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Complications Of Postpartum. Postpartum Hemorrhage. Postpartum Hemorrhage. Early Occurs when blood loss is greater than 500 ml. in the first 24 hours after a vaginal delivery or greater than 1000 ml after a cesarean birth *Normal blood loss is about 300 - 500 ml.)

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postpartum hemorrhage
Postpartum Hemorrhage
  • Early
    • Occurs when blood loss is greater than

500 ml. in the first 24 hours after a vaginal delivery or greater than 1000 ml after a cesarean birth

*Normal blood loss is about 300 - 500 ml.)

  • Late
    • Hemorrhage that occurs after the first 24 hours
postpartum hemorrhage4
Postpartum Hemorrhage
  • Other definitions:
  • A decrease in the hematocrit of 10 points between time of admission and time postbirth
  • Need for fluid replacement following childbirth
main causes of early hemorrhage are
Main Causes of Early Hemorrhage are:
  • Uterine Atony
  • Lacerations
  • Retained Placental Fragments
  • Inversion of the Uterus
  • Placenta Accreta
uterine atony
Uterine Atony

The myometrium fails to contract and the uterus fills with blood because of the lack of pressure on the open blood

vessels of the placental site.

uterine atony predisposing factors
Uterine Atony Predisposing Factors




of the


Trauma due

to Obstetrical





with Pitocin

Excessive use of

Analgesia / Anesthesia

uterine atony8
Uterine Atony
  • Most common cause of Hemorrhage
  • Key to successful management is:


  • Nurse many times can predict which women are at risk for hemorrhaging.
uterine atony9
Uterine Atony

A boggy uterus that does not

respond to massage








Bright Red


Unusual pelvic discomfort or backache

nursing care
Nursing Care
  • Assess and Document Bleeding
  • Fundal massage and express clots
  • Bimanual Compression
  • Assess Vital Signs (shock)
nursing care11
Nursing Care
  • Give medications
    • Pitocin
    • Methergine
    • Carboprost Tromethamine (Hemabate)

(May inject the medications directly

into the uterus)

  • Replace blood / fluids
  • D & C, Hysterectomy
post partum hemorrhage lacerations
Post Partum Hemorrhage*Lacerations*

1. Spontaneous or Precipitous delivery

2. Size, Presentation, and Position of baby

3. Contracted Pelvis

4. Vulvar, perineal, and vaginal varices

  • Signs and Symptoms

1. Bright red bleeding where there is a

steady trickle of blood and the uterus

remains firm.

2. Hypovolemia

postpartum hemorrhage lacerations
  • Treatment and Nursing Care

1. Meticulous inspection of the entire

lower birth canal

2. Suture any bleeders

3. Vaginal pack-- nurse may remove and

assess bleeding after removal

4. Blood replacement

test yourself
Test Yourself !
  • You are assigned to Mrs. B. who delivered vaginally. As you do your post-partum assessment, you notice that she has a large amount of lochia rubra.
    • What would be the first measure to determine if it is related to uterine atony or a laceration?
    • Answer: feel the fundus- if firm

Bleeding into the soft tissues surrounding

the episiotomy or laceration.

May follow forceps or vacuum extraction

*A unit or more of blood may

be in the hematoma


Major Symptom: PAIN- deep, severe, unrelieved, feelings of pressure

Many times bleeding is concealed. Major symptom is rectal pain and tachycardia.


May have to be incised and drained.

inversion of the uterus
Inversion of the Uterus
  • The uterus inverts or turns inside out after delivery.
  • Complete inversion - a large red rounded mass protrudes from the vagina
  • Incomplete inversion - uterus can not be seen, but felt
  • Predisposing Factors:
    • Traction applied on the cord before the placenta has separated.

