NURSING CARE OF A FAMILY EXPERIENCING A POSTPARTAL

COMPLICATIONS
Sunday, December 4, 2022 5:50 AM

POSTPARTAL HEMORRHAGE
- 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).
- In specific agencies, the loss may not be considered hemorrhage until it reaches 1000 mL.
Hemorrhage may occur either early (within the first 24 hours) or late (anytime after the first 24
hours during the remaining days of the 6-week puerperium).
- The greatest danger of hemorrhage is in the first 24 hours because of the grossly denuded and
unprotected uterine area left after detachment of the placenta.

CONDITIONS THAT INCREASE A WOMAN’S RISK FOR POSTPARTAL HEMORRHAGE

UTERINE ATONY
- Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartal hemorrhage
(Poggi, 2007).
- The uterus must remain in a contracted state after birth to keep the open vessels at the placental
site from bleeding.
- When caring for a woman in whom any of these conditions are present, be especially cautious in
your observations and be on guard for signs of uterine bleeding. This is especially important
because many postpartal women are discharged within 48 hours after birth.

NURSING DIAGNOSIS AND RELATED INTERVENTIONS

 Nursing Diagnosis: Deficient fluid volume related to excessive blood loss after birth.
 Outcome Evaluation: Client’s blood pressure remains higher than 100/60 mm Hg; pulse
remains between 70 and 90 beats per minute; lochia flow is less than one saturated perineal
pad per hour.

INTERVENTIONS:
1. Estimate the amount of blood a postpartal woman has lost by counting the number of
perineal pads saturated in given lengths of time such as half-hour intervals, you can form a
rough estimate of blood loss.
2. Always be sure to turn a woman on her side when inspecting for blood loss, to be certain that
a large amount of blood is not pooling undetected beneath her.
3. Palpate a woman’s fundus at frequent intervals post partally to be certain that her uterus is
remaining in a state of contraction. This is the best measure for preventing early hemorrhage.
○ When palpating a uterine fundus, if you are unsure whether you have located it, the
uterus is probably in a state of relaxation. Under normal circumstances, a well-

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 uterus is probably in a state of relaxation. Under normal circumstances, a well-
contracted uterus is firm and easily recognized because it feels like no other abdominal
organ.
4. Remain with the woman after massaging her fundus, to be certain the uterus is not relaxing
again. Observe carefully, including fundal height and consistency and lochia, for the next 4
hours.

5. Frequent assessments of lochia (to be certain that the amount of the flow is under a
saturated pad per hour, and that any clots are small), as well as vital signs, particularly pulse
and blood pressure, are equally important.
6. Offer a bedpan or assist the woman with ambulating to the bathroom at least every 4 hours to
be certain her bladder is empty. A full bladder pushes an uncontracted uterus into an even
more uncontracted state. To reduce bladder pressure, insertion of a urinary catheter may be
ordered.

7. If a woman is experiencing respiratory distress from decreasing blood volume, administer

oxygen by face mask at a rate of about 4 L/min. Position her supine to allow adequate blood
flow to her brain and kidneys.

8. Obtain vital signs frequently and make sure to interpret them accurately, looking for trends.
For example, a continuously rising pulse rate is an ominous pattern.

9. Consistent frequent assessments of uterine tone and vital signs and laboratory assessments
such as hemoglobin and hematocrit levels help to detect blood loss before this point is ever
reached.

10. Explain that these measures, although disturbing, are important for her welfare. Obtain vital
signs as quickly and gently as possible, so that a woman feels a minimum of discomfort and
disruption, allowing her time to rest.

LACERATIONS

- Small lacerations or tears of the birth canal are common and may be considered a normal
consequence of childbearing. Large lacerations, however, can cause complications.

They occur most often:

• With difficult or precipitate births

• In primigravidas

• With the birth of a large infant (9 lb)

• With the use of a lithotomy position and instruments.

- Either cervical, vaginal, or perineal lacerations may occur. After birth, any time a uterus feels firm
but bleeding persists, suspect a laceration of one of these three sites.

TYPES OF LACERATIONS

CERVICAL LACERATIONS
• Lacerations of the cervix are usually found on the sides of the cervix, near the branches of the
uterine artery.
• Causes: (1) Rigidity of cervix, (2) abnormal structure due to scarring from previous surgery, and
(3) Rapid delivery of head in breech presentation.

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 RETAINED PLACENTAL FRAGMENTS
- A placenta does not deliver in its entirety; fragments of it separate and are left behind. Because the
portion retained keeps the uterus from contracting fully, uterine bleeding occurs.
- To detect the complication of retained placenta, every placenta should be inspected carefully after
birth to see that it is complete.
- Retained placental fragments may also be detected by ultrasound.
- A blood serum sample that contains human chorionic gonadotropin hormone (hCG) also reveals
that part of a placenta is still present.

ASSESSMENT
• If an undetected retained fragment is large, bleeding will be apparent in the immediate
postpartal period, because the uterus cannot contract with the fragment in place.
• If the fragment is small, bleeding may not be detected until postpartum day 6 to 10, when the
woman notices an abrupt discharge and a large amount of blood. On examination, usually the
uterus is not fully contracted.

THERAPEUTIC MANAGEMENT
• Removal of the retained placental fragment is necessary to stop the bleeding. Usually, a
dilatation and curettage (D&C) is performed to remove the placental fragment.
• Because the hemorrhage from retained fragments may be delayed until after a woman is at
home, be certain a woman knows to continue to observe the color of lochia discharge and to
report any tendency for the discharge to change from lochia serosa or alba back to rubra.

UTERINE INVERSION
- Uterine inversion is prolapse of the fundus of the uterus through the cervix so that the uterus turns
inside out. This usually occurs immediately after birth.

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 SUBINVOLUTION
- Subinvolution is INCOMPLETE RETURN OF THE UTERUS to its prepregnant size and shape.
- With subinvolution, at a 4- or 6- week postpartal visit, the uterus is still enlarged and soft. Lochial
discharge usually is still present.
- Subinvolution may result from a small retained placental fragment, a mild endometritis (infection
of the endometrium), or an accompanying problem such as a uterine myoma that is interfering
with complete contraction.
- Causes: Grand multiparity, Overdistension of Uterus and Maternal Ill-health

PERINEAL HEMATOMAS
- A perineal hematoma is a collection of blood in the subcutaneous layer of tissue of the perineum.
The overlying skin, as a rule, is intact with no noticeable trauma. Such blood collections can be
caused by injury to blood vessels in the perineum during birth.
- They are most likely to occur after rapid, spontaneous births and in women who have perineal
varicosities.
- They may occur at the site of an episiotomy or laceration repair if a vein was punctured during
repair. Although they can cause a woman acute discomfort and concern, they usually represent only
minor bleeding.

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 POSTPARTUM INFECTION
- A puerperal infection is always potentially serious, because, although it usually begins as only a
local infection, it can spread to involve the peritoneum (peritonitis) or the circulatory system
(septicemia). These conditions can be fatal in a woman whose body is already stressed from
childbirth.
- Theoretically, the uterus is sterile during pregnancy and until the membranes rupture. After
rupture, pathogens can invade. The risk of infection is even greater if tissue edema and trauma are
present.
- 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

CONDITIONS THAT INCREASE A WOMAN’S RISK FOR POSTPARTAL INFECTION

1. Rupture of the membranes more than 24 hours before birth (bacteria may have started to
invade the uterus while the fetus was still in utero)
2. Placental fragments retained within the uterus (the tissue necroses and serves as an
excellent bed for bacterial growth)
3. Postpartal hemorrhage (the woman’s general condition is weakened)
4. Pre-existing anemia (the body’s defense against infection is lowered)
5. Prolonged and difficult labor, particularly instrument births (trauma to the tissue may leave
lacerations or fissures for easy portals of entry for infection)
6. Internal fetal heart monitoring (contamination may have been introduced with placement
of the scalp electrode)
7. Local vaginal infection was present at the time of birth (direct spread of infection has
occurred)
8. The uterus was explored after birth for a retained placenta or abnormal bleeding site
(infection was introduced with exploration)

COMMON GUIDELINES FOR THE WOMAN WITH A POSTPARTAL INFECTION

1. As a rule, the baby of a mother with an increased temperature (100.4° F [38° C]) for two
consecutive 24-hour periods exclusive of the first 24 hours is kept in an isolation nursery until
the cause of the infection is determined. The mother may have an upper respiratory tract or
gastrointestinal infection that is unrelated to childbearing but transmittable to a newborn.
2. If the cause of the fever is found to be related to childbirth but involves a closed infection,
such as thrombophlebitis, with no danger of the baby contracting the disease, the woman
may care for her child as long as she maintains bed rest in the prescribed position while doing
so.
3. If the infection involves drainage such as can occur with endometritis or a perineal abscess,
newborn visiting may be contraindicated. If rooming-in is continued, the mother should wash

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 newborn visiting may be contraindicated. If rooming-in is continued, the mother should wash
her hands thoroughly before holding her infant. She should never place her baby on the
bottom bed sheet, where there may be some infected drainage from her perineal pad (furnish
a clean sheet to spread over the covers).

4. Most hospitals are reluctant to return a baby to a central nursery after a baby has visited in a
room where there is an infection. The hospital should provide a small nursery that may be
used as an isolation nursery for these situations, or the baby can be placed in a closed Isolette
in a central nursery or continue to be cared for in the woman’s room.
5. If the woman has a high fever, breast milk may be deficient. With modern antimicrobial
therapy, puerperal infections are limited, and the period of high fever usually is transient. If it
appears that the course of the infection will be long, a woman may choose to discontinue
breastfeeding.

6. If it is necessary for a woman to discontinue breastfeeding, she needs to be assured that she
can meet the needs of the child through bottle feeding.

7. If a woman is going to be hospitalized beyond the usual time, she may have to make
arrangements for the discharge and care of her baby.

THROMBOPHLEBITIS
- PHLEBITIS is inflammation of the lining of a blood vessel. THROMBOPHLEBITIS is inflammation with
the formation of blood clots.

