MODULE 11: High - Risk Postpartum Conditions

Question 1

A woman with a postpartum complication is at risk from three points of view

Answer 1

a. Her own health
b. Her future child-bearing potential
c. Her ability to bond with her new infant

Question 2

Postpartum Complications

Answer 2

Most postpartum complications are preventable, and if they do occur, the majority can be treated effectively

Question 2

Who are at risk for Postpartum Complications

Answer 2

a. Conditions that distend the uterus beyond the average capacity.
b. Conditions that could have caused cervical/ uterine lacerations
c. Conditions with varied placental site or attachment
d. Conditions that leave the uterus unable to contract readily
e. Conditions that lead to inadequate blood coagulation

Question 2

Postpartum Hemorrhage

Answer 2

a. Loss of more than 500 ml of blood at the time of delivery or immediately after
b. One of the most important causes of maternal mortality
c. A major potential danger in the immediate postpartum period

d. May occur either:
- Early- within 24 hours.
- Late- anytime after the 1st 24 hours during the remaining days of the 6-week puerperium

Question 2

Early Postpartum Hemorrhage

Answer 2

a. Uterine atony
b. Lacerations
c. Perineal Hematomas
d. Disseminated Intravascular Coagulation

Question 3

Late Postpartum Hemorrhage

Answer 3

a. Retained Placental Fragments
b. Subinvolution

Question 3

Uterine Atony

Answer 3

a. Relaxation of the uterus due to the loss of muscle tone
b. The most common cause of postpartum hemorrhage.
c. Uterine Atony allows hemorrhage to flow into the uterus

Question 4

Uterus remain in a contracted state

Answer 4

Allow the open vessels at the placental site to seal

Question 5

Uterine Atony

Answer 5

Poor uterine tone > Inability to maintain a contracted state > “boggy” uterus & large amounts of dark red blood with clots

Question 6

Predisposing Factors

Answer 6

a. Multiple gestation
b. Large baby ( >9 lbs.)
c. Polyhydramnios
d. Inhalation of anesthesia
e. Prolonged labor with maternal exhaustion

Question 7

Laceration of the Birth Canal

Answer 7

a. Small lacerations or tears of the birth canal are common
- Large lacerations are considered as complication

b. It may occur either cervical, vaginal or perineal area
c. Firm uterus but with steady trickle of bright red blood (arterial) are the indications of laceration

Question 8

Classifications of Perineal Laceration

Answer 8

a. First degree
- Vaginal mucous membrane, skin of perineum to the fourchette

b. Second degree
- Vagina, perineal skin, fascia, levator ani muscle, perennial body

c. Third degree
- Entire perineum extending to reach the external sphincter of the rectum

d. Fourth degree
- Entire perineum, rectal sphincter, some of the mucous membrane of the rectum

Question 9

Predisposing Factors

Answer 9

a. Primigravidas
b. Difficult or precipitate births
c. Birth of large infant
d. Use of a lithotomy position
e. Operative birth
f. Rapid birth

Question 10

Cervical Laceration

Answer 10

This is difficult to repair because bleeding can be so intense that it obstructs the visualization

Question 11

Vaginal Laceration

Answer 11

Since vaginal tissue is friable, lacerations are hard to repair

Question 12

Perineal Laceration

Answer 12

Perineal lacerations are easily treated

Question 13

Perineal Hematoma

Answer 13

a. Localized collections of the blood in loose connective tissue beneath the skin that covers
- The external genitalia
- Beneath the vaginal mucosa
- The broad ligaments

b. Usually occurs without lacerations of the overlying tissue
c. Commonly found in perineal and vaginal area

Question 14

Predisposing Factors: Perineal Hematomas

Answer 14

a. Trauma during
- Spontaneous birth
- Forceps application or delivery

b. Inadequate suturing of an episiotomy
c. Delayed homeostasis or difficult or prolonged second stage of labor or both

Question 15

Clinical Manifestation: Perineal Hematoma’s

Answer 15

a. Complaints of pressure and excruciating pain in the perineal area

b. Discolored skin that is tight, full feeling and painful to touch
- This may be the first sign to be observed

c. Decrease or absence of lochia flow in the vagina is impeded

Question 16

Late Postpartum Hemorrhage: Retained Placental Fragments

Answer 16

a. Incomplete expulsion of the placenta
b. The main cause of late postpartum hemorrhage

c. This usually happens with a succenturiate placenta (placenta with
an accessory lobe) or placenta accreta (placenta fuses with the
myometrium).
- Ultrasound is done to check retained ‘pf’

