complications of the postpartum period. hemmorhage early postpartum hemmorhageearly postpartum...
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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