Defined as blood loss of more than 500 mL following

vaginal delivery or more than 1000 mL following cesarean

delivery.
A loss of these amounts within 24 hours of delivery
→ About 70% of these cases are d/t

Whereas such losses are termed if

they occur 24 hours after delivery → d/t

It usually happens within 1 day of giving birth, but it can

happen up to 12 weeks after having a baby.
 one → Uterine Atony
rauma → Uterine Rupture, Lacerations
Clo ing → Coagulopathy ( hrombin)
issue → Retained Placenta (RPOC)

(70% of cases): the placenta has been expelled,

but the uterus fails to retract. The uterus gets larger, extends,
and becomes soft. Factors for uterine atony include:
overstretching (polyhydramnios, multiple pregnancy, fetal
macrosomia)
(10% of cases): the entire placenta or a
fragment of the placenta remains in the uterus.
(20% of cases): uterine rupture, particularly in
case of vaginal delivery in women with a scarred uterus but also
in women without uterine scarring; cervical and vaginal
lacerations; uterine inversion.
Perform initial management as quickly as possible and do
not wait 30 minutes to perform further obstetric
management →
Start transfusion as quickly as possible.
If necessary, perform one of the additional compression
measures:

Apply pressure to the abdominal aorta (just above the

umbilicus) until the femoral pulse is no longer palpable

Uterine compression between fingers in the vagina and a

hand on the abdomen
Uterine compression between the fist and a hand on the
abdomen
→ Placing one hand in the vagina and pushing against the
body of the uterus while the other hand compresses the
fundus from above through the abdominal wall.
 Is an inflammation or irritation of the lining of the uterus (the
endometrium).
Placental fragments that could be a possible cause of the
infection
Bacteria gain access to the uterus through the vagina and enter
the uterus either at the time of birth or during the postpartum
period.
Sexually transmitted infections (STIs), such as chlamydia and
gonorrhea
Genital tuberculosis
Infections resulting from the mixture of normal vaginal bacteria.

Hysteroscopy
Placement of an intrauterine device (IUD)
Dilation and Curettage
 ↑ in temperature, with accompanying chills, loss of appetite,
and general malaise.
Her uterus usually is not well contracted and is painful to touch
→ lower abdominal area, or rectal area
Lochia usually is and has a foul odor.

Sitting in a semi-Fowler’s position or walking encourages lochia

drainage by gravity and helps prevent pooling of infected
secretions.
Proper hand washing techniques before and after handling pads.
As with any infection, Endometritis can be controlled best if it is
discovered early →
If the infection is limited to the endometrium, the course of
infection will be about 7 to 10 days.
Be certain she knows to take the full course of antibiotics
prescribed so the infection is completely eradicated and does
not return → 100 mg q12 hours for 14 days.
 If a post partum px. has a suture line on her
perineum from an episiotomy or a laceration
repair, a ready portal of entry exists for bacterial
invasion.
An infected suture line appears reddened and
edematous and often contains infected
secretions.
One or two stitches may have sloughed away, so
an area of the suture line is open with purulent
drainage present.

The px. may or may have an ↑ temperature

depending on the systemic effect and spread of
the infection.
Pain, heat, and a feeling of pressure.
Infection of the peritoneal cavity, usually occurs as an extension
of endometritis.
The infection spreads from the uterus through the lymphatic
system or directly through the fallopian tubes or uterine wall to
the peritoneal cavity.
An abscess may form in the cul-de-sac of Douglas because this is
the lowest point of the peritoneal cavity and gravity causes
infected material to localize there.

