NUR1 233 Lecture Notes - Arteriole, Leukocytosis, Adrenal Gland

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Published on 13 Jun 2012
McGill University
NUR1 233
Chapter 23: Postpartum Complications
Postpartum Hemorrhage
More than 500mL of blood after vaginal birth and more than 1000mL of blood after cesarean birth
Either 10% change in hematocrit between admission for labor and postpartum or need for erythrocyte transfusion
Early: within 24 hours
Late or secondary: more than 24 hours but less than 6 weeks
Etiology and risk factors
o Dark blood: venous origin perhaps from varices or superficial lacerations of birth canal
o Right blood: arterial and may indicate deep lacerations of cervix
o Spurts of blood with clots: partial placental separation
o Failure of blood to clot or remain clotted indicates a pathological condition such as disseminated intravascular
coagulation (DIC)
o Placenta: excessive bleeding during period from the separation of the placenta to its expulsion or removal
results of incomplete placental separation, undue manipulatoin of fundus, or excessive traction on the cord
o After placenta out: atony of uterus failure to contract, or prolapse of uterus into vagina
o Late PPH: result of infection, subinvolution of the placental site, retained placental tissue, or coagulopathy
Uterine atony
o Hypotonia of uterus
o Leading cause of PPH 1/20 births
o If the uterus is flaccid after detachment of all or part of the placenta, brisk venous bleeding occurs and normal
coagulation of the open vasculature is impaired and continues until the uterine muscle is contracted
o Uterine over stretched and contracts poorly
o Other causes: traumatic birth, use of halogenated anesthesia, or magnesium sulfate, rapid or prolonged labor,
use of oxytocin for labor induction or augmentation, and uterine atony in previous pregnancy
Lacerations in genital tract
o Should be suspected if bleeding continues despite firm, contracted uterine fundus can be slow trickle, an
oozing, or frank hemorrhage
o Factors which influence: operative birth, precipitous birth, congenital abnormalities of maternal soft parts,
and contracted pelvis size, abnormal presentation, and position of fetus relative size of presenting part and
the birth canal previous scarring from infection injury or surgery vulvar, perinea, and vaginal
o Extremem vascularity in the labia and periclitoral areas often result in profuse bleeding if lacerations
hematomas may also be present
o Most common: lacerations of perineum 1st, 2nd, 3rd, 4th degree episiotomy may extend to become 3rd or 4th
degree laceration
o Prolonged pressure of fetal head on vagina: interferes with circulation and may produce ischemic or
pressure necrosis
o After bleeding care: analgesia for pain, hot or cold applications, increased roughage in diet, increased fluid
intake, stool softner
o Most common: vulvar hematomas most are visible
o Most common symptom: pain
o Most common reason: forceps-assisted birth, episiotomy, or primigravidity
o Least common: retroperineal but are life threatening caused by laceration of one of the vessels attached to
the hypogastric artery usually associated with rupture of a cesarean scar during labor
o Cervical lacerations: at lateral angles of the external os - shallow and bleeding minimal
o Hematomas surginally evacuated
o Postpartum care for hematomas: pain relief, monitoring bleeding, replacing fluids, and reviewing lab
Retained placenta
o Nonadherent retained placenta: partial separation of a normal placenta, entrapment of the partially or
completely separated placenta by an hourglass constriction ring of uterus, mismanagement of the 3rd stage of
labor, or abnormal adherence of the entire placenta or a portion of the placenta to the uterine wall
Management: manual separation and removal by the primary health care provider
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Document Summary

More than 500ml of blood after vaginal birth and more than 1000ml of blood after cesarean birth. Either 10% change in hematocrit between admission for labor and postpartum or need for erythrocyte transfusion. Late or secondary: more than 24 hours but less than 6 weeks. Uterine atony: hypotonia of uterus, leading cause of pph 1/20 births. Management: manual separation and removal by the primary health care provider. Supplementary anesthesia is usually not needed for women who have had regional anesthesia for birth. Placental accreta: incidence increasing because of cesarean births. Bleeding with complete or total placenta accreta may not occur unless separation of the placenta is attempted. Placenta accreta: slight penetration of myometrium by placental trophoblast. Placenta increta: deep penetration of myometrium by placenta. Placenta percreta: perforation of uterus by placenta. With more extensive involvement bleeding becomes profuse when delivery of the placenta is attempted.

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