CHAPTER 28 1 Recognize the causes of four types of postpartum complications: hemorrhage, infection, venous disorders, and postpartum mood disorders. 2 Assess factors for increased risk for the selected complications. 3 Define specific treatments for selected postpartum complications. 4 Analyze assessment data and select appropriate actions to prevent or minimize effects of selected postpartum complications. 5 Design health education strategies to prevent, minimize the effects of and/or enhance recovery from postpartum hemorrhage, infection, venous disorders, and postpartum mood disorders. 6 Select strategies to provide care to the high-risk postpartum woman and her family based on analysis and synthesis of her needs in her particular situation. A Definition: Postpartum hemorrhage has classically been defined in several ways: 1. Blood loss greater than 500 mL in the first 24 hours after delivery (greater than 1000 mL blood loss after cesarean delivery) 2. A change in postpartum hemoglobin concentration 3. Blood loss requiring transfusion (Smeltzer, Bare, Hinkle, & Cheever, 2008) 4. Accurate estimates of blood loss are not easily obtained and have made estimates of the incidence of postpartum hemorrhage difficult (Francois & Foley, 2007). B Incidence: The overall incidence of postpartum hemorrhage is 4% to 6% of deliveries (Francois & Foley, 2007). 1. Primary or early postpartum hemorrhage: occurring within the first 24 hours after delivery 2. Secondary or delayed postpartum hemorrhage: occurring 24 hours to 12 weeks after delivery D Causes (Francois & Foley, 2007; Lowdermilk, 2007) 2. Lacerations of the upper or lower genitourinary tracts a. May result in hematoma formation, which are collections of blood in the pelvic tissue (may involve the vulva, vaginal or retroperitoneal area) resulting from damage to a vessel wall without laceration of the tissue b. Episiotomy, instrumental delivery, and primigravidity increase the risk of vaginal hematoma formation (Cunningham et al, 2005). 3. Retained products of conception 4. Invasive placental implantation: placenta accreta, placenta increta, placenta percreta 5. Uterine inversion or rupture 6. Blood coagulation disorders a. Disseminated intravascular coagulation (DIC) can cause or be a result of postpartum hemorrhage. b. Abruptio placentae, fetal demise, or amniotic fluid embolism may be the underlying cause of DIC (see Chapter 21 for a complete discussion of hemorrhagic disorders). 1. Risk factors: Despite many known risk factors, postpartum hemorrhage is unpredictable and may occur when no risk factors are present (Burtelow et al, 2007; Francois & Foley, 2007). Known risk factors are: a. Precipitous or prolonged first or second stage of labor or both b. Overstretching of the uterus (large fetus, hydramnios, or multiple gestation) c. Drugs (general anesthesia, magnesium sulfate, prolonged use of oxytocin) d. Trauma through the use of forceps or other intravaginal manipulations, such as internal podalic version or forceps rotation e. Previous postpartum hemorrhage, uterine rupture, or uterine surgery (cesarean section or dilation and curettage) f. Past placenta previa; placenta accreta, increta, or percreta. The incidence of placenta accreta may be increasing due to a higher cesarean section rate. g. Current diagnosis of placenta previa h. Uterine malformation or uterine fibroids i. Maternal exhaustion, malnutrition, anemia, or pregnancy-induced hypertension (PIH) j. Coagulation disorders, such as idiopathic thrombocytopenia, purpura, or von Willebrand disease 2. Physical findings (Lowdermilk, 2007) (1) Dizziness, fainting, lightheadedness (2) Tachycardia, tachypnea, weak pulse, decreasing blood pressure (3) Oliguria, profound hypotension, and signs of shock (weak pulse, increased respirations, shallow respirations, and pale, clammy skin) do not appear until hemorrhage is advanced because of increased fluid and blood volume of pregnancy (Lowdermilk, 2007). b. Uterine atony/retained placental fragments (1) Firm uterus with bright red blood (2) Extreme perineal or pelvic pain (3) Bluish bulging area just under the skin surface A Anticipated medical intervention (Francois & Foley, 2007) 1. Prompt response to request for evaluation of excessive bleeding 3. Examination for vaginal or cervical lacerations 4. Removal of retained products of conception 5. Depending on clinical situation, institution, available personnel and available equipment, other interventions may include: 6. After initial postdelivery assessment a. Continue to assess the height and position of the fundus at least each shift. (1) If uterus is soft and boggy, perform uterine massage. (2) For mild uterine bogginess, in addition to fundal massage, put infant to breast if mother is breastfeeding. b. Monitor lochia for color, odor, amount, consistency, or clots. Weigh used pads whenever there is a question of continued heavy bleeding (1 g equals 1 mL). c. Monitor and record vital signs. d. Guard against inaccurate assessment of postpartal bleeding (due to pooling unnoticed underneath the mother or poor lighting (Pillitteri, 2007). 