Complications of Post Partum

Complications of Postpartum Period

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POSTPARTUM HEMORRHAGE

EarlyOccurs when blood loss is greater than 500 ml. in the first 24 hours after a vaginal

delivery or greater than 1000 ml after a cesarean birth

*Normal blood loss is about 300 - 500 ml.)

LateHemorrhage that occurs after the first 24

hoursRetained placenta--necrosed, fibrin

deposits, placental polyps, sloughing bleeding 2

PREDISPOSING FACTORS OF POSTPARTUM

HEMORRHAGE Uterine over-distension--large infant, etc.

Grand multiparity

Anesthesia or MgSO4

Trauma

Abnormal labor pattern--hypo or hypertonia

Oxytocin during labor

Prolonged labor

Hx of maternal anemia, hemorrhage3

MAIN CAUSES OF EARLY HEMORRHAGE

Uterine Atony

Lacerations

Retained Placental Fragments

Inversion of the Uterus

Placenta Accreta

Hematomas

Coagulation Problems

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POSTPARTUM HEMORRHAGE

*LACERATIONS* Predisposing Factors

Spontaneous or Precipitous deliverySize, Presentation, and Position of babyContracted PelvisVulvar, cervical, perineal, urethral area and

vaginal varices

Signs and SymptomsBright red bleeding where there is a steady

trickle of blood and the uterus remains firm.Hypovolemia

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Treatment and Nursing CareMeticulous inspection of the entire lower

birth canal

Suture any bleedersVaginal pack-- nurse may remove and

assess bleeding after removal

Blood replacement

POSTPARTUM HEMORRHAGE *LACERATIONS*

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POSTPARTUM HEMORRHAGEPREVENTION

Risk assessment

Inspect placenta

Explore uterus

Avoid over-manipulation of uterus

If at risk, type and crossmatch and

start IV

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SIGNS AND SYMPTOMS OF HEMORRHAGE

Excessive bleeding (>2pads/30min-1hr) or bright

red bleeding, large clots

Boggy fundus

Backache

Light headedness, nausea

Visual disturbances

Anxiety

Pale/ashen color, clammy skin

Elevated P, RR, & Temp; BP same or lower8

NURSING CARE / TREATMENT FOR

POSTPARTUM HEMORRHAGE Summon help

Elevate legs, lower head

Check uterine tone, massage, assess effect

Increase or begin O2

Increase or begin IV

IV Oxytocin

D&C

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UTERINE ATONY

**The myometrium fails to contract and

the uterus fills with blood because of

the lack of pressure on the open vessels of the placental site

The myometrium fails to contract and

the uterus fills with blood because of

the lack of pressure on the open blood

vessels of the placental site.

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PREDISPOSING FACTORS OF UTERINE ATONY

Prolonged labor

Over distentionof theUterus

Grand multiparity

Excessive use of Analgesia / Anesthesia

Intra-partumStimulation with Pitocin

Trauma dueto Obstetrical Procedures

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UTERINE ATONY

Most common cause of Hemorrhage

Slow, steady or massive hemorrhage, sometimes

underestimated or hidden behind a clot

VS may not change immediately

Key to successful management is:

PREVENTION!

Nurse can often predict which women are at risk

for hemorrhaging.

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SIGNS & SYMPTOMS OF UTERINE ATONY

Signs & Symptoms

Excessive orBright Red Bleeding

Abnormal Clots

A boggy uterus that does not respond to massage

Unusual pelvic discomfort or backache

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UTERINE ATONY

Document Vaginal Bleeding

Fundal massage / Bimanual Compression

Assess Vital Signs (shock)

Give medications--Pitocin, Methergine, Hemabate

Replace blood / fluids

D & C, Curetage, Iliac Ligation, Hysterotomy/ectomy

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TEST YOURSELF !

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You are assigned to Mrs. B. who delivered vaginally. As you do your post-partum assessment, you notice that she has a large amount of lochia rubra.

What would be the first measure to determine if it is related to uterine atony or a laceration?

RETAINED PLACENTAL FRAGMENTS

Incomplete separation of the placenta and fragments of placental tissue retained.

