POSTPARTUM COMPLICATION

POST PARTAL HEMORRHAGE

 Leading cause of maternal mortality, that’s why hospital birth to be closely monitored
 Excessive blood loss during or after the third stage labor.
 Accepted normal average blood loss is 500 ml in vaginal delivery and 1000 ml at CS
 The most dangerous time at which hemorrhage is likely to occur is during the first hour post partum
 Blood loss more than 500 cc. (normal blood loss 250- 350 cc)
 Leading cause of maternal mortality associated with childbearing

Incidence

 The overall incidence is 3-6% in all deliveries

 Vaginal delivery is associated with a 3.9% incidence of postpartum hemorrhage
 Cesarean delivery is associated with a 6.4% incidence of postpartum hemorrhage.
 Delayed postpartum hemorrhage occurs in 1-2 % of patients.

CAUSES

The cause of postpartal hemorrhage can be remembered easily by using the mnemonic 4T’s

4Ts

1. Tone- refers to the failure of the uterine myometrial muscle fibers to contract and retract

What are the causes:

 Overdistention- if overly stretched can affect uterine muscle. It is due to macrosomia, hydramnios, multiple
pregnancy
 Fatigue- prolonged labor, precipitate labor, oxytocic drugs
 Infection- chorioamnionitis, endometritis, septicemia
 Uterine structural abnormality
 Hypoxia due to hypoperfusion or Couvelaire uterus
 Placental site in the lower uterine segment
 Distention with blood before or after placental delivery
 Inhibition of contractions by drugs- anesthetic agents, nitrates, NSAIDS, Mg S04, nifedipine, beta-
symptomimetics

2. Tissue- presence of retained placental tissues presents full uterine contractions resulting in failure to seal off bleeding
vessels. Preterm gestation especially in less than 24 hours weeks gestation

 Abnormal adhesions such as accreta, increta and percreta

 site stop the oozing of blood vessels of the uterus
3. Trauma- 20% of the postpartum hemorrhage is due to trauma anywhere in the genital tract

 Lacerations and episiotomy

 Hematoma
 CS
 Uterine rupture and uterine inversion
 Uterine perforation during forceps application or curettage

4. Thrombosis- clot formation and fibrin deposition on the placenta

 Disorders of the coagulation system and platelets, whether preexistent or acquired can result in bleeding or
aggravate bleeding.
 Acquired disorders - HELLP syndrome, DIC
 Preexistent coagulation disorder- thrombocytopenic purpura

TYPES OF POSTPARTUM HEMORRHAGE

1. Early Post-partum hemorrhage – occurs during the first 24 hrs after delivery, occurs 14 hours

Causes of early postpartum hemorrhage

 Uterine Atony – uterus is not well contracted, relaxed or boggy most frequent cause)
 Lacerations of birth canal
 Inversionof the uterus
 Hypofibrinogenemia
 Clotting defect

2. Late Postpartum Hemorrhage- Occurs from 24 hours after birth to 4 weeks postpartum.

Causes of late postpartal hemorrhage

 Retained Placental Fragments

 Subinvolution of the uterus
 Infection

NURSING MANAGEMENT

 Fundal massage for uterus to contract

 Offer a bedpan or assist with ambulating to the bathroom at least every 4 hours to keep of the woman’s
bladder empty
 If a woman is experiencing respiratory distress from decreasing blood volume, mask administer oxygen by
face mask of 4 L/min rate
 Supine position to allow adequate blood flow to herbrain and kidneys.
 Obtain vital signs frequently

BLOOD LOSS

NSD- normal is 350-500

CS- normal is 1000 or less

UTERINE ATONY
 soft boggy uterus
 failure to contract
 Failure of the uterus to contract continuously after delivery.
 It is the most common cause of Post partal hemorrhage and often occurs following delivery of the baby and
up to 24 hours after the delivery of the placenta.,
 Relaxation of the uterus

