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The Postpartum Period Puerperium = fourth trimester of pregnancy - the 6-week interval between the birth of the newborn and the return of the reproductive.

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Presentation on theme: "The Postpartum Period Puerperium = fourth trimester of pregnancy - the 6-week interval between the birth of the newborn and the return of the reproductive."— Presentation transcript:

1 The Postpartum Period Puerperium = fourth trimester of pregnancy - the 6-week interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state

2 Uterine Involution Uterine Involution: Uterine fundal descent:
return of the uterus to its pre-pregnancy size and condition, which begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle Uterine fundal descent: immediately after birth uterus is in the midline approximately 2 cm below the level of the umbilicus, size of grapefruit (like 16 weeks of gestation), weighs approximately 1000 g. Within 12 hours the fundus may be approximately 1 cm above the umbilicus During next few days the fundus descends 1 to 2 cm (fingerbreadth) every 24 hours. By the sixth postpartum day the fundus is normally located halfway between the umbilicus and the symphysis pubis. A week after birth the uterus once again lies in the true pelvis. After the ninth postpartum day the uterus should not be palpable abdominally.

3 Uterine Involution Increased estrogen and progesterone levels are responsible for stimulating the massive growth of the uterus during pregnancy. Prenatal uterine growth results from both hyperplasia, an increase in the number of muscle cells, and from hypertrophy, an enlargement of the existing cells. Postpartally, the decrease in these hormones causes autolysis, the self-destruction of excess hypertrophied tissue. The additional cells laid down during pregnancy remain and account for the slight increase in uterine size after each pregnancy. Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection.

4 Lochia Assessment Lochia–vaginal discharge after childbirth.
It takes 6 weeks for the vagina to regain its pre-pregnancy contour. For the first 2 hours after birth the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochia flow should steadily decrease. Lochia: rubra, serosa or alba Assessment of lochia includes noting color, presence and size of clots and foul odor. Day lochia rubra (blood with small pieces of decidua and mucus)                                Day – lochia serosa (pink or pinkish brown serous exudate with old blood, cervical mucus, erythrocytes and leukocytes, tissue debris) Day lochia alba (yellowish white discharge with leucocytes, decidua, epithelian cells, mucus, serum, bacteria) The amount of lochia is usually less after cesarean births. Flow of lochia usually increases with ambulation and breastfeeding and receives an oxytocin medication

5 LOCHIAL AND NONLOCHIAL BLEEDINGLOCHIAL BLEEDINGNONLOCHIAL BLEEDING
Lochia usually trickles from the vaginal opening. The steady flow is greater as the uterus contracts A gush of lochia may result as the uterus is massaged. If it is dark in color, it has been pooled in the relaxed vagina, and the amount soon lessens to a trickle of bright red lochia (in the early puerperium). Bleeding If the bloody discharge spurts from the vagina, there may be cervical or vaginal tears in addition to the normal lochia. If the amount of bleeding continues to be excessive and bright red, a tear may be the source.

6 Cervix The cervix is soft immediately after birth.
By 18 hours postpartum it has shortened, become firm, and regained its form. The cervix up to the lower uterine segment remains edematous, thin, and fragile for several days after birth. The ectocervix (portion of the cervix that protrudes into the vagina) appears bruised and has some small lacerations—optimal conditions for the development of infection. The cervical os, which dilated to 10 cm during labor, closes gradually. Two fingers may still be introduced into the cervical os for the first 4 to 6 days postpartum; however, only the smallest curette can be introduced by the end of 2 weeks. The external cervical os never regains its prepregnant appearance; it is no longer shaped like a circle but appears as a jagged slit that is often described as a "fishmouth." Lactation delays the production of cervical and other estrogen-influenced mucus and mucosal characteristics.

