MODULE 11: High - Risk Postpartum Conditions Flashcards
A woman with a postpartum complication is at risk from three points of view
a. Her own health
b. Her future child-bearing potential
c. Her ability to bond with her new infant
Postpartum Complications
Most postpartum complications are preventable, and if they do occur, the majority can be treated effectively
Who are at risk for Postpartum Complications
a. Conditions that distend the uterus beyond the average capacity.
b. Conditions that could have caused cervical/ uterine lacerations
c. Conditions with varied placental site or attachment
d. Conditions that leave the uterus unable to contract readily
e. Conditions that lead to inadequate blood coagulation
Postpartum Hemorrhage
a. Loss of more than 500 ml of blood at the time of delivery or immediately after
b. One of the most important causes of maternal mortality
c. A major potential danger in the immediate postpartum period
d. May occur either:
- Early- within 24 hours.
- Late- anytime after the 1st 24 hours during the remaining days of the 6-week puerperium
Early Postpartum Hemorrhage
a. Uterine atony
b. Lacerations
c. Perineal Hematomas
d. Disseminated Intravascular Coagulation
Late Postpartum Hemorrhage
a. Retained Placental Fragments
b. Subinvolution
Uterine Atony
a. Relaxation of the uterus due to the loss of muscle tone
b. The most common cause of postpartum hemorrhage.
c. Uterine Atony allows hemorrhage to flow into the uterus
Uterus remain in a contracted state
Allow the open vessels at the placental site to seal
Uterine Atony
Poor uterine tone > Inability to maintain a contracted state > “boggy” uterus & large amounts of dark red blood with clots
Predisposing Factors
a. Multiple gestation
b. Large baby ( >9 lbs.)
c. Polyhydramnios
d. Inhalation of anesthesia
e. Prolonged labor with maternal exhaustion
Laceration of the Birth Canal
a. Small lacerations or tears of the birth canal are common
- Large lacerations are considered as complication
b. It may occur either cervical, vaginal or perineal area
c. Firm uterus but with steady trickle of bright red blood (arterial) are the indications of laceration
Classifications of Perineal Laceration
a. First degree
- Vaginal mucous membrane, skin of perineum to the fourchette
b. Second degree
- Vagina, perineal skin, fascia, levator ani muscle, perennial body
c. Third degree
- Entire perineum extending to reach the external sphincter of the rectum
d. Fourth degree
- Entire perineum, rectal sphincter, some of the mucous membrane of the rectum
Predisposing Factors
a. Primigravidas
b. Difficult or precipitate births
c. Birth of large infant
d. Use of a lithotomy position
e. Operative birth
f. Rapid birth
Cervical Laceration
This is difficult to repair because bleeding can be so intense that it obstructs the visualization
Vaginal Laceration
Since vaginal tissue is friable, lacerations are hard to repair
Perineal Laceration
Perineal lacerations are easily treated
Perineal Hematoma
a. Localized collections of the blood in loose connective tissue beneath the skin that covers
- The external genitalia
- Beneath the vaginal mucosa
- The broad ligaments
b. Usually occurs without lacerations of the overlying tissue
c. Commonly found in perineal and vaginal area
Predisposing Factors: Perineal Hematomas
a. Trauma during
- Spontaneous birth
- Forceps application or delivery
b. Inadequate suturing of an episiotomy
c. Delayed homeostasis or difficult or prolonged second stage of labor or both
Clinical Manifestation: Perineal Hematoma’s
a. Complaints of pressure and excruciating pain in the perineal area
b. Discolored skin that is tight, full feeling and painful to touch
- This may be the first sign to be observed
c. Decrease or absence of lochia flow in the vagina is impeded
Late Postpartum Hemorrhage: Retained Placental Fragments
a. Incomplete expulsion of the placenta
b. The main cause of late postpartum hemorrhage
c. This usually happens with a succenturiate placenta (placenta with
an accessory lobe) or placenta accreta (placenta fuses with the
myometrium).
