postpartum

Postpartum Complications

Postpartum Complications: Principles

• The most frequent cause of postpartum hemorrhage is uterine atony.

• Anything that overdistends the uterus, causes it to contract poorly or overworks the uterus is a set-up for uterine atony.

Postpartum Hemorrhage- Continues to be a leading cause of maternal morbidity and death in the US- Can occur with little warning

- Definitions (PP lecture) * also include 10% drop in Hct between admission and postpartum - 50% underestimation of blood loss


Postpartum Complications- Most common cause (90%) is uterine atony (marked hypotonia)- Less common causes are retained placenta, placenta accreta, cervical/vaginal lacerations, uterine rupture- Predisposing causes of uterine atony * Multiparity * Hydramnios * Macrosomic fetus * Traumatic birth * Rapid or prolonged labor


* Use of magnesium sulfate * Use of oxytocin * Multiple pregnancy- Management of uterine atony * Manual massage of the uterus * Expression of clots * Eliminate bladder distention

* IV of lactated Ringer’s or normal saline with 10-40 units of oxytocin added

* Ergonovine or methyl-ergonovine (IM) if not hypertensive


- Non-adherent Retained Placenta * May result from partial separation of the placenta or entrapment of the partially or fully separated placenta * Treated by manual removal of the placenta * If no epidural, nitrous oxide and oxygen inhalation


- Adherent Retained Placenta * Unknown etiology * Probably implantation in a defective area of endometrium * Manual removal is unsuccessful and laceration or perforation of uterine wall may result from attempts * Degrees of adherence - Placenta accreta = slight penetration of myometrium


- Placenta increta = deep penetration of myometrium - Placenta percreta = penetration to the point of perforation of the myometrium * Treatment may indicate hysterectomy and blood replacement - Inversion of the uterus * Potentially life-threatening complication * 1 in 2000-2500 births


* Partial or complete * Contributing factors - Fundal implantation of placenta - Vigorous fundal pressure - Excessive traction to cord - Uterine atony, fibroids or abnormally adherent placenta - Most often in multiparas with placenta accreta/increta

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- Coagulopathies * When bleeding continues with no identifiable source, a coagulopathy must be considered * Coagulation status must be assessed quickly and continuously * Abnormal results depend on the cause and may include: - Increased prothrombin time - Increased partial prothrombin time


- Decreased platelets - Decreased fibrinogen level - Increased fibrin degradation products - Prolonged bleeding time * Idiopathic throbocytopenia * Von Willebrand Disease


* Disseminated intravascular coagulation (DIC) - Diffuse and consumes large amounts of clotting factors - Widespread external and internal bleeding - Predisposing factors: abruptio placentae, amniotic fluid embolism, dead fetus syndrome (6 weeks), severe pre-eclampsia, septicemia, cardiopulmonary arrest, hemorrhage


* Diagnosis - Spontaneous bleeding from gums and nose - Petechiae around blood pressure cuff- Thromboembolic Disease

* Types - Superficial venous thrombosis saphenous)

- Deep venous thrombosis (foot to iliofemoral region


- Pulmonary embolism (complication of DVT) * Incidence has decreased because of early ambulation after birth * Major causes - Venous stasis - Hypercoagulation * Medical management - Superficial – analgesic (NSAID), rest with elevation of the leg, elastic stockings


- Local application of heat may also be used- Deep vein thrombosis – IV heparin (5-7 days), bedrest with affected leg elevated, analgesia followed by elastic stockings and oral anticoagulant therapy (warfarin) for 3 months * Woman should be encouraged not to massage area and, when on bedrest, not to flex knees sharply * Anticoagulant therapy for 6 months


Postpartum Complications-Pulmonary embolism * Signs/symptoms - Shortness of breath

- Diaphoresis - Chest pain - Tachycardia * Treated with continuous IV heparin followed by intermittent subcutaneous or oral

Postpartum Infections

- Puerperal Infection (“Childbed Fever”) - Any infection of the genital canal that begins within 28 days after abortion, miscarriage or childbirth - Definition is a fever of 38o C (100.4o F) on 2 successive days of the first 10 days postpartum (not counting 1st 24 hours after birth


- Common infections * Endometritis * Wound infections * Mastitis * UTIs * URIs - More common in women with concurrent medical or immunosuppressive conditions


- Also increased risk with * A Cesarean or other operative birth * Prolonged labor * Prolonged rupture of membranes * Internal fetal or uterine monitoring - Signs/symptoms * Endometritis - Pelvic pain - Uterine tenderness - Foul-smelling, profuse lochia


* Wound infection - Erythema, edema, warmth, tenderness, sero-purulent drainage wound separation * Mastitis - Almost always unilateral - Develops well after milk flow established - Usually hemolytic S. aureus


- Infected nipple fissure usually the initial lesion - Accompanied by inflammatory edema and engorgement that obstruct milk flow in the region and generalized mastitis follows - Chills, fever, malaise, pain - Treated by antibiotics and emptying breasts q 2-4 hours by feeding, manual expression or pump


Postpartum Psychological Complications - Grieving * Normal response to loss of a child or loss of the “ideal” child * The woman grieves the “death” of the idealized child

* May interfere with the ability to bond with the child


Postpartum Complications * Death of a baby - Questions about what happened - Bewilderment, resentfulness, bitterness - Most women interested in seeing the baby and this is therapeutic - Staff and patients, friends and relatives tend to avoid a woman whose baby has died

- Woman needs the opportunity to talk about it

Perinatal depression * Prevalence of major and minor depression begins to rise after delivery and peaks in the 3rd month * Postpartum “Blues” - 50% of women have symptoms - Peak on 5th postpartum day - considered a normal part of early motherhood - Go away within 10 days

- Depression * “Blues” vs. Depression vs. Psychosis (handout)

* Blues - Emotional lability - Feelings of sadness - Related to hormone shifts, fatigue, sleep deprivation * Depression - Feelings continue beyond the immediate postpartal period and longer than 1 year


* Postpartum Depression - May occur in 10% - 23% of women - A true, major depression - Can last into the 2nd year after delivery - Risk factors * Past history of depression (often bipolar) * Depression during pregnancy * Previous history of postpartum depression * Life stress * Poor social support


* History “baby blues” * History of severe PMS * Poor marital relationship * Family history of postpartum depression - Symptoms * Feeling of sadness, extreme fatigue, inability to stop crying, anxiety about her own or the baby’s health, insecurity and psychosomatic symptoms


* Cheryl Beck (PPSS)

- “Teetering on the edge” - “Brain is full of cobwebs” - “…I have lost my self” * Basic psychosocial problem with control- Postpartum Psychosis * Response to the crisis of childbearing

* Majority of these women have had symptoms of mental illness that precede the pregnancy


Postpartum Complications * Other major life crises can precipitate the same illness * Exceptional sadness, out of touch with reality, thoughts of infanticide or that the child is possessed

* This is a psychiatric emergency and requires hospital admission * Do not leave the woman alone and do not leave her alone with her infant * Risks of suicide and infanticide are significant

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