Postpartal Complications

• • Assessment findings: prolonged lochial discharge, irregular or excessive bleeding, larger than normal uterus, boggy uterus occasionally
  • Diagnostic test findings: internal examination showing massive bleeding, evidence of sepsis, subinvolution of the uterus
  • Signs and symptoms: irregular cramps, abnormal lochial discharge, excessive uterine bleeding
• Subinvolution of the uterus:

  • Definition: incomplete return of the uterus to its pre-pregnancy size and shape
  • Etiology/Cause: uterine atony, placental fragments preventing effective contraction, small retained placental fragment, mild endometritis, uterine myoma, grand multiparity, overdistension of uterus, ill maternal health, caesarean section, uterine prolapse, uterine fibroid, persistent lochia/fresh bleeding, long labor, precipitate labor, anesthesia, full bladder, difficult delivery, retained placenta, maternal infection/uterine sepsis
• Management:

  • Medical: conservative medical therapy, fertility-sparing percutaneous embolotherapy
  • Pharmacologic: oral antibiotic prescribed for tender uterus, methylergonovine, oxytocin, carboprost tromethamine
  • Anticoagulants: heparin sodium injection, Lovenox, warfarin sodium
  • Nursing problems: fluid volume deficit, uterine atony
• Uterine Atony:

  • Definition: relaxation of the uterus, most frequent cause of postpartum hemorrhage
  • Etiology/Cause: uterine overdistention, multiple gestation, fetal macrosomia, prolonged oxytocin
  • Signs and symptoms: uncontrolled postpartum hemorrhage, drop in arterial blood pressure, increased heart rate, pain in lower back, delayed capillary refill
  • Management: uterine massage, bimanual uterine compression, blood transfusion, tamponade techniques
  • Nursing interventions: monitor BP and pulse, palpate uterus and massage, save perineal pads, assess lochia frequently
• Hemorrhage:

  • Definition: blood loss of 500 ml or more following a vaginal birth, 1000 ml following a cesarean birth or 10% decrease in hematocrit level
  • Etiology/Cause: uterine atony, trauma, retained placental fragments, development of DIC
  • Predisposing factors: hypotonic contractions, overdistended uterus, multiparity, large newborn, forceps delivery, cesarean delivery
  • Risk factors: abruptio placentae, missed abortion
  • Management: uterine fundal massage, uterotonic drugs, oxytocin IV, methergine IM, hemabate IM, prostaglandins, ergot alkaloids
• • Nursing interventions: monitor BP and pulse, palpate uterus and massage, save perineal pads, assess lochia frequently
• • Signs of laceration: bright red blood with clots oozing continuously from the site and a uterus that remains firm
• Factors that may lead to postpartum hemorrhage include:

  • Abruptio placentae
  • Missed Abortion
  • Placenta previa
  • Uterine infection
  • Uterine inversion
  • Severe preeclampsia
  • Amniotic fluid embolism
  • Intrauterine fetal death
  • Uterine Atony (primary cause)
  • Laceration of the cervix (occurs immediately after delivery of the placenta)
  • Lacerations of the birth canal or perineum
  • Retained placental fragments
  • DIC (Disseminated Intravascular Coagulation)
  • Oozing of blood
  • More frequent saturated pads
  • Signs of uterine atony: the uterus is soft and relaxed
• Primary or Early postpartum hemorrhage occurs within the first 24 hours after delivery, with blood loss in excess of 500mL during the first 24 hours postpartum.

  Secondary or Late postpartum hemorrhage occurs 24 hours to 12 weeks postpartum, with uterine blood loss in excess of 500mL during the remaining 6-week postpartum period but after 24 hours
• Signs and symptoms of postpartum hemorrhage include:

  • Uncontrolled bleeding
  • Decreased blood pressure
  • Increased heart rate
  • Decrease in the red blood cell count
  • Swelling and pain in the vagina and nearby area if bleeding is from a hematoma
  • Restlessness, lightheadedness, and dizziness
  • Pale skin, decreased sensorium, and rapid, shallow respirations
  • Urine output less than 25mL/hr
  • Cold clammy skin
  • Delayed capillary refill
  • Signs of shock
• Management options for postpartum hemorrhage:

  Medical:

  • Blood transfusion and IV replacement
  • Administration of Oxygen
  • Cold therapy, ligation of the bleeding vessel, or evacuation of the hematoma

  Pharmacologic:

