Complications During the Postpartum Period

postpartum hemorrhage

a cumulative blood loss of at least 1000ml, or bleeding of any amount accompanied by manifestations of hypovolemia within 24 hr of birth

uterine atony

loss of uterine tone due to ineffective contractions

retained placenta

a placenta that is not expelled within 30 mins of the birth

subinvolution

failure of the uterus to return to its prepregnant state

uterine inversion

collapse of the uterine fundus into the uterine cavity and cervix

hematomas

similar to a bruise but its affects larger vessels leading to swelling and discoloration

prolonged labor

labor lasting longer than 20 hr since the onset of contractions

multiparity

indicated a client who has had two or more viable pregnancies lasting at least 20 weeks

operative vaginal birth

birthing requiring the use of instruments to aid in the birth of the fetus

polyhydramnios

excessive amount of amniotic fluid surrounding the fetus in pregnancy

macrosomia

a fetus or newborn who is larger than average 9-10lbs

Uterine

Atony is the primary cause of PPH

Causes of PPH

uterine atony, retained placenta fragments and lacerations

Antepartum PPH

history of high BP, high BMI (greater than 40) and placenta accreta

Intrapartum PPH

labor inductions, prolonged second stage of labor

Postpartum PPH

uterine atony, retained placement fragments, lacerations & full bladder

Clinical Manifestations of PPH

Early and Late PPH presentations

Vital Signs monitoring blood loss and shock

Nursing Interventions of PPH

Third Stage of Labor: uterotonic medication, cord traction and delayed cord clamping

Quantification of Blood Loss- faciltiy protocols

Immediate Postpartum Period- fundal assessment, uterine massage and oxytocin

PPH Risk Factors

An oxytocin-induced labor that lasts longer than 24 hr, prolonged labor, prolonged second stage of labor,

Four or more previous births;

Hematocrit less than 30%;

Platelet count less than 70,000;

Multiple gestation

Placenta accerate

placenta chorionic villi invade the decidua basalis attaching to the uterine myometrium

von Willebrand disease

hereditary disorder with a noted deficiency of von Willebrand factor which is required to maintain expected hemostatsis

Tone (Uterine Atony):

The uterus fails to contract, making it "boggy" and causing rapid bleeding.

Trauma:

Lacerations, uterine rupture, or inversion during delivery, sometimes requiring surgical repair.

Tissue:

Retained placenta or clots preventing the uterus from contracting fully

Thrombin:

Coagulation disorders (e.g., von Willebrand disease, DIC) preventing proper clotting

Tone Causes

placenta previa, overdistention of the uterus, uterine relaxants, previous PPH

trauma causes

c-section, episiotomy, macrosomia

tissue causes

retained placenta, placenta accreta, retained products of conception

thrombin

pre-e, placental abruption, pyrexia in labor, bleed disorders

early/primary PPH

presentation of heavy vaginal bleeding immediatley after birth up to 24 hr postpartum

late/secondary PPH

presentation of heavy vaginal bleeding 24 hr post birth and up to 6 weeks post partum

PPH: Nursing Interventions

Assessment of fundal placement and uterine tone every 15 min for at least 2 hr

Uterine massage to improve uterine tone

Administration of intravenous oxytocin during the postpartum period per hospital policy and physician prescription

Administration of 10 units of oxytocin intramuscularly (IM) if intravenous access is not available

Quantification of blood loss per facility protocol

Continued assessments using the 4 Ts of PPH

Documentation according to facility protocol

Placement of an indwelling urinary catheter to accurately monitor intake and output

Nonpharmacological interventions for PPH

Bimanual Uterine Massage

Pharmacologic Intervention

Uterotonics

Blood Products

Surgical Interventions

Tamponade intrauterine

balloon to reduce bleeding

PPH Management tx anemia

placenta accreta

the placenta attaches too deeply into the edomentrium and partially invades the myometrium

placenta increta

the placenta readily invade the myometrium

placenta percreta

the placenta penetrates through the endometrium and may attach to nearby organs

Uterine Inversion

Rare but serious postpartum complication

Secondary to PPH and can lead to shock

High maternal mortality rate if not managed promptly

Subinvolution of the Uterus Etiology:

Secondary PPH, typically occurs in the 2nd week postpartum week

Subinvolution of the Uterus

Clinical Manifestations:

Enlarged, boggy uterus with sudden onset of vaginal bleeding postpartum

Subinvolution of the Uterus

Nursing Interventions: Client stabilization, Similar to PPH care, large bore IV catheters, lab testing, VS monitoring, administering uterotonics and potential blood products and client education

Uterine inversion

is an emergency where the uterus turns inside out, often immediately after birth, leading to shock

Subinvolution

is the failure of the uterus to return to its normal, smaller size in the weeks following delivery. Inversion is a structural emergency, while subinvolution is a postpartum recovery issue

Postpartum Shock

Etiology

primary cause is PPH

Postpartum Shock Clinical Manifestations:

BP 85/45 or less, HR 110 or greater, SPO2 less than 95%, excessive thirst, restlessness, fear, decreased urinary output, pallor, ringing in the ears (tinitis)

Nursing Interventions for postpartum shock

use of anti-shock garment to maintain BP

Medical Management for postpartum shock

PRBCs blood products

Infusion of fibrinogen concentrate and platelets

Postpartum Infections Etiology

Endometritis

Mastitis

Wound Infections

Sepsis

Clinical Manifestations of Postpartum Infections

Endometritis: Fever, uterine tenderness, foul-smelling lochia, chills, headache, malaise

Mastitis: Flu-like symptoms, fever, redness, swelling, pain in the affected breast

Wound Infection: Warmth, pain, swelling at incision site, purulent drainage

Sepsis: Hypotension, hypoxia, hypothermia, impaired consciousness, oliguria, tachycardia, tachypnea

Nursing Interventions for postpartum infections

Endometritis, Mastitis, Wound Infection: Frequent assessments, antibiotic therapy, pain management, client education on hygiene and medication adherence

Sepsis: Frequent vital sign checks, broad-spectrum antibiotics, crystalloid solution administration, blood culture collection

Risk Factors for PP infections

age younger than 17 older than 40

bacterial vaginosis

black ethnicity

diabetes

bladder cath

frequent cervical exams

hypertension

internal FHR

manual removal of placenta

PPH

post/preterm birth

smoking