6. Selected Postpartum Complications



Selected Postpartum Complications


Postpartum Hemorrhage


Postpartum hemorrhage (PPH) is a life-threatening event that can occur with little warning and is often unrecognized until the mother has profound symptoms.




NURSING ALERT


Early discharge increases the potential for acute episodes of PPH to occur outside the hospital or birth center setting. Discharge teaching should emphasize the signs of normal involution, as well as potential complications.


Risk Factors and Etiology




Uterine Atony


Uterine atony is marked hypotonia of the uterus and is the leading cause of PPH.



Management



ent Assess vital signs every 15 minutes during the first hour after birth to identify trends related to blood loss (e.g., tachycardia, tachypnea, decreasing blood pressure) (see Box 6-2 for noninvasive assessments of cardiac output).



NURSING ALERT


Vital signs may not be reliable indicators of shock immediately postpartum because of the physiologic adaptations of this period.


ent Firmly massage the uterine fundus


ent Express clots from the uterus.


ent Eliminate bladder distention by voiding or catheterization.


ent Notify the primary health care provider.


ent Administer a continuous IV infusion of 10 to 40 units of oxytocin in 1000 ml of lactated Ringer’s or normal saline solution.


ent Administer other medications, such as ergonovine (Ergotrate) or methylergonovine (Methergine) or prostaglandin F2α, IM to stimulate uterine contraction according to standing orders or protocol. See Appendix B for the table comparing medications used to manage PPH.


ent Administer crystalloid solutions or blood or blood products to restore the woman’s intravascular volume.


ent Give oxygen 10 to 12 L/min by nonrebreather face mask.


ent Obtain laboratory studies including complete blood count (CBC) with platelet count, fibrinogen, fibrin split products, prothrombin time, and partial thromboplastin time.


ent If the preceding procedures are ineffective, the bleeding can be managed surgically by vessel ligation (uteroovarian, uterine, or hypogastric), selective arterial embolization, or hysterectomy.


ent Provide explanations to the woman and the family about interventions being performed and the need to act quickly.



NURSING ALERT


Use of ergonovine or methylergonovine is contraindicated in the presence of hypertension or cardiovascular disease. Prostaglandin F2α should be used cautiously in women with cardiovascular disease or asthma.



Lacerations of the Genital Tract


Hemorrhage caused by lacerations of the cervix, vagina, or the perineum should be suspected if bleeding continues despite a firm, contracted uterine fundus. This bleeding can be a slow trickle, oozing, or frank hemorrhage.



ent Lacerations of the perineum are the most common of all injuries of the lower portion of the genital tract. They are classified as first, second, third, or fourth degree. An episiotomy can extend to become either a third- or fourth-degree laceration.


ent Most cervical lacerations are shallow, and bleeding is minimal. More extensive lacerations can extend into the vaginal vault or into the lower uterine segment.


ent Pelvic hematomas may be vulvar, vaginal, or retroperitoneal in origin.


ent Vulvar hematomas are the most common. Pain is the most common symptom, and most vulvar hematomas are visible.


ent Vaginal hematomas occur in association with a forceps-assisted birth, an episiotomy, or primigravidity. Symptoms include persistent perineal or rectal pain or a feeling of pressure in the vagina.


ent A retroperitoneal hematoma may cause minimal pain, and the initial symptoms may be signs of shock.


Management


After the bleeding has been controlled, the care of the woman with lacerations of the perineum is similar to that for women with episiotomies (analgesia as needed for pain and hot or cold applications as necessary).




NURSING ALERT


To avoid injury to the suture line, do not give a woman with third- or fourth-degree lacerations rectal suppositories or enemas.


Retained Placenta



Management



Inversion of the Uterus



ent Uterine inversion is an emergency situation requiring immediate recognition, replacement of the uterus within the pelvic cavity, and correction of associated clinical conditions.



SAFETY ALERT


The umbilical cord should not be pulled on strongly unless the placenta has definitely separated.


ent Uterine inversion in which the placenta remains attached and the uterus is pulled inside out can be partial or complete.


ent Complete inversion appears as a large, red, rounded mass that protrudes 20 to 30 cm outside the introitus.


ent Incomplete inversion cannot be seen but must be felt; a smooth mass can be palpated through the dilated cervix.


ent Contributing factors to uterine inversion include:


ent Fundal implantation of the placenta


ent Manual extraction of the placenta


ent Short umbilical cord


ent Uterine atony


ent Leiomyomas


ent Abnormally adherent placental tissue


ent Primary presenting signs are hemorrhage, shock, and pain in the absence of an abdominally palpable fundus.


Management



Subinvolution of the Uterus


Subinvolution is the failure of the uterus to return to a nonpregnant state.



Management



Discharge Teaching


Discharge instructions for the woman who has had PPH are similar to those for any postpartum woman.



Hemorrhagic (Hypovolemic) Shock


Hemorrhage may result in hemorrhagic (hypovolemic) shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised and death may occur.



Management



ent Restore circulating blood volume.


ent Rapidly infuse an IV of crystalloid solution given at a rate of 3 ml infused for every 1 ml of estimated blood loss.


ent Packed red blood cells (RBCs) are usually infused if the woman is still actively bleeding.


ent Infuse fresh-frozen plasma if clotting factors and platelet count are below normal values.


ent Auscultate breath sounds before beginning fluid volume replacement.


ent Treat the cause of the hemorrhage.


ent Monitor the pulse, respirations, and blood pressure.


ent Assist with the placement of a central venous pressure (CVP) or pulmonary artery (Swan-Ganz) catheter.


ent Monitor the pulmonary artery pressure or pulmonary artery wedge pressure as ordered.


ent Inspect for oozing at sites of incisions or injections and presence of petechiae or ecchymosis in areas not associated with surgery or trauma (evaluation for DIC).


ent Monitor oxygen saturation with a pulse oximeter.



NURSING ALERT


Measurements of oxygen saturation with a pulse oximeter may not be accurate in a woman with hypovolemia or decreased perfusion.


ent Assess level of consciousness (woman may report “seeing stars” or feeling dizzy or nauseated; she can be restless and orthopneic, and confused).


ent Continuous electrocardiographic monitoring may be indicated.


ent Insert an indwelling catheter with urometer to monitor urinary output (30 ml/hr indicates adequate organ perfusion).


Coagulopathies



Idiopathic Thrombocytopenic Purpura


Idiopathic or immune thrombocytopenia purpura (ITP) is an autoimmune disorder in which antiplatelet antibodies decrease the life span of the platelets.


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Related posts:

  1. 8. Selected Newborn Complications
  2. 7. The Newborn
  3. 1. Pregnancy
  4. 2. Selected Pregnancy Complications

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Jul 18, 2016 | Posted by in NURSING | Comments Off on 6. Selected Postpartum Complications

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