POSTPARTUM

COMPLICATIONS
 SHOCK

• Is a condition in which the cardiovascular system fails to

provide essential oxygen and nutrients to the cells. Many
organs can be damaged as a result.
• Shock is a life-threatening condition that occurs when the
body is not getting enough blood flow.
 MAIN TYPES OF SHOCK:

• Cardiogenic shock – caused by pulmonary embolism,

anemia, hypertension or cardiac disorders
• Hypovolemic shock – caused by postpartum hemorrhage or
blood clotting disorders
• Anaphylactic shock – caused by allergic responses to drugs
administered
• Septic shock – caused by puerperal infection
• Neurogenic shock – caused by damage to the nervous system.
 CAUSES:

• Heart problems such as heart attack or heart failure

• Low blood volume as with heavy bleeding or dehydration
• Changes in blood vessels as with infection or severe allergic
reactions
• Certain medicines that significantly reduce heart function or
blood pressure.
 HEMORRHAGE

• Traditionally defined as blood loss greater than 500 ml after

vaginal birth or 1000ml after cesarean delivery
• Early postpartum hemorrhage – occurs within 24 hrs after
delivery
• Late postpartum hemorrhage – occurs after 24 hrs up to 6
weeks after delivery
• Major risk is hypovolemic shock
 1. HYPOVOLEMIC SHOCK

• Occurs when the volume of blood is depleted and the cannot

fill the circulatory system
• The woman can die if blood loss does not stop and the blood
volume is not corrected
• Body’s response to hypovolemia
• Initially, increased heart rate and respiratory rate – increases the oxygen
content and more quickly circulate the remaining blood ( compensatory
mechanism )
• The first blood pressure change is narrow pulse pressure ( a falling
systolic pressure and a rising diastolic pressure) – the BP continues
falling and eventually cannot be detected.
• Blood flow to essential organs gradually stops to make more
blood available for vital organs (heart and brain) – causing
skin and mucous membrane to become pale, cold and clammy
• As blood loss continues, flow to the brain decreases, resulting
in mental changes, such as anxiety, confusion, restlessness and
lethargy
• As blood flow to kidney decreases, they respond by
conserving fluid – urine output decreases and eventually stops
 MEDICAL MANAGEMENT

• Stopping the blood loss

• IV fluids to maintain the circulating volume and replace fluids
• Giving blood transfusions to replace lost RBC
• Giving oxygen to increase the saturation of remaining blood
cells
• Placing an indwelling catheter to assess urine output, which
reflects kidney function
 NURSING CARE

• Assess VS every 15 mins until stable

• Routine frequent assessment of lochia in the fourth stage of
labor helps to identify early postpartum hemorrhage
• When the amount of lochia is normal and the uterus in firm but signs of
hypovolemia is evident, the cause may be a large hematoma
• Excessive bright red bleeding despite a firm fundus may indicate a
cervical or vaginal laceration
• Occurrence of petechiae, bleeding from venipuncture sites or oliguria
may indicate a blood clotting problem
• In the first hour postpartum the perineal pad should be
weighed to determined the output amount (1g=1ml)
• I and O should be recorded and IV therapy monitored
• Careful explanation to the mother and provide emotional
support
 2. ANEMIA

• Occurs after hemorrhage because of the lost RBC

• The woman may feel dizzy or light-headed and is likely to
faint, especially in charging position quickly
• Difficulty in meeting needs due to less tissue perfusion
• Iron supplements are prescribed to provide adequate amounts
of this mineral for manufacturer of RBC
3. EARLY POSTPARTUM HEMORRHAGE

Results from one of the following:

