Postpartum Complications

1. Postpartum Complications Twila Brown, PhD, RN

2. Postpartum Hemorrhage • Blood loss greater than 500 mL • Early postpartum hemorrhage • First 24 hours after delivery • Uterine atony • Lacerations of the genital tract • Hematomas • Uterine rupture • Late postpartal hemorrhage • Usually 1-2 weeks • Retention of placental tissue

3. Causes Over distention Dysfunctional labor Induction Cesarean Grand multiparity Preeclampsia Retained placenta fragments Asian or Hispanic Assessment Fundus Soft Difficult to find Above expected level Lochia Excessive Bright red Clots Early Postpartal Hemorrhage: Uterine atony

4. Early Postpartal Hemorrhage: Uterine atony • Interventions • Assess for bleeding • Assess fundal height • Encourage voiding • Oxytocin (Pitocin) • Fundal massage • Contact physician • Methylergonovine (Methergine) • IV fluid and/or transfusion • Bimanual compression of uterus • Ligation of uterine vessels or hysterectomy

5. Early Postpartal Hemorrhage:Lacerations • Perineal, vaginal, cervical • Predisposing factors • Primiparous • Precipitous delivery • Macrosomia • Forceps or vacuum-assisted birth • Mediolateral episiotomy • Assessment • Firm uterus • Bright red blood • Stream of unclotted blood

6. Early Postpartal Hemorrhage:Hematomas • Blood in soft subcutaneous tissue • Predisposing factors • Prolonged pressure of fetal head • Forceps or vacuum extraction • Prolonged or precipitous labor • Macrosomia • Pudendal anesthesia • Subperitoneal hemotoma • Uterine artery branch or vessels in broad ligament • Severe pain and hypovolemic shock

7. Early Postpartal Hemorrhage: Hematomas • Vaginal • Assessment • Unilateral purplish discoloration • Pain • Feeling of fullness in vagina or rectal pressure • Difficult voiding • Intervention • Analgesia • Ice packs • Sitz bath • Surgery

8. Late Postpartum Hemorrhage • Assessment • Subinvolution • Lochia • Fails to progress from rubra to alba • Saturation of more than 1 pad per hour • Abnormal clots • Bladder distention • Increased rectal, back, or pelvic pain • Increased pulse or decreased blood pressure • Signs of anemia

9. Late Postpartal Hemorrhage • Intervention • Teach • Signs of hemorrhage • Massage fundus • Iron administration • Pitocin or Methergine • IV fluid or blood transfusion, • Oxygen • Dilation and curettage

10. Puerperal Infections • Reproductive tract associated with childbirth • Metritis, perineal or cesarean wound • Causes of metritis • Cesarean - Prolonged labor • PROM - Multiple vaginal exams • Scalp electrodes - Internal uterine monitor • OB trauma - Instrument assisted birth • Manual removal of placenta • Prexisting infection • Compromised health status

11. Assessment Abd/Uterine pain Foul smelling vaginal discharge Fever 101-104 F Chills Malaise 30% increase in WBC Interventions CBC Cultures Hygiene Abscess is drained IV antibiotics Antipyretics ICU hospitalization Puerperal Infections: Metritis

12. Puerperal Infections: Perineal and Cesarean wounds • Perineal wound • Assessment • Cesarean wound • Assessment • Intervention • Sutures removed • Drain purulent material • Antibiotics • Analgesics • Warm compress or sitz baths

13. Overdistention of the Bladder • Cause • Unable to empty bladder due to trauma or anesthesia • Assessment • Distended bladder • Displaced uterus, increased vaginal bleeding, boggy uterus, backache, restless • Intervention • Encourage voiding • Perineal ice packs • Pour water over perineum • Aseptic straight catheter X 1

14. Urinary Tract Infections • Cause • Retention of urine • Bacteria from catheterization • Cystitis • Assessment • Intervention • Increase fluids >> Void frequently • Empty bladder >> Urine culture and antibiotics • Prevention • Hygiene • Void q 2-4 hrs • Increase acidity in urine

15. Urinary Tract Infections • Pyelonephritis • Assessment • UTI signs >> High fever • Chills >> Flank pain • N&V >> Acutely ill • Management • IV antibiotics >> Increase fluids • Antipyretics >> Analgesic • Follow-up culture in 2 weeks

16. Mastitis • Infection of breast tissue • Causes • Bacteria enters through cracks in nipple • Milk stasis • Poor hand washing • Breast not dry or wet breast pad • Incorrect placement of baby causes sore nipples • Assessment • Fever > 101 F and chills, acutely ill • Flu-like symptoms, malasia, headache • Painful, warm, red area of breast

