Postpartum Complications. Postpartum Complications: Principles The most frequent cause of postpartum hemorrhage is uterine atony. Anything that overdistends.

Postpartum Complications

Postpartum Complications: Principles

• The most frequent cause of postpartum hemorrhage is uterine atony.

• Anything that overdistends the uterus, causes it to contract poorly or overworks the uterus is a set-up for uterine atony.

Postpartum Hemorrhage

- Continues to be a leading cause of maternal morbidity and death in the US

- Can occur with little warning

- Definitions (PP lecture) * also include 10% drop in Hct between admission and postpartum

- 50% underestimation of blood loss



- Most common cause (90%) is uterine atony (marked hypotonia)

- Less common causes are retained placenta, placenta accreta, cervical/vaginal lacerations, uterine rupture

- Predisposing causes of uterine atony

* Multiparity * Hydramnios

* Macrosomic fetus * Traumatic birth

* Rapid or prolonged labor


* Use of magnesium sulfate

* Use of oxytocin

* Multiple pregnancy

- Management of uterine atony

* Manual massage of the uterus

* Expression of clots

* Eliminate bladder distention

* IV of lactated Ringer’s or normal saline with 10-40 units of oxytocin added

* Ergonovine or methyl-ergonovine (IM) if not hypertensive


- Non-adherent Retained Placenta

* May result from partial separation of the placenta or entrapment of the partially or fully separated placenta

* Treated by manual removal of the placenta

* If no epidural, nitrous oxide and oxygen inhalation


- Adherent Retained Placenta

* Unknown etiology

* Probably implantation in a defective area of endometrium

* Manual removal is unsuccessful and laceration or perforation of uterine wall may result from attempts

* Degrees of adherence

- Placenta accreta = slight penetration of myometrium


- Placenta increta = deep penetration of myometrium

- Placenta percreta = penetration to the point of perforation of the myometrium

* Treatment may indicate hysterectomy and blood replacement

- Inversion of the uterus

* Potentially life-threatening complication

* 1 in 2000-2500 births


* Partial or complete

* Contributing factors

- Fundal implantation of placenta

- Vigorous fundal pressure

- Excessive traction to cord

- Uterine atony, fibroids or abnormally adherent placenta

- Most often in multiparas with placenta accreta/increta

-


- Coagulopathies

* When bleeding continues with no identifiable source, a coagulopathy must be considered

* Coagulation status must be assessed quickly and continuously

* Abnormal results depend on the cause and may include:

- Increased prothrombin time

- Increased partial prothrombin time


- Decreased platelets

- Decreased fibrinogen level

- Increased fibrin degradation products

- Prolonged bleeding time

* Idiopathic throbocytopenia

* Von Willebrand Disease


* Disseminated intravascular coagulation (DIC)

- Diffuse and consumes large amounts of clotting factors

- Widespread external and internal bleeding

- Predisposing factors: abruptio placentae, amniotic fluid embolism, dead fetus syndrome (6 weeks), severe pre-eclampsia, septicemia, cardiopulmonary arrest, hemorrhage


* Diagnosis - Spontaneous bleeding from gums and nose

- Petechiae around blood pressure cuff

- Thromboembolic Disease

* Types

- Superficial venous thrombosis saphenous)

- Deep venous thrombosis (foot to iliofemoral region


- Pulmonary embolism (complication of DVT)

* Incidence has decreased because of early ambulation after birth

* Major causes

- Venous stasis

- Hypercoagulation

* Medical management

- Superficial – analgesic (NSAID), rest with elevation of the leg, elastic stockings


- Local application of heat may also be used

- Deep vein thrombosis – IV heparin (5-7 days), bedrest with affected leg elevated, analgesia followed by elastic stockings and oral anticoagulant therapy (warfarin) for 3 months

* Woman should be encouraged not to massage area and, when on bedrest, not to flex knees sharply

