HIGH RISK g.

Prior history of postpartum hemorrhage

POST PARTUM CLIENT h. Endometritis
Topics To Discuss: i. Prolonged use of magnesium sulfate or other
1. Post Partal Hemorrhage tocolytic therapy
2. Postpartal Puerperial Infection
3. Thromboembolic Disorders 5. Conditions that lead to inadequate blood
4. Urinary System Disorders coagulation
5. Cardiovascular System Disorder a. Fetal death
6. Reproductive System Disorders b. Disseminated intravascular coagulation
7. Emotional & Psychological Complications
4 Main Causes of Postpartal Hemorrhage
1. Uterine Atony
POSTPARTAL HEMORRHAGE
- relaxation of the uterus
- any blood loss from the uterus greater than 500
mL within a 24-hour period. Clinical Manifestations
1. Abrupt gush of blood from the placental
Four Main Causes: site.
1. Uterine Atony 2. Increased, thready, & weak pulse
2. Lacerations 3. Decreased blood pressure
3. Retained placental fragments 4. Increased& shallow respirations
4. Disseminated intravascular coagulation 5. Pale clammy skin
5. Subinvolution
6. Increasing anxiety
Factors that Predispose to Therapeutic Management
Uterine Bleeding: 1. Obtain vital signs.
1. Conditions that distend the uterus beyond 2. Administer O2 inhalation.
average capacity 3. Empty bladder every 4 hours.
a. Multiple gestation 4. Fundal/Uterine massage to encourage
b. Hydramnios contraction
(Excessive amount of amniotic fluid) 5. Bimanual compression
c. Large baby (over 9 lbs) - inserting one hand in the vagina while
d. Presence of uterine myomas (fibroid tumors) pushing against the fundus through the abdominal
wall with the other hand.
2. Conditions that could have caused cervical or
uterine lacerations Therapeutic Management:
a. Operative delivery (Drug therapy)
b. Rapid delivery - IV Oxytocin (Pitocin)
- IM Methergine (Methylergonovine Maleate)
3. Conditions with varied placental site & - Prostaglandin F
attachment (S/E: Nausea, Diarrhea, Tachycardia,
a. Placenta previa Hypertension)
b. Placenta accrete - Blood transfusion
c. Premature separation of the placenta - Surgical Procedure (Hysterectomy)
d. Retained placental fragments
2. Lacerations
4. Conditions that leave the uterus unable to 1. Cervical Lacerations
contract readily - usually found on the sides of the cervix near
a. Deep anesthesia or analgesia the branches of the uterine artery
b. Maternal age over 30 years
c. Previous uterine surgery Therapeutic Management:
d. Prolonged & difficult labor 1. Repair of cervical laceration.
e. Possible chorioamnionitis
f. Secondary maternal illness
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2. Vaginal Lacerations 1. Treat the underlying cause.
2. Monitor signs of bleeding
Therapeutic Management: 3. Administer O2 inhalation.
1. Vaginal repair 4. Blood transfusion e.g. Whole blood, Fresh
2. Catheter insertion frozen plasma with fibrinogen.
5. Meds:
3. Perineal Lacerations  Vitamin K ( Aquamephyton)
- usually occurs when the woman is placed in  Pitressin (Vasopresin)
a lithotomy position, increasing tension on  Heparin
the perineum.
5. Subinvolution
Therapeutic Management: - incomplete return of the uterus to its prepregnant
1. Episiorrhaphy size & shape.
2. Increase fluid intake.
3. Provide stool softener Causes:
1. Small retained placental fragment.
3. Retained Placental Fragments
2. Endometritis
3. Myoma
Clinical Manifestations:
1. Presence of retained fragments
Therapeutic Management:
(through sonogram)
1. Methylergonovine (Methergine)
2. (+) serum HCG
2. Antibiotic therapy
3. Signs of bleeding/shock
 
Therapeutic Management:
1. Removal of the placental fragments
e.g. D&C POSTPARTAL PUERPERIAL INFECTION
2. Methotrexate administration. - infection of the genital tract after delivery
or abortion.

4. Disseminated Intravascular Coagulation Risk Factors:

- a complex syndrome of activated coagulation 1. Rupture of the membrane over 24 hours
that results in bleeding & thrombosis. before birth.
2. Placental fragments that have been retained
Predisposing Factors: within the uterus.
1. Premature separation of placenta 3. Postpartum hemorrhage
2. Hypertension of pregnancy 4. Pre-existing anemia
3. Amniotic fluid embolism 5. Prolonged and difficult labor, particularly
4. Placental retention instrumental births.
5. Septic abortion 6. Internal fetal heart monitoring.
6. Retention of dead fetus 7. Local vaginal infection present at the time of
  delivery.
Clinical Manifestations: 8. The uterus was explored after birth.
1. Purpura, petechia, & ecchymosis on the
skin, mucous membrane, heart lining 1. Endometritis
2. Prolonged bleeding from venipuncture. - an infection in the endometrium, the
3. Tachycardia & hypotension lining of the uterus, usually associated
4. Uncontrolled hemorrhage during surgery with chorioamionitis and cesearan birth.
or childbirth
5. Oliguria Clinical Manifestations:
1. Temperature elevation over 38° C.
2. Chills
Therapeutic Management: 3. Loss of appetite

