Postpartum ComplicationsPostpartum Complications
Postpartum Physical Assessment
B - breast
U - uterus
B - bowels
B - bladder
L - lochia
E - episiotomy
Routine care for the postpartum woman: Health promotion and disease
prevention (1)• Give Vitamin A 200,000 IU.• Provide preventive treatment for
hookworm to prevent anemia in endemic areas.
• Provide iron/folic acid supplementation for at least 30 days postpartum to prevent and treat anemia.
Routine care for the postpartum woman: Educate about danger signs (1)
Vaginal bleeding:
• More than 2 or 3 pads soaked in 20-30 minutes after delivery, OR
• Bleeding increases rather than decreases after delivery
Severe abdominal pain
Fever and too weak to get out of bed
Routine care for the postpartum woman: Educate about danger signs (2)
• Fast or difficult breathing
• Severe headache, blurred vision
• Convulsions
Routine care for the postpartum woman: Educate about danger signs (3)
• Pain in the perineum or draining pus
• Foul-smelling lochia
Dribbling of urine or pain on micturition
Routine care for the postpartum woman: Educate about danger signs (4)
The woman doesn’t feel well.
Breasts swollen, red or tender breasts, or sore nipples
Routine care for the postpartum woman: Educate about danger signs (5)
Postpartum Hemorrhage Postpartum Hemorrhage ((PPHPPH))
Definition and incidenceDefinition and incidence
PPH traditionally defined as loss of more than:PPH traditionally defined as loss of more than:
• 500 ml of blood after vaginal birth500 ml of blood after vaginal birth
• 1000 ml after cesarean birth1000 ml after cesarean birth
Cause of maternal morbidity and mortalityCause of maternal morbidity and mortality
Life-threatening with little warning Life-threatening with little warning
Often unrecognized until profound symptoms Often unrecognized until profound symptoms
The causes of postpartum hemorrhage can
be thought of as the four Ts:
Etiology of PPH
tone,
tissue,
trauma,
thrombin
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Postpartum Hemorrhage Postpartum Hemorrhage Etiology and risk factors (1)Etiology and risk factors (1)
UterineUterine atony atony
• Marked hypotonia of uterus Marked hypotonia of uterus
• Leading cause of PPH, Leading cause of PPH, complicating approximately 1 complicating approximately 1 in 20 birthsin 20 births
• Brisk venous bleeding with Brisk venous bleeding with impaired coagulation until the impaired coagulation until the uterine muscle contractsuterine muscle contracts
Uterine atonyUterine atony
Multiple gestation,
high parity,
prolonged labor
chorioamnionitis,
augmented labor,
tocolytic agents
Postpartum Hemorrhage Postpartum Hemorrhage Etiology and risk factors (1)Etiology and risk factors (1)
Explore the uterine cavity.
Inspect vagina and cervix for lacerations.
If the cavity is empty, Massage and give methylergonovine 0.2 mg, the dose can be repeated every 2 to 4 hours.
Rectal 800mcg. Misoprostol is beneficial.
Management of uterine atony
During the administration of uterotonic agents, bimanual compression may control hemorrhage. The physician places his or her fist in the vagina and presses on the anterior surface of the uterus while an abdominal hand placed above the fundus presses on the posterior wall. This while the Blood for transfusion made available.
Management of uterine atony
Complications of Puerperium
Uterine Atony (Cont’d)
• Treatment
Uterine compression
Oxytocics
– Early suckling causes endogenous release of oxytocin
– Oxytocin IV/IM 10 units
– Methylergonovine
– Methyl prostoglandin F
Postpartum Hemorrhage Postpartum Hemorrhage Etiology and risk factors (2)Etiology and risk factors (2)
Lacerations of genital tractLacerations of genital tract
• Should be suspected if bleeding continues with a firm, Should be suspected if bleeding continues with a firm, contracted funduscontracted fundus
• Includes perineal and cervical lacerations as well as pelvic Includes perineal and cervical lacerations as well as pelvic hematomashematomas
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Lacerations and traumaLacerations and trauma
Planned
•Cesarean section,
•episiotomy
Unplanned
•Vaginal/cervical tear,
•surgical trauma
Postpartum Hemorrhage Postpartum Hemorrhage Etiology and risk factors (2)Etiology and risk factors (2)
Postpartum Hemorrhage Postpartum Hemorrhage
Genital tract lacerations Management
Genital trauma always must be eliminated first if the uterus is
firm.
