Complications of

Post Partum
POSTPARTUM HEMORRHAGE
Early
Occurs when blood loss is greater than
500 ml. in the first 24 hours after a vaginal
delivery or greater than 1000 ml after a cesarean
birth
*Normal blood loss is about 300 - 500 ml.)
Late
Hemorrhage that occurs after the first 24 hours
MAIN CAUSES OF EARLY
HEMORRHAGE ARE:

Uterine Atony

Lacerations

Retained Placental Fragments

Inversion of the Uterus

Placenta Accreta

Hematomas

UTERINE ATONY
**The myometrium fails to contract and
the uterus fills with blood because of
the lack of pressure on the open
vessels of the placental site
The myometrium fails to contract and

the uterus fills with blood because of

the lack of pressure on the open blood

vessels of the placental site.
UTERINE ATONY
PREDISPOSING FACTORS
Prolonged
labor
Overdistention
of the
Uterus
Grandmultiparity
Excessive use of
Analgesia / Anesthesia
Intrapartum
Stimulation
with Pitocin
Trauma due
to Obstetrical
Procedures
UTERINE ATONY
Most common cause of Hemorrhage

Key to successful management is:
PREVENTION!

Nurse many times can predict which women
are at risk for hemorrhaging.



UTERINE ATONY


Signs
and
Symptoms
Excessive
or
Bright Red
Bleeding
Abnormal
Clots
A boggy uterus that does not
respond to massage
Unusual pelvic discomfort or backache
NURSING CARE OF UTERINE
ATONY

Document Vaginal Bleeding

Fundal massage / Bimanual Compression

Assess Vital Signs (shock)

Give medications--Pitocin, Methergine, Hemabate

D & C, Hysterotomy/ectomy, Replace blood / fluids
POST PARTUM HEMORRHAGE

*LACERATIONS*
PREDISPOSING FACTORS
1. Spontaneous or Precipitous delivery
2. Size, Presentation, and Position of baby
3. Contracted Pelvis
4. Vulvar, cervical, perineal, uretheral area and vaginal
varices

Signs and Symptoms
1. Bright red bleeding where there is a steady
trickle of blood and the uterus remains firm.
2. Hypovolemia


POSTPARTUM HEMORRHAGE

*LACERATIONS*

Treatment and Nursing Care
1. Meticulous inspection of the entire
lower birth canal
2. Suture any bleeders
3. Vaginal pack-- nurse may remove and
assess bleeding after removal
4. Blood replacement


TEST YOURSELF !
You are assigned to Mrs. B. who delivered
vaginally. As you do your post-partum
assessment, you notice that she has a large
amount of lochia rubra.


What would be the first measure to determine
if it is related to uterine atony or a laceration?
RETAINED PLACENTAL FRAGMENTS
This occurs when there is incomplete
separation of the placenta and fragments of
placental tissue retained.

Signs
Boggy , relaxed uterus
Dark red bleeding
Treatment
D & C
Administration of Oxytocins
Administration of Prophylactic antibiotics
HEMATOMA
Major Symptom: PAIN- deep, severe, unrelieved,
feelings of pressure

Many times bleeding is concealed. Major symptom is
rectal pain and tachycardia.


Treatment:
May have to be incised and drained.

INVERSION OF THE UTERUS
The uterus inverts or turns inside out after
delivery.
Complete inversion - a large red rounded mass
protrudes from the vagina
Incomplete inversion - uterus can not be seen, but felt

