Postpartum Postpartum ComplicationsComplications

Twila Brown, PhD, RNTwila Brown, PhD, RN

Postpartum HemorrhagePostpartum Hemorrhage

Blood loss greater than 500 mLBlood loss greater than 500 mL Early postpartum hemorrhageEarly postpartum hemorrhage

– First 24 hours after deliveryFirst 24 hours after delivery» Uterine atonyUterine atony» Lacerations of the genital tract Lacerations of the genital tract » HematomasHematomas» Uterine ruptureUterine rupture

Late postpartal hemorrhageLate postpartal hemorrhage– Usually 1-2 weeks Usually 1-2 weeks – Retention of placental tissueRetention of placental tissue

Early Postpartal Hemorrhage:Early Postpartal Hemorrhage: Uterine atony Uterine atony

CausesCauses– Over distentionOver distention– Dysfunctional laborDysfunctional labor– InductionInduction– Cesarean Cesarean – Grand multiparityGrand multiparity– PreeclampsiaPreeclampsia– Retained placenta Retained placenta

fragmentsfragments– Asian or HispanicAsian or Hispanic

AssessmentAssessment– Fundus Fundus

» SoftSoft» Difficult to findDifficult to find» Above expected levelAbove expected level

– LochiaLochia» ExcessiveExcessive» Bright redBright red» ClotsClots

Early Postpartal Hemorrhage:Early Postpartal Hemorrhage: Uterine atony Uterine atony

InterventionsInterventions– Assess for bleedingAssess for bleeding– Assess fundal heightAssess fundal height– Encourage voidingEncourage voiding– Oxytocin (Pitocin)Oxytocin (Pitocin)– Fundal massageFundal massage– Contact physicianContact physician– Methylergonovine (Methergine)Methylergonovine (Methergine)– IV fluid and/or transfusionIV fluid and/or transfusion– Bimanual compression of uterusBimanual compression of uterus– Ligation of uterine vessels or hysterectomyLigation of uterine vessels or hysterectomy

Early Postpartal Hemorrhage:Early Postpartal Hemorrhage: LacerationsLacerations

Perineal, vaginal, cervicalPerineal, vaginal, cervical Predisposing factorsPredisposing factors

– Primiparous Primiparous – Precipitous deliveryPrecipitous delivery– MacrosomiaMacrosomia– Forceps or vacuum-assisted birthForceps or vacuum-assisted birth– Mediolateral episiotomyMediolateral episiotomy

AssessmentAssessment– Firm uterus Firm uterus – Bright red bloodBright red blood– Stream of unclotted bloodStream of unclotted blood

Early Postpartal Hemorrhage:Early Postpartal Hemorrhage: HematomasHematomas

Blood in soft subcutaneous tissue Blood in soft subcutaneous tissue Predisposing factorsPredisposing factors

– Prolonged pressure of fetal headProlonged pressure of fetal head– Forceps or vacuum extractionForceps or vacuum extraction– Prolonged or precipitous laborProlonged or precipitous labor– MacrosomiaMacrosomia– Pudendal anesthesiaPudendal anesthesia

Subperitoneal hemotomaSubperitoneal hemotoma– Uterine artery branch or vessels in broad ligamentUterine artery branch or vessels in broad ligament– Severe pain and hypovolemic shockSevere pain and hypovolemic shock

Early Postpartal Hemorrhage:Early Postpartal Hemorrhage: Hematomas Hematomas

VaginalVaginal– AssessmentAssessment

» Unilateral purplish discoloration Unilateral purplish discoloration » PainPain» Feeling of fullness in vagina or rectal pressureFeeling of fullness in vagina or rectal pressure» Difficult voidingDifficult voiding

– InterventionIntervention» AnalgesiaAnalgesia» Ice packsIce packs» Sitz bathSitz bath» SurgerySurgery

Late Postpartum HemorrhageLate Postpartum Hemorrhage AssessmentAssessment

– Subinvolution Subinvolution – Lochia Lochia

» Fails to progress from rubra to albaFails to progress from rubra to alba» Saturation of more than 1 pad per hour Saturation of more than 1 pad per hour » Abnormal clotsAbnormal clots

– Bladder distentionBladder distention– Increased rectal, back, or pelvic painIncreased rectal, back, or pelvic pain– Increased pulse or decreased blood pressureIncreased pulse or decreased blood pressure– Signs of anemiaSigns of anemia

