Nursing Management

1. Frequent monitoring of vital signs.

Subinvolution of the Uterus
2. Daily evaluation of fundal height to
document involution
Definition
3. Early ambulation postpartum per
Subinvolution is incomplete return of the uterus to doctor’s order
its prepregnant size and shape. 4. Facilitate client’s voiding.
5. Teach the mother to report persistent
 at a 4- or 6-week postpartal visit, the bright red bleeding or return of red
uterus is still enlarged and soft. bleeding after it has changed to pink or
 Lochial discharge usually is still present. white
 May result from a small retained placental 6. Report blood loss.
fragment, a mild endometritis (infection of 7. Prepare for possible surgical operation.
the endometrium), or an accompanying 8. Assist the client and family to deal with
problem such as a uterine myoma that is physical and emotional stresses of
postpartum complications
interfering with complete contraction.

Cause
Medical Management
 Endometritis (Uterine Sepsis) 1. The hemoglobin or hematocrit levels will
 Retained Placental Fragments be evaluated
 Pelvic Infection 2. Give IV Fluids - maintain circulating
volume and to replace fluid loss
 Uterine Fibroids
3. Conservative medical therapy
Other conditions include: 4. Antimicrobial therapy for endometritis.

 Over distention (multiple gestation,

polyhydramnios) Pharmacological management
 Grand multipara 1. Administration of oxytocic medication to
improve uterine muscle tone. Oxytocic
 Cesarean Section
medication includes:
 Prolapse of Uterus  Methergine®-a drug of choice
 Retroversion of Uterus since it can be given by mouth.
 Pitocin®- stimulates uterine
Signs and Symptoms:
contractions by increasing
 Lochial discharge: reddish-brown intracellular calcium.
 Prolonged lochial flow  Ergotrate®-used to prevent
 Irregular or at times excessive (profuse) and control uterine atony and
hemorrhage before and after
vaginal bleeding
delivery.
 Large, flabby uterus on bimanual
 Warfarin sodium (Coumadin,
examination Warfilone) - Interferes with
 Irregular cramp like pain in cases of hepatic synthesis of vitamin K –
retained products or rise of temperature in dependent clotting factors
sepsis  Anticoagulants-Blocks the
 The uterine height is stationary conversion of prothrombin to
thrombin and fibrinogen to fibrin
Management: thus decreasing clotting ability
1. Oral administration of methylergonovine,  Oral administration of
0.2 mg four times daily - improve uterine methylergon ovine 0.2mg four
times daily, to improve uterine
tone and complete involution.
tone and complete involution.
2. Suggest an endometritis, an oral antibiotic
 If the uterus feels tender to
if uterus is tender to palpation
palpation, suggesting
3. Being certain that women are able to
endometritis is present, an oral
recognize the normal process of involution antibiotic will be prescribed.
and lochial discharge before hospital  Administer iron if necessary.
discharge helps women to be able to  Analgesics (Ibuprofen) are
identify subinvolution and seek early given for pain.
health care if it occurs.

Surgical Management
 Dilation and curettage (D&C) to remove
any placental fragments.
  Hysterectomy
 Fertility- sparing percutaneous
embolotherapy

Uterine Atony
Definition

Uterine atony, or relaxation of the uterus, is the

most frequent cause of postpartal hemorrhage.

 The uterus must remain in a contracted

state after birth to keep the open vessels
at the placental site from bleeding.