Rupture of the uterus is described as complete or incomplete and should be differentiated from dehiscence of a cesarean section scar.
Postpartum Hemorrhage Postpartum Hemorrhage Etiology and risk factors (2)Etiology and risk factors (2)
UTERINE RUPTURE
The reported incidence
for all pregnancies is 0.05%,
After one previous lower segment cesarean section 0.8%
After two previous lower segment cesarean section is 5%
all pregnancies following myomectomy may be complicated by uterine rupture.
Postpartum Hemorrhage Postpartum Hemorrhage Etiology and risk factors (2)Etiology and risk factors (2)
UTERINE RUPTURE
Complete rupture describes a full-thickness defect of the uterine wall and serosa resulting in direct communication between the uterine cavity and the peritoneal cavity.
Postpartum Hemorrhage Postpartum Hemorrhage Etiology and risk factors (2)Etiology and risk factors (2)
UTERINE RUPTURE
Incomplete rupture describes a defect of the uterine wall that is contained by the visceral peritoneum or broad ligament. In patients with prior cesarean section,
Postpartum Hemorrhage Postpartum Hemorrhage Etiology and risk factors (2)Etiology and risk factors (2)
UTERINE RUPTURE
dehiscence describes partial separation of the scar with minimal bleeding, with the peritoneum and fetal membranes remaining intact.
Postpartum Hemorrhage Postpartum Hemorrhage Etiology and risk factors (2)Etiology and risk factors (2)
UTERINE RUPTURE
The identification or suspicion of uterine rupture must be followed by an immediate and simultaneous response from the obstetric team.
Surgery should not be delayed owing to hypovolemic shock because it may not be easily reversible until the hemorrhage is controlled.
Management of Rupture Uterus
Upon entering the abdomen, aortic compression can be applied to decrease bleeding.
Oxytocin should be administered to effect uterine contraction to assist in vessel constriction and to decrease bleeding.
Hemostasis can then be achieved by ligation of the hypogastric artery, uterine artery, or ovarian arteries.
Management of Rupture Uterus
At this point, a decision must be made to perform hysterectomy or to repair the rupture site. In most cases, hysterectomy should be performed.
In selected cases, repair of the rupture can be attempted. When rupture occurs in the body of the uterus,
bladder rupture must be ruled out by clearly mobilizing and inspecting the bladder to ensure that it is intact. This avoids injury on repair of the defect as well.
Management of Rupture Uterus
A lower segment lateral rupture can cause transection of the uterine vessels. The vessels can retract toward the pelvic side wall, and the site of bleeding must be isolated before placing clamps to avoid injury to the ureter and iliac vessels.
Typically, longitudinal tears, especially those in a lateral position, should be treated by hysterectomy, whereas low transverse tears may be repaired.
Management of Rupture Uterus
Trauma-Second most common cause of early postpartum hemorrhage
Lacerations – suspect this in the birth canal if uterine bleeding continues with a contracted fundus
Hematomas- bleeding into loose connective tissue as the vulva or vagina
• Vulva- discolored bulging mass
• Surgical excision if they are large & ligation
Postpartum Hemorrhage Postpartum Hemorrhage Etiology and risk factors (3)Etiology and risk factors (3)
Retained placentaRetained placenta
• Nonadherent retained placenta – managed by Nonadherent retained placenta – managed by manual separation and removal by the primary manual separation and removal by the primary care providercare provider
• Adherent retained placenta – may be caused by Adherent retained placenta – may be caused by implantation into defective endometriumimplantation into defective endometrium
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Postpartum Hemorrhage Postpartum Hemorrhage Etiology and risk factors (3)Etiology and risk factors (3)
Three classifications of adherent Three classifications of adherent
retained placentaretained placenta
• Placenta acreta – slight penetration Placenta acreta – slight penetration
of myometrium by placental trophoblastof myometrium by placental trophoblast
• Placenta increta – deep penetrationPlacenta increta – deep penetration
of myometrium by placentaof myometrium by placenta
• Placenta percreta – perforation of uterus by placentaPlacenta percreta – perforation of uterus by placenta
Patient will experience profuse bleeding when Patient will experience profuse bleeding when delivery of the placenta is attempted.delivery of the placenta is attempted.