7 VAGINA AND PERINEUM Vagina Perineum
vaginal mucosa is thin, atrophic, with decrease amount of lubrication and without rugae as a result of estrogen deprivation which lead to coital discomfort (dyspareunia) until ovarian function returns and menstruation resumes. The greatly distended, smooth-walled vagina gradually returns to its prepregnancy size by 6 to 8 weeks after childbirth. Rugae reappear by approximately the fourth week, but they are never as prominent as they are in the nulliparous woman. Most rugae are permanently flattened. Perineum the introitus is erythematous and edematous, especially in the area of the episiotomy or laceration repair. It is barely distinguishable from that of a nulliparous woman Episiotomy. Most episiotomies are visible only if the woman is lying on her side with her upper buttock raised or if she is placed in the lithotomy position. Hemorrhoids (anal varicosities) are commonly seen. Internal hemorrhoids may evert while the woman is pushing during birth. Women often experience associated symptoms such as itching, discomfort, and bright red bleeding with defecation. Hemorrhoids usually decrease in size within 6 weeks of childbirth.

8 Endocrine System Placental hormones (human chorionic somatomammotropin, estrogens, cortisol, and the placental enzyme insulinase) dramatically decrease and reverse the diabetogenic effects of pregnancy, resulting in significantly lower blood sugar levels in the immediate puerperium. Estrogen and progesterone levels drop markedly after expulsion of the placenta and reach their lowest levels 1 week postpartum. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy. In nonlactating women, estrogen levels begin to rise by 2 weeks after birth and by postpartum day 17 are higher than in women who breastfeed β-Human chorionic gonadotropin disappears from maternal circulation in 14 days

9 Endocrine System Pituitary hormones and ovarian function
The persistence of elevated serum prolactin levels in breastfeeding women appears to be responsible for suppressing ovulation. Because levels of follicle-stimulating hormone (FSH) have been shown to be identical in lactating and nonlactating women, it is thought that the ovulation is suppressed in lactating women because the ovary does not respond to FSH stimulation when increased prolactin levels are present Prolactin levels in blood rise progressively throughout pregnancy. In nonlactating women, prolactin levels decline after birth and reach the prepregnant range in 4 to 6 weeks In breastfeeding woman prolactin levels remain elevated into the sixth week after birth, and influence by the frequency of breastfeeding, the duration of each feeding, and the degree to which supplementary feedings are used. Ovulation occurs as early as 27 days after birth in nonlactating women, with a mean time of 70 to 75 days. Approximately 70% of nonbreastfeeding women resume menstruating by 3 months after birth. In women who breastfeed, the mean length of time to initial ovulation is 17 weeks. In lactating women, both resumption of ovulation and return of menses are determined in large part by breastfeeding patterns. Many women ovulate before their first postpartum menstrual period occurs; thus there is need to discuss contraceptive options early in the puerperium. The first menstrual flow after childbirth is usually heavier than normal. Within three to four cycles the amount of menstrual flow returns to the woman's prepregnancy volume

10 BREASTS Promptly after birth, there is a decrease in the concentrations of hormones (i.e., estrogen, progesterone, hCG, prolactin, cortisol, and insulin) that stimulated breast development during pregnancy. The time it takes for these hormones to return to prepregnancy levels is determined in part by whether the mother breastfeeds her infant. BREASTFEEDING MOTHERS As lactation is established, a mass (lump) may be felt in the breast. Unlike the lumps associated with fibrocystic breast disease or cancer (which may be consistently palpated in the same location), a filled milk sac shifts position from day to day. Before lactation begins, the breasts feel soft and a yellowish fluid, colostrum, can be expressed from the nipples. After lactation begins, the breasts feel warm and firm. Tenderness may persist for approximately 48 hours after the start of lactation. Bluish-white milk with a skim-milk appearance (true milk) can be expressed from the nipples. The nipples are examined for erectility and signs of irritation such as cracks, blisters, or reddening. NONBREASTFEEDING MOTHERS The breasts generally feel nodular in contrast to the granular feel of breasts in nonpregnant women. The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. Colostrum is present for the first few days after childbirth. Palpation of the breast on the second or third day, as milk production begins, may reveal tissue tenderness in some women. On the third or fourth postpartum day, engorgement may occur. The breasts are distended (swollen), firm, tender, and warm to the touch (because of vasocongestion). Breast distention is caused primarily by the temporary congestion of veins and lymphatics rather than by an accumulation of milk. Milk is present but should not be expressed. Axillary breast tissue (the tail of Spence) and any accessory breast or nipple tissue along the milk line may be involved. Engorgement resolves spontaneously, and discomfort decreases usually within 24 to 36 hours. A breast binder or tight bra, ice packs, or mild analgesics may be used to relieve discomfort. Nipple stimulation is avoided. If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.

