Postpartal Hemorrhage and Puerperal Infections

Refers to excessive blood loss during or after the third stage of labor

postpartum hemorrhage

Blood loss for vaginal delivery

500 mL

Blood loss for cesarian delivery

1000 mL

When does primary, early, or acute PPH occur?

within first 24 hours

When does secondary or late PPH occur?

from 24 hours to 6 weeks

This relates to retrogressive maternal changes

involution of uterus and vagina

This relates to progressive maternal changes

milk production

Common causes of early, acute, or primary PPH?

• Uterine atony

• Lacerations of the birth canal (vaginal or perineal) & hematoma

• Uterine rupture & inversion of the uterus

Common causes of secondary or late PPH?

• Retained placental fragments (Spurts of blood w/ clots indicates partial placental separation)

• Placental Adhesions (Accreta, Increta, Percreta

• Subinvolution of the uterus

• Infection

Causes of PPH?

• tone (uterine atony)

• trauma (lacerations)

• tissue (retained placental tissue)

• thrombin (coagulation disorders)

Management of PPH

A - assess bleeding

B - bleeding control

C - causes identification

Upon diagnosis or admission of a patient with PPH, in what position should we place them to improve venous return?

Trendelenburg position

Prevention of PPH

AMTSL

• controlled cord traction and countertractions

• administer 10 IU oxytocin

• uterine massage

• Relaxation of the uterus (marked hypotonia)

• Most frequent cause of postpartum hemorrhage

• Occur most in Asian, Hispanic, and Black

uterine atony

Risk factors of tone (uterine atony)

• overdistention: macrosomia, hydramnios, multiple pregnancy

• fatigue: prolonged labor, precipitate labor, oxytocic drugs

• (tocolytics) inhibition of contractions by drugs: anesthetic agents, nitrates, NAIDS, MgSO4, beta sympathomimetics, nifedine

• Infection: chorioamnionitis, endomyometritis, septicemia

• uterine structural abnormality

• hypoxia due to hypoperfusion or Couvelaire uterus

• placental site in the lower uterine segment

• distention w/ blood before or after placental delivery

S/S of uterine atony

• soft boggy uterus

• high fundus (didn’t undergo involution)

• tachycardia & hypotension (compensatory mechanism)

• abrupt gush of blood vaginally from the placental site - w/

  sudden uterine relaxation

• seepage of blood - w/ gradual vaginal bleeding

• shock - if bleeding is extremely copious (loss of 30-40% of blood volume.

What is the hallmark symptom of uterine atony?

soft boggy uterus

Signs of shock

• increased, thready, & weak pulse.

• decreased BP.

• increased & shallow respirations.

• pale, clammy skin; & increasing anxiety.

Management of tone (uterine atony)

• drain bladder and attempt fundal massage

• bolus or dilute IV oxytocin

• carboprost, tromethanine (Hemabate), methergine, carbetocin, hisoprostone, prostaglandin F2a derivative, misoprostol (Cytotec), tranexamic acid

If oxytocin is not effective at maintaining tone, what are other medications that can be administered?

• carboprost tromethamine (Hemabate)

• methylergonovine maleate (methergine)

• carbotocin

• hisoprostone

• prostaglandin F2a derivative

• prostaglandin E1 analogue

• misoprostol (Cytotec)

• tranexamic acid

Prostaglandins are given with this medication as they cause nausea and diarrhea as side effects

antiemetic

Methergine is contraindicated in what types of patients?

hypertensive

Additional measures in managing uterine atony

• Bimanual massage

• Balloon tamponade

• Uterine packing

• Sonogram

• Blood replacement

• Elevate the lower extremities to improve circulation to essential organs

• Offer bedpan or assist w/ ambulating to the bathroom at least every 4h to be certain bladder is empty.

• To reduce bladder pressure, insertion of a urinary catheter may be prescribed

• O2 administration by mask @ 4L/ min - if w/ respiratory distress from decreasing blood volume

• Position to supine to allow adequate blood flow to her brain and kidneys.

• Obtain v/s frequently & interpret them accurately.

