Postpartum
complications II
Lectures 12
Prepared by MD, PhD Kuziv I.
Postpartum complications
Postpartum hemorrhage
Hemorrhagic shock
Coagulopathies
Thromboembolic disease
Main Causes of Early Hemorrhage
are:
1.
2.
3.
4.
5.
Uterine Atony
Lacerations
Retained Placental fragments
Inversion of the Uterus
Placenta Accreta
The Two Principles that
Govern PPH Treatment
I.
The bleeding
must be
arrested
II. The maternal
volume must
be restored
Uterine Atony
Etiology and
Pathophysiology:
The most frequent cause of
postpartal
hemorrhage
is
UTERINE
ATONY.
The
myometrium fails to contract
and the uterus fills with blood
because of the lack of
pressure on the open vessels
of the placental site.
Signs and Symptoms:
1.
Excessive or bright red bleeding
2.
A boggy uterus that does not respond to massage
3.
Abnormal clots
4.
Any unusual pelvic discomfort or backache
Management of Postpartum
Hemorrhage
 Close observation of fundal
height and bleeding after
delivery for at least 1 hour
 Common protocol for fundal
height massage: Q15min X 1
hr, Q30min X1 hr, Q1hr X
4hrs, Qshift + PRN)
 Make sure bladder is drained
 If uterine massage is
ineffective, pharmacologic
agents are indicated
LACERATIONS
ETIOLOGY AND PATHOPHYSIOLOGY:
Lacerations of the birth canal are second only to uterine
atony as a major cause of postdelivery hemorrhage.
Predisposing Factors:
1. Spontaneous or Precipitous delivery
2. Size, Presentation, and Position of
3. Contracted Pelvis
4. Vulvar, perineal, and vaginal varices
baby
LACERATIONS
ETIOLOGY AND PATHOPHYSIOLOGY:
Lacerations of the birth canal are second only to uterine
atony as a major cause of postdelivery hemorrhage.
Predisposing Factors:
1. Spontaneous or Precipitous delivery
2. Size, Presentation, and Position of
3. Contracted Pelvis
4. Vulvar, perineal, and vaginal varices
baby
RETAINED PLACENTAL
FRAGMENTS
Etiology and Pathophysiology:
 This occurs when there is incomplete separation of the placenta
and fragments of placental tissue retained.
Signs and Symptoms:
 – Boggy , relaxed uterus
 – Dark red bleeding
Treatment and Nursing Care:
– D & C - clean out any
fragments that may be left
– Administration of Oxytocins –
to contract the uterus
– Administration of Prophylactic
antibiotics
INVERSION OF THE UTERUS
Etiology and Pathophysiology:
The uterus inverts or turns inside out
after delivery.
 Complete inversion - a large red
rounded mass protrudes from the
vagina
 Incomplete inversion - uterus can not
be seen, but felt
INVERSION OF THE UTERUS
Etiology and Pathophysiology:
The uterus inverts or turns inside out
after delivery.
 Complete inversion - a large red
rounded mass protrudes from the
vagina
 Incomplete inversion - uterus can not
be seen, but felt
PLACENTA ACCRETA
Etiology and Pathophysiology:
Placenta accreta is a condition that occurs when all or
part of the decidua basalis is absent and the placenta
grows directly onto the uterine muscle. This may be
partial where only a portion abnormally adhered or it
may be complete where all adhered.
PLACENTA ACCRETA
Etiology and Pathophysiology:
Placenta accreta is a condition that occurs when all or
part of the decidua basalis is absent and the placenta
grows directly onto the uterine muscle. This may be
partial where only a portion abnormally adhered or it
may be complete where all adhered.
Signs and Symptoms:
– During the third stage of
labor, the placenta does not
want to separate.
– Attempts to remove the
placenta in the usual manner
are unsuccessful, and
lacerations or perforation of
Treatment:
the uterus may occur
1. If it is only small portions
that are attached, then these
may be removed manually
2. If large portion is
attached--a Hysterectomy is
necessary!
