MARIANO MARCOS STATE UNIVERSITY

College of Health Sciences

LESSON 3: NURSING CARE OF THE POSTPARTUM CLIENT

Introduction of the Lesson and Presentation of Outcomes

Although the puerperium is usually a period of health, complications can occur. When
they do, immediate intervention is essential to prevent long-term disability and interference
with parent–child relationships. A woman with a postpartal complication is at risk from three
points of view: her own health, her future childbearing potential, and her ability to bond with
her new infant. Her family may be disrupted because of an extended hospital stay that
removes her from other family members. Financial difficulties may arise because of the need
for additional child and health care. Fortunately, most postpartal complications are
preventable, and if they do occur, the majority can be treated effectively without long-term
complications.

At the end of this lesson, you must have:

1. Described common deviations from the normal that can occur during the
puerperium.
2. Identified critical thinking to analyze ways that promote family-centered nursing
care when a postpartal complication occurs.
3. Formulated nursing diagnoses related to deviations from the normal during the
puerperium.
4. Identified expected outcomes for a postpartal woman experiencing a complication.
5. Formulated nursing interventions that meet the special needs of a family with a
postpartal complication, such as planning for an extended hospitalization.
6. Implemented nursing care when a postpartal complication such as hemorrhage,
infection, or postpartal psychosis develops.
7. Evaluated expected outcomes for achievement and effectiveness of care.
8. Integrated knowledge of postpartal complications with the nursing process to
achieve quality maternal and child health nursing care.

Warm -up Activity

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Before you go to the learning inputs, try to list down five (5) nursing
diagnoses/problems and its inferences related to the problems encountered by
postpartum women.

Learning Input

1. Postpartum Hemorrhage
- Excessive bleeding - loss of more than 500 ml of blood at the time of delivery or
immediately after
- leading cause of maternal death
- Occurs in 5% to 8% of women postpartally (Poggi, 2007).
- Traditionally, postpartal hemorrhage has been defined as any blood loss from the
uterus greater than 500 mL within a 24-hour period (Pavone, Purinton, & Petersen,
2007).

a. Early postpartum hemorrhage

- Bleeding during the third stage of labor or within the first stage of
labor or within the first 24 hours of delivery. Uterine atony is the most
common cause of early postpartal bleeding.

b. Late or secondary postpartal hemorrhage

- Bleeding after 24 hours until the sixth week post-partum.
a. Uterine atony - relaxation of the uterus, is the most frequent cause of postpartal
hemorrhage
Causes:
1. Overdistention of the uterus
2. Effects of anesthesia
3. Prolonged difficult labor
4. Placenta previa
5. Abruption placenta
6. Multiparity
7. Precipitate labor
8. Incomplete placental separation

Signs and symptoms:

1. Relaxed uterus
2. Abrupt gush of blood
3. Signs and symptoms of shock

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Management:

1. Assess the blood loss appropriately.

2. Palpate a woman’s fundus at frequent intervals postpartally to be certain
that her uterus is remaining in a state of contraction.
3. Uterine massage
4. Oxytocic agents
❖ When oxytocin is given intravenously, its action is immediate.
However, be aware that oxytocin has a short duration of action,
approximately 1 hour, so symptoms of uterine atony can recur
quickly after administration of only a single dose
5. Blood replacements
6. Bimanual compression
7. Administration of prostaglandin
8. Offer a bedpan or assist the woman with ambulating to the bathroom
9. If a woman is experiencing respiratory distress from decreasing blood
volume, administer oxygen by face mask at a rate of about 4 L/min.
10. Hysterectomy

b. Lacerations – tear in the perineum or vulva, bleeding persists despite firm uterus
Sites:
a. Cervical – usually found on the sides of the cervix near the branches of the
uterine artery.
- occurs immediately after delivery of the placenta, when the
physician or nurse midwife is still in attendance.

