1. Post partum complication
Dr: Sahar Anwar Rizk

2. Post partum complication
Types of post partum complications:
1- post partum hemorrhage
2- puerperal sepsis

3. post partum hemorrhage
post partum hemorrhage
Postpartum hemorrhage is a significant cause of maternal morbidity and mortality.
Postpartum hemorrhage, the loss of more than 500 mL of blood after delivery, occurs in up to 18 percent of births and is the most common maternal morbidity in developed countries. Although risk factors and preventive strategies are clearly documented, not all cases are expected or avoidable.

4. Risk Factors for Postpartum Hemorrhage
Prolonged third stage of labor
Preeclampsia
Mediolateral episiotomy
Previous postpartum hemorrhage
Twin pregnancy
Arrest of descent
Soft-tissue lacerations
Asian ethnicity
Augmented labor
Forceps or vacuum delivery
Midline episiotomy
Nulliparity& high parity
Systemic diseases

5. Type of post partum hemorrhage:
1-Primary post partum hemorrhage: occur during the first 24 hrs after delivery
2-Secondary post partum hemorrhage: occurring more than 24 hrs after delivery. It can occur along 6 weeks after delivery

6. 1-Primary post partum hemorrhage
Major cause:
A tonic uterus:
It is the most common cause of post partum hemorrhage with separation of the placenta ,the uterine sinuses cannot compressed effectively.

7. 2-Trumatic :
Hemorrhage occurs due to trauma of the uterus, cervix, vagina following vaginal or operative delivery
Delay during episiotomy
3-Mixed
4-Blood coagulating disorder:
A acquired or congenital blood coagulation disorder.

8. Factors affecting efficient uterine contraction &retraction
Placental :
Incomplete separation of placenta
Retained cotyledon &membrane
Placenta previa
Prolonged labor
Multiple pregnancy
General anesthesia
Full bladder
Manipulation of the uterus during third stage

9. Clinical manifestation of PPH
If blood loss more than 750-1,250
BP normal or decrease
Pulse normal or elevated
Mild vasoconstriction
Normal urinary out put
Aware , alert, oriented

10. Atonic uterus (1,250-1,750)
Systolic BP<90 to 100mm/hg
Moderate tachycardia b/m
Moderate vasoconstriction, skin pallor ,cold, moist
Decrease urinary out put
Increase restlessness

11. Atonic uterus ( )
Systolic BP <60mm/Hg
Sever bradycardia >120 b/m
Pronounced vasoconstriction ( extreme pallor, cold ,clammy cyanotic lips and finger)
Urinary output ceases (anurea)
Mental stupor , lethargy, semi-comatose
*Uterus is flabby and become hard on massaging in a tonic PPH
*Uterus is well contracted in traumatic PPH

12. How is postpartum hemorrhage diagnosed?
How is postpartum hemorrhage diagnosed?
In addition to a complete medical history and physical examination, diagnosis is usually based on symptoms, with laboratory tests often helping with the diagnosis. Tests used to diagnose postpartum hemorrhage may include:
estimation of blood loss (this may be done by counting the number of saturated pads, or by weighing of packs and sponges used to absorb blood; 1 milliliter of blood weighs approximately one gram)
pulse rate and blood pressure measurement
hematocrit (red blood cell count)
clotting factors in the blood

13. Prevention of PPH Ante partum
Complete history-----to identify high risk pt who are likely to develop PPH
Improve health status especially to rise hg
Hospital delivery of high risk pt who develop polyhydramnios, multiple pregnancy, sever anemia
Routine blood grouping

14. Intrapartum PPH Careful administration of sedatives
Avoid hasty delivery of the infant
Prophylactic administration of oxytocin
Avoid massaging the uterus before separation of placenta
Examine the utero –vaginal canal for trauma
Effective management of the fourth stage of labor

15. Management of Postpartum Hemorrhage

16. The aim of treatment of postpartum hemorrhage is to find and stop the cause of the bleeding as quickly as possible. Treatment for postpartum hemorrhage may include:
medication (to stimulate uterine contractions)
manual massage of the uterus (to stimulate contractions)
removal of placental pieces that remain in the uterus
examination of the uterus and other pelvic tissues
packing the uterus with sponges and sterile materials (to compress the bleeding area in the uterus)
tying-off of bleeding blood vessels
laparotomy - surgery to open the abdomen to find the cause of the bleeding.
hysterectomy - surgical removal of the uterus; in most cases, this is a last re

17. Observation of the mother
Record pulse, BP, every 15 min
Palpate uterus every 15 min ----contraction
Check temp /4 hrs
Examine lochia for amount & consistency
Examine IV infusion
Hourly urine output
Intake &output chart
Relive anxiety
Administer prophylactic antibiotic

18. Uterotonic Agents.
Uterotonic agents include oxytocin, ergot alkaloids (Methergine ), and prostaglandins.
Oxytocin stimulates the upper segment of the myometrium to contract rhythmically, which constricts spiral arteries and decreases blood flow through the uterus.30 Oxytocin is an effective first-line treatment for post

19. Technique of bimanual massage for uterine atony
Bimanual uterine compression massage is performed by placing one hand in the vagina and pushing against the body of the uterus while the other hand compresses the fundus from above through the abdominal wall. The posterior aspect of the uterus is massaged with the abdominal hand and the anterior aspect with the vaginal hand.

20. Nursing management Assess pt Identify risk group: Vital sign
State of the uterus
Natural of bleeding
S&S of blood loss
compare laboratory report

21. Nursing intervention:
If atonic
Inform obst
Feel the consistency of the uterus
Massage the uterus
Assess the physical condition
Monitor TPR &BP
Put the infant on breast
Prepare the instrument

22. Administer oxytocin
Start IV infusion
Empty bladder
Examine placenta
Reassure the mother
In trumatic:
press on the tear or laceration
Prepare the equipment

23. Secondary post partum hg
Commonly occur 10-14day PP
Common cause:
retained bit of cotyledon
Separation of slough exposing a blood vessels
Sub involution at the placental sit

24. S&S Sudden episode of bleeding Sub involution Sepsis Anemia
Management:
Reassurance
Monitor TPR
IV, empty bladder, give medication

25. Puerperal sepsis:
It is an infection of the genital tract that occur at any time between the onset of rupture of the membrane or labor & the 42ed day post partum or abortion :
The following are present:
Pelvic pain
Fever 38.5
Abnormal vaginal discharge
Foul odor &sub involution

26. Microorganisms commonly involved in PPGTI
Gram positive
Gram negative
Microorganism that sexually transmitted

27. Risk factors for PP infection
Related to general infection risk
Related to labor and delivery
Related to operative risk factors

28. Principle clinical feature
Elevated temp
Suprapubic pain
Foul smell lochia
Uterine involution
General symptoms
Laboratory investigation

29. Preventive measures Ante partum Intrapartum Post partum
Nursing management