Postpartum Postpartum ComplicationsComplicationsJacqueline Arah Lim Tario R.N.Jacqueline Arah Lim Tario R.N.

I. Postpartum I. Postpartum HemorrhageHemorrhage

I. Postpartum HemorrhageI. Postpartum Hemorrhage

• Obstetrical emergency that can follow Obstetrical emergency that can follow vaginal or cesarean deliveryvaginal or cesarean delivery

• DefinitionDefinition– Excessive bleeding that makes the patient Excessive bleeding that makes the patient

symptomatic (lightheaded, syncope) and/or symptomatic (lightheaded, syncope) and/or results in signs of hypovolemia (hypotension, results in signs of hypovolemia (hypotension, tachycardia, oliguria)tachycardia, oliguria)

POSTPARTUM HEMORRHAGEPOSTPARTUM HEMORRHAGE

--Blood loss of more than 500 cc for NSD Blood loss of more than 500 cc for NSD and 800 cc for CSand 800 cc for CS

EARLY POSTPARTUM HEMORRHAGELATE POSTPARTUM HEMORRHAGE

EARLY POSTPARTUM EARLY POSTPARTUM HEMMORHAGEHEMMORHAGE

• 1. Uterine Atony

Most common cause of postpartum hemorrhage-Uterus fails to contract therefore becoming relaxed and boggy

RISK FACTORSRISK FACTORS

• Overdistention of the uterus

• Caesarean section

• Placental accidents

• Rapid or prolonged and difficult labor

• Deep inhalation anesthesia

Management Management (Uterine Atony)(Uterine Atony)

– Fundal massage; bimanual uterine Fundal massage; bimanual uterine compression compression

Management Management (Uterine Atony)(Uterine Atony)

• Ice compress

• Fast drip IV fluids and oxytocin administration per doctor’s order

• Let the baby suck the nipple of the mother

• If all other option fail to manage hemorrhage ligation of uterine arteries and vessels hysterectomy maybe indicated

EARLY POSTPARTUM EARLY POSTPARTUM HEMMORHAGEHEMMORHAGE

• 2.LacerationDEGREES OF LACERATION

1ST degree- extends through vagina and perineal skin2nd degree- extends deeply into the perineal soft tissue and

down to but not including the exernal anal sphincter3rd degree- extends through the perineum and anal

sphincter4th degree- extends through the perineum, anal sphincter

and extends through the rectal mucosa to expose the lumen of the rectum

Management Management (LACERATION)(LACERATION)

• Surgical repair (Episiorraphy)

• Low residue diet, stool softeners, sitz bath, daily peri light and good perineal hygiene and prescribed post-partum

EARLY POSTPARTUM EARLY POSTPARTUM HEMMORHAGEHEMMORHAGE

• 3.HEMATOMA

-purplish discoloration of the subcutaneous tissue of the vagina or perineum

Management Management (HEMATOMA)(HEMATOMA)

• Cold compress

Apply for 10-20 minutes then rest for 30 minutes. Do this alternately for 24 hours

EARLY POSTPARTUM EARLY POSTPARTUM HEMMORHAGEHEMMORHAGE

4.Disseminated Intravascular Coagulation (DIC)– An acquired disorder of blood clotting in which

the fibrinogen levels falls to below effective limits.

EARLY POSTPARTUM EARLY POSTPARTUM HEMMORHAGE (DIC)HEMMORHAGE (DIC)

• Predisposing Factor:

-abruptio placenta

-placental retention

-still birth• S/Sx:

-bleeding to any part of the body and oozing of blood

(Early symptoms)-easy bruising and bleeding from the intravenous site

Management Management (DIC)(DIC)

• Blood transfusion or prepare for hysterectomy

EARLY POSTPARTUM EARLY POSTPARTUM HEMMORHAGE HEMMORHAGE

5. UTERINE INVERSION-should be immediately repositioned

vaginally-placenta should not be removed if

still attached to the uterus until after it has repositioned-Administer Terbutaline as ordered-Administer Oxytocin as ordered

LATE POSTPARTUM LATE POSTPARTUM HEMORRHAGEHEMORRHAGE

Retained Placental Fragments

Management:

Dilatation and Curretage/ Manual extraction of the uterus

Uterotonic Agents for PPHUterotonic Agents for PPH

OxytocinOxytocin

(Pitocin)(Pitocin)

10 units/ml10 units/ml

Dilute 20-Dilute 20-40 units in 40 units in 1 L NS1 L NS

10 IU IM10 IU IM

IVIV

IMIM

ContinuousContinuous

Infusion, Infusion, 250 ml/hr250 ml/hr

Nausea, vomitingNausea, vomiting

Water intox with Water intox with prolonged IV useprolonged IV use

Hypersensitivity to Hypersensitivity to the drugthe drug

Room Room temptemp

CarboprostCarboprost

(Hemabate)(Hemabate)

15-methyl PG 15-methyl PG F2aF2a

0.25 mg/ml0.25 mg/ml

0.25 mg0.25 mg IMIM

IMMIMM

Q 15-90 min Q 15-90 min not to not to exceedexceed

8 doses8 doses

Nausea, vomitingNausea, vomiting

DiarrheaDiarrhea

Fever/ChillsFever/Chills

HAHA

HypertensionHypertension

BronchoconstrictionBronchoconstriction

Hypersensitivity to Hypersensitivity to the drugthe drug

Use with caution Use with caution in patients with in patients with HTN or asthmaHTN or asthma

