Presentation on theme: "Postpartal Complications"— Presentation transcript:
1Postpartal Complications Usually a period of health but complications do occur.Woman at risk in three points of view:Her own healthHer future childbearing potentialHer ability to bond with her new infantFamily is disrupted, hospital stay is longer, increased cost, difficult to cope.Most complications are preventable, and if they do occur they can be treated.
2Postpartal Complications HemorrhageInfectionThrombophlebitisUrinary System DisordersCardiovascular System DisordersReproductive System DisordersEmotional and Psychological Complications
3Postpartal Complications Assessment findings may be extremely subtle.Tenderness in calf of legSlight increase in painSlight elevation in temperature (serious 1st 24 hours)Slight increase in lochiaThings that are more than usualDo not rely on the mother’s report, she wants to go home
4Postpartal Complications Provide for measures that restore the woman quickly to health, and promote contact with her child and support person.If she can not see the baby she needs contact by phone with the nursery. A photo of the infant, a note written about the progress as if from the baby.1 in 500 develop depression and even psychosis.Reinforcement is needed, support and remind that it is a temporary situation.
5Postpartal Hemorrhage Any blood loss from the uterus greater than 500 mL. within a 24 hour period.Can occur early, within 24 hours or late, anytime after the first 24 hours during the remaining days of the 6 week puerperium.4 main causes:Uterine atonyLacerationsRetained placental fragmentsDIC disceminated intravascular coagulation
6Postpartal Hemorrhage Uterine Atony:Relaxation of the uterusMost frequent cause of hemorrhageUterus must remain in a contracted state to allow open vessels at the placental site to seal.Box p. 695 list some factors.Multiple gestation, hydraminios, lg baby, myomas
7Postpartal Hemorrhage Assessment:Abrupt gush of blood from placental siteLg. amount of vaginal bleedingSymptoms of shock and blood lossA saturated pad can hold 25 to 50 mL.Count pads to estimate blood loss(q 30 min)Weigh pads the subtract the difference (1 g weight equals 1 mL volume of blood.Turn woman on side to inspect for pooling beneath her.
8Postpartal Hemorrhage Box 25.2 p. 696 outcomes and interventionsPalpate uterus; keep contracted, detecting relaxation is 1st and most important assessment.LochiaVSTreatment:Uterine massage to encourage contractionIV oxytocin – maintain uterine tone (10 to 40 U per 1000 mL of 5% dextrose) (1 hr.)IM Methergine
9Postpartal Hemorrhage Bimanual Massage:One hand in vagina while pushing against fundus through the abdominal wall with the other hand. (painful)Sonogram to detect placental fragmentsExamine manually and insert packing.Prostaglandin Administration:Prostaglandin F IM to initiate contractionsWatch for nausea, diarrhea, tachycardia, and hypertension.
10Postpartal Hemorrhage Blood Replacement:Type and cross matchSome may donate during pregnancy.Hysterectomy:Ligation of uterine or hysterectomy as last resort.Comfort and support.“Why me”, grief, anger, glad to be alive.
11Postpartal Hemorrhage Nursing interventions:Observe fundal height, consistency, and lochia for 4 hours.Offer bedpan or ambulate to BR q 4 hours or catheter may be ordered.O2 4 L/minute by face mask.SupineVS increase pulse, decrease B/PFatigue- needs restMay need iron therapy, help at home.Monitor for infection
12Postpartal Hemorrhage Lacerations:Small tears or lacerations of the birth canal are common. Large lacerations are complications.Occur:With difficult or precipitate birthsIn primigravidasWith birth of a large infant >9 lbs.With the use of a lithotomy position and instruments.Either cervical, vaginal, or perineal.
13Postpartal Hemorrhage If uterus is firm but bleeding persists, suspect a laceration.Cervical Laceration:Found on the sides of cervix near branches of uterine artery.May gush, bright red, immediately after delivery of the placenta.Treatment:Repair laceration (difficult to see)Reassure, may need anesthetic for pain.
14Postpartal Hemorrhage Vaginal Lacerations:Harder to repair, some oozing, may need packing. Remove in 24 to 48 hours.Foley catheter inserted due to pressure on urethra.Packing left to long causes stasis, infection similar to toxic shock syndrome.Perineal Laceration:Occur when in lithotomy position for birth, which increases tension on perineum.
15Postpartal Hemorrhage Four categories: (table 25.1 p. 700)From vaginal mucous membranes to rectumTreatment:Sutured and treated same as episiotomy repair.Document the degree.Heal slower due to tearing and ragged edgesDiet high in fluids, stool softener, no rectal temps, suppositories or enemas.
16Postpartal Hemorrhage Retained Placental Fragments:Portions retained keep uterus from contracting fully, uterine bleeding occurs.Happens with a succenturiate placenta ( an accessory lobe), placenta accreta (fused with myometrium because of abnormal decidua basalis layer.May need surgically removed.Inspect placenta carefully after birth to see if it is complete.
