9. complication of postpartum


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9. complication of postpartum

  1. 1. Complication of postpartum POSTPARTUM HEMORRHAGE
  2. 2. POSTPARTUM HEMORRHAGE • Postpartum hemorrhage involves a loss of 500 mL or more of blood; it occurs most frequently in the first hour after delivery. • Төрсний дараах цус харвалт гэдэг нь 500 мл буюу түүнээс дээш хэмжээний цус, бөгөөд төрсний дараа эхний нэг цагт болно.
  3. 3. Pathophysiology/Etiology Early postpartum hemorrhage 1. Uterine atony—relaxation of the uterus secondary to: a. Multiple pregnancy—causes overdistention of uterus and a larger placental site b. Polyhydramnios (excessive amniotic fluid) c. High parity d. Prolonged labor with maternal exhaustion e. Deep anesthesia f. Fibromyomata—prevents uterus from contracting g. Retained placental fragments—result from manual removal of placenta, abnormal adherent placenta (placenta accreta)
  4. 4. Early postpartum hemorrhage 2. Laceration of the vagina, cervix, or perineum secondary to: a. Forceps delivery, especially rotation forceps b. Large infant c. Multiple pregnancy
  5. 5. Clinical Manifestations 1. With uterine atony uterus is soft or boggy, often difficult to palpate, and will not remain contracted; excessive vaginal bleeding occurs. 2. Lacerations of the vagina, cervix, or perineum cause bright red, continuous bleeding even when the fundus is firm. 3. Hemorrhage usually occurs about the tenth postpartum day with retained placental fragments.(late postpartum hemorrhage)
  6. 6. Management 1. For uterine atony, oxytocin (Pitocin) or methylergonovine (Methergine) are prescribed. 2. Pain medication may be needed to counter uterine contractions. 3. If placental fragments have been retained, curettage of the uterus is indicated. 4. Lacerations may need to be repaired
  7. 7. Nursing Assessment 1. Assess for hypotension, tachycardia, change in respiratory rate, decrease in urine output, and change in mental status—may indicate hypovolemic shock. 2. Assess location and firmness of uterine fundus. 3. Percuss and palpate for bladder distention, which may interfere with contracting of the uterus. 4. Monitor amount and type of bleeding or lochia present and the presence of clots. 5. Inspect for intactness of any perineal repair
  8. 8. Nursing Diagnoses A. Anxiety related to unexpected blood loss and uncertainty of outcome B. Fluid Volume Deficit related to blood loss C. Risk for Infection related to blood loss and vaginal examinations
  9. 9. Nursing Interventions A. Decreasing Anxiety 1. Maintain a quiet and calm atmosphere. 2. Provide information about the situation and explain everything as it is done; answer questions that the woman and her family ask. 3. Encourage the presence of a support person.
  10. 10. B. Maintaining Fluid Volume 1. Maintain or start a large-bore IV line if vaginal bleeding becomes heavy. 2. Ensure that crossmatched blood is available. 3. Infuse oxytocin, IV fluids, and blood products at prescribed rate. 4. Monitor CBC for anemia.
  11. 11. C. Preventing Infection 1. Maintain aseptic technique. 2. Evaluate for symptoms of infection, chilling, and elevated temperature, changes in white blood cell count, uterine tenderness, and odor of lochia. 3. Administer antibiotics as prescribed.
  12. 12. Patient Education/Health Maintenance 1. Educate the woman about the cause of the hemorrhage. 2. Teach the woman the importance of eating a balanced diet and taking vitamin supplements. 3. Advise the woman that she may feel tired and fatigued and to schedule daily rest periods. 4. Advise the woman to notify her health care provider of increased bleeding or other changes in her status.
  13. 13. Evaluation A. Verbalizes concerns about her well-being B. Vital signs stable, urine output adequate, hematocrit stable C. Remains afebrile, WBC count within normal limits
  14. 14. POSTPARTUM HEMATOMAS ТӨРСНИЙ ДАРААХ ЦУС ХУРАЛТ • Postpartum hematomas are localized collections of blood in loose connective tissue beneath the skin that covers the external genitalia, beneath the vaginal mucosa, or in the broad ligaments.