Uterine atony
• Lack of normal muscle tone of the uterus
• Caused by uterine overdistention, retained placental fragments,
prolonged labor, full bladder, or use of drugs during labor that relaxes
the uterus
• Characteristics:
• Uterus is difficult to feel or boggy
• Fundal height is often high (above umbilicus)
• Lochia is increased and may contain large clots
 MEDICAL AND NURSING
MANAGEMENT:
• Massage a boggy uterus
• For bladder distention: let client void or catheterization
• Let infant suck breast to stimulate contraction
• Oxytocin or methergine are often indicated
• Correct the cause of bleeding
• Hysterectomy, through rare, is needed if other measures do not
correct it
• Should be kept in NPO until bleeding stops
Genital trauma
• Lacerations of the reproductive tract (perineum, vagina, cervix
or area around the urethra)
• Likely to occur if there is rapid labor, forceps or vacuum delivery
• Blood loss is usually bright red than lochia and flows in a continuous
trickle
• Uterus is firm
Treatment:
• Notify physician for suturing
NURSING CARE:
• Report s/s of bleeding
• Keep client on NPO
• Hematomas of the reproductive tract
• Collection of blood within the tissues
• Usually on the vulva or inside the vagina
• Seen as a bluish or purplish mass
• Severe discomfort that analgesics do not relieve
TREATMENT:
• Small hematomas usually resolve without treatment
• Larger ones may require incision and drainage of the clots
• Bleeding vessel is ligated or the area is packed with a hemostatic
material to stop the bleeding
NURSING CARE:
• Ice pack is sufficient for small hematomas
• Keep on NPO until the physician has examined the client
4. LATE POSTPARTUM HEMORRHAGE

• Usually occurs after discharge from the hospital and usually

results from:
• Retention of placental fragments
• Subinvolution of the uterus
TREATMENT:
• Administration of oxytocin, methergin or prostaglandins
• Dilation and curretage
NURSING CARE:
• Watch for s/s of shock
• Instruct client to report the following:
• Persistent bright red bleeding
• Return of red bleeding after it has changed to pinkish or white.
OTHER COMPLICATIONS:
 THROMBOEMBOLIC DISORDER

• A venous thrombosis is a blood clot within the vein

• The size of clot increases as more blood passes it and deposits
more platelets, fibrin and cells
• Often causes inflammation in the blood vessel walls
• A pregnant client is at risk because of the compression of the
blood vessels by the heavy uterus by pressure behind the knees
when the legs are placed in the stirrup, or by blood vessel
injury during cesarean section
• Normally, the levels of fibrinogen and other clotting factors,
increase during pregnancy, whereas levels of clot-dissolving
factors decrease -> causing a state of hypercoagulability
• If the woman has varicose veins or remains in bed rest her
state of hypercoagulability places her at an increased risk for
thrombus formation
 TYPES:
• Superficial vein thrombosis (SVT) involves the saphenous
vein of the lower leg and is characterized by a painful, hard,
reddened, warm vein that is easily seen
• Deep vein Thrombosis (DVT) can involve veins from the feet
to the femoral area and is characterized by pain, calf,
tenderness, leg edema, color changes, pain when walking, and
sometimes a positive Homan’s sign
• Pulmonary embolism (PE) occurs when the pulmonary artery
is obstructed by a blood clot that breaks off (embolism) and
lodges in the lungs
• It may have a dramatic s/s such as sudden chest pain, cough, dyspnea,
decreased level of consciousness and signs of heart failure
 TREATMENT

• SVT is treated with analgesics, local application of heat, and

elevation of the legs to promote venous drainage
• DVT is treated similarly with the addition of SQ or IV
anticoagulants
• Clients PE is transferred to the ICU for observation
 NURSING CARE:

Prevention of thrombi is important:

• Pregnant woman should not cross their legs because it
empedes blood flow
• If elevated, no pressure or sharp flexion of legs so as not to
impede blood flow
• Encourage early ambulation or ROM during postpartum
period
• Antiembolic stockings are indicated if varicose veins are
present
• Place padding in stirrups during delivery
• If in anticoagulant therapy:
• Teach s/s of excess anticoagulation such as prolonged bleeding from
minor injuries, bleeding gums, nosebleeds and unexplained bruising
• Use a soft toothbrush and avoid minor traumas
 HEART DISEASE