Late Postpartal HemorrhageLate Postpartal Hemorrhage

InterventionIntervention– TeachTeach

» Signs of hemorrhageSigns of hemorrhage» Massage fundusMassage fundus» Iron administrationIron administration

– Pitocin or MetherginePitocin or Methergine– IV fluid or blood transfusion, IV fluid or blood transfusion, – OxygenOxygen– Dilation and curettageDilation and curettage

Puerperal InfectionsPuerperal Infections

Reproductive tract associated with childbirthReproductive tract associated with childbirth– Metritis, perineal or cesarean woundMetritis, perineal or cesarean wound

Causes of metritisCauses of metritis– CesareanCesarean - Prolonged labor - Prolonged labor – PROMPROM - Multiple vaginal exams- Multiple vaginal exams– Scalp electrodesScalp electrodes - Internal uterine monitor- Internal uterine monitor– OB traumaOB trauma - Instrument assisted birth- Instrument assisted birth– Manual removal of placentaManual removal of placenta– Prexisting infectionPrexisting infection– Compromised health statusCompromised health status

Puerperal Infections:Puerperal Infections: Metritis Metritis

AssessmentAssessment– Abd/Uterine painAbd/Uterine pain– Foul smelling Foul smelling

vaginal dischargevaginal discharge– Fever 101-104 FFever 101-104 F– Chills Chills – MalaiseMalaise– 30% increase in 30% increase in

WBCWBC

InterventionsInterventions– CBCCBC– CulturesCultures– HygieneHygiene– Abscess is drainedAbscess is drained– IV antibioticsIV antibiotics– Antipyretics Antipyretics – ICU hospitalizationICU hospitalization

Puerperal Infections:Puerperal Infections: Perineal and Cesarean wounds Perineal and Cesarean wounds

Perineal woundPerineal wound– AssessmentAssessment

Cesarean woundCesarean wound– AssessmentAssessment

InterventionIntervention– Sutures removedSutures removed– Drain purulent materialDrain purulent material– AntibioticsAntibiotics– AnalgesicsAnalgesics– Warm compress or sitz bathsWarm compress or sitz baths

Overdistention of the BladderOverdistention of the Bladder CauseCause

– Unable to empty bladder due to trauma or anesthesiaUnable to empty bladder due to trauma or anesthesia AssessmentAssessment

– Distended bladderDistended bladder– Displaced uterus, increased vaginal bleeding, boggy Displaced uterus, increased vaginal bleeding, boggy

uterus, backache, restlessuterus, backache, restless InterventionIntervention

– Encourage voidingEncourage voiding– Perineal ice packsPerineal ice packs– Pour water over perineumPour water over perineum– Aseptic straight catheter X 1Aseptic straight catheter X 1

Urinary Tract InfectionsUrinary Tract Infections Cause Cause

– Retention of urineRetention of urine– Bacteria from catheterizationBacteria from catheterization

CystitisCystitis– AssessmentAssessment– InterventionIntervention

» Increase fluidsIncrease fluids >> Void frequently>> Void frequently» Empty bladderEmpty bladder >> Urine culture and >> Urine culture and

antibioticsantibiotics– PreventionPrevention

» HygieneHygiene» Void q 2-4 hrsVoid q 2-4 hrs» Increase acidity in urineIncrease acidity in urine

Urinary Tract InfectionsUrinary Tract Infections PyelonephritisPyelonephritis

– AssessmentAssessment» UTI signsUTI signs >> High fever>> High fever» ChillsChills >> Flank pain>> Flank pain» N&VN&V >> Acutely ill>> Acutely ill

– ManagementManagement» IV antibioticsIV antibiotics >> Increase fluids>> Increase fluids» AntipyreticsAntipyretics >> Analgesic >> Analgesic » Follow-up culture in 2 weeksFollow-up culture in 2 weeks

MastitisMastitis Infection of breast tissueInfection of breast tissue CausesCauses

– Bacteria enters through cracks in nippleBacteria enters through cracks in nipple– Milk stasisMilk stasis– Poor hand washingPoor hand washing– Breast not dry or wet breast padBreast not dry or wet breast pad– Incorrect placement of baby causes sore nipplesIncorrect placement of baby causes sore nipples