11 Fourth Stage of Labor Goal of nursing care is to assist woman and their partners during their initial transition to parenting Nursing's role is to monitor the recovery of the new mother and infant, to identify and manage promptly any deviations from the normal processes that may occur, and to promote and support parent-infant attachment

12 Fourth Stage of Labor First 1 to 2 hours after birth
During this time, maternal organs undergo their initial readjustment to the nonpregnant state and the functions of body systems begin to stabilize. Meanwhile, the newborn continues the transition from intrauterine to extrauterine existence Excellent time to begin Breastfeeding Encouraging of the mother Colostrum prompting elimination of meconium

13 Care in the Immediate Postpartum Period
Assessment During first hour every 15 minutes During second hours every 30 minutes VS (Ps, BP, T) fundal height and firmness bladder distension amount of lochia presence of edema status of perineum, Postanesthesia recovery (every 15 min) Activity Respiration BP Level of cosciousness Color general anesthesia Awake, alert, orient to time, place, and person, respiratory rate, oxygen saturation levels at least 95%, as measured by a pulse oximeter epidural or spinal anesthesia should be able to raise her legs, extended at the knees, off the bed, or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed. The numb or tingling, prickly sensation should be entirely gone from her legs. Often, it takes 1.5 to 2 hours for these anesthetic effects to disappear. Providing comfort measures Analgesics Promoting bladder elimination Providing fluid and food

14 Nursing Care After Cesarean Birth
Same as with normal vaginal delivery except Postanesthesia recovery Monitoring of abdominal dressing Urinary catheter Respiratory care Prevention of thrombophlebitis Interventions for pain Slide 14

15 Postpartum Physical Assessment
B - breast U - uterus B - bowels B - bladder L - lochia E - episiotomy

16 General Assessment Enter the room quietly, speak quietly.
Wash hands and provide for privacy. Inform patient before turning on lights. Note LOC, activity level, position, color, general demeanor. Take note of the total environment: Safety/patient considerations Note equipment and medical devices

17 Breast Assessment Breasts: Soft, engorged, filling, swelling, redness, tenderness. Nipples: Inverted, everted, cracked, bleeding, bruised, presence of colostrum or breastmilk. Colostrum–yellowish fluid rich in antibodies and high in protein. Engorgement occurs by day 3 or 4. Due to vasoconstriction as milk production begins Lactation ceases within a week if breastfeeding is never begun or is stopped.

18 Nipple soreness is a portal of entry for bacteria - breast infection (Mastitis).
Maternal after pains: may be due to breastfeeding and multiparity Always stay with the client when getting out of bed for the first time – hypotension effect and excess bleeding When assessing fundal height, if you notice any discrepancies in fundal height have patient void and then reassess.

19 Assessing Uterine Fundus
Location in relation to umbilicus Degree of firmness Is it at Midline or deviated to one side? Bladder Full? A boggy uterus may indicate uterine atony or retained placental fragments. Boggy refers to being inadequately contracted and having a spongy rather than firm feeling.

20 Massaging the Fundus Every 15 mins during the 1st hr, every 30 mins during the next hr, and then, every hr until the patient is ready for transfer. Document fundal height. Evaluate from the umbilicus using fingerbreadths. This is recorded as 2 fingers below the umbilicus (U/2), one finger above the umbilicus (1/U), and so forth. The fundus should remain in the midline. If it deviates from the middle- distended bladder.

21 Uterine Atony Lack of muscle tone in the cervix.
Uterus feels soft and boggy The bladder has increased capacity and decreased muscle tone.  This leads to over-distension of the bladder, incomplete emptying of bladder, retention of residual urine and increased risk of UTI and postpartum hemorrhage.

