Complications in Third and Fourth Stage of Labor

Post Partum Hemorrhage Placenta Adherent Uterine Inversion Shock

1 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Post Partum Hemorrhage

is a maternal blood loss from the genital tract at any time following the babys birth up to 6 weeks after delivery. 2 Types Primary PPH if it occurs during the 3rd stage of labor or within 24hrs of delivery Secondary PPH if bleeding occurs after 24hrs following birth up to 6 weeks postpartum
2 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Main Causes of PPH

Uterine Atony (Atonic Uterus) Lacerations (Trauma) Retained Placenta Blood Coagulation Disorder

3 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Uterine Atony
A failure of the myometrium to contract and retract to compress torn blood vessels and control blood loss.
Normal postpartum condition with contracted uterus preventing hemorrhage.

4 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Causes of atonic uterine action

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Incomplete placental separation Retained cotyledon, placental fragment or membranes Precipitate labor Prolonged labor Polyhydramnios or multiple pregnancy Placenta previa Placenta abruption General anesthesia (e.g.: halothane, cylopropane) Mismanagement of third stage of labor A full bladder
5 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Predisposing Factors
1. Previous history of PPH or retained placenta 2. High parity 3. Presence of fibrosis 4. Maternal anemia 5. Ketoacidosis

6 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Signs and Symptoms

Visible bleeding > 500 mL Pallor Rising pulse rate Falling BP Maternal collapse Altered LOC (restless or drowsy) Boggy uterus (soft, distending and lacking tone) may be little of no visible blood loss
7 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Prophylaxis
Screening thorough and accurate health history Delivery arrangements must be explained carefully Early detection and treatment of anemia (Hgb > 10 g/dl) Good management during the first and second stage of labor to prevent prolonged labor and ketoacidosis Prophylactic administration of oxytocic agent Prepare 2 units of cross-matched blood for placenta previa
8 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Treatment of PPH
3 Basic Principles (CSR) 1. 2. Call a doctor
F So that help in on the way whatever happens; pts condition can deteriorate very rapidly which urgently requires physicians assistance.

Stop the bleeding

Fundal massage F To increase uterine contraction and tone. Administer oxytocic agent (Methergine, Oxytocin, Carboprost thromethamine) F To stimulates contraction of uterine smooth muscles. F Caution: Ergometrine should NOT be given more than 2 doses as it may cause pulmonary hypertension. Empty the uterus F To ensure constriction of the uterine blood vessels.

3.

Resuscitate the mother

F Competent action will be crucial in reducing the risk of maternal morbidity or even death.
9 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Resuscitating the mother

1. 2. 3. 4. Initiate IV infusion while peripheral veins are easily negotiated. To provide a route for oxytocic agents or fluid replacement. Lift the legs to allow blood to drain from into the central circulation. The foot of the bed should NOT be raised as this encourages pooling of blood in the uterus, which prevents contraction. Offer bedpan or insert catheter. Full bladder may interfere with uterine contraction and to minimize trauma during operative procedure. Do not move a collapsed woman prior to resuscitation. Withdraw 10mL of blood for hemoglobin estimation and for crossmatching compatible blood. In preparation for blood loss replacement. If bleeding is uncontrolled, further action is required. Infuse oxytocic agent 40 units in 1L of dextrose/saline to run over 8-12hrs, will ensure continued uterine contraction.
10 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

5. 6.

7.

Nursing Diagnoses
Fluid volume deficit r/t decrease in blood volume/loss of ECF. Altered tissue perfusion r/t reduction in tissue oxygenation and rapidity of blood loss. Anxiety r/t feelings of uncertainty and apprehension. Risk for infection r/t retention of placental tissue and excessive blood loss. Knowledge deficit r/t the cause of the excessive bleeding.
11 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Treatment
Bimanual compression of the uterus and D&C to remove clots. Repair of lacerations IV replacement of fluids and blood If bleeding persist, uterine rupture must be suspected Hysterectomy
12 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Nursing Interventions
Monitor v/s to assess for complications. Continue to monitor 24-48hrs. Inspect the placenta and membranes for completeness since retained fragments are often responsible for uterine atony. Massage the fundus, and express clots from the uterus. Perform a pad count to assess the amount of vaginal bleeding. Monitor lochia, including amount, color, and odor to assess for infection. Monitor fundus for location to assess for uterine displacement. Provide emotional support to help alleviate fear and anxiety. Provide quiet period, private room, restricted to visitors to promote recovery. If bleeding at home, lie down flat until help arrives.
13 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Placenta Adherent
A condition where the placenta remains attached to the uterus for an abnormally long time following birth.
2 Types 1. Partially adherent. The uterus is well contracted. Deliver the placenta by applying controlled cord traction or manually if unsuccessful. 2. Complete adherent. Does not usually bleed however, the longer the placenta remains in situ the greater the risk of partial separation, which may cause profuse hemorrhage.
14 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Management
Bimanual compression of the uterus Manual removal of the placenta

15 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Uterine Inversion
A rare complication of vaginal delivery in which the uterus partially or completely turns inside out.

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Classifications
According to severity According to timing of the prolapse 1. Acute prolapse occur within 24 hours of delivery. 2. Subacute over 24hrs up to 30th postpartum day.

