Transcript Mosby`s EMT-Basic Textbook

Chapter 23
Postpartum Complications
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
1 of 34
Postpartum Hemorrhage

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
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
2 of 34
Postpartum Hemorrhage

Etiology and risk factors

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
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
3 of 34
Postpartum Hemorrhage

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

Retained placenta
• Nondherent retained placenta – managed by manual
separation and removal by the primary care provider
• Adherent retained placenta – may be caused by
implantation into defective endometrium
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
4 of 34
Postpartum Hemorrhage

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)
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
5 of 34
Postpartum Hemorrhage

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
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
6 of 34
Postpartum Hemorrhage

Subinvolution of uterus – delayed
involution of the uterus

Usually see late post partum bleeding

Causes include retained placental fragments
and infection
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
7 of 34
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
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
8 of 34
Care Management

Plan of care and implementation

Initial treatment – fundal massage, expression
of clots, relief of bladder distension, IV fluids

Medications – Table 25-1

Medical management
• Hypotonic uterus – examine for retained placental
fragments, medications, surgical interventions
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
9 of 34
Care Management

Medical management – cont.
• 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
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
10 of 34
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
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
11 of 34
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
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
12 of 34
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
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
13 of 34
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
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
14 of 34
Thromboembolic Disease


Medical management

Superficial – analgesia, rest/elevation, TED hose

Deep – anticoagulant therapy, bedrest/elevation,
TED hose

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!!
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
15 of 34
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

Mastitis
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
16 of 34
Care Management

Prevention is the best intervention

Hand washing

Good maternal perineal hygiene

Antibiotic administration

Wound management

Breast care
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
17 of 34
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
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
18 of 34
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
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
19 of 34
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
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
20 of 34
Types of Fistulas That May Develop
in Vagina, Uterus, and Rectum
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
21 of 34
Postpartum Psychologic Complications

Mental health disorders in postpartum
period have implications for mother,
newborn, and entire family

Interfere with attachment to newborn and
family integration

May threaten safety and well-being of mother,
newborn, and other children
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
22 of 34
Postpartum Psychologic Complications

Postpartum depression without psychotic
features

PPD: an intense and pervasive sadness with
severe and labile mood swings

Treatment options
• Antidepressants, anxiolytic agents, and
electroconvulsive therapy
• Psychotherapy focuses fears and concerns of new
responsibilities and roles, and monitoring for
suicidal or homicidal thoughts
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
23 of 34
Postpartum Psychologic Complications

Postpartum depression with psychotic
features

Postpartum psychosis: syndrome
characterized by depression, delusions, and
thoughts of harming either infant or herself

Psychiatric emergency, and may require
psychiatric hospitalization

Antipsychotics and mood stabilizers such as
lithium are treatments of choice
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
24 of 34
Loss and Grief

Losses of what was hoped for, dreamed
about, and/or planned

Any perception of loss of control during
the birthing experience

Birth of a child with handicap

Maternal death

Fetal or neonatal death
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
25 of 34
Loss and Grief


Conceptual model of parental grief

Acute distress

Intense grief

Reorganization
Anticipatory grief
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
26 of 34
Loss and Grief

Plan of care and implementation

Communicating and care techniques
• Actualize the loss
• Provide time to grieve
• Interpret normal feelings
• Allow for individual differences
• Cultural and spiritual needs of parents
• Physical comfort
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
27 of 34
Loss and Grief

Plan of care and implementation

Options for parents
• Seeing and holding
• Bathing and dressing
• Privacy
• Visitations: other family members or friends
• Religious rituals/funeral arrangements
• Special memories
• Pictures
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
28 of 34
Maternal Death

Rare for woman to die in childbirth

Families are at risk for developing
complicated bereavement and altered
parenting of surviving baby and other
children in family

Referral to social services can help
combat potential problems before they
develop
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
29 of 34
Key Points

Postpartum hemorrhage is most common
and serious type of excessive obstetric
blood loss

Hemorrhagic (hypovolemic) shock is an
emergency situation; the perfusion of
body organs may become severely
compromised and death may ensue

Potential hazards of therapeutic
interventions may further compromise the
woman with hemorrhagic disorders
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
30 of 34
Key Points

Postpartum infection is a major cause of
maternal morbidity and mortality

Postpartum urinary tract infections are
common because of trauma experienced
during labor

Breast infection affects about 1% of
women soon after childbirth
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
31 of 34
Key Points

Structural disorders of uterus and vagina
related to pelvic relaxation are often the
delayed but direct result of childbearing

Understanding of grief responses and
bereavement process is fundamental to
the nursing process

Therapeutic communication and
counseling techniques can help families in
identifying their feelings and in feeling
comfortable in expressing their grief
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
32 of 34
Key Points

Follow-up after discharge is an essential
component in providing care to families
who have experienced a loss

Nurses need to be aware of their own
feelings of grief and loss to provide a
nonjudgmental environment of care and
support for bereaved families
Mosby items and derived items © 2006, 2002 by Mosby, Inc.
33 of 34