Transcript 15_Pharmacotherapy of Postpartum

The Postpartum Period
• Puerperium = fourth trimester of
pregnancy - the 6-week interval between
the birth of the newborn and the return of
the reproductive organs to their normal
nonpregnant state
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Uterine Involution
•
Uterine Involution:
– return of the uterus to its pre-pregnancy
size and condition, which begins
immediately after expulsion of the
placenta with contraction of the uterine
smooth muscle
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Uterine fundal descent:
– immediately after birth uterus is in the
midline approximately 2 cm below the
level of the umbilicus, size of grapefruit
(like 16 weeks of gestation), weighs
approximately 1000 g.
– Within 12 hours the fundus may be
approximately 1 cm above the umbilicus
– During next few days the fundus
descends 1 to 2 cm (fingerbreadth)
every 24 hours.
– By the sixth postpartum day the fundus
is normally located halfway between the
umbilicus and the symphysis pubis.
– A week after birth the uterus once again
lies in the true pelvis.
– After the ninth postpartum day the
uterus should not be palpable
abdominally.
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Uterine Involution
• Increased estrogen and progesterone levels are
responsible for stimulating the massive growth of the
uterus during pregnancy. Prenatal uterine growth results
from both hyperplasia, an increase in the number of
muscle cells, and from hypertrophy, an enlargement of
the existing cells. Postpartally, the decrease in these
hormones causes autolysis, the self-destruction of
excess hypertrophied tissue. The additional cells laid
down during pregnancy remain and account for the slight
increase in uterine size after each pregnancy.
• Subinvolution is the failure of the uterus to return to a
nonpregnant state. The most common causes of
subinvolution are retained placental fragments and
infection.
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Lochia Assessment
• Lochia–vaginal discharge after childbirth.
• It takes 6 weeks for the vagina to regain its pre-pregnancy contour.
• For the first 2 hours after birth the amount of uterine discharge should
be approximately that of a heavy menstrual period. After that time, the
lochia flow should steadily decrease.
• Lochia: rubra, serosa or alba
•
Assessment of lochia includes noting color, presence and size of clots and
foul odor.
•
Day 1- 3 - lochia rubra (blood with small pieces of decidua and
mucus)
Day 4-10-22-27 – lochia serosa (pink or pinkish brown serous exudate with
old blood, cervical mucus, erythrocytes and leukocytes, tissue debris)
Day 11- 21 - lochia alba (yellowish white discharge with leucocytes, decidua,
epithelian cells, mucus, serum, bacteria)
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• The amount of lochia is usually less after cesarean births. Flow of
lochia usually increases with ambulation and breastfeeding and
receives an oxytocin medication
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LOCHIAL AND NONLOCHIAL
BLEEDINGLOCHIAL
BLEEDINGNONLOCHIAL BLEEDING
Lochia
• Lochia usually trickles
from the vaginal opening.
The steady flow is greater
as the uterus contracts
• A gush of lochia may
result as the uterus is
massaged. If it is dark in
color, it has been pooled
in the relaxed vagina, and
the amount soon lessens
to a trickle of bright red
lochia (in the early
Bleeding
• If the bloody discharge
spurts from the vagina,
there may be cervical or
vaginal tears in addition
to the normal lochia.
• If the amount of bleeding
continues to be
excessive and bright red,
a tear may be the
source.
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Cervix
• The cervix is soft immediately after birth.
• By 18 hours postpartum it has shortened, become firm, and
regained its form.
• The cervix up to the lower uterine segment remains edematous,
thin, and fragile for several days after birth.
• The ectocervix (portion of the cervix that protrudes into the vagina)
appears bruised and has some small lacerations—optimal
conditions for the development of infection.
• The cervical os, which dilated to 10 cm during labor, closes
gradually.
• Two fingers may still be introduced into the cervical os for the first 4
to 6 days postpartum; however, only the smallest curette can be
introduced by the end of 2 weeks.
• The external cervical os never regains its prepregnant appearance;
it is no longer shaped like a circle but appears as a jagged slit that
is often described as a "fishmouth."
• Lactation delays the production of cervical and other estrogen6
influenced mucus and mucosal characteristics.
VAGINA AND PERINEUM
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Vagina
– vaginal mucosa is thin, atrophic, with decrease amount of lubrication and without
rugae as a result of estrogen deprivation which lead to coital discomfort
(dyspareunia) until ovarian function returns and menstruation resumes.