CAUSES

 Overdistention : hydramnios, multiple pregnancy, macrosomia

 Complication of labor- Precipitate , prolonged labor, tired uterus
 Uterine relaxing agents: anesthesia, analgesia, terbutaline, magnesium sulfate, nitroglycerine
 Oxytocin given during labor
Headache, lightheadedness, dizziness, uterine contraction occurs less than 2 minutes
 High parity and advanced maternal age
 Infection: amnionitis and chorioamnionitis
 Presence of fibroid tumors that interfere with uterine contractions
 Over massage of the uterus that results in very strong uterine contractions and eventual fatigue
 Retained placental fragments
After placental delivery check the completeness, sometimes Dilation and curettage is used
 Prolonged third stage of labor

ASSESSMENT

 uterus relaxes, gush of blood occurs

 Vaginal bleeding which is extremely large and the client may experience shock (increase RR & PR, decrease BP)
 If the uterus suddenly relaxes, there will be abrupt gush of blood from the placental site.
 Vaginal bleeding which is extremely large and the client mayexhibit symptoms of shock and blood loss.

THERAPEUTIC MANAGEMENT

 Hysterectomy- if the other management do not work

 Intravenous infusion of oxytocin (pitocin) to help uterus maintain tone
 The usual dose is 10-40U per 1000ml of5%dextrose solution
 Intramuscular Methylergonovine ( methergin) - sometimes not use because decrease breast milk
 Bimanual massage- one hand in vagina and 1 hand is in the fundus, should be in gloves
 Prostaglandin administration- same action with oxytocin and Methylergonovine
 Blood replacement

Gauge should be large

  Hysterectomy- if the other management do not work

RETAINED PLACENTAL FRAGMENTS

 Depends on the type of placenta being implanted (placenta accrete, placenta increta, placenta precreta?)
 6% of vaginal deliveries
 The most common cause of post partal hemorrhage.
 Have increased risk of recurrence of retained placental fragments in subsequent deliveries.
 Incidence: occurs in 6% of vaginal deliveries.

CAUSES

 Partial separation of a normal placenta

 Manual removal of placenta
 Abnormal adherent placenta, accrete, increta or perceta
 Abnormal placental adhesion

Counter traction- use to deliver placenta

-one hand on abdomen, one hand on forceps then when contracting, pull it downward

SUBINVOLUTION OF THE UTERUS

 Occurs when there is a delay in the return of the prepregnant size, shape and function
  Another late sign of postpartum hemorrhage
 Delay of uterus to return to pre-pregnancy stage

ASSESSMENT

 Enlarged and boggy uterus

 Prolonged or reversal pattern in lochial discharge
 Foul odor in lochia if caused by infection
 Backache

CAUSES

 Retained placental fragments

 Infection- endometritis
 Uterine tumors

THERAPEUTIC MANAGEMENT

 Initially the physician may order Ergonovine Maleate .2mg to stimulate uterine contractions for 2 weeks. If
bleeding continues after 2 weeks, D and Cis performed
 Treating the cause (remove tumor, give antibiotics if due to infection, D &C if due to uterine atony)
 Removal of uterine tumors and antibiotics for infection
 Evacuation of the retained placental fragments by D and C

NURSING MANAGEMENT

 Uterine Massage- first nursing action

 Ice compress
 Oxytocin administration
 Empty bladder
 Bimanual Compression to explore if there are retained placental fragments
 Hysterectomy

POSTPARTAL PUERPERIAL INFECTION

 Reproductive tract infection developing after delivery
 May spread to the peritoneum (peritonitis) or the circulatory system (septicemia)

RISK FACTORS

 Rupture of the membrane more than 24 hours before birth

 Placental fragments retained within the uterus ( the tissue necroses and serves as an excellent bed for bacterial
growth)
 Postpartal hemorrhage ( the woman’s general condition is weakened)
  Pre-existing anemia ( the body’s defense against infection is lowered)
 Prolonged and difficult labor, particularly instrument births ( trauma to the tissue may leave lacerations or
fissures for easy portals of entry for infection)
 Internal fetal heart monitoring ( contamination may have been introduced in the placement of the scalp
electrode)
 Local vaginal infection was present at the time of birth (direct spread of infection has occurred)
 The uterus was explored after birth for a retained placenta or abdominal bleeding site (infection was introduced
with exploration)

