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Complications of Postpartum

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Placental Accreta Placental Accreta 9 10 11 12 15 17 18 20 21 22 23 24 25 26 27 29 30 33 31 32 34 35 36 39 40 POSTPARTUM CYSTITIS POSTPARTUM CYSTITIS Prevention ... – PowerPoint PPT presentation

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Title: Complications of Postpartum


1
Complications of Postpartum
2
Postpartum Hemorrhage
  • Early
  • Occurs when blood loss is greater than
  • 500 ml. in the first 24 hours after a vaginal
    delivery or greater than 1000 ml after a cesarean
    birth
  • Normal blood loss is about 300 - 500 ml.)
  • Late
  • Hemorrhage that occurs after the first 24 hours

3
Main Causes of Early Hemorrhage are
  • Uterine Atony
  • Lacerations
  • Retained Placental Fragments
  • Inversion of the Uterus
  • Placenta Accreta
  • Hematomas

4
Uterine Atony
  • The myometrium fails to contract and
  • the uterus fills with blood because of
  • the lack of pressure on the open
  • vessels of the placental site

5
Uterine Atony Predisposing Factors
Prolonged labor
Overdistention of the Uterus
Trauma due to Obstetrical Procedures
Grandmultiparity
Intrapartum Stimulation with Pitocin
Excessive use of Analgesia / Anesthesia
6
Uterine Atony
  • Most common cause of Hemorrhage
  • Key to successful management is
  • PREVENTION!
  • Nurse many times can predict which women are at
    risk for hemorrhaging.

7
Uterine Atony
A boggy uterus that does not respond to
massage
Signs and Symptoms
Abnormal Clots
Excessive or Bright Red Bleeding

Unusual pelvic discomfort or backache
8
Nursing Care of uterine atony
  • Document Vaginal Bleeding
  • Fundal massage / Bimanual Compression
  • Assess Vital Signs (shock)
  • Give medications--Pitocin, Methergine, Hemabate
  • D C, Hysterotomy/ectomy, Replace blood /
    fluids

9
Post Partum Hemorrhage Lacerations
  • PREDISPOSING FACTORS
  • 1. Spontaneous or Precipitous delivery
  • 2. Size, Presentation, and Position of baby
  • 3. Contracted Pelvis
  • 4. Vulvar, cervical, perineal, uretheral area and
    vaginal varices
  • Signs and Symptoms
  • 1. Bright red bleeding where there is a
    steady
  • trickle of blood and the uterus
    remains firm.
  • 2. Hypovolemia

10
POSTPARTUM HEMORRHAGE LACERATIONS
  • Treatment and Nursing Care
  • 1. Meticulous inspection of the entire
  • lower birth canal
  • 2. Suture any bleeders
  • 3. Vaginal pack-- nurse may remove and
  • assess bleeding after removal
  • 4. Blood replacement

11
Test Yourself !
  • You are assigned to Mrs. B. who delivered
    vaginally. As you do your post-partum
    assessment, you notice that she has a large
    amount of lochia rubra.
  • What would be the first measure to determine if
    it is related to uterine atony or a laceration?

12
Retained Placental Fragments
  • This occurs when there is incomplete
  • separation of the placenta and fragments of
  • placental tissue retained.
  • Signs
  • Boggy , relaxed uterus
  • Dark red bleeding
  • Treatment
  • D C
  • Administration of Oxytocins
  • Administration of Prophylactic antibiotics

13
Hematoma
  • Major Symptom PAIN- deep, severe, unrelieved,
    feelings of pressure
  • Many times bleeding is concealed. Major symptom
    is rectal pain and tachycardia.
  • Treatment
  • May have to be incised and drained.