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– The greatly distended, smooth-walled vagina gradually returns to its
prepregnancy size by 6 to 8 weeks after childbirth. Rugae reappear by
approximately the fourth week, but they are never as prominent as they are in
the nulliparous woman. Most rugae are permanently flattened.
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Perineum
– the introitus is erythematous and edematous, especially in the area of the
episiotomy or laceration repair. It is barely distinguishable from that of a
nulliparous woman
– Episiotomy. Most episiotomies are visible only if the woman is lying on her side
with her upper buttock raised or if she is placed in the lithotomy position.
– Hemorrhoids (anal varicosities) are commonly seen. Internal hemorrhoids may
evert while the woman is pushing during birth. Women often experience
associated symptoms such as itching, discomfort, and bright red bleeding with
defecation. Hemorrhoids usually decrease in size within 6 weeks of childbirth.
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Endocrine System
• Placental hormones (human chorionic
somatomammotropin, estrogens, cortisol, and the
placental enzyme insulinase)
– dramatically decrease and reverse the diabetogenic effects of
pregnancy, resulting in significantly lower blood sugar levels in
the immediate puerperium.
– Estrogen and progesterone levels drop markedly after expulsion
of the placenta and reach their lowest levels 1 week postpartum.
Decreased estrogen levels are associated with breast
engorgement and with the diuresis of excess extracellular fluid
accumulated during pregnancy.
– In nonlactating women, estrogen levels begin to rise by 2 weeks
after birth and by postpartum day 17 are higher than in women
who breastfeed
– β-Human chorionic gonadotropin disappears from maternal
circulation in 14 days
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Endocrine System
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Pituitary hormones and ovarian function
– The persistence of elevated serum prolactin levels in breastfeeding women
appears to be responsible for suppressing ovulation. Because levels of folliclestimulating hormone (FSH) have been shown to be identical in lactating and
nonlactating women, it is thought that the ovulation is suppressed in lactating
women because the ovary does not respond to FSH stimulation when increased
prolactin levels are present
– Prolactin levels in blood rise progressively throughout pregnancy.
– In nonlactating women, prolactin levels decline after birth and reach the
prepregnant range in 4 to 6 weeks
– In breastfeeding woman prolactin levels remain elevated into the sixth week after
birth, and influence by the frequency of breastfeeding, the duration of each
feeding, and the degree to which supplementary feedings are used.
– Ovulation occurs as early as 27 days after birth in nonlactating women, with a
mean time of 70 to 75 days. Approximately 70% of nonbreastfeeding women
resume menstruating by 3 months after birth.
– In women who breastfeed, the mean length of time to initial ovulation is 17
weeks. In lactating women, both resumption of ovulation and return of menses
are determined in large part by breastfeeding patterns. Many women ovulate
before their first postpartum menstrual period occurs; thus there is need to
discuss contraceptive options early in the puerperium.
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– The first menstrual flow after childbirth is usually heavier than normal. Within
three to four cycles the amount of menstrual flow returns to the woman's
BREASTS
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Promptly after birth, there is a decrease in the concentrations of hormones (i.e., estrogen,
progesterone, hCG, prolactin, cortisol, and insulin) that stimulated breast development during
pregnancy. The time it takes for these hormones to return to prepregnancy levels is determined in
part by whether the mother breastfeeds her infant.
BREASTFEEDING MOTHERS
As lactation is established, a mass (lump) may be felt in the breast. Unlike the lumps associated
with fibrocystic breast disease or cancer (which may be consistently palpated in the same
location), a filled milk sac shifts position from day to day. Before lactation begins, the breasts feel
soft and a yellowish fluid, colostrum, can be expressed from the nipples. After lactation begins, the
breasts feel warm and firm. Tenderness may persist for approximately 48 hours after the start of
lactation. Bluish-white milk with a skim-milk appearance (true milk) can be expressed from the
nipples. The nipples are examined for erectility and signs of irritation such as cracks, blisters, or
reddening.
