2Post partum complication Types of post partum complications:1- post partum hemorrhage2- puerperal sepsis
3post partum hemorrhage post partum hemorrhagePostpartum 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.
4Risk Factors for Postpartum Hemorrhage Prolonged third stage of laborPreeclampsiaMediolateral episiotomyPrevious postpartum hemorrhageTwin pregnancyArrest of descentSoft-tissue lacerationsAsian ethnicityAugmented laborForceps or vacuum deliveryMidline episiotomyNulliparity& high paritySystemic diseases
5Type of post partum hemorrhage: 1-Primary post partum hemorrhage: occur during the first 24 hrs after delivery2-Secondary post partum hemorrhage: occurring more than 24 hrs after delivery. It can occur along 6 weeks after delivery
61-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.
72-Trumatic :Hemorrhage occurs due to trauma of the uterus, cervix, vagina following vaginal or operative deliveryDelay during episiotomy3-Mixed4-Blood coagulating disorder:A acquired or congenital blood coagulation disorder.
8Factors affecting efficient uterine contraction &retraction Placental :Incomplete separation of placentaRetained cotyledon &membranePlacenta previaProlonged laborMultiple pregnancyGeneral anesthesiaFull bladderManipulation of the uterus during third stage
9Clinical manifestation of PPH If blood loss more than 750-1,250BP normal or decreasePulse normal or elevatedMild vasoconstrictionNormal urinary out putAware , alert, oriented
10Atonic uterus (1,250-1,750)Systolic BP<90 to 100mm/hgModerate tachycardia b/mModerate vasoconstriction, skin pallor ,cold, moistDecrease urinary out putIncrease restlessness
11Atonic uterus ( )Systolic BP <60mm/HgSever bradycardia >120 b/mPronounced 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
12How 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 measurementhematocrit (red blood cell count)clotting factors in the blood
13Prevention of PPH Ante partum Complete history-----to identify high risk pt who are likely to develop PPHImprove health status especially to rise hgHospital delivery of high risk pt who develop polyhydramnios, multiple pregnancy, sever anemiaRoutine blood grouping
14Intrapartum PPH Careful administration of sedatives Avoid hasty delivery of the infantProphylactic administration of oxytocinAvoid massaging the uterus before separation of placentaExamine the utero –vaginal canal for traumaEffective management of the fourth stage of labor
16The 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 uterusexamination of the uterus and other pelvic tissuespacking the uterus with sponges and sterile materials (to compress the bleeding area in the uterus)tying-off of bleeding blood vesselslaparotomy - 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
17Observation of the mother Record pulse, BP, every 15 minPalpate uterus every 15 min ----contractionCheck temp /4 hrsExamine lochia for amount & consistencyExamine IV infusionHourly urine outputIntake &output chartRelive anxietyAdminister prophylactic antibiotic
18Uterotonic 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
19Technique 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.
20Nursing management Assess pt Identify risk group: Vital sign State of the uterusNatural of bleedingS&S of blood losscompare laboratory report
21Nursing intervention: If atonicInform obstFeel the consistency of the uterusMassage the uterusAssess the physical conditionMonitor TPR &BPPut the infant on breastPrepare the instrument
22Administer oxytocinStart IV infusionEmpty bladderExamine placentaReassure the motherIn trumatic:press on the tear or lacerationPrepare the equipment
23Secondary post partum hg Commonly occur 10-14day PPCommon cause:retained bit of cotyledonSeparation of slough exposing a blood vesselsSub involution at the placental sit
24S&S Sudden episode of bleeding Sub involution Sepsis Anemia Management:ReassuranceMonitor TPRIV, empty bladder, give medication
25Puerperal 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 painFever 38.5Abnormal vaginal dischargeFoul odor &sub involution
26Microorganisms commonly involved in PPGTI Gram positiveGram negativeMicroorganism that sexually transmitted
27Risk factors for PP infection Related to general infection riskRelated to labor and deliveryRelated to operative risk factors