Postpartum Complications Flashcards
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
- Assessed by EBL or QBL (preferred)
- Use QBL for a perinatal woman with a hemorrhage
- We weigh the amount of blood and the clots
Postpartum Hemorrhage
Remains a major cause of maternal morbidity and mortality worldwide
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* 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
Late Postpartum Hemorrhage
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Occurs within the first 24 hours > delivery (within 1st hour of birth)
Cumulative blood loss of 1000 mL or greater
Early Postpartum Hemorrhage
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
Management
* Measures to contract the uterus
* Provide fluid replacement
> Help offset any blood and volume loss that’s occurring
Uterine Atony - Risk Factors
- Overdistention of uterus in pregnancy
- Polyhydramnios
- Multifetal pregnancies
- LGA fetuses
- Multiparity
- Obesity
- Prolonged labor
- Precipitous labor
- If induced or augmented with Oxytocin
- If there’s placental fragment retention
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
Management
* Repairing the trauma before extensive blood loss occurs [surgical repair = with a hematoma → evacuation (suctioning clot out of the tissues)]
* Visualization of lacerations
- 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)
- Signs of hypovolemia but the fundus is firm because blood loss is occurring elsewhere
- Hematomas often go undetected
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
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]
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
* 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)
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
metabolic acidosis
Signs & Symptoms
* Tachycardia
* Hypotension
* Increased respiratory rate
* Pale, cool, clammy skin
* Changes in mental status (anxiety → confusion → lethargy)
* Urine output decreases
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
___ 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
Oxytocin
Methergine
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
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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
Uterine subinvolution
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
Methergine
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
Thromboembolic disorders
* Thrombus
* Thrombophlebitis
* Embolus
* Superficial Venous Thrombosis
* Deep Venous Thrombosis
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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
Deep Venous Thrombosis
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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
Thrombus
thrombus; thrombophlebitis
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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
Superficial Venous Thrombosis (SVT)
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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
Embolus
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)
Venous stasis
* Compression of the large vessels of the legs happening by the enlarging uterus
- Blood flow poor and blood “stuck” within the veins
Hypercoagulation
* Factors that prevent clot formation are decreased and factors that promote clot formation that’re increased (throughout pregnancy)
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
- 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
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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
Pulmonary Embolism
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
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
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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
Puerperal Infection
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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
Endometritis
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
* Can affect the abdomen as a whole → peritonitis
* Use Fowler’s position to promote drainage of lochia
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
* 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
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
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
mastitis
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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
Septic pelvic thrombophlebitis
Affective Disorders
* Peripartum Depression
* Postpartum Blues
* Postpartum Depression
* Postpartum Psychosis
* Bipolar II Disorder
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Is a fluctuation between extremes of mood
Bipolar II Disorder
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Is a more rare condition; a psychiatric emergency condition requiring hospitalization
Agitation, irritability, infanticide/suicide
Postpartum Psychosis
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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
Peripartum depression
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)
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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
Posttraumatic Stress Disorder (PTSD)
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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
Postpartum Obsessive Compulsive Disorder (OCD)
