1. Postpartum Complications
Dr. Areefa

2. Subinvolution
Is the slowing or halting of normal postpartum return of reproductive organs to their pre-pregnancy state.
Causes:
Pelvic infection.
Retention of placental fragments.
Fibroid tumor.
Any other factors that interferes with myometrial contractions.
Clinical Manifestations:
Uterus larger or softer than expected for postpartum date.
Prolonged lochia discharge (after one month or more)
Irregular uterine bleeding.
Backache or sensation of weight in pelvis.

3. Management and Nursing Interventions:
Explain and implement plan of care.
Administration of Ergonovine Maleate as prescribed to increase uterine contractility.
Prepare the woman for uterine curettage if placental fragments have been retained.
Administer suitable antibiotics for infection as prescribed.
Instruct the woman to report signs of infection, vaginal bleeding or any tissue passed vaginally.
Describe complications and usual treatment regimen.
Correct misinformation regarding condition and complications.

4. Postpartum Hemorrhage
Is defined as a loss of blood in excess of 500 ml in the 1st 24 hours following delivery. It occurs more frequently in the 1st hour following delivery.
Causes:
Uterine atony “Relaxation of the uterine muscles”
It occurs secondary to:
Multiple pregnancy: causes overdistention of uterus and larger placental site.
High parity.
Prolonged labor with maternal exhaustion.
Deep anesthesia: provide uterine relaxation.
Fibromyomata: prevents uterus from contracting.
Retained placental fragments.
Polyhydramnios.
Macrosomia.
Laceration of the vagina, cervix or perineum secondary to:
Forceps delivery.
Large infant.
Multiple pregnancy.
Retained placental fragments:
These fragments are the major cause of late postpartum hemorrhage.
Results from placenta accreta or manual removal of placenta.
Retained placenta:
Hemorrhage may occur after the delivery of baby and before delivery of the placenta.

5. Clinical Manifestations:
Uterine atony:
Uterus is soft, often difficult to palpate and will not remain contracted.
Bleeding is steady and slow rather than sudden and massive.
Blood pressure and pulse may not change until blood loss is significant.
Lacerations:
Fundus is firm, bleeding is bright red.
On examination lacerations are found.
Retained placental fragments:
Hemorrhage usually occurs about the 10th postpartum day.
Excessive blood loss: pallor, restlessness, dyspnea, thready pulse, hypotension, chills and air hunger.

6. Management and Nursing Interventions:
Monitor changes in physiologic status:
Monitor vital signs frequently.
Describe number and saturation of perineal pads used per hour.
Describe character and amount of vaginal bleeding.
Evaluate uterine firmness, height and position.
Restore fluid/blood volume:
Administer IV fluids as prescribed to restore fluid volume.
Administer blood as prescribed.
When cause has been determined, prepare the woman for further treatment:
Uterine atony:
Vigorous massage is instituted.
Oxytocics such as Methylergonovin (Methergin) and Oxytocin (Pitocin) may be given.
Laceration:

7. Prepare the woman for return to delivery room for inspection and repair.
Retained placental fragments:
Prepare the woman for curettage of the uterus.
Retained placenta:
The physician manually removes the placenta by inserting a gloved hand into the uterus and placing the other hand externally on the fundus.
O2 at 4-7 L/min is given by facemask.
Help reduce anxiety:
Determine major cause of mother’s anxiety.
Explain current status and prescribed treatment regimen.
Correct misinformation regarding states or potential complications.
Keep the woman/family informed of changes in physiologic status or treatment plan with emphasis on improvement condition.

8. Postpartum Hematomas
Are localized collections of blood in loose connective tissue beneath the skin that covers the external genitalia or vaginal mucosa.
Causes:
Trauma during spontaneous labor.
Trauma during forceps delivery.
Inadequate suturing of an episiotomy.
Clinical Manifestations:
Vulvar Hematoma: development of sensitive swelling covered by discolored skin, pain.
Vaginal Hematoma: feeling of vaginal pressure, inability to void, mass may be seen in introitus.

9. Nursing Interventions:
Explain and implement plan of care:
Application of ice may minimize hematoma initially depending on amount and site of bleeding.
Warm compresses may be applied to hematoma to promote comfort and healing.
Incision, drainage and ligation of bleeding point may be necessary.
Comfortable positioning.
Analgesics for pain as prescribed.
Describe complications and prescribed treatment regimen.
Correct misinformation regarding complications

10. Puerperal Infection “Puerperal Sepsis”
Is any clinical infection of the genital canal that occurs within 28 days after abortion or delivery.
Postpartum infection of genital tract usually of the endometrium that may remain localized or may extend to various parts of the body.
Infections may result from bacteria commonly found in the vagina (endogenous) or from the induction of pathogens from outside the vagina (exogenous)
The most common microorganisms are Streptococci, E .coli, Staphylococci, Sexually Transmitted Diseases (STDs), Anaerobic microorganisms as Tetanus and gas gangrene.
Puerperal infection may occur anywhere in the pelvis or birth canal as endometritis, vaginitis, vulvitis.