• Hysterectomy or suturing

Complications of uterine atony?

• PPH

• anemia

• infection

• chronic fatigue

• hypovolemic shock

These are tears of the birth canal

lacerations

S/S of lacerations

• bleeding

• pain

• swelling

• bruising

• visible tears

• difficulty with bowel movement or urination

Causes of trauma

• rapid delivery

• uterine perforation during forceps application or curettage

• lacerations and episiotomy

• hematoma

• caesarian section

• uterine rupture and uterine inversion

Causes of lacerations

• fetal factors (macrosomia, shoulder dystocia, abnormal fetal position)

• maternal factors (primigravida, rapid or prolonged labor, vacuum extraction, use of lithotomy position and instruments)

• inadequate perineal support

Types of lacerations

• perineal

• vaginal

• cervical

• urethral

• This type of laceration is usually on the sides of the cervix near the branches of the uterine artery

• Brighter red blood gushes from vaginal opening

cervical lacerations

Management of cervical lacerations

• Repair of a cervical laceration.

• Remain calm - if possible, stand beside the woman, at the head of the table.

• Regional Anesthesia to relax uterine muscles & prevent pain - if laceration is extensive or difficult to repair.

• This type of lacerations are rare

• Easier to assess than cervical lacerations, because they are easier to view

• Indicated by dark blood because of its venous origin, varices or superficial lacerations of the birth or vaginal canal

vaginal lacerations

Management of vaginal lacerations

• repair (suture)

• balloon tamponade

• vaginal packing - to maintain pressure on suture line

• indwelling (foley) urinary catheter

• Usually occur when a woman is placed in a lithotomy position for birth, because this position increases tension on the perineum.

• Most common laceration.

perineal lacerations

This type of perineal lacerations involves the vagina and perineal skin (vaginal mucous membranes and skin of the perineum to the fourchette)

first degree

This type of perineal laceration extends to the vagina, perineal muscle, but not the anal sphincter (vagina, perineal skin, fascia levator ani muscle, and perineal body)

second degree

This type of perineal laceration extends into the anal sphincter (entire perineum, extending to reach the external sphincter of the rectum)

third degree

This type of perineal laceration extends to the rectal sphincter (entire perineum, rectal sphincter and some of the mucous membrane of the rectum)

fourth degree

Management of perineal lacerations

• Episiorraphy (treated as an episiotomy repair- ligation of bleeding vessels)

• Both lacerations & episiotomy incisions tend to heal in the same length of time.

• High fiber & fluid diet

• Stool softener (Dulcolax, Colase, Docusate)

• No enema or rectal suppositories - for 3rd or 4th degree laceration

• No rectal thermometer

Complications of lacerations

• hemorrhage

• infection

• anal incontinence

• dyspareunia (painful intercourse)

• chronic pelvic pain

Preventions of lacerations

• perineal massage

• controlled delivery of the head

• avoiding routine episiotomy

• use of forceps and vacuum

• positioning during labor (should be upright position)

When patient is in labor, what should be the position to minimize lacerations?

upright position

Causes of tissue (retained placental tissue)

• placenta previa

• placenta accrete

• manual removal of placenta

• presence of succenturiate or accessory lobe

• preterm gestation especially in less than 24 weeks gestation

• abnormal adhesions such as accreta, increta and percreta

• This is when placenta does not deliver in its entirety (placenta succenturiate; adherent placenta) that keeps from contracting

• 1-3% vaginal delivery

• 10% caesarean delivery

retained placental fragments

S/S of retained placental fragments

• large retained fragments - bleeding is apparent in the immediate postpartum period, because the uterus cannot contract with the fragment in place.

• uncontracted uterus on examination

• detected through ultrasound and HCG levels

If the fragment retained in the placenta is small, when does bleeding happen in which it is abrupt?

postpartum day 6 - 10

Management of retained placental fragments

• D & C - to remove retained fragments under anesthesia

• Balloon occlusion & embolization of internal iliac arteries - to minimize blood loss

• Antibiotics: methotrexate - to destroy the retained placental tissue

• Blood transfusion

• Instruct woman to observe the color of loch a (change form lochia serosa or alba back to rubra)

• Check cotyledons (must be 15 - 30)

• Hysterectomy (in severe cases)

This medication is given to destroy the retained placental tissue

methotrexate

• The prolapse of the fundus of the uterus through the cervix so that the uterus turns inside out.