22 Bowels & Bladder When was the patients last bowel movement?
Is she passing flatus? (gas) Assess for bowel sounds Voiding pattern - without difficulty/pain, urine may be blood tinged from lochia Nursing interventions: Assist to the bathroom. Use measures to encourage voiding (privacy). Encourage use of peri-bottle with warm water, fluids, fiber, frequent ambulation, stool softeners; teach effects of pain medication.

23 Urinary System A full bladder can displace the uterus and lead to postpartum hemorrhage In the woman who voids frequently, small amounts of urine may have increased residual urine because her bladder does not empty completely Residual urine in the bladder may promote the growth of microorganisms Slide 23

24 Lochia: Pad Count Scant: 1-inch stain on pad in 1 hour
Light/small: 4 inches in 1 hour Moderate: 6 inches in 1 hour Heavy/large: Pad saturated in 1 hour Excessive: Pad saturated in 15 min Can estimate blood loss by weighing pads: 500 mL = 1 lb. or 454 g

25 Episiotomy/Perineal Assessment
Patient in lateral Sims (side lying) position. Use the acronym REEDA Redness, Edema, Ecchymosis, Discharge, Approximation of suture lines “edges of episiotomy”) to guide assessment. Even if there is no episiotomy, the perineum should still be assessed. Nursing care and patient teaching Cold packs Topical and systemic medications Nonpharmacologic pain relief methods Unusual perineal discomfort may be a symptom of impending infection or hematoma. Hemorrhoids ?

26 Episiotomy Pain Relief
Instruct Mother: Tighten her buttocks and perineum before sitting to prevent pulling on the episiotomy and perineal area and to release tightening after being seated. Rest several times a day with feet elevated. Practice Kegel exercise many times a day to increase circulation to the perineal area and to strengthen the perineal muscles.

27 Postpartum Physical Assessment
B - breast U - uterus B - bowels B - bladder L - lochia E - episiotomy

28 Routine care for the postpartum woman: Educate about danger signs (1)
Vaginal bleeding: More than 2 or 3 pads soaked in minutes after delivery, OR Bleeding increases rather than decreases after delivery Notes to the facilitator: Present slides and briefly resume the danger signs that indicate a postpartum woman may be having a complication. Emphasize the importance of educating women and their partners about danger signs so that they can recognize them in a timely fashion.

29 Routine care for the postpartum woman: Educate about danger signs (2)
Severe abdominal pain Fever and too weak to get out of bed

30 Routine care for the postpartum woman: Educate about danger signs (3)
Fast or difficult breathing Severe headache, blurred vision Convulsions

31 Routine care for the postpartum woman: Educate about danger signs (4)
Pain in the perineum or draining pus Foul-smelling lochia Dribbling of urine or pain on micturition

32 Routine care for the postpartum woman: Educate about danger signs (5)
The woman doesn’t feel well. Breasts swollen, red or tender breasts, or sore nipples

33 Postpartum Hemorrhage (PPH)
Definition and incidence PPH traditionally defined as loss of more than: 500 ml of blood after vaginal birth 1000 ml after cesarean birth Cause of maternal morbidity and mortality Life-threatening with little warning Often unrecognized until profound symptoms

34 Etiology of PPH tone, tissue, trauma, thrombin
The causes of postpartum hemorrhage can be thought of as the four Ts: tone, tissue, trauma, thrombin

35 Postpartum Hemorrhage Etiology and risk factors (1)
Uterine atony Marked hypotonia of uterus Leading cause of PPH, complicating approximately 1 in 20 births Brisk venous bleeding with impaired coagulation until the uterine muscle contracts 35 of 34

36 Postpartum Hemorrhage Etiology and risk factors (1)
Uterine atony Multiple gestation, high parity, prolonged labor chorioamnionitis, augmented labor, tocolytic agents

37 Management of uterine atony
Explore the uterine cavity. Inspect vagina and cervix for lacerations. If the cavity is empty, Massage and give methylergonovine 0.2 mg, the dose can be repeated every 2 to 4 hours. Rectal 800mcg. Misoprostol is beneficial.

