1. Postpartum complications
Dr Maryam

2. Remember!!! Majority of death occur during puerperium
Dr Maryam

3. Prevention of the complications is very essential .
Although the puerperium is usually a period of health , complications can occur .
When the complications happened , immediate intervention is essential to prevent long-term disability and interference with parent-child relationships .
Prevention of the complications is very essential .
Dr Maryam

4. Most postpartal complications are preventable And If they do occur , the majority can be treated effectively .
Dr Maryam

5. Postpartum Hemorrhage
Dr Maryam

6. Postpartum Hemorrhage
. . . the most common and severe type of obstetric hemorrhage, is an enigma even to the present day obstetrician as it is sudden, often unpredicted, assessed subjectively and can be catastrophic. The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period.
Dr Maryam

7. Postpartum Hemorrhage
Obstetrical emergency that can follow vaginal or cesarean delivery
Definition: Any blood loss from the uterus greater than 500 cc in NSVD or 1000 in C section .
Early : Within the first 24 hours
Late : Any time after the first 24 hours during the remaining days of the 6-week puerperium
Excessive bleeding that makes the patient symptomatic (lightheaded, syncope) and/or results in signs of hypovolemia (hypotension, tachycardia, oliguria)
Dr Maryam

8. ASSESSMENT OF BLOOD LOSS AFTER DELIVERY
Difficult
Mostly Visual estimation (So, Subjective & Inaccurate)
Underestimation is likely
Clinical picture -Misleading
Our mothers-malnourished, anemic, less blood volume
Dr Maryam

9. Early PPH
Uterine atony
Lacerations
Episiotomy
Tear
Dr Maryam

10. Uterine atony Or relaxation of the uterus
The most frequent cause of early PPH
Dr Maryam

11. Risk Factors for Postpartum hemorrhage
Prolonged and difficult labor
Previous PPH
Overdistended uterus ( multiple gestation , hydramnios, large baby )
Use of magnesium sulfate, preeclampsia
Induction or augmentation of labor
Operative birth
Rapid birth
High parity
Dr Maryam

12. Prophylactic oxytocin should be offered routinely in the management of the third stage of labor as they reduce the risk of PPH by about 60%.
Dr Maryam

13. SYMPTOMS & SIGNS Blood loss Systolic BP Signs & Symptoms 10-15 Normal
(% B Vol)
Systolic BP
( mm of Hg)
Signs & Symptoms
10-15
Normal
postural hypotension
15-30
slight fall
PR, thirst, weakness
30-40
60-80
pallor,oliguria, confusion
40+
40-60
anuria, air hunger, coma, death
Dr Maryam

14. Nursing interventions in uterine atony
The first step in controlling hemorrhage is to attempt uterine massage to encourage contraction .
Remain with the woman after massaging her fundus , to be certain the uterus is not relaxing again .
Observe carefully , including fundal height and consistency and lochia for the next 4 hours .
If the uterus cannot remain contracted , a dilute IV infusion of oxytocin (pitocin) to help the uterus maintain tone .
The usual dosage of oxytocin : IU per ml of RL .
Dr Maryam

15. Dr Maryam

16. Nursing interventions in uterine atony,cont
Offer a bedpan or assist the woman with ambulating to the bathroom at least every 4 hours to keep her bladder empty .
A full bladder pushes an uncontracted uterus into an even more uncontracted state .
To reduce bladder pressure ,insertion of a urinary catheter may be ordered.
Obtain vital signs frequently and make sure to interpret them accurately , looking for trends .For example , a continuously rising PR is an omnious pattern .
If the woman is experiencing respiratory distress from decreasing blood volume , administer oxygen by face mask at a rate of 4 L/ min . Position her supine to allow adequate blood flow to her brain and kidneys.
Dr Maryam

17. Other uterotonic drugs
Carboprost (Hemabate) 250mcg IM q15-90min up to 2mg
Methylergonovine (Methergine) 0.2mg IM q2-4h
CBC, Type and cross, coag studies
Dr Maryam

18. Lacerations Small lacerations or tears of the birth canal are common .
Large lacerations are complications .
After birth , any time uterus feels firm but bleeding persists, suspect a laceration of one these 3 sites :
Vaginal
Cervical
Perineal
First degree : the skin only
2nd degree : Perineal muscle but not the anal sphincter
3rd degree : anal sphincter
4th degree : rectal or anal mucosa
Dr Maryam

