Complications of the Postpartum Period

1. Complications of the Postpartum Period

2. Hemmorhage • Early postpartum hemmorhage • >500 ml in first 24 hrs (blood loss often underestimated) • Late or delayed • >500 cc after first 24 hrs.

3. 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

4. Prevention • Risk assessment • Inspect placenta • Explore uterus • Avoid overmanipulation of uterus • If at risk type and Xmatch and start IV

5. 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

6. Actions to take • Summon help • Check uterine tone, massage, assess effect • Elevate legs, lower head • Increase or begin O2 • Increase or begin IV

7. Early Postpartum Hemorrhage Within the first 24 hrs • Causes • uterine atony • lacerations • retained secundines • coagulation problems

8. 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

9. 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

10. 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 Late postpartum hemorrhage Treatment, massage, IV oxytocin, D&E

11. 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

12. Symptoms • Severe pain • Difficulty voiding • Mass felt on vaginal exam • Flank pain • Abdominal distension • Shock

13. Treatment • Ice • I & D (incision and drainage) • Packing

14. 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

15. 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)

16. Types of Infections • Endometritis • Parametritis • Peritonitis • Pyelonephritis • Cystitis • Thrombophlebitis • Mastitis, abcess

17. Predisposing Factors Antenatal factors • poor nutrition • low SES • Hx of Infections • Anemia • Immunodeficiency

18. Intrapartum predisposing factors • Prolonged labor • PROM • Poor aseptic technique • Birth trauma • Multiple exams • Internal monitoring • Episiotomy • C section

19. Postpartum Predisposing Factors • Manual removal of placenta • Hemorrhage • Retained secundines

20. Aerobic 30% B hemolitc strep E.coli Klebsiella Proteus Pseudomonas Staph Anerobic 70% Bacteriodes Peptococcus C. perfringes Causative Organisms

21. Localized • Episiotomy • Lacerations • C section incision

22. 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

23. Salpingitis, Oopheritis May be caused by gonorrhea, chlamidia • unilateral or bilateral abd pain • chills, fever • mass • tachycardia • may lead to sterility

24. Pelvic Cellulitis, (parametritis) Infection of the connective tissue of pelvis • frequently infecting the broad ligament and causing severe pain. • May ascend from cervical lacerations

25. 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

26. 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

27. High temp chills malaise lethargy pain subinvolution Tachycardia local or referred pain rebound tenderness thirst distension nausea and vomiting Symptoms of Peritonitis

28. Cystitis Bladder infection • urgency • frequency • burning • dysuria • suprapubic pain • hematuria

29. 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

30. Prevention and treatment • Force fluids • Insure complete emptying of bladder • Sterile technique for cath • Good perineal care • Antibiotics

31. Thrombophlebitis Blood clot associated with bacterial infection Etiologies •  blood clotting factors • postpartal thrombocytosis (platelets) • thromboplastin release (placenta, amnion) • fibrinolysin and fibrinogen inhibitors

32. Tenderness heat redness low grade fever + homans sign tachycardia Treatment elevation heat TEDs analgesic bedrest? Antibiotics? Superficial

33. 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

34. 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

35. Treatment • Call MD • O2 • Demerol • Papaverine or other “clot busters” • Aminophylline • heparin • Streptokinase

36. Disseminated Intravascular Coagulation (DIC) •  prothrombin and platelets • widespread formation of intravascular clots • clotting factor expended • severe generalized hemorrhaging Life threatening!

37. Etiologies • Septic shock • placental/uterine hemmorhage • IUFD • Amniotic fluid embolism • thrombi secondary to preeclampsia • thrombi secondary to thrombophlebitis

38. Early signs of DIC •  protime •  fibrinogen • thrombocytopenia • bleeding from gums • bleeding from puncture sites • ecchymosis Treatment complex, packed cells, fibrinogen, whole blood, plasma