Chapter 22 Nursing Management of the Postpartum Woman at Risk

Postpartum hemorrhage (PPH): as a blood loss greater than 500 mL after vaginal birth or more
than 1,000 mL after a cesarean birth
 major obstetric hemorrhage is defined as a blood loss of more than 1,500 to 2,500 mL or
bleeding that required more than 5 units of transfused blood
 majority of these deaths occur within 4 hours of childbirth, which indicates that they are
a consequence of the third stage of labor management
 symptoms of hemorrhage or shock from blood loss may be hidden by normal plasma
volume increases that occur during pregnancy
 Complications: organ failure, shock, edema, thrombosis, acute respiratory distress,
sepsis, anemia, intensive care admissions, and prolonged hospitalization
 Most common cause of PPH is uterine atony, failure of the uterus to contract and
retract after birth
 Other causes of PPH include 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

 4 T’s:
o Tone: uterine atony, distended bladder
 overdistention of the uterus multiple gestation, fetal macrosomia,
hydramnios, fetal abnormality, placenta previa, precipitous birth, or
retained placental fragments, a full bladder!!
 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
 Overdistention is a factor that leads to UTERINE ATONY
 uterine massage is used to treat uterine atony
o Tissue: retained placenta and clots; uterine subinvolution
 Failure of complete placental separation and expulsion leads to retained
fragments, which occupy space and prevent the uterus from contracting
 fully to clamp down on blood vessels; this can lead to hemorrhage. Clots
can also occupy space, which inhibits uterine contractions
 tears or fragments left inside may indicate an accessory lobe or placenta
accreta (an uncommon condition in which the chorionic villi adhere to
the myometrium, causing the placenta to adhere abnormally to the
uterus and not separate and deliver spontaneously)
 If retained placental fragments are the cause, the fragments are usually
manually separated and removed and a uterine stimulant is given to
promote the uterus to expel fragments
 Subinvolution refers to incomplete involution of the uterus or failure to
return to its normal size and condition after birth, the myometrial fibers
of the uterus do not contract effectively and causes relaxation
 Complications: hemorrhage, pelvic peritonitis, salpingitis, and
abscess formation
 Causes: retained placental fragments, distended bladder,
excessive maternal activity prohibiting proper recovery, uterine
myoma, and infection
 Clinical picture includes a postpartum 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
o Trauma: lacerations, hematoma, inversion, rupture
 Damage to the genital tract may occur spontaneously or through the
manipulations used during birth
 Lacerations and hematomas resulting from birth trauma can cause
significant blood loss
 hematoma formation is associated with episiotomy, instrumental birth,
or nulliparity
 Uterine inversion happens when the top of the uterus collapses into the
inner cavity due to excessive fundal pressure or pulling on the umbilical
cord when the placenta is still firmly attached to the fundus after the
infant has been born
 TREATMENT: giving uterine relaxants and immediate manual
replacement by the health care provider
 uterine rupture can occur and cause damage to the genital tract
 signs and symptoms combine pain, fetal heart rate abnormalities,
and vaginal bleeding
 Cervical lacerations commonly occur during a forceps delivery or in
mothers who have not been able to resist bearing down before the cervix
is fully dilated
 Lacerations can arise during manipulations to resolve shoulder dystocia.
Lacerations should always be suspected in the face of a contracted uterus
with bright-red blood continuing to trickle out of the vagina
o Thrombin: coagulopathy (pre-existing or acquired)
 Disorders that interfere with the clot formation can lead to postpartum
hemorrhage
 Abnormal results typically include decreased platelet and fibrinogen
levels, increased prothrombin time, partial thromboplastin time, and
fibrin degradation products, and a prolonged bleeding time

