Nursing Care of a Family Experiencing a

Postpartal Complication
Slide Title
Postpartal Hemorrhage
• Significant hemorrhage occurs in 5% to 8% of
women postpartally
• defined as any blood loss from the uterus greater
than 500 mL within a 24-hour period
• 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).
Postpartal Hemorrhage
• Five main causes:
1. uterine atony,
2. lacerations,
3. retained placental fragments,
4. uterine inversion,
5. disseminated intravascular
coagulation
Most
Common
Cause of
Postpartal
Hemorrhage
Postpartal Hemorrhage
1. Uterine Atony
– Relaxation of the uterus
– MC cause of postpartal hemorrhage
– Bleeding from veins
Postpartal Hemorrhage
• Therapeutic Management
– Control bleeding by performing uterine massage
– Observe carefully, including fundal height and
consistency and lochia, for the next 4 hours
– intravenous infusion of oxytocin
– IM Carboprost tromethamine (Hemabate), a
prostaglandin F2a derivative, or
methylergonovine maleate (Methergine)
– Rectal misoprostol, a prostaglandin E1 analogue,
may be administered rectally
Postpartal Hemorrhage
• Other Management
– VS and uterine tone
– Lab – Hgb and Hct
– Bimanual Massage
– Prostaglandin Administration
• IM; Adverse effects – nausea, diarrhea, tachycardia, and
hypertension
– Blood Replacement
• Iron therapy; exertion and postpartal exercises may be restricted to
promote rest and healing
– Monitor for signs of infection
– Hysterectomy or Suturing
• sutures or balloon compression
Postpartal Hemorrhage
2. Lacerations
– 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, vaginal, or perineal lacerations
Postpartal Hemorrhage
2.1. Cervical Lacerations
– Occurs immediately after the delivery of
the placenta
– Bright red bleeding (from arteries)
– Management:
• Repair
• If extensive, regional anesthesia may be
needed to relax the uterine muscles and to
prevent pain
Postpartal Hemorrhage
2.2. Vaginal Lacerations
– Rare; easier to assess than cervical lacerations
– Hard to repair because of friable vaginal tissue
– Management:
• After repair, packing may be placed to maintain
pressure on the suture line and prevent bleeding
• IFC because the packing causes pressure on the
urethra and can interfere with voiding
• Be sure to remove packing before discharge
Postpartal Hemorrhage
2.3. Perineal Lacerations
– Lithotomy position increases tension, which causes
laceration, on the perineum
– Management:
• Treated as an episiotomy repair
• 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
• fourth-degree lacerations can lead to long-term dyspareunia, rectal
incontinence, or sexual dissatisfaction
Postpartal Hemorrhage
3. Retained Placental Fragments
– Usually happens with placenta succenturiata or placenta
accreta
– Assessment:
• UTZ; hCG on blood serum
• If fragment is small, bleeding may occur at 6 t0 20 days postpartum
• Uterus is not fully contracted
– Management:
• D&C
• Balloon occlusion and embolization of the internal iliac arteries
may minimize blood loss
• Methotrexate to destroy placental fragments
• Advise woman to monitor lochia discharge
Postpartal Hemorrhage
4. Uterine Inversion
– prolapse of the fundus of the uterus
– uterus turns inside out
– Never attempt to remove placenta
– Replace placenta, oxytocin after
replacement
Postpartal Hemorrhage
5. Disseminated Intravascular Coagulation
– deficiency in clotting ability caused by
vascular injury
– associated with premature separation
of the placenta, a missed early
miscarriage, or fetal death in utero
– treat underlying cause
Postpartal Hemorrhage
6. Subinvolution
– incomplete return of the uterus to its
prepregnant size and shape
– at a 4- or 6- week postpartal visit, the uterus is
still enlarged and soft
– 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
Postpartal Hemorrhage
– Management:
• Oral administration of methylergonovine, 0.2
mg four times daily
• If the uterus is tender to palpation, suggesting
endometritis, an oral antibiotic also will be
prescribed
• chronic loss of blood from subinvolution will
result in infection or anemia and lack of
energy, conditions that possibly could interfere
with infant bonding
Postpartal Hemorrhage
7. Perineal Hematomas
– collection of blood in the subcutaneous layer of
tissue of the perineum
• can be caused by injury to blood vessels in the perineum
during birth
– Overlying skin is intact, no noticeable trauma
– most likely to occur after rapid, spontaneous births
and in women who have perineal varicosities
– may occur at the site of an episiotomy or laceration