ASSESSMENT

 Assessment- localized in the vagina, vulva, perineum

 Pain
 Fever
 Edema
 Redness
 Firmness
 Tenderness
 Burning on urination
 Wound discharge
 Temperature >100.4 (38) after 1st 24 hours or any of the first 10 days is normal because there is increase WBC of
20,000 related to stress or trauma but not after

PREVENTION

 Use sterile gloves, instruments during labor, birth and postpartal period.
 Proper perineal care by the client,(front-back)
 Handwashing
 The client should have her own bedpan and perineal supplies and should not share them.
 Antibiotics but culture and sensitivity is done first to determine what type of antibiotic ( ampicillin, gentamicin,
3rd generation cephalosporins (cefixime)
 No antibiotics during breastfeeding ==== observe infant for the presence of white plaque or thrush (oral
candida) ===because the portion of the maternal antibiotic passes into the breastmilk and cause
overgrowth of fungal organisms ===== a decreased in microorganisms in the bowel caused by an
antibiotic passed in breast milk may lead to insufficient Vitamin K formation and decreased blood
clotting ability.
 Hot sitz bath 2x a day.
 Sit in lukewarm water with solution, usually they use commode chair
 If at home, others boil guava leaves then client sit on a pale

Management: antibiotic after culture and sensitivity testing of the isolated organisms

 Group B streptococci
 Eschirichia coli
 Staphylococcus == cause of toxic syndrome similar to puerperial infection
ENDOMETRITIS
 An infection of the endometrium, the lining of the uterus.
 Bacteria gain access through the vagina and enter the uterus at the time of birth or during the postpartal period.

ASSESSMENT

 Temperature elevation on the third and 4 th postpartal day == occurs at the same time during breast filling
 Increase WBC 20,000-30,000cells.mm3 (NORMAL)
 Chills
 Loss of appetite
 General malaise
 Uterus not well contracted and painful to touch
 Strong afterpains
 Lochia is dark brown, foul odor
 ==== if accompanied with high fever == lochia may be scant or absent
 Placental fragments confirmed by UTZ

DANGER OF ENDOMETRITIS

 Tubal scarring
 Interference with future fertility

MANAGEMENT

 Lochia is infected if the lining of uterus is infected so encourage the client to walk for the lochia to be out from
the body (most important independent nursing intervention)
 Antibiotic == Clindamycin (Cleocin) === determined by a culture of the lochia.
 Vaginal culture using a sterile swab rather than from a perineal pad
 Oxytocic agent === methylergonovine == to encourage uterine contraction
 Increase fluid intake
 Analgesic === for afterpains
 Sitting in a fowler’s position or walking == encourage lochia drainage by gravity == helps prevent pooling of
infected secretions.
 == Wear gloves when changing perineal pad
 Early recognition of signs:
 Know normal color
 Know normal quantity and odor of discharge
 Note size, consistency, tenderness of a normal postpartal uterus

PERINEAL HEMATOMA
 Collection of blood in the subcutaneous layer tissue of the perineum.
  Caused by the injury to the blood vessels in the perineum during birth.
 Occur during rapid spontaneous birth and perineal varicosities.
 May occur at the site of episiotomy or laceration repair if a vein was punctured during repair.
 Present minor bleeding and discomfort.

