Complications of Postpartum

Complications of Postpartum
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:
1.
2.
3.
4.
5.
Uterine Atony
Lacerations
Retained Placental Fragments
Inversion of the Uterus
Placenta Accreta
2. Fundal massage, be sure bladder is empty. Massage

and leave alone. Dont overmassage.
3. Assess V/S for hypovolemic shock.
4. IVs with oxytocin Pitocin. If woman has a normal
blood pressure then may give Methergine or Ergotrate to
contract uterus.
5. D&C or Hysterotomy elevate and hold uterus out of
pelvis and massage.
6. Hysterectomy if unable to control bleeding
LACERATIONS
ETIOLOGY AND PATHOPHYSIOLOGY:
Uterine Atony
Etiology and Pathophysiology:
The most frequent cause of postpartal hemorrhage is
UTERINE ATONY. The myometrium fails to contract and the
uterus fills with blood because of the lack of pressure on the
open vessels of the placental site.
Predisposing Factors:
1. Prolonged labor
2.
Over distention of the uterus
3.
Grandmultiparity
4.
Excessive use of analgesics and anesthesia
5.
Intrapartum stimulation with Pitocin
6.
Trauma due to obstetrical procedures
In most cases the nurse can predict which woman is at risk

for hemorrhage. The key to successful management is
PREVENTION. Prevention begins with adequate nutrition,
good prenatal care, and early diagnosis and management of
any complication. Traumatic procedures should be avoided
such as intrauterine manipulation., forceps rotation, and
overmassage of fundus.
Signs and Symptoms:
1. Excessive or bright red bleeding
2. A boggy uterus that does not respond to massage
3. Abnormal clots
4. Any unusual pelvic discomfort or backache
Nursing Care:
*The fundus should be well contracted, midline, firm, and
recede 1 FB/day.
1. Carefully document vaginal bleeding by counting or
weighing of peri pads. 1 GM. = 1 ML.
Lacerations of the birth canal are second only to uterine

atony as a major cause of postdelivery hemorrhage.
1. Spontaneous or Precipitous delivery
2. Size, Presentation, and Position of baby
3. Contracted Pelvis
4. Vulvar, perineal, 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
**Continuous bleeding from so-called minor sources may be
just as dangerous as a sudden loss of a large amount of
blood.
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
RETAINED PLACENTAL FRAGMENTS
This occurs when there is incomplete separation of the
placenta and fragments of placental tissue retained.
Signs and Symptoms:
Boggy , relaxed uterus
Dark red bleeding
D & C - clean out any fragments that may be left
Administration of Oxytocins to contract the uterus
Administration of Prophylactic antibiotics
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
Traction applied on the cord before the placenta has
separated.
**Dont pull on the cord unless the placenta has separated.
Incorrect traction and pressure applied to the fundus,
especially when the uterus is flaccid
**Dont use the fundus to push the placenta out
1. Replace the uterus--manually replace and pack uterus
2. Combat shock, which is usually out of proportion to the
blood loss
3. Blood and Fluid replacement
4. Give Oxytocin
5. Initiate broad spectrum antibiotics
6. 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
Placenta accreta is a condition that occurs when all or part of
the decidua basalis is absent and the placenta grows directly
onto the uterine muscle. This may be partial where only a
portion abnormally adhered or it may be complete where all
adhered.
Signs and Symptoms:
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:
1. If it is only small portions that are attached, then these
may be removed manually
2. If large portion is attached--a Hysterectomy is
necessary!
HEMATOMA
Bleeding into the tissues of the perineal area can cause
hematoma formation. May have at least 500 cc. Pooled in
the hematoma. May be around the episiotomy site.
Signs and Symptoms:

Occasionally, late postpartal hemorrhage occurs around the
fifth to the fifteenth day after delivery when the woman is
home and recovering. The most frequent causes are:
1.
Retained placental fragments
2. Subinvolution the uterus fails to follow the normal

pattern of involution and remains enlarged.
SIGNS AND SYMPTOMS:
1.
Lochia fails to progress from rubra to serosa to alba.
2.
The uterus is higher in the abdomen.
3.
Irregular or excessive bleeding.
TREATMENT AND NURSING CARE:

1.
Oral administration of Methergine for 24-48 hours.
2.
D&C
PUERPERAL INFECTIONS
A Puerperal Infection is an infection of the genital tract,
usually of the endometrium associated with parturition and
generally encompasses the time from delivery to 6 weeks
postpartum. Can occur after abortion or delivery.
CAUSATIVE FACTORS:
The vagina and cervix of pregnant women generally contain
pathogenic bacteria sufficient to cause infection. Generally,
other factors must be present, however, for infection to
occur.
The most common infecting organisms are HEMOLYTIC
STREPTOCOCCUS GROUPS A or B. Other aerobic
bacteria responsible are: E. Coli, Klebsiella, and
Pseudomonas. Anaerobic bacteria include Clostridium.
PREDISPOSING FACTORS:
1. Trauma
2. Hemorrhage
1.
Pain perineal. More than normal amount of pain.
Mild analgesics are not sufficient to decrease the amount of
pain.
3. Prolonged labor
4. Urinary tract infection
2.
5. Anemia
Hard, firm, area on the perineum
6. Hematomas (perineal)
1.
I & D incision and drainage. May leave in a
penrose drain.
7. Excessive vaginal exams
2.
Dressing changes
3.
Replace the blood loss
4.
Comfort measures
LATE POSTPARTUM HEMORRHAGE
8. P.R.O.M.
Signs and Symptoms:
1. Temperature of 100.4F (38.0C) or higher, the
temperature to occur on any two consecutive days of the first
ten postpartum days, exclusive of the first 24 hours, and to
be taken by mouth. **This definition is established by the
Joint Commission on Maternal Welfare .
3. Malaise, anorexia, chills, tachycardia
A less severe complication of the puerperium is localized

infection of the episiotomy, perineal lacerations, vaginal or
vulva lacerations. Wound infection of abdominal incision site
following cesarean birth. With a localized infection, there is
no foul smelling lochia.
4. Pelvic pain
Signs and Symptoms:
Following delivery of the placenta, the placenta site provides

an excellent culture media for bacterial growth. The site in
the contracted uterus is 4 cm. round, dark red, elevated area
composed of numerous veins. The remaining portion of
decidua is also susceptible because of thinness and
hypervascularity. The cervix may also present bacterial
breeding ground because of multiple small lacerations.
1.
2. Profuse, foul smelling vaginal discharge, sometimes

frothy.
Complications of Puerperal Infections:

1. Pelvic cellulitis
2. Peritonitis
SIGNS OF CONDITION WORSENING:
1.
Fever spiking to 102F to 104F
2.
Elevated white blood count
3.
Chills
4.
Extreme lethargy
5.
Nausea and vomiting
6.
Abdominal rigidity and rebound tenderness
TREATMENT AND NURSING CARE:
Reddened, edematous, firm, tender edges of the skin.
2. Edges separate and purulent material mixed with

serosangious liquid drains from the wound.
Antibiotics
Wound care
MASTITIS
A distinction needs to be made between true mastitis and
localized inflammation of the breasts resulting from a
blocked milk duct. A blocked milk duct responds readily to
breast massage. In Mastitis there is a bacteria caused
infection that needs vigorous intervention. Almost always
unilateral and develops well after the flow of milk is
established.
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:
Diagnosis of the infection site is accomplished by physical

exam, blood work, and urinalysis. Culture of urine and body
discharges.
1.
Antibiotic therapy Broad spectrum
2.
Warm sitz baths
3. Promote drainage have pt. lie in High Fowlers

position so wont go up and out tubes to the abdominal
cavity
4. Maintain Fluid and Electrolyte balance at least 3000 to
4000 cc/day. IVs
5.
Keep uterus contracted give oxytocin drugs
6.
Provide narcotic analgesics for alleviation of pain
7.
Nasogastric suction if develops peritonitis
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
o keep pads snug
o change pads frequently
o wipe front to back
o use peri bottle after each elimination
LOCALIZED INFECTION
Signs and Symptoms:

1.
Marked engorgement and pain.
2. Chills, fever, tachycardia, hardness and reddening of

breasts.
3.
Enlarged and tender lymph nodes.

