ALL

• Postpartum


  The period after childbirth
• Factors increasing the risk for postpartum complications

  • Operative procedure (forceps, CS, Vacuum extraction)
  • History of DM
  • Prolonged labor more than 24 hours
  • Use of indwelling catheter
  • Anemia
  • Multiple vaginal examinations during labor
  • Prolonged rupture of membranes more than 24 hours
  • Manual extraction of placenta
  • Compromised immune system
• Postpartum danger signs


  • Fever more than 38 C
  • Foul smelling lochia
  • Visual changes
  • Calf pain
  • Swelling, redness or discharge at episiotomy site
  • Dysuria, burning or incomplete emptying of the bladder
  • Shortness of breath
  • Depression or extreme mood swings
• Postpartum hemorrhage (PPH)


  Loss of 500 ml of blood during the first 24 hours postpartum in vaginal birth; 1000 ml in cesarean
• Types of PPH


  • Early PPH or Primary PPH
  • Late PPH or Secondary PPH
• Early PPH or Primary PPH

  Occurs in the first 24 hours, 70% due to uterine atony
• Late PPH or Secondary PPH

  Occurs from 24 hours to 12 weeks, caused by retained placental tissue of infection
• Assessment for hemorrhage and shock

  • Persistent significant bleeding: Perineal pad is soaked within 15 minutes
  • Restlessness, increased pulse rate, decreased blood pressure, cool and clammy skin, ashen or grayish color
  • Complaints of weakness, lightheadedness, and dyspnea
• Uterine atony


  Poorly contracted uterus that does not adequately compress large open vessels at the placental site
• Causes of uterine atony

  • Overdistention of uterus (hydramnios, multiple pregnancy)
  • Multiparity and advanced maternal age
  • Deep Anesthesia or analgesia
  • Overmassage of the uterus
  • Presence of fibroid tumors
  • Induction of labor by oxytocin
  • Distention of bladder
  • Retained placental fragments
• Assessments for uterine atony

  • Boggy uterus
  • Excessive vaginal bleeding with blood clots
  • Late signs of shock (air hunger, anxiety, apprehension)
• Management of uterine atony

  • Massage the uterus gently
  • Keep the bladder empty
  • Monitor vital signs and amount of blood loss
  • Administer oxytocin as ordered
  • Blood transfusion and IVF to replace blood loss
  • Manual exploration of the uterine cavity, cervix and vagina for retained placental fragments and laceration
  • Curettage if there are retained placental fragments
  • Bimanual uterine compression
  • Hysterectomy as the last resort
• Causes of lacerations (cervix, vagina, perineum)

  • Operative delivery (Forceps delivery)
  • Precipitate delivery
  • Large infant (over 9 lbs)
  • Multiple pregnancy
  • Primigravidas
  • Abnormal fetal presentation and position
• Assessment of lacerations


  • Bright red vaginal bleeding with firm fundus
• Management of lacerations


  • Return woman to delivery room for inspection and repair
  • Vaginal packing – maintain pressure on the suture line
  • Third and fourth degree lacerations - no enema or rectal suppository, avoid constipation, no rectal temperature
• Classifications of laceration


  • First degree: Fourchette - Vaginal mucus membrane, Perineal skin
  • Second degree: Fourchette – perineal skin, Muscles of perineal body
  • Third degree: Fourchette - muscles of perineal body, Anal sphincter
  • Fourth degree: Fourchette - anal sphincter, Mucous membrane of rectum
• Retained placental fragments


  When the placenta doesn't completely come out of the uterus after the baby is born
• Causes of retained placental fragments

  • Partial separation of a normal placenta
  • Manual removal of placenta
  • Entrapment of placenta in the uterus
  • Abnormal adherent placenta (accreta)
• Assessment of retained placental fragments

  • Boggy uterus
  • Excessive vaginal bleeding with blood clots
  • Late signs of shock (air hunger, anxiety, apprehension)
• Management of retained placental fragments

  • Dilatation and curettage (D and C) to remove adherent placenta
  • Hysterectomy if manual removal and other techniques are unsuccessful
• Hematoma


  Localized collection of blood in the tissues; occurs internally, involves vaginal sulcus or other organs
• Causes of hematoma (P-FIV)

  • Precipitate labor
  • Forceps delivery
  • Inadequate suturing of episiotomy or laceration
  • Vulvar varicosities
• Assessment of hematoma


  • Perineal pain
  • Swelling
  • Discoloration of skin over the swollen area
  • Feeling of pressure over the vagina
  • Sensitive, bulging mass in the perineal area with discolored skin
  • Inability to void
  • Decreased hemoglobin and hematocrit levels
  • Changes in vitals signs >SHOCK
• Management of hematoma


  • Small hematomas do not usually need treatment, reabsorbed spontaneously
  • Large hematomas - incision and ligation of bleeding vessels
  • Monitor abnormal pain or perineal pressure
  • Watch out for signs of hypovolemic shock
  • Ice compress on hematoma site
  • Analgesic for pain
  • Application of ice packs to stop bleeding by vasoconstriction
  • Broad spectrum antibiotics to prevent or treat infection
  • Blood transfusion to combat hypovolemia
• Subinvolution


  Incomplete involution or failure of the uterus to return to its normal size and condition
• Assessment of subinvolution


  • Uterine Pain on Palpation
  • Uterus larger than expected
  • More than normal vaginal bleeding
• Management of subinvolution


  • Assess vital signs
  • Assess uterus and fundus
  • Monitor for urine pain and vaginal bleeding
  • Elevate legs to promote venous return
  • Encourage frequent voiding
  • Monitor Hgb and Hct
  • Administer methylergonovine maleate
• Puerperal infection


  Also known as childbed fever, describes infection of genital tract postpartum
• Infecting organisms


  • Anaerobic streptococci
  • Escherichia coli
  • Chlamydia trachomatis
  • Staphylococci
• Causes of puerperal infection

  • PROM (Premature Rupture Of membrane)
  • Prolonged labor
  • Postpartum hemorrhage
  • Anemia
  • Retained placental fragments
  • Intrauterine manipulation: manual exploration of the uterus
  • Excessive vaginal examination (IE) during labor
  • Malnutrition
  • Instrumental deliveries
  • Presence of infection elsewhere in the body or in the genital tract during labor, delivery and puerperium
  • Sexual intercourse near labor or after membranes have ruptured
• Assessment of puerperal infection

  • Fever (elevation of temperature 100.4F and above for 2 consecutive days or more after the first 25 hours postpartum)
  • Foul smelling lochia or vaginal discharge
  • Rapid pulse, chills
  • Abdominal pain or tenderness
  • Uterus is boggy
  • Body malaise
  • Lack of appetite
  • Perineal discomfort
  • Nausea and vomiting
• Management of puerperal infection

  • Good prenatal nutrition
  • Prevention of anemia and hemorrhage
  • Good maternal hygiene
  • Strict adherence to aseptic technique during labor and delivery
  • Well balanced-diet to promote healing: Increased Vit. C, increased Protein, adequate calories
  • Administer antibiotics
• Different puerperal infections


  • Infection of the perineum, vulva and cervix
  • Endometritis
  • Urinary Tract Infections
  • Mastitis
• Signs and symptoms of perineum, vulva and cervix infection

  • Pain and sensation of heat or feeling of pressure on the affected area
  • Presence of pus
  • Fever
  • Redness, swelling
  • Dysuria
• Management of perineum, vulva and cervix infection

  • Observe good perineal hygiene
  • Change perineal pad frequently to avoid contamination and reinfection
  • Wash hand before and after changing perineal pads
  • Perineal heat lamp, sitz bath, warm compress to promote healing and comfort
  • Sutures are removed to open the area and to establish drainage and prevent extension of infection to surrounding tissues
  • The wound is repaired when there is no more pus and infection is already treated
  • Analgesics are prescribed for pain and antibiotics to combat infection
  • The mother is encouraged to feed her baby as the infection is localized and the risk of infecting the baby can be avoided if proper preventive measures are observed
• Endometritis


  Infection of the lining of the uterus (Endometrium)
• Causes of endometritis


  • Cesarean Section
  • PROM
  • Prolonged labor
• Signs and symptoms of endometritis

  • Fever, Chills, Tachycardia
  • Profuse and foul smelling lochia
  • Body malaise, Lack of appetite, backache and headache
  • Boggy and enlarged uterus – delayed involution
  • Uterine tenderness especially when palpated
• Management of endometritis


  • Antibiotic therapy to combat infection (clindamycin)
  • Analgesics for pain
  • Methergine/ Oxytocin may be ordered to promote involution
  • Increase OFI to combat fever (Overflow incontinence)
  • Place in semi-fowler's or walking position to promote drainage
• Urinary tract infection


  Infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract