Common

Postpartum
Complications
LACERATION
S
 LACERATION
Vaginal : S
anterior
posterior
lateral wall
Perineal:
first degree – skin
second degree – muscles
third degree – external anal sphincter
fourth degree – rectal sphincter and
rectal mucus membrane
Cervical:
lateral
 SIGNS AND SYMPTOMS OF FACTORS CAUSING
LACERATIONS LACERATIONS:

Firm and Contracted Precipitate labor

Uterus Dystocia
Malpresentation
Bright red Bleeding Large babies
Instrumentation
Tear in the birth canal, Lithotomy position
and perineum Rapid cervical dilatation
Primigravida
MANAGEMENT OF MEDICAL
LACERATIONS MANAGEMENT

Surgical Repair Vaginal pack

Cessation of bleeding Analgesics

Prevent Infection Antibiotics

Alleviate pain Stool softener

SURGICAL MANAGEMENT OF
LACERATIONS

Surgical Repair

Regional anesthesia
 NURSING DIAGNOSIS AND
MANAGEMENT OF LACERATIONS
Alteration in Comfort; Pain

> cold compress on the perineum

>perineal douch
> high fiber diet
> increase OFI
> NSAIDS as ordered
Potential for infection

> perineal douche

> pat dry the perineum
> frequent change of gowns and
perineal pads
> proper nutrition
> increased OFI
> prophylactic antibiotic as
ordered
HEMATOMA
 HEMATOMA
SIGNS AND SYMPTOMS OF HEMATOMA

severe perineal and pelvic pain not

relieved by analgesia
bluish bulging under the skin
tenderness
firm to palpate
minor bleeding
 FACTORS CAUSING
HEMATOMA
Rapid Spontaneous birth

Varicosities

Episiorrhaphy

Lacerations
MANAGEMENT OF HEMATOMAS
MEDICAL MANAGEMENT:
Analgesics
Cold Compress

SURGICAL MANAGEMENT:
Incision and drainage
Removal of sutures
Packing
Ligation of vessels
 NURSING DIAGNOSIS AND
INTERVENTIONS
Alteration in comfort; Pain

> proper referral

> ice pack application on the
perineum
> analgesics as ordered
> assist for surgical
intervention
 UTERINE
inversion
 UTERINE INVERSION
FACTORS CAUSING UTERINE INVERSION
SIGNS AND SYMPTOMS:

Visualization of protruded uterus Pulling the umbilical cord before

placental separation
Sudden gush of large amount of blood
Extreme pushing of the fundus

Hypovolemic shock after 10 minutes Fundal implantation of the placenta

GOAL OF CARE OF UTERINE INVERSION

Prevent Hemorrhage

Johnson’s Maneuver

Prevent Shock

Prevent Infection

Prevent Death
 MEDICAL SURGICAL
MANAGEMENT MANAGEMENT
Initially:
Tocolytic Johnson’s Maneuver
General anesthesia
Nitroglycerin patch Surgical Replacement

Hysterectomy
Oxytoxic agents
Double intravenous fluid Laparotomy
Oxygen administration
Ready for CPR General Anesthesia
Antibiotics
Blood Transfusion
 NURSING DIAGNOSIS AND
INTERVENTION

Fluid Volume Deficit

Altered Cardiac Output
Altered Tissue Perfusion

Determine the degree of inversion

Assess VS, NVS, and CRT
Evaluate blood loss
Use large needles/canula for intravenous fluid
Regulate IVF and BT as ordered
Administer oxygen by face mask
 Anxiety
Risk for infection
Emotional support
Stay with the client Aseptic technique
Listen Administer prophylactic
Give factual antibiotics
informations
 LATE
POSTPARTUM
HEMORRHAGE

Retained Placental
Fragments

Subinvolution

Endometritis
RETAINED PLACENTAL FRAGMENTS
Signs and Symptoms:
Incomplete placental delivery

Uterus remains large

Bright red bleeding

+ HCG in the blood

+ ultrasound result
 MEDICAL MANAGEMENT OF RETAINED
FACTORS CAUSING RETAINED
PLACENTA
PLACENTAL FRAGMENTS
Oxytocin administration
Failure to inspect after
Maleate intramuscular
placental delivery
Methotrexate
Placenta accreta
IVF

