WK11: Post-partum Complications

I. POSTPARTAL HEMORRHAGE

• Hemorrhage, one of the most important causes of maternal mortality associated with childbearing, poses a possible threat throughout pregnancy and is also a major potential danger in the immediate postpartal period. 

• Postpartal hemorrhage has been defined as any blood loss from the uterus greater than 500 mL within a 24-hour period (Pavone, Purinton, & Petersen, 2007). 

• In specific agencies, the loss may not be considered hemorrhage until it reaches 1000 mL.

• Hemorrhage may occur either early (within the first 24 hours) or late (anytime after the first 24 hours during the remaining days of the 6-week puerperium).   The greatest danger of hemorrhage is in the first 24 hours because of the grossly denuded and unprotected uterine area left after detachment of the placenta.

• There are five main causes for postpartal hemorrhage: uterine atony, lacerations, retained placental fragments, uterine inversion, and disseminated intravascular coagulation.

A. Uterine Atony

• Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartal hemorrhage (Poggi, 2007). The uterus must remain in a contracted state after birth to keep the open vessels at the placental site from bleeding.

• If the uterus suddenly relaxes, there will be an abrupt gush of blood vaginally from the placental site. If the vaginal bleeding is extremely copious, a woman will exhibit symptoms of shock and blood loss. 

• This can occur immediately after birth or more gradually, over the first postpartum hour, as the uterus slowly becomes uncontracted.

• It is difficult to estimate the amount of blood a postpartal woman has lost, because it is difficult to estimate the amount of blood it takes to saturate a perineal pad. The amount is between 25 and 50 mL. 

• By counting the number of perineal pads saturated in given lengths of time such as half-hour intervals, you can form a rough estimate of blood loss. Five pads saturated in half an hour is obviously a different situation from five pads saturated in 8 hours.

• Weighing perineal pads before and after use and then subtracting the difference is an accurate way to measure vaginal discharge: 1 g of weight is comparable to 1 mL of blood volume.

• Palpate a woman’s fundus at frequent intervals postpartally to be certain that her uterus is remaining in a state of contraction. This is the best measure for preventing early hemorrhage.

• Factors that predispose to poor uterine tone or any inability to maintain a contracted state are:

  • Deep anesthesia or analgesia 

  • Labor initiated or assisted with an oxytocin agent 

  • Maternal age greater than 35 years 

  • High parity 

  • Previous uterine surgery 

  • Prolonged and difficult labor 

  • Possible chorioamnionitis Secondary maternal illness (e.g., anemia) 

  • Prior history of postpartum hemorrhage Endometritis 

  • Prolonged use of magnesium sulfate or other tocolytic therapy

Therapeutic Management:

• 1. Bimanual Massage

  • If fundal massage and administration of oxytocin or methylergonovine are not effective in stopping uterine bleeding, a sonogram may be done to detect possible retained placental fragments. The woman’s physician or nurse-midwife may attempt bimanual compression. With this procedure, the physician or nurse-midwife inserts one hand into a woman’s vagina while pushing against the fundus through the abdominal wall with the other hand.

• 2. Prostaglandin Administration

  • Prostaglandins promote strong, sustained uterine contractions. Intramuscular injection of prostaglandin F22 is another way to initiate uterine contractions

  • Carboprost tromethamine

  • (Hemabate), a prostaglandin F2a derivative, or methylergonovine maleate (Methergine), an ergot compound, given intramuscularly, are second possibilities. Rectal misoprostol, a prostaglandin E1 analogue, may be administered rectally. Hemabate may be repeated every 15 to 90 minutes up to 8 doses; methylergonovine may be repeated every 2 to 4 hours up to 5 doses.

  • The usual dosage of oxytocin is 10 to 40 U per 1000 mL of a Ringer’s lactate solution. When oxytocin is given intravenously, its action is immediate

• 3. Blood Replacement

  • Blood transfusion to replace blood loss with postpartal hemorrhage may be necessary. Make certain that blood typing and cross-matching were done when the woman was admitted and that blood is available.

  • Women who experience postpartal hemorrhage tend to have a longer than average recovery period, because the physiologic exhaustion of body systems can interfere with their recovery. Iron therapy may be prescribed to ensure good hemoglobin formation. Activity level, exertion,and postpartal exercise may be restricted somewhat.

  • Monitor her temperature closely in the postpartal period, to detect the earliest signs of developing infection.

• 4.  Hysterectomy or Suturing

  • Usually, therapeutic management is effective in halting bleeding. In the rare instance of extreme uterine atony, sutures or balloon compression may be used to halt bleeding (Nelson & O’Brien, 2007).

  • Embolization of pelvic and uterine vessels by angiographic techniques may be successful. As a last resort, ligation of the uterine arteries or a hysterectomy may be necessary.

  • Open lines of communication between the couple and health care providers that allow a family to vent its feelings are most helpful to a couple in this crisis.

B. Lacerations 

Small lacerations or tears of the birth canal are common and may be considered a normal consequence of childbearing. Large lacerations, however, can cause complications. They occur most often:

• With difficult or precipitate births

• In primigravidas

• With the birth of a large infant (9 lb)

• With the use of a lithotomy position and instruments

• 1. Cervical Lacerations 

• Lacerations of the cervix are usually found on the sides of the cervix, near the branches of the uterine artery. If the artery is torn, the blood loss may be so great that blood gushes from the vaginal opening. Because this is arterial bleeding, it is brighter red than the venous blood lost with uterine atony. 

• Therapeutic Management: 

  • Repair of a cervical laceration is difficult, because the bleeding can be so intense that it obstructs visualization of the area. Be certain that a physician or nurse-midwife has adequate space to work, adequate sponges and suture supplies, and a good light source.

