Transcript Postpartum Hemorrhage

COMPLICATIONS OF POSTPARTUM
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
MAIN CAUSES OF EARLY
HEMORRHAGE ARE:

Uterine Atony

Lacerations

Retained Placental Fragments

Inversion of the Uterus

Placenta Accreta

Hematomas
UTERINE ATONY
**The myometrium fails to contract and
the uterus fills with blood because of
the lack of pressure on the open
vessels of the placental site
UTERINE ATONY
PREDISPOSING FACTORS
Prolonged
labor
Trauma due
to Obstetrical
Procedures
Intrapartum
Stimulation
with Pitocin
Overdistention
of the
Uterus
Grandmultiparity
Excessive use of
Analgesia / Anesthesia
UTERINE ATONY
 Most
 Key
common cause of Hemorrhage
to successful management is:
PREVENTION!
 Nurse
many times can predict which
women are at risk for hemorrhaging.
UTERINE ATONY
A boggy uterus that does not
respond to massage
Abnormal
Clots
Signs
and
Symptoms
Excessive
or
Bright Red
Bleeding
Unusual pelvic discomfort or backache
NURSING CARE
OF UTERINE ATONY

Document Vaginal Bleeding

Fundal massage / Bimanual Compression

Assess Vital Signs (shock)

Give medications--Pitocin, Methergine,
Hemabate

D & C, Hysterotomy/ectomy, Replace blood /
fluids
POST PARTUM HEMORRHAGE
*LACERATIONS*

PREDISPOSING FACTORS
1. Spontaneous or Precipitous delivery
2. Size, Presentation, and Position of baby
3. Contracted Pelvis
4. Vulvar, cervical, perineal, uretheral area 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
POSTPARTUM HEMORRHAGE
*LACERATIONS*
 Treatment
and Nursing Care
1. Meticulous inspection of the entire
lower birth canal
2. Suture any bleeders
3. Vaginal pack-- nurse may remove and
assess bleeding after removal
4. Blood replacement
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?
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
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.
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

Predisposing Factors:
felt
Traction applied on the cord before the placenta has
separated.
**Don’t pull on the cord unless the placenta has
separated.
 Incorrect traction and pressure applied to the fundus,
especially when the uterus is flaccid
**Don’t use the fundus to “push the placenta out”

UTERINE INVERSION AND REPLACEMENT
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

PLACENTA ACCRETA
All or part of the decidua basalis is absent and the
Placenta grown directly into the uterine muscle.
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
 If
it is only small portions that are
attached, then these may be removed
manually
 If
large portion is attached--a
Hysterectomy is necessary!
LATE POSTPARTUM HEMORRHAGE
Most common cause is Retained Placental
fragments
 Sub involution


Treatment
 D&C
 Methergine
ARE THESE EARLY, LATE, OR BOTH ?

Uterine Atony

_________________

Retained placental
fragments

_________________

Lacerations

_________________

Inversion of the uterus

_________________

Placenta accreta

_________________

Hematoma

_________________
POSTPARTUM INFECTIONS
POSTPARTUM 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
POSTPARTUM INFECTIONS
 Predisposing
Factors
1. Trauma
2. Hemorrhage
3. Prolonged labor
4. Urinary Tract Infections
5. Anemia and Hematomas
6. Excessive vaginal exams
7. P R O M
CRITICAL TO REMEMBER
 Signs
and Symptoms of Postpartum
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
POSTPARTUM INFECTION
TREATMENT AND NURSING CARE
• 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
Test Yourself !
 What
is the classic sign of a
Postpartum Infection?
COMPLICATIONS OF
POSTPARTUM INFECTIONS
Pelvic Cellulitis
Peritonitis
Signs and Symptoms:
Spiking a fever of 102 0 F to 104 0 F
Elevated WBC
Chills
Extreme Lethargy
Nausea and Vomiting
Abdominal Rigidity and Rebound Tenderness
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

