Cebu Doctors’ University

College of Nursing
Mandaue City, Cebu

NCM 109 THEORY

POSTNATAL COMPLICATIONS

(Subinvolution of the uterus, Uterine atony, Hemorrhage, Retained Placental

Fragments, Disseminated Intravascular Coagulation)

SECTION 2B- Group 1:

MS. ACOP, ASH LEE

MS. ALILIN, MARIANNE IZABELLE
MS. ALOLOD, JASMIN
MS. ALONSO, DEVON JEAN
MS. ALTAVAS, CHRISTINA ALEXIS
MS. AMPARO, ABIGAIL
MS. ARREZA, GILLIAN
MS. BABON, KRYSTYL JAN LYKA
MS. BANGUD, KRIZHA MARIE
MR. BARTE, REGIL MARK
MS. BEJONA, JULIA NICOLE
MR. BERDIN, NATHAN NIEL ALLNNY

Mrs. Josie Fe O. Mingo, R.N, M.A.N

Clinical Instructor

Date Submitted: February 19, 2021

 TABLE OF CONTENTS

Learning Outcomes for Intranatal Complications PAGE

A. Subinvolution of the uterus 4

B. Uterine atony 10

C. Hemorrhage 19

D. Retained Placental Fragments 28

E. Disseminated Intravascular Coagulation 38

References 45
 NCM 109: Care of Mother and Child at Risk or With Problems
(Acute or Chronic)

Postnatal Complications

Learning Outcome:

Objectives: After various online classroom and laboratory activities, the Level II students
will be able to:

General Instructions:

1. Divide the class into 4 groups same as your RLE groupings. (3 topics midterm and 2
topics finals).

2. Each group will have assigned report to prepare. The report will have the following
content:
2.1. Definition/Description of the disease or complication
A. Subinvolution of the uterus
B. Uterine atony
C. Hemorrhage
D. Retained Placental Fragments
E. Disseminated Intravascular Coagulation

2.2 Etiology/Cause

2.3 Types if Applicable

2.4 Signs and Symptoms

2.5 Nursing Diagnosis (1)

2.6 Management *Nursing, Medical, Pharmacologic, Surgical

2.7 Relevant Pictures/Videos

2.8 One (1) Nursing Care plan on each complication

3. Pass an initial draft thru Assignment tab and coordinate with the teacher in charge.

4. Reporting will start after the pretest of NCM 109 and it should be comprehensive and
well-prepared with proper video presentation.
 SUBINVOLUTION OF THE UTERUS

1.1 Definition/Description of the disease or complication

- Slowing or retardation of the process of involution is known as
subinvolution. The uterus is most affected by subinvolution. Subinvolution
of the uterus is the incomplete return of the uterus to its pre-pregnant
size and shape.

- The fundal height remains stationary. At the 4th or 6th week postpartum
visit, the uterus is soft and baggy, lochia is reddish-brown and profuse.

1.2 Etiology/Cause
- Subinvolution may be caused by any condition which interferes with good
uterine contractions such as:
 Endometritis (Uterine Sepsis)
 Retained Placental Fragments
 Pelvic Infection
 Uterine Fibroids

Other conditions include:

 Over distention (multiple gestation, polyhydramnios)
 Grand multipara
 Cesarean Section
 Prolapse of Uterus
 Retroversion of Uterus

1.3 Types of Applicable

None

1.4 Signs and Symptoms

 Lochial discharge: reddish-brown
 Prolonged lochial flow
 Irregular or at times excessive (profuse) vaginal bleeding
 Large, flabby uterus on bimanual examination
 Irregular cramp like pain in cases of retained products or rise of temperature in
sepsis
 The uterine height is stationary
1.5 Nursing Diagnosis (1)
 Risk for infection related to alteration in the involution process of the uterus.

1.6 Relevant Pictures/Videos

1.7Management *Nursing, Medical, Pharmacological, Surgical

Nursing Medical Pharmacological Surgical

management Management management Management

o Frequent o The o Administration o Dilation and

monitoring of hemoglobin or of oxytocic curettage
vital signs. hematocrit medication (D&C) to
o Daily levels will be to improve remove any
evaluation of evaluated. uterine muscle placental
fundal height o Give IV Fluids - tone. Oxytocic fragments.
to document maintain medication o Hysterectomy
involution circulating includes: o Fertility-
o Early volume and to (a) Methergine®-a sparing
ambulation replace fluid drug of choice since percutaneous
postpartum loss it can be given by embolotherap
mouth. y
 per doctor’s o Conservative (b) Pitocin®-
order medical therapy stimulates uterine
o Facilitate o Antimicrobial contractions by
client’s therapy for increasing
voiding. endometritis. intracellular calcium.
o Teach the (c) Ergotrate®-used
mother to to prevent and
report control uterine atony
persistent and hemorrhage
bright red before and after
bleeding or delivery.
return of red o Warfarin
bleeding after sodium
it has changed (Coumadin,
to pink or Warfilone) -
white Interferes with
o Report blood hepatic
loss. synthesis of
o Prepare for vitamin K –
possible dependent
surgical clotting factors
operation. (II,VII, IX, X)
o Assist the o Anticoagulan
client and ts-Blocks the
family to deal conversion of
with physical prothrombin to
and emotional thrombin and
stresses of fibrinogen to
postpartum fibrin thus
complications decreasing
clotting ability
o Oral
administration
of
methylergon
ovine 0.2mg
four times
daily, to
improve
uterine tone
and complete
involution.
o If the uterus
feels tender to
 palpation,
suggesting
endometritis is
present, an
oral
antibiotic will
be prescribed.
o Administer
iron if
necessary.
o Analgesics
(Ibuprofen)
are given for
pain.
1.8 One (1) Nursing Care Plan on each complication
Needs/ Nursing Scientific Basis Objectives of Nursing Actions Rationale
Problems/ Cues Diagnosis Care

