NUR1213

4. Conditions that lead to inadequate blood

Nursing Care of the coagulation
Postpartum Client
OUTLINE Signs of Pospartal Hemorrhage
I. Postpartum Hemorrhage
II. Uterine Atony  Excessive or bright red bleeding
III. Lacerations  A boggy fundus that does not respond to
IV. Hematoma massage
V. Uterine Inversion  Abnormal clots
VI. Retained Placental Fragments in the  Any unusual pelvic discomfort or
Uterus backache
VII. Uterine Subinvolution  Persistent bleeding in the presence of a
VIII. Disseminated Intravascular firmly contracted uterus
Coagulation  Rise in the level of the fundus of the uterus
IX. Puerperal Infection  Increased pulse or decreased BP
X. Urinary Tract Infection  Hematoma formation or bulging/ shiny
XI. Postpartal Psychiatric Disorder skin in the perineal area
 Decreased level of consciousness
Postpartum complications may be serious it could
cause personal injury, leave a. woman with her
future fertility impaired, or even death.

I. Postpartum Hemorrhage

Hemorrhage is a major threat during pregnancy,

and one of the primary cause of maternal
mortality.

Primary Post-Partum Hemorrhage

 Blood loss from birth canal of 500 ml or

more
 Early: within the first 24 hours following
Predisposing factors
birth
 Greatest danger because of the grossly
 Overdistention of the uterus
denuded and unprotected uterine are left
- Multiparity
after detachment of placenta.
- Large babies
- Polyhydramnios
Secondary Post-Partum Hemorrhage
- Multiple pregnancies
- Presence of uterine Myomas (fibroid
 Abnormal bleeding after 24 hours to six
tumors)
weeks after birth.
 Cesarean Section
Conditions that Increase a women’s risk for a  Prolonged and Difficult labor
postpartal hemorrhage  Placental accidents (previa or abruptio)

1. Conditions that distend the uterus beyond
average capacity
2. Conditions that could have caused cervical or
uterine lacerations
3. Conditions that leave the uterus unable to
contract readily
Four main reasons for postpartum hemorrhage
1. Tone: Atonic uterus
2. Trauma: Lacerations, hematomas, inversion,
rupture
3. Tissue: Retained tissue, Invasive placenta
4. Thrombin: Coagulopathies
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II. Uterine Atony
Consequences of PPH
The uterus, although empty, fails to contract and
 Circulatory collapse leading to shock and control bleeding from the placental site.
death
 Puerperal anemia and morbidity The commonest and potentially most dangerous
 Damage to the pituitary blood supply also cause of post-partum hemorrhage.
known as Sheehan’s syndrome. A
hypopituitarism caused by ischemic
necrosis due to blood loss and
hypovolemic shock.
 Fear of further pregnancies

Nursing Management!
 Assist with appropriate treatment
 Prevent excessive blood loss and resulting
complications
 Provide physical and emotional support
 Provide client and family education
Primary Post-Partum Hemorrhage Nursing
Interventions!
1. Identify client at risk for condition
2. Monitor fundus frequently if bleeding occurs;
when stable, every 15 minutes for 1-2 hours, than
at appropriate intervals.
3. Monitor maternal vital signs for indication of
shock
4. Administer medications, IV fluids as ordered5.
5. Measure I&O
6. Remain with client for support and explanations
of procedure
7. Keep client warm
8. Prepare for clients return to delivery room if
needed for repair of laceration or removal of
placental fragment
9. Monitor for signs of DIC
To be certain, do not rely solely on a woman’s
report of perineal healing or amount of lochia.
Always inspect her perineum yourself.
Predisposing Causes of Uterine Atony
 Excessive uterine distention
 Exhaustion of the uterine musculature
 Multiparity
 Prolonged labor
 Labor augmented with Syntocinon
 General anesthesia
 Placenta previa
 Abruptio placenta – the ‘Couvelaire’
uterus may not be contract
Situation resulting in drug related relaxation of
uterine musculature
a. The use of MgSO4 for preeclampsia
b. The use of general anesthesia for caesarean
delivery
Signs and Symptoms of uterine atony
 Signs of shock -  blood pressure,  pulse,
 anxiety and irritability.
 Bleeding
 Noncontracted, boggy uterine fundus

