Postpartum Complications

Postpartum Complications: Principles The most frequent cause of postpartum hemorrhage is uterine atony. Anything that overdistends the uterus, causes it to contract poorly or overworks the uterus is a set-up for uterine atony.

Postpartum Hemorrhage - Continues to be a leading cause of maternal morbidity and death in the US - Can occur with little warning - Definitions (PP lecture) * also include 10% drop in Hct between admission and postpartum - 50% underestimation of blood loss Postpartum Complications

- Most common cause (90%) is uterine atony (marked hypotonia) - Less common causes are retained placenta, placenta accreta, cervical/vaginal lacerations, uterine rupture - Predisposing causes of uterine atony * Multiparity * Hydramnios * Macrosomic fetus * Traumatic birth * Rapid or prolonged labor

Postpartum Complications * Use of magnesium sulfate * Use of oxytocin * Multiple pregnancy - Management of uterine atony * Manual massage of the uterus * Expression of clots * Eliminate bladder distention

* IV of lactated Ringer’s or normal saline with units of oxytocin added * Ergonovine or methyl-ergonovine (IM) if not hypertensive Postpartum Complications

- Non-adherent Retained Placenta * May result from partial separation of the placenta or entrapment of the partially or fully separated placenta * Treated by manual removal of the placenta * If no epidural, nitrous oxide and oxygen inhalation Postpartum Complications

- Adherent Retained Placenta * Unknown etiology * Probably implantation in a defective area of endometrium * Manual removal is unsuccessful and laceration or perforation of uterine wall may result from attempts * Degrees of adherence - Placenta accreta = slight penetration of myometrium Postpartum Complications

- Placenta increta = deep penetration of myometrium - Placenta percreta = penetration to the point of perforation of the myometrium * Treatment may indicate hysterectomy and blood replacement - Inversion of the uterus * Potentially life-threatening complication * 1 in births Postpartum Complications

* Partial or complete * Contributing factors - Fundal implantation of placenta - Vigorous fundal pressure - Excessive traction to cord - Uterine atony, fibroids or abnormally adherent placenta - Most often in multiparas with placenta accreta/increta - Postpartum Complications

- Coagulopathies * When bleeding continues with no identifiable source, a coagulopathy must be considered * Coagulation status must be assessed quickly and continuously * Abnormal results depend on the cause and may include: - Increased prothrombin time - Increased partial prothrombin time Postpartum Complications

- Decreased platelets - Decreased fibrinogen level - Increased fibrin degradation products - Prolonged bleeding time * Idiopathic throbocytopenia * Von Willebrand Disease Postpartum Complications

* Disseminated intravascular coagulation (DIC) - Diffuse and consumes large amounts of clotting factors - Widespread external and internal bleeding - Predisposing factors: abruptio placentae, amniotic fluid embolism, dead fetus syndrome (6 weeks), severe pre-eclampsia, septicemia, cardiopulmonary arrest, hemorrhage Postpartum Complications

* Diagnosis - Spontaneous bleeding from gums and nose - Petechiae around blood pressure cuff - Thromboembolic Disease * Types - Superficial venous thrombosis saphenous) - Deep venous thrombosis (foot to iliofemoral region Postpartum Complications

- Pulmonary embolism (complication of DVT) * Incidence has decreased because of early ambulation after birth * Major causes - Venous stasis - Hypercoagulation * Medical management - Superficial – analgesic (NSAID), rest with elevation of the leg, elastic stockings Postpartum Complications

- Local application of heat may also be used - Deep vein thrombosis – IV heparin (5-7 days), bedrest with affected leg elevated, analgesia followed by elastic stockings and oral anticoagulant therapy (warfarin) for 3 months * Woman should be encouraged not to massage area and, when on bedrest, not to flex knees sharply * Anticoagulant therapy for 6 months Postpartum Complications

-Pulmonary embolism * Signs/symptoms - Shortness of breath - Diaphoresis - Chest pain - Tachycardia * Treated with continuous IV heparin followed by intermittent subcutaneous or oral

Postpartum Infections - Puerperal Infection (“Childbed Fever”) - Any infection of the genital canal that begins within 28 days after abortion, miscarriage or childbirth - Definition is a fever of 38 o C (100.4 o F) on 2 successive days of the first 10 days postpartum (not counting 1 st 24 hours after birth Postpartum Complications

- Common infections * Endometritis * Wound infections * Mastitis * UTIs * URIs - More common in women with concurrent medical or immunosuppressive conditions Postpartum Complications

- Also increased risk with * A Cesarean or other operative birth * Prolonged labor * Prolonged rupture of membranes * Internal fetal or uterine monitoring - Signs/symptoms * Endometritis - Pelvic pain - Uterine tenderness - Foul-smelling, profuse lochia Postpartum Complications

* Wound infection - Erythema, edema, warmth, tenderness, sero-purulent drainage wound separation * Mastitis - Almost always unilateral - Develops well after milk flow established - Usually hemolytic S. aureus Postpartum Complications

- Infected nipple fissure usually the initial lesion - Accompanied by inflammatory edema and engorgement that obstruct milk flow in the region and generalized mastitis follows - Chills, fever, malaise, pain - Treated by antibiotics and emptying breasts q 2-4 hours by feeding, manual expression or pump Postpartum Complications

Postpartum Psychological Complications - Grieving * Normal response to loss of a child or loss of the “ideal” child * The woman grieves the “death” of the idealized child * May interfere with the ability to bond with the child Postpartum Complications

* Death of a baby - Questions about what happened - Bewilderment, resentfulness, bitterness - Most women interested in seeing the baby and this is therapeutic - Staff and patients, friends and relatives tend to avoid a woman whose baby has died - Woman needs the opportunity to talk about it

Perinatal depression * Prevalence of major and minor depression begins to rise after delivery and peaks in the 3 rd month * Postpartum “Blues” - 50% of women have symptoms - Peak on 5 th postpartum day - considered a normal part of early motherhood - Go away within 10 days - Depression * “Blues” vs. Depression vs. Psychosis (handout) * Blues - Emotional lability - Feelings of sadness - Related to hormone shifts, fatigue, sleep deprivation * Depression - Feelings continue beyond the immediate postpartal period and longer than 1 year Postpartum Complications

* Postpartum Depression - May occur in 10% - 23% of women - A true, major depression - Can last into the 2 nd year after delivery - Risk factors * Past history of depression (often bipolar) * Depression during pregnancy * Previous history of postpartum depression * Life stress * Poor social support Postpartum Complications

* History “baby blues” * History of severe PMS * Poor marital relationship * Family history of postpartum depression - Symptoms * Feeling of sadness, extreme fatigue, inability to stop crying, anxiety about her own or the baby’s health, insecurity and psychosomatic symptoms Postpartum Complications

* Cheryl Beck (PPSS) - “Teetering on the edge” - “Brain is full of cobwebs” - “…I have lost my self” * Basic psychosocial problem with control - Postpartum Psychosis * Response to the crisis of childbearing * Majority of these women have had symptoms of mental illness that precede the pregnancy Postpartum Complications

* Other major life crises can precipitate the same illness * Exceptional sadness, out of touch with reality, thoughts of infanticide or that the child is possessed * This is a psychiatric emergency and requires hospital admission * Do not leave the woman alone and do not leave her alone with her infant * Risks of suicide and infanticide are significant