I. Physiologic Risk for The incomplete General Measures to minimize

Risk infection return of the uterus Objectives: the signs and
related to to its normal state symptoms of risk for
A. Risk for alteration in increases the risk of After 2 days of infection through:
infection the involution the mother to holistic nursing
process of the acquire infection. care, the client will 1.Monitor vital signs, 1.Alterations
Objective cues: uterus As bleeding be able to: lochia (character, from normal
o Larger than progresses, amount, odor, are signs of
normal coagulation factors 1. achieve a timely presence of clots), infection and
uterus are becoming progress in fundal height and retained
o Prolonged ineffective against healing. status of episiotomy. fragments in
lochial infection. However, the uterus.
discharge one of the main Specific
o Profuse factors in the Objectives:
vaginal pathogenesis of 2.To manually
2.Inform the patient
bleeding puerperal infections After 8 hours of removed the
that a possible
o Flabby is the lack of student nurse to retained
uterus surgical operation
adequate postnatal client interaction, placental
may be performed.
follow-up, which the client will be tissues.
Subjective cues: leads to delayed able to:
o “My delivery recognition and
3.Teach patient on 3.Appropriate
lasted for a increased risk for 1.identify
performing perineal care for the
short while complications. Early interventions to
care and hygiene. perineum
my vagina recognition through prevent or reduce reduces the
hurts. I also a detailed clinical risk for infection. chances of
noticed a workup is
bruising in mandatory,
my area” as as sepsis and 2.verbalize bacterial
verbalized shock can develop understanding of invasion.
by the and be fatal in the individual
patient. absence of proper causative or risk 4.Review WBC 4.Increased
therapy. factors. count, hemoglobin, white blood
and hematocrit cell count
levels. indicates an
Source: infection.
Symptoma- a better Anemia often
diagnosis accompanies
(https://www.symp infection,
toma.com/en/info/p delays the
uerperal-infection) wound
healing, and
weaken the
immune
system

5.Alterations
5.Tell the female in coagulation
patient to inform the may lead to
health care provider increased
when there is an blood loss with
increase in menstrual regular menstr
bleeding as indicated uation.
by an increase in the
number of sanitary
pads used.
6.Administer iron 6.To correct
supplement as anemia. And
indicated. possibly
improves
wound
healing.

7.Provide 7.This helps in

psychological and patient’s
emotional support to assurance and
the patient. calming.

Sources:
Vera, M.
(September
07, 2020).
Risk for
Infection
Nursing Care
Plan.
Nurselabs.
Retrieved on
February 16,
2020 from
https://nursesl
abs.com/risk-
for-infection/.
 UTERINE ATONY

2.1 Definition/Description of the disease or complication

Uterine atony or relaxation of the uterus is the most frequent cause of
postpartum hemorrhage. It occurs most often in Asian, Hispanic, and Black Women
(Grobman, Bailit, Rice, et al., 2015).

2.2 Etiology/Cause
Some of the most common causes of uterine atony are:
 Prolonged labor or delayed labor
 Rapid labor
 Overdistention of the uterus (enlargement of the uterus) because of the
presence of excess amniotic fluid (a condition called polyhydramnios) or a
large baby
 Administration of oxytocin, general anesthesia, or other drugs during labor
 Inducing labor using medication

2.3 Types
None

2.4 Signs and Symptoms

 Uterus remains relaxed and without any tension after giving birth.
 Uncontrollable and excessive bleeding post-delivery of a baby.
 A drop in blood pressure
 An increase in the heart rate
 Pain
 Back pain

2.5 Nursing Diagnosis (1)

 Deficient fluid volume related to excessive blood loss after birth.
2.6 Management *Nursing, Medical, Pharmacological, Surgical