Partial separation caused by:pulling on the corduterine massage prior to separationplacenta accreta

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SignsBoggy, relaxed uterusDark red bleeding

TreatmentD & CMassageManual removalAdministration of OxytocinsAdministration of Prophylactic

antibiotics

RETAINED PLACENTAL FRAGMENTS

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HEMATOMA Result from injury to a blood vessel, usually in vagina or vulva,

may extend upward into broad ligament or other pelvic structures.Develop rapidlyMay contain 300-500ml blood

Major Signs & Symptoms: Pain- deep, severe, unrelieved, flank pain, feelings of

pressureBleeding may be concealed and may lead to shock Major symptom is rectal pain and tachycardia.Difficulty voidingMass felt on vaginal examAbdominal distension

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HEMATOMAIcePackingIncised and drained

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SUBINVOLUTION Uterus remains large, does not involute

Causes: retained placental fragments, infection

Symptoms: Lochia fails to progress Returns to rubra Leukorrhea with backache and infection

Treatment: methergine curettage antibiotics

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INVERSION OF THE UTERUS

The uterus inverts or turns inside out after delivery.

Complete inversion - a large red rounded mass protrudes from the vagina

Incomplete inversion - uterus can not be seen, but felt

Predisposing Factors:Traction applied on the cord before the placenta

has separated.**Don’t pull on the cord unless the placenta has separated.

Incorrect traction and pressure applied to the fundus, especially when the uterus is flaccid

**Don’t use the fundus to “push the placenta out”21


Traction onthe cordstarts the uterus toinvert

Uterus continuesto be pulled andinverted

Uterus

Placenta

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Vagina

UterusInverted

Vagina

Uterus manually pushed backinto place

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TREATMENT / NURSING CARE FOR INVERSION OF

THE UTERUS Replace the uterus--manually replace and pack

uterus Combat shock, which is usually out of

proportion to the blood loss Blood and Fluid replacement Give Oxytocin Initiate broad spectrum antibiotics May need to insert a Nasogastric tube to

minimize a paralytic ileus

Notify the Recovery Nurse what has occurred!Care must be taken when massaging

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PLACENTA ACCRETAAll or part of the decidua basalis is absent and the Placenta grown directly into the uterine muscle.

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PLACENTA ACCRETA

During the third stage of labor, the placenta does not want to separate.

Attempts to remove the placenta in the usual manner are unsuccessful, and lacerations or perforation of the uterus may occur

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PLACENTA ACCRETA

Treatment:If it is only small portions that are

attached, then these may be removed manually

If large portion is attached--a Hysterectomy is necessary!

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ARE THESE EARLY, LATE, OR BOTH ?

Uterine Atony

Retained placental fragments

Lacerations

Inversion of the uterus

Placenta accreta

Hematoma

_________________

_________________

_________________

_________________

_________________

_________________

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POSTPARTUM INFECTIONS

Definition: Infection of the genital tract that occurs

within 28 days after abortion or deliveryA.k.a puerperal infection

Causative Organisms:Aerobic 30%: B hemolitic strep; E.coli; Klebsiella;

Proteus; Pseudomonas; StaphAnaerobic 70%: Bacteriodes; Peptococcus;

C. perfringes

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TYPES OF INFECTIONS

Endometritis

Parametritis

Peritonitis

Pyelonephritis

Cystitis

Thrombophlebitis

Mastitis, abcess 30


INFECTIONS Antenatal:

Poor nutrition Low SES Hx of Infections Anemia Immunodeficiency

Intrapartum: Prolonged labor PROM Poor aseptic technique Birth trauma

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INFECTIONS Intrapartum (Continued):

Multiple exams Internal monitoring Episiotomy C section

Postpartum: Manual removal of placenta Hemorrhage Retained secundines

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Temperature increase of 100.4 or higher on any 2 consecutive days of the first 10 days post-partum, not including the first 24 hours.

Foul smelling lochia, discharge Malaise Anorexia Tachycardia Chills Pelvic Pain Elevated WBC 33

SIGNS AND SYMPTOMS OF POSTPARTUM

INFECTION

Administer broad spectrum antibiotics

Provide with warm sitz baths

Promote drainage--have pt. lie in HIGH fowlers position

Force fluids and hydrate with IV’s 3000 - 4000 cc. / day

Keep uterus contracted, give Methergine

Provide analgesics for alleviation of pain

Nasogastric suction if peritonitis develops34

TREATMENT / NURSING CARE FOR POSTPARTUM

INFECTION

TEST YOURSELF!