Management:
1. Suturing- repair is difficult because bleeding may be so intense, it
obstructs visualization of the area

b. Vaginal – Although they are rare, lacerations can also occur in the vagina.
They are easier to assess than cervical lacerations, because they are easier to
view.
Management:
1. Suturing- Because vaginal tissue is friable, vaginal lacerations are also hard
to repair.

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2. Vaginal packing- Some oozing often occurs after a repair, so the vagina may
be packed to maintain pressure on the suture line.
3. Indwelling urinary catheter (Foley catheter) may be placed at the same time,
because the packing causes pressure on the urethra and can interfere with
voiding.
b. Perineal– Occurs when a woman is placed in a lithotomy position for birth,
because this position increases tension on the perineum.

Degree of perineal lacerations:

First degree Vaginal mucous membrane and skin of the perineum to the
fourchette
Second Vagina, perineal skin, fascia, levator ani muscle, and perineal
degree body
Third degree Entire perineum, extending to reach the external sphincter of
the rectum
Fourth degree Entire perineum, rectal sphincter, and some of the mucous
membrane of the rectum

Management:
1. Suturing
2. Encourage the client have diet high in fluid.
3. Stool softener may be prescribed for the first week after birth to prevent
constipation and hard stools, which could break the sutures.

c. Retained placental fragments – part of placental tissue is left in the uterus

interfering with uterine contractions.
Signs and symptoms:
1. Vaginal bleeding
2. Soft or non-palpable uterus
3. Signs and symptoms of shock

Management:
1. Dilatation and curettage -to remove the placental fragment
2. Monitor vital signs and I and O
3. Massage fundus until firm
4. Ice cap on the fundus
5. Estimate blood loss
6. Fluid replacement and administration of oxytocin

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7. Facilitate frequent bladder emptying

8. Psychological support

d. Sub-involution – failure of the uterus to return to its prepregnant state

Causes:
1. Retained placental fragments
2. Infection
3. Uterine tumors

Signs and symptoms:

1. Enlarged boggy uterus
2. Prolonged lochial discharge
3. Backache

Management:
1. Administration of methergine
2. Antibiotics
3. Dilatation and Curettage
4. Client instruction for signs and symptoms to report

e. Hematoma – collection of blood in the subcutaneous layer of tissue of the perineum

Causes:
1. Vulvar varicosities
2. Precipitate labor
3. Injury to the blood vessels in the perineum during birth
4. Inadequate suturing of lacerations
5. Rupture of vein during episiorrhapy

Signs and symptoms:

1. Perineal pain
2. Swelling
3. Skin discoloration
4. Tenderness
5. Feeling of pressure over the vagina

Management:
1. Ligation of bleeders
2. Analgesics
3. Ice packs
4. Antibiotics

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Learning Input

2. Postpartal/Puerperal Infection

a. Puerperal infection – Any infection of the reproductive organs that occurs within the
first 6 weeks after childbirth or 4 weeks after abortion; usually localized in the
endometrium.
- Postpartum infections are the leading cause of nosocomial
infections and maternal morbidity and mortality.
- An oral temperature greater than 38 degree Celsius taken
twice, 6 hours apart on any 2 of the first 10 days postpartum,
excluding the first 24 hours after delivery.

Causes:
1. Bacterial causative agents, both aerobic and anaerobic (the most
common being anaerobic streptococci
2. Escherichia coli

If infection occurs, the prognosis for complete recovery depends on:

▪ Virulence of the invading organism
▪ The woman’s general health
▪ Portal of entry
▪ Degree of uterine involution at the time of the microorganism invasion
▪ Presence of lacerations in the reproductive tract

Predisposing factors:
1. Strongest predictors of developing a puerperal infection:
a. Duration of labor > 18 hours
b. Route of delivery: The single most significant risk for postpartum
infections – 2o times greater than in the vaginal birth is cesarean
section
c. Colonization of amniotic fluid
2. Rupture of membrane over 24h before birth
3. Retained placental fragments
4. Postpartal hemorrhage
5. Pre-existing anemia and malnutrition; obesity
6. Instrumental birth
7. Internal fetal monitoring
8. Local vaginal infection at the time of birth – UTI, STDs
9. Invasive procedures in prolonged labor with frequent vaginal
examinations

