Postpartum Physical Assessment B - breast U - uterus B - bowels B - bladder L - lochia E - episiotomy
Routine care for the postpartum woman: Health promotion and disease prevention (1) • Give Vitamin A 200,000 IU. • Provide preventive treatment for hookworm to prevent anemia in endemic areas. • Provide iron/folic acid supplementation for at least 30 days postpartum to prevent and treat anemia.
Routine care for the postpartum woman: Educate about danger signs (1) • Vaginal bleeding: • More than 2 or 3 pads soaked in 20-30 minutes after delivery, OR • Bleeding increases rather than decreases after delivery
Routine care for the postpartum woman: Educate about danger signs (2) Severe abdominal pain Fever and too weak to get out of bed
Routine care for the postpartum woman: Educate about danger signs (3) • Fast or difficult breathing • Severe headache, blurred vision • Convulsions
Routine care for the postpartum woman: Educate about danger signs (4) • Pain in the perineum or draining pus • Foul-smelling lochia Dribbling of urine or pain on micturition
Routine care for the postpartum woman: Educate about danger signs (5) The woman doesn’t feel well. Breasts swollen, red or tender breasts, or sore nipples
Postpartum Hemorrhage (PPH) • Definition and incidence • PPH traditionally defined as loss of more than: • 500 ml of blood after vaginal birth • 1000 ml after cesarean birth • Cause of maternal morbidity and mortality • Life-threatening with little warning • Often unrecognized until profound symptoms
Etiology of PPH The causes of postpartum hemorrhage can be thought of as the four Ts: • tone, • tissue, • trauma, • thrombin
Postpartum Hemorrhage Etiology and risk factors (1) • Uterine atony • Marked hypotonia of uterus • Leading cause of PPH, complicating approximately 1 in 20 births • Brisk venous bleeding with impaired coagulation until the uterine muscle contracts
Postpartum Hemorrhage Etiology and risk factors (1) Uterine atony • Multiple gestation, • high parity, • prolonged labor • chorioamnionitis, • augmented labor, • tocolytic agents
Management of uterine atony • Explore the uterine cavity. • Inspect vagina and cervix for lacerations. • If the cavity is empty, Massage and give methylergonovine 0.2 mg, the dose can be repeated every 2 to 4 hours. • Rectal 800mcg. Misoprostol is beneficial.
Management of uterine atony During the administration of uterotonic agents, bimanual compression may control hemorrhage. The physician places his or her fist in the vagina and presses on the anterior surface of the uterus while an abdominal hand placed above the fundus presses on the posterior wall. This while the Blood for transfusion made available.
Complications of Puerperium • Uterine Atony (Cont’d) • Treatment • Uterine compression • Oxytocics • Early suckling causes endogenous release of oxytocin • Oxytocin IV/IM 10 units • Methylergonovine • Methyl prostoglandin F
Postpartum Hemorrhage Etiology and risk factors (2) • Lacerations of genital tract • Should be suspected if bleeding continues with a firm, contracted fundus • Includes perineal and cervical lacerations as well as pelvic hematomas
Postpartum Hemorrhage Etiology and risk factors (2) Lacerations and trauma • Unplanned • Vaginal/cervical tear, • surgical trauma • Planned • Cesarean section, • episiotomy
Postpartum Hemorrhage Genital tract lacerations Management Genital trauma always must be eliminated first if the uterus is firm.
Postpartum Hemorrhage Etiology and risk factors (2)UTERINE RUPTURE Rupture of the uterus is described as completeor incomplete and should be differentiated from dehiscenceof a cesarean section scar.
Postpartum Hemorrhage Etiology and risk factors (2)UTERINE RUPTURE The reported incidence for allpregnanciesis 0.05%, After one previous lower segment cesarean section 0.8% After two previous lower segment cesarean section is 5% all pregnancies following myomectomy may be complicated by uterine rupture.
Postpartum Hemorrhage Etiology and risk factors (2)UTERINE RUPTURE Complete rupture describes a full-thickness defect of the uterine wall and serosa resulting in direct communication between the uterine cavity and the peritoneal cavity.
