Chapter 28: Postpartum Maternal Complications Flashcards
What are the most common postpartum complications?
- Hemorrhage
- Thromboembolic disorders
- Infection
- Postpartum mood and anxiety disorders
Postpartum hemorrhage is defined as
- Blood loss of >500 mL after vaginal birth and >1000 mL after c-section.
- Decreased hematocrit of > 10% since admission.
Early Postpartum Hemorrhage occurs
- Within the first 24 hours after birth.
- Common during the first hour after delivery.
Late Postapartum Hemorrhage occurs
After 24 hours or up to 6-12 weeks after birth.
What is the main cause of early postpartum hemorrhage?
-Uterine atony
What are other causes of early postpartum hemorrhage?**
- Trauma to birth canal during labor and delivery
- Hematoma
- Retention of placental fragments
- Abnormalities of coagulation
Uterine Atony
Lack of muscle tone -> failure of the uterine muscle fibers to contract firmly around the blood vessels when the placenta separates.
Relaxed uterine muscles can lead to
Rapid bleeding of endometrial arteries at the placental site.
What are predisposing factors for uterine atony?
- Overdistention of uterus (i.e multiple gestation, a large infant, hydramnios)
- Multiparity (muscle fibers that have been stretched)
- Intrapartum factors
What are intrapartum factors that predispose a women to uterine atony?
· Barely effective contractions = prolonged labor
· Excessively vigorous contractions = precipitate labor.
· Labor that was induced or augmented with oxytocin
· Retention of a large segment of the placenta
What are clinical manifestations of early postpartum hemorrhage?
o A uterine fundus that is difficult to locate
o A soft or “boggy” feel when the fundus is located
o A uterus that becomes firm as it is massaged but loses its tone when massage is stopped
o A fundus that is located above the expected level
o Excessive lochia, especially if it is bright red
o Excessive clots expelled
What are normal findings of the uterus for the first 24 hours after childbirth?
- Uterus should feel like a firmly contracted ball roughly the size of a large grapefruit.
- Should be easily located at about the level of the umbilicus.
- Lochia should be dark red and moderate in amount.
Saturation of one peripad with lochia in 15 minutes =
Excessive loss of blood
A constant, steady trickle or slow seeping of lochia
Is just as dangerous as the saturation of one peripad in 15 minutes.
Non-Pharmacologic Interventions for Early Postpartum Hemorrhage
- If uterus is not firmly contracted, first intervention is to massage the fundus until firm in order to express cots that may have accumulated in uterus.**
- Empty bladder
How can an accumulation of clots in the uterus cause a postpartum hemorrhage?
It interferes with the ability of the uterus to contract effectively.
How are clots expressed from the uterus?
- By applying firm but gentle pressure on the fundus in the direction of the vagina.
- Critical that the uterus is contracted before attempting to express clots.
Pushing on an un-contracted uterus could
Invert the uterus and cause massive hemorrhage and rapid shock.
Why is emptying the bladder an important intervention in postpartum hemorrhage?
A full bladder lifts the uterus, moving it up and to the side, preventing effective contraction of the uterine muscles.
What are pharmacological measures for early postpartum hemorrhage?
- Rapid IV of dilute oxytocin (pitocin)
- If oxytocin isn’t effective, prostaglandin F20 is used.
- Methylergonovine (Methergine)
- Misoprostol (Cytotec) or Prostin E2 (Dinoprostone)
Methylergonovine (Methergine): Contraindications
Elevates blood pressure and should not be given in women who are hypertensive.
What can be done to treat postpartum hemorrhage uterine massage and pharmacological measures are ineffective?
- Physician or nurse-midwife may use bimanual compression of the uterus to stop the bleeding. (One hand is inserted into the vagina and the other compresses the uterus through the abdominal wall)
- Balloon may be inserted into the uterus to apply pressure against uterine surface to stop the bleeding.
- Uterine packing may also be used.
- May be necessary to return woman to delivery area for exploration of uterine cavity and removal of placental fragments that interfere with uterine contraction.
What is the last resort treatment for a woman with an uncontrollable postpartum hemorrhage?