Nursing Medical Pharmacological Surgical

management Management management Management

 Attempt  Bimanual  Carboprost o Hysterectomy

fundal compression tromethamine or Suturing
massage to may be
encourage repeated every  With extreme
contraction. 15 to 90 bleeding,
 Remain with minutes up to embolization
a woman 8 doses; of pelvic and
after methylergonovi uterine
massaging ne maleate vessels by
her fundus  Administer may be angiographic
and assess to oxygen by repeated every techniques
be certain face mask at 2 to 4 hours up may be
her uterus is a rate of to 5 doses. necessary.
not relaxing about 10-12  Administer a  Last resort
again. L/min bolus or a will be
 Continue to  Sonogram dilute ligation of the
assess for intravenous uterine
the next 4 infusion of arteries or a
hours. oxytocin hysterectomy
 Assess blood (PItocin) to
pressure help maintain o Uterine atony
prior to tone (lang, can usually
administratio Zhao, & be controlled
n and about Robertson, by uterotonic
15 minutes  Blood 2015). drugs alone
afterward to replacement  Oxytocin given or in
detect the intravenously combination
potentially (IV). with fertility
dangerous  If oxytocin is preserving
side effect not effective at procedures.
(which is an maintaining
increase in tone,
blood carboprost
pressure). tromethamine
 Elevate the (Hemabate) or
woman’s methylergonovi
lower ne maleate
extremities to (Methergine),
improve both are given
circulation to bedpan or assist the woman to the
essential bathroom at least every 4 hours to be
organs. certain her bladder is emptying
 Offer a because a full bladder predisposes a
 woman to intramuscularly
uterine , are second
atony. possibilities.
 Administer  Misoprostol
oxygen by (Cytotec) may
face mask at also be
a rate of administered
about 10 to rectally to
12 L/min if decrease
the woman is postpartum
experiencing hemorrhage.
respiratory
distress from
decreasing
blood
volume.
 Position her
supine (flat)
to allow
adequate
blood flow to
her brain and
kidneys.
 Obtain vital
signs
frequently
and assess
them for
 trends such
as a
continually
decreasing
blood
pressure with
a
continuously
rising pulse
rate.

2.7 Relevant Pictures/Videos

2.8 One (1) Nursing Care plan on each complication
Needs/ Nursing Scientific Basis Objectives of Nursing Actions Rationale
Problems/ Cues Diagnosis Care

II. Physiologic Deficient When the uterus General Measures to aid

Deficit fluid volume suddenly relaxes, Objectives: patient having risk
related to there will be an for fluid volume
B. Deficient Fluid excessive abrupt gush of After 1 week of deficit:
Volume blood loss blood vaginally patient-nurse
after birth. from the placental intervention, the
Objective Cues: site. This can occur patient will be able 1.Monitor and 1.Decrease in
 Restlessness immediately after to: document vital signs circulating
 Irritability birth but is more especially BP and HR. blood volume
 Facial likely to occur 1.verbalize can cause
grimace gradually, over the awareness of hypotension
 Pale and first postpartum causative factors and
clammy skin hour, as the uterus and behaviors tachycardia.
 3 perineal slowly loses its essential to Alteration in
pads tone. correct fluid HR is a
saturated deficit. compensatory
within one If the loss of blood mechanism to
hour is extremely 2.explain maintain
 Upon copious, a woman measures that can cardiac output.
palpation, will quickly begin to be taken to treat
uterus feels exhibit symptoms of or prevent fluid 2.Assess skin turgor 2.Signs of
relaxed hypovolemic shock volume loss. and oral mucous dehydration
 Rapid and such as falling membranes for signs are also
weak pulse blood pressure; 3.describe of dehydration. detected
 Shallow rapid, weak, or symptoms that through the
respiration thready pulse; indicate the need skin.
increased and to consult with Longitudinal
health care
provider.
  V/s taken as shallow Specific furrows may
follows: respirations; pale, Objectives: be noted along
-T:38 C clammy skin; and the tongue.
-P:50 bpm increasing anxiety. After 8 hours of
-R:24 bpm nursing 3.Observe urinary 3.To evaluate
-BP: 80/50 If the blood loss is intervention, the output, color, and degree of fluid
unnoticed seepage, client will be able measure amount and deficit.
Subjective cues: there is little to: specific gravity.
 “I feel pain in change in pulse and
my pubic blood pressure at 1.maintain fluid 4.Measure a 24-hour 4.This will help
area and my first because of volume at a intake and output. in determining
back hurts”, circulatory functional level as Observe for signs of the fluid loss.
as verbalized compensation. evidenced by voiding difficulty. A urine output
by the client. Suddenly, however, individually of 30-50
the system can adequate ml/hr. or more
compensate no hemoglobin, indicates an
more, and the pulse hematocrit, stable adequate
rate rises rapidly vital signs, and circulating
and becomes weak. good uterine volume.
Blood pressure then contractility. Voiding
drops abruptly.With difficulty may
slow bleeding, a happen with
woman develops hematomas in
these symptoms the upper of
over a period of the vagina
hours; the result of causing
continued seepage, pressure in the
however, can be as urethra.
life threatening as a
sudden profuse loss
of blood
(Andrighetti, 5.Prepare the patient 5.Blood
2013). for blood transfusion
replacement. may be
Source: needed to
Silbert-Flagg, J., & replace blood
Pillitteri, A. (2018). loss with
Maternal & Child postpartum
Health Nursing (8th hemorrhage.
edition, Vol. 1).
Wolters Kluwer.
6.Administer oxytocin 6.To increase
intravenously. contractions
and promote
uterine
involution and
lessen blood
loss.

7. Coordinate with 7. To aid the

the physician to mother in
administer oxygen by breathing and
face mask at a rate have sufficient
of 10 to 12 L/min if oxygen supply.
the woman is
experiencing
respiratory distress.

