Postpartum Complications - www.jinekolojivegebelik.com

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Information about Postpartum Complications - www.jinekolojivegebelik.com

Published on March 15, 2008

Author: jinekolojivegebelik

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Postpartum Complications - www.jinekolojivegebelik.com

Postpartum Complications Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Postpartum Hemorrhage Definition and incidence PPH traditionally defined as loss of more than: 500 ml of blood after vaginal birth 1000 ml after cesarean birth Cause of maternal morbidity and mortality Life-threatening with little warning Often unrecognized until profound symptoms Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Definition and incidence

PPH traditionally defined as loss of more than:

500 ml of blood after vaginal birth

1000 ml after cesarean birth

Cause of maternal morbidity and mortality

Life-threatening with little warning

Often unrecognized until profound symptoms

Postpartum Hemorrhage Etiology and risk factors Uterine atony Marked hypotonia of uterus Leading cause of PPH, complicating approximately 1 in 20 births Brisk venous bleeding with impaired coagulation until the uterine muscle contracts Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Etiology and risk factors

Uterine atony

Marked hypotonia of uterus

Leading cause of PPH, complicating approximately 1 in 20 births

Brisk venous bleeding with impaired coagulation until the uterine muscle contracts

Postpartum Hemorrhage Lacerations of genital tract Should be suspected if bleeding continues with a firm, contracted fundus Includes perineal and cervical lacerations as well as pelvic hematomas Retained placenta Nondherent retained placenta – managed by manual separation and removal by the primary care provider Adherent retained placenta – may be caused by implantation into defective endometrium Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Lacerations of genital tract

Should be suspected if bleeding continues with a firm, contracted fundus

Includes perineal and cervical lacerations as well as pelvic hematomas

Retained placenta

Nondherent retained placenta – managed by manual separation and removal by the primary care provider

Adherent retained placenta – may be caused by implantation into defective endometrium

Postpartum Hemorrhage Three classifications of adherent retained placenta Placenta acreta – slight penetration of myometrium by placental trophoblast Placenta increta – deep penetration of myometrium by placenta Placenta percreta – perforation of uterus by placenta Patient will experience profuse bleeding when delivery of the placenta is attempted. Management includes blood replacement and surgical intervention (hysterectomy) Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Three classifications of adherent retained placenta

Placenta acreta – slight penetration of myometrium by placental trophoblast

Placenta increta – deep penetration of myometrium by placenta

Placenta percreta – perforation of uterus by placenta

Patient will experience profuse bleeding when delivery of the placenta is attempted.

Management includes blood replacement and surgical intervention (hysterectomy)

Postpartum Hemorrhage Inversion of uterus (turning inside out) May be life-threatening A complete inversion protrudes out of the vagina Primary signs – hemorrhage, shock, pain Prevention is the best measure – don’t pull on the umbilical cord unless there is definite separation of the placenta Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Inversion of uterus (turning inside out)

May be life-threatening

A complete inversion protrudes out of the vagina

Primary signs – hemorrhage, shock, pain

Prevention is the best measure – don’t pull on the umbilical cord unless there is definite separation of the placenta

Postpartum Hemorrhage Subinvolution of uterus – delayed involution of the uterus Usually see late post partum bleeding Causes include retained placental fragments and infection Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Subinvolution of uterus – delayed involution of the uterus

Usually see late post partum bleeding

Causes include retained placental fragments and infection

Care Management Assessment Bleeding assessed for color and amount Perineum inspected for signs of lacerations or hematomas to determine source of bleeding Vital signs may not be reliable indicators because of postpartum adaptations Measurements during first 2 hours may identify trends related to blood loss Bladder distension Laboratory studies of hemoglobin and hematocrit levels Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Assessment

Bleeding assessed for color and amount

Perineum inspected for signs of lacerations or hematomas to determine source of bleeding

