trauma always must be eliminated first if the uterus is

firm.

43

Rupture of the uterus is described as complete or incomplete and should be differentiated from dehiscence of a cesarean section scar.


UTERINE RUPTURE

44

The reported incidence

for all pregnancies is 0.05%,

After one previous lower segment cesarean section 0.8%

After two previous lower segment cesarean section is 5%

all pregnancies following myomectomy may be complicated by uterine rupture.


UTERINE RUPTURE

45

Complete rupture describes a full-thickness defect of the uterine wall and serosa resulting in direct communication between the uterine cavity and the peritoneal cavity.


UTERINE RUPTURE

46

Incomplete rupture describes a defect of the uterine wall that is contained by the visceral peritoneum or broad ligament. In patients with prior cesarean section,


UTERINE RUPTURE

47

dehiscence describes partial separation of the scar with minimal bleeding, with the peritoneum and fetal membranes remaining intact.


UTERINE RUPTURE

48

The identification or suspicion of uterine rupture must be followed by an immediate and simultaneous response from the obstetric team.

Surgery should not be delayed owing to hypovolemic shock because it may not be easily reversible until the hemorrhage is controlled.

Management of Rupture Uterus

49

Upon entering the abdomen, aortic compression can be applied to decrease bleeding.

Oxytocin should be administered to effect uterine contraction to assist in vessel constriction and to decrease bleeding.

Hemostasis can then be achieved by ligation of the hypogastric artery, uterine artery, or ovarian arteries.


50

At this point, a decision must be made to perform hysterectomy or to repair the rupture site. In most cases, hysterectomy should be performed.

In selected cases, repair of the rupture can be attempted. When rupture occurs in the body of the uterus,

bladder rupture must be ruled out by clearly mobilizing and inspecting the bladder to ensure that it is intact. This avoids injury on repair of the defect as well.


51

A lower segment lateral rupture can cause transection of the uterine vessels. The vessels can retract toward the pelvic side wall, and the site of bleeding must be isolated before placing clamps to avoid injury to the ureter and iliac vessels.

Typically, longitudinal tears, especially those in a lateral position, should be treated by hysterectomy, whereas low transverse tears may be repaired.


52

Trauma-Second most common cause of early postpartum

hemorrhage– Lacerations – suspect this

in the birth canal if uterine bleeding continues with a contracted fundus

– Hematomas- bleeding into loose connective tissue as the vulva or vagina

• Vulva- discolored bulging mass

• Surgical excision if they are large & ligation

53


– Retained placentaRetained placenta• Nonadherent retained placenta – managed Nonadherent retained placenta – managed

by manual separation and removal by the by manual separation and removal by the primary care providerprimary care provider

• Adherent retained placenta – may be caused Adherent retained placenta – may be caused by implantation into defective endometriumby implantation into defective endometrium

53 of 34

54

Postpartum Postpartum Hemorrhage Hemorrhage

Etiology and risk Etiology and risk factors (3)factors (3)–Three classifications of adherent Three classifications of adherent

retained placentaretained placenta• Placenta acreta – slight penetration Placenta acreta – slight penetration of myometrium by placental trophoblastof myometrium by placental trophoblast• Placenta increta – deep penetrationPlacenta increta – deep penetration of myometrium by placentaof myometrium by placenta• Placenta percreta – perforation of uterus by Placenta percreta – perforation of uterus by placentaplacenta

–Patient will experience profuse bleeding when Patient will experience profuse bleeding when delivery of the placenta is attempted.delivery of the placenta is attempted.

