NCM 109: Care of Mother & Child at Risk w/ Problems

Lesson 5: Post-partal Complications

POSTPARTUM HEMORRHAGE PREDISPOSING FACTORS:

A. Conditions that distend the uterus beyond average

UTERINE ATONY
capacity
→ Lack of tone, is the most frequent cause of » Multiple Gestation
postpartum hemorrhage. » Hydramnios
→ The uterus must remain in a contracted state after » Large baby
birth to allow the open vessels at the placental » Presence of uterine myomas
site to seal. B. Conditions that could have caused cervical or
→ The first step in controlling postpartum uterine tears
hemorrhage in the event of uterine atony is to » Operative delivery
attempt uterine massage to encourage » Rapid delivery
contraction. C. Conditions with varied placental site or attachment
→ If the uterus cannot remain contracted, the » Placenta previa
physician invariably orders an intramuscular » Placenta accreta
injection of Methergine or a dilute intravenous » Abruprio placenta
infusion of oxytocin to help the uterus maintain D. Conditions that leave the uterus too exhausted to
tone. contract readily
» Deep anesthesia or analgesia
» Labor initiated or assisted with an oxytocin
agent
» Maternal age over 30 years
» High parity
» Prolonged and difficult labor
» Secondary maternal illness such as anemia
» Endometritis
» Prolonged use of magnesium sulfate or
oxytocin
→ If uterine massage and administration of E. Conditions that lead to inadequate blood
methergine and oxytocin are not effective, the coagulation
physician may attempt bimanual compression » Fetal death
(one hand inserted into the vagina and the other » Disseminated intravascular coagulation
pushing against the fundus through the
ASSESSMENT FINDINGS:
abdominal wall).
→ It may be necessary to explore the uterine cavity ʘ Sudden uterine relaxation
for retained placental fragments. ʘ Vaginal bleeding (abrupt or seeping)
→ Uterine packing may be placed to help halt ʘ Symptoms of shock and blood loss
bleeding.
→ If all other therapeutic measures fail in achieving
uterine atony, ligation of the uterine arteries or
hysterectomy, although rare, may be performed.

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NCM 109: Care of Mother & Child at Risk w/ Problems
Lesson 5: Post-partal Complications
NURSING IMPLICATIONS: involved to approximate edges. Large lacerations
are complications that occur most often:
□ Palpate the fundus at frequent intervals to
• With difficult or precipitate deliveries
ascertain that the uterus is remaining is a state of
• In primigravidas
contraction.
• With the birth of a large infant (over 9lbs)
□ Assess vital signs and lochia per protocol and
• With the use of a lithotomy position and
observe for signs of blood loss and shock.
instruments.
□ Perform gentle but firm uterine massage while
supporting the base of the uterus to encourage
uterine involution.

□ Perform a perineal pad count in given lengths of
time to assess better blood loss.
□ Weigh perineal pads before and after use to
measure vaginal discharge more accurately.
□ Be prepared to administer an intramuscular
injection of methergine or a dilute intravenous
infusion of oxytocin to help the uterus maintain
tone.
CERVICAL LACERATIONS
→ are usually found on the sides of the cervix near
the branches of the uterine artery. Because it is
arterial bleeding, the blood seen will be brighter
red than the venous blood lost with uterine atony.
Blood may gush from the vaginal opening. If the
cervical laceration appears to be extensive or
difficult to repair, it may be necessary for the
woman to be given a regional anesthetic for
relaxation of the uterine muscle and to prevent
pain.

□ Assess the client’s blood pressure before

administering oxytocin or methergin because
these medications can cause hypertension and
therefore should not be administered if the
client’s blood pressure is over 140/90 mmHg.
VAGINAL LACERATIONS
□ Obtain appropriate laboratory specimens such as
crossmatching if it is determined that the client’s → although rare, lacerations can also occur in the
blood loss requires her to receive blood vagina. These are easier to assess because they
replacement. are easier to view. Vagina may be packed to
maintain pressure on the suture line. An
LACERATIONS indwelling urinary catheter may be placed at the
→ is a ragged cut. It may involve the skin layer or same time, because the packing causes pressure
may penetrate to deeper subcutaneous tissue or on the urethra and can interfere with voiding.
tendons. Bleeding should be halted by pressure
on the edge of the laceration. After cleaning, the
area is sutured through each layer of tissue

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NCM 109: Care of Mother & Child at Risk w/ Problems
Lesson 5: Post-partal Complications
RETAINED PLACENTAL FRAGMENTS

→ Retained placental fragments occurs when the

placenta does not deliver in its entirety but
separates and leaves fragments behind.
→ This results in uterine bleeding because the
portion retained keeps the uterus from
contracting fully.
→ It occurs with placental anomaly, most likely with
a succenturiate placenta.
→ A placenta accreta that remains after birth, may
need to be surgically removed or treated with
methotrexate.
PERINEAL LACERATIONS

→ usually occur when the woman is delivered from a

lithotomy position, because this position increases
tension on the perineum. Perineal lacerations are
sutured and treated as an episiotomy repair.

