Postpartum Complications

Question 1

Postpartum Hemorrhage (PPH)

Complications that do occur during the postpartum period can be life-threatening

PPH is a major cause of maternal death and morbidity worldwide

Answer 1

• Assessed by EBL or QBL (preferred)
• Use QBL for a perinatal woman with a hemorrhage
• We weigh the amount of blood and the clots

Question 2

Postpartum Hemorrhage

Remains a major cause of maternal morbidity and mortality worldwide

?

* From 24 hours after birth up to 6 weeks postpartum

* Subinvolution of the uterus

* Retained placental fragments
- 1. Uterus can’t contract effectively; 2. and is keeping flow of blood from mother to what was baby, open
- Assess the placenta to make sure no pieces remaining
- Provider does a manual exploration (give a broad-spectrum antibiotic after)
- We could also suspect that a PPH is happening because of an infection
> Think infection as the cause? Because of uterine tenderness, foul-smelling lochia associated or if mother has a fever
- May need to go to the OR; perform a D&C

Answer 2

Late Postpartum Hemorrhage

Question 3

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Occurs within the first 24 hours > delivery (within 1st hour of birth)

Cumulative blood loss of 1000 mL or greater

Answer 3

Early Postpartum Hemorrhage

Question 4

PPH: Uterine Atony [relaxed uterus]

Manifestations

* Fundus is difficult to locate

* “Boggy fundus” - soft, blends in with abdominal tissues

* Fundus firms with massage (but doesn’t stay firm)

* Excessive lochia and clots

Answer 4

Management

* Measures to contract the uterus

* Provide fluid replacement
> Help offset any blood and volume loss that’s occurring

Question 5

Uterine Atony - Risk Factors

• Overdistention of uterus in pregnancy
• Polyhydramnios
• Multifetal pregnancies
• LGA fetuses
• Multiparity
• Obesity
• Prolonged labor

Answer 5

• Precipitous labor
• If induced or augmented with Oxytocin
• If there’s placental fragment retention

Question 6

PPH: Trauma

Soft tissue trauma (2nd most common cause of early PPH) [trauma to the birth canal]

* May cause postpartum hemorrhage

* Lacerations of the birth canal

* Hematomas - can be vaginal, vulvar, or retroperitoneal

Answer 6

Management

* Repairing the trauma before extensive blood loss occurs [surgical repair = with a hematoma → evacuation (suctioning clot out of the tissues)]

* Visualization of lacerations

Question 7

• See vaginal, cervical, perineal lacerations
• We can’t visualize a vaginal or retroperitoneal hematoma (vulvar we can)
• Woman experiences deep, severe, unrelieved pain and often reports a sensation of pressure (there is a pooling of blood growing in tissues where it doesn’t belong)

Answer 7

• Signs of hypovolemia but the fundus is firm because blood loss is occurring elsewhere
• Hematomas often go undetected

Question 8

PPH: Predisposing Factors

Overdistension of the uterus / multiparity / precipitate labor or delivery / prolonged labor

Operative vaginal delivery [one that puts at highest risk of hematoma] / Cesarean birth / manual removal of placenta / uterine inversion

Answer 8

Placenta previa, accreta, or low implantation / medications (tocolytics, mag sulfate) / general anesthesia / chorioamnionitis

Clotting disorders / previous PPH or uterine surgery / DIC / uterine leiomyomas (fibroids) [are typically at the fundus and impair the uterus’ ability to contract appropriately]

Question 9

Hypovolemic Shock

Women can tolerate blood loss near that of blood that was added during pregnancy

Manifestations

Therapeutic Management

Nursing Considerations
* Response plan in place
* Review events after

Answer 9

* Locate source of bleeding to stop the loss of blood

* Be prepared on the unit = PPH cart

* Identify those with risk factors

* Provide prophylactic rx’s and checks (maybe checking the fundus a little more than we normally would)

Question 10

Can typically tolerate 1500-2000 mL blood loss

Normal vaginal blood loss is 500 mL or less and Cesarean is 1000 mL or less

* This blood loss deprives the vital organs of O2 which leads mother into ___, eventually circulating volume is inefficient to perfuse cardiac and brain tissue which leads to anoxia which results in maternal death

Answer 10

metabolic acidosis

Question 11

Signs & Symptoms

* Tachycardia
* Hypotension
* Increased respiratory rate
* Pale, cool, clammy skin
* Changes in mental status (anxiety → confusion → lethargy)
* Urine output decreases