–Management includes blood replacement and Management includes blood replacement and surgical intervention (hysterectomy)surgical intervention (hysterectomy)

54 of 34

55


• Inversion of uterus (turning inside out)Inversion of uterus (turning inside out)– May be life-threateningMay be life-threatening– A complete inversion protrudes out of the A complete inversion protrudes out of the

vaginavagina– Primary signs – hemorrhage, shock, painPrimary signs – hemorrhage, shock, pain– Prevention is the best measure – don’t pull on Prevention is the best measure – don’t pull on

the umbilical cord unless there is definite the umbilical cord unless there is definite separation of the placentaseparation of the placenta

55 of 34

56

Postpartum Postpartum Hemorrhage Hemorrhage

Etiology and risk Etiology and risk factors4factors4

Inversion of uterus (turning Inversion of uterus (turning inside out)inside out)

57


• Subinvolution of uterus – delayed involution of Subinvolution of uterus – delayed involution of the uterusthe uterus– Usually see late post partum bleedingUsually see late post partum bleeding– Causes include retained placental fragments Causes include retained placental fragments

and infectionand infection

57 of 34

58

58 of 34

Postpartum Hemorrhage Postpartum Hemorrhage Care ManagementCare Management

• AssessmentAssessment– Bleeding assessed for color and amountBleeding assessed for color and amount– Perineum inspected for signs of lacerations or Perineum inspected for signs of lacerations or

hematomas to determine source of bleedinghematomas to determine source of bleeding– Vital signs may not be reliable indicators Vital signs may not be reliable indicators

because of postpartum adaptationsbecause of postpartum adaptations• Measurements during first 2 hours may identify trends Measurements during first 2 hours may identify trends

related to blood lossrelated to blood loss– Bladder distensionBladder distension– Laboratory studies of Laboratory studies of hemoglobin and hematocrit hemoglobin and hematocrit levelslevels

59

• Plan of care and implementationPlan of care and implementation– Initial treatment – fundal massage, expression Initial treatment – fundal massage, expression

of clots, relief of bladder distension, IV fluidsof clots, relief of bladder distension, IV fluids– Medical managementMedical management

• Hypotonic uterus – examine for retained placental Hypotonic uterus – examine for retained placental fragments, medications, surgical interventionsfragments, medications, surgical interventions

• Bleeding with a contracted uterus – identify and Bleeding with a contracted uterus – identify and treat underlying causetreat underlying cause

• Uterine inversion – emergency replacement of the Uterine inversion – emergency replacement of the uterus into the pelvic cavityuterus into the pelvic cavity

• Subinvolution – medications, surgical interventionSubinvolution – medications, surgical intervention

59 of 34


60

60 of 34

• Plan of care and implementationPlan of care and implementation– Nursing interventionsNursing interventions

• Vital signs, uterine assessment, medication Vital signs, uterine assessment, medication administration, notification of primary care provideradministration, notification of primary care provider

• Providing explanations about interventions and need to Providing explanations about interventions and need to act quicklyact quickly

• Once stable, ongoing post partum assessments and careOnce stable, ongoing post partum assessments and care• Instructions in increasing dietary iron, protein intake, and Instructions in increasing dietary iron, protein intake, and

iron supplementationiron supplementation• May need assistance with infant care and household May need assistance with infant care and household

activities until strength regainedactivities until strength regained


61

Guidelines by the Scottish Executive Committee of the RCOG

COMMUNICATE. RESUSCITATE. MONITOR / INVESTIGATE. STOP THE BLEEDING.

62

COMMUNICATEcall 6

• Call experienced midwife

• Call obstetric registrar & alert consultant

• Call anaesthetic registrar , alert consultant

• Alert haematologist

• Alert Blood Transfusion Service

• Call porters for delivery of specimens / blood

63

RESUSCITATE• IV access with 14 G cannula X 2 • Head down tilt • Oxygen by mask, 8 litres / min• Transfuse

•Crystalloid (eg Hartmann’s)

•Colloid (eg Gelofusine)

•once 3.5 litres infused, GIVE ‘O NEG’ If no cross-matched blood available OR give uncross-matched own-group blood, as available

•Give up to 1 liter Fresh Frozen Plasma and 10 units cryoprecipitate if clinically indicated

