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Post-Partum Complications

Post-Partum Complications. SG # 8 Prof. Unn Hidle Updated Spring 2010. HEMORRHAGE. HEMORRHAGE. Description : (overall category of hemorrhage) Bleeding of 500 mL or more following delivery Traditional definition vs. “new” definition: Traditional : NVD => 500cc C-section => 1000cc

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Post-Partum Complications

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  1. Post-Partum Complications SG # 8 Prof. Unn Hidle Updated Spring 2010

  2. HEMORRHAGE

  3. HEMORRHAGE • Description: (overall category of hemorrhage) • Bleeding of 500 mL or more following delivery • Traditional definition vs. “new” definition: • Traditional: • NVD => 500cc • C-section => 1000cc • “New” criteria: • Decreased Hct of 10 points OR • The need for fluid replacement afterbirth

  4. Early PP Hemorrhage • Assessment • Hemorrhage occurs during first 24 hours after delivery • >500cc of blood loss • Caused by: • retained fragments of placenta • UTERINE ATONY • 80-90% of the cases • Blood may be expelled or retained in the vagina • perineal injuries/lacerations • inversion of uterus • Episiotomy • Hematomas: vulvar, vaginal, subperitoneal • Coagulation disorders (i.e. hemophilia, thalassemia)

  5. HEMORRHAGE

  6. Predisposing factors • Multiparity • Multiple gestations • Anesthesia (relaxes the uterus) • Uterine infections • Pitocin used for induction or augmentation of labor • Trauma from forceps delivery • Malnutrition (esp. decreased Folic Acid and iron) • Anemia • PIH

  7. Most Common Causes of Hemorrhage • Residual placenta • Bleeding from placenta accreata – parts of the placenta adhers to the endometrium, in this case the chorionic villi attaches directly to the myometrium of the uterus (accounts for 80% of adherent placenta to the endometrium) • Placenta accreata may cause: • Maternal hemorrhage • Failure of the placenta to separate • Less common to bleed from placenta increta or placenta percreta (other placenta adherences) • Abdominal hysterectomy may be necessary, depending on involvement • Retained placenta: Surgical removal (D&C)

  8. Uterine Atony

  9. D&C: Dilitation & Curettage

  10. Early PP hemorrhage • Laceration of the birth canal • If there is post-partum hemorrhage and the fundus is firm, suspect laceration • Vaginal lacerations: Surgical repair • Cervical laceration: • Repair is usually accomplished by turning the cervix inside out and suturing

  11. Assessment of Early PP Hemorrhage • In what order? • Bradycardia • Tachycardia • Tachypnea with shallow respirations • Diaphoretic • Cool, clammy skin • Hypotension • Overall: signs of hypovolemic shock

  12. Treatment • Remember, this is immediately PP! • FIRST… Externally massage fundus if boggy – DON’T over-massage • Bimanual massage? • What if it is a C-section? • Oxytocin / Pitocin • PRBC transfusion or other blood products

  13. HEMORRHAGE

  14. Possible Medications • Pitocin • Methylergonivine maleate (Metergine) • Prostaglandins (PGF2a); Prostin: • Uterine stimulant – increase contraction of uterus • Most effective if hemorrhage is caused by uterine atony • Used if Pitocin is not successful

  15. Prostaglandin SE and interventions • Fever & chills: • Temp Q1-2 hours • Antipyretics • Respiratory: Wheezing, cough, bronchospasms: • Auscultate lungs and treat accordingly • CV: flushing, headaches, bradycardia, arrhythmias, increased DBP, edema: • Frequent assessment • Correct any electrolyte imbalance • ?diuretics

  16. Metabolic: Hypocalcemia, hypokalemia or hyperkalemia, hypoglycemia: • Correct electrolyte imbalance via IV • GI: N/V, diarrhea: • Antiemetic &/or antidiarrheal – pre-med. • What else is Prostaglandins used for? • Induction (PGE2) – cervical ripening

  17. Late PP Hemorrhage • Definition: • Hemorrhage occurs after the first 24 hours following delivery • Usually within 1-2 weeks after childbirth

  18. Etiology: Late PP Hemorrhage • Subinvolution of the placenta site (due to): • Retained placental fragments • Signs of subinvolution: • Fundal height is greater than expected • Makes sure the woman ambulates and empties bladder • Lochia rubra fails to progress from • RUBRA----SEROSA----ALBA • Lochia rubra that persists > 2 weeks PP is highly suggestive of subinvolution