17Postpartal Hemorrhage Assessment:Lg. Fragment, bleeding, uterus can not contract.Sm.fragment, bleeding at day 6 to 10 postpartum. Woman notices an abrupt discharge of blood.If placental tissue is present; elevated serum HCG present.Sonogram.Treatment:
18Postpartal Hemorrhage Removal of fragments (D&C)Methotrexate to destroy retained placental tissue.Teach woman to monitor color of lochiaDisseminated Intravascular Coagualtion:Deficiency in clotting ability caused by vascular injury.Subinvolution:Incomplete return of uterus to its prepregnant size and shape.
19Postpartal Hemorrhage Postpartal visit in 4 to 6 weeks, the uterus is still enlarged and soft.Lochial discharge still present.Results from-sm. placental fragments, mild endometritis, or myoma.Management:Methergine 0.2 mg four times a day.Oral antibiotic (endometritis)AnemiaTeach normal process of involution at D/C
20Postpartal Hemorrhage Perineal Hematomas:Collection of blood in the subcutaneous layer of tissue of perineum.Injury to blood vessels during birth.Assessment:Woman reports severe pain in perineal area or feeling pressure between her legs. Check for hematoma.Purplish color and swelling. (2 cm to 8 cm)Tender and palpates as firm globe.
21Postpartal Hemorrhage Management:Report presence, size, degree of discomfort.Analgesic, ice, may absorb in 3 to 4 days or may need incised.Puerperal InfectionUterus is sterile during pregnancy and until membranes rupture.Greater risk if tissue edema and trauma are present. (Box 25.3 p. 702)Pathogens invade.
22Infection Prognosis for recovery depends on: Virulence of the invading organismGeneral health of the womanPort of entryDegree of uterine involutionPresence of lacerations in the reproductive tract.Always serious, it can spread to peritonitis or septicemia. Can be fatal.
23Infection Management Antibiotic after C&S Ampicillin, Gentamicin, SupraxUse gloves and sterile instruments.Proper perineal careMay need isolationPump breasts if breast feedingGive support
24Infection Endometritis: Infection of endometrium, lining of uterus. Assessment:Temperature elevation, usually on 3rd to 4th day postpartum > for 2 days.Normal WBC 20,000 to 30,000Chills, loss of appetite, general malaise.Sonogram for infected placental fragments.Management:Cleocin, oxytocic agent, fluids, analgesic.
25Infection Fowlers position or ambulate. Lasts 7 to 10 days. May be discharged on IV antibiotic at home.Can lead to tubal scarring and infertility.Infection of the PerineumAssessment:Suture line, or laceration is port for entry of bacteria.Generally remain localized.SS-pain, heat, feeling of pressure, inflammation at suture line.
26Infection Culture any drainage Management: Remove perineal sutures to open area and allow to drain.Packing (iodoform gauze) to keep open.Antibiotic, analgesic, sitz bath or warm compresses, change peri pads frequently.Heals by tertiary intention.Monitor infant for thrush, bruising, decreased vitamin K > poor clotting.
27Infection Peritonitis Infection of the peritoneal cavity. Major cause of death from puerperal infectionSpreads through lymphatic system or fallopian tubes or uterine wall.May settle in cul-de-sac of Douglas.Assessment:SS-(guarding) rigid abdomen, abdominal pain, high fever, rapid pulse, vomiting, appears ill.
28Infection Management: Often accompanied by paralytic ileus. Insert NG tube to prevent vomiting and rest the bowel.IV or TPNAnalgesic, antibiotic.May have infertility due to scarring and adhesions in peritoneum.
29ThrombophlebitisInflammation of the lining of a blood vessel with the formation of blood clots.Usually an extension of endometrial infection.Causes:Increased fibrinogen level that is still elevated from pregnancy leading to clotting.Dilation of lower extremity veins due to pressure of fetal head during pregnancy and birth.Inactivity or prolonged time in stirrups.
30Thrombophlebitis Classified as SVD or DVT. Prone women: With varicose veinsObesePrevious thrombophlebitisOver 30 yrs. of age with increased parityFamily history.Prevention:Prevent endometritisAmbulation
31Thrombophlebitis Limit time in stirrups Exam tables well padded Support stockingsFemoral ThrombophlebitisFemoral, saphenous, or popliteal veins involved.Arterial spasm often diminishes arterial circulation to the leg. This plus edema give the leg a white appearance.Assessment:
32Thrombophlebitis10th day after birth; elevated temperature, chills, pain, redness in leg.Leg swells below the lesion, appears shiny and white. Homans’ sign positive, diameter of leg increased.Doppler US or contrast venography to confirm diagnosis.Management:Bedrest, elevate leg, anticoagulants and moist heat, analgesic, antibiotic.APTT, PT
33ThrombophlebitisCoumarin, streptokinase or urokinase, Heparin. Later may be placed on aspirin.With treatment will last a few days but it takes 4 to 6 weeks to resolve.Pelvic ThrombophlebitisInvolves the ovarian, uterine, or hypogastric veins.Follows mild endometritisOccurs on day 14 or 15.Assessment:Suddenly extremely ill, high fever, chills,
34Thrombophlebitis General malaise. Necroses the vein and results in a pelvic abscess. Can become systemic and result in lung, kidney or heart valve abscess.Management:Bedrest, antibiotics, and anticoagulants.Disease lasts 6 to 8 weeks.May need incised by laparotomyTubal scarring > infertility.Teach preventive measures.
