Postpartum Complications
Ricci Chapter 22 and ATI Chapters 20-22
Postpartum Hemorrhage (PPH)
Severe bleeding post-delivery. Can be up to 2 weeks after delivery. Major cause of maternal mortality.
“any amount of bleeding that places the mother in hemodynamic jeopardy”
Risks: previous hemorrhage, multiples, large fetus, multiple pregnancies, prolonged labor, precipitous labor, assisted delivery,
placenta previa, placental abruption, induction, uterine overdistention, uterine atony, retained placental fragments,
coagulopathy diseases
Main causes
Uterine atony is the inability of the uterus to contract (most common) – number 1 cause. A floppy, uncontrolled uterus
results in significant blood loss. UTERUS SHOULD BE FIRM, NOT BOGGY.
Injury to the birth canal during delivery.
Retention of tissue from the placenta or fetus
Bleeding disorders (coagulopathies) – the most dangerous being DIC.
Briefly explain the “4 T’s”
Tone uterine atony, distended bladder
Tissue retained placenta and clots, uterine subinvolution
Trauma lacerations, hematoma, inversion, rupture
Thrombin coagulopathy (pre-existing or acquired), platelets, PT and PTT – will add to the bleeding.
Assessment
Early = first 24 hours Saturating pads within 15 minutes or less or puddle
Late = after the first 24 hours up until 12 weeks. of blood in bed
Loss of 500 ml of blood for vaginal delivery Remember the chux underneath patient.
Loss of 1000 ml of blood for c-section Look for blood clots bigger than a quarter
Monitor fundus, bleeding, VS (capillary refill as well) Signs of hypovolemic shock - LOC, restless, pale,
Urine output (if they have oliguria) diaphoretic, hypotensive, tachycardic, weak,
Boggy uterus on assessment or puddle of blood or tachypnea
constant ooze or trickle Restlessness and tachycardia are early signs.
Hypotension is a late sign
Therapeutic Management
Fundal massage/assessment
q15 minutes for 1st hours
q30 minutes x 2
every hour x 4
assessment of location and bleeding
fundal massage should be performed until the
uterus firmly contracts and is firm
estimated blood loss (EBL) make sure to turn patient
and look under them to qualify all of bleeding
can weigh pads: 1g = 1 mL
Labs H/H – 6 hrs after to see effects
Might need blood type screening.
Fluid volume replacement!
Supplemental oxygen!
Catheter foley!
Trendelenburg position + elevate mom’s leg to promote venous return.
Medications (uterotonic drugs) – used when fundal massage doesn’t work.
Oxytocin (Pitocin) stimulates uterine muscle contraction, promotes milk ejection reflex.
o SE: hypersensitivity or hypertension.
o Given IV.
Misoprostol (Cytotec) – helps stimulate the uterus and make it firm to stop bleeding.
Rev. Fall 2019
, Postpartum Complications
Ricci Chapter 22 and ATI Chapters 20-22
Dinoprostone (Prostin E2) used after failed attempts at control of hemorrhage with oxytoxic agents.
o SE: NV, diarrhea, flushing, bradycardia, bronchospasm, wheezing, cough, chills and fever.
Methylergonovine maleate (Methergine)
o Does the patient have HTN? Due to vasoconstriction, methylergonovine should not be given to patients
with HTN and other medications used with caution because it’s SE is HTN!
o Given IM.
Carpropost theramine (Hemabate)
o Does the pt. have asthma or active cardiovascular disease? carboprost cause bronchospasms.
Monitor:
o s/s of MI, HTN, bradycardia, nausea, dysrhythmias
o VS per order set, especially BP
o Hemorrhage and note response to medications
May need pain meds due to painful, yet necessary, uterine cramping.
Get baseline vitals before starting.
Blood products may be indicated, depending on severity.
D&C or hysterectomy.
Thrombolytic conditions that can lead to PPH
Thrombosis is a blood clot within the vein.
Thrombophlebitis is the inflammation of the vessel caused by a clot.
Postpartum patients are at an risk due to the of clotting factors during this time.
Risks: HTN, smoking, sedentary lifestyle, operated vaginal delivery, etc.
Assessment
Diminished pulses Therapeutic Management
Unequal swelling/edema
Early ambulation!
Pain/tenderness
Doppler studies if detected.
Skin discoloration
SCDs.
Monitor for embolus (PE, stroke, MI)
Heat packs may relieve some pain (moist heat)
PE S/S: (SOB, chest pain, anxiety, BP, tachypnea)
IV heparin may be ordered.
Patient Education
Avoid massaging the area, restrictive clothing, crossing legs, prolonged sitting or standing
Educate about discharge meds (anticoagulants) and F/U appointments
Get up and walk around every hour
Do NOT go on long car rides or plane rides within 4 weeks of delivery without discussing with your provider!
Hematoma
Result of injury to a blood vessel from birth trauma. Most often in assisted deliveries (vacuum, forceps)
Large hematoma can contain over 500mL of blood.
Assessment
Acute severe pain
Cannot void due to hematoma obstructing flow
Apparent bulging area, skin discolored
S/S hypovolemic shock AGAIN….. its hypotension, tachycardia, febrile and pallor
Therapeutic Management
Prepare to administer IVF, pain meds, blood products
Monitor I&O’s, vitals
May need to insert foley if urinary obstruction has occurred.
Rev. Fall 2019
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