Puerperal Complications AKA Post Partum Complications

1
POST PARTUM
COMPLICATIONS Lecture 9
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Endometritis

• Infection of Uterus endometrium, myometrium, or
  parametrium.
• Caused by E.Coli, Staph, Group A/B
  Streptococcus.
• Occurs within 10 days, abortion or delivery.
• Granulocytes in lochia endometrial lining -
  help prevent infection
• Risk factors PROM, C/S, multiple pelvic exams,
  UTI, GBS, DM, poor nutrition, poor health,
  catheterization.
• T 100.4 x 2 C/S most common cause of
  infection followed by UTI.

3

• S/S
• fever, chills, malaise, abd.pain, uterine
  cramping tenderness, foul-smelling lochia,
  tachycardia.
• LAB findings CBC Blood cxs. WBC gt 20,000
  indicates infection 20,000 - normal gt delivery.
  
• Blood cx may be for bacteremia. Send UA, urine
  cx lochia cx.
• TX
• po fluids, hypothermia blankets, ice packs to
  head/groin.
• Broad spectrum antibiotics. Ampicillan,
  cephalosporin, gentamycin, clindamycin for 2-3
  days.
• Antipyretics Tylenol /or pain meds.as well.

4
Wound Infection

• Common Sites incision, perineum episiotomy
  laceration, vagina. port of entry
• S/S REEDA erythema, ecchymosis, edema, purulent
  drainage, wound edges not approximated, pain,
  tenderness.
• Management Remove some staples/sutures . Allow
  wound to drain.
• Irrigation packing of wound, broad spectrum AB,
  wound blood cx, analgesics, warm compresses.
• Perineal care wipe front to back warm water .

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GI

• Paralytic Ileus hard abdomen with absent bowel
  sounds, N V, abd.distention pain.
• NG tube to low intermittent suction NPO
• IVF

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Subinvolution of Uterus

• Major complication gt del. involving postpartum
  bleeding gt 500 ml. caused by uterine atony
• Delayed return of uterus to its normal size and
  functions.
• Normally descends 1 cm/day PP.
• S/S larger than normal uterus, heavy flow,
  fatigue, back pain.
• Methergine 0.2 mg po q 4 x 24 hrs.
• Tx with AB as directed. Possible DC.
• Common Causes retained placenta pelvic
  infection.
• Teach self palpation of uterus _at_ home

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Postpartum Hemorrhage

• Caused by overdistention of uterus
• large infant, multiple gestation, retained
  placenta pelvic infection grand multip gt 5
  Precipitous delivery prolonged labor, clotting
  disorders.
• Uterus boggy - soft. Relaxed uterus prevents
• constriction of blood vessels _at_ uteroplacetal
  site.
• SS profuse bleeding, clots.
• Massage til firm. Assess for continued bleeding
  passage of clots.

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PP Hemorrhage

• Manage
• 20-30 units of Pitocin in liter RL
• Massage uterus
• Methergine 0.2 mg po q 4h x 24hr.
• Monitor BP before giving may BP or may give
  Methergine 0.2 mg. IM stat q4 po x 24hrs. Also
  used Hemabate, Prostin prostaglandins.
• Remove clots /or retained placenta may need DC
  or hysterectomy. IV RL, transfusion with whole
  blood,

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Late P.P.H

• Appears 24 hours to month gt delivery.
• Caused by retention of small piece of tissue
• Tissue necrosis gt delivery and sloughs off,
  causing bleeding at site.
• Teach mom s/s PP hemorrhage to contact HCP if
  bleeding.
• Remove pieces of retained placenta by dilation
  curettage (DC)
• Do bimanual compression for bleeding.
• Follow tx for PP hemorrhage.

10
Uterine Prolapse

• Relaxation of uterine muscle uterus protrudes
  from vagina.
• Ligaments over stretched dont return to
  normal.
• Common after vaginal births or large infants.
• Manifests _at_ menopause d/t decreased estrogen.
• TX severe prolapse hysterectomy
• milder prolapse pessary supportive device

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Mastitis

• Develops after breast milk is established,
  2-4wks.PP
• D/t ineffective or infrequent breast feeding or
  milk stasis from engorgement, skipping breast.
• E.Coli or Staph.aureus carried on hands of mom.
  Enters nipple thru crack or blister.
• S/S fever, chills, malaise, localized erythema
  tenderness of breast tissue.
• Tx Warm soaks to both breasts as needed
  pumping put baby on breast more often.
• Analgesics ABs - Amoxicillan 250mg.po TID.

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UTI

• 2-4 develop UTI postpartum.
• Bladder hypotonic gt del. residual urine
  reflux results.
• Freq. VEs, catheterizations birth trauma.
• S/S dysuria, low grade fever, urgency,
  frequency. temp.
• UA urine cx.
• E.Coli most common pathogen 75 of cases.
• Bactrim sulfanomide, Ampicillan, cephalexin po
  Keflex.

13
Thrombophlebitis

• aka Superficial thrombophlebitis
• Rate 5x higher in preg.women.
• Inflammation of vein wall.
• Risk factors women with extensive varicosities,
  smoking, inactivity, obesity, C/S, age gt 35.
• Occurs within few days postop.
• Localized swelling, erythemia, tenderness.
  Unilateral affects one leg/calf or other.
• Tx warm soaks to affected area elevation of
  extremities analgesics.
• No ambulation for 1 wk then OK to ambulate. No
  anticoagulants _at_ this time. Support stockings
  recommended. Avoid standing too long.

14
Deep Vein Thrombosis

• Caused by inflammatory process
• Collection of blood factors, mainly fibrin,
  accumulates may be released .
• 1 in 2,000 preg - deep veins of calves, thigh,
  pelvis.
• Prevent by early ambulation 6-8 hrs. post op
• ROM exercises changing positions often.
• Teds stockings, compression boots post op. TEDS
  stockings are used in pts. with hx of phlebitis,
  C/S, or varicose veins.
• Diagnosis Dopplers studies gold standard
  diagnosing.

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DVT

• S/S
• frank pain in calf/hip inability to walk upon
  rising Homans tenderness with local calf
  swelling, heat, redness measure both calves
  compare.
• Treatment
• Bedrest leg elevation Anticoagulants PT/PTT
  prior to therapy during for therapeutic dosing.
  
• Heparin or Lovenox SC . Analgesics.
• Septic pelvic thrombophebilits often with C/S
  thrombus formation in pelvis.
• May proceed to pulmonary embolis life
  threatening.
• PE fragments of clot carried to lung can be
  fatal.

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Pulmonary Embolism

• Fragments of blood clot carried to lungs.
• S/S sudden, sharp chest pain, tachycardia,
  syncope fainting, tachypnea, rales, cough,
  hemoptysis.
• ABGs show decreased PO2 chest x-ray gt pleural
  effusion atelectasis.
• Manage Dissolve clot maintain pulmonary
  circulation. Initiate IV heparin therapy asap.
• O2, bedrest ICU admission, ABGs, O2 sat,
  VS, narcotics to alleviate pain anxiety.