1. First degree fundus reaches the internal os.

2. Second degree uterus body is inverted to internal os. 3. Third degree uterus, cervix and vagina are inverted and are visible.

3. Chronic more than 30 days after delivery.

17 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Causes
Associated with uterine atony and cervical dilation: Mismanagement in the 3rd stage of labor Combining fundal pressure and cord traction to deliver the placenta Use of fundal pressure while the uterus is atonic Pathologically adherent placenta Primiparity Fetal macrosomia (abnormally large size of body) Short umbilical cord Sudden emptying or distended uterus
18 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Interventions
1. 2. Call the physician including appropriate medical support. STAT attempt to replace to the uterus by pushing with the palm along the direction of the vagina.

19 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Interventions
3. Initiate IV access and fluid replacement. 4. If placenta is still attached, it SHOULD be left in situ as attempts to remove it at this stage may result in uncontrollable hemorrhage. 5. Once the uterus is repositioned, the nurse/midwife should keep the hand in situ until firm contraction. 6. Administer oxytocic agents.
20 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Medical Management
If manual replacement fails Hydrostatic method of replacement instillation of warm saline infused into the vagina Medications to relax the constriction and facilitate the return. Throughout the events, the mother and partner should be kept informed of what is happening. V/S including LOC is of utmost importance.

21 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Shock
A complex syndrome involving a reduction in blood flow to the tissues with resulting dysfunction of organs and cells.

3 Types 1. Hypovolemic the result of a reduction in intravascular volume 2. Cardiogenic impaired ability of the heart to pump blood 3. Distributive an abnormality in the vascular system that produces a maldistribution of the circulatory system (septic and anaphylactic shock)
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Hypovolemic Shock
Loss of circulating fluid volume or blood Decrease venous return to the heart Ventricles of the are inadequately filled Reduction in stroke volume and cardiac output Decrease blood pressure Decrease oxygen supply to the tissues Altered cell function
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Hypovolemic Shock
Decrease blood pressure SNS activation (receptors at aorta and carotid arteries) Adrenaline is released from the medulla and aldosterone from the adrenal cortex Vasoconstriction and cardiac output venous return to the heart

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Hypovolemic Shock
Compensatory mechanism fails Inadequate perfusion to vital organs Further fall in BP and cardiac output Insufficient supply to coronary arteries Poor peripheral circulation Multisystem failure and irreparable cell damage Death
25 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Effects of Shock on Vital Organs

Brain. cerebral flow = LOC deteriorates, increasingly unresponsive, pain response Lungs. dead spaces, ischemia alters surfactant production, edema, failure. Kidneys. Ischemia, urine output GI tract. Ischemia Liver. Altered metabolism of drug and hormone
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Management of Shock
1. Maintain the airway. Turned unto side and administer 40% oxygen at 4-6 LPM. 2. Replace fluids. Plasma expander or fresh frozen plasma of pts blood crossmatched. 3. Avoid warmth. Constriction of the peripheral blood supply occurs in response to the shock and keeping the mother warm may interfere with this response, causing further deterioration in condition. 27
Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Clinical Observations
1. 2. 3. 4. 5. 6. 7. Assessment of LOC. Continuous monitoring of blood pressure (q 30mins) note any drop. Cardiac rhythm may be monitored continuously. Measurement of UO hourly, using indwelling catheter. Assessment of skin color, core and peripheral temperature hourly. Hemodynamic measure of pressure in right atrium. Fluid balance is maintained accurately. Observation of the occurrence of further bleeding, including oozing from wound or puncture site.
28 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Central Venous Pressure

The pressure in the right atrium or superior vena cava. It is an indicator of the volume of blood returning to the heart and reflects the competence of the heart as a pump and the peripheral vascular resistance. Normal: 5 10 cmH2O Below 5 cmH20 = shock
29 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Method of Measuring CVP

Pt should be lying flat Base of manometer calibrated in 0 cmH20 aligned with the level of the right atrium. 3-way tap is opened and filled with IV fluid. The fluid will fall and rise with respiratory effort and should be allowed to stabilize before reading. The highest level the fluid reaches is used for the CVP measurement. Once completed, fluid is returned to the infusion position.
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31 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Principles of Care of CVP

1. Prevention of infection. Strict asepsis, regular inspection for signs of infection and precautions to prevent contamination during clinical procedures. 2. Maintaining a closed system. Caution catheters should not be disconnected as it may cause profuse bleeding or possible air embolus. 3. Maintaining patency of the catheter by preventing clot formation.
32 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Septic Shock
A form of distributive shock where an overwhelming infection develops commonly from gram negative organisms (E. coli, Proteus, or Pseudomonas pyocyaneus).

33 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Septic Shock
Overwhelming infection Damaged cells release histamine and enzymes Vasodilation and increased permeability of the capillaries Reduced systemic vascular resistance Vasodilation and hypotension continue
34 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009

Management of Septic Shock

Goal: preventing further deterioration by restoring circulatory volume and eradication of the infection. Identify the source of infection and protect reinfection. Antibiotic treatment after blood cultures. UTZ to detect retained products of conception. Keep informed of progress.
35 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009