14
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15
Inversion of the Uterus
  • The uterus inverts or turns inside out after
    delivery.
  • Complete inversion - a large red rounded mass
    protrudes from the vagina
  • Incomplete inversion - uterus can not be seen,
    but felt
  • Predisposing Factors
  • Traction applied on the cord before the placenta
    has separated.
  • Dont pull on the cord unless the placenta has
    separated.
  • Incorrect traction and pressure applied to the
    fundus, especially when the uterus is flaccid
  • Dont use the fundus to push the placenta out

16
Uterine inversion and replacement
17
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18
Treatment and Nursing Care
  • Replace the uterus--manually replace and pack
    uterus
  • Combat shock, which is usually out of proportion
    to the blood loss
  • Blood and Fluid replacement
  • Give Oxytocin
  • Initiate broad spectrum antibiotics
  • May need to insert a Nasogastric tube to minimize
    a paralytic ileus
  • Notify the Recovery Nurse what has occurred!
  • Care must be taken when massaging

19
Placental Accreta
20
Placenta Accreta
  • Signs
  • During the third stage of labor, the placenta
    does not want to separate.
  • Attempts to remove the placenta in the usual
    manner are unsuccessful, and lacerations or
    perforation of the uterus may occur

21
Treatment
  • If it is only small portions that are attached,
    then these may be removed manually
  • If large portion is attached--a Hysterectomy is
    necessary!

22
Late Postpartum Hemorrhage
  • Most common cause is Retained Placental fragments
  • Sub involution
  • Treatment
  • D C
  • Methergine

23
Are these Early, Late, or Both ?
  • Uterine Atony
  • Retained placental fragments
  • Lacerations
  • Inversion of the uterus
  • Placenta accreta
  • Hematoma
  • _________________
  • _________________
  • _________________
  • _________________
  • _________________
  • _________________

24
Postpartum Infections
25
Postpartum Infections
  • Definition
  • Infection of the genital tract that
    occurs
  • within 28 days after abortion or delivery
  • Causes
  • Streptococcus Groups A and B
  • Clostridium, E. Coli

26
Postpartum Infections
  • Predisposing Factors
  • 1. Trauma
  • 2. Hemorrhage
  • 3. Prolonged labor
  • 4. Urinary Tract Infections
  • 5. Anemia and Hematomas
  • 6. Excessive vaginal exams
  • 7. P R O M

27
Critical to Remember
  • Signs and Symptoms of Postpartum
  • Infection
  • 1.Temperature increase of 100.4 or higher
  • on any 2 consecutive days of the first
  • 10 days post-partum, not including the
  • first 24 hours.
  • 2. Foul smelling lochia, discharge
  • 3. Malaise, Anorexia, Tachycardia, chills
  • 4. Pelvic Pain
  • 5. Elevated WBC

28
Postpartum INFECTION

TREATMENT AND NURSING CARE
  • Administer broad spectrum antibiotics
  • Provide with warm sitz baths
  • Promote drainage--have pt. lie in HIGH fowlers
    position
  • Force fluids and hydrate with IVs 3000 - 4000
    cc. / day
  • Keep uterus contracted, give Methergine
  • Provide analgesics for alleviation of pain
  • Nasogastric suction if peritonitis develops

29
Test Yourself !
  • What is the classic sign of a Postpartum
    Infection?

30
Complications of Postpartum Infections
Pelvic Cellulitis Peritonitis
Signs and Symptoms
Spiking a fever of 102 0 F to 104 0 F Elevated
WBC Chills Extreme Lethargy Nausea and
Vomiting Abdominal Rigidity and Rebound Tenderness
31
Preventive Measures
  • Prompt treatment of anemia
  • Well-balanced diet
  • Avoidance of intercourse late in pregnancy
  • Strict asepsis during labor and delivery
  • Teaching of postpartum hygiene measures
  • keep pads snug
  • change pads frequently
  • wipe front to back
  • use peri bottle after each elimination

32
Localized Infection
  • Infection of the Episiotomy, Perineal
    laceration, Vaginal or vulva lacerations
  • Wound infection of incision site
  • Signs
  • Reddened, edematous, firm, tender edges of skin
  • Edges seperate and purulent material drains from
    the wound.
  • Treatment
  • Antibiotics
  • Wound care

33
Check yourself
  • Mrs. X. was admitted with endometritis
  • and Mrs. Y. was admitted with an infection
  • in her cesarean incision. Are both classified
  • as a Puerperal Infection?
  • What would be the major difference in
  • presenting symptoms you would note on
  • nursing assessment?

