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POSTPARTUM HEMORRHAGE – blood loss greater than 500 mL
after vaginal birth or more than 1,000 mL after a cesarean birth.
early postpartum hemorrhage - Blood loss that occurs within
24 hours of birth; late postpartum hemorrhage - blood loss
that occurs 24 hours to 6 weeks after birth
typical signs of PPH - falling blood pressure, increasing pulse rate,
and decreasing urinary output) do not appear until as much as
1,800 to 2,100 mL of blood has been lost.
causes of PPH - lacerations of the genital tract, episiotomy, retained
placental fragments, uterine inversion, coagulation disorders,
large for gestational age newborn, failure to progress during the
second stage of labor, placenta accreta, induction or
augmentation of labor with oxytocin, surgical birth, and
hematomas of the vulva, vagina, or subperitoneal areas.
“5 T’s”:
1. Tone: uterine atony, distended bladder
2. Tissue: retained placenta and clots
3. Trauma: vaginal, cervical, or uterine injury
4. Thrombin: coagulopathy (preexisting or acquired)
5. Traction: causing uterine inversion
Tone (abnormalities of uterine contractions)
uterine atony - failure of the uterus to contract and retract after
birth.
Management: uterine massage
Overdistention - caused by multifetal gestation, fetal macrosomia,
hydramnios, fetal abnormality, placental fragments; prolonged
or rapid, forceful labor, especially if stimulated by oxytocin;
bacterial toxins (e.g., chorioamnionitis, endomyometritis,
septicemia); use of anesthesia, especially halothane; and
magnesium sulfate used in the treatment of preeclampsia.
major risk factor for uterine atony, which can lead to hypovolemic
shock. A distended bladder can also displace the uterus from the
midline to either side, which impedes its ability to contract to
reduce bleeding.
Uterine muscle exhaustion – caused by Rapid labor, Prolonged
labor, Oxytocin use
Uterine infection – caused by Maternal fever, Prolonged rupture of
membranes
Tissue (retained in uterus)
Classic signs of placental separation – small gush of blood,
lengthening of the umbilical cord, a slight rise of the uterus in
the pelvis.
placenta accrete- chorionic villi adhere to the myometrium,
causing the placenta to adhere abnormally to the uterus and not
separate and deliver spontaneously.
uterine inversion - A prolapse of the uterine fundus to or through
the cervix so that the uterus is turned inside out after birth.
Risk for: grand multiparity, abnormal adherence of the placenta,
excessive traction on the umbilical cord, vigorous fundal
pressure, precipitous labor, or vigorous manual removal of the
placenta.
Symptoms: pain, profuse bleeding, and shock.
Management: Gentle pushing of the uterus back into position (under
general anesthesia) by the health care provider, followed by
oxytocin to augment uterine contractions and antibiotic therapy
to prevent infection.
Subinvolution - incomplete involution of the uterus or failure to
return to its normal size and condition after birth.
Complications: hemorrhage, pelvic peritonitis, salpingitis, and
abscess formation.
Causes: retained placental fragments, distended bladder, uterine
myoma, and infection. All of these conditions contribute to
delayed postpartum bleeding.
Signs:fundal height that is higher than expected, with a boggy
uterus; the lochia fails to change colors from red to serosa to
alba within a few weeks. Usually identified at the woman’s
postpartum examination 4 to 6 weeks after birth with a
bimanual vaginal examination or ultrasound.
Treatment: stimulating the uterus to expel fragments with a uterine
stimulant, and antibiotics are given to prevent infection.
Trauma (of the genital tract)

Damage to the genital tract
Lacerations and hematomas from birth trauma can cause blood loss.
Hematomas can present as pain or as a change in vital signs
disproportionate to the amount of blood loss.
Lacerations anywhere - Precipitate birth or operative birth
Laceration extensions - Malposition of fetus, Previous uterine surgery
Thrombin
Thrombosis (blood clots) helps to prevent postpartum hemorrhage
immediately after birth by providing hemostasis.
Coagulation disturbances should be suspected in women with a
family history of such abnormalities and women with a history of
menorrhagia.
