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Complications of the Postpartum Period

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Complications of the Postpartum Period Hemmorhage Early postpartum hemmorhage 500 ml in first 24 hrs (blood loss often underestimated) Late or delayed 500 cc after ... – PowerPoint PPT presentation

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Title: Complications of the Postpartum Period


1
Complications of the Postpartum Period
2
Hemmorhage
  • Early postpartum hemmorhage
  • gt500 ml in first 24 hrs (blood loss often
    underestimated)
  • Late or delayed
  • gt500 cc after first 24 hrs.

3
Predisposing factors
  • Uterine overdistension--large infant,etc.
  • Grand multiparity
  • Anesthesia or MgSO4
  • Trauma
  • Abnormal labor pattern--hypo or hypertonia
  • Oxytocin during labor
  • Prolonged labor
  • Hx of maternal anemia, hemorrhage

4
Prevention
  • Risk assessment
  • Inspect placenta
  • Explore uterus
  • Avoid overmanipulation of uterus
  • If at risk type and Xmatch and start IV

5
Signs of Impending Hemorrhage
  • Excessive bleeding (gt2pads/30min-1hr)
  • Light headedness, nausea, visual disturbances
  • Anxiety, pale/ashen color, clammy skin
  • Increasing P and R, BP same or lower

6
Actions to take
  • Summon help
  • Check uterine tone, massage, assess effect
  • Elevate legs, lower head
  • Increase or begin O2
  • Increase or begin IV

7
Early Postpartum Hemorrhage
  • Within the first 24 hrs
  • Causes
  • uterine atony
  • lacerations
  • retained secundines
  • coagulation problems

8
Uterine atony
  • Failure of the uterus to stay firmly contracted
  • Slow, steady or massive hemorrhage, sometimes
    underestimated or hidden behind a clot
  • VS may not change immediately
  • Treatment
  • bimanual massage
  • oxytoxics
  • curretage
  • surgery iliac ligation or hysterectomy

9
Retained placenta or fragments
  • Partial separation caused by
  • pulling on the cord
  • uterine massage prior to separation
  • placenta accreta
  • Treatment
  • massage
  • manual removal
  • oxytoxics
  • D E

10
Late postpartum hemorrhage
  • Hemorrhage occurring after 24 hrs
  • retained placenta--necrosed, fibrin deposits,
    placental polyps, sloughing?bleeding
  • Symptoms
  • excessive or bright red bleeding
  • boggy fundus
  • large clots
  • backache
  • ?T-P-R, ?BP

Treatment, massage, IV oxytocin, DE
11
Hematomas
  • Result from injury to a blood vessel, usually in
    vagina or vulva, may extend upward into broad
    ligament or other pelvic structures
  • develop rapidly
  • may contain 300-500ml blood

12
Symptoms
  • Severe pain
  • Difficulty voiding
  • Mass felt on vaginal exam
  • Flank pain
  • Abdominal distension
  • Shock

13
Treatment
  • Ice
  • I D (incision and drainage)
  • Packing

14
Subinvolution
  • Uterus remains large, does not involute
  • Causes, retained placental fragments, infection
  • Symptoms
  • Lochia fails to progress
  • Returns to rubra
  • Leukorrhea with backache and infection
  • Treatment
  • methergine
  • curretage
  • antibiotics

15
Puerperal Infection
  • Definition
  • Temp of 101o or more in the first 24 hrs
    following delivery
  • Temp of 1004 or higher on any 2 of the first10 pp
    days (with the exception of the first 24 hrs)

16
Types of Infections
  • Endometritis
  • Parametritis
  • Peritonitis
  • Pyelonephritis
  • Cystitis
  • Thrombophlebitis
  • Mastitis, abcess

17
Predisposing Factors
  • Antenatal factors
  • poor nutrition
  • low SES
  • Hx of Infections
  • Anemia
  • Immunodeficiency

18
Intrapartum predisposing factors
  • Prolonged labor
  • PROM
  • Poor aseptic technique
  • Birth trauma
  • Multiple exams
  • Internal monitoring
  • Episiotomy
  • C section

19
Postpartum Predisposing Factors
  • Manual removal of placenta
  • Hemorrhage
  • Retained secundines

20
Causative Organisms
  • Aerobic 30
  • B hemolitc strep
  • E.coli
  • Klebsiella
  • Proteus
  • Pseudomonas
  • Staph
  • Anerobic 70
  • Bacteriodes
  • Peptococcus
  • C. perfringes