ASSESSMENT FINDINGS:

ʘ Excessive post-partal bleeding

ʘ Uterus not fully contracted
ʘ Elevated serum HCG
ʘ Placental fragments visible on
ultrasonography

CLASSIFICATION OF PERINEAL LACERATIONS

1. First degree – involves the vaginal mucous

membrane and the skin of the perineum.
2. Second degree – involves not only the vaginal
mucous membrane, perineal skin but also the
muscles.
3. Third degree – involves not only the vaginal
mucous membrane, perineal skin and muscles,
but also the external sphincter of the rectum.
4. Fourth degree – involving the mucous membrane
of the rectum.

NURSING IMPLICATIONS:

□ Thoroughly examine the placenta after birth to

make sure it is intact.
□ Keep in mind that if the undetected retained
fragment is large, the bleeding is apparent in the
immediate postpartum period; if the fragment is

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NCM 109: Care of Mother & Child at Risk w/ Problems
Lesson 5: Post-partal Complications
small, bleeding may not be detected until the 6th
or 10th postpartum day.
□ Perform fundal checks after births and assess for
height, consistency, and uterine bleeding.
□ Assist with dilation and curettage to remove the
retained placental fragments.
□ Instruct the client to observe her lochia discharge
at home and report any tendency for the
discharge to change from lochia alba to rubra, or Dilation of cervix and curettage to remove fragments
a sudden discharge of a large amount of blood. of the placenta from the uterine wall.

SUBINVOLUTION PERINEAL HEMATOMA

→ is incomplete return of the uterus to its
prepregnant size and shape. With subinvolution,
at a 4 or 6 weeks postpartal visit, the uterus is still
enlarged and soft.
→ Subinvolution may result from a small retained
placental fragment, a mild endometritis, or an
accompanying problem, such as a myoma that is
interfering with complete contraction.
→ Perineal hematoma is a collection of blood in the
subcutaneous layer of tissue of the perineum.
→ As a rule, the overlying skin is intact with no
noticeable trauma.
→ Such collections may be caused by injury to blood
vessels in the perineum during birth; they are
most likely to occur following rapid spontaneous
deliveries and in women who have perineal
varicosities,
→ It may occur at an episiotomy or laceration repair
site if a vein was pricked during repair.
→ They can cause the woman acute discomfort and
concern, but, fortunately, they usually represent
only minor bleeding.

ASSESSMENT FINDINGS:

ʘ Severe pain in perineal area

ʘ Complaints of pressure between the legs
ʘ Purplish discoloration
ʘ Obvious swelling (2cm to 8 cm in diameter)
NURSING IMPLICATIONS:
ʘ Tender, fluctuant area on palpation
□ Oral administration of methylergonovine
generally is prescribed to improve uterine tone
and complete involution.
□ If the uterus is tender on palpation, suggesting
endometritis, an oral antibiotic also may be
prescribed.
□ A chronic loss of blood from subinvolution will
result in anemia and lack of energy.

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NCM 109: Care of Mother & Child at Risk w/ Problems
Lesson 5: Post-partal Complications
NURSING IMPLICATIONS: NURSING IMPLICATIONS:

□ Inspect the perineal area closely for presence of
hematoma.
□ Assess its size and degree of discomfort and notify
the physician
□ Administer a mild analgesic as prescribed for pain
relief.
□ Apply an ice pack to help prevent further
bleeding.
□ Be aware that if the hematoma is large when
discovered, the client may have to be returned to
the delivery to have the site incised and the
bleeding vessel ligated.
□ Advise the client that the hematoma should be
absorbed over the next 6 weeks.
□ If the episiotomy line is open to drain the
hematoma, anticipate the line being left open and
packed with gauze; prepare for packing removal in
24 to 48 hours.
□ Administer antibiotic as prescribed.
□ Provide sitz baths or warm compress as
prescribed to hasten drainage and cleanse the
area.
□ Instruct the client to change perineal pads
frequently because they may be contaminated by
discharge; if left in place for a long time, they
might cause vaginal contamination.
□ Teach the client to wash her hands after handling
perineal pads to prevent transmission of infection.
□ Instruct the client to wipe from front to back after
a bowel movement to prevent bringing feces
forward onto the healing area.

