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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. Uterine overdistension--large infant,etc. Grand multiparity Anesthesia or MgSO 4
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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.
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
Prevention • 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 • 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 • 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
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 Late postpartum hemorrhage 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 • 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 • Endometritis • Parametritis • Peritonitis • Pyelonephritis • Cystitis • Thrombophlebitis • Mastitis, abcess
Predisposing Factors Antenatal factors • poor nutrition • low SES • Hx of Infections • Anemia • Immunodeficiency
Intrapartum predisposing factors • 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
Aerobic 30% B hemolitc strep E.coli Klebsiella Proteus Pseudomonas Staph Anerobic 70% Bacteriodes Peptococcus C. perfringes Causative Organisms
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 • 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
High temp chills malaise lethargy pain subinvolution Tachycardia local or referred pain rebound tenderness thirst distension nausea and vomiting Symptoms of Peritonitis
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 • 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
Tenderness heat redness low grade fever + homans sign tachycardia Treatment elevation heat TEDs analgesic bedrest? Antibiotics? Superficial
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 Deep Vein Thrombosis
Symptoms--sudden onset dyspnea sweating pallor cyanosis confusion hypertension cough/hemoptysis Tachycardia SOB Temp jugular pressur chest pain sense of impending death pressure in bowel/rectum Pulmonary Embolisman Obstetrical emergency
Treatment • 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 • 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