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Complications Of Postpartum

Complications Of Postpartum. Postpartum Hemorrhage. Postpartum Hemorrhage. Early Occurs when blood loss is greater than 500 ml. in the first 24 hours after a vaginal delivery or greater than 1000 ml after a cesarean birth *Normal blood loss is about 300 - 500 ml.)

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Complications Of Postpartum

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  1. Complications Of Postpartum

  2. Postpartum Hemorrhage

  3. Postpartum Hemorrhage • Early • Occurs when blood loss is greater than 500 ml. in the first 24 hours after a vaginal delivery or greater than 1000 ml after a cesarean birth *Normal blood loss is about 300 - 500 ml.) • Late • Hemorrhage that occurs after the first 24 hours

  4. Postpartum Hemorrhage • Other definitions: • A decrease in the hematocrit of 10 points between time of admission and time postbirth • Need for fluid replacement following childbirth

  5. Main Causes of Early Hemorrhage are: • Uterine Atony • Lacerations • Retained Placental Fragments • Inversion of the Uterus • Placenta Accreta

  6. Uterine Atony The myometrium fails to contract and the uterus fills with blood because of the lack of pressure on the open blood vessels of the placental site.

  7. Uterine Atony Predisposing Factors Prolonged labor Overdistention of the Uterus Trauma due to Obstetrical Procedures Grandmultiparity Intrapartum Stimulation with Pitocin Excessive use of Analgesia / Anesthesia

  8. Uterine Atony • Most common cause of Hemorrhage • Key to successful management is: PREVENTION! • Nurse many times can predict which women are at risk for hemorrhaging.

  9. Uterine Atony A boggy uterus that does not respond to massage Abnormal Clots Signs and Symptoms Excessive or Bright Red Bleeding Unusual pelvic discomfort or backache

  10. Nursing Care • Assess and Document Bleeding • Fundal massage and express clots • Bimanual Compression • Assess Vital Signs (shock)

  11. Nursing Care • Give medications • Pitocin • Methergine • Carboprost Tromethamine (Hemabate) (May inject the medications directly into the uterus) • Replace blood / fluids • D & C, Hysterectomy

  12. Trauma

  13. Post Partum Hemorrhage*Lacerations* • PREDISPOSING FACTORS 1. Spontaneous or Precipitous delivery 2. Size, Presentation, and Position of baby 3. Contracted Pelvis 4. Vulvar, perineal, and vaginal varices • Signs and Symptoms 1. Bright red bleeding where there is a steady trickle of blood and the uterus remains firm. 2. Hypovolemia

  14. POSTPARTUM HEMORRHAGELACERATIONS • Treatment and Nursing Care 1. Meticulous inspection of the entire lower birth canal 2. Suture any bleeders 3. Vaginal pack-- nurse may remove and assess bleeding after removal 4. Blood replacement

  15. Test Yourself ! • You are assigned to Mrs. B. who delivered vaginally. As you do your post-partum assessment, you notice that she has a large amount of lochia rubra. • What would be the first measure to determine if it is related to uterine atony or a laceration? • Answer: feel the fundus- if firm

  16. Hematoma Bleeding into the soft tissues surrounding the episiotomy or laceration. May follow forceps or vacuum extraction *A unit or more of blood may be in the hematoma

  17. Hematoma Major Symptom: PAIN- deep, severe, unrelieved, feelings of pressure Many times bleeding is concealed. Major symptom is rectal pain and tachycardia. Treatment: May have to be incised and drained.

  18. Inversion of the Uterus • The uterus inverts or turns inside out after delivery. • Complete inversion - a large red rounded mass protrudes from the vagina • Incomplete inversion - uterus can not be seen, but felt • Predisposing Factors: • Traction applied on the cord before the placenta has separated. **Don’t pull on the cord unless the placenta has separated. • Incorrect traction / pressure applied to the fundus, when the uterus is flaccid **Don’t use the fundus to “push the placenta out”

  19. Inversion of the Uterus Placenta Uterus Uterus continues to be pulled and inverted Traction on the cord starts the uterus to invert

  20. Inversion of the Uterus Uterus Manually pushed back into place Vagina Vagina Uterus Inverted

  21. Treatment and Nursing Care • Replace the uterus--manually replace and pack uterus • Combat shock, which is usually out of proportion to the blood loss • Blood and Fluid replacement • Give Oxytocin • Initiate broad spectrum antibiotics • May need to insert a Nasogastric tube to minimize a paralytic ileus Notify the Recovery Nurse what has occurred! Care must be taken when massaging

  22. Placenta Accreta All or part of the decidua basalis is absent and the Placenta grows directly into the uterine muscle.

  23. Placenta Accreta • Signs: • During the third stage of labor, the placenta does not want to separate. • Attempts to remove the placenta in the usual manner are unsuccessful, and lacerations or perforation of the uterus may occur • Treatment • Removal of the uterus Hysterectomy

  24. Treatment • If it is only small portions that are attached, then these may be removed manually • If large portion is attached--a Hysterectomy is necessary!

