Transcript 14_postpartum complication (Hemorrhage)

Postpartum Complications
Postpartum Physical Assessment

B - breast

U - uterus

B - bowels

B - bladder

L - lochia
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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 2030 minutes after delivery, OR
• Bleeding increases rather than
decreases after delivery
Routine care for the postpartum woman:
Educate about danger signs (2)
Severe abdominal pain
Fever and too weak to get
out of bed
Routine care for the postpartum woman:
Educate about danger signs (3)
•
Fast or difficult breathing
•
Severe headache, blurred
vision
•
Convulsions
Routine care for the postpartum woman:
Educate about danger signs (4)
•
•
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 (5)
The woman doesn’t
feel well.
Breasts swollen, red or
tender breasts, or sore
nipples
Postpartum Hemorrhage (PPH)
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Definition and incidence
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PPH traditionally defined as loss of more than:
• 500 ml of blood after vaginal birth
• 1000 ml after cesarean birth
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Cause of maternal morbidity and mortality
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Life-threatening with little warning
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Often unrecognized until profound symptoms
Etiology of PPH
The causes of postpartum hemorrhage can
be thought of as the four Ts:
tone,
tissue,
trauma,
thrombin
Postpartum Hemorrhage
Etiology and risk factors (1)
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Uterine atony
• Marked hypotonia of uterus
• Leading cause of PPH,
complicating approximately 1
in 20 births
• Brisk venous bleeding with
impaired coagulation until the
uterine muscle contracts
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Postpartum Hemorrhage
Etiology and risk factors (1)
Uterine atony
Multiple gestation,
high parity,
prolonged labor
chorioamnionitis,
augmented labor,
 tocolytic agents
Management of uterine atony
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Explore the uterine cavity.
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Inspect vagina and cervix for lacerations.
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If the cavity is empty, Massage and give
methylergonovine 0.2 mg, the dose can be
repeated every 2 to 4 hours.
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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.
Complications of Puerperium
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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
Etiology and risk factors (2)

Lacerations of genital tract
• Should be suspected if bleeding continues with a
firm, contracted fundus
• Includes perineal and cervical lacerations as well as
pelvic hematomas
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Postpartum Hemorrhage
Etiology and risk factors (2)
Lacerations and trauma
Planned
•Cesarean section,
•episiotomy
Unplanned
•Vaginal/cervical tear,
•surgical trauma
Postpartum Hemorrhage
Genital tract lacerations Management
Genital trauma always
must be eliminated
first if the uterus is
firm.
Postpartum Hemorrhage
Etiology and risk factors (2)
UTERINE RUPTURE
Rupture of the uterus is
described as complete or
incomplete and should be
differentiated from dehiscence
of a cesarean section scar.
Postpartum Hemorrhage
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
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
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
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.
Management of Rupture Uterus
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
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Upon entering the abdomen, aortic
compression can be applied to decrease
bleeding.
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Oxytocin should be administered to effect
uterine contraction to assist in vessel
constriction and to decrease bleeding.
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Hemostasis can then be achieved by ligation
of the hypogastric artery, uterine artery, or
ovarian arteries.
Management of Rupture Uterus
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At this point, a decision must be made to perform
hysterectomy or to repair the rupture site. In most
cases, hysterectomy should be performed.
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In selected cases, repair of the rupture can be
attempted. When rupture occurs in the body of the
uterus,
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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
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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.
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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
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Lacerations – suspect this
in the birth canal if uterine
bleeding continues with a
contracted fundus
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Hematomas- bleeding into
loose connective tissue
as the vulva or vagina
• Vulva- discolored bulging
mass
• Surgical excision if they
are large & ligation
Postpartum Hemorrhage
Etiology and risk factors (3)
 Retained
placenta
• Nonadherent retained placenta – managed
by manual separation and removal by the
primary care provider
• Adherent retained placenta – may be
caused by implantation into defective
endometrium
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Postpartum Hemorrhage
Etiology and risk factors (3)
Three
classifications of adherent
retained placenta
• Placenta acreta – slight penetration
of myometrium by placental trophoblast
• Placenta increta – deep penetration
of myometrium by placenta
• Placenta percreta – perforation of uterus by placenta
Patient
will experience profuse bleeding when
delivery of the placenta is attempted.
Management
includes blood replacement and
surgical intervention (hysterectomy)
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Postpartum Hemorrhage
Etiology and risk factors (4)
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Inversion of uterus (turning inside out)
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May be life-threatening
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A complete inversion protrudes out of the
vagina
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Primary signs – hemorrhage, shock, pain
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Prevention is the best measure – don’t pull on
the umbilical cord unless there is definite
separation of the placenta
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Postpartum Hemorrhage
Etiology and risk factors4
Inversion of uterus (turning
inside out)
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Postpartum Hemorrhage
Etiology and risk factors (5)
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Subinvolution of uterus – delayed involution of
the uterus
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Usually see late post partum bleeding
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Causes include retained placental fragments
and infection
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Postpartum Hemorrhage
Care Management
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Assessment
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Bleeding assessed for color and amount
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Perineum inspected for signs of lacerations or
hematomas to determine source of bleeding
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Vital signs may not be reliable indicators because
of postpartum adaptations
• Measurements during first 2 hours may identify trends
related to blood loss
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Bladder distension
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Laboratory studies of
hemoglobin and hematocrit
levels
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Postpartum Hemorrhage
Care Management
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Plan of care and implementation
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Initial treatment – fundal massage, expression
of clots, relief of bladder distension, IV fluids
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Medical management
• Hypotonic uterus – examine for retained placental
fragments, medications, surgical interventions
• Bleeding with a contracted uterus – identify and treat
underlying cause
• Uterine inversion – emergency replacement of the
uterus into the pelvic cavity
• Subinvolution – medications, surgical intervention
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Postpartum Hemorrhage
Care Management
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Plan of care and implementation
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Nursing interventions
• Vital signs, uterine assessment, medication
administration, notification of primary care provider
• Providing explanations about interventions and need to
act quickly
• Once stable, ongoing post partum assessments and
care
• Instructions in increasing dietary iron, protein intake,
and iron supplementation
• May need assistance with infant care and household
activities until strength regained
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Guidelines
by the Scottish Executive Committee of
the RCOG
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COMMUNICATE.
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RESUSCITATE.

