Module 5: Postpartum complications

Primary Post-Partum Hemorrhage

• early blood loss from the birth canal of 500 ml or more within 2 hours of delivery

Secondary Post-Partum Hemorrhage

• late/ abnormal bleeding after 24 hours birth

• cause: retained placental fragments

• management: dilatation and curettage, ultrasound, antibiotics

predisposing factor of post-partum hemorrhage

• overdistention of the uterus

  • Multiparity

  • macrosomia

  • polyhydramnios

  • multiple pregnancy

• cesarean birth

• prolonged and difficult labor

• placental accidents (previa and abruptio)

4 T’s of Post-partum hemorrhage

1. Tone

2. Trauma

3. Tissue

4. Thrombin

Tone

• atonic uterus - uterus is not well contracted, relaxed, or boggy

• 70% incidence

Trauma

• lacerations, hematomas, inversion, rupture

• 20% incidence

Tissue

• retained tissue, invasive placenta

• 10% incidence

thrombin

• coagulopathies

• 1% incidence

consequences of PPH

• circulatory collapse to shock and death

• puerperal anemia

• fear of further pregnancies

Sheehan’s syndrome

damage to the pituitary blood supply

uterine atony

• the uterus, although empty, fails to contract and control bleeding from the placental site

• most common and potentially most dangerous cause of post partum hemorrhage

predisposing factors of uterine atony

• excessive uterine distention

• multiparity

• prolonged labor

• labor augmented with syntocinon

• general anesthesia

• placenta previa

• abruptio placenta

uterine atony management

• massage uterus

• ice compress

• oxytocin administration

• empty bladder

• bimanual compression to explore retained placental fragments

• hysterectomy

laceration

• happens in the cervix, vagina, or perineum

• perineal tears may follow any vaginal delivery

• persistent bleeding from a contracted firm uterus

• incidence: common in precipitate delivery, macrosomia, difficult in delivery, shoulder dystocia

first degree laceration

vaginal mucous membrane and skin of the perineum to the fourchette laceration

second degree laceration

vagina, perineal skin, fasci, levator ani muscle, and perineal body laceration

third degree laceration

entire perineum, and reaches sphincter of the rectum laceration

fourth degree laceration

entire perineum, rectal sphincter, and some of the mucous membrane of the rectum

midline episiotomy

type of episiotomy that is easy, rare faulty healing, minimal post operative pain, excellent anatomical result, less blood loss, rare dyspareunia

mediolateral episiotomy

type of episiotomy that is more difficult, common faulty healing and post operative pain, and more blood loss

hematoma

• due to injury to blood vessels in the perineum during delivery

• Incidence: common in precipitate delivery and those with perineal varicosities

• Treatment:

  • Ice compress in the 1st 24 hours

  • oral analgesics as rx

  • site is incised and bleeding vessel ligated

uterine inversion

• fundus is forced through the cervix so that the uterus is turned inside out

• insertion of placenta at the fundus, so that as fetus is rapidly delivered, fundus is pulled down

• strong fundal push, attempts to deliver the placenta before sigs of separation

• management: hysterectomy

Subinvolution

• delayed return of the enlarged uterus to normal size and function

• causes: retained placenta, endometritis, uterine fibroids

Subinvolution Clinical Manifestation

• prolonged lochial discharge

• irregular or excessive bleeding

• larger than normal uterus

• boggy uterus

Puerperal pyrexia

• temperature of 38C maintained for or recurring within 24 hours, within 21 days

• requires a complete physical examination and urine specimen, throat swab or sputum, high vaginal swab and in some cases blood culture

Puerperal pyrexia clinical manifestation

• fever

• localized vaginal, vulvar, perineal infections

• manifestations of endometritis

• parametritis

• S&S of peritonitis

Puerperal pyrexia nursing management

• promote resolution of the infectious process

• provide client and family teaching

Puerperal pyrexia prevention

• during pregnancy

  • correct anemia

  • avoid coitus

  • douching last 2 months

• during labor

  • strict aseptic technique

  • minimum perineal and vaginal laceration

  • avoid URTI

  • replace blood loss

• during puerperium

  • clean/replace perineal pads

  • perineal flushing every after urination and bowel movement

thrombophlebitis

• condition in which there is both inflammation and a blood clot in a vein. can occur either superficial or deep veins

• may be seen in the veins of the legs or pelvis

• may result from injuries, infection or the normal increase in circulating clotting factors in the pregnant and newly delivered woman

thrombophlebitis assessment/cues

• pain in thrombus area

• redness, edema

• elevated temperature and chills

• peripheral pulses decreases

• positive homan’s sign

thrombophlebitis nursing intervention

• maintain bed rest with leg elevated on pillow

• apply moist heat

• administer analgesic

• administer anticoagulant therapy (heparin) observe clients for signs of bleeding

• massage legs

• heparin - monitor ptt - protamine sulfate

• coumadin - monitor PT - Vitamin K

mastitis

• infection of the breast, usually unilateral

• frequently caused by cracked nipples

• causative agent: hemolytic S. Aureus

• may result in breast abscess

mastitis assessment

• redness, tenderness, hardened area

• chills and malaise

• high VS - Temp and PR

mastitis nursing intervention

• teach importance of hand washing before touching breast

• antibiotic therapy

• apply ice

• empty breast regularly

post-partum mood disorder

• post-partum blues

• post-partum depression w/o psychotic features

• postpartum pyschosis

post partum blues manifestation

• weeping

• anxiety

• fatigue

• mood instability

post-partum depression w/o psychotic features manifestation

• confusion

• fatigue

• agitation

• feeling of hopelessness

• alteration in mood

postpartum pyschosis manifestation

• delusion

• auditory hallucination

• hyperactivity