CHAPTER III

Nursing Care of the High-Risk Postpartal Client

This chapter focuses on the discussion of nursing assessment and management of postpartal
complications.

Duration: 6 hours

Intended Learning Outcomes:

1. To discuss the different signs and symptoms of postpartal complications.
2. To identify the priority nursing diagnoses for each postpartal complication.
3. To develop a plan of care for clients experiencing problems during the
postpartum stage.
4. To explain the different nursing interventions and their rationale based on the
identified nursing goals.
5. To evaluate the effectiveness of the different nursing interventions and make
some revisions or modifications if necessary.

Key Terms:
• Postpartum
• Hemorrhage
• Infection
• Thrombophlebitis
• Psychiatric disorder

Lesson 1: Postpartal Hemorrhage

➢ refers to excessive blood loss during or after the third stage of labor.
➢ Leading cause of maternal mortality.

Causes: 4 T’s
1. Tone – refers to the failure of the uterine muscles to contract.
2. Tissue – Presence of retained placental tissues prevents full uterine contractions.
3. Trauma – caused by lacerations and episiotomy, hematoma, CS, uterine rupture and
uterine inversion
4. Thrombosis – clot formation and fibrin deposition on the placental site stop the oozing
of blood from the blood vessels of the uterus. Disorders of the coagulation system and
platelets, whether persistent or acquired can result in bleeding.

Assessment of blood loss and hemorrhage

1. Assess the fundus, vital signs, vaginal bleeding, Hgb and Hct.
2. Palpate the fundus and determine its consistency, size and position.
3. Inspect the vagina and perineal area for continuous oozing of blood and hematoma
formation.
4. Monitor blood loss per vagina: weigh perineal pad.
5. Monitor vital signs particularly PR and BP.
6. Monitor urine output (30 cc/hr or 1ml/kg).
 7. Monitor tissue perfusion.
8. Auscultation of the lung fields helps detect pulmonary edema or the development of
adult respiratory distress syndrome.
9. Assess level of consciousness.
10. Laboratory work: CBC, prothrombin time/activated partial thromboplastin time
(PT/aPTT)
11. Ultrasound is performed to detect causes of hemorrhage such as retained placental
fragments and occult hematoma.
12. Angiography is done when embolization of bleeding vessels is to be performed.
13. Assess signs of hypovolemic shock (Cold skin, confusion, pallor, anxiety, decrease in urine
output, general weakness, tachypnea, falling unconscious, moist skin and increased
sweating)

A. Early Postpartal Hemorrhage

➢ A blood loss greater than 500 ml in the first 24 hours after vaginal delivery (CS: greater
than 1000 ml)

Causes:
Uterine atony
Lacerations
Disseminated intravascular coagulation
Hematoma

Uterine Atony
➢ Refers to the failure of uterus contract continuously after delivery.
➢ Characterized by boggy or relaxed uterus & profuse bleeding.
➢ Most common cause of PPH
➢ Incidence: 1 for every 20 deliveries

Causes
1. Overstretched uterus (multiple gestation, macrosomia, hydramnios)
2. Complication of labor: precipitous labor, prolonged labor,
3. Uterine relaxing agents: anesthesia, analgesia, terbutaline magnesium sulfate,
nitroglycerine
4. High parity and advanced maternal age
5. Retained placental fragments
6. Infection: amnionitis, chorioamnionitis
7. Oxytocin given during labor

Nursing Management:
a. Massage the uterus
b. Keep the bladder empty
c. Modified trendelenburg
d. IV fast drip/ oxytocin IV drip
 e. Breastfeeding – posterior pituitary gland will release oxytocin so uterus will contract.

