Postpartum Complications Twila Brown, PhD, RN

Postpartum Hemorrhage Blood loss greater than 500 mL Early postpartum hemorrhage First 24 hours after delivery Uterine atony Lacerations of the genital tract Hematomas Uterine rupture Late postpartal hemorrhage Usually 1-2 weeks Retention of placental tissue

Early Postpartal Hemorrhage: Uterine atony Causes Over distention Dysfunctional labor Induction Cesarean Grand multiparity Preeclampsia Retained placenta fragments Asian or Hispanic Assessment Fundus Soft Difficult to find Above expected level Lochia Excessive Bright red Clots

Early Postpartal Hemorrhage: Uterine atony Interventions Assess for bleeding Assess fundal height Encourage voiding Oxytocin (Pitocin) Fundal massage Contact physician Methylergonovine (Methergine) IV fluid and/or transfusion Bimanual compression of uterus Ligation of uterine vessels or hysterectomy

Early Postpartal Hemorrhage: Lacerations Perineal, vaginal, cervical Predisposing factors Primiparous Precipitous delivery Macrosomia Forceps or vacuum-assisted birth Mediolateral episiotomy Assessment Firm uterus Bright red blood Stream of unclotted blood

Early Postpartal Hemorrhage: Hematomas Blood in soft subcutaneous tissue Predisposing factors Prolonged pressure of fetal head Forceps or vacuum extraction Prolonged or precipitous labor Macrosomia Pudendal anesthesia Subperitoneal hemotoma Uterine artery branch or vessels in broad ligament Severe pain and hypovolemic shock

Early Postpartal Hemorrhage: Hematomas Vaginal Assessment Unilateral purplish discoloration Pain Feeling of fullness in vagina or rectal pressure Difficult voiding Intervention Analgesia Ice packs Sitz bath Surgery

Late Postpartum Hemorrhage Assessment Subinvolution Lochia Fails to progress from rubra to alba Saturation of more than 1 pad per hour Abnormal clots Bladder distention Increased rectal, back, or pelvic pain Increased pulse or decreased blood pressure Signs of anemia

Late Postpartal Hemorrhage Intervention Teach Signs of hemorrhage Massage fundus Iron administration Pitocin or Methergine IV fluid or blood transfusion, Oxygen Dilation and curettage

Puerperal Infections Reproductive tract associated with childbirth Metritis, perineal or cesarean wound Causes of metritis Cesarean - Prolonged labor PROM - Multiple vaginal exams Scalp electrodes - Internal uterine monitor OB trauma - Instrument assisted birth Manual removal of placenta Prexisting infection Compromised health status

Puerperal Infections: Metritis Assessment Abd/Uterine pain Foul smelling vaginal discharge Fever 101-104 F Chills Malaise 30% increase in WBC Interventions CBC Cultures Hygiene Abscess is drained IV antibiotics Antipyretics ICU hospitalization

Puerperal Infections: Perineal and Cesarean wounds Perineal wound Assessment Cesarean wound Intervention Sutures removed Drain purulent material Antibiotics Analgesics Warm compress or sitz baths

Overdistention of the Bladder Cause Unable to empty bladder due to trauma or anesthesia Assessment Distended bladder Displaced uterus, increased vaginal bleeding, boggy uterus, backache, restless Intervention Encourage voiding Perineal ice packs Pour water over perineum Aseptic straight catheter X 1

Urinary Tract Infections Cause Retention of urine Bacteria from catheterization Cystitis Assessment Intervention Increase fluids >> Void frequently Empty bladder >> Urine culture and antibiotics Prevention Hygiene Void q 2-4 hrs Increase acidity in urine

Urinary Tract Infections Pyelonephritis Assessment UTI signs >> High fever Chills >> Flank pain N&V >> Acutely ill Management IV antibiotics >> Increase fluids Antipyretics >> Analgesic Follow-up culture in 2 weeks

Mastitis Infection of breast tissue Causes Bacteria enters through cracks in nipple Milk stasis Poor hand washing Breast not dry or wet breast pad Incorrect placement of baby causes sore nipples Assessment Fever > 101 F and chills, acutely ill Flu-like symptoms, malasia, headache Painful, warm, red area of breast