Tenderness in your abdomen

Pain in your abdomen that gets more intense with motion or
touch
Abdominal bloating or distention
Nausea and vomiting
Constipation
↓Urine output
Anorexia
Fever and chills
 Complete blood count (CBC), can measure your white
blood cell count (WBC).
An ↑ WBC count usually signals inflammation or infection.
Requires insertion of a nasogastric tube to prevent
vomiting and to rest the bowel.
Intravenous fluid will then be necessary
Analgesics for pain relief and intravenous antibiotics to
treat the infection.
Peritonitis can interfere with future fertility because it can
leave scarring and adhesions in the peritoneum
↓
Separate the fallopian tubes from the ovaries to the extent
that ova can no longer easily enter the tubes
Hormonal and mechanical changes can promote urinary stasis
and vesicoureteral reflux. (+)
Along with an already short urethra (approximately 3-4 cm in
females)
& difficulty with hygiene due to a distended pregnant belly
“The most common bacterial infections during pregnancy”
Pushing with labor may also have allowed some secretions to
enter the urinary urethra.
Additional risk factors for complicated UTI in pregnancy include
the following:
Immunosuppression
Pre-existing diabetes
Sickle cell anemia
Neurogenic bladder
Smoking
Recurrent or persistent UTIs before pregnancy
Age < 20 years
Burning on urination, possibly blood in the urine (hematuria),
and a feeling of frequency or that she always has to void.
The pain feels so sharp on voiding that she may resist voiding,
further compounding the problem of urinary stasis.
The px. may also have a low-grade fever and discomfort from
lower abdominal pain.

Obtain a clean-catch urine specimen from any woman with

symptoms of UTI
Encourage a woman to drink large amounts of fluid (a glass
every hour) to help flush the infection from her bladder.
Discuss with the woman common methods that all women
should use to prevent urinary tract infections such as voiding
after intercourse as more assurance that she can remain
infection free.
A broad-spectrum antibiotic will be prescribed:
Amoxicillin: 250 mg TID
Cephalexin: 500 mg BID
 Blood clots (thrombi) form in blood vessels.
An embolus is a blood clot that travels through the
bloodstream and blocks an artery.
It can occur at any trimester in pregnancy, but studies
suggest that it is more common during the first half of
pregnancy.

Inflammation of the lining of a blood vessel.

 here is a blood clot in the vein (thrombosis or
thromboembolism) that causes swelling and pain.

If the vein that has the clot is just under the skin, this type of
clot does not usually travel to the lungs unless it reaches the
deep veins.
But it can be painful and treatment may be needed

This type of clot can travel to the lungs (pulmonary embolism)

and block blood flow to the lungs.
In severe cases, this can lead to death. Most DVTs require
treatment right away.

Swelling of the leg or arm (sometimes this happens suddenly)

Pain or tenderness in the area of the clot
Feeling of increased warmth in the area of the clot
Red or discolored skin in the area of the clot
 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 so blood
circulation is sluggish.

Are older than age 35 years or have increased parity

Have preexistent obesity and a pregnancy weight gain greater
than the recommended weight gain, which can lead to inactivity
and lack of exercises
Have preexisting varicose veins
Smoking → Nicotine causes vasoconstriction and reduces blood
flow.
 This is a clot in the long vein in your thigh.
(The femoral, saphenous, or popliteal veins are involved.)
Symptoms: swelling, redness, and pain in your leg.
Causes: Immobility, hx of deep vein thrombosis
Accompanied with arterial spasm often → diminishing
arterial circulation to the leg/s
↓
Unilateral localized symptoms such as redness, swelling,
warmth, and a hard inflamed vessel in the affected leg
This ↓ed circulation, along with edema, gives the leg a
white or drained appearance.
Usually appearing about 10 days after birth.
The woman’s leg begins to swell below the lesion at the
point at which venous circulation is blocked. Her skin may
become so stretched from swelling that it appears shiny
and white.
 Involves the ovarian, uterine, or hypogastric veins.
Inflammation of the blood vessels in the pelvic area
causes a partial obstruction, which leads to slowed
blood flow and clots in the stagnant blood in the
vessel.

fever
chills
abdominal pain or tenderness
flank or back pain
a “ropelike” mass in the abdomen
nausea
vomiting
The fever will persist even after taking antibiotics.
Her infection can be so severe it necrotize the vein
and results in a pelvic abscess
 Regardless of the type of thrombophlebitis, teach women
preventive measures to reduce the risk of recurrence with
future pregnancies such as wearing non-constricting clothing
on their lower extremities, resting with the feet elevated, and
ambulating daily.

