POST PARTUM COMPLICATIONS Lecture 9 1

Endometritis Infection of Uterus: endometrium, myometrium, or parametrium. Caused by: E.Coli, Staph, Group A/B Streptococcus. Occurs within 10 days, abortion or delivery. Granulocytes in lochia & endometrial lining - help prevent infection Risk factors: PROM, C/S, multiple pelvic exams, UTI, +GBS, DM, poor nutrition, poor health, catheterization. T = 100.4 x 2 ; C/S most common cause of infection followed by UTI. 2

Blood cx may be + for bacteremia. Send UA, urine cx; lochia cx. S/S: fever, chills, malaise, abd.pain, uterine cramping & tenderness, foul-smelling lochia, tachycardia. LAB findings: CBC & Blood cx’s. WBC > 20,000 [indicates infection] 20,000 - normal > delivery. Blood cx may be + for bacteremia. Send UA, urine cx; lochia cx. TX: ^ po fluids, hypothermia blankets, ice packs to head/groin. Broad spectrum antibiotics. Ampicillan, cephalosporin, gentamycin, clindamycin for 2-3 days. Antipyretics [Tylenol] &/or pain meds.as well. 3

Wound Infection Common Sites: incision, perineum [episiotomy & laceration], vagina. [port of entry] S/S REEDA: erythema, ecchymosis, edema, purulent drainage, wound edges not approximated, pain, tenderness. Management: Remove some staples/sutures . Allow wound to drain. Irrigation & packing of wound, broad spectrum AB, wound & blood cx, analgesics, warm compresses. Perineal care: wipe front to back; warm water . 4

GI Paralytic Ileus: hard abdomen with absent bowel sounds, N V, abd.distention & pain. NG tube to low intermittent suction; NPO; IVF 5

Subinvolution of Uterus Major complication > del. involving postpartum bleeding > 500 ml. [caused by uterine atony] Delayed return of uterus to its normal size and functions. Normally descends 1 cm/day PP. S/S: larger than normal uterus, heavy flow, fatigue, back pain. Methergine 0.2 mg po q 4 x 24 hrs. Tx with AB as directed. Possible D&C. Common Causes: retained placenta & pelvic infection. Teach: self palpation of uterus [@ home] 6

Postpartum Hemorrhage Caused by overdistention of uterus: large infant, multiple gestation, retained placenta & pelvic infection; grand multip > 5; Precipitous delivery; prolonged labor, clotting disorders. Uterus “boggy” - soft. Relaxed uterus prevents constriction of blood vessels @ uteroplacetal site. S&S: profuse bleeding, ^ clots. Massage til firm. Assess for continued bleeding & passage of clots. 7

PP Hemorrhage Manage: 20-30 units of Pitocin in liter RL Massage uterus Methergine 0.2 mg po q 4h x 24hr. Monitor BP before giving; may ^ BP or may give Methergine 0.2 mg. IM stat & q4 po x 24hrs. Also used: Hemabate, Prostin [prostaglandins]. Remove clots &/or retained placenta; may need D&C or hysterectomy. IV RL, transfusion with whole blood, 8

Late P.P.H Appears 24 hours to month > delivery. Caused by retention of small piece of tissue Tissue necrosis > delivery and sloughs off, causing bleeding at site. Teach mom s/s PP hemorrhage & to contact HCP if ^ bleeding. Remove pieces of retained placenta by dilation & curettage (D&C) Do bimanual compression for ^ bleeding. Follow tx for PP hemorrhage. 9

Uterine Prolapse Relaxation of uterine muscle; uterus protrudes from vagina. Ligaments over stretched & don’t return to normal. Common after vaginal births or large infants. Manifests @ menopause d/t decreased estrogen. TX: severe prolapse: hysterectomy milder prolapse: pessary [supportive device] 10

Mastitis Develops after breast milk is established, 2-4wks.PP D/t ineffective or infrequent breast feeding or milk stasis from engorgement, skipping breast. E.Coli or Staph.aureus; carried on hands of mom. Enters nipple thru crack or blister. S/S: fever, chills, malaise, localized erythema & tenderness of breast tissue. Tx: Warm soaks to both breasts as needed; pumping; put baby on breast more often. Analgesics; AB’s - Amoxicillan 250mg.po TID. 11

UTI ~ 2-4 % develop UTI postpartum. Bladder hypotonic > del. & residual urine & reflux results. Freq. VE’s, catheterizations & birth trauma. S/S: dysuria, low grade fever, urgency, & frequency. ^ temp. UA & urine cx. E.Coli most common pathogen ~ 75% of cases. Bactrim [sulfanomide], Ampicillan, cephalexin {po Keflex}. 12

Thrombophlebitis aka “Superficial thrombophlebitis” Rate 5x higher in preg.women. Inflammation of vein wall. Risk factors: women with extensive varicosities, smoking, inactivity, obesity, C/S, age > 35. Occurs within few days postop. Localized swelling, erythemia, tenderness. Unilateral; affects one leg/calf or other. Tx: warm soaks to affected area; elevation of extremities; analgesics. No ambulation for 1 wk; then OK to ambulate. No anticoagulants @ this time. Support stockings recommended. Avoid standing too long. 13

Deep Vein Thrombosis Caused by inflammatory process Collection of blood factors, mainly fibrin, accumulates & may be released . [1 in 2,000 preg] - deep veins of calves, thigh, pelvis. Prevent by early ambulation 6-8 hrs. post op ROM exercises; changing positions often. Teds stockings, compression boots post op. {TEDS} stockings are used in pts. with hx of phlebitis, C/S, or varicose veins. Diagnosis: Doppler’s studies [gold standard] diagnosing. 14

DVT S/S: frank pain in calf/hip; inability to walk upon rising; + Homan’s ; + tenderness with local calf swelling, heat, redness; measure both calves & compare. Treatment: Bedrest & leg elevation; Anticoagulants; PT/PTT prior to therapy & during for therapeutic dosing. Heparin or Lovenox SC . Analgesics. Septic pelvic thrombophebilits: often with C/S; thrombus formation in pelvis. May proceed to pulmonary embolis = life threatening. PE: fragments of clot carried to lung; can be fatal. 15

Pulmonary Embolism Fragments of blood clot carried to lungs. S/S: sudden, sharp chest pain, tachycardia, syncope [fainting], tachypnea, rales, cough, hemoptysis. ABG’s show decreased PO2; chest x-ray > pleural effusion & atelectasis. Manage: Dissolve clot & maintain pulmonary circulation. Initiate IV heparin therapy asap. O2, bedrest; ICU admission, ABG’s, O2 sat, VS, narcotics to alleviate pain & anxiety. 16