1. Complications of Post Partum1

2. 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 ml.)
Late
Hemorrhage that occurs after the first 24 hours 2

3. Main Causes of Early Hemorrhage are:
Uterine Atony
Lacerations
Retained Placental Fragments
Inversion of the Uterus
Placenta Accreta
Hematomas 3

4. Uterine Atony 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.
**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 4

5. Uterine Atony Predisposing Factors
Prolonged
labor
Overdistention
of the
Uterus
Trauma due
to Obstetrical
Procedures
Grandmultiparity
Grandmultiparity: >5
Trauma: forceps, lacerations
Overdistention of the uterus, retention of placental fragments
By knowing these factors, you can anticipate complications and reduce the risk of excessive bleeding
Intrapartum
Stimulation
with Pitocin
Excessive use of
Analgesia / Anesthesia 5

6. 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.

7. Uterine Atony Signs and Symptoms A boggy uterus that does not
respond to massage
Abnormal
Clots
Excessive or
Bright Red
Bleeding
Signs
and
Symptoms
Unusual pelvic discomfort or backache 6

8. 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 7

9. 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
***Bright red blood vs. dark red of lochia 8

10. 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 9

11. 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?
Feel the fundus
assess perineum 10

12. 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 11

13. Hematoma Treatment: May have to be incised and drained.
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.

14. 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.
**Don’t pull on the cord unless the placenta has separated.
Incorrect traction and pressure applied to the fundus, especially when the uterus is flaccid
**Don’t use the fundus to “push the placenta out” 12

15. Inversion of the Uterus
Placenta
Uterus
Uterus continues
to be pulled and
inverted
Traction on
the cord
starts the
uterus to
invert 13

16. Inversion of the Uterus
Manually
pushed back
into place
Vagina
Vagina
Uterus
Inverted 14

17. 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 15

18. Placenta Accreta All or part of the decidua basalis is absent and the
Placenta grown directly into the uterine muscle. 16

19. Signs: Placenta Accreta
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 17

20. 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! 18

21. Are these Early, Late, or Both ?
Uterine Atony
Retained placental fragments
Lacerations
Inversion of the uterus
Placenta accreta
Hematoma
_________________
Early
Early/late 21

22. Postpartum Infections

23. 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 22

24. 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 23

25. Critical to Remember Signs and Symptoms of Postpartum Infection
1.Temperature increase of 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 24

26. TREATMENT AND NURSING CARE
Postpartum INFECTION
TREATMENT AND NURSING CARE
Administer broad spectrum antibiotics
Provide with warm sitz baths
Promote drainage--have pt. lie in HIGH fowlers position
Force fluids and hydrate with IV’s cc. / day
Keep uterus contracted, give Methergine
Provide analgesics for alleviation of pain
Nasogastric suction if peritonitis develops 25

27. What is the classic sign of a Postpartum Infection?
Test Yourself !
What is the classic sign of a Postpartum Infection?
> x 2 days excluding the 1st 24 hours 26

28. Complications of Postpartum Infections
Pelvic Cellulitis
Peritonitis
Signs and Symptoms:
Spiking a fever of F to F
Elevated WBC
Chills
Extreme Lethargy
Nausea and Vomiting
Abdominal Rigidity and Rebound Tenderness 27

29. 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

30. 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 29

31. 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? 30

32. Postpartum Cystitis

33. Postpartum Cystitis Prevention:
Monitor the patients urination diligently!
Don’t allow to go longer than 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

34. Mastitis
Marked Engorgement, Pain, Chills, Fever, Tachycardia, Hardness and Redness, Enlarged and tender lymph nodes 33

36. 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 31

37. 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 32

38. Treatment of Mastitis Rest
Appropriate Antibiotics--Usually Cephalosporins
Hot and / or Cold Packs
Don’t 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 34

39. Mastitis Meticulous handwashing Preventive Measures Frequent feedings
and massage
distended area to
help emptying
Preventive Measures
Rotate position of
baby on the breast 35

40. Complication of Mastitis
Breast Abscess
Breast Feeding is stopped on the affected side, but may feed on the
unaffected side.
Treatment: Incision and Drainage 36

41. 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 Homan’s Sign 39

42. Complication 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

43. Postpartum Psychiatric Disorders
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.
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 40

44. The Most common Mood Disorders are:
Baby Blues
Postpartum Depression
Bipolar Disorder

45. 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

46. 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 SSRI’s)
Childcare assistance

47. Predisposing factors Assessments Postpartum Psychosis
Similar to those of postpartum depression
Assessments
Grandiosity
Decreased need for sleep (insomnia)
Flight of ideas
Psychomotor agitation/hyperactivity
Rejection of infant

48. 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

49. 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?