 Idiopathic thrombocytopenia purpura (ITP)
 autoimmune disorder of increased platelet destruction caused by
autoantibodies, which can increase a woman’s risk of
hemorrhaging
 Glucocorticoids and intravenous immunoglobulin, intravenous
anti-RhoD, and platelet transfusions may be given for ITP
 Perinatal management of ITP should also include maintenance of
maternal platelet count and regular monitoring of fetal growth
along with prediction and prevention of fetal passive immune
thrombocytopenia
 VON WILLEBRAND DISEASE
 congenital bleeding disorder that is inherited as an autosomal
dominant trait
 prolonged bleeding time, a deficiency of von Willebrand factor,
and impairment of platelet adhesion
 common symptoms of vWD include bleeding gums, easy bruising,
menorrhagia, blood in urine and stools, nosebleeds and
hematomas, GI bleeds are rare
 Will be fine during pregnancy since levels increase, worry about
postpartum
 Give desmopressin and plasma concentrates that contain von
Willebrand factor
 Delayed postpartum hemorrhage may occur, watch for up to 2
weeks
 DIC secondary to another issue, must fix first issue to fix DIC
 the 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
 Occurs as a complication of abruptio placentae, amniotic fluid
embolism, intrauterine fetal death with prolonged retention of
the fetus, acute fatty liver of pregnancy, severe preeclampsia,
HELLP syndrome (hemolysis, i.e., the breakdown of red blood
cells, elevated liver enzymes, and low platelet count), septicemia,
and postpartum hemorrhage
 Clinical features include petechiae, ecchymoses, bleeding gums,
fever, hypotension, acidosis, hematomas, tachycardia,
 proteinuria, uncontrolled bleeding during birth, and acute renal
failure
 Maintain tissue perfusion through aggressive administration of
fluid therapy, oxygen, heparin, and blood products

Nursing Assessment:
o A soft, boggy uterus that deviates from the midline suggests that a full bladder is
interfering with uterine involution. If the uterus is not in correct position (midline), it will
not be able to contract to control bleeding.
o Assess the amount of bleeding, Weighing or counting peri pads or using a Signaling a
Postpartum Hemorrhage Emergency mat would provide a more accurate estimate of
blood loss (each square on the mat would absorb up to 50 mL of blood)
 o If bleeding continues even though there are no lacerations, suspect retained placental
fragments
o Trauma is suspected, attempt to identify the source and document it. Typically, the
uterus will be firm with a steady stream or trickle of unclotted bright-red blood noted in
the perineum
o Assess for hematoma, uterus would be firm, with bright-red bleeding, Observe for a
localized bluish bulging area just under the skin surface in the perineal area.
 severe perineal or pelvic pain and will have difficulty voiding
 may exhibit hypotension, tachycardia, and anemia
o Inspect the skin and mucous membranes for gingival bleeding or petechiae and
ecchymoses
o Check venipuncture sites for oozing or prolonged bleeding
o Assess lochia amount
o Urinary output would be diminished, with signs of acute renal failure
o Increased pulse rate and a decreased level of consciousness

Nursing Management:
 Initial management steps are aimed at improving uterine tone with immediate fundal
massage, intravenous fluid resuscitation, and administration of uterotonic medications
 Then move on to aggressive interventions such as bimanual compression, internal
uterine packing, and/or balloon tamponade techniques are employed by the health care
provider
 Transfusion of blood products should be instituted without hesitation once estimates of
bleeding reach 1,500 mL
 Massage the boggy uterus to stimulate contractions and expression of any accumulated
blood clots while supporting the lower uterine segme

