1. Postpartal Complications
Usually a period of health but complications do occur.
Woman at risk in three points of view:
Her own health
Her future childbearing potential
Her ability to bond with her new infant
Family is disrupted, hospital stay is longer, increased cost, difficult to cope.
Most complications are preventable, and if they do occur they can be treated.

2. Postpartal Complications
Hemorrhage
Infection
Thrombophlebitis
Urinary System Disorders
Cardiovascular System Disorders
Reproductive System Disorders
Emotional and Psychological Complications

3. Postpartal Complications
Assessment findings may be extremely subtle.
Tenderness in calf of leg
Slight increase in pain
Slight elevation in temperature (serious 1st 24 hours)
Slight increase in lochia
Things that are more than usual
Do not rely on the mother’s report, she wants to go home

4. Postpartal Complications
Provide for measures that restore the woman quickly to health, and promote contact with her child and support person.
If she can not see the baby she needs contact by phone with the nursery. A photo of the infant, a note written about the progress as if from the baby.
1 in 500 develop depression and even psychosis.
Reinforcement is needed, support and remind that it is a temporary situation.

5. Postpartal Hemorrhage
Any blood loss from the uterus greater than 500 mL. within a 24 hour period.
Can occur early, within 24 hours or late, anytime after the first 24 hours during the remaining days of the 6 week puerperium.
4 main causes:
Uterine atony
Lacerations
Retained placental fragments
DIC disceminated intravascular coagulation

6. Postpartal Hemorrhage
Uterine Atony:
Relaxation of the uterus
Most frequent cause of hemorrhage
Uterus must remain in a contracted state to allow open vessels at the placental site to seal.
Box p. 695 list some factors.
Multiple gestation, hydraminios, lg baby, myomas

7. Postpartal Hemorrhage
Assessment:
Abrupt gush of blood from placental site
Lg. amount of vaginal bleeding
Symptoms of shock and blood loss
A saturated pad can hold 25 to 50 mL.
Count pads to estimate blood loss(q 30 min)
Weigh pads the subtract the difference (1 g weight equals 1 mL volume of blood.
Turn woman on side to inspect for pooling beneath her.

8. Postpartal Hemorrhage
Box 25.2 p. 696 outcomes and interventions
Palpate uterus; keep contracted, detecting relaxation is 1st and most important assessment.
Lochia VS
Treatment:
Uterine massage to encourage contraction
IV oxytocin – maintain uterine tone (10 to 40 U per 1000 mL of 5% dextrose) (1 hr.)
IM Methergine

9. Postpartal Hemorrhage
Bimanual Massage:
One hand in vagina while pushing against fundus through the abdominal wall with the other hand. (painful)
Sonogram to detect placental fragments
Examine manually and insert packing.
Prostaglandin Administration:
Prostaglandin F IM to initiate contractions
Watch for nausea, diarrhea, tachycardia, and hypertension.

10. Postpartal Hemorrhage
Blood Replacement:
Type and cross match
Some may donate during pregnancy.
Hysterectomy:
Ligation of uterine or hysterectomy as last resort.
Comfort and support.
“Why me”, grief, anger, glad to be alive.

11. Postpartal Hemorrhage
Nursing interventions:
Observe fundal height, consistency, and lochia for 4 hours.
Offer bedpan or ambulate to BR q 4 hours or catheter may be ordered.
O2 4 L/minute by face mask.
Supine
VS increase pulse, decrease B/P
Fatigue- needs rest
May need iron therapy, help at home.
Monitor for infection

12. Postpartal Hemorrhage
Lacerations:
Small tears or lacerations of the birth canal are common. Large lacerations are complications.
Occur:
With difficult or precipitate births
In primigravidas
With birth of a large infant >9 lbs.
With the use of a lithotomy position and instruments.
Either cervical, vaginal, or perineal.

13. Postpartal Hemorrhage
If uterus is firm but bleeding persists, suspect a laceration.
Cervical Laceration:
Found on the sides of cervix near branches of uterine artery.
May gush, bright red, immediately after delivery of the placenta.
Treatment:
Repair laceration (difficult to see)
Reassure, may need anesthetic for pain.

14. Postpartal Hemorrhage
Vaginal Lacerations:
Harder to repair, some oozing, may need packing. Remove in 24 to 48 hours.
Foley catheter inserted due to pressure on urethra.
Packing left to long causes stasis, infection similar to toxic shock syndrome.
Perineal Laceration:
Occur when in lithotomy position for birth, which increases tension on perineum.

15. Postpartal Hemorrhage
Four categories: (table 25.1 p. 700)
From vaginal mucous membranes to rectum
Treatment:
Sutured and treated same as episiotomy repair.
Document the degree.
Heal slower due to tearing and ragged edges
Diet high in fluids, stool softener, no rectal temps, suppositories or enemas.

16. Postpartal Hemorrhage
Retained Placental Fragments:
Portions retained keep uterus from contracting fully, uterine bleeding occurs.
Happens with a succenturiate placenta ( an accessory lobe), placenta accreta (fused with myometrium because of abnormal decidua basalis layer.
May need surgically removed.
Inspect placenta carefully after birth to see if it is complete.

