NCM 109 I OBST ETRICS

TOPIC OUTLINE  Five pads saturated in half an hour (differentiate

NURSING CARE OF THE POSTPARTUM CLIENT from used pads)
1. POST-PARTUM HEMORRHAGE
A. EARLY POST-PARTUM HEMORRHAGE o Weigh pads before and after use
B. LATE POST-PARTUM HEMORRHAGE (accurate)
C. SUB INVOLUTION o 1 gm = 1 ml of blood volume
2. POST-PARTUM PUERPERAL INFECTION
A. ENDOMETRIOSIS
B. WOUND INFECTION
C. MASTITIS
D. UTI
E. RESPIRATORY TRACT INFECTION
F. OTHER POSTPARTAL INFECTIONS
3. LACERATIONS
A. CERVICAL
B. VAGINAL
C. PERINEAL
4. PERINEAL HEMATOMAS
5. THROMBOEMBOLIC DISORDERS
A. PHLEBITIS
B. THROMBOPHLEBITIS
C. FEMORAL THROMBOPHLEBITIS
D. PELVIC THROMBOPHLEBITIS
5. POST-PARTUM PSYCHIATRIC DISORDER
A. DELIVERED AN ILL OR PHYSICALLY
CHALLENGED INFANT
B. WOMAN WHOSE NEWBORN HAS DIED
C. POSTPARTAL DEPRESSION
D. POSTPARTUM PSYCHOSIS EARLY OR PRIMARY PPH
 Blood loss within 24 hours of delivery

CAUSES
POSTPARTUM/POSTPARTAL PERIOD
 Also called Puerperium
1. Uterine Atony
 Begins about six weeks after childbirth
 Relaxation of uterus
 The mother's reproductive organs return to their
 Failure of the uterus to contract and retract
original nonpregnant condition
following delivery of the baby up to 4 hours
 Complications may arise and those that are not after delivery
prevented can impact the personal life of the 2. Tone
woman, as well her family
 Failure of contraction and retraction of
 Fortunately, MOST of these complications are myometrial
preventable
 muscle fibers
 Fatigue (prolonged labor/rapid forceful
POSTPARTUM HEMORRHAGE (PPH) labor)
 One of the primary causes of maternal mortality  Inhibition of contractions by drugs
associated with childbearing (anesthesia, nitrates, NSAIDS, mgso4)
 Placental implantation site in the lower
FOUR MAIN REASONS
uterine segment
 Bacterial toxins (chorio-amnionitis,
o 4 T’s of PPH (Tone; Trauma; Tissue; Thrombin
endomyometritis, septicemia)
1. Uterine atony - (Tone)
2. Trauma (lacerations, hematomas, uterine
inversions or uterine rupture) - (Trauma)
3. Retained placental fragments - (Tissue)
4. Development of disseminated intravascular
coagulation (DIC)- (Thrombin)

 blood loss of more than

o 500 mL (vaginal delivery)
o 1000 mL (cesarean delivery)

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 NCM 109 I OBST ETRICS
b. Acquired secondary to HELLP
syndrome (hemolysis, elevated liver
enzymes, and low platelet count)

a) Hypoxia (hypoperfusion or Couvelaire c. Abruptio placentae

uterus in abruptio placentae) d. Disseminated intravascular
b) Hypothermia (massive resuscitation or coagulation (DIC)
prolonged uterine exteriorization) e. Sepsis
c) Over distension can be caused by:
 multifetal gestation RISK FACTORS
 fetal macrosomia
 polyhydramnios 1. Birth weight
 fetal abnormality 2. Labor induction and augmentation
 Uterine structural abnormality 3. Chorioamnionitis
 Failure to deliver the placenta or 4. Magnesium sulfate use
distension with blood before or after 5. Previous PPH
placental delivery
3. Tissue SIGNS AND SYMPTOMS
 Failure of complete separation of the
1. Shock and blood loss
placenta occurs in placenta accreta
a) Placenta Accreta  Decreased blood pressure
 placenta attaches too deep in the  Increased thready weak heart rate
uterine wall but it does not penetrate  Increased and shallow respiration
the uterine muscle  Pale cold clammy skin
 the most common (approx. 75% of all  Increasing anxiety
cases) 2. Decreased RBC count
b) All patients with Placenta Previa should 3. Swelling and pain in the vaginal and perineal
be informed of the risk of severe PPH, area.
including the possible need for
transfusion and hysterectomy. PREVENTION
c) Retained Blood (cause uterine
distension and prevent effective 1. Active management of third stage of labor
contraction)  Uterotonic administration (oxytocin)
immediately upon delivery of the baby
 Early cord clamping and cutting
 Gentle cord traction with uterine counter
traction when the uterus is well contracted
(Brandt-Andrews maneuver)
2. Turn to sides when checking for blood loss
3. Palpate woman’s fundus (contracted)
4. Frequently assess lochia and vital signs (pulse
and BP)