PREVENTION:
Treatment of Mastitis:
1. Rest
2. Appropriate Antibiotics--Usually Cephalosporins
3. Hot and / or Cold Packs
4. Dont 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
Diligent monitoring of the bladder during the recovery period

and preventive health measures greatly reduce the number
of women who get overdistention.
a. Encourage mother to void regular and complete
emptying, proper wiping techniques and good perineal care.
b. Catheterize with extreme gentleness and sterility.
Signs and Symptoms:
1.
Frequency, urgency
2.
Dysuria
PREVENTATIVE MEASURES:
3.
Nocturia
1. Meticulous hand washing by all personnel.
2. Frequent feedings of infant. If the mother finds that one

area of breasts feel distended, several methods may help:
1.
Cath urine for C&S
2.
Antibiotics - Ampicillin
3.
Urinary tract antispasmotic
4.
Force fluids
a. rotate position of baby for nursing so that babys gums

compress different sinuses each time.
b. If breast not emptied at feeding manual expression or
breast pump can assure that breast is emptied.
c. As infant nurses, mother should massage distended area
to help emptying.
COMPLICATION:
A complication of mastitis is development of a BREAST
ABSCESS. Breast feeding is discontinued on the affected
side, but may feed on the unaffected side.
TREATMENT:
The abscess is incised and drained and may need to teach
mom how to change dressings.
PUERPEAL CYSTITIS
Diuresis is a normal physiological function during the
immediate postpartal period. The body uses this mechanism
to begin to eliminate the extra fluid volume that has
accumulated during pregnancy.
Stretching or trauma to the base of the bladder occurs to
some degree in any vaginal delivery, the resulting edema of
the trigone is great enough to obstruct the urethra and to
cause acute retention. Anesthesia can inhibit normal neural
control of the bladder and lead to overdistention and
decrease bladder sensitivity. So, Residual urine and Bladder
trauma can lead to CYSTITIS.
THROMBOEMBOLC DISEASE
Superficial thrombophlebitis is limited to the superficial
saphenous veins, whereas deep thrombophlebitis generally
involves most of deep venous system.
PREDISPOSING FACTORS:
1.
2.
3.
Slowing of blood flow in legs usually in Moms

who have a Cesarean delivery.
Trauma to the vessels during delivery.
Signs and Symptoms:
1. Sudden onset of pain, tenderness of calf, redness and

an increase in skin temp.
2. Positive Homans Sign.
Heparin it does not cross into breast milk.
COMPLICATION:
PULMONARY EMBOLI substernal chest pain, sudden and
intense; dyspnea; pallor and cyanosis; increased jugular
pressure; confusion; hypotension; sudden apprehension;
hemoptysis.

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Complications of Postpartum

2. Fundal massage, be sure bladder is empty. Massage

Over distention of the uterus

Excessive use of analgesics and anesthesia

Intrapartum stimulation with Pitocin

Trauma due to obstetrical procedures

In most cases the nurse can predict which woman is at risk

Lacerations of the birth canal are second only to uterine

Etiology and Pathophysiology:

Retained placental fragments

2. Subinvolution the uterus fails to follow the normal

Lochia fails to progress from rubra to serosa to alba.

The uterus is higher in the abdomen.

Irregular or excessive bleeding.

TREATMENT AND NURSING CARE:

Oral administration of Methergine for 24-48 hours.

Hard, firm, area on the perineum

Treatment and Nursing Care:

7. Excessive vaginal exams

Replace the blood loss

LATE POSTPARTUM HEMORRHAGE

3. Malaise, anorexia, chills, tachycardia

A less severe complication of the puerperium is localized

Signs and Symptoms:

Following delivery of the placenta, the placenta site provides

2. Profuse, foul smelling vaginal discharge, sometimes

Complications of Puerperal Infections:

Fever spiking to 102F to 104F

Elevated white blood count

Nausea and vomiting

Abdominal rigidity and rebound tenderness

TREATMENT AND NURSING CARE:

Reddened, edematous, firm, tender edges of the skin.

2. Edges separate and purulent material mixed with

Diagnosis of the infection site is accomplished by physical

Antibiotic therapy Broad spectrum

Warm sitz baths

3. Promote drainage have pt. lie in High Fowlers

Keep uterus contracted give oxytocin drugs

Provide narcotic analgesics for alleviation of pain

Nasogastric suction if develops peritonitis

Signs and Symptoms:

Marked engorgement and pain.

2. Chills, fever, tachycardia, hardness and reddening of

Enlarged and tender lymph nodes.

Diligent monitoring of the bladder during the recovery period

1. Meticulous hand washing by all personnel.

Treatment and Nursing Care:

2. Frequent feedings of infant. If the mother finds that one

Cath urine for C&S

Urinary tract antispasmotic

a. rotate position of baby for nursing so that babys gums

Slowing of blood flow in legs usually in Moms

1. Sudden onset of pain, tenderness of calf, redness and

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