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.

4. Routine care for the postpartum woman: Educate about danger signs (1) Vaginal bleeding: More than 2 or 3 pads soaked in 20- 30 minutes after delivery, OR Bleeding increases rather than decreases after delivery

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

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

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

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

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

10. The causes of postpartum hemorrhage can be thought of as the four Ts: Etiology of PPH  t one,  t issue,  t rauma,  t hrombin

11. 11 of 34 Postpartum Hemorrhage Etiology and risk factors (1)  Uterine atony Marked hypotonia of uterus Marked hypotonia of uterus Leading cause of PPH, complicating approximately 1 in 20 births Leading cause of PPH, complicating approximately 1 in 20 births Brisk venous bleeding with impaired coagulation until the uterine muscle contracts Brisk venous bleeding with impaired coagulation until the uterine muscle contracts

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

13.   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. Management of uterine atony

14. 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. Management of uterine atony

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 Should be suspected if bleeding continues with a firm, contracted fundus Includes perineal and cervical lacerations as well as pelvic hematomas Includes perineal and cervical lacerations as well as pelvic hematomas 16 of 34

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

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

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

20. 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. Postpartum Hemorrhage Etiology and risk factors (2) Postpartum Hemorrhage Etiology and risk factors (2) UTERINE RUPTURE

21. 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. Postpartum Hemorrhage Etiology and risk factors (2) Postpartum Hemorrhage Etiology and risk factors (2) UTERINE RUPTURE

22. 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, Postpartum Hemorrhage Etiology and risk factors (2) Postpartum Hemorrhage Etiology and risk factors (2) UTERINE RUPTURE

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

24. 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. Management of Rupture Uterus

25.   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. Management of Rupture Uterus

26.   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. Management of Rupture Uterus

27.   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. Management of Rupture Uterus

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 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 Adherent retained placenta – may be caused by implantation into defective endometrium 29 of 34

30. Postpartum Hemorrhage Etiology and risk factors (3)  Three classifications of adherent retained placenta Placenta acreta – slight penetration Placenta acreta – slight penetration of myometrium by placental trophoblast Placenta increta – deep penetration Placenta increta – deep penetration of myometrium by placenta of myometrium by placenta Placenta percreta – perforation of uterus 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) 30 of 34

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 31 of 34

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 33 of 34

34. 34 of 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 Measurements during first 2 hours may identify trends related to blood loss  Bladder distension  Laboratory studies of hemoglobin and hematocrit levels

35.  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 Hypotonic uterus – examine for retained placental fragments, medications, surgical interventions Bleeding with a contracted uterus – identify and treat underlying cause Bleeding with a contracted uterus – identify and treat underlying cause Uterine inversion – emergency replacement of the uterus into the pelvic cavity Uterine inversion – emergency replacement of the uterus into the pelvic cavity Subinvolution – medications, surgical intervention Subinvolution – medications, surgical intervention 35 of 34 Postpartum Hemorrhage Care Management

36. 36 of 34  Plan of care and implementation  Nursing interventions Vital signs, uterine assessment, medication administration, notification of primary care provider Vital signs, uterine assessment, medication administration, notification of primary care provider Providing explanations about interventions and need to act quickly Providing explanations about interventions and need to act quickly Once stable, ongoing post partum assessments and care Once stable, ongoing post partum assessments and care Instructions in increasing dietary iron, protein intake, and iron supplementation Instructions in increasing dietary iron, protein intake, and iron supplementation May need assistance with infant care and household activities until strength regained May need assistance with infant care and household activities until strength regained Postpartum Hemorrhage Care Management

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  g   Syntocinon infusion (30 units in 500 ml)   IM Carboprost (500  g)   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 I. I. At laparotomy, direct intramyometrial injection of Carboprost (Haemabate) 0.5mg II. II. Bilateral ligation of uterine arteries III. III. Bilateral ligation of internal iliac (hypogastric arteries) IV. IV. 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 45 of 34

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. 47 of 34 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 Removal of fetus Treatment for infection Treatment for infection Preeclampsia or eclampsia Preeclampsia or eclampsia Removal of placental abruption Removal of placental abruption

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

49. 49 of 34 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 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!! 51 of 34

52. Thank you!