Postpartum Complications: Hemorrhage & Risk Factors

• Postpartum complications are deviations from the normal puerperium.
• Goals are to reduce maternal mortality and increase breastfeeding rates.
• Common complications include hemorrhages, puerperal infections, thrombophlebitis, embolism, mastitis, and emotional/psychological issues.

Postpartum Hemorrhage

• Primary cause of maternal mortality linked to childbirth
• Defined as blood loss from the uterus exceeding 500 ml within 24 hours post-delivery

Main Reasons for Hemorrhage

• Uterine Atony
• Trauma such as lacerations, hematomas, uterine inversion, or uterine rupture
• Retained placental fragments
• Disseminated Intravascular Coagulation (DIC)

Risk Factors that Distend the Uterus

• Multiple gestation
• Polyhydramnios
• Macrosomia
• Uterine myomas

Conditions that affect the Uterus's Ability to Contract

• Deep anesthesia or analgesia
• Labor initiated with oxytocin
• High parity or maternal age exceeding 35
• Uterine surgery history
• Prolonged Labor
• Chorioamnionitis or endometritis
• Anemia
• Prior postpartum hemorrhage
• Use of MgSO4 or other tocolytics

Risk Factors Leading to Inadequate Blood Coagulation

• Fetal death
• Disseminated intravascular coagulation (DIC)

Factors Causing Cervical or Uterine Lacerations

• Operative birth
• Rapid Birth

Factors Causing Varied placental Site or Attachment

• Placenta Previa
• Placenta Accreta
• Premature separation of the placenta
• Retained placental fragments

Uterine Atony

• Uterine relaxation that is the most frequent cause of of postpartum hemorrhage
• Uterus must remain in contracted state for vessels at the placental site to seal

Signs of Uterine Atony

• A sudden gush of blood/ slow trickle combined with a large amount of bleeding soaking more than one peripad in (25-50 ml/hr), can weigh pads for blood loss estimate
• Shock
• Boggy Fundus
• Pain and tachycardia

Therapeutic Management for Uterine Atony

• Fundal massage should be performed first and assess for firmness
• Assess for signs of hypovolemic shock
• Oxytocin (Pitocin) infusion
• Methergine IM
• Hemabate - Prostaglandin F₂a derivative given IM
• Misoprostol (Cytotec) - Prostaglandin E₁ analogue given rectally
• Elevate patient's lower extremities and empty bladder
• Administer O2 if there is respiratory distress (RD), 10-12 L/min & keep in supine position to allow adequate blood flow
• Monitor patient's vital sign
• Bimanual compression
• Prepare for emergency hysterectomy

Lacerations

• Include cervical, vaginal, and perineal lacerations
• Common causes include precipitate birth, primigravida, LGA babies, lithotomy position, and instrument use
• Symptoms include bleeding and a firm fundus

Cervical Lacerations

• Repair can be difficult and requires calm
• Anesthesia is needed to relax the uterine muscle and prevent pain
• Provider needs adequate room, sponges, sutures, and good lighting to visualize

Vaginal Lacerations

• Easier to locate, but difficult to suture
• May need packing to prevent oozing for 24-48 hours and must be removed or results include TSS
• Use of uterine balloon tapenade or tamponade
• Foley Catheter

Perineal Lacerations

• Occurs due to the lithotomy position & sutured

Degrees of Perineal Lacerations

• First degree involves the vaginal mucous membrane and skin of the perineum to the fourchette
• Second degree involves the vagina,perineal skin, fascia, levator ani muscle, and perineal body
• Third degree involves the entire perineum and reaches the external sphincter of the rectum
• Fourth Degree involves the entire perineum, rectal sphincter, and some of the mucous membrane of the rectum

Retained Placental Fragments

• Placenta doesn't deliver entirely w/ fragments separating or being left behind, causing uterus not to contract which causes bleeding

Assessment for Retained Placental Fragments

• Bleeding in the postpartum period (uterus cannot contract)
• Uterus is not fully contracted on examination

Management for Retained Placental Fragments

• Dilation and curettage (D&C) to to remove the retained placental fragments
• Methotrexate to to destroy retained placental tissue
• Balloon occlusion and embolization of internal iliac arteries
• Hysterectomy

