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Complications Of
Postpartum
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Postpartum Hemorrhage
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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
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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
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Main Causes of Early Hemorrhage are:
• Uterine Atony
• Lacerations
• Retained Placental Fragments
• Inversion of the Uterus
• Placenta Accreta
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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.
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Uterine Atony Predisposing Factors
Prolonged labor Overdistention
of theUterus
Grandmultiparity
Excessive use of Analgesia / Anesthesia
IntrapartumStimulation with Pitocin
Trauma dueto ObstetricalProcedures
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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.
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Uterine Atony
Signs and Symptoms
Excessive orBright Red Bleeding
Abnormal Clots
A boggy uterus that does not respond to massage
Unusual pelvic discomfort or backache
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Nursing Care
• Assess and Document Bleeding
• Fundal massage and express clots
• Bimanual Compression
• Assess Vital Signs (shock)
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Nursing Care• Give medications
– Pitocin– Methergine– Carboprost Tromethamine
(Hemabate) (May inject the medications directly
into the uterus)
• Replace blood / fluids
• D & C, Hysterectomy
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Trauma
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Post Partum Hemorrhage*Lacerations*
• PREDISPOSING FACTORS1. Spontaneous or Precipitous
delivery2. Size, Presentation, and Position of
baby3. Contracted Pelvis4. 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
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POSTPARTUM HEMORRHAGELACERATIONS
• Treatment and Nursing Care1. Meticulous inspection of the entire lower birth canal2. Suture any bleeders3. Vaginal pack-- nurse may remove
and assess bleeding after removal4. Blood replacement
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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
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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
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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.
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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”
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Inversion of the Uterus
Traction onthe cordstarts the uterus toinvert
Uterus continuesto be pulled andinverted
Uterus
Placenta
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Inversion of the Uterus
Vagina
UterusInverted
Vagina
Uterus Manually pushed backinto place
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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
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Placenta AccretaAll or part of the decidua basalis is
absent and the Placenta grows directly into the uterine muscle.
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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
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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!
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Late PostpartumHemorrhage
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Late Postpartum Hemorrhage
• Most common cause is Retained Placental fragments
• Sub involution
• Treatment
–D & C–Methergine
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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
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Are these Early, Late, or Both ?
• Uterine Atony
• Retained placental fragments
• Lacerations
• Inversion of the uterus
• Placenta accreta
• Hematoma
• _________________
• _________________
• _________________
• _________________
• _________________
• _________________
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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
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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
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Thromboembolic Disorder
• Predisposing FactorsSlowing of blood in the legsTrauma to the veinsHypercoagulation
• Signs and SymptomsSudden onset of painTenderness of the calfReddness and an increase in skin
temperaturePositive Homan’s Sign
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Thromboembolic Disease
• TreatmentHeparin --it does not cross into
breast milkAntidote: protamine sulfateTeach patient to report any
unusual bleeding, or petchiae, bleeding gums, hematuria, epistasis, etc.
• ComplicationPulmonary Emboli
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When a postpartum patient Complains of chest pain
or severe dyspnea
Respond quickly
Usually sign of Pulmonary Emboli
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Puerperal Infection
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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
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Puerperal Infections
• Predisposing Factors 1. Trauma
2. Hemorrhage3. Prolonged labor4. Urinary Tract Infections5. Anemia and Hematomas6. Excessive vaginal exams
7. P R O M
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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
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PUERPERAL INFECTION
• 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
TREATMENT AND NURSING CARE
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• 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.
Test Yourself !
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Complications of Puerperal Infections
Pelvic Cellulitis Peritonitis
Spiking a fever of 102 0 F to 104 0 FElevated WBCChillsExtreme LethargyNausea and VomitingAbdominal Rigidity and Rebound Tenderness
Signs and Symptoms:
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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
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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
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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
Check Yourself
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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
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Mastitis
• Types:
–Mammary Cellulitis - inflammation of the connective tissue between the lobes in the breast
–Mammary Adenitis - infection in the ducts and lobes of the breasts
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PoorPositioning
of Infant
Im properbreaking of
suction
StrongSucking
Infant
FirstNursing
Experience
AbruptW eaning
Supplem entalFeedings
Intervalbetw een
nursing too long
"Lazy Feeder"
Development of Mastitis
Nipple Trauma Pain Impaired Engorgement Let down
Cracked Stasis nipples of milk
Entry for Bacteria Plugged ducts
MastitisTreatment, No TreatmentProblem will resolve Breast Abscess
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Mastitis
Marked EngorgementPainChills, Fever, TachycardiaHardness and RednessEnlarged and tender lymph nodes
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Treatment of Mastitis• Rest
• Appropriate Antibiotics--Usually Cephalosporins
• Hot and / or Cold Packs
• Don’t Stop 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
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Mastitis
Preventive Measures
Meticuloushandwashing
Frequent feedingsand massagedistended area tohelp emptying
Rotate position ofbaby on the breast
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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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Test YourselfThe major causative organism of mastitis is _________________________. Mastitis develops mainly in ______________ who are nursing .
