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NUR1 233
Sonia Elizabeth Semenic

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 varicosities 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 – 1 , 2 , 3 , 4 degree – episiotomy may extend to become 3 or 4h 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  Hematomas 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 results  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 3 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  Supplementary anesthesia is usually not needed for women who have had regional anesthesia for birth  Administration of light NO and oxygen inhalation anesthesia or IV thiopental facilitates intrauterine exploration and placental sepration – continued at risk for PPH and infection o Adhered retained placenta: result from zygote implantation in an area of defective endometrium so that no zone of sepration exists between the placenta and decidua  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  Degrees of placental attachment:  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  There is less blood loss if the diagnosis is made antenatally and no attempt is made to remove the placenta  Treatment: blood component replacement therapy – hysterectomy maybe  Subinvolution of uterus o Delayed return of uterus to normal size and function o Causes: retained placental fragments and pelvic infection o Signs and symptoms: prolonged lochial discharge, irregular or excessive bleeding, hemorrhage o Pelvic examination: larger than normal uterus that may be boggy o Treatment: ergonovine 0.2mg every 4 hours for 2-3 days and antibiotic therapy more common  D&C may be needed to remove retained placental fragments  Hypotonic uterus o Oxygen: can be give to enhance O2 delivery to the cells o Urinary catheter: inserted to monitor urine output as a measure of intravascular volume o Lab: CBC with platelet count, fibrinogen, fibrin split products, prothrombin time, and partial thromboplastin time o If bleeding contin
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