UTERINE ATONY

NURSING CARE OF A It is known as relaxed uterus. This condition can be caused by

anesthesia, analgesia administration, oxytocin assisted labor,
FAMILY EXPERIENCING 35 years old above, high parity, history of uterine surgery,
prolonged/difficult labor, infection (e.g. chorioamnionitis or

A POSTPARTAL endometritis), secondary maternal illness, history of PPH, and

prolonged used of CNS depressant or tocolytic therapy

COMPLICATION Management

Learning Outcomes □ Uterine massage

□ 4 hours after, assess for lochia, fundal ht and
1 Describe a woman at risk for common deviations from consistency
normal that can occur during the puerperium.
2 Assess a woman and her family for deviations from the □ Ice
normal during the puerperium. □ IV oxytocin
3 Integrate knowledge of postpartum complications with □ Methylergonovine maleate IM q2-4hrs x 5 doses
the nursing process to promote quality maternal and □ Carboprost tromethamine q15-90mins x 8 doses
child health nursing care.
□ Misoprostol rectally
Course Outline □ Offer bedpan (di makatayo and nagtatae d/t prosta)
□ Assist ambulating q4 to bathroom
Postpartum Hemorrhage □ Monitor VS. WOF si/sx hypovolemic shock
 Uterine Atony
 Lacerations □ Blood transfusion
 Retained placental fragments □ Hysterectomy
 Uterine Inversion
 DIC LACERATIONS
Puerperal Infection
 Endometritis It is a small lacerations or tear after giving birth. It is common
 Perineal Infection and may considered as normal consequence of childbearing.
 Peritonitis However, large lacerations can cause complications.
Mastitis
Emotional and Psychological Complications of Puerperium They occur most often in patients with difficult and
 Postpartal Blues precipitate birth, primigravidas, macrosomatic infants,
 Postpartal Depression lithotomy position, and forceps birth.
 Postpartal Psychosis
Types of Laceration

a. Cervical Lacerations
POSTPARTUM HEMORRHAGE
 Arterial blood = bright red
Blood loss from the uterus greater than 500mL within 24-  Difficult to repair.
hour period.  Provide space to work, adequate sponges,
suture supplies, and good light source for the
□ Early – within the 1st 24 hours physician or nurse-midwife.
b. Vaginal Lacerations
□ Late – after 24 hours – 6 weeks
 Easy to repair.
CAUSES  Vaginal tissue is friable.
 After surgery, there is still some oozing.
 Uterine Atony  IFC to avoid contacting urine to the perineum.
 Lacerations  Documentation of packing time & location.
 Retained placental fragments  Packing >24hrs can lead to TSS.
 Uterine Inversion c. Perineal Lacerations
 DIC  Episiotomy repair.
 Documentation.
 High fluid dieat & stool softners.

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  3rd & 4th degree lacerations = no enema, UTERINE INVERSION
suppositories or rectal temperature.
 4th degree lacerations = dyspareunia, rectal The uterus turned inside and out during birth or placenta
incontinence, or sexual dissatisfaction. delivery occurs in varying degrees. Total inversion - protrudes
from the vagina.
Classification Involvement
Upon examination the inverted uterus, massive bleeding
First Vaginal mucous membrane and perineal
gushes from the vagina, and unpalpable fundus in abdomen.
skin to the fourchette.
Prolonged bleeding from this condition can progress into
Second Vagina, perineal skin, fascia, levator ani
hypovolemic shock.
muscle, and perineal body.
Third Entire perineum, extending to reach the Management
external sphincter of rectum.
Fourth Entire perineum, rectal sphincter, & some □ Frequent VS monitoring
rectal mucous membrane.
□ Anticipate CPR
□ IV fluid replacement
□ Oxygen administration
□ General anesthesia, nitroglycerine, tocolytic drug
□ Prophylactic antibiotics therapy

DIC
It is an acquired blood clotting disorder due to low fibrinogen
level. The early symptom of DIC is bleeding or bruising in the
IV site.

Management

RETAINED PLACENTAL FRAGMENTS
Some portion of placenta is still retained inside the uterus
that prevent it from contracting that can lead or progress
onto bleeding. After birth, placenta should be inspected at
the Duncan side to see if it is complete. Common findings are
abrupt discharge and uncontracted uterus upon palpation.
Small Fragments: PP bleeding 6-10 days.
□ Heparin administration
□ Cryoprecipitate or FFP transfusion
□ Health teaching: medication, explanation of what is
happening
SUBINVOLUTION
It is an incomplete return size and shape of uterus. By 4 or 6
weeks PP, the uterus is still enlarged and soft. The lochial
discharge is usually present.

Large Fragments: immediate bleeding during PP period. Causes

Diagnostics  Small retained placental fragment

□ Ultrasound: for confirmation & detection
□ Blood sample: high levels of hCG
Management
□ Placental removal through D&C
□ Balloon occlusion
□ Embolization of internal iliac arteries
□ Methotrexate
 Mild endometritis
 There’s accompanying condition (uterine myoma)
Management
□ Methylergonovine 0.2 PO QID
□ Antibiotics PO (endometritis)
□ Health Teaching: How to recognize normal process
of involution and local discharge before hospital
discharge.