Vital signs may not be reliable indicators because of postpartum adaptations

Measurements during first 2 hours may identify trends related to blood loss

Bladder distension

Laboratory studies of hemoglobin and hematocrit levels

Care Management Plan of care and implementation Initial treatment – fundal massage, expression of clots, relief of bladder distension, IV fluids Medications – Table 25-1 Medical management Hypotonic uterus – examine for retained placental fragments, medications, surgical interventions Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Plan of care and implementation

Initial treatment – fundal massage, expression of clots, relief of bladder distension, IV fluids

Medications – Table 25-1

Medical management

Hypotonic uterus – examine for retained placental fragments, medications, surgical interventions

Care Management Medical management – cont. Bleeding with a contracted uterus – identify and treat underlying cause Uterine inversion – emergency replacement of the uterus into the pelvic cavity Subinvolution – medications, surgical intervention Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Medical management – cont.

Bleeding with a contracted uterus – identify and treat underlying cause

Uterine inversion – emergency replacement of the uterus into the pelvic cavity

Subinvolution – medications, surgical intervention

Care Management Plan of care and implementation Nursing interventions Vital signs, uterine assessment, medication administration, notification of primary care provider Providing explanations about interventions and need to act quickly Once stable, ongoing post partum assessments and care Instructions in increasing dietary iron, protein intake, and iron supplementation May need assistance with infant care and household activities until strength regained Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Plan of care and implementation

Nursing interventions

Vital signs, uterine assessment, medication administration, notification of primary care provider

Providing explanations about interventions and need to act quickly

Once stable, ongoing post partum assessments and care

Instructions in increasing dietary iron, protein intake, and iron supplementation

May need assistance with infant care and household activities until strength regained

Hemorrhagic (Hypovolemic) Shock Emergency situation in which blood is diverted to the brain and heart May not see signs until post partum patient loses 30% to 40% of blood volume Medical management – restore circulating blood volume and treat underlying cause Nursing interventions – monitor tissue perfusion, see emergency box Fluid or blood replacement therapy Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Emergency situation in which blood is diverted to the brain and heart

May not see signs until post partum patient loses 30% to 40% of blood volume

Medical management – restore circulating blood volume and treat underlying cause

Nursing interventions – monitor tissue perfusion, see emergency box

Fluid or blood replacement therapy

Coagulopathies Idiopathic thrombocytopenic purpura (ITP) – decreased platelet life span, need to control platelet stability von Willebrand disease—type of hemophilia Disseminated intravascular coagulation (DIC) Pathologic clotting Correction of underlying cause Removal of fetus Treatment for infection Preeclampsia or eclampsia Removal of placental abruption Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Idiopathic thrombocytopenic purpura (ITP) – decreased platelet life span, need to control platelet stability

von Willebrand disease—type of hemophilia

Disseminated intravascular coagulation (DIC)

Pathologic clotting

Correction of underlying cause

Removal of fetus

Treatment for infection

Preeclampsia or eclampsia

Removal of placental abruption

Thromboembolic Disease Results from blood clot caused by inflammation or partial obstruction of vessel May be superficial or deep venous thrombosis or a pulmonary embolus Incidence and etiology Venous stasis Hypercoagulation Clinical manifestations – redness and swelling in the affected extremity, pain, positive Homan’s sign Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Results from blood clot caused by inflammation or partial obstruction of vessel

May be superficial or deep venous thrombosis or a pulmonary embolus

Incidence and etiology

Venous stasis

Hypercoagulation

Clinical manifestations – redness and swelling in the affected extremity, pain, positive Homan’s sign

Thromboembolic Disease Medical management Superficial – analgesia, rest/elevation, TED hose Deep – anticoagulant therapy, bedrest/elevation, TED hose Pulmonary embolus – IV heparin therapy Nursing interventions assessment of the affected area, signs of bleeding, personal care, medication administration Teach not to massage affected area!! Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Medical management

Superficial – analgesia, rest/elevation, TED hose

Deep – anticoagulant therapy, bedrest/elevation, TED hose

Pulmonary embolus – IV heparin therapy

Nursing interventions

assessment of the affected area, signs of bleeding, personal care, medication administration

Teach not to massage affected area!!

