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Chapter 17 Postpartum Complications Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1
Effects of Hemorrhage Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 2
Objectives Define key terms listed. List three major causes of postpartum hemorrhage. Identify nursing interventions in the care of the woman with postpartum hemorrhage. Describe the dangers that deep vein thrombosis presents. Explain the nursing care of a woman who has a thromboembolism. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 3
Common Postpartum Complications Hemorrhage Thromboembolic disorders Subinvolution of uterus Infections Depression Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 4
Postpartum Hemorrhage Blood loss of More than 500 mL after uncomplicated vaginal birth 1000 mL after a cesarean birth Can occur Early (first 24 hours after delivery) Late (between 24 hours and 6 weeks after birth) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 5
Causes of Postpartum Hemorrhage Early: uterine atony and laceration Late: retained placental fragment or subinvolution Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 6
Management of Hypovolemic Shock Recognize specific cause Stop blood loss Start IV fluids Monitor vital signs Provide supplemental oxygen Insert indwelling Foley catheter Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 7
Early Postpartum Hemorrhage Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 8
Uterine Atony and Causes Inability of myometrium muscle to contract and stay contracted around open blood vessels Mechanical factors include Retained placental fragments Large blood clots Extreme uterine distention (multifetal) Full urinary bladder Metabolic factors Muscle exhaustion due to lactic acid buildup Hypocalcemia Drugs Magnesium sulfate Calcium channel blockers Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 9
Trauma and Lacerations Includes vaginal, cervical, and perineal Suspect when excessive bleeding occurs and uterus is firm Vaginal bleeding typically bright red Lochia is dark red, not profuse or continuous Monitor for signs of shock Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 10
Retained Placenta Prevents uterus from contracting effectively Oxytocics given to expel fragments of placenta May require D&E to remove remaining fragments Placenta accreta may result in profuse bleeding and may require hysterectomy Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 11
Hematoma May result from injury to blood vessels in perineum or vagina If in soft tissue, will typically see bulging, bluish mass Can contain between 250 and 500 mL of blood Perineal pain is a distinguishing characteristic May not be able to void or defecate Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 12
Late Postpartum Hemorrhage Typically a result of subinvolution Could be caused by a vascular area, retained placental fragments, infection Fundus may appear higher than expected with persistent lochia rubra Infection may manifested by a foul odor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 13
Subinvolution of the Uterus Occurs when uterus fails to return to its nonpregnant size May result from Small retained placental fragment Mild endometritis Excessively vigorous massage Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 14
Disseminated Intravascular Coagulation (DIC) Clotting and anticoagulation stimulation occur at the same time Release of thromboplastin uses up available fibrinogen and platelets Results in profuse bleeding and intravascular clotting Often secondary condition associated with Abruptio placentae Gestational hypertension Missed abortion Fetal demise Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 15
Signs of DIC Oozing from IV insertion site Petechiae Ecchymosis Oliguria Restlessness In pregnancy and early postpartum, shock is considered late sign of DIC Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 16
Von Willebrand’s Disease Inherited disorder Decrease in plasma factor VIII (essential for proper platelet function) History of easy bruising, frequent nosebleeds, heavy menses Symptoms may be masked during pregnancy Hemorrhage from this disease is treated with cryoprecipitate to raise factor VIII levels in the blood Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 17
Anaphylactoid Syndrome of Pregnancy Known as amniotic fluid embolism Caused by unanticipated entrance of amniotic fluid into maternal circulation Triggers release of mediators that cause pulmonary artery vasospasm and hypoxia Can lead to myocardial damage, especially in the left side of the mother’s heart Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 18
Prevention of Hemorrhage Prophylactic administration of uterotonic drugs (oxytocin) after placenta delivered Early clamping of cord and assisted delivery of placenta Massage of uterine fundus Observation for and prevention of bladder distention Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 19
Assessment and Management of Postpartum Hemorrhage Monitor vital signs, I&O, level of consciousness Weigh peripads (1 g = 1 mL of blood) Massage fundus until firm; express clots Medications may be required to stop the bleeding Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 20
Thrombophlebitis and Thromboembolism Thrombophlebitis: inflammation of inner blood vessel wall with a blood clot attached to it When clot tears away from vessel wall and moves into blood circulation, it is called a thrombus If ends up in lungs, it is a pulmonary embolus, a common postpartum complication Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 21
Assessment and Nursing Care Subjective signs of pain on palpation of calves and when foot is passively dorsiflexed May be indicative of Homans’ sign Can have a deep vein thrombosis (DVT) in absence of Homans’ sign Compare pulses and size in both lower extremities May note increased diameter of 1 leg from edema due to venous inflammation If pain extends above knee, it is indicative of DVT Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 22
Management Superficial venous thrombosis Rest Antiembolism stockings Analgesics for comfort Elevation of leg Frequent ambulation to help prevent clots DVT Anticoagulation therapy Monitoring of serum for clotting factors (i.e., PT, PTT, INR) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 23
Pulmonary Embolism 1 of 3 leading causes of maternal death (others are hemorrhage and gestational hypertension) Embolism can occlude vessel and obstruct blood flow into lungs Embolectomy may be required What are the signs and symptoms? Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 24
