Complications of

Post Partum
 POSTPARTUM HEMORRHAGE
 Early
 Occurs when blood loss is greater than
500 ml. in the first 24 hours after a vaginal
delivery or greater than 1000 ml after a
cesarean birth
*Normal blood loss is about 300 - 500 ml.)

 Late
 Hemorrhage that occurs after the first 24
hours
 MAIN CAUSES OF EARLY
HEMORRHAGE ARE:

 Uterine Atony

 Lacerations

 Retained Placental Fragments

 Inversion of the Uterus

 Placenta Accreta

 Hematomas
 UTERINE ATONY

The myometrium fails to contract and

**The myometrium fails to contract and
the uterus
the uterus fills
fillswith
withblood
blood because
because of
of
the lack of pressure on the open
the lackof
vessels ofthe
pressure on the
placental siteopen blood

vessels of the placental site.

 UTERINE ATONY
PREDISPOSING FACTORS
Prolonged Overdistention
labor of the
Uterus
Trauma due
to Obstetrical
Procedures
Grandmultiparity

Intrapartum
Stimulation
with Pitocin Excessive use of
Analgesia / Anesthesia
 UTERINE ATONY
 Most common cause of Hemorrhage

 Key to successful management is:

PREVENTION!

 Nurse
many times can predict which
women are at risk for hemorrhaging.
 UTERINE ATONY

A boggy uterus that does not

respond to massage

Abnormal Excessive
Clots Signs or
Bright Red
and Bleeding
Symptoms

Unusual pelvic discomfort or backache

 NURSING CARE OF UTERINE
ATONY

 Document Vaginal Bleeding

 Fundal massage / Bimanual Compression

 Assess Vital Signs (shock)

 Give medications--Pitocin, Methergine,

Hemabate

 D & C, Hysterotomy/ectomy, Replace blood /

fluids
POST PARTUM HEMORRHAGE

*LACERATIONS*

 PREDISPOSING FACTORS
1. Spontaneous or Precipitous delivery
2. Size, Presentation, and Position of baby
3. Contracted Pelvis
4. Vulvar, cervical, perineal, uretheral area and vaginal
varices

 Signs and Symptoms

1. Bright red bleeding where there is a steady
trickle of blood and the uterus remains firm.
2. Hypovolemia
 POSTPARTUM HEMORRHAGE

*LACERATIONS*

 Treatment and Nursing Care

1. Meticulous inspection of the entire
lower birth canal
2. Suture any bleeders
3. Vaginal pack-- nurse may remove and
assess bleeding after removal
4. Blood replacement
TEST YOURSELF !
 You are assigned to Mrs. B. who delivered
vaginally. As you do your post-partum
assessment, you notice that she has a large
amount of lochia rubra.

 What would be the first measure to

determine if it is related to uterine atony or
a laceration?
RETAINED PLACENTAL FRAGMENTS
 This occurs when there is incomplete
separation of the placenta and fragments of
placental tissue retained.

 Signs
 Boggy , relaxed uterus
 Dark red bleeding
 Treatment
 D&C
 Administration of Oxytocins
 Administration of Prophylactic antibiotics
 HEMATOMA
Major Symptom: PAIN- deep, severe,
unrelieved, feelings of pressure

Many times bleeding is concealed. Major symptom

is rectal pain and tachycardia.

Treatment:
May have to be incised and drained.
 INVERSION OF THE UTERUS
 The uterus inverts or turns inside out after
delivery.
 Complete inversion - a large red rounded mass
protrudes from the vagina
 Incomplete inversion - uterus can not be seen, but
felt

 Predisposing Factors:
 Traction applied on the cord before the placenta has
separated.
**Don’t pull on the cord unless the placenta has
separated.
 Incorrect traction and pressure applied to the fundus,
especially when the uterus is flaccid
**Don’t use the fundus to “push the placenta out”
 INVERSION OF THE UTERUS

Placenta

Uterus

Uterus continues
to be pulled and
Traction on inverted
the cord
starts the
uterus to
invert
 INVERSION OF THE UTERUS Uterus
Manually
pushed back
into place

