1. Postpartum Complications
Chapter 17
Postpartum Complications
Review chapter objectives.
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Effects of Hemorrhage
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Objectives
Define key terms listed.
List three major causes of postpartum hemorrhage.
Identify nursing interventions in the care of the woman with postpartum hemorrhage.
Describe the dangers that deep vein thrombosis presents.
Explain the nursing care of a woman who has a thromboembolism.
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4. Common Postpartum Complications
Hemorrhage
Thromboembolic disorders
Subinvolution of uterus
Infections
Depression
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5. Postpartum Hemorrhage
Blood loss of
More than 500 mL after uncomplicated vaginal birth
1000 mL after a cesarean birth
Can occur
Early (first 24 hours after delivery)
Late (between 24 hours and 6 weeks after birth)
See Box 17-1 and Safety Alert—Signs of Hemorrhage (p. 344).
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6. Causes of Postpartum Hemorrhage
Early: uterine atony and laceration
Late: retained placental fragment or subinvolution
Woman may demonstrate tachycardia and tachypnea due to the reduced blood volume. She may also have pale, clammy skin and pale mucous membranes. As blood loss continues, she may become confused, restless, anxious, and lethargic.
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7. Management of Hypovolemic Shock
Recognize specific cause
Stop blood loss
Start IV fluids
Monitor vital signs
Provide supplemental oxygen
Insert indwelling Foley catheter
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8. Early Postpartum Hemorrhage
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9. Uterine Atony and Causes
Inability of myometrium muscle to contract and stay contracted around open blood vessels
Mechanical factors include
Retained placental fragments
Large blood clots
Extreme uterine distention (multifetal)
Full urinary bladder
Metabolic factors
Muscle exhaustion due to lactic acid buildup
Hypocalcemia
Drugs
Magnesium sulfate
Calcium channel blockers
Aside from observing for and reporting signs of shock, what else should the nurse observe for? Answer: a soft, boggy uterus that may be above the umbilicus.
What are some of the possible drugs that may be administered to treat early postpartum hemorrhage? Answer: high doses of oxytocin, administration of vitamin K, recombinant activated factor VIIa.
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10. Trauma and Lacerations
Includes vaginal, cervical, and perineal
Suspect when excessive bleeding occurs and uterus is firm
Vaginal bleeding typically bright red
Lochia is dark red, not profuse or continuous
Monitor for signs of shock
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Retained Placenta
Prevents uterus from contracting effectively
Oxytocics given to expel fragments of placenta
May require D&E to remove remaining fragments
Placenta accreta may result in profuse bleeding and may require hysterectomy
What is the term used for a placenta that adheres to the uterine wall? Answer: placenta accreta.
If bleeding cannot be stopped by medication or dilation and evacuation (D&E), what other option is required? Answer: hysterectomy.
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Hematoma
May result from injury to blood vessels in perineum or vagina
If in soft tissue, will typically see bulging, bluish mass
Can contain between 250 and 500 mL of blood
Perineal pain is a distinguishing characteristic
May not be able to void or defecate
Depending on size of hematoma, may require ice packs alternated with heat or may require surgical removal.
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13. Late Postpartum Hemorrhage
Typically a result of subinvolution
Could be caused by a vascular area, retained placental fragments, infection
Fundus may appear higher than expected with persistent lochia rubra
Infection may manifested by a foul odor
Subinvolution can also be caused by ___________. Answer: excessively vigorous massage.
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14. Subinvolution of the Uterus
Occurs when uterus fails to return to its nonpregnant size
May result from
Small retained placental fragment
Mild endometritis
Excessively vigorous massage
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15. Disseminated Intravascular Coagulation (DIC)
Clotting and anticoagulation stimulation occur at the same time
Release of thromboplastin uses up available fibrinogen and platelets
Results in profuse bleeding and intravascular clotting
Often secondary condition associated with
Abruptio placentae
Gestational hypertension
Missed abortion
Fetal demise
Discussed more fully in Chapter 13.
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Signs of DIC
Oozing from IV insertion site
Petechiae
Ecchymosis
Oliguria
Restlessness
In pregnancy and early postpartum, shock is considered late sign of DIC
Why is shock a late sign of DIC? Answer: because the increased blood volume during pregnancy delays evidence of serious blood loss.
A decreasing pulse pressure with continued bleeding may indicate a serious problem and should be reported to the health care provider immediately.
How can DIC be treated? Answer: recombinant activated factor VIIa can reverse symptoms.
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17. Von Willebrand’s Disease
Inherited disorder
Decrease in plasma factor VIII (essential for proper platelet function)
History of easy bruising, frequent nosebleeds, heavy menses
Symptoms may be masked during pregnancy
Hemorrhage from this disease is treated with cryoprecipitate to raise factor VIII levels in the blood
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18. Anaphylactoid Syndrome of Pregnancy
Known as amniotic fluid embolism
Caused by unanticipated entrance of amniotic fluid into maternal circulation
Triggers release of mediators that cause pulmonary artery vasospasm and hypoxia
Can lead to myocardial damage, especially in the left side of the mother’s heart
Mediators are bradykinin, cytokines, prostaglandins, leukotrines, thromboxane, and others.
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19. Prevention of Hemorrhage
Prophylactic administration of uterotonic drugs (oxytocin) after placenta delivered
Early clamping of cord and assisted delivery of placenta
Massage of uterine fundus
Observation for and prevention of bladder distention
What are the signs of uterine atony? Answer: uterine fundus above level of umbilicus; excessive lochia; soft, boggy uterine fundus; or a fundus that is displaced to the right may indicate a distended bladder.
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20. Assessment and Management of Postpartum Hemorrhage
Monitor vital signs, I&O, level of consciousness
Weigh peripads (1 g = 1 mL of blood)
Massage fundus until firm; express clots
Medications may be required to stop the bleeding
See Box 17-2 (p. 346) and Nursing Care Plan 17-1 (pp ).
Review Skill 12-1 in Chapter 12 (p. 227).
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21. Thrombophlebitis and Thromboembolism
Thrombophlebitis: inflammation of inner blood vessel wall with a blood clot attached to it
When clot tears away from vessel wall and moves into blood circulation, it is called a thrombus
If ends up in lungs, it is a pulmonary embolus, a common postpartum complication
See Box 17-3 (p. 349).
All postpartum women are at risk .
Hypercoagulability of bleed at delivery prevents hemorrhage.
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22. Assessment and Nursing Care
Subjective signs of pain on palpation of calves and when foot is passively dorsiflexed
May be indicative of Homans’ sign
Can have a deep vein thrombosis (DVT) in absence of Homans’ sign
Compare pulses and size in both lower extremities
May note increased diameter of 1 leg from edema due to venous inflammation
If pain extends above knee, it is indicative of DVT
See Patient Teaching—Measures to Prevent Thrombophlebitis (p. 349).
CT or magnetic resonance angiography, as well us ultrasound or duplex scan, may show presence of thrombus.
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Management
Superficial venous thrombosis
Rest
Antiembolism stockings
Analgesics for comfort
Elevation of leg
Frequent ambulation to help prevent clots
DVT
Anticoagulation therapy
Monitoring of serum for clotting factors (i.e., PT, PTT, INR)
Teach woman to do early ambulation, avoid prolonged sitting and crossing of legs, elevate legs when possible, and ensure adequate fluid intake; these are all preventive measures.
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Pulmonary Embolism
1 of 3 leading causes of maternal death (others are hemorrhage and gestational hypertension)
Embolism can occlude vessel and obstruct blood flow into lungs
Embolectomy may be required
What are the signs and symptoms?
Immediate nursing interventions include raising head of bed to facilitate breathing, providing supplemental oxygen, and notifying health care provider.
Signs and symptoms
Chills
Hypotension
Dyspnea
Chest pain
Tachypnea and apprehension
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25. Risk Factors for Postpartum Hemorrhage
Risk factors for postpartum hemorrhage include:
Hydramnios
Bladder distention
Macrosomia
Uterine atony
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26. Audience Response System Question 1
This type of embolism can cause significant damage to the heart of a postpartum woman.
Pulmonary fluid
Cerebral
Amniotic fluid
Aortal
Answer: C. Once release into the woman’s blood circulation, it triggers the release of mediators that cause pulmonary artery vasospasm and hypoxia
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27. Puerperal Infections/Depression
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Objectives
List four common sites for puerperal infection.
Describe predisposing factors for infections of the reproductive system.
Discuss the nursing care of a woman who has an infected episiotomy.
Compare postpartum blues with postpartum psychosis.
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Puerperal Sepsis
Puerperal infection (fever)
Bacterial infections arising in genital tract after delivery
Infections other than genital tract
Mastitis
Urinary tract infection
Symptoms include
Fever of 38° C (100.4° F) or higher after first 24 hours following delivery
Fever persisting for at least 2 days within the first 10 days postpartum
See Safety Alert—Signs and Symptoms of Postpartum (Puerperal) Infection (p. 350).