38 Management of uterine atony
During the administration of uterotonic agents, bimanual compression may control hemorrhage. The physician places his or her fist in the vagina and presses on the anterior surface of the uterus while an abdominal hand placed above the fundus presses on the posterior wall. This while the Blood for transfusion made available.

39 Complications of Puerperium
Uterine Atony (Cont’d) Treatment Uterine compression Oxytocics Early suckling causes endogenous release of oxytocin Oxytocin IV/IM 10 units Methylergonovine Methyl prostoglandin F

40 Postpartum Hemorrhage Etiology and risk factors (2)
Lacerations of genital tract Should be suspected if bleeding continues with a firm, contracted fundus Includes perineal and cervical lacerations as well as pelvic hematomas 40 of 34

41 Lacerations and trauma
Postpartum Hemorrhage Etiology and risk factors (2) Lacerations and trauma  Unplanned Vaginal/cervical tear, surgical trauma  Planned Cesarean section, episiotomy

42 Postpartum Hemorrhage Genital tract lacerations Management
Genital trauma always must be eliminated first if the uterus is firm.

43 Postpartum Hemorrhage Etiology and risk factors (2) UTERINE RUPTURE
Rupture of the uterus is described as complete or incomplete and should be differentiated from dehiscence of a cesarean section scar.

44 Postpartum Hemorrhage Etiology and risk factors (2) UTERINE RUPTURE
The reported incidence for all pregnancies is 0.05%, After one previous lower segment cesarean section 0.8% After two previous lower segment cesarean section is 5% all pregnancies following myomectomy may be complicated by uterine rupture.

45 Postpartum Hemorrhage Etiology and risk factors (2) UTERINE RUPTURE
Complete rupture describes a full-thickness defect of the uterine wall and serosa resulting in direct communication between the uterine cavity and the peritoneal cavity.

46 Postpartum Hemorrhage Etiology and risk factors (2) UTERINE RUPTURE
Incomplete rupture describes a defect of the uterine wall that is contained by the visceral peritoneum or broad ligament. In patients with prior cesarean section,

47 Postpartum Hemorrhage Etiology and risk factors (2) UTERINE RUPTURE
dehiscence describes partial separation of the scar with minimal bleeding, with the peritoneum and fetal membranes remaining intact.

48 Management of Rupture Uterus
The identification or suspicion of uterine rupture must be followed by an immediate and simultaneous response from the obstetric team. Surgery should not be delayed owing to hypovolemic shock because it may not be easily reversible until the hemorrhage is controlled.

49 Management of Rupture Uterus
Upon entering the abdomen, aortic compression can be applied to decrease bleeding. Oxytocin should be administered to effect uterine contraction to assist in vessel constriction and to decrease bleeding. Hemostasis can then be achieved by ligation of the hypogastric artery, uterine artery, or ovarian arteries.

50 Management of Rupture Uterus
At this point, a decision must be made to perform hysterectomy or to repair the rupture site. In most cases, hysterectomy should be performed. In selected cases, repair of the rupture can be attempted. When rupture occurs in the body of the uterus, bladder rupture must be ruled out by clearly mobilizing and inspecting the bladder to ensure that it is intact. This avoids injury on repair of the defect as well.

51 Management of Rupture Uterus
A lower segment lateral rupture can cause transection of the uterine vessels. The vessels can retract toward the pelvic side wall, and the site of bleeding must be isolated before placing clamps to avoid injury to the ureter and iliac vessels. Typically, longitudinal tears, especially those in a lateral position, should be treated by hysterectomy, whereas low transverse tears may be repaired.