RefrigRefrig

Methylergon-Methylergon-ovineovine

(Methergine)(Methergine)

0.2 mg/ml0.2 mg/ml

0.2 mg0.2 mg IMIM Q 10 min x Q 10 min x 22

Q 2 – 4 hrsQ 2 – 4 hrs

Nausea, vomitingNausea, vomiting

Hypertension, esp Hypertension, esp in pts with PIH or in pts with PIH or chronic HTNchronic HTN

HypotensionHypotension

HypertensionHypertension

PreeclampsiaPreeclampsia

Hypersensitivity to Hypersensitivity to the drugthe drug

RefrigRefrig

Protect Protect from lightfrom light

MisoprostolMisoprostol

(Cytotec)(Cytotec)

100 and 200 100 and 200 mcg tabsmcg tabs

600-1000 600-1000 mcgmcg

PRPR Single doseSingle dose Nausea, vomitingNausea, vomiting

ShiveringShivering

FeverFever

DiarrheaDiarrhea

Hypersensitivity to Hypersensitivity to the drugthe drug

Room Room temptemp

Drug Dose Route Freq Side Effects Contraind. StoreDrug Dose Route Freq Side Effects Contraind. Store

Causes of Postpartum HemorrhageCauses of Postpartum Hemorrhage

Four TsFour Ts CauseCause Approximate Approximate incidence (%)incidence (%)

ToneTone Atonic uterusAtonic uterus 7070

TraumaTraumaLacerations, Lacerations, hematomas, hematomas, inversion, ruptureinversion, rupture

2020

TissueTissue Retained tissue, Retained tissue, invasive placentainvasive placenta 1010

ThrombinThrombin CoagulopathiesCoagulopathies 11

II. INFECTIONII. INFECTION

• 1.INFECTION OF THE PERINEUM

2-3 stitches are dislodge, with a purulent drainage

2.Postpartum Endometritis2.Postpartum Endometritis

• Infection of the lining of the Infection of the lining of the uterus specifically the uterus specifically the endometriumendometrium

PP EndometritisPP Endometritis

• Polymicrobial, ascending infectionPolymicrobial, ascending infection– Mixture of aerobes and anaerobes from genital tractMixture of aerobes and anaerobes from genital tract– BV and colonization with GBS increase likelihood of BV and colonization with GBS increase likelihood of

infectioninfection

• Clinical manifestations (occur within 5 days pp)Clinical manifestations (occur within 5 days pp)– Fever – most common signFever – most common sign– Uterine tendernessUterine tenderness– Foul lochiaFoul lochia– LeukocytosisLeukocytosis– Bacteremia – in 10-20%, usually a single organismBacteremia – in 10-20%, usually a single organism

PP EndometritisPP Endometritis

• TreatmentTreatment– Broad spectrum IV abx Broad spectrum IV abx

• Clindamycin 900mg IV q8h and Clindamycin 900mg IV q8h and • Gentamicin 1.5mg/kg IV q8hGentamicin 1.5mg/kg IV q8h

– Treat until afebrile for 24-48h and clinically Treat until afebrile for 24-48h and clinically improved; oral therapy not necessaryimproved; oral therapy not necessary

– Add ampicillin 2g IV q4h to regimen when not Add ampicillin 2g IV q4h to regimen when not improving to cover resistant enterococciimproving to cover resistant enterococci

III. Postpartum III. Postpartum DepressionDepression

Postpartum DepressionPostpartum Depression

• Inadequate emotional support received from their partners or extreme stress caused by new mothering responsibilities are other contributing factors.

Postpartum DepressionPostpartum Depression

• Most common complicationMost common complication– Occurs in 13% (1 in 8) of women after pregnancyOccurs in 13% (1 in 8) of women after pregnancy– Recurs in 1 in 4 with prior depressionRecurs in 1 in 4 with prior depression– Begins within 4 weeks after deliveryBegins within 4 weeks after delivery

• Multifactorial etiologyMultifactorial etiology– Rapid decline in hormones, genetic susceptibility, life Rapid decline in hormones, genetic susceptibility, life

stressorsstressors

• Risk FactorsRisk Factors– Prior h/o depression, family h/o mood disorders, Prior h/o depression, family h/o mood disorders,

stressful life eventsstressful life events

PP DepressionPP Depression

• Differential DiagnosisDifferential Diagnosis– Baby Blues / Postpartum bluesBaby Blues / Postpartum blues

– – common, transient mood disturbancecommon, transient mood disturbance• Sadness, weeping, irritability, anxiety, and confusionSadness, weeping, irritability, anxiety, and confusion• Occurs in 40 - 80% of postpartum womenOccurs in 40 - 80% of postpartum women• Sx peak 4Sx peak 4thth – 5 – 5thth day pp and resolve by 10 – 14 days day pp and resolve by 10 – 14 days

– Postpartum psychosisPostpartum psychosis• Psychiatric emergency due to risk of infanticide or suicidePsychiatric emergency due to risk of infanticide or suicide• Bizarre behavior, disorganization of thought, hallucinations, Bizarre behavior, disorganization of thought, hallucinations,

delusionsdelusions• usually occurs in first 2 weeks ppusually occurs in first 2 weeks pp

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