Question 17

Clinical Manifestation

Answer 17

a. Slow, reddish oozing (6th-10th postpartum day)
b. Positive hCG blood serum sample
d. Not fully contracted uterus
d. Abdominal pain or tenderness
e. Low persistent backache

Question 18

Subinvolution

Answer 18

a. Failure of the uterus to revert to through gradual reduction in size and placement

b. It may be caused by:
○ Infection
○ Tumors in the uterus
○ Mild endometritis

Question 19

Clinical Manifestation: Subinvolution

Answer 19

a. Uterus remains enlarged
b. Fundus in higher in the abdomen than anticipated
c. Lochia does not progress from rubra to serosa to alba
d. If caused by infection: possible leukorrhea & backache

Question 20

Postpartum Infection

Answer 20

a. Any infection of the reproductive tract, usually occurring within 10 days of birth
b. Second leading cause of maternal mortality
c. The most common cause is polymicrobial ascent
d. The main pathway for spread of infection is the broad ligament

Question 21

Predisposing Factors: Postpartum Infection

Answer 21

a. Prolonged rupture of membranes b. Cesarean birth c. Trauma during birth process d. Poor perineal hygiene e. Retained placental fragments

Question 22

Endometritis

Answer 22

a. Infection of the endometrium (lining of the uterus) b. Bacteria gains access to the uterus through the vagina either at the time of birth or during the postpartum period c. It may occur with any birth but it is associated with chorioamnionitis and cesarean birth

Question 23

Clinical Manifestation: Endometritis

Answer 23

a. Fever (occurs on the 3rd and 4th postpartum day) ○ Increase oral temperature to more than (38.C) for 2 consecutive 24-hour periods. b. Chills c. Dark brown lochia with foul odor d. Loss of appetite e. General malaise f. Uterus not well contracted & painful to touch

Question 24

Infection of the Perineum

Answer 24

A woman with a suture line on her perineum is a greater risk of acquiring infection of the perineum since it is the portal of entry for bacterial invasion

Question 25

Clinical Manifestation: Urinary Tract infection

Answer 25

a. Pain in the suprapubic area or at costovertebral angle b. Fever b. Burning, urgency, frequency on urination d. Increased WBC count & hematuria e. e. Urine Culture (+) for causative organism ○ To know appropriate antibiotics to be given

Question 25

Urinary Tract Infection

Answer 25

It may be caused by: ○ Coliform bacteria ○ Coupled with bladder trauma during delivery ○ Break in technique during catheterization → Bacteria may be introduced into the bladder

Question 26

Clinical Manifestations: Mastitis

Answer 26

a. Redness, tenderness, or hardened area in the breast (usually unilateral) b. Chills c. Malaise d. Elevated temp and heart rate e. Breast milk becomes scan

Question 26

Clinical Manifestations: Infection of the Perineum

Answer 26

a. Manifested with s/sx of Suture line infection: ○ Pain on the infected area ○ The area is warm to touch ○ Feeling of pressure ● May or may not have an elevated temperature (depending the spread of infection) ● Inflammation on the suture line ● Presence of purulent drainage on the area of the suture line

Question 26

Mastitis

Answer 26

a. Known as the infection of the breast. b. Causative organism usually hemolytic S. aureus c. Frequently caused by cracked & fissured nipple due to improper latching d. If untreated, may result in breast abscess

Question 27

Thrombophlebitis

Answer 27

a. Inflammation of the lining of a blood vessel with the formation of blood clots. b. It is classified as or that might occur after delivery: Femoral Thrombophlebitis, Pelvic Thrombophlebitis & Pulmonary Embolism.

