You are on page 1of 26

Postpartum Complications

Postpartum Hemorrhage
The leading cause of mortality nowadays in women of childbearing age. A blood loss that exceeds 500 ml after a vaginal birth or 1,000ml. After a cesarean birth. Early Postpartum Hemorrhage blood loss in the first 24 hrs. after childbirth. Late Postpartum Hemorrhage occurs after the first 24 hrs.

Predisposing Factors in Postpartum Hemorrhage


Overdistention of the uterus ( Multiple Gestation, LGA, Hydramnios ) Multiparity ( > 5 ) Use of tocolytic drugs in precipitate labor or delivery Prolonged labor Use of forceps or vacuum extractor Ceasarean birth Manual removal of the placenta Previous postpartum hemorrhage General anesthesia Low implantation of placenta Administration of MgSO4 Clotting disorders Previous uterine surgery

Early Postpartum Hemorrhage

Causes :
Uterine Atony 80% - 90% Trauma / lacerations to the birth canal during labor and delivery Hematoma formation Early Signs of Postpartum Hemorrhage - An uncontracted uterus - Large gush or steady trickle of blood from the vagina - Saturation of more than 1 peripad per hour - Severe unrelieved perineal or rectal pain - Tachycardia

Uterine Atony
The lack of muscle tone that results in the failure of the uterine muscle fibers to contract firmly around blood vessels when the placenta separates. 24 hrs. after birth uterus should be a firmly contracted ball resembling a grapefruit located at the level of the umbilicus. Lochia is dark red, moderate in amount, saturation of 1 pad/hr. is excessive.

Signs :
Uterine fundus that is difficult to locate Soft or boggy feel when fundus is located Uterus that becomes firm when massaged but loses its tone when massage is stopped. Uterine fundus that is located above expected level Excessive lochia

Management :
Uterine massage and expression of clots Pharmacologic measures 20 u oxytocin in 1 L D5LRS per doctors order Methylergonovine 0.2mg.IM per doctors order If postpartum hemorrhage is uncontrollable , do a Hysterectomy.

TRAUMA
can include vaginal, cervical, perineal lacerations and hematoma If with lacerations of the birth canal, theres excessive uterine bleeding when fundus is contracted firmly and on the right location. Bleeding is bright red, oozing, slow trickle or frank hemorrhage.

Factors that causes the incidence of obstetric lacerations :


Operative birth Precipitate delivery Congenital abnormalities of the maternal soft parts Contracted pelvis Size, abnormal presentation and position of the fetus Relative size of the presenting part and birth canal Previous scarring from infection, injury, operation Vulvar, perineal and vaginal varicosities

Hematomas

occur when bleeding into a loose connective tissue occurs while overlying tissue remains intact. Blood collects 25-500 ml. in the soft tissue Related to vascular injury during spontaneous or assisted delivery involving the vulva or vagina. Vulvar hematoma a discolored bulging mass producing deep ,severe, unrelieved pain with feelings of pressure.
Severe vulvar pain Unilateral purplish discoloration of the perineum or buttocks which are firm and tender. Feeling fullness in the vagina

Symptoms :

Management:
1. Application of small ice packs 2. Surgical evacuation

Retained Placenta

Non-adherent Retained Placenta


Results from partial separation of a normal placenta, entrapment of the partially or completely separated placenta by an hourglass constriction ring of the uterus, mismanagement of the third stage of labor or abnormal adherence of the entire placenta or a portion of the placenta to the uterine wall. Management :
Manual separation and removal by a primary health care provider under light anesthesia to facilitate exploration and removal

Adherent Retained Placenta

Thought to be a result from zygotic implantation in an area of defective myometrium so that there is no zone of separation between the placenta and the decidua. Attempts to remove the placenta in the usual manner is unsuccessful, laceration or perforation of the uterine wall may result putting woman in a greater risk of PPH and infection.

Degrees of attachment:

Placenta Accreta slight penetration of myometrium by placental trophoblast. Placenta Increta deep penetration of myometrium by placenta Placenta Percreta perforation of the uterus by the placenta Management Blood component replacement therapy Hysterectomy

Late Postpartum Hemorrhage

Blood loss of more than 500 ml. later than 24 hrs after delivery. Sometimes not occuring until 5-15 days after delivery

Causes :
Sub-involution delayed return of uterus to its prepregnant size and consistency. Retained placental fragments
Predisposing Factors : Attempts to deliver placenta before separation Manual removal of the placenta Placenta accreta Management : Oxytocin, Methylergometrine or Prostaglandins Curettage Broadspectrum antibiotics if there is infection ( fever, uterine tenderness, foul smelling lochia )

Uterine Inversion
Occurs when the uterus completely or partly turns inside out, usually during the 3rd stage of labor. Predisposing Factors :

Pulling on the umbilical cord before the placenta detaches from the uterine wall Fundal pressure during birth Fundal pressure on an incompletely contracted uterus after birth Increased intra-abdominal pressure An abnormally adherent placenta Congenital weakness of the uterine wall Fundal placental implantation

Signs : Uterus is either absent from the abdomen or a depression in the fundal area is present Management : - Doctor tries to replace the uterus through the vagina into a normal position - Laparotomy - if the above is not possible - Hysterectomy - After replacement, oxytocin is given to contract the uterus

