Complications Of

Postpartum

Postpartum Hemorrhage

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

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

Main Causes of Early Hemorrhage are:

• Uterine Atony

• Lacerations

• Retained Placental Fragments

• Inversion of the Uterus

• Placenta Accreta

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.

Uterine Atony Predisposing Factors

Prolonged labor Overdistention

of theUterus

Grandmultiparity

Excessive use of Analgesia / Anesthesia

IntrapartumStimulation with Pitocin

Trauma dueto ObstetricalProcedures

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.

Uterine Atony

Signs and Symptoms

Excessive orBright Red Bleeding

Abnormal Clots

A boggy uterus that does not respond to massage

Unusual pelvic discomfort or backache

Nursing Care

• Assess and Document Bleeding

• Fundal massage and express clots

• Bimanual Compression

• Assess Vital Signs (shock)

Nursing Care• Give medications

– Pitocin– Methergine– Carboprost Tromethamine

(Hemabate) (May inject the medications directly

into the uterus)

• Replace blood / fluids

• D & C, Hysterectomy

Trauma

Post Partum Hemorrhage*Lacerations*

• PREDISPOSING FACTORS1. Spontaneous or Precipitous

delivery2. Size, Presentation, and Position of

baby3. Contracted Pelvis4. 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

POSTPARTUM HEMORRHAGELACERATIONS

• Treatment and Nursing Care1. Meticulous inspection of the entire lower birth canal2. Suture any bleeders3. Vaginal pack-- nurse may remove

and assess bleeding after removal4. Blood replacement

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

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

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.

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.**Don’t pull on the cord unless the

placenta has separated.– Incorrect traction / pressure applied

to the fundus, when the uterus is flaccid

**Don’t use the fundus to “push the placenta out”

Inversion of the Uterus

Traction onthe cordstarts the uterus toinvert

Uterus continuesto be pulled andinverted

Uterus

Placenta

Inversion of the Uterus

Vagina

UterusInverted

Vagina

Uterus Manually pushed backinto place

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

Placenta AccretaAll or part of the decidua basalis is

absent and the Placenta grows directly into the uterine muscle.

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

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!

Late PostpartumHemorrhage

Late Postpartum Hemorrhage

• Most common cause is Retained Placental fragments

• Sub involution

• Treatment

–D & C–Methergine

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

Are these Early, Late, or Both ?

• Uterine Atony

• Retained placental fragments

• Lacerations

• Inversion of the uterus

• Placenta accreta

• Hematoma

• _________________

• _________________

• _________________

• _________________

• _________________

• _________________

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

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

Thromboembolic Disorder

• Predisposing FactorsSlowing of blood in the legsTrauma to the veinsHypercoagulation

• Signs and SymptomsSudden onset of painTenderness of the calfReddness and an increase in skin

temperaturePositive Homan’s Sign

Thromboembolic Disease

• TreatmentHeparin --it does not cross into

breast milkAntidote: protamine sulfateTeach patient to report any

unusual bleeding, or petchiae, bleeding gums, hematuria, epistasis, etc.

• ComplicationPulmonary Emboli

When a postpartum patient Complains of chest pain

or severe dyspnea

Respond quickly

Usually sign of Pulmonary Emboli

Puerperal Infection

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

Puerperal Infections

• Predisposing Factors 1. Trauma

2. Hemorrhage3. Prolonged labor4. Urinary Tract Infections5. Anemia and Hematomas6. Excessive vaginal exams

7. P R O M

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

PUERPERAL INFECTION

• Administer Broad Spectrum Antibiotics

• Provide with warm sitz baths• Promote drainage--have pt. lie in HIGH

fowlers position• Force fluids and hydrate with IV’s

3000 - 4000 cc. / day • Keep uterus contracted, give

methergine• Provide analgesics for alleviation of

pain• Nasogastric suction if peritonitis

develops

TREATMENT AND NURSING CARE

• 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.

Test Yourself !

Complications of Puerperal Infections

Pelvic Cellulitis Peritonitis

Spiking a fever of 102 0 F to 104 0 FElevated WBCChillsExtreme LethargyNausea and VomitingAbdominal Rigidity and Rebound Tenderness

Signs and Symptoms:

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

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

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

Check Yourself

Puerperal Cystitis

• Prevention:• Monitor the patients urination

diligently!• Don’t 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

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

PoorPositioning

of Infant

Im properbreaking of

suction

StrongSucking

Infant

FirstNursing

Experience

AbruptW eaning

Supplem entalFeedings

Intervalbetw een

nursing too long

"Lazy Feeder"

Development of Mastitis

Nipple Trauma Pain Impaired Engorgement Let down

Cracked Stasis nipples of milk

Entry for Bacteria Plugged ducts

MastitisTreatment, No TreatmentProblem will resolve Breast Abscess

Mastitis

Marked EngorgementPainChills, Fever, TachycardiaHardness and RednessEnlarged and tender lymph nodes

Treatment of Mastitis• Rest

• Appropriate Antibiotics--Usually Cephalosporins

• Hot and / or Cold Packs

• Don’t 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

Mastitis

Preventive Measures

Meticuloushandwashing

Frequent feedingsand massagedistended area tohelp emptying

Rotate position ofbaby on the breast

Complication of Mastitis

Breast Abscess

Breast Feeding is stopped on the affected side, but may feed on the unaffected side.

Treatment: Incision and Drainage

Test YourselfThe 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 ________________.

Puerperal PsychiatricDisorders

Mood Disorders

• The Most common Mood Disorders are:

– Postpartum Depression

– Postpartum Psychosis

Postpartum Depression

• Predisposing Factors:– Primiparity– Ambivalence about the pregnancy– History of Depression– Environmental and Family Stress

issues– Dissatisfaction with herself

Postpartum DepressionAssessment

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

directionsAnorexia Persistent Sleeplessness Poor personal Hygiene Feelings of unworthiness

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.

Nursing CareAntidepressant Drugs

a. SSRI• Prozac, Paxil, Zoloft

b. Cyclic compounds• Tofranil, Asendin, Norpramin,

Sinequanc. MAO Inhibitors

• Nardil, Parnated. Other:

• Wellbutrin, Effexor, Desyrile. Lithium, Depakene, Tegretol for bipolar disorder

Treatment for Depression

2. Psychotherapy

3. Encourage communication with her husband or support person who is available to provide support when loneliness or anxiety becomes a problem

4. Explain importance of good nutrition and rest

Treatment and Nursing Care

5. Discuss changes that normally occur in the beginning weeks after taking a baby home

6. Although some of her feelings may seem “unreasonable”, she should acknowledge these feelings to herself and insist that others acknowledge them too.

7. Re-introduce the baby to the mother at the mother own pace

Convey a caring attitude

This helps mothers decrease their emotional distress and guide them in

regaining their well-being

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

Schizophrenia

Signs and Symptoms Irritability, Hyperactivity Insomnia; Exhibit little need for

sleepMood labilityHostility toward spouse is

obviousOverly Suspicious, seldom aware

they have a problemOften believe hers to have been

an immaculate conceptionAbandons reality, totally

neglects her infantMay have delusions and

erroneously belief that baby is dead, malformed or severely ill; hallucinations

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.

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?

• 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?

The End