  25. Late Postpartum Hemorrhage

  26. Late Postpartum Hemorrhage • Most common cause is Retained Placental fragments • Sub involution • Treatment • D & C • Methergine

  27. Retained Placental Fragments • This occurs when there is incomplete separation of the placenta and fragments of placental tissue retained. • Signs • Boggy , relaxed uterus • Dark red bleeding • Treatment • D & C • Administration of Oxytocins • Administration of Prophylactic antibiotics

  28. Are these Early, Late, or Both ? • Uterine Atony • Retained placental fragments • Lacerations • Inversion of the uterus • Placenta accreta • Hematoma • _________________ • _________________ • _________________ • _________________ • _________________ • _________________

  29. ReviewEarly Signs of Hemorrhage • An uncontracted uterus – boggy • Large gush, steady trickle, oozing, or seeping of blood from the vagina • Saturation of more than one pad in 15 minutes • Severe unrelieved perineal or rectal pain • Tachycardia

  30. ReviewHypovolemic Shock • Signs • Tachycardia • Drop in B/P • Narrowing of pulse pressure • Tachypnea • Skin becomes pale and cool and can progress to cold and clammy • Becomes anxious  confused lethargic • Urinary output decreases • Treatment • Blood/Fluid replacements, oxygen, surgery

  31. Thromboembolic Disorder • Predisposing Factors • Slowing of blood in the legs • Trauma to the veins • Hypercoagulation • Signs and Symptoms • Sudden onset of pain • Tenderness of the calf • Reddness and an increase in skin temperature • Positive Homan’s Sign

  32. Thromboembolic Disease • Treatment • Heparin --it does not cross into breast milk • Antidote: protamine sulfate • Teach patient to report any unusual bleeding, or petchiae, bleeding gums, hematuria, epistasis, etc. • Complication • Pulmonary Emboli

  33. When a postpartum patient Complains of chest pain or severe dyspnea Respond quickly Usually sign of Pulmonary Emboli

  34. Puerperal Infection

  35. Puerperal Infections • Definition Infection of the genital tract that occurs within 28 days after abortion or delivery • Causes Streptococcus Groups A and B Clostridium, E. Coli

  36. Puerperal Infections • Predisposing Factors 1. Trauma 2. Hemorrhage 3. Prolonged labor 4. Urinary Tract Infections 5. Anemia and Hematomas 6. Excessive vaginal exams 7. P R O M

  37. Critical to Remember • Signs and Symptoms of Puerperal Infection 1.Temperature increase of 100.4 or higher on any 2 consecutive days of the first 10 days post-partum, not including the first 24 hours. 2. Foul smelling lochia, discharge 3. Malaise, Anorexia, Tachycardia, chills 4. Pelvic Pain 5. Elevated WBC

  38. PUERPERAL INFECTION TREATMENT AND NURSING CARE • Administer Broad Spectrum Antibiotics • Provide with warm sitz baths • Promote drainage--have pt. lie in HIGH fowlers position • Force fluids and hydrate with IV’s 3000 - 4000 cc. / day • Keep uterus contracted, give methergine • Provide analgesics for alleviation of pain • Nasogastric suction if peritonitis develops

  39. Test Yourself ! • What is the classic sign of a Puerperal Infection? • Answer: Temperature increase of 100.4 or higher on any 2 consecutive days of the first 10 days post-partum, not including the first 24 hours.

  40. Complications of Puerperal Infections Pelvic Cellulitis Peritonitis Signs and Symptoms: Spiking a fever of 102 0 F to 104 0 F Elevated WBC Chills Extreme Lethargy Nausea and Vomiting Abdominal Rigidity and Rebound Tenderness

  41. Preventive Measures • Prompt treatment of anemia • Well-balanced diet • Avoidance of intercourse late in pregnancy • Strict asepsis during labor and delivery • Teaching of postpartum hygiene measures • keep pads snug • change pads frequently • wipe front to back • use peri bottle after each elimination

  42. Wound Infection • Infection of the Episiotomy, Perineal laceration, Vaginal or vulva lacerations • Wound infection of Cesarean incision site • Signs: • Reddened, edematous, firm, tender edges of skin • Edges separate and purulent material drains from the wound. • Treatment • Antibiotics • Wound care

  43. Check Yourself • Mrs. X. was admitted with endometritis • and Mrs. Y. was admitted with an infection • in her cesarean incision. Are both classified • as a Puerperal Infection? • Answer: yes • What would be the major difference in • presenting symptoms you would note on • nursing assessment? • Answer: foul smelling lochia

  44. Puerperal Cystitis • Prevention: • Monitor the patients urination diligently! • Don’t allow to go longer than 3 - 4 hours before intervening. • Treatment • Antibiotics -- Ampicillin • Urinary Tract Antispasmotics • Causes: • Stretching or Trauma to the base of the bladder results in edema of the trigone that is great enough to obstruct the urethra and to cause acute retention. • Anesthesia

  45. Mastitis • Types: • Mammary Cellulitis- inflammation of the connective tissuebetweenthe lobes in the breast • Mammary Adenitis - infectioninthe ducts and lobes of the breasts

  46. Nipple Trauma Pain Impaired Engorgement Let down Cracked Stasis nipples of milk Entry for Bacteria Plugged ducts Mastitis Treatment, No Treatment Problem will resolveBreast Abscess

  47. Mastitis Marked Engorgement Pain Chills, Fever, Tachycardia Hardness and Redness Enlarged and tender lymph nodes

  48. Treatment of Mastitis • Rest • Appropriate Antibiotics--Usually Cephalosporins • Hot and / or Cold Packs • Don’tStop Breast Feeding because: • If the milk contains the bacteria, it also contains the antibiotic • Sudden cessation of lactation will cause severe engorgement which will only complicate the situation • Breastfeeding stimulates circulation and moves the bacteria containing milk out of the breast

  49. Mastitis Meticulous handwashing Rotate position of baby on the breast PreventiveMeasures Frequent feedings and massage distended area to help emptying

  50. Complication of Mastitis Breast Abscess Breast Feeding is stopped on the affected side, but may feed on the unaffected side. Treatment: Incision and Drainage

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