Postpartal Complications Usually a period of health but complications do occur. Woman at risk in...

Postpartal Complications

Usually a period of health but complications do occur.

Woman at risk in three points of view:

• Her own health

• Her future childbearing potential

• Her ability to bond with her new infant

Family is disrupted, hospital stay is longer, increased cost, difficult to cope.

Most complications are preventable, and if they do occur they can be treated.


Hemorrhage

Infection

Thrombophlebitis

Urinary System Disorders

Cardiovascular System Disorders

Reproductive System Disorders

Emotional and Psychological Complications


Assessment findings may be extremely subtle.

• Tenderness in calf of leg

• Slight increase in pain

• Slight elevation in temperature (serious 1st 24 hours)

• Slight increase in lochia

• Things that are more than usual

• Do not rely on the mother’s report, she wants to go home


Provide for measures that restore the woman quickly to health, and promote contact with her child and support person.

If she can not see the baby she needs contact by phone with the nursery. A photo of the infant, a note written about the progress as if from the baby.

1 in 500 develop depression and even psychosis.

Reinforcement is needed, support and remind that it is a temporary situation.

Postpartal Hemorrhage

Any blood loss from the uterus greater than 500 mL. within a 24 hour period.

Can occur early, within 24 hours or late, anytime after the first 24 hours during the remaining days of the 6 week puerperium.

4 main causes:

• Uterine atony

• Lacerations

• Retained placental fragments

• DIC disceminated intravascular coagulation


Uterine Atony:

• Relaxation of the uterus

• Most frequent cause of hemorrhage

• Uterus must remain in a contracted state to allow open vessels at the placental site to seal.

• Box 25.1 p. 695 list some factors.

– Multiple gestation, hydraminios, lg baby, myomas


Assessment:

• Abrupt gush of blood from placental site

• Lg. amount of vaginal bleeding

• Symptoms of shock and blood loss

• A saturated pad can hold 25 to 50 mL.

• Count pads to estimate blood loss(q 30 min)

• Weigh pads the subtract the difference (1 g weight equals 1 mL volume of blood.

• Turn woman on side to inspect for pooling beneath her.


Box 25.2 p. 696 outcomes and interventions• Palpate uterus; keep contracted, detecting

relaxation is 1st and most important assessment.

• Lochia • VSTreatment:• Uterine massage to encourage contraction• IV oxytocin – maintain uterine tone (10 to

40 U per 1000 mL of 5% dextrose) (1 hr.)• IM Methergine


Bimanual Massage:

• One hand in vagina while pushing against fundus through the abdominal wall with the other hand. (painful)

• Sonogram to detect placental fragments

• Examine manually and insert packing.

Prostaglandin Administration:

• Prostaglandin F IM to initiate contractions

– Watch for nausea, diarrhea, tachycardia, and hypertension.


Blood Replacement:

• Type and cross match

• Some may donate during pregnancy.

Hysterectomy:

• Ligation of uterine or hysterectomy as last resort.

• Comfort and support.

• “Why me”, grief, anger, glad to be alive.

Postpartal HemorrhageNursing interventions:

• Observe fundal height, consistency, and lochia for 4 hours.

• Offer bedpan or ambulate to BR q 4 hours or catheter may be ordered.

• O2 4 L/minute by face mask.

• Supine

• VS increase pulse, decrease B/P

• Fatigue- needs rest

• May need iron therapy, help at home.

• Monitor for infection

Postpartal HemorrhageLacerations:

Small tears or lacerations of the birth canal are common. Large lacerations are complications.

Occur:

• With difficult or precipitate births

• In primigravidas

• With birth of a large infant >9 lbs.

• With the use of a lithotomy position and instruments.

Either cervical, vaginal, or perineal.

Postpartal HemorrhageIf uterus is firm but bleeding persists, suspect

a laceration.

Cervical Laceration:

• Found on the sides of cervix near branches of uterine artery.

• May gush, bright red, immediately after delivery of the placenta.

Treatment:

• Repair laceration (difficult to see)

• Reassure, may need anesthetic for pain.


Vaginal Lacerations:

• Harder to repair, some oozing, may need packing. Remove in 24 to 48 hours.

• Foley catheter inserted due to pressure on urethra.

• Packing left to long causes stasis, infection similar to toxic shock syndrome.

Perineal Laceration:

• Occur when in lithotomy position for birth, which increases tension on perineum.


Four categories: (table 25.1 p. 700)

• From vaginal mucous membranes to rectum

Treatment:

• Sutured and treated same as episiotomy repair.

• Document the degree.

• Heal slower due to tearing and ragged edges

• Diet high in fluids, stool softener, no rectal temps, suppositories or enemas.


Retained Placental Fragments:

• Portions retained keep uterus from contracting fully, uterine bleeding occurs.

• Happens with a succenturiate placenta ( an accessory lobe), placenta accreta (fused with myometrium because of abnormal decidua basalis layer.

• May need surgically removed.

• Inspect placenta carefully after birth to see if it is complete.


Assessment:

• Lg. Fragment, bleeding, uterus can not contract.

• Sm.fragment, bleeding at day 6 to 10 postpartum. Woman notices an abrupt discharge of blood.

• If placental tissue is present; elevated serum HCG present.

• Sonogram.

Treatment:


• Removal of fragments (D&C)

• Methotrexate to destroy retained placental tissue.

• Teach woman to monitor color of lochia

Disseminated Intravascular Coagualtion:

• Deficiency in clotting ability caused by vascular injury.

Subinvolution:

• Incomplete return of uterus to its prepregnant size and shape.


• Postpartal visit in 4 to 6 weeks, the uterus is still enlarged and soft.

• Lochial discharge still present.

• Results from-sm. placental fragments, mild endometritis, or myoma.

Management:

• Methergine 0.2 mg four times a day.

• Oral antibiotic (endometritis)

• Anemia

• Teach normal process of involution at D/C

Postpartal HemorrhagePerineal Hematomas:

• Collection of blood in the subcutaneous layer of tissue of perineum.

• Injury to blood vessels during birth.

Assessment:

• Woman reports severe pain in perineal area or feeling pressure between her legs. Check for hematoma.

• Purplish color and swelling. (2 cm to 8 cm)

• Tender and palpates as firm globe.


Management:

• Report presence, size, degree of discomfort.

• Analgesic, ice, may absorb in 3 to 4 days or may need incised.

Puerperal Infection

Uterus is sterile during pregnancy and until membranes rupture.

Greater risk if tissue edema and trauma are present. (Box 25.3 p. 702)

Pathogens invade.

Infection

Prognosis for recovery depends on:

• Virulence of the invading organism

• General health of the woman

• Port of entry

• Degree of uterine involution

• Presence of lacerations in the reproductive tract.

Always serious, it can spread to peritonitis or septicemia. Can be fatal.

InfectionManagement

• Antibiotic after C&S

– Ampicillin, Gentamicin, Suprax

• Use gloves and sterile instruments.

• Proper perineal care

• May need isolation

• Pump breasts if breast feeding

• Give support

Infection

Endometritis:

Infection of endometrium, lining of uterus.

Assessment:

• Temperature elevation, usually on 3rd to 4th day postpartum > 100.4 for 2 days.

• Normal WBC 20,000 to 30,000

• Chills, loss of appetite, general malaise.

• Sonogram for infected placental fragments.

Management:

• Cleocin, oxytocic agent, fluids, analgesic.

Infection• Fowlers position or ambulate.

• Lasts 7 to 10 days. May be discharged on IV antibiotic at home.

• Can lead to tubal scarring and infertility.

Infection of the Perineum

Assessment:

• Suture line, or laceration is port for entry of bacteria.

• Generally remain localized.

• SS-pain, heat, feeling of pressure, inflammation at suture line.

Infection• Culture any drainage

Management:

• Remove perineal sutures to open area and allow to drain.

• Packing (iodoform gauze) to keep open.

• Antibiotic, analgesic, sitz bath or warm compresses, change peri pads frequently.

• Heals by tertiary intention.

• Monitor infant for thrush, bruising, decreased vitamin K > poor clotting.

Infection

Peritonitis

Infection of the peritoneal cavity.

Major cause of death from puerperal infection

Spreads through lymphatic system or fallopian tubes or uterine wall.

May settle in cul-de-sac of Douglas.

Assessment:

• SS-(guarding) rigid abdomen, abdominal pain, high fever, rapid pulse, vomiting, appears ill.

Infection

Management:

• Often accompanied by paralytic ileus. Insert NG tube to prevent vomiting and rest the bowel.

• IV or TPN

• Analgesic, antibiotic.

• May have infertility due to scarring and adhesions in peritoneum.

Thrombophlebitis

Inflammation of the lining of a blood vessel with the formation of blood clots.

• Usually an extension of endometrial infection.

Causes:

• Increased fibrinogen level that is still elevated from pregnancy leading to clotting.

• Dilation of lower extremity veins due to pressure of fetal head during pregnancy and birth.

• Inactivity or prolonged time in stirrups.

Thrombophlebitis• Classified as SVD or DVT.

Prone women:

• With varicose veins

• Obese

• Previous thrombophlebitis

• Over 30 yrs. of age with increased parity

• Family history.

Prevention:

• Prevent endometritis

• Ambulation

Thrombophlebitis

• Limit time in stirrups

• Exam tables well padded

• Support stockings

Femoral Thrombophlebitis

• Femoral, saphenous, or popliteal veins involved.

• Arterial spasm often diminishes arterial circulation to the leg. This plus edema give the leg a white appearance.

Assessment:

Thrombophlebitis• 10th day after birth; elevated temperature,

chills, pain, redness in leg.

• Leg swells below the lesion, appears shiny and white. Homans’ sign positive, diameter of leg increased.

• Doppler US or contrast venography to confirm diagnosis.

Management:

• Bedrest, elevate leg, anticoagulants and moist heat, analgesic, antibiotic.

• APTT, PT

Thrombophlebitis• Coumarin, streptokinase or urokinase,

Heparin. Later may be placed on aspirin.

