High Risk Post-Partum Client 3. Empty bladder every 4 hours.

4. Fundal/Uterine massage to encourage

contraction
1. Postpartal Hemorrhage
5. Bimanual compression
- Any blood loss from the uterus greater than 500 mL within
- inserting one hand in the vagina while
a 24-hour period.
pushing against the fundus through the
abdominal wall with the other hand.
Four Main Causes:
6. Drug therapy:
1. Uterine Atony
a. IV Oxytocin (Pitocin)
2. Lacerations
b. IM Methergine (Methylergonovine
3. Retained placental fragments
Maleate)
4. Disseminated intravascular coagulation
c. Prostaglandin F
S/E: Nausea, Diarrhea,
Factors That Predispose to uterine bleeding:
Tachycardia, Hypertension
1. Conditions that distend the uterus beyond
7. Blood transfusion
average capacity
8. Surgical Procedure
a. Multiple gestation
a. Hysterectomy
b. Hydramnios (Excessive amount of amniotic fluid)
c. Large baby (over 9 lb)
a. Lacerations
d. Presence of uterine myomas (fibroid tumors)
i. Cervical lacerations
– usually found on the sides of
2. Conditions that could have caused cervical or uterine
the cervix near the branches of
lacerations
the uterine artery.
a. Operative delivery
Therapeutic Management:
b. Rapid delivery
1. Repair of cervical laceration.
3. Conditions with varied placental site & attachment
ii. Vaginal laceration
a. Placenta previa
Therapeutic management:
b. Placenta accrete
1. Vaginal repair
c. Premature separation of the placenta
2. Catheter insertion
d. Retained placental fragments
iii. Perineal lacearions
4. Conditions that leave the uterus unable to contract
– usually occur when the woman
readily
is placed in a lithotomy position,
a. Deep anesthesia or analgesia
increasing tension on the
b. Maternal age over 30 years
perineum.
c. Previous uterine surgery
Therapeutic Management:
d. Prolonged & difficult labor
1. Eipisiorrhaphy
e. Possible chorioamnionitis
2. Increase fluid intake.
f. Secondary maternal illness
3. Provide stool softener
g. Prior history of postpartum hemorrhage
h. Endometritis
b. Retained Placental Fragments
i. Prolonged use of magnesium sulfate or other
Clinical Manifestations:
tocolytic therapy
1. Presence of retained fragments (through
sonogram)
5. Conditions that lead to inadequate blood coagulation
2. (+) serum HCG
a. Fetal death
3. Signs of bleeding/shock
b. Disseminated intravascular coagulation
Therapeutic Management:
1. Removal of the placental fragments e.g.
D&C
a. Uterine Atony
2. Methotrexate administration.
- Relaxation of the uterus
c. Disseminated Intravascular Coagulation
Clinical Manifestation:
- a complex syndrome of activated
1. Abrupt gush of blood from the placental site.
coagulation that results in bleeding &
2. Increased, thready, & weak pulse
thrombosis.
3. Decreased blood pressure
4. Increased& shallow respirations
Predisposing Factors:
5. Pale clammy skin
1. Premature separation of placenta
6. Increasing anxiety
2. Hypertension of pregnancy
3. Amniotic fluid embolism
Therapeutic Management:
4. Placental retention
1. Obtain vital signs.
5. Septic abortion
2. Administer O2 inhalation.
6. Retention of dead fetus
1
 5. Foul smelling, dark brown lochia
Clinical Manifestations: 6. Increased WBC count
1. Purpura, petechia, & ecchymosis on
the skin, mucous membrane, heart Therapeutic Management:
lining 1. Monitor color, quantity, and
2. Prolonged bleeding from odor of lochia.
venipuncture. 2. Monitor size, consistency, & presence
3. Tachycardia & hypotension of tenderness in uterus.
4. Uncontrolled hemorrhage during 3. Increase fluid intake.
surgery or childbirth 4. Place the client in Fowler’s position.
5. Oliguria 5. Encourage ambulation.
6. TSB
Therapeutic Management: 7. Drug therapy:
1. Treat the underlying cause. a. Oxytoxic agent
2. Monitor signs of bleeding - to encourage uterine
3. Administer O2 inhalation. contraction.
4. Blood transfusion e.g. Whole blood, b. Antibiotic agent [Clindamycin
Fresh frozen plasma with fibrinogen. (Cleocin)]
5. Meds: c. Antipyretic agents
a. Vitamin K ( Aquamephyton)
b. Pitressin (Vasopresin) Complications:
c. Heparin 1. Tubal scarring
2. Infertility

d. Subinvolution
- Incomplete return of the uterus to its
prepregnant size & shape.
b. Infection in the Perineum (Wound
Cause: Infection)
1. Small retained placental fragment. - Infection in the suture line on
2. Endometritis the perineum from an
3. Myoma episiotomy. (localized infection)

Therapeutic Management: Clinical Manifestations:

1. Methylergonovine (Methergine) 1. Pain, heat, & feeling of pressure in the
2. Antibiotic therapy sutured area.
2. Elevated temperature.
2. Postpartal Puerperial Infection 3. Opened suture line with purulent
- Infection of the genital tract after delivery drainage.
or abortion.
Therapeutic Management:
Risk Factors: 1. Remove perineal sutures to open the
1. Rupture of the membrane over 24 hours area and allow for
before birth. drainage.
2. Placental fragments that have been retained 2. Sitz bath or warm compress to hasten
within the uterus. drainage & cleanse the
3. Postpartum hemorrhage area
4. Pre-existing anemia 3. Drug therapy:
5. Prolonged and difficult labor, particularly a. Antipyretic agent.
instrumental births. b. Analgesic
6. Internal fetal heart monitoring. c. Systemic or topical antibiotic
7. Local vaginal infection present at the time - Be alert to the
of delivery. problems in infant as a result of
8. The uterus was explored after birth. maternal
antibiotic therapy:
a. Endometritis 1. Assess the mouth of
- an infection in the endometrium, the infant for thrush.
lining of the uterus, usually associated 2. Assess infant for easy
with chorioamionitis and cesearan birth. bruising.

Clinical Manifestations: b. Mastitis

1. Temperature elevation over 38 C. - infection of the breast that occur as
2. Chills early as 7th day pospartal due to an
3. Loss of appetite entry of microorganisms from
4. General body malaise cracked and fissured nipples.
2
 - Revealed about 10th day after birth
Clinical Manifestation: 1. Elevated temperature
1. Localized pain, swelling, and redness. 2. Chills
2. Fever 3. Pain & redness on the affected legs.
4.Skin is stretched, shiny and white (Milk
Therapeutic Management: leg or Phlegmasia Alba Dolens)
1. Cold or ice compress & a good 5. (+) Homan’s sign
supportive bra, provides pain relief. 6. Enlarged diameter of the leg.
2. Warm compress to reduce
inflammation.
3. Breastfeeding is continued. Therapeutic Management:
4. Antibiotic therapy. 1. Bedrest with the affected leg elevated.
2. Moist heat application.
Preventive Measures: 3. Provide good back, buttocks, & heel
1. Position the baby correctly during care.
feeding & grasp the nipple properly. 4. Drug Therapy:
2. Release the baby’s grasp on the nipple a. Antibiotic - to reduce initial
before removing the baby from the infection.
breast. b. Analgesic for pain
3. Wash hands between handling perineal c. Anticoagulant therapy
pads & breasts. - Coumadin or Heparin
4. Expose nipples to air for at least part of d. Thrombolytic agent
every day. - Streptokinase or
5. Use vitamin E ointment to soften Urokinase
nipples everyday.
2. Pelvic Thrombophlebitis
- involves ovarian, uterine, or hypogastric
3. Thromboembolic Disorders veins.
a. Thrombophlebitis
- inflammation of the lining of a Risk Factors:
blood vessel with the formation *Same with Femoral thrombophlebitis
of blood clots.
- It occurs because of: Clinical Manifestations:
1. Increased fibrinogen level that 1. High fever
is 2. Chills
still elevated from pregnancy 3. Generalized body malaise
leading to increased blood 4. Pelvic abscess
clotting.
Therapeutic Management:
2. Dilation of lower extremity veins 1. CBR
due to pressure of the fetal head 2. Antibiotic therapy
during pregnancy & birth. 3. Anticoagulants

3. The relative inactivity of the Complications:

period or a prolonged time period of delivery or 1. Pelvic abscess
birthing room stirrups that leads to pooling, 2. Lung, kidney, heart valve abscess
stasis,
& clotting of blood in the lower extremities.

Thrombophlebitis 3. Pulmonary Embolus

- classified as: Superficial Vein Disease (SVD) or - Pulmonary emboli occluding the
Deep Vein Thrombosis (DVT) pulmonary artery as a
complication of
Risk Factors: thrombophlebitis.
1. Varicose veins - an emergency situation – risk for
2. Obesity cardiopulmonary arrest.
3. History of thrombophlebitis
4. Women over 30 y.o. with increased Signs:
parity 1. Sudden sharp chest pain
2. Tachypnea
1. Femoral Thrombophlebitis 3. Tachycardia
- involves femoral, saphenous, or popliteal 4. Orthopnea
veins. 5. Cyanosis

Clinical Manifestations: Management:

3
 1. Oxygen administration - due to the PIH that developed during
2. Clot is lysed. pregnancy, mild pre-existing hypertension
3. Transfer to the intensive care unit for may increase in severity during the first
continuing care few hours or days after birth.

