Postpartum Complications - www.jinekolojivegebelik.com

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Postpartum Complications - www.jinekolojivegebelik.com

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Postpartum Complications - www.jinekolojivegebelik.com

  1. 1. Postpartum Complications Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  2. 2. Postpartum Hemorrhage <ul><li>Definition and incidence </li></ul><ul><ul><li>PPH traditionally defined as loss of more than: </li></ul></ul><ul><ul><ul><li>500 ml of blood after vaginal birth </li></ul></ul></ul><ul><ul><ul><li>1000 ml after cesarean birth </li></ul></ul></ul><ul><ul><li>Cause of maternal morbidity and mortality </li></ul></ul><ul><ul><li>Life-threatening with little warning </li></ul></ul><ul><ul><li>Often unrecognized until profound symptoms </li></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  3. 3. Postpartum Hemorrhage <ul><li>Etiology and risk factors </li></ul><ul><ul><li>Uterine atony </li></ul></ul><ul><ul><ul><li>Marked hypotonia of uterus </li></ul></ul></ul><ul><ul><ul><li>Leading cause of PPH, complicating approximately 1 in 20 births </li></ul></ul></ul><ul><ul><ul><li>Brisk venous bleeding with impaired coagulation until the uterine muscle contracts </li></ul></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  4. 4. Postpartum Hemorrhage <ul><ul><li>Lacerations of genital tract </li></ul></ul><ul><ul><ul><li>Should be suspected if bleeding continues with a firm, contracted fundus </li></ul></ul></ul><ul><ul><ul><li>Includes perineal and cervical lacerations as well as pelvic hematomas </li></ul></ul></ul><ul><ul><li>Retained placenta </li></ul></ul><ul><ul><ul><li>Nondherent retained placenta – managed by manual separation and removal by the primary care provider </li></ul></ul></ul><ul><ul><ul><li>Adherent retained placenta – may be caused by implantation into defective endometrium </li></ul></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  5. 5. Postpartum Hemorrhage <ul><ul><li>Three classifications of adherent retained placenta </li></ul></ul><ul><ul><ul><li>Placenta acreta – slight penetration of myometrium by placental trophoblast </li></ul></ul></ul><ul><ul><ul><li>Placenta increta – deep penetration of myometrium by placenta </li></ul></ul></ul><ul><ul><ul><li>Placenta percreta – perforation of uterus by placenta </li></ul></ul></ul><ul><ul><li>Patient will experience profuse bleeding when delivery of the placenta is attempted. </li></ul></ul><ul><ul><li>Management includes blood replacement and surgical intervention (hysterectomy) </li></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  6. 6. Postpartum Hemorrhage <ul><li>Inversion of uterus (turning inside out) </li></ul><ul><ul><li>May be life-threatening </li></ul></ul><ul><ul><li>A complete inversion protrudes out of the vagina </li></ul></ul><ul><ul><li>Primary signs – hemorrhage, shock, pain </li></ul></ul><ul><ul><li>Prevention is the best measure – don’t pull on the umbilical cord unless there is definite separation of the placenta </li></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  7. 7. Postpartum Hemorrhage <ul><li>Subinvolution of uterus – delayed involution of the uterus </li></ul><ul><ul><li>Usually see late post partum bleeding </li></ul></ul><ul><ul><li>Causes include retained placental fragments and infection </li></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  8. 8. Care Management <ul><li>Assessment </li></ul><ul><ul><li>Bleeding assessed for color and amount </li></ul></ul><ul><ul><li>Perineum inspected for signs of lacerations or hematomas to determine source of bleeding </li></ul></ul><ul><ul><li>Vital signs may not be reliable indicators because of postpartum adaptations </li></ul></ul><ul><ul><ul><li>Measurements during first 2 hours may identify trends related to blood loss </li></ul></ul></ul><ul><ul><li>Bladder distension </li></ul></ul><ul><ul><li>Laboratory studies of hemoglobin and hematocrit levels </li></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  9. 9. Care Management <ul><li>Plan of care and implementation </li></ul><ul><ul><li>Initial treatment – fundal massage, expression of clots, relief of bladder distension, IV fluids </li></ul></ul><ul><ul><li>Medications – Table 25-1 </li></ul></ul><ul><ul><li>Medical management </li></ul></ul><ul><ul><ul><li>Hypotonic uterus – examine for retained placental fragments, medications, surgical interventions </li></ul></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  10. 10. Care Management <ul><ul><li>Medical management – cont. </li></ul></ul><ul><ul><ul><li>Bleeding with a contracted uterus – identify and treat underlying cause </li></ul></ul></ul><ul><ul><ul><li>Uterine inversion – emergency replacement of the uterus into the pelvic cavity </li></ul></ul></ul><ul><ul><ul><li>Subinvolution – medications, surgical intervention </li></ul></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  11. 