Complications

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Complications Of Postpartum
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Postpartum Hemorrhage
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Postpartum Hemorrhage

• Early
• Occurs 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.)
• Late
• Hemorrhage that occurs after the first 24 hours

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Postpartum Hemorrhage

• Other definitions
• A decrease in the hematocrit of 10 points between
  time of admission and time postbirth
• Need for fluid replacement following childbirth

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Main Causes of Early Hemorrhage are

• Uterine Atony
• Lacerations
• Retained Placental Fragments
• Inversion of the Uterus
• Placenta Accreta

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Uterine Atony
The myometrium fails to contract and the uterus
fills with blood because of the lack of pressure
on the open blood vessels of the placental
site.
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Uterine Atony
Predisposing Factors
Prolonged labor
Overdistention of the Uterus
Trauma due to Obstetrical Procedures
Grandmultiparity
Intrapartum Stimulation with Pitocin
Excessive use of Analgesia / Anesthesia
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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.

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Uterine Atony
A boggy uterus that does not respond to
massage
Abnormal Clots
Signs and Symptoms
Excessive or Bright Red Bleeding

Unusual pelvic discomfort or backache
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Nursing Care

• Assess and Document Bleeding
• Fundal massage and express clots
• Bimanual Compression
• Assess Vital Signs (shock)

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Nursing Care

• Give medications
• Pitocin
• Methergine
• Carboprost Tromethamine (Hemabate)
• (May inject the medications directly
• into the uterus)
• Replace blood / fluids
• D C, Hysterectomy

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Trauma
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Post Partum HemorrhageLacerations

• PREDISPOSING FACTORS
• 1. Spontaneous or Precipitous delivery
• 2. Size, Presentation, and Position of baby
• 3. Contracted Pelvis
• 4. Vulvar, perineal, 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

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POSTPARTUM HEMORRHAGELACERATIONS

• Treatment and Nursing Care
• 1. Meticulous inspection of the entire
• lower birth canal
• 2. Suture any bleeders
• 3. Vaginal pack-- nurse may remove and
• assess bleeding after removal
• 4. Blood replacement

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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?
• Answer feel the fundus- if firm

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Hematoma
Bleeding into the soft tissues surrounding the
episiotomy or laceration. May follow forceps
or vacuum extraction
A unit or more of blood may be in the hematoma
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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.

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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.
• Dont pull on the cord unless the placenta has
  separated.
• Incorrect traction / pressure applied to the
  fundus, when the uterus is flaccid
• Dont use the fundus to push the placenta out

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Inversion of the Uterus
Placenta
Uterus
Uterus continues to be pulled and inverted
Traction on the cord starts the uterus to invert
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Inversion of the Uterus
Uterus Manually pushed back into place
Vagina
Vagina
Uterus Inverted
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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 ileus
• Notify the Recovery Nurse what has occurred!
• Care must be taken when massaging

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Placenta Accreta
All or part of the decidua basalis is absent and
the Placenta grows directly into the uterine
muscle.
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Placenta Accreta

• Signs
• 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
• Removal of the uterus Hysterectomy

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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!

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Late Postpartum Hemorrhage
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Late Postpartum Hemorrhage

• Most common cause is Retained Placental fragments
• Sub involution
• Treatment
• D C
• Methergine

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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

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Are these Early, Late, or Both ?

• Uterine Atony
• Retained placental fragments
• Lacerations
• Inversion of the uterus
• Placenta accreta
• Hematoma

• _________________
• _________________
• _________________
• _________________
• _________________
• _________________

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ReviewEarly Signs of Hemorrhage

• An uncontracted uterus boggy
• Large gush, steady trickle, oozing, or seeping of
  blood from the vagina
• Saturation of more than one pad in 15 minutes
• Severe unrelieved perineal or rectal pain
• Tachycardia

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ReviewHypovolemic Shock

• Signs
• Tachycardia
• Drop in B/P
• Narrowing of pulse pressure
• Tachypnea
• Skin becomes pale and cool and can progress to
  cold and clammy
• Becomes anxious ? confused ?lethargic
• Urinary output decreases
• Treatment
• Blood/Fluid replacements, oxygen, surgery