NONBREASTFEEDING MOTHERS
The breasts generally feel nodular in contrast to the granular feel of breasts in nonpregnant
women. The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. Colostrum is present
for the first few days after childbirth. Palpation of the breast on the second or third day, as milk
production begins, may reveal tissue tenderness in some women. On the third or fourth
postpartum day, engorgement may occur. The breasts are distended (swollen), firm, tender, and
warm to the touch (because of vasocongestion). Breast distention is caused primarily by the
temporary congestion of veins and lymphatics rather than by an accumulation of milk. Milk is
present but should not be expressed. Axillary breast tissue (the tail of Spence) and any accessory
breast or nipple tissue along the milk line may be involved. Engorgement resolves spontaneously,
and discomfort decreases usually within 24 to 36 hours. A breast binder or tight bra, ice packs, or
mild analgesics may be used to relieve discomfort. Nipple stimulation is avoided. If suckling is
never begun (or is discontinued), lactation ceases within a few days to a week.
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Fourth Stage of Labor
• Goal of nursing care is to assist woman
and their partners during their initial
transition to parenting
• Nursing's role is to monitor the recovery of
the new mother and infant, to identify and
manage promptly any deviations from the
normal processes that may occur, and to
promote and support parent-infant
attachment
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Fourth Stage of Labor
• First 1 to 2 hours after birth
– During this time, maternal organs undergo
their initial readjustment to the nonpregnant
state and the functions of body systems begin
to stabilize.
– Meanwhile, the newborn continues the
transition from intrauterine to extrauterine
existence
– Excellent time to begin Breastfeeding
• Encouraging of the mother
• Colostrum prompting elimination of meconium
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Care in the Immediate
Postpartum Period
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Assessment
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During first hour every 15 minutes
During second hours every 30 minutes
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Postanesthesia recovery (every 15 min)
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Activity
Respiration
BP
Level of cosciousness
Color
general anesthesia
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Awake, alert, orient to time, place, and person, respiratory rate, oxygen saturation levels at least 95%, as measured by a
pulse oximeter
epidural or spinal anesthesia
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VS (Ps, BP, T)
fundal height and firmness
bladder distension
amount of lochia
presence of edema
status of perineum,
should be able to raise her legs, extended at the knees, off the bed, or to flex her knees, place her feet flat on the bed, and
raise her buttocks well off the bed. The numb or tingling, prickly sensation should be entirely gone from her legs. Often, it
takes 1.5 to 2 hours for these anesthetic effects to disappear.
Providing comfort measures
Analgesics
Promoting bladder elimination
Providing fluid and food
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Nursing Care After Cesarean
Birth
• Same as with normal vaginal delivery except
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Postanesthesia recovery
Monitoring of abdominal dressing
Urinary catheter
Respiratory care
Prevention of thrombophlebitis
Interventions for pain
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Slide 14
Postpartum Physical
Assessment
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B - breast
U - uterus
B - bowels
B - bladder
L - lochia
E - episiotomy
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General Assessment
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Enter the room quietly, speak quietly.
Wash hands and provide for privacy.
Inform patient before turning on lights.
Note LOC, activity level, position, color,
general demeanor.
• Take note of the total environment:
– Safety/patient considerations
– Note equipment and medical devices
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Breast Assessment
• Breasts: Soft, engorged, filling, swelling,
redness, tenderness.
• Nipples: Inverted, everted, cracked,
bleeding, bruised, presence of colostrum or
breastmilk.
• Colostrum–yellowish fluid rich in antibodies
and high in protein.
• Engorgement occurs by day 3 or 4. Due to
vasoconstriction as milk production begins
• Lactation ceases within a week if
breastfeeding is never begun or is stopped.
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• Nipple soreness is a portal of entry for
bacteria - breast infection (Mastitis).
• Maternal after pains: may be due to
breastfeeding and multiparity
• Always stay with the client when getting
out of bed for the first time – hypotension
effect and excess bleeding
• When assessing fundal height, if you
notice any discrepancies in fundal height
have patient void and then reassess.
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Assessing Uterine Fundus
• Location in relation to
umbilicus
• Degree of firmness
• Is it at Midline or deviated to
one side?
• Bladder Full?
• A boggy uterus may indicate
uterine atony or retained
placental fragments.
• Boggy refers to being
inadequately contracted and
having a spongy rather than
firm feeling.
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Massaging the Fundus
• Every 15 mins during the 1st hr,
every 30 mins during the next hr,
and then, every hr until the patient
is ready for transfer.
• Document fundal height.
• Evaluate from the umbilicus using
fingerbreadths.
• This is recorded as 2 fingers
below the umbilicus (U/2), one
finger above the umbilicus (1/U),
and so forth.
• The fundus should remain in the
midline. If it deviates from the
middle- distended bladder.
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Uterine Atony
• Lack of muscle tone in the cervix.
• Uterus feels soft and boggy
• The bladder has increased capacity and
decreased muscle tone.