  15. 15. Perineal hematoma
  16. 16. Pathophysiology/Etiology 1. Trauma during spontaneous labor 2. Trauma during forceps application or delivery 3. Inadequate suturing of an episiotomy
  17. 17. Clinical Manifestations 1. Complaints of pressure and pain, often noting that the pain is excruciating 2. Discolored skin that is tight, full feeling, and painful to touch 3. Possible decrease in blood pressure, tachycardia
  18. 18. Complications 1. Hypovolemia and shock from extreme blood loss 2. Anemia, infection 3. Increased length of postpartum recovery period
  19. 19. Management 1. Small hematomas are left to resolve on their own - ice packs may be applied. 2. Large hematomas may require evacuation of the blood and ligation of the bleeding vessel. 3. Analgesics and antibiotics may be ordered (due to increased chance of infection).
  20. 20. Nursing Interventions/Patient Education 1. Inspect perineal and vulva area for signs of a hematoma when woman complains of pain or pressure after delivery. 2. Inspect the vaginal area for signs of a hematoma if woman is unable to void after anesthesia has worn off. 3. Monitor vital signs at least every 10 to 15 minutes and evaluate for signs of shock. 4. Relieve pain of a hematoma by applying an ice bag to perineal area, medicating with mild analgesics, and positioning for comfort to decrease pressure on the affected area. 5. Help relieve voiding problems by assisting to bathroom to void if able to ambulate. 6. If she is unable to void, catheterize. 7. Teach the woman the importance of eating a balanced diet and to include food high in iron. 8. Encourage the woman to take vitamin supplements and to take medications as ordered.
  21. 21. PUERPERAL INFECTION • Puerperal infection is a postpartum infection of the genital tract, usually of the endometrium, that may remain localized or may extend to various parts of the body.
  22. 22. Pathophysiology/Etiology • Bacterial organisms either are introduced from external sources or are normally present in the genital tract and are carried to the uterus. • Predisposing factors include: 1. Prolonged labor or rupture of membranes (PROM) 2. Number of vaginal examinations 3. Infection elsewhere in the body 4. Anemia, malnutrition 5. Size and number of perineal lacerations 6. Intrauterine manipulation 7. Retained placental fragments of membranes 8. Lapse in aseptic technique 9. Poor perineal hygiene 10. Cesarean section
  23. 23. Clinical Manifestations • Diagnosis is made by sustained fever of 38°C (100.4°F) or higher occurring on any two of the first 10 days postpartum, excluding the first 24 hours. Symptoms depend on site and extension of infection.
  24. 24. Puerperal fever
  25. 25. Endometritis A. Endometritis Postpartum infection involving the endometrium 1. Uterus usually larger than expected for postdelivery day. 2. Lochia may be profuse, bloody, and foul smelling. 3. Chills and fever occur if lochial discharge is obstructed by clots. 4. Infection may spread to myometrium, parametrium, uterine (fallopian) tubes, peritoneum, and blood.
  26. 26. B. Parametritis • B. Parametritis (Pelvic Cellulitis) Infection of the pelvic (connective tissue spread by the lymphatic system within the uterine wall. Often a result of an infected wound in the cervix, vagina, perineum, or lower uterine segment 1. Chills, fever (38.8°-40.0°C; 102°-104°F), tachycardia 2. Severe unilateral or bilateral pain in lower abdomen 3. Enlarged and tender uterus 4. Uterine position may become fixed as it is displaced by the exudate along the broad ligament.
  27. 27. Parametritis & peritonitis
  28. 28. Management 1. Aseptic technique, avoid cross infection Hand wash medical personal. 2. Antibiotic therapy is instituted after cultures are obtained and causative agent identified. 3. Supportive therapy is used to control pain and to maintain hydration and nutritional status. 4. Drainage is indicated for abscess development.
  29. 29. Complications • Thrombophlebitis may result from puerperal infection spread along the veins. 1. Femoral thrombophlebitis—appears 10 to 20 days after delivery as pain in calf, positive Homan's sign, fever, edema 2. Pelvic thrombophlebitis a. Infection of the veins of uterine wall and broad ligament usually caused by anaerobic streptococci b. Severe repeated chills and wide range of temperature changes occur about 2 weeks after delivery. 3. Strict bed rest, anticoagulants, and antibiotics are indicated.
  30. 30. Thrombophlebitis & Homan’s sign
  31. 31. Nursing Interventions/Patient Education 1. Perform postpartum assessment, noting uterine tenderness on palpation and the color, amount, and odor of lochia. 2. Monitor vital signs for signs of infection. 3. Assess knowledge and skill of perineal hygiene; teach proper technique and assist, if necessary. 4. Provide for adequate rest periods. 5. Position in high Fowler's position to promote drainage. 6. Administer antibiotics and analgesics, as ordered.