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Thromboembolic Disorder

• Predisposing Factors
• Slowing of blood in the legs
• Trauma to the veins
• Hypercoagulation
• Signs and Symptoms
• Sudden onset of pain
• Tenderness of the calf
• Reddness and an increase in skin temperature
• Positive Homans Sign

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Thromboembolic Disease

• Treatment
• Heparin --it does not cross into breast milk
• Antidote protamine sulfate
• Teach patient to report any unusual bleeding, or
  petchiae, bleeding gums, hematuria, epistasis,
  etc.
• Complication
• Pulmonary Emboli

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When a postpartum patient Complains of chest
pain or severe dyspnea Respond quickly Usually
sign of Pulmonary Emboli
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Puerperal Infection
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Puerperal Infections

• Definition
• Infection of the genital tract that
  occurs within 28 days after abortion or
  delivery
• Causes
• Streptococcus Groups A and B
• Clostridium, E. Coli

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Puerperal Infections

• Predisposing Factors
• 1. Trauma
• 2. Hemorrhage
• 3. Prolonged labor
• 4. Urinary Tract Infections
• 5. Anemia and Hematomas
• 6. Excessive vaginal exams
• 7. P R O M

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Critical to Remember

• Signs and Symptoms of Puerperal Infection
• 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. Foul smelling lochia, discharge
• 3. Malaise, Anorexia, Tachycardia, chills
• 4. Pelvic Pain
• 5. Elevated WBC

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PUERPERAL INFECTION

TREATMENT AND NURSING CARE

• Administer Broad Spectrum Antibiotics
• Provide with warm sitz baths
• Promote drainage--have pt. lie in HIGH fowlers
  position
• Force fluids and hydrate with IVs 3000 - 4000
  cc. / day
• Keep uterus contracted, give methergine
• Provide analgesics for alleviation of pain
• Nasogastric suction if peritonitis develops

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Test Yourself !

• What is the classic sign of a Puerperal
  Infection?
• Answer 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.

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Complications of Puerperal Infections
Pelvic Cellulitis Peritonitis
Signs and Symptoms
Spiking a fever of 102 0 F to 104 0 F Elevated
WBC Chills Extreme Lethargy Nausea and
Vomiting Abdominal Rigidity and Rebound Tenderness
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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 snug
• change pads frequently
• wipe front to back
• use peri bottle after each elimination

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Wound Infection

• Infection of the Episiotomy, Perineal
  laceration, Vaginal or vulva lacerations
• Wound infection of Cesarean incision site
• Signs
• Reddened, edematous, firm, tender edges of skin
• Edges separate and purulent material drains from
  the wound.
• Treatment
• Antibiotics
• Wound care

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Check 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?
• Answer yes
• What would be the major difference in
• presenting symptoms you would note on
• nursing assessment?
• Answer foul smelling lochia

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Puerperal Cystitis

• Prevention
• Monitor the patients urination diligently!
• Dont allow to go longer than 3 - 4 hours before
  intervening.
• Treatment
• Antibiotics -- Ampicillin
• Urinary Tract Antispasmotics
• 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

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Mastitis

• Types
• Mammary Cellulitis - inflammation of the
  connective tissue between the lobes in the breast
• Mammary Adenitis - infection in the ducts and
  lobes of the breasts

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Nipple Trauma Pain Impaired
Engorgement
Let down
Cracked
Stasis nipples
of milk
Entry for Bacteria
Plugged ducts
Mastitis
Treatment,
No Treatment Problem will resolve
Breast Abscess
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Mastitis
Marked Engorgement Pain Chills, Fever,
Tachycardia Hardness and Redness Enlarged and
tender lymph nodes
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Treatment of Mastitis

• Rest
• Appropriate Antibiotics--Usually Cephalosporins
• Hot and / or Cold Packs
• Dont Stop 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