repair if a vein was punctured during repair
– Minor bleeding
Postpartal Hemorrhage
– Assessment:
• Woman may report severe pain on the the perineal area
• Tender on palpation
– Management:
• Report the presence of a hematoma, its size, and the
degree of the woman’s discomfort
• mild analgesic as ordered
• Ice pack
• May be absorbed in 3 to 4 days
• If it continues to enlarge, advise the woman to return to
the birthing home for incision and ligation of bleeding
vessel (under local anesthesia)
Puerperal Infection
• Infection of the reproductive tract
• Uterus is sterile during pregnancy but after membranes
rupture, pathogens can invade
• If infection occurs, the prognosis for complete recovery
depends on:
– Virulence of the invading organism
– The woman’s general health
– Portal of entry
– Degree of uterine involution at the time of the
microorganism invasion
– Presence of lacerations in the reproductive tract
Puerperal Infection
• Conditions That Increase a Woman’s Risk for Postpartal Infection
1. Rupture of the membranes more than 24 hours before birth (bacteria
may have started to invade the uterus while the fetus was still in utero)
2. Placental fragments retained within the uterus (the tissue necroses and
serves as an excellent bed for bacterial growth)
3. Postpartal hemorrhage (the woman’s general condition is weakened)
4. Pre-existing anemia (the body’s defense against infection is lowered)
5. Prolonged and difficult labor, particularly instrument births (trauma to
the tissue may leave lacerations or fissures for easy portals of entry for
infection)
6. Internal fetal heart monitoring (contamination may have been
introduced with placement of the scalp electrode)
7. Local vaginal infection was present at the time of birth (direct spread of
infection has occurred)
8. The uterus was explored after birth for a retained placenta or abnormal
bleeding site (infection was introduced with exploration)
Puerperal Infection
• Can spread to the peritoneum and
circulation
• appropriate antibiotic after culture and
sensitivity testing of the isolated organism
– MC: group b strep, E. coli,
staphylococcus (cause of toxic shock
syndrome)
Puerperal Infection
• Common Guidelines for the Woman With a Postpartal
Infection
– As a rule, the baby of a mother with an increased temperature
(100.4° F [38° C]) for two consecutive 24-hour periods exclusive
of the first 24 hours is kept in an isolation nursery until the
cause of the infection is determined. The mother may have an
upper respiratory tract or gastrointestinal infection that is
unrelated to childbearing but transmittable to a newborn.
– If the cause of the fever is found to be related to childbirth but
involves a closed infection, such as thrombophlebitis, with no
danger of the baby contracting the disease, the woman may
care for her child as long as she maintains bed rest in the
prescribed position while doing so.
Puerperal Infection
– 3. If the infection involves drainage such as can occur with
endometritis or a perineal abscess, newborn visiting may be
contraindicated. If rooming-in is continued, the mother
should wash her hands thoroughly before holding her infant.
She should never place her baby on the bottom bed sheet,
where there may be some infected drainage from her
perineal pad (furnish a clean sheet to spread over the covers).
– Most hospitals are reluctant to return a baby to a central
nursery after a baby has visited in a room where there is an
infection. The hospital should provide a small nursery that
may be used as an isolation nursery for these situations, or
the baby can be placed in a closed Isolette in a central nursery
or continue to be cared for in the woman’s room.
Puerperal Infection
– If the woman has a high fever, breast milk may be deficient.
With modern antimicrobial therapy, puerperal infections are
limited, and the period of high fever usually is transient. If
the mother is too ill to nurse her baby during this time or if
she is receiving an anticoagulant or antibiotic that is passed
in breast milk and would be harmful to the baby, the infant
should be fed by a supplementary milk formula. The
woman’s breast milk can be manually expressed or pumped
to maintain the production of milk so it will be available
when she is again able to nurse. You may need to assist her
with this, because she fatigues easily and her energy level
may not be enough to support her good intentions. If it
appears that the course of the infection will be long, a
woman may choose to discontinue breastfeeding.