64

MONITOR / INVESTIGATE • Cross-match 6 units • Full blood count • Clotting screen • Continuous pulse / BP / • ECG / Oximeter • Foley catheter: urine output • CVP monitoring • Discuss transfer to ITU

65

STOP THE BLEEDING

• Exclude causes of bleeding other than uterine atony • Ensure bladder empty • Uterine compression • IV syntocinon 10 units • IV ergometrine 500 g • Syntocinon infusion (30 units in 500 ml) • IM Carboprost (500 g) • Surgery earlier rather than late • Hysterctomy early rather than late (GRADE B)

66

If conservative measures fail to control haemorrhage, initiate surgical haemostasis SOONER RATHER THAN LATER I. At laparotomy, direct

intramyometrial injection of Carboprost (Haemabate) 0.5mg

II. Bilateral ligation of uterine arteries III. Bilateral ligation of internal iliac

(hypogastric arteries) IV. Hysterectomy (GRADE C)

67

Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of placenta accreta or uterine rupture)(GRADE C)

68

Whole blood frequently is used for rapid correction of volume loss because of its ready availability, but component therapy is ideal. A general practice has been to transfuse 1 unit of fresh-frozen plasma for every 3 to 4 units of red cells given to patients who are bleeding profusely

69

Hemorrhagic (Hypovolemic) Hemorrhagic (Hypovolemic) ShockShock

• Emergency situation in which blood is Emergency situation in which blood is diverted to the brain and heartdiverted to the brain and heart– May not see signs until post partum patient May not see signs until post partum patient

loses 30% to 40% of blood volumeloses 30% to 40% of blood volume• Medical management – restore circulating Medical management – restore circulating

blood volume and treat underlying causeblood volume and treat underlying cause• Nursing interventions – monitor tissue Nursing interventions – monitor tissue

perfusion, see emergency boxperfusion, see emergency box• Fluid or blood replacement therapyFluid or blood replacement therapy

69 of 34

70

Prophylactic oxytocics should be offered routinely in the management of the third stage of labour as they reduce the risk of PPH by about 60%.

(GRADE A)

71

71 of 34

CoagulopathiesCoagulopathies• Idiopathic thrombocytopenic purpura (ITP) – Idiopathic thrombocytopenic purpura (ITP) –

decreased platelet life span, need to control decreased platelet life span, need to control platelet stabilityplatelet stability

• von Willebrand disease—type of hemophiliavon Willebrand disease—type of hemophilia• Disseminated intravascular coagulation (DIC)Disseminated intravascular coagulation (DIC)

– Pathologic clottingPathologic clotting

– Correction of underlying causeCorrection of underlying cause• Removal of fetusRemoval of fetus• Treatment for infectionTreatment for infection• Preeclampsia or eclampsiaPreeclampsia or eclampsia• Removal of placental abruptionRemoval of placental abruption

72

CoagulationCoagulation disordersdisorders

Congenital

Von Willebrand's disease

Acquired

DIC,

dilutional coagulopathy,

heparin

73

73 of 34

Thromboembolic DiseaseThromboembolic Disease• Results from blood clot caused by Results from blood clot caused by

inflammation or partial obstruction of vesselinflammation or partial obstruction of vessel• May be superficial or deep venous May be superficial or deep venous

thrombosis or a pulmonary embolusthrombosis or a pulmonary embolus• Incidence and etiologyIncidence and etiology

– Venous stasisVenous stasis– HypercoagulationHypercoagulation

• Clinical manifestations – redness and Clinical manifestations – redness and swelling in the affected extremity, pain, swelling in the affected extremity, pain, positive Homan’s signpositive Homan’s sign

74

Thromboembolic DiseaseThromboembolic Disease Homan’s Sign

Press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot (dorsiflex)

75

Thromboembolic DiseaseThromboembolic Disease• Medical managementMedical management