* Anticoagulant therapy for 6 months



-Pulmonary embolism

* Signs/symptoms

- Shortness of breath

- Diaphoresis

- Chest pain

- Tachycardia

* Treated with continuous IV heparin followed by intermittent subcutaneous or oral

Postpartum Infections

- Puerperal Infection (“Childbed Fever”) - Any infection of the genital canal that begins within 28 days after abortion, miscarriage or childbirth

- Definition is a fever of 38o C (100.4o F) on 2 successive days of the first 10 days postpartum (not counting 1st 24 hours after birth


- Common infections

* Endometritis

* Wound infections

* Mastitis

* UTIs

* URIs

- More common in women with concurrent medical or immunosuppressive conditions


- Also increased risk with

* A Cesarean or other operative birth

* Prolonged labor

* Prolonged rupture of membranes

* Internal fetal or uterine monitoring

- Signs/symptoms

* Endometritis

- Pelvic pain - Uterine tenderness - Foul-smelling, profuse lochia


* Wound infection

- Erythema, edema, warmth, tenderness, sero-purulent drainage wound separation

* Mastitis

- Almost always unilateral

- Develops well after milk flow established

- Usually hemolytic S. aureus


- Infected nipple fissure usually the initial lesion

- Accompanied by inflammatory edema and engorgement that obstruct milk flow in the region and generalized mastitis follows

- Chills, fever, malaise, pain

- Treated by antibiotics and emptying breasts q 2-4 hours by feeding, manual expression or pump


Postpartum Psychological Complications

- Grieving

* Normal response to loss of a child or loss of the “ideal” child

* The woman grieves the “death” of the idealized child

* May interfere with the ability to bond with the child



* Death of a baby

- Questions about what happened

- Bewilderment, resentfulness, bitterness

- Most women interested in seeing the baby and this is therapeutic

- Staff and patients, friends and relatives tend to avoid a woman whose baby has died

- Woman needs the opportunity to talk about it

Perinatal depression

* Prevalence of major and minor depression begins to rise after delivery and peaks in the 3rd month

* Postpartum “Blues”

- 50% of women have symptoms

- Peak on 5th postpartum day

- considered a normal part of early motherhood

- Go away within 10 days

- Depression

* “Blues” vs. Depression vs. Psychosis (handout)

* Blues

- Emotional lability - Feelings of sadness - Related to hormone shifts, fatigue, sleep deprivation

* Depression - Feelings continue beyond the immediate postpartal period and longer than 1 year


* Postpartum Depression

- May occur in 10% - 23% of women

- A true, major depression

- Can last into the 2nd year after delivery

- Risk factors

* Past history of depression (often bipolar)

* Depression during pregnancy

* Previous history of postpartum depression

* Life stress

* Poor social support


* History “baby blues”

* History of severe PMS

* Poor marital relationship

* Family history of postpartum depression

- Symptoms

* Feeling of sadness, extreme fatigue, inability to stop crying, anxiety about her own or the baby’s health, insecurity and psychosomatic symptoms


* Cheryl Beck (PPSS)

- “Teetering on the edge” - “Brain is full of cobwebs” - “…I have lost my self”

* Basic psychosocial problem with control

- Postpartum Psychosis

* Response to the crisis of childbearing

* Majority of these women have had symptoms of mental illness that precede the pregnancy



* Other major life crises can precipitate the same illness

* Exceptional sadness, out of touch with reality, thoughts of infanticide or that the child is possessed

* This is a psychiatric emergency and requires hospital admission

* Do not leave the woman alone and do not leave her alone with her infant

* Risks of suicide and infanticide are significant

Postpartum Complications. Postpartum Complications: Principles The most frequent cause of postpartum hemorrhage is uterine atony. Anything that overdistends.

Documents

adherent placenta

placenta percreta

placenta increta

separated placenta

prolonged labor slide

nonadherent retained

bladder distention slide

perforation of uterine