Source: Fluid
Volume Deficit
(Dehydration)
Nursing Care
Plans. (2016,
October 21).
Retrieved
February 16,
2021, from
Nurseslabs
website:
https://nursesl
abs.com/defici
ent-fluid-
volume/
 HEMORRHAGE

3.1 Definition/Description of the disease or complication

Hemorrhage, one of the primary causes of maternal mortality associated with

childbearing, is a major threat during pregnancy, throughout labor, and continuing into
the postpartum period. Traditionally, postpartum hemorrhage is defined as blood loss of
500 ml or more following a vaginal birth; this occurs in as many as 5% to 15% of
postpartum women (Dahlke, Menez-Figueroa, Maggio et al., 2015). With a cesarean
birth, hemorrhage is present when there is a 1,000 ml blood loss or a 10% decrease in
hematocrit level.

3.2 Etiology/Cause

The four main reasons for postpartum hemorrhage are:

 Uterine atony
 Trauma (lacerations, hematomas, uterine inversion or uterine rupture)
 Retained placental fragments
 Development of disseminated intravascular coagulation (DIC).

These causes are generally referred to as the four T’s of postpartum: tone, trauma,
tissue and thrombin.

3.3 Types if Applicable

1. Early/ Primary postpartum hemorrhage - within the first 24 hours following

birth
- Greatest danger due to the grossly denuded and unprotected uterine
area after the detachment of the placenta
2. Late/ Secondary postpartum hemorrhage - from 24 hours to 6 weeks after
birth

3.4 Signs and Symptoms

 Uncontrolled bleeding
 Decreased blood pressure
 Increased heart rate
  Decrease in the red blood cell count
 Swelling and pain in the vagina and nearby area if bleeding is from hematoma
 Signs of shock
o Pallor
o Dizziness or fainting
o Weakness or fatigue
o Nausea
o Clammy skin

3.5 Nursing Diagnosis (1)

 Deficient fluid volume: lochia discharge related to childbirth.

3.6 Management *Nursing, Medical, Pharmacologic, Surgical

Nursing Medical Pharmacological Surgical

management Management management Management

 Massage the  Administer  Administer o Laceration

uterus to oxygen by oxytocin to repair
stimulate facemask help the o Uterine
contractions at the rate uterine curettage to
 Position the prescribed maintain remove
mother in by the tone placental
Trendelenbur doctor if  If oxytocin is fragments
g supine with the mother unavailable o Balloon
legs elevated is or is tamponade
to improve experiencin ineffective o Compressive
circulation to g alone, suture
essential respiratory ergometrine techniques
organs like distress. or oxytocin- o Hypogastric
the brain and  Administer ergometrine artery ligation
the kidneys. IV infusion (syntometrin o Hysterectomy
 Measure or blood e) can be to surgically
maternal transfusion offered as a remove the
blood loss as second line uterus
by counting prescribed treatment.
and
weighing
 perineal by the  Prostaglandin
pads. doctor. can be given
 Explain the  Catheteriza as a 3rd line
situation to tion, to treatment if
the mother reduce the other
and possibility medications
significant of bladder are
others. pressure. unavailable.
 Reassess the  Bimanual  Administer
vital signs of compressio misoprostol
the mother n - if fundal orally or
frequently for massage sublingually
trends such and to increase
as: administrati uterine tone.
continually on of
decreasing uterotonics
blood are not
pressure with effective at
a stopping
continuously uterine
rising pulse bleeding, a
rate. sonogram
 Offer bedpan may be
or assist done to
mother to detect
the bathroom possible
at least every retained
4 hours to be placental
certain her fragments.
bladder is
empty as a
full bladder
predisposes a
woman to
uterine atony
3.7 Relevant Pictures/Videos
3.8 One (1) Nursing Care plan on each complication
Needs/ Nursing Scientific Basis Objectives of Nursing Actions Rationale
Problems/ Cues Diagnosis Care

III. Physiologic Deficient fluid Loss of blood from General Measures to alleviate
Deficit volume as the uterus more Objectives: adequacy in the
evidenced by than 500 ml within patient’s fluid volume
C. Deficient lochia a 24-hour period is After 2 days of through:
Fluid Volume discharge called postpartum student nurse-
related to hemorrhage. It may client interaction, 1.Assess and record 1.The amount
Objective Cues: postpartum be immediate or the client will to: the type, amount, of blood loss
hemorrhage late occurring from and site of the and the
o BP: 100/70 the first 24 hours of 1.recover a normal bleeding; Count and presence of
mmHg delivery up to the range of fluid weigh perineal pads blood clots will
o Respiratory remaining days of volume. and if possible, save help to
rate: 24 the 6- week blood clots to be determine the
bpm puerperium. The Specific evaluated by the appropriate
o Lochia first 24 hours after Objectives: physician. replacement
discharge delivery is the most needs of the
(rubra) dangerous part After 8 hours of patient.
o Dry mucous wherein postpartum student nurse-
membranes hemorrhage must client interaction, 2.Monitor vital signs 2.Increased
o Decreased be monitored the client will: including systolic and heart rate, low
skin/tongue closely due to prior diastolic blood blood
turgor detachment of the 1.have a lochia pressure, pulse and pressure,
o Inconsistenc placenta. flow of less than heart rate. Check for cyanosis,
y in weight one saturated the capillary refill and delayed
o Dry mucous Source: Hope, I. perineal pad per observe nail beds and capillary refill
membranes (2018, Jan. 23). hour. mucous membranes. indicates
Fluid Volume hypovolemia
Deficit-Post Partum and impending
 o Decreased Hemorrhage shock.
skin/tongue Nursing Care Plan. Decrease fluid
turgor Retrieved from volume of 30-
o Inconsistenc https://rnspeak.co 50% will
y in weight m/fluid-volume- reflect
deficit-post-partum- changes in the
hemorrhage- blood
Subjective Cues: nursing-care-plan/ pressure.