• This leads to over-distension of the
bladder, incomplete emptying of bladder,
retention of residual urine and increased
risk of UTI and postpartum hemorrhage.
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Bowels & Bladder
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When was the patients last bowel movement?
Is she passing flatus? (gas)
Assess for bowel sounds
Voiding pattern - without difficulty/pain, urine may
be blood tinged from lochia
• Nursing interventions: Assist to the bathroom. Use
measures to encourage voiding (privacy).
Encourage use of peri-bottle with warm water,
fluids, fiber, frequent ambulation, stool softeners;
teach effects of pain medication.
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Urinary System
• A full bladder can displace the uterus and lead to
postpartum hemorrhage
• In the woman who voids frequently, small
amounts of urine may have increased residual
urine because her bladder does not empty
completely
• Residual urine in the bladder may promote the
growth of microorganisms
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Slide 23
Lochia: Pad Count
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Scant: 1-inch stain on pad in 1 hour
Light/small: 4 inches in 1 hour
Moderate: 6 inches in 1 hour
Heavy/large: Pad saturated in 1 hour
Excessive: Pad saturated in 15 min
Can estimate blood loss by weighing pads:
500 mL = 1 lb. or 454 g
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Episiotomy/Perineal Assessment
• Patient in lateral Sims (side lying) position.
• Use the acronym REEDA
– Redness, Edema, Ecchymosis, Discharge,
Approximation of suture lines “edges of episiotomy”) to
guide assessment.
• Even if there is no episiotomy, the perineum
should still be assessed.
– Nursing care and patient teaching
• Cold packs
• Topical and systemic medications
• Nonpharmacologic pain relief methods
• Unusual perineal discomfort may be a symptom of
impending infection or hematoma.
Hemorrhoids ?
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Episiotomy Pain Relief
• Instruct Mother:
• Tighten her buttocks and perineum before
sitting to prevent pulling on the episiotomy
and perineal area and to release
tightening after being seated.
• Rest several times a day with feet
elevated.
• Practice Kegel exercise many times a day
to increase circulation to the perineal area
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and to strengthen the perineal muscles.
Postpartum Physical Assessment
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B - breast
U - uterus
B - bowels
B - bladder
L - lochia
E - episiotomy
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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
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Routine care for the postpartum woman:
Educate about danger signs (2)
Severe abdominal pain
Fever and too weak to get
out of bed
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Routine care for the postpartum woman:
Educate about danger signs (3)
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Fast or difficult breathing
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Severe headache, blurred
vision
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Convulsions
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Routine care for the postpartum woman:
Educate about danger signs (4)
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Pain in the perineum or
draining pus
Foul-smelling lochia
Dribbling of urine or pain
on micturition
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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
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Postpartum Hemorrhage (PPH)
• Definition and incidence
– PPH traditionally defined as loss of more
than:
• 500 ml of blood after vaginal birth
• 1000 ml after cesarean birth
– Cause of maternal morbidity and mortality
– Life-threatening with little warning
– Often unrecognized until profound symptoms
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Etiology of PPH
The causes of postpartum hemorrhage can
be thought of as the four Ts:
tone,
tissue,
trauma,
thrombin
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Postpartum Hemorrhage
Etiology and risk factors (1)
– 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
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Management of uterine
atony
• 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.
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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
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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
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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
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Postpartum Hemorrhage
Genital tract lacerations
Management
Genital trauma always
must be eliminated
first if the uterus is
firm.
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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.
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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.
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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.
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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,
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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.
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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.
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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.
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Management of Rupture
Uterus
 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.
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Management of Rupture
Uterus
 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.
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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
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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)
• Inversion of uterus (turning inside out)
– May be life-threatening
– A complete inversion protrudes out of the
vagina
– Primary signs – hemorrhage, shock, pain
– Prevention is the best measure – don’t pull on
the umbilical cord unless there is definite
separation of the placenta
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Hemorrhage
Etiology
and
risk
Inversion of uterus (turning
inside out) factors4

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Postpartum Hemorrhage
Etiology and risk factors (5)
• Subinvolution of uterus – delayed involution of
the uterus
– Usually see late post partum bleeding
– Causes include retained placental fragments
and infection
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Postpartum Hemorrhage
Care Management
• Assessment
– Bleeding assessed for color and amount
– Perineum inspected for signs of lacerations or
hematomas to determine source of bleeding
– Vital signs may not be reliable indicators because
of postpartum adaptations
• Measurements during first 2 hours may identify trends
related to blood loss
– Bladder distension
– Laboratory studies of
hemoglobin and hematocrit
levels
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Postpartum Hemorrhage
Care Management
• Plan of care and implementation
– Initial treatment – fundal massage, expression
of clots, relief of bladder distension, IV fluids
– 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 59
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Postpartum Hemorrhage
Care Management
• Plan of care and implementation
– 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
COMMUNICATE.