LOCALIZED INFECTION
Infection of the Episiotomy, Perineal
laceration, Vaginal or vulva lacerations
 Wound infection of incision site


Signs:
Reddened, edematous, firm, tender edges of
skin
 Edges seperate and purulent material
drains from the wound.
 Treatment
 Antibiotics
 Wound care

CHECK YOURSELF
 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?
 What would be the major difference in
presenting symptoms you would note on
nursing assessment?
POSTPARTUM CYSTITIS
POSTPARTUM CYSTITIS
• Prevention:
• Monitor the patients urination diligently!
• Don’t allow to go longer than 3 - 4 hours before
intervening.
• Treatment
• Antibiotics -- Ampicillin
• Urinary Tract Antispasmodics
• 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
MASTITIS
Marked Engorgement
Pain
Chills, Fever, Tachycardia
Hardness and Redness
Enlarged and tender
lymph nodes
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
Development of Mastitis
Improper
breaking of
suction
First
Nursing
Experience
Supplemental
Feedings
"Lazy Feeder"
Poor
Positioning
of Infant
Strong
Sucking
Infant
Abrupt
Weaning
Interval
between
nursing too long
Nipple Trauma
Pain
Impaired
Let down
Cracked
nipples
Engorgement
Stasis
of milk
Entry for Bacteria
Plugged ducts
Mastitis
Treatment, Problem will resolve
No Treatment
Breast Abscess
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

MASTITIS
Preventive Measures
Meticulous
handwashing
Frequent feedings
and massage
distended area to
help emptying
Rotate position of
baby on the breast
COMPLICATION OF MASTITIS
Breast Abscess
Breast Feeding is stopped on the affected side, but may feed on the
unaffected side.
Treatment: Incision and Drainage
THROMBOEMBOLIC DISEASE
Predisposing Factors
Slowing of blood in the legs
Trauma to the veins
Signs and Symptoms
Sudden onset of pain
Tenderness of the calf
Redness and an increase in skin
temperature
Positive Homan’s Sign
Treatment
Heparin --it does not cross into breast milk
Antidote: protamine sulfate
Teach patient to report any unusual bleeding, or
petchiae, bleeding gums, hematuria, epistaxis, etc.
Complication
Pulmonary Emboli
POSTPARTUM PSYCHIATRIC
DISORDERS
Mental Health problems can complicate the
puerperium.
There are days when each new mother may feel
inadequate, but the mother who has a constant
feeling of inadequacy needs professional
counseling.
Pregnancy alone is not a cause of a psychiatric
Illness; however, the psychological and physiological
stressors relating to pregnancy may bring on an
emotional crisis
MOOD DISORDERS
The
Most common Mood
Disorders are:
 Adjustment
reaction with mood
depression “baby blues”
 Postpartum major mood disorder
“Postpartum Depression”
 Postpartum psychosis
“BABY BLUES”
 50-80%
of moms are affected
 Self-limiting (up to 10 days)
 Cause

Seems to be related to changes in progesterone,
estrogen and prolactin levels
 Symptoms
Tearful yet happy
 Overwhelmed

 Treatment
POSTPARTUM MAJOR MOOD DISORDER
“POSTPARTUM DEPRESSION”

Risk factors:
Primiparity
 History of postpartum depression
 Lack of social and relationship support


Clinical Therapy:
Counseling, support groups
 Medication (usually SSRI’s)
 Childcare assistance

POSTPARTUM PSYCHOSIS
 Predisposing
Factors:
 Similar to those of postpartum depression
 Assessment:
 Grandiosity
 Decreased need for sleep (insomnia)
 Flight of ideas
 Psychomotor agitation / hyperactivity
 Rejection of infant
TREATMENT FOR MOOD DISORDERS
Drug therapy (previous slide)
Psychotherapy
Explain importance of good nutrition and rest
Some of her feelings may seem “unreasonable”
Re-introduce the baby to the mother at the
mother’s own pace





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?