LATE POSTPARTUM
HEMORRHAGE
Etiology and Pathophysiology:
Occasionally, late postpartal
hemorrhage occurs around the fifth to
the fifteenth day after delivery when the
woman is home and recovering. The
most frequent causes are:
 1.
Retained placental fragments
 2.
Subinvolution – the uterus fails
to follow the normal pattern of
involution and remains enlarged.
SIGNS AND SYMPTOMS:
 Lochia fails to progress
from rubra to serosa to
alba.
 The uterus is higher in
the abdomen.
 Irregular or excessive
bleeding.
TREATMENT AND
NURSING CARE:
 Oral administration of
Methergine for 24-48
hours.
D&C
Thromboembolic Conditions
 Thrombophlebitis–the formation of a clot in an inflamed
vein.
 Risk factors include maternal age over 35, cesarean
birth, prolonged time in stirrups, obesity, smoking, and
history of varicosities or venous thromboses.
 Prevention: client needs to ambulate early after delivery.
Thromboembolic Conditions
 Thrombophlebitis–the formation of a clot in an inflamed
vein.
 Risk factors include maternal age over 35, cesarean
birth, prolonged time in stirrups, obesity, smoking, and
history of varicosities or venous thromboses.
 Prevention: client needs to ambulate early after delivery.
Thromboembolic Conditions
 Thrombophlebitis–the formation of a clot in an inflamed
vein.
 Risk factors include maternal age over 35, cesarean
birth, prolonged time in stirrups, obesity, smoking, and
history of varicosities or venous thromboses.
 Prevention: client needs to ambulate early after delivery.
THROMBOEMBOLIC DISEASE
Superficial thrombophlebitis is limited to the superficial saphenous veins,
whereas deep thrombophlebitis generally involves most of deep venous
system.
 PREDISPOSING FACTORS:
 Slowing of blood flow in legs –
usually in Moms who have a
Cesarean delivery.
 Trauma to the vessels during
delivery.
THROMBOEMBOLIC DISEASE
Superficial thrombophlebitis is limited to the superficial saphenous veins,
whereas deep thrombophlebitis generally involves most of deep venous
system.
 PREDISPOSING FACTORS:
 Slowing of blood flow in legs –
usually in Moms who have a
Cesarean delivery.
 Trauma to the vessels during
delivery.
Assessment of Edema & Homan’s Sign
 Assess legs for presence and degree of edema; may have
dependent edema in feet and legs.
 Assess for Homan’s sign- thromboembolism should be negative
 Press down gently on the patient’s knee (legs extended flat on bed)
ask her to flex her foot (dorsiflex)
Signs and Symptoms:
Sudden onset of pain,
tenderness of calf, redness and
an increase in skin temp.
Positive Homan’s Sign.
Treatment and Nursing Care:
Heparin – it does not cross into breast milk.
Signs and Symptoms:
Sudden onset of pain,
tenderness of calf, redness and
an increase in skin temp.
Positive Homan’s Sign.
Treatment and Nursing Care:
Heparin – it does not cross into breast milk.
Signs and Symptoms:
Sudden onset of pain,
tenderness of calf, redness and
an increase in skin temp.
Positive Homan’s Sign.
Treatment and Nursing Care:
Heparin – it does not cross into breast milk.
Signs and Symptoms:
Sudden onset of pain,
tenderness of calf, redness and
an increase in skin temp.
Positive Homan’s Sign.
Treatment and Nursing Care:
Heparin – it does not cross into breast milk.
COMPLICATION:
PULMONARY EMBOLI –
substernal chest pain,
sudden and intense;
dyspnea; pallor and
cyanosis; increased
jugular pressure;
confusion;
hypotension; sudden
apprehension;
hemoptysis.
COMPLICATION:
PULMONARY EMBOLI –
substernal chest pain,
sudden and intense;
dyspnea; pallor and
cyanosis; increased
jugular pressure;
confusion;
hypotension; sudden
apprehension;
hemoptysis.
Thank you for attention