9. complication of postpartum

Complication of postpar-tum

POSTPARTUM HEMOR-RHAGE

POSTPARTUM HEMORRHAGE

• Postpartum hemorrhage involves a loss of 500 mL or more of blood; it occurs most frequently in the first hour after delivery.

• Төрсний дараах цус харвалт гэдэг нь 500 мл буюу түүнээс дээш хэмжээний цус, бөгөөд төрсний дараа эхний нэг цагт болно.

Pathophysiology/Etiology

Early postpartum hemorrhage1. Uterine atony—relaxation of the uterus secondary to: a. Multiple pregnancy—causes overdistention of uterus

and a larger placental site b. Polyhydramnios (excessive amniotic fluid) c. High parity d. Prolonged labor with maternal exhaustion e. Deep anesthesia f. Fibromyomata—prevents uterus from contracting g. Retained placental fragments—result from manual

removal of placenta, abnormal adherent placenta (pla-centa accreta)

Early postpartum hemorrhage

2. Laceration of the vagina, cervix, or perineum secondary to:

a. Forceps delivery, especially rotation forceps

b. Large infant c. Multiple pregnancy

Clinical Manifestations

1. With uterine atony uterus is soft or boggy, often difficult to palpate, and will not remain contracted; excessive vaginal bleeding oc-curs.

2. Lacerations of the vagina, cervix, or per-ineum cause bright red, continuous bleed-ing even when the fundus is firm.

3. Hemorrhage usually occurs about the tenth postpartum day with retained placental fragments.(late postpartum hemorrhage)

Management

1. For uterine atony, oxytocin (Pitocin) or methylergonovine (Methergine) are prescribed.

2. Pain medication may be needed to counter uterine contractions.

3. If placental fragments have been re-tained, curettage of the uterus is indi-cated.

4. Lacerations may need to be repaired

Nursing Assessment

1. Assess for hypotension, tachycardia, change in respiratory rate, decrease in urine output, and change in mental status—may indicate hypov-olemic shock.

2. Assess location and firmness of uterine fundus.3. Percuss and palpate for bladder distention,

which may interfere with contracting of the uterus.

4. Monitor amount and type of bleeding or lochia present and the presence of clots.

5. Inspect for intactness of any perineal repair

Nursing Diagnoses

A. Anxiety related to unexpected blood loss and uncertainty of outcome

B. Fluid Volume Deficit related to blood loss

C. Risk for Infection related to blood loss and vaginal examinations

Nursing Interventions

A. Decreasing Anxiety1. Maintain a quiet and calm atmos-

phere.2. Provide information about the situa-

tion and explain everything as it is done; answer questions that the woman and her family ask.

3. Encourage the presence of a support person.

B. Maintaining Fluid Volume

1. Maintain or start a large-bore IV line if vaginal bleeding becomes heavy.

2. Ensure that crossmatched blood is available.

3. Infuse oxytocin, IV fluids, and blood products at prescribed rate.

4. Monitor CBC for anemia.

C. Preventing Infection

1. Maintain aseptic technique.2. Evaluate for symptoms of infection,

chilling, and elevated temperature, changes in white blood cell count, uterine tenderness, and odor of lochia.

3. Administer antibiotics as prescribed.

Patient Education/Health Maintenance

1. Educate the woman about the cause of the hemorrhage.

2. Teach the woman the importance of eating a balanced diet and taking vitamin supple-ments.

3. Advise the woman that she may feel tired and fatigued and to schedule daily rest peri-ods.

4. Advise the woman to notify her health care provider of increased bleeding or other changes in her status.

Evaluation

A. Verbalizes concerns about her well-being

B. Vital signs stable, urine output ade-quate, hematocrit stable

C. Remains afebrile, WBC count within normal limits

POSTPARTUM HEMATOMASТӨРСНИЙ ДАРААХ ЦУС ХУРАЛТ

• Postpartum hematomas are localized collections of blood in loose connec-tive tissue beneath the skin that covers the external genitalia, be-neath the vaginal mucosa, or in the broad ligaments.

