Dr Maryam

Postpartum complications

Dr Maryam

Remember!!!

Majority of death occurduring puerperium

Dr Maryam

Although the puerperium is usually a period of health , complications can occur .

When the complications happened , immediate intervention is essential to prevent long-term disability and interference with parent-child relationships .

Prevention of the complications is very essential .

Dr Maryam

Most postpartal complications are preventable

And

If they do occur , the majority can be treated effectively .

Dr Maryam

Postpartum Hemorrhage

Dr Maryam

. . . the most common and severe type of obstetric hemorrhage, is an enigma even to the present day obstetrician as it is sudden, often unpredicted, assessed subjectively and can be catastrophic. The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period.

Postpartum Hemorrhage

Dr Maryam

Obstetrical emergency that can follow vaginal or cesarean delivery

Definition: Any blood loss from the uterus greater than 500 cc in NSVD or 1000 in C section . ◦ Early : Within the first 24 hours ◦ Late : Any time after the first 24 hours during the

remaining days of the 6-week puerperium

Excessive bleeding that makes the patient symptomatic (lightheaded, syncope) and/or results in signs of hypovolemia (hypotension, tachycardia, oliguria)

Postpartum Hemorrhage

Dr Maryam

Difficult Mostly Visual estimation (So, Subjective &

Inaccurate) Underestimation is likely Clinical picture -Misleading Our mothers-malnourished, anemic, less

blood volume

ASSESSMENT OF BLOOD LOSS AFTER DELIVERY

Dr Maryam

Uterine atony Lacerations

◦ Episiotomy◦ Tear

Early PPH

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Or relaxation of the uterus The most frequent cause of early PPH

Uterine atony

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◦ Prolonged and difficult labor◦ Previous PPH◦ Overdistended uterus ( multiple gestation ,

hydramnios, large baby ) ◦ Use of magnesium sulfate, preeclampsia◦ Induction or augmentation of labor◦ Operative birth ◦ Rapid birth ◦ High parity

Risk Factors for Postpartum hemorrhage

Dr Maryam

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

Dr Maryam

SYMPTOMS & SIGNSBlood loss (% B Vol)

Systolic BP( mm of Hg)

Signs & Symptoms

10-15 Normal postural hypotension

15-30 slight fall PR, thirst, weakness

30-40 60-80 pallor,oliguria, confusion

40+ 40-60 anuria, air hunger, coma, death

Dr Maryam

The first step in controlling hemorrhage is to attempt uterine massage to encourage contraction .

Remain with the woman after massaging her fundus , to be certain the uterus is not relaxing again .

Observe carefully , including fundal height and consistency and lochia for the next 4 hours .

If the uterus cannot remain contracted , a dilute IV infusion of oxytocin (pitocin) to help the uterus maintain tone .

The usual dosage of oxytocin : 10-40 IU per 1000 ml of RL .

Nursing interventions in uterine atony

Dr Maryam

Dr Maryam

Offer a bedpan or assist the woman with ambulating to the bathroom at least every 4 hours to keep her bladder empty .

A full bladder pushes an uncontracted uterus into an even more uncontracted state .

To reduce bladder pressure ,insertion of a urinary catheter may be ordered.

Obtain vital signs frequently and make sure to interpret them accurately , looking for trends .For example , a continuously rising PR is an omnious pattern .

If the woman is experiencing respiratory distress from decreasing blood volume , administer oxygen by face mask at a rate of 4 L/ min . Position her supine to allow adequate blood flow to her brain and kidneys.

Nursing interventions in uterine atony,cont

Dr Maryam

Carboprost (Hemabate) 250mcg IM q15-90min up to 2mg

Methylergonovine (Methergine) 0.2mg IM q2-4h

Other uterotonic drugs

Dr Maryam

Small lacerations or tears of the birth canal are common .

Large lacerations are complications . After birth , any time uterus feels firm but bleeding

persists, suspect a laceration of one these 3 sites : ◦ Vaginal ◦ Cervical ◦ Perineal

First degree : the skin only 2nd degree : Perineal muscle but not the anal sphincter 3rd degree : anal sphincter 4th degree : rectal or anal mucosa

Lacerations

Dr Maryam

Simple adhesion: The placenta may fail to separate completely from the uterine muscle due to lack of contraction of the uterine muscles( The placenta is said to be retained when it is not expelled from the uterus even 30 minutes after the delivery of the baby) . This is is the commonest cause for retention of placenta.