Question 28

Predisposing Factors: Thrombophlebitis

Answer 28

a. Obese & overweight mothers b. History of varicose veins c. History of thrombophlebitis d. 30 years of age with increased parity e. (+) Family History of thrombophlebitis

Question 29

Ankle Brachial Sign

Answer 29

a. Measure the ankle and brachial pressure b. Get the systolic brachial pressure and systolic ankle pressure c. If SBP = 120/80 and SAP = 100/80 → 120/100= 1.2 (ABI) d. ABI of 1.0-1.4 is normal e. ABI of 0.9-1.0 is borderline

Question 29

Clinical Manifestation: Thrombophlebitis

Answer 29

a. Pain/discomfort in area of thrombus (legs, pelvis, chest) b. If in the leg: pain, edema, redness over affected area. c. Elevated temperature & chills d. Decreased peripheral pulses d. (+) Homan's sign e. If in a deep vein: leg may be cool and pale

Question 30

Pulmonary Embolism

Answer 30

a. This is a MEDICAL EMERGENCY ○ Sudden sharp chest pain ○ Tachypnea ○ Tachycardia ○ Orthopnea (inability to breathe except in upright position) ○ Cyanosis

Question 30

Homan's Sign

Answer 30

a. Assessment through dorsiflexion b. First support the patient's thigh with one hand and his foot with the other. Bend his leg slightly at the knee, and then firmly and abruptly dorsiflex the ankle. Resulting deep calf pain indicates a positive homans sign (the patient may also resist ankle dorsiflexion or flex the knee involuntarily if Positive.) c. Ask first if there is pain: if there is pain, do not execute (automatic POSITIVE for Homan’s sign) d. After dorsiflexion: ○ If bumagsak yung foot - negative ○ If nag stay as flexed - positive

Question 31

Postpartum Psychiatric Disorders

Answer 31

a. 85% of women experience some type of mood disturbances that are the result of high hormonal fluctuations that occur during and immediately after birth b. 10% to 15% of women develop more significant symptoms of depression or anxiety c. Women with a prior history of postpartum psychiatric disorders have a 50% chance of recurrence

Question 32

Categories of Postpartum Psychiatric Disorders

Answer 32

a. Postpartum Blues b. Postpartum Depression c. Postpartum Psychosis

Question 33

Causes of Postpartum Psychiatric Disorders

Answer 33

a. The causes are not quite clear but research suggest that the following factors may contribute to the onset of illness: ○ Hormonal Imbalances ○ Life stresses ○ Situational Risks (condition of life- maybe related to loss of job/lack of finances)

Question 34

Predisposing Factors: Postpartum Psychiatric Disorder

Answer 34

a. Prenatal or previous depression b. Prenatal or previous psychosis or bipolar or schizophrenia c. Life stress d. Lack of social support e. Marital dissatisfaction f. Hsiotry of sexual abuse g. Traumatic birth experience h. High expectation of birth/parenting i. Unwanted pregnancy j. Physical problems with the baby k. Problems with health providers

Question 35

Postpartum Blues

Answer 35

a. Unpleasant feeling of the mother following childbirth b. Occurs 3-5 days after delivery c. Lasts up to 2 weeks after delivery 50% to 85% of women experience postpartum blues (80% of primigravidas) d. Do not interfere with woman’s ability to function

Question 35

Clinical Manifestation: Postpartum Blues

Answer 35

a. Mood swings b. Sadness c. Irritability d. Crying e. Decreased Concentration f. Trouble sleeping

Question 36

Clinical Manifestations: Postpartum Depression

Answer 36

a. Lack of joy in life b. Feelings of shame, guilt, or inadequacy c. Severe mood swings d. Loss of appetite e. Difficulty bonding with the baby f. Insomnia g. Withdrawal from family and friends

Question 36

Postpartum Depression

Answer 36

a. A major form of depression and is less common and more intense than postpartum blues b. Occur in approximately 10% to 20% of new mothers c. May develop as a result of pre-existing depression which worsens after birth (due to hormonal imbalances) d. It may occur entirely out of the blue e. Happens anytime after giving birth and lasts up to 1 year or longer f. It affects the ability of care fo the baby as well as the handling of other daily activities

Question 37

Postpartum Psychosis

Answer 37

a. An episode of bipolar illness (Manic episodes) b. Most severe and rarest form of postpartum depression c. It occurs in approximately 1 to 2 per 1000 women d. First to two weeks after childbirth e. Characterized by a loss of contact with reality for extended periods of time. f. This is a psychiatric as well as a medical emergency and requires immediate treatment g. 5% suicide rate and a 4% infanticide rate h. Confusion and disorientation i. Auditory Hallucinations and delusions j. Paranoia k. Rapidly shifting depressed or elated mood l. Illogical thoughts m/.Periods of delirium or mania m. Suicidal or homicidal thoughts