PUERPERIAL COMPLICATIONS

I. Postpartum Hemorrhage

a. Early postpartum hemorrhage

- Blood loss of more than 500 ml in the first 24 hours due to:

1. Uterine atony

2. Lacerations

b. Late PPH

- Blood loss more than 500 ml in the next 24 hours due to:

1. Retained placental parts

2. DIC defects

DANGERS FROM PPH:

1. Shehaan’s Syndrome

- Necrosis of the pituitary gland, that results to:

a. Loss of pubic hair

b. Breast shrinking

c. Loss of libido

d. Amenorrhea

2. Hypovolemia

3. Renal Failure

II. Puerperial Sepsis

- Infection from the genital tract within 6 weeks.

- 3 leading causative agents:

1. Streptococci

2. Staphylococci

3. E. Coli
 - Forms of Puerperial Sepsis

1. Endometritis

2. Thrombophlebitis

3. Mastitis

CAUSES OF PPH:

1. UTERINE ATONY – loss of ability to maintain its contracted state

Causes: full bladder

Uterine exhaustion

Parity more than 5

Nursing Care: massage gently ice

Empty the bladder

Physician

2. LACERATION OF THE CERVIX, PERINEUM OR VAGINAL WALL

Causes: Large fetus

Forcep delivery

Rigid cervix, perineum and vaginal wall

Precipitate delivery

Mismanagement of 2nd stage

Signs and Symptoms: Bright red (arteries)

Firm fundus

Perineal heat and pressure

Nursing Care: Apply direct manual pressure

Prepare for repair

Ice cap in the first 24 hours

Heat therapy

3. Retained Placental Parts – leading cause of PPH after the first 24 hours
 Signs and Symptoms: dark red (placental site)

Placenta is incomplete

Nursing Care: prepare for Pitocin drip

Curettage

Manual extraction

4. Disseminated Intravascular Coagulation – failure of the blood at the placental

site to clot due to hypofibrinogenemia

Causes: Mixed Abortion

Abruptio Placenta (central)

Signs and Symptoms: dark red

Firm fundus

Complete placenta

Nursing Care: assist in the administration of clotting factors (FFP;

cryoprecipitate; CF VIII)

- To be thawed at room temperature only for 30 minutes

- Do not shake

- It must be consumed in 30 minutes

FORMS OF PUERPERIAL SEPSIS

1. Endometritis

- Infected lining of the uterus

- Causes: existing vaginitis

Poor aseptic technique

PROM

Coitus 2 weeks before EDC

 Infected personnel

- Signs and Symptoms: fever after 24hours

Subinvoluted uterus

1 postpartum day – decrease 1 cm

Foul odor lochia

Abdominal tenderness

- Nursing Care

1. Maintain high Fowler’s position to prevent spread.

2. Diet: high in protein, Vitamin C, iron

3. Vaginal discharge must be sent to the lab for C&S

4. Antibiotic Therapy

- Penicillin (safe when breastfeeding)

2. Thrombophlebitis

- Inflamed wall of veins in lower extremities due to blood clots

- Causes: delayed ambulation

Unpadded stirups

Trauma to the veins

Varicosities

- Signs and Symptoms:

(+) Homan’s sign – dorsiflexion of the toes produces pain on the calf

Milky leg – Phlegmasia alba dolens

Pelvic pain

- Nursing Care:

1. NEVER MASSAGE

2. Elevate the leg higher than the heart to promote venous return

3. Assist in heparin therapy

 4. Breast Massage

5. Clean with sterile water

HIGH-RISK PREGNANCY

A. ABORTION

- Termination of pregnancy before fetus reaches 600 grams or 24

weeks

- Causes:

1. FIRST TRIMESTER

- Defective zygote (number 1 cause)

- Blighted ovum

- Defective germ plasm

- Medical diseases

- Trauma

2. SECOND TRIMESTER

- Incompetent cervix

- Medical diseases

- Trauma

- Malnutrition

- Types:

THREATENED – cervix is close; bleeding is slight; mild abdominal pain

- Nursing Care:

1. CBR for 48 hours

2. Save all pads, tissues and clots for evaluation

 3. Diet must be low in fiber – SOFT DIET

4. Administer progesterone

5. Emotional support

6. Health teaching – no coitus for 2 weeks

INEVITABLE – cervix is open; bleeding is moderate to profuse; severe back

ache

- Nursing Care:

1. Prepare for D&C

IMMINENT – BOW ruptures (first sign)

HABITUAL – 3 or more successive abortion

- Cause:

1. Incompetent cervix (2nd) – cervix that dilates on or before

the 20th week of gestation

2. Trauma from previous delivery

3. Congenital

- Management for next pregnancy

CERCLAGE – cervical suture is applied around the cervical os

between the 14th and 16th week of gestation

2 types of cervical suture:

a. SHIRODKAR SUTURE – permanently closed method of

delivery: CS

b. MCDONALD’S SUTURE – temporary; can be removed by 38

weeks

Effects of Cerclage

- Abdominal cramps few days at least 2 days

 - Vaginal spotting for about few hours

- No coitus and vaginal douche for 2 weeks

MISSED – fetus died and was retained in the uterus

- Signs and Symptoms:

1. Uterus doesn’t increase in size

2. Pregnancy test ( - )

3. Brownish vaginal discharge

4. Absence of FHT and fetal movements

- Nursing Care:

1. Prepare the woman for Pitocin drip

2. Administer the following as required:

a. Antibiotic – penicillin to prevent puerperial sepsis

b. Fibrinogen – to prevent postpartum hemorrhage

c. RhoGam

d. LSA – Lactation Suppressing Agent

B. ECTOPIC PREGNANCY

- Extra uterine gestation

- Types:

1. TUBAL – the most common: ampulla

Most dangerous site: interstitial

2. OVARIAN

3. CERVICAL

4. ABDOMINAL

- Method of delivery: Exploratory Laparotomy

 - Causes:

1. Narrowed tubal lumen (tumor, adhesion, salphingitis,

scar)

2. Endometritis

3. IUD

4. Endometriosis – growth of endometrial tissues

(menorrhagia present/dysmenorrhea)

- Signs and Symptoms (will manifest only when tube begins to

rupture: between 9th and 12th week of gestation (1st Trimester)

1. Sharp, stabbing pain “knife-like” on the lower outer

quadrant radiating to the shoulder “Kher’s sign”

2. Cullen’s sign: bluish discoloration of umbilical area

(internal hemorrhage)

3. rigid abdomen

4. elevated WBC (leukocytosis) – suggestive of trauma

5. Normal temperature

6. Cul de sac mass

7. BP decreasing and pulse is rapid

- Nursing Care:

1. Prevention of Hypovolemic shock through IV therapy

2. Blood Transfusion

3. Laparotomy to ligate bleeders

4. Salphingoorraphy

5. Monitor her vital signs

C. HYADITIFORM MOLE

- Degeneration and proliferation of the chorionic villi forming a

cluster of cyst containing clear fluid
 - Cause: unknown, but there are theories that cause onset

1. Poor nutrition (low in protein)

2. Age below 18 years old

- Signs and Symptoms:

1. Highly positive pregnancy test (1,000,000 u HCG)

2. Big-for-date uterus (undue enlargement)

3. Vaginal bleeding with moles (beginning on 4th month)

4. Absence of FHT, fetal movement, fetal parts, fetal outline,

fetal skeleton

- Earliest Detection:

1. 10 weeks Doppler

2. 18 weeks Fetoscope

3. 20 weeks Stethoscope

- Management:

1. Evacuation of moles by:

a. Vacuum extraction

b. D&C – sample of moles must be sent to the lab for

biopsy

c. Methotrexate therapy

2. Urinalysis is done monthly for 1 year

- To determine presence of HCG

- If present and continuously increasing,

suggestive of another H. mole (choriocarcinoma)

3. Inform her that pregnancy is contraindicated for a year.

4. Contraception is necessary except for pills with estrogen

- Estrogen delays the decrease of HCG level

and favors increase vascularity

5. Emotional support
D. PLACENTA PREVIA OR UNAVOIDABLE HEMORRHAGE

- Low lying placenta

METHOD OF DELIVERY: CS

Causes:

1. Unfavorable upper uterine segment – tumors, scars, necrosis

Types of Placenta Previa:

1. Marginal – reaches the margin of cervix (NSD)

2. Partial – covers the cervical os

3. Complete – Center of placenta covers cervical os

Signs and Symptoms (forceful laceration at the placental sute by cervical

effacement and dilatation)

1. Painless vaginal bleeding

2. Soft uterus

3. Dark red bleeding from mother

4. Not always accompanied by fetal distress

Management:

1. High – Fowler’s position

2. No IE

3. Monitor VS of mother then FHT

4. Scheduled CS

Dangers from Placenta Previa:

1. Antepartum hemorrhage
 2. Prematurity

3. Puerperial sepsis

E. ABRUPTIO PLACENTA

- Also known as accidental hemorrhage

- Refers to premature separation of the normally implanted

placenta

Causes:

1. Increase BP in the placental site – vena caval pressure

2. HPN/ hypotension

3. DM

4. Titanic contraction

5. Trauma

6. Disparity

Type of Abruptio Placenta:

1. Central – begins at the center producing the following:

-painful, hard board-like uterus

-concealed hemorrhage

- with 100% fetal distress

-copper-colored uterus “convelaire”

2. Marginal – will result to:

- revealed hemorrhage

-painless

- fetal distress 100%

- soft uterus

- 20% of cases
 Nursing Care:

1. Upon admission, administer oxygen.

2. CBR

3. Left Sim’s – improve the circulation

4. Prepare the woman for stat CS

(classical, then low segment transverse)

Dangers from Abruptio Placenta:

1. Antepartum hemorrhage as early as 6 months

2. Onset of PIH

3. Prematurity

4. Neonatal Mortality

5. DIC (concealed hemorrhage)

6. Infection

Adherent Placenta

1. Placenta Accreta – P. villi invade the endometrium (D&C)

2. Placenta Increta – P. villi invade the myometrium (hysterectomy)

3. Placenta Percreta – P. villi invade the peremetrium (hysterectomy)