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Signs and symptoms:

1. Fever, chills and tachycardia
2. Change in the color, amount, odor(foul) and consistency of lochia
3. Painful/tender uterine fundus, delayed uterine involution
4. Body malaise, anorexia, headache
5. Dysuria, burning sensation on urination, costovertebral tenderness

Complications:
1. Pelvic inflammatory disease
2. Pelvic cellulites
3. Generalized peritonitis
4. Puerperal sepsis one of the leading causes of maternal mortality

Management:
1. Maintain bed rest
2. Start with ordered antibiotics stat (after appropriate specimen is
obtained); a broad-spectrum antibiotic directed at multiple organisms
often are administered prophylactically for cesarean sections and
prolonged rupture of membranes
3. Observe standard precautions and careful handwashing.
4. Monitor vital signs and I &O; force fluids – 3,000 to 4,000 ml if not
contraindicated and encourage frequent voiding
5. Promote drainage of secretions
6. Teach regarding perineal hygiene
7. Provide nutritious, high calorie, high protein, high iron diet
8. Promote client’s comfort

b. Infection of the perineum, vulva, and cervix

Signs and Symptoms:

1.Pain/pressure on the affected area
2. (+) pus
3. Fever
4. Redness and swelling
5. Dysuria

Management:
1. Proper perineal hygiene
2. Perineal heat lamp, sitz bath, warm compress
3. Establish drainage
4. Analgesics
5. Antibiotics

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c. Endometritis – infection of the endometrium

Risk factors:
1. Cesarean Section
2. PROM
3. Prolonged labor

Signs and symptoms:

1. Fever/chills
2. Foul smelling lochia
3. Boggy and enlarged uterus
4. Uterine tenderness
5. Body malaise
6. Lack of appetite
7. Backache

Management:
1. Antibiotic therapy
2. Analgesic
3. Oxytocin
4. Increase fluid intake
5. Frequent changing of perineal pad
6. Nutritious diet
7. Monitor V/S

3. Thromboembolic disorders

a. Thrombophlebitis - inflammation of the lining of the blood vessels with associated

blood clot formation

Predisposing factors:
1. Varicosities
2. Multiparity, advanced age: over 30 y/o
3. Obesity
4. Use of estrogen supplement
5. History of thromboembolic disease
6. Bedrest; prolonged immobility
7. Operative delivery (CS)

Types:
A. Femoral – occurs 10 days after delivery
Signs and symptoms:
1. Milk leg

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2. Elevated body temp and chills

3. Decrease milk production
4. Pain, stiffness and redness of the affected leg
5. Swelling and edema of the leg; 2-3 times larger than the non-affected leg
6. (+) Homan’s sign- pain in the calf of the leg on dorsiflexion of the foot
▪ diameter of the leg at thigh or calf level may be increased
compared with the other leg.
▪ Doppler ultrasound or contrast venography usually is ordered

Management:
1. Bed rest
2. Anticoagulant
3. Heat application
4. Analgesics
5. Antibiotics

B. Pelvic – 14-15th day postpartum

Signs and symptoms:

1. High fever
2. Chills
3. General malaise
4. Pelvic abscess

Management:
1. Bed rest
2. Anticoagulant
3. Antibiotic

Preventive Measures:
1. Not wearing constricting clothing such as garters or tight stockings
on the lower extremities
2. Resting with the feet elevated
3. Ambulating daily during pregnancy.
4. Caution a woman to tell her physician or nurse-midwife before her
next pregnancy of the difficulty she experienced this time, so that
extra prophylactic precautions can be taken to prevent
thrombophlebitis.

