post delivery problems Flashcards
postpartum hemorrhage
defined as blood loss requiring transfusion or a 10% decrease in hematocrit btw admission and postpartum period
what is the 3rd leading cause of maternal mortalicty in advanced gestational age?
postpartum hemorrhage
what are causes of post partum hemorrhage?
MC: uterine atony (unable to contract to stop the bleeding
also: Uterine Rupture, Cervical or Vaginal Tears, Placenta Accreta, Congestion, Bleeding Disorder, Disseminated Intravascular Coagulation
what are RF for spontaneous rupture of the uterus
grand multiparity, malpresentation, previous uterine surgery, and oxytocin induction of labor (rupture of c sect scar in vag delivery)
what are rf for hemorrhage?
rapid or prolonged labor, overdistended uterus, c section
what is early PP hemorrhage?
occurs less than 24 hrs after delivery
what problems are associated with early hemor?
abnormal involution of placental site, cervical or vaginal lacerations, retained portions of the uterus
what is late postpartum hemo?
after 24 hrs to 6 wks postpartume,
what mcommonly causes late pp hemorrhage?
subinvolution of uterus, retained products of conception, endometritis
s/sx of pp hemorrhage
Hypovolemic Shock → Hypotension, tachycardia, pale/clammy scale, decreased capillary refill
Uterine Atony → Soft, boggy uterus with dilated cervix
may have foul smelling lochia
dx studies for pp hemo
CBC to evaluate hemoglobin & hematocrit
US may detect the bleeding source
management of pp hemo
initially: uterine massage and compression
Suction & Curettage → May be needed if there is retained products
Antibiotics in some case
what is first line medical management of pp hemo?
Oxytocin IV, Methylergonovine, Prostaglandin Agents (IM Carboprost tromethamine, Misoprostol) → These agents enhance uterine contractions & are only used if the uterus is soft & boggy
what does a subinvolution uterus respond to?
oral agents like methylergonovine maleate, or ergonovine maleate
what causes almost 20 % of pp hemorrhages?
Excessive bleeding from an episiotomy, lacerations, or both
uterus, cervix, vagina, or vulva
what do you need to watch for after perineal lacerations?
hematomas → Bleeding is concealed and can be particularly dangerous because it may go unrecognized for several hours and become apparent only when shock occurs
what sx may suggest a laceration or bleeding from epsiotomy
Persistent bleeding (especially bright red) and a well-contracted, firm uterus
episiotomy infection s/sx
Pain at episiotomy site = Most common symptom → Spontaneous drainage frequent so a mass rarely forms
Incontinence of flatus & stool may be presenting sx of episiotomy that breaks down & heals spontaneously
Inspection of the episiotomy site shows disruption of wound & gaping of incision → Necrotic membrane may cover wound → Should be debrided if possible
rectovaginal fistula has formed
Integrity of the anal sphincter should be evaluated
tx of perineal lacerations
Warm sitz baths or Hubbard tank treatments help debridement process.
Attempts to close an infected, disrupted episiotomy are likely to fail and may make ultimate closure more difficult
Surgical closure by perineorrhaphy should be undertaken only after granulation tissue has thoroughly covered the wound site
endometritis
infxn of uterine endometrium
what is chorioamnionitis
fetal membrane infxt
when is endometritis most common
after c section or when membranes ruptured more than 24 hrs before delivery
etiology of endometritis?
polymicrobial
mc: anaerobic streptococci
when do s/sx of endometritis most commonly occur
2-3 days postpartum
s/sx of endometritis
\+ever (>38°C/100.4°F), tachycardia, abdominal pain & uterine tenderness after C-section, 2-3 days postpartum or postabortal (may present later) \+adnexal tnderness \+Mainly clinical diagnosis \+May have vaginal bleeding/discharge \+May have foul smelling lochia
dx studies of endometritis
WBC >20000
UA
tx of endometritis post c-section
Clindamycin + Gentamicin → May add Ampicillin for additional GBS coverage → Ampicillin/Sulbactam = Alternative
tx of endometritis ppoast vag delivery or chorioamniontis
amp + genta
what can be used for endometritis prophylaxis
1st Generation Cephalosporin x 1 dose during C-section to reduce the incidence
post-partum depression
major depression 2 wks-12 mnhts PP
pp blues onset
2-4 days
duration of pp bludes
resolves w/in 10 days
s/sx of pp blues
Mild insomnia, anhedonia, fatigue, depressed mood, irritability
No thoughts of harming baby
tx of pp blues
non, self limited
pp depression
2 wks to 2 mnths pp
duration of pp depression
3-14 mnths
s/sx of pp depresion
Irritability, sleep & mood disturbances, eating changes, anxiety
May have thoughts of harming baby
tx for pp depression
+/- antidepresants
PP of endometritis
Prolonged rupture of membranes (> 24 hrs), chorioamniotis, too many digital vag exams, prolonged labor, toxemia, c section esp if he of BV, anemia, poor nutrition, low socioeconomic status, coitus near term
S/Sx of endometritis
Fever, soft tender ut,
Lochia +/- foul odor, WBC
More severe: high fever, malaise, abd tenderness. Ileus, hypotension, generalized sepsis
Diminished bowel sounds, +/- abd distentionbe
What is early fever (w/in hours of deliver) and hypotension pathognomic for infxn?
With B hemolytic streptococci
Complications of endometritis
Tubo-ovarian abscess
Labs for endometritis
CBC
Bacteremia- mycoplasma and bactericides predominant
UA
Lochia cultures
Tx of endometritis
IV abx
Clinda+ amino (genta)
Ampicillin
IV abx continued until or afebrile for 24 hours
Ddx endometritis
Uti, pna,
What if fever continues w/ endometritis after tx?
Further eval for abscess, hematomas, wound infxn, septic pelvic thrombophlebitis