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MONITOR / INVESTIGATE.
STOP THE BLEEDING.
COMMUNICATE
call 6
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Call experienced midwife
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Call obstetric registrar & alert consultant
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Call anaesthetic registrar , alert consultant
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Alert haematologist
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Alert Blood Transfusion Service
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Call porters for delivery of specimens / blood
RESUSCITATE
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IV access with 14 G cannula X 2
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Head down tilt
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Oxygen by mask, 8 litres / min
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Transfuse
•Crystalloid (eg Hartmann’s)
•Colloid (eg Gelofusine)
•once 3.5 litres infused, GIVE ‘O NEG’ If no crossmatched blood available OR give uncrossmatched own-group blood, as available
•Give up to 1 liter Fresh Frozen Plasma and 10 units
cryoprecipitate if clinically indicated
MONITOR / INVESTIGATE
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Cross-match 6 units
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Full blood count
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Clotting screen
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Continuous pulse / BP /
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ECG / Oximeter
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Foley catheter: urine output
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CVP monitoring
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Discuss transfer to ITU
STOP THE BLEEDING
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Exclude causes of bleeding other than uterine atony
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Ensure bladder empty
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Uterine compression
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IV syntocinon 10 units
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IV ergometrine 500 mg
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Syntocinon infusion (30 units in 500 ml)
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IM Carboprost (500 mg)
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Surgery earlier rather than late
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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) Shock
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Emergency situation in which blood is
diverted to the brain and heart
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May not see signs until post partum patient
loses 30% to 40% of blood volume
Medical management – restore circulating
blood volume and treat underlying cause
Nursing interventions – monitor tissue
perfusion, see emergency box
Fluid 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)
Coagulopathies
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Idiopathic thrombocytopenic purpura (ITP) –
decreased platelet life span, need to control
platelet stability
von Willebrand disease—type of hemophilia
Disseminated intravascular coagulation (DIC)
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Pathologic clotting
 Correction of underlying cause
• Removal of fetus
• Treatment for infection
• Preeclampsia or eclampsia
• Removal of placental abruption
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Coagulation disorders
Congenital
Acquired
DIC,
Von Willebrand's disease
dilutional coagulopathy,
heparin
Thromboembolic Disease
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Results from blood clot caused by inflammation
or partial obstruction of vessel
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May be superficial or deep venous thrombosis
or a pulmonary embolus
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Incidence and etiology
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Venous stasis
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Hypercoagulation
Clinical manifestations – redness and swelling
in the affected extremity, pain, positive Homan’s
sign
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Thromboembolic 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 Disease
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Medical management
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Superficial – analgesia, rest/elevation
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Deep – anticoagulant therapy, bedrest/elevation,
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Pulmonary embolus – IV heparin therapy
Nursing interventions
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assessment of the affected area, signs of bleeding,
personal care, medication administration
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Teach not to massage affected area!!
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Thank you!