MODULE 4: POSTPARTUM COMPLICATIONS

Learning Objectives
By the end of this section, you should be able to identify complications during the postpartum period
and potential nursing interventions required.
Recommended Resources
Review a chapter on maternal postpartum complications during the postpartum period in a current
Maternal Child Nursing Care textbook.

Introduction to Postpartum Complications

During the postpartum period, complications can occur. Comprehensive nursing assessment and
safe competent care can help to decrease potential postpartum complications. This folder will
address complications including:
 Postpartum hemorrhage
 Thromboembolic disorders
 Postpartum infections
 Psychological complications
 Perinatal loss and grief that can occur during the postpartum period
Postpartum Hemorrhage (PPH)
The primary cause of maternal death is postpartum hemorrhage (PPH), which occurs in 5% of
deliveries (Society of Obstetricians and Gynaecologists of Canada, guidelines, Active Management of
the Third Stage of Labour: Prevention and Treatment of Postpartum Hemorrhage).
PPH is defined as excessive bleeding that occurs during the first 24 hours of the postpartum period
(early PPH). However, PPH can occur after the first 24 hours and up to six weeks after birth (late
PPH) (London et. al., 2017 and Perry et. al., 2017). Therefore, continuous assessment is required, as
well as client education regarding signs and symptoms.
Risk factors and causes of PPH include, but are not limited to:
 Uterine atony
 Trauma during delivery
 Retention of placental tissue
 Coagulation disorders
Potential signs of PPH:
 Excessive bleeding
 Boggy fundus
 Abnormally large clots
 Elevated fundus level
 Hematoma in perineal area
 Increased pulse and temperature, decreased BP
 Decreased level of consciousness
Nursing Interventions:
 Active management and ongoing assessment of PPH risk factors, signs and symptoms.
 Take measures to ensure that the placenta is delivered within 30 minutes after birth.
 Periodic assessment of vaginal bleeding. Measure blood loss if it occurs.
 Frequent assessment of fundal height and uterine tone as required.
 Firm massage of uterine fundus if atony occurs.
 Uterine stimulants may be required if massage is not effective.
 Monitor bladder and urine output. Encouraging woman to empty bladder.
 Assess perineal area for hematomas or trauma from birth.
 Monitor for signs and symptoms of hemorrhage or hypovolemic shock.
 Vital signs, circulatory status (i.e. auscultate heart and breath sounds, skin assessment), urine
output, level of consciousness and mental status.
Learning Activity 1
Test Yourself!

1. Which of the following is the priority nursing action for a postpartum hemorrhage?

Please select the correct option and then click the "Check Your Answer" button.

a. Massage the uterus until firm

b. Insert foley to empty bladder
c. Call for help
d. Insert large-bore needle for venous access
That’s correct!

2. Which of the following clients is at highest risk of postpartum hemorrhage?

Please select the correct option and then click the "Check Your Answer" button.

a. An 18 year old, nulliparity, woman who had a quick delivery

b. A 35 year old, multiparity, who had a prolonged labour
c. A 26 year old, multiparity, who received an epidural
d. A 23 year old, nulliparity who delivered twins vaginally
That’s correct!

3. Postpartum hemorrhage rates have decreased due to advancement in technology in

postpartum care.

Please select the correct option and then click the "Check Your Answer" button.

a. True
b. False
That’s correct

Venous Thromboembolic Disorders (VTE)

Venous thromboembolism (VTE) results from blood clots obstructing blood flow in a superficial or
deep vein. Three postpartum thromboembolic disorders include: superficial venous thrombosis, deep
venous thrombosis, and pulmonary embolism (Perry et. al., 2017).
Some example of risk factors and causes of VTE include:
 Venous stasis (from prolonged bed rest or immobility)
 Hypercoagulation or coagulation deficiency
 Cesarean birth
 Trauma during birth
 Varicose veins
 Multiparity
 Personal or family history of VTE disease
 Diabetes
 Advanced maternal age (>35 years)
 Anemia
 Malignancy
 Obesity
 Cigarette smoking
 Potential signs of VTE
 Warm, red, enlarged hardened vein on legs
 Calf tenderness and swelling with pain
 Dyspnea and tachypnea, tachycardia, chest pain and apprehension with pulmonary embolism
 Nursing Interventions:
 Assess for signs of pulmonary embolism
 Emergent treatment required if pulmonary embolism is suspected
 Encourage early ambulation
 Promote activity while on bed rest
 Assess legs for peripheral pulses and skin for edema, colour, temperature, pain
 Encourage fluids
 Use TED stockings or compression device as required
 Educate client about avoiding prolonged sitting, standing, crossing legs and restrictive clothing
 Elevate legs while sitting
 Obtain lab values (i.e. PT, PTT) and diagnostic tests as required
Learning Activity 2
Test Yourself!