SURGICAL MANAGEMENT OR RETAINED PLACENTA

Dilatation and Curettage

Hysterectomy
NURSING DIAGNOSIS AND MANAGEMENT

Fluid Volume Deficit

Decreased cardiac Output

Altered Tissue Perfusion

Risk for infection

Anxiety
 MEDICAL MANAGEMENT OF UTERINE SUBINVOLUTION
SUBINVOLUTION OF THE Oxytocin
UTERUS M. Maleate

Signs and Symptoms: IVF

Uterus remains large

SURGICAL MANAGEMENT OF UTERINE
SUBINVOLUTION
Lochia is profused
Hysterectomy
Altered pattern of lochia
NURSING DIAGNOSIS AND MANAGEMENT
Fluid Volume Deficit

FACTORS CAUSING UTERINE SUBINVOLUTION Altered Cardiac Output

Altered Tissue Perfusion

Retained Placental fragments
Alteration in thermoregulation; hyperthermia
Endometritis
Anxiety
Uterine Myoma
Fear
 DISSEMINATED INTRAVASCULAR FACTORS CAUSING DIC
COAGULATION
PIH

Signs and Symptoms: Abruptio Placenta

Mild oozing of venipuncture site
Incomplete Abortion
Petechiae
Septic Abortion

Prolonged retention of dead fetus

GOAL OF MANAGEMENT OF DIC
Amniotic fluid Embolism
Treat underlying conditions Hypertonic labor

Stop Clotting Sepsis

Restore normal clotting

functions
DISSEMINATED INTRAVASCULAR
COAGULATION
 NURSING DIAGNOSIS AND
MEDICAL MANAGEMENT OF DIC
INTERVENTIONS
Heparin Actual/Potential Fluid Volume Deficit

Blood Replacement Frequent monitoring

Evaluate blood loss

Fresh Frozen Plasma
Gentle handling of patient
Platelet Replacement
Frequent turning to sides

Gentle mouth care

Puerperal
infection
 PUERPERAL INFECTION
Infection of the genital tract during
postpartum
 TYPES OF INFECTION

Infection of the Perineum

Endometritis

Peritonitis

Mastitis
Endometritis
= an infection of the inner lining
(endometrium) of the uterus

= bacteria may gain access from the

vagina into the uterus maybe during
delivery process
Signs and Symptoms of Endometritis

> fever for 2 consecutive 24 hours usually on the 3 rd

or 4th day excluding the first 24 hours
postpartum
> chills
> lost of appetite
> general malaise
> abdominal tenderness
> uterine atony
> strong afterpains
> dark brown foul smelling lochia
Management of Endometritis

> antibiotics
> oxytoxic
> analgesics
> antipyretics
Infection of the Perineum

= very rare because of improved

aseptic technique
= occurs at the suture line or repair of
lacerations
Signs and Symptoms of Infection of the
Perineum

> pain on the perineum

> swelling
> heat
> pressure on the perineum
> one or two stitches slough off
> purulent discharges from
suture line
> may be afebrile unless systemic
Management of the Infection of the Perineum
> systemic or topical antibiotics
> analgesics
> hot sitz bath
> warm compress
> perineal sutures may be removed to allow drainage
> packing with gauge
 PERITONITIS
= an infection of the peritoneal cavity

= usually an extension of endometritis

= gravest of postpartum complications

= common cause of mortality death from

puerperal infection
Signs and Symptoms of Peritonitis

> rigid abdomen with guarding behavior

> abdominal pain
> high fever
> rapid pulse
> vomiting
> appearance of acutely ill
Management of Peritonitis
> large dose of antibiotics
> NGT to relieve vomiting and rest the bowel
> IVF
> parenteral feeding
> analgesics
> antipyretics
MASTITI
S
MASTITIS ?

= infection of the breast tissues

= occurs as early as 7 days postpartum or not until the

baby is weeks or months of age

= etiology:
Staphylococcus Cracked nipples
Streptococcus Clogged ducts
Eschericia Bruises of the breasts
Signs and Symptoms of Mastitis
> localized pain, swelling, and redness
> fever
> body malaise
> rapid pulse
> scanty breast milk
Management of Mastitis

> broad spectrum antibiotics

> analgesics
> antipyretics
> warm or cold compress
> supportive bra
> constant emptying
> incision and drainage
 Nursing Diagnosis of
Puerperal Infection

* Actual/potential for infection

* Alteration in thermoregulation;
hyperthermia
* Alteration in comfort; pain
* Social Isolation
Thrombophlebitis
= It is the inflammation of the
lining of the vessel in which a
clot attaches to the vessel wall.