Uterine inversion

• Prolapse of the fundus through the cervix with the uterus turning inside out
• Disseminated Intravascular Coagulation (DIC)
• Deficiency in clotting ability is result of vascular injury
• Associated with premature separation of the placenta, early missed miscarriage, fetal death in utero

Subinvolution

• Incomplete return of the uterus to its prepregnant size
• Results from retained placental fragments, mild endometriosis, or uterine myoma

Management for Subinvolution

• Oral Methergine 0.2mg 4x daily to improve uterine tone and complete involution
• Oral antibiotics

Perineal Hematomas

• Collection of blood in the subcutaneous tissue of the perineum
• Injury to a blood vessel, likely after rapid birth, or woman with perineal varicosities
• May occur from vein rupture during episiotomy
• Represent Minor Bleeding

Assessment for Perineal Hematomas

• Severe perineal pain or pressure between the legs
• Purplish discoloration and swelling
• Size may be small as 2 cm or as large as 8 cm in diameter
• Hematomas are tender in palpation

Management for Perineal Hematomas

• Report size and discomfort level, administer analgesic, apply ice pack
• Vessels can be ligated under local anesthesia, packing of incision site

Puerperal Infections

• Another major cause of maternal death
• Infection risk is greater if tissue edema and trauma are present
• Recovery prognosis depends on woman's health, virulence, route of entry, uterine involution, and lacerations
• Can involve peritonitis or septicemia
• Treat with antibiotics after culture and sensitivity tests

Endometritis

• A type of puerperal infection
• Infection of the endometrium, commonly associated with chorioamnionitis and CS birth

Assessment Findings for Endometritis

• Benign temperature elevation w/ accompanying chills
• Elevated WBC and loss of appetite/body malaise
• The uterus does not contract well and is tender to touch
• Strong after pains and dark brown, foul-smelling lochia

Management of Endometritis

• Antibiotics like Clindamycin
• Oxytocic agent Methergine
• Increase fluid intake
• Analgesics for pain relief
• Sitting in Semi-Fowler's position or walking to encourage vaginal discharge drainage
• Wearing gloves when changing perineal pad
• Good handwashing techniques

Infection of the Perineum

• Infection from suture line in her perineum from an episiotomy or a laceration repair
• Assessment: Localized pain, heat, pressure, possible elevation in temperature, inflammation of the suture line with slough of stitches and purulent drainage
• Management: Open and pack the site, apply systemic/ local antibiotic and analgesic, Sitz bath, moist warm compress treatments, change perineal pads daily, front to back wiping

Peritonitis

• A type of puerperal infection
• Infection of the peritoneal cavity, which is the most serious complication of childbearing and a major cause
• Rigid abdomen, abdominal pain, high fever, rapid pulse, vomiting, acute illness, improperly-contracted uterus
• Management: Insertion of nasogastric tube (NGT), IVF or TPN, analgesics, and antibiotics

Thrombophlebitis

• Inflammation of the lining of the blood vessels with the forming of blood clots
• Two classifications- Superficial Vein Disease (SVD) or Deep Vein Thrombosis (DVT)

Factors increasing the risk of thrombophlebitis include when women:

• Are relatively inactive in labor and during the early puerperium
• Spend prolonged time in a birthing room with their legs positioned in stirrups
• Have preexistent obesity and a pregnancy weight gain greater than the recommended weight gain
• Have preexisting varicose veins
• Develop a postpartal infection
• Have a history of a previous thrombophlebitis
• Are older than 35 years or have increased parity
• Have a high incidence of thrombophlebitis in their family
• Smoke cigarettes because nicotine causes vasoconstriction and reduces blood flow

Preventative Measures against Thrombophlebitis during childbirth

• Good aseptic technique and ambulation
• Limiting time in obstetric stirrups
• Wearing support stockings for 2 weeks after birth
• Have exercise program

Femoral Thrombophlebitis

• Involves the femoral, saphenous or popliteal veins
• Formerly known as phlegmasia alba dolens or milk leg (white leg)
• The site is vein, but an accompanying arterial spasm often occurs, diminishing arterial circulation to the leg
• Decreased circulation and edema are the cause of a white or drained leg appearance