Idiopathic thrombocytopenia purpura (ITP) is a disorder of
increased platelet destruction caused by autoantibodies, a
decrease in the number of circulating platelets in the absence of
toxic exposure or a disease associated with a low platelet count.
Management: Glucocorticoids and intravenous immunoglobulin,
intravenous anti-RhoD, and platelet transfusion. maintenance of
maternal platelet count and regular monitoring of fetal growth
along with prediction and prevention of fetal passive immune
thrombocytopenia
von Willebrand disease (vWD) is a congenital bleeding disorder
that is inherited as an autosomal dominant trait. It is
characterized by a prolonged bleeding time, a deficiency of von
Willebrand factor, and impairment of platelet adhesion.
Management: desmopressin and plasma concentrates that contain
von Willebrand factor.
common symptoms: nosebleeds, hematomas, Prolonged bleeding
from trivial wounds, oral cavity bleeding, and excessive
menstrual bleeding. Gastrointestinal bleeding is rare.
Disseminated intravascular coagulation (DIC) - clotting system
is abnormally activated, resulting in widespread clot formation in
the small vessels throughout the body, which leads to the
depletion of platelets and coagulation factors.
Risk factors: fetal death with prolonged retention of the fetus, severe
preeclampsia, HELLP syndrome, septicemia, and hemorrhage.
Signs & symptoms: petechiae, ecchymoses, bleeding gums, fever,
hypotension, acidosis, hematomas, tachycardia, proteinuria,
uncontrolled bleeding during birth, and acute renal failure
Treatment: Maintain tissue perfusion through aggressive
administration of fluid therapy, oxygen, heparin, and blood
products. The most important treatment concept in DIC is that it
is a secondary manifestation of an underlying disorder.
Therapeutic Management: fragments are usually manually
separated and removed and a uterine stimulant is given to
promote the uterus to expel fragments. Antibiotics are
administered to prevent infection. Lacerations are sutured or
repaired.
Nursing Management:
Massage the uterus if uterine atony is noted. The uterine muscles
are sensitive to touch; massage stimulates the muscle fibers to
contract. Massage the boggy uterus to stimulate contractions
and expression of any accumulated blood clots while supporting
the lower uterine segment.
Administer a uterotonic drug. Medication is needed to cause the
uterus to contract in order to control bleeding from the placental
site. Ex. Oxytocin (Pitocin); a synthetic analog of prostaglandin
E1, misoprostol (Cytotec) or dinoprostone (Prostin E2);
methylergonovine maleate (Methergine); and a derivative of
prostaglandin (PGF2α), carboprost (Hemabate), are drugs used
to manage postpartum hemorrhage.
Maintain the primary IV infusion and be prepared to start a second
infusion at another site if blood transfusions are necessary. Draw
blood for type and cross-match and send it to the laboratory.
Administer oxytocics as ordered, correlating and titrating the
infusion rate to assessment findings of uterine firmness and
lochia. Assess for visible vaginal bleeding, and count or weigh
perineal pads.
Check vital signs every 15 to 30 minutes.
Prepare the woman for removal of retained placental fragments.

• Cesarean birth (allows bacterial entry due to break in protective
Continually assess the woman for signs and symptoms of
skin barrier)
hemorrhagic shock.
• Urinary catheterization (could allow entry of bacteria into
If the woman develops DIC, institute emergency measures to control
bladder due to break in aseptic technique)
bleeding and impending shock and prepare to transfer her to the

Regional
anesthesia that decreases perception of need to void
intensive care unit.
(causes urinary stasis and increases risk of urinary tract
THROMBOEMBOLIC CONDITIONS
infection)
A thrombosis (blood clot within a blood vessel) can cause
• Staff attending to woman are ill (promotes droplet infection from
thrombophlebitis (an inflammation of the blood vessel lining),
personnel)
which in turn can lead to a thromboembolism (obstruction of a
• Compromised health status, such as anemia, obesity, smoking,
blood vessel by a blood clot carried by the circulation from the
drug abuse (reduces the body’s immune system and decreases
site of origin).
ability to fight infection)
Superficial venous thrombosis - involves the saphenous venous
• Preexisting colonization of lower genital tract with bacterial
system and is confined to the lower leg. Superficial
vaginosis, Chlamydia trachomatis, group B streptococci, S.
thrombophlebitis - caused by the use of the lithotomy position
aureus, and E. coli (allows microbes to ascend)
during birth. Deep venous thrombosis - involves deep veins
• Retained placental fragments (provides medium for bacterial
from the foot to the calf, to the thighs, or pelvis. Pulmonary
growth)
embolism –caused by dislodging and migrating of thrombi to
• Manual removal of a retained placenta (causes trauma to the
the lungs.
lining of the uterus and thus opens up sites for bacterial
Deep venous thrombosis (DVT) – can lead to pulmonary emboli,
invasion)
which may cause chest pain, breathlessness, and sudden death.
• Insertion of fetal scalp electrode or intrauterine pressure
Signs are calf pain, edema, and venous distention.
catheters for internal fetal monitoring during labor (provides
Nursing Management
entry into uterine cavity)
focuses on preventing thrombotic conditions, promoting adequate
• Instrument-assisted childbirth, such as forceps or vacuum
circulation if thrombosis occurs, and educating the client about
extraction (increases risk of trauma to genital tract, which
preventive measures, anticoagulant therapy, and danger signs.
provides bacteria access to grow)
POSTPARTUM INFECTION
• Trauma to the genital tract, such as episiotomy or lacerations
Fever of 100.4° F (38° C) or higher after the first 24 hours after
(provides a portal of entry for bacteria)
childbirth, occurring on at least 2 of the first 10 days after birth,
• Prolonged labor with frequent vaginal examinations to check
exclusive of the first 24 hours.
progress (allows time for bacteria to multiply and increases
Risk factors - surgical birth, prolonged rupture of membranes, long
potential exposure to microorganisms or trauma)
labor with multiple vaginal examinations, extremes of client age,
• Poor nutritional status (reduces body’s ability to repair tissue)
low socioeconomic status, and anemia during pregnancy.
• Gestational diabetes (decreases body’s healing ability and
provides higher glucose levels on skin and in urine, which
Metritis - infection that involves the endometrium, decidua, and
encourages bacterial growth)
adjacent myometrium of the uterus. Parametritis - involves the
• Break in aseptic technique during surgery or birthing process
broad ligament, ovaries and fallopian tubes. Septic pelvic
(allows entry of bacteria)
thrombophlebitis - infection spreads along venous routes into
Nursing Management
the pelvis. Endometritis - involve more than just the
• Maintain aseptic technique when performing invasive procedures
endometrial lining.
such as urinary catheterization, when changing dressings, and
S/S - Lower abdominal tenderness or pain on one or both sides,
during all surgical procedures.
Temperature elevation (.38º C), Foul-smelling lochia, Anorexia,
• Use good handwashing technique before and after each client
Nausea, Fatigue and lethargy, Leukocytosis and elevated
care activity.
sedimentation rate
• Reinforce measures for maintaining good perineal hygiene.
Sites of wound infection - cesarean surgical incisions, the
• Use adequate lighting and turn the client to the side to assess
episiotomy site in the perineum, and genital tract lacerations.
the episiotomy site.
Wound infections usually show up until 24 to 48 hours after
• Screen all visitors for any signs of active infections to reduce the
birth.
client’s risk of exposure.
S/S - Weeping serosanguineous or purulent drainage, Separation of

Review
the client’s history for preexisting infections or chronic
or unapproximated wound edges, Edema, Erythema,
conditions.
Tenderness, Discomfort at the site, Maternal fever, Elevated
• Monitor vital signs and laboratory results for any abnormal
white blood cell count.
values.
Urinary tract infections - caused by invasive manipulation of the
• Monitor the frequency of vaginal examinations and length of
urethra (e.g., urinary catheterization), frequent vaginal
labor.
examinations, and genital trauma increase the likelihood of a
• Assess frequently for early signs of infection, especially fever
urinary tract infection.
and the appearance of lochia.
S/S – Urgency, Frequence, Dysuria, Flank pain, Low-grade fever,
• Inspect wounds frequently for inflammation and drainage.
Urinary retention, Hematuria, Urine positive for nitrates, Cloudy
• Encourage rest, adequate hydration, and healthy eating habits.
urine with strong odor
• Reinforce preventive measures during any interaction with the
Mastitis - an inflammation of the breast that occur within the first 2
client.
weeks postpartum. Causes: insufficient drainage of the breast,
rapid weaning, oversupply of milk, pressure on the breast from a
POSTPARTUM AFFECTIVE DISORDERS
poorly fitting bra, a blocked duct, missed feedings, and
Postpartum or baby blues - The woman exhibits mild depressive
breakdown of the nipple via fissures, cracks, or blisters. Risk for:
symptoms of anxiety, irritability, mood swings, tearfulness,
breast abscess. Treatment: Effective milk removal, pain
increased sensitivity, feelings of being overwhelmed, and
medication, and antibiotic therapy.
fatigue. The “blues” typically peak on postpartum days 4 and 5
S/S: Flu-like symptoms, including malaise, fever, and chills; Tender,
and usually resolve by day 10. Treatment- reassurance and
hot, red, painful area on one breast; Inflammation of breast
validation of the woman’s experience, as well as assistance in
area, Breast tenderness, Cracking of skin around nipple or
caring for herself and the newborn.
areola, Breast distention with milk.
Postpartum depression (PPD) is a form of clinical depression that
AT RISK FOR POSTPARTUM INFECTION
can affect women, and less frequently men, after childbirth.
• Prolonged (.18 to 24 hours) premature rupture of membranes
S/S – Restless, Worthless, Guilty, Hopeless, Moody, Overwhelmed,
(removes the barrier of amniotic fluid so bacteria can ascend)
Loss of enjoyment, Low energy level, Loss of libido

sleep. maternal stress. leading to an increased risk for obstruction. peeling. and hematocrit. Congenital anomalies (heart. Decreased surface area. Substance abuse. Vernix caseosa and lanugo are absent. Diabetes mellitus with vascular disease. Lose her memory. or weight. Inability to clear fluid from passages. Failure to seek any prenatal care. Mood swings and emotional stress. leading to transient tachypnea Common physical characteristics of preterm infants may include: • Birthweight of less than 5. downy hair). 2012). Low socioeconomic status. Scrawny appearance. Large for gestational age (LGA) describes newborns whose birthweight is above the 90th percentile on a growth chart and who weigh more than 4. Doubts about the ability to be a good mother. Long nails preterm newborn’s breathing ability and adjustment to extrauterine life include: • Surfactant deficiency. Abundant vernix caseosa Nursing Management: Promoting Oxygenation. such as squirming. History of previous preterm birth. Substandard living conditions. skin turgor. breathing) • Exploring their perception of the newborn’s condition and offering explanations • Validating their anxiety and behaviors as normal reactions to stress and trauma • Providing a physical presence and support during emotional outbursts • Exploring the coping strategies they used successfully in the past and encouraging their use now • Encouraging frequent visits to the NICU • Addressing their reactions to the NICU environment and explaining all equipment used • Identifying family and community resources available to them Some of the challenges facing the late preterm newborn include: • Respiratory distress (related to pulmonary immaturity. Extreme maternal stress. • Avoid using tape on the newborn’s skin to prevent tearing. use clean gloves to handle dirty diapers and dispose of them properly. Placenta previa. and maternal diabetes.. • Adhere to standard precautions. Experience a lack of pleasure. Maintaining Thermal Regulation To promote nutrition and fluid balance in the preterm newborn: • Measure daily weight and plot it on a growth curve. Absent to a few creases in the soles and palms. Multiple gestation. and tachypnea. and respirations • Fussiness and irritability Developmental care includes these strategies: • Clustering care to promote rest and conserve the infant’s energy • Flexed positioning to simulate in utero positioning • Environmental management to reduce noise and visual stimulation • Kangaroo care to promote skin-to-skin sensation • Placement of twins in the same isolette or open crib to reduce stress • Activities to promote self-regulation and state regulation: • Surrounding the newborn with nesting rolls/devices • Swaddling with a blanket to maintain the flexed position • Providing sheepskin or a waterbed to simulate the uterine environment • Providing nonnutritive sucking (calms the infant) • Providing objects to grasp (comforts the newborn) • Promotion of parent–infant bonding by making parents feel welcome in the NICU • Open.Chronic hypertension. transparent skin with visible veins. Loose and dry skin that appears oversized. tracheoesophageal fistula). Poorly formed ear pinna. Smoking or exposure to passive smoke. It is commonly associated with a variety of neonatal conditions like prematurity. retained lung fluid. Decreased placental weight. creatinine.Head disproportionately large compared to rest of body (asymmetric). blood pressure. Small for gestational age (SGA) describes newborns that typically weigh less than 2. Head disproportionately larger than chest circumference. Hemoglobinopathies (sickle cell anemia). Include the following interventions when caring for a preterm or postterm newborn to prevent infection: • Assess for risk factors in maternal history that place the newborn at increased risk. Feel negatively toward her baby.Abnormal cord insertion. Placental insufficiency • Fetal factors . • Assess fluid status by monitoring weight. temperature elevation.Cry a lot. working long hours. A newborn is also classified as SGA if his or her birthweight is at or below the 10th percentile as correlated with the number of weeks of gestation. • Assess oxygen saturation levels and initiate oxygen therapy as ordered if oxygen saturation levels fall below acceptable parameters. leading to apnea. Loss of freedom and old identity Risk factors . • Encourage nuzzling at the breast in conjunction with kangaroo care if the newborn is stable.. Maternal age of >20 or <35 years old. rubella. Withdraw from friends and family. 23. • Use equipment that can be thrown away after use. • Use sterile gloves when assisting with any invasive procedure. Have changes in appetite. and screen all visitors for contagious infections. • Assess feeding tolerance. pliable cartilage. GESTATIONAL AGE VARIATIONS • Preterm infant—born before 37 completed weeks of gestation • Late preterm infant (near term)—34 to 366/7 weeks • Full term infant—38 through 41 completed weeks of gestation • Postterm infant—42 weeks or more Postterm newborns typically exhibit the following characteristics: • Dry. typically an early sign of infection.1) • Very low birthweight: less than 1. • Remove all jewelry on your hands prior to washing hands. Feelings of being less attractive. 18. Thin umbilical cord. methamphetamines). and fontanels ( Gardner et al. diaphragmatic hernia. or tachypnea. Preeclampsia. Wasted appearance of extremities.Trisomy 13. Thin umbilical cord. Creases that cover the entire soles of the feet. chorioamnionitis). urine specific gravity. Wide-eyed. Worry about hurting the baby. infarction. attempt to minimize the use of invasive procedures. Exposure to occupational hazards. Smaller respiratory passages. or very physical labor. Substance abuse. Low self-esteem. • Monitor for changes in vital signs such as temperature instability. Chronic renal disease. Substandard living conditions or low socioeconomic status. • Monitor intake.500 g (5 lb 8 oz) at term due to less growth than expected in utero. intrauterine growth restriction. lethargy. Turner’s syndrome. 2011). Be alert for signs of dehydration. Chronic abruption. diabetes). Be unable to make decisions or focus. RESUSCITATING THE NEWBORN. Periodontal disease of the mouth. cocaine. and measure gastric residuals before the next tube feeding. Chronic fetal infection (cytomegalovirus [CMV]. FACTORS CONTRIBUTING TO THE BIRTH OF SGA NEWBORNS • Maternal causes . The following terms describe other newborns with marginal weights at birth and of any gestational age: • Low birthweight: less than 2. urinary tract infection. limited ability to flex the trunk and extremities to decrease exposed surface area) • Hypoglycemia related to the first two challenges (respiratory distress and cold stress) • Apnea (related to poor respiratory control and immaturity) • Jaundice and hyperbilirubinemia (related to immature