Postpartum Hemorrhage Etiology and risk factors (2)UTERINE RUPTURE Incomplete rupture describes a defect of the uterine wall that is contained by the visceral peritoneum or broad ligament. In patients with prior cesarean section,
Postpartum Hemorrhage Etiology and risk factors (2)UTERINE RUPTURE dehiscence describes partial separation of the scar with minimal bleeding, with the peritoneum and fetal membranes remaining intact.
Management of Rupture Uterus The identification or suspicion of uterine rupture must be followed by an immediate and simultaneous response from the obstetric team. Surgery should not be delayed owing to hypovolemic shock because it may not be easily reversible until the hemorrhage is controlled.
Management of Rupture Uterus • Upon entering the abdomen, aortic compression can be applied to decrease bleeding. • Oxytocin should be administered to effect uterine contraction to assist in vessel constriction and to decrease bleeding. • Hemostasis can then be achieved by ligation of the hypogastric artery, uterine artery, or ovarian arteries.
Management of Rupture Uterus • At this point, a decision must be made to perform hysterectomy or to repair the rupture site. In most cases, hysterectomy should be performed. • In selected cases, repair of the rupture can be attempted. When rupture occurs in the body of the uterus, • bladder rupture must be ruled out by clearly mobilizing and inspecting the bladder to ensure that it is intact. This avoids injury on repair of the defect as well.
Management of Rupture Uterus • A lower segment lateral rupture can cause transection of the uterine vessels. The vessels can retract toward the pelvic side wall, and the site of bleeding must be isolated before placing clamps to avoid injury to the ureter and iliac vessels. • Typically, longitudinal tears, especially those in a lateral position, should be treated by hysterectomy, whereas low transverse tears may be repaired.
Trauma-Second most common cause of early postpartum hemorrhage • Lacerations – suspect this in the birth canal if uterine bleeding continues with a contracted fundus • Hematomas- bleeding into loose connective tissue as the vulva or vagina • Vulva- discolored bulging mass • Surgical excision if they are large & ligation
Postpartum Hemorrhage Etiology and risk factors (3) • Retained placenta • Nonadherent retained placenta – managed by manual separation and removal by the primary care provider • Adherent retained placenta – may be caused by implantation into defective endometrium 29 of 34
Postpartum Hemorrhage Etiology and risk factors (3) • Three classifications of adherent retained placenta • Placenta acreta – slight penetration of myometrium by placental trophoblast • Placenta increta – deep penetration of myometrium by placenta • Placenta percreta – perforation of uterus by placenta • Patient will experience profuse bleeding when delivery of the placenta is attempted. • Management includes blood replacement and surgical intervention (hysterectomy)
Postpartum Hemorrhage Etiology and risk factors (4) • Inversion of uterus (turning inside out) • May be life-threatening • A complete inversion protrudes out of the vagina • Primary signs – hemorrhage, shock, pain • Prevention is the best measure – don’t pull on the umbilical cord unless there is definite separation of the placenta
Postpartum Hemorrhage Etiology and risk factors4 • Inversion of uterus (turning inside out)
Postpartum Hemorrhage Etiology and risk factors (5) • Subinvolution of uterus – delayed involution of the uterus • Usually see late post partum bleeding • Causes include retained placental fragments and infection
Postpartum Hemorrhage Care Management • Assessment • Bleeding assessed for color and amount • Perineum inspected for signs of lacerations or hematomas to determine source of bleeding • Vital signs may not be reliable indicators because of postpartum adaptations • Measurements during first 2 hours may identify trends related to blood loss • Bladder distension • Laboratory studies of hemoglobin and hematocrit levels
Postpartum Hemorrhage Care Management • Plan of care and implementation • Initial treatment – fundal massage, expression of clots, relief of bladder distension, IV fluids • Medical management • Hypotonic uterus – examine for retained placental fragments, medications, surgical interventions • Bleeding with a contracted uterus – identify and treat underlying cause • Uterine inversion – emergency replacement of the uterus into the pelvic cavity • Subinvolution – medications, surgical intervention
Postpartum Hemorrhage Care Management • Plan of care and implementation • Nursing interventions • Vital signs, uterine assessment, medication administration, notification of primary care provider • Providing explanations about interventions and need to act quickly • Once stable, ongoing post partum assessments and care • Instructions in increasing dietary iron, protein intake, and iron supplementation • May need assistance with infant care and household activities until strength regained
Guidelines by the Scottish Executive Committee of the RCOG • COMMUNICATE. • RESUSCITATE. • MONITOR / INVESTIGATE. • STOP THE BLEEDING.
COMMUNICATEcall 6 • Callexperienced midwife • Callobstetric registrar & alert consultant • Callanaesthetic registrar , alert consultant • Alerthaematologist • Alert Blood Transfusion Service • Callporters for delivery of specimens / blood
RESUSCITATE • IV access with 14 G cannula X 2 • Head down tilt • Oxygen by mask, 8 litres / min • Transfuse • Crystalloid (eg Hartmann’s) • Colloid (eg Gelofusine) • once 3.5 litres infused, GIVE ‘O NEG’ If no cross-matched blood available OR give uncross-matched own-group blood, as available • Give up to 1 liter Fresh Frozen Plasma and 10 units cryoprecipitate if clinically indicated
MONITOR / INVESTIGATE • Cross-match 6 units • Full blood count • Clotting screen • Continuous pulse / BP / • ECG / Oximeter • Foley catheter: urine output • CVP monitoring • Discuss transfer to ITU
STOP THE BLEEDING • Exclude causes of bleeding other than uterine atony • Ensure bladder empty • Uterine compression • IV syntocinon 10 units • IV ergometrine 500 mg • Syntocinon infusion (30 units in 500 ml) • IM Carboprost (500 mg) • Surgery earlier rather than late • Hysterctomy early rather than late (GRADE B)
If conservative measures fail to control haemorrhage, initiate surgical haemostasisSOONER RATHER THAN LATER • At laparotomy, direct intramyometrial injection of Carboprost (Haemabate) 0.5mg • Bilateral ligation of uterine arteries • Bilateral ligation of internal iliac (hypogastric arteries) • Hysterectomy (GRADE C)
Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of placenta accreta or uterine rupture)(GRADE C)
Whole blood frequently is used for rapid correction of volume loss because of its ready availability, but component therapy is ideal. A general practice has been to transfuse 1 unit of fresh-frozen plasma for every 3 to 4 units of red cells given to patients who are bleeding profusely
Hemorrhagic (Hypovolemic) Shock • Emergency situation in which blood is diverted to the brain and heart • May not see signs until post partum patient loses 30% to 40% of blood volume • Medical management – restore circulating blood volume and treat underlying cause • Nursing interventions – monitor tissue perfusion, see emergency box • Fluid or blood replacement therapy
Prophylactic oxytocics should be offered routinely in the management of the third stage of labour as they reduce the risk of PPH by about 60%. (GRADE A)
Coagulopathies • Idiopathic thrombocytopenic purpura (ITP) – decreased platelet life span, need to control platelet stability • von Willebrand disease—type of hemophilia • Disseminated intravascular coagulation (DIC) • Pathologic clotting • Correction of underlying cause • Removal of fetus • Treatment for infection • Preeclampsia or eclampsia • Removal of placental abruption
Coagulationdisorders Acquired DIC, dilutionalcoagulopathy, heparin Congenital Von Willebrand's disease
Thromboembolic Disease • Results from blood clot caused by inflammation or partial obstruction of vessel • May be superficial or deep venous thrombosis or a pulmonary embolus • Incidence and etiology • Venous stasis • Hypercoagulation • Clinical manifestations – redness and swelling in the affected extremity, pain, positive Homan’s sign
Thromboembolic DiseaseHoman’s Sign Press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot (dorsiflex)