Complications of Post Partum

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

MAIN CAUSES OF EARLY HEMORRHAGE ARE:

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

UTERINE ATONY
The myometrium fails to contract and **The myometrium fails to contract and the uterus uterus fills fills with because of of the withblood blood because the lack of pressure on the open the lack of ofthe pressure on site the open blood vessels placental
vessels of the placental site.

UTERINE ATONY PREDISPOSING FACTORS

Prolonged labor Trauma due to Obstetrical Procedures Overdistention of the Uterus

Grandmultiparity

Intrapartum Stimulation with Pitocin

Excessive use of Analgesia / Anesthesia

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
A boggy uterus that does not respond to massage

Abnormal Clots

Signs and Symptoms

Excessive or Bright Red Bleeding

Unusual pelvic discomfort or backache

NURSING CARE OF UTERINE ATONY

Document Vaginal Bleeding

Fundal massage / Bimanual Compression

Assess Vital Signs (shock)

Give medications--Pitocin, Methergine, Hemabate

D & C, Hysterotomy/ectomy, Replace blood / fluids

POST PARTUM HEMORRHAGE *LACERATIONS*

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

*LACERATIONS*

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

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?

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

D&C Administration of Oxytocins Administration of Prophylactic antibiotics

Treatment

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

INVERSION OF THE UTERUS

Placenta

Uterus

Traction on the cord starts the uterus to invert

Uterus continues to be pulled and inverted

INVERSION OF THE UTERUS

Uterus Manually pushed back into place

Vagina

Vagina

Uterus Inverted

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 ACCRETA
All or part of the decidua basalis is absent and the Placenta grown 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

If

it is only small portions that are attached, then these may be removed manually

If

large portion is attached--a Hysterectomy is necessary!

ARE THESE EARLY, LATE, OR BOTH ?

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

_________________ _________________

_________________ _________________ _________________ _________________

Hematoma

POSTPARTUM INFECTIONS

POSTPARTUM 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

POSTPARTUM 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

CRITICAL TO REMEMBER
Signs

and Symptoms of Postpartum 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

POSTPARTUM 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

Test Yourself !

What

is the classic sign of a Postpartum Infection?

COMPLICATIONS OF POSTPARTUM 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

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

LOCALIZED INFECTION
Infection of the Episiotomy, Perineal laceration, Vaginal or vulva lacerations Wound infection of incision site

Signs:

Reddened, edematous, firm, tender edges of skin Edges seperate and purulent material drains from the wound. Treatment Antibiotics Wound care

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 postpartum Infection? What would be the major difference in presenting symptoms you would note on nursing assessment?

POSTPARTUM CYSTITIS

POSTPARTUM CYSTITIS
Prevention: Monitor the patients urination diligently! Dont allow to go longer than 3 - 4 hours before intervening. Treatment Antibiotics -- Ampicillin Urinary Tract Antispasmodics 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
Marked Engorgement, Pain, Chills, Fever, Tachycardia, Hardness and Redness, Enlarged and tender lymph nodes

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

Development of Mastitis
Improper breaking of suction
Poor Positioning of Infant

First Nursing Experience

Strong Sucking Infant

Supplemental Feedings

"Lazy Feeder"

Abrupt Weaning

Interval between nursing too long

Nipple Trauma Cracked nipples Entry for Bacteria

Pain

Impaired Let down

Engorgement Stasis of milk Plugged ducts

Mastitis Treatment, Problem will resolve No Treatment

Breast Abscess

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

MASTITIS

Meticulous handwashing

Preventive Measures

Frequent feedings and massage distended area to help emptying

Rotate position of baby 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

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

Treatment Heparin --it does not cross into breast milk Antidote: protamine sulfate Teach patient to report any unusual bleeding, or
petchiae, bleeding gums, hematuria, epistaxis, etc.

Complication
Pulmonary Emboli

POSTPARTUM PSYCHIATRIC DISORDERS

Mental Health problems can complicate the puerperium. There are days when each new mother may feel inadequate, but the mother who has a constant feeling of inadequacy needs professional counseling. Pregnancy alone is not a cause of a psychiatric Illness; however, the psychological and physiological stressors relating to pregnancy may bring on an emotional crisis

MOOD DISORDERS
The

Most common Mood Disorders are:

Baby

Blues

Postpartum Bipolar

Depression

Disorder

BABY BLUES
50-80% of moms are affected Self-limiting (up to 10 days) Cause

Seems to be related to changes in progesterone, estrogen, and prolactin levels

Symptoms
Tearful yet happy overwhelmed

Treatment

POSTPARTUM MAJOR MOOD DISORDER POSTPARTUM DEPRESSION

Risk

factors:

Primiparity History of postpartum depression Lack of social and relational support

Clinical

therapies

Counseling and support groups Medication (usually SSRIs) Childcare assistance

POSTPARTUM PSYCHOSIS
Predisposing

factors

Similar to those of postpartum depression

Assessments

Grandiosity Decreased need for sleep (insomnia) Flight of ideas Psychomotor agitation/hyperactivity Rejection of infant

TREATMENT FOR MOOD DISORDERS

Drug therapy Psychotherapy Explain the importance of good nutrition and rest Reintroduce the mother to the baby at the mothers own pace

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?