c omplications of p ostpartum. p ostpartum h emorrhage early occurs when blood loss is greater than...
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COMPLICATIONS OF POSTPARTUM
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
hours
MAIN CAUSES OF EARLY HEMORRHAGE ARE:
Uterine Atony
Lacerations
Retained Placental Fragments
Inversion of the Uterus
Placenta Accreta
Hematomas
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
UTERINE ATONY PREDISPOSING FACTORS
Prolonged labor
Overdistentionof theUterus
Grandmultiparity
Excessive use of Analgesia / Anesthesia
IntrapartumStimulation with Pitocin
Trauma dueto Obstetrical Procedures
UTERINE ATONY Most common cause of Hemorrhage
Key to successful management is:
PREVENTION!
Nurse many times can predict which women are at risk for hemorrhaging.
UTERINE ATONY
Signs and Symptoms
Excessive orBright Red Bleeding
Abnormal Clots
A boggy uterus that does not respond to massage
Unusual pelvic discomfort or backache
NURSING CARE OF UTERINE ATONY
Document Vaginal Bleeding
Fundal massage / Bimanual Compression
Assess Vital Signs (shock)
Give medications--Pitocin, Methergine, Hemabate
D & C, Hysterotomy/ectomy, Replace blood / fluids
POST PARTUM HEMORRHAGE *LACERATIONS*
PREDISPOSING FACTORS1. Spontaneous or Precipitous delivery2. Size, Presentation, and Position of baby3. Contracted Pelvis4. Vulvar, cervical, perineal, uretheral area and
vaginal varices
Signs and Symptoms 1. Bright red bleeding where there is a steady trickle of blood and the uterus remains
firm. 2. Hypovolemia
POSTPARTUM HEMORRHAGE
*LACERATIONS*
Treatment and Nursing Care1. Meticulous inspection of the entire lower birth canal2. Suture any bleeders3. Vaginal pack-- nurse may remove and assess bleeding after removal4. Blood replacement
TEST YOURSELF !
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
This occurs when there is incomplete separation of the placenta and fragments of placental tissue retained.
Signs Boggy , relaxed uterus Dark red bleeding
Treatment D & C Administration of Oxytocins Administration of Prophylactic antibiotics
HEMATOMA
Major Symptom: PAIN- deep, severe, unrelieved, feelings of pressure
Many times bleeding is concealed. Major symptom is rectal pain and tachycardia.
Treatment: May have to be incised and drained.
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”
INVERSION OF THE UTERUS
Traction onthe cordstarts the uterus toinvert
Uterus continuesto be pulled andinverted
Uterus
Placenta
INVERSION OF THE UTERUS
Vagina
UterusInverted
Vagina
Uterus Manually pushed backinto place
TREATMENT AND NURSING CARE
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 ileusNotify the Recovery Nurse what has
occurred!Care must be taken when massaging
PLACENTA ACCRETA
All or part of the decidua basalis is absent and the Placenta grown directly into the uterine muscle.
PLACENTA ACCRETASigns:
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
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!
LATE POSTPARTUM HEMORRHAGE
Most common cause is Retained Placental fragments
Sub involution
Treatment D & CMethergine
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
POSTPARTUM INFECTIONS DefinitionDefinition
Infection of the genital tract that occurs
within 28 days after abortion or delivery
Causes Streptococcus Groups A and B Clostridium, E. Coli
POSTPARTUM INFECTIONS
Predisposing Factors 1. Trauma
2. Hemorrhage3. Prolonged labor4. Urinary Tract Infections5. Anemia and Hematomas6. Excessive vaginal exams 7. P R O M
CRITICAL TO REMEMBER
Signs and Symptoms of Postpartum Infection 1.1.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. 2. 2. Foul smelling lochia, discharge 3. 3. Malaise, Anorexia, Tachycardia, chills
4. 4. Pelvic Pain
5. 5. Elevated WBC
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 develops
TREATMENT AND NURSING CARE
What is the classic sign of a Postpartum Infection?
Test Yourself !