Vagina Vagina

Uterus
Inverted
TREATMENT AND NURSING CARE

 Replace the uterus--manually replace and pack

uterus
 Combat shock, which is usually out of
proportion to the blood loss
 Blood and Fluid replacement

 Give Oxytocin

 Initiate broad spectrum antibiotics

 May need to insert a Nasogastric tube to

minimize a paralytic ileus
Notify the Recovery Nurse what has occurred!
Care must be taken when massaging
 PLACENTA ACCRETA
All or part of the decidua basalis is absent and the
Placenta grown directly into the uterine muscle.
PLACENTA ACCRETA
 Signs:
 During the third stage of labor, the
placenta does not want to separate.
 Attempts to remove the placenta in
the usual manner are unsuccessful,
and lacerations or perforation of the
uterus may occur
TREATMENT

 Ifit is only small portions that are

attached, then these may be removed
manually

 If
large portion is attached--a
Hysterectomy is necessary!
 ARE THESE EARLY, LATE, OR BOTH ?
 Uterine Atony  _________________

 Retained placental  _________________

fragments

 Lacerations  _________________

 Inversion of the uterus  _________________

 Placenta accreta  _________________

 Hematoma  _________________
POSTPARTUM INFECTIONS
 POSTPARTUM INFECTIONS
 Definition
Infection of the genital tract that occurs
within 28 days after abortion or delivery

 Causes
Streptococcus Groups A and B
Clostridium, E. Coli
POSTPARTUM INFECTIONS
 Predisposing Factors
1. Trauma
2. Hemorrhage
3. Prolonged labor
4. Urinary Tract Infections
5. Anemia and Hematomas
6. Excessive vaginal exams
7. P R O M
 CRITICAL TO REMEMBER
 Signsand Symptoms of Postpartum
Infection
1.Temperature increase of 100.4 or higher
on any 2 consecutive days of the first
10 days post-partum, not including the
first 24 hours.
2. Foul smelling lochia, discharge
3. Malaise, Anorexia, Tachycardia, chills
4. Pelvic Pain
5. Elevated WBC
 POSTPARTUM INFECTION

TREATMENT AND NURSING CARE

• Administer broad spectrum antibiotics

• Provide with warm sitz baths

• Promote drainage--have pt. lie in HIGH fowlers position

• Force fluids and hydrate with IV’s 3000 - 4000 cc. / day

• Keep uterus contracted, give Methergine

• Provide analgesics for alleviation of pain

• Nasogastric suction if peritonitis develops

 Test Yourself !

 Whatis the classic sign of a

Postpartum Infection?
 COMPLICATIONS OF
POSTPARTUM INFECTIONS
Pelvic Cellulitis

Peritonitis
Signs and Symptoms:
Spiking a fever of 102 0 F to 104 0 F
Elevated WBC
Chills
Extreme Lethargy
Nausea and Vomiting
Abdominal Rigidity and Rebound Tenderness
PREVENTIVE MEASURES
 Prompt treatment of anemia
 Well-balanced diet

 Avoidance of intercourse late in pregnancy

 Strict asepsis during labor and delivery

 Teaching of postpartum hygiene measures

 keep pads snug

 change pads frequently
 wipe front to back
 use peri bottle after each elimination
LOCALIZED INFECTION
 Infection of the Episiotomy, Perineal
laceration, Vaginal or vulva lacerations
 Wound infection of incision site
 Signs:
Reddened, edematous, firm, tender edges of

skin
 Edges seperate and purulent material
drains from the wound.
 Treatment
 Antibiotics
 Wound care
 CHECK YOURSELF

 Mrs. X. was admitted with endometritis

and Mrs. Y. was admitted with an infection

in her cesarean incision. Are both classified

as a postpartum Infection?