RESUSCITATE.
 MONITOR / INVESTIGATE.
STOP THE BLEEDING.
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COMMUNICATE
call 6
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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
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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 crossmatched blood available OR give uncrossmatched own-group blood, as available
•Give up to 1 liter Fresh Frozen Plasma and 10 units
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cryoprecipitate if clinically indicated
MONITOR / INVESTIGATE
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Cross-match 6 units
Full blood count
Clotting screen
Continuous pulse / BP /
ECG / Oximeter
Foley catheter: urine output
CVP monitoring
Discuss transfer to ITU
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STOP THE BLEEDING
• Exclude causes of bleeding other than uterine atony
• Ensure bladder empty
• Uterine compression
• IV syntocinon 10 units
• IV ergometrine 500 mg
• Syntocinon infusion (30 units in 500 ml)
• IM Carboprost (500 mg)
• Surgery earlier rather than late
• Hysterctomy early rather than late
(GRADE B)
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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)
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Resort to hysterectomy
SOONER RATHER
THAN LATER
(especially in cases of
placenta accreta or
uterine rupture)
(GRADE C)
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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
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Hemorrhagic (Hypovolemic)
Shock
• Emergency situation in which blood is
diverted to the brain and heart
– 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)
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Coagulopathies
• Idiopathic thrombocytopenic purpura (ITP) –
decreased platelet life span, need to control
platelet stability
• von Willebrand disease—type of hemophilia
• Disseminated intravascular coagulation (DIC)
– 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
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Thromboembolic Disease
• Results from blood clot caused by
inflammation or partial obstruction of vessel
• May be superficial or deep venous
thrombosis or a pulmonary embolus
• Incidence and etiology
– Venous stasis
– 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)
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Thromboembolic Disease
• Medical management
– Superficial – analgesia, rest/elevation
– Deep – anticoagulant therapy, bedrest/elevation,
– Pulmonary embolus – IV heparin therapy
• Nursing interventions
– assessment of the affected area, signs of
bleeding, personal care, medication
administration
– Teach not to massage affected area!!
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Postpartum Infections
 Endometritis – malodorous lochia, fever
(100.6), chills, abdominal pain, uterine
tenderness, tachycardia and subinvolution
 The infection may spread to cause peritonitis and septic pelvic
thrombophlebitis
 Treat with IV antibiotics
 Emotional support
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Postpartum Infections
• Puerperal sepsis: any infection of
genital canal within 28 days after
abortion or birth
• Most common infecting agents are
numerous streptococcal and anaerobic
organisms
• Endometritis
• Wound infections
• Urinary tract infections
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Complications of Puerperium
• Fever
– UTI/Pyelonephritis
– DVT/Thrombophlebitis
– “Milk fever” (Lasts < 24 hours)
– Drug reaction
– Perineal infection(Day five)
– Pulmonary Atelectasis (48 hours)
– Mastitis (2-3 weeks post partum)
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Postpartum Infections
Endometritis
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Postpartum Endometritis
• Infection of the decidua (pregnancy
endometrium)
• Incidence
– <3% after vaginal delivery
– 10-50% after cesarean delivery
• 5-15% after scheduled elective cesareans
• Risk Factors
– Prolonged labor, prolonged ROM, multiple vaginal
exams, internal monitors, maternal DM, meconium,
manual removal of placenta, low socioeconomic
status
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PP Endometritis
• Polymicrobial, ascending infection
– Mixture of aerobes and anaerobes from genital tract
– BV and colonization with GBS increase likelihood of
infection
• Clinical manifestations (occur within 5 days pp)
–
–
–
–
–
Fever – most common sign
Uterine tenderness
Foul lochia
Leukocytosis
Bacteremia – in 10-20%, usually a single organism
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PP Endometritis
• Workup
– CBC
– Blood cultures
– Urine culture
– DNA probe for GC/chlamydia
– Imaging studies if no response to adequate
abx in 48-72h
• CT scan abd/pelvis
• US abd/pelvis
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PP Endometritis
• Treatment
– Broad spectrum IV abx
• Clindamycin 900mg IV q8h and
• Gentamicin 1.5mg/kg IV q8h
– Treat until afebrile for 24-48h and clinically improved;
oral therapy not necessary
– Add ampicillin 2g IV q4h to regimen when not
improving to cover resistant enterococci
• Prevention
– Abx prophylaxis for women undergoing C-section
• Cefazolin 1-2g IV as single dose
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Postpartum Infections
Mastitis - A breast infection occurring 1-2 weeks
after childbirth
 Engorgement and blocked mild duct increases risk
 Fever, localized breast pain, redness,warmth and inflammation
 Breastfeeding should continue
 Antibiotics
 Nurse's role is to support, educate and refer
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Mastitis
• Infection of the lactating breast- 2nd or 3rd
week after birth
• Caused by S. aureus, often on hands of
mother or caregivers
• Can enter through a crack in the nipple
• Engorgement & stasis of milk frequently
precede mastitis
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Mastitis Continued
• SIGNS & SYMPTOMS:
– Feels like the flu with fatigue & aching
muscles
– Fever of 101.1F
– Localized area of redness & inflammation
• THERAPEUTIC MANAGEMENT
– ATB & decompression of breast by
breastfeeding or pumping
– Bedrest during acute phase
– Fluids & analgesics for discomfort
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Postpartum Infections
Mastitis
Puerperal Mastitis usually caused by common skin bacteria
particularly staphylococcus being introduced into the ductal system
through
87
Postpartum Infections
Mastitis
 Breast infections may cause
 pain,
 redness,
 warmth of the breast along with the
following symptoms:
 Tenderness and swelling
 Body aches
 Fatigue
 Breast engorgement
 Fever and chills
 Rigor or shaking
88
Postpartum Infections
Mastitis
Most breast infections occur in breastfeeding women when bacteria
enters the breast through cracks in the nipple. In severe infections,
abscesses may occur. Antibiotics may be indicated for treatment. 89
Postpartum Infections
Mastitis
90
Postpartum Infections
Mastitis
91
Postpartum Infections
Care Management
• Prevention is the best intervention
– Hand washing
– Good maternal perineal hygiene
• Antibiotic administration
• Wound management
• Breast care
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Sequelae of Childbirth Trauma
• Disorders of uterus and vagina related to
pelvic relaxation and urinary incontinence,
are often result of childbearing
• Uterine displacement and prolapse
– Posterior displacement, or retroversion
– Retroflexion and anteflexion
– Prolapse a more serious displacement
• Cervix and body of uterus protrude through vagina
and vagina is inverted
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Sequelae of Childbirth Trauma
Uterine prolapse
Uterine prolapse occurs when
the uterus falls through the
cervix (the connection between
the uterus and the vagina) into
the vagina. Symptoms and
treatment depends on how
much of the uterus has fallen
into the vagina.
94
Sequelae of Childbirth Trauma
Uterine prolapse
95
Sequelae of Childbirth Trauma
Uterine prolapse
96
Sequelae of Childbirth Trauma
Uterine prolapse
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Sequelae of Childbirth Trauma
Uterine prolapse
98
Sequelae of Childbirth Trauma
• Cystocele and rectocele
– Cystocele: protrusion of bladder downward
into vagina when support structures in
vesicovaginal septum are injured
– Rectocele is herniation of anterior rectal wall
through relaxed or ruptured vaginal fascia and
rectovaginal septum
• Urinary incontinence
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Sequelae of Childbirth Trauma
Cystocele and rectocele
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Sequelae of Childbirth Trauma
Cystocele and rectocele
101
Sequelae of
Childbirth
Trauma
Cystocele and
rectocele
102
Sequelae of Childbirth Trauma
Cystocele and rectocele
103
Sequelae of Childbirth Trauma
Cystocele and rectocele
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Sequelae of Childbirth Trauma
Cystocele and rectocele
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Sequelae of Childbirth Trauma
• Genital fistulas
– May result from congenital anomaly,
gynecologic surgery, obstetric trauma, cancer,
radiation therapy, gynecologic trauma, or
infection
• Vesicovaginal: between bladder and genital tract
• Urethrovaginal: between urethra and vagina
• Rectovaginal: between rectum or sigmoid colon
and vagina
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Types of Fistulas That May Develop
in Vagina, Uterus, and Rectum
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