-The reason for occurrence is usually

4. Urinary System Disorders retention of some placental fragments.

1. Urinary Retention Cardinal symptoms:

- Result of inadequate bladder emptying Proteinuria
due to decreased voiding sensation after birth as a Edema
result of edema of the bladder as a result of Hypertension
pressure of fetal head during birth.
- If allowed to continue – permanent Management:
damage to the bladder may occur from loss of - Bed rest
bladder tone that may lead to permanent - Quiet atmosphere
incontinence. - Monitor vital signs and urine output
- Administration of Magnesium sulfate, or
Signs: - Administration of Antihypertensive
1. Small, frequent urination agent
2. Palpable urinary bladder - May have D&C
3. Urine output of less than 100 ml in 8- hour - Monitor for seizure
period - typically occurs 6-24 hours
4. Residual urine output greater than 100 ml. after
birth.
Management: - Seizure after 72 hours after
1. Indwelling aseptic urinary catheterization birth
2. Stimulating urination - hear running water; is probably not related to
letting her hold her hand under warm running childbearing.
water. - Psychological comfort
3. Patient health education:
 Importance of catheterization
 Pain relief measures Reproductive System Disorders
 Importance of early ambulation to
prevent complications 1. Reproductive Tract Displacement
- occurs due to weakened support system
of
2. Urinary Tract Infection the uterus after delivery.
- usually occurs from catheterized woman - problems of retro flexion, ante flexion,
at the time of childbirth or in the retro version, and ante version or
postpartum period. prolapsed of the uterus may occur
= interfere future childbearing, infertility,
Clinical Manifestation: continued pain or a feeling of lower
1. Burning on urination abdominal pain or discomfort
2. Frequency, urgency, & hesitancy to - if walls of the vagina are weakened, a
urinate.  Cystocele
3. Sharp pain on urination - out pouching of the bladder
4. Low-grade fever into the vaginal wall, or
5. Hematuria  Rectocele
6. Increased WBC count. - out pouching of the rectum into
the vaginal wall

Therapeutic Management: Causes/ Factors:

1. Increase fluid intake. 1. Multiparity
2. TSB 2. After a forceps birth
3. Drug therapy:
a. Analgesic for pain. Management:
b. Antipyretic for fever 1. Surgical repair
c. Antibiotic therapy 2. Kegel’s exercise

Cardiovascular System Disorder

2. Separation of the Symphysis Pubis
Postpartum Pregnancy-induced - due to the overstretching of the
Hypertension ligaments of the symphysis pubis during
birth.
4
 - disappointments in the child

Signs & Symptoms:

1. Acute pain on walking & turning 3. POSTPARTAL PSYCHOSIS
2. External leg rotation - As many as 1 woman in 500 has enough
3. Waddling gait symptoms during the year after birth of a child to
4. Swollen and tenderness over the be considered psychiatrically ill.
symphysis pubis - probably a response to the crisis of childbearing.
- majority have had symptoms of mental illness
Management: before pregnancy
1. Bed rest
2. Application of pelvic binder for 4-6
weeks
period, during this time, avoid heavy PRECIPITATING FACTORS
lifting - Previous mental illness
materials until complete healing of the - a death in the family
pelvic ligament has occurred. - loss of job or income
3. Advise for cesarean birth for future - divorce
pregnancy. - other major life crisis
MANIFESTATIONS:
1. Appears exceptionally sad
2. Lost contact with reality
= distorted cognitive thought processes.
EMOTIONAL & PSYCHOLOGICAL = altered sensory and perceptual field
COMPLICATIONS OF THE
PUERPERIUM

RELATED FACTORS:
1. Extreme stress
2. Giving birth to an infant who in one way or
another does not meet her expectation = wrong
sex; physically or cognitively challenged; born
with an illness

1. POST PARTAL BLUES / BABY BLUES

- Feeling of sadness (1-10) days after the childbirth.
- As many as 20% of women, this normal feeling
continue beyond the immediate postpartum period,
and may be present for more than a year.
- In addition to an overall feelings of sadness, a
woman may notice:
 extreme fatigue
 increased anxiety about her own or
infant’s health
 an inability to stop crying
 insecurity
 psychosomatic symptoms
(nausea, vomiting, diarrhea)

RELATED FACTORS
- Response to the anticlimactic feeling after birth
- Related to hormonal shifts

2. POSTPARTAL DEPRESSION
- a more serious problem than the normal “baby
blues”.

RISK FACTORS
- history of depression
- troubled childhood
- low self-esteem
- stress in the home or at work
- lack of effective support people
- different expectations between partners
5
1
COMPARING POSTPARTAL BLUES, DEPRESSION, & PSYCHOSIS

POST PARTAL POST PARTAL POST PARTAL

BLUE DEPRESSION PSYCHOSIS
ONSET 1-10 days pp 1 -12 mos pp Within 1st yr after birth
Anxiety, feeling of loss, Delusion, hallucination of
SYMPTOMS Sadness, tears
sadness infant or self-harm
INCIDENCE 70% of all births 10 % of all births 1 – 2% of all births
Possible activation of previous
Hx of previous depression,
Hormonal and stress mental illness, hormonal
ETIOLOGY hormonal response, lack of
of life changes changes, family hx of bipolar
social support
disorder
Psychotherapy,
THERAPY Support, empathy Counseling, drug therapy
Drug therapy
Refer to psychiatric care,
Offer compassion and
NURSING ROLE Refer for counseling safeguarding the mother from
understanding
self/infant injury