bilirubin conjugation and excretion) • Feeding challenges related to immature suck and swallowing reflexes • Sepsis because maternal antibodies are not fully transferred prior to the 37th week • Neurodevelopmental delay (related to brain and central nervous system immaturity) . Reduced subcutaneous fat stores. Long. Infants who are appropriate for gestational age have lower morbidity and mortality than other groups.000 g (8 lb 13 oz) at term due to accelerated growth for length of gestation (Raju. Have recurrent thoughts of suicide and death Causes .Unresolved feelings about the pregnancy. ADMINISTERING OXYGEN. leading to the development of respiratory distress syndrome. calculate fluid and caloric intake daily. Radiation exposure. especially along suture lines. TORCH group infections • Placental factors . Poor muscle tone and flexion. Immature respiratory control centers. leading to atelectasis. • Continually assess for enteral feeding intolerance. arching • Limb withdrawal and thrashing movements • Increase in heart rate. wash hands upon entering the nursery and in between caring for newborns. Smoking or exposure to passive smoke.g. pulse.    S/S in new mother . Appropriate for gestational age (AGA) describes a newborn with a weight that falls within the 10th to 90th percentile for that particular gestational age.g. Exposure to occupational hazards. Maternal nutrition (malnutrition or obesity). Have pains in her body that do not subside. cesarean section) • Thermoregulation issues (less brown and white. Breast and nipples not clearly delineated. laboratory test results such as serum electrolyte levels. Maternal age of less than 20 or more than 35 years old. Scaphoid abdomen (sunken appearance). • Encourage and support breastfeeding by facilitating maternal breast pumping.5 lb) (Fig. tachycardia. sunken fontanels. Placental complications (placenta previa or abruption placentae). Limited or lack of social support network Newborn at Risk Factors of high-risk pregnancy: • Maternal nutrition (malnutrition or overweight). Abundant hair on scalp. Numerous life stressors. urinary output. • Avoid coming to work when ill. Substance abuse (heroin. Living at a high altitude (hypoxia).000 g (2 lb 3 oz) SGA S/S . Show a lack of concern for herself. from changes in work and home routines. • Monitor laboratory test results for changes. Limited vernix and lanugo. hypertension. measure abdominal girth. blood urea nitrogen. and 21. Multiple fetal gestation Nursing Management Hypoglycemia in a neonate is defined as blood glucose value below 40 mg/dL. such as a decrease in urinary output. Minimal scrotal rugae in male infants. Fused eyelids. Unstable chest wall. Abuse and violence.5 pounds. Autoimmune diseases. wrinkled skin. Fontanels wide and soft with overriding sutures. Poor muscle tone over buttocks and cheeks. Soft and spongy skull bones. alert expression.. especially over the face and back. wooly in appearance. toxoplasmosis). Lack of social support network. Undescended testes • Plentiful lanugo (soft.500 g (5. honest communication with parents and staff • Collaboration with the parents in planning the infant’s care Nursing interventions aimed at reducing parental anxiety include: • Reviewing with them the events that have occurred since birth • Providing simple relaxation and calming techniques (visual imagery. lack of adequate surfactant. prominent labia and clitoris in female infants. kicking. Exhibit a lack of energy and motivation. Suspect pain if the newborn exhibits the following: • Sudden high-pitched cry • Facial grimace with furrowing of brow and quivering chin • Increased muscle tone • Oxygen desaturation • Body posturing.Poor coping skills.500 g (3 lb 5 oz) • Extremely low birthweight: less than 1. cracked. Maternal disease (e. Act detached toward others and infant. Meconiumstained skin and fingernails. Minimal subcutaneous fat. Lack interest in her baby. Periodontal disease. Wide skull sutures secondary to inadequate bone growth. Matted scalp hair. syphilis. with soft. thin extremities. Fatigue after delivery from lack of sleep or broken sleep. Thin. auscultate bowel sounds. Abuse and violence. Inadequate assistance from partner. Lack of prenatal care. Maternal infection (e. Decreased amount of breast tissue. Previous psychological problems or a family history of psychiatric disorders.