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PERINEAL HEMATOMA Poor uterine involution: increased amt
There is a collection of blood in the subq tissue of perineum High fever: scant or absent
and the skin overlying is intact with no noticeable trauma.
This can be caused by injury to the blood vessels in perineum Management
during birth.
□ Antibiotics
This most likely occur after rapid, spontaneous births and in
□ Oxytocin (Mathergine)
women who have perineal varicosities. Also, it can occur at
the site of an episiotomy or laceration repair if a vein was □ Additional fluid
punctured during repair. □ Fowler’s
□ Infection control measures
There is a severe pain in the perineal area or feeling of
pressure between her legs. There’s a presence of purplish □ Health teaching: si/sx of endometritis
hematoma with obvious swelling and tender to palpate. The
feeling is fluctuant, but as seepage into the area continuous PERINEAL INFECTION
and tissue is drawn taut, firm to palpate.
Episiorrhapy increase the risk for infection due to portal of
Management entry. There’s a localized infection, pain, heat, feeling of
pressure, slough, and purulent drainage.
□ Report: size of hematoma, degree of woman’s
Management
discomfort to primary care provider.
□ Mild analgesic for pain. □ Suture removal for draining
□ Ice pack □ Antibiotics (topical or systemic)
□ Incision & ligation under local anesthesia. □ Analgesics
□ Sitz bath
PUERPERAL INFECTION
□ Infection control measures
The uterus is theretically sterile but once the membranes
rupture, the pathogens can invade. Risk for infection is high
PERITONITIS
or greater if tissue edema & trauma are present.
An infection at the peritoneal cavity that usually occurs as an
This infection is always considered as potentially serious, extension of endometritis. This is one of the gravest
because, it usually begins as only as a local infection. This can complications of childbearing and high mortality rate from
can spread and involve the peritoneum (peritonitis) or puerperal infection.
circulatory system (septicemia).
The infection spreads through lymphatic system or fallopian
Conditions that increase a woman’s risk for postpartal tubes or uterine wall of peritoneal cavity. Abscess may form
infection in the cul-de-sac of Douglas.

 ROM more than 24 hours before birth. The findings are rigid abdomen, abdominal pain, febrile, rapid
 Retained placental fragments. pulse, vomiting, and appearance of acutely ill. Uterus is well
 PPH contracted and abdomen is soft to palpate. Check for
 Pre-existing anemia. paralytic ileus.
 Prolonged and difficult labor, particularly instrument
births. Management
 Internal fetal heart monitoring.
 Local vaginal infection was present at birth delivery. □ NGT, IVF, or TPN
 The uterus was explored after birth for a retained □ Analgesics
placenta or abnormal bleeding site.
□ Antibiotics

ENDOMETRITIS
It is the infection of endometrium, the lining of the uterus.
The clinical manifestation of endometritis are fever, elevated
WBC PP, chills, loss of appetite, general malaise,
uncontracted uterus and painful to touch, dark brown lochia.
MASTITIS
The infection of the breast that occur as early as seventh
postpartal day or not until the baby is weeks or months.
Microorganisms usually enters through cracked & fissured
nipples. Cracked and fissured nipples prevention is the key.
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Preventive Measures Therapy: Support, empathy

1 Baby positioning and grasps nipple properly. Nursing Role: Offer compassion and understanding
2 Releasing baby’s grasps before removing from the
breast.
POSTPARTAL DEPRE SSION
3 Hand washing between perineal pads & touching
breast. Onset: 1-2 mos after birth
4 Expose nipple to air.
5 Vitamin E ointment application to nipple. Symptoms: Anxiety, feeling of loss, sadness
6 Breastfeeding on the unaffected nipple.
Incidence: 10% of all births
The assessment findings usually are unilateral and epidemic
Etiology: Hx of previous depression, hormonal response, lack
mastitis may be bilateral. The affected area is painful,
of support
swollen, and reddened. Fever is the first symptom and the
breast milk is scant. Therapy: Counselling, drug therapy
Management Nursing Role: Refer to counselling

□ Antibiotics
POSTPARTAL PSYCHOSIS
□ Continue breastfeeding and keep it emptied.
Onset: Within the first year after birth
□ Manueal expression.
□ Cold/ ice compression Symptoms: Delusion of hallucinations of harming infant or
□ Warm/ hot compress herself
□ Good supportive bra Incidence: 1-2% of all births

EMOTIONAL AND PSYCHOLOGICAL Etiology: Possible activation of previous mental illness,

COMPLICATIONS OF PUERPERIUM hormonal changes, family hx of bipolar d/o

Any woman who is extremely stressed or who gives birth to Therapy: Psychotherapy, drug therapy
an infant who in any way does not meet her expectations
may have difficulty bonding with her infant. Nursing Role: Refer to psychiatric care, safeguarding the
mother from injury to self or the newborn
Inability to bond is a PP complication with far-reaching
implications, possibly affecting the future health of the entire
family.

If the woman whose newborn has died, the most common

reaction of the mother is “Why me? Of all women here, why
did my baby die?” Most women are interested in seeing the
baby. This is generally therapeutic because it helps them
begin grieving.

Clean the baby, wrap the baby in an infant blanket, and bring
him or her to the parents. Remain with them, but give them
time to handle and inspect the child as they wish.

POSTPARTAL BLUES
Onset: 1-10 days after birth

Symptoms: sadness, tears

Incidence: 70& of all births

Etiology: Probable hormonal changes, stress of the life

changes

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