Post-Partum ComplicationsHEMORRHAGESlide 3Early PP HemorrhageHEMORRHAGEPredisposing factorsMost Common Causes of HemorrhageUterine AtonyD&C: Dilitation & CurettageEarly PP hemorrhageAssessment of Early PP HemorrhageTreatmentSlide 13Possible MedicationsProstaglandin SE and interventionsPowerPoint PresentationLate PP HemorrhageEtiology: Late PP HemorrhageLOCHIA FLOWOther assessmentSlide 21NURSINGSlide 23INFECTIONSlide 25Slide 26PUEPERAL INFECTIONSPREVENTION of infection1) ENDOMETRITIS / METRITISSigns / SymptomsTREATMENT2) PELVIC CELLULITIS / PARAMETRITISSigns and SymptomsSlide 343) PERITONITIS4) SALPINGITISSlide 37Slide 38THROMBO EMBOLIC DISEASETHROMBOPHLEBITISSlide 41Increased risk with:Risks (continued)Different types:Superficial ThrombophlebitisSlide 46Slide 47Femoral & pelvic thrombophlebitisSigns and symptoms: Depends on the vein involvedSlide 50Deep Vein ThrombosisSlide 52Specific treatment for conditionsSlide 54Slide 55Slide 56Slide 57Pelvic ThrombophlebitisSlide 59CLIENT EDUCATION FOR THROMBOPHLEBITISDischarge teaching for CoumadinPULMONARY EMBOLISMSlide 63Slide 64Slide 65Treatment continuedSUBINVOLUTION OF UTERUSSlide 68Slide 69Slide 70MASTITISSlide 72Slide 73Slide 74Urinary Tract InfectionsSlide 76Slide 77Common UTI’s in PP clientsSlide 79VULVAR HEMATOMASlide 81Slide 82HEMATOMASlide 84THE END!!!Post-Partum ComplicationsSG # 8Prof. Unn HidleUpdated Spring 2010HEMORRHAGEHEMORRHAGEDescription: (overall category of hemorrhage)Bleeding of 500 mL or more following deliveryTraditional definition vs. “new” definition:Traditional:NVD => 500ccC-section => 1000cc“New” criteria:Decreased Hct of 10 points OR The need for fluid replacement after birthEarly PP HemorrhageAssessmentHemorrhage occurs during first 24 hours after delivery>500cc of blood lossCaused by: retained fragments of placentaUTERINE ATONY 80-90% of the casesBlood may be expelled or retained in the vaginaperineal injuries/lacerationsinversion of uterusEpisiotomyHematomas: vulvar, vaginal, subperitoneal Coagulation disorders (i.e. hemophilia, thalassemia)HEMORRHAGEPredisposing factorsMultiparityMultiple gestationsAnesthesia (relaxes the uterus)Uterine infectionsPitocin used for induction or augmentation of laborTrauma from forceps deliveryMalnutrition (esp. decreased Folic Acid and iron)AnemiaPIHMost Common Causes of HemorrhageResidual placentaBleeding from placenta accreata – parts of the placenta adhers to the endometrium, in this case the chorionic villi attaches directly to the myometrium of the uterus (accounts for 80% of adherent placenta to the endometrium)Placenta accreata may cause:Maternal hemorrhageFailure of the placenta to separateLess common to bleed from placenta increta or placenta percreta (other placenta adherences)Abdominal hysterectomy may be necessary, depending on involvementRetained placenta: Surgical removal (D&C)Uterine AtonyD&C: Dilitation & CurettageEarly PP hemorrhageLaceration of the birth canalIf there is post-partum hemorrhage and the fundus is firm, suspect lacerationVaginal lacerations: Surgical repairCervical laceration: Repair is usually accomplished by turning the cervix inside out and suturingAssessment of Early PP HemorrhageIn what order?BradycardiaTachycardiaTachypnea with shallow respirationsDiaphoreticCool, clammy skinHypotension Overall: signs of hypovolemic shockTreatmentRemember, this is immediately PP!FIRST… Externally massage fundus if boggy – DON’T over-massageBimanual massage?What if it is a C-section?Oxytocin / PitocinPRBC transfusion or other blood productsHEMORRHAGEPossible MedicationsPitocinMethylergonivine maleate (Metergine) Prostaglandins (PGF2a); Prostin:Uterine stimulant – increase contraction of uterusMost effective if hemorrhage is caused by uterine atonyUsed if Pitocin is not successfulProstaglandin SE and interventionsFever & chills: Temp Q1-2 hoursAntipyreticsRespiratory: Wheezing, cough, bronchospasms: Auscultate lungs and treat accordinglyCV: flushing, headaches, bradycardia, arrhythmias, increased DBP, edema: Frequent assessmentCorrect any electrolyte imbalance?diureticsMetabolic: Hypocalcemia, hypokalemia or hyperkalemia, hypoglycemia: Correct electrolyte imbalance via IV GI: N/V, diarrhea: Antiemetic &/or antidiarrheal – pre-med.What else is Prostaglandins used for?Induction (PGE2) – cervical ripeningLate PP HemorrhageDefinition:Hemorrhage occurs after the first 24 hours following deliveryUsually within 1-2 weeks after childbirthEtiology: Late PP HemorrhageSubinvolution of the placenta site (due to):Retained placental fragmentsSigns of subinvolution:Fundal height is greater than expectedMakes sure the woman ambulates and empties bladder Lochia rubra fails to progress from  RUBRA----SEROSA----ALBALochia rubra that persists > 2 weeks PP is highly suggestive of subinvolutionLOCHIA FLOWOther assessmentBlood loss may be excessive, but rarely poses the same risk as early PP hemorrhageGeneralized signs of SHOCK:Early s/s of shock:Tachycardia leading into bradycardiaThready pulseShallow respirationshypotensionLate s/s of shock:Cool, clammyPale skin“Air hunger”May lapse into unconsciousnessDeath without proper interventionsTreatmentD&C: Removal of retained fragmentsFluid replacementPossible blood transfusionFe supplementationAntibiotic therapyNURSINGVS – How often?Externally massage uterus to stimulate contractions (DON’T overmassage)Stimulate contractionsExpress any clots – gentle downward pressureABCs:Assess airway and breathingOxygen supplementation (6-8L via mask)Maintain O2 saturation >95%NURSINGStrict I&OMaintain urine output >30cc/h (adult)Possibly insert Foley catheterAssess for need of IV fluid bolusesMonitor CVP if CVL in placeNormal 10-12 mmHg Monitor for intravascular depletionCBC: H/HObserve if Hct is <30Transfuse if Hct is <21RestINFECTIONINFECTIONDescription Any infection of the reproductive organs that occurs within 28 days of delivery or abortionCategories of Infections:Puerperal infection: overall category An infection of the reproductive tract associated with childbirth that occurs up to 6 weeks PP1) Endometritis