1. Complications Of Postpartum1

2. Postpartum
Hemorrhage

3. 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
1. There are various ways to describe postpartum hemorrhage.
a. Differentiate between early and late postpartal hemorrhage.
b. The traditional definition of postpartal hemorrhage has been a loss of more than
_____ ml. of blood following a vaginal birth and more than _______ml. after a
cesarean birth. 2

4. Postpartum Hemorrhage
Other definitions:
A decrease in the hematocrit of 10 points between time of admission and time postbirth
Need for fluid replacement following childbirth
c. This definition is currently being questioned. What other factors could be used to
define postpartal hemorrhage?

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

6. vessels of the placental site.
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. 4

7. Uterine Atony Predisposing Factors
Prolonged
labor
Overdistention
of the
Uterus
Trauma due
to Obstetrical
Procedures
Grandmultiparity
Intrapartum
Stimulation
with Pitocin
What are the predisposing / contributing factors leading to uterine atony? (Be able to explain why)
See Box 28-1 on page 697 for additional predisposing factors.
Excessive use of
Analgesia / Anesthesia 5

8. 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.

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

10. Nursing Care Assess and Document Bleeding
Fundal massage and express clots
Bimanual Compression
Assess Vital Signs (shock)
3. What treatment and nursing care measures are utilized in restoring health for the client
with uterine atony? 7

11. (May inject the medications directly
Nursing Care
Give medications
Pitocin
Methergine
Carboprost Tromethamine (Hemabate)
(May inject the medications directly
into the uterus)
Replace blood / fluids
D & C, Hysterectomy

12. Trauma

13. Post Partum Hemorrhage *Lacerations*
PREDISPOSING FACTORS
1. Spontaneous or Precipitous delivery
2. Size, Presentation, and Position of baby
3. Contracted Pelvis
4. Vulvar, perineal, 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
4. What are the signs and symptoms, treatment and nursing care for the client with lacerations? 8

14. 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
4. What are the signs and symptoms, treatment and nursing care for the client with lacerations? 9

15. 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?
Answer: feel the fundus- if firm
5. During assessment of a postpartum client, the nurse finds the woman lying in a pool of blood. How would the nurse determine if it is due to uterine atony or lacerations? 10

16. Hematoma *A unit or more of blood may
Bleeding into the soft tissues surrounding
the episiotomy or laceration.
May follow forceps or vacuum extraction
*A unit or more of blood may
be in the hematoma 19

17. 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.
8. What is the most distinguishing symptom of a hematoma? How many ml. can be in a hematoma?
9. How is a hematoma treated?

18. 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 / pressure applied to the fundus, when the uterus is flaccid
**Don’t use the fundus to “push the placenta out”
10. What is the contributing factor leading to the uterus inverting after delivery? (What is the normal amount of time for the placenta to detach from the uterine wall?) 12

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

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

21. 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
11. How is uterine inversion treated?
12. What is one of the most important things to convey following treatment for an inverted uterus? 15

22. Placenta Accreta
All or part of the decidua basalis is absent and the Placenta grows directly into the uterine muscle.
13. What is placenta accreta? How is this diagnosed? 16

23. 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
Removal of the uterus Hysterectomy
13.How is placenta accreta diagnosed? 17

24. If large portion is attached--a Hysterectomy is necessary!
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

25. Late Postpartum
Hemorrhage

26. Late Postpartum Hemorrhage
Most common cause is Retained Placental fragments
Sub involution
Treatment
D & C
Methergine 20

27. 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
6. What are the signs and symptoms of retained placental fragments?
 7. What is the treatment and nursing care for retained placental fragments? 11

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

29. Review Early Signs of Hemorrhage
An uncontracted uterus – boggy
Large gush, steady trickle, oozing, or seeping of blood from the vagina
Saturation of more than one pad in 15 minutes
Severe unrelieved perineal or rectal pain
Tachycardia

30. Review Hypovolemic Shock
Signs
Tachycardia
Drop in B/P
Narrowing of pulse pressure
Tachypnea
Skin becomes pale and cool and can progress to cold and clammy
Becomes anxious  confused lethargic
Urinary output decreases
Treatment
Blood/Fluid replacements, oxygen, surgery