PUERPERAL INFECTIONS

INFECTION OF THE PERINEUM

→ Infections of the perineum generally remain

localized or manifest the symptoms of any suture
line infection.
→ A laceration repair or an episiotomy is a ready
portal of entry for bacterial invasion.

ENDOMETRITIS

→ An infection of the endometrium, is a postpartum

complication, usually occurring 48 to 72 hours
after delivery.
→ Bacteria gain access to the uterus through the
vagina and enter the uterus either at the time of
Infected Perineal Stitches
birth or during the postpartum period.
ASSESSMENT FINDINGS: → If the infection is limited to the endometrium, the
course is about 7 to 10 days.
ʘ Pain, heat, and feeling of pressure around → Endometritis can lead to tubal scarring and
suture line interfere with future fertility.
ʘ Normal or elevated temperature
ʘ Inflamed suture line
ʘ Open suture line or sloughing away of one or
two sutures
ʘ Appearance of pus

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NCM 109: Care of Mother & Child at Risk w/ Problems
Lesson 5: Post-partal Complications
ASSESSMENT FINDINGS: → Women most prone to thrombophlebitis are
those with varicose veins, those who are obese,
ʘ Elevated temperature (38ºC) for 2
those who had a previous thrombophlebitis,
consecutive 24-hour periods
women over 30 years old with increased parity
ʘ Large, tender, poorly contracted uterus
who were in a stirrups position for a longtime
ʘ Severe postpartum cramping
during birth, and those who have high incidence
ʘ Brownish, red, foul-smelling lochia
of thrombophlebitis in their family.
→ With femoral thrombophlebitis, it often occurs on
the 10th postpartum day.
→ With pelvic thrombophlebitis, it often occurs on
the 14th or 15th day of the puerperium.
→ With pelvic thrombophlebitis, an abscess may
form (necessitating incision by laparotomy), which
NURSING IMPLICATIONS: may cause tubal scarring and interfere with future
pregnancies.
□ Inspect the perineum at least twice daily for
redness, edema, ecchymosis, and discharge.
□ Assess fundal size, consistency, and tenderness
for changes indicating poor involution.
□ Evaluate for abdominal pain, fever, and malaise.
□ Assess lochia for color, quantity, and odor; report
any foul-smelling lochia.
□ Obtain culture and sensitivity of lochia.
□ Administer appropriate antibiotic as prescribed.
□ Provide additional fluid to combat fever.
□ Administer an analgesic as ordered to relieve
severe cramping and discomfort.
ASSESSMENT FINDINGS:
□ Urge the client to use Fowler’s position and
ambulation to encourage lochia drainage by Femoral Thrombophlebitis
gravity and prevent pooling of infected secretions.
ʘ Elevated temperature and chills
THROMBOPHLEBITIS ʘ Stiffness, pain and redness in the affected leg
ʘ Leg edema with shiny skin (milk leg)
→ Thrombophlebitis is inflammation of the lining of ʘ (+) Homans’ sign
a blood vessel with the formation of clots.
→ When thrombophlebitis occurs in the post-partal Pelvic Thrombophlebitis
period, it is usually an extension of an endometrial ʘ Feeling of sudden, extreme illness
infection. ʘ High fever
→ Thrombophlebitis is prone to occur in the post- ʘ Chills
partal period when blood-clotting ability is high ʘ General malaise
because of increased fibrinogen; dilation of lower ʘ Pelvic abscess
extremity veins owing to pressure of fetal head
during pregnancy and birth; and the relative NURSING IMPLICATIONS:
inactivity of the period that leads to pooling,
□ Provide prevention of endometritis and
stasis, and clotting of blood in the lower
thrombophlebitis by using good aseptic
extremities.
technique.
□ Encourage early ambulation to increase
circulation in the lower extremities and decrease
the possibility of clot formation.
□ Be certain that client does not remain in a
lithotomy and stirrups position for more than an

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NCM 109: Care of Mother & Child at Risk w/ Problems
Lesson 5: Post-partal Complications
hour, and be certain to pad the stirrups to prevent
any sharp pressure against the calf of the legs in
this position.
□ Provide support stockings to the postpartum
client who has varicose veins to increase venous
circulation and help prevent stasis.
□ Encourage bed rest with the affected leg elevated
for the client with femoral thrombophlebitis.
□ Obtain daily blood coagulation levels before
administering any anticoagulants.
□ Administer anticoagulants, analgesics, and
antibiotics as prescribed.
□ Apