POSTPARTUM COMPLICATIONS

1
POSTPARTUM COMPLICATIONS

• CHAPTER 18

2
FIVE CATEGORIES OF COMPLICATIONS

• Hemorrhage
• Thromboembolic disorders
• Subinvolution of the uterus
• Infections
• Depression

3
POSTPARTUM HEMORRHAGE

• MOST COMMON CAUSE OF EXCESSIVE BLEEDING DURING
  CHILDBEARING CYCLE
• DEFINED AS LOSS OF MORE THAN 500 ML OF BLOOD
  FOLLOWING UNCOMPLICATED VAGINAL BIRTH OR 1000ML
  OF BLOOD AFTER C-S
• FIRST 24 HOURS IS MOST CRITICAL TIME
• BOX 18-1 RISK FACTORS

4
PP HEMORRHAGE

• NOTORIOUSLY INACCURATE-WHY?
• DUE TO INCREASE IN BLOOD VOLUME DURING PREGNANCY
  THE WOMAN CAN TOLERATE MOST BLOOD LOSS IF NOT
  EXCESSIVE
• HH WILL DECREASE SLIGHTLY WITH 450-500ML OF
  BLOOD LOSS
• MAJOR CAUSES uterine atony, laceration of
  vagina, cervix, perineum, and retained placental
  fragments

5
STAGES OF PP HEMORRHAGE

• EARLY PP HEMORRHAGE-1ST 24 HR CAUSED BY UTERINE
  ATONY LACERATION
• LATER PP HEMORRHAGE- FROM 24 HOURS TO 6 WEEKS PP
  CAUSED BY RETAINED PLACENTAL FRAGMENTS
  SUBINVOLUTION OF THE UTERUS

6
UTERINE ATONY (hypotonic uterus)

• The inability of the uterine muscle to contract
  stay contracted around the open blood vessels
• 1 CAUSE OF EARLY PP HEMMORHAGE
• Placental fragments, clots, extreme uterine
  distention, precipitate births, forceps, lactic
  acid build-up r/t exhaustion, hypocalcemia, drugs
  like Magnesium Sulfate to prevent seizures

7
LACERATIONS TRAUMA

• Lacerations- tears in the vagina, cervix, or
  perineum. May occur with difficult or
  precipitate deliveries, large newborn, use of
  forceps or vacuum extractors
• S/S - excessive bleeding with a firm fundus
  blood is usually bright red continuous
  trickling of blood out of the vagina

8
RETAINED PLACENTA HEMATOMA

• Retained Placenta
• may result in early or late bleeding
• examine the placenta
• oxytocin given after delivery of placenta to
  help them be expelled completely
• may require DC
• placenta accreta placenta adheres to uterine
  wall must be surgically removed

• Hematomas
• perineal pain with firm uterus
• bulging, bluish mass in perineal area

9
Coagulation Pathology

• DIC
• Clotting anticoagulation occur at the same time
• treat the cause which may be abruptio
  placentae, gestational HTN, missed AB, fetal
  death in utero

• Von Willebrands Disease
• an inherited disorder with defect in platelet
  function
• treated with administration of clotting factor
• Amniotic Fluid Embolism
• when the amniotic fluid enters the mothers
  blood circulation causes an anaphylactic
  reaction. Can result in death

10
Prevention of Hemorrhage

• Use of Pitocin after delivery of placenta
• Massage of the uterine fundus
• Assessment of fundus bleeding with prompt
  intervention

11
Signs and Symptoms of PP Hemorrhage

• Boggy uterus (not firm about the size of a
  grapefruit)
• Uterus above level of umbilicus
• Excessive lochia

12
Assessment Management of PP Hemorrhage box
18-2, nursing care plan 18-1

• ID the cause of the hemorrhage
• Stop the blood loss
• Start or maintain IV fluids
• Monitor V/S
• Provide 02
• Insert f/c to measure accurate IO to assess
  kidney function
• Accurate assessment of blood loss by weighing
  pads underpads 1G1ML/CC

13
WHAT CAN YOU AS THE NURSE DO?

• ADMINISTER IV OXYTOCIN AS PRESCRIBED TO CAUSE THE
  UTERUS TO CONTRACT
• MASSAGE THE UTERUS IN A CIRCULAR MOTION AND
  EXPRESS CLOTS
• MONITOR LOCHIA CAREFULLY!
• NEVER push on an uncontracted uterus- can cause
  inversion and hemorrhage!!
• Fig 18-1

14
THROMBOPHLEBITIS THROMBOEMBOLISM

• Vein Inflammation
• Box 18-3-Risks
• May affect superficial or deep veins
• measures to prevent thrombophlebitis- Fast
  Focus 18-1
• rest, TED hose analgesics

• Deep Vein Thrombosis pain and edema in the calf
  Homans sign
• more common w/ C-sections
• IV Heparin is started
• PTTS are done
• Protamine Sulfate is on hand Heparin antidote

15
PULMONARY EMBOLISM

• ONE OF THREE LEADING CAUSES OF MATERNAL DEATH
• OCCURS WHEN FRAGMENTS OF A BLOOD CLOT DISLODGE
  AND ARE CARRIED TO THE PULMONARY ARTERY WHERE
  THEY CAN OCCLUDE THE VESSEL
• IF CIRCULATION IS COMPROMISED, DEATH MAY OCCUR IN
  MINUTES!!

16
THE DIAGNOSIS

• VENTILATION/PERFUSION SCAN
• BLOOD GASES
• X-RAYS
• PULMONARY ANGIOGRAM
• REQUIRES ICU CARE
• CRISIS INTERVENTION WITH EMERGENCY TEAM

17
SIGNS AND SYMPTOMS

• CHILLS
• HYPOTENSION
• DYSPNEA
• CHEST PAIN
• ABDOMINAL PAIN
• TACHYPNEA AND APPREHENSION

18
IMMEDIATE NURSING ACTION

• ELEVATE HOB
• O2 BY MASK
• IV FLUIDS
• PULSE OX
• FREQUENT V/S
• HEPARIN

19
POSTPARTUM INFECTIONS

• First category
• REPRODUCTIVE SYS. INFECTIONS, PUERPERAL INFECTION
  AND FEVER
• BACTERIAL INFECTIONS OF GENITAL TRACT

• Second category
• SITES OTHER THAN GENITAL TRACT Include
  MASTITIS, UTIS, AND ARE R/T PREGNANCY, LABOR,
  BIRTH, AND LACTATION

20
INFECTIONS--SEE FAST FOCUS 18-2 BOX 18-4

• Uterus vagina open after vaginal delivery
  provide easy access to microorganisms
• Most effective method of prevention is scrupulous
  aseptic technique during labor, delivery post
  partum
• Each vaginal exam increases the risk of pathogens
  entering the vagina
• Increased risk of infection with c-sections due
  to altered skin integrity

21
ENDOMETRITIS

• Most common puerperal infection
• If not treated can spread to peritoneum become
  peritonitis
• S/S onset within 24 hrs of delivery, uterine
  tenderness enlargement, foul odor to lochia,
  malaise, fatigue, tachycardia, elevated
  temperature
• Nursing care blood cultures, supportive care to
  include administration of antibiotics lochia,
  pain relief

22
WOUND INFECTION

• Most common site is the perineum c-s surgical
  incision
• Use REEDA for assessment of perineum
• S/S fever, increased drainage, redness, warmth
  of site
• Stress importance of frequent perineal hygiene
  peri pad changes

23
URINARY TRACT INFECTIONBox 18-4

• May occur after birth due to hypotonia of
  bladder, urinary stasis, birth trauma, catheter
  insertion, frequent vag exams, or epidural
  anesthesia
• S/S dysuria, frequency, urgency, low-grade
  fever
• Pylonephritis may develop with CVA tenderness,
  chills, fever, hematuria
• Cystitis usually treated on outpatient basis with
  antibiotics
• Nursing stress proper perineal hygiene, wiping
  the perineum from front to back

24
MASTITIS

• Infection of the breasts may occur as early as
  the 7th postpartum day or 2-3 weeks later
• Risks milk stasis, nipple trauma, poor
  breastfeeding technique, improper handwashing

• S/S painful, tender localized hard mass
  reddened area to usually one breast, fever,
  chills, malaise
• Treatment antibiotics, complete emptying of
  both breasts with feeding, wear a supportive bra
• Fast focus 18-3

25
POSTPARTUM BLUES DEPRESSION

• 1. POSTPARTUM BLUES
• 2. POSTPARTUM DEPRESSION
• 3. POSTPARTUM PSYCHOSIS

26
THE BLUES

• TRANSIENT WEEPINESS
• MOOD CHANGES
• ANXIETY
• IRRITABILITY
• FEW DAYS PP TO 10-14 DAYS
• CAUSE- HORMONES?

27
DEPRESSION

• S/S wt loss, sleeplessness, ambivalence towards
  the newborn family
• If S/S present refer for MD follow up sooner than
  the traditional 6 weeks
• Risks
• hx of previous depressive episodes
• hx of limited support system
• low self-esteem
• dissatisfaction with education, economics, or
  partner choice

28
PSYCHOSIS

• S/S signs of depression, suicidal thoughts,
  delusions
• Mother child are at risk
• Should be referred for psychiatric treatment
• Nursing provide support, encourage expression
  of feelings, validate feelings, support groups,
  marital counseling as needed