What is the classic sign of a Postpartum Infection?

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Pelvic Cellulitis Peritonitis

o Spiking a fever of 102 0 F to 104 0 Fo Elevated WBCo Chillso Extreme Lethargyo Nausea and Vomitingo Abdominal Rigidity and Rebound Tenderness

Signs and Symptoms:

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COMPLICATIONS OF POSTPARTUM INFECTIONS

PREVENTIVE MEASURES FOR POSTPARTUM

INFECTION Prompt treatment of anemia Well-balanced diet Avoidance of intercourse late in pregnancy Strict asepsis during labor and delivery Teaching of postpartum hygiene

measures:keep pads snugchange pads frequentlywipe front to backuse peri bottle after each elimination

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Infection of the Episiotomy, Perineal laceration, Vaginal or vulva lacerations

Wound infection of incision site

Signs:Reddened, edematous, firm, tender edges

of skinEdges separate and purulent material

drains from the wound.

Treatment:AntibioticsWound care

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LOCALIZED INFECTION

Mrs. X. was admitted with endometritis and Mrs. Y. was admitted with an infection in her cesarean incision. Are both classified as a postpartum Infection?

What would be the major difference in presenting symptoms you would note on nursing assessment?

TEST YOURSELF!

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ENDOMETRITIS Infection of the endometrium:

placental site decidua Cervix

Symptoms: discharge (scant to profuse), bloody, foul smelling uterine tenderness jagged, irregular temp elevations tachycardia, chills, subinvolution

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PYELONEPHRITIS

Kidney infection, usually of the R. kidney Ascends from bladder. Hx of asymptomatic bacteruria or pyelonephritis

Signs and Symptoms: Spiking temp Shaking chills Flank pain, CVA pain Nausea and vomiting Urgency, frequency, dysuria Back pain

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PREVENTION AND TREATMENT FOR PYELONEPHRITIS

Force fluids

Insure complete emptying of bladder

Sterile technique for cath

Good perineal care

Antibiotics

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MASTITIS

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SIGNS AND SYMPTOMS OF MASTITIS

Marked Engorgement Pain Chills Fever Tachycardia Hardness and Redness, Enlarged and tender lymph nodes

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TYPES OF MASTITIS

Types: Mammary Cellulitis - inflammation of

the connective tissue between between the lobes in the breast

Mammary Adenitis Mammary Adenitis - infection inin the ducts and lobes of the breasts

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PoorPositioning

of Infant

Im properbreaking of

suction

StrongSucking

Infant

FirstNursing

Experience

AbruptW eaning

Supplem entalFeedings

Intervalbetw een

nursing too long

"Lazy Feeder"

Development of Mastitis

Nipple Trauma Pain Impaired Engorgement Let down

Cracked Stasis nipples of milk

Entry for Bacteria Plugged ducts

MastitisTreatment, No TreatmentProblem will resolve Breast Abscess

COMPLICATION OF MASTITIS

Breast AbscessBreast Abscess

Breast Feeding is stopped on the affected side, but may feed on the unaffected side.Treatment: Incision and Drainage 47

NURSING CARE / TREATMENT OF MASTITIS

Rest Appropriate Antibiotics--Usually Cephalosporins

Hot and / or Cold Packs Don’t Breast Feeding because:

If the milk contains the bacteria, it also contains the antibiotic

Sudden cessation of lactation will cause severe engorgement which will only complicate the situation

Breastfeeding stimulates circulation and moves the bacteria containing milk out of the breast

StopStop

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PREVENTING MASTITIS

Preventive Measures

Meticulous hand washing

Frequent feedingsand massagedistended area tohelp emptying

Rotate position ofbaby on the breast

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THROMBOPHLEBITIS

Blood clot associated with bacterial infection

Etiologies: blood clotting factorspostpartal thrombocytosis (platelets)thromboplastin release (placenta,

amnion)fibrinolysin and fibrinogen inhibitors

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THROMBOPHLEBITIS Signs and Symptoms:

Tenderness Heat Redness Low grade fever + Homans sign Tachycardia

Treatment elevation heat TEDs analgesic bedrest Antibiotics

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THROMBOEMBOLIC DISEASE

Predisposing Factors: Slowing of blood in the legs Trauma to the veins

Signs and Symptoms: Sudden onset of pain Tenderness of the calf Redness and an increase in skin temperature Positive Homan’s Sign

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Nursing Care/ Treatment: Heparin --it does not cross into breast milkAntidote: protamine sulfateTeach patient to report any unusual bleeding,

or petechiae, bleeding gums, hematuria, epistaxis, etc.