Mastitis Intervention Bed rest - Increase fluids Supportive bra - Antibiotics Analgesic Breast feed frequently Warm compress before feeding Cold packs between feedings Drain abscess Prevention Early feedings and frequent feedings Change baby’s feeding positions Massage clogged duct Empty breast at each feeding Nipple care

Thromboembolic Disorders Blood clot formed from impeded blood flow Causes Hypercoagulability of blood Venous stasis Injury to epithelium of vessels Increased risk Prevention Avoid dehydration Avoid trauma to legs in stirrups Early postpartum ambulation Leg exercises to support venous return No smoking Antiembolism stockings

Thromboembolic Disorders Superficial thrombophelbitis 3 to 4th day after delivery Assessment Tenderness >> Localized heat Swelling >> Redness No or low fever Intervention Elevate leg >> Bed rest Local moist heat >> Analgesia Support hose Little risk of pulmonary embolism

Thromboembolic Disorders Deep vein thrombosis 10 to 20 days after delivery Assessment Swelling Pain Erythema Heat Pedal edema Low to high fever Positive Homan’s Sometimes decreased perfusion Chills

Thromboembolic Disorders Deep vein thrombosis Intervention Bed rest >> Elevate leg Analgesia >> Antibiotics Anticoagulant therapy IV heparin Coumadin for 2 to 6 months Monitor for pulmonary embolism Antiembolism stockings after symptoms:

Thromboembolic Disorders Pulmonary embolism Clot moves to pulmonary artery Assessment Dyspnea >> Chest pain Cough >> Hemoptysis Cyanosis >> Hypotension Tachypnea >> Tachycardia Treatment Alert physician >> Elevate head of bed Oxygen >> Narcotics Anticoagulation with heparin

Psychiatric Disorders: Adjustment reaction with depressed mood Postpartum blues or baby blues Assessment Within a few days after delivery and last a few hours to 10 or more days Mild depression with interspersed happier feelings Tearful without reason Feel overwhelmed, unable to cope, fatigued, anxious, irritable, oversensitive Intervention Provide reassurance Assist with self and infant care

Psychiatric Disorders: Post partum major mood disorder Postpartum depression Assessment During first year - 4th week to 3 months Sad/frequent crying Poor decision making Insomnia or excessive sleeping Appetite change Feelings of worthlessness No interest in activities Feel inadequate as a mother

Psychiatric Disorders: Post partum major mood disorder Risk factors Primiparity Ambivalence to pregnancy History of depression Lack of support Treatment Medication Risk for suicide Group and individual therapy Assistance with child care and ADL’s

Psychiatric Disorders: Postpartum psychosis Risk factors Previous psychosis - Poor social support Assessment Seen within 3 months - Agitation Insomnia - Hyperactivity Labile mood - Confusion Irrational thoughts - Poor concentration Poor judgment - Delusions/Hallucinations Intervention Hospitalization - Antipsychotic medication Social support - Psychotherapy Considered an emergency due to suicide/infantcide risk

References Hogan, M.A., & Glazebrook, R.S. (2007). Maternal-newborn nursing: Reviews and rationales. Upper Saddle River, NJ: Prentice Hall. Ladewig, P.A., London, M.L., & Davidson, M.R. (2006). Contemporary maternal-newborn nursing care (6th ed.). Upper Saddle River, NJ: Prentice Hall. Littleton, L.Y., & Engebretson, J.C. (2005). Maternity nursing care. Clifton Park, NY: Thomson Delmar Learning. Murray, S. S., & McKinney, E. S. (2006). Foundations of maternal-newborn nursing (4th ed.). St. Louis, MO: Saunders. Olds, S.B., London, M.L., Ladewig, P.W., & Davidson, M.R. (2004). Maternal-newborn nursing & women’s health care (7th ed.). Upper Saddle River, NJ: Prentice Hall. Silvestri, L.A. (2002). Saunders comprehensive review for NCLEX-RN (2nd ed.). Philadelphia: W.B. Sanders. Straight A’s in maternal-neonatal nursing. (2004). Philadelphia: Lippincott Williams & Wilkins.

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