Interventions
Etiology/Cause
uterus suddenly relaxes – abrupt gush of
 Prolonged labor or delayed labor blood vaginally from the placental site
 Rapid labor vaginal bleeding is extremely copious - woman
 Overdistention of the uterus (enlargement will exhibit symptoms of shock and blood loss.
of the uterus) because of the presence of Amount of blood in a perineal pad – 25 to 50
excess amniotic fluid (a condition called ml
polyhydramnios) or a large baby By counting the number of perineal pads
 Administration of oxytocin, general saturated in given lengths of time such as half-
anesthesia, or other drugs during labor hour intervals, you can form a rough estimate
 Inducing labor using medication of blood loss.
250 ml – grave situation
Signs and Symptoms Be sure you differentiate between saturated
and used when counting pads.
 Uterus remains relaxed and without any o Weighing perineal pads before and
tension after giving birth.
after use and then subtracting the
 Uncontrollable and excessive bleeding difference is an accurate way to
post-delivery of a baby. measure vaginal discharge: 1 g of
 A drop in blood pressure weight is comparable to 1 mL of blood
 An increase in the heart rate volume.
 Pain Always be sure to turn a woman on her side
 Back pain when inspecting for blood loss, to be certain
that a large amount of blood is not pooling
undetected beneath her.
Palpate a woman’s fundus at frequent
intervals postpartally to be certain that her
uterus is remaining in a state of contraction.
When palpating a uterine fundus, if you are doses.
unsure whether you have located it, the uterus 2. Administer a bolus or a dilute
is probably in a state of relaxation intravenous infusion of oxytocin
a well-contracted uterus is firm and easily (PItocin) to help maintain tone
recognized because it feels like no other 3. Oxytocin given intravenously (IV).
abdominal organ. 4. If oxytocin is not effective at maintaining
Frequent assessments of lochia, vital signs, tone, carboprost tromethamine
pulse and blood pressure, are equally (Hemabate) or methylergonovine
important maleate (Methergine), both are given
5. Misoprostol (Cytotec) may also be
Nursing Management administered rectally to decrease
1. Attempt fundal massage to encourage postpartum hemorrhage.
contraction.
2. Remain with a woman after massaging
her fundus and assess to be certain her Surgical Management
uterus is not relaxing again. 1. Hysterectomy or Suturing - effective in
3. Continue to assess for the next 4 hours. halting bleeding
4. Assess blood pressure prior to
administration and about 15 minutes Signs of Shock
afterward to detect the potentially
dangerous side effect (which is an 1. increased, thready, and weak pulse;
increase in blood pressure). 2. decreased blood pressure;
5. Elevate the woman’s lower extremities 3. increased and shallow respirations;
to improve circulation to essential 4. pale, clammy skin;
organs. 5. increasing anxiety.
6. Offer a bedpan or assist the woman to
the bathroom at least every 4 hours to
Haemorrhage
be certain her bladder is emptying
because a full bladder predisposes a Definition
woman to uterine atony.
7. Administer oxygen by face mask at a Hemorrhage, one of the primary causes of
rate of about 10 to 12 L/min if the maternal mortality associated with childbearing, is
woman is experiencing respiratory a major threat during pregnancy, throughout labor,
distress from decreasing blood volume. and continuing into the postpartum period.
8. Position her supine (flat) to allow
adequate blood flow to her brain and  any blood loss from the uterus greater
kidneys. than 500 mL within a 24-hour period
9. Obtain vital signs frequently and assess  the loss may not be considered
them for trends such as a continually hemorrhage until it reaches 1000 mL
decreasing blood pressure with a
Etiology/Cause
continuously rising pulse rate.
The four main reasons for postpartum hemorrhage
are:
Medical Management
1. Bimanual compression - detect possible  Uterine atony
retained placental fragments.  Trauma (lacerations, hematomas, uterine
2. Prostaglandin Administration – promote inversion or uterine rupture)
strong, sustained uterine contractions.
 Retained placental fragments
Observe for nausea, diarrhea,
tachycardia, and hypertension  Development of disseminated
3. Administer oxygen by face mask at a intravascular coagulation (DIC).
rate of about 10-12 L/min
These causes are generally referred to as the four
4. Sonogram
T’s of postpartum: tone, trauma, tissue and
5. Blood replacement
thrombin

Types
Pharmacological management
1. Carboprost tromethamine may be 1. Early/ Primary postpartum hemorrhage
repeated every 15 to 90 minutes up to 8  within the first 24 hours following
doses; methylergonovine maleate may birth
be repeated every 2 to 4 hours up to 5
  greatest danger of hemorrhage is alone, ergometrine or oxytocin-
in the first 24 hours because of the ergometrine (syntometrine) can be
grossly denuded and unprotected offered as a second line treatment.
uterine area left after detachment 3. Prostaglandin can be given as a 3rd line
of the placenta. treatment if other medications are
2. Late/ Secondary postpartum hemorrhage unavailable
 from 24 hours to 6 weeks after 4. Administer misoprostol orally or
sublingually to increase uterine tone.
birth