11. Care Management <ul><li>Plan of care and implementation </li></ul><ul><ul><li>Nursing interventions </li></ul></ul><ul><ul><ul><li>Vital signs, uterine assessment, medication administration, notification of primary care provider </li></ul></ul></ul><ul><ul><ul><li>Providing explanations about interventions and need to act quickly </li></ul></ul></ul><ul><ul><ul><li>Once stable, ongoing post partum assessments and care </li></ul></ul></ul><ul><ul><ul><li>Instructions in increasing dietary iron, protein intake, and iron supplementation </li></ul></ul></ul><ul><ul><ul><li>May need assistance with infant care and household activities until strength regained </li></ul></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  12. 12. Hemorrhagic (Hypovolemic) Shock <ul><li>Emergency situation in which blood is diverted to the brain and heart </li></ul><ul><ul><li>May not see signs until post partum patient loses 30% to 40% of blood volume </li></ul></ul><ul><li>Medical management – restore circulating blood volume and treat underlying cause </li></ul><ul><li>Nursing interventions – monitor tissue perfusion, see emergency box </li></ul><ul><li>Fluid or blood replacement therapy </li></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  13. 13. Coagulopathies <ul><li>Idiopathic thrombocytopenic purpura (ITP) – decreased platelet life span, need to control platelet stability </li></ul><ul><li>von Willebrand disease—type of hemophilia </li></ul><ul><li>Disseminated intravascular coagulation (DIC) </li></ul><ul><ul><li>Pathologic clotting </li></ul></ul><ul><ul><li>Correction of underlying cause </li></ul></ul><ul><ul><ul><li>Removal of fetus </li></ul></ul></ul><ul><ul><ul><li>Treatment for infection </li></ul></ul></ul><ul><ul><ul><li>Preeclampsia or eclampsia </li></ul></ul></ul><ul><ul><ul><li>Removal of placental abruption </li></ul></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  14. 14. Thromboembolic Disease <ul><li>Results from blood clot caused by inflammation or partial obstruction of vessel </li></ul><ul><li>May be superficial or deep venous thrombosis or a pulmonary embolus </li></ul><ul><li>Incidence and etiology </li></ul><ul><ul><li>Venous stasis </li></ul></ul><ul><ul><li>Hypercoagulation </li></ul></ul><ul><li>Clinical manifestations – redness and swelling in the affected extremity, pain, positive Homan’s sign </li></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  15. 15. Thromboembolic Disease <ul><li>Medical management </li></ul><ul><ul><li>Superficial – analgesia, rest/elevation, TED hose </li></ul></ul><ul><ul><li>Deep – anticoagulant therapy, bedrest/elevation, TED hose </li></ul></ul><ul><ul><li>Pulmonary embolus – IV heparin therapy </li></ul></ul><ul><li>Nursing interventions </li></ul><ul><ul><li>assessment of the affected area, signs of bleeding, personal care, medication administration </li></ul></ul><ul><ul><li>Teach not to massage affected area!! </li></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  16. 16. Postpartum Infections <ul><li>Puerperal sepsis: any infection of genital canal within 28 days after abortion or birth </li></ul><ul><li>Most common infecting agents are numerous streptococcal and anaerobic organisms </li></ul><ul><li>Endometritis </li></ul><ul><li>Wound infections </li></ul><ul><li>Urinary tract infections </li></ul><ul><li>Mastitis </li></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  17. 17. Care Management <ul><li>Prevention is the best intervention </li></ul><ul><ul><li>Hand washing </li></ul></ul><ul><ul><li>Good maternal perineal hygiene </li></ul></ul><ul><li>Antibiotic administration </li></ul><ul><li>Wound management </li></ul><ul><li>Breast care </li></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  18. 18. Sequelae of Childbirth Trauma <ul><li>Disorders of uterus and vagina related to pelvic relaxation and urinary incontinence, are often result of childbearing </li></ul><ul><li>Uterine displacement and prolapse </li></ul><ul><ul><li>Posterior displacement, or retroversion </li></ul></ul><ul><ul><li>Retroflexion and anteflexion </li></ul></ul><ul><ul><li>Prolapse a more serious displacement </li></ul></ul><ul><ul><ul><li>Cervix and body of uterus protrude through vagina and vagina is inverted </li></ul></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  19. 19. Sequelae of Childbirth Trauma <ul><li>Cystocele and rectocele </li></ul><ul><ul><li>Cystocele: protrusion of bladder downward into vagina when support structures in vesicovaginal septum are injured </li></ul></ul><ul><ul><li>Rectocele is herniation of anterior rectal wall through relaxed or ruptured vaginal fascia and rectovaginal septum </li></ul></ul><ul><li>Urinary incontinence </li></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  20. 20. Sequelae of Childbirth Trauma <ul><li>Genital fistulas </li></ul><ul><ul><li>May result from congenital anomaly, gynecologic surgery, obstetric trauma, cancer, radiation therapy, gynecologic trauma, or infection </li></ul></ul><ul><ul><ul><li>Vesicovaginal: between bladder and genital tract </li></ul></ul></ul><ul><ul><ul><li>Urethrovaginal: between urethra and vagina </li></ul></ul></ul><ul><ul><ul><li>Rectovaginal: between rectum or sigmoid colon and vagina </li></ul></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  21. 21. Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34 Types of Fistulas That May Develop in Vagina, Uterus, and Rectum