The patient has no knowledge of “normal” lochia Medical Treatment

or fundal height against which to accurately
compare her own condition. a. Intravenous fluids
b. Oxytocin administration
An increased temperature during the first 24 hours c. methergine/prostin
after birth is an extremely serious finding. Report d. Blood transfusion
greater than 38.0 C. e. Hysterectomy

Primary Post-Partum Hemorrhage Nursing Interventions

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a. Palpate the fundus
b. Massage the fundus
c. Monitor patient’s vital distention
e. Bimanual compression

Bimanual uterine compression – an intervention

performed by a skilled birth attendant, where one
hand is placed in the vagina and pushed against
the body of the uterus.

III. Lacerations

1. Cervical Lacerations: usually found on the

sides of the cervix

2. Vaginal Lacerations: occurs in the vagina and

easier to assess the cervical lacerations, because
this position increases tension on the perineum.
Causes
3. Perineal Lacerations: usually occur when a
woman is placed in a lithotomy position for birth,  Rapid descent of the fetus
because this position increases tension on the  Pushing prior to complete cervical
perineum. effacement and dilatation
 Large fetus
Degrees of perineal lacerations
 Forceps application
 Uncontrolled, forceful extension of the
A. First degree: tear of vaginal mucous
fetal head
membranes and skin of the perineum to the
Signs and symptoms
fourchette.

B. Second degree: tear of the vagina, perineal  Obvious body injury

skin, fascia, levator ani muscle, and perineal body.  Bright red bleeding
 Signs of shock-rapid, thready pulse, falling
C. Third degree: tear of the perineum, and reaches blood pressure, increasing anxiety of the
the external sphincter of the rectum. patient.

D. Fourth degree: tear of the entire perineum, Medical treatment

rectal sphincter, and some of the mucous
membrane of the rectum.
 Suturing of the laceration
 Vaginal packing
 Blood transfusion if the patient’s
hematocrit is low and the patient is
symptomatic.

Nursing Intervention

 Observe for vaginal bleeding

 Monitor Vital signs
 Flag the patient’s chart for vaginal packing
in place

IV. Hematoma
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Vulvar hematoma – is localized collection of  Uterus may be boggy due to its inability to
blood in the connective tissue beneath the skin contract properly.
covering the external genitalia or vaginal  Signs of shock
mucosa.  Sudden rise in uterine fundal height
indicating the formation of clots inside the
Causes uterine cavity.

a. Rapid, Spontaneous delivery Medical Treatment

b. Perineal varicosities
c. Episiotomy repairs a. Manual removal of the remaining placenta is
d. Laceration of perineal tissues done by the physician, if it is a result of
incomplete separations of the placenta with
Signs and Symptoms increased vaginal bleeding.
b. Attempted removal by sharp curettage
 Pain c. Intravenous fluids are administered
 Mass d. Oxytocic drugs are given immediately after
 Swelling either procedure
 Inability to void
 Fullness or pressure Nursing Interventions

Medical Treatment  Check the uterine fundus tone frequently

 Check the nature and amount of lochia
 Analgesics flow
 Opening  Keep accurate count of perineal pads
 Ligated  Monitor patient’s vital signs
 Packing  Observe for signs of shock
 Apply ice  Turn the patient on her side to prevent
 Observe pooling blood under her
 Flag  Provide emotional support to the patient
and family
V. Uterine Inversion
VII. Uterine Subinvolution
 Fundus is forced through the cervix so that
the uterus is turned inside out. Uterine subinvolution – is a slowing of the
 Insertion of placenta at the fundus, so that process of involution or shrinking of the uterus;
as fetus is rapidly delivered, fundus is delayed return of the enlarged uterus to normal
pulled down. size and function.
 Strong fundal push, attempts to deliver the
placenta before signs of separation. Causes

Secondary Post-Partum Hemorrhage  Endometritis

 Retained placental fragments
VI. Retained Placental Fragments in the  Pelvic infection
Uterus  Uterine fibroids

