Postpartum Complications Postpartum Complications II

Lecture 11Prepared by MD, PhD Kuziv I.

SubinvolutionSubinvolutionis the failure of is the failure of the uterus to the uterus to return to a return to a

nonpregnant nonpregnant state. The most state. The most common causes common causes of subinvolution of subinvolution

are retained are retained placental placental

fragments and fragments and infection.infection.

LACERATIONS 

ETIOLOGY AND PATHOPHYSIOLOGY:Lacerations of the birth canal are second only to uterine atony as a major cause of postdelivery

hemorrhage. Predisposing Factors: 1. Spontaneous or Precipitous delivery2. Size, Presentation, and Position of baby3. Contracted Pelvis4. Vulvar, perineal, and vaginal varices

HEMATOMA

Etiology and Pathophysiology:Bleeding into the tissues of the perineal area can cause hematoma formation. May have at least 500cc. Pooled in the hematoma. May be around the episiotomy site.

Signs and Symptoms:

1.  Pain – perineal. More than normal amount of pain. Mild analgesics are not sufficient to decrease the amount of pain.

2.  Hard, firm, area on the perineum

Treatment and Nursing Care:

1. I & D – incision and drainage. May leave in a penrose drain.

2. Dressing changes3. Replace the blood loss4. Comfort measures

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Sequelae of Childbirth Sequelae of Childbirth Trauma Trauma

Disorders of uterus and Disorders of uterus and vagina related to pelvic vagina related to pelvic relaxation and urinary relaxation and urinary incontinence, are often incontinence, are often result of childbearing result of childbearing

Uterine displacement Uterine displacement and prolapseand prolapse Posterior displacement, Posterior displacement,

or retroversionor retroversion Retroflexion and Retroflexion and

anteflexionanteflexion Prolapse a more serious Prolapse a more serious

displacementdisplacement Cervix and body of uterus Cervix and body of uterus

protrude through vagina protrude through vagina and vagina is inverted and vagina is inverted

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Types of Fistulas That May Develop Types of Fistulas That May Develop in Vagina, Uterus, and Rectumin Vagina, Uterus, and Rectum

NEUROLOGIC SYSTEMNEUROLOGIC SYSTEM Neurologic changes during the Neurologic changes during the

puerperium are those that result from puerperium are those that result from a reversal of maternal adaptations to a reversal of maternal adaptations to pregnancy and those resulting from pregnancy and those resulting from trauma during labor and childbirth. trauma during labor and childbirth.

Pregnancy-induced neurologic Pregnancy-induced neurologic discomforts abate after birth. discomforts abate after birth. Elimination of physiologic Elimination of physiologic edema through the diuresis that edema through the diuresis that follows childbirth relieves carpal follows childbirth relieves carpal tunnel syndrome by easing tunnel syndrome by easing compression of the median compression of the median nerve.nerve.

Postpartum DepressionPostpartum Depression Postpartum depression is a nonpsychotic Postpartum depression is a nonpsychotic

depressive episode that begins in the depressive episode that begins in the postpartum period due to decreased postpartum period due to decreased estrogen levelestrogen level

Symptoms: changes in appetite or weight, Symptoms: changes in appetite or weight, sleep, and psychomotor activity; decreased sleep, and psychomotor activity; decreased energy; feeling of worthlessness or guilt; energy; feeling of worthlessness or guilt; difficulty thinking, concentrating or making difficulty thinking, concentrating or making decisions; or recurrent thoughts of death or decisions; or recurrent thoughts of death or suicidal ideation, plans, or attempts. suicidal ideation, plans, or attempts.

Postpartum Postpartum PsychosisPsychosis

A very serious type of A very serious type of PPD illness that can PPD illness that can affect new mothers. affect new mothers.

Begin 2-3 weeks post Begin 2-3 weeks post deliverydelivery

Fatigue, restlessness, Fatigue, restlessness, insomnia, crying liable insomnia, crying liable emotions, inability to emotions, inability to move, irrationally move, irrationally statements incoherence statements incoherence confusion and obsessive confusion and obsessive concerns about the concerns about the infant’s healthinfant’s health

Psychiatric emergencyPsychiatric emergency

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Postpartum Psychologic Postpartum Psychologic ComplicationsComplications

Mental health disorders in postpartum Mental health disorders in postpartum period have implications for mother, period have implications for mother, newborn, and entire familynewborn, and entire family Interfere with attachment to newborn and Interfere with attachment to newborn and

family integrationfamily integration May threaten safety and well-being of May threaten safety and well-being of

mother, newborn, and other childrenmother, newborn, and other children

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Postpartum Psychologic Postpartum Psychologic ComplicationsComplications

Postpartum depression Postpartum depression without psychotic featureswithout psychotic features PPD: an intense and pervasive PPD: an intense and pervasive

sadness with severe and labile sadness with severe and labile mood swings mood swings

Treatment options Treatment options Antidepressants, anxiolytic Antidepressants, anxiolytic

agents, and electroconvulsive agents, and electroconvulsive therapytherapy

Psychotherapy focuses fears and Psychotherapy focuses fears and concerns of new responsibilities concerns of new responsibilities and roles, and monitoring for and roles, and monitoring for suicidal or homicidal thoughts suicidal or homicidal thoughts

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Postpartum Psychologic Postpartum Psychologic ComplicationsComplications

Postpartum depression with psychotic Postpartum depression with psychotic featuresfeatures Postpartum psychosis: syndrome Postpartum psychosis: syndrome

characterized by depression, delusions, characterized by depression, delusions, and thoughts of harming either infant or and thoughts of harming either infant or herself herself

Psychiatric emergency, and may require Psychiatric emergency, and may require psychiatric hospitalizationpsychiatric hospitalization

Antipsychotics and mood stabilizers such Antipsychotics and mood stabilizers such as lithium are treatments of choiceas lithium are treatments of choice

PLACENTA ACCRETA 

Etiology and Pathophysiology:Placenta accreta is a condition that occurs when all or part of the decidua basalis is absent and the placenta grows directly onto the uterine muscle. This may be partial where only a portion abnormally adhered or it may be complete where all adhered.