• Common in multiparous women and with placenta accreta and increta

uterine inversion

Types of uterine inversion

• complete

• incomplete

• subclinical (no clinical signs and only during ultrasound)

This type of uterine inversion can not be seen but can be felt (no prolapse)

incomplete or partial inversion

This type of uterine inversion protrudes 20 - 39 cm outside the introitus

complete inversion

Causes of uterine inversion

• Fundal implantation of the placenta

• Vigorous fundal pressure

• Excessive traction applied to the cord

• Uterine atony

S/S of uterine inversion

• Culkin’s sign (uterus being firm and round during placental delivery)

• sudden gush of blood

• mobile and prolapsed uterus

• abdominal pain

• lengthening of the cord

Prevention of uterine inversion

umbilical cord should not be pulled on unless the placenta has definitely separated.

Management of uterine inversion

• IV fluid therapy

• Blood products

• Manual repositioning

• Tocolytics or halogenated anesthetics before uterine replacement (magnesium sulfate, terbutaline, nitroglycerin)

• Oxygen

• Replacement of the Uterus within the pelvic cavity

• Oxytocic agents after repositioning

• A deficiency in clotting ability caused by vascular injury

• An acquired disorder of blood clotting in w/c the fibrinogen level falls to below effective limits

• Associated with premature separation of the placenta, amniotic fluid embolism, placental retention, septic abortion, retention of dead fetus

disseminated intravascular coagulation

Risk factors of thrombin (coagulation disorders)

eclampsia (HELLP syndrome)

Management of thrombin (coagulation disorders)

• blood products (frozen plasma for fibrinogen, platelet concentrate)

Early symptoms of disseminated intravascular coagulation

easy bruising or bleeding from an IV site

Causes of DIC

• infection (sepsis; gram - )

• obstetric causes (abruption placenta, fluid embolism, pre-eclampsia)

• trauma

• bleeding and thrombosis (due to consumption of clotting factors)

Most common cause of DIC

Sepsis (Gram -)

S/S of DIC

• bruising

• petechiae

• bleeding gums

• prolonged bleeding in wounds

Diagnostic tests for DIC

• prolonged prothrombin time

• activated partial thromboplastin time

Supportive management of DIC

• anticoagulants: low-dose heparin for sepsis DIC

• platelet transfusions

• fresh frozen plasma and clotting factors

Incomplete or delay return of the uterus to is prepregnant size, shape, and function

subinvolution

Causes of subinvolution that interferes with complete contraction

• pelvic infection - endometritis (major cause)

• retained placental fragments

• uterine myoma/tumors

Major cause of subinvolution

endometritis

S/S of subinvolution

• Enlarged or overdistended & soft (boggy) uterus that is larger than normal

• Prolonged or reversal pattern in lochia discharge

• Foul odor in lochia if caused by infection (key sign)

• Irregular or excessive bleeding

• Uterine tenderness

• Backache

Key sign of subinvolution

Foul odor in lochia

Management of subinvolution

• methylergonovine (Ergonovine) maleate 0.2 mg QID to stimulate uterine contractions for 3-4 days or 2 weeks

• D&C if bleeding is continuous and for retained placental fragments

• Removal of uterine tumors & antibiotics for infection

This medication is used to stimulate uterine contractions for 3 - 4 days or 2 weeks to manage subinvolution

methylergonovine (Ergonovine) maleate 0.2 mg QID

In assessing lochia discharge of the patient, how do we position patient?

turn to the side

Each saturated pd holds how much blood?

approximately 25 - 50 mL of blood

When is blood loss excessive?

interval of 30 minutes / 5 pads/8hours

• A collection of blood in the subcutaneous layer of perineal tissue caused by injury to blood vessels in the perineum during birth.