  19. LOCHIA FLOW

  20. Other assessment • Blood loss may be excessive, but rarely poses the same risk as early PP hemorrhage • Generalized signs of SHOCK: • Early s/s of shock: • Tachycardia leading into bradycardia • Thready pulse • Shallow respirations • hypotension • Late s/s of shock: • Cool, clammy • Pale skin • “Air hunger” • May lapse into unconsciousness • Death without proper interventions

  21. Treatment • D&C: Removal of retained fragments • Fluid replacement • Possible blood transfusion • Fe supplementation • Antibiotic therapy

  22. NURSING • VS – How often? • Externally massage uterus to stimulate contractions (DON’T overmassage) • Stimulate contractions • Express any clots – gentle downward pressure • ABCs: • Assess airway and breathing • Oxygen supplementation (6-8L via mask) • Maintain O2 saturation >95%

  23. NURSING • Strict I&O • Maintain urine output >30cc/h (adult) • Possibly insert Foley catheter • Assess for need of IV fluid boluses • Monitor CVP if CVL in place • Normal 10-12 mmHg • Monitor for intravascular depletion • CBC: H/H • Observe if Hct is <30 • Transfuse if Hct is <21 • Rest

  24. INFECTION

  25. INFECTION • Description • Any infection of the reproductive organs that occurs within 28 days of delivery or abortion • Categories of Infections: • Puerperal infection: overall category • An infection of the reproductive tract associated with childbirth that occurs up to 6 weeks PP • 1) Endometritis or metritis • 2) Pelvic cellulites / Parametritis • 3) Peritonitis • 4) Salpinitis

  26. PUEPERAL INFECTIONS • Infection of the reproductive tract associated with childbirth • Occurs any time up to 6 weeks PP • Standard definition of puerperal morbidity: • Temperature =>38.0 C (100.4F) - check hospital policy • Occurring on any 2 of the first 10 PP days excluding the first 24 hours • The vagina and cervix of approximately 70% of all healthy pregnant women contain pathogenic bacteria that are sufficiently virulent to cause excessive infection • Other factors MUST be present for infection to occur • Pathogens may include: • Proteus mirabills, Pseudomonas, Clostridium, E. coli, Strep., Staph., Perfingins………..

  27. PREVENTION of infection • GOOD HYGIENE!!!!!!! • PREVENT cross-bacterial contamination! • Aseptic technique • Proper use of peri-bottle • Do not use fingers to separate labia • Limit vaginal exam to two during L&D • Masks, hats and gloves in DR • Proper nutrition • Decrease PP stress

  28. 1) ENDOMETRITIS / METRITIS • Inflammation of the endometrium 48-72 hours post-delivery • Placental site (after the expulsion of placenta) provides an excellent culture media for bacterial growth • Causative organisms: • Genital mycoplasm • Chlamydia trachomatis*

  29. Signs / Symptoms • Lochia: reddish-brown with FOUL odor (if infection caused by beta-hemolytic strep, lochia may be odorless) • Temp >100 with “high’s and lows” in terms of temperature spikes……. Chills • CBC: Elevated WBC • Tachycardia • Headaches, malaise • Anorexia • Backache • Prolonged after-pains with enlarged, tender uterus

  30. TREATMENT • HIGH FOWLER’S POSITION!!!!! • Prevent spreading • Promote drainage….. gravity • Antibiotics • Increase fluids • Oral oxytocics (increase contractions), i.e. Metergin PO • Rest • “Isolation” …… private room • STOP “direct” breastfeeding: • Preserver energy • Express milk mechanically/manually to prevent loosing production

  31. 2) PELVIC CELLULITIS / PARAMETRITIS • Infection involving the connective tissue of the broad ligament …….. OR • In more severe cases, the connective tissue of ALL the pelvic structures • Ascending infection in the pelvis by way of the LYMPHATICS in the uterine wall • May also occur if pathogenic organisms invade a CERVICAL LACERATION that extend upward = DIRECT PATHWAY INTO THE PELVIS

  32. Signs and Symptoms • High fevers: 102-104 F (39-40C) • Chills • Tachycardia • Malaise, lethargy • Abdominal pain • Subinvolution of the uterus • Local and referred rebound tenderness **