52 Trauma-Second most common cause of early postpartum hemorrhage
Lacerations – suspect this in the birth canal if uterine bleeding continues with a contracted fundus Hematomas- bleeding into loose connective tissue as the vulva or vagina Vulva- discolored bulging mass Surgical excision if they are large & ligation

53 Postpartum Hemorrhage Etiology and risk factors (3)
Retained placenta Nonadherent retained placenta – managed by manual separation and removal by the primary care provider Adherent retained placenta – may be caused by implantation into defective endometrium 53 of 34

54 Postpartum Hemorrhage Etiology and risk factors (3)
Three classifications of adherent retained placenta Placenta acreta – slight penetration of myometrium by placental trophoblast Placenta increta – deep penetration of myometrium by placenta Placenta percreta – perforation of uterus by placenta Patient will experience profuse bleeding when delivery of the placenta is attempted. Management includes blood replacement and surgical intervention (hysterectomy) 54 of 34

55 Postpartum Hemorrhage Etiology and risk factors (4)
Inversion of uterus (turning inside out) May be life-threatening A complete inversion protrudes out of the vagina Primary signs – hemorrhage, shock, pain Prevention is the best measure – don’t pull on the umbilical cord unless there is definite separation of the placenta 55 of 34

56 Postpartum Hemorrhage Etiology and risk factors4
Inversion of uterus (turning inside out)

57 Postpartum Hemorrhage Etiology and risk factors (5)
Subinvolution of uterus – delayed involution of the uterus Usually see late post partum bleeding Causes include retained placental fragments and infection 57 of 34

58 Postpartum Hemorrhage Care Management
Assessment Bleeding assessed for color and amount Perineum inspected for signs of lacerations or hematomas to determine source of bleeding Vital signs may not be reliable indicators because of postpartum adaptations Measurements during first 2 hours may identify trends related to blood loss Bladder distension Laboratory studies of hemoglobin and hematocrit levels 58 of 34

59 Postpartum Hemorrhage Care Management
Plan of care and implementation Initial treatment – fundal massage, expression of clots, relief of bladder distension, IV fluids Medical management Hypotonic uterus – examine for retained placental fragments, medications, surgical interventions Bleeding with a contracted uterus – identify and treat underlying cause Uterine inversion – emergency replacement of the uterus into the pelvic cavity Subinvolution – medications, surgical intervention 59 of 34

60 Postpartum Hemorrhage Care Management
Plan of care and implementation Nursing interventions Vital signs, uterine assessment, medication administration, notification of primary care provider Providing explanations about interventions and need to act quickly Once stable, ongoing post partum assessments and care Instructions in increasing dietary iron, protein intake, and iron supplementation May need assistance with infant care and household activities until strength regained 60 of 34

61 Guidelines by the Scottish Executive Committee of the RCOG
COMMUNICATE. RESUSCITATE. MONITOR / INVESTIGATE. STOP THE BLEEDING.

62 COMMUNICATE call 6 Call experienced midwife
Call obstetric registrar & alert consultant Call anaesthetic registrar , alert consultant Alert haematologist Alert Blood Transfusion Service Call porters for delivery of specimens / blood

63 RESUSCITATE IV access with 14 G cannula X 2 Head down tilt
Oxygen by mask, 8 litres / min Transfuse Crystalloid (eg Hartmann’s) Colloid (eg Gelofusine) once 3.5 litres infused, GIVE ‘O NEG’ If no cross-matched blood available OR give uncross-matched own-group blood, as available Give up to 1 liter Fresh Frozen Plasma and 10 units cryoprecipitate if clinically indicated

64 MONITOR / INVESTIGATE Cross-match 6 units Full blood count
Clotting screen Continuous pulse / BP / ECG / Oximeter Foley catheter: urine output CVP monitoring Discuss transfer to ITU

65 STOP THE BLEEDING Exclude causes of bleeding other than uterine atony
Ensure bladder empty Uterine compression IV syntocinon 10 units IV ergometrine 500 mg Syntocinon infusion (30 units in 500 ml) IM Carboprost (500 mg) Surgery earlier rather than late Hysterctomy early rather than late (GRADE B)

66 If conservative measures fail to control haemorrhage, initiate surgical haemostasis SOONER RATHER THAN LATER At laparotomy, direct intramyometrial injection of Carboprost (Haemabate) 0.5mg Bilateral ligation of uterine arteries Bilateral ligation of internal iliac (hypogastric arteries) Hysterectomy (GRADE C)

