OB Ex 2: Post Partum Complications

ch 22; PPH, infection, mastitis, PPD

Post Partum Hemorrhage (PPH)

defined as a cumulative blood loss greater than 1,000 mL with signs and symptoms of hypovolemia within 24 hours of the birth process, regardless of the route of delivery.

• most common cause of PPH is uterine atony, failure of the uterus to contract and retract after birth.

• Any factor that causes the uterus to relax after birth will cause bleeding, even a full bladder that displaces the uterus.

The 5 Ts

helpful way to rememeber the causes of PPH

1. Tone: uterine atony, distended bladder

2. Tissue: retained placenta and clots; uterine subinvolution

3. Trauma: lacerations, hematoma, inversion, rupture

4. Thrombin: coagulopathy (preexisting or acquired)

5. Traction: too much pulling on umbilical cord

Clinical Manifestations of Shock Due to Blood Loss

• Mild: Diaphoresis, increased capillary refilling, cool extremities, maternal anxiety

• Moderate: Tachycardia, postural hypotension, oliguria

• Severe (>40%): Hypotension, agitation/confusion, hemodynamic instability

Uterine atony

Altered uterine muscle tone most commonly results from overdistention of the uterus.

Overdistention can be caused by

• multiple gestation, fetal macrosomia, obesity, hydramnios, fetal abnormality, placenta previa, precipitous birth, or retained placental fragments, fever, prolonged or rapid, forceful labor stimulated by oxytocin, anesthesia, & magnesium sulfate

• A distended bladder can also displace the uterus from the midline to either side, which impedes its ability to contract to reduce bleeding.

Subinvolution

refers to incomplete involution of the uterus or failure to return to its normal size and condition after birth.

Causes: retained placental fragments, distended bladder, being active, uterine myoma, and infection.

Condition is identified at the woman’s postpartum examination 4 to 6 weeks after birth with a bimanual vaginal examination or ultrasound.

Treatment is directed toward stimulating the uterus to expel fragments with a uterine stimulant, and antibiotics are given to prevent infection.

von Willebrand disease

a congenital bleeding disorder that is inherited as an autosomal dominant trait.

• Characterized by a prolonged bleeding time

• Impairment of platelet adhesion

• a deficiency of von Willebrand factor

• diagnosed more frequently in women because of menorrhagia

Common symptoms of von Willebrand disease include bleeding gums, easy bruising, menorrhagia, blood in urine and stools, nosebleeds, and hematomas.

Menorrhagia

is heavy menstrual bleeding that lasts more than 7 days.

Hellp Syndrome

Hemolysis, Elevated Liver enzymes and Low Platelets. A life-threatening pregnancy complication usually considered to be a variant of preeclampsia.

S/s:

• Epigastric (abdominal) or substernal (chest) pain, including abdominal or chest tenderness and upper right side pain (from liver distention)

• Nausea, vomiting, or indigestion with pain after eating

• Headache that won't go away, even after taking medication such as acetaminophen

• Shoulder pain or pain when breathing deeply

• Bleeding

• Changes in vision including blurred vision, seeing double, or flashing lights or auras

• Swelling, especially of the face or hands

• Shortness of breath, difficult breathing, or gasping for air

Disseminated Intravascular Coagulation (DIC)

the clotting system is abnormally activated, resulting in widespread clot formation in the small vessels throughout the body, which leads to the depletion of platelets and coagulation factors.

Typically a secondary diagnosis to another major complication (hellp, placental abruption, ect)

Presents with: petechiae, ecchymoses, bleeding gums, fever, hypotension, acidosis, hematomas, tachycardia, proteinuria, uncontrolled bleeding during birth, and acute renal failure

Treatment: fluid therapy, oxygen, heparin, and blood products.

PPH Nursing Care

• Boggy uterus ---> fundal massage

• Meds

• Weigh pads, chux, linens for more accurate estimate of blood loss

• QBL 1 gram = 1 mL blood

• Frequent fundal checks and VS

• IV access, bladder assessment

• Blood replacement

Uterotonic meds

• Oxytocin (Pitocin): must be diluted

• Misoprostol (Cytotec)

• Carboprost (Hemabate): contraindicated w/ asthma

• Methylergonovine maleate (Methergine): Contraindicated w/ hypertension/pre-eclampsia

Tranexamic acid (TXA)

 an antifibrinolytic agent. It works by blocking the breakdown of blood clots, which prevents bleeding. TXA is not a uterotonic.  

D&C

dilatation and curettage

• surgery to get retained tissue out of uterus

Puerperal/Post-Partum Infection

• Intrauterine placental site 

• Laceration 

• Episiotomy

• C/S incision

• Prolonged ROM

Signs & Symptoms

• Fever

• Chills

• Body aches

• Cramping or abdominal pain

• Foul-smelling lochia 

• ↑ WBCs

PP Infection risk factors

• C/S

• Prolonged ROM (>24 hrs)

• Multiple vag exams

• Poor health

  • Obesity, smoking, DM, etc. 

• Catheter/anethesia 

• Trauma 

• Instrument-assisted birth

• Retained products/manual removal 

REEDA

Assessment of perineum

• Redness

• Edema

• Ecchymosis

• Discharge

• Approximation

Mastitis

• Inflammation or infection of breast tissue

• Bacteria enters through cracks in the nipples or from plugged milk ducts ⇒ infection of milk ducts

Signs & Symptoms:

• Localized redness, warmth, hard area, tenderness, general pain of the breasts

• Lethargy, fever

Mastitis Nursing Care

• Antibiotics, warm moist compresses

• Continue breastfeeding

• Analgesics for pain

• Good nutrition, fluids, rest

• Prevention is key!

  • Hand hygiene

  • Watch for breastfeeding positioning and infant latch-on

  • Breast massage for plugged ducts 

Thrombophlebitis

an inflammation of the blood vessel lining due to a blood clot.

• Signs/symptoms:

  • Redness

  • Swelling

  • Warmth

  • Tenderness

  •  Fever

  • Leg pain.

Treatment: Immobilization, elevation, heat packs, analgesics, heparin IV or warfarin (Coumadin)

Prevention: Encourage early and regular ambulation, possible SCDs or leg/foot exercise

Baby Blues

Occurs first 3-10 days post partum, usually lasts a few days to a week or two. Caused by hormonal changes and drops in hormonal levels; may also be due, in part, to lifestyle alteration

s/s:

• Ambivalence

• Mood swings

• Anxiety

• Cries easily

• Self-doubt

• Irritability

Post Partum Depression

• Clinical depression of post partum onset

• Usually occurs at 4-6 weeks post partum.  Often feel worse over time, symptoms can linger for months.

• Can progress to postpartum psychosis, including hallucinations, self harm and harm to others. Postpartum psychosis is an emergency requiring immediate medical attention. 

PPD risk factors

• History/family history of depression**

• Lack of social support

• Life stress

• Poor coping skills

• Low socio-economic status

• Single marital status

• Poor relationship with FOC 

• Poor self-image

PPD s/s

• Denial, isolation, anger

• Helplessness, hopelessness

• ↓ energy and concentration

• Feeling overwhelmed, feelings of guilt

• Sleep disorders, eating disorders

• Disinterest in baby; unable to care for self or baby

• Suicidal thoughts

PPD Intervention s

• Educate all new parents of the possibility and etiology. Differentiate between depression and the baby blues.

• Screening: Assess all new parents, especially at post partum visits and well-baby visits.

• Combination of medication and therapy is best practice.

• Early treatment important

• Possible prophylaxis