Puerperal Infection
– If it is necessary for a woman to discontinue breastfeeding, she
needs to be assured that she can meet the needs of the child
through bottle feeding.
– If a woman is going to be hospitalized beyond the usual time, she
may have to make arrangements for the discharge and care of
her baby. She may be interested in a homemaker service or
temporary foster care if she has no close friends or family. If she
has older children at home, she needs to keep in close contact
with them, calling them on the telephone or writing them short
notes if possible. If the infant is housed in a high-risk nursery, she
needs to see a photograph of the newborn (a Polaroid or digital
camera should be a piece of equipment on every postpartal unit)
and hear daily reports of his or her progress and well-being.
Puerperal Infection
1. Endometritis
– Infection of the lining of the uterus
– Bacteria gain access to the uterus through
the vagina and enter the uterus either at the
time of birth or during the postpartal period
– usually associated with chorioamnionitis and
cesarean birth
– can lead to tubal scarring and interference
with future fertility
Puerperal Infection
• Assessment:
– Fever, usually 3rd to 4th postpartal day but may occur on first
postpartal day (more than 100.4° F (38° C) for two
consecutive 24-hour periods, except day 1)
– Fever may occur at the same time (4th day) with breast filling
– a woman may have accompanying chills, loss of appetite,
and general malaise
– uterus usually is not well contracted and is painful to the
touch
– Lochia usually is dark brown and has a foul odor
– UTZ to check for placental fragments which may cause
infection
 Puerperal Infection
• Management
– appropriate antibiotic, such as clindamycin (Cleocin)
– obtain the culture from the vagina
– oxytocic agent such as methylergonovine, may be
prescribed to encourage uterine contraction
– additional fluid to combat the fever
– Analgesic
– Sitting in a Fowler’s position or walking encourages
lochia drainage by gravity and helps prevent
pooling of infected secretions
Puerperal Infection
• Infection of the Perineum
– A suture line acts as a portal of entry for
bacterial invasion
– localized infection
– S/S: pain, heat and feeling of pressure,
may or may not have fever,
inflammation on site
Puerperal Infection
• Management:
– Culture the discharge
– Physician or nurse-midwife may remove sutures to
allow drainage
– Topical antibiotic
– Analgesic
– Sitz bath/moist warm compress/ Hubbard tank
treatrment
– Remind the woman to change perineal pads frequently
– Encourage the woman to ambulate
 Puerperal Infection
• Peritonitis
– infection of the peritoneal cavity
– usually occurs as an extension of endometritis.
– one of the gravest complications of childbearing
and is a major cause of death from puerperal
infection
– infection spreads through the lymphatic system or
directly through the fallopian tubes or uterine wall
to the peritoneal cavity
– An abscess may form in the cul-de-sac of Douglas
Puerperal Infection
• Assessment:
– S/S: rigid abdomen, abdominal pain, high fever,
rapid pulse, vomiting, and the appearance of
being acutely ill
– often accompanied by paralytic ileus (blockage of
inflamed intestines)
– leaves scarring and adhesions in the peritoneum
which may cause infertility
• Adhesions formed this way may separate the fallopian
tubes from the ovaries to the extent that ova can no
longer easily enter the tubes.
Puerperal Infection
• Management:
– insertion of a nasogastric tube to
prevent vomiting and rest the bowel
– Intravenous fluid or total parenteral
nutrition may be necessary
– Analgesics
– Antibiotics
Thrombophlebitis
• Phlebitis is inflammation of the lining
of a blood vessel.
• Thrombophlebitis is inflammation
with the formation of blood clots.
• When thrombophlebitis occurs in the
postpartal period, it is usually an
extension of an endometrial infection
Thrombophlebitis
• It tends to occur because:
– A woman’s fibrinogen level is still elevated from pregnancy,
leading to increased blood clotting.