  • Oxytocin or methylergonovine may be given IV or IM
  • Pitocin to maintain the tone of the uterus
  • Carboprost tromethamine to promote sustained uterine contractions

  Surgical:

  • D&C (Dilatation & Curettage)
  • Hysterectomy
  • Suturing for extreme uterine atony to stop the bleeding
• Nursing interventions for postpartum hemorrhage:

  • Estimate the amount of blood loss
  • Measure vaginal discharge
  • Inspect for blood loss
  • Assess vital signs
  • Assess lochia frequently
  • Assess for signs of shock
  • Assess the fundus and lochia
  • Stay with the patient
• Retained placental fragments:

  • Definition: fragments of placenta left attached to the uterus
  • Etiology/Cause: uterus not contracting properly, umbilical cord snapping, abnormal placental attachment
  • Types: Placenta Adherens, Trapped Placenta, Placenta Accreta
  • Signs and symptoms: failure of placenta to leave the body, fever, foul-smelling discharge, heavy bleeding, severe pain
  • Management: antibiotic prophylaxis, oxytocin, removal of retained placental fragments, D&C, methotrexate, hysterectomy
• • Nursing interventions: instruct clients to report changes in lochial discharge, uterine exploration and removal under anesthesia
• Disseminated Intravascular Coagulation (DIC):

  • Definition: abnormal blood clotting throughout the body's blood vessels
  • Etiology/Cause: release of procoagulants, systemic inflammatory response, obstetrical complications
  • Assessment and diagnostic test findings: decreased platelet count, low prothrombin, elevated thrombin time, decreased fibrinogen, abnormal D-dimer analysis
  • Complications: acute to patients with life-threatening illnesses
  • Types: Acute DIC (develops quickly), Chronic DIC (happens slowly)
• • Signs and symptoms: easy bruising, bleeding, pain, redness, warmth, swelling, blood in stools or urine, low blood pressure, chest pain, trouble breathing, headaches, confusion
  • Implications: maternal death if hypo-fibrinogen does not reverse, fetal/neonate risk from maternal sepsis
• Maternal implications:

  • Death if hypo-fibrinogen does not reverse
• Fetal/Neonate implications:

  • Fetus not directly affected
  • At risk from maternal sepsis, acidosis, and hypotension
  • Major risk to fetus/neonate hypoxia
• Management:

  • Medical:
  • Blood and fibrinogen transfusions
  • Treatment of underlying conditions
  • Immediate delivery
  • Pharmacologic:
  • Heparin:
  • Non-symptomatic type of DIC
  • Synthetic protease inhibitors and Antifibrinolytic therapy:
  • With the bleeding and massive bleeding types of DIC
  • Natural protease inhibitors:
  • With the organ failure type of DIC, while antifibrinolytic treatment is not
• Nursing Interventions:

  • Halt underlying result: premature placenta -> end pregnancy with delivery of fetus and placenta
  • Administration of heparin:
  • IV then Subq, to halt clotting cascade, stop marked coagulation, cautiously given after birth
  • Assess the client’s breath sounds
  • Assess cough for signs of bloody sputum
  • Assess for tachycardia, shortness of breath, and use of accessory muscles
• Laceration and Types:

  • Definition:
  • Tears in perineum, vagina, or cervix due to stretching of tissues during childbirth
  • Small lacerations are normal in childbearing, but large lacerations can be sources of infection or hemorrhage
  • Lacerations occur in the cervix, vagina, and perineum
  • Nursing Problems for laceration:
  • Impaired tissue integrity
  • Nursing problems of Hematoma
  • Bleeding
  • Prone to laceration:
  • Primigravida mothers
  • Macrosomic babies
• Episiotomy:

  • An incision made into the perineum to facilitate delivery and prevent lacerations and overstretching of the pelvic floor
  • Incision types: median and mediolateral
  • Indications:
  • Rapid labor and delivery
  • Large baby
  • Malposition of the fetus
  • Facilitate repair of the laceration & promote healing
  • Spare the infant’s head from prolonged pressure & pushing against the perineum which may result in brain damage especially in premature infants
  • Shorten the second stage of labor
• Episiotomy Classifications:

  • First degree: Small tear that only extends through the lining of the vagina
  • Second degree: Extends through the vaginal lining and tissue, but not the rectal lining or anal sphincter
  • Third degree: Involves the vaginal lining, tissues, and part of the anal sphincter
  • Fourth degree: Includes the vaginal lining, tissues, anal sphincter, and rectal lining
• Perineal Hematoma:

  • Definition:
  • Collection of blood in the subcutaneous layer of tissue of the perineum
  • Overlying skin intact with no noticeable trauma
  • Blood accumulates underneath
  • Usually only represent minor bleeding
• Vulvar Hematoma:

  • Definition:
  • Collection of blood in the vulva
  • Hematoma occurs as a result of damage to one of the larger blood vessels in the body, specifically in the vulva or perineum
  • Already clotted
  • Can develop in non-obstetric settings as well, despite being a common obstetric complication
• Perineal Hematoma Management:

  • Pharmacologic:
  • Prescribe mild analgesic for pain relief
  • Surgical:
  • Incision of the site
  • Vessel ligation under anesthesia
  • If episiotomy incision; may be left open and packed with gauze rather than resutured
  • Remove gauze packing in 24 to 48 hours
• Vulvar Hematoma Management:

  • Pharmacologic:
  • Prescribe mild analgesic for pain relief
  • Surgical:
  • Incision of the site
  • Vessel ligation under anesthesia
  • If episiotomy incision; may be left open and packed with gauze rather than resutured
  • Remove gauze packing in 24 to 48 hours
• Signs and Symptoms of Perineal Hematoma:

  • Bubbling or bulging skin near the anus
  • Mild to severe pain, depending on the size
  • Bloody stools
• Management:

  • Pharmacologic:
  • Rx mild analgesic for pain relief
  • Surgical:
  • Incision of the site
  • Vessel ligation under anesthesia
  • If episiotomy incision; may be left open and packed with gauze rather than resutured
  • Remove gauze packing in 24 to 48 hours
• Nursing Interventions:

  • Report presence of hematoma: size and degree of discomfort
  • Report a definite size (5 cm) rather than “large or small”
  • Apply ice pack (covered with towel)
  • Patient teaching: Keep site clean and dry
• Edema:

  • Postpartum edema, or postpartum swelling
  • Caused by an excess amount of fluid remaining in the body tissue after childbirth
  • Swelling can lead to the skin looking stretched and inflamed, and sometimes will cause the outer layer of the skin to look puffy or shiny
• Etiology/Cause of Edema:

  • During pregnancy, hormones cause the body to retain fluid
  • Risk Problems: pre-eclampsia, eclampsia, dietary lifestyle
• Types of Edema:

  1. Breast engorgement

  2. Hemorrhoids

  3. Water retention
• Management:

  • Pharmacologic:
  • Drug: Diuretic drugs (Furosemide)
  • Over-the-counter creams, ointments, suppositories or pads containing ingredients such as witch hazel, or hydrocortisone and lidocaine
  • Medical:
  • Closed hemorrhoidectomy – treat internal hemorrhoids
• Nursing Interventions:

  • During the first 24 hours after the surgery, place an icepack over the surgical site
  • A warm pack can also be helpful during the recovery period
  • Patient teachings: Apply an over-the-counter hemorrhoid cream or use pads containing witch hazel or a numbing agent
  • Soak regularly in a warm bath or sitz bath
  • Limited fluid and sodium intake
• Mastitis:

  • Infection of the breast
  • Inflammation of the breast tissue usually caused by infection or by stasis of milk in the ducts
• Etiology/Cause of Mastitis:

  • Injury to breast – overdistention, stasis (missed feedings, a bra that is too tight or impaired infant sucking)
  • Organism comes from the oral cavity of the infant
• Assessment Findings of Mastitis:

  • Breast tenderness or warmth to the touch
  • Breast swelling
  • Thickening of breast tissue, or a breast lump
  • Pain or a burning sensation continuously or while breast-feeding
  • Skin redness, often in a wedge-shaped pattern
  • Generally feeling ill
  • Fever of 101 F (38.3 C) or greater
• Management:

  • Pharmacologic:
  • Antibiotics effective against penicillin-resistant staph
  • Pain relievers: Acetaminophen, Ibuprofen, Analgesics
  • Surgical:
  • Requires surgical drainage in the operating room
  • Excisional biopsy
  • Partial mastectomy
• • Massage the area using a gentle circular motion
  • Administer antibiotics and complete antibiotic regimen
  • Offer comfort measures such as supportive bra, apply cold or heat application over localized abscess
  • Reinforce meticulous handwashing
  • Breastfeed frequently
  • Perform adequate breast and nipple care
  • Observe for signs of infection and pain
  • Health Teachings: Do warm showers, wear loose bras