PLACENTAL ABNORMALITIES identified to prevent accidental treating of a vasa

previa
NORMAL PLACENTA
 Bleeds profusely
 Weighs approximately 500g  Emergency C section
 Is 15 to 20 cm in diameters POSTPARTUM COMPLICATIONS
 1,5 to 3.0 cm thick
 Its weight is approximately 1/6th of the fetus POSTPARTUM HEMORRHAGE

 Loss of more than 500 ml of blood after normal

PLACENTA SUCCENTURIATA
 Has one or more accessory lobes connected to
the main placenta by blood vessels
 Will be removed manually (D&C)
 May lead to a placental tissue left behind
PLACENTA CIRCUMCALLATA
 The chorion membrane begins at the edge of the
placenta ad spread to envelop the fetus: no
chorion covers the fetal side of the placenta
 No problem in circulation, but possible for
bleeding complications
BATTLEDORE PLACENTA
delivery and 1000 ml after CS
 10% change in haematocrit
 Leading cause of maternal death
 Early PP haemorrhage: within the 1st 24 hours
(uterine atony, lacerations)
 Late PP haemorrhage: anytime after the 1st 24
hours until 6-12 weeks (retained tissues)
 Causes
o Uterine atony
o Trauma to the birth canal
o Retained placental fragments (spurts of
blood)
o DIC
o Laceration
 Dark red: venous source probably
superficial laceration
 Bright red: arterial source (cervical)

 The cord is inserted marginally rather than UTERINE ATONY

centrally
 Bleeding may occur  Lack of muscle tone resulting in failure to
contract
 Bleeding comes from the endometrial arteries at
VELAMENTOUS INSERTION OF THE CORD the placental site
 Most common cause of death in the postpartum
 Is a situation in which the cord, instead of period
entering the placenta directly, separates into  Sudden relaxation
small vessels that reach the placenta by  Causes
spreading across a fold of amnion o Over distention
o Multiple gestation
o Large infant
VASA PREVIA o Hydramnios
o Multiparity
 Umbilical vessels of a velamentous cord
o Prolonged labor
insertion cross the cervical os and therefore
o Induced labor
deliver before the fetus
o Precipitate labor
 The vessels may tear with cervical dilatation, just
o Clotting disorders
as placenta previa may tear.
o Chorioamnionitis
 Before inserting any instrument such as an
o General anethesia
internal fetal monitor, structures should be
 Clinical Manifestations

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 o Uterine fundus difficult to locate (boggy or
flabby)
o Soft, boggy fundus
o Uterus that becomes firm during massage
but relaxes after massage
o Fundus located above the expected level
o Excessive lochia (bright red)
o Note that the napkin is replaced every 15
minutes and is fully soaked
o Excessive clots
 Management
o Massage: bimanual uterine massage to
promote contraction (every 15 minute
interval, 15 sec duration)
o Nipple stimulation may be used
o Gentle pressure on the fundus to express
the clots (careful with risk of inversion)
o Check bladder for distention
o Bimanual compression of the uterus
o Laparotomy – abdominal opening
o Ligation of bleeders
o Hysterectomy
 Medications
o Oxytocin (intermittent contraction)
o Methergin (continuous contraction)
o Analogs of prostaglandin (PGF) IM or
intramyometrial - promotes strong
sustained uterine contraction
o Examples: carbopost tromethamine
(Hemabate, prostin)
o S/E: nausea, diarrhea, tachycardia
PERINEAL LACERATION
 Degrees:
o First – vagina, perineal skin
o Second – vagina, peroneal skin levaror ani
muscle, fascia, perineal body
o Third – entire perineum and extends to the
external sphincter of the rectum
o Fourth – rectal sphincter to rectum
 MD will repair
 3-4 weeks will heal
 Management
o Surgical repair
o No enema, rectal suppository, rectal
temperature (3rd and 4th degree)
o Stool softeners
o Increase fluids
 Associated problems due to lacerations
o Cystocele – puching downward of the
bladder
o Rectocele - pouching forward of the rectum
PERINEAL HEMATOMA
 Occurs when bleeding into loose connective
tissue occurs while overlying tissues remain
intact
 Rapid bleeding into the soft tissues causes pain,
swelling, bulging mass
 Ice packs put intermittently until 48 hours
LATE POSPARTUM BLEEDING

TRAUMA RETAINED PLACENTAL TISSUE

LACERATIONS  The retained part prevents contraction

 Associated with placenta succinturiate or accreta
 Sometimes necessary to use vaginal packing  Assessment:
after the repair o Sub involution
 Indwelling catheter o Bleeding on day 6-10 PP
 Be sure to record the time the vaginal pack was o Small or large clot
inserted (should be left in place only for 24-48  Management:
hours) o D and C
1. Cervical – found on the sides, near the branches o Methotrexate (for accrete)
of the uterine (bright red bleeding, gushing
 Surgical repair
2. Vaginal – rare, easier to access than cervical HYPOVOLEMIC SHOCK
laceration, harder to repair
 1500-2000ml blood loss (normal: 5000-6000 mL)
 Pathophysiology

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 Intervention DEEP VENOUS THROMBOSIS
o IVF (LR, NM)
 Clinical Manifestations:
o Blood transfusion
o Warm legs but cold feet (because no more
o Indwelling catheter
circulation)
o O2 at 8-10 L/min (FACE MASK)
o Pain on the leg, groin lower back
o Bedrest
o Swelling of the leg at least 2 cm larger than
o Provide emotional support
the other leg
SUBINVOLUTION OF THE UTERUS o Erythema, heat, tenderness
o Positive homan’s sign
 Delayed or incomplete return of the uterus to a
 Diagnosis:
non-pregnant state
o Doppler
 Caused by small retained fragments, pelvic o MRI
infection o D dimer test (if result is positive, go for
 Signs and symptoms: ultrasound)
o 4-6 weeks. PP: soft, tender, prolonged  Management:
lochia, pelvic pain, backache, fatigue, o Coumadin or heparin to prevent further
persistent malaise bleeding
 Management o Thrombolytic agents – streptoccinase
o Oxytocin (Methergine) o Analgesics for pain (aspirin is not given!)
o Antibiotics o Moist heat to relieve pain and increase
o D&C circulation
o Early ambulation o Gradual ambulation
o Breastfeeding (preventive measure)

PULMONARY EMBOLISM
THROMBO EMBOLITIC DISORDERS
 Pathophysiology:
 Thrombus – a collection of blood factors primary
o Serious complication of DVT (70% of
platelets and fibrin
women with PE have DVT)
 Incidence and Etiology
 Clinical Manifestations:
o Venous stasis – prolonged standing
o Dyspnea, chest pain, tachycardia, and
o Hypercoagulation – changes in fibrinogen
tachypnea
and clotting factors during pregnancy
o Pulmonary rales, cough
o Blood vessel injury – trauma at birth
o Hemoptysis (expectoration of blood or
bloody sputum)
SUPERFICIAL VENOUS THROMBOSIS
o Abdominal pan
 Clinical Manifestations
o Low-grade fever
o Swelling
o Redness
o Edema
o Warmth pain on the calf
 Managements
o Analgesics (no anticoagulants!)
o Rest
o Elastic stocking
o Elevation of lower extremities

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