Transcript Complications of the Postpartum Period

Complications of the
Postpartum Period
Hemmorhage
• Early postpartum hemmorhage
– >500 ml in first 24 hrs (blood loss often
underestimated)
• Late or delayed
– >500 cc after first 24 hrs.
Predisposing factors
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Uterine overdistension--large infant,etc.
Grand multiparity
Anesthesia or MgSO4
Trauma
Abnormal labor pattern--hypo or hypertonia
Oxytocin during labor
Prolonged labor
Hx of maternal anemia, hemorrhage
Prevention
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Risk assessment
Inspect placenta
Explore uterus
Avoid overmanipulation of uterus
If at risk type and Xmatch and start IV
Signs of Impending
Hemorrhage
• Excessive bleeding (>2pads/30min-1hr)
• Light headedness, nausea, visual
disturbances
• Anxiety, pale/ashen color, clammy skin
• Increasing P and R, BP same or lower
Actions to take
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Summon help
Check uterine tone, massage, assess effect
Elevate legs, lower head
Increase or begin O2
Increase or begin IV
Early Postpartum Hemorrhage
Within the first 24 hrs
• Causes
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uterine atony
lacerations
retained secundines
coagulation problems
Uterine atony
Failure of the uterus to stay firmly contracted
• Slow, steady or massive hemorrhage,
sometimes underestimated or hidden behind
a clot
• VS may not change immediately
Treatment
• bimanual massage
• oxytoxics
• curretage
• surgery iliac ligation or hysterectomy
Retained placenta or fragments
Partial separation caused by:
• pulling on the cord
• uterine massage prior to separation
• placenta accreta
Treatment:
• massage
• manual removal
• oxytoxics
• D&E
Late postpartum hemorrhage
Hemorrhage occurring
after 24 hrs
• retained placenta-necrosed, fibrin
deposits, placental
polyps,
sloughingbleeding
Symptoms
• excessive or bright
red bleeding
• boggy fundus
• large clots
• backache
• T-P-R, BP
Treatment, massage, IV oxytocin, D&E
Hematomas
Result from injury to a blood vessel,
usually in vagina or vulva, may extend
upward into broad ligament or other
pelvic structures
• develop rapidly
• may contain 300-500ml blood
Symptoms
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Severe pain
Difficulty voiding
Mass felt on vaginal exam
Flank pain
Abdominal distension
Shock
Treatment
• Ice
• I & D (incision and drainage)
• Packing
Subinvolution
Uterus remains large, does not involute
Causes, retained placental fragments, infection
Symptoms:
• Lochia fails to progress
• Returns to rubra
• Leukorrhea with backache and infection
Treatment:
• methergine
• curretage
• antibiotics
Puerperal Infection
Definition:
Temp of 101o or more in the first 24 hrs
following delivery
Temp of 1004 or higher on any 2 of the
first10 pp days (with the exception of the
first 24 hrs)
Types of Infections
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Endometritis
Parametritis
Peritonitis
Pyelonephritis
Cystitis
Thrombophlebitis
Mastitis, abcess
Predisposing Factors
Antenatal factors
• poor nutrition
• low SES
• Hx of Infections
• Anemia
• Immunodeficiency
Intrapartum predisposing
factors
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Prolonged labor
PROM
Poor aseptic technique
Birth trauma
Multiple exams
Internal monitoring
Episiotomy
C section
Postpartum Predisposing
Factors
• Manual removal of placenta
• Hemorrhage
• Retained secundines
Causative Organisms
Aerobic 30%
• B hemolitc strep
• E.coli
• Klebsiella
• Proteus
• Pseudomonas
• Staph
Anerobic 70%
• Bacteriodes
• Peptococcus
• C. perfringes
Localized
• Episiotomy
• Lacerations
• C section incision
Endometritis
Infection of the endometrium
• placental site
• decidua
• cervix
Symptoms--discharge (scant to profuse),
bloody, foul smelling
uterine tenderness
jagged, irregular temp elevations
tachycardia, chills, subinvolution
Salpingitis, Oopheritis
May be caused by gonorrhea, chlamidia
• unilateral or bilateral abd pain
• chills, fever
• mass
• tachycardia
• may lead to sterility
Pelvic Cellulitis, (parametritis)
Infection of the connective tissue of pelvis
• frequently infecting the broad ligament
and causing severe pain.
• May ascend from cervical lacerations
Parametritis symptoms
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Spiking temp to 104
chills, flushing, sweating
tachycardia, tachypnea
uterine tenderness, cramping
change in LOC/agitation,delerium,
disorientation
• change in lochia
• cervical or uterine tenderness on vag
exam
• WBC elevation
Peritonitis
Life threatening infection of the
peritoneum
• Abcesses on the uterine ligaments, in the
cul de sac, and/or in the
subdiaphragmatic space
• May result from pelvic thrombophlebitis
Symptoms of Peritonitis
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High temp
chills
malaise
lethargy
pain
subinvolution
• Tachycardia
• local or referred
pain
• rebound tenderness
• thirst
• distension
• nausea and
vomiting
Cystitis
Bladder infection
• urgency
• frequency
• burning
• dysuria
• suprapubic pain
• hematuria
Pyelonephritis
Kidney infection, usually of the R.
kidney.Ascends from bladder.
•Spiking temp
•Shaking chills
•Flank pain, CVA pain
•Nausea and vomiting
•Hx of asymptomatic bacteruria or
pyelonephritis
•Urgency, frequency, dysuria
•Back pain
Prevention and treatment
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Force fluids
Insure complete emptying of bladder
Sterile technique for cath
Good perineal care
Antibiotics
Thrombophlebitis Blood clot
associated with bacterial infection
Etiologies
•  blood clotting factors
• postpartal thrombocytosis (platelets)
• thromboplastin release (placenta, amnion)
• fibrinolysin and fibrinogen inhibitors
Superficial
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Tenderness
heat
redness
low grade fever
+ homans sign
tachycardia
Treatment
• elevation
• heat
• TEDs
• analgesic
• bedrest?
• Antibiotics?
Deep Vein Thrombosis
Symptoms
• edema
• low grade fever
• chills
• pain in limb below
affected area
• “milk leg”
• decreased peripheral
pulses
Dx--doppler
Tx:
• heparin to coumadin
• antibiotics
• TEDs
• bedrest
• elevation
• analgesics
Pulmonary Embolism
an Obstetrical emergency
Symptoms--sudden onset
• dyspnea
• sweating
• pallor
• cyanosis
• confusion
• hypertension
• cough/hemoptysis
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Tachycardia
SOB
 Temp
 jugular pressur
chest pain
sense of impending
death
• pressure in
bowel/rectum
Treatment
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Call MD
O2
Demerol
Papaverine or other “clot busters”
Aminophylline
heparin
Streptokinase
Disseminated Intravascular
Coagulation (DIC)
•  prothrombin and platelets
• widespread formation of intravascular
clots
• clotting factor expended
• severe generalized hemorrhaging
Life threatening!
Etiologies
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Septic shock
placental/uterine hemmorhage
IUFD
Amniotic fluid embolism
thrombi secondary to preeclampsia
thrombi secondary to thrombophlebitis
Early signs of DIC
•  protime
•  fibrinogen
• thrombocytopenia
• bleeding from gums
• bleeding from puncture sites
• ecchymosis
Treatment complex, packed cells,
fibrinogen, whole blood, plasma