21
Localized
  • Episiotomy
  • Lacerations
  • C section incision

22
Endometritis
  • Infection of the endometrium
  • placental site
  • decidua
  • cervix
  • Symptoms--discharge (scant to profuse), bloody,
    foul smelling
  • uterine tenderness
  • jagged, irregular temp elevations
  • tachycardia, chills, subinvolution

23
Salpingitis, Oopheritis
  • May be caused by gonorrhea, chlamidia
  • unilateral or bilateral abd pain
  • chills, fever
  • mass
  • tachycardia
  • may lead to sterility

24
Pelvic Cellulitis, (parametritis)
  • Infection of the connective tissue of pelvis
  • frequently infecting the broad ligament and
    causing severe pain.
  • May ascend from cervical lacerations

25
Parametritis symptoms
  • Spiking temp to 104
  • chills, flushing, sweating
  • tachycardia, tachypnea
  • uterine tenderness, cramping
  • change in LOC/agitation,delerium, disorientation
  • change in lochia
  • cervical or uterine tenderness on vag exam
  • WBC elevation

26
Peritonitis
  • Life threatening infection of the peritoneum
  • Abcesses on the uterine ligaments, in the cul de
    sac, and/or in the subdiaphragmatic space
  • May result from pelvic thrombophlebitis

27
Symptoms of Peritonitis
  • High temp
  • chills
  • malaise
  • lethargy
  • pain
  • subinvolution
  • Tachycardia
  • local or referred pain
  • rebound tenderness
  • thirst
  • distension
  • nausea and vomiting

28
Cystitis
  • Bladder infection
  • urgency
  • frequency
  • burning
  • dysuria
  • suprapubic pain
  • hematuria

29
Pyelonephritis
  • Kidney infection, usually of the R.
    kidney.Ascends from bladder.
  • Spiking temp
  • Shaking chills
  • Flank pain, CVA pain
  • Nausea and vomiting
  • Hx of asymptomatic bacteruria or pyelonephritis
  • Urgency, frequency, dysuria
  • Back pain

30
Prevention and treatment
  • Force fluids
  • Insure complete emptying of bladder
  • Sterile technique for cath
  • Good perineal care
  • Antibiotics

31
Thrombophlebitis Blood clot associated with
bacterial infection
  • Etiologies
  • ? blood clotting factors
  • postpartal thrombocytosis (?platelets)
  • thromboplastin release (placenta, amnion)
  • ?fibrinolysin and fibrinogen inhibitors

32
Superficial
  • Tenderness
  • heat
  • redness
  • low grade fever
  • homans sign
  • tachycardia
  • Treatment
  • elevation
  • heat
  • TEDs
  • analgesic
  • bedrest?
  • Antibiotics?

33
Deep Vein Thrombosis
  • Symptoms
  • edema
  • low grade fever
  • chills
  • pain in limb below affected area
  • milk leg
  • decreased peripheral pulses
  • Dx--doppler
  • Tx
  • heparin to coumadin
  • antibiotics
  • TEDs
  • bedrest
  • elevation
  • analgesics

34
Pulmonary Embolism an Obstetrical emergency
  • Symptoms--sudden onset
  • dyspnea
  • sweating
  • pallor
  • cyanosis
  • confusion
  • hypertension
  • cough/hemoptysis
  • Tachycardia
  • SOB
  • ? Temp
  • ? jugular pressur
  • chest pain
  • sense of impending death
  • pressure in bowel/rectum

35
Treatment
  • Call MD
  • O2
  • Demerol
  • Papaverine or other clot busters
  • Aminophylline
  • heparin
  • Streptokinase

36
Disseminated Intravascular Coagulation (DIC)
  • ? prothrombin and platelets
  • widespread formation of intravascular clots
  • clotting factor expended
  • severe generalized hemorrhaging
  • Life threatening!

37
Etiologies
  • Septic shock
  • placental/uterine hemmorhage
  • IUFD
  • Amniotic fluid embolism
  • thrombi secondary to preeclampsia
  • thrombi secondary to thrombophlebitis

38
Early signs of DIC
  • ? protime
  • ? fibrinogen
  • thrombocytopenia
  • bleeding from gums
  • bleeding from puncture sites
  • ecchymosis
  • Treatment complex, packed cells, fibrinogen,
    whole blood, plasma

39
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