OB- Postpartum Complications

Postpartum Hemorrhage (PPH)

loss of more than 500 ml after vaginal birth or more than 1000ml after C-section

leading cause of maternal morbidity and mortality

often unrecognized until mother has profound symptoms

can sometimes be prevented by careful examination of factors that predispose pt to excessive bleeding

early/Acute/primary PPH

<24 hrs after birth

Late/Secondary PPH

>24 hrs and up to 12 wks after birth

Classic S/S of Shock

may not be present until loss of 30-40% of blood volume

hypovolemic and septic shock

Etiology of PPH

marked hypotonia of uterus

leading cause of PPH

What is PPH associated with?

high parity

polyhydramnios- lots of amniotic fluid

macrosomic fetus- big baby

obesity

multifetal gestation

Etiology and Risk Factors: Retained products of conception

excessive bleeding, boggy uterus

Etiology and Risk Factors: Placental Complications

non-adherent retained placenta

adherent retained placenta (total, partial, or focal)

Etiology and Risk Factors: Lacerations of genital tract

if bleeding despite a firm, contacted uterine function

If blood is dark red

uterus bleeding

If blood light red

bleeding from vagina/uterus

Inversion of Uterus

fundus collapses into the uterine cavity (inside out) after birth

rare, but potentially life threatening

incomplete, complete, or prolapsed

primary s/s- hermorrhage, shock, and pain

Subinvolution of uterus

uterine subinvolution is a slowing of the process of involution or shrinking of the uterus

Causes: endometritis, retained placental fragments, pelvic infection, and uterine fibroids

S/S: prolonged lochial discharge, irregular/excessive bleeding/hemorrhage

Interventions of PPH: Primary Interventions

identify and treat the cause

massage the fundus

express clots in the uterus

eliminate bladder distension

continuous IV infusion of 10-40 units of oxytocin w/1L LR or NS

Interventions of PPH: If no response to oxytocin give uterotonic

uterotonic (firm up fundus)

Methylergonovine (methergine)- cant give to somoneone w/HTN

Carboprost (Hemabate)- dont give to pt w/asthma

Misoprostol (Cytotec)- 80% get explosive diarrhea; give loperamide

Other Interventions of PPH

Tranexamic Acid (TXA)- helps blood coagulate

Bakari or JADA intrauterine device

Blood products

oxygen via nonrebreather mask

Bakri Balloon

puts pressure on each side of uterus

JADA

used more frequently

connected to suction and suctions uterus

never leave more than 24 hrs

Hemorrhagic (Hypovolemic) Shock

results from hemorrhage- perfusion of organs may become severely compromised and can lead to death

Medical management of Hypovolemic Shock

Pitocin, methergine, hemabate, misoprostol

restore circulating blood volume

Nursing Interventions for Hypovolemic Shock

ensure patent airway

measure urine output at least 30ml/hr

monitor pulse and blood pressure

fluid or blood replacement therapy

idiopathic/Immune Thrombocytopenic Purpura (ITP)

blood disorder characterized bt decrease in number of platelets in blood

S/S: easy brusining, bleeding gums, and internal bleeding

treatments may include steroids/blood products

Von Willebrand Diseases (VWD)

blood does not clot properly

blood contains proteins that help blood clot when needed —> von Willebrand factor (VWF)

treatment may include desmopressin and specialized care team

VTE

caused by blood clot or clots inside blood vessel by inflammation or obstruction

caused in pregnancy/postpartum: hypercoagulability (increased fibrogin and thrombin) or venous stasis

highest incidence, 3 wks after birth

3 conditions of VTE

Superficial venous thrombosis

DVT

PE

factor V Leiden

blood clotting disorder that is inherited, heterozygous disorder primarily in caucasians

Antiphospholipid Syndrome (APS)

autoimmune condition where Antiphospholipid antibodies attack and damage parts of cells and increase blood clots

Risk factors of Blood Clotting Disorders

DVTs, PEs, miscarriage, stillbirth

Treatment for Blood Clotting Disorders

low does aspirin (81 mg)

Lovenox- timing is consideration for an epidural or surgery

Heparin (action is shorter so preferred near due date)

Antidote for Heparin

protamine sulfate

DIC

proteins that control bleeding become overreactive

affects ppl recovering from complications from pregnancy and delivery- preeclampsia, PPH

S/S: bleeding at wound site, nose, gums, mouth. easy bruising or petechiae on body, chest pain, swelling or pain in leg

treat w/anticoagulants and blood products

avoid invasive procedures

Purperal Infection

clinical infection of genital tract

occurs within 28 days after miscarriage, induced abortion, or birth

100.4 fever or greater on 2 successive days of first 10 postpartum days (not including 1st 24hrs after birth)

Other Infections

Chorioannionitis and endometritis

wound infections

UTIs

mastitis

Mood Disorders

80% of women experience a mild depression “baby blues”- resolve within few days to 2 wks

10-15% experience more serious depression

paternal postpartum depression

PDD

intense and pervasive sadness w/severe and labile mood swings

1st few months after birth

PDD Management

antidepressants, anxiolytic agents, mood stabilizers, ECT

psychotherapy focuses fears and concerns (CBT, support groups, Interpersonal psychtherapy)

care and Management of PDD

screen for PDD and anxiety

Edinburgh Postnatal Depression Screen (EPDS)

nursing care in postpartum unit, home, and community

referrals, providing safety, psych hospialization, psychotropic meds

Anxiety Disorders

symptoms of anxiety that impair functioning

GAS

Panic disorder

OCD

PTSD

social anxiety phobia

Postpartum Psychosis

characterized by depression, delusions, and thoughts about harming infant and self

onset: 1st 2-4 wks after birth

psychiatric emergency and may require hospitalization

associated w/bipolar (or manic depressive) disorder