Presentation on theme: "Complications of Post Partum. P OSTPARTUM H EMORRHAGE Early Occurs when blood loss is greater than 500 ml. in the first 24 hours after a vaginal delivery."— Presentation transcript:
Complications of Post Partum
P OSTPARTUM H EMORRHAGE 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 ml.) Late Hemorrhage that occurs after the first 24 hours
M AIN C AUSES OF E ARLY H EMORRHAGE ARE : Uterine Atony Lacerations Retained Placental Fragments Inversion of the Uterus Placenta Accreta Hematomas
U TERINE A TONY **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 The myometrium fails to contract and the uterus fills with blood because of the lack of pressure on the open blood vessels of the placental site.
U TERINE A TONY P REDISPOSING F ACTORS Prolonged labor Overdistention of the Uterus Grandmultiparity Excessive use of Analgesia / Anesthesia Intrapartum Stimulation with Pitocin Trauma due to Obstetrical Procedures
U TERINE A TONY Most common cause of Hemorrhage Key to successful management is : PREVENTION! Nurse many times can predict which women are at risk for hemorrhaging.
U TERINE A TONY Signs and Symptoms Excessive or Bright Red Bleeding Abnormal Clots A boggy uterus that does not respond to massage Unusual pelvic discomfort or backache
N URSING C ARE OF U TERINE A TONY Document Vaginal Bleeding Fundal massage / Bimanual Compression Assess Vital Signs (shock) Give medications--Pitocin, Methergine, Hemabate D & C, Hysterotomy/ectomy, Replace blood / fluids
P OST P ARTUM H EMORRHAGE *L ACERATIONS * 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
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
T EST Y OURSELF ! 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?
R ETAINED P LACENTAL F RAGMENTS 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
H EMATOMA 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.
I NVERSION OF THE U TERUS 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. ** Don’t pull on the cord unless the placenta has separated. Incorrect traction and pressure applied to the fundus, especially when the uterus is flaccid ** Don’t use the fundus to “push the placenta out”
I NVERSION OF THE U TERUS Traction on the cord starts the uterus to invert Uterus continues to be pulled and inverted Uterus Placenta
I NVERSION OF THE U TERUS Vagina Uterus Inverted Vagina Uterus Manually pushed back into place
T REATMENT AND N URSING C ARE 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
P LACENTA A CCRETA All or part of the decidua basalis is absent and the Placenta grown directly into the uterine muscle.
P LACENTA A CCRETA 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
T REATMENT If it is only small portions that are attached, then these may be removed manually If large portion is attached--a Hysterectomy is necessary!
A RE THESE E ARLY, L ATE, OR B OTH ? Uterine Atony Retained placental fragments Lacerations Inversion of the uterus Placenta accreta Hematoma _________________
P OSTPARTUM I NFECTIONS
Definition Infection of the genital tract that occurs within 28 days after abortion or delivery Causes Streptococcus Groups A and B Clostridium, E. Coli
P OSTPARTUM I NFECTIONS 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
C RITICAL TO R EMEMBER Signs and Symptoms of Postpartum Infection 1. 1.Temperature increase of or higher on any 2 consecutive days of the first 10 days post-partum, not including the first 24 hours Foul smelling lochia, discharge Malaise, Anorexia, Tachycardia, chills Pelvic Pain Elevated WBC
P OSTPARTUM INFECTION Administer broad spectrum antibiotics Provide with warm sitz baths Promote drainage--have pt. lie in HIGH fowlers position Force fluids and hydrate with IV’s cc. / day Keep uterus contracted, give Methergine Provide analgesics for alleviation of pain Nasogastric suction if peritonitis develops TREATMENT AND NURSING CARE
What is the classic sign of a Postpartum Infection? Test Yourself !
C OMPLICATIONS OF P OSTPARTUM I NFECTIONS Pelvic Cellulitis Peritonitis Spiking a fever of F to F Elevated WBC Chills Extreme Lethargy Nausea and Vomiting Abdominal Rigidity and Rebound Tenderness Signs and Symptoms:
P REVENTIVE M EASURES 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
L OCALIZED I NFECTION 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
C HECK YOURSELF Mrs. X. was admitted with endometritis and Mrs. Y. was admitted with an infection in her cesarean incision. Are both classified as a postpartum Infection? What would be the major difference in presenting symptoms you would note on nursing assessment?
P OSTPARTUM C YSTITIS
Prevention: Monitor the patients urination diligently! Don’t allow to go longer than 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
M ASTITIS Marked Engorgement, Pain, Chills, Fever, Tachycardia, Hardness and Redness, Enlarged and tender lymph nodes
M ASTITIS Types: between Mammary Cellulitis - inflammation of the connective tissue between the lobes in the breast Mammary Adenitis in Mammary Adenitis - infection in the ducts and lobes of the breasts
Nipple Trauma Pain Impaired Engorgement Let down Cracked Stasis nipples of milk Entry for Bacteria Plugged ducts Mastitis Treatment, No Treatment Problem will resolve Breast Abscess
T REATMENT OF M ASTITIS Rest Appropriate Antibiotics-- Usually Cephalosporins Hot and / or Cold Packs Don’t 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
M ASTITIS Preventive Measures Meticulous handwashing Frequent feedings and massage distended area to help emptying Rotate position of baby on the breast
C OMPLICATION OF M ASTITIS Breast Abscess Breast Feeding is stopped on the affected side, but may feed on the unaffected side. Treatment: Incision and Drainage
T HROMBOEMBOLIC D ISEASE 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 Homan’s Sign
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
P OSTPARTUM P SYCHIATRIC D ISORDERS 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 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.
M OOD D ISORDERS The Most common Mood Disorders are: Baby Blues Postpartum Depression Bipolar Disorder
B ABY 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
P OSTPARTUM M AJOR M OOD D ISORDER “P OSTPARTUM D EPRESSION ” Risk factors: Primiparity History of postpartum depression Lack of social and relational support Clinical therapies Counseling and support groups Medication (usually SSRI’s) Childcare assistance
P OSTPARTUM P SYCHOSIS Predisposing factors Similar to those of postpartum depression Assessments Grandiosity Decreased need for sleep (insomnia) Flight of ideas Psychomotor agitation/hyperactivity Rejection of infant
T REATMENT FOR MOOD DISORDERS Drug therapy Psychotherapy Explain the importance of good nutrition and rest Reintroduce the mother to the baby at the mothers own pace
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?