COMPLICATIONS OF POSTPARTUM INFECTIONS
Pelvic Cellulitis Peritonitis
Spiking a fever of 102 0 F to 104 0 FElevated WBCChillsExtreme LethargyNausea and VomitingAbdominal Rigidity and Rebound Tenderness
Signs and Symptoms:
PREVENTIVE MEASURES
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
LOCALIZED INFECTION
Infection of the Episiotomy, Perineal laceration, Vaginal or vulva lacerations
Wound infection of incision site Signs:
Reddened, edematous, firm, tender edges of skin
Edges seperate and purulent material drains from the wound.
TreatmentAntibioticsWound care
CHECK YOURSELFCHECK YOURSELFCHECK YOURSELFCHECK YOURSELF
Mrs. X. was admitted with endometritis
and Mrs. Y. was admitted with an infection
in her cesarean incision. Are both classified
as a Puerperal Infection?
What would be the major difference in
presenting symptoms you would note on
nursing assessment?
POSTPARTUM CYSTITIS
POSTPARTUM CYSTITIS• Prevention:
• Monitor the patients urination diligently!• Don’t allow to go longer than 3 - 4 hours before
intervening.• Treatment
• Antibiotics -- Ampicillin• Urinary Tract Antispasmodics
• Causes:• Stretching or Trauma to the base of the bladder
results in edema of the trigone that is great enough to obstruct the urethra and to cause acute retention.
• Anesthesia
MASTITISMarked EngorgementPainChills, Fever, TachycardiaHardness and RednessEnlarged and tender lymph nodes
MASTITIS
Types:
Mammary Cellulitis - inflammation of the connective tissue betweenbetween the lobes in the breast
Mammary AdenitisMammary Adenitis - infection inin the ducts and lobes of the breasts
PoorPositioning
of Infant
Im properbreaking of
suction
StrongSucking
Infant
FirstN ursing
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
Mastitis
Treatment, Problem will resolve Breast Abscess No Treatment
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
MASTITIS
Preventive Measures
Meticuloushandwashing
Frequent feedingsand massagedistended area tohelp emptying
Rotate position ofbaby on the breast
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
THROMBOEMBOLIC DISEASEPredisposing Factors
Slowing of blood in the legsTrauma to the veins
Signs and SymptomsSudden onset of painTenderness of the calfRedness and an increase in skin
temperaturePositive Homan’s Sign
TreatmentHeparin --it does not cross into breast milkAntidote: protamine sulfateTeach patient to report any unusual bleeding, or
petchiae, bleeding gums, hematuria, epistaxis, etc.
ComplicationPulmonary Emboli
POSTPARTUM PSYCHIATRIC DISORDERS
Pregnancy alone is not a cause of a psychiatric Illness; however, the psychological and physiological stressors relating to pregnancy may bring on an emotional crisis
Mental Health problems can complicate the puerperium.
There are days when each new mother may feel
inadequate, but the mother who has a constant
feeling of inadequacy needs professional counseling.
MOOD DISORDERS
The Most common Mood Disorders are:Adjustment reaction with mood
depression “baby blues”Postpartum major mood
disorder “Postpartum Depression”
Postpartum psychosis
“BABY BLUES”
50-80% of moms are affected Self-limiting (up to 10 days) Cause
Seems to be related to changes in progesterone, estrogen and prolactin levels
Symptoms Tearful yet happy Overwhelmed
Treatment
POSTPARTUM MAJOR MOOD DISORDER “POSTPARTUM DEPRESSION” Risk factors:
Primiparity History of postpartum depression Lack of social and relationship support
Clinical Therapy: Counseling, support groups Medication (usually SSRI’s) Childcare assistance
POSTPARTUM PSYCHOSIS Predisposing Factors:
Similar to those of postpartum depression
Assessment:GrandiosityDecreased need for sleep (insomnia)Flight of ideasPsychomotor agitation / hyperactivityRejection of infant
TREATMENT FOR MOOD DISORDERS
Drug therapy (previous slide)
Psychotherapy
Explain importance of good nutrition and rest
Some of her feelings may seem “unreasonable”
Re-introduce the baby to the mother at the
mother’s own pace
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?
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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