– Superficial – analgesia, rest/elevationSuperficial – analgesia, rest/elevation

– Deep – anticoagulant therapy, Deep – anticoagulant therapy, bedrest/elevation, bedrest/elevation,

– Pulmonary embolus – IV heparin therapyPulmonary embolus – IV heparin therapy

• Nursing interventions Nursing interventions – assessment of the affected area, signs of assessment of the affected area, signs of

bleeding, personal care, medication bleeding, personal care, medication administrationadministration

– Teach not to massage affected area!!Teach not to massage affected area!!75 of 34

76

Postpartum Infections

Endometritis – malodorous lochia, fever (100.6), chills, abdominal pain, uterine

tenderness, tachycardia and subinvolution The infection may spread to cause peritonitis and septic pelvic

thrombophlebitis Treat with IV antibiotics

Emotional support

77

77 of 34

Postpartum InfectionsPostpartum Infections• Puerperal sepsis: any infection of genital Puerperal sepsis: any infection of genital

canal within 28 days after abortion or birthcanal within 28 days after abortion or birth

• Most common infecting agents are Most common infecting agents are numerous streptococcal and anaerobic numerous streptococcal and anaerobic organismsorganisms

• EndometritisEndometritis

• Wound infectionsWound infections

• Urinary tract infectionsUrinary tract infections

• MastitisMastitis

78

Complications of Puerperium

• Fever– UTI/Pyelonephritis– DVT/Thrombophlebitis– “Milk fever” (Lasts < 24 hours)– Drug reaction– Perineal infection(Day five)– Pulmonary Atelectasis (48 hours)– Mastitis (2-3 weeks post partum)

79

Postpartum InfectionsPostpartum Infections EndometritisEndometritis

80

Postpartum Endometritis

• Infection of the decidua (pregnancy endometrium)

• Incidence– <3% after vaginal delivery– 10-50% after cesarean delivery

• 5-15% after scheduled elective cesareans

• Risk Factors– Prolonged labor, prolonged ROM, multiple vaginal

exams, internal monitors, maternal DM, meconium, manual removal of placenta, low socioeconomic status

81

PP Endometritis

• Polymicrobial, ascending infection– Mixture of aerobes and anaerobes from genital tract– BV and colonization with GBS increase likelihood of

infection

• Clinical manifestations (occur within 5 days pp)– Fever – most common sign– Uterine tenderness– Foul lochia– Leukocytosis– Bacteremia – in 10-20%, usually a single organism

82

PP Endometritis

• Workup– CBC– Blood cultures– Urine culture– DNA probe for GC/chlamydia– Imaging studies if no response to adequate

abx in 48-72h• CT scan abd/pelvis• US abd/pelvis

83

PP Endometritis

• Treatment– Broad spectrum IV abx

• Clindamycin 900mg IV q8h and • Gentamicin 1.5mg/kg IV q8h

– Treat until afebrile for 24-48h and clinically improved; oral therapy not necessary

– Add ampicillin 2g IV q4h to regimen when not improving to cover resistant enterococci

• Prevention– Abx prophylaxis for women undergoing C-section

• Cefazolin 1-2g IV as single dose

84

Postpartum Infections

Mastitis - A breast infection occurring 1-2 weeks after childbirth

Engorgement and blocked mild duct increases risk Fever, localized breast pain, redness,warmth and inflammation

Breastfeeding should continue Antibiotics

Nurse's role is to support, educate and refer

85

Mastitis

• Infection of the lactating breast- 2nd or 3rd week after birth

• Caused by S. aureus, often on hands of mother or caregivers

• Can enter through a crack in the nipple

• Engorgement & stasis of milk frequently precede mastitis

86

Mastitis Continued

• SIGNS & SYMPTOMS:– Feels like the flu with fatigue & aching

muscles– Fever of 101.1F– Localized area of redness & inflammation

• THERAPEUTIC MANAGEMENT– ATB & decompression of breast by

breastfeeding or pumping– Bedrest during acute phase– Fluids & analgesics for discomfort