Question 12

Interventions for Hemorrhage

Preventing Hemorrhage

Collaboration with the Provider
* Uterine massage (to express any clots in the uterus; we cannot push unless the uterus is contracted because it increases the risk of uterine inversion, increasing the risk of hemorrhage and chance of hypovolemic shock)

* Check bladder for distention and empty if full

* Laboratory studies

* Administer fluids and medications

Question 13

___ is given prophylactically in all births to prevent PPH (* refer to page 384)

___ as a 2nd choice rx
* Can’t give this to patients who have a hypertensive disorder, if pre-eclamptic, gestational htn, chronic htn, or BP readings hypertensive

Answer 13

Oxytocin

Methergine

Question 14

Misoprostol can be given bucally or rectally

Carboprost Tromethamine - “Hemabate” - can give directly into the uterine muscle

> See this in C-sections

* Don’t give to asthmatic patients [as can cause acute bronchoconstriction] and give as a last choice because a side effect is excessive diarrhea

Question 15

?

A slower than expected return of the uterus to its nonpregnant size and consistency

* Happens from a full bladder, retained placental fragments, or pelvic infection

Answer 15

Uterine subinvolution

Question 16

Therapeutic Management

Can give ___ orally (will provide long, sustained contractions of the uterus)

If an infection is the cause, it’ll respond to antibiotic therapy

Answer 16

Methergine

Question 17

Nursing Considerations

* Not usually noticeable until > discharge

* Educate mom on how to palpate her fundus, how to locate it, and for her to know where it should be

* Have her contact the HCP if there’s an abnormality

Question 18

Thromboembolic disorders

* Thrombus

* Thrombophlebitis

* Embolus

* Superficial Venous Thrombosis

* Deep Venous Thrombosis

Question 19

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Can occur from the foot to the ileofemoral region

Predisposes someone to a PE

Evaluate entire leg

Homan’s sign not really used anymore

Use US for evaluation

Provide anticoagulation therapy as needed

Use of compression boots and get patient up and walking

Answer 19

Deep Venous Thrombosis

Question 20

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Is a collection of blood factors (primarily platelets and fibrin) on a vessel wall

When a vessel wall develops an inflammatory response to the ___, ___ occurs and this further occludes the vessel

Answer 20

Thrombus

thrombus; thrombophlebitis

Question 21

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Is associated with varicose veins

Limited to the calf area and can see swelling, redness, tenderness, and warmth

Might even palpate an enlarged, hardened, or cord-like vein

Treat with analgesics, rest, elastic support (is superficial); use warm packs, encourage elevation, provide anti-inflammatory rx’s

Answer 21

Superficial Venous Thrombosis (SVT)

Question 22

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Is a mass composed of a thrombus and this could also be composed of amniotic fluid

Can obstruct the capillary beds in another part of the body and we typically see this in the lungs in the postpartum period
* Be on the lookout for PE

Answer 22

Embolus

Question 23

Thromboembolic Disorders

* During pregnancy and in the immediate postpartum period there is a high risk of blood clot formation

Major causes

* Venous stasis

* Hypercoagulation

* Blood vessel injury (includes any vascular damage)

Question 24

Venous stasis

* Compression of the large vessels of the legs happening by the enlarging uterus

• Blood flow poor and blood “stuck” within the veins

Answer 24

Hypercoagulation

* Factors that prevent clot formation are decreased and factors that promote clot formation that’re increased (throughout pregnancy)

Question 25

Factors Increasing Thrombosis Risk \* Inactivity or bed rest [main] - Cesarean birth related to prolonged time in bed and decreased movement - Sepsis - Smoking - History of previous thrombosis - Varicose veins - Diabetes mellitus - Trauma - Prolonged labor

Answer 25

- Prolonged time in stirrups during second stage - Maternal age \>35 - Increased parity - Dehydration - Family history (first-degree) - Use of forceps - Antiphospholipid antibody syndrome - Inherited thrombophilias - Air travel

Question 26

? Serious complication of deep vein thrombosis (DVT) Can lead to maternal morbidity and mortality Anaphylactoid syndrome Death may occur within minutes Fragments of a blood clot dislodge and get carried to the lungs where they block the pulmonary artery

Answer 26

Pulmonary Embolism

Question 27

Anaphylactoid syndrome is smiliar to PE Have parts of the amniotic fluid (e.g. vernix) that are traveling to the lungs and block off the vessels Dissolve the clot and maintain pulmonary circulation Get orders from the provider We may provide O₂, narcotic analgesics, have patient on bedrest