Postpartum Infections Puerperal sepsis: any infection of genital canal within 28 days after abortion or birth Most common infecting agents are numerous streptococcal and anaerobic organisms Endometritis Wound infections Urinary tract infections Mastitis Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Puerperal sepsis: any infection of genital canal within 28 days after abortion or birth

Most common infecting agents are numerous streptococcal and anaerobic organisms

Endometritis

Wound infections

Urinary tract infections

Mastitis

Care Management Prevention is the best intervention Hand washing Good maternal perineal hygiene Antibiotic administration Wound management Breast care Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Prevention is the best intervention

Hand washing

Good maternal perineal hygiene

Antibiotic administration

Wound management

Breast care

Sequelae of Childbirth Trauma Disorders of uterus and vagina related to pelvic relaxation and urinary incontinence, are often result of childbearing Uterine displacement and prolapse Posterior displacement, or retroversion Retroflexion and anteflexion Prolapse a more serious displacement Cervix and body of uterus protrude through vagina and vagina is inverted Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Disorders of uterus and vagina related to pelvic relaxation and urinary incontinence, are often result of childbearing

Uterine displacement and prolapse

Posterior displacement, or retroversion

Retroflexion and anteflexion

Prolapse a more serious displacement

Cervix and body of uterus protrude through vagina and vagina is inverted

Sequelae of Childbirth Trauma Cystocele and rectocele Cystocele: protrusion of bladder downward into vagina when support structures in vesicovaginal septum are injured Rectocele is herniation of anterior rectal wall through relaxed or ruptured vaginal fascia and rectovaginal septum Urinary incontinence Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Cystocele and rectocele

Cystocele: protrusion of bladder downward into vagina when support structures in vesicovaginal septum are injured

Rectocele is herniation of anterior rectal wall through relaxed or ruptured vaginal fascia and rectovaginal septum

Urinary incontinence

Sequelae of Childbirth Trauma Genital fistulas May result from congenital anomaly, gynecologic surgery, obstetric trauma, cancer, radiation therapy, gynecologic trauma, or infection Vesicovaginal: between bladder and genital tract Urethrovaginal: between urethra and vagina Rectovaginal: between rectum or sigmoid colon and vagina Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Genital fistulas

May result from congenital anomaly, gynecologic surgery, obstetric trauma, cancer, radiation therapy, gynecologic trauma, or infection

Vesicovaginal: between bladder and genital tract

Urethrovaginal: between urethra and vagina

Rectovaginal: between rectum or sigmoid colon and vagina

Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34 Types of Fistulas That May Develop in Vagina, Uterus, and Rectum

Postpartum Psychologic Complications Mental health disorders in postpartum period have implications for mother, newborn, and entire family Interfere with attachment to newborn and family integration May threaten safety and well-being of mother, newborn, and other children Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Mental health disorders in postpartum period have implications for mother, newborn, and entire family

Interfere with attachment to newborn and family integration

May threaten safety and well-being of mother, newborn, and other children

Postpartum Psychologic Complications Postpartum depression without psychotic features PPD: an intense and pervasive sadness with severe and labile mood swings Treatment options Antidepressants, anxiolytic agents, and electroconvulsive therapy Psychotherapy focuses fears and concerns of new responsibilities and roles, and monitoring for suicidal or homicidal thoughts Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Postpartum depression without psychotic features

PPD: an intense and pervasive sadness with severe and labile mood swings

Treatment options

Antidepressants, anxiolytic agents, and electroconvulsive therapy

Psychotherapy focuses fears and concerns of new responsibilities and roles, and monitoring for suicidal or homicidal thoughts

