Postpartum Complications. Postpartum Physical Assessment B - breast U - uterus B - bowels B - bladder L - lochia E - episiotomy

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


• Fast or difficult breathing

• Severe headache, blurred vision

• Convulsions


• Pain in the perineum or draining pus

• Foul-smelling lochia

Dribbling of urine or pain on micturition


The woman doesn’t feel well.

Breasts swollen, red or tender breasts, or sore nipples


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


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


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

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.


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.


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.


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,


UTERINE RUPTURE

dehiscence describes partial separation of the scar with minimal bleeding, with the peritoneum and fetal membranes remaining intact.


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.


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.


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.


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


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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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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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)


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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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


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!

Documents

Postpartum Complications. Postpartum Physical Assessment B - breast U - uterus B - bowels B - bladder L - lochia E - episiotomy