– Dilatation of lower extremity veins is still present as a result
of pressure of the fetal head during pregnancy and birth.
– The relative inactivity of the period or a prolonged time
spent in delivery or birthing room stirrups leads to pooling,
stasis, and clotting of blood in the lower extremities.
– Obesity from increased weight before pregnany and
pregnancy weight gain can lead to relative inactivity and lack
of exercise.
– The woman smokes cigarettes
Thrombophlebitis
• Classified as:
– superficial vein disease (SVD)
– deep vein thrombosis (DVT)
• Risk Factors:
– those who are obese
– have varicose veins
– have had a previous thrombophlebitis,
– older than 35 years of age with increased parity,
– have a high incidence of thrombophlebitis in their
family
Thrombophlebitis
• Prevention of endometritis by the use of
good aseptic technique during birth helps
to prevent thrombophlebitis
• Encourage ambulation to promote venous
return and prevent clot formation
• Support stockings for varicose veins
– To be put on before a woman rises in
the morning
 Thrombophlebitis
• Preventive Measures:
– Ask primary care provider if you can use a
sidelying or back-lying (supine recumbent)
position for birth, rather than a lithotomy position
(lithotomy position can increase the tendency for
pooling of blood in the lower extremities).
– If you will be using a lithotomy position, ask for
padding on the stirrups to prevent calf pressure.
– Drink adequate fluids to be certain you’re not
dehydrated (6–8 glasses of fluid/day).
Thrombophlebitis
– Do not sit with your knees bent sharply, and avoid
wearing constricting clothing such as knee-high stockings.
– Ambulate as soon after birth as you are able. Early
ambulation is the best preventive measure. When resting
in bed, wiggle your toes or do leg lifts to improve venous
return.
– Ask your primary care provider if he or she recommends
support stockings in the immediate postpartal period. Be
certain to put these on before ambulating in the
morning, before leg veins fill.
– Quit smoking as this is associated with the development
of thrombophlebitis.
Thrombophlebitis
• Femoral Thrombophlebitis
– femoral, saphenous, or popliteal veins are
involved
– an accompanying arterial spasm often occurs,
diminishing arterial circulation to a leg as well
• This decreased circulation, along with edema, gives the
leg a white or drained appearance
– formerly called milk leg or phlegmasia alba
dolens (“white inflammation”)
• was formerly believed that breast milk drained into the
leg, giving it its white appearance
Thrombophlebitis
• Assessment:
– S/S: elevated temperature, chills, pain, and redness
in the affected leg about 10 days after birth
– leg begins to swell below the lesion at the point at
which venous circulation is blocked
– skin becomes so stretched from swelling that it
appears shiny and white
– Homans’ sign (pain in the calf of the leg on
dorsiflexion of the foot) may be positive
– Doppler ultrasound or contrast venography usually is
ordered to confirm the diagnosis
Thrombophlebitis
• Management:
– bed rest with the affected leg elevated
– administration of anticoagulants
– application of moist heat
– A bed cradle keeps pressure of the bedclothes off
the affected leg, both to decrease the sensitivity of
the leg and to improve circulation
– Provide good back, buttocks, and heel care.
– Check for bed wrinkles so that a woman does not
develop the secondary problem of a pressure ulcer
while on bed rest.
Thrombophlebitis
– Never massage the skin over the clot; this could loosen
the clot, causing a pulmonary or cerebral embolism.