PLACENTA ACCRETA Etiology and Pathophysiology:

Placenta accreta is a condition that occurs when all or part of the decidua basalis is absent and the placenta grows directly onto the uterine muscle. This may be partial where only a portion abnormally adhered or it may be complete where all adhered.

Signs and Symptoms:– 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:1.    If it is only small portions that are attached, then these may be removed manually

2.    If large portion is attached--a Hysterectomy is necessary!

LATE POSTPARTUM HEMORRHAGE

Etiology and Pathophysiology:

Occasionally, late postpartal hemorrhage occurs around the fifth to the fifteenth day after delivery when the woman is

home and recovering. The most frequent causes are:

1. Retained placental fragments 2. Subinvolution – the uterus

fails to follow the normal pattern of involution and remains enlarged.

SIGNS AND SYMPTOMS:

Lochia fails to progress from rubra to serosa to alba.The uterus is higher in the abdomen.Irregular or excessive bleeding. 

TREATMENT AND NURSING CARE:

Oral administration of Methergine for 24-48 hours.

D & C

Thromboembolic ConditionsThromboembolic Conditions Thrombophlebitis–the Thrombophlebitis–the

formation of a clot in formation of a clot in an inflamed vein.an inflamed vein.

Risk factors include Risk factors include maternal age over 35, maternal age over 35, cesarean birth, cesarean birth, prolonged time in prolonged time in stirrups, obesity, stirrups, obesity, smoking, and history smoking, and history of varicosities or of varicosities or venous thromboses.venous thromboses.

Prevention: client Prevention: client needs to ambulate needs to ambulate early after delivery.early after delivery.

Thromboembolic ConditionsThromboembolic Conditions Thrombophlebitis–the Thrombophlebitis–the

formation of a clot in formation of a clot in an inflamed vein.an inflamed vein.

Risk factors include Risk factors include maternal age over maternal age over 35, cesarean birth, 35, cesarean birth, prolonged time in prolonged time in stirrups, obesity, stirrups, obesity, smoking, and history smoking, and history of varicosities or of varicosities or venous thromboses.venous thromboses.

Prevention: client Prevention: client needs to ambulate needs to ambulate early after delivery.early after delivery.

Thromboembolic ConditionsThromboembolic Conditions Thrombophlebitis–the Thrombophlebitis–the

formation of a clot in formation of a clot in an inflamed vein.an inflamed vein.

Risk factors include Risk factors include maternal age over 35, maternal age over 35, cesarean birth, cesarean birth, prolonged time in prolonged time in stirrups, obesity, stirrups, obesity, smoking, and history of smoking, and history of varicosities or venous varicosities or venous thromboses.thromboses.

Prevention: client Prevention: client needs to ambulate needs to ambulate early after delivery.early after delivery.

THROMBOEMBOLIC DISEASE

PREDISPOSING FACTORS:

Slowing of blood flow in legs – usually in Moms who have a Cesarean delivery.

Trauma to the vessels during delivery.

Superficial thrombophlebitis is limited to the superficial saphenous veins, whereas deep thrombophlebitis generally involves most of deep venous

system.

THROMBOEMBOLIC DISEASE

PREDISPOSING FACTORS:

Slowing of blood flow in legs – usually in Moms who have a Cesarean delivery.

Trauma to the vessels during delivery.

Superficial thrombophlebitis is limited to the superficial saphenous veins, whereas deep thrombophlebitis generally involves most of deep venous

system 

Assessment of Edema & Homan’s Assessment of Edema & Homan’s SignSign

Assess legs for presence and degree of edema; may have dependent edema in feet and legs.

Assess for Homan’s sign- thromboembolism should be negative

Press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot (dorsiflex)

Signs and Symptoms:Sudden onset of pain,

tenderness of calf, redness and an increase in skin

temp.Positive Homan’s Sign.

Treatment and Nursing Care:

Heparin – it does not cross into breast milk.

Signs and Symptoms:Sudden onset of pain,

tenderness of calf, redness and an increase in

skin temp.Positive Homan’s Sign.

Treatment and Nursing Care:

Heparin – it does not cross into breast milk.

Signs and Symptoms:

Sudden onset of pain, tenderness of calf,

redness and an increase in skin temp.

Positive Homan’s Sign

Treatment and Nursing Care:

Heparin – it does not cross into breast milk.

Signs and Symptoms:Sudden onset of pain,

tenderness of calf, redness and an increase in

skin temp.Positive Homan’s Sign.

Treatment and Nursing Care:

Heparin – it does not cross into breast milk.

Thank you for attention