Nursing care of Family

Experiencing Postpartum
Complication
Chapter 25
Page 647
Postpartal Hemorrhage
Major danger in the immediate
postpartal period
Loss of blood greater than
500ml within 24 hour period
May occur within 24 hours
(early)
May occur anytime after the
first 24 hours during the
remaining days of the 6-week
puerperium (late)
 5 main causes of postpartal
hemorrhage
Uterine atony
Lacerations
Retained placental fragments
Uterine inversion
Disseminated intravascular
coagulation (DIC)

Note : 4Ts of post partum hemorrhage

(Tone, trauma, tissue and thrombin
UTERINE ATONY (relaxation of
the uterus)
Uterus fails to contract
Risk Factors : Box 25.3 p. 650
Management:
Massage gently (fundal
massage)
Keep bladder empty
An over distended bladder leads
to atony of the bladder wall,
resulting in urinary distension,
which provides an environment
favourable to infection.
Monitor vital signs and blood loss
● Weigh perineal pad before and after use to measure
accurately amount of blood loss
● Check under the hips
● Tachycardia and hypotension - Most significant changes in
hemorrhage

Administer oxytocin (Pitocin)

Methergine
Bimanual massage
Prostaglandin administration, Misoprostol
Elevate the lower extremeties
Oxygen (10-12L/min)
Blood transfusion and IVF
to replace blood loss
Manual exploration of the uterine body, cervix and
vagina
for retained fragments and lacerations
Curettage
If due to retained placental fragments
Ligation of uterine arteries
Hysterectomy
LACERATIONS
Tears in vaginal canal
● A constant trickle of blood
and a firm fundus are usually
indicative of a vaginal tear
● Cervical lacerations, vaginal
lacerations and perineal
lacerations
● Cause : precipitate labor,
primigravida, LGA,
lithotomy position and
instruments
Classification of Perineal Lacerations (Table 25.1
page 654)
● First degree
● Second degree
● Third degree
● Fourth degree

Lithotomy position increase tension in the perineum.

Management
1. Return woman to the delivery room
► for inspection and repair
2. Vaginal packing
► To maintain pressure on the suture line
► Remove packing after 24 to 48 hours
3. For 3rd and 4th degree lacerations
► No enema
► No rectal suppository
► Temperature should not be taken
rectally
► Constipation should be avoided
RETAINED PLACENTAL
FRAGMENTS
Most common cause of late
postpartum hemorrhage
Inhibit effective contraction of the
uterus resulting in uterine atony
and hemorrhage
HCG hormone indicates the
presence of placenta in the uterus
Considered as the major cause of
early postpartum hemorrhage
RETAINED PLACENTAL
FRAGMENTS
S/S
Bleeding(large fragments)
Bleeding 6 –10 days pp (small
fragments)
Uncontracted uterus.
RETAINED PLACENTAL
FRAGMENTS

Management
1. D and C
2. Manual removal of placenta
3. Hysterectomy
4. Methotrexate for
5. placenta accreta
UTERINE INVERSION
Prolapse of the fundus of the
uterus through the cervix so
that the uterus turns inside out
Causes:
Traction is applied to the
umbilical cord to remove the
placenta
Pressure is applied to the
uterine fundus when the uterus
is not contracted
Management:
Never attempt to replace an inversion
may increase the bleeding
Never attempt to remove the placenta if it is attached
may create large surface area for bleeding
IV fluid administration
Administer O2 by mask
Assess vital signs
Be prepared to do CPR if the woman’s heart fail from
the sudden blood loss
Administration of general anesthesia, nitroglycerin or tocolytic
drug IV
to relax the uterus
Don’t administer oxytocin
it compounds the inversion or it makes the uterus more tense
and difficult to replace
Administration of oxytocin after manual replacement
helps the uterus to contract and remain in its natural place
Antibiotic
to prevent infection
Notify that cesarean may be necessary
SUBINVOLUTION OF THE UTERUS
Delay in the return of the uterus to its prepregnant size, shape
and function

Subinvoluted uterus
Uterus is larger than normal and vaginal bleeding with clots
Signs and symptoms
1. Enlarged and boggy uterus
2. Prolonged lochial discharge
► Persistent lochia rubra
3. Backache
 Management
1. Prone and knee-chest positions
■ Encourage the return of the uterus to each usual
anteverted position
2. Ergonovine maleate
► to stimulate uterine contractions 0.2mg four
times a day for three days
4. Antibiotics
► infection
4. D and C
if there are retained placental fragments
5. Instruct the woman to report the following signs:
Fever
Vaginal bleeding
Passage of tissue
Perineal Hematomas

