Complications of the

Postpartum Period

Hemmorhage
Early postpartum hemmorhage
>500 ml in first 24 hrs (blood loss often
underestimated)

Late or delayed
>500 cc after first 24 hrs.

Predisposing factors

Uterine overdistension--large infant,etc.

Grand multiparity
Anesthesia or MgSO4
Trauma
Abnormal labor pattern--hypo or hypertonia
Oxytocin during labor
Prolonged labor
Hx of maternal anemia, hemorrhage

Prevention

Risk assessment
Inspect placenta
Explore uterus
Avoid overmanipulation of uterus
If at risk type and Xmatch and start IV

Signs of Impending
Hemorrhage
Excessive bleeding (>2pads/30min-1hr)
Light headedness, nausea, visual
disturbances
Anxiety, pale/ashen color, clammy skin
Increasing P and R, BP same or lower

Actions to take

Summon help
Check uterine tone, massage, assess effect
Elevate legs, lower head
Increase or begin O2
Increase or begin IV

Early Postpartum Hemorrhage

Within the first 24 hrs
Causes

uterine atony
lacerations
retained secundines
coagulation problems

Uterine atony

Failure of the uterus to stay firmly contracted

Slow, steady or massive hemorrhage, sometimes
underestimated or hidden behind a clot
VS may not change immediately
Treatment
bimanual massage
oxytoxics
curretage
surgery iliac ligation or hysterectomy

Retained placenta or fragments

Partial separation caused by:
pulling on the cord
uterine massage prior to separation
placenta accreta
Treatment:
massage
manual removal
oxytoxics
D&E

Late postpartum hemorrhage

Hemorrhage occurring
after 24 hrs
retained placenta-necrosed, fibrin
deposits, placental
polyps,
sloughingbleeding

Symptoms
excessive or bright red
bleeding
boggy fundus
large clots
backache
T-P-R, BP

Treatment, massage, IV oxytocin, D&E

Hematomas
Result from injury to a blood vessel,
usually in vagina or vulva, may extend
upward into broad ligament or other
pelvic structures
develop rapidly
may contain 300-500ml blood

Symptoms

Severe pain
Difficulty voiding
Mass felt on vaginal exam
Flank pain
Abdominal distension
Shock

Treatment
Ice
I & D (incision and drainage)
Packing

Subinvolution
Uterus remains large, does not involute
Causes, retained placental fragments, infection
Symptoms:
Lochia fails to progress
Returns to rubra
Leukorrhea with backache and infection

Treatment:
methergine
curretage
antibiotics

Puerperal Infection
Definition:
Temp of 101o or more in the first 24 hrs
following delivery
Temp of 1004 or higher on any 2 of the
first10 pp days (with the exception of the
first 24 hrs)

Types of Infections

Endometritis
Parametritis
Peritonitis
Pyelonephritis
Cystitis
Thrombophlebitis
Mastitis, abcess

Predisposing Factors
Antenatal factors
poor nutrition
low SES
Hx of Infections
Anemia
Immunodeficiency

Intrapartum predisposing
factors

Prolonged labor
PROM
Poor aseptic technique
Birth trauma
Multiple exams
Internal monitoring
Episiotomy
C section

Postpartum Predisposing
Factors
Manual removal of placenta
Hemorrhage
Retained secundines

Causative Organisms
Aerobic 30%
B hemolitc strep
E.coli
Klebsiella
Proteus
Pseudomonas
Staph

Anerobic 70%
Bacteriodes
Peptococcus
C. perfringes

Localized
Episiotomy
Lacerations
C section incision

Endometritis
Infection of the endometrium
placental site
decidua
cervix
Symptoms--discharge (scant to profuse),
bloody, foul smelling
uterine tenderness
jagged, irregular temp elevations
tachycardia, chills, subinvolution

Salpingitis, Oopheritis
May be caused by gonorrhea, chlamidia
unilateral or bilateral abd pain
chills, fever
mass
tachycardia
may lead to sterility

Pelvic Cellulitis, (parametritis)

Infection of the connective tissue of pelvis
frequently infecting the broad ligament
and causing severe pain.
May ascend from cervical lacerations

Parametritis symptoms

Spiking temp to 104

chills, flushing, sweating
tachycardia, tachypnea
uterine tenderness, cramping
change in LOC/agitation,delerium,
disorientation
change in lochia
cervical or uterine tenderness on vag exam
WBC elevation

Peritonitis
Life threatening infection of the
peritoneum
Abcesses on the uterine ligaments, in the
cul de sac, and/or in the
subdiaphragmatic space
May result from pelvic thrombophlebitis

Symptoms of Peritonitis

High temp
chills
malaise
lethargy
pain
subinvolution

Tachycardia
local or referred pain
rebound tenderness
thirst
distension
nausea and vomiting

Cystitis
Bladder infection
urgency
frequency
burning
dysuria
suprapubic pain
hematuria

Pyelonephritis
Kidney infection, usually of the R.
kidney.Ascends from bladder.
Spiking temp
Shaking chills
Flank pain, CVA pain
Nausea and vomiting
Hx of asymptomatic bacteruria or
pyelonephritis
Urgency, frequency, dysuria
Back pain

Prevention and treatment

Force fluids
Insure complete emptying of bladder
Sterile technique for cath
Good perineal care
Antibiotics

Thrombophlebitis Blood clot

associated with bacterial infection
Etiologies
blood clotting factors
postpartal thrombocytosis (platelets)
thromboplastin release (placenta, amnion)
fibrinolysin and fibrinogen inhibitors

Superficial

Tenderness
heat
redness
low grade fever
+ homans sign
tachycardia

Treatment
elevation
heat
TEDs
analgesic
bedrest?
Antibiotics?

Deep Vein Thrombosis

Symptoms
edema
low grade fever
chills
pain in limb below
affected area
milk leg
decreased peripheral
pulses

Dx--doppler
Tx:
heparin to coumadin
antibiotics
TEDs
bedrest
elevation
analgesics

Pulmonary Embolism
an Obstetrical emergency
Symptoms--sudden onset
dyspnea
sweating
pallor
cyanosis
confusion
hypertension
cough/hemoptysis

Tachycardia
SOB
Temp
jugular pressur
chest pain
sense of impending
death
pressure in
bowel/rectum

Treatment

Call MD
O2
Demerol
Papaverine or other clot busters
Aminophylline
heparin
Streptokinase

Disseminated Intravascular
Coagulation (DIC)
prothrombin and platelets
widespread formation of intravascular
clots
clotting factor expended
severe generalized hemorrhaging

Life threatening!

Etiologies

Septic shock
placental/uterine hemmorhage
IUFD
Amniotic fluid embolism
thrombi secondary to preeclampsia
thrombi secondary to thrombophlebitis

Early signs of DIC

protime
fibrinogen
thrombocytopenia
bleeding from gums
bleeding from puncture sites
ecchymosis

Treatment complex, packed cells, fibrinogen,

whole blood, plasma