Postpartum Psychologic Complications Postpartum depression with psychotic features Postpartum psychosis: syndrome characterized by depression, delusions, and thoughts of harming either infant or herself Psychiatric emergency, and may require psychiatric hospitalization Antipsychotics and mood stabilizers such as lithium are treatments of choice Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Postpartum depression with psychotic features

Postpartum psychosis: syndrome characterized by depression, delusions, and thoughts of harming either infant or herself

Psychiatric emergency, and may require psychiatric hospitalization

Antipsychotics and mood stabilizers such as lithium are treatments of choice

Loss and Grief Losses of what was hoped for, dreamed about, and/or planned Any perception of loss of control during the birthing experience Birth of a child with handicap Maternal death Fetal or neonatal death Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Losses of what was hoped for, dreamed about, and/or planned

Any perception of loss of control during the birthing experience

Birth of a child with handicap

Maternal death

Fetal or neonatal death

Loss and Grief Conceptual model of parental grief Acute distress Intense grief Reorganization Anticipatory grief Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Conceptual model of parental grief

Acute distress

Intense grief

Reorganization

Anticipatory grief

Loss and Grief Plan of care and implementation Communicating and care techniques Actualize the loss Provide time to grieve Interpret normal feelings Allow for individual differences Cultural and spiritual needs of parents Physical comfort Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Plan of care and implementation

Communicating and care techniques

Actualize the loss

Provide time to grieve

Interpret normal feelings

Allow for individual differences

Cultural and spiritual needs of parents

Physical comfort

Loss and Grief Plan of care and implementation Options for parents Seeing and holding Bathing and dressing Privacy Visitations: other family members or friends Religious rituals/funeral arrangements Special memories Pictures Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Plan of care and implementation

Options for parents

Seeing and holding

Bathing and dressing

Privacy

Visitations: other family members or friends

Religious rituals/funeral arrangements

Special memories

Pictures

Maternal Death Rare for woman to die in childbirth Families are at risk for developing complicated bereavement and altered parenting of surviving baby and other children in family Referral to social services can help combat potential problems before they develop Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Rare for woman to die in childbirth

Families are at risk for developing complicated bereavement and altered parenting of surviving baby and other children in family

Referral to social services can help combat potential problems before they develop

Key Points Postpartum hemorrhage is most common and serious type of excessive obstetric blood loss Hemorrhagic (hypovolemic) shock is an emergency situation; the perfusion of body organs may become severely compromised and death may ensue Potential hazards of therapeutic interventions may further compromise the woman with hemorrhagic disorders Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Postpartum hemorrhage is most common and serious type of excessive obstetric blood loss

Hemorrhagic (hypovolemic) shock is an emergency situation; the perfusion of body organs may become severely compromised and death may ensue

Potential hazards of therapeutic interventions may further compromise the woman with hemorrhagic disorders

Key Points Postpartum infection is a major cause of maternal morbidity and mortality Postpartum urinary tract infections are common because of trauma experienced during labor Breast infection affects about 1% of women soon after childbirth Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Postpartum infection is a major cause of maternal morbidity and mortality

Postpartum urinary tract infections are common because of trauma experienced during labor

Breast infection affects about 1% of women soon after childbirth

Key Points Structural disorders of uterus and vagina related to pelvic relaxation are often the delayed but direct result of childbearing Understanding of grief responses and bereavement process is fundamental to the nursing process Therapeutic communication and counseling techniques can help families in identifying their feelings and in feeling comfortable in expressing their grief Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Structural disorders of uterus and vagina related to pelvic relaxation are often the delayed but direct result of childbearing

Understanding of grief responses and bereavement process is fundamental to the nursing process

Therapeutic communication and counseling techniques can help families in identifying their feelings and in feeling comfortable in expressing their grief

Key Points Follow-up after discharge is an essential component in providing care to families who have experienced a loss 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 Mosby items and derived items © 2006, 2002 by Mosby, Inc. of 34

Follow-up after discharge is an essential component in providing care to families who have experienced a loss

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

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