= may not appear until 10-20 days

after delivery
three major causes:

> venous stasis

> hypercoagulability

> damage of the intima of the

blood vessels
Compression of large vessels
of legs and pelvis

Dilatation of veins

Pooling of blood

Inflammation of veins

Thrombus formation
 Thromboxane Decrease fibrinolytic factors
(plasminogen & antithrombin)

Elevate coagulation factors

Thrombus formation
Other Factors:

> varicosities

> obesity

> history of thrombophlebitis

> oral contraceptives

> age >35 years old

> multiparity

> diabetes millitus

> smoking
 Clasifications of Thrombophlebitis
according to the depth

a. Superficial venous thrombosis

- limited to the calf only
- swelling of extremety, redness, tenderness,
and warm, pain while walking

b. Deep vein thrombosis

- often absent or diffused signs
- swelling, erythema, edema, heat, tenderness
- phlegmasia
 Classifications of Thrombophlebitis
according to location

a.Femoral
= fever, chills, pain, redness,
= swelling of extremeties,
= White - stretched skin,
= + homan’s sign

b. Pelvic
= ovarian, uterine, hypogastric vein
= high fever
= chills
= body malaise
Management of thrombophlebitis
> Anticoagulant (Warfarin, Heparin)
> Thrombolytic (Streptokinase,
Urokinase)
> Analgesics ( except aspirin)
> laparotomy – locate and incise to
remove affected veins
> monitoring of prothrombin time
Nursing Diagnosis and Management of
Thrombophlebitis
• Alteration in Comfort; pain
> rest
> elevate legs
> antiembolic stockings
> avoid standing for long period of time
> moist heat application
> DO NOT MASSAGE
Nursing Diagnosis and Management of
Thrombophlebitis

Altered Tissue Perfusion

> constantly check the skin
> passive range of motion exercise
> prevent skin ulcerations
> proper nutrition
> avoid gatch or pillow under the knee
Nursing Diagnosis and Management of
Thrombophlebitis
Risk for Injury (bleeding) related to therapy
> obtain baseline coagulation
> avoid IM injection of other drugs
> rotate injection site
> inject heparin subcutaneously, do not
massage
> prepare Protamin Sulfate ( antidote of
Heparin)
> prepare Vitamin K ( antidote of Warfarin)
How to prevent thrombophlebitis?
> avoid wearing constriciting clothings
> rest while feet elevated
> ambulate daily during pregnancy
> limit woman in lithotomy position
> aseptic technique in invasive procedures
> if with varicose veins, wear support stockings first 2 weeks postpartum
> avoid in 1 position for long period of time
> avoid leg crossing
> increase oral fluid intake
> early ambulation after pregnancy
> if cannot ambulate, PROM exercises
> avoid pillows under the knees
> don’t smoke
 EMOTIONAL
AND
PSYCHOLOGICAL
POSTPARTAL
COMPLICATIONS
 Emotional Phases of Postpartum

• Taking-in Phase

• Taking-hold Phase

• Letting go phase
 POSTPARTUM BLUES

It is a maternal adjustment reaction accompanied

by irritability, anxiety, and a mild let-down feeling
usually occurring between the 2nd to 3rd postpartum
day through the 1st to 2nd postpartum week.
Signs and symptoms of Postpartum Blues

> Insomia
> depressed mood
> headache
> poor concentration
> tearfulness
> confusion
> mood labile
Factors causing Postpartum Blues
> sudden drop of hormone at about 72 hours postpartum
> disappointments of body changes
> extreme disappointments of labor and birth
> inadequate emotional support from partner
> extreme stress from mothering role
Management of Postpartum Blues

> allow woman to talk and cry

> work through their feelings

> encourage family support

 POSTPARTUM
DEPRESSION

It is a mood disturbance that is characterized by feelings of

sadness, despair, apathy, and discouragement caused by
loss in the person’s life or by neurobiological imbalance of
neurotransmitters.

It occurs 30 days to 6 months after birth

 Signs and Symptoms of
Postpartum Depression

> excessive crying

> feeling of inadequacy
> low self-esteem
> inability to cope
> anorexia
> insomia
> psychosomatic symptoms
> depressive or manic mood flactuation
> social withdrawal
Factors causing Postpartum
Depression
> history of depression
> troubled childhood
> stress in the home or at work
> lack self-esteem
> lack of support system
Management of Postpartum Depression

> nurse-patient relationship

- therapeutic relationship

> psychopharmacologic
- antidepressive drugs

> Milleu therapy

– forceful manipulation of the environment
 POSTPARTUM PSYCHOSIS

It is a disrupted mental state in which an individual struggles

to distinguish the external world from his internally generated
perceptions.