Lacerations
➢ More common after operative obstetrics, a firm uterus with bright red blood or a steady
stream of unclotted blood
➢ Predisposing factors: Primipara, precipitous labor, macrosomia, forceps or vacuum-
assisted birth, mediolateral episiotomy
➢ Degree of lacerations
1. Cervical
2. Perineal
Classification of Perineal Laceration
1ST DEGREE - Vaginal skin & mucus membrane
2ND DEGREE - 1st degree + muscles of vagina
3RD DEGREE - 2nd degree + external sphincter of rectum
4TH DEGREE - 3rd degree + mucus membrane of rectum
Management: Episiorrhapy
3. Vaginal
Causes
1. Primigravida
2. Operative delivery: forceps vacuum extraction, episiotomy
3. Precipitate delivery
4. Large infant
5. Multiple pregnancy
6. Abnormal fetal presentation and position

Management
1. Repair of laceration

Disseminated intravascular coagulation - Deficiency in clotting ability caused by vascular

injury.
Management: Blood transfusion
Hematoma - is a localized collection of blood in connective or soft tissue under the skin that
follows injury of or laceration to a blood vessel without injury to the overlying tissue. The most
common sign or symptom is unremitting pain and pressure.

Vulvar hematoma

Types:
1. Genital hematomas
• Vulvar hematomas – first symptom is excruciating pain.
• Vaginal hematomas – manifested by severe perineal pain, feeling of pressure,
inability to void, sudden appearance of movable and sensitive mass adjacent to
the vagina.
• Vulvovaginal hematomas
2. Retroperitoneal hematomas

Risk factors
1. Vulvar varicosities
2. Precipitate labor
3. Inadequate suturing of episiotomy or lacerations
4. Primipara
5. Prolonged 2nd stage of labor
6. Large infant
7. Forceps or vacuum assisted birth

Signs and Symptoms

1. Lower genital tract hematomas is generally associate with:
• Intense pain that is out of proportion to what seems apparent.
• Localized tenderness
• Swelling
• Discoloration of skin over the swollen area
• Feeling of pressure over the vagina
• If in posterior vagina, it may cause sensation of rectal pressure.
2. Broad ligament hematomas may be palpated as enlarging masses next to the uterus.

Management:
1. If the hematoma is less than 3 to 5 cm in diameter, the physician usually orders palliative
treatments such as ice to the area for the first 12 hours along with pain medication, and
close observation of the area for extension of the hematoma. After 12 hours, sitz baths
 are prescribed to replace the application of ice. Sitz baths are therapeutic in providing
comfort and in facilitating reabsorption of the clot.
2. A hematoma larger than 5 cm may require incision and drainage with the possible
placement of a drain.
3. Blood transfusion if severe bleeding occurs.

B. Late postpartal hemorrhage

➢ Bleeding that occurs any time after the first 24 hours

Retained Placental Fragments

• The most common cause of late PPH
Causes
1. Partial separation of a normal placenta
2. Manual removal of placenta
3. Entrapment of placenta in the uterus
4. Abnormal adherent placenta – accrete, increta, and percreta
5. Abnormal placental adhesion is most likely in:
- Previous PPH
- Previous CS
- Placenta previa
- High Parity

Complications
1. Infection
2. May interfere with adequate milk production in breastfeeding mothers as it may
continue to produce hormones like estrogen that inhibit prolactin secretion.

Signs and Symptoms

1. Passage of large clots
2. Heavy bleeding
3. Presence of tears or missing cotyledons on inspection of placenta.

Management
1. Confirmation is done by:
• Manual uterine exploration
• Ultrasound can show residual trophoblastic tissue, blood clots, and decidua in the
uterus.
2. D and C to remove adherent placenta.
3. Hysterectomy if manual removal/ D and C is not successful or will result in grave
complications such as severe hemorrhage, DIC and perforation of the uterus.