– Analgesics and antibiotic
• Aspirin serves as analgesic and anticoagulant
– anticoagulant (coumarin derivative or heparin) or a
thrombolytic agent such as streptokinase or urokinase
to dissolve the clot through the activation of fibrinolytic
precursors and prevent further clot formation
– Baseline activated partial thromboplastin time (aPTT) or
prothrombin time (PT) is obtained
• Blood coagulation levels daily to determine the effectiveness
of the drug therapy
Thrombophlebitis
– Heparin, an anticoagulant, can be
administered by continuous intravenous
infusion or intermittently by
intravenous or subcutaneous injection
• Educate woman on proper subcutaneous
administration upon discharge
• Breastfeeding may be continued
• Protamine sulfate – heparin antagonist
Thrombophlebitis
– Warfarin (coumadin) if woman does not plan
to breastfeed infant
– antidote: Vitamin K
– Assess for possible signs of bleeding
• bleeding gums
• ecchymotic spots on the skin
• oozing from an episiotomy suture line
– Lochia is increased with anticoagulant
treatment
• record the amount of discharge (no. of pads)
Thrombophlebitis
– affected leg may never return to its
former size and may always cause
discomfort after long periods of standing
– Anticoagulant therapy may need to be
continued for 3 to 6 months
– acute symptoms of femoral
thrombophlebitis last only a few days, but
the full course of the disease takes 4 to 6
weeks before it is resolved
Thrombophlebitis
• Pelvic Thrombophlebitis
– involves the ovarian, uterine, or hypogastric
veins
– occurs later than femoral thrombophlebitis,
often around the 14th or 15th day of the
puerperium
– Risk factors same as femoral
thrombophlebitis
– disease runs a long course of 6 to 8 weeks
Thrombophlebitis
• Assessment :
– a woman suddenly becomes
extremely ill, with high fever, chills,
and general malaise
– infection can be so severe it necroses
the vein and results in a pelvic abscess
– It can become systemic and result in a
lung, kidney, or heart valve abscess.
Thrombophlebitis
• Management:
– total bed rest and administration of antibiotics and
anticoagulants
– If an abscess forms, it can be located by sonogram and
incised by laparotomy, if necessary
• Formation of an abscess is associated with a high mortality rate
• An inflammation of this extent may leave tubal scarring and
interfere with future fertility
• A woman may need surgery to remove the affected vessel before
she attempts to become pregnant again
– teach women preventive measures to reduce the risk of
recurrence with future pregnancies
Thrombophlebitis
• Pulmonary Embolus
– obstruction of the pulmonary artery by a blood clot; it usually
occurs as a complication of thrombophlebitis
– S/S:
• sudden, sharp chest pain;
• tachypnea;
• tachycardia;
• orthopnea (inability to breathe except in an upright position);
• cyanosis (the blood clot is obstructing the pulmonary artery, blocking blood
flow to the lungs and return to the heart)
– O2 administration
– ICU admission as woman is at high risk for cardiopulmonary arrest
– Condition guarded until clot is lysed or adheres in the pulmonary
artery wall and is reabsorbed
Mastitis
• infection of the breast
• may occur as early as the seventh
postpartal day or not until the baby is
weeks or months old
• organism causing the infection usually
enters through cracked and fissured
nipples
 Mastitis
• measures that prevent cracked and fissured nipples also help
prevent mastitis:
– Making certain the baby is positioned correctly and grasps the
nipple properly, including both nipple and areola
– Releasing a baby’s grasp on the nipple before removing the
baby from the breast
– Washing hands between handling perineal pads and touching
the breasts
– Exposing nipples to air for at least part of every day
– Using a vitamin E ointment to soften nipples daily
– If a woman has one cracked and one well nipple, encourage
her to begin breastfeeding (when the infant sucks most
forcefully) on the unaffected nipple.
Mastitis
• Infection may come from the nasal–oral cavity of
the infant
– Staph. Aureus (which the infant acquired in the
hospital)
– Candidiasis
– By sucking on a nipple, the infant introduces the
organisms into the milk ducts, where they
proliferate (breast milk is an excellent medium
for bacterial growth)
• Epidemic breast abscess
Mastitis
• Assessment:
– usually unilateral
– epidemic mastitis, because it originates
with the infant, may be bilateral
– The affected breast is painful, swollen, and
reddened
– Fever accompanies these first symptoms
within hours, and breast milk becomes
scant.