1. A pulmonary embolism obstructs blood flow to which part of the body?

Please select the correct option and then click the "Check Your Answer" button.

a. Lower legs
b. Upper arms
c. Lungs
d. Heart
That’s correct!

2. Which medication should not be given to a woman on anticoagulants?

Please select the correct option and then click the "Check Your Answer" button.

a. Tylenol
b. Aspirin
c. Advil
d. Benadryl
That's correct!

3. Which nursing intervention would decrease the risk of thromboembolic disease in

postpartum women?

Please select the correct option and then click the "Check Your Answer" button.

a. Encourage fluids to avoid dehydration

b. Limit mobility to avoid dislodging clots
c. Provide analgesics for pain as needed
d. Encourage bed rest to support flow of blood
That’s correct!

Postpartum Infections
Postpartum infections can vary depending on the site of infection and cause. Common postpartum
infections include: puerperal fever, endometritis, wound infection, mastitis, urinary tract infections, and
respiratory tract infections (London et. al., 2017 and Perry et. al., 2017). Postpartum infections are
most commonly caused by streptococcal and anaerobic organisms.
Some examples of risk factors of postpartum infections include:
 Compromised health status (i.e. concurrent medical or immunosuppressive conditions, poor
nutritional state, obesity, etc.)
 Prolonged labour or ruptured membranes
 Caesarean birth and vaginal episiotomy or lacerations
 Retained placenta tissue
 Chorioamnionitis
 Catheterization
 Multiple internal examinations
Potential signs of postpartum infections (varies according to infection site):
 Presence of fever of > 38 degrees Celsius (100.4 degrees Fahrenheit) on two consecutive
days
 Increased pulse
 Chills
 Nausea
 Fatigue and lethargy
 Pain or tenderness at incision site (i.e Caesarian, laceration repair or episiotomy)
 Foul-smelling vaginal discharge
 Erythema, edema, swelling and warmth at site
 Dysuria, frequency and urgency, urinary retention, hematuria, or pyuria
Nursing Interventions (varies according to infection site):
 Frequent assessment of infection site and vital signs
 Education regarding proper hygiene technique (i.e. hand hygiene, changing perineal pads,
perineal care: wiping front to back, etc.)
 Encourage fluids to avoid dehydration
 Comfort measure depending on site of infection (i.e. sitz bath, warm compresses, analgesics
as required and ordered, etc.)
 Provide information of signs and symptoms of infection and when to contact primary
healthcare provider
 Use aseptic techniques when providing care
 Provide information sheet on postpartum infections prior to discharge

Learning Activity 3
Test Yourself!

1. Which of the following factors increases the risk of mastitis?

Please select the correct option and then click the "Check Your Answer" button.

a. Loose-fitting bra
b. Alternating breasts during feeding
c. Use of plastic-lined breast pads
d. Air-drying breasts after feeding
That’s correct!

2. What should the nurse assess when inspecting a cesarean wound?

Please select the correct option and then click the "Check Your Answer" button.
 a. Pallor, soft and shiny skin texture
b. Ecchymosis, edema, and approximation
c. Cyanosis, discharge, and induration
d. Jaundice, foul smelling discharge, and pain
That’s correct.

3. A preventative measure of postpartum infection includes proper perineal care, which

involves wiping the perineum back to front.

Please select the correct option and then click the "Check Your Answer" button.

a. True
b. False
That’s correct!

