Postpartum Complications

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Postpartum Complications
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Postpartum Complications Principles

• The most frequent cause of postpartum hemorrhage
  is uterine atony.
• Anything that overdistends the uterus, causes it
  to contract poorly or overworks the uterus is a
  set-up for uterine atony.

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Postpartum Complications
Postpartum Hemorrhage- Continues to be a
leading cause of maternal morbidity and death
in the US- Can occur with little warning
- Definitions (PP lecture) also include
10 drop in Hct between admission
and postpartum - 50 underestimation of
blood loss
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Postpartum Complications
- Most common cause (90) is uterine atony
(marked hypotonia)- Less common causes are
retained placenta, placenta accreta,
cervical/vaginal lacerations, uterine
rupture- Predisposing causes of uterine
atony Multiparity Hydramnios
Macrosomic fetus Traumatic birth
Rapid or prolonged labor
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Postpartum Complications
Use of magnesium sulfate Use of
oxytocin Multiple pregnancy- Management
of uterine atony Manual massage of the
uterus Expression of clots
Eliminate bladder distention
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Postpartum Complications
IV of lactated Ringers or normal saline
with 10-40 units of oxytocin added
Ergonovine or methyl-ergonovine (IM) if not
hypertensive

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Postpartum Complications
- Non-adherent Retained Placenta May
result from partial separation of the
placenta or entrapment of the partially or
fully separated placenta Treated by manual
removal of the placenta If no
epidural, nitrous oxide and oxygen
inhalation
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Postpartum Complications

• Adherent Retained Placenta Unknown
  etiology Probably implantation in a
  defective area of endometrium Manual
  removal is unsuccessful and laceration or
  perforation of uterine wall may result from
  attempts Degrees of adherence -
  Placenta accreta slight penetration of
  myometrium

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Postpartum Complications
- Placenta increta deep penetration of
myometrium - Placenta percreta
penetration to the point of perforation of
the myometrium Treatment may indicate
hysterectomy and blood replacement -
Inversion of the uterus Potentially
life-threatening complication 1 in
2000-2500 births
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Postpartum Complications
Partial or complete Contributing
factors - Fundal implantation of placenta
- Vigorous fundal pressure - Excessive
traction to cord - Uterine atony, fibroids
or abnormally adherent placenta -
Most often in multiparas with placenta
accreta/increta -
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Postpartum Complications

• - Coagulopathies When bleeding continues
  with no identifiable source, a coagulopathy
  must be considered Coagulation
  status must be assessed quickly and
  continuously Abnormal results depend
  on the cause and may include - Increased
  prothrombin time - Increased partial
  prothrombin time

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Postpartum Complications
- Decreased platelets - Decreased
fibrinogen level - Increased fibrin
degradation products - Prolonged bleeding
time Idiopathic throbocytopenia Von
Willebrand Disease
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Postpartum Complications
Disseminated intravascular coagulation
(DIC) - Diffuse and consumes large amounts
of clotting factors - Widespread external and
internal bleeding - Predisposing factors
abruptio placentae, amniotic fluid embolism,
dead fetus syndrome (6 weeks), severe
pre-eclampsia, septicemia, cardiopulmonary
arrest, hemorrhage
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Postpartum Complications
Diagnosis - Spontaneous bleeding from
gums and nose - Petechiae around
blood pressure cuff - Thromboembolic Disease
Types - Superficial venous thrombosis
saphenous) - Deep venous thrombosis (foot
to iliofemoral region
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Postpartum Complications
- Pulmonary embolism (complication of DVT)
Incidence has decreased because of early
ambulation after birth Major causes -
Venous stasis - Hypercoagulation
Medical management - Superficial
analgesic (NSAID), rest with elevation of
the leg, elastic stockings
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Postpartum Complications
- Local application of heat may also be
used- Deep vein thrombosis IV heparin
(5-7 days), bedrest with affected leg
elevated, analgesia followed by elastic
stockings and oral anticoagulant therapy
(warfarin) for 3 months Woman should
be encouraged not to massage area and,
when on bedrest, not to flex knees
sharply Anticoagulant therapy for 6
months
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Postpartum Complications