 Administer a uterotonic drug if repeated fundal massage and expression of clots fail;
important intervention used to prevent PPH. DRUG CHART PAGE 806
o Pitocin–never give undiluted as a bolus injection intravenously
 o Cytotec–allergy, active cardiovascular disease, pulmonary or hepatic disease
o Prostin E2–active cardiac, pulmonary, renal, or hepatic disease
o Methergine–if the woman is hypertensive, do not administer
o Hemabate–contraindicated with asthma due to risk of bronchial spasm
 Draw blood for type and cross-match and send it to the laboratory. Administer oxytocics
as ordered
 Check vital signs every 15 to 30 minutes and LOC
 Monitor her complete blood count to identify any deficit or assess the adequacy of
replacement
 Prepare the woman for removal of retained placental fragments
 Monitor for Hemorrhagic Shock: Monitor the woman’s blood pressure, pulse, capillary
refill, mental status, and urinary output
o Prepare the woman for a splenectomy if the bleeding tissues do not respond to
medical management
o avoiding any medications with antiplatelet activity such as aspirin,
antihistamines, or nonsteroidal anti-inflammatory drugs (NSAIDs)
 Institute Emergency Measures If DIC Develops: Be ready to replace fluid volume,
administer blood component therapy, and optimize the mother’s oxygenation and
perfusion status to ensure adequate cardiac output and end-organ perfusion
o Observe for early signs of ecchymosis, including spontaneous bleeding from
gums or nose, petechiae, excessive bleeding from the cesarean incision site or
intravenous site, hematuria, and blood in the stool
 Preventing Postpartum Hemorrhage:
o Avoid an episiotomy unless an emergency birth is necessary
o administration of a uterotonic medication after birth of anterior shoulder,
controlled and gentle cord traction to deliver the placenta, and uterine massage
after the placenta is out
o Nurses must identify and correct anemia and screen for coagulopathies before
labor and birth
o After birth inspect for full placenta is removed
o Having a hemorrhage cart with supplies and instruction cards on every OB unit
o Having immediate access to medications used to treat a massive hemorrhage
o Establishing a response team within the hospital that can be called
o Developing emergency-release transfusion protocols in the blood bank
o Educating all staff on protocols and holding unit-based drills frequently
o Careful monitoring of the mother’s vital signs, laboratory tests (in particular,
coagulation testing) and immediate diagnosis of the cause of PPH
Venous thromboembolism
three most common venous thromboembolic conditions occurring during the postpartum
period are superficial venous thrombosis, DVT, and PE
 Risk for postpartum venous thromboembolism is highest during the first three weeks
after childbirth, and can occur up to 12 weeks postpartum
 Nursing Assessment:
o Risk factors in the woman’s history such as use of oral contraceptives before the
pregnancy, smoking, employment that necessitates prolonged standing, history
of thrombosis, thrombophlebitis, or endometritis, or evidence of current
varicosities, prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-
induced distensibility of the veins of the lower legs during pregnancy, severe
anemia, varicose veins, advanced maternal age (older than 34 years), and
multiparity
o Suspect superficial venous thrombosis in a woman with varicose veins who
reports tenderness and discomfort over the site of the thrombosis, most
commonly in the calf area
o S/S: Calf swelling, erythema, warmth, tenderness, and pedal edema may be
noted
o PE S/S: unexplained sudden onset of shortness of breath and severe chest pain,
tachypnea, tachycardia, hypotension, syncope, distention of the jugular vein,
decreased oxygen saturation (shown by pulse oximetry), cardiac arrhythmias,
hemoptysis, and a sudden change in mental status as a result of hypoxemia
 Nursing Management:
o Preventing venous stasis by encouraging activity that causes leg muscles to
contract and promotes venous return (leg exercises and walking)
o Dorsi/plantar flexion of feet with prolonged sitting to promote venous return
o Using intermittent sequential compression devices to produce passive leg muscle
contractions until the woman is ambulatory
o Elevating the woman’s legs above her heart level to promote venous return
o Stopping smoking to reduce or prevent vascular vasoconstriction
o Applying compression stockings and removing them daily for inspection of legs
o Using postoperative deep-breathing exercises to improve venous return by
relieving the negative thoracic pressure on leg veins
o Reducing hypercoagulability with the use of aspirin or anticoagulation therapy
o Preventing venous pooling by avoiding pillows under knees, not crossing legs for
long periods, and not leaving legs up in stirrups for long periods
o Padding stirrups to reduce pressure against the popliteal angle
o Avoiding sitting or standing in one position for prolonged periods
o Avoiding trauma to legs to prevent injury to the vein wall
o Increasing fluid intake to prevent dehydration
o Avoiding the use of oral contraceptives
o Early ambulation is the easiest and most cost-effective method
o A low-molecular-weight heparin such as enoxaparin (Lovenox) can be given or
rivaroxaban (Xarelto), apixaban (Eliquis), or dabigatran etexilate (Pradaxa) can be
given
o Superficial Venous Thrombosis:
 administer NSAIDs for analgesia, provide for rest and elevation of the
affected leg, apply warm compresses to the affected area to promote
healing, and use antiembolism stockings to promote circulation to the
extremities.
o DVT
 Implement bed rest or limited ambulation if ordered and elevation of the
affected extremity
 Anti-embolism stockings
 Sequential compression stockings
 Warm moist compresses on leg
o Anticoagulant therapy using a continuous intravenous infusion of low molecular-
weight heparin along with vitamin K antagonists usually is initiated to prolong
the clotting time and prevent extension of the thrombosis
o Monitor Labs:
 aPTT should be 35-45 seconds, whole-blood partial thromboplastin time,
and platelet levels
o Switch to oral anticoags after IV
o PE
 Administer oxygen via mask or cannula as ordered
 Initiate intravenous low molecular-weight heparin therapy titrated
according to the results of the coagulation studies
 Maintain the client on bed rest
 Administer analgesics as ordered for pain relief
 Be prepared to assist with administering thrombolytic agents, such as
alteplase (tPA) to dissolve emboli
Postpartum Infection PPI
 Postpartum infection is defined as a fever of 100.4° F (38° C) or higher after the first 24
hours after childbirth, occurring on at least 2 of the first 10 days after birth, exclusive of
the first 24 hours
 Risk factors include surgical birth, prolonged rupture of membranes, long labor with
multiple vaginal examinations, inadequate hand hygiene, internal fetal monitoring,
uterine manipulation, chorioamnionitis, instrumental birth, obesity, untreated infection
prior to birth, retained placental fragments, obesity, gestational diabetes, extremes of
client age, low socioeconomic status, and anemia during pregnancy
 following microorganisms: Staphylococcus aureus, Escherichia coli, Klebsiella,
Gardnerella vaginalis, gonococci, coliform bacteria, group A or B hemolytic streptococci,
Chlamydia trachomatis, and the anaerobes that are common to bacterial vaginosis

Metritis: endometritis
 infectious condition that involves the endometrium, decidua, and adjacent myometrium
of the uterus
 increased risk with C-section
 one dose of prophylactic antibiotic therapy administered one hour before any cesarean
section and this has become standard practice in the United States today
 broad-spectrum antibiotics are used to treat the infection
 restore and promote fluid and electrolyte balance, provide analgesia

Surgical Site Infections:

 cesarean surgical incisions, the episiotomy site in the perineum, and genital tract
lacerations
 symptoms may not show up until 24 to 48 hours after birth
 opening of the wound to allow drainage
 Aseptic wound management with sterile gloves and frequent dressing changes
 Hand hygeniene, frequent perineal pad changes, hydration, and ambulation to prevent
stasis
 Parenteral antibiotics and analgesics for pain

Urinary Tract Infections:

 E. coli, Klebsiella, Proteus, and Enterobacter species
 urinary catheterization), frequent vaginal examinations, and genital trauma increase the
likelihood of a urinary tract infection
 Common cause of fever
 Antibiotics, cranberry juice, vitamin C, fluids

Mastitis:
 inflammation of the mammary gland
 may occur within the first 2 days to 2 weeks postpartum
  Risk factors associated with mastitis include stasis of milk due to infrequent,
inconsistent breastfeeding, and nipple trauma
 Causes: insufficient drainage of the breast, rapid weaning, oversupply of milk, pressure
on the breast from a poorly fitting bra, a blocked duct, missed feedings, and breakdown
of the nipple via fissures, cracks, or blisters
 upper, outer quadrant of the breast is the most common site
 Effective milk removal, pain medication, and antibiotic therapy have been the mainstays
of treatment
 Increasing the frequency of nursing is advised. Lactation need not be suppressed
 ice or warm packs and analgesics may be needed

Nursing Assessment:
 PPI is commonly associated with an elevated temperature, as mentioned previously.
Other generalized signs and symptoms may include chills, foul-smelling vaginal
discharge, headache, malaise, restlessness, anxiety, and tachycardia. In addition, the
woman may have specific signs and symptoms based on the type and location of the
infection.

 Woman’s perineum status

o Redness—area may also feel warm to touch
o Edema—may indicate infection or a hematoma
o Ecchymosis—may indicate vaginal trauma
o Discharge—should follow the expected lochia pattern
o Approximation of skin edges— should be well aligned without gaps
Nursing Management:
 Maintain aseptic technique when performing invasive procedures such as urinary
catheterization, when changing dressings, and during all surgical procedures
 Use good hand hygiene technique before and after each client care activity.
 Reinforce measures for maintaining good perineal hygiene.
 Practice standard precautions whenever in contact with blood, body fluids, and
excretions.
 Use adequate lighting and turn the client to the side to assess the episiotomy site.
 Use extreme caution when handling sharp instruments, specimens, and waste disposal.
 Screen all visitors for any signs of active infections to reduce the client’s risk of
exposure.
 Review the client’s history for pre-existing infections or chronic conditions.
 Monitor vital signs and laboratory results for any abnormal values.
 Monitor the frequency of vaginal examinations and length of labor.
 Assess frequently for early signs of infection, especially fever and the appearance of
lochia.
 Inspect wounds frequently for inflammation and drainage.
 Encourage rest, adequate hydration, and healthy eating habits.
 Reinforce preventive measures during any interaction with the client
Postpartum Affective Disorders:
 The delivery of a newborn is associated with positive feelings such as happiness, joy, and
gratitude for the birth of a healthy infant
 They may experience fear about loss of control; they may feel scared, alone, or guilty, or
as if they have somehow failed
 Plummeting levels of estrogen and progesterone immediately after birth can contribute
to postpartum mood disorders

Postpartum Blues:
 80% of women develop the Blues
 rapid cycling mood symptoms during the first postpartum week typically.
 mild depressive symptoms of anxiety, irritability, mood swings, tearfulness, increased
sensitivity, despondency, feelings of being overwhelmed, difficulty thinking clearly, and
fatigue
 Peak on Postpartum Day 4/5 and resolve by Day 10
 20% will go on to develop Postpartum Depression