C. Subinvolution

• incomplete return of the uterus to its prepregnant size, shape and function.
 Causes
1. Retained placental fragments
2. Infection – endometritis
3. Uterine tumors

Signs and Symptoms

1. Enlarged and boggy uterus
2. Prolonged or reversal patterns in lochial discharge.
3. Foul odor in lochia if caused by infection.
4. Backache

Management :
• Dilatation and Curettage (D&C) except placenta increta, percreta
Acreta – attached placenta to myometrium.
Increta – deeper attachment of placenta to myometrium
Percreta – invasion of placenta to perimetrium
• manual extraction of fragments
• massaging of uterus.
• Treat the cause: antibiotics for infection; removal of uterine tumors, evacuation of
retained placental fragments by D and C

Lesson 2: Puerperal infection

Puerperal Sepsis
➢ Any infection of the reproductive organs that occurs within the first 6 weeks after childbirth
➢ Affects 2-8% of postpartum women.
➢ Defined by two documented temperatures greater than 380C(100.4F) on any two successive
days after the first 24 hours following delivery in the absence of any other apparent fever
source

Pathogenesis of Postpartum Infection

 Almost always caused by bacteria normally present in the genitalia
 70% of infections are caused by mixed aerobic and anaerobic organisms (Group A, B, and
D streptococci, E. coli, G. vaginalis, Bacteroides species)
 Infection tends to be more serious in women who have undergone C-section

Risk Factors:
 Operative delivery (CS-20x)
 Prolonged labor (>18 hours) /rupture of membranes (>24 hours)
 Multiple pelvic examinations
 Lower socioeconomic status
 Intrapartum fever or diagnosis of chorioamnionitis
 Obesity
 History of UTI and STDs
 Internal fetal monitoring
 Anemia
  Malnutrition
Assessment Findings:
 Fever, chills and tachycardia
 Change in the color, amount, odor (foul) and consistency of lochia
 Painful and tender uterine fundus, delayed uterine involution
 Body malaise, anorexia, headache
 Burning sensation on urination, dysuria

Evaluation of postpartum fever

 Consider potential sources:
5 W’s -- wind (lungs), water (urinary tract), walking (DVT), wound (cellulitis), womb
(endometritis); also consider breast engorgement and/or mastitis and infection involving
IV access sites.

Prognosis
 Improved with early detection and appropriate management

Prevention
 prevention and early treatment of anemia in pregnancy
 strict asepsis
 prevention of lacerations – warm compress, sitz bath, perineal heat lamp
 good management of the 3rd stage
 perineal cleanliness
 adequate treatment of dystocia and PROM with antibiotics
 hygiene and proper attire of personnel

Management
 Start with ordered antibiotics
 Maintain bedrest
 Observe standard precautions
 Monitor v/s, I and O
 Teach perineal hygiene
 Provide nutritious, high caloric, high protein, high iron diet

A. Endometritis
➢ Infection of endometrial lining
➢ Chorioamnionitis and cesarean birth
➢ Tubal scarring and interference with future fertility

Causative Agents:
 Microorganisms of the vaginal flora:E. coli, klebsiella pneumoniae and proteus species
 Group A streptococci – postpartum day 1 or 2
 E. coli, anaerobic bacteria – day 3 and 4
 Chlamydia trachomatis – more than 7 days
 Anaerobic gram-negative bacilli – following CS

Manifestations:
 Fever (3rd or 4th day)-greater than 100.4 degree-Farenheit
 Tachycardia
 Malaise, chills, backache, headache
 Profuse foul smelling lochia-remains rubra longer
 Excess fundal tenderness
 Delayed involution (lochia doesn’t follow RSA)
 Boggy and enlarged uterus

Management
 Administration of antibiotic, oxytocic and analgesic
 Increase fluid intake
 Bedrest with BRPs
 Assess pain and involution
 Sitting in fowler’s/walking
 Good perineal hygiene

B. Wound infection

 Most common site is the perineum and CS surgical incision

 Signs and symptoms:
- Fever
- increased drainage that is often foul smelling
- redness
- warmth at the site
- ecchymosis
- pain on the area
 Stress importance of frequent perineal hygiene and peri pad changes
Causative Agent
 Staphylococcus or Streptococcus species and gram-negative organisms.