• Associated with vaginal delivery and involvement of instrumental assistance or trauma

perineal hematoma

S/S of perineal (vulvar) hematoma

• Minimal to severe pain @ perineal area or feeling of pressure between legs; shock if not manage.

• Purple swelling due to collection of blood in the connective tissue (as small as 2 cm or as large as 8 cm in diameter).

• Palpates as a firm globe and is tender

Causes of perineal hematomas

• precipitate birth

• perineal varicosities

• vein puncture during episiorraphy

Types of hematomas aside from perineal hematoma

• vulvar

• vaginal

• retroperitoneal

This type of hematoma is the most common during birth

vulvar hematoma

This type of hematoma is commonly associated with forceps assisted delivery, episiotomy or primigravida

vaginal hematoma

• This type of hematoma is the least common but are life threatening

• Caused by the rupture of one of the vessels attached to the hypogastric artery (rupture of a cesarean scar during labor)

retroperitoneal

Management of perineal hematomas

• Assess, document, & report degree of discomfort, hematoma size (in cm w/ each inspection) & location.

• Observe for hypovolemic shock, swelling, and pain

• Mild analgesic for pain relief (per doctor’s order)

• Draining under anesthesia & packing (24 - 48 hrs)

• Cold therapy or Ice pack (covered w/ towel to prevent thermal injury to skin) - prevent further bleeding

• Incision & ligation (evacuation) of bleeding vessel (hematoma) under local anesthesia - if large or continues to increase in size

Management of a small hematoma

• ice pack over perineum

• pain relievers

Management of large hematoma

• surgical drainage

• repair torn vessels

• A general term used to describe infection of the genital tract after delivery

• After rupture of the membranes, pathogens can invade

• Risk of infection is even greater if tissue edema and trauma are present

puerperal infection

Prognosis for puerperal infections

• Virulence of the invading organism

• The woman’s general health

• Portal of entry

• Degree of uterine involution at the time of the microorganism invasion

• Presence of lacerations in the

  reproductive tract

Risk factors or causes of puerperal infections

C - cesarean section delivery

H - high number of vaginal exam

A - anemia; poor nutritional status

M - multiple pregnancies; macrosomia

P - prolonged labor, premature rupture of membranes

I - instrumental assistance delivery

O - obstetric trauma (laceration)

N - non-aseptic delivery environment

• retained placental fragments

• PPH

• local vaginal infection

Common pathogens that causes puerperal infections

S - streptococcus A

E - escherichia coli (aerobic gram-negative bacilli)

A - anaerobic

N - neisseria

These infections cause toxic shock syndrome

staphylococcal infections

S/S of puerperal infections

• fever

• foul smelling lochia or vaginal discharge

• rapid pulse, chills

• abdominal pain or tenderness

• body malaise

• lack of appetite

• perineal discomfort

• nausea and vomiting

S/S of puerperal infection using FATWASH

F - fever

A - abdominal pain

T - tachycardia

W - wound site tenderness

A - anorexia

S - swelling

H - hematological disorders

Management of puerperal infections

antibiotic after culture and sensitivity testing

Types of puerperal infections

P - pelvic abscess
E - endometritis
W - wound infection
M - mastitis
U - UTI

• Infection of the lining of the uterus, the endometrium

• Often an ascending polymicrobial infection which occurs when vaginal organisms invade the endometrial cavity during labor and birth.

• Most common uterine puerperal infection.

endometritis

Endometritis is commonly associated with what?

• chorioamnionitis

• cesarean birth

Causative agents of endometritis

• Escherichia coli

• Klebsiella pneumoniae

• Proteus species.

Endometritis occurring on PP day 1 or 2 is most frequently caused by what group of pathogens?

group A streptococci

Endometritis developing on PP day 3 or 4 is most frequently caused by what group of pathogens?

enteric bacteria: e coli or anaerobic bacteria

Endometritis developing more than 7 days after delivery is most frequently caused by what group of pathogens?

chlamydia trachomatis