31. Thromboembolic Disorder
Predisposing Factors
Slowing of blood in the legs
Trauma to the veins
Hypercoagulation
Signs and Symptoms
Sudden onset of pain
Tenderness of the calf
Reddness and an increase in skin temperature
Positive Homan’s Sign
31.In the past, you have learned that thromboembolic disorders were mainly due to immobility. Since the postpartum woman is
not immobile, what are the causes of a thromboembolic disorder? 39

32. Thromboembolic Disease
Treatment
Heparin --it does not cross into breast milk
Antidote: protamine sulfate
Teach patient to report any unusual bleeding, or petchiae, bleeding gums, hematuria, epistasis, etc.
Complication
Pulmonary Emboli
32. What is the treatment and nursing care for the woman with a thromboembolic disease?

33. When a postpartum patient Complains of chest pain or severe dyspnea
Respond quickly
Usually sign of Pulmonary Emboli

34. Puerperal
Infection

35. Puerperal 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

36. Puerperal 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

37. Critical to Remember Signs and Symptoms of Puerperal 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
16. The main causative organism for a puerperal infection is _____________________.
17. The classic definition for a puerperal infection established by the Joint Committee on Maternal Welfare is a temperature of ______0F or higher, with the temperature occurring on any ____ of the first ____ postpartum days, exclusive of the first ___ hours . 24

38. PUERPERAL 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
19. What are additional signs and symptoms of a puerperal infection / endometritis?
 20.Describe the treatment and nursing care for the woman with a puerperal infection. 25

39. Test Yourself ! What is the classic sign of a Puerperal Infection?
Answer: Temperature increase of or higher on any 2 consecutive days of the first 10 days post-partum, not including the first 24 hours. 26

40. Complications of Puerperal 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
21. There are two main complications associated with puerperal infections which are pelvic ___________________ and _____________________________. What are signs and
symptoms? 27

41. 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
22. List important concepts to be included in client-teaching to promote health and prevent development of a puerperal infection?

42. Wound Infection
Infection of the Episiotomy, Perineal laceration, Vaginal or vulva lacerations
Wound infection of Cesarean incision site
Signs:
Reddened, edematous, firm, tender edges of skin
Edges separate and purulent material drains from the wound.
Treatment
Antibiotics
Wound care
23. A postpartum woman has all the classic signs of a puerperal infection. How would the nurse distinguish if it was endometritis or an infected perineal or cesarean wound infection? 29

43. Check Yourself and Mrs. Y. was admitted with an infection
Mrs. X. was admitted with endometritis
and Mrs. Y. was admitted with an infection
in her cesarean incision. Are both classified
as a Puerperal Infection?
Answer: yes
What would be the major difference in
presenting symptoms you would note on
nursing assessment?
Answer: foul smelling lochia 30

44. Puerperal Cystitis Prevention:
Monitor the patients urination diligently!
Don’t allow to go longer than hours before intervening.
Treatment
Antibiotics -- Ampicillin
Urinary Tract Antispasmotics
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
24. A common problem in postpartum is the Risk for urinary tract infection due to overdistention of the bladder and trauma to the bladder.
What health promotion and maintenance measures could the nurse implement to decrease the chance of the woman developing this
infection? 38

45. 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
25. Match the following types of mastitis: 31

46. Nipple Trauma Pain Impaired Engorgement Let down
Cracked Stasis
nipples of milk
26. There are several factors associated with the development of Mastitis. Provide health promotion and health maintenance measures
for each of the contributing factors.
Entry for Bacteria Plugged ducts
Mastitis
Treatment, No Treatment
Problem will resolve Breast Abscess 32

47. Mastitis Marked Engorgement Pain Chills, Fever, Tachycardia
Hardness and Redness
Enlarged and tender
lymph nodes
27. What are the signs and symptoms displayed by the woman? 33

48. Treatment of Mastitis Rest
Appropriate Antibiotics--Usually Cephalosporins
Hot and / or Cold Packs
Don’t Stop 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
28. Why should the woman with mastitis NOT discontinue breast feeding? 34