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4. General body malaise day pospartal due to an entry of microorganisms
5. Foul smelling, dark brown lochia from cracked and fissured nipples.
6. Increased WBC count
Clinical Manifestations:
Therapeutic Management: 1. Localized pain, swelling, and redness.
1. Monitor color, quantity, and odor of lochia. 2. Fever
2. Monitor size, consistency, & presence of  
tenderness in the uterus. Therapeutic Management:
3. Increase fluid intake. 1. Cold or ice compress & a good supportive bra,
4. Place the client in Fowler’s position. provides pain relief.
5. Encourage ambulation 2. Warm compress to reduce inflammation.
6. TSB 3. Continue breastfeeding
7. Drug Therapy 4. Antibiotic therapy
a. Oxytoxic gent
– to encourage uterine contraction. Preventive Measures:
b. Antibiotic agent [Clindamycin (Cleocin)] 1. Position the baby correctly during feeding
c. Antipyretic agents & grasp the nipple properly.
  2. Release the baby’s grasp on the nipple before
Complications: removing the baby from the breast.
1. Tubal scarring 3. Wash hands between handling perineal pads
2. Infertility & breasts.
4. Expose nipples to air for at least part of
2. Infection in the Puerperium every day.
(Wound Infection) 5. Use vitamin E ointment to soften nipples
- infection in the suture line on the perineum everyday.
from an episiotomy (localized infection).  

Clinical Manifestations: Thromboembolic Disorders

1. Pain, heat, & feeling of pressure a. Thrombophlebitis
in the sutured area. - inflammation of the lining of a blood
2. Elevated temperature. vessel with the formation of
3. Opened suture line with purulent drainage. - blood clots.
  - classified as Superficial Vein Disease (SVD)
Therapeutic Management: or Deep Vein Thrombosis (DVT)
1. Remove perineal sutures to open the area and - It occurs because of:
allow for drainage. 1. Increased fibrinogen level that is still
2. Sitz bath or warm compress to hasten drainage & elevated from pregnancy leading to
cleanse the area increased blood clotting.
3. Drug therapy: 2. Dilation of lower extremity veins due to
a. Antipyretic agent. pressure of the fetal head during
b. Analgesic pregnancy & birth.
c. Systemic or topical antibiotic 3. The relative inactivity of the period or a
*Be alert to the probs in infant as a result of prolonged time period of delivery or
maternal antibiotic therapy: birthing room stirrups that leads to
1. Assess the mouth of infant for thrush. pooling, stasis, & clotting of blood in the
2. Assess infant for easy bruising. lower extremities.

Risk Factors:
1. Varicose veins
2. Obesity
3. Mastitis 3. History of thrombophlebitis
4. Women over 30 y.o. w/ increased parity
- infection of the breast that occurs as early as 7th

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TYPES OF THROMBOPHLEBITIS - Pulmonary emboli occluding the pulmonary
1. Femoral Thrombophlebitis artery as a complication of thrombophlebitis.
- involves femoral, saphenous, or - an emergency situation – risk for
popliteal veins. cardiopulmonary arrest.

Clinical Manifestations: Signs:

*Revealed about 10th day after birth 1. Sudden sharp chest pain
1. Elevated temperature 2. Tachypnea
2. Chills 3. Tachycardia
3. Pain & redness on the affected legs. 4. Orthopnea
4. Skin is stretched, shiny and white 5. Cyanosis
(Milk leg or Phlegmasia Alba Dolens)
5. (+) Homan’s sign Management:
6. Enlarged diameter of the leg. 1. Oxygen administration
2. Clot is lysed.
Therapeutic Management: 3. Transfer to the intensive care unit for
1. Bedrest with the affected leg elevated. continuing care
2. Moist heat application.
3. Provide good back, buttocks, & heel care. Urinary System Disorders
4. Drug Therapy: 1. Urinary Retention
a. Antibiotic - to reduce initial infection. - Result of inadequate bladder emptying due to
b. Analgesic - for pain decreased voiding sensation after birth as a result
c. Anticoagulant therapy of edema of the bladder as a result of pressure of
- Coumadin or Heparin fetal head during birth.
d. Thrombolytic agent - If allowed to continue – permanent damage to the
- Streptokinase or Urokinase bladder may occur from loss of bladder tone that
may lead to permanent incontinence.