MANAGEMENT
 Therapeutic Management
a. Removal of retained placenta
b. Dilatation and curettage (D & C)  Uterine Atony
c. Methotrexate (If cannot be removed) 1. Uterine massage
to destroy retained placenta 2. Medications (if uterine massage is
d. Instruct the woman to observe the unsuccessful)
color of lochia at home o IV Oxytocin (Pitocin)
4. Trauma o Carbopost tromethamine (Hamabate) IM
 Damage to the genital tract injection
 Uterine rupture (previous CS scars) o Misoprostol rectal suppository
 Prolonged or vigorous labor (CPD, Oxytocin, 3. Elevate woman’s lower extremities (improve
Prostaglandins) circulation)
 Extra uterine or intrauterine manipulation of 4. Offer bedpan or assist woman to the bathroom
the fetus at least every 4 hours (urinary catheter may be
prescribed)
 Cervical laceration (forceps delivery)
5. Administer oxygen by face mask 10 to 12
L/min
5. Thrombosis
6. Obtain vital signs frequently (watch out for
 Preexistent or acquired abnormalities
decreasing BP and increasing PR)
(Thrombocytopenia)
 May be related to:
 Bimanual Massage
a. Preexisting disease (idiopathic
thrombocytopenic purpura)

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 NCM 109 I OBST ETRICS

 Transfusion of packed RBC and other blood  uterine massage

products 4. Identification of patients with a coagulation
 Surgical Management defect
o Hysterectomy
or suturing

LATE OR SECONDARY PPH MANAGEMENT

 blood loss 24 hours after delivery
 Surgery
CAUSES 1. Repair of arteries
2. Hysterectomy
1. Uterine atony 3. Uterine curettage
2. Rapid or prolonged labor 4. Repair of hematoma
3. Over distended uterus 5. Removal of retained placenta
4. Large baby  Insertion of a catheter into the uterine artery under
5. One or more previous pregnancies x-ray guidance
6. Uterine infection o Followed by embolization (blockage) of the
7. Medications that relax the uterus uterine artery is a possible alternative to
8. Failure to deliver placenta surgery
9. Birth trauma (lacerations of cervix and/or
vagina)
10. Bleeding disorder SUBINVOLUTION
11. Anticoagulant medications  Incomplete return of the uterus to its pre pregnant
12. Uterine inversion (caused by failure of the size and shape
placenta to detach from the uterus) o (4th-6th week postpartum) uterus still enlarged
13. Retained products of conception after delivery and soft
of the placenta (small pieces of placenta  Still with lochial discharge
and/or fetal membranes)
CAUSES
RISK FACTORS
1. Small retained placental fragments
1. Prolonged active labor 2. Mild endometriosis
2. Problems with the placenta (e.g., retained 3. Uterine myoma (interfering with uterine
placenta, placenta Previa) contraction)
3. Multiple pregnancy 4. Pelvic Infection
4. Preeclampsia 5. Uterine Fibroids
5. Obesity
6. Induced labor  Signs and Symptoms
7. Episiotomy
8. Large fetus 1. Abnormal lochial discharge either excessive or
9. History of postpartum hemorrhage prolonged.
10. Asian or Hispanic ethnicity 2. Profused vaginal bleeding
11. Maternal blood disorders 3. Large, flabby uterus
12. Forceps or vacuum delivery 4. Irregular cramp like pain in cases of retained
13. Cesarean section products or rise of temperature in sepsis
14. Never having carried a pregnancy (previously)
15. Stillbirth
16. Epidural anesthesia MANAGEMENT
17. Prolonged labor
18. Low-dose aspirin during pregnancy  Methergine given orally (0.2 mg four times a day)
o To improve uterine tone and complete
SIGN AND SYMPTOMS involution
o Pitocin, Ergotrate
1. Decreased blood pressure  Oral antibiotics, Antimicrobial therapy for
2. Increased heart rate endometritis
3. Decreased red blood cell count
 Dilation and curettage (D&C) to remove any
4. Swelling and pain in the vaginal and perineal
placental fragments.
area