ASSESSMENT

 Severe pain in the perineal area

 Feeling of pressure between legs (feel firm globe between)
 With hematoma == purplish discoloration with swelling 2cm or 8cm in diameter
 Tenderness during palpation
 Palpates as firm globe

MANAGEMENT

 Report the presence of hematoma: size, degree of woman’s discomfort

 Assess the size by measuring it in centimeters with each inspection.
 Describe a hematoma (small, large)
 Describe the lesion
 Administer mild analgesic == pain relief
 Apply an ice pack (covered with towel to prevent thermal injury to the skin)
 If the hematoma is large or continues to increase === return the woman in the delivery room to have the site
incised and vessel be ligated under local anesthesia.
 If an episiotomy incision line is opened to drain a hematoma, it may be left open and packed with gauze rather
than re-sutured.
 Packing is usually removed within 24-48 hours
 Instruct the client before discharge that she has to keep the area dry (because if wet or moist, microorganisms
can grow)

THROMBOEMBOLIC DISORDERS
 Thrombi or blood clots are formed when there is stasis of circulation or repair of damaged tissue.
 The postpartum woman is especially susceptible for the formation of thrombi because of increased fibrinogen
and prothrombin levels which increases blood coagulability.
 Thrombi have a tendency to occlude circulation and are a good medium of bacterial growth.

RISK FACTORS

 Varicosities of the legs

 Obesity
 Over 30 years old
 Multiparity
 Use of estrogen supplement or oral contraceptives
 History of thromboembolic disease
 Anesthesia, surgery
 Smoking
  Trauma to extremities- raise legs at the same time and cover stirrups to prevent trauma or injury to the lower
extremities, trauma could lead to thromboembolic disorder. Take note of time because prolong raising of legs
could lead the the disorder- impedes circulation/venous return
 DM

CAUSES

 Injury to blood vessels usually occurs during delivery, indwelling catheterization and infection
 Increased clotting that normally occurs during pregnancy and after delivery and with the use of oral
contraceptives
 Blood stasis that occurs as a result of varicose veins, bed rest after CS and prolonged inactivity

DIAGNOSIS

1. Doppler ultrasound

2. X-ray dye injection call venogram

Inject a dye, they’ll see the flow if it covered all, if they see the there’s obstruction then they can diagnose

TYPES

1. Superficial thrombophlebitis

 Inflammation affecting the superficial veins of the extremities, the veins that are near the skin and visible to the
eye. Main symptom is tenderness and pain in the affected vein followed by edema
 Location of the clot can be seen by the eye on inspection of the painful and reddened area in the affected leg.
These blood clots are large and hard enough to be felt by palpation

2. Deep vein thrombophlebitis

 Located deep within a muscle tissue. Since vein is surrounded by the muscles, blood clot may break free during
muscular movement and travel in the circulation
 Thrombus- blood clot that does not move
 Emboli/Embolus- moving blood clot
 The main danger is of the emboli (moving blood clot is called embolus, stationary blood clot is thrombus)
reaching the lungs and obstruct pulmonary blood flow resulting in pulmonary embolism. There is more swelling
in deep vein thrombosis than in superficial vein thrombosis
 shortness of breath, chest pain and tachypnea if pulmonary embolism occurs

TYPES ACCORDING TO VEINS AFFECTED

1. Femoral Thrombophlebitis

Infection of the veins of the legs femoral, popliteal veins

MANIFESTATIONS
  Homan’s sign- calf pain when the foot is dorsiflexed
 Milk leg or phlegmasia alba dolens- the leg is shiny white in appearance because of extreme swelling and lack of
circulation
 Swelling of affected leg, pain stiffness
 Fever
 infection of the ovarian, uterine and pelvic veins manifestations are

 Fever and chills

 Pain in the lower abdomen or flank

 Palpable parametrail mass in some cases.

MANGEMENT

 Early ambulation after delivery (NSD)

 Passive exercises on bed (CS)
 If woman already have it, then use of support stocking in the woman with varicosities to promote circulation
and prevent stasis. Instruct the patient to put stocking before rising from the bed in the morning
 Provide adequate hydration
 Avoid trauma to extremities
 Pad stirrups well
 Avoid prolonged sitting, standing or sitting
 Avoid pressure on the vessels
 If post CS encourage leg exercises to promote venous return while patient is not yet able to get out of bed
 Avoid activities that contribute to venous stasis such as prolonged bed rest,standing and sitting.