Management includes blood replacement and Management includes blood replacement and surgical intervention (hysterectomy)surgical intervention (hysterectomy)
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Postpartum Hemorrhage Postpartum Hemorrhage Etiology and risk factors (4)Etiology and risk factors (4)
Inversion of uterus (turning inside out)Inversion of uterus (turning inside out)
May be life-threateningMay be life-threatening
A complete inversion protrudes out of the A complete inversion protrudes out of the vaginavagina
Primary signs – hemorrhage, shock, painPrimary signs – hemorrhage, shock, pain
Prevention is the best measure – don’t pull on Prevention is the best measure – don’t pull on the umbilical cord unless there is definite the umbilical cord unless there is definite separation of the placentaseparation of the placenta
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Postpartum Hemorrhage Postpartum Hemorrhage Etiology and risk factors4Etiology and risk factors4
Inversion of uterus (turning Inversion of uterus (turning inside out)inside out)
Postpartum Hemorrhage Postpartum Hemorrhage Etiology and risk factors (5)Etiology and risk factors (5)
Subinvolution of uterus – delayed involution of Subinvolution of uterus – delayed involution of the uterusthe uterus
Usually see late post partum bleedingUsually see late post partum bleeding
Causes include retained placental fragments Causes include retained placental fragments and infectionand infection
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Postpartum Hemorrhage Postpartum Hemorrhage Care ManagementCare Management
AssessmentAssessment Bleeding assessed for color and amountBleeding assessed for color and amount
Perineum inspected for signs of lacerations or Perineum inspected for signs of lacerations or hematomas to determine source of bleedinghematomas to determine source of bleeding
Vital signs may not be reliable indicators because of Vital signs may not be reliable indicators because of postpartum adaptationspostpartum adaptations
• Measurements during first 2 hours may identify trends Measurements during first 2 hours may identify trends related to blood lossrelated to blood loss
Bladder distensionBladder distension
Laboratory studies of Laboratory studies of
hemoglobin and hematocrit hemoglobin and hematocrit
levelslevels
Plan of care and implementationPlan of care and implementation
Initial treatment – fundal massage, expression of Initial treatment – fundal massage, expression of clots, relief of bladder distension, IV fluidsclots, relief of bladder distension, IV fluids
Medical managementMedical management
• Hypotonic uterus – examine for retained placental Hypotonic uterus – examine for retained placental fragments, medications, surgical interventionsfragments, medications, surgical interventions
• Bleeding with a contracted uterus – identify and treat Bleeding with a contracted uterus – identify and treat underlying causeunderlying cause
• Uterine inversion – emergency replacement of the Uterine inversion – emergency replacement of the uterus into the pelvic cavityuterus into the pelvic cavity
• Subinvolution – medications, surgical interventionSubinvolution – medications, surgical intervention
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Postpartum Hemorrhage Postpartum Hemorrhage Care ManagementCare Management
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Plan of care and implementationPlan of care and implementation
Nursing interventionsNursing interventions
• Vital signs, uterine assessment, medication administration, Vital signs, uterine assessment, medication administration, notification of primary care providernotification of primary care provider
• Providing explanations about interventions and need to act Providing explanations about interventions and need to act quicklyquickly
• Once stable, ongoing post partum assessments and careOnce stable, ongoing post partum assessments and care
• Instructions in increasing dietary iron, protein intake, and Instructions in increasing dietary iron, protein intake, and iron supplementationiron supplementation
• May need assistance with infant care and household May need assistance with infant care and household activities until strength regainedactivities until strength regained
Postpartum Hemorrhage Postpartum Hemorrhage Care ManagementCare Management
Guidelines by the Scottish Executive Committee of
the RCOG
COMMUNICATE.
RESUSCITATE.
MONITOR / INVESTIGATE.
STOP THE BLEEDING.