It is almost always ________________ and develops well after the flow of milk has been established.
There are two types of mastitis. One that develops between the lobes of the breast is called____________________. The one that developswithin the lobes and ducts of the breast is called __________________. Mammary cellulitis mainly develops due to _______________.Mammary adenitis develops when ____________________of the breasts occurs. With improper treatment or no treatment, mastitis can lead to ________________.
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Puerperal PsychiatricDisorders
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Mood Disorders
• The Most common Mood Disorders are:
– Postpartum Depression
– Postpartum Psychosis
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Postpartum Depression
• Predisposing Factors:– Primiparity– Ambivalence about the pregnancy– History of Depression– Environmental and Family Stress
issues– Dissatisfaction with herself
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Postpartum DepressionAssessment
Persistent lack of interest or energy, loss of usual emotional response toward her spouse or family
Obsessive thoughts of failure as mother, incompetent, inadequate parent
Anxiety, Irritability Forgetfulness; Inability to follow
directionsAnorexia Persistent Sleeplessness Poor personal Hygiene Feelings of unworthiness
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Postpartum Depression
• Creates strain on the family
• Family members may decrease their interactions with the depressed woman when she needs support the most.
• Infants of depressed mothers tend to be fussier and more discontented. They show fewer positive facial expressions.
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Nursing CareAntidepressant Drugs
a. SSRI• Prozac, Paxil, Zoloft
b. Cyclic compounds• Tofranil, Asendin, Norpramin,
Sinequanc. MAO Inhibitors
• Nardil, Parnated. Other:
• Wellbutrin, Effexor, Desyrile. Lithium, Depakene, Tegretol for bipolar disorder
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Treatment for Depression
2. Psychotherapy
3. Encourage communication with her husband or support person who is available to provide support when loneliness or anxiety becomes a problem
4. Explain importance of good nutrition and rest
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Treatment and Nursing Care
5. Discuss changes that normally occur in the beginning weeks after taking a baby home
6. Although some of her feelings may seem “unreasonable”, she should acknowledge these feelings to herself and insist that others acknowledge them too.
7. Re-introduce the baby to the mother at the mother own pace
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Convey a caring attitude
This helps mothers decrease their emotional distress and guide them in
regaining their well-being
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Postpartum PsychosisSCHIZOPHRENIA
• Far less common
• May surface when the mother does not have the ability to adjust to and cope with her new obligations as a mother
• Affects mostly adolescents and younger adults
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Schizophrenia
Signs and Symptoms Irritability, Hyperactivity Insomnia; Exhibit little need for
sleepMood labilityHostility toward spouse is
obviousOverly Suspicious, seldom aware
they have a problemOften believe hers to have been
an immaculate conceptionAbandons reality, totally
neglects her infantMay have delusions and
erroneously belief that baby is dead, malformed or severely ill; hallucinations
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Treatment and Nursing Care Remove the baby from the situation
Hospitalization
Antipsychotic Medications Stelazine, Clozaril, Risperdal, Haldol,
Navane
When she is better, then bring the baby back for short visits at first. Give praise for small tasks that the mother can accomplish with the baby.
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Review• What is the time difference between early
and late postpartum hemorrhage?
• What is the most common cause of postpartum hemorrhage?
• How will the nurse recognize uterine atony?
• What is the FIRST nursing action if uterine atony is discovered?
• What would the nurse suspect if the placenta fails to release from the uterine wall after delivery?
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• How do the signs and symptoms of hematoma differ from those of uterine atony or a laceration?
• What laboratory study should the nurse suspect if the woman is on heparin anticoagulation?
• What is the significance of a board-like abdomen in a woman who has endometritis?
• Why is it important that the breast-feeding mother with mastitis empty her breasts completely?
• What is the KEY difference between postpartum blues and postpartum depression?
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The End