VNSG 1230 - Complicated Postpartum Notes

Complicated Postpartum

Pregnancy and childbirth are natural processes, but complications can arise, affecting both the mother and the family. Nurses need to be aware of potential problems and their impact.

Hemorrhage

Definition

A leading cause of maternal mortality associated with childbearing. It can occur throughout pregnancy but poses a significant risk in the immediate postpartum period.

• Average blood loss during vaginal delivery: 300-500 ml.
• Postpartum hemorrhage definition: Blood loss exceeding 1000 ml within 24 hours after delivery.
• Accompanying signs: Drop in blood pressure by 30 mm Hg or a hemoglobin decrease of 3 grams.
• Early postpartum hemorrhage: Occurs within the first 24 hours.
• Late postpartum hemorrhage: Develops most commonly within the following 2 weeks but may occur up to 6 weeks postpartum.
• Hemorrhage complicates approximately 4% of deliveries.

Signs and Symptoms

• Sudden gush or continuous trickle of blood.
• Soft, boggy, non-contracted uterus, potentially difficult to locate.
• Uterus firms up with massage but loses tone when massage is discontinued.
• Uterus located above the expected level.
• Changes in vital signs: Decreased blood pressure, increased pulse.
• Anxiety, restlessness.
• Dizziness, weakness.

Causes and Treatment

Uterine Atony

Uterus relaxes and fails to contract, resulting in a boggy uterus that won't stay firm. Causes include excessive manipulation of the uterus, prolonged labor, multiple pregnancies, and overstretching of the uterus (twins, large fetus, hydramnios).

• Saturation of more than one peri-pad per hour is considered excessive.
• Treatment:
  • Oxytocics: Typically, Pitocin is administered first, rapidly IV. If bleeding continues and the uterus doesn't contract, Hemabate or Methergine is given IM to contract the uterus.
  • Methergine can be followed with oral administration but used cautiously due to the risk of hypertension.
  • Fundal massage along with oxytocics.
  • Hysterectomy if all else fails to keep the uterus contracted and hemorrhaging continues.

Trauma to the Birth Canal

Second most common cause of early postpartum hemorrhage.

• Lacerations: Can occur during spontaneous (precipitous) or operative delivery of a large infant. Bleeding might present as a continuous trickle from the vagina. Lacerations can affect the perineum, vagina, cervix, or urethral meatus area.
  • Treatment: Locate and suture the laceration.
• Hematomas: Result from injury to blood vessels in the perineum or suture slippage, leading to bleeding into loose connective tissue while the overlying tissue remains intact. Hematomas appear as discolored, bulging masses, causing deep, severe, unrelieved pain and pressure.
  • Treatment: Evacuate the hematoma and re-suture the area.

Uterine Inversion

Caused by applying pressure on the fundus when the uterus is not contracted or supported, or pulling on the umbilical cord to remove the placenta.

• Treatment: Attempt to manually replace the uterus back into position shortly after the inversion. If the cervix swells, making replacement impossible, a hysterectomy may be necessary.

Late Postpartum Hemorrhage

Retained placental fragments due to manual removal of the placenta, poor management of the second stage of labor, or growth of the placenta into the uterine muscles (placenta accreta). Bleeding may occur later in the postpartum period (day 6 to 10 or later), indicated by a change in lochia back to rubra (reversal of flow).

• Treatment: Typically involves a D&C to remove any retained placental fragments.

Nursing Responsibilities

• Objective data assessment:
  • Fundal firmness.
  • Amount and color of lochia.
  • Presence of clots.
  • Vital signs.
  • Perineum swelling or discoloration.
  • Voiding pattern.
• Subjective data assessment:
  • Vague statements from the mother like "I feel all wet" or "I feel like something just came out down there."
  • Complaints of pressure.
  • Perineal pain or pressure, especially with increasing severity.
• In cases of increased bleeding, large clots, or tissue, save and weigh peri-pads and linen savers. One gram by weight equals 1 ml by volume of blood. $weight (g) = volume (ml)$

Postpartum Blues, Depression, Psychosis

Usual Cause

Most women experience some immediate postpartum depression or sadness (postpartum blues) following delivery, often as a response to the anticlimactic feeling after labor and hormonal shifts (decline in estrogen and progesterone levels).

Time Frame

Typically occurs around the 3rd to 5th day postpartum, manifesting as extreme fatigue, sadness, inability to stop crying, increased anxiety about the mother's or infant’s health, insecurity, and psychosomatic symptoms (nausea, vomiting, diarrhea). Other symptoms include mood swings and perceiving oneself as inadequate. Depression lasting beyond a few days may indicate a neurotic process, potentially linked to lack of support, marital problems, anxiety during pregnancy, stressful life events, or a history of previous depression. Postpartum psychosis may appear in women within a year after delivery, likely in response to the crisis of childbearing rather than the physical aspects. Nearly a third of these women had prior mental illness symptoms. Psychiatric care is necessary.

• Usually seen as severe distress resulting in changes in thought, emotion, and behavior.

Appropriate Actions

Treatment may involve antidepressant medications, counseling, and sometimes hospitalization. There's a 5% risk of suicide or harm to self/others.

Puerperal Infection

Definition

Any infection of the reproductive tract, breasts, uterus, perineum, bladder.

• In the US, postpartum infection is estimated at 1-8% of all deliveries. Endometritis is the most common source.

Causes

• Rupture of membranes over 24 hours before delivery, allowing bacterial invasion of the uterus prior to birth.
• Retained placental fragments.
• Postpartum hemorrhage, weakening the woman's defenses.
• Preexisting anemia.
• Prolonged and difficult labor.
• Internal monitors.
• Local vaginal infection at delivery.
• Endometritis is usually caused by streptococcus but may be due to e-coli, characterized by lower abdominal tenderness (one or both sides), adnexal and/or perimetrial tenderness. Some patients have foul-smelling lochia without signs of infection; others may have scanty, odorless lochia (particularly with streptococcus).
• Mastitis: commonly caused by Staphylococcus. Irritation/cracking of nipples allows bacterial invasion, or improper emptying of breasts leads to milk stasis. Most likely during the first 2 months postpartum.
• UTI: Related to urinary stasis, more common with prolonged labor, multiple vaginal exams, frequent catheterizations, or operative delivery. The most common organism is E. coli.
• Cholecystitis: Common due to increased calcium levels in pregnancy; may require cholecystectomy, usually after delivery.

Signs and Symptoms

Postpartum infection may be suspected if the patient complains of extreme uterine tenderness, foul-smelling lochia, or has an elevated temperature, or if breasts are red, warm, and painful. The usual increase in WBC is not a reliable indicator, as WBC may be as high as 20-30 in a pregnant woman. An increase in oral temperature above 100.4°F for two consecutive 24-hour periods, excluding the first 24 hours after birth, may be accompanied by sub-involution of the uterus. $(Temperature > 100.4°F)$

Treatment

• Analgesics and antibiotics.
• May require debridement of the wound.

Thromboembolic Conditions

Increased risk from venous stasis and a relaxed vascular system. 75% occur during the first 3 days postpartum.

• Careful assessment of postpartum patient, including Homan's sign and assessment of lower extremities.
• Early ambulation is key to prevention.
• Clots can break off and travel via the circulatory system; the most common area for clot to settle is the pulmonary system.

Classic Symptoms of Pulmonary Embolism

• Tachypnea, dyspnea, pleuritic chest pain.
• Apprehension and anxiety.
• Cough.
• Decreasing oxygen saturation readings.

Treatment

• Heparinization, possible ventilator support.