67 Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of placenta accreta or uterine rupture) (GRADE C)

68 Whole blood frequently is used for rapid correction of volume loss because of its ready availability, but component therapy is ideal. A general practice has been to transfuse 1 unit of fresh-frozen plasma for every 3 to 4 units of red cells given to patients who are bleeding profusely

69 Hemorrhagic (Hypovolemic) Shock
Emergency situation in which blood is diverted to the brain and heart May not see signs until post partum patient loses 30% to 40% of blood volume Medical management – restore circulating blood volume and treat underlying cause Nursing interventions – monitor tissue perfusion, see emergency box Fluid or blood replacement therapy 69 of 34

70 Prophylactic oxytocics should be offered routinely in the management of the third stage of labour as they reduce the risk of PPH by about 60%. (GRADE A)

71 Coagulopathies Idiopathic thrombocytopenic purpura (ITP) – decreased platelet life span, need to control platelet stability von Willebrand disease—type of hemophilia Disseminated intravascular coagulation (DIC) Pathologic clotting Correction of underlying cause Removal of fetus Treatment for infection Preeclampsia or eclampsia Removal of placental abruption 71 of 34

72 Acquired Congenital Coagulation disorders DIC,
dilutional coagulopathy, heparin Congenital Von Willebrand's disease

73 Thromboembolic Disease
Results from blood clot caused by inflammation or partial obstruction of vessel May be superficial or deep venous thrombosis or a pulmonary embolus Incidence and etiology Venous stasis Hypercoagulation Clinical manifestations – redness and swelling in the affected extremity, pain, positive Homan’s sign 73 of 34

74 Thromboembolic Disease Homan’s Sign
Press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot (dorsiflex)

75 Thromboembolic Disease
Medical management Superficial – analgesia, rest/elevation Deep – anticoagulant therapy, bedrest/elevation, Pulmonary embolus – IV heparin therapy Nursing interventions assessment of the affected area, signs of bleeding, personal care, medication administration Teach not to massage affected area!! 75 of 34

76 Postpartum Infections
Endometritis – malodorous lochia, fever (100.6), chills, abdominal pain, uterine tenderness, tachycardia and subinvolution The infection may spread to cause peritonitis and septic pelvic thrombophlebitis Treat with IV antibiotics Emotional support

77 Postpartum Infections
Puerperal sepsis: any infection of genital canal within 28 days after abortion or birth Most common infecting agents are numerous streptococcal and anaerobic organisms Endometritis Wound infections Urinary tract infections Mastitis 77 of 34

78 Complications of Puerperium
Fever UTI/Pyelonephritis DVT/Thrombophlebitis “Milk fever” (Lasts < 24 hours) Drug reaction Perineal infection(Day five) Pulmonary Atelectasis (48 hours) Mastitis (2-3 weeks post partum)

79 Postpartum Infections Endometritis

80 Postpartum Endometritis
Infection of the decidua (pregnancy endometrium) Incidence <3% after vaginal delivery 10-50% after cesarean delivery 5-15% after scheduled elective cesareans Risk Factors Prolonged labor, prolonged ROM, multiple vaginal exams, internal monitors, maternal DM, meconium, manual removal of placenta, low socioeconomic status

81 PP Endometritis Polymicrobial, ascending infection
Mixture of aerobes and anaerobes from genital tract BV and colonization with GBS increase likelihood of infection Clinical manifestations (occur within 5 days pp) Fever – most common sign Uterine tenderness Foul lochia Leukocytosis Bacteremia – in 10-20%, usually a single organism

82 PP Endometritis Workup CBC Blood cultures Urine culture
DNA probe for GC/chlamydia Imaging studies if no response to adequate abx in 48-72h CT scan abd/pelvis US abd/pelvis CT scan to exclude septic pelvic thrombophlebitis, ovarian vein thrombosis, phlegmon; US can be nl or show retained POC or intrauterine hematoma.