  32. 32. Nursing Interventions/Patient Education 7. Explain the benefit of perineal washing or sitz baths and demonstrate setup. 8. Explain the need for good handwashing technique and how contamination of vagina from the rectum occurs. 9. Show how to place perineal pads and medications; encourage to change pads with each voiding, bowel movement, or every 4 hours while awake. 10. Encourage minimal separation from the infant and continuation of breast-feeding, as able. 11. Promote good handwashing technique for the mother before contact with the infant.
  33. 33. AMNIOTIC FLUID EMBOLISM • Amniotic fluid embolism is the escape of amniotic fluid containing debris such as meconium, lanugo, and vernix caseosa into the maternal circulation, • usually resulting in deposition of fluid or debris in the pulmonary arterioles, resulting rapidly in respiratory distress, shock, and the possible development of DIC. • Amniotic fluid embolism is rare and usually fatal.
  34. 34. Pathophysiology/Etiology 1. The exact mechanism causing amniotic fluid embolism is unclear. 2. It usually occurs in the intrapartum period. 3. Myometrial vessels are exposed, usually at the placental site and contractions are especially forceful. A thromboplastin-like substance is found in amniotic fluid, which causes defibrination leading to DIC. 4. Predisposing conditions include abruptio placentae, uterine rupture, intrauterine fetal demise, and high parity.
  35. 35. Clinical Manifestations 1. Sudden dyspnea and chest pain 2. Cyanosis, tachycardia 3. Pulmonary edema 4. Profound shock due to: a. Anaphylaxis, which causes vascular collapse b. Uterine bleeding with development of hypofibrinogenemia
  36. 36. Management 1. Endotracheal intubation 2. Administration of IV crystalloid fluids 3. Administration of blood products and heparin to combat DIC 4. Establishment of central venous pressure line 5. Immediate delivery of the fetus 6. Initiation of cardiopulmonary resuscitation if needed
  37. 37. Nursing Assessment/Interventions 1. Be alert to signs and symptoms of potential amniotic fluid embolism. 2. Monitor maternal vital signs and fetal heart rate frequently to assess for signs of shock and fetal/maternal demise. 3. Administer oxygen via face mask to assist respiration status. 4. Alert medical staff immediately and assist with emergency procedures such as delivery and with the cardiopulmonary resuscitation as needed. 5. Provide information and comfort to the family or support persons. If unable to do this personally due to the emergent needs of the woman, delegate another member of the staff to stay with the family or support persons.
  38. 38. POSTPARTUM DEPRESSION • Postpartum depression may occur in the first 2 weeks after delivery • Etiology: unknown, - Hormonal theory– decrease estrogen level As like as menstrual period, menopause - Psychosocial aspect; lack of support system, unwanted baby - Cultural aspect; male dominant, favorable sex baby
  39. 39. • postparum blue : a normal developmental crisis related to the adjustments that are being made relative to the new role of parent, along with the added responsibilities, fatigue, and excitement that go with the birth. • If a woman is unable to work through her feelings within about 2 weeks, and the symptoms continue, a more serious depression is indicated. • postpartum depression; social, cultural, physiologic and psychological factors experienced may contribute to postpartum • Postpartum psychosis; a severe form of depression that occurs in a small percentage of women giving birth.
  40. 40. Clinical Manifestations 1. Exaggerated and prolonged periods of irritability, moodiness, hostility, fatigue 2. Ineffective coping 3. Withdrawal and inappropriate response to the infant or family 4. Loss of interest in activities 5. Insomnia
  41. 41. Management • Signs and symptoms may be overlooked, making the diagnosis of depression difficult. • Counseling with a mental health professional, medication, and continuous support from family and friends may be helpful in managing the depressed patient. • If untreated, the woman may not fully recover and possibly harm the infant or others. refer to psychologist
  42. 42. Nursing Interventions/Patient Education 1. Listen to the woman regarding her adjustment to role of mother and observe for any clinical manifestations suggesting depression. 2. Ask the woman about the infant's behavior. Negative statements about the infant may suggest that the woman is having difficulty coping. 3. Provide support and encourage husband, family and friends to support and assist with the infant and mother. Physical support as well as emotional support may be indicated. 5. Educate the woman that treatment may help alleviate her symptoms and allow her to better care for herself and infant.