Complications of Post Partum 1

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 2

Main Causes of Early Hemorrhage are: Uterine Atony Lacerations Retained Placental Fragments Inversion of the Uterus Placenta Accreta Hematomas 3

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. **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 4

Uterine Atony Predisposing Factors Prolonged labor Overdistention of the Uterus Trauma due to Obstetrical Procedures Grandmultiparity Grandmultiparity: >5 Trauma: forceps, lacerations Overdistention of the uterus, retention of placental fragments By knowing these factors, you can anticipate complications and reduce the risk of excessive bleeding Intrapartum Stimulation with Pitocin Excessive use of Analgesia / Anesthesia 5

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 A boggy uterus that does not respond to massage Abnormal Clots Excessive or Bright Red Bleeding Signs and Symptoms Unusual pelvic discomfort or backache 6

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 7

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 ***Bright red blood vs. dark red of lochia 8

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 9

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? Feel the fundus assess perineum 10

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 11

Hematoma Treatment: May have to be incised and drained. 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 and pressure applied to the fundus, especially when the uterus is flaccid **Don’t use the fundus to “push the placenta out” 12

Inversion of the Uterus Placenta Uterus Uterus continues to be pulled and inverted Traction on the cord starts the uterus to invert 13

Inversion of the Uterus Manually pushed back into place Vagina Vagina Uterus Inverted 14

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 15

Placenta Accreta All or part of the decidua basalis is absent and the Placenta grown directly into the uterine muscle. 16

Signs: Placenta Accreta 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 17

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! 18

Are these Early, Late, or Both ? Uterine Atony Retained placental fragments Lacerations Inversion of the uterus Placenta accreta Hematoma _________________ Early Early/late 21

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 22

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 23

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 24

TREATMENT AND NURSING CARE 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 IV’s 3000 - 4000 cc. / day Keep uterus contracted, give Methergine Provide analgesics for alleviation of pain Nasogastric suction if peritonitis develops 25

What is the classic sign of a Postpartum Infection? Test Yourself ! What is the classic sign of a Postpartum Infection? > 100.4 x 2 days excluding the 1st 24 hours 26

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 27

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 29

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? 30

Postpartum Cystitis

Postpartum Cystitis Prevention: Monitor the patients urination diligently! Don’t 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 33

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 31

Nipple Trauma Pain Impaired Engorgement Let down Cracked Stasis nipples of milk Entry for Bacteria Plugged ducts Mastitis Treatment, No Treatment Problem will resolve Breast Abscess 32

Treatment of Mastitis Rest Appropriate Antibiotics--Usually Cephalosporins Hot and / or Cold Packs Don’t 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 Stop 34

Mastitis Meticulous handwashing Preventive Measures Frequent feedings and massage distended area to help emptying Preventive Measures Rotate position of baby on the breast 35

Complication of Mastitis Breast Abscess Breast Feeding is stopped on the affected side, but may feed on the unaffected side. Treatment: Incision and Drainage 36

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 Homan’s Sign 39

Complication 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 40

The Most common Mood Disorders are: Baby Blues Postpartum Depression Bipolar 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 SSRI’s) Childcare assistance

Predisposing factors Assessments Postpartum Psychosis 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?