Assessments for Femoral Thrombophlebitis

• Elevated temperature, chills, pain, and redness in the affected leg about 10 days after birth
• Leg begins to swell below the lesion where the vein is blocked, stretches the skin, giving it a white and shiny appearance
• Positive Homan's sign
• Increased leg diameter at the thigh or calf, compared with opposite leg

Therapeutic Management for Femoral Thrombophlebitis

• Bed rest with legs elevated, provide buttocks and heel care
• Check the bed for wrinkles, do not massage the clot
• Moist and warm compress, application of antibiotic, anticoagulant or thrombolytic agent for clot formation Prevention

Pelvic Thrombophlebitis

• Involves the ovarian, uterine, or hypogastric vein and usually follows a mild endometritis and occurs around 14th – 15th day puerperium
• Assessment:- Sudden high fever, chills, general malaise, infection causes necrosis of the vein and results in pelvic abscess
• Can be caused by infection which becomes systemic with abscesses on the lung, heart, and kidney
• Management- Total bed rest, administration of antibiotic and anticoagulant, incision of abscess by laparotomy, teach on preventive measures

Preventive Measures to Take

• Not wearing constricting clothes, resting with feet elevated, and daily ambulation during pregnancy

Pulmonary Embolus

• Obstructed pulmonary artery by a clot, as a complication of thrombophlebitis causing an emergency situation
• Assessment includes sharp chest pain, tachypnea, tachycardia, orthopnea, and cyanosis
• Give O2 and anticoagulant

Mastitis

• Breast infection occurring as early as 7th post-partal-months later
• Organisms enter through cracked nipples from the infant's nose (Staphylococcus aureus)

Mastitis Preventative Measures

• Baby positioned correctly, and nipple/areola grasped properly
• Release the baby from the nipple before removing baby from the breast
• Hand-wash after both breasts and handling perineal pads
• Expose the nipples to air and use vitamin E ointment
• If one nipple is cracked, BF on the unaffected nipple

Manifestations of Mastitis

• The breast is painful, swollen, and reddened, with fever and scanty milk
• Antibiotics, cold/ice packs and supportive bra are necessary for treatment
• Discontinue breastfeeding with pumping, if abscess forms

Urinary System Disorders

• Include retention and infections

Urinary Retention

• Occurs due to bladder emptying
• Output of less than 100 ml
• Distended upon percussion/palpation with small, frequent voiding
• Insert a catheter and offer aid and analgesics

Urinary Tract Infections

• Assessment: Burning in urination, blood in the urine, feeling of frequency, painful voiding, low grade fever, discomfort from lower abdominal pain
• Treatment: Flush infection with fluids, offer Amoxicillin/Ampicillin an oral analgesic (Acetaminophen/Tylenol) to reduce pain

Cardiovascular System Disorders

• Consist of Postpartal Preeclampsia

Postpartal Preeclampsia

• Same symptom as antepartal PIH - proteinuria, edema, hypertension
• Same measures with antepartal PIH
• Retained placental fragments
• Seizure develops 6-24 hours after birth, if after 72 hours, unrelated

Reproductive System Disorders

• Include reproductive tract displacement

Reproductive Tract Displacement

• Due to weak support leading to retroflexion, anteflexion, retroversion, anteversion,prolapse w/ future childbearing & fertility interference
• Cystocele and Rectocele
• High parity and forceps birth can cause it Treatment: Surgery with Kegel's exercise which strengthens perineal muscles

Postpartum Blues

• Occur within 1-10 days of having a baby, with tears and stress of new child
• Remedy is support, empathy, compassion and understanding

Postpartum Depression

• Occurs 1-12 months postpartum with anxiety and sadness
• History of depression, hormonal changes and possible lack of social support
• Counsel with drugs and therapy

Postpartum Psychosis

• Delusions and hallucination during 1st year after birth and could mean bipolar disorder
• Refer to psychiatrist and keep family in tact

Nursing Diagnosis

• Deficient fluid volume due to increased lochia flow
• Risk of infection related to episiotomy
• Ineffective peripheral tissue perfusion related to circulation from thrombophlebitis
• Situational low self-esteem related to feed infant secondary to mastitis
• Social isolation due to precautions Necessary to protect the infant from others from infection transmission
• Risk for impaired parenting related to separation from infant due to infection
• Ineffective breastfeeding related to infection of the breasts