Nursing Assessment
1. REEDA
Redness
Edema
Ecchymosis
Discharge
Approximation of skin edges
2. Generalized fever, localized tissue warmth
3. Tenderness

Perineal Infections
 Usually occur on the 3rd – 4th day after giving birth
 Common causes:
a. Infected lochia (endometritis)
b. Fecal contamination of the wound
c. Poor hygiene
 Causative agents: microorganisms of the vaginal flora
 Abdominal wound infections
 Often results from contamination of CS incision by m.o of the vaginal flora
 Most common risk factors:
a. DM
b. Hypertension
c. Obesity
d. Treatment with corticosteroids
e. Immunosuppression
f. f. Chorioamnionitis
g. Prolonged labor
h. Prolonged rupture of membrane
i. Prolonged operating time
j. Excessive blood loss
k. Abdominal twin delivery

Management
 Antibiotic therapy
 Good perineal hygiene
 Semi-fowler’s position to promote drainage
 Analgesic for pain
 Increase fluid intake

C. UTI
➢ Bacterial invasion of the kidneys or bladder (CYSTITIS) usually caused by Escherichia coli
➢ Often appears 2-3 days after birth
➢ Common during puerperium because of trauma to the bladder after delivery, urinary
retention and overdistention of the bladder due to anesthesia, catheterization

Risk Factors
 CS
 Forceps and vacuum delivery
 Tocolysis
 Induction of labor
 Maternal renal disease
 Pre-eclampsia, eclampsia
 Previous UTI during pregnancy

Assessment Findings
 Low-grade fever
 suprapubic pain, flank pain
 hematuria
 Pain/burning on urination
 Urinary frequency
 Urgency of urination

Management
 Administer antibiotics as ordered: 3-7 days, ciprofloxacin, amoxicillin, norfloxacin
 Provide warm baths and allow to void in water to alleviate painful voiding.
  Force fluids. You may give 3 liters of fluid per day
 Encourage measures to acidify urine (acid-ash diet).
 Analgesics for pain
 Regular emptying of the bladder
 Provide client teaching and discharge planning concerning
a. Avoidance of tub baths
b. Avoidance of bubble baths that might irritate urethra
c. Importance for women to wipe perineum from front to back
d. Increase in foods/fluids that acidify urine.

Lesson 3: Thromboembolic disorders

Thrombophlebitis – infection of the lining of the vein with formation of thrombi.

Predisposing Factors
• The fibrinogen level is still elevated from pregnancy
• Dilatation of lower extremity veins is still present
• The relative inactivity of the period or a prolonged time spent in delivery or birthing room
stirrups

Risk Factors
• Obesity
• Varicose veins
• Previous thrombophlebitis
• Older than 30 y/o with ↑ parity
• High familial incidence
• Smoking
• Use of estrogen supplement
• Anesthesia, surgery
• DM

Causes
1. Injury to blood vessels usually occur during delivery, indwelling catheterization and
infection.
2. Increased blood clotting that normally occurs during pregnancy and after delivery and
with the use of oral contraceptives.
3. Blood stasis that occurs as a result of varicose veins, bed rest after CS and prolonged
inactivity.

Types According to Location

1. Superficial thrombophlebitis - inflammation affecting the superficial veins of the
extremities.
2. Deep vein thrombophlebitis/deep vein thrombosis – this is inflammation of a vein
located deep within a muscle tissue.

Types According to Veins Affected

1. Femoral Thrombophlebitis – infection of the veins of the legs
 Assessment
• Fever
• Chills
• Swelling of affected leg, pain, stiffness
• Redness (10 days after birth)
• Milk leg or Phlegmasia Alba dolens - shiny and white in appearance
• + Homan’s sign
• Increased leg diameter
Management
• Bed rest with the affected leg elevated
• Administer anticoagulants /thrombolytic agents
• Apply moist heat
• Use of bed cradle
• Back, buttocks, and heel care
• Check for bed wrinkles
• Administer analgesics

2. Pelvic Thrombophlebitis – infection of the ovarian, uterine and pelvic veins.

Manifestations
• Fever and chills
• Pain in the lower abdomen or flank
• Palpable parametrial mass in some cases

Management
1. Prevention
a. Early ambulation after delivery
b. Use of support stockings in women with varicosities
c. Avoid trauma on extremities: Pad stirrups well, limit the time a woman remains in OB
stirrups, avoid pressure on popliteal vessels
d. Avoid activities that contribute to venous stasis such as prolonged bed rest, standing
and sitting.
2. Superficial venous thrombosis involving small clots in the absence of infection usually
resolves without anticoagulant treatment. The management is directed towards relief of
pain and resolution of clot:
• Application of heat to relieve pain
• Aspirin and ibuprofen. Aspirin should never be given to woman who is receiving
heparin.
• Avoid massaging the area
3. Deep vein thrombosis requires intensive management to prevent serious complications
like pulmonary embolism.
• Hospitalization during the acute phase
• Bedrest
• Leg elevation
• Anticoagulant therapy
-Heparin – keep antagonist, protamine sulfate, available
- mother may breastfeed infant as it is not passed to breastmilk.
- Dicumarol – keep antagonist, vitamin K, available.
- passed on breastmilk
 • Monitor:
1. partial thromboplastin time (PTT) – should be done before the first dose of
heparin is given, whenever the dosage level is changed, when heparin has
reached a constant level in the blood.
- Normal: between 60-70 seconds
- Low levels in a patient on heparin indicate underdosage (increase dosage);
high levels indicate too much heparin is present (reduce dosage)
2. activated partial thromboplastin time (APTT) – normal: between 25-40 secs.
- An APTT longer than 100 secs indicates spontaneous bleeding.
Educate patient on home coagulant therapy:
- Report abnormal signs: fever, bleeding gums, nose bleeds, headache,
hemoptysis, hematemesis, petechiae, spontaneous bruising, heavy
bleeding, dizziness, sudden abdominal pain, blood in urine and stool,
muscle and joint pain.
- Avoid aspirins and NSAIDS while taking anticoagulants
• Apply warm wet compress dressings to promote circulation and for comfort.
• Administer prescribed antibiotic to combat infection and analgesic to relieve pain.
• Surgery may be used if the affected vein is likely to present a long term threat of
producing blood clots that will release emboli.

Lesson 4: Postpartal Psychiatric Disorder

➢ Many types of psychiatric problems may occur in the postpartum.

➢ The Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition (DSM-IV) classifies
postpartum onset mood disorders and proposes that postpartal psychiatric disorders be
considered one diagnostic syndrome with 3 subclasses; a fourth area, postpartum onset
of panic disorder, has also been describe.
1. Adjustment reaction with depressed mood is also known as postpartum, maternal, or
baby blues.
• Occurs in as many as 50-80 percent of mothers and is characterized by mild depression
interspersed with happier feelings
• The blues typically occur within a few days after the baby’s birth and are self-limiting,
lasting from 1-10 days, more severe in primiparas.
• Seems to be related to the rapid alteration in estrogen, progesterone and prolactin
levels at birth.
• New mothers feel overwhelmed unable to cope, fatigued, anxious, irritable and
oversensitive; episodic tearfulness occurs without any reason.
2. Postpartum major mood disorder, also known as postpartum depression.
• Develop in about 8 to 26 percent of all postpartal women.
• May occur anytime in the first postpartum years, most often occurs around the 4th
week.
• generally lasts for 3-6 months, with 25% of patients still affected at 1 year.
Symptoms
1. sadness
2. frequent crying
 3. insomnia
4. appetite change
5. difficulty concentrating and making decisions
6. feelings of worthlessness
7. obsessive thoughts of inadequacy as a person/parent
8. lack of interest in usual activities
9. lack of concerns about personal appearance
10. irritability and hostility toward the new baby may be seen