Risk Factors for Postpartum Hemorrhage Risk factors for postpartum hemorrhage include: Hydramnios Bladder distention Macrosomia Uterine atony Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 25
Audience Response System Question 1 This type of embolism can cause significant damage to the heart of a postpartum woman. A.Pulmonary fluid B.Cerebral C.Amniotic fluid D.Aortal Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 26
Puerperal Infections/Depression Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 27
Objectives List four common sites for puerperal infection. Describe predisposing factors for infections of the reproductive system. Discuss the nursing care of a woman who has an infected episiotomy. Compare postpartum blues with postpartum psychosis. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 28
Puerperal Sepsis Puerperal infection (fever) Bacterial infections arising in genital tract after delivery Infections other than genital tract Mastitis Urinary tract infection Symptoms include Fever of 38° C (100.4° F) or higher after first 24 hours following delivery Fever persisting for at least 2 days within the first 10 days postpartum Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 29
Postpartum (Puerperal) Infection Associated risk factors Physiologic changes during pregnancy increase risk Labor: amniotic fluid, blood, lochia decrease acidity of vagina, thus increasing growth of pathogens; premature rupture of membranes Most women do not get an infection because of granulocytes in the lochia and endometrium Prevention Meticulous adherence to aseptic techniques, hand hygiene, and perineal care Minimize number of vaginal examinations Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 30
Endometritis Infection of endometrial lining, decidua, and adjacent myometrium of uterus Symptoms begin 2nd to 5th day postpartum Uterine tenderness and enlargement Foul odor or purulent lochia Malaise, fatigue, tachycardia Temperature elevation Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 31
Wound Infection Common in women with history of chorioamnionitis, intraamniotic infection, hemorrhage, diabetes mellitus, and obesity Multiple vaginal examinations Most common sites Perineum Cesarean incision site Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 32
Assessment and Management REEDA Redness Edema Ecchymosis Discharge Approximation Necrotizing fasciitis is serious complication Blue discoloration and numbness of wound edges Aggressive treatment is essential Patients with chorioamnionitis and endometritis are at risk for septic shock Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 33
Urinary Tract Infection and Pyelonephritis Can occur after birth from hypotonia of bladder, urinary stasis, birth trauma, catheterization, frequent vaginal examinations, or epidural anesthesia Symptoms: dysuria, frequency, urgency, and low- grade fever Pyelonephritis: the above symptoms plus Costovertebral angle tenderness, chills, fever, malaise, hematuria, nausea, and vomiting Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 34
Mastitis Usually occurs around 2 to 3 weeks after birth Interlobular connective tissue of 1 breast usually involved Painful or tender localized hard mass; reddened area Fever, chills, and malaise Causes Milk stasis Nipple trauma Poor breastfeeding technique Inadequate handwashing Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 35
Care of Mastitis Antibiotics In many cases, can continue to breastfeed from both breasts Ice or warm packs Moist heat promotes comfort and increases circulation Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 36
Postpartum Blues Transient state; rarely lasts more than 10 to 14 days May complain of feeling overwhelmed and unable to cope, and may be oversensitive with periods of unexplained tearfulness Treatment: rest, anticipatory guidance, empathy, reassurance, support, and assistance Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 37
Postpartum Depression Includes general signs of depression such as weight loss, sleeplessness, and ambivalence Women at high risk Have unstable or abusive family environment History of previous depressive episode History of limited support system Low self-esteem Dissatisfaction with education, economics, or partner Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 38
Postpartum Psychosis Similar to other psychoses Early signs of depression or may start abruptly within 3 weeks following birth Confusion, restlessness, anxiety, and suicidal thoughts Delusional thoughts may be expressed Safety of woman and her newborn are at risk Psychiatric interventions, including medications Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 39
The Nurse’s Role Provide support and referral Encourage woman to express feelings, provide validation, address personal conflicts, and reinforce personal power and autonomy A woman’s culture, experiences, and coping strategies influence her adjustment to becoming a mother Above all, listen to what the woman is saying, verbally and with her body language Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 40
Discussion What type of infection typically begins 2 to 5 days postpartum? A.Endometritis B.Mastitis C.Pyelonephritis D.Chorioamnionitis Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 41
Review Key Points Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 42
Chapter 10 Nursing Care of Women with Complications After Birth.
Chapter 33 Postpartum Complications Mosby items and derived items © 2012, 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
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Postpartum Hemorrhage(PPH) 产后出血 林建华. Major causes of death for pregnancy women （ maternal mortality) Postpartum hemorrhage （ 28%) heart diseases pregnancy-induced.
Post Partum Hemorrhage PPH. Definition: Blood loss in excess of 500 ml with vaginal delivery or in excess of 1000 ml following delivery by caesarian.
Puerperal fever IG: Sio Cheong Un IG: Sio Cheong Un 2011/4/4 2011/4/4.
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SALAH M.OSMAN CLINICAL MD. * It is an excessive blood loss from the genital tract after delivery of the foetus exceeding 500 ml or affecting the general.
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FEVER AFTER LABOR Dianne MP Graham, MD, CCFP Kelowna, BC, Canada Based on WHO Document on Managing Complications In Pregnancy, 2000.
Puerperium Dr. Yasir Katib MBBS, FRCSC Perinatologest.
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