17. Postpartal Hemorrhage
Assessment:
Lg. Fragment, bleeding, uterus can not contract.
Sm.fragment, bleeding at day 6 to 10 postpartum. Woman notices an abrupt discharge of blood.
If placental tissue is present; elevated serum HCG present.
Sonogram.
Treatment:

18. Postpartal Hemorrhage
Removal of fragments (D&C)
Methotrexate to destroy retained placental tissue.
Teach woman to monitor color of lochia
Disseminated Intravascular Coagualtion:
Deficiency in clotting ability caused by vascular injury.
Subinvolution:
Incomplete return of uterus to its prepregnant size and shape.

19. Postpartal Hemorrhage
Postpartal visit in 4 to 6 weeks, the uterus is still enlarged and soft.
Lochial discharge still present.
Results from-sm. placental fragments, mild endometritis, or myoma.
Management:
Methergine 0.2 mg four times a day.
Oral antibiotic (endometritis)
Anemia
Teach normal process of involution at D/C

20. Postpartal Hemorrhage
Perineal Hematomas:
Collection of blood in the subcutaneous layer of tissue of perineum.
Injury to blood vessels during birth.
Assessment:
Woman reports severe pain in perineal area or feeling pressure between her legs. Check for hematoma.
Purplish color and swelling. (2 cm to 8 cm)
Tender and palpates as firm globe.

21. Postpartal Hemorrhage
Management:
Report presence, size, degree of discomfort.
Analgesic, ice, may absorb in 3 to 4 days or may need incised.
Puerperal Infection
Uterus is sterile during pregnancy and until membranes rupture.
Greater risk if tissue edema and trauma are present. (Box 25.3 p. 702)
Pathogens invade.

22. Infection Prognosis for recovery depends on:
Virulence of the invading organism
General health of the woman
Port of entry
Degree of uterine involution
Presence of lacerations in the reproductive tract.
Always serious, it can spread to peritonitis or septicemia. Can be fatal.

23. Infection Management Antibiotic after C&S
Ampicillin, Gentamicin, Suprax
Use gloves and sterile instruments.
Proper perineal care
May need isolation
Pump breasts if breast feeding
Give support

24. Infection Endometritis: Infection of endometrium, lining of uterus.
Assessment:
Temperature elevation, usually on 3rd to 4th day postpartum > for 2 days.
Normal WBC 20,000 to 30,000
Chills, loss of appetite, general malaise.
Sonogram for infected placental fragments.
Management:
Cleocin, oxytocic agent, fluids, analgesic.

25. Infection Fowlers position or ambulate.
Lasts 7 to 10 days. May be discharged on IV antibiotic at home.
Can lead to tubal scarring and infertility.
Infection of the Perineum
Assessment:
Suture line, or laceration is port for entry of bacteria.
Generally remain localized.
SS-pain, heat, feeling of pressure, inflammation at suture line.

26. Infection Culture any drainage Management:
Remove perineal sutures to open area and allow to drain.
Packing (iodoform gauze) to keep open.
Antibiotic, analgesic, sitz bath or warm compresses, change peri pads frequently.
Heals by tertiary intention.
Monitor infant for thrush, bruising, decreased vitamin K > poor clotting.

27. Infection Peritonitis Infection of the peritoneal cavity.
Major cause of death from puerperal infection
Spreads through lymphatic system or fallopian tubes or uterine wall.
May settle in cul-de-sac of Douglas.
Assessment:
SS-(guarding) rigid abdomen, abdominal pain, high fever, rapid pulse, vomiting, appears ill.

28. Infection Management:
Often accompanied by paralytic ileus. Insert NG tube to prevent vomiting and rest the bowel.
IV or TPN
Analgesic, antibiotic.
May have infertility due to scarring and adhesions in peritoneum.

29. Thrombophlebitis
Inflammation of the lining of a blood vessel with the formation of blood clots.
Usually an extension of endometrial infection.
Causes:
Increased fibrinogen level that is still elevated from pregnancy leading to clotting.
Dilation of lower extremity veins due to pressure of fetal head during pregnancy and birth.
Inactivity or prolonged time in stirrups.

30. Thrombophlebitis Classified as SVD or DVT. Prone women:
With varicose veins
Obese
Previous thrombophlebitis
Over 30 yrs. of age with increased parity
Family history.
Prevention:
Prevent endometritis
Ambulation

31. Thrombophlebitis Limit time in stirrups Exam tables well padded
Support stockings
Femoral Thrombophlebitis
Femoral, saphenous, or popliteal veins involved.
Arterial spasm often diminishes arterial circulation to the leg. This plus edema give the leg a white appearance.
Assessment:

32. Thrombophlebitis
10th day after birth; elevated temperature, chills, pain, redness in leg.
Leg swells below the lesion, appears shiny and white. Homans’ sign positive, diameter of leg increased.
Doppler US or contrast venography to confirm diagnosis.
Management:
Bedrest, elevate leg, anticoagulants and moist heat, analgesic, antibiotic.
APTT, PT

33. Thrombophlebitis
Coumarin, streptokinase or urokinase, Heparin. Later may be placed on aspirin.
With treatment will last a few days but it takes 4 to 6 weeks to resolve.
Pelvic Thrombophlebitis
Involves the ovarian, uterine, or hypogastric veins.
Follows mild endometritis
Occurs on day 14 or 15.
Assessment:
Suddenly extremely ill, high fever, chills,

34. Thrombophlebitis General malaise.
Necroses the vein and results in a pelvic abscess. Can become systemic and result in lung, kidney or heart valve abscess.
Management:
Bedrest, antibiotics, and anticoagulants.
Disease lasts 6 to 8 weeks.
May need incised by laparotomy
Tubal scarring > infertility.
Teach preventive measures.

