Postpartum complications II

Lectures 12

Prepared by MD, PhD Kuziv I.

Postpartum complications

Postpartum hemorrhage

Hemorrhagic shock

Coagulopathies

Thromboembolic disease

Main Causes of Early Hemorrhage Main Causes of Early Hemorrhage are:are:

1. Uterine Atony2.    Lacerations3.    Retained Placental fragments4.    Inversion of the Uterus5.    Placenta Accreta

The Two Principles that Govern PPH Treatment

I. The bleeding must be arrested

II. The maternal volume must be restored

M a n a g e m e n t o f P o s t p a r t u m H e m o r r h a g eM a n a g e m e n t o f P o s t p a r t u m H e m o r r h a g e

Surgical Options

Prostaglandin or Methergineor Both

Bimanual Compression

Atony

ManualExplorationor Curettage

Ultrasound

Retained

SurgicalOptions

AbnormalImplantation

Placenta

SurgicalRepair

Laceration or Rupture

Vital Signs/HelpI.V. / Oxygen

Foley CatheterFlow Sheet

Postpartum Hemorrhage

Uterine Atony

Etiology and Pathophysiology:

The most frequent cause of postpartal hemorrhage is UTERINE ATONY. The myometrium fails to contract and the uterus fills with blood because of the lack of pressure on the open vessels of the placental site.

Signs and Symptoms:

1. Excessive or bright red bleeding

2. A boggy uterus that does not respond to massage

3. Abnormal clots

4. Any unusual pelvic discomfort or backache

Management of Postpartum Hemorrhage

Close observation of fundal height and bleeding after delivery for at least 1 hour

Common protocol for fundal height massage: Q15min X 1 hr, Q30min X1 hr, Q1hr X 4hrs, Qshift + PRN)

Make sure bladder is drained

If uterine massage is ineffective, pharmacologic agents are indicated

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 delivery

2. Size, Presentation, and Position of baby

3. Contracted Pelvis

4. Vulvar, perineal, and vaginal varices

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 delivery

2. Size, Presentation, and Position of baby

3. Contracted Pelvis

4. Vulvar, perineal, and vaginal varices

RETAINED PLACENTAL FRAGMENTS

Etiology and Pathophysiology:

This occurs when there is incomplete separation of the placenta and fragments of placental tissue retained.

 Signs and Symptoms:

–  Boggy , relaxed uterus

–  Dark red bleeding

Treatment and Nursing Care:–  D & C - clean out any fragments that may be left–  Administration of Oxytocins – to contract the uterus–  Administration of Prophylactic antibiotics

INVERSION OF THE UTERUS

Etiology and Pathophysiology:

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

INVERSION OF THE UTERUS

Etiology and Pathophysiology:

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

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 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 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 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 SignAssessment of Edema & Homan’s Sign

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.

COMPLICATION:

PULMONARY EMBOLI –

substernal chest pain,

sudden and intense;

dyspnea; pallor and

cyanosis; increased

jugular pressure;

confusion; hypotension;

sudden apprehension;

hemoptysis.

COMPLICATION:

PULMONARY EMBOLI –

substernal chest pain,

sudden and intense;

dyspnea; pallor and

cyanosis; increased

jugular pressure;

confusion; hypotension;

sudden apprehension;

hemoptysis.

Thank you for attention