NCMA 217: CARE OF THE MOTHER, CHILD, & ADOLESCENT (WELL CLIENT)
MIDTERM REVIEWER
1ST SEMESTER WEEK 7-11
Week 11: Post-partum Complications
STUDY GUIDE
Although the puerperium is usually a period of health,
complications can occur. When they do, immediate
intervention is essential to prevent long-term disability
and interference with parent–child relationships.
A woman with a postpartal complication is at risk from
three points of view: her own health, her future
childbearing potential, and her ability to bond with her
new infant.
POST PARTUM COMPLICATIONS
POSTPARTAL HEMORRHAGE
Hemorrhage, one of the most important causes of
maternal mortality associated with childbearing, poses a
possible threat throughout pregnancy and is also a major
potential danger in the immediate postpartal period.
• Postpartal hemorrhage has been defined as any
blood loss from the uterus greater than 500 mL
within a 24-hour period (Pavone, Purinton, &
Petersen, 2007).
• In specific agencies, the loss may not be
considered hemorrhage until it reaches 1000
mL.
Hemorrhage may occur either early (within the first 24
hours) or late (anytime after the first 24 hours during the
remaining days of the 6-week puerperium).
• The greatest danger of hemorrhage is in the first
24 hours because of the grossly denuded and
unprotected uterine area left after detachment of
the placenta.
There are five main causes for postpartal hemorrhage:
uterine atony, lacerations, retained placental fragments,
uterine inversion, and disseminated intravascular
coagulation.
UTERINE ATONY
Uterine atony, or relaxation of the uterus, is the most
frequent cause of postpartal hemorrhage (Poggi, 2007).
The uterus must remain in a contracted state after birth
to keep the open vessels at the placental site from
bleeding.
If the uterus suddenly relaxes, there will be an abrupt
gush of blood vaginally from the placental site. If the
vaginal bleeding is extremely copious, a woman will
exhibit symptoms of shock and blood loss.
This can occur immediately after birth or more gradually,
over the first postpartum hour, as the uterus slowly
becomes uncontracted.
It is difficult to estimate the amount of blood a postpartal
woman has lost, because it is difficult to estimate the
amount of blood it takes to saturate a perineal pad. The
amount is between 25 and 50 mL.
2ND YEAR NURSING
• By counting the number of perineal pads
saturated in given lengths of time such as half-
hour intervals, you can form a rough estimate of
blood loss. Five pads saturated in half an hour is
obviously a different situation from five pads
saturated in 8 hours.
Weighing perineal pads before and after use and then
subtracting the difference is an accurate way to measure
vaginal discharge: 1 g of weight is comparable to 1 mL
of blood volume.
Palpate a woman’s fundus at frequent intervals
postpartally to be certain that her uterus is remaining in
a state of contraction. This is the best measure for
preventing early hemorrhage.
Factors that predispose to poor uterine tone or any
inability to maintain a contracted state are:
• Labor initiated or assisted with an oxytocin agent
• Maternal age greater than 35 years
• High parity
• Previous uterine surgery
• Prolonged and difficult labor
• Possible chorioamnionitis Secondary maternal
illness (e.g., anemia)
• Prior history of postpartum hemorrhage
Endometritis
• Prolonged use of magnesium sulfate or other
tocolytic therapy
THERAPEUTIC MANAGEMENT:
• BIMANUAL MASSAGE
o If fundal massage and administration of
oxytocin or methylergonovine are not
effective in stopping uterine bleeding, a
sonogram may be done to detect
possible retained placental fragments.
o The woman’s physician or nurse-
midwife may attempt bimanual
compression. With this procedure, the
physician or nurse-midwife inserts one
hand into a woman’s vagina while
pushing against the fundus through the
abdominal wall with the other hand.
• PROSTAGLANDIN ADMINISTRATION
o Prostaglandins promote strong,
sustained uterine contractions.