“Duha na ka adlaw 3.Measure a 24-hour 3.This will help

nilabay gikan sa intake and output. in determining
akong Observe for signs of the fluid loss.
pagpanganak pero voiding difficulty. A urine output
sige gihapon ko ug of 30-50
dugo ug ml/hr. or more
nagpanlipong ko”, indicates an
as verbalized by adequate
the patient. circulating
volume.
Voiding
difficulty may
happen with
hematomas in
the upper
portion of the
vagina causing
pressure in the
urethra.

4.Maintain a bed 4.The position

rest with an increases
elevation of
the legs by 20-30° venous return,
and trunk horizontal. making sure a
greater
availability of
blood to the
brain and
other vital
organs.
Bleeding may
be decreased
with the bed

5. Start 1 or 2 IV 5.This is
infusion(s) of isotonic important for
or electrolyte fluids rapid or
with an 18-gauge multiple
catheter or via a infusions of
central venous line. fluids or blood
Administer fresh products to
whole blood or other increase
blood products (e.g., circulating
platelet concentrate, volume and
plasma, enhance
cryoprecipitate) as clotting.
indicated Note: Each
unit of whole
blood
increases the
hematocrit
level by three
 percentage
points.

6.Antibiotics
6.Antibiotic therapy act as
(based on culture prophylaxis to
and sensitivity of the prevent
lochia) infection or
may be
needed for an
infection that
caused or
contributed to
uterine
subinvolution
or
hemorrhage.

7.Administer 7.It helps

methylergonovine as improve the
prescribed by the blood supply
physician. in the perineal
area.

Source:
Martin, P.
(2019, June
08). 8
Postpartum
Hemorrhage
Nursing Care
Plans.
Retrieved
https://nursesl
abs.com/postp
artum-
hemorrhage-
nursing-care-
plans/.
 Retained Placental Fragments

4.1. Definition/Description of the disease or complication

 Retained Placental Fragments is a rare complication affecting only about 1 out of

3,000 percent of all deliveries that occurs when all or a portion of the placenta is
left inside the uterus after the baby's birth.
 Sometimes, however, part or all of the placenta can be retained inside the womb
because a portion has grown through the uterine muscle or is "caught" inside a
corner of the uterus as it contracts down.
 Occasionally, a placenta does not detach in its entirety, fragments of it separate
and are left still attached to the uterus. Because the portion retained it keeps the
uterus from contracting fully, uterine bleeding occurs.
 Removing such a deeply embedded placenta can lead to severe postpartal
hemorrhage (Silver, 2015).

4.2 Etiology/Cause
The following are common circumstances that result in a retained placenta:
 Placenta adherens
o It takes place when all or part of the placenta is stuck to the wall of the
woman’s womb. In rare situations, this happens because the placenta has
become deeply embedded within the womb.
 Trapped Placenta
o It results when the placenta detaches from the uterus but is not delivered.
Instead, it becomes trapped behind a closed cervix or a cervix that has
partially closed.
 Placenta Accreta
o It takes place when the placenta has become deeply embedded in the
womb, possibly due to a previous cesarean section scar.

 Women who are at risk for a retained placenta include those who've had:
 A previous C-section
 A premature delivery before 34 weeks
 A stillborn baby
 Uterine abnormalities
 A long first or second stage of labor
 Retained placenta during a previous delivery
 4.3 Types if Applicable
There are three scenarios in which a retained placenta can occur:

 Placenta adherens, which happens because the uterine muscles don’t contract
enough to make the placenta separate from the uterine wall and expel it from
the womb.

 Trapped placenta, which happens when the placenta separates from the
uterus but does not naturally exit the mother’s body. This can occur when the
cervix begins to close before the entire placenta is excreted.

 Placenta accreta, which happens when the placenta grows into the deeper
layer of the uterus and is unable to naturally detach from the organ. This is the
most dangerous type of retained placenta and can lead to a hysterectomy and
blood transfusions.
4.4 Signs and Symptoms
 Large amount of persistent bleeding
 Uterus found to not be fully contracted upon examination
 Signs of shock
 Sudden rise of fundal height indicating formation of clots in the uterine cavity

4.5 Nursing Diagnosis (1)

 Risk for bleeding related to retained placental fragments secondary to giving birth.

