Postpartum Complications Flashcards
1st degree laceration
Tear limited to fourchette, superficial skin, or vaginal mucosa
2nd degree laceration
Extends to perineal muscles and fascia
Spares anal sphincter
3rd degree laceration
Tear includes anal sphincter
4th degree laceration
Tear extends into rectal mucosa
Laceration risk factors
Operative vaginal birth - forceps, vacuum
Cephalopelvic disproportion
Macrosomia
Abnormal presentation/position
Prolonged pressure on vaginal mucosa from fetal head
Prior scarring of birth canal from infection, injury, operation
Laceration complication
Infection
Hemorrhage
Pain
Elimination disturbances/incontinence
What might be a clue that a laceration is present?
Vaginal bleeding even though uterus is firm and contracted
Postpartum hemorrhage
OB emergency following vaginal or C/S delivery
Early - hemorrhage in first 24 hrs
Late - hemorrhage after 24 hrs up to 12 weeks
PP hemorrhage diagnosis
Cumulative blood loss >1000 mL
OR
Blood loss w/ signs/sx of hypovolemia w/in 24 hrs after birth
Causes of early PP hemorrhage
Atony Hematoma Retained tissue Lacerations Coagulation defects Distended bladder
PP hemorrhage risk factors
Grand multiparity (5+ births) Overdistention of uterus - LGA, macrosomia, twins, polyhydramnios Rapid, prolonged labor Retained placenta Placenta previa Abruptio placentae Drugs - tocolytics, Mg sulfate, general anesthesia, prolonged oxytocin use Operative procedures - C/S, vacuum, forceps Uterine fibroids Hx of PP hemorrhage Coagulation defects Hx of hemorrhage
Management of Immediate PP hemorrhage
Uterine massage
Removal of retained tissue/clots
Meds
Monitor for signs of hypovolemic shock
Meds for subinvolution/PP hemorrhage
Pitocin 10-20 units IM or IV
Misoprostol (Cytotec) 800 mcg rectal
Methergine 0.2 mg IM - avoid in HTN
Hemabate 250 mcg IM - caution w/ asthma; potential significant diarrhea
Hematomas
Collection of clotted blood within tissues appearing as bulging, bluish mass in pelvic region, vagina, or broad ligament
Hematoma causes
Bleeding lacerations
Injury to blood vessel in absence of lac/incision
Hematoma expected findings
Pain, pressure, difficulty voiding
Hematoma risk factors
Nulliparous Macrosomia/LGA Preeclampsia Prolonged second stage of labor Multifetal Vulvar varicosities Clotting disorders
Hematoma treatment
Conservative measures
Surgery
Arterial embolization
3 common thromboembolisms in PP
Superficial venous thrombophlebitis
DVT
PE
Common DVT sx
Pain in leg or groin
Swelling of leg, erythema, heat, tenderness
DVT Diagnosis
Venous US, Doppler flow analysis, MRI
DVT prevention
Prophylactic heparin if high risk
Early ambulation
Avoid pillows under knees
SCD, stockings
DVT Risk factors
Pregnancy C/S Operative vaginal birth PE, varicosities Immobility Obesity Smoking Multiparity Age >35 Hx of VTE
PE sx
Dyspnea, chest pain, tachycardia, tachypnea, hemoptysis, low pulse ox
PE nursing interventions
Frequent RR & VS assessment Auscultate breath sounds Call for help Admin O2 at 8-20 L/min via tight face mask Raise head of bed Narcotic analgesics for pain IV access
Thrombophlebitis nursing interventions
Bed rest Elevate extremity above level of heart Frequent position changes Intermittent/continuous moist heat NO massage of affected area Measure leg circumferences Thigh-high antiembolism stockings Administer analgesics Administer anticoagulants for DVT
Patient education on anticoagulants
Avoid aspirin, ibuprofen Use electric razor for shaving Avoid alcohol (warfarin) Brush teeth gently Avoid rubbing/massaging legs Avoid periods of prolonged sitting/crossing legs
Two week PP visit
C/S patients - check steri-strips
All other birthing persons w/ access
Mental Health Assessment
6 week PP visit
H&P
Assessments - Brain/Blues, Breast/Bottle, Bottom, Bleeding, Bladder, Bowel, Baby, Birth Control
Labs - diabetes screen, Hgb
6 week PP visit - physical exam
Physical survey Palpate thyroid Breast exam Abdomen - resolution of diastasis? Perineum Bimanual exam - pelvic floor muscles, cervix closure, complete involution Speculum exam if needed, f/u Pap? Possible rectal exam
Postpartum Infections
Endometritis, Mastitis, Wound infections, UTI
Endometritis
Infection of uterus, most common, usually beginning on day 3-4 PP beginning at placental attachment site and spreading
Wound infection sites
C/S, episiotomies, lacs, trauma wounds
Mastitis
Infection of breast, usually unilateral; can progress to abscess if untreated
Endometritis risk factors
Prolonged labor Prolonged ROM Multiple cervical exams Internal fetal or uterine monitoring Large amount of meconium in amniotic fluid Manual placenta removal Low SES Maternal DM, severe anemia PTB BV Operative vaginal delivery Postterm pregnancy HIV infection GBS colonization
Endometritis signs/sx
Appear ‘sick’ - fever, chills, malaise, abdominal pain/tenderness/cramping, uterine tenderness, purulent, malodorous lochia, fatigue, loss of appetite
Endometritis treatment
IV broad-spectrum abx initially - penicillins, cephalosporins, clindamycin, gentamicin
Comfort measures
Mastitis signs/sx
Preceded by engorgement, stasis of milk
‘Flu-like’ - fever, chills, achiness, headache, localized lump, wedge-shaped area of pain, redness, heat, inflammation, enlarged axillary LNs, tender, palpable hard region
Mastitis complication
Abscess
Mastitis risk factors
Milk stasis Nipple trauma Poor breastfeeding technique Decrease in feeding frequency Contamination of breasts due to poor hygiene
Mastitis treatment
PO abx
Heat/cold application
Analgesics
Continue feeding on both sides! (milk is not infected)
UTI PP risk factors
Postpartal hypotonic bladder or urethra Epidural anesthesia Urinary bladder catheterization Frequent pelvic exams Genital tract injuries Hx of UTIs C/S birth
UTI complication
Pyelonephritis w/ permanent kidney damage –> renal failure
UTI signs/sx
Urgency, frequency, dysuria, pelvic discomfort Fever, chills, malaise VS changes Urinary retention Pain in suprapubic region CVA tenderness
UTI diagnosis
Urinalysis - WBC, RBC, protein, bacteria
UTI treatment
PO abx Maintain hydration Proper perineal care Frequent urination Acetaminophen for pain
Wound infection signs/sx
Fever, redness, swelling around incision, drainage/bleeding, abdominal pain, pain at incision site, not approximated/dehiscence
Wound infection management
Office visit - potential I&D, culture
Abx prescribed
Analgesics for pain
Warm compresses, sitz baths
Painful intercourse management
Vaginal dryness (low E2), lac, episiotomy
Use lubricant, E2 therapy
If persists past 3 months, refer to gynecology or PT