• Affects a small percentage of pregnant women

• During a normal pregnancy, the increase in heart rate, blood
volume and cardiac output places a physiological strain on the
heart that may not be tolerated in a woman with pre existing
heart disease
• Cardiac failure can occur prenatally, during labor or in the
postpartum period
 CLASSIFICATIONS:

• CLASS I- no limitation of physical activity

• CLASS II- slight limitation of physical activity; ordinary
activity causes fatigue, palpitation, dyspnea or angina
• CLASS III- moderate to marked limitation of physical
activity; less than ordinary causes fatigue, etc.
• CLASS IV- unable to carry on any activity without
experiencing discomfort.
 ASSESSMENT:
Clinical manifestation:
• Thrombosis- due to increased clotting factor
• Due to the increased demands of pregnancy, the woman’s
heart may not meet theses and s/s of congestive heart failure
may occur.
• Persistent cough, often with expectoration of mucus that may be blood-
tinged
• Moist lung sounds because of fluids in the lungs
• Fatigue or fainting on exertion
• Orthopnea
• Severe pitting edema of the lower extremities or generalized edema
• Palpitations
• Changes in FHT indicating hypoxia or growth restriction if placental
blood flow is reduced
• During labor, each contraction temporarily shifts 300-500 ml
of blood from the uterus and placenta to the woman’s
circulation, possibly overloading her weakened heart
• Excess interstitial fluid rapidly returns to the circulation after
birth, predisposing the woman to circulatory overload during
the postpartum period.
 TREATMENT:

• Usually under the care of an obstetrician and a cardiologist

• More prenatal visits are recommended
1. DIET - Should gain enough but excessive weight gain is
avoided because it adds to the demands of the heart
2. BED REST – especially after the 30th week of gestation to
ensure that pregnancy is carried to term or at least 36 weeks.
3. MEDICATIONS:
a. DIGITALIS
b. IRON PREPARATIONS, e.g.
Fer-in-sol/Feosol – anemia should be prevented because the body
compensates by increasing cardiac output, thus further increasing cardiac
workload.
4. Classes III and IV are not put on lithotomy position during
delivery to avoid increasing venous return. The semi-sitting
position is preferred to facilitate easy respirations.
5. Anesthetic of choice is caudal anesthesia for effortless
pushless and painless delivery.
Remember: Gravidocardiac are not allowed to push with
contractions ( to prevent Valsalva manuever which increases
venous return to already weak, damaged heart.)
6. Ergotrate and other oxytocics, scopolamine,
diethylstilbestrol and oral contraceptives are contraindicated
because they cause fluid retention and promote,
thromboembolisation.
7. Most critical period – the period immediately following
delivery because – the 30%-50% increase in blood volume
during pregnancy will be reabsorbed into the mother’s
circulation in a matter of 5-10 minutes and the weak heart
must make rapid adjustment to this change.
8. Limiting of physical activity to decrease heart demand
(frequent rest periods to strict bed rest)
9. Drug therapy includes:
• Heparin- to prevent clot formation
• Warfarin (Coumadin) – an anticoagulant is not used because it can cause
birth defects (has teratogenic effects)
• The usual drugs to treat hypertension and arrythmias are not
used due to fetal complications
• Beta adrenergic - causes fetal bradycardia, respiratory depression, and
hypoglycemia
• Thiazide diuretics - has harmful effects on the fetus
• Angiotensin-converting enzyme (ACE) inhibitors – are contraindicated
during pregnancy
10. Vaginal birth is preferred over cesarean delivery because it
carries less risk for infection or respiratory complications
that further tax the impaired heart
11. Forceps or vacuum extraction deliveries may be used to
decrease the need for maternal pushing
 NURSING CARE:

Goal: client education on heparin therapy

• Explain why the change of treatment if she is on warfarin
therapy before the pregnancy
• Teach how to administer medication
• Advise on the importance of laboratory tests, which include
• Partial thromboplastin time (PTT)
• Activated partial thromboplastin time (aPTT)
• Platelet counts
• Stress the importance of reporting immediately s/s of heparin
overdose such as:
• Bruising without reason
• Petechiae
• Bleeding of nose and gums
Goal: to prevent developmental of CHF
• Teach s/s of CHF
• Provide rest periods
• Advise to stop activity when dyspnea is experienced
• Need to plan her diet so that she has enough calories but
without gaining too much weight
• Identify stressors (because stress increases the demands on the
heart) and ways to avoid them
 ANEMIA