4.6 Management *Nursing, Medical, Pharmacologic, Surgical

Nursing Medical Pharmacological Surgical

management Management management Management

 Frequently  Assess for  Assess for o Manual

assess the signs and signs and removal or
patient’s symptoms of symptoms of Curettage
hypovolemic hypovolemic
fundus and under
shock. shock.
lochia. anesthesia.
-Begin I.V. infusion -Begin I.V. infusion
-Initially at least with normal saline with normal saline
every 15 minutes to solution. solution.
detect changes. -Anticipate the -Anticipate the need
-Notify health care need for fluid for fluid replacement
providers if the replacement and and blood
fundus does not blood component component therapy
remain contracted therapy as ordered. as ordered.
or if lochia  Obtain 
increases. venous blood Obtain
 Perform specimens, venous blood
fundal as ordered, specimens, as
massage as for complete ordered, for
indicated to blood count, complete
assist with electrolyte blood count,
uterine measuremen electrolyte
involution. ts, type and measurement
 Weigh crossmatchin s, type and
perineal pads g, and crossmatchin
to determine coagulation g, and
the extent of studies. coagulation
blood loss.  Intramuscula studies.
 Turn the r  Intramuscular
patient to the administratio administration
side and n of of
inspect under prostaglandi prostaglandin,
the buttocks n, to help to help the
for pooling of the uterus uterus
blood. contract. contract.
 Inspect
perineal area
closely.
 Assess intake
and output.
 Inform
patients of
danger signs
and
symptoms
suggesting
bleeding.
4.7 Relevant Pictures/Videos
Video Link: https://www.youtube.com/watch?v=4iHSXADzc98
4.8 One (1) Nursing Care plan on each complication
Needs/ Nursing Scientific Basis Objectives of Nursing Actions Rationale
Problems/ Cues Diagnosis Care

IV. Physiologic Risk for Postpartum General Measures to aid

Risk bleeding bleeding, the loss of Objective: patient to minimize
related to more than 500 mL risk of bleeding after
D. Risk for excessive of blood after After 3 days of the third stage of
bleeding blood loss delivery, occurs in student nurse and labor:
secondary to up to 18 percent of client interaction,
Objective cues: retained births and is the the client will be 1. Monitor vital 1.Changes in
placental most common able to: signs, compare BP and pulse
 Vaginal fragments. maternal morbidity with client’s may be used
bleeding in developed 1. not present any normal and for rough
 Lochia is countries. Although signs and previous estimate of
heavy with risk factors and symptoms of readings. blood loss.
moderate preventive bleeding.
amount of strategies are 2. Note client’s 2.Symptomato
clots clearly documented, Specific individual logy is useful
not all cases are Objectives: physiological in identifying
expressed
expected or response to severity and
 Blood loss of
avoidable. After 8 hours of bleeding, such length of
about 550 ml student nurse and as changes in bleeding
during first 24 Retained placenta client interaction, mentation, episodes.
hours after after vaginal the client will be weakness,
delivery. delivery, which able to: restlessness,
 Upon occurs in around 1– anxiety, pallor,
abdominal 3% of deliveries, is 1. experience diaphoresis,
palpation, a relatively common lochia reducing in tachypnea,
fundus feels cause of obstetrical amount and and
boggy and morbidity. This is lightening in color.
 slightly above typically diagnosed 2. observe fundus temperature
the level of when the placenta that is firm, elevation.
the umbilicus fails to midline, and
 Decreased spontaneously decreasing in 3. Instruct 3.To monitor
strength separate during the height. patients to do bleeding and
 Restlessness third stage of labor pad counts. assess blood
when a patient 3. have vital signs Weight the loss.
 Thread pulse
experiences returning within pads before
 Dyspnea and excessive bleeding normal values: and after to
chills in absence of T- 37.0°C determine the
 Pallor placenta separation P- 80 bpm amount of
 Irritability or if there is R- 18cpm blood loss of
 Vital signs confirmation of BP- 110/60 mmHg patient.
taken as placenta tissue
follows: remaining after the 4. verbalize 4. Monitor 4.Aids in
majority of the understanding of laboratory establishing
T- 38.5°C placenta delivers signs and studies: Hgb, blood
P- 132 bpm spontaneously. symptoms of Hct, RBC replacement
R- 25 bpm bleeding count, and needs and
BP- 90/60 mmHg Although retained associated with BUN or monitoring
placenta is an retained placental creatinine effectiveness
Subjective cues: obstetrical fragments after levels. of therapy.
complication birth.
As verbalized by the encountered 5. Provide stool 5.Prevents
patient “ika duha relatively softener as straining for
nako nag ilis ug infrequently on the prescribed. stool with
diaper sa duha ka labor and delivery resultant
oras kay mapuno floor, recognizing increase in
dayon unya ubay patient risk factors intra-
ubay ang tibugol na and understanding abdominal
dugo.” management are pressure and
important steps in risk of
mitigating this bleeding
morbidity. hemorrhoidal.