Predisposing Factors:
Traction applied on the cord before the placenta has
separated.
**Dont pull on the cord unless the placenta has
separated.
Incorrect traction and pressure applied to the fundus,
especially when the uterus is flaccid
**Dont use the fundus to push the placenta out
INVERSION OF THE UTERUS
Traction on
the cord
starts the
uterus to
invert
Uterus continues
to be pulled and
inverted
Uterus
Placenta
INVERSION OF THE UTERUS
Vagina
Uterus
Inverted
Vagina
Uterus
Manually
pushed back
into place
TREATMENT AND NURSING CARE
Replace the uterus--manually replace and pack uterus
Combat shock, which is usually out of proportion
to the blood loss
Blood and Fluid replacement
Give Oxytocin
Initiate broad spectrum antibiotics
May need to insert a Nasogastric tube to
minimize a paralytic ileus
Notify the Recovery Nurse what has occurred!
Care must be taken when massaging
PLACENTA ACCRETA
All or part of the decidua basalis is absent and the
Placenta grown directly into the uterine muscle.
PLACENTA ACCRETA
Signs:
During the third stage of labor, the
placenta does not want to separate.
Attempts to remove the placenta in the
usual manner are unsuccessful, and
lacerations or perforation of the uterus
may occur
TREATMENT

If it is only small portions that are
attached, then these may be removed
manually


If large portion is attached--a
Hysterectomy is necessary!
ARE THESE EARLY, LATE, OR BOTH ?
Uterine Atony

Retained placental
fragments

Lacerations

Inversion of the uterus

Placenta accreta

Hematoma
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POSTPARTUM INFECTIONS
POSTPARTUM INFECTIONS
Definition
Infection of the genital tract that occurs
within 28 days after abortion or delivery

Causes
Streptococcus Groups A and B
Clostridium, E. Coli




POSTPARTUM INFECTIONS
Predisposing Factors
1. Trauma
2. Hemorrhage
3. Prolonged labor
4. Urinary Tract Infections
5. Anemia and Hematomas
6. Excessive vaginal exams
7. P R O M

CRITICAL TO REMEMBER
Signs and Symptoms of Postpartum
Infection
1.Temperature increase of 100.4 or higher
on any 2 consecutive days of the first
10 days post-partum, not including the
first 24 hours.
2. Foul smelling lochia, discharge
3. Malaise, Anorexia, Tachycardia, chills
4. Pelvic Pain
5. Elevated WBC
POSTPARTUM INFECTION


Administer broad spectrum antibiotics

Provide with warm sitz baths

Promote drainage--have pt. lie in HIGH fowlers position

Force fluids and hydrate with IVs 3000 - 4000 cc. / day

Keep uterus contracted, give Methergine

Provide analgesics for alleviation of pain

Nasogastric suction if peritonitis develops


TREATMENT AND NURSING CARE
What is the classic sign of a
Postpartum Infection?
Test Yourself !
COMPLICATIONS OF
POSTPARTUM INFECTIONS
Pelvic Cellulitis

Peritonitis
Spiking a fever of 102
0
F to 104
0
F
Elevated WBC
Chills
Extreme Lethargy
Nausea and Vomiting
Abdominal Rigidity and Rebound Tenderness
Signs and Symptoms:
PREVENTIVE MEASURES
Prompt treatment of anemia
Well-balanced diet
Avoidance of intercourse late in pregnancy
Strict asepsis during labor and delivery
Teaching of postpartum hygiene measures
keep pads snug
change pads frequently
wipe front to back
use peri bottle after each elimination
LOCALIZED INFECTION
Infection of the Episiotomy, Perineal laceration,
Vaginal or vulva lacerations
Wound infection of incision site
Signs:
Reddened, edematous, firm, tender edges of
skin
Edges seperate and purulent material drains
from the wound.
Treatment
Antibiotics
Wound care
CHECK YOURSELF
Mrs. X. was admitted with endometritis

and Mrs. Y. was admitted with an infection

in her cesarean incision. Are both classified

as a postpartum Infection?