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

50. Complication of Mastitis
Breast Abscess
Breast Feeding is stopped on the affected side, but may feed on the unaffected side.
Treatment: Incision and Drainage
29. If the woman with mastitis does not get appropriate treatment, the condition can worsen into a breast abscess. What is different in
diagnosing breast abscess from mastitis?
The woman with a breast abscess is treated with an I&D (incision and drainage) procedure. Explain this procedure and the related
nursing care. 36

51. Test Yourself The major causative organism of mastitis is
_________________________.
Mastitis develops mainly in ______________ who are nursing .
It is almost always ________________ and develops well
after the flow of milk has been established.
There are two types of mastitis. One that develops between
the lobes of the breast is called____________________.
The one that developswithin the lobes and ducts of the
breast is called __________________.
Mammary cellulitis mainly develops due to _______________.
Mammary adenitis develops when ____________________
of the breasts occurs. With improper treatment or no
treatment, mastitis can lead to ________________. 37

52. Puerperal Psychiatric
Disorders

53. Mood Disorders The Most common Mood Disorders are:
Postpartum Depression
Postpartum Psychosis

54. Postpartum Depression
Predisposing Factors:
Primiparity
Ambivalence about the pregnancy
History of Depression
Environmental and Family Stress issues
Dissatisfaction with herself
33. What are the risk factors associated with postpartum depression?

55. Postpartum Depression
Assessment
Persistent lack of interest or energy, loss of usual emotional response toward her spouse or family
Obsessive thoughts of failure as mother, incompetent, inadequate parent
Anxiety, Irritability
Forgetfulness; Inability to follow directions
Anorexia
Persistent Sleeplessness
Poor personal Hygiene
Feelings of unworthiness 41

56. Postpartum Depression
Creates strain on the family
Family members may decrease their interactions with the depressed woman when she needs support the most.
Infants of depressed mothers tend to be fussier and more discontented. They show fewer positive facial expressions.

57. Nursing Care Antidepressant Drugs a. SSRI Prozac, Paxil, Zoloft
b. Cyclic compounds
Tofranil, Asendin, Norpramin, Sinequan
c. MAO Inhibitors
Nardil, Parnate
d. Other:
Wellbutrin, Effexor, Desyril
e. Lithium, Depakene, Tegretol for bipolar
disorder 42

58. Treatment for Depression
Psychotherapy
Encourage communication with her husband or support person who is available to provide support when loneliness or anxiety becomes a problem
Explain importance of good nutrition and rest
35. What is the treatment and nursing care for the woman with depression and for the woman with psychosis including prevention strategies?

59. Treatment and Nursing Care
Discuss changes that normally occur in the beginning weeks after taking a baby home
Although some of her feelings may seem “unreasonable”, she should acknowledge these feelings to herself and insist that others acknowledge them too.
Re-introduce the baby to the mother at the mother own pace

60. Convey a caring attitude
This helps mothers decrease their emotional distress and guide them in regaining their
well-being

61. Postpartum Psychosis SCHIZOPHRENIA
Far less common
May surface when the mother does not have the ability to adjust to and cope with her new obligations as a mother
Affects mostly adolescents and younger adults

62. Schizophrenia Signs and Symptoms Irritability, Hyperactivity
Insomnia; Exhibit little need for sleep
Mood lability
Hostility toward spouse is obvious
Overly Suspicious, seldom aware they have a problem
Often believe hers to have been an immaculate conception
Abandons reality, totally neglects her infant
May have delusions and erroneously belief that baby is dead, malformed or severely ill; hallucinations 43

63. Treatment and Nursing Care
Remove the baby from the situation
Hospitalization
Antipsychotic Medications
Stelazine, Clozaril, Risperdal, Haldol, Navane
When she is better, then bring the baby back for short visits at first. Give praise for small tasks that the mother can accomplish with the baby. 44

64. Review
What is the time difference between early and late postpartum hemorrhage?
What is the most common cause of postpartum hemorrhage?
How will the nurse recognize uterine atony?
What is the FIRST nursing action if uterine atony is discovered?
What would the nurse suspect if the placenta fails to release from the uterine wall after delivery?

65. 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?

66. The End 45