Be certain the weight of a hot pack or pad does not rest on the
affected part, causing an obstruction to flow of blood.
(medications that dissolve clots) may also be
prescribed; these should be initiated within the first 24 hours
for best results
↓
→ catalyze the
production of plasmin, which in turn leads to the breakdown of
the fibrin mesh structure in blood clots
 Postpartum Psychiatric Disorder
Any woman who is extremely stressed or who gives birth to an
infant who in any way does not meet her expectations such as
being the wrong sex, being physically or cognitively
challenged, or being ill may become so depressed she has
difficulty bonding with her infant.
POSTPARTAL DEPRESSION
This probably occurs as a response to the anticlimactic
feeling after birth
Related to hormonal shifts as the levels of estrogen,
progesterone, and gonadotropin-releasing hormone in her
body ↓es.
Manifestation: Overwhelming sadness, can occur in both new
mothers and fathers.
May notice extreme fatigue, an inability to stop crying,
↑ed anxiety about their own or their infant’s health,
insecurity (unwillingness to be left alone or inability to make
decisions), psychosomatic symptoms (nausea and vomiting,
diarrhea), and either depressive or extreme mood
fluctuations.
The syndrome can interfere with breastfeeding, child care, and
returning to a career
 Risk factors:
History of depression
Troubled childhood
Low self-esteem
Stress in the home or at work
Lack of effective support
Different expectations between partners (e.g., if a
woman wants a child and her partner does not)
Disappointment in the child (e.g., a boy instead of a girl)
It is difficult to predict which women will develop
postpartal depression before birth because childbirth can
result in so many varied reactions.
A number of depression scales to help detect postpartum
depression are available:
Edinburgh Postnatal Depression Scale [EPDS])
 NURSING MANAGEMENT
Assess the woman’s psychological health even before the delivery.
Assess her history of illnesses to determine if she needs any counseling
prior to her delivery to avoid postpartum depression.
Assist the woman in planning for her daily activities, such as her
nutrition program, exercise, and sleep.
Recommend support groups to the woman so she can have a system
where she can share her feelings.
Advise the woman to take some time for herself every day so she can
have a break from her regular baby care.
Encourage the woman to keep in touch with her social circle as they
can also serve as her support system.
The patient engages more in social activities.
The patient can express her feelings and insecurities.
The patient can perform her activities of daily living.
 POSTPARTAL PSYCHOSIS
It affects around 1 in 500 mothers after giving birth.
When the illness coincides with the postpartal
period or occurs during the following year
A response to the crisis of childbearing

By definition, psychosis exists when a person has

lost contact with reality.
Because of this break with reality, the woman may
deny she has had a child and, when the child is
brought to her, insist she was never pregnant.
She may voice thoughts of infanticide or that her
infant is possessed.
She may interpret your contrasting opinion as
threatening and respond with anger or threats.
 Confusion and disorientation, about the day and time
and who people are
Concentration can be affected and your mind may feel
foggy or that it is overloaded with too many thoughts
Severe physical anxiety or agitation, such that you
cannot stay still
Variable mood, either on a high, irritable or depressed
Insomnia, feeling like you need less sleep and perhaps
going days without sleeping
Delusions or thoughts that are not true and that are
often paranoid – that the hospital staff are spies, that
your partner is an imposter in disguise.
These thoughts may seem bizarre or silly when you are
well, but in the middle of the illness they can seem real
Hallucinations or impaired sensations where you either
hear, see or smell things that are not present
Strange sensations that you are not really yourself and
there are others controlling your actions and thoughts
Thoughts of and/or plans to harm yourself and your
baby.
 NURSING MANAGEMENT
Always keep in mind when evaluating women during pregnancy
or the puerperium that postpartum psychosis, although rare, does
exist.
If observation tells you a woman is not functioning in reality, you
cannot improve her concept of reality by simple measures such as
explaining what her correct perception should be because her sensory
input is too disturbed to comprehend this.
Do not leave the woman alone because her distorted perception might
lead her to harm herself.
In addition, don’t leave her alone with her infant because she could
harm the infant as well.
Remembering childbearing can lead to this degree of mental illness
helps you to put childbearing into perspective.
Because it can cause such a crisis in a woman’s life, it cannot be
considered an everyday incident in anyone’s life.
A woman with postpartal psychosis usually appears exceptionally sad.
The woman needs referral to a professional psychiatric counselor and
probably antipsychotic medication.