These fragments are the major cause of late Signs and Symptoms
postpartum hemorrhage.
 Prolonged lochia flow
Signs and Symptoms  Profuse vaginal bleeding
 Large, flabby uterus
 Large amount of bright red bleeding or
persistent trickle type bleeding. Medical Treatment
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a. Administration of oxytocic medication to Other infections
improve uterine muscle tone: Rubella
Cytomegalovirus
- Methergine Herpes
- Pitocin
- Ergotrate Means to Prevent the spread of Puerperal infection
in hospitals.
b. Dilation and Curettage
 Restrict personnel with respiratory
c. Antimicrobial infections from working with patients
 Use caps, mask, gowns, and gloves when
Nursing Intervention working in delivery rooms
 Use sterilized equipment within control
 Prevent excessive blood loss, infection, dates
other complications  Wash hands meticulously (staff)
 Correct breaks in sterile techniques
a. Massage uterus immediately
b. Monitor vital signs  Instruct the patient on hand washing and
c. Administer medications cleansing her perineum from front to back
d. Prepare for possible D & C  Limit unnecessary organisms from the
rectum and vagina into the uterus.
VIII. Disseminated Intravascular
Coagulation Signs of wounds infection
Is a deficiency in clotting ability caused by  Edema, warmth, redness, tenderness,
vascular injury. It may occur in any woman in the and pain
postpartal period, but it is usually associated with
 Edges of the wound may full apart, and
premature separation of the placenta, a missed
seropurulent drainage may be present.
early miscarriage, or fetal death.
 Fever and malaise
IX. Puerperal Infection
Therapeutic Management
 Refers to bacterial infections after - Incision and drainage of the affected area
childbirth - Broad spectrum antibiotics
 Occurs in 3% of all women in vaginal birth - Analgesics
 Occurs in 15% to 20% of all woman who - Warm compression or sitz baths
had cesarean births
 It is one of the leading causes of maternal Signs and Symptoms
deaths
 Pain
Most common postpartum infections  Fever
 Localized tenderness and or swelling and
1. Metritis redness
2. Mastitis
3. Wound infections Medical Treatment
4. Urinary tract infections
5. Septic pelvic thrombophlebitis - Antibiotic therapy
6. Peritonitis - Anticoagulant therapy-heparin
- Blood transfusion as needed
TORCH = infections that can be devastating to
the fetus or newborn Nursing Management
Toxoplasmosis
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- Heparin – Monitor Prothrombin time –  Denial of existence of infant
Protamine sulfate  Mood swings
- Coumadin – Monitor Prothrombin –
Vitamin K Postpartum Depression

X. Urinary Tract Infection  Begins within 4 weeks after delivery

Symptoms typically begin on the 1st or 2nd
postpartum day.
Dysuria, urgency, and frequency of urination,
low-grade fever
 Almost every woman notices some
immediate (1 to 10 days postpartum)
feelings of sadness (post partal blues) after
childbirth
A. Baby blues

Upper urinary tract infection such as - Common, transient mood disturbance

pyelonephritis may develop on the 3 rd or 4th day - Sadness, weeping, irritability, anxiety, and
with chills, spiking fever, costovertebral angle confusion
tenderness, flank pain, and nausea and vomiting. - Occurs in 40-80% of postpartum women

XI. Post Partal Psychiatric Disorder B. Postpartum psychosis

Any woman who is extremely stressed or who
gives birth to an infant who in any way does not
meet her expectations such as being the wrong
sex, being physically or cognitively challenged, or
being ill may have difficulty bonding with her
infant.
- Psychiatric emergency due to risk of
infanticide or suicide
- Bizarre behavior, disorganization of
thought, hallucinations, delusions
- Occurs usually in first 2 weeks

Postpartal Psychosis/Physiologic
Maladaptation

 A major psychiatric complication in three

of a thousand pregnant women
 15% occurs during the prenatal period
 85% occurs during postpartal
 Appears usually appears the third day after
delivery.

Most common conditions are typically identified

as:

 Maternity blues, postpartum blues, baby

blues, or 3rd, 4th or 10th day blues
 Postpartum or postnatal depression
 Postpartum or puerperal psychosis
 Postpartum panic disorder
 Postpartum obsessive-compulsive disorder

Signs and Symptoms

 Withdrawal
 Depression
 Hostility
 Suspicion