- Ultrasound is done to check retained ‘pf’
Clinical Manifestation
a. Slow, reddish oozing (6th-10th postpartum day)
b. Positive hCG blood serum sample
d. Not fully contracted uterus
d. Abdominal pain or tenderness
e. Low persistent backache
Subinvolution
a. Failure of the uterus to revert to through gradual reduction in size and placement
b. It may be caused by:
○ Infection
○ Tumors in the uterus
○ Mild endometritis
Clinical Manifestation: Subinvolution
a. Uterus remains enlarged
b. Fundus in higher in the abdomen than anticipated
c. Lochia does not progress from rubra to serosa to alba
d. If caused by infection: possible leukorrhea & backache
Postpartum Infection
a. Any infection of the reproductive tract, usually occurring within 10 days of birth
b. Second leading cause of maternal mortality
c. The most common cause is polymicrobial ascent
d. The main pathway for spread of infection is the broad ligament
Predisposing Factors: Postpartum Infection
a. Prolonged rupture of membranes
b. Cesarean birth
c. Trauma during birth process
d. Poor perineal hygiene
e. Retained placental fragments
Endometritis
a. Infection of the endometrium (lining of the uterus)
b. Bacteria gains access to the uterus through the vagina either at the time of birth or during the postpartum period c. It may occur with any birth but it is associated with chorioamnionitis and cesarean birth
Clinical Manifestation: Endometritis
a. Fever (occurs on the 3rd and 4th postpartum day)
○ Increase oral temperature to more than (38.C) for 2 consecutive 24-hour periods.
b. Chills
c. Dark brown lochia with foul odor
d. Loss of appetite
e. General malaise
f. Uterus not well contracted & painful to touch
Infection of the Perineum
A woman with a suture line on her perineum is a greater risk of acquiring infection of the perineum since it is the portal of entry for bacterial invasion
Clinical Manifestation: Urinary Tract infection
a. Pain in the suprapubic area or at costovertebral angle
b. Fever
b. Burning, urgency, frequency on urination
d. Increased WBC count & hematuria e.
e. Urine Culture (+) for causative organism ○ To know appropriate antibiotics to be given
Urinary Tract Infection
It may be caused by:
○ Coliform bacteria
○ Coupled with bladder trauma during delivery
○ Break in technique during catheterization → Bacteria may be introduced into the bladder
Clinical Manifestations: Mastitis
a. Redness, tenderness, or hardened area in the breast (usually unilateral)
b. Chills
c. Malaise
d. Elevated temp and heart rate
e. Breast milk becomes scan
Clinical Manifestations: Infection of the Perineum
a. Manifested with s/sx of Suture line infection:
○ Pain on the infected area
○ The area is warm to touch
○ Feeling of pressure
● May or may not have an elevated temperature (depending the spread of infection)
● Inflammation on the suture line
● Presence of purulent drainage on the area of the suture line
Mastitis
a. Known as the infection of the breast. b. Causative organism usually hemolytic S. aureus
c. Frequently caused by cracked & fissured nipple due to improper latching
d. If untreated, may result in breast abscess
Thrombophlebitis
a. Inflammation of the lining of a blood vessel with the formation of blood clots.
b. It is classified as or that might occur after delivery: Femoral Thrombophlebitis, Pelvic Thrombophlebitis & Pulmonary Embolism.
Predisposing Factors: Thrombophlebitis
a. Obese & overweight mothers
b. History of varicose veins
c. History of thrombophlebitis
d. 30 years of age with increased parity e. (+) Family History of thrombophlebitis
Ankle Brachial Sign
a. Measure the ankle and brachial pressure
b. Get the systolic brachial pressure and systolic ankle pressure
c. If SBP = 120/80 and SAP = 100/80 → 120/100= 1.2 (ABI)
d. ABI of 1.0-1.4 is normal
e. ABI of 0.9-1.0 is borderline
Clinical Manifestation: Thrombophlebitis
a. Pain/discomfort in area of thrombus (legs, pelvis, chest)
b. If in the leg: pain, edema, redness over affected area.
