Complications of the Postpartum Period

Hemmorhage Early postpartum hemmorhageEarly postpartum hemmorhage –>500 ml in first 24 hrs (blood loss often underestimated) Late or delayedLate or delayed –>500 cc after first 24 hrs.

Predisposing factors Uterine overdistension--large infant,etc. Grand multiparity Anesthesia or MgSO 4 Trauma Abnormal labor pattern--hypo or hypertonia Oxytocin during labor Prolonged labor Hx of maternal anemia, hemorrhage

Prevention Risk assessment Inspect placenta Explore uterus Avoid overmanipulation of uterus If at risk type and Xmatch and start IV

Signs of Impending Hemorrhage Excessive bleeding (>2pads/30min-1hr) Light headedness, nausea, visual disturbances Anxiety, pale/ashen color, clammy skin Increasing P and R, BP same or lower

Actions to take Summon help Check uterine tone, massage, assess effect Elevate legs, lower head Increase or begin O 2 Increase or begin IV

Early Postpartum Hemorrhage Within the first 24 hrs Causes –uterine atony –lacerations –retained secundines –coagulation problems

Uterine atony Failure of the uterus to stay firmly contracted Slow, steady or massive hemorrhage, sometimes underestimated or hidden behind a clot VS may not change immediatelyTreatment bimanual massage oxytoxics curretage surgery iliac ligation or hysterectomy

Retained placenta or fragments Partial separation caused by: pulling on the cord uterine massage prior to separation placenta accreta Treatment: massage manual removal oxytoxics D & E

Late postpartum hemorrhage Hemorrhage occurring after 24 hrs retained placenta-- necrosed, fibrin deposits, placental polyps, sloughing  bleeding Symptoms excessive or bright red bleeding boggy fundus large clots backache  T-P-R,  BP Treatment, massage, IV oxytocin, D&E

Hematomas Result from injury to a blood vessel, usually in vagina or vulva, may extend upward into broad ligament or other pelvic structures develop rapidly may contain ml blood

Symptoms Severe pain Difficulty voiding Mass felt on vaginal exam Flank pain Abdominal distension Shock

Treatment Ice I & D (incision and drainage) Packing

Subinvolution Uterus remains large, does not involute Causes, retained placental fragments, infection Symptoms: Lochia fails to progress Returns to rubra Leukorrhea with backache and infection Treatment: methergine curretage antibiotics

Puerperal Infection Definition: Temp of 101 o or more in the first 24 hrs following delivery Temp of or higher on any 2 of the first10 pp days (with the exception of the first 24 hrs)

Types of Infections Endometritis Parametritis Peritonitis Pyelonephritis Cystitis Thrombophlebitis Mastitis, abcess

Predisposing Factors Antenatal factors poor nutrition low SES Hx of Infections Anemia Immunodeficiency

Intrapartum predisposing factors Prolonged labor PROM Poor aseptic technique Birth trauma Multiple exams Internal monitoring Episiotomy C section

Postpartum Predisposing Factors Manual removal of placenta Hemorrhage Retained secundines

Causative Organisms Aerobic 30% B hemolitc strep E.coli Klebsiella Proteus Pseudomonas Staph Anerobic 70% Bacteriodes Peptococcus C. perfringes

Localized Episiotomy Lacerations C section incision

Endometritis Infection of the endometrium placental site decidua cervix Symptoms--discharge (scant to profuse), bloody, foul smelling uterine tenderness jagged, irregular temp elevations tachycardia, chills, subinvolution

Salpingitis, Oopheritis May be caused by gonorrhea, chlamidia unilateral or bilateral abd pain chills, fever mass tachycardia may lead to sterility

Pelvic Cellulitis, (parametritis) Infection of the connective tissue of pelvis frequently infecting the broad ligament and causing severe pain. May ascend from cervical lacerations

Parametritis symptoms Spiking temp to 104 chills, flushing, sweating tachycardia, tachypnea uterine tenderness, cramping change in LOC/agitation,delerium, disorientation change in lochia cervical or uterine tenderness on vag exam WBC elevation

Peritonitis Life threatening infection of the peritoneum Abcesses on the uterine ligaments, in the cul de sac, and/or in the subdiaphragmatic space May result from pelvic thrombophlebitis

Symptoms of Peritonitis High temp chills malaise lethargy pain subinvolution Tachycardia local or referred pain rebound tenderness thirst distension nausea and vomiting

Cystitis Bladder infection urgency frequency burning dysuria suprapubic pain hematuria

Pyelonephritis Kidney infection, usually of the R. kidney.Ascends from bladder. Spiking temp Shaking chills Flank pain, CVA pain Nausea and vomiting Hx of asymptomatic bacteruria or pyelonephritis Urgency, frequency, dysuria Back pain

Prevention and treatment Force fluids Insure complete emptying of bladder Sterile technique for cath Good perineal care Antibiotics

Thrombophlebitis Thrombophlebitis Blood clot associated with bacterial infection Etiologies  blood clotting factors postpartal thrombocytosis (  platelets) thromboplastin release (placenta, amnion)  fibrinolysin and fibrinogen inhibitors

Superficial Tenderness heat redness low grade fever + homans sign tachycardia Treatment elevation heat TEDs analgesic bedrest? Antibiotics?

Deep Vein Thrombosis Symptoms edema low grade fever chills pain in limb below affected area “milk leg” decreased peripheral pulses Dx--doppler Tx: heparin to coumadin antibiotics TEDs bedrest elevation analgesics

Pulmonary Embolism an Obstetrical emergency Symptoms--sudden onset dyspnea sweating pallor cyanosis confusion hypertension cough/hemoptysis Tachycardia SOB  Temp  jugular pressur chest pain sense of impending death pressure in bowel/rectum

Treatment Call MD O 2 Demerol Papaverine or other “clot busters” Aminophylline heparin Streptokinase

Disseminated Intravascular Coagulation (DIC)  prothrombin and platelets widespread formation of intravascular clots clotting factor expended severe generalized hemorrhaging Life threatening!

Etiologies Septic shock placental/uterine hemmorhage IUFD Amniotic fluid embolism thrombi secondary to preeclampsia thrombi secondary to thrombophlebitis

Early signs of DIC  protime  fibrinogen thrombocytopenia bleeding from gums bleeding from puncture sites ecchymosis Treatment complex, packed cells, fibrinogen, whole blood, plasma