Manual separation can be done easily.

Late PPH : RETAINED PLACENTA

Dr Maryam

Dr Maryam

Morbid adhesion :Morbid adhesion of the placenta can occur when the placenta is implanted deeply into the uterine muscles and thus fails to separate

◦ Accreta : An invasion of the myometrium which does not penetrate the entire thickness of the muscle.

◦ Increta :Occurs when the placenta further extends into the myometrium.

◦ Percreta :The worst form of the condition is when the placenta penetrates the entire myometrium to the uterine serosa(invades through entire uterine wall).

The safest treatment is a planned cesarian section and abdominal hysterectomy if placenta accreta is diagnosed before birth.

Late PPH : RETAINED PLACENTA

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Occasionally , a placenta does not deliver in its entirety ; fragments of it separate and are left behind .

The portion retained keeps the uterus from contracting fully , uterine bleeding occurs .

Removal of the placental fragments is necessary to stop the bleeding .

Retained placental fragments

Dr Maryam

Is incomplete return of the uterus to its prepregnant size and shape .

In this case , at a 4-6-week postpartal visit , the uterus is still enlarged and soft

subinvolution

Dr Maryam

A collection of blood in the subcutaneous layer of tissue of the perineum .

The overlying skin , as a rule , is intact with no noticeable trauma .

Report the presence of the hematoma , its size , and the degree of the woman’s discomfort

Perineal hematomas

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Theoretically , the uterus is sterile during pregnancy and until the membranes rupture .After rupture , pathogens can invade .

The risk of infection is even greater if tissue edema and trauma are present .

Puerperal infection

Dr Maryam

Using an appropriate antibiotic after culture and sensitivity

Organisms commonly cultured postpartally :◦ Group B streptococci◦ Aerobic gram-negative bacilli such as Escherichia

coli

Therapeutic management

Dr Maryam

An increase in oral temperature to more than 100.4 F ( 38 C ) for two consecutive 24 –hour periods , excluding the first 24-hour period after birth

Febrile condition suggesting infection

Dr Maryam

Infection of the decidua (pregnancy endometrium):

fever on the 3rd or 4th postpartal day . ◦ lower abdominal tenderness on one or both sides

of the abdomen, ◦ adnexal and parametrial tenderness elicited with

bimanual examination,

Postpartum Endometritis

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◦ If a woman has a suture line on her perineum from episiotomy or a laceration repair , a portal of entry exist for bacterial invasion

◦ erythema, ◦ edema, ◦ tenderness out of proportion to expected

postpartum pain, ◦ discharge from the wound or episiotomy site.

◦ Drainage from wound site should be differentiated from normal postpartum lochia and foul-smelling lochia, which may be suggestive of endometritis.

Wound infections or episiotomy infections,

Dr Maryam

Dr Maryam

Inflammation with the formation of blood clots.

In postpartal period , it is usually an extension of an endometrial infection.

Classified : ◦ Superficial vein disease ( SVD ) ◦ Deep vein thrombosis ( DVT )

thrombophlebitis

Dr Maryam

Using a good aseptic technique Ambulation and limiting the time woman

remains in a bed

Prevention of thrombophlebitis

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Obstruction of the pulmonary artery by a blood clot

It usually occurs as a complication of thrombophlebitis

Pulmonary embolous

Dr Maryam

Infection of the breast May occur as early as the 7th postpartal day rapid onset very tender, engorged, erythematous breasts Infection frequently is unilateral. During lactation are common

Mastitis

Dr Maryam

Breast infections can be very aggressive with high fevers developing quickly.

Immediate treatment is important to keep an otherwise simple mastitis from developing an abscess, requiring surgical drainage.

Dr Maryam

Usually caused by common skin bacteria (particularly staphylococcus) being introduced into the ductal system through cracked nipples and the inoculation by the newborn suckling.

Dr Maryam

Occurs as a result of inadequate bladder emptying .

Urinary retention

Dr Maryam

A woman who is catheterized at the time of childbirth or during the postpartal period is prone to development of UTI .

Symptoms :◦ Dysuria ◦ Hematuria ◦ Frequent urination ◦ Sharp pain during voiding

Urinary tract infection

Dr Maryam

Urinalysis Urine culture Antibiotic therapy

Therapeutic Management