Postpartum Infections

Puerperal Infection
Term used to describe bacterial infections after childbirth A fever of 38 C ( 100.4 F ) or higher after the first 24 hrs. after childbirth occuring on at least 3 of the first 10 days after the first 24 hrs. During the first 24 hrs. a slight elevation may occur because of dehydration or the exertion of labor Organisms can move from the vagina, cervix, uterus and out of the fallopian tube to infect the ovaries and the peritoneal cavity. Blood vessels or lymphatics can carry infection to the rest of the body.- Septicemia Causative organisms can be Staphylococcus aureus, gonococci, coliform bacteria, and rarely by Clostridia

Risk or Predisposing Factors:

Cesarean birth increases the risk 5x because of trauma to tissues Prolonged labor Colonization of the vagina with pathogenic organisms History of previous infections ( UTI, mastitis thrombophlebitis) Trauma Prolonged rupture of membranes Catheterization Excessive number of vaginal examinations Retained placental fragments Hemorrhage Poor general health( fatigue, anemia, frequent minor illness) Poor nutrition ( < PRO, Vitamin C ) Poor hygiene Medical conditions such as DM Low socioeconomic status

Signs and Symptoms of Postpartum Infection


Fever and chills Pain and redness of wounds Purulent wound drainage or wound edges not approximating Tachycardia Uterine Subinvolution Abnormal duration of lochia or foul odor Elevated white blood cell count Frequency or urgency of urination, dysuria or hematuria Suprapubic pain Localized area of warmth, redness or tenderness in the breast Body aches, general malaise

Endometritis
Infection of the uterus with pelvic cellulitis involving the decidua, myometrium, and parametrial tissues Caused by organisms that are normal inhabitants of the vagina and cervix ( E. coli, bacteroids, staphylococcus, anaerobic non-hemolytic streptococcus Signs and Symptoms :
Occurs during the first 2-7 days Fever, chills, malaise,anorexia, abdominal pain and cramping, uterine tenderness,purulent foul smelling lochia, tachycardia, subinvolution

Management :
Broad spectrum antibiotics IV Ampicillin, Cephalosporins, Gentamycin, Clindamycin Antipyretics and Oxytocics which increases drainage of lochia and involution

Complications :
Salphingitis Oophoritis Peritonitis Pelvic Thrombophlebitis

Thrombophlebitis
Involves the saphenous veins and confined to the lower leg Can be prevented by early ambulation after childbirth. Ambulation prevents stasis of blood in the legs and decrease likelihood of thrombus formation. Thrombus is a collection of blood factors, platelet, and fibrin on a vessel wall. Its formation is associated with inflammatory process in the vessel wall ( Thrombophlebitis)

3 Major Causes of Thrombosis :


Venous stasis occurs from compression of the large vessels of the pelvis and legs by the enlarging uterus
Woman stands for prolonged periods of time Prolonged time in stirrups for delivery and repair of episiotomy

Hypercoagulation

- Levels of most coagulation factors are increased and fibrinolytic symptoms is suppressed which hinders clot disintegration Blood Vessel Injury - specifically to the intima of the blood vessel

Factors that increases the risk of Thrombosis :


Inactivity Obesity Cesarean birth Smoking History of previous thrombosis Varicose veins Diabetes Mellitus Prolonged time in stirrups Maternal age older than 35 years Parity greater than 3

Clinical Manifestations :
Pain and tenderness in the lower extremity Physical examination may reveal warmth, redness and an enlarged hardened vein over the site of the thrombosis Deep vein thrombosis is more common in pregnancy and is characterized by unilateral leg pain, calf tenderness, and swelling

Management : - Analgesia ( NSAID )


- Rest with elevation of the affected leg - Use of elastic stockings - Local application of heat - For Deep Vein Thrombosis Anticoagulant, Bedrest, Analgesia, use of elastic stockings

Peritonitis Inflammation of the membrane lining the walls of the abdominal and pelvic cavities and may lead to pelvic abscess. Subinvolution of the Uterus - refers to a slower than expected return of the uterus to its pre-pregnancy size after childbirth. - Uterus descends at the rate of 1 cm. or 1 fingerbreadth per day. By 2 weeks it should not be palpable above the symphysis pubis.

Causes of Subinvolution of the Uterus


Retained placental fragments Pelvic infection

Signs :
Prolonged lochial discharge Irregular or excessive uterine bleeding Pelvic pain or feelings of heaviness Backache, fatigue and persistent malaise On bimanual exam, uterus feels larger and softer than normal during puerperium Treatment : Methylergonovine Maleate 0.2 mg every 3-4 hrs for 24-48 hrs. Antimicrobial therapy

Mastitis
An infection of the lactating breast occuring during the 2nd or 3rd wk. after birth although it may develop at anytime during breastfeeding. Common in mothers nursing for the first time and affects only one breast. Causes :

Staphylococcus aureus or E. coli- enters thru cracks or fissures in the nipple Engorgement and stasis of milk Constriction of breast from too tight brassiere may interfere with emptying of milk ducts Fatigued and stressed out mothers

Symptoms :
Flu like with fatigue and aching muscles Fever of 38.4C or higher Chills, malaise and headache Localized area of redness and inflammation Purulent discharge rare

Management : - Antibiotic therapy - Decompression of the breast by breastfeeding or pump - Application of heat or ice packs, breast support - Analgesics

You might also like