1. POST PARTUM
COMPLICATIONS
Lecture 9 1

2. Endometritis
Infection of Uterus: endometrium, myometrium, or parametrium.
Caused by: E.Coli, Staph, Group A/B Streptococcus.
Occurs within 10 days, abortion or delivery.
Granulocytes in lochia & endometrial lining - help prevent infection
Risk factors: PROM, C/S, multiple pelvic exams, UTI, +GBS, DM, poor nutrition, poor health, catheterization.
T = x 2 ; C/S most common cause of infection followed by UTI. 2

3. Blood cx may be + for bacteremia. Send UA, urine cx; lochia cx.
S/S:
fever, chills, malaise, abd.pain, uterine cramping & tenderness, foul-smelling lochia, tachycardia.
LAB findings: CBC & Blood cx’s. WBC > 20,000 [indicates infection] 20,000 - normal > delivery.
Blood cx may be + for bacteremia. Send UA, urine cx; lochia cx.
TX:
^ po fluids, hypothermia blankets, ice packs to head/groin.
Broad spectrum antibiotics. Ampicillan, cephalosporin, gentamycin, clindamycin for 2-3 days.
Antipyretics [Tylenol] &/or pain meds.as well. 3

4. Wound Infection
Common Sites: incision, perineum [episiotomy & laceration], vagina. [port of entry]
S/S REEDA: erythema, ecchymosis, edema, purulent drainage, wound edges not approximated, pain, tenderness.
Management: Remove some staples/sutures . Allow wound to drain.
Irrigation & packing of wound, broad spectrum AB, wound & blood cx, analgesics, warm compresses.
Perineal care: wipe front to back; warm water . 4

5. GI
Paralytic Ileus: hard abdomen with absent bowel sounds, N V, abd.distention & pain.
NG tube to low intermittent suction; NPO;
IVF 5

6. Subinvolution of Uterus
Major complication > del. involving postpartum bleeding > 500 ml. [caused by uterine atony]
Delayed return of uterus to its normal size and functions.
Normally descends 1 cm/day PP.
S/S: larger than normal uterus, heavy flow, fatigue, back pain.
Methergine 0.2 mg po q 4 x 24 hrs.
Tx with AB as directed. Possible D&C.
Common Causes: retained placenta & pelvic infection.
Teach: self palpation of uterus home] 6

7. Postpartum Hemorrhage
Caused by overdistention of uterus:
large infant, multiple gestation, retained placenta & pelvic infection; grand multip > 5; Precipitous delivery; prolonged labor, clotting disorders.
Uterus “boggy” - soft. Relaxed uterus prevents
constriction of blood uteroplacetal site.
S&S: profuse bleeding, ^ clots.
Massage til firm. Assess for continued bleeding & passage of clots. 7

8. PP Hemorrhage Manage: 20-30 units of Pitocin in liter RL
Massage uterus
Methergine 0.2 mg po q 4h x 24hr.
Monitor BP before giving; may ^ BP or may give Methergine 0.2 mg. IM stat & q4 po x 24hrs. Also used: Hemabate, Prostin [prostaglandins].
Remove clots &/or retained placenta; may need D&C or hysterectomy. IV RL, transfusion with whole blood, 8

9. Late P.P.H Appears 24 hours to month > delivery.
Caused by retention of small piece of tissue
Tissue necrosis > delivery and sloughs off, causing bleeding at site.
Teach mom s/s PP hemorrhage & to contact HCP if ^ bleeding.
Remove pieces of retained placenta by dilation & curettage (D&C)
Do bimanual compression for ^ bleeding.
Follow tx for PP hemorrhage. 9

10. Uterine Prolapse
Relaxation of uterine muscle; uterus protrudes from vagina.
Ligaments over stretched & don’t return to normal.
Common after vaginal births or large infants.
menopause d/t decreased estrogen.
TX: severe prolapse: hysterectomy
milder prolapse: pessary [supportive device] 10

11. Mastitis Develops after breast milk is established, 2-4wks.PP
D/t ineffective or infrequent breast feeding or milk stasis from engorgement, skipping breast.
E.Coli or Staph.aureus; carried on hands of mom. Enters nipple thru crack or blister.
S/S: fever, chills, malaise, localized erythema & tenderness of breast tissue.
Tx: Warm soaks to both breasts as needed; pumping; put baby on breast more often.
Analgesics; AB’s - Amoxicillan 250mg.po TID. 11

12. UTI ~ 2-4 % develop UTI postpartum.
Bladder hypotonic > del. & residual urine & reflux results.
Freq. VE’s, catheterizations & birth trauma.
S/S: dysuria, low grade fever, urgency, & frequency. ^ temp.
UA & urine cx.
E.Coli most common pathogen ~ 75% of cases.
Bactrim [sulfanomide], Ampicillan, cephalexin {po Keflex}. 12

13. Thrombophlebitis aka “Superficial thrombophlebitis”
Rate 5x higher in preg.women.
Inflammation of vein wall.
Risk factors: women with extensive varicosities, smoking, inactivity, obesity, C/S, age > 35.
Occurs within few days postop.
Localized swelling, erythemia, tenderness. Unilateral; affects one leg/calf or other.
Tx: warm soaks to affected area; elevation of extremities; analgesics.
No ambulation for 1 wk; then OK to ambulate. No this time. Support stockings recommended. Avoid standing too long. 13

14. Deep Vein Thrombosis Caused by inflammatory process
Collection of blood factors, mainly fibrin, accumulates & may be released .
[1 in 2,000 preg] - deep veins of calves, thigh, pelvis.
Prevent by early ambulation 6-8 hrs. post op
ROM exercises; changing positions often.
Teds stockings, compression boots post op. {TEDS} stockings are used in pts. with hx of phlebitis, C/S, or varicose veins.
Diagnosis: Doppler’s studies [gold standard] diagnosing. 14

15. DVT
S/S:
frank pain in calf/hip; inability to walk upon rising; + Homan’s ; + tenderness with local calf swelling, heat, redness; measure both calves & compare.
Treatment:
Bedrest & leg elevation; Anticoagulants; PT/PTT prior to therapy & during for therapeutic dosing.
Heparin or Lovenox SC . Analgesics.
Septic pelvic thrombophebilits: often with C/S; thrombus formation in pelvis.
May proceed to pulmonary embolis = life threatening.
PE: fragments of clot carried to lung; can be fatal. 15

16. Pulmonary Embolism Fragments of blood clot carried to lungs.
S/S: sudden, sharp chest pain, tachycardia, syncope [fainting], tachypnea, rales, cough, hemoptysis.
ABG’s show decreased PO2; chest x-ray > pleural effusion & atelectasis.
Manage: Dissolve clot & maintain pulmonary circulation. Initiate IV heparin therapy asap.
O2, bedrest; ICU admission, ABG’s, O2 sat, VS, narcotics to alleviate pain & anxiety. 16