35Pulmonary Embolus Obstruction of pulmonary artery with a blood clot. EmergencySudden sharp chest pain, tachypnea, tachycardia, orthopnea, cyanosis.O2ICUMastitisInfection of the breast. Occurs on 7th day to weeks or month.
36Mastitis Organism enters through cracked and fissured nipples. Preventive measures:Position baby correctly and grasps nipple properly.Release baby’s grasp on nipple before removing from the breast.Wash handsExpose nipples to air for part of day.Vitamin E daily
37Mastitis May come from oral-nasal cavity of the infant. Assessment: Usually unilateral, pain, swelling, redness, fever and scant breast milk.Management:Broad spectrum antibioticContinue breast feedingCold or ice compressesSupport bra
38Mastitis Warm, wet compresses Lasts 2 to 3 days May abscess Urinary System DisordersUrinary Retention:Inadequate bladder emptying.Bladder sensation is decreased due to edema from the pressure of birth.Permanent damage may occur from loss of muscle tone.
39Urinary System Disorders Assessment:Associated with use of anesthesia and forceps.Percussion or palpationVoiding is frequent, sm. And inadequate.Always measure 1st voiding after birth. If < 100 mL suspect retension.Catheterize after voiding, if > 100mL it is retention.Leave Foley in place
40Urinary System Disorders Management:CatheterizationAfter 24 hours clamp then remove.Fluids, analgesics,Void within 8 hours.Present for no longer than 48 hours.Urinary Tract InfectionBacteria may be introduced into bladder.Assessment:Burning on urination, blood, feeling of
41Urinary System Disorders Frequency, pain, low grade fever and discomfort from lower abdominal pain.Clean catch urine specimenManagement:Sulfa drugs contraindicated for breast feeding.Antibiotic-ampicillinFliuds -1 glass /hourAnalgesics5 to 7 days to eradicate completely.
42Cardiovascular System Disorders Postpartal Pregnancy-Induced HypertensionPIHMay have a preexisting hypertension.SS- proteinuria, edema, hypertension.Tx.- bedrest, quiet atmosphere, VS, urine output and Magnesium sulfate or antihypertensive medication.Usually some placenta is still present.Once a D&C is completed B/P decreases.Seizures occur 6 to 24 hours after birth.
43Reproductive System Disorders Reproductive Tract Displacement:Ligaments may no longer be able to maintain the uterus in its usual position or level after pregnancy.Problem: retroflexion, anteflexion, retroversion, anteversion or prolapse.May interfere with fertility, may cause continued pain in lower abdomen.Cystocele, rectocele, stress incontinenceHigh parity
44Reproductive System Disorders Separation of the Symphysis Pubis:Ligaments may be stretched by birth and tear.Woman feels acute pain on turning or walking. Legs rotate externally (waddle)Defect over symphysis pubis, area is swollen and tender.Tx. – bedrest, binder, avoid heavy lifting4 to 6 weeks to healMay need cesarean birth for future.
45Emotional Complications Difficult bonding with infant.Child Born with an Illness:Sex of childAnger, hurt, disappointment, griefLoss of self esteemFeelings that child is not realShock to the coupleICU visitsOpen lines of communication
46Complications Woman Whose Child Has Died: Questions about what happened.Bewildered, bitter, resentful, “Why me”Clean the baby and wrap in blanket and let the parents see the baby.Stay with them, complete forms, provide a private room.Postpartal Depression:Almost every woman has some feelings of sadness in 1 to 10 days after childbirth.
47Complications Response to anticlimatic feelings after birth. Related to hormonal shifts-estrogen, progesterone, corticotropin releasing hormone levels decline.Extreme fatigue, inability to stop crying, increased anxiety about health, insecurity, psychosomatic symproms (N/V) and depressed or manic mood fluctuations.May need counseling and/or antidepressant therapy.Table 25.2 p. 714 comparisons
48Complications Postpartal Psychosis: 1 woman in 500 Response to the crisis of childbearing.May previously had mental illnessLost contact with reality, may deny she had a child.Mat respond as threatening, angerDo not leave alone because the distorted perception might lead her to harm herself.