The disorder may become apparent 2 to 3 weeks after birth

to as long as 6 to 12 months.
Factors causing Postpartum Psychosis

> major life crisis

> previous mental illness
> family history of mental illness
> hormonal changes
 Signs and Symptoms of
Postpartum Psychosis

> suicidal and infanticidal thoughts

> dissociated

> delusional

> confused

> distortion of reality

Management of Postpartum Psychosis

> professional psychiatric counselling

> antipsychotic drugs

> hospitalization

> woman must be observed during her

interaction with her child
 Nursing Diagnosis and
Management
of Postpartum Emotional
Disturbances

Risk for/Actual Ineffective coping

> Convey a caring attitude

> Acknowledge that the woman feels depressed
> Assure that it is not her fault
> encourage support from family members
> Adequate rest and nutrition
INFERTILIT
Y
Normally…….

50% of couples conceive within 6

months

35% conceive within 12 months

 The inability to conceive after at
least 1 year of sexual
intercourse at least 4 times a week
without contraception…….

Infertility
Primary infertility
no previous history of conception

Secondary Infertility
inability to conceive after previous
successful pregnancy
 Etiology of Female Infertility
Vaginal problems:
vaginal infections
anatomic abnormalities
sexual dysfunction
highly acidic vaginal
environment

Cervical
changes during ovulation
cervical incompetence
 Etiology of Female Infertility
Uterine
functional
structural

Tubal
scarring
PID
endometriosis

Ovarian
anovulation
oligo-ovulation
secretory
 Etiology of Male Infertility
Congenital
absence of vas deferens and testes

Ejaculatory
retrograde ejaculation

Sperm abnormalities
oligospermia
aspermia
inadequate maturation
inadequate motiliy
inability to deposit sperm
into the vagina
blockage of sperm
 Etiology of Male Infertility

Testicular
orchitis
cryptorchidism
trauma
radiation

Coital
obesity
nerve damage
impotence
 Etiology of Male Infertility

Drugs
Methotrexate
Amebicides
Sex hormone

Other factors:
STD
stress
inadequate nutrition
alcohol & nicotine
 Interactive Problems
⮚Insufficient frequency of SI
⮚Poor timing of intercourse
⮚Development of antibodies
against partner’s sperm
⮚Use of spermicidal lubricants
⮚Inability of he sperm to
penetrate the egg
 Diagnostic Studies
Semen Analysis
after 48 – 72 hours of abstinence
serial analysis 74 days apart

Cervical Mucous assessment

fern test
spinnbarkei test
Postcoital Test
SI at presumed ovulatory state
after48 hour abstinence
Check cervical mucus

Basal Body Recording

oral temp when awakening
increase temp 12-14 days
before menses- ovulation
Serum Progesterone Test
blood examination during luteal phase
normal progesterone – 10mg/ml

Endometrial Biopsy
histologic information
about endometrial tissue
identify adequate secretory
tissues
Hysterosalpingography
radiopaque dye is inserted into the uterus
radiograph is taken after 24 hours
done before ovulation or after menses has ceased

Ultrasound Imaging
determine patency of fallopian tube
determine the depth and consistency of uterine
lining
non invasive and can be done during menses
Hysteroscopy
visual inspection of the uterus
determine uterine adhesion
and other abnormalities

Other tests
Immunoassay of semen and female serum
determine antibody formation
against partner’s sperm
Serum penetration assay
determine the ability of the sperm
to penetrate the zona pellucida
 MANAGEMENT OF
INFERTILITY

1. Management of underlying problems

= douche with alkaline solution 30 minutes
before intercourse
= remove environmental hazards
= surgery
= medications
antibiotic
testosterone
estrogen
= sexual therapy
 MANAGEMENT OF
INFERTILITY

2. Assisted Reproductive Techniques

= artificial insemination
= In vitro fertilization
= Gamete intrafallopian transfer (GIFT)
= Zygote intrafallopian transfer (ZIFT)
= Surrogate embryo transfer
= Surrogate mothering
 Nursing
Diagnosis
Anxiety
Ineffective family and individual
coping
Decreased self – esteem
Knowledge Deficit
Spiritual Distress
Fear
Grief