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Complications of Postpartum

Complications of Postpartum. 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

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Complications of Postpartum

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  1. Complications of Postpartum

  2. 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

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

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

  5. 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

  6. 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.

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

  8. Nursing Care of uterine atony • Document Vaginal Bleeding • Fundal massage / Bimanual Compression • Assess Vital Signs (shock) • Give medications--Pitocin, Methergine, Hemabate • D & C, Hysterotomy/ectomy, Replace blood / fluids

  9. Post Partum Hemorrhage *Lacerations* • PREDISPOSING FACTORS 1. Spontaneous or Precipitous delivery 2. Size, Presentation, and Position of baby 3. Contracted Pelvis 4. Vulvar, cervical, perineal, uretheral area 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

  10. POSTPARTUM HEMORRHAGE *LACERATIONS* • 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

  11. 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?

  12. 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

  13. 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.

  14. 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 and pressure applied to the fundus, especially when the uterus is flaccid **Don’t use the fundus to “push the placenta out”

  15. Uterine inversion and replacement

  16. 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

  17. Placental Accreta

  18. 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

  19. 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!

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

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

  22. Postpartum Infections

  23. Postpartum 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

  24. Postpartum 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

  25. Critical to Remember • Signs and Symptoms of Postpartum 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

  26. Postpartum 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

  27. Test Yourself ! • What is the classic sign of a Postpartum Infection?

  28. Complications of Postpartum 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

  29. 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

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

  31. 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? • What would be the major difference in presenting symptoms you would note on nursing assessment?

  32. Postpartum Cystitis

  33. Postpartum Cystitis • Prevention: • Monitor the patients urination diligently! • Don’t allow to go longer than 3 - 4 hours before intervening. • Treatment • Antibiotics -- Ampicillin • Urinary Tract Antispasmodics • 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

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

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

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

  37. Treatment of Mastitis • Rest • Appropriate Antibiotics--Usually Cephalosporins • Hot and / or Cold Packs • Don’t 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 Stop

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

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

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

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

  42. Postpartum Psychiatric Disorders Mental Health problems can complicate the puerperium. There are days when each new mother may feel inadequate, but the mother who has a constant feeling of inadequacy needs professional counseling. Pregnancy alone is not a cause of a psychiatric Illness; however, the psychological and physiological stressors relating to pregnancy may bring on an emotional crisis

  43. Mood Disorders • The Most common Mood Disorders are: • Adjustment reaction with mood depression “baby blues” • Postpartum major mood disorder “Postpartum Depression” • Postpartum psychosis

  44. “Baby Blues” • 50-80% of moms are affected • Self-limiting (up to 10 days) • Cause • Seems to be related to changes in progesterone, estrogen and prolactin levels • Symptoms • Tearful yet happy • Overwhelmed • Treatment

  45. Postpartum Major Mood Disorder “Postpartum Depression” • Risk factors: • Primiparity • History of postpartum depression • Lack of social and relationship support • Clinical Therapy: • Counseling, support groups • Medication (usually SSRI’s) • Childcare assistance

  46. Postpartum Psychosis • Predisposing Factors: • Similar to those of postpartum depression • Assessment: • Grandiosity • Decreased need for sleep (insomnia) • Flight of ideas • Psychomotor agitation / hyperactivity • Rejection of infant

  47. Treatment for Mood Disorders Drug therapy (previous slide) Psychotherapy Explain importance of good nutrition and rest Some of her feelings may seem “unreasonable” Re-introduce the baby to the mother at the mother’s own pace

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