PREVENTION POSTPARTUM INFECTION / PUERPERAL

INFECTION
1. Avoiding episiotomy
2. Receiving continuous care during labor RISK FACTORS
3. Active management of third stage of labor
 use oxytocin 1. Rupture of membrane more than 24 hours
 controlled delivery of placenta before birth

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 NCM 109 I OBST ETRICS
2. Retained placental fragments oFor 2 consecutive 24-hour periods
3. Post partal hemorrhage excluding the first 24 hours after birth
4. Pre-existing anemia o Chills
2. Loss of appetite
3. General malaise
4. Dark brown foul-smelling lochia

CAUSES MANAGEMENT

 Ultrasound (confirms retained placental fragments

as a cause for infection)
 Antibiotics are given (clindamycin)
 Encourage fowler’s position and walking (drain
lochia by gravity and avoid pooling of infected
secretions)

COMPLICATIONS

 Tubal scarring
 Interference with future fertility
 Local spread of colonized bacteria following
vaginal delivery
WOUND INFECTION (EPISIOTOMY/CS INCISION)
 More common with cesarean delivery
SIGNS AND SYMPTOMS
SIGNS AND SYMPTOMS
1. Flank pain, dysuria, and frequency of UTIs
2. Erythema and drainage (surgical incision or
1. Pain and heat
episiotomy site)
2. Erythema
3. Respiratory symptoms (cough, pleuritic chest
3. Edema
pain, or dyspnea) in cases of respiratory
4. Tenderness out of proportion to expected
infection or septic pulmonary embolus
postpartum pain
5. Discharge from the wound or episiotomy site
TREATMENT
(foul-smelling lochia)
 Appropriate antibiotics MANAGEMENT
 After C and S testing
 Pain medications  Open suture line to allow for drainage,
debridement, and irrigation
 Perineal packs
ENDOMETRITIS
 Broad-spectrum antibiotics
 The most common postpartum infection
 Analgesics
 Infection of the endometrium
 Sitz bath, moist warm compresses. hubbard tank
 Characterized by lower abdominal tenderness on treatment (hasten drainage and cleanse the areas)
one or both sides of the abdomen
 Adnexal and parametrial tenderness elicited with
bimanual examination

MASTITIS
 Infection of the breasts from the nasaloral cavity
of the newborn acquired in the hospital
SIGNS AND SYMPTOMS (staphylococcus aureus)
 Occurs as early as 7th postpartum day
1. Temperature elevation (most commonly
>38.3°c) o

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 NCM 109 I OBST ETRICS
SIGNS AND SYMPTOMS

 Very Tender, Engorged, Erythematous Breasts

 Fever LACERATIONS
 Breastmilk Becomes Scant  Small laceration of tears of the birth canal (normal
 Infection frequently is unilateral consequence of childbearing)
 Can occur in the cervix, vagina or perineum
PREVENTION

1. Proper breastfeeding positions SIGN AND SYMPTOMS

2. Remove baby’s grasp on nipple before
removing baby from the breasts
3. Exposing nipples to air for at least part of the
day
4. Washing hands between handling perineal
pads and touching the breasts
5. Using vitamin E ointment to soften nipples
daily
6. If has one cracked and one well nipple,
encourage to begin breastfeeding on the
unaffected nipple (when the infant sucks
forcefully)
1. Uterus is firm but bleeding persists
CAUSES
Large lacerations can be sources of infection and
occur more often to:
1. With difficult or precipitate births
2. In primigravidas
3. With the birth of large infants (>9 lbs)
4. With use of lithotomy position and instruments

MANAGEMENT
CERVICAL LACERATIONS
 Antibiotics (Flucoxallin, Erythromycin)  Usually found on the sides of the cervix, near the
 Ice packs, analgesics, and breast support (for branches of the uterine artery
pain) o Blood is brighter red
 Warm wet compresses (for inflammation and  Occurs immediately after detachment of the
edema) placenta
 Continue breastfeeding (empty breasts to prevent
growth of bacteria)
 Surgical drainage

URINARY TRACT INFECTIONS

 Common to catheterized woman during childbirth

SIGNS AND SYMPTOMS

1. Burning on urination
2. Sometime blood in the urine MANAGEMENT
3. Frequency in urination
4. Suprapubic tenderness  Suturing
5. Elevated temperature  Stay with patient and encourage patient to remain
calm
MANAGEMENT  If difficult to repair or extensive will require regional
anesthesia to relax uterine muscle and prevent
 Fluids (help flush infections from the bladder) pain
 Antibiotics (amoxicillin or ampicillin)
 Oral analgesics
VAGINAL LACERATIONS
 Easy to locate and assess
RESPIRATORY TRACT INFECTIONS
 Tachypnea
 Rales
 Crackles
 Rhonchi
 Consolidation