35. Pulmonary Embolus Obstruction of pulmonary artery with a blood clot.
Emergency
Sudden sharp chest pain, tachypnea, tachycardia, orthopnea, cyanosis. O2
ICU
Mastitis
Infection of the breast. Occurs on 7th day to weeks or month.

36. Mastitis Organism enters through cracked and fissured nipples.
Preventive measures:
Position baby correctly and grasps nipple properly.
Release baby’s grasp on nipple before removing from the breast.
Wash hands
Expose nipples to air for part of day.
Vitamin E daily

37. Mastitis May come from oral-nasal cavity of the infant. Assessment:
Usually unilateral, pain, swelling, redness, fever and scant breast milk.
Management:
Broad spectrum antibiotic
Continue breast feeding
Cold or ice compresses
Support bra

38. Mastitis Warm, wet compresses Lasts 2 to 3 days May abscess
Urinary System Disorders
Urinary Retention:
Inadequate bladder emptying.
Bladder sensation is decreased due to edema from the pressure of birth.
Permanent damage may occur from loss of muscle tone.

39. Urinary System Disorders
Assessment:
Associated with use of anesthesia and forceps.
Percussion or palpation
Voiding is frequent, sm. And inadequate.
Always measure 1st voiding after birth. If < 100 mL suspect retension.
Catheterize after voiding, if > 100mL it is retention.
Leave Foley in place

40. Urinary System Disorders
Management:
Catheterization
After 24 hours clamp then remove.
Fluids, analgesics,
Void within 8 hours.
Present for no longer than 48 hours.
Urinary Tract Infection
Bacteria may be introduced into bladder.
Assessment:
Burning on urination, blood, feeling of

41. Urinary System Disorders
Frequency, pain, low grade fever and discomfort from lower abdominal pain.
Clean catch urine specimen
Management:
Sulfa drugs contraindicated for breast feeding.
Antibiotic-ampicillin
Fliuds -1 glass /hour
Analgesics
5 to 7 days to eradicate completely.

42. Cardiovascular System Disorders
Postpartal Pregnancy-Induced Hypertension
PIH
May have a preexisting hypertension.
SS- proteinuria, edema, hypertension.
Tx.- bedrest, quiet atmosphere, VS, urine output and Magnesium sulfate or antihypertensive medication.
Usually some placenta is still present.
Once a D&C is completed B/P decreases.
Seizures occur 6 to 24 hours after birth.

43. Reproductive System Disorders
Reproductive Tract Displacement:
Ligaments may no longer be able to maintain the uterus in its usual position or level after pregnancy.
Problem: retroflexion, anteflexion, retroversion, anteversion or prolapse.
May interfere with fertility, may cause continued pain in lower abdomen.
Cystocele, rectocele, stress incontinence
High parity

44. Reproductive System Disorders
Separation of the Symphysis Pubis:
Ligaments may be stretched by birth and tear.
Woman feels acute pain on turning or walking. Legs rotate externally (waddle)
Defect over symphysis pubis, area is swollen and tender.
Tx. – bedrest, binder, avoid heavy lifting
4 to 6 weeks to heal
May need cesarean birth for future.

45. Emotional Complications
Difficult bonding with infant.
Child Born with an Illness:
Sex of child
Anger, hurt, disappointment, grief
Loss of self esteem
Feelings that child is not real
Shock to the couple
ICU visits
Open lines of communication

46. Complications Woman Whose Child Has Died:
Questions about what happened.
Bewildered, bitter, resentful, “Why me”
Clean the baby and wrap in blanket and let the parents see the baby.
Stay with them, complete forms, provide a private room.
Postpartal Depression:
Almost every woman has some feelings of sadness in 1 to 10 days after childbirth.

47. Complications Response to anticlimatic feelings after birth.
Related to hormonal shifts-estrogen, progesterone, corticotropin releasing hormone levels decline.
Extreme fatigue, inability to stop crying, increased anxiety about health, insecurity, psychosomatic symproms (N/V) and depressed or manic mood fluctuations.
May need counseling and/or antidepressant therapy.
Table 25.2 p. 714 comparisons

48. Complications Postpartal Psychosis: 1 woman in 500
Response to the crisis of childbearing.
May previously had mental illness
Lost contact with reality, may deny she had a child.
Mat respond as threatening, anger
Do not leave alone because the distorted perception might lead her to harm herself.