83 PP Endometritis Treatment Prevention Broad spectrum IV abx
Clindamycin 900mg IV q8h and Gentamicin 1.5mg/kg IV q8h Treat until afebrile for 24-48h and clinically improved; oral therapy not necessary Add ampicillin 2g IV q4h to regimen when not improving to cover resistant enterococci Prevention Abx prophylaxis for women undergoing C-section Cefazolin 1-2g IV as single dose

84 Postpartum Infections
Mastitis - A breast infection occurring 1-2 weeks after childbirth Engorgement and blocked mild duct increases risk Fever, localized breast pain, redness,warmth and inflammation Breastfeeding should continue Antibiotics Nurse's role is to support, educate and refer

85 Mastitis Infection of the lactating breast- 2nd or 3rd week after birth Caused by S. aureus, often on hands of mother or caregivers Can enter through a crack in the nipple Engorgement & stasis of milk frequently precede mastitis

86 Mastitis Continued SIGNS & SYMPTOMS: THERAPEUTIC MANAGEMENT
Feels like the flu with fatigue & aching muscles Fever of 101.1F Localized area of redness & inflammation THERAPEUTIC MANAGEMENT ATB & decompression of breast by breastfeeding or pumping Bedrest during acute phase Fluids & analgesics for discomfort

87 Postpartum Infections Mastitis
    Puerperal Mastitis usually caused by common skin bacteria particularly staphylococcus being introduced into the ductal system through

88 Postpartum Infections Mastitis
Breast infections may cause pain, redness, warmth of the breast along with the following symptoms: Tenderness and swelling Body aches Fatigue Breast engorgement Fever and chills Rigor or shaking

89 Postpartum Infections Mastitis
Most breast infections occur in breastfeeding women when bacteria enters the breast through cracks in the nipple. In severe infections, abscesses may occur. Antibiotics may be indicated for treatment.

90 Postpartum Infections Mastitis

91 Postpartum Infections Mastitis

92 Postpartum Infections Care Management
Prevention is the best intervention Hand washing Good maternal perineal hygiene Antibiotic administration Wound management Breast care 92 of 34

93 Sequelae of Childbirth Trauma
Disorders of uterus and vagina related to pelvic relaxation and urinary incontinence, are often result of childbearing Uterine displacement and prolapse Posterior displacement, or retroversion Retroflexion and anteflexion Prolapse a more serious displacement Cervix and body of uterus protrude through vagina and vagina is inverted 93 of 34

94 Sequelae of Childbirth Trauma Uterine prolapse
Uterine prolapse occurs when the uterus falls through the cervix (the connection between the uterus and the vagina) into the vagina. Symptoms and treatment depends on how much of the uterus has fallen into the vagina.

95 Sequelae of Childbirth Trauma Uterine prolapse

96 Sequelae of Childbirth Trauma Uterine prolapse

97 Sequelae of Childbirth Trauma Uterine prolapse

98 Sequelae of Childbirth Trauma Uterine prolapse

99 Sequelae of Childbirth Trauma
Cystocele and rectocele Cystocele: protrusion of bladder downward into vagina when support structures in vesicovaginal septum are injured Rectocele is herniation of anterior rectal wall through relaxed or ruptured vaginal fascia and rectovaginal septum Urinary incontinence 99 of 34

100 Sequelae of Childbirth Trauma Cystocele and rectocele

101 Sequelae of Childbirth Trauma Cystocele and rectocele

102 Sequelae of Childbirth Trauma Cystocele and rectocele

103 Sequelae of Childbirth Trauma Cystocele and rectocele

104 Sequelae of Childbirth Trauma Cystocele and rectocele

105 Sequelae of Childbirth Trauma Cystocele and rectocele

106 Sequelae of Childbirth Trauma
Genital fistulas May result from congenital anomaly, gynecologic surgery, obstetric trauma, cancer, radiation therapy, gynecologic trauma, or infection Vesicovaginal: between bladder and genital tract Urethrovaginal: between urethra and vagina Rectovaginal: between rectum or sigmoid colon and vagina 106 of 34

107 Types of Fistulas That May Develop in Vagina, Uterus, and Rectum


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