Postpartum Psychological Complications

Postpartum psychological complications refers to various perinatal mood disorders including “baby
blues”, anxiety or minor and major depressive episodes, and psychosis that can occur up to 12
months after birth (Perry et. al., 2017). It is important to assess all postpartum women for
psychological complications and educate them and their support people on the signs and symptoms
of psychological complications prior to discharge.
Risk factors of the various postpartum psychological complications include but are not
limited to:
 Previous personal or family mental health history
 Mood disorders during pregnancy (i.e. depression or anxiety)
 Increased stressors during perinatal period
 Lack of social support
 Age (< risk with younger women)
 Discontent with birthing experience or feeding problems
 Preterm or ill newborn
 Death of newborn
Potential signs of postpartum psychological complications (varies according to specific
complication):
 Mood swings
 Anxiety
 Irritability
 Poor concentration
 Tearfulness
 Psychosomatic symptoms (i.e. trembling, nausea, palpitations, dyspnea, etc.)
 Fatigue
 Insomnia or difficulty sleeping
 Change in appetite
 Change in behaviour and interaction with newborn and others
 Inability to care for self or newborn
 Visual or auditory hallucinations
 Suicidal or homicidal ideation
Nursing Interventions (varies according to specific complication):
 Assess for signs of postpartum mood disorders. Incorporate screening tools according to
protocol.
 Encourage the women to talk about her birthing experience, feelings and transition into the
new role.
 Educate the postpartum woman and her support people about signs and symptoms of
psychological complications.
 Teach about the importance of self-care: balanced diet, adequate sleep, exercise, setting
realistic expectations, and seeking out support groups.
 Encourage the postpartum woman to ask for help from family and friends when needed, and to
accept help when offered.
 Provide information sheet and resources related to postpartum psychological complications
prior to discharge.
 Refer to mental health specialist or other interprofessional team members as needed.
Learning Activity 4
Test Yourself!

1. A postpartum woman states she is not sleeping at night, feels restless, is fatigued and
is experiencing visual hallucinations. These are symptoms of which postpartum
psychological complication?

Please select the correct option and then click the "Check Your Answer" button.

a. Postpartum anxiety disorder

b. Postpartum psychosis
c. Postpartum mood disorder
d. Postpartum depression
That’s correct!

2. Mother-infant attachment issues are a complication of perinatal mood disorders.

Please select the correct option and then click the "Check Your Answer" button.

a. True
b. False
That is correct!

3. Approximately 80% of postpartum women experience “baby blues” after birth.

Please select the correct option and then click the "Check Your Answer" button.

a. True
b. False
That is correct! (Perry et al., 2017, p.621)

Perinatal Loss and Grief

Perinatal loss and grief is individualized to the person experiencing the loss. It can refer to perception
of the birthing experience, the birth of a newborn that was not expected (e.g. gender, physical
appearance, congenital anomaly) or death of the mother or newborn. The nurse’s role is to provide
genuine, empathetic care to the mother and/or family and provide support through the grieving
process.
Newborn death can be the result of:
 Birth defects (i.e congenital malformation, deformation and chromosomal abnormalities)
 Prematurity, short gestation and low birth weight
 Effects of maternal complication of pregnancy
 Birth trauma
 Acute illness
 Sudden infant death syndrome (SIDS)
Maternal death can be the result of:
 Disease of the circulatory system
 Obstetric embolism
 Hypertension
 Postpartum hemorrhage
 Puerperal infections

Nursing Interventions:
 Support is individualized to the client (and family), specifically depending on stage of the
grieving process.
 Use therapeutic communication to encourage client(s) to express their feelings and experience
with the loss.
 Support client(s) in the decision-making process, incorporating spiritual and cultural values,
beliefs, communication, and practices.
 Allow the opportunity for the mother (and family) to see, hold, care for and/or name the
newborn. It is an individualized decision that should not be pressured. If chosen, the nurse needs
to explain what to expect and support the mother/family during the process. Offer time alone, if
requested.
 Ask if the mother/family would like mementos of the newborn. For example, card with birth
information (i.e. date, weight and height) and hand or foot imprint.
 Provide bereavement support resources to the mother/family prior to discharge.
 With maternal death, support the family with grieving, decision-making process, and new
perspective of role and family.

Learning Activity 5
Test Yourself!

1. Which of the following factors increase the risk of maternal death?

Please select the correct option and then click the "Check Your Answer" button.

a. Multiple gestations
b. Prolonged labour
c. Cesarean section delivery
d. A maternal age of 40 years and older
That’s correct! For 1996/97-2010/11, women 40 years and older had 3.6 (95% CI: 2.1-6.0) times
the rate experienced by women aged 20-24 years (Public Health Agency of Canada: Maternal
Mortality in Canada, Table 4).

2. Maternal complication during pregnancy is the leading cause of newborn deaths.

Please select the correct option and then click the "Check Your Answer" button.

a. True
b. False
That’s correct! It is congenital malformation, deformations, and chromosomal abnormalities
(Statistics Canada: Leading causes of death, infants, by sex, Canada)

Summary
Thorough assessments can help nurses to identify postpartum risk factors, as well as signs and
symptoms of potential complications during the postpartum period.  If complications occur, it is
important for nurses to provide safe, efficient care and support the mother, newborn and family.