**Don’t pull on the cord unless the placenta has separated.

    • Incorrect traction / pressure applied to the fundus, when the uterus is flaccid

**Don’t use the fundus to “push the placenta out”

inversion of the uterus19
Inversion of the Uterus



Uterus continues

to be pulled and


Traction on

the cord

starts the

uterus to


inversion of the uterus20
Inversion of the Uterus



pushed back

into place





treatment and nursing care
Treatment and Nursing Care
  • Replace the uterus--manually replace and pack uterus
  • Combat shock, which is usually out of proportion to the blood loss
  • Blood and Fluid replacement
  • Give Oxytocin
  • Initiate broad spectrum antibiotics
  • May need to insert a Nasogastric tube to minimize a paralytic ileus

Notify the Recovery Nurse what has occurred!

Care must be taken when massaging

placenta accreta
Placenta Accreta

All or part of the decidua basalis is absent and the Placenta grows directly into the uterine muscle.

placenta accreta23
Placenta Accreta
  • Signs:
    • During the third stage of labor, the placenta does not want to separate.
    • Attempts to remove the placenta in the usual manner are unsuccessful, and lacerations or perforation of the uterus may occur
  • Treatment
    • Removal of the uterus Hysterectomy
  • If it is only small portions that are attached, then these may be removed manually
  • If large portion is attached--a Hysterectomy is necessary!

Late Postpartum


late postpartum hemorrhage
Late Postpartum Hemorrhage
  • Most common cause is Retained Placental fragments
  • Sub involution
  • Treatment
    • D & C
    • Methergine
retained placental fragments
Retained Placental Fragments
  • This occurs when there is incomplete

separation of the placenta and fragments of

placental tissue retained.

  • Signs
    • Boggy , relaxed uterus
    • Dark red bleeding
  • Treatment
    • D & C
    • Administration of Oxytocins
    • Administration of Prophylactic antibiotics
are these early late or both
Are these Early, Late, or Both ?
  • Uterine Atony
  • Retained placental fragments
  • Lacerations
  • Inversion of the uterus
  • Placenta accreta
  • Hematoma
  • _________________
  • _________________
  • _________________
  • _________________
  • _________________
  • _________________
review early signs of hemorrhage
ReviewEarly Signs of Hemorrhage
  • An uncontracted uterus – boggy
  • Large gush, steady trickle, oozing, or seeping of blood from the vagina
  • Saturation of more than one pad in 15 minutes
  • Severe unrelieved perineal or rectal pain
  • Tachycardia
review hypovolemic shock
ReviewHypovolemic Shock
  • Signs
    • Tachycardia
    • Drop in B/P
    • Narrowing of pulse pressure
    • Tachypnea
    • Skin becomes pale and cool and can progress to cold and clammy
    • Becomes anxious  confused lethargic
    • Urinary output decreases
  • Treatment
    • Blood/Fluid replacements, oxygen, surgery
thromboembolic disorder
Thromboembolic Disorder
  • Predisposing Factors
    • Slowing of blood in the legs
    • Trauma to the veins
    • Hypercoagulation
  • Signs and Symptoms
    • Sudden onset of pain
    • Tenderness of the calf
    • Reddness and an increase in skin temperature
    • Positive Homan’s Sign
thromboembolic disease
Thromboembolic Disease
  • Treatment
    • Heparin --it does not cross into breast milk
    • Antidote: protamine sulfate
    • Teach patient to report any unusual bleeding, or petchiae, bleeding gums, hematuria, epistasis, etc.
  • Complication
    • Pulmonary Emboli

When a postpartum patient

Complains of chest pain

or severe dyspnea

Respond quickly

Usually sign of Pulmonary Emboli




puerperal infections
Puerperal Infections
  • Definition

Infection of the genital tract that occurs within 28 days after abortion or delivery

  • Causes

Streptococcus Groups A and B

Clostridium, E. Coli

puerperal infections36
Puerperal Infections
  • Predisposing Factors

1. Trauma

2. Hemorrhage

3. Prolonged labor

4. Urinary Tract Infections

5. Anemia and Hematomas

6. Excessive vaginal exams

7. P R O M

critical to remember
Critical to Remember
  • Signs and Symptoms of Puerperal Infection

1.Temperature increase of 100.4 or higher

on any 2 consecutive days of the first

10 days post-partum, not including the

first 24 hours.