• Pulmonary embolism Signs/symptoms -
  Shortness of breath
• - Diaphoresis - Chest pain -
  Tachycardia Treated with continuous IV
  heparin followed by intermittent
  subcutaneous or oral

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Postpartum Complications
Postpartum Infections - Puerperal Infection
(Childbed Fever) - Any infection of the
genital canal that begins within 28 days
after abortion, miscarriage or childbirth
- Definition is a fever of 38o C (100.4o F)
on 2 successive days of the first 10 days
postpartum (not counting 1st 24 hours after
birth
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Postpartum Complications
- Common infections Endometritis
Wound infections Mastitis
UTIs URIs - More common in women with
concurrent medical or immunosuppressive
conditions
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Postpartum Complications
- Also increased risk with A Cesarean
or other operative birth Prolonged
labor Prolonged rupture of membranes
Internal fetal or uterine monitoring -
Signs/symptoms Endometritis -
Pelvic pain - Uterine tenderness -
Foul-smelling, profuse lochia
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Postpartum Complications
Wound infection - Erythema, edema,
warmth, tenderness, sero-purulent
drainage wound separation Mastitis
- Almost always unilateral -
Develops well after milk flow
established - Usually hemolytic S. aureus
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Postpartum Complications
- Infected nipple fissure usually the
initial lesion - Accompanied by inflammatory
edema and engorgement that obstruct milk
flow in the region and generalized
mastitis follows - Chills, fever, malaise,
pain - Treated by antibiotics and emptying
breasts q 2-4 hours by feeding,
manual expression or pump
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Postpartum Complications
Postpartum Psychological Complications -
Grieving Normal response to loss of a
child or loss of the ideal child
The woman grieves the death of the
idealized child May interfere
with the ability to bond with the child
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Postpartum Complications
Death of a baby - Questions about
what happened - Bewilderment,
resentfulness, bitterness -
Most women interested in seeing the baby
and this is therapeutic - Staff and
patients, friends and relatives tend to
avoid a woman whose baby has died
- Woman needs the opportunity to talk
about it
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Postpartum Complications
Perinatal depression Prevalence of major
and minor depression begins to rise after
delivery and peaks in the 3rd month
Postpartum Blues - 50 of women have
symptoms - Peak on 5th postpartum day -
considered a normal part of early
motherhood - Go away within 10
days - Depression Blues vs.
Depression vs. Psychosis (handout)
Blues - Emotional lability -
Feelings of sadness - Related to hormone
shifts, fatigue, sleep deprivation
Depression - Feelings continue beyond the
immediate postpartal period and longer
than 1 year
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Postpartum Complications
Postpartum Depression - May occur in 10 -
23 of women - A true, major depression -
Can last into the 2nd year after delivery -
Risk factors Past history of depression
(often bipolar) Depression during
pregnancy Previous history of postpartum
depression Life stress Poor social
support
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Postpartum Complications
History baby blues History
of severe PMS Poor marital relationship
Family history of postpartum
depression - Symptoms Feeling of
sadness, extreme fatigue, inability to
stop crying, anxiety about her own or the
babys health, insecurity and
psychosomatic symptoms
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Postpartum Complications
Cheryl Beck (PPSS) - Teetering on
the edge - Brain is full of cobwebs
- I have lost my self Basic
psychosocial problem with control- Postpartum
Psychosis Response to the crisis of
childbearing Majority of these women have
had symptoms of mental illness that precede
the pregnancy
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Postpartum Complications
Other major life crises can precipitate
the same illness Exceptional sadness, out of
touch with reality, thoughts of infanticide
or that the child is possessed
This is a psychiatric emergency and requires
hospital admission Do not leave the woman
alone and do not leave her alone with her
infant Risks of suicide and infanticide are
significant