Sources: 6. Instruct client 6.These

Perlman, N.C., & to avoid use of medications
Carusi, D.A. aspirin reduce platelet
(October 07, 2019). products and aggregation,
Retained Placenta nonsteroidal prolonging the
After Vaginal anti- coagulation
Delivery: Risk inflammatory process,
Factors and drugs. increasing risk
Management. of bleeding.
Retrieved on
February 15, 2021 7. Administer a 7.Transfusions
from plain NSS may be
https://www.ncbi.nl Intravenous required in the
m.nih.gov/pmc/artic Fluid to initially event of
les/PMC6789409/. start blood persistent or
transfusion massive
Anderson, J.M. before possible spontaneous
(March 15, 2007). complications bleeding.
Prevention and like shock as
Management of prescribed.
Postpartum
Hemorrhage.
Retrieved on
February 15, 2021
from
https://www.aafp.o
rg/afp/2007/0315/p Source:
875.html. Doenges, M.,
Moorhouse,
M.F., & Murr,
A. (2010).
Nursing Care
Plans:
Guidelines for
Individualizing
Client Care
Across the Life
Span. C&E
Publishing,
Inc.: 839
EDSA, South
Triangle,
Quezon City,
Philippines.
 Disseminated Intravascular Coagulation

5.1 Definition/Description of the disease or complication

Disseminated Intravascular Coagulation (DIC) is a condition in which all small blood
clots develop throughout the bloodstream, blocking small blood vessels. The increased
clotting depletes the platelets and clotting factors needed to control bleeding, causing
excessive bleeding.

5.2 Etiology/Cause
Is caused by another medical condition that makes the body’s normal blood
clotting process become overactive. The clots can reduce or block blood flow, damaging
organs. It begins with excessive bleeding. The excessive clotting is usually stimulated
by a substance that enters the blood as part of a disease (such as an infection or
certain cancers) or as a complication of childbirth, retention of a dead fetus, or surgery.
Clotting factors caused by some cancers or pregnancy complications.

Pregnancy complications that produce clotting factors include placental

abruption, in which the placenta separates from the uterus, and amniotic fluid
embolism, in which amniotic fluid that surrounds the unborn baby enters the mother’s
bloodstream. As DIC progresses, the overactive clotting uses up platelets and clotting
factors, which are proteins that help with normal blood clotting. Without these platelets
and clotting factors, DIC can cause bleeding just beneath the skin, in the nose or
mouth, or deep inside the body.

5.3 Types if Applicable

 Acute Disseminated Intravascular Coagulation
It is generally seen with severe sepsis, trauma, acute promyelocytic leukemia or acute
obstetrical emergencies like abruptio placenta. Acute DIC develops when the blood is
exposed to a large amount of tissue factor, leading to a significant generation of
thrombin. There is rapid systemic activation of the coagulation system and the end
result is generally diffuse bleeding with possible hemodynamic instability and
microangiopathy with end organ dysfunction as described above.

 Chronic Disseminated Intravascular Coagulation

It is generally seen with advanced malignancies (such as Trousseau’s syndrome, aortic
aneurysm, in which the blood is exposed to small or intermittent amounts of tissue
factor, leading to localized activation of the coagulation system. Venous and arterial
thrombosis predominate as the marrow and liver can maintain adequate platelet
counts and
coagulation factors respectively, thus preventing an overt consumptive process leading
to bleeding.

5.4 Signs and Symptoms

 Presence of bruises
 Bleeding easily in the nose, gums, or mouth
 Chest pain
 Shortness of breath
 Hypotension (low blood pressure)
 Blood clot (Ecchymoses and petechiae form on the skin)
 Pain, swelling and redness (Signs for Deep Vein Thrombosis of the leg)
 Heart attack, lung, and kidney problems
 Neurologic: Confusion, trouble speaking, speech changes, seizures, or dizziness

5.5 Nursing Diagnosis (1)

 Ineffective tissue perfusion related to disruption of blood circulation as evidenced
by capillary refill time of 4 seconds.

5.6 Management *Nursing, Medical, Pharmacologic, Surgical

Nursing Medical Pharmacological Surgical

management Management management Management

 Antithrombin  Heparin: is  Cesarean

 Monitor vital Therapy section
used as
signs (AT): AT  Endovascular
especially BP therapy (or
monotherap surgery
 Minimizing prophylaxis)
y (1,500 to
BP taking 3,000 in patients
using units/day, 2 with slowly
sphygmoman days) is evolving
ometer to preferably DIC who
reduce employed have (or are
bruising instead of
 Monitor at risk of)
heparin
platelet count venous
monotherap
 Provide y or heparin- thromboem
emotional AT therapy bolism.
support to because of
the patient. the
 Assess renal hemorrhagic
function.
 Assess skin side effects
and tissue/ of heparin.
organs for
dysfunction.
 Reduce
bleeding by
instructing
patient to
use a soft
bristled
toothbrush,
avoid eating
hard foods.
 Assess for
bleeding.
5.7 Relevant Pictures/Videos
5.8 One (1) Nursing Care plan on each complication
Needs/ Nursing Scientific Basis Objectives of Nursing Actions Rationale
Problems/ Cues Diagnosis Care