It tends to occur because:

○ A woman’s fibrinogen level is still elevated from pregnancy, leading to increased blood
clotting.
○ Dilatation of lower extremity veins is still present as a result of pressure of the fetal head
during pregnancy and birth.
○ The relative inactivity of the period or a prolonged time spent in delivery or birthing room
stirrups leads to pooling, stasis, and clotting of blood in the lower extremities.
○ Obesity from increased weight before pregnany and pregnancy weight gain can lead to relative
inactivity and lack of exercise.
○ The woman smokes cigarettes.

PREVENTING THROMBOPHLEBITIS

• Ask your primary care provider if you can use a sidelying or back-lying (supine recumbent)
position for birth, rather than a lithotomy position (lithotomy position can increase the tendency for
pooling of blood in the lower extremities).

• If you will be using a lithotomy position, ask for padding on the stirrups to prevent calf pressure.

• Drink adequate fluids to be certain you’re not dehydrated (6–8 glasses of fluid/day).

• Do not sit with your knees bent sharply, and avoid wearing constricting clothing such as knee-high
stockings.

• Ambulate as soon after birth as you are able. Early ambulation is the best preventive measure.
When resting in bed, wiggle your toes or do leg lifts to improve venous return.

• Ask your primary care provider if he or she recommends support stockings in the immediate
postpartal period. Be certain to put these on before ambulating in the morning, before leg veins fill.

• Quit smoking as this is associated with the development of thrombophlebitis.

MASTITIS
- Mastitis (infection of the breast) may occur as early as the seventh postpartal day or not until the
baby is weeks or months old (Reddy et al., 2007).

- The organism causing the infection usually enters through cracked and fissured nipples. Therefore,

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- The organism causing the infection usually enters through cracked and fissured nipples. Therefore,
measures that prevent cracked and fissured nipples also help prevent mastitis.

These measures include:

○ • Making certain the baby is positioned correctly and grasps the nipple properly, including
both nipple and areola

○ • Releasing a baby’s grasp on the nipple before removing the baby from the breast

○ • Washing hands between handling perineal pads and touching the breasts

○ • Exposing nipples to air for at least part of every day

○ • Using a vitamin E ointment to soften nipples daily

○ • If a woman has one cracked and one well nipple, encourage her to begin breastfeeding
(when the infant sucks most forcefully) on the unaffected nipple.

URINARY RETENTION
- Urinary retention occurs as a result of inadequate bladder emptying.
- After childbirth, bladder sensation for voiding is decreased because of bladder edema caused by the
pressure of birth. Unable to empty, the bladder fills to overdistention.
- When the woman does void, instead of emptying completely, the bladder empties only a small
portion of its contents (retention with overflow). As a result, it becomes overdistended again.
Bladder overdistention is potentially serious. If it is allowed to continue, permanent damage may
occur from loss of bladder tone, leading to permanent incontinence (Chelmow, Aronson, & Wosu,
2007).

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 POSTPARTAL PREGNANCY-INDUCED HYPERTENSION
- Mild pre-existing hypertension may increase in severity during the first few hours or days after
birth. Rarely, PIH (Pregnancy Induced Hypertension) develops for the first time in a woman who has
had no prenatal or intranatal symptoms. When this happens, the cardinal symptoms are the same as
those of prenatal PIH: proteinuria, edema, and hypertension (Bailis & Witter, 2007).
- The treatment measures for postpartal PIH are: bed rest, a quiet atmosphere, frequent monitoring
of vital signs and urine output, and administration of magnesium sulfate or an antihypertensive
agent.
- The reason the condition occurs is usually retention of some placental material. The woman may be
taken to surgery to have a D&C to be certain that all placental fragments have been removed from
her uterus. After the D&C, blood pressure often falls dramatically to normal.

REPRODUCTIVE TRACT DISPLACEMENT

- If the support systems of the uterus are weakened because of pregnancy, the ligaments may no
longer be able to maintain the uterus in its usual position or level after pregnancy.
- Problems of retroflexion, anteflexion, retroversion, and anteversion or prolapse of the uterus may
occur.
- These uterine displacement disorders may interfere with future childbearing and fertility and may
cause continued pain or a feeling of lower abdominal heaviness or discomfort

SEPARATION OF THE SYMPHYSIS PUBIS

- During pregnancy, many women feel some discomfort at the symphysis pubis because of relaxation
of the joint preparatory to birth.
- If a fetus is unusually large or fetal position is not optimal, the ligaments of the symphysis pubis may
be so stretched by birth that they actually tear.
- After birth, the woman experiences acute pain on turning or walking; her legs tend to rotate
externally, giving her a waddling gait.
- A defect over the symphysis pubis can be palpated; the area is swollen and tender to touch.

TREATMENT:
• Bed rest and the application of a snug pelvic binder to immobilize the joint are necessary to
relieve pain and allow healing.
• As with all ligament injuries, a 4- to 6-week period is necessary for healing to take place.
During this time, a woman may need to arrange for a person to help her with child care at
home.
• She should avoid heavy lifting for an extended period, until healing in the pubic ligaments is
complete.
• She may be advised to consider cesarean birth for any future pregnancy.

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