c. Elevated temperature & chills d. Decreased peripheral pulses
d. (+) Homan’s sign
e. If in a deep vein: leg may be cool and pale
Pulmonary Embolism
a. This is a MEDICAL EMERGENCY
○ Sudden sharp chest pain
○ Tachypnea ○ Tachycardia
○ Orthopnea (inability to breathe except in upright position)
○ Cyanosis
Homan’s Sign
a. Assessment through dorsiflexion
b. First support the patient’s thigh with one hand and his foot with the other. Bend his leg slightly at the knee, and then firmly and abruptly dorsiflex the ankle. Resulting deep calf pain indicates a positive homans sign (the patient may also resist ankle dorsiflexion or flex the knee involuntarily if Positive.)
c. Ask first if there is pain: if there is pain, do not execute (automatic POSITIVE for Homan’s sign)
d. After dorsiflexion: ○ If bumagsak yung foot - negative ○ If nag stay as flexed - positive
Postpartum Psychiatric Disorders
a. 85% of women experience some type of mood disturbances that are the result of high hormonal fluctuations that occur during and immediately after birth
b. 10% to 15% of women develop more significant symptoms of depression or anxiety
c. Women with a prior history of postpartum psychiatric disorders have a 50% chance of recurrence
Categories of Postpartum Psychiatric Disorders
a. Postpartum Blues
b. Postpartum Depression
c. Postpartum Psychosis
Causes of Postpartum Psychiatric Disorders
a. The causes are not quite clear but research suggest that the following factors may contribute to the onset of illness:
○ Hormonal Imbalances
○ Life stresses
○ Situational Risks (condition of life- maybe related to loss of job/lack of finances)
Predisposing Factors: Postpartum Psychiatric Disorder
a. Prenatal or previous depression
b. Prenatal or previous psychosis or bipolar or schizophrenia
c. Life stress
d. Lack of social support
e. Marital dissatisfaction
f. Hsiotry of sexual abuse
g. Traumatic birth experience
h. High expectation of birth/parenting
i. Unwanted pregnancy
j. Physical problems with the baby k. Problems with health providers
Postpartum Blues
a. Unpleasant feeling of the mother following childbirth
b. Occurs 3-5 days after delivery
c. Lasts up to 2 weeks after delivery 50% to 85% of women experience postpartum blues (80% of primigravidas)
d. Do not interfere with woman’s ability to function
Clinical Manifestation: Postpartum Blues
a. Mood swings
b. Sadness
c. Irritability
d. Crying
e. Decreased Concentration
f. Trouble sleeping
Clinical Manifestations: Postpartum Depression
a. Lack of joy in life
b. Feelings of shame, guilt, or inadequacy
c. Severe mood swings
d. Loss of appetite
e. Difficulty bonding with the baby
f. Insomnia
g. Withdrawal from family and friends
Postpartum Depression
a. A major form of depression and is less common and more intense than postpartum blues
b. Occur in approximately 10% to 20% of new mothers
c. May develop as a result of pre-existing depression which worsens after birth (due to hormonal imbalances)
d. It may occur entirely out of the blue
e. Happens anytime after giving birth and lasts up to 1 year or longer
f. It affects the ability of care fo the baby as well as the handling of other daily activities
Postpartum Psychosis
a. An episode of bipolar illness (Manic episodes)
b. Most severe and rarest form of postpartum depression
c. It occurs in approximately 1 to 2 per 1000 women
d. First to two weeks after childbirth
e. Characterized by a loss of contact with reality for extended periods of time.
f. This is a psychiatric as well as a medical emergency and requires immediate treatment
g. 5% suicide rate and a 4% infanticide rate
h. Confusion and disorientation
i. Auditory Hallucinations and delusions j. Paranoia
k. Rapidly shifting depressed or elated mood
l. Illogical thoughts
m/.Periods of delirium or mania
m. Suicidal or homicidal thoughts