AssessmentAssessment– Fever Fever >> 101 F and chills, acutely ill 101 F and chills, acutely ill– Flu-like symptoms, malasia, headacheFlu-like symptoms, malasia, headache– Painful, warm, red area of breast Painful, warm, red area of breast

MastitisMastitis InterventionIntervention

– Bed restBed rest - Increase fluids- Increase fluids– Supportive braSupportive bra - Antibiotics - Antibiotics– AnalgesicAnalgesic– Breast feed frequently Breast feed frequently – Warm compress before feedingWarm compress before feeding– Cold packs between feedingsCold packs between feedings– Drain abscessDrain abscess

PreventionPrevention– Early feedings and frequent feedingsEarly feedings and frequent feedings– Change baby’s feeding positionsChange baby’s feeding positions– Massage clogged ductMassage clogged duct– Empty breast at each feedingEmpty breast at each feeding– Nipple careNipple care

Thromboembolic DisordersThromboembolic Disorders Blood clot formed from impeded blood flowBlood clot formed from impeded blood flow CausesCauses

– Hypercoagulability of bloodHypercoagulability of blood– Venous stasisVenous stasis– Injury to epithelium of vesselsInjury to epithelium of vessels

Increased riskIncreased risk PreventionPrevention

– Avoid dehydration Avoid dehydration – Avoid trauma to legs in stirrups Avoid trauma to legs in stirrups – Early postpartum ambulationEarly postpartum ambulation– Leg exercises to support venous returnLeg exercises to support venous return– No smokingNo smoking– Antiembolism stockingsAntiembolism stockings

Thromboembolic DisordersThromboembolic Disorders Superficial thrombophelbitisSuperficial thrombophelbitis

– 3 to 43 to 4thth day after delivery day after delivery– AssessmentAssessment

» TendernessTenderness >> Localized heat>> Localized heat» SwellingSwelling >> Redness>> Redness» No or low feverNo or low fever

– InterventionIntervention» Elevate legElevate leg >> Bed rest>> Bed rest» Local moist heat Local moist heat >> Analgesia>> Analgesia» Support hoseSupport hose

– Little risk of pulmonary embolismLittle risk of pulmonary embolism

Thromboembolic DisordersThromboembolic Disorders Deep vein thrombosisDeep vein thrombosis

» 10 to 20 days after delivery10 to 20 days after delivery– AssessmentAssessment

» SwellingSwelling» PainPain» ErythemaErythema» HeatHeat» Pedal edemaPedal edema» Low to high feverLow to high fever» Positive Homan’s Positive Homan’s » Sometimes decreased perfusionSometimes decreased perfusion» ChillsChills

Thromboembolic DisordersThromboembolic Disorders Deep vein thrombosisDeep vein thrombosis

– InterventionIntervention» Bed restBed rest >> Elevate leg>> Elevate leg» Analgesia Analgesia >> Antibiotics>> Antibiotics» Anticoagulant therapyAnticoagulant therapy

IV heparinIV heparinCoumadin for 2 to 6 monthsCoumadin for 2 to 6 months

» Monitor for pulmonary embolismMonitor for pulmonary embolism» Antiembolism stockings after symptoms: Antiembolism stockings after symptoms:

Thromboembolic DisordersThromboembolic Disorders Pulmonary embolismPulmonary embolism

– Clot moves to pulmonary artery Clot moves to pulmonary artery – AssessmentAssessment

» DyspneaDyspnea >> Chest pain>> Chest pain» CoughCough >> Hemoptysis>> Hemoptysis» CyanosisCyanosis >> Hypotension>> Hypotension» TachypneaTachypnea >> Tachycardia>> Tachycardia

– TreatmentTreatment» Alert physicianAlert physician >> Elevate head of bed>> Elevate head of bed» OxygenOxygen >> Narcotics>> Narcotics» Anticoagulation with heparinAnticoagulation with heparin

Psychiatric Disorders:Psychiatric Disorders: Adjustment reaction with depressed mood Adjustment reaction with depressed mood

Postpartum blues or baby bluesPostpartum blues or baby blues AssessmentAssessment

– Within a few days after delivery and last a few Within a few days after delivery and last a few hours to 10 or more dayshours to 10 or more days

– Mild depression with interspersed happier feelingsMild depression with interspersed happier feelings– Tearful without reason Tearful without reason – Feel overwhelmed, unable to cope, fatigued, Feel overwhelmed, unable to cope, fatigued,

anxious, irritable, oversensitiveanxious, irritable, oversensitive InterventionIntervention

