1. Postpartum Complications
Chapter 23
Postpartum Complications
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2. Postpartum Hemorrhage
Definition and incidence
PPH traditionally defined as loss of more than:
500 ml of blood after vaginal birth
1000 ml after cesarean birth
Cause of maternal morbidity and mortality
Life-threatening with little warning
Often unrecognized until profound symptoms
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3. Postpartum Hemorrhage
Etiology and risk factors
Uterine atony
Marked hypotonia of uterus
Leading cause of PPH, complicating approximately 1 in 20 births
Brisk venous bleeding with impaired coagulation until the uterine muscle contracts
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4. Postpartum Hemorrhage
Lacerations of genital tract
Should be suspected if bleeding continues with a firm, contracted fundus
Includes perineal and cervical lacerations as well as pelvic hematomas
Retained placenta
Nondherent retained placenta – managed by manual separation and removal by the primary care provider
Adherent retained placenta – may be caused by implantation into defective endometrium
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5. Postpartum Hemorrhage
Three classifications of adherent retained placenta
Placenta acreta – slight penetration of myometrium by placental trophoblast
Placenta increta – deep penetration of myometrium by placenta
Placenta percreta – perforation of uterus by placenta
Patient will experience profuse bleeding when delivery of the placenta is attempted.
Management includes blood replacement and surgical intervention (hysterectomy)
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6. Postpartum Hemorrhage
Inversion of uterus (turning inside out)
May be life-threatening
A complete inversion protrudes out of the vagina
Primary signs – hemorrhage, shock, pain
Prevention is the best measure – don’t pull on the umbilical cord unless there is definite separation of the placenta
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7. Postpartum Hemorrhage
Subinvolution of uterus – delayed involution of the uterus
Usually see late post partum bleeding
Causes include retained placental fragments and infection
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Care Management
Assessment
Bleeding assessed for color and amount
Perineum inspected for signs of lacerations or hematomas to determine source of bleeding
Vital signs may not be reliable indicators because of postpartum adaptations
Measurements during first 2 hours may identify trends related to blood loss
Bladder distension
Laboratory studies of hemoglobin and hematocrit levels
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Care Management
Plan of care and implementation
Initial treatment – fundal massage, expression of clots, relief of bladder distension, IV fluids
Medications – Table 25-1
Medical management
Hypotonic uterus – examine for retained placental fragments, medications, surgical interventions
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Care Management
Medical management – cont.
Bleeding with a contracted uterus – identify and treat underlying cause
Uterine inversion – emergency replacement of the uterus into the pelvic cavity
Subinvolution – medications, surgical intervention
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Care Management
Plan of care and implementation
Nursing interventions
Vital signs, uterine assessment, medication administration, notification of primary care provider
Providing explanations about interventions and need to act quickly
Once stable, ongoing post partum assessments and care
Instructions in increasing dietary iron, protein intake, and iron supplementation
May need assistance with infant care and household activities until strength regained
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12. Hemorrhagic (Hypovolemic) Shock
Emergency situation in which blood is diverted to the brain and heart
May not see signs until post partum patient loses 30% to 40% of blood volume
Medical management – restore circulating blood volume and treat underlying cause
Nursing interventions – monitor tissue perfusion, see emergency box
Fluid or blood replacement therapy
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Coagulopathies
Idiopathic thrombocytopenic purpura (ITP) – decreased platelet life span, need to control platelet stability
von Willebrand disease—type of hemophilia
Disseminated intravascular coagulation (DIC)
Pathologic clotting
Correction of underlying cause
Removal of fetus
Treatment for infection
Preeclampsia or eclampsia
Removal of placental abruption
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14. Thromboembolic Disease
Results from blood clot caused by inflammation or partial obstruction of vessel
May be superficial or deep venous thrombosis or a pulmonary embolus
Incidence and etiology
Venous stasis
Hypercoagulation
Clinical manifestations – redness and swelling in the affected extremity, pain, positive Homan’s sign
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15. Thromboembolic Disease
Medical management
Superficial – analgesia, rest/elevation, TED hose
Deep – anticoagulant therapy, bedrest/elevation, TED hose
Pulmonary embolus – IV heparin therapy
Nursing interventions
assessment of the affected area, signs of bleeding, personal care, medication administration
Teach not to massage affected area!!
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16. Postpartum Infections
Puerperal sepsis: any infection of genital canal within 28 days after abortion or birth
Most common infecting agents are numerous streptococcal and anaerobic organisms
Endometritis
Wound infections
Urinary tract infections
Mastitis
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Care Management
Prevention is the best intervention
Hand washing
Good maternal perineal hygiene
Antibiotic administration
Wound management
Breast care
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18. 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
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19. Sequelae of Childbirth Trauma
Cystocele and rectocele
Cystocele: protrusion of bladder downward into vagina when support structures in vesicovaginal septum are injured
Rectocele is herniation of anterior rectal wall through relaxed or ruptured vaginal fascia and rectovaginal septum
Urinary incontinence
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20. Sequelae of Childbirth Trauma
Genital fistulas
May result from congenital anomaly, gynecologic surgery, obstetric trauma, cancer, radiation therapy, gynecologic trauma, or infection
Vesicovaginal: between bladder and genital tract
Urethrovaginal: between urethra and vagina
Rectovaginal: between rectum or sigmoid colon and vagina
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21. Types of Fistulas That May Develop in Vagina, Uterus, and Rectum
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22. 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
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23. 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
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24. 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
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Loss and Grief
Losses of what was hoped for, dreamed about, and/or planned
Any perception of loss of control during the birthing experience
Birth of a child with handicap
Maternal death
Fetal or neonatal death
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Loss and Grief
Conceptual model of parental grief
Acute distress
Intense grief
Reorganization
Anticipatory grief
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Loss and Grief
Plan of care and implementation
Communicating and care techniques
Actualize the loss
Provide time to grieve
Interpret normal feelings
Allow for individual differences
Cultural and spiritual needs of parents
Physical comfort
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Loss and Grief
Plan of care and implementation
Options for parents
Seeing and holding
Bathing and dressing
Privacy
Visitations: other family members or friends
Religious rituals/funeral arrangements
Special memories
Pictures
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Maternal Death
Rare for woman to die in childbirth
Families are at risk for developing complicated bereavement and altered parenting of surviving baby and other children in family
Referral to social services can help combat potential problems before they develop
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Key Points
Postpartum hemorrhage is most common and serious type of excessive obstetric blood loss
Hemorrhagic (hypovolemic) shock is an emergency situation; the perfusion of body organs may become severely compromised and death may ensue
Potential hazards of therapeutic interventions may further compromise the woman with hemorrhagic disorders
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31. Mosby items and derived items © 2006, 2002 by Mosby, Inc.
Key Points
Postpartum infection is a major cause of maternal morbidity and mortality
Postpartum urinary tract infections are common because of trauma experienced during labor
Breast infection affects about 1% of women soon after childbirth
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32. Mosby items and derived items © 2006, 2002 by Mosby, Inc.
Key Points
Structural disorders of uterus and vagina related to pelvic relaxation are often the delayed but direct result of childbearing
Understanding of grief responses and bereavement process is fundamental to the nursing process
Therapeutic communication and counseling techniques can help families in identifying their feelings and in feeling comfortable in expressing their grief
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Key Points
Follow-up after discharge is an essential component in providing care to families who have experienced a loss
Nurses need to be aware of their own feelings of grief and loss to provide a nonjudgmental environment of care and support for bereaved families
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