Download Post partum complication

Post partum complication
Dr: Sahar Anwar Rizk
Post partum complication
Types of post partum complications:
1- post partum hemorrhage
2- puerperal sepsis
post partum hemorrhage
Postpartum hemorrhage is a significant
cause of maternal morbidity and mortality.
Postpartum hemorrhage, the loss of more
than 500 mL of blood after delivery, occurs
in up to 18 percent of births and is the
most common maternal morbidity in
developed countries. Although risk factors
and preventive strategies are clearly
documented, not all cases are expected or
avoidable.
 Risk Factors for Postpartum Hemorrhage
 Prolonged third stage of labor
 Preeclampsia
 Mediolateral episiotomy
 Previous postpartum hemorrhage
 Twin pregnancy
 Arrest of descent
 Soft-tissue lacerations
 Asian ethnicity
 Augmented labor
 Forceps or vacuum delivery
 Midline episiotomy
 Nulliparity& high parity
 Systemic diseases
Type of post partum hemorrhage:
1-Primary post partum hemorrhage: occur
during the first 24 hrs after delivery
2-Secondary post partum hemorrhage:
occurring more than 24 hrs after delivery.
It can occur along 6 weeks after delivery
1-Primary post partum hemorrhage
Major cause:
A tonic uterus:
It is the most common cause of post
partum hemorrhage with separation of the
placenta ,the uterine sinuses cannot
compressed effectively.
2-Trumatic :
Hemorrhage occurs due to trauma of the
uterus, cervix, vagina following vaginal or
operative delivery
Delay during episiotomy
3-Mixed
4-Blood coagulating disorder:
A acquired or congenital blood coagulation
disorder.
Factors affecting efficient uterine
contraction &retraction

1.
2.
3.
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Placental :
Incomplete separation of placenta
Retained cotyledon &membrane
Placenta previa
Prolonged labor
Multiple pregnancy
General anesthesia
Full bladder
Manipulation of the uterus during third stage
Clinical manifestation of PPH
If blood loss more than 750-1,250
BP normal or decrease
Pulse normal or elevated
Mild vasoconstriction
Normal urinary out put
Aware , alert, oriented
Atonic uterus (1,250-1,750)
Systolic BP<90 to 100mm/hg
Moderate tachycardia 100-120b/m
Moderate vasoconstriction, skin pallor
,cold, moist
Decrease urinary out put
Increase restlessness
Atonic uterus (1.800-2.500)
Systolic BP <60mm/Hg
Sever bradycardia >120 b/m
Pronounced vasoconstriction ( extreme
pallor, cold ,clammy cyanotic lips and
finger)
Urinary output ceases (anurea)
Mental stupor , lethargy, semi-comatose
*Uterus is flabby and become hard on
massaging in a tonic PPH
*Uterus is well contracted in traumatic PPH
 How is postpartum hemorrhage diagnosed?
 In addition to a complete medical history and
physical examination, diagnosis is usually based
on symptoms, with laboratory tests often helping
with the diagnosis. Tests used to diagnose
postpartum hemorrhage may include:
 estimation of blood loss (this may be done by
counting the number of saturated pads, or by
weighing of packs and sponges used to absorb
blood; 1 milliliter of blood weighs approximately
one gram)
 pulse rate and blood pressure measurement
 hematocrit (red blood cell count)
 clotting factors in the blood
Prevention of PPH
Ante partum
Complete history-----to identify high risk pt
who are likely to develop PPH
Improve health status especially to rise hg
Hospital delivery of high risk pt who develop
polyhydramnios, multiple pregnancy, sever
anemia
Routine blood grouping
Intrapartum PPH
Careful administration of sedatives
Avoid hasty delivery of the infant
Prophylactic administration of oxytocin
Avoid massaging the uterus before
separation of placenta
Examine the utero –vaginal canal for trauma
Effective management of the fourth stage of
labor
Management of Postpartum Hemorrhage

 The aim of treatment of postpartum hemorrhage is to
find and stop the cause of the bleeding as quickly as
possible. Treatment for postpartum hemorrhage may
include:

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medication (to stimulate uterine contractions)
manual massage of the uterus (to stimulate contractions)
removal of placental pieces that remain in the uterus
examination of the uterus and other pelvic tissues
packing the uterus with sponges and sterile materials (to
compress the bleeding area in the uterus)
 tying-off of bleeding blood vessels
 laparotomy - surgery to open the abdomen to find the
cause of the bleeding.
 hysterectomy - surgical removal of the uterus; in most
cases, this is a last re
Observation of the mother
 Record pulse, BP, every 15 min
 Palpate uterus every 15 min ----contraction
 Check temp /4 hrs
 Examine lochia for amount & consistency
 Examine IV infusion
 Hourly urine output
 Intake &output chart
 Relive anxiety
 Administer prophylactic antibiotic
Uterotonic Agents .
Uterotonic agents include oxytocin, ergot
alkaloids (Methergine ), and
prostaglandins.
Oxytocin stimulates the upper segment of
the myometrium to contract rhythmically,
which constricts spiral arteries and
decreases blood flow through the
uterus 30.Oxytocin is an effective first-line
treatment for post
Technique of bimanual massage for uterine
atony
 Bimanual uterine
compression massage is
performed by placing one
hand in the vagina and
pushing against the body of
the uterus while the other
hand compresses the fundus
from above through the
abdominal wall. The posterior
aspect of the uterus is
massaged with the abdominal
hand and the anterior aspect
with the vaginal hand.
Nursing management
Assess pt
Identify risk group:
Vital sign
State of the uterus
Natural of bleeding
S&S of blood loss
 compare laboratory report
Nursing intervention:
 If atonic
 Inform obst
 Feel the consistency of the uterus
 Massage the uterus
 Assess the physical condition
 Monitor TPR &BP
 Put the infant on breast
 Prepare the instrument
Administer oxytocin
Start IV infusion
Empty bladder
Examine placenta
Reassure the mother
In trumatic:
press on the tear or laceration
Prepare the equipment
Secondary post partum hg
Commonly occur 10-14day PP
Common cause:
 retained bit of cotyledon
Separation of slough exposing a blood
vessels
Sub involution at the placental sit
S&S
Sudden episode of bleeding
Sub involution
Sepsis
Anemia
Management:
Reassurance
Monitor TPR
IV, empty bladder, give medication
Puerperal sepsis:
It is an infection of the genital tract that
occur at any time between the onset of
rupture of the membrane or labor & the
42ed day post partum or abortion :
The following are present:
Pelvic pain
Fever 38.5
Abnormal vaginal discharge
Foul odor &sub involution
Microorganisms commonly involved in
PPGTI
Gram positive
Gram negative
Microorganism that sexually transmitted
Risk factors for PP infection
Related to general infection risk
Related to labor and delivery
Related to operative risk factors
Principle clinical feature
Elevated temp
Suprapubic pain
Foul smell lochia
Uterine involution
General symptoms
Laboratory investigation
Preventive measures
Ante partum
Intrapartum
Post partum
Nursing management