19. Late PPH : RETAINED PLACENTA
Simple adhesion: The placenta may fail to separate completely from the uterine muscle due to lack of contraction of the uterine muscles( The placenta is said to be retained when it is not expelled from the uterus even 30 minutes after the delivery of the baby) . This is is the commonest cause for retention of placenta.
Manual separation can be done easily.
Dr Maryam

20. Dr Maryam

21. Late PPH : RETAINED PLACENTA
Morbid adhesion :Morbid adhesion of the placenta can occur when the placenta is implanted deeply into the uterine muscles and thus fails to separate
Accreta : An invasion of the myometrium which does not penetrate the entire thickness of the muscle.
Increta :Occurs when the placenta further extends into the myometrium.
Percreta :The worst form of the condition is when the placenta penetrates the entire myometrium to the uterine serosa(invades through entire uterine wall).
The safest treatment is a planned cesarian section and abdominal hysterectomy if placenta accreta is diagnosed before birth.
Dr Maryam

22. Retained placental fragments
Occasionally , a placenta does not deliver in its entirety ; fragments of it separate and are left behind .
The portion retained keeps the uterus from contracting fully , uterine bleeding occurs .
Removal of the placental fragments is necessary to stop the bleeding .
Dr Maryam

23. subinvolution
Is incomplete return of the uterus to its prepregnant size and shape .
In this case , at a 4-6-week postpartal visit , the uterus is still enlarged and soft
Dr Maryam

24. Perineal hematomas
A collection of blood in the subcutaneous layer of tissue of the perineum .
The overlying skin , as a rule , is intact with no noticeable trauma .
Report the presence of the hematoma , its size , and the degree of the woman’s discomfort
Dr Maryam

25. Puerperal infection
Theoretically , the uterus is sterile during pregnancy and until the membranes rupture .After rupture , pathogens can invade .
The risk of infection is even greater if tissue edema and trauma are present .
Dr Maryam

26. Therapeutic management
Using an appropriate antibiotic after culture and sensitivity
Organisms commonly cultured postpartally :
Group B streptococci
Aerobic gram-negative bacilli such as Escherichia coli
Dr Maryam

27. Febrile condition suggesting infection
An increase in oral temperature to more than F ( 38 C ) for two consecutive 24 –hour periods , excluding the first 24-hour period after birth
Dr Maryam

28. Postpartum Endometritis
Infection of the decidua (pregnancy endometrium):
fever on the 3rd or 4th postpartal day .
lower abdominal tenderness on one or both sides of the abdomen,
adnexal and parametrial tenderness elicited with bimanual examination,
Dr Maryam

29. Wound infections or episiotomy infections,
If a woman has a suture line on her perineum from episiotomy or a laceration repair , a portal of entry exist for bacterial invasion
erythema,
edema,
tenderness out of proportion to expected postpartum pain,
discharge from the wound or episiotomy site.
Drainage from wound site should be differentiated from normal postpartum lochia and foul-smelling lochia, which may be suggestive of endometritis.
Dr Maryam

30. Dr Maryam

31. thrombophlebitis Inflammation with the formation of blood clots.
In postpartal period , it is usually an extension of an endometrial infection.
Classified :
Superficial vein disease ( SVD )
Deep vein thrombosis ( DVT )
Dr Maryam

32. Prevention of thrombophlebitis
Using a good aseptic technique
Ambulation and limiting the time woman remains in a bed
Dr Maryam

33. Pulmonary embolous Obstruction of the pulmonary artery by a blood clot
It usually occurs as a complication of thrombophlebitis
Dr Maryam

34. Mastitis Infection of the breast
May occur as early as the 7th postpartal day
rapid onset
very tender, engorged, erythematous breasts
Infection frequently is unilateral.
During lactation are common
Dr Maryam

35. Breast infections can be very aggressive with high fevers developing quickly.
Immediate treatment is important to keep an otherwise simple mastitis from developing an abscess, requiring surgical drainage.
Dr Maryam

36. Usually caused by common skin bacteria (particularly staphylococcus) being introduced into the ductal system through cracked nipples and the inoculation by the newborn suckling.
Dr Maryam

37. Urinary retention Occurs as a result of inadequate bladder emptying .
Dr Maryam

38. Urinary tract infection
A woman who is catheterized at the time of childbirth or during the postpartal period is prone to development of UTI .
Symptoms :
Dysuria
Hematuria
Frequent urination
Sharp pain during voiding
Dr Maryam

39. Therapeutic Management
Urinalysis
Urine culture
Antibiotic therapy
Dr Maryam