1. Postpartum complications II
Lectures 12
Prepared by MD, PhD Kuziv I.

2. Postpartum complications
Postpartum hemorrhage
Hemorrhagic shock
Coagulopathies
Thromboembolic disease

3. Main Causes of Early Hemorrhage are:
1. Uterine Atony
2.    Lacerations
3.    Retained Placental fragments
4.    Inversion of the Uterus
5.    Placenta Accreta

4. The Two Principles that Govern PPH Treatment
The bleeding must be arrested
The maternal volume must be restored

6. Etiology and Pathophysiology:
Uterine Atony
Etiology and Pathophysiology:
The most frequent cause of postpartal hemorrhage is UTERINE ATONY. The myometrium fails to contract and the uterus fills with blood because of the lack of pressure on the open vessels of the placental site.

7. Signs and Symptoms: 1. Excessive or bright red bleeding
2. A boggy uterus that does not respond to massage
3. Abnormal clots
4. Any unusual pelvic discomfort or backache

11. Management of Postpartum Hemorrhage
Close observation of fundal height and bleeding after delivery for at least 1 hour
Common protocol for fundal height massage: Q15min X 1 hr, Q30min X1 hr, Q1hr X 4hrs, Qshift + PRN)
Make sure bladder is drained
If uterine massage is ineffective, pharmacologic agents are indicated

12. 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

13. 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

14. RETAINED PLACENTAL FRAGMENTS
Etiology and Pathophysiology:
This occurs when there is incomplete separation of the placenta and fragments of placental tissue retained.
 Signs and Symptoms:
–  Boggy , relaxed uterus
–  Dark red bleeding
Treatment and Nursing Care:
–  D & C - clean out any fragments that may be left
–  Administration of Oxytocins – to contract the uterus
–  Administration of Prophylactic antibiotics

15. INVERSION OF THE UTERUS
Etiology and Pathophysiology:
The uterus inverts or turns inside out after delivery.
Complete inversion - a large red rounded mass protrudes from the vagina
Incomplete inversion - uterus can not be seen, but felt

16. INVERSION OF THE UTERUS
Etiology and Pathophysiology:
The uterus inverts or turns inside out after delivery.
Complete inversion - a large red rounded mass protrudes from the vagina
Incomplete inversion - uterus can not be seen, but felt

17. 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.

18. 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.

19. 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!

20. 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.

21. TREATMENT AND NURSING CARE:
Oral administration of Methergine for 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.

22. 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.

23. 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.

24. 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.

25. 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.

26. 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.

27. 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)

28. 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.

29. 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.

30. 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.

31. 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.

32. COMPLICATION:
PULMONARY EMBOLI – substernal chest pain, sudden and intense; dyspnea; pallor and cyanosis; increased jugular pressure; confusion; hypotension; sudden apprehension; hemoptysis.

33. COMPLICATION:
PULMONARY EMBOLI – substernal chest pain, sudden and intense; dyspnea; pallor and cyanosis; increased jugular pressure; confusion; hypotension; sudden apprehension; hemoptysis.

34. Thank you for attention