Signs and Symptoms

Surgical Management
 Uncontrolled bleeding 1. Laceration repair
 Decreased blood pressure 2. Uterine curettage to remove placental
 Increased heart rate fragments
 Decrease in the red blood cell count 3. Balloon tamponade
 Swelling and pain in the vagina and 4. Compressive suture techniques
nearby area if bleeding is from hematoma 5. Hypogastric artery ligation
6. Hysterectomy to surgically remove the
 Signs of shock o Pallor
uterus
 Dizziness or fainting
 Weakness or fatigue
 Nausea
 Clammy skin
Definition
Nursing management Retained Placental Fragments
 placenta does not deliver in its entirety;
1. Massage the uterus to stimulate
contractions fragments of it separate and are left
2. Position the mother in Trendelenburg behind.
supine with legs elevated to improve Portion retained keeps the uterus from contracting
circulation to essential organs like the fully - uterine bleeding occurs.
brain and the kidneys.
3. Measure maternal blood loss by Most likely to happen with:
counting and weighing perineal pads.
4. Explain the situation to the mother and  succenturiate placenta - a placenta with an
significant others. accessory lobe
5. Reassess the vital signs of the mother  Placenta accrete - a placenta that fuses
frequently for trends such as: with the myometrium because of an
continually decreasing blood pressure abnormal decidua basalis layer
with a continuously rising pulse rate.
6. Offer bedpan or assist mother to the To detect the complication of retained placenta…
bathroom at least every 4 hours to be
certain her bladder is empty as a full 1. every placenta should be inspected
bladder predisposes a woman to uterine carefully after birth to see that it is
atony complete
2. may also be detected by ultrasound
3. A blood serum sample that contains
Medical Management human chorionic gonadotropin hormone
1. Administer oxygen by facemask at the (hCG) also reveals that part of a placenta
rate prescribed by the doctor if the is still present.
mother is experiencing respiratory
distress.
2. Administer IV infusion or blood
transfusion as prescribed by the doctor
3. Catheterization, to reduce the possibility
of bladder pressure.
4. Bimanual compression - if fundal
massage and administration of
uterotonics are not effective at stopping Etiology/Cause
uterine bleeding
5. Sonogram may be done to detect The following are common circumstances that
possible retained placental fragments. result in a retained placenta:

 Placenta adherens - It takes place when

Pharmacological management all or part of the placenta is stuck to the
1. Administer oxytocin to help the uterine wall of the woman’s womb.
maintain tone  Trapped Placenta - It results when the
2. If oxytocin is unavailable or is ineffective placenta detaches from the uterus but is
 not delivered. Instead, it becomes trapped 3. Weigh perineal pads to determine the
behind a closed cervix or a cervix that has extent of blood loss.
partially closed. 4. Turn the patient to the side and inspect
 Placenta Accreta - It takes place when the under the buttocks for pooling of blood.
placenta has become deeply embedded in 5. Inspect perineal area closely.
the womb, possibly due to a previous 6. Assess intake and output.
cesarean section scar. 7. Inform patients of danger signs and
symptoms suggesting bleeding.
Women who are at risk for a retained placenta
include those who've had:
Medical and Pharmacological Management
 previous C-section 1. Assess for signs and symptoms of
 premature delivery before 34 weeks hypovolemic shock.
 stillborn baby  Begin I.V. infusion with normal
saline solution.
 Uterine abnormalities
 Anticipate the need for fluid
 long first or second stage of labor replacement and blood
 Retained placenta during a previous component therapy as ordered.
delivery 2. Obtain venous blood specimens, as
ordered, for complete blood count,
Signs and Symptoms
electrolyte measurements, type and
 Large amount of persistent bleeding crossmatching, and coagulation studies
3. Intramuscular administration of
 Uterus found to not be fully contracted
prostaglandin, to help the uterus
upon examination
contract.
 Signs of shock
 Sudden rise of fundal height indicating
formation of clots in the uterine cavity Surgical Management
Manual removal or Curettage under anesthesia
Assessment

 Undetected retained fragment is large =

bleeding
 Fragment is small = bleeding may not be
detected until postpartum day 6 to 10,
when the woman notices an abrupt
discharge and a large amount of blood.

Management

1. Removal of the retained placental

fragment is necessary to stop the bleeding
- a dilatation and curettage (D&C) is
performed to remove the placental
fragment
2. Balloon occlusion and embolization of the
internal iliac arteries may minimize blood
loss
3. Methotrexate may be prescribed to
destroy the retained placental tissue
4. be certain a woman knows to continue to
observe the color of lochia discharge and
to report any tendency for the discharge to
change from lochia serosa or alba back to
rubra.

Nursing management
1. Frequently assess the patient’s fundus
and lochia.
 Initially at least every 15
minutes to detect changes.
 Notify health care providers if
the fundus does not remain
contracted or if lochia
increases.
2. Perform fundal massage as indicated to
assist with uterine involution.