COMMUNICATEcall 6
Call experienced midwife
Call obstetric registrar & alert consultant
Call anaesthetic registrar , alert consultant
Alert haematologist
Alert Blood Transfusion Service
Call porters for delivery of specimens / blood
RESUSCITATE IV access with 14 G cannula X 2
Head down tilt
Oxygen by mask, 8 litres / min
Transfuse
•Crystalloid (eg Hartmann’s)
•Colloid (eg Gelofusine)
•once 3.5 litres infused, GIVE ‘O NEG’ If no cross-matched blood available OR give uncross-matched own-group blood, as available
•Give up to 1 liter Fresh Frozen Plasma and 10 units cryoprecipitate if clinically indicated
MONITOR / INVESTIGATE
Cross-match 6 units
Full blood count
Clotting screen
Continuous pulse / BP /
ECG / Oximeter
Foley catheter: urine output
CVP monitoring
Discuss transfer to ITU
STOP THE BLEEDING
Exclude causes of bleeding other than uterine atony
Ensure bladder empty
Uterine compression
IV syntocinon 10 units
IV ergometrine 500 g
Syntocinon infusion (30 units in 500 ml)
IM Carboprost (500 g)
Surgery earlier rather than late
Hysterctomy early rather than late
(GRADE B)
If conservative measures fail to control haemorrhage, initiate surgical haemostasis SOONER RATHER THAN LATER
I. At laparotomy, direct intramyometrial injection of Carboprost (Haemabate) 0.5mg
II. Bilateral ligation of uterine arteries
III. Bilateral ligation of internal iliac (hypogastric arteries)
IV. Hysterectomy
(GRADE C)
Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of placenta accreta or uterine rupture)(GRADE C)
Whole blood frequently is used for rapid correction of volume loss because of its ready availability, but component therapy is ideal. A general practice has been to transfuse 1 unit of fresh-frozen plasma for every 3 to 4 units of red cells given to patients who are bleeding profusely
Hemorrhagic (Hypovolemic) ShockHemorrhagic (Hypovolemic) Shock
Emergency situation in which blood is Emergency situation in which blood is diverted to the brain and heartdiverted to the brain and heart
May not see signs until post partum patient May not see signs until post partum patient loses 30% to 40% of blood volumeloses 30% to 40% of blood volume
Medical management – restore circulating Medical management – restore circulating blood volume and treat underlying causeblood volume and treat underlying cause
Nursing interventions – monitor tissue Nursing interventions – monitor tissue perfusion, see emergency boxperfusion, see emergency box
Fluid or blood replacement therapyFluid or blood replacement therapy
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Prophylactic oxytocics should be offered routinely in the management of the third stage of labour as they reduce the risk of PPH by about 60%.
(GRADE A)
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CoagulopathiesCoagulopathies Idiopathic thrombocytopenic purpura (ITP) – Idiopathic thrombocytopenic purpura (ITP) –
decreased platelet life span, need to control decreased platelet life span, need to control platelet stabilityplatelet stability
von Willebrand disease—type of hemophiliavon Willebrand disease—type of hemophilia Disseminated intravascular coagulation (DIC)Disseminated intravascular coagulation (DIC)
Pathologic clottingPathologic clotting Correction of underlying causeCorrection of underlying cause
• Removal of fetusRemoval of fetus
• Treatment for infectionTreatment for infection
• Preeclampsia or eclampsiaPreeclampsia or eclampsia
• Removal of placental abruptionRemoval of placental abruption
CoagulationCoagulation disordersdisorders
Congenital
Von Willebrand's disease
Acquired
DIC,
dilutional coagulopathy,
heparin
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Thromboembolic DiseaseThromboembolic Disease
Results from blood clot caused by inflammation Results from blood clot caused by inflammation or partial obstruction of vesselor partial obstruction of vessel
May be superficial or deep venous thrombosis May be superficial or deep venous thrombosis or a pulmonary embolusor a pulmonary embolus
Incidence and etiologyIncidence and etiology Venous stasisVenous stasis
HypercoagulationHypercoagulation
Clinical manifestations – redness and swelling Clinical manifestations – redness and swelling in the affected extremity, pain, positive in the affected extremity, pain, positive Homan’s signHoman’s sign
Thromboembolic DiseaseThromboembolic Disease Homan’s Sign
Press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot (dorsiflex)
Thromboembolic DiseaseThromboembolic Disease
Medical managementMedical management
Superficial – analgesia, rest/elevationSuperficial – analgesia, rest/elevation
Deep – anticoagulant therapy, bedrest/elevation, Deep – anticoagulant therapy, bedrest/elevation,
Pulmonary embolus – IV heparin therapyPulmonary embolus – IV heparin therapy
Nursing interventions Nursing interventions
assessment of the affected area, signs of bleeding, assessment of the affected area, signs of bleeding, personal care, medication administrationpersonal care, medication administration
Teach not to massage affected area!!Teach not to massage affected area!!
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Thank you!