  22. 22. Postpartum Psychologic Complications <ul><li>Mental health disorders in postpartum period have implications for mother, newborn, and entire family </li></ul><ul><ul><li>Interfere with attachment to newborn and family integration </li></ul></ul><ul><ul><li>May threaten safety and well-being of mother, newborn, and other children </li></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  23. 23. Postpartum Psychologic Complications <ul><li>Postpartum depression without psychotic features </li></ul><ul><ul><li>PPD: an intense and pervasive sadness with severe and labile mood swings </li></ul></ul><ul><ul><li>Treatment options </li></ul></ul><ul><ul><ul><li>Antidepressants, anxiolytic agents, and electroconvulsive therapy </li></ul></ul></ul><ul><ul><ul><li>Psychotherapy focuses fears and concerns of new responsibilities and roles, and monitoring for suicidal or homicidal thoughts </li></ul></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  24. 24. Postpartum Psychologic Complications <ul><li>Postpartum depression with psychotic features </li></ul><ul><ul><li>Postpartum psychosis: syndrome characterized by depression, delusions, and thoughts of harming either infant or herself </li></ul></ul><ul><ul><li>Psychiatric emergency, and may require psychiatric hospitalization </li></ul></ul><ul><ul><li>Antipsychotics and mood stabilizers such as lithium are treatments of choice </li></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  25. 25. Loss and Grief <ul><li>Losses of what was hoped for, dreamed about, and/or planned </li></ul><ul><li>Any perception of loss of control during the birthing experience </li></ul><ul><li>Birth of a child with handicap </li></ul><ul><li>Maternal death </li></ul><ul><li>Fetal or neonatal death </li></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  26. 26. Loss and Grief <ul><li>Conceptual model of parental grief </li></ul><ul><ul><li>Acute distress </li></ul></ul><ul><ul><li>Intense grief </li></ul></ul><ul><ul><li>Reorganization </li></ul></ul><ul><li>Anticipatory grief </li></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  27. 27. Loss and Grief <ul><li>Plan of care and implementation </li></ul><ul><ul><li>Communicating and care techniques </li></ul></ul><ul><ul><ul><li>Actualize the loss </li></ul></ul></ul><ul><ul><ul><li>Provide time to grieve </li></ul></ul></ul><ul><ul><ul><li>Interpret normal feelings </li></ul></ul></ul><ul><ul><ul><li>Allow for individual differences </li></ul></ul></ul><ul><ul><ul><li>Cultural and spiritual needs of parents </li></ul></ul></ul><ul><ul><ul><li>Physical comfort </li></ul></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  28. 28. Loss and Grief <ul><li>Plan of care and implementation </li></ul><ul><ul><li>Options for parents </li></ul></ul><ul><ul><ul><li>Seeing and holding </li></ul></ul></ul><ul><ul><ul><li>Bathing and dressing </li></ul></ul></ul><ul><ul><ul><li>Privacy </li></ul></ul></ul><ul><ul><ul><li>Visitations: other family members or friends </li></ul></ul></ul><ul><ul><ul><li>Religious rituals/funeral arrangements </li></ul></ul></ul><ul><ul><ul><li>Special memories </li></ul></ul></ul><ul><ul><ul><li>Pictures </li></ul></ul></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  29. 29. Maternal Death <ul><li>Rare for woman to die in childbirth </li></ul><ul><li>Families are at risk for developing complicated bereavement and altered parenting of surviving baby and other children in family </li></ul><ul><li>Referral to social services can help combat potential problems before they develop </li></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  30. 30. Key Points <ul><li>Postpartum hemorrhage is most common and serious type of excessive obstetric blood loss </li></ul><ul><li>Hemorrhagic (hypovolemic) shock is an emergency situation; the perfusion of body organs may become severely compromised and death may ensue </li></ul><ul><li>Potential hazards of therapeutic interventions may further compromise the woman with hemorrhagic disorders </li></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  31. 31. Key Points <ul><li>Postpartum infection is a major cause of maternal morbidity and mortality </li></ul><ul><li>Postpartum urinary tract infections are common because of trauma experienced during labor </li></ul><ul><li>Breast infection affects about 1% of women soon after childbirth </li></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  32. 32. Key Points <ul><li>Structural disorders of uterus and vagina related to pelvic relaxation are often the delayed but direct result of childbearing </li></ul><ul><li>Understanding of grief responses and bereavement process is fundamental to the nursing process </li></ul><ul><li>Therapeutic communication and counseling techniques can help families in identifying their feelings and in feeling comfortable in expressing their grief </li></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34
  33. 33. Key Points <ul><li>Follow-up after discharge is an essential component in providing care to families who have experienced a loss </li></ul><ul><li>Nurses need to be aware of their own feelings of grief and loss to provide a nonjudgmental environment of care and support for bereaved families </li></ul>Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

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