Answer 27

Watch for S/S: changes in RR, assessing breath sounds, showing signs of "air hunger", a dyspnea, tachycardia, pallor, cyanosis O₂ at 8-10 L/min via tight face mask Patient may need ICU level of care

Question 28

? Are bacterial infections that can occur \> childbirth Can happen anytime from rupture of membranes to up to 42 days \> childbirth \* Endometritis \* Wound infections \* Urinary tract infection \* Mastitis \* Septic pelvic thrombophlebitis

Answer 28

Puerperal Infection

Question 29

? Is an infection of muscle in the lower lining of the uterus More common post C-section Fever, chills, malaise, anorexia, abdominal pain, cramping, uterine tenderness, purulent foul-smelling lochia, tachycardia, also may be subinvolution of the uterus occurring

Answer 29

Endometritis

Question 30

Endometritis \* Treatments with IV antibiotics like cephalosporins, clindamycin, gentamycin, or ampicillin \* Give prophylactic antibiotics before skin incision occurs \* If spreads outside the uterus, could affect the ovaries and fallopian tubes and can lead to sterility

Answer 30

\* Can affect the abdomen as a whole → peritonitis \* Use Fowler's position to promote drainage of lochia

Question 31

Wound Infections \* C-sections, episiotomy, or women who sustain lacerations at birth Risk factors - obesity, diabetes, hemorrhage, anemia, chorioamnionitis, corticosteroid therapy, multiple vaginal exams \* See edema, warmth, erythema, tenderness and pain; edges of wound may pull apart; may see seropurulent drainage

Answer 31

\* If untreated, can lead to generalized signs of infection \* May need an incision and drainage of the affected area \* Start on broad-spectrum antibiotics \* Will require women to be readmitted for care

Question 32

Urinary tract infection (UTI) \* Urinary stasis is common after birth; an increased risk of cystitis or pyelonephritis \* S/S: dysuria, urgency, frequency, suprapubic pain, hematuria, low-grade fever \* Give oral antibiotics and analgesics: [common] phenazopyridine = pyridium \> Will turn urine bright orange \* Oral intake 2500-3000 mL/day; dilute out the urine \* Educate on UTI prevention

Question 33

Specific for the postpartum woman = ___ - an infection of the breast \* Common in first 12 weeks after childbirth but can happen anytime during breastfeeding Common causative agent - S. aureus Enters through an injured area of the breast Flu-like symptoms; systemic Axillary lymph node enlargement If untreated, can progress to a breast abscess Prescribe antibiotic therapy and continue to breastfeed or at least pump

Answer 33

mastitis

Question 34

? Is the least common of the puerperal infections Is essentially a thrombophlebitis that develops along the pelvic venous system Abdomen, groin or flank pain Fever, tachycardia, GI distress, decreased bowel sounds \* Does not respond to antibiotic therapy and have to give anticoagulation Require readmission to hospital

Answer 34

Septic pelvic thrombophlebitis

Question 35

Affective Disorders \* Peripartum Depression \* Postpartum Blues \* Postpartum Depression \* Postpartum Psychosis \* Bipolar II Disorder

Question 36

? Is a fluctuation between extremes of mood

Answer 36

Bipolar II Disorder

Question 37

? Is a more rare condition; a psychiatric emergency condition requiring hospitalization Agitation, irritability, infanticide/suicide

Answer 37

Postpartum Psychosis

Question 38

? Could occur during pregnancy or in the postpartum period At least 2 weeks of depressed mood or loss of interest in almost all activities Need to meet 4 of the below criteria; - Changes in appetite or weight - Sleep - Psychomotor activity - Decreased energy - Feelings of worthlessness or guilt - Difficulty thinking, concentrating, or making decisions Can develop in pregnancy or 12 months following birth Fathers can suffer too Treatment includes SSRI's or tricyclic antidepressants

Answer 38

Peripartum depression

Question 39

Anxiety Disorders Panic Disorder \* Tachycardia, palpitations, shortness of breath, chest pain \* Fear of dying \* Repetitive episodes Postpartum Obsessive Compulsive Disorder (OCD) Posttraumatic Stress Disorder (PTSD)

Question 40

? A condition in which childbirth is perceived as a traumatic event Involves nightmares and flashbacks Is important to talk about the experience and how it was perceived

Answer 40

Posttraumatic Stress Disorder (PTSD)

Question 41

? A condition in which the mother is consumed with thoughts of harm occurring to the baby CBT and/or pharmacological methods can be used as treatment

Answer 41

Postpartum Obsessive Compulsive Disorder (OCD)