Mastitis
• Management:
– antibiotics effective against penicillinresistant
staphylococci such as dicloxacillin or a
cephalosporin
– Breastfeeding is continued, because keeping the
breast emptied of milk helps to prevent growth
of bacteria
– Cold or ice compresses and a good supportive
bra help with pain relief until the process
improves
Mastitis
– Warm, wet compresses may be ordered to reduce
inflammation and edema
– May lead to breast abscess if untreated
• large portion of the breast and rupture through the skin,
with thick, purulent drainage, necessitating incision and
drainage of the abscess
• breastfeeding on that breast is discontinued
• formula feeding will be an acceptable alternative
– Reassure woman that this is not associated with
breast cancer and does not interfere with future BF
potential
Urinary System Disorders
• Urinary Retention
– occurs as a result of inadequate bladder
emptying
– After childbirth, bladder sensation for voiding is
decreased because of bladder edema caused
by the pressure of birth
– Bladder distention may cause loss of bladder
tone leading to urinary incontinence
– associated with the use of anesthesia,
especially epidural anesthesia
Urinary System Disorders
• With primary overdistention, a woman
does not void at all
• With urinary retention and overflow, a
woman is able to void
– Measure the amount of first voiding
after birth
– if this voiding is less than 100 mL,
suspect urinary retention
Urinary System Disorders
• Residual – the amount of urine left in
the bladder after voiding
– Greater than 100 ml
– Typically, her physician or nurse-
midwife writes an order such as,
“Catheterize for residual urine. If
this is greater than 100 mL, leave
indwelling catheter in place.”
Urinary System Disorders
• use strict antiseptic technique to prevent
introducing pathogenic bacteria into the sterile
urinary tract and causing a urinary tract infection
• Always use an indwelling (Foley) catheter rather
than a temporary one (straight catheter) to
catheterize
• Vulvar edema often distorts the position and
appearance of the urinary meatus – postpartal
catheterization may be difficult
Urinary System Disorders
• Management:
– IFC
– Ambulation to prevent complications such as
thrombophlebitis
– Encourage the woman to void by the end of 6
hours after removal of the catheter
• If a woman has not voided by 8 hours after catheter
removal, the physician or nurse-midwife may order
reinsertion of the indwelling catheter for an
additional 24 hours
Urinary System Disorders
• Urinary Tract Infection
– symptoms of burning on urination,
possibly blood in the urine (hematuria),
and a feeling of frequency or that she
always has to void, low-grade fever and
discomfort from lower abdominal pain
Urinary System Disorders
• Management:
– Sulfa drugs CI to breastfeeding as it
causes jaundice in the newborwn
– Broad spectrum antibiotics are
prescribed
– Increase OFI
– Oral analgesic for pain
 Cardiovascular System Disorders
• Postpartal Pregnancy-Induced Hypertension
– reason the condition occurs is usually retention of
some placental material
– S/S: proteinuria, edema, and hypertension
– Seizures typically develop 6 to 24 hours after birth
• Seizures after 72 hours may not be related to PIH
– TX: bed rest, a quiet atmosphere, frequent monitoring
of vital signs and urine output, and administration of
magnesium sulfate or an antihypertensive agent
– Woman can be reassured that symptoms of this
condition fades quickly
 Reproductive System Disorders
• Reproductive Tract Displacement
– Problems of retroflexion, anteflexion, retroversion,
and anteversion or prolapse of the uterus may occur
• ligaments may no longer be able to maintain the uterus in its
usual position or level after pregnancy
– a cystocele (outpouching of the bladder into the vaginal
wall) or a rectocele (outpouching of the rectum into the
vaginal wall) may occur
• Occurs due to weakened vaginal wall
– If stress incontinence (involuntary voiding on exertion)
occurs, Kegel exercises to strengthen perineal muscles
may be helpful
 Reproductive System Disorders
• Separation of the Symphysis Pubis
– women feel some discomfort at the symphysis pubis because
of relaxation of the joint preparatory to birth
– After birth, the woman experiences acute pain on turning or
walking; her legs tend to rotate externally, giving her a
waddling gait.
– A defect over the symphysis pubis can be palpated; the area is
swollen and tender to touch
– Tx:
• Bed rest and the application of a snug pelvic binder to immobilize the joint are
necessary to relieve pain and allow healing
– 4- to 6-week period is necessary for healing to take place
• avoid heavy lifting for an extended period, until healing in the pubic ligaments is
complete.
• consider cesarean birth for any future pregnancy
Emotional and Psychological Complications of the Puerperium

• 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
• Inability to bond is a postpartal complication
with far-reaching implications, possibly
affecting the future health of the entire family.