 What would be the major difference in

presenting symptoms you would note on

nursing assessment?
POSTPARTUM CYSTITIS
 POSTPARTUM CYSTITIS
• Prevention:
• Monitor the patients urination diligently!
• Don’t allow to go longer than 3 - 4 hours before
intervening.
• Treatment
• Antibiotics -- Ampicillin
• Urinary Tract Antispasmodics
• Causes:
• Stretching or Trauma to the base of the bladder results
in edema of the trigone that is great enough to obstruct
the urethra and to cause acute retention.
• Anesthesia
 MASTITIS

Marked Engorgement, Pain, Chills,

Fever, Tachycardia, Hardness and
Redness, Enlarged and tender
lymph nodes
 MASTITIS
 Types:
 Mammary Cellulitis - inflammation of
the connective tissue between the lobes in
the breast

 Mammary Adenitis - infection in the

ducts and lobes of the breasts
 Development of Mastitis

Improper First Supplemental "Lazy Feeder"

breaking of Nursing Feedings
suction Experience

Poor Strong Abrupt Interval

Positioning Sucking Weaning between
of Infant Infant nursing too long

Nipple Trauma Pain Impaired Engorgement

Let down

Cracked Stasis
nipples of milk

Entry for Bacteria Plugged ducts

Mastitis
Treatment, No Treatment
Problem will resolve Breast Abscess
 TREATMENT OF MASTITIS
 Rest

 Appropriate Antibiotics--Usually Cephalosporins

 Hot and / or Cold Packs

 Don’t Stop Breast Feeding because:

 If the milk contains the bacteria, it also contains
the antibiotic
 Sudden cessation of lactation will cause severe
engorgement which will only complicate the
situation
 Breastfeeding stimulates circulation and moves
the bacteria containing milk out of the breast
 MASTITIS Meticulous
handwashing

Frequent feedings
and massage
Preventive Measures distended area to
help emptying

Rotate position of
baby on the breast
COMPLICATION OF MASTITIS

Breast Abscess

Breast Feeding is stopped on the affected side, but may feed on the
unaffected side.
Treatment: Incision and Drainage
THROMBOEMBOLIC DISEASE
Predisposing Factors
Slowing of blood in the legs
Trauma to the veins

Signs and Symptoms

Sudden onset of pain
Tenderness of the calf
Redness and an increase in skin
temperature
Positive Homan’s Sign
Treatment
Heparin --it does not cross into breast milk
Antidote: protamine sulfate
Teach patient to report any unusual bleeding, or
petchiae, bleeding gums, hematuria, epistaxis, etc.

Complication
Pulmonary Emboli
 POSTPARTUM PSYCHIATRIC
DISORDERS

Mental Health problems can complicate the

puerperium.
There are days when each new mother may feel
inadequate, but the mother who has a constant
feeling of inadequacy needs professional
counseling.
Pregnancy alone is not a cause of a psychiatric
Illness; however, the psychological and physiological
stressors relating to pregnancy may bring on an
emotional crisis
MOOD DISORDERS

The Most common Mood

Disorders are:
 Baby Blues

 Postpartum Depression

 Bipolar Disorder
 BABY BLUES
 50-80% of moms are affected
 Self-limiting (up to 10 days)

 Cause
 Seems to be related to changes in progesterone,
estrogen, and prolactin levels
 Symptoms
 Tearful yet happy
 overwhelmed

 Treatment
 POSTPARTUM MAJOR MOOD DISORDER
“POSTPARTUM DEPRESSION”
 Risk factors:
 Primiparity
 History of postpartum depression
 Lack of social and relational support

 Clinical therapies
 Counseling and support groups
 Medication (usually SSRI’s)
 Childcare assistance
 POSTPARTUM PSYCHOSIS
 Predisposing factors
 Similar to those of postpartum
depression

 Assessments
 Grandiosity
 Decreased need for sleep (insomnia)
 Flight of ideas
 Psychomotor agitation/hyperactivity
 Rejection of infant
TREATMENT FOR MOOD DISORDERS
 Drug therapy
 Psychotherapy

 Explain the importance of good nutrition and rest

 Reintroduce the mother to the baby at the

mothers own pace
 How do the signs and symptoms of hematoma differ
from those of uterine atony or a laceration?

 What laboratory study should the nurse suspect if

the woman is on heparin anticoagulation?

 What is the significance of a board-like abdomen in

a woman who has endometritis?

 Why is it important that the breast-feeding mother

with mastitis empty her breasts completely?

 What is the KEY difference between postpartum

blues and postpartum depression?