2. Pelvic Thrombophlebitis Signs:

- involves ovarian, uterine, or 1. Small, frequent urination
hypogastric veins. 2. Palpable urinary bladder
3. Urine output of less than 100 ml in 8-hour period
Risk Factors: 4. Residual urine output greater than 100 ml.
1. Same with Femoral thrombophlebitis
Management:
Clinical Manifestations: 1. Indwelling aseptic urinary catheterization
1. High fever 2. Stimulating urination - hear running water;
2. Chills letting her hold her hand under warm running
3. Generalized body malaise water.
4. Pelvic abscess 3. Patient health education:
4. Importance of catheterization
Therapeutic Management: 5. Pain relief measures
1. CBR 6. Importance of early ambulation to prevent
2. Antibiotic therapy complications.
3. Anticoagulants
2. Urinary Tract Infection
Complications: - usually occurs from catheterized woman at the
1. Pelvic abscess time of childbirth or in the postpartum period.
2. Lung, kidney, heart valve abscess
Clinical Manifestation:
1. Burning on urination
3. Pulmonary Embolus 2. Frequency, urgency, & hesitancy to urinate.

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3. Sharp pain on urination  Cystocele - out pouching of the bladder into
4. Low-grade fever the vaginal wall), or
5. Hematuria  Rectocele - out pouching of the rectum into
6. Increased WBC count. the vaginal wall.

Therapeutic Management: Causes/ Factors:

1. Increase fluid intake. 1. Multiparity
2. TSB 2. After a forceps birth
3. Drug therapy:
a. Analgesic for pain. Management:
b. Antipyretic for fever 1. Surgical repair
c. Antibiotic therapy 2. Kegel’s exercise

Cardiovascular System Disorder

1. Postpartum Pregnancy-induced 2. Separation of the Symphysis Pubis
Hypertension - due to the overstretching of the
- due to the PIH that developed during pregnancy, ligaments of the symphysis pubis
mild pre- existing hypertension may increase in during birth.
severity during the first few hours or days after
birth. Signs & Symptoms:
- the reason for occurrence is usually retention of 1. Acute pain on walking & turning
some placental fragments. 2. External leg rotation
3. Waddling gait
Cardinal Symptoms: 4. Swollen and tenderness over the symphysis
1. Proteinuria pubis
2. Edema
3. Hypertension Management:
1. Bed rest
Management: 2. Application of pelvic binder for 4-6 weeks
1. Bed rest period, during this time, avoid heavy lifting
2. Quiet atmosphere materials until complete healing of the pelvic
3. Monitor vital signs and urine output ligament has occurred.
4. Administration of Magnesium sulfate, or 3. Advise for cesarean birth for future pregnancy.
5. Administration of Antihypertensive agent
6. May have D&C
7. Monitor for seizure EMOTIONAL & PSYCHOLOGICAL
– typically occurs 6-24 hours after birth. COMPLICATIONS
- seizure after 72 hours after birth is  
probably not related to childbearing. Related Factors:
8. Psychological comfort 1. Extreme stress
2. Giving birth to an infant who in one way or
Reproductive System Disorders another does not meet her expectation e.g.
1. Reproductive Tract Displacement = wrong sex, physically or cognitively challenged,
- occurs due to weakened support system of the born with an illness
uterus after delivery.
- problems of retro flexion, ante flexion, retro
version, and ante version or prolapsed of the uterus 1. Post Partal Blues /
may occur = interfere future childbearing, Baby Blues
infertility, continued pain or a feeling of lower - feeling of sadness (1-10) days after the childbirth.
abdominal pain or discomfort - as many as 20% of women, this normal feeling
- if walls of the vagina are weakened, a continue beyond the immediate postpartum
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 period, and may be present for more than a 2. Lost contact with reality
year. = distorted cognitive thought processes.
- in addition to an overall feelings of sadness, a = altered sensory and perceptual field
woman may notice:
 extreme fatigue
 increased anxiety about her own or infant’s
health Thank you!
 an inability to stop crying Prepare for a quiz next meeting!
 insecurity
 psychosomatic symptoms (nausea,
vomiting, diarrhea)

Related Factors:
1. Response to the anticlimactic feeling after birth
2. Related to hormonal shifts

2. Postpartal Depression
- a more serious problem than the normal “baby
blues”.

Risk Factors:
- history of depression
- troubled childhood
- low self-esteem
- stress in the home or at work
- lack of effective support people
- different expectations between partners
- disappointments in the child

3. Postpartal Psychosis
- as many as 1 woman in 500 has enough
symptoms during the year after birth of a child to
be considered psychiatrically ill.
- probably a response to the crisis of childbearing.
- majority have had symptoms of mental illness
before pregnancy

Postpartal Psychosis

Precipitating Factors:
- previous mental illness
- a death in the family
- loss of job or income
- divorce
- other major life crisis

Manifestations:
1. Appears exceptionally sad
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