Postpartum Depression:
 S/S:
o Restless
o Worthless
o Guilty
o Hopeless
o Moody
o Sad
o Overwhelmed
o Loss of enjoyment
o Low energy level
o Loss of libido
 The new mother may also:
o Cry a lot
o Exhibit a lack of energy and motivation
o Be unable to make decisions or focus
o Lose her memory
o Experience a lack of pleasure
o Have changes in, sleep, or weight
o Show a lack of concern for herself
o Withdraw from friends and family
o Have pains in her body that do not subside
o Feel negatively toward her baby
o Appetite disturbances
o Feelings of isolation from others
o Lack interest in her baby
 o Worry about hurting the baby
o Act detached toward others and infant
o Have recurrent thoughts of suicide and death
 Gradual onset and becomes evident within the first 6 weeks postpartum
 What can lead to PPD:
o Unresolved feelings about the pregnancy
o Fatigue after delivery from lack of sleep or broken sleep
o Feelings of being less attractive
o Inadequate assistance from partner
o Lack of social support network
o History of sexual or physical abuse
o Unemployment or financial insecurity
o Doubts about the ability to be a good mother
o Stress from changes in work and home routines
o Loss of freedom and old identity
 If prior depression, Prophylactic antidepressant therapy may be needed during the third
trimester or immediately after giving birth
 Partner can develop PPD, may seem more angry and anxious than sad, yet depression is
present. Peak at 3-6 months post partum
o Factors that increase the risk of paternal PPD include a personal history of
depression and/or anxiety, a low level of marital satisfaction, excessive financial
stressors, a lack of significant other or partner’s parental leave, and the feeling
that there is a great discrepancy between one’s expectations of parenthood and
its realities
 EPDS is a self-report, quick, and easy screening tool for PPD that consists of 10 questions
with four possible responses
o couple fill out the tool according to their symptoms during the past 7 days, with
each response given a score of 0 to 3 points, creating a maximum score of 30
 PDSS is a self-report, 35-item Likert-type response scale divided into seven conceptual
domains:
o Anxiety/insecurity
o Sleep/eating disturbance
o Emotional liability
o Loss of self-esteem
o Guilt/shame
o Cognitive impairment
o Suicidal thoughts
PDSS takes 5 to 10 minutes to administer and is used during the postpartum period
Postpartum Psychosis:
 an emergency psychiatric condition, can result in a significant increased risk for suicide
and infanticide
 Symptoms of postpartum psychosis, such as mood lability, delusional beliefs,
hallucinations, and disorganized thinking, can be frightening for the women who are
affected and for their families
 surfaces within 3 months of giving birth and is manifested by sleep disturbances,
fatigue, depression, and hypomania
 mother will be tearful, confused, and preoccupied with feelings of guilt and
worthlessness
 Depression will escalate to delirium, hallucinations, extreme disorganization of thought,
anger toward herself and her infant, bizarre behavior, delusions, disorientation,
depersonalization, delirium-like appearance, manifestations of mania, and thoughts of
hurting herself and the infant
 Should not be left alone with their infants

Risk Factors for Postpartum Affective Disorders:

 Poor coping skills
 First pregnancy
 Low self-esteem
 Numerous life stressors
 History of abuse
 Mood swings and emotional stress
 Previous psychological problems or a family history of psychiatric disorders
 Substance abuse
 Limited or lack of social support network

Nursing Assessment:
 Ask about her sleeping habits, noting any problems with insomnia
 observe for verbal and nonverbal indicators of anxiety as well as her ability to
concentrate during the interaction
  Assess nutritional intake

Nursing Management:
 Encourage the client to verbalize what she is going through and emphasize the
importance of keeping her expectations realistic
 Assist the woman in structuring her day to regain a sense of control
 Tell woman it is okay to need help after birth
 Have available referral sources for psychotherapy and support groups appropriate for
women experiencing postpartum adjustment difficulties
 Help woman to have realistic expectations
 “Have you felt down, depressed, or hopeless lately?”
 “Have you felt little interest or pleasure in doing things recently?”
 Nurses can suggest several interventions to assist the new mother in obtaining
adequate sleep such as bathing the newborn at night before bedtime, asking for help
from family to assist in nighttime diaper changes, and taking naps throughout the day
when the newborn sleeps. These simple helpful interventions may be a valuable
prevention measure to assist in increasing the mother’s wellness and reduce the risk of
postpartum depression.