• With treatment will last a few days but it takes 4 to 6 weeks to resolve.

Pelvic Thrombophlebitis

Involves the ovarian, uterine, or hypogastric veins.

Follows mild endometritis

Occurs on day 14 or 15.

Assessment:

Suddenly extremely ill, high fever, chills,

Thrombophlebitis

General malaise.

Necroses the vein and results in a pelvic abscess. Can become systemic and result in lung, kidney or heart valve abscess.

Management:

• Bedrest, antibiotics, and anticoagulants.

• Disease lasts 6 to 8 weeks.

• May need incised by laparotomy

• Tubal scarring > infertility.

• Teach preventive measures.

Pulmonary Embolus

Obstruction of pulmonary artery with a blood clot.

• Emergency

• Sudden sharp chest pain, tachypnea, tachycardia, orthopnea, cyanosis.

• O2

• ICU

Mastitis

Infection of the breast. Occurs on 7th day to weeks or month.

Mastitis • Organism enters through cracked and

fissured nipples.

Preventive measures:

• Position baby correctly and grasps nipple properly.

• Release baby’s grasp on nipple before removing from the breast.

• Wash hands

• Expose nipples to air for part of day.

• Vitamin E daily

Mastitis

• May come from oral-nasal cavity of the infant.

Assessment:

• Usually unilateral, pain, swelling, redness, fever and scant breast milk.

Management:

• Broad spectrum antibiotic

• Continue breast feeding

• Cold or ice compresses

• Support bra

Mastitis

• Warm, wet compresses

• Lasts 2 to 3 days

• May abscess


Urinary Retention:

• Inadequate bladder emptying.

• Bladder sensation is decreased due to edema from the pressure of birth.

• Permanent damage may occur from loss of muscle tone.


Assessment:

• Associated with use of anesthesia and forceps.

• Percussion or palpation

• Voiding is frequent, sm. And inadequate.

• Always measure 1st voiding after birth. If < 100 mL suspect retension.

• Catheterize after voiding, if > 100mL it is retention.

• Leave Foley in place


Management:

• Catheterization

• After 24 hours clamp then remove.

• Fluids, analgesics,

• Void within 8 hours.

• Present for no longer than 48 hours.

Urinary Tract Infection

Bacteria may be introduced into bladder.

Assessment:

• Burning on urination, blood, feeling of


Frequency, pain, low grade fever and discomfort from lower abdominal pain.

• Clean catch urine specimen

Management:

• Sulfa drugs contraindicated for breast feeding.

• Antibiotic-ampicillin

• Fliuds -1 glass /hour

• Analgesics

• 5 to 7 days to eradicate completely.

Cardiovascular System Disorders

Postpartal Pregnancy-Induced Hypertension

PIH

May have a preexisting hypertension.

SS- proteinuria, edema, hypertension.

Tx.- bedrest, quiet atmosphere, VS, urine output and Magnesium sulfate or antihypertensive medication.

• Usually some placenta is still present.

• Once a D&C is completed B/P decreases.

• Seizures occur 6 to 24 hours after birth.


Reproductive Tract Displacement:

• Ligaments may no longer be able to maintain the uterus in its usual position or level after pregnancy.

• Problem: retroflexion, anteflexion, retroversion, anteversion or prolapse.

• May interfere with fertility, may cause continued pain in lower abdomen.

• Cystocele, rectocele, stress incontinence

• High parity


Separation of the Symphysis Pubis:

• Ligaments may be stretched by birth and tear.

• Woman feels acute pain on turning or walking. Legs rotate externally (waddle)

• Defect over symphysis pubis, area is swollen and tender.

• Tx. – bedrest, binder, avoid heavy lifting

• 4 to 6 weeks to heal

• May need cesarean birth for future.

Emotional Complications

Difficult bonding with infant.

Child Born with an Illness:

• Sex of child

• Anger, hurt, disappointment, grief

• Loss of self esteem

• Feelings that child is not real

• Shock to the couple

• ICU visits

• Open lines of communication

Complications

Woman Whose Child Has Died:

• Questions about what happened.

• Bewildered, bitter, resentful, “Why me”

• Clean the baby and wrap in blanket and let the parents see the baby.

• Stay with them, complete forms, provide a private room.

Postpartal Depression:

• Almost every woman has some feelings of sadness in 1 to 10 days after childbirth.

Complications

• Response to anticlimatic feelings after birth.

• Related to hormonal shifts-estrogen, progesterone, corticotropin releasing hormone levels decline.

• Extreme fatigue, inability to stop crying, increased anxiety about health, insecurity, psychosomatic symproms (N/V) and depressed or manic mood fluctuations.

• May need counseling and/or antidepressant therapy.

• Table 25.2 p. 714 comparisons

Complications

Postpartal Psychosis:

• 1 woman in 500

• Response to the crisis of childbearing.

• May previously had mental illness

• Lost contact with reality, may deny she had a child.

• Mat respond as threatening, anger

• Do not leave alone because the distorted perception might lead her to harm herself.

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