Complications of the Complications of the Postpartum PeriodPostpartum Period

HemmorhageHemmorhage

• Early postpartum hemmorhageEarly postpartum hemmorhage– >500 ml in first 24 hrs (blood loss often

underestimated)

• Late or delayedLate or delayed– >500 cc after first 24 hrs.

Predisposing factorsPredisposing factors

• Uterine overdistension--large infant,etc.• Grand multiparity

• Anesthesia or MgSO4

• Trauma• Abnormal labor pattern--hypo or hypertonia• Oxytocin during labor• Prolonged labor• Hx of maternal anemia, hemorrhage

PreventionPrevention

• Risk assessment

• Inspect placenta

• Explore uterus

• Avoid overmanipulation of uterus

• If at risk type and Xmatch and start IV

Signs of Impending Signs of Impending HemorrhageHemorrhage

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

• Light headedness, nausea, visual disturbances

• Anxiety, pale/ashen color, clammy skin

• Increasing P and R, BP same or lower

Actions to takeActions to take

• Summon help

• Check uterine tone, massage, assess effect

• Elevate legs, lower head

• Increase or begin O2

• Increase or begin IV

Early Postpartum HemorrhageEarly Postpartum Hemorrhage

Within the first 24 hrs

• Causes– uterine atony– lacerations– retained secundines– coagulation problems

Uterine atonyUterine atonyFailure of the uterus to stay firmly contractedFailure of the uterus to stay firmly contracted

• Slow, steady or massive hemorrhage, sometimes underestimated or hidden behind a clot

• VS may not change immediately

TreatmentTreatment

• bimanual massage

• oxytoxics

• curretage

• surgery iliac ligation or hysterectomy

Retained placenta or fragmentsRetained placenta or fragmentsPartial separation caused by:

• pulling on the cord

• uterine massage prior to separation

• placenta accreta

Treatment:

• massage

• manual removal

• oxytoxics

• D & E

Late postpartum hemorrhageLate postpartum hemorrhage

Hemorrhage occurring after 24 hrs

• retained placenta--necrosed, fibrin deposits, placental polyps, sloughingbleeding

Symptoms• excessive or bright red

bleeding• boggy fundus• large clots• backache T-P-R, BP

Treatment, massage, IV oxytocin, D&E

HematomasHematomas

Result from injury to a blood vessel, usually in vagina or vulva, may extend upward into broad ligament or other pelvic structures

• develop rapidly

• may contain 300-500ml blood

SymptomsSymptoms

• Severe pain

• Difficulty voiding

• Mass felt on vaginal exam

• Flank pain

• Abdominal distension

• Shock

TreatmentTreatment

• Ice

• I & D (incision and drainage)

• Packing

SubinvolutionSubinvolutionUterus 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• curretage• antibiotics

Puerperal InfectionPuerperal Infection

Definition:

Temp of 101o or more in the first 24 hrs following delivery

Temp of 1004 or higher on any 2 of the first10 pp days (with the exception of the first 24 hrs)

Types of InfectionsTypes of Infections

• Endometritis

• Parametritis

• Peritonitis

• Pyelonephritis

• Cystitis

• Thrombophlebitis

• Mastitis, abcess

Predisposing FactorsPredisposing Factors

Antenatal factors

• poor nutrition

• low SES

• Hx of Infections

• Anemia

• Immunodeficiency

Intrapartum predisposing Intrapartum predisposing factorsfactors

• Prolonged labor• PROM• Poor aseptic technique• Birth trauma• Multiple exams• Internal monitoring• Episiotomy• C section