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Mastitis
Meticulous handwashing
Rotate position of baby on the breast
Preventive Measures
Frequent feedings and massage distended area
to help emptying
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Complication of Mastitis
Breast Abscess
Breast Feeding is stopped on the affected side,
but may feed on the unaffected side. Treatment
Incision and Drainage
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Test Yourself
The major causative organism of mastitis is
_________________________. Mastitis
develops mainly in ______________ who are nursing
. It is almost always ________________ and
develops well after the flow of milk has
been established. There are two types of
mastitis. One that develops between the
lobes of the breast is called____________________.
The one that developswithin the lobes and
ducts of the breast is called
__________________. Mammary cellulitis
mainly develops due to _______________. Mammary
adenitis develops when ____________________ of
the breasts occurs. With improper treatment or
no treatment, mastitis can lead to
________________.
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Puerperal Psychiatric Disorders
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Mood Disorders

• The Most common Mood Disorders are
• Postpartum Depression
• Postpartum Psychosis

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Postpartum Depression

• Predisposing Factors
• Primiparity
• Ambivalence about the pregnancy
• History of Depression
• Environmental and Family Stress issues
• Dissatisfaction with herself

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Postpartum Depression

• Assessment
• Persistent lack of interest or energy, loss of
  usual emotional response toward her spouse or
  family
• Obsessive thoughts of failure as mother,
  incompetent, inadequate parent
• Anxiety, Irritability
• Forgetfulness Inability to follow directions
• Anorexia
• Persistent Sleeplessness
• Poor personal Hygiene
• Feelings of unworthiness

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Postpartum Depression

• Creates strain on the family
• Family members may decrease their interactions
  with the depressed woman when she needs support
  the most.
• Infants of depressed mothers tend to be fussier
  and more discontented. They show fewer positive
  facial expressions.

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Nursing Care

• Antidepressant Drugs
• a. SSRI
• Prozac, Paxil, Zoloft
• b. Cyclic compounds
• Tofranil, Asendin, Norpramin, Sinequan
• c. MAO Inhibitors
• Nardil, Parnate
• d. Other
• Wellbutrin, Effexor, Desyril
• e. Lithium, Depakene, Tegretol for bipolar
• disorder

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Treatment for Depression

1. Psychotherapy
2. Encourage communication with her husband or
   support person who is available to provide
   support when loneliness or anxiety becomes a
   problem
3. Explain importance of good nutrition and rest

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Treatment and Nursing Care

• Discuss changes that normally occur in the
  beginning weeks after taking a baby home
• Although some of her feelings may seem
  unreasonable, she should acknowledge these
  feelings to herself and insist that others
  acknowledge them too.
• Re-introduce the baby to the mother at the mother
  own pace

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Convey a caring attitude
This helps mothers decrease their emotional
distress and guide them in regaining their
well-being
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Postpartum PsychosisSCHIZOPHRENIA

• Far less common
• May surface when the mother does not have the
  ability to adjust to and cope with her new
  obligations as a mother
• Affects mostly adolescents and younger adults

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Schizophrenia

• Signs and Symptoms
• Irritability, Hyperactivity
• Insomnia Exhibit little need for sleep
• Mood lability
• Hostility toward spouse is obvious
• Overly Suspicious, seldom aware they have a
  problem
• Often believe hers to have been an immaculate
  conception
• Abandons reality, totally neglects her infant
• May have delusions and erroneously belief that
  baby is dead, malformed or severely ill
  hallucinations

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Treatment and Nursing Care

• Remove the baby from the situation
• Hospitalization
• Antipsychotic Medications
• Stelazine, Clozaril, Risperdal, Haldol, Navane
• When she is better, then bring the baby back for
  short visits at first. Give praise for small
  tasks that the mother can accomplish with the
  baby.

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Review

• What is the time difference between early and
  late postpartum hemorrhage?
• What is the most common cause of postpartum
  hemorrhage?
• How will the nurse recognize uterine atony?
• What is the FIRST nursing action if uterine atony
  is discovered?
• What would the nurse suspect if the placenta
  fails to release from the uterine wall after
  delivery?

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• 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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The End