34
Postpartum Cystitis
35
Postpartum Cystitis
  • Prevention
  • Monitor the patients urination diligently!
  • Dont allow to go longer than 3 - 4 hours before
    intervening.
  • Treatment
  • Antibiotics -- Ampicillin
  • Urinary Tract Antispasmodics
  • Causes
  • Stretching or Trauma to the base of the bladder
    results in edema of the trigone that is great
    enough to obstruct the urethra and to cause acute
    retention.
  • Anesthesia

36
Mastitis
Marked Engorgement Pain Chills, Fever,
Tachycardia Hardness and Redness Enlarged and
tender lymph nodes
37
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38
Mastitis
  • Types
  • Mammary Cellulitis - inflammation of the
    connective tissue between the lobes in the breast
  • Mammary Adenitis - infection in the ducts and
    lobes of the breasts

39
Nipple Trauma Pain Impaired
Engorgement
Let down
Cracked
Stasis nipples
of milk
Entry for Bacteria
Plugged ducts
Mastitis
Treatment, Problem will resolve
Breast Abscess No Treatment
40
Treatment of Mastitis
  • Rest
  • Appropriate Antibiotics--Usually Cephalosporins
  • Hot and / or Cold Packs
  • Dont Breast Feeding because
  • If the milk contains the bacteria, it also
    contains the antibiotic
  • Sudden cessation of lactation will cause severe
    engorgement which will only complicate the
    situation
  • Breastfeeding stimulates circulation and moves
    the bacteria containing milk out of the breast

Stop
41
Mastitis
Meticulous handwashing
Frequent feedings and massage distended area
to help emptying
Preventive Measures
Rotate position of baby on the breast
42
Complication of Mastitis
Breast Abscess
Breast Feeding is stopped on the affected side,
but may feed on the unaffected side. Treatment
Incision and Drainage
43
Thromboembolic Disease
  • Predisposing Factors
  • Slowing of blood in the legs
  • Trauma to the veins
  • Signs and Symptoms
  • Sudden onset of pain
  • Tenderness of the calf
  • Redness and an increase in skin temperature
  • Positive Homans Sign

44
  • Treatment
  • Heparin --it does not cross into breast milk
  • Antidote protamine sulfate
  • Teach patient to report any unusual bleeding, or
    petchiae, bleeding gums, hematuria, epistaxis,
    etc.
  • Complication
  • Pulmonary Emboli

45
Postpartum Psychiatric
Disorders
Mental Health problems can complicate the
puerperium. There are days when each new
mother may feel inadequate, but the mother who
has a constant feeling of inadequacy needs
professional counseling.
Pregnancy alone is not a cause of a
psychiatric Illness however, the psychological
and physiological stressors relating to pregnancy
may bring on an emotional crisis
46
Mood Disorders
  • The Most common Mood Disorders are
  • Adjustment reaction with mood depression baby
    blues
  • Postpartum major mood disorder Postpartum
    Depression
  • Postpartum psychosis

47
Baby Blues
  • 50-80 of moms are affected
  • Self-limiting (up to 10 days)
  • Cause
  • Seems to be related to changes in progesterone,
    estrogen and prolactin levels
  • Symptoms
  • Tearful yet happy
  • Overwhelmed
  • Treatment

48
Postpartum Major Mood Disorder Postpartum
Depression
  • Risk factors
  • Primiparity
  • History of postpartum depression
  • Lack of social and relationship support
  • Clinical Therapy
  • Counseling, support groups
  • Medication (usually SSRIs)
  • Childcare assistance

49
Postpartum Psychosis
  • Predisposing Factors
  • Similar to those of postpartum depression
  • Assessment
  • Grandiosity
  • Decreased need for sleep (insomnia)
  • Flight of ideas
  • Psychomotor agitation / hyperactivity
  • Rejection of infant

50
Treatment for Mood Disorders
  • Drug therapy (previous slide)
  • Psychotherapy
  • Explain importance of good nutrition and rest
  • Some of her feelings may seem unreasonable
  • Re-introduce the baby to the mother at the
    mothers own pace

51
  • How do the signs and symptoms of hematoma differ
    from those of uterine atony or a laceration?
  • What laboratory study should the nurse suspect if
    the woman is on heparin anticoagulation?
  • What is the significance of a board-like abdomen
    in a woman who has endometritis?
  • Why is it important that the breast-feeding
    mother with mastitis empty her breasts
    completely?
  • What is the KEY difference between postpartum
    blues and postpartum depression?
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