87

Puerperal Mastitis usually caused by common skin bacteria particularly staphylococcus being introduced into the ductal system through

Postpartum InfectionsPostpartum InfectionsMastitisMastitis

88

Breast infections may cause pain, redness, warmth of the breast along with the

following symptoms: Tenderness and swelling Body aches Fatigue Breast engorgement Fever and chills Rigor or shaking


http://www.emedicinehealth.com/script/main/art.asp?articlekey=58902

http://www.emedicinehealth.com/script/main/art.asp?articlekey=40571

89

Most breast infections occur in breastfeeding women when bacteria enters the breast through cracks in the nipple. In severe infections, abscesses may occur. Antibiotics may be indicated for treatment.


90


91


92

Postpartum Infections Postpartum Infections Care ManagementCare Management

• Prevention is the best interventionPrevention is the best intervention– Hand washingHand washing– Good maternal perineal hygieneGood maternal perineal hygiene

• Antibiotic administrationAntibiotic administration

• Wound managementWound management

• Breast careBreast care

92 of 34

93

93 of 34

Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma

• Disorders of uterus and vagina related to Disorders of uterus and vagina related to pelvic relaxation and urinary incontinence, pelvic relaxation and urinary incontinence, are often result of childbearing are often result of childbearing

• Uterine displacement and prolapseUterine displacement and prolapse– Posterior displacement, or retroversionPosterior displacement, or retroversion– Retroflexion and anteflexionRetroflexion and anteflexion– Prolapse a more serious displacementProlapse a more serious displacement

• Cervix and body of uterus protrude through vagina Cervix and body of uterus protrude through vagina and vagina is inverted and vagina is inverted

94

Uterine prolapse occurs when the uterus falls through the cervix (the connection between the uterus and the vagina) into the vagina. Symptoms and treatment depends on how much of the uterus has fallen into the vagina.

Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma Uterine prolapseUterine prolapse

95


96


97


98


99

99 of 34

Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma

• Cystocele and rectoceleCystocele and rectocele– Cystocele: protrusion of bladder downward Cystocele: protrusion of bladder downward

into vagina when support structures in into vagina when support structures in vesicovaginal septum are injuredvesicovaginal septum are injured

– Rectocele is herniation of anterior rectal wall Rectocele is herniation of anterior rectal wall through relaxed or ruptured vaginal fascia and through relaxed or ruptured vaginal fascia and rectovaginal septum rectovaginal septum

• Urinary incontinenceUrinary incontinence

100

Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma Cystocele and rectoceleCystocele and rectocele

101


102

Sequelae of Sequelae of Childbirth Childbirth Trauma Trauma

Cystocele and Cystocele and rectocelerectocele

103


104


105


106

106 of 34

Sequelae of Childbirth TraumaSequelae of Childbirth Trauma

• Genital fistulasGenital fistulas– May result from congenital anomaly, May result from congenital anomaly,

gynecologic surgery, obstetric trauma, cancer, gynecologic surgery, obstetric trauma, cancer, radiation therapy, gynecologic trauma, or radiation therapy, gynecologic trauma, or infectioninfection• Vesicovaginal: between bladder and genital tractVesicovaginal: between bladder and genital tract• Urethrovaginal: between urethra and vaginaUrethrovaginal: between urethra and vagina• Rectovaginal: between rectum or sigmoid colon Rectovaginal: between rectum or sigmoid colon

and vaginaand vagina

107

107 of 34

Types of Fistulas That May Develop Types of Fistulas That May Develop in Vagina, Uterus, and Rectumin Vagina, Uterus, and Rectum

1 The Postpartum Period Puerperium = fourth trimester of pregnancy - the 6-week interval between the...

Documents

Transcript of 1 The Postpartum Period Puerperium = fourth trimester of pregnancy - the 6-week interval between the...