– Provide reassurance Provide reassurance – Assist with self and infant careAssist with self and infant care

Psychiatric Disorders:Psychiatric Disorders: Post partum major mood disorder Post partum major mood disorder

Postpartum depressionPostpartum depression AssessmentAssessment

– During first year - 4During first year - 4thth week to 3 months week to 3 months– Sad/frequent cryingSad/frequent crying– Poor decision making Poor decision making – Insomnia or excessive sleepingInsomnia or excessive sleeping– Appetite changeAppetite change– Feelings of worthlessnessFeelings of worthlessness– No interest in activitiesNo interest in activities– Feel inadequate as a motherFeel inadequate as a mother

Psychiatric Disorders:Psychiatric Disorders: Post partum major mood disorder Post partum major mood disorder

Risk factorsRisk factors– PrimiparityPrimiparity– Ambivalence to pregnancyAmbivalence to pregnancy– History of depressionHistory of depression– Lack of supportLack of support

TreatmentTreatment– MedicationMedication– Risk for suicideRisk for suicide– Group and individual therapyGroup and individual therapy– Assistance with child care and ADL’sAssistance with child care and ADL’s

Psychiatric Disorders:Psychiatric Disorders: Postpartum psychosis Postpartum psychosis

Risk factorsRisk factors– Previous psychosisPrevious psychosis - Poor social support- Poor social support

AssessmentAssessment– Seen within 3 months Seen within 3 months - Agitation - Agitation – Insomnia Insomnia - Hyperactivity- Hyperactivity– Labile moodLabile mood - Confusion- Confusion– Irrational thoughtsIrrational thoughts - Poor concentration- Poor concentration– Poor judgmentPoor judgment - Delusions/Hallucinations- Delusions/Hallucinations

InterventionIntervention– HospitalizationHospitalization - Antipsychotic medication- Antipsychotic medication– Social supportSocial support - Psychotherapy- Psychotherapy– Considered an emergency due to suicide/infantcide riskConsidered an emergency due to suicide/infantcide risk

ReferencesReferences Hogan, M.A., & Glazebrook, R.S. (2007). Hogan, M.A., & Glazebrook, R.S. (2007). Maternal-newborn Maternal-newborn

nursing: Reviews and rationalesnursing: Reviews and rationales. Upper Saddle River, NJ: . Upper Saddle River, NJ: Prentice Hall.Prentice Hall.

Ladewig, P.A., London, M.L., & Davidson, M.R. (2006). Ladewig, P.A., London, M.L., & Davidson, M.R. (2006). Contemporary maternal-newborn nursing careContemporary maternal-newborn nursing care (6 (6thth ed.). Upper ed.). Upper Saddle River, NJ: Prentice Hall.Saddle River, NJ: Prentice Hall.

Littleton, L.Y., & Engebretson, J.C. (2005). Littleton, L.Y., & Engebretson, J.C. (2005). Maternity nursing Maternity nursing carecare. Clifton Park, NY: Thomson Delmar Learning.. Clifton Park, NY: Thomson Delmar Learning.

Murray, S. S., & McKinney, E. S. (2006). Murray, S. S., & McKinney, E. S. (2006). Foundations of Foundations of maternal-newborn nursingmaternal-newborn nursing (4 (4thth ed.). St. Louis, MO: Saunders. ed.). St. Louis, MO: Saunders.

Olds, S.B., London, M.L., Ladewig, P.W., & Davidson, M.R. Olds, S.B., London, M.L., Ladewig, P.W., & Davidson, M.R. (2004). (2004). Maternal-newborn nursing & women’s health careMaternal-newborn nursing & women’s health care (7 (7thth ed.). Upper Saddle River, NJ: Prentice Hall.ed.). Upper Saddle River, NJ: Prentice Hall.

Silvestri, L.A. (2002). Silvestri, L.A. (2002). Saunders comprehensive review for Saunders comprehensive review for NCLEX-RNNCLEX-RN (2 (2ndnd ed.). Philadelphia: W.B. Sanders. ed.). Philadelphia: W.B. Sanders.

Straight A’s in maternal-neonatal nursingStraight A’s in maternal-neonatal nursing. (2004). Philadelphia: . (2004). Philadelphia: Lippincott Williams & Wilkins.Lippincott Williams & Wilkins.

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