Complication: Pulmonary Emboli

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THROMBOEMBOLIC DISEASE

DEEP VEIN THROMBOSIS Symptoms:

edemalow grade feverchillspain in limb

below affected area

“milk leg”decreased

peripheral pulses

Diagnosis:Doppler

Treatment:heparin to coumadinantibioticsTEDsbedrestelevationanalgesics

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PULMONARY EMBOLISM (PE)

Signs and Symptoms- of sudden onset PE:

dyspnea sweating pallor cyanosis confusion hypertension cough/hemoptysis

Tachycardia SOB Temp jugular pressure chest pain sense of impending

death pressure in

bowel/rectum

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**PE is an Obstetrical Emergency**

NURSING CARE / TREATMENT OF

PULMONARY EMBOLISM Call MD

O2

Demerol

Papaverine or other “clot busters”

Aminophylline

heparin

Streptokinase

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DISSEMINATED INTRAVASCULAR

COAGULATION (DIC) prothrombin and platelets widespread formation of intravascular

clots clotting factor expended severe generalized hemorrhaging

DIC is life threatening!

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DIC ETIOLOGIES

Septic shock

placental/uterine hemorrhage

IUFD

Amniotic fluid embolism

thrombi secondary to preeclampsia

thrombi secondary to thrombophlebitis

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EARLY SIGNS AND NURSING CARE /

TREATMENT FOR DIC Early Signs:

protime fibrinogen thrombocytopenia bleeding from gums bleeding from puncture sites Ecchymosis

Treatment complex: Packed cells Fibrinogen Whole blood Plasma 59

Signs and Symptoms:

Respirations: Rapid and shallowPulse: Rapid, weak, irregularBlood pressure: Decreasing (late sign)Skin: Cool, pale, clammy

Urinary output: Decreasing

Level of consciousness: Lethargy → coma

Mental status: Anxiety → coma

Central venous pressure: Decreased

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HEMORRHAGIC SHOCK

HEMORRHAGIC SHOCK

Nursing Care:Summon assistance and equipment.

Start intravenous infusion per standing orders.

Ensure patent airway; administer oxygen.

Continue to monitor status

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POSTPARTUM PSYCHIATRIC DISORDERS

o Mental Health problems can complicate the puerperium.

o There are days when each new mother may feel inadequate, but the mother who has a constant feeling of inadequacy needs professional counseling.

o Pregnancy alone is not a cause of a psychiatric illness.

o However, the psychological and physiological stressors relating to pregnancy may bring on an emotional crisis.

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MAJOR POSTPARTUM MOOD DISORDERS

The most common postpartum mood disorders are:Baby BluesPostpartum DepressionBipolar Disorder

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BABY BLUES

50-80% of moms are affected Self-limiting (up to 10 days)

CauseSeems to be related to changes in

progesterone, estrogen, and prolactin levels

SymptomsTearful yet happyOverwhelmed

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POSTPARTUM DEPRESSION

Risk factors:PrimiparityHistory of postpartum depressionLack of social and relational

support

Clinical therapies:Counseling and support groupsMedication (usually SSRI’s)Childcare assistance 65

POSTPARTUM PSYCHOSIS

Predisposing factorsSimilar to those of postpartum

depression

AssessmentsGrandiosityDecreased need for sleep (insomnia)Flight of ideasPsychomotor agitation/hyperactivityRejection of infant

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TREATMENT FOR MOOD DISORDERS

Drug therapy

Psychotherapy

Explain the importance of good

nutrition and rest

Reintroduce the mother to the baby at

the mothers own pace

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TEST YOURSELF!

How do the signs and symptoms of hematoma differ from those of uterine atony or a laceration?

What laboratory study should the nurse suspect if the woman is on heparin anticoagulation?

What is the significance of a board-like abdomen in a woman who has endometritis?

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TEST YOURSELF!

Why is it important that the breast-feeding mother with mastitis empty her breasts completely?

What is the KEY difference between postpartum blues and postpartum depression?

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Complications of Post Partum

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