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?