1. Postpartum Complications

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

3. Routine care for the postpartum woman: Health promotion and disease prevention (1)
Give Vitamin A 200,000 IU.
Provide preventive treatment for hookworm to prevent anemia in endemic areas.
Provide iron/folic acid supplementation for at least 30 days postpartum to prevent and treat anemia.
Notes to the facilitator:
Provide an interactive lecture on prophylactic treatments to provide to all women.

4. 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.

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

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

7. 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

8. 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

9. 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

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

11. 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

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

13. 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.

14. 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.

15. 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

16. 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

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

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

19. 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.

20. 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.

21. 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.

22. 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,

23. 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.

24. 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.

25. 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.

26. 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.

27. 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.

28. 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

29. 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
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30. 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)

31. 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

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

33. 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

34. 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

35. 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

36. 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

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

38. 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

39. 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

40. 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

41. 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)

42. 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)

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

44. 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

45. 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

46. 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)

47. 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

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

49. 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

50. 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)

51. 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!!

52. Thank you!