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Chapter 23 Postpartum Complications Mosby items and derived items © 2006, 2002 by Mosby, Inc. 1 of 34 Postpartum Hemorrhage 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 Mosby items and derived items © 2006, 2002 by Mosby, Inc. 2 of 34 Postpartum Hemorrhage Etiology and risk factors 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 Mosby items and derived items © 2006, 2002 by Mosby, Inc. 3 of 34 Postpartum Hemorrhage 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 Retained placenta • Nondherent retained placenta – managed by manual separation and removal by the primary care provider • Adherent retained placenta – may be caused by implantation into defective endometrium Mosby items and derived items © 2006, 2002 by Mosby, Inc. 4 of 34 Postpartum Hemorrhage 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) Mosby items and derived items © 2006, 2002 by Mosby, Inc. 5 of 34 Postpartum Hemorrhage 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 Mosby items and derived items © 2006, 2002 by Mosby, Inc. 6 of 34 Postpartum Hemorrhage Subinvolution of uterus – delayed involution of the uterus Usually see late post partum bleeding Causes include retained placental fragments and infection Mosby items and derived items © 2006, 2002 by Mosby, Inc. 7 of 34 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 Mosby items and derived items © 2006, 2002 by Mosby, Inc. 8 of 34 Care Management Plan of care and implementation Initial treatment – fundal massage, expression of clots, relief of bladder distension, IV fluids Medications – Table 25-1 Medical management • Hypotonic uterus – examine for retained placental fragments, medications, surgical interventions Mosby items and derived items © 2006, 2002 by Mosby, Inc. 9 of 34 Care Management Medical management – cont. • 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 Mosby items and derived items © 2006, 2002 by Mosby, Inc. 10 of 34 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 Mosby items and derived items © 2006, 2002 by Mosby, Inc. 11 of 34 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 Mosby items and derived items © 2006, 2002 by Mosby, Inc. 12 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 • Treatment for infection • Preeclampsia or eclampsia • Removal of placental abruption Mosby items and derived items © 2006, 2002 by Mosby, Inc. 13 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 Mosby items and derived items © 2006, 2002 by Mosby, Inc. 14 of 34 Thromboembolic Disease Medical management Superficial – analgesia, rest/elevation, TED hose Deep – anticoagulant therapy, bedrest/elevation, TED hose 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!! Mosby items and derived items © 2006, 2002 by Mosby, Inc. 15 of 34 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 Mosby items and derived items © 2006, 2002 by Mosby, Inc. 16 of 34 Care Management Prevention is the best intervention Hand washing Good maternal perineal hygiene Antibiotic administration Wound management Breast care Mosby items and derived items © 2006, 2002 by Mosby, Inc. 17 of 34 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 Mosby items and derived items © 2006, 2002 by Mosby, Inc. 18 of 34 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 Mosby items and derived items © 2006, 2002 by Mosby, Inc. 19 of 34 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 Mosby items and derived items © 2006, 2002 by Mosby, Inc. 20 of 34 Types of Fistulas That May Develop in Vagina, Uterus, and Rectum Mosby items and derived items © 2006, 2002 by Mosby, Inc. 21 of 34 Postpartum Psychologic Complications Mental health disorders in postpartum period have implications for mother, newborn, and entire family Interfere with attachment to newborn and family integration May threaten safety and well-being of mother, newborn, and other children Mosby items and derived items © 2006, 2002 by Mosby, Inc. 22 of 34 Postpartum Psychologic Complications Postpartum depression without psychotic features PPD: an intense and pervasive sadness with severe and labile mood swings Treatment options • Antidepressants, anxiolytic agents, and electroconvulsive therapy • Psychotherapy focuses fears and concerns of new responsibilities and roles, and monitoring for suicidal or homicidal thoughts Mosby items and derived items © 2006, 2002 by Mosby, Inc. 23 of 34 Postpartum Psychologic Complications Postpartum depression with psychotic features Postpartum psychosis: syndrome characterized by depression, delusions, and thoughts of harming either infant or herself Psychiatric emergency, and may require psychiatric hospitalization Antipsychotics and mood stabilizers such as lithium are treatments of choice Mosby items and derived items © 2006, 2002 by Mosby, Inc. 24 of 34 Loss and Grief Losses of what was hoped for, dreamed about, and/or planned Any perception of loss of control during the birthing experience Birth of a child with handicap Maternal death Fetal or neonatal death Mosby items and derived items © 2006, 2002 by Mosby, Inc. 25 of 34 Loss and Grief Conceptual model of parental grief Acute distress Intense grief Reorganization Anticipatory grief Mosby items and derived items © 2006, 2002 by Mosby, Inc. 26 of 34 Loss and Grief Plan of care and implementation Communicating and care techniques • Actualize the loss • Provide time to grieve • Interpret normal feelings • Allow for individual differences • Cultural and spiritual needs of parents • Physical comfort Mosby items and derived items © 2006, 2002 by Mosby, Inc. 27 of 34 Loss and Grief Plan of care and implementation Options for parents • Seeing and holding • Bathing and dressing • Privacy • Visitations: other family members or friends • Religious rituals/funeral arrangements • Special memories • Pictures Mosby items and derived items © 2006, 2002 by Mosby, Inc. 28 of 34 Maternal Death Rare for woman to die in childbirth Families are at risk for developing complicated bereavement and altered parenting of surviving baby and other children in family Referral to social services can help combat potential problems before they develop Mosby items and derived items © 2006, 2002 by Mosby, Inc. 29 of 34 Key Points Postpartum hemorrhage is most common and serious type of excessive obstetric blood loss Hemorrhagic (hypovolemic) shock is an emergency situation; the perfusion of body organs may become severely compromised and death may ensue Potential hazards of therapeutic interventions may further compromise the woman with hemorrhagic disorders Mosby items and derived items © 2006, 2002 by Mosby, Inc. 30 of 34 Key Points Postpartum infection is a major cause of maternal morbidity and mortality Postpartum urinary tract infections are common because of trauma experienced during labor Breast infection affects about 1% of women soon after childbirth Mosby items and derived items © 2006, 2002 by Mosby, Inc. 31 of 34 Key Points Structural disorders of uterus and vagina related to pelvic relaxation are often the delayed but direct result of childbearing Understanding of grief responses and bereavement process is fundamental to the nursing process Therapeutic communication and counseling techniques can help families in identifying their feelings and in feeling comfortable in expressing their grief Mosby items and derived items © 2006, 2002 by Mosby, Inc. 32 of 34 Key Points Follow-up after discharge is an essential component in providing care to families who have experienced a loss Nurses need to be aware of their own feelings of grief and loss to provide a nonjudgmental environment of care and support for bereaved families Mosby items and derived items © 2006, 2002 by Mosby, Inc. 33 of 34
