Postpartum Complications

Front 1

Postpartum Hemorrhage defined as

Back 1

loss of 500 mL or more of blood after vaginal birth; 1000 mL or more after cesarean birth.
10% change in HCT between admission for labor and postpartum

Front 2

Postpartum Hemorrhage - Early Stage

Back 2

Occurs within 24 hours after birth

Front 3

Postpartum Hemorrhage - Late Stage

Back 3

(Secondary) Occurs more than 24 hours but less than y weeks after birth

Front 4

Blood: venous origin (superficial lacerations of birth canal)

Back 4

Dark Blood

Front 5

Blood: arterial (deep laceration of cervix)

Back 5

Bright Blood

Front 6

Blood: Spurts of blood with clots

Back 6

Placental Separation

Front 7

Leading cause of early PPH

Back 7

Uterine Atony

Front 8

Uterine Atony
Causes:

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1. Overdistended uterus (lg fetus, multiples, hydraminos, distention w/clots)
2. Halogenated anesthesia
3. Magnesium sulfate
4. High Parity
5 Prolonged or oxytocin-induced labor
6. Trauma during labor/birth (forceps, vacuum, cesarean)
7. Prior history of uterine atony

Front 9

Uterine Atony
Treatment:

Back 9

Fundal massage
Bimanual compression (one fist inside vagina, other hand massages uterus from abdomen, performed by HCP)
Meds

Front 10

Medication Treatment for PPH
Causes contraction of uterus

Back 10

Oxytocin (pitocin) - IV or IM
Methylergonovine (Methergine) - IV or IM
Prostaglandins F-2 alpha (Prostin) - IM
Misoprostol (Cytotec) - PO or Rectal

Front 11

Causes and Risk Factors for PPH

Back 11

Uterine Atony
Lacerations of the Birth Canal
Hematomas
Retained Placenta
Inversion of the Uterus
Subinvolution of the Uterus

Front 12

Lacerations of the Birth Canal
Most common injury:

Back 12

Lacerations of the perineum and episiotomy

Front 13

Lacerations of the Birth Canal
Treatment:

Back 13

analgesia; application of hot or cold; increase roughage in diet; increase fluids; stool softeners; avoid rectal suppositories or enemas if 3rd or 4th degree laceration present

Front 14

Hematomas:
4 Types:

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Vaginal
Cervical
Vulvar (most common)
Retroperitoneal (least common)

Front 15

Hematomas:
Treatment:

Back 15

Surgical evacuation

Front 16

Retained Placenta
2 Types

Back 16

Nonadherent and Adherent

Front 17

Nonadherent Retained Placenta
Causes:

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1. Partial separation of normal placenta
2. Entrapment of partially or completely separated placenta by constriction of the uterus
3. Mismanagement of 3rd stage of labor
4. Abnormal adherence of placenta to uterine wall

Front 18

Adherent Retained Placenta
Causes:

Back 18

Results from implantation in an area of defective endometrium.
Placenta accreta; increta or percreta

Front 19

Retained Placenta
Treatment:

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Make diagnosis antenatally
Do not attempt to remove the placenta
Blood replacement therapy
Hysterectomy

Front 20

Inversion of the Uterus
3 Types

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1. Incomplete - cannot be seen - must be felt
2. Complete - lining of fundus crosses through cervical os and forms mass in the vagina
3. Prolapsed - large, red, rounded mass protrudes outside the introits.

Front 21

Inversion of the Uterus
Causes:

Back 21

1. Fundal implantation of the placenta
2. Vigorous fundal pressure
3. Excessive traction applied to cord
4. Fetal macrosomia
5. Tocolysis
6. Prolonged labor
7. Uterine Atony
8. Abnormally adherent placental tissue

Front 22

Inversion of the Uterus
Risk Factors:

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1. Multiparity
2. Placental accreta or increta

Front 23

Inversion of the Uterus
Treatment:

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1. Replacement of the uterus into it's proper position
2. Fluid replacement
3. Tocolytics or halogenated anesthetics (to relax uterus)
4. Oxytocic agents after uterine repositioning
5. Broad spectrum abx
6. Avoidance of aggressive fundal massage

Front 24

Subinvolution of the Uterus

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Delayed return of the enlarged uterus to normal size and function

Front 25

Subinvolution of the Uterus
Causes:

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1. Retained placental fragments
2. Pelvic infection

Front 26

Subinvolution of the Uterus
Signs/Symptoms

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1. Prolonged lochial discharge
2. Irregular or excessive bleeding
3. Hemorrhage

Front 27

Subinvolution of the Uterus
Treatment:

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1. Depends on Cause:
2. Ergonovine 0.2 mg q4hr x 2-3 days and abx most common.
3. D&C

Front 28

Hemorrhagic (Hypovolemic Shock)

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Perfusion of body organs may become severely compromised due to excessive blood loss.

Medical Emergency

Front 29

Hemorrhagic (Hypovolemic Shock)
Signs/Symptoms:

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Respirations - rapid & shallow
Pulse - rapid, weak, irregular
BP - decreasing (late sign)
Skin - cool, clammy, pale
UO - decreasing
LOC - lethargy progressing to coma "seeing stars"
Mental status- anxious progressing to coma
Central venous pressure - decreased

Front 30

Hemorrhagic (Hypovolemic Shock)
Treatment:

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1. Call for assistance and equipment
2. Start IV infusion per protocol (rapid IV infusion of LR or NS - 3 ml infused for each 1 ml blood loss)
Oxygen 10-12 L/min via nonrebreathing face mask
Monitor pulse & BP
Foley to monitor UO
Labs (H/H, platelets, coagulation profile)

Front 31

Hemorrhagic (Hypovolemic Shock)
EKG monitoring if:

Back 31

Hypotensive
Tachycardic
Continuing to bleed profusely