Postpartum Predisposing Postpartum Predisposing FactorsFactors

• Manual removal of placenta

• Hemorrhage

• Retained secundines

Causative OrganismsCausative Organisms

Aerobic 30%• B hemolitc strep• E.coli• Klebsiella• Proteus• Pseudomonas• Staph

Anerobic 70%• Bacteriodes• Peptococcus• C. perfringes

LocalizedLocalized

• Episiotomy

• Lacerations

• C section incision

EndometritisEndometritisInfection of the endometrium

• placental site

• decidua

• cervix

Symptoms--discharge (scant to profuse), bloody, foul smelling

uterine tenderness

jagged, irregular temp elevations

tachycardia, chills, subinvolution

Salpingitis, OopheritisSalpingitis, Oopheritis

May be caused by gonorrhea, chlamidia

• unilateral or bilateral abd pain

• chills, fever

• mass

• tachycardia

• may lead to sterility

Pelvic Cellulitis, (parametritis)Pelvic Cellulitis, (parametritis)

Infection of the connective tissue of pelvis

• frequently infecting the broad ligament and causing severe pain.

• May ascend from cervical lacerations

Parametritis symptoms• Spiking temp to 104• chills, flushing, sweating• tachycardia, tachypnea• uterine tenderness, cramping• change in LOC/agitation,delerium,

disorientation• change in lochia• cervical or uterine tenderness on vag exam• WBC elevation

PeritonitisPeritonitis

Life threatening infection of the peritoneum

• Abcesses on the uterine ligaments, in the cul de sac, and/or in the subdiaphragmatic space

• May result from pelvic thrombophlebitis

Symptoms of PeritonitisSymptoms of Peritonitis

• High temp

• chills

• malaise

• lethargy

• pain

• subinvolution

• Tachycardia• local or referred pain• rebound tenderness• thirst• distension• nausea and vomiting

CystitisCystitis

Bladder infection

• urgency

• frequency

• burning

• dysuria

• suprapubic pain

• hematuria

PyelonephritisPyelonephritisKidney infection, usually of the R. kidney.Ascends from bladder.•Spiking temp•Shaking chills•Flank pain, CVA pain•Nausea and vomiting•Hx of asymptomatic bacteruria or pyelonephritis•Urgency, frequency, dysuria•Back pain

Prevention and treatmentPrevention and treatment

• Force fluids

• Insure complete emptying of bladder

• Sterile technique for cath

• Good perineal care

• Antibiotics

Thrombophlebitis Thrombophlebitis Blood clot associated with bacterial infection

Etiologies blood clotting factors

• postpartal thrombocytosis (platelets)

• thromboplastin release (placenta, amnion)fibrinolysin and fibrinogen inhibitors

Superficial

• Tenderness• heat• redness• low grade fever• + homans sign• tachycardia

Treatment• elevation• heat• TEDs• analgesic• bedrest?• Antibiotics?

Deep Vein Thrombosis

Symptoms• edema• low grade fever• chills• pain in limb below

affected area• “milk leg”• decreased peripheral

pulses

Dx--doppler

Tx:• heparin to coumadin• antibiotics• TEDs• bedrest• elevation• analgesics

Pulmonary Embolisman Obstetrical emergency

Symptoms--sudden onset• dyspnea• sweating• pallor• cyanosis• confusion• hypertension• cough/hemoptysis

• Tachycardia• SOB Temp jugular pressur• chest pain• sense of impending

death• pressure in

bowel/rectum

Treatment

• Call MD

• O2

• Demerol

• Papaverine or other “clot busters”

• Aminophylline

• heparin

• Streptokinase

Disseminated Intravascular Coagulation (DIC)

prothrombin and platelets

• widespread formation of intravascular clots

• clotting factor expended

• severe generalized hemorrhaging

Life threatening!

Etiologies

• Septic shock

• placental/uterine hemmorhage

• IUFD

• Amniotic fluid embolism

• thrombi secondary to preeclampsia

• thrombi secondary to thrombophlebitis

Early signs of DIC

protime fibrinogen

• thrombocytopenia

• bleeding from gums

• bleeding from puncture sites

• ecchymosis

Treatment complex, packed cells, fibrinogen, whole blood, plasma