17. Mastitis • Intervention • Bed rest - Increase fluids • Supportive bra - Antibiotics • Analgesic • Breast feed frequently • Warm compress before feeding • Cold packs between feedings • Drain abscess • Prevention • Early feedings and frequent feedings • Change baby’s feeding positions • Massage clogged duct • Empty breast at each feeding • Nipple care

18. Thromboembolic Disorders • Blood clot formed from impeded blood flow • Causes • Hypercoagulability of blood • Venous stasis • Injury to epithelium of vessels • Increased risk • Prevention • Avoid dehydration • Avoid trauma to legs in stirrups • Early postpartum ambulation • Leg exercises to support venous return • No smoking • Antiembolism stockings

19. Thromboembolic Disorders • Superficial thrombophelbitis • 3 to 4th day after delivery • Assessment • Tenderness >> Localized heat • Swelling >> Redness • No or low fever • Intervention • Elevate leg >> Bed rest • Local moist heat >> Analgesia • Support hose • Little risk of pulmonary embolism

20. Thromboembolic Disorders • Deep vein thrombosis • 10 to 20 days after delivery • Assessment • Swelling • Pain • Erythema • Heat • Pedal edema • Low to high fever • Positive Homan’s • Sometimes decreased perfusion • Chills

21. Thromboembolic Disorders • Deep vein thrombosis • Intervention • Bed rest >> Elevate leg • Analgesia >> Antibiotics • Anticoagulant therapy • IV heparin • Coumadin for 2 to 6 months • Monitor for pulmonary embolism • Antiembolism stockings after symptoms:

22. Thromboembolic Disorders • Pulmonary embolism • Clot moves to pulmonary artery • Assessment • Dyspnea >> Chest pain • Cough >> Hemoptysis • Cyanosis >> Hypotension • Tachypnea >> Tachycardia • Treatment • Alert physician >> Elevate head of bed • Oxygen >> Narcotics • Anticoagulation with heparin

23. Psychiatric Disorders: Adjustment reaction with depressed mood • Postpartum blues or baby blues • Assessment • Within a few days after delivery and last a few hours to 10 or more days • Mild depression with interspersed happier feelings • Tearful without reason • Feel overwhelmed, unable to cope, fatigued, anxious, irritable, oversensitive • Intervention • Provide reassurance • Assist with self and infant care

24. Psychiatric Disorders: Post partum major mood disorder • Postpartum depression • Assessment • During first year - 4th week to 3 months • Sad/frequent crying • Poor decision making • Insomnia or excessive sleeping • Appetite change • Feelings of worthlessness • No interest in activities • Feel inadequate as a mother

25. Psychiatric Disorders: Post partum major mood disorder • Risk factors • Primiparity • Ambivalence to pregnancy • History of depression • Lack of support • Treatment • Medication • Risk for suicide • Group and individual therapy • Assistance with child care and ADL’s

26. Psychiatric Disorders: Postpartum psychosis • Risk factors • Previous psychosis - Poor social support • Assessment • Seen within 3 months - Agitation • Insomnia - Hyperactivity • Labile mood - Confusion • Irrational thoughts - Poor concentration • Poor judgment - Delusions/Hallucinations • Intervention • Hospitalization - Antipsychotic medication • Social support - Psychotherapy • Considered an emergency due to suicide/infantcide risk

27. References • Hogan, M.A., & Glazebrook, R.S. (2007). Maternal-newborn nursing: Reviews and rationales. Upper Saddle River, NJ: Prentice Hall. • Ladewig, P.A., London, M.L., & Davidson, M.R. (2006). Contemporary maternal-newborn nursing care (6th ed.). Upper Saddle River, NJ: Prentice Hall. • Littleton, L.Y., & Engebretson, J.C. (2005). Maternity nursing care. Clifton Park, NY: Thomson Delmar Learning. • Murray, S. S., & McKinney, E. S. (2006). Foundations of maternal-newborn nursing (4th ed.). St. Louis, MO: Saunders. • Olds, S.B., London, M.L., Ladewig, P.W., & Davidson, M.R. (2004). Maternal-newborn nursing & women’s health care (7th ed.). Upper Saddle River, NJ: Prentice Hall. • Silvestri, L.A. (2002). Saunders comprehensive review for NCLEX-RN (2nd ed.). Philadelphia: W.B. Sanders. • Straight A’s in maternal-neonatal nursing. (2004). Philadelphia: Lippincott Williams & Wilkins.

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