2. Superficial Venous Thrombosis

 Involving small clots in the absence of infection usually resolves without anticoagulant treatment.
 The management is directed towards relief of pain and resolution of clot which include

 Application of heat to relieve pain

 Aspirin and ibuprofen- anti inflammatory drugs to relieve pain and prevent inflammation

 If the woman is receiving heparin, aspirin should never be given to her.

 Instruct to avoid massaging the area

DVT/ Deep vein thrombosis

 Requires intensive management to prevent serious complications like pulmonary embolism

 Legs should be elevated (first action), then apply heat or immobilized

MANAGEMENT

 Hospitalization during acute phase

 Bedrest until signs and symptoms disappear. Gradual ambulation after disappearance of signs and symptoms
but the patient must wear elastic stockings to improve circulation in the leg and prevent venous stasis
 Leg elevation
 Anticoagulant therapy to prevent venous stasis
  Heparin is safe because it does not cross placenta If there’s heparin toxicity then have protamine
sulfate. Mother may breasfeed as it is not passed to breastmilk
 Warfarin (oral), ready vit k as antidote
 Dicumarol- passed on breastmilk, so mother must stop breastfeeding.
 Monitor PTT level or APTT Apply warm wet compress dressing to promote circulation and for comfort
Administer prescribed antibiotic to combat infection and analgesic to relieve pain
 Surgery may be used if the affected vein is likely to present a long-term threat of producing blood clots. Surgery
is also done when other managements are not effective

2 major complications associated with the hypercoagulable state brought by pregnancy

 Thrombophlebitis- Infection of the lining of the vein with formation of thrombi (thrombo for the presence of
clots and phlebitis meaning inflammation of the lining of blood vessels.

 Venous Thrombosis/ phlebothrombosis-if the inflammation is minor and involves only superficial veins
of the extremities.

Location of the clot can be seen by the eye on inspection of the painful and reddened area in the affected leg.
These blood clots are large and hard enough to be felt by palpation

 Thrombophlebitis - if the inflammation involves deep veins

 Pulmonary embolism- may occur when these thrombi formed in the deep leg veins are carried by circulation to
the pulmonary artery and obstruct blood flow to the lungs. It is rare but when it happens it is life threatening

MASTITIS
 Inflammation of the breast tissue due to stasis of milk or infection of the lactiferous ducts
 Breast milk clog into those ducts

 Due to:
 Breast injury (overdistention, stasis, cracking of the nipples because of poor attachment)
 Missed feeding
 Tight feeding bra
 Impaired infant sucking related to attachment during feeding

Signs of good attachment:

 Widely open mouth

 Chin touching the chest
 Areola below?
 Feeding the baby should be every 2 to 3 hours. If there will be mixed feeding knowing there will be
engorgement, mother will feel lump on her breast
 Infectious agents are introduced through maternal hands or infants mouth, cracked nipples
 Symptoms appear by 3rd or 4th week postpartum
  If not manage abscess will appear and pain

ASSESSMENT

 Fever
 Chills
 General discomfort
 Pain
 Malaise
 Localized pain
 Increased heart rate
 Breast engorgement, firmness and reddening
 Sore and fissured nipples
 Breasr is somewhat red and firm
 Axillary lymph nodes tenderness and there’s swelling

MANAGEMENT

 Evaluate s/s of infection

 Administer antibiotics but it is contraindicated if there is breastfeeding (can affect microorganism in the bowel of
the baby that helps in production of vit k)
 Milk breast expression if there’s problem with sucking
 Warm compress
 Educate
 Provide comfort measures (pillow, ice packs, warm compress)
 Discuss infection through proper handwashing and immediate attention to clogged milk ducts
 Give pillow to provide comfort, put under brear
 Encourage frequent breastfeeding, proper beast care (water only because use of soap can cause dryness), and
nipple care
 Educate the patient and her family

Clogged ducts- is due to missed feeding so encourage frequent feeding

Retracted nipple, there’s problem with the release of breast milk can also cause mastitis- the clog will be more thicker
and painful.

If not managed then can lead to breast abscess so incision is needed to drain pus