Hysterectomy
Fluid Replacement in Early Postpartum Hemorrhage
-LR
-Whole blood
-Packed RBC
-Normal Saline
-Plasma extenders
Need enough fluid to maintain a UO: 30-60 ml/hr.
Early Postpartum Hemorrhage: Trauma
- Second most common cause of early postpartum hemorrhage.
- Can include vaginal, cervical or perineal lacerations as well as hematomas.
What are predisposing factors for trauma in early postpartum hemorrhage?
- Many of the same factors that increase the risk of uterine atony increase the risk of soft tissue trauma during childbirth.
- Induction and augmentation of labor and use of assistive devices such as a vacuum extractor.
What are types of trauma associated with early postpartum hemorrhage?
Lacerations
Hematomas
What are the most common sites for lacerations associated with early postpartum hemorrhage?
Vagina
Perineum
Cervix
Around urethral meatus
When do lacerations usually occur?
During the second stage of labor.
Lacerations of the birth canal should always be suspected if
- Excessive uterine bleeding continues when the fundus is contracted firmly and is at the expected location.
- Color is bright red (lochia is usually dark red)
- Bleeding is heavy or may appear to be minor with a steady trickle of blood that continues.
Hematomas
Occurs when bleeding into loose connective tissue occurs while overlying tissue remains intact.
Hematomas develop as a result of
- blood vessel injury in spontaneous deliveries
- deliveries in which vacuum extractors or forceps are used.
Hematomas may be found in what areas?
Vulvar, vagina and retroperitoneal
The rapid bleeding into soft tissue may cause a
Visible vulvar hematoma; a discolored bulging mass that is sensitive to the touch.
Hematomas in the vagina or retroperitoneal areas
Cannot be seen
Pain associated with hematomas
Produces deep, severe, unrelieved pain and feelings of pressure that are not relieved by usual pain-relief measures.
Formation of a hematoma should also be suspected if**
The mother demonstrates systemic signs of concealed blood loss such as tachycardia or decreasing blood pressure when the fundus is firm and lochia is within normal limits.
What is the therapeutic management for trauma associated with early postpartum hemorrhage?
- Surgical repair is often necessary. (D/t difficult visualizing lacerations of the vagina or cervix)
- Small hematomas usual reabsorb naturally.
- Large hematomas may require incision, evacuation of the clots and location of the bleeding so that it can be ligated.
Common causes of late postpartum hemorrhage are
- Subinvolution
- Retention of placental fragments
- Infection of the uterus
Subinvolution
Delayed return of the uterus to its non pregnant size and consistency.
How can retention of placental fragments lead to late postpartum hemorrhage?
Clots form around the retain fragments, and excessive bleeding can occur when the clots slough away several days after delivery.
How is retention of placental fragments preventable?
Nurse-midwife or Physical carefully inspects the placenta to determine whether it is intact. If a portion of the placenta is missing, the HCP manually explores the uterus, locates the missing fragments and removes them.
What are predisposing factors for retention of placental fragments?
➢ Manual removal of placenta
➢ Placenta Accreta (abnormal adherence of the placenta to the uterine wall)
➢ Previous C-section
➢ Uterine Leiomyomas
Therapeutic Management of Late Postpartum Hemorrhage
- Is directed toward the control of excessive bleeding.
- Include pharmacological measures
Pharmacological measures for late postpartum hemorrhage
- Oxytocin
- Methylergonovine
- Prostaglandins
- Broad spectrum antibiotics (if postpartum infection is suspected)
What can be used to identify placental fragments that remain in the uterus?
Sonography
Bleeding is considered heavy if
Saturation of 1 pad/hr
Bleeding is considered excessive if
Saturation of 1 pad/15 min
What are nursing implications for abnormal S&S of lochia?
- Assess for trauma
- Save and weigh pads, linen savers, and bed linens so estimation of blood loss is more accurate.
Abnormal UO
< 30 ml/hr
Abnormal skin findings
Cool, damp, pale
If the skin is cool, damp and pale, the nurse should
- Look for signs of hypovolemia
- Assessment and management nay entire health care team is necessary.