What would be the major difference in

presenting symptoms you would note on

nursing assessment?
POSTPARTUM CYSTITIS
POSTPARTUM CYSTITIS
Prevention:
Monitor the patients urination diligently!
Dont allow to go longer than 3 - 4 hours before
intervening.
Treatment
Antibiotics -- Ampicillin
Urinary Tract Antispasmodics
Causes:
Stretching or Trauma to the base of the bladder results in
edema of the trigone that is great enough to obstruct the
urethra and to cause acute retention.
Anesthesia

MASTITIS
Marked Engorgement, Pain, Chills,
Fever, Tachycardia, Hardness and
Redness, Enlarged and tender
lymph nodes


MASTITIS
Types:
Mammary Cellulitis - inflammation of the
connective tissue between the lobes in the
breast

Mammary Adenitis - infection in the ducts
and lobes of the breasts
Poor
Positioning
of Infant
Improper
breaking of
suction
Strong
Sucking
Infant
First
Nursing
Experience
Abrupt
Weaning
Supplemental
Feedings
Interval
between
nursing too long
"Lazy Feeder"
Development of Mastitis
Nipple Trauma Pain Impaired Engorgement
Let down
Cracked Stasis
nipples of milk


Entry for Bacteria Plugged ducts
Mastitis
Treatment, No Treatment
Problem will resolve Breast Abscess
TREATMENT OF MASTITIS
Rest

Appropriate Antibiotics--Usually Cephalosporins

Hot and / or Cold Packs

Dont Breast Feeding because:
If the milk contains the bacteria, it also contains the
antibiotic
Sudden cessation of lactation will cause severe
engorgement which will only complicate the situation
Breastfeeding stimulates circulation and moves the
bacteria containing milk out of the breast

Stop
MASTITIS
Preventive Measures
Meticulous
handwashing
Frequent feedings
and massage
distended area to
help emptying

Rotate position of
baby on the breast
COMPLICATION OF MASTITIS
Breast Abscess
Breast Feeding is stopped on the affected side, but may feed on the
unaffected side.
Treatment: Incision and Drainage


THROMBOEMBOLIC DISEASE
Predisposing Factors
Slowing of blood in the legs
Trauma to the veins

Signs and Symptoms
Sudden onset of pain
Tenderness of the calf
Redness and an increase in skin temperature
Positive Homans Sign
Treatment
Heparin --it does not cross into breast milk
Antidote: protamine sulfate
Teach patient to report any unusual bleeding, or
petchiae, bleeding gums, hematuria, epistaxis, etc.


Complication
Pulmonary Emboli

POSTPARTUM PSYCHIATRIC
DISORDERS
Pregnancy alone is not a cause of a psychiatric
Illness; however, the psychological and physiological
stressors relating to pregnancy may bring on an
emotional crisis

Mental Health problems can complicate the
puerperium.
There are days when each new mother may feel
inadequate, but the mother who has a constant
feeling of inadequacy needs professional
counseling.

MOOD DISORDERS
The Most common Mood
Disorders are:
Baby Blues

Postpartum Depression

Bipolar Disorder


BABY BLUES
50-80% of moms are affected
Self-limiting (up to 10 days)
Cause
Seems to be related to changes in progesterone,
estrogen, and prolactin levels
Symptoms
Tearful yet happy
overwhelmed
Treatment
POSTPARTUM MAJOR MOOD DISORDER
POSTPARTUM DEPRESSION
Risk factors:
Primiparity
History of postpartum depression
Lack of social and relational support

Clinical therapies
Counseling and support groups
Medication (usually SSRIs)
Childcare assistance
POSTPARTUM PSYCHOSIS

Predisposing factors
Similar to those of postpartum depression

Assessments
Grandiosity
Decreased need for sleep (insomnia)
Flight of ideas
Psychomotor agitation/hyperactivity
Rejection of infant
TREATMENT FOR MOOD DISORDERS
Drug therapy
Psychotherapy
Explain the importance of good nutrition and rest
Reintroduce the mother to the baby at the mothers
own pace
How do the signs and symptoms of hematoma differ
from those of uterine atony or a laceration?

What laboratory study should the nurse suspect if the
woman is on heparin anticoagulation?

What is the significance of a board-like abdomen in a
woman who has endometritis?

Why is it important that the breast-feeding mother with
mastitis empty her breasts completely?

What is the KEY difference between postpartum blues
and postpartum depression?