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b. Pulmonary Embolism- an obstruction of the pulmonary artery by a blood clot;

complication of thrombophlebitis
Signs & Symptoms:
1.Sudden, sharp chest pain
2. Tachypnea
3. Tachycardia
4. Orthopnea
5. Cyanosis

Management:
1. Administer oxygen immediately as patient is at high risk for
cardiopulmonary arrest.
2. Transfer to an intensive care unit for continuing care

4.Postpartum Psychiatric Disorders

a. Postpartal blues- feeling of sadness after childbirth; related to hormonal shifts as
the level of estrogen, progesterone and gonadotropin-releasing hormone in the body
decline
b. Postpartal Depression- a more serious problem than postpartal blues; occurs in
women who are disappointed in some aspects of their newborn or who have poor
family support.
Risk Factors:
▪ History of depression
▪ Troubled childhood
▪ Low self-esteem
▪ Stress in the home or work
▪ Lack of effective support
▪ Disappointment in the child

Manifestations:

a. Sad, hopeless, overwhelmed

b. Restless or irritable
c. Crying a lot
d. Lose pleasure in everyday things
e. Anorexia, lose weight (some hungry, 1 appetite)
f. No energy, motivation

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g. Withdrawal from friends or family

h. Headache, chest pains, palpitations, hyperventilation
i. Being afraid of hurting the baby or oneself, not interested in self

Management:
a. Rest
b. Do not put pressure
c. Ask for help w/ household chores
d. Talk to husband, partner, family, friends
e. Don't spend a lot of time alone
f. Spend time alone w/ husband or partner

c. Postpartum Psychosis –a mental illness which coincides with the postpartum

period; a response to the crisis of childbearing

Precipitating Factors:
1.A death in the family
2. Loss of job or income
3. Divorce or other major life crisis

Signs & Symptoms:

1. Exceptionally sad
2. Has lost contact with reality
-may deny she has a child
-insist she was never pregnant
-may voice thoughts of infanticide
-may voice out that her infant is possessed

Nursing Care:
1. Early recognition
2. Explore potential sources/contributory factors
3. Support positive parenting behavior
4. Give medication as ordered
5. Make appropriate referral
6. Maintain contact with the baby
7. Assist in developing feelings of self-worth and confidence in her ability to
accomplish the task associated with the role of a mother

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Activity

After integrating the learning inputs, try to answer these situations accordingly to
what you have understood.

1. Mary Blackhawk, whom you met at the beginning of the chapter, was having heavy
vaginal bleeding at 4 hours after birth. Because she was sleeping, however, she
was totally unaware of it. What action on your part would have prevented so much
blood loss? What action would be most appropriate now?
2. 2. Eight hours after birth, Mary Blackhawk tells you that she has frequency and
burning on urination. She had a urinary tract infection during pregnancy, so she
recognizes the symptoms. She has some medicine left from pregnancy and tells
you that she will take it to cure the infection. What advice would you give her?
3. 3. When Mary returns for a postpartal checkup, you no tice red streaks on both
legs along the course of her veins, and she has pain on dorsiflexion of her foot. You
are concerned that she is developing thrombophlebitis. Describe a plan of care
that could have reduced this risk during labor and in the immediate postpartal
period.

Wrap-up Activity

Based from the learning inputs, answer the following:

1. Why is effective postnatal care so important?

2. Why are women at high risk in the postnatal period?
3. Identify postpartum care to the postpartum woman.

Post-Assessment
Your instructor thru MVLE will give a summative test on the lessons of the chapter.
Please wait for further instructions. Good luck!

References

Pillitteri, A. (2014). Maternal & child health nursing, care of the child bearing & childrearing
family (7th ed.). Lippincott: Williams, &Wilkins.

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 MARIANO MARCOS STATE UNIVERSITY

College of Health Sciences

2nd Floor CAS Bldg. #16S Quiling Sur, City of Batac, Ilocos Norte
 elp@mmsu.edu.ph  +63(961)262-09-90 www.mmsu.edu.ph