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30. Postpartum (Puerperal) Infection
Associated risk factors
Physiologic changes during pregnancy increase risk
Labor: amniotic fluid, blood, lochia decrease acidity of vagina, thus increasing growth of pathogens; premature rupture of membranes
Most women do not get an infection because of granulocytes in the lochia and endometrium
Prevention
Meticulous adherence to aseptic techniques, hand hygiene, and perineal care
Minimize number of vaginal examinations
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Endometritis
Infection of endometrial lining, decidua, and adjacent myometrium of uterus
Symptoms begin 2nd to 5th day postpartum
Uterine tenderness and enlargement
Foul odor or purulent lochia
Malaise, fatigue, tachycardia
Temperature elevation
Blood cultures and IV antibiotics typically obtained and provided.
Supportive care and rest, including pain relief measures.
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Wound Infection
Common in women with history of chorioamnionitis, intraamniotic infection, hemorrhage, diabetes mellitus, and obesity
Multiple vaginal examinations
Most common sites
Perineum
Cesarean incision site
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33. Assessment and Management
Necrotizing fasciitis is serious complication
Blue discoloration and numbness of wound edges
Aggressive treatment is essential
Patients with chorioamnionitis and endometritis are at risk for septic shock
REEDA
Redness
Edema
Ecchymosis
Discharge
Approximation
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34. Urinary Tract Infection and Pyelonephritis
Can occur after birth from hypotonia of bladder, urinary stasis, birth trauma, catheterization, frequent vaginal examinations, or epidural anesthesia
Symptoms: dysuria, frequency, urgency, and low-grade fever
Pyelonephritis: the above symptoms plus
Costovertebral angle tenderness, chills, fever, malaise, hematuria, nausea, and vomiting
See Box 17-4 (p. 351).
Woman may also experience cystitis, which is treated on an outpatient basis with oral antibiotics.
Nursing care includes vital signs every 4; encouraging increased fluid intake to help dilute bacterial count and flush infection from urinary bladder. Acidification of urine inhibits bacterial growth. Review perineal hygiene. Woman may be given antispasmodic medications too.
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Mastitis
Usually occurs around 2 to 3 weeks after birth
Interlobular connective tissue of 1 breast usually involved
Painful or tender localized hard mass; reddened area
Fever, chills, and malaise
Causes
Milk stasis
Nipple trauma
Poor breastfeeding technique
Inadequate handwashing
Refer to Chapter 11 for correct positioning of infant on breast.
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36. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
Care of Mastitis
Antibiotics
In many cases, can continue to breastfeed from both breasts
Ice or warm packs
Moist heat promotes comfort and increases circulation
Nurse should reinforce with woman how to prevent breast engorgement, breast support, proper hand hygiene, and breastfeeding techniques.
See Patient Teaching—Self-Care for Mastitis (p. 352).
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Postpartum Blues
Transient state; rarely lasts more than 10 to 14 days
May complain of feeling overwhelmed and unable to cope, and may be oversensitive with periods of unexplained tearfulness
Treatment: rest, anticipatory guidance, empathy, reassurance, support, and assistance
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38. Postpartum Depression
Includes general signs of depression such as weight loss, sleeplessness, and ambivalence
Women at high risk
Have unstable or abusive family environment
History of previous depressive episode
History of limited support system
Low self-esteem
Dissatisfaction with education, economics, or partner
Edinburgh Postnatal Depression Scale
Treatment includes counseling and medications.
Symptoms can last for a year; if left untreated, woman may progress to psychosis and suicide.
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Postpartum Psychosis
Similar to other psychoses
Early signs of depression or may start abruptly within 3 weeks following birth
Confusion, restlessness, anxiety, and suicidal thoughts
Delusional thoughts may be expressed
Safety of woman and her newborn are at risk
Psychiatric interventions, including medications
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The Nurse’s Role
Provide support and referral
Encourage woman to express feelings, provide validation, address personal conflicts, and reinforce personal power and autonomy
A woman’s culture, experiences, and coping strategies influence her adjustment to becoming a mother
Above all, listen to what the woman is saying, verbally and with her body language
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Discussion
What type of infection typically begins 2 to 5 days postpartum?
Endometritis
Mastitis
Pyelonephritis
Chorioamnionitis
Answer A: Endometritis presents with uterine tenderness and enlargement; foul odor or purulent lochia; malaise, fatigue, tachycardia; temperature elevation
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Review Key Points
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