11. Predisposing Factors:
1. Prolonged labor Postpartum hemorrhage PROM.
4. Infection elsewhere in the body Intrauterine manipulation.
6. Anemia Retention of placental fragments Malnutrition.

12. Endometritis usually at the placental site, localized infection may be followed by salpingitis, peritonitis & pelvic abscess formation, septicemia may develop, secondary abscesses may arise in distant sites such as the lungs or liver. Pulmonary embolism or septic shock with DIC from any serious genital infection may prove fatal.
Clinical Findings:
Symptoms may be mild or fulminating.
Any fever that is a temperature of 38 C or more on 2 successive days, not counting the 1st 24 hours after delivery must be considered caused by puerperal infection in the absence of another cause.

13. Parametritis “Pelvic Cellulitis
Infection of the pelvic connective tissue.
Chills, fever, tachycardia, severe unilateral or bilateral pain in the lower abdomen and tenderness on vaginal examination usually occur about the 4th postpartum day.
May result from infected wound in the cervix, vagina, peritoneum or lower uterine segment.
Uterus may be longer than expected.
Pelvis area warm with an extremely sensitive spot due to an abscess underneath.
Incision and drainage is performed if an abscess form.

14. Thrombophelibitis Pelvic Thrombophelibitis:
Infection of veins supplying uterine wall and broad ligament.
Symptoms usually begin during 2nd week following delivery.
The women may have severe chills and intermittent high fever (40 C).
? Redness, increase skin temperature, blood cultures are taken to isolate the organisms.

15. Femoral Thrombophelibitis:
Pain, tenderness, redness, hotness, edema of the calf or thigh.
Bacteremia
Presence of bacteria in the blood stream.
Result of infected thrombi breaking loose.
Chills, fever, tachypnea, pale skin, cyanosis of the lips and fingers, increase lochial secretions with foul odor.
Peritonitis
Inflammation of the peritoneum.
Chills, high fever, tachycardia, vomiting, severe abdominal pain.

16. Diagnostic Evaluation:
Clinical history.
Physical examination.
Leukocytosis, high neutrophils.
Culture and sensitivity for discharge and blood for both aerobic and anaerobic organisms.
Lung scan, chest X-ray.

17. Management and Nursing Interventions:
The most effective and cheapest treatment of puerperal infection is prevention.
Preventive measures include:
Good prenatal nutrition.
Treatment of anemia.
Control of intranatal hemorrhage.
Good maternal hygiene.
Prolonged labor should be avoided.
Traumatic vaginal delivery should be avoided.
Best aseptic techniques by medical personnel.
Determine source of woman’s anxiety regarding complications.
Explain prescribed treatment regimen.
Correct misinformation.
Monitor the woman’s condition:

18. Institute comfort measures:
Good skin care.
Soothing sponge bath.
Frequent change of perineal pads.
Analgesics as prescribed.
Assist the woman/family in planning for child care required by prolonged hospitalization. 

19. Mastitis
Mastitis is inflammation of breast tissue.
It may involve formation of subareolar abscess in the underlying milk glands or connective tissue and fat around the lobes and lobules.
Is unilateral and develops well after the flow of milk has been established.
Cause:
Usually due to Staphylococcus aureus derived from the nursing infant’s nose and throat.
Clinical Manifestations:
Symptoms may occur at the end of the 1st postpartum week but usually occur in the 3rd to the 4th week postpartum.
Elevated temperature (usually not above 398).
Tachycardia
Breast pain.
Breast hardening and redness.

20. Management and Nursing Intervention:
Avoid missed feedings, waiting too long between feedings.
Maintain cleanliness and personal hygiene.
Use comfort measures- breast support, tight binder or brassier.
Analgesics as prescribed.
Application of heat to affected breast if suppuration is present.
Suitable antibiotic as prescribed.
If breast milk is contaminated,, empty breast on affected side with breast pump and discard milk until infection is controlled.
If abscess forms, incision and drainage may be necessary.
Correct misinformation regarding condition and complication.
Keep the woman/family informed of changes in physiologic status and treatment plan.

21. Postpartum UTI
Causes:
Bladder trauma during delivery.
Urinary retention due to anesthesia, venous congestion causing overdistention of the bladder.
Frequent catheterization.
Clinical Manifestations:
Elevated temperature and chills.
Urinary frequency.
Pain on urination.
Flank pain.

22. Management and Nursing Interventions:
Explain and implement plan of care:
Monitor vital signs, degree and site of pain.
Instruct the woman to increase fluid intake.
Instruct the woman to empty her bladder completely each time she urinates.
Administer suitable antibiotics, analgesics, and antispasmodics as prescribed.
Encourage the woman to rest.
Describe complications and general treatment regimen.
Correct misinformation regarding condition and complications.

23. THANKS