Postpartum Complications I Lecture 11 Prepared by MD, PhD Kuziv I.

Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection.

ETIOLOGY AND PATHOPHYSIOLOGY: 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

Etiology and Pathophysiology: HEMATOMA Etiology and Pathophysiology: Bleeding into the tissues of the perineal area can cause hematoma formation. May have at least 500cc. Pooled in the hematoma. May be around the episiotomy site.

Signs and Symptoms: 1.  Pain – perineal. More than normal amount of pain. Mild analgesics are not sufficient to decrease the amount of pain. 2.  Hard, firm, area on the perineum

Treatment and Nursing Care: 1. I & D – incision and drainage. May leave in a penrose drain. 2. Dressing changes 3. Replace the blood loss 4. Comfort measures

Sequelae of Childbirth Trauma Disorders of uterus and vagina related to pelvic relaxation and urinary incontinence, are often result of childbearing Uterine displacement and prolapse Posterior displacement, or retroversion Retroflexion and anteflexion Prolapse a more serious displacement Cervix and body of uterus protrude through vagina and vagina is inverted 7 of 34

Types of Fistulas That May Develop in Vagina, Uterus, and Rectum

NEUROLOGIC SYSTEM Neurologic changes during the puerperium are those that result from a reversal of maternal adaptations to pregnancy and those resulting from trauma during labor and childbirth. Pregnancy-induced neurologic discomforts abate after birth. Elimination of physiologic edema through the diuresis that follows childbirth relieves carpal tunnel syndrome by easing compression of the median nerve.

Postpartum Depression Postpartum depression is a nonpsychotic depressive episode that begins in the postpartum period due to decreased estrogen level Symptoms: changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feeling of worthlessness or guilt; difficulty thinking, concentrating or making decisions; or recurrent thoughts of death or suicidal ideation, plans, or attempts.

Postpartum Psychosis A very serious type of PPD illness that can affect new mothers. Begin 2-3 weeks post delivery Fatigue, restlessness, insomnia, crying liable emotions, inability to move, irrationally statements incoherence confusion and obsessive concerns about the infant’s health Psychiatric emergency

Postpartum Psychologic Complications Mental health disorders in postpartum period have implications for mother, newborn, and entire family Interfere with attachment to newborn and family integration May threaten safety and well-being of mother, newborn, and other children 12 of 34

Postpartum Psychologic Complications Postpartum depression without psychotic features PPD: an intense and pervasive sadness with severe and labile mood swings Treatment options Antidepressants, anxiolytic agents, and electroconvulsive therapy Psychotherapy focuses fears and concerns of new responsibilities and roles, and monitoring for suicidal or homicidal thoughts 13 of 34

Postpartum Psychologic Complications Postpartum depression with psychotic features Postpartum psychosis: syndrome characterized by depression, delusions, and thoughts of harming either infant or herself Psychiatric emergency, and may require psychiatric hospitalization Antipsychotics and mood stabilizers such as lithium are treatments of choice 14 of 34

Etiology and Pathophysiology: 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.

Etiology and Pathophysiology: 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.

TREATMENT AND NURSING CARE: Oral administration of Methergine for 24-48 hours. D & C SIGNS AND SYMPTOMS: Lochia fails to progress from rubra to serosa to alba. The uterus is higher in the abdomen. Irregular or excessive bleeding.  

Thromboembolic Conditions Thrombophlebitis–the formation of a clot in an inflamed vein. Risk factors include maternal age over 35, cesarean birth, prolonged time in stirrups, obesity, smoking, and history of varicosities or venous thromboses. Prevention: client needs to ambulate early after delivery.

Thromboembolic Conditions Thrombophlebitis–the formation of a clot in an inflamed vein. Risk factors include maternal age over 35, cesarean birth, prolonged time in stirrups, obesity, smoking, and history of varicosities or venous thromboses. Prevention: client needs to ambulate early after delivery.

Thromboembolic Conditions Thrombophlebitis–the formation of a clot in an inflamed vein. Risk factors include maternal age over 35, cesarean birth, prolonged time in stirrups, obesity, smoking, and history of varicosities or venous thromboses. Prevention: client needs to ambulate early after delivery.

THROMBOEMBOLIC DISEASE Superficial thrombophlebitis is limited to the superficial saphenous veins, whereas deep thrombophlebitis generally involves most of deep venous system. PREDISPOSING FACTORS: Slowing of blood flow in legs – usually in Moms who have a Cesarean delivery. Trauma to the vessels during delivery.

THROMBOEMBOLIC DISEASE Superficial thrombophlebitis is limited to the superficial saphenous veins, whereas deep thrombophlebitis generally involves most of deep venous system  PREDISPOSING FACTORS: Slowing of blood flow in legs – usually in Moms who have a Cesarean delivery. Trauma to the vessels during delivery.

Assessment 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)

Treatment and Nursing Care: 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.

Treatment and Nursing Care: 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.

Treatment and Nursing Care: 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.

Treatment and Nursing Care: 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.

Thank you for attention