  • If the cervical laceration appears to be extensive or difficult to repair, it may be necessary for the woman to be given a regional anesthetic to relax the uterine muscle and to prevent pain

• 2. Vaginal Lacerations

  •  Although they are rare, lacerations can also occur in the vagina. They are easier to assess than  cervical lacerations, because they are easier to view. 

• Therapeutic Management: 

  • Because vaginal tissue is friable, vaginal lacerations are also hard to repair. Some oozing often occurs after a repair, so the vagina may be packed to maintain pressure on the suture line. If packing is inserted, document in a woman’s nursing care plan when and where it was placed, so you can be certain it will be removed after 24 to 48 hours or before discharge.

  • An indwelling urinary catheter (Foley catheter) may be placed at the same time, because the packing causes pressure on the urethra and can interfere with voiding. 

• 3. Perineal Lacerations

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

• Therapeutic Management: 

  • Perineal lacerations are sutured and treated as an episiotomy repair. Make certain that the degree of the laceration is documented, because women with fourth degree lacerations need extra precautions to avoid having repair sutures loosened or infected.

  • A diet high in fluid and a stool softener may be prescribed for the first week after birth to prevent constipation and hard stools, which could break the sutures.

  • Any woman who has a third- or fourth-degree laceration should not have an enema or a rectal suppository prescribed or have her temperature taken rectally, because the hard tips of equipment could open sutures near to or including those of the rectal sphincter

C. Retained Placental Fragments

• Occasionally, a placenta does not deliver in its entirety; fragments of it separate and are left behind. Because the portion retained keeps the uterus from contracting fully, uterine bleeding occurs. To detect the complication of retained placenta, every placenta should be inspected carefully after birth to see that it is complete.

• Retained placental fragments may also be detected by ultrasound. A blood serum sample that contains human chorionic gonadotropin hormone (hCG) also reveals that part of a placenta is still present.

• Therapeutic Management: 

  • Removal of the retained placental fragment is necessary to stop the bleeding. Usually, a dilatation and curettage (D&C) is performed to remove the placental fragment.

  • Methotrexate may be prescribed to destroy the retained placental tissue

II. Uterine Inversion

 Uterine inversion is prolapse of the fundus of the uterus through the cervix so that the uterus turns inside out. This usually occurs immediately after birth.

III. Disseminated Intravascular Coagulation

Disseminated intravascular coagulation (DIC) is a deficiency in clotting ability caused by vascular injury. It may occur in any woman in the postpartal period, but it is usually associated with premature separation of the placenta, a missed early miscarriage, or fetal death in utero.

IV. Subinvolution 

• is incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a 4- or 6week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present. Subinvolution may result from a small retained placental fragment, a mild endometritis (infection of the endometrium), or an accompanying problem such as a uterine myoma that is interfering with complete contraction.

•   Therapeutic Management: 

  • Oral administration of methylergonovine, 0.2 mg four times daily, usually  is prescribed to improve uterine tone and complete involution. If the uterus is tender to palpation, suggesting endometritis, an oral antibiotic also will be prescribed.

V. Mastitis

• Mastitis (infection of the breast) may occur as early as the seventh postpartal day or not until the baby is weeks or months old (Reddy et al., 2007). The organism causing the infection usually enters through cracked and fissured nipples.

• Therapeutic Management :

  • Treatment consists of antibiotics. Breastfeeding is continued, because keeping the breast emptied of milk helps to prevent growth of bacteria.

VI. EMOTIONAL AND PSYCHOLOGICAL COMPLICATIONS

• A Woman Whose Child Is Born With an Illness or Is Physically Challenged 

• Most women say during pregnancy they do not care about the sex of their child so long as the child is born healthy. This can make them feel cheated when this one requirement is not met. They can feel angry, hurt, and disappointed. They may feel a loss of self-esteem: they have given birth to an imperfect child, and so they see themselves as imperfect.

• Postpartal Depression

  • Almost every woman notices some immediate (1 to 10 days postpartum) feelings of sadness (postpartal “blues”) after childbirth. This probably occurs as a response to the anticlimactic feeling after birth and also probably is related to hormonal shifts as the levels of estrogen, progesterone, and gonadotropin-releasing hormone in her body decline or rise (Baker, 2008).

  • The sensations of overwhelming sadness can interfere with breastfeeding, child care, and returning to work. In addition to an overall feeling of sadness, a woman may notice extreme fatigue, an inability to stop crying, increased anxiety about her own or her infant’s health, insecurity (unwillingness to be left alone or inability to make decisions), psychosomatic symptoms (nausea and vomiting, diarrhea), and either depressive or manic mood fluctuations.

  • Depression of this kind is termed postpartal depression and reflects a more serious problem than normal “baby blues” Risk factors for postpartal depression include a history of depression, a troubled childhood, low self-esteem, stress in the home or at work, and lack of effective support people.

  • A woman may need counseling and possibly antidepressant therapy to integrate the experience of childbirth into her life

• Postpartal Psychosis 

  • A woman with postpartal psychosis usually appears exceptionally sad. By definition, psychosis exists when a person has lost contact with reality. A psychosis is a severe mental illness that requires referral to a professional psychiatric counselor and antipsychotic medication.

  • A woman with a postpartal psychosis may deny that she has had a child and, when the child is brought to her, insist that she was never pregnant. 

  • A psychosis is a severe mental illness that requires referral to a professional psychiatric counselor and antipsychotic medication.

  • While waiting for such a skilled professional to arrive, do not leave the woman alone, because her distorted perception might lead her to harm herself. Nor should you leave her alone with her infant.