2. Foul smelling lochia, discharge

3. Malaise, Anorexia, Tachycardia, chills

4. Pelvic Pain

5. Elevated WBC

puerperal infection


  • Administer Broad Spectrum Antibiotics
  • Provide with warm sitz baths
  • Promote drainage--have pt. lie in HIGH fowlers position
  • Force fluids and hydrate with IV’s 3000 - 4000 cc. / day
  • Keep uterus contracted, give methergine
  • Provide analgesics for alleviation of pain
  • Nasogastric suction if peritonitis develops

Test Yourself !

  • What is the classic sign of a Puerperal Infection?
  • Answer: Temperature increase of 100.4 or higher on any 2 consecutive days of the first 10 days post-partum, not including the first 24 hours.
complications of puerperal infections
Complications of Puerperal Infections

Pelvic Cellulitis


Signs and Symptoms:

Spiking a fever of 102 0 F to 104 0 F

Elevated WBC


Extreme Lethargy

Nausea and Vomiting

Abdominal Rigidity and Rebound Tenderness

preventive measures
Preventive Measures
  • Prompt treatment of anemia
  • Well-balanced diet
  • Avoidance of intercourse late in pregnancy
  • Strict asepsis during labor and delivery
  • Teaching of postpartum hygiene measures
    • keep pads snug
    • change pads frequently
    • wipe front to back
    • use peri bottle after each elimination
wound infection
Wound Infection
  • Infection of the Episiotomy, Perineal laceration, Vaginal or vulva lacerations
  • Wound infection of Cesarean incision site
  • Signs:
    • Reddened, edematous, firm, tender edges of skin
    • Edges separate and purulent material drains from the wound.
  • Treatment
    • Antibiotics
    • Wound care

Check Yourself

  • Mrs. X. was admitted with endometritis
  • and Mrs. Y. was admitted with an infection
  • in her cesarean incision. Are both classified
  • as a Puerperal Infection?
  • Answer: yes
  • What would be the major difference in
  • presenting symptoms you would note on
  • nursing assessment?
  • Answer: foul smelling lochia
puerperal cystitis
Puerperal Cystitis
  • Prevention:
    • Monitor the patients urination diligently!
    • Don’t allow to go longer than 3 - 4 hours before intervening.
  • Treatment
    • Antibiotics -- Ampicillin
    • Urinary Tract Antispasmotics
  • Causes:
    • Stretching or Trauma to the base of the bladder results in edema of the trigone that is great enough to obstruct the urethra and to cause acute retention.
    • Anesthesia
  • Types:
    • Mammary Cellulitis- inflammation of the connective tissuebetweenthe lobes in the breast
    • Mammary Adenitis - infectioninthe ducts and lobes of the breasts

Nipple Trauma Pain Impaired Engorgement

Let down

Cracked Stasis

nipples of milk

Entry for Bacteria Plugged ducts


Treatment, No Treatment

Problem will resolveBreast Abscess


Marked Engorgement


Chills, Fever, Tachycardia

Hardness and Redness

Enlarged and tender

lymph nodes

treatment of mastitis
Treatment of Mastitis
  • Rest
  • Appropriate Antibiotics--Usually Cephalosporins
  • Hot and / or Cold Packs
  • Don’tStop Breast Feeding because:
    • If the milk contains the bacteria, it also contains the antibiotic
    • Sudden cessation of lactation will cause severe engorgement which will only complicate the situation
    • Breastfeeding stimulates circulation and moves the bacteria containing milk out of the breast



Rotate position of

baby on the breast


Frequent feedings

and massage

distended area to

help emptying

complication of mastitis
Complication of Mastitis

Breast Abscess

Breast Feeding is stopped on the affected side, but may feed on the unaffected side.

Treatment: Incision and Drainage

test yourself51
Test Yourself

The major causative organism of mastitis is


Mastitis develops mainly in ______________ who are nursing .

It is almost always ________________ and develops well

after the flow of milk has been established.