Intramuscular injection of prostaglandin
F22 is another way to initiate uterine
contractions.
o Carboprost tromethamine
o (Hemabate), a prostaglandin F2a
derivative, or methylergonovine
maleate (Methergine), an ergot
compound, given intramuscularly, are
second possibilities. Rectal
misoprostol, a prostaglandin E1
analogue, may be administered
rectally. Hemabate may be repeated
 every 15 to 90 minutes up to 8 doses;
methylergonovine may be repeated
every 2 to 4 hours up to 5 doses.
o The usual dosage of oxytocin is 10 to
40 U per 1000 mL of a Ringer’s lactate
solution. When oxytocin is given
intravenously, its action is immediate
• BLOOD REPLACEMENT
o Blood transfusion to replace blood loss
with postpartal hemorrhage may be
necessary. Make certain that blood
typing and cross-matching were done
when the woman was admitted and
that blood is available.
o Women who experience postpartal
hemorrhage tend to have a longer than
average recovery period, because the
physiologic exhaustion of body
systems can interfere with their
recovery. Iron therapy may be
prescribed to ensure good hemoglobin
formation.
o Activity level, exertion,and postpartal
exercise may be restricted somewhat.
o Monitor her temperature closely in the
postpartal period, to detect the earliest
signs of developing infection.
• HYSTERECTOMY OR SUTURING
o Usually, therapeutic management is
effective in halting bleeding. In the rare
instance of extreme uterine atony,
sutures or balloon compression may be
used to halt bleeding (Nelson &
O’Brien, 2007).
o Embolization of pelvic and uterine
vessels by angiographic techniques
may be successful. As a last resort,
ligation of the uterine arteries or a
hysterectomy may be necessary.
o Open lines of communication between
the couple and health care providers
that allow a family to vent its feelings
are most helpful to a couple in this
crisis.
LACERATIONS
Small lacerations or tears of the birth canal are common
and may be considered a normal consequence of
childbearing. Large lacerations, however, can cause
complications. They occur most often:
• With difficult or precipitate births
• In primigravidas
• With the birth of a large infant (9 lb)
• With the use of a lithotomy position and
instruments
CERVICAL LACERATIONS
Lacerations of the cervix are usually found on the sides
of the cervix, near the branches of the uterine artery. If
the artery is torn, the blood loss may be so great that
blood gushes from the vaginal opening. Because this is
arterial bleeding, it is brighter red than the venous blood
lost with uterine atony.
Therapeutic Management:
• Repair of a cervical laceration is difficult,
because the bleeding can be so intense that it
obstructs visualization of the area. Be certain
that a physician or nurse-midwife has adequate
space to work, adequate sponges and suture
supplies, and a good light source.
• If the cervical laceration appears to be extensive
or difficult to repair, it may be necessary for the
woman to be given a regional anesthetic to relax
the uterine muscle and to prevent pain
VAGINAL LACERATIONS
Although they are rare, lacerations can also occur in the
vagina. They are easier to assess than cervical
lacerations, because they are easier to view.
Therapeutic Management:
• Because vaginal tissue is friable, vaginal
lacerations are also hard to repair. Some oozing
often occurs after a repair, so the vagina may be
packed to maintain pressure on the suture line.
If packing is inserted, document in a woman’s
nursing care plan when and where it was placed,
so you can be certain it will be removed after 24
to 48 hours or before discharge.
• An indwelling urinary catheter (Foley catheter)
may be placed at the same time, because the
packing causes pressure on the urethra and can
interfere with voiding.
PERINEAL LACERATIONS
Lacerations of the perineum usually occur when a
woman is placed in a lithotomy position for birth,
because this position increases tension on the perineum.
Therapeutic Management:
• Perineal lacerations are sutured and treated as
an episiotomy repair. Make certain that the
degree of the laceration is documented,
because women with fourthdegree lacerations
need extra precautions to avoid having repair
sutures loosened or infected.
• A diet high in fluid and a stool softener may be
prescribed for the first week after birth to prevent
 constipation and hard stools, which could break
the sutures.
• Any woman who has a third- or fourth-degree
laceration should not have an enema or a rectal
suppository prescribed or have her temperature
taken rectally, because the hard tips of
equipment could open sutures near to or
including those of the rectal sphincter
RETAINED PLACENTAL FRAGMENTS
Occasionally, a placenta does not deliver in its entirety;
fragments of it separate and are left behind. Because the
portion retained keeps the uterus from contracting fully,
uterine bleeding occurs.
• To detect the complication of retained placenta,
every placenta should be inspected carefully
after birth to see that it is complete.
Retained placental fragments may also be detected by
ultrasound. A blood serum sample that contains human
chorionic gonadotropin hormone (hCG) also reveals that
part of a placenta is still present.