7. In the presence of continued or new onset of excessive bleeding: b. Activate postpartum hemorrhage response team, if available within institution (massive transfusion protocols for hemorrhage anticipated to require more than 10 units of packed red blood cells) (Burtelow et al, 2007; Chichester, 2005). (1) Quickly assemble a multidisciplinary care team. (2) Provide for rapid availability of blood products. d. Ensure intravenous (IV) access for fluid replacement, medications, and blood product replacement. f. Continue assessments and interventions previously listed. g. Administer uterotonic drugs as ordered (Francois & Foley, 2007). (1) Oxytocin (Pitocin): 10 to 40 units in 500 to 1000 mL of crystalloid solution, by IV infusion (Ladewig, London, and Davidson 2010) (a) DO NOT give undiluted oxytocin as an IV bolus. (b) Doses of oxytocin higher than 20 units will be ordered only for short amounts of time. (2) Methylergonovine (Methergine): 0.2 mg intramuscularly (IM) every 2 to 4 hours, unless contraindicated by maternal hypertension (Ladewig et al., 2010) (3) Carboprost tromethamine (Hemabate): 0.25 mg IM every 15 to 90 minutes, 8-dose maximum, contraindicated with active cardiac, pulmonary (asthma), renal, or hepatic disease (Ladewig et al., 2010) (4) Misoprostol (Cytotec): 800 to 1000 mcg per rectum as a single dose (Ladewig et al, 2010) h. Administer blood component products as ordered. i. Monitor for signs of transfusion reaction or reaction to oxytocic agents (fever, chills, diarrhea, nausea or vomiting with carboprost tromethamine, and tachycardia or fever with misoprostol. j. Keep woman flat to supply blood to heart and brain. k. Catheterization of distended bladder if indicated. Indwelling catheter may be ordered to monitor mother’s condition. l. Keep accurate intake and output (I&O). m. Facilitate arrangements for adequate anesthesia, if required. n. Assist care provider during examination for lacerations and retained placental fragments if indicated by continued hemorrhage. o. Facilitate arrangements for surgical intervention if medical control of hemorrhage is unsuccessful. p. Stay with woman and use physical touch if appropriate. q. Offer reassurance and support to mother and family. r. Give information to woman and her family in clear, brief statements. 8. Following stabilization of the woman after a postpartum hemorrhage: a. Coordinate nursing interventions with the mother’s schedule to allow for rest periods that are undisturbed. b. Assist mother with activities of daily living (ADLs). c. Encourage appropriate nutritional intake and increased fluids. d. Encourage woman to take vitamins and iron tablets. e. Encourage techniques for standing and moving slowly to minimize orthostatic hypotension. f. Mobilize support system or resources. A Explain normal lochia changes and encourage mother to report any episodes of recurrent excessive bleeding or unusual blood clots, especially after discharge from the hospital. B Review danger signs and when to call care provider: excessive bleeding, signs of infection. C Identify self-care measures to facilitate recovery from postpartum hemorrhage: increased rest, ways to minimize orthostatic changes, need for adequate nutrition and fluid intake, and arrangements for help with infant care (Lowdermilk, 2007). D Educate mother about need for iron supplementation, importance of compliance, duration of treatment, possible side effects, and measures to control side effects. E Encourage mother to share history of postpartum hemorrhage with future care providers. 1. Postpartum febrile morbidity is defined by the U.S. Joint Commission on Maternal Welfare as an oral temperature of greater than or equal to 38° C (100.4° F) on any two of the first 10 days postpartum or 38.7° C (101.6° F) or higher during the first 24 hours, taken by a standard technique at least four times a day. 2. Short-term temperature elevations not requiring antibiotic therapy are common and may be due to: B Types of postpartum infection (1) Usually a mixture of several aerobic and anaerobic organisms from the genital tract (2) Chlamydia trachomatis infection more common when onset is 2 or more weeks after delivery. (a) 1% to 3% after vaginal delivery (b) 5% to 15% after elective cesarean section without rupture of membranes (c) 15% to 20% after cesarean section following extended labor with rupture of membranes with antibiotic prophylaxis (d) 30% to 35% after cesarean section in the same situation without antibiotic prophylaxis (4) Use of single-dose perioperative antimicrobial prophylaxis has dramatically reduced the incidence and severity of postcesarean endometritis and wound infection (Cunningham et al, 2005). b. Cesarean section wound infection (1) Occurs after the third or fourth postoperative day (2) Can be masked by early postoperative fever c. Perineal wound infection: rare progression to necrotizing fasciitis can be life threatening and require aggressive surgical debridement 3. Other: viral infection, upper respiratory infection, appendicitis, etc. 1. Risk factors (Duff, 2007; Lowdermilk, 2007) a. Cesarean birth: most important risk factor e. Prolonged rupture of membranes f. Multiple vaginal examinations during labor h. Traumatic delivery, intrauterine manipulation, manual removal of placenta j. Malnutrition, general debilitation k. Preexisting infection or colonization of the lower genital tract such as bacterial vaginosis, herpes, etc. m. Droplet infection from personnel, breaks in aseptic technique n. Foley catheter in place more than 24 hours o. Perineal lacerations (third or fourth degree) q. Meconium-stained amniotic fluid (Tran, Caughey, & Musci, 2003) a. Infections of the genital tract: varies by site (3) Foul-smelling lochia (amount can be normal, scant, or profuse) (11) Increased pulse rate (100 to 140 beats per minute [bpm]) (13) Increased pain, redness, drainage, induration, or poorly approximated edges of episiotomy of perineal lacerations b. Urinary tract infections (Lowdermilk, 2007) c. Infections of the breast/mastitis (Betzold, 2007) (1) Temperature elevated up to 40° C (104.1° F) (4) Hard, red, and tender irregular mass in one or both breasts (5) Severe to acute pain and tenderness in one or both breasts d. Wound infections from cesarean section or dehiscence (Duff, 2007) (1) Elevated temperature on third or fourth postpartum day (2) Drainage of pus or blood from the wound (3) Red and inflamed appearance of repaired edges
Postpartum Complications
POSTPARTUM HEMORRHAGE
CLINICAL PRACTICE
INTERVENTIONS
HEALTH EDUCATION
POSTPARTUM INFECTIONS
Introduction
CLINICAL PRACTICE
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