Perineal hematoma


1. Trauma during spontaneous labor2. Trauma during forceps application or

delivery3. Inadequate suturing of an epi-

siotomy


1. Complaints of pressure and pain, of-ten noting that the pain is excruciat-ing

2. Discolored skin that is tight, full feel-ing, and painful to touch

3. Possible decrease in blood pressure, tachycardia

Complications

1. Hypovolemia and shock from ex-treme blood loss

2. Anemia, infection3. Increased length of postpartum re-

covery period

Management

1. Small hematomas are left to resolve on their own - ice packs may be ap-plied.

2. Large hematomas may require evacuation of the blood and ligation of the bleeding vessel.

3. Analgesics and antibiotics may be ordered (due to increased chance of infection).

Nursing Interventions/Patient Education

1. Inspect perineal and vulva area for signs of a hematoma when woman complains of pain or pressure after delivery.

2. Inspect the vaginal area for signs of a hematoma if woman is unable to void after anesthesia has worn off.

3. Monitor vital signs at least every 10 to 15 minutes and evaluate for signs of shock.

4. Relieve pain of a hematoma by applying an ice bag to perineal area, medicating with mild analgesics, and positioning for comfort to de-crease pressure on the affected area.

5. Help relieve voiding problems by assisting to bathroom to void if able to ambulate.

6. If she is unable to void, catheterize. 7. Teach the woman the importance of eating a balanced diet and to in-

clude food high in iron. 8. Encourage the woman to take vitamin supplements and to take med-

ications as ordered.

PUERPERAL INFECTION

• Puerperal infection is a postpartum infection of the genital tract, usually of the endometrium, that may re-main localized or may extend to var-ious parts of the body.


• Bacterial organisms either are introduced from external sources or are normally present in the genital tract and are carried to the uterus.

• Predisposing factors include:1. Prolonged labor or rupture of membranes (PROM)2. Number of vaginal examinations3. Infection elsewhere in the body4. Anemia, malnutrition5. Size and number of perineal lacerations6. Intrauterine manipulation7. Retained placental fragments of membranes8. Lapse in aseptic technique9. Poor perineal hygiene 10. Cesarean section


• Diagnosis is made by sustained fever of 38°C (100.4°F) or higher occurring on any two of the first 10 days post-partum, excluding the first 24 hours. Symptoms depend on site and ex-tension of infection.

Puerperal fever

Endometritis

A. Endometritis Postpartum infection involving the endometrium

1. Uterus usually larger than expected for post-delivery day.

2. Lochia may be profuse, bloody, and foul smelling.

3. Chills and fever occur if lochial discharge is obstructed by clots.

4. Infection may spread to myometrium, parametrium, uterine (fallopian) tubes, peri-toneum, and blood.

B. Parametritis

• B. Parametritis (Pelvic Cellulitis) Infection of the pelvic (connective tissue spread by the lymphatic system within the uterine wall. Often a result of an infected wound in the cervix, vagina, perineum, or lower uter-ine segment

1. Chills, fever (38.8°-40.0°C; 102°-104°F), tachycardia 2. Severe unilateral or bilateral pain in lower abdomen 3. Enlarged and tender uterus4. Uterine position may become fixed as it is displaced

by the exudate along the broad ligament.

Parametritis & peritonitis

Management

1. Aseptic technique, avoid cross infection Hand wash medical personal.2. Antibiotic therapy is instituted after cultures

are obtained and causative agent identified. 3. Supportive therapy is used to control pain

and to maintain hydration and nutritional status.

4. Drainage is indicated for abscess develop-ment.

Complications

• Thrombophlebitis may result from puerperal infection spread along the veins.

1. Femoral thrombophlebitis—appears 10 to 20 days after de-livery as pain in calf, positive Homan's sign, fever, edema

2. Pelvic thrombophlebitis a. Infection of the veins of uterine wall and broad ligament

usually caused by anaerobic streptococci b. Severe repeated chills and wide range of temperature

changes occur about 2 weeks after delivery.3. Strict bed rest, anticoagulants, and antibiotics are indi-

cated.

Thrombophlebitis & Homan’s sign


1. Perform postpartum assessment, noting uter-ine tenderness on palpation and the color, amount, and odor of lochia.

2. Monitor vital signs for signs of infection.3. Assess knowledge and skill of perineal hygiene;

teach proper technique and assist, if necessary.4. Provide for adequate rest periods. 5. Position in high Fowler's position to promote

drainage. 6. Administer antibiotics and analgesics, as or-

dered.