Therapeutic Management:
• Removal of the retained placental fragment is
necessary to stop the bleeding. Usually, a is related to hormonal shifts as the levels of
dilatation and curettage (D&C) is performed to
remove the placental fragment.
o Methotrexate may be prescribed to
destroy the retained placental tissue
UTERINE INVERSION
Uterine inversion is prolapse of the fundus of the uterus
through the cervix so that the uterus turns inside out.
This usually occurs immediately after birth.
DISSEMINATED INTRAVASCULAR
COAGULATION
Disseminated intravascular coagulation (DIC) is a
deficiency in clotting ability caused by vascular injury. It
may occur in any woman in the postpartal period, but it
is usually associated with premature separation of the
placenta, a missed early miscarriage, or fetal death in
utero.
SUBINVOLUTION
is incomplete return of the uterus to its prepregnant size
and shape. With subinvolution, at a 4- or 6week
postpartal visit, the uterus is still enlarged and soft.
Lochial discharge usually is still present.
Subinvolution may result from a small retained placental
fragment, a mild endometritis (infection of the
endometrium), or an accompanying problem such as a
uterine myoma that is interfering with complete
contraction.
Therapeutic Management:
• Oral administration of methylergonovine, 0.2
mg four times daily, usually is prescribed to
improve uterine tone and complete involution. If
the uterus is tender to palpation, suggesting
endometritis, an oral antibiotic also will be
prescribed.
MASTITIS
Mastitis (infection of the breast) may occur as early as
the seventh postpartal day or not until the baby is weeks
or months old (Reddy et al., 2007).
The organism causing the infection usually enters
through cracked and fissured nipples.
Therapeutic Management:
• Treatment consists of antibiotics.
• Breastfeeding is continued, because keeping
the breast emptied of milk helps to prevent
growth of bacteria.
EMOTIONAL AND PSYCHOLOGICAL
COMPLICATIONS
A Woman Whose Child Is Born with an Illness or Is
Physically Challenged
Most women say during pregnancy they do not care
about the sex of their child so long as the child is born
healthy. This can make them feel cheated when this one
requirement is not met. They can feel angry, hurt, and
disappointed. They may feel a loss of self-esteem: they
have given birth to an imperfect child, and so they see
themselves as imperfect.
POSTPARTAL DEPRESSION
Almost every woman notices some immediate (1 to 10
days postpartum) feelings of sadness (postpartal
“blues”) after childbirth.
• This probably occurs as a response to the
anticlimactic feeling after birth and also probably
estrogen, progesterone, and gonadotropin-
releasing hormone in her body decline or rise
(Baker, 2008).
The sensations of overwhelming sadness can interfere
with breastfeeding, child care, and returning to work. In
addition to an overall feeling of sadness, a woman may
notice extreme fatigue, an inability to stop crying,
increased anxiety about her own or her infant’s health,
insecurity (unwillingness to be left alone or inability to
make decisions), psychosomatic symptoms (nausea and
vomiting, diarrhea), and either depressive or manic
mood fluctuations.
Depression of this kind is termed postpartal depression
and reflects a more serious problem than normal “baby
blues”
• Risk factors for postpartal depression include a
history of depression, a troubled childhood, low
self-esteem, stress in the home or at work, and
lack of effective support people.
A woman may need counseling and possibly
antidepressant therapy to integrate the experience of
childbirth into her life
POSTPARTAL PSYCHOSIS
A woman with postpartal psychosis usually appears
exceptionally sad. By definition, psychosis exists when a
person has lost contact with reality. A psychosis is a
severe mental illness that requires referral to a
professional psychiatric counselor and antipsychotic
medication.
A woman with a postpartal psychosis may deny that she
has had a child and, when the child is brought to her,
insist that she was never pregnant.
A psychosis is a severe mental illness that requires
referral to a professional psychiatric counselor and
antipsychotic medication.
While waiting for such a skilled professional to arrive, do
not leave the woman alone, because her distorted
perception might lead her to harm herself. Nor should
you leave her alone with her infant.
 TERMINOLOGIES
HEMORRHAGE – loss of blood greater than 500 mL
within a 24-hour period

HYSTERECTOMY – Is an operation to remove a

woman's uterus.

LACERATION – a deep cut or tear in skin or flesh.