OTHER POSTPARTAL INFECTIONS

 Perineal cellulitis
 Respiratory complications from anesthesia
 Retained products of conception

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 NCM 109 I OBST ETRICS
MANAGEMENT
 Report the presence of hematoma
 Balloon Tamponade if suturing is not effective  Describe a definite size (in cm) rather than
 Vaginal pack (maintain pressure on the suture line) descriptive (small or large)
o Removed after 24 to 48 hours or before  Mild analgesia (pain)
hospital discharge  Apply ice pack covered with towel to prevent
 Indwelling urinary catheter (pressure from vaginal further bleeding
pack may have an effect with voiding
 Documentation THROMOEMBOLIC DISORDERS

PERINEAL LACERATIONS PHLEBITIS

 Lacerations at the perineum (Lithotomy Position)  Inflammation of the lining of the blood vessels

MANAGEMENT

 Sutured and treated same as episiotomy

 Documentation
 Diet high in fluid and a stool softener
 3rd-4h degree – enema or rectal suppository

THROMBOPHLEBITIS
 Inflammation with a formation of blood clots
 Superficial Vein Disease (SVD) or Deep Vein
Thrombosis (DVT)

CAUSES

1. Elevated Fibrinogen Level (increased blood

clotting)
2. Dilatation of lower extremity veins (pressure
of fetal head during pregnancy and birth)
3. Relative inactivity of the period or prolonged
time spent in delivery or birthing stirrups
o Leads to pooling, stasis and clotting of
blood in the lower extremities
4. Obesity (increased weight) before pregnancy
and pregnancy weight gain (inactivity and lack
of exercise)
5. Smoking

PREVENTION

1. Prevent endometriosis
2. Ambulation
3. Limiting time in stirrups
PERINEAL HEMATOMAS 4. Wearing of support stockings for first 2 weeks
 A collection of blood in the subcutaneous layer of after birth if with varicosities during pregnancy
tissue of the perineum o Placed on or before rising from bed in the
 Overlaying skin is intact with no noticeable trauma morning (before venous congestion had
 More likely to occur after rapid spontaneous occurred)
births and in women who have perineal o Removed twice a day
varicosities. o Check skin underneath for mottling or
inflammation
SIGNS AND SYMPTOMS

1. Severe pain in the perineum

2. Purplish discoloration in the area with obvious
swelling
3. Appears as a firm globe and feels tender

MANAGEMENT

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 NCM 109 I OBST ETRICS
o May breastfeed
 Coumadin
o Vitamin K (antidote for Coumadin)
o Cannot breastfeed (passed in breast
milk)
7. Assess for bleeding
8. Prescribed with salicylic acid (aspirin) for pain
o Prevents blood clotting
9. Thrombolytics (streptokinase or urokinase
o Dissolves clot

FEMORAL THROMBOPHLEBITIS
 Involves femoral, saphenous or popliteal veins
PELVIC THROMBOPHLEBITIS
 Involves ovarian, uterine or hypogastric veins
 Follows a mild endometriosis and occurs later than
femoral thrombophlebitis (14th or 15th day of
pueperium)

SIGNS AND SYMPTOMS

1. Palpable pelvic veins

2. Tachycardia that is out of proportion to the
SIGNS AND SYMPTOMS fever
1. Often arterial spasms occurs (diminishing 3. High fever, chills and general malaise
arterial circulation to legs) 4. Pelvic abscess
o Drained or white appearance
o Swelling (edema) PREVENTION
2. Elevated temp
3. Chills 1. Not wearing constricting clothing
4. Pain 2. Resting with feet elevated
5. Redness in the affected leg about 10 days 3. Ambulating daily during pregnancy
after birth
6. Homan’s Sign TREATMENT
 Pain in the calf of the leg on dorsiflexion of
the foot 1. Total bed rest
2. Surgery for affected vessel before next
pregnancy
3. Antibiotics
4. Anticoagulants

POSTPARTAL PSYCHIATRIC DISORDERS

 Extremely stresses woman
 Gives birth to infants that does not meet her
expectations
 Inability to bond

