47349097 Postpartum Complications

8/3/2019 47349097 Postpartum Complications

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Complications of the

Postpartum Period


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Hemmorhage

Early postpartum hemmorhage

>500 ml in first 24 hrs (blood loss often

underestimated)

Late or delayed

>500 cc after first 24 hrs.


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Predisposing factors

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


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Prevention

Risk assessment

Inspect placenta

Explore uterus

Avoid overmanipulation of uterus

If at risk type and Xmatch and start IV


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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


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Actions to take

Summon help

Check uterine tone, massage, assess effect

Elevate legs, lower head

Increase or begin O2

Increase or begin IV


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Early Postpartum Hemorrhage

Within the first 24 hrs

Causes

uterine atony

lacerations

retained secundines

coagulation problems


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Uterine atonyFailure 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


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Retained placenta or fragmentsPartial separation caused by:

pulling on the cord

uterine massage prior to separation

placenta accretaTreatment:

massage

manual removal oxytoxics

D & E


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Late postpartum hemorrhage

Hemorrhage occurring

after 24 hrs

retained placenta--necrosed, fibrin

deposits, placental

polyps,

sloughingbleeding

Symptoms

excessive or bright

red bleeding boggy fundus

large clots

backache T-P-R, BP

Treatment, massage, IV oxytocin, D&E


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Hematomas

Result from injury to a blood vessel,

usually in vagina or vulva, may extend

upward into broad ligament or otherpelvic structures

develop rapidly

may contain 300-500ml blood


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Symptoms

Severe pain

Difficulty voiding

Mass felt on vaginal exam

Flank pain

Abdominal distension Shock


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Treatment

Ice

I & D (incision and drainage)

Packing


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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


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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)


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Types of Infections

Endometritis

Parametritis

Peritonitis

Pyelonephritis

Cystitis Thrombophlebitis

Mastitis, abcess


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Predisposing Factors

Antenatal factors

poor nutrition

low SES

Hx of Infections

Anemia Immunodeficiency


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Intrapartum predisposing

factors Prolonged labor

PROM

Poor aseptic technique

Birth trauma

Multiple exams Internal monitoring

Episiotomy

C section


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Postpartum Predisposing

Factors Manual removal of placenta

Hemorrhage

Retained secundines


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Causative Organisms

Aerobic 30%

B hemolitc strep

E.coli

Klebsiella

Proteus

Pseudomonas Staph

Anerobic 70%

Bacteriodes

Peptococcus

C. perfringes


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Localized

Episiotomy

Lacerations

C section incision


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EndometritisInfection of the endometrium

placental site

decidua

cervixSymptoms--discharge (scant to profuse),

bloody, foul smelling

uterine tendernessjagged, irregular temp elevations

tachycardia, chills, subinvolution


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Salpingitis, Oopheritis

May be caused by gonorrhea, chlamidia

unilateral or bilateral abd pain

chills, fever

mass

tachycardia

may lead to sterility


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Pelvic Cellulitis, (parametritis)

Infection of the connective tissue of pelvis

frequently infecting the broad ligament

and causing severe pain.

May ascend from cervical lacerations


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Parametritis symptoms

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


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Peritonitis

Life threatening infection of the

peritoneum

Abcesses on the uterine ligaments, in thecul de sac, and/or in the

subdiaphragmatic space

May result from pelvic thrombophlebitis


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Symptoms of Peritonitis

High temp

chills

malaise

lethargy

pain

subinvolution

Tachycardia

local or referred

pain

rebound tenderness

thirst

distension

nausea and

vomiting


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Cystitis

Bladder infection

urgency

frequency

burning

dysuria

suprapubic pain

hematuria


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PyelonephritisKidney infection, usually of the R.

kidney.Ascends from bladder.

Spiking temp

Shaking chills

Flank pain, CVA pain

Nausea and vomiting

Hx of asymptomatic bacteruria orpyelonephritis

Urgency, frequency, dysuria

Back pain


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Prevention and treatment

Force fluids

Insure complete emptying of bladder

Sterile technique for cath

Good perineal care

Antibiotics


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Thrombophlebitis Blood clotassociated with bacterial infection

Etiologies

blood clotting factors

postpartal thrombocytosis (platelets)

thromboplastin release (placenta, amnion)

fibrinolysin and fibrinogen inhibitors


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Superficial

Tenderness

heat

redness low grade fever

+ homans sign

tachycardia

Treatment

elevation

heat TEDs

analgesic

bedrest?

Antibiotics?


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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


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Pulmonary Embolism

an Obstetrical emergencySymptoms--sudden onset

dyspnea

sweating pallor

cyanosis

confusion

hypertension

cough/hemoptysis

Tachycardia

SOB

Temp jugular pressur chest pain

sense of impendingdeath

pressure in

bowel/rectum


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Treatment

Call MD

O2

Demerol

Papaverine or other clot busters

Aminophylline

heparin

Streptokinase


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Disseminated Intravascular

Coagulation (DIC) prothrombin and platelets widespread formation of intravascular

clots

clotting factor expended

severe generalized hemorrhaging

Life threatening!


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Etiologies

Septic shock

placental/uterine hemmorhage

IUFD

Amniotic fluid embolism

thrombi secondary to preeclampsia

thrombi secondary to thrombophlebitis

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47349097 Postpartum Complications