Emotional and Psychological Complications of the Puerperium

• A Woman Whose Child Is Born With an Illness or Is Physically

Challenged
– The image of the “perfect” child she thought she was
carrying has died
– They can feel angry, hurt, and disappointed
– may feel a loss of self-esteem: they have given birth to an
imperfect child, and so they see themselves as imperfect
– any abnormality should be explained with the couple
– Open lines of communication between the parents and
the hospital staff that allow for free discussion of feelings
and fears will do much to strengthen parent–child
relationships and prepare for future hospitalizations or
Emotional and Psychological Complications of the Puerperium

• A Woman Whose Newborn Has Died

– Most women are interested in seeing the baby, this
is generally therapeutic because it helps them begin
grieving
– “Do you want to talk about what’s happened?” or
“How do you feel?
– “One door closes, another one opens” or “God
must have another purpose for you.”
– Do not place a woman whose child has died in a
hospital room with a woman who has a healthy baby
 Emotional and Psychological
Complications of the Puerperium
• Postpartal Depression
– feelings of sadness (postpartal “blues”) after childbirth – 1 to 10
days postpartum
– occurs as a response to the anticlimactic feeling after birth and also
probably is related to hormonal shifts as the levels of estrogen,
progesterone, and gonadotropin-releasing hormone in her body
decline or rise
– The sensations of overwhelming sadness can interfere with
breastfeeding, child care, and returning to work
– 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
Emotional and Psychological Complications of the Puerperium

• Risk factors: a history of depression, a troubled

childhood, low self-esteem, stress in the home
or at work, and lack of effective support people
– If factors are identified, pregnancy
counseling may be able to prevent symptoms
• A woman may need counseling and possibly
antidepressant therapy to integrate the
experience of childbirth into her life
Emotional and Psychological Complications of the Puerperium

• Postpartal Psychosis
– 1 woman in 500 has symptoms
– a response to the crisis of childbearing
– majority of these women have had symptoms of mental
illness before pregnancy
– A woman with postpartal psychosis usually appears
exceptionally sad
– 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
Key Points for Review
• Establishing a firm family–newborn relationship may be
difficult when a woman has a postpartal complication.
Investigate ways that will allow a woman to care for her
baby, or offer necessary support to family members so that
they can fulfill this role.
• Hemorrhage (defined as a loss of blood greater than 500 mL
within a 24-hour period) is a major potential danger in the
immediate postpartal period. The most frequent cause of
postpartal hemorrhage is uterine atony. Continuous limited
blood loss can be as important over time as sudden, intense
bleeding. With hemorrhage, administration of oxytocin may
be necessary to initiate uterine tone and halt the bleeding.
• Other causes of hemorrhage include lacerations (vaginal, cervical,
or perineal) and retained placental fragments. Lacerations are
most apt to occur with forceps birth or with the birth of a large
infant. Disseminated intravascular coagulation can also cause
postpartum hemorrhage.
• Puerperal infection (a temperature greater than 100.4° F or 38.0°
C) is a potential complication after any birth until the denuded
placental surface has healed. Retained placental fragments and
the use of internal fetal heart monitoring leads are potential
sources of infection.
• Thrombophlebitis, an inflammation of the lining of a blood vessel,
occurs most often as an extension of an endometrial infection.
Therapy includes bed rest with moist heat applications and
anticoagulant therapy. Never massage the leg of a woman with
thrombophlebitis; doing so can cause the clot to move and
become a pulmonary embolus, a possibly fatal complication.
• Mastitis is infection of the breast. The symptoms
include pain, swelling, and redness. Antibiotic
therapy is necessary.
• A woman whose child is born with a physical or
cognitive challenge needs special consideration after
birth. This is obviously a time of stress, and a woman
needs supportive nursing care.
• Postpartal “blues” are a normal accompaniment to
birth. Postpartal depression (a feeling of extreme
sadness) and postpartal psychosis (an actual
separation from reality) are not normal and need
accurate assessment so a woman can receive
adequate therapy for these conditions.