Risk factors
1. Primiparity
2. Ambivalence about maintaining the pregnancy
3. History of postpartum depression or bipolar illness
4. History of mood disorder or premenstrual dysphoric disorder (not necessarily the milder
and less-specific menstrual syndrome.
5. Lack of social support
6. Family history of depression, bipolar illness, and/or anxiety
7. Marital dissatisfaction
8. Anxiety/depression during pregnancy
9. Infant-related stressors such as problematic temperament in the baby
10. Adverse life-events or stressors
11. Inadequate support from family or friends
12. Body image and eating disorders

Treatment
1. Medication – selective serotonin reuptake inhibitors such as sertraline (Zoloft), paroxetine
(Paxil) and fluoxetine (Prozac)
2. Individual/group psychotherapy
3. Practical assistance with child care and other demands of daily life

3. Postpartum psychosis
➢ The most severe and the rarest postpartum psychiatric disorder
➢ Has an incidence rate of 1-2 per 1,000
➢ Evident within the first 3 months postpartum

Risk Factors
1. Previous puerperal psychosis
2. History of manic depressive disorder
3. Obsessive personality
4. Family history of mood disorder
5. Prenatal stressors

Symptoms
1. Agitation
2. Hyperactivity
3. Insomnia
4. Lability
5. Confusion
 6. Irrationality
7. Difficulty remembering or concentrating
8. Poor judgment
9. Delusions
10. hallucinations

Management
1. Hospitalization especially when woman exhibits signs of postpartum psychosis such as
hallucinations and delusions. This is because psychotic women are at risk of committing
suicide and in very rare cases, of harming their unborn child or infants.
2. Removal of infant from the mother for safety considerations.
3. Medications: antipsychotic medications, sedatives
4. Electroconvulsive therapy is the last resort if other treatment fails,
5. Psychotherapy (long term)

4. Postpartum onset panic disorder – characterized by frightening panic attacks that include
acute onset of anxiety, fear, rapid breathing, palpitation, and a sense of doom.

Assessment
1. History of previous psychological problems
2. Adequacy of coping skills
3. Degree of self-esteem
4. Presence of mood swings, emotional distress, restlessness, irritability, guilt, extreme anxiety
about the baby, anorexia, inability to complete activities of daily living

Priority Nursing Diagnoses

1. Risk for impaired parenting
2. Ineffective coping
3. Risk for impaired parent-child attachment
4. Risk for compromised family coping

Planning/goal-setting
1. Client and family will recognize common postpartum psychological changes.
2. Client will be free from psychological maladaptation.
3. Client and family will recognize signs of psychological impairment and will contact
appropriate resources at time of discharge;
4. Client will function adequately as a parent.

Implementation
1. Observe client with baby, by herself, and with family and friends
2. Recognize early signs of problems
3. Seek client referral to psychiatrist for evaluation of psychological status
4. Support positive parenting behaviors
5. Discuss client’s plans for her baby and herself
6. Refer client to social services, if indicated

Evaluation
1. Client uses appropriate coping strategies to care for self and baby
 2. Client has realistic expectations for self and baby.
3. Client perceives that she is receiving the support she needs.
4. Client has support for depressive episodes.
5. Client and family share feelings and concerns openly.
6. Appropriate bonding is observed and baby is safe.

Teacher’s Insight:

Most women do not experience a complication during the postpartum period, but when they
do it can be life threatening and disruptive to the family unit. Hemorrhage, coagulation
disorders, and infections are the primary physiological complications. Women may also
experience problems later in life due to tissue and reproductive organ trauma related to the
childbirth. Postpartum depression and postpartum psychosis are the main psychological
complications.

A focus of postpartum nursing care is to reduce women’s risks for complications related to
childbirth and to identify complications early for prompt interventions. The woman needs to
be evaluated by her health care provider when a complication is suspected.