• Is the reduced ability of the blood to carry oxygen to the cells

• Hemoglobin levels lower than 10.5g/dl in the 2nd trimester and
below 11g/dl in the 1st and 3rd trimester indicate anemia during
pregnancy
 ASSESSMENT

Clinical manifestation:
• Take note that an anemic woman have vague symptoms to
none
• Some s/s include:
• Fatigue easily and have little energy
• Skin and mucous membrane are pale
• Shortness of breath, a pounding heart, and a rapid pulse may occur with
severe anemia
The woman who develops anemia gradually has fewer symptoms than the
woman who becomes anemic abruptly
4 anemias are significant during pregnancy:
• Nutritional anemia
• Iron-deficiency anemia
• Folic acid-deficiency anemia
• Genetic anemia
• Sickle cell anemia ( deficient of oxygen)
• Thalassemia (poor hemoglobin Formation)
 TREATMENT:

Nutritional anemia:
• Iron or folic supplements
Genetic anemia:
• Treatment is geared towards preventing complications
 NURSING CARE

Goal: to assist on the above treatment

• Teach woman what foods are rich in Iron and folic
• Iron - meats. Chicken, liver, green, leafy vegetables, whole or enriched
grain products, nuts, tofu, eggs, dried fruits
• Folic acid – green leafy vegetables, asparagus, green beans, fruits,
whole grains, liver, legumes, yeast
• Teach also woman how to absorb iron more in the diet
• Although milk is beneficial in pregnancy, it should not be taken at the
same time wit iron supplement because the iron will not be absorbed
easily
• Foods high in Vitamin C may enhance absorption
• Do not take antacids wit iron
• Inform woman that iron makes the stool dark green to black in
color and that mild gastrointestinal discomfort may occur
• For women with sickle cell anemia, they should prevent
dehydration and activities that may cause hypoxia
• For women with thalassemia, they are taught to situations in
which infections are more likely and to report any s/s of
infection immediately
BLOOD INCOMPATIBILITY BETWEEN THE
PREGNANT WOMAN AND FETUS
• The placenta allows maternal and fetal blood to be close
enough to exchange oxygen and waste products without
actually mixing
• However, small leaks that allows fetal blood to enter the
mother’s circulation may occur during pregnancy or when the
placenta detaches from the uterus during the third stage of
labor (1-2 drops of fetal blood may initiate antibody
production)
• No problem occurs if maternal and fetal blood types are
compatible
• But if the maternal and fetal blood factors differ, the mother’s
body will produce antibodies, process is called
ISOIMMUNIZATION -> these antibodies will cross the
placenta and destroy the foreign fetal red blood cells, process
called SENSITIZATION
 ABO INCOMPATIBILTY

• Results when the mother’s blood group is type O (contains

anti-A and anti-B antibodies) and the fetus blood type is either
type A,B or AB
• Milder form of isoimmunization
• Can occur in the first pregnancy
• Does not necessarily increases in severity with each
subsequent pregnancy
 RH (RHESUS) INCOMPATIBILTY

• Happens when Rh antigens enter the blood of an Rh negative

mother and she produces Rh antibodies (proteins) which
crosses the placenta and destroy the Rh positive RBC’s
• Affects the second or subsequent pregnancies, rarely the first
pregnancy, and severity of disorder progresses if treatment is
not made
 ASSESSEMENT