7. Explain the benefit of perineal washing or sitz baths and demonstrate setup.

8. Explain the need for good handwashing technique and how contamination of vagina from the rectum occurs.

9. Show how to place perineal pads and medications; encourage to change pads with each voiding, bowel movement, or every 4 hours while awake.

10. Encourage minimal separation from the infant and continuation of breast-feeding, as able.

11. Promote good handwashing technique for the mother before contact with the infant.

AMNIOTIC FLUID EM-BOLISM

• Amniotic fluid embolism is the escape of amniotic fluid containing debris such as meconium, lanugo, and vernix caseosa into the maternal circulation,

• usually resulting in deposition of fluid or debris in the pulmonary arterioles, result-ing rapidly in respiratory distress, shock, and the possible development of DIC.

• Amniotic fluid embolism is rare and usu-ally fatal.


1. The exact mechanism causing amniotic fluid em-bolism is unclear.

2. It usually occurs in the intrapartum period.3. Myometrial vessels are exposed, usually at the

placental site and contractions are especially forceful. A thromboplastin-like substance is found in amniotic fluid, which causes defibrination lead-ing to DIC.

4. Predisposing conditions include abruptio placen-tae, uterine rupture, intrauterine fetal demise, and high parity.


1. Sudden dyspnea and chest pain2. Cyanosis, tachycardia3. Pulmonary edema4. Profound shock due to: a. Anaphylaxis, which causes vascu-

lar collapse b. Uterine bleeding with development

of hypofibrinogenemia

Management

1. Endotracheal intubation2. Administration of IV crystalloid fluids3. Administration of blood products and

heparin to combat DIC4. Establishment of central venous pres-

sure line5. Immediate delivery of the fetus6. Initiation of cardiopulmonary resusci-

tation if needed

Nursing Assessment/Interventions

1. Be alert to signs and symptoms of potential amniotic fluid embolism.

2. Monitor maternal vital signs and fetal heart rate frequently to assess for signs of shock and fetal/maternal demise.

3. Administer oxygen via face mask to assist respiration status.

4. Alert medical staff immediately and assist with emergency procedures such as delivery and with the cardiopulmonary resuscitation as needed.

5. Provide information and comfort to the family or support per-sons.

If unable to do this personally due to the emergent needs of the woman, delegate another member of the staff to stay with the family or support persons.

POSTPARTUM DEPRESSION

• Postpartum depression may occur in the first 2 weeks after delivery

• Etiology: unknown, - Hormonal theory– decrease estrogen level As like as menstrual period, menopause - Psychosocial aspect; lack of support sys-

tem, unwanted baby- Cultural aspect; male dominant, favorable

sex baby

• postparum blue : a normal developmental crisis related to the adjustments that are being made relative to the new role of parent, along with the added responsibilities, fatigue, and excitement that go with the birth.

• If a woman is unable to work through her feel-ings within about 2 weeks, and the symptoms continue, a more serious depression is indicated.

• postpartum depression; social, cultural, physio-logic and psychological factors experienced may contribute to postpartum

• Postpartum psychosis; a severe form of depres-sion that occurs in a small percentage of women giving birth.


1. Exaggerated and prolonged periods of irritability, moodiness, hostility, fa-tigue

2. Ineffective coping 3. Withdrawal and inappropriate re-

sponse to the infant or family 4. Loss of interest in activities 5. Insomnia

Management

• Signs and symptoms may be overlooked, making the diagnosis of depression difficult.

• Counseling with a mental health profes-sional, medication, and continuous support from family and friends may be helpful in managing the depressed patient.

• If untreated, the woman may not fully re-cover and possibly harm the infant or oth-ers. refer to psychologist


1. Listen to the woman regarding her adjustment to role of mother and observe for any clinical manifestations suggesting depression.

2. Ask the woman about the infant's behavior. Negative statements about the infant may suggest that the woman is having difficulty coping.

3. Provide support and encourage husband, family and friends to support and assist with the infant and mother. Physical support as well as emotional support may be indicated.

5. Educate the woman that treatment may help allevi-ate her symptoms and allow her to better care for herself and infant.

Health & Medicine

9. complication of postpartum