DELIVERED AN ILL OR PHYSICALLY

CHALLENGED INFANT
 Angry, hurt and disappointed
TREATMENT  Loss of self-esteem
 Responds with grief reaction
1. Bedrest with affected leg elevated
2. Never massage the skin over the clot (could MANAGEMENT
loosen clot and cause pulmonary or cerebral
embolism)  Reinforce information
3. Moist and warm compress can decrease  Review the problem
inflammation  Let parents care of child after birth (touch, relate
4. Analgesics and claim infant)
5. Antibiotics  Open communication between parents and
6. Anticoagulant (Coumadin derivative or hospital staff
heparin)
 Heparin WOMAN WHOSE NEWBORN HAS DIED
o Protamine sulphate (antidote for  Questions:
heparin) should be available o “What happened”

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 NCM 109 I OBST ETRICS
o “Why me”
 Feels bewildered, bitter and resentful POSTPARTUM PSYCHOSIS
 Mental illness that coincides with postpartum
MANAGEMENT period (very rare)
 Response to childbearing crisis
 Requests to see baby (therapeutic in grieving  Majority had symptoms of mental illness before
process) pregnancy
 Health professionals should clean and wrap baby  Others:
 Remain with parents and allow them to inspect the o Death in the family
child as they wish o Loss of job or income
 Allow them to take photograph of the child o Major life crisis
 Remind parents to sign required papers
 Therapeutic questions SIGNS AND SYMPTOMS
o How do you feel?
o Do you want to talk about what’s 1. Exceptional sadness
happened? 2. Woman has lost contact with reality
 Provide a private room to give opportunity to 3. May deny she has a child
grieve 4. Voice out infanticide (her infant is possessed)
5. Maybe threatened by health professionals
POSTPARTAL DEPRESSION o May respond with anger
 Postpartal Blues (Feeling of sadness)
o One to ten days postpartum TREATMENT
o Normally occurs
a. As a response to the anticlimactic feeling 1. Refer to psychiatric doctors for proper
after birth management
b. Hormonal shifts as levels of estrogen, 2. Do not leave with infant
progesterone and gonadotropin-releasing 3. Antipsychotics medications
hormone decrease or rise
 Postpartal blues that continue beyond immediate
postpartum period and may even be present for
longer than 1 year
o overwhelming feeling of sadness
o interferes with breastfeeding, child care
and returning to work KEY POINTS
 Hemorrhage is a major potential danger in the
SIGNS AND SYMPTOMS immediate postpartum period. o The most frequent
causes are uterine atony or retained placental
1. Extreme fatigue fragments.
2. Inability to stop crying o Continuous limited blood loss can be as
3. Increased anxiety about her own or infant’s important as sudden, intense bleeding.
health o Administration of oxytocin or uterotonics
4. Insecurity may be necessary to Initiate uterine tone
o Unwillingness to be left alone and halt the bleeding
o Inability to make decisions  Other causes of hemorrhage include lacerations
5. Psychosomatic symptoms (vaginal, cervical, or perineal) and DIC. o
o Nausea o Lacerations are more opt to occur with an
o Vomiting instrument birth or with the birth of a large
o Diarrhea infant
6. Depressive and manic mood fluctuations  Puerperal infection (a temperature greater than
100.4 F (38.0 C) after the first 24 hours is a
RISK FACTORS potential complication after any birth until the
denuded placental surface has healed.
1. History of depression o Retained placental fragments and the use
2. Troubled childhood of internal fetal monitoring leads are
3. Low self-esteem potential sources of infection
4. Stress in home or at work  Thrombophlebitis, an inflammation of the lining of a
5. Lack of effective support people blood vessel, occurs most often as an extension of
6. Disappointment in the child an endometrial infection.
7. Different expectations between partners o Therapy includes bed rest with moist heat
applications and anticoagulant therapy.
TREATMENT o Never massage the leg of a woman with
thrombophlebitis.
1. Counselling o Doing so can cause the clot to move and
2. Antidepressant therapy become a pulmonary embolus, which is
probably a fatal complication.

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 NCM 109 I OBST ETRICS

 Mastitis is an infection of the breast.

o The symptoms include pain, swelling,
redness. Antibiotic therapy is necessary to
promote healing.
 Postpartum blues are a normal accompaniment to
birth.
o Postpartum depression (a feeling of
extreme sadness) and postpartum
psychosis (an actual separation from
reality) are not normal and need accurate
assessment so a woman can receive
adequate therapy for these conditions.
 A woman whose child dies at birth or is born with
physical or cognitive challenge needs special
consideration after birth.
o This obviously creates a time of stress,
and a woman needs supportive nursing
care.
 Establishing a firm family-newborn relationship
may be difficult when a woman has a postpartum
complication.
o Planning a nursing care that allows a
woman to care for her baby and begin her
new family role not only meets QSEN
competencies but also best meets a
family’s total needs

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