Diagnostic:
• Prenatal screening
• Indirect Coomb’s test – performed on the mother’s serum to measure
the number of Rh (+) antibodies (critical level is usually defined as
greater than titer of 1:8)
• ANTIBODY re screening is usually done at 24, 28 and 32 weeks AOG to
detect any developing sensitization during the pregnancy
• Obtain prenatal history – check to see if mother has had
previous abortions, pregnancies terminated beyond eight
weeks or has received a blood transfusions
• Post delivery detection
• Direct Coomb’s test - reveals presence of maternal antibodies attached
to RBCs of an Rh(+) infant
• Umbilical cord blood is obtained
• If titer is 1:64, indicates extreme degree of hemolytic disease
• Other fetal tests include:
• Hemoglobin and hematocrit may be decreased
• Increased reticulocyte count
• Elevated bilirubin
 CLINICAL MANIFESTATION

• The woman has no obvious effects

• Increased levels of these antibodies are present in antibody
titers
• Results to erythroblastosis fetalis (fetal hemolysis) – depends
of severity
 TREATMENT

• Primary management is to prevent the manufacturer if anti-Rh

antibodies
• Rho(D) immune globulin (RhoGAM) is administered to the Rh (-)
mother
• First dose at 28 weeks AOG (MICRhoGAM -50mg)
• Second dose within 72 hours after birth of an Rh(+) infant or abortus
• Also given after amniocentesis and to women who experience bleeding
during pregnancy, ectopic pregnancy, abortion or blood transfusion
• RhoGAM is not effective if sensitization has already occurred.
• An intrauterine transfusion may be done for the severity
anemic fetus

NURSING CARE:
Goal: to assist in above treatment
• Document in the chart the Rh factor of the woman
• Inform physician of Rh factor
EFFECTS OF A HIGH-RISK PREGNANCY
ON THE FAMILY
DISRUPTION OF USUAL ROLES
The woman who has difficulty pregnancy must often remain
on bed rest at home or in the hospital
Others must assume their usual roles in the family, in addition
to their own obligations
Nurses can help families adjust to these disruptions by
identifying sources of support to help maintain reasonably
normal household function
FINANCIAL DIFFICULTIES
• Women may stop from working
• Medical costs are rising
• Social service referrals may help the family cope with their
expenses
DELAYED ATTACHMENT TO THE INFANT
• Pregnancy normally involves gradual acceptance of and
emotional attachment to the fetus
• The woman with high risk pregnancy may stop planning for
the child and may withdraw emotionally to protect herself
from pain and loss if the outcome is poor.
LOSS OF EXPECTED BIRTH EXPERIENCE
• Couples rarely anticipate problems when they begin a
pregancy
• Most have specific expectations about how their pregnancy,
particularly the birth, will proceed
• At high-risk pregnancy may result in the loss of their expected
experience
• Perinatal loss shatters the hopes of the couple and may exhibit
mourning behaviors associated with the various stages of the
grieving process
• The nurse can help the couple cope and undergo the grieving
process
• Allowing parents to remain together in privacy
• Accepting behaviors related to grieving
• Developing a plan of care to provide support to the family
• Offering parents an opportunity to hold the infant, if they choose
• Preparing parents for the appearance of the infant
• Providing parents with educational materials and referrals to support
groups
• Discussing wishes concerning religious and cultural beliefs
NONINVASIVE TECHNOLOGIES IN THE
FUTURE OF PRENATAL CARE
AMNISURE
Identifies a placental protein that is present in the amniotic
fluid to help diagnose premature rupture of the membranes
3-D ULTRASOUND
Enables clear in utero identification of malformations, such as
cleft lip or palate, abdominal wall defects, and spinal
anomalies
Early tests can measures gestational sac and cervical volume
to enable early treatment of incompetent cervix and
intrauterine growth restriction
FETAL DNA
Free fetal DNA in maternal blood circulation is normal, but
high levels may be an early indicator of preeclampsia
FETAL TROPHOBLAST CELLS
Cells isolated from the maternal external cervical opening at
12-15 weeks AOG can provide identification of genetic
disorders
The test is safer than amniocentesis for this purpose
PROTEOMIC TECHNOLOGY
Amniotic fluid protein studied by proteomic technology,
referred to as SELDI-TOF-MS, enables identification of
intrauterine inflammation that may lead to preterm birth of
fetal inujry
Early diagnosis and treatment can prevent premature birth.