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8/3/2019 47349097 Postpartum Complications
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Complications of the
Postpartum Period
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Hemmorhage
Early postpartum hemmorhage
>500 ml in first 24 hrs (blood loss often
underestimated)
Late or delayed
>500 cc after first 24 hrs.
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Predisposing factors
Uterine overdistension--large infant,etc.
Grand multiparity
Anesthesia or MgSO4
Trauma
Abnormal labor pattern--hypo or hypertonia Oxytocin during labor
Prolonged labor
Hx of maternal anemia, hemorrhage
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Prevention
Risk assessment
Inspect placenta
Explore uterus
Avoid overmanipulation of uterus
If at risk type and Xmatch and start IV
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Signs of Impending
Hemorrhage Excessive bleeding (>2pads/30min-1hr)
Light headedness, nausea, visual
disturbances
Anxiety, pale/ashen color, clammy skin
Increasing P and R, BP same or lower
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Actions to take
Summon help
Check uterine tone, massage, assess effect
Elevate legs, lower head
Increase or begin O2
Increase or begin IV
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Early Postpartum Hemorrhage
Within the first 24 hrs
Causes
uterine atony
lacerations
retained secundines
coagulation problems
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Uterine atonyFailure of the uterus to stay firmly contracted
Slow, steady or massive hemorrhage,sometimes underestimated or hidden behind
a clot
VS may not change immediately
Treatment
bimanual massage
oxytoxics
curretage
surgery iliac ligation or hysterectomy
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Retained placenta or fragmentsPartial separation caused by:
pulling on the cord
uterine massage prior to separation
placenta accretaTreatment:
massage
manual removal oxytoxics
D & E
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Late postpartum hemorrhage
Hemorrhage occurring
after 24 hrs
retained placenta--necrosed, fibrin
deposits, placental
polyps,
sloughingbleeding
Symptoms
excessive or bright
red bleeding boggy fundus
large clots
backache T-P-R, BP
Treatment, massage, IV oxytocin, D&E
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Hematomas
Result from injury to a blood vessel,
usually in vagina or vulva, may extend
upward into broad ligament or otherpelvic structures
develop rapidly
may contain 300-500ml blood
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Symptoms
Severe pain
Difficulty voiding
Mass felt on vaginal exam
Flank pain
Abdominal distension Shock
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Treatment
Ice
I & D (incision and drainage)
Packing
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Subinvolution
Uterus remains large, does not involute
Causes, retained placental fragments, infection
Symptoms:
Lochia fails to progress
Returns to rubra
Leukorrhea with backache and infection
Treatment:
methergine
curretage
antibiotics
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Puerperal Infection
Definition:
Temp of 101o or more in the first 24 hrs
following delivery
Temp of 1004 or higher on any 2 of the
first10 pp days (with the exception of the
first 24 hrs)
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Types of Infections
Endometritis
Parametritis
Peritonitis
Pyelonephritis
Cystitis Thrombophlebitis
Mastitis, abcess
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Predisposing Factors
Antenatal factors
poor nutrition
low SES
Hx of Infections
Anemia Immunodeficiency
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Intrapartum predisposing
factors Prolonged labor
PROM
Poor aseptic technique
Birth trauma
Multiple exams Internal monitoring
Episiotomy
C section
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Postpartum Predisposing
Factors Manual removal of placenta
Hemorrhage
Retained secundines
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Causative Organisms
Aerobic 30%
B hemolitc strep
E.coli
Klebsiella
Proteus
Pseudomonas Staph
Anerobic 70%
Bacteriodes
Peptococcus
C. perfringes
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Localized
Episiotomy
Lacerations
C section incision
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EndometritisInfection of the endometrium
placental site
decidua
cervixSymptoms--discharge (scant to profuse),
bloody, foul smelling
uterine tendernessjagged, irregular temp elevations
tachycardia, chills, subinvolution
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Salpingitis, Oopheritis
May be caused by gonorrhea, chlamidia
unilateral or bilateral abd pain
chills, fever
mass
tachycardia
may lead to sterility
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Pelvic Cellulitis, (parametritis)
Infection of the connective tissue of pelvis
frequently infecting the broad ligament
and causing severe pain.
May ascend from cervical lacerations
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Parametritis symptoms
Spiking temp to 104 chills, flushing, sweating
tachycardia, tachypnea
uterine tenderness, cramping
change in LOC/agitation,delerium,
disorientation
change in lochia cervical or uterine tenderness on vag
exam
WBC elevation
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Peritonitis
Life threatening infection of the
peritoneum
Abcesses on the uterine ligaments, in thecul de sac, and/or in the
subdiaphragmatic space
May result from pelvic thrombophlebitis
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Symptoms of Peritonitis
High temp
chills
malaise
lethargy
pain
subinvolution
Tachycardia
local or referred
pain
rebound tenderness
thirst
distension
nausea and
vomiting
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Cystitis
Bladder infection
urgency
frequency
burning
dysuria
suprapubic pain
hematuria
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PyelonephritisKidney infection, usually of the R.
kidney.Ascends from bladder.
Spiking temp
Shaking chills
Flank pain, CVA pain
Nausea and vomiting
Hx of asymptomatic bacteruria orpyelonephritis
Urgency, frequency, dysuria
Back pain
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Prevention and treatment
Force fluids
Insure complete emptying of bladder
Sterile technique for cath
Good perineal care
Antibiotics
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Thrombophlebitis Blood clotassociated with bacterial infection
Etiologies
blood clotting factors
postpartal thrombocytosis (platelets)
thromboplastin release (placenta, amnion)
fibrinolysin and fibrinogen inhibitors
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Superficial
Tenderness
heat
redness low grade fever
+ homans sign
tachycardia
Treatment
elevation
heat TEDs
analgesic
bedrest?
Antibiotics?
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Deep Vein Thrombosis
Symptoms
edema
low grade fever chills
pain in limb below
affected area milk leg
decreased peripheral
pulses
Dx--doppler
Tx:
heparin to coumadin antibiotics
TEDs
bedrest
elevation
analgesics
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Pulmonary Embolism
an Obstetrical emergencySymptoms--sudden onset
dyspnea
sweating pallor
cyanosis
confusion
hypertension
cough/hemoptysis
Tachycardia
SOB
Temp jugular pressur chest pain
sense of impendingdeath
pressure in
bowel/rectum
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Treatment
Call MD
O2
Demerol
Papaverine or other clot busters
Aminophylline
heparin
Streptokinase
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Disseminated Intravascular
Coagulation (DIC) prothrombin and platelets widespread formation of intravascular
clots
clotting factor expended
severe generalized hemorrhaging
Life threatening!
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Etiologies
Septic shock
placental/uterine hemmorhage
IUFD
Amniotic fluid embolism
thrombi secondary to preeclampsia
thrombi secondary to thrombophlebitis