Postpartum Complications. Postpartum Complications: Principles The most frequent cause of postpartum hemorrhage is uterine atony. Anything that overdistends

Postpartum Complications

Postpartum Complications: Principles

• The most frequent cause of postpartum hemorrhage is uterine atony.

• Anything that overdistends the uterus, causes it to contract poorly or overworks the uterus is a set-up for uterine atony.

Postpartum Hemorrhage

- Continues to be a leading cause of maternal morbidity and death in the US

- Can occur with little warning

- Definitions (PP lecture) * also include 10% drop in Hct between admission and postpartum

- 50% underestimation of blood loss



- Most common cause (90%) is uterine atony (marked hypotonia)

- Less common causes are retained placenta, placenta accreta, cervical/vaginal lacerations, uterine rupture

- Predisposing causes of uterine atony

* Multiparity * Hydramnios

* Macrosomic fetus * Traumatic birth

* Rapid or prolonged labor


* Use of magnesium sulfate

* Use of oxytocin

* Multiple pregnancy

- Management of uterine atony

* Manual massage of the uterus

* Expression of clots

* Eliminate bladder distention

* IV of lactated Ringer’s or normal saline with 10-40 units of oxytocin added

* Ergonovine or methyl-ergonovine (IM) if not hypertensive


- Non-adherent Retained Placenta

* May result from partial separation of the placenta or entrapment of the partially or fully separated placenta

* Treated by manual removal of the placenta

* If no epidural, nitrous oxide and oxygen inhalation


- Adherent Retained Placenta

* Unknown etiology

* Probably implantation in a defective area of endometrium

* Manual removal is unsuccessful and laceration or perforation of uterine wall may result from attempts

* Degrees of adherence

- Placenta accreta = slight penetration of myometrium


- Placenta increta = deep penetration of myometrium

- Placenta percreta = penetration to the point of perforation of the myometrium

* Treatment may indicate hysterectomy and blood replacement

- Inversion of the uterus

* Potentially life-threatening complication

* 1 in 2000-2500 births


* Partial or complete

* Contributing factors

- Fundal implantation of placenta

- Vigorous fundal pressure

- Excessive traction to cord

- Uterine atony, fibroids or abnormally adherent placenta

- Most often in multiparas with placenta accreta/increta

-


- Coagulopathies

* When bleeding continues with no identifiable source, a coagulopathy must be considered

* Coagulation status must be assessed quickly and continuously

* Abnormal results depend on the cause and may include:

- Increased prothrombin time

- Increased partial prothrombin time


- Decreased platelets

- Decreased fibrinogen level

- Increased fibrin degradation products

- Prolonged bleeding time

* Idiopathic throbocytopenia

* Von Willebrand Disease


* Disseminated intravascular coagulation (DIC)

- Diffuse and consumes large amounts of clotting factors

- Widespread external and internal bleeding

- Predisposing factors: abruptio placentae, amniotic fluid embolism, dead fetus syndrome (6 weeks), severe pre-eclampsia, septicemia, cardiopulmonary arrest, hemorrhage


* Diagnosis - Spontaneous bleeding from gums and nose

- Petechiae around blood pressure cuff

- Thromboembolic Disease

* Types

- Superficial venous thrombosis saphenous)

- Deep venous thrombosis (foot to iliofemoral region


- Pulmonary embolism (complication of DVT)

* Incidence has decreased because of early ambulation after birth

* Major causes

- Venous stasis

- Hypercoagulation

* Medical management

- Superficial – analgesic (NSAID), rest with elevation of the leg, elastic stockings


- Local application of heat may also be used

- Deep vein thrombosis – IV heparin (5-7 days), bedrest with affected leg elevated, analgesia followed by elastic stockings and oral anticoagulant therapy (warfarin) for 3 months

* Woman should be encouraged not to massage area and, when on bedrest, not to flex knees sharply

* Anticoagulant therapy for 6 months



-Pulmonary embolism

* Signs/symptoms

- Shortness of breath

- Diaphoresis

- Chest pain

- Tachycardia

* Treated with continuous IV heparin followed by intermittent subcutaneous or oral

Postpartum Infections

- Puerperal Infection (“Childbed Fever”) - Any infection of the genital canal that begins within 28 days after abortion, miscarriage or childbirth

- Definition is a fever of 38o C (100.4o F) on 2 successive days of the first 10 days postpartum (not counting 1st 24 hours after birth


- Common infections

* Endometritis

* Wound infections

* Mastitis

* UTIs

* URIs

- More common in women with concurrent medical or immunosuppressive conditions


- Also increased risk with

* A Cesarean or other operative birth

* Prolonged labor

* Prolonged rupture of membranes

* Internal fetal or uterine monitoring

- Signs/symptoms

* Endometritis

- Pelvic pain - Uterine tenderness - Foul-smelling, profuse lochia


* Wound infection

- Erythema, edema, warmth, tenderness, sero-purulent drainage wound separation

* Mastitis

- Almost always unilateral

- Develops well after milk flow established

- Usually hemolytic S. aureus


- Infected nipple fissure usually the initial lesion

- Accompanied by inflammatory edema and engorgement that obstruct milk flow in the region and generalized mastitis follows

- Chills, fever, malaise, pain

- Treated by antibiotics and emptying breasts q 2-4 hours by feeding, manual expression or pump


Postpartum Psychological Complications

- Grieving

* Normal response to loss of a child or loss of the “ideal” child

* The woman grieves the “death” of the idealized child

* May interfere with the ability to bond with the child



* Death of a baby

- Questions about what happened

- Bewilderment, resentfulness, bitterness

- Most women interested in seeing the baby and this is therapeutic

- Staff and patients, friends and relatives tend to avoid a woman whose baby has died

- Woman needs the opportunity to talk about it

Perinatal depression

* Prevalence of major and minor depression begins to rise after delivery and peaks in the 3rd month

* Postpartum “Blues”

- 50% of women have symptoms

- Peak on 5th postpartum day

- considered a normal part of early motherhood

- Go away within 10 days

- Depression

* “Blues” vs. Depression vs. Psychosis (handout)

* Blues

- Emotional lability - Feelings of sadness - Related to hormone shifts, fatigue, sleep deprivation

* Depression - Feelings continue beyond the immediate postpartal period and longer than 1 year


* Postpartum Depression

- May occur in 10% - 23% of women

- A true, major depression

- Can last into the 2nd year after delivery

- Risk factors

* Past history of depression (often bipolar)

* Depression during pregnancy

* Previous history of postpartum depression

* Life stress

* Poor social support


* History “baby blues”

* History of severe PMS

* Poor marital relationship

* Family history of postpartum depression

- Symptoms

* Feeling of sadness, extreme fatigue, inability to stop crying, anxiety about her own or the baby’s health, insecurity and psychosomatic symptoms


* Cheryl Beck (PPSS)

- “Teetering on the edge” - “Brain is full of cobwebs” - “…I have lost my self”

* Basic psychosocial problem with control

- Postpartum Psychosis

* Response to the crisis of childbearing

* Majority of these women have had symptoms of mental illness that precede the pregnancy



* Other major life crises can precipitate the same illness

* Exceptional sadness, out of touch with reality, thoughts of infanticide or that the child is possessed

* This is a psychiatric emergency and requires hospital admission

* Do not leave the woman alone and do not leave her alone with her infant

* Risks of suicide and infanticide are significant

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Postpartum Complications. Postpartum Complications: Principles The most frequent cause of postpartum hemorrhage is uterine atony. Anything that overdistends