A collection of blood in the subcutaneous layer of tissue of

the perineum may be caused by injury to blood vessels in
the perineum during birth
Signs and symptoms
Severe pain in the perineal area or a feeling pressure
between her legs
Purplish discoloration with obvious swelling
Management:
Report the presence of hematoma, its size the degree of
the woman’s discomfort
Administer mild analgesic
Apply ice pack
Large hematoma – ligation of bleeding vessels
Keep suture line clean and dry
Hot sitz bath once or twice daily.
 Puerperal Infection
Infection of the reproductive tract which is
another leading cause of maternal mortality
Temperature of greater than 100.4°F or 38°C
Risk factors associated for puerperal infection
history of previous puerperal infection
CS
Trauma
prolonged rupture of membranes
prolonged labor
excessive number of vaginal exam
retained placental fragments
Postpartal hemorrhage
Management:
Appropriate antibiotics
To decrease the chance of infection and pain,
intercourse should be postponed until the lochia
stops and the episiotomy is healed.
Any article or instruments introduce into the birth
canal should be sterile
Proper perineal care
Proper handwashing technique
Complication
Peritonitis
septicemia
Endometritis
Infection of the endometrium, the lining of the uterus
Signs and symptoms
Elevated temperature (38degree for 2 cons 24 hours
Firm, tender uterus
Soft abdomen
Lochia is dark brown and has foul odor
Management
Appropriate antibiotics such as clindamycin (Cleocin)
Oxytocic agent to encourage uterine contraction
Additional fluid to combat fever
Analgesic for pain relief
Fowler’s position or walking to encourage lochia drainage
and prevent pooling of infected secretions
Infection of the Perineum
Localized infection or bacterial invasion on the
woman’s suture line on her perineum from an
episiotomy /laceration repair
S/S – pain, heat, feeling of pressure in suture line,
elevated temp, inflammation with purulent discharge,
wound dehiscence
Management
analgesic
Removal of suture and drainage
Packing (iodoform gauze)
Systemic or topical antibiotic
Sitz bath or warm compress
Change perineal pads frequently
Encourage ambulation
Peritonitis

Peritonitis- Infection of the peritoneal cavity is

usually an extension of endometritis
One of the gravest complication of childbearing
and is a major cause of death from puerperal
infection
Signs and symptoms
Rigid abdomen (guarding) first sign
Abdominal pain
High fever
Rapid pulse
Vomiting
Appearance of acutely ill
Management:
NGT insertion
IVF
TPN
Analgesic
antibiotics
Urinary Tract Infection
Signs and symptoms
Burning on urination
Hematuria
Feeling of frequency of urination
Sharp pain on voiding
Low-grade fever
Lower abdominal pain
Management
Increase fluid intake
Acidification of the urine -inhibits multiplication
of bacteria
Effective urine-acidifying fluid
- Apricot juice
- Prunes juice
- Cranberry juice
Antibiotics- broad spectrum
Thrombophlebitis

Inflammation of the lining of

a blood vessel with the
formation of blood clots

Classification:
Superficial vein disease
(SVD)
Deep vein thrombosis (DVT)
causes
Fibrinogen level is still elevated from pregnncy
Dilatation of lower extremity veins
Inactivity
Obesity, with varicose veins,
thrombosis that is limited to the superficial veins
of the saphenous system is treated with
analgesics, rest, elevation of the affected
extremity and elastic support stockings.
thrombosis of superficial veins usually is accompanied by
signs and symptoms of inflammation
Enlarged, swollen veins
Femoral thrombophlebitis
The femoral, saphenous and popliteal veins are
involved
Homan’s sign – pain in the calf of leg on
dorsiflexion
White or drained appearance of leg (milk leg or
phlegmasia alba dolens)
Elevated temp, chills and redness of affected leg
Management
Prevention of endometritis
Ambulation and limiting time in
stirrups
Bed rest with moist heat application
Bed cradle
Anticoagulant therapy such as heparin
(may breastfeed) or warfarin
(discontinue breastfeeding)
Never massage the leg of a woman
with thrombophlebitis
(May cause clot to move and become
a pulmonary embolus)
Pelvic Thrombophlebitis
Involves ovarian, uterine or hypogastric vein
usually follows mild endometritis
Risk factors: same as femoral thrombophlebitis
s/s : suddenly become extremely ill, high fever, chills
and general malaise
Tx: total bed rest, analgesics, antibiotics and
anticoagulants
Preventive measures: not wearing constricting clothing
on lower extremities, resting with feet elevated, and
ambulating daily during pregnancy
Pulmonary embolus
Obstruction of the pulmonary artery by a blood clot
Signs
Sudden, sharp chest pain
Tachypnea, tachycardia
Orthopnea (inability to breath except in an upright
position)
Cyanosis
Management: Oxygen administration
Emotional and psychological complications of the puerperium

A woman whose child is born with an illness or

is physically challenge
A woman whose newborn has died
Management
tell the parents of the defect
allow parents to care for the child
allow verbalization of feelings and fears
place in private room
Postpartal blues
“Baby blues”
Feelings of overwhelming sadness (1 to 10 days post
partum)
Occur as a response to the anticlimactic feeling after
birth
Probably related to the hormonal shifts on the levels of
estrogen and progesterone and gonadotropin-releasing
hormone after separation of placenta.
Evidenced by tearfulness, feeling of inadequacy, mood
lability, anorexia, and sleep disturbance.
Postpartal depression
Feeling of sadness
Extreme fatigue
Inability to stop crying
Increase anxiety about her own and her infant’s health
Insecurity
Psychosomatic symptoms (nausea and vomiting)
postpartum depression takes place starting on the10th
day after birth
Risk factors
History of depression
Troubled childhood
Low-self esteem stress in the home or at
work
Lack of effective support people

Management
Counseling and possibly antidepressant
therapy
Postpartal Psychosis
Psychosis exists when a person has lost
contact with reality
Illness coincide with the postpartal
period
Probably a response to the crisis of
childbearing
Management
Counseling or psychiatric care
Antipsychotic medication
God bless
you!