  33. Treatment • Obtain blood cultures for sensitivity • Antibiotics • Monitor fluid status: I&O • Pain management: Analgesics • HIGH FOWLER’S POSITION • I&D for abscess in cul-de-sac of Douglas to prevent rupture of fluid

  34. 3) PERITONITIS • “Infection spreading through the lymphatics” • Involves the peritoneal cavity: • Uterine ligaments • Cul-de-sac of Douglas • Subdiaphragmatic space • S/S: • ACUTELY ILL!!!!! • Severe pain, high fevers, altered respiratory status (rapid / shallow), tachycardia, excessive thirst, N/V, abdominal distension and marked anxiety • Treatment: • Same as with parametritis

  35. 4) SALPINGITIS • Tubal infection: Fallopean tubes • Always a risk of INFERTILITY as a result of occlusion of the fallopean tubes • Cause: • Ascending infection • S/S: • ACUTELY ILL!!!! ----- similar to peritonitis • Treatment: • Antibiotics • Analgesics and sedatives to promote rest • Fluid – I&O

  36. THROMBO EMBOLIC DISEASE

  37. THROMBOPHLEBITIS • Thrombus = clot • Phlebitis = inflammation of the wall of a vein • Inflammation of a vein with clot formation • Usually firmly attached to vessel wall • Thrombophlebites versus phleothrombosis

  38. Thrombophlebitis: • INFLAMMATORY • Thrombus formed secondary to inflammation of the vein wall • More firmly attached (decreased risk of “traveling”) • No embolism (only if in pelvis) • Phleothrombosis= venous thrombosis • NON-INFLAMMATORY • Clot formed by venous stasis • More loosely attached (increased risk of “traveling”) • Increased risk for embolism

  39. Increased risk with: • DIC • Anemia • Existing varicose veins ---- venous stasis • Increased blood clotting factors • Thrombocytosis: Increased platelets (viscous) • Release of thromboplastin: from the tissue of the decidua placenta and fetal membranes • Increased amounts of fibrinolysis inhibitors

  40. Risks (continued) • Increased maternal age >30 years • Obesity • Multiparity • Endometritis • Anesthesia and surgery with trauma to vessels • Existing cardiac disease • (Previously: estrogen for supression of lactation)

  41. Different types: • Superficial Thrombophlebitis • Femoral Thrombophlebitis • Pelvic Thrombophlebitis

  42. Superficial Thrombophlebitis • More common PP than during pregnancy • Clot often involves the smaller saphenous veins • Common in women with pre-existing varicose veins • S/S: Usually present after 3-4 days PP • Tenderness and pain in the affected lower extremity • Positive Homan sign • Warm and pinkish-red color over thrombus area • Palpable thrombus that feels bumpy and hard • Slightly elevated pulse rate • Temperature normal to low grade fever

  43. Superficial Thrombophlebitis

  44. Treatment: • Local heat • Elevate affected leg • Bedrest, analgesics • Ted stocking or venodyne boots • Yes, verified that even with thrombus they are used!!!!! • Usually NOT anticoagulant unless complications develop (remember, embolism is EXTREMELY RARE) • Occasionally the involved veins have incompetent valves and as a result, the problem may spread to the deeper leg veins such as the femoral vein……….

  45. Femoral & pelvic thrombophlebitis • Included in the overall category DVT • More frequently seen in women with history of thrombosis • Obstetrical complications (hydramnios, PIH and C/S are putting women at risk

  46. Signs and symptoms: Depends on the vein involved • Femoral: • Chills and fever • Malaise • Pain, stiffness, and swelling of the affected leg • Shiny, white skin over the affected area • Homans’ sign is usually NEGATIVE but in some cases may be positive (depending on the vein involved) • Diminished peripheral pulses • Popliteal: • Pain in popliteal and lateral tibial area

  47. Anterior and posterior tibial veins: • Pain in ENTIRE lower leg and foot • Iliofemoral veins: • Pain in LOWER ABDOMEN • OVERALL s/s: • Fever is usually LOW GRADE • Homan sign is USUALLY NEGATIVE but may in some cases be positive. Pain is often the result from calf pressure • Pale and cool limb to touch due to reflex arterial spasm: • Referred to as “MILK LEG” or “PHLEGMASIA ALBA DOLENS” • Peripheral pulses decreased

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