V. Physiologic Ineffective Ineffective tissue General Measures to show no

Deficit tissue perfusion is defined Objective: further worsening/
perfusion as “a decrease in repetition of deficits:
E. Ineffective related to oxygen resulting in After 1 week of
tissue perfusion disruption of the failure to student nurse and 1. Assist with 1.Gently
blood nourish the tissues client interaction, position changes repositioning a
Objective cues: circulation as at the capillary the client will be patient from a
 Capillary evidenced by level”. Ineffective able to: supine to
refill time capillary refill tissue perfusion sitting/standin
of 4 time of 4 occurs where this 1. show no further g position can
seconds seconds. exchange of gases worsening of reduce the risk
 Edema between the blood deficit. for orthostatic
 Alteration of and the cells is blood pressure
skin color disrupted, meaning Specific changes.
 Petechiae the cells (and Objectives:
 BP: 90/40 ultimately the 2. Assess presence, 2.Useful in
mmHg tissues and organs) After 8 hours of location, and degree identifying the
stop getting student nurse and of swelling or edema quantifying
Subjective cues: adequate oxygen client interaction, formation. edema
“Malipong ko unya supply. The oxygen the client will be involved.
sakit sad akong and nutrients able to:
tiil” as verbalized subsequently 3. Provide foot and 3.It prevents
by the client. diffuse from the 1. maintain ankle exercise when venous stasis
blood into the maximum tissue the client is having a and further
interstitial fluid and perfusion to vital hard time in circulatory
then into the body organs, as ambulation; promote compromise.
cells. Insufficient evidenced by
arterial blood flow warm and dry skin, active and passive
causes decreased present and strong ROM exercise.
nutrition and peripheral pulses,
oxygenation at the vitals within 4. Administer 4.These
cellular level. patient’s normal medication (such as medications
range, balanced antiplatelet/anticoagu facilitate
I&O, absence lants) as prescribed perfusion for
References: edema, normal to treat underlying most causes of
Ineffective tissue ABGs, alert LOC, problem. Note the impairment.
perfusion (n.d). and absence of response. Antiplatelet/an
Retrieved February chest pain. ticoagulants
16, 2021 from reduced blood
https://study.com/a 2. verbalizes or viscosity and
cademy/lesson/ineff demonstrates coagulation.
ective-tissue- normal sensations
perfusion-definition- and movement as
risk.html appropriate. 5. Provide a calf-high 5.Pneumatic
pneumatic compression
3. state when to compression device devices can be
contact physician for immobile patients effective in
or health-care as prescribed by the preventing
professional physician. deep vein
thrombosis in
the immobile
patient.

6. Collaborate with a 6.Malnutrition

dietitian about the contributes to
nutritional status of anemia, which
the client with DIC. further
compounds
 the lack of
oxygenation to
tissues.

7. Collaborate with 7.Understandi

the attending ng expected
physician in events and
explaining all the sensations can
procedures and help eliminate
treatments with the anxiety
client experiencing associated
DIC. with the
unknown.

Reference:
Ineffective
tissue
perfusion –
Nursing
diagnosis &
care plan.
Retrieved
February 16,
2021, from
https://nursesl
abs.com/ineffe
ctive-tissue-
perfusion/
References:

 Martin, P. (2019, June 2). 8 Postpartum Hemorrhage Nursing Care Plans.

Retrieved from https://nurseslabs.com/postpartum-hemorrhage-nursing-care-

plans/3/

 2021. Symptoma. Retrieved from https://www.symptoma.com/en/info/puerperal-

infection

 Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & Child Health Nursing (8th

edition, Vol. 1). Wolters Kluwer.

 Chitnis, R. (2019, December 9). Uterine Atony - Reasons, Signs, and Treatment.

FirstCryParenting. https://parenting.firstcry.com/articles/uterine-atony-causes-

signs-risks-and-treatment/

 M. (2020, September 7). Uterine Atony: Symptoms, Risks and Prevention.

Parenting Healthy Babies. https://parentinghealthybabies.com/uterine-atony-

symptoms-risks-and- prevention/#:%7E:text=Apart%20from%20insufficient

%20uterine%20contractio

n,%20other%20complications%20of,orthostatic%20hypotension%202%20Anem

ia%203%20Fatigue%20and%20tiredness

 Prabhcharan Gill, Anjali Patel, & Van, J. W. (2020, July 10). Uterine Atony.

Retrieved February 15, 2021, from Nih.gov website:

https://www.ncbi.nlm.nih.gov/books/NBK493238/Disseminated Intravascular
 Coagulation (DIC) By Joel L. Moake, By, Moake, J., & Last full review/revision Jan

2020| Content last modified Jan 2020. (n.d.). Disseminated intravascular

coagulation (DIC) - blood disorders. Retrieved February 16, 2021, from

https://www.msdmanuals.com/home/blood-disorders/bleeding-due-to-clotting-

disorders/disseminated-intravascular-coagulation-dic

 Disseminated intravascular coagulation. (n.d.). Retrieved February 16, 2021,

from https://www.nhlbi.nih.gov/health-topics/disseminated-intravascular-

coagulation

 NursingCrib. (2012, September 20). Disseminated intravascular coagulation (dic).

Retrieved February 15, 2021, from https://nursingcrib.com/nursing-notes-

reviewer/medical-surgical-nursing/disseminated-intravascular-coagulation-dic/

 Nursestudynet. (2020, November 15). Disseminated intravascular coagulation

dic nursing diagnosis interventions and care plans. Retrieved February 15, 2021,

from https://nursestudy.net/dic-nursing-care-plans/