There are two types of mastitis. One that develops between

the lobes of the breast is called____________________.

The one that developswithin the lobes and ducts of the

breast is called __________________.

Mammary cellulitis mainly develops due to _______________.

Mammary adenitis develops when ____________________

of the breasts occurs. With improper treatment or no

treatment, mastitis can lead to ________________.

mood disorders
Mood Disorders
  • The Most common Mood Disorders are:
    • Postpartum Depression
    • Postpartum Psychosis
postpartum depression
Postpartum Depression
  • Predisposing Factors:
    • Primiparity
    • Ambivalence about the pregnancy
    • History of Depression
    • Environmental and Family Stress issues
    • Dissatisfaction with herself
postpartum depression55
Postpartum Depression


  • Persistent lack of interest or energy, loss of usual emotional response toward her spouse or family
  • Obsessive thoughts of failure as mother, incompetent, inadequate parent
  • Anxiety, Irritability
  • Forgetfulness; Inability to follow directions
  • Anorexia
  • Persistent Sleeplessness
  • Poor personal Hygiene
  • Feelings of unworthiness
postpartum depression56
Postpartum Depression
  • Creates strain on the family
  • Family members may decrease their interactions with the depressed woman when she needs support the most.
  • Infants of depressed mothers tend to be fussier and more discontented. They show fewer positive facial expressions.
nursing care57
Nursing Care

Antidepressant Drugs


  • Prozac, Paxil, Zoloft

b. Cyclic compounds

  • Tofranil, Asendin, Norpramin, Sinequan

c. MAO Inhibitors

  • Nardil, Parnate

d. Other:

  • Wellbutrin, Effexor, Desyril

e. Lithium, Depakene, Tegretol for bipolar


treatment for depression
Treatment for Depression
  • Psychotherapy
  • Encourage communication with her husband or support person who is available to provide support when loneliness or anxiety becomes a problem
  • Explain importance of good nutrition and rest
treatment and nursing care59
Treatment and Nursing Care
  • Discuss changes that normally occur in the beginning weeks after taking a baby home
  • Although some of her feelings may seem “unreasonable”, she should acknowledge these feelings to herself and insist that others acknowledge them too.
  • Re-introduce the baby to the mother at the mother own pace

Convey a caring attitude

This helps mothers decrease their emotional distress and guide them in regaining their


postpartum psychosis schizophrenia
Postpartum PsychosisSCHIZOPHRENIA
  • Far less common
  • May surface when the mother does not have the ability to adjust to and cope with her new obligations as a mother
  • Affects mostly adolescents and younger adults

Signs and Symptoms

  • Irritability, Hyperactivity
  • Insomnia; Exhibit little need for sleep
  • Mood lability
  • Hostility toward spouse is obvious
  • Overly Suspicious, seldom aware they have a problem
  • Often believe hers to have been an immaculate conception
  • Abandons reality, totally neglects her infant
  • May have delusions and erroneously belief that baby is dead, malformed or severely ill; hallucinations
treatment and nursing care63
Treatment and Nursing Care
  • Remove the baby from the situation
  • Hospitalization
  • Antipsychotic Medications
    • Stelazine, Clozaril, Risperdal, Haldol, Navane
  • When she is better, then bring the baby back for short visits at first. Give praise for small tasks that the mother can accomplish with the baby.
  • What is the time difference between early and late postpartum hemorrhage?
  • What is the most common cause of postpartum hemorrhage?
  • How will the nurse recognize uterine atony?
  • What is the FIRST nursing action if uterine atony is discovered?
  • What would the nurse suspect if the placenta fails to release from the uterine wall after delivery?

How do the signs and symptoms of hematoma differ from those of uterine atony or a laceration?

  • What laboratory study should the nurse suspect if the woman is on heparin anticoagulation?
  • What is the significance of a board-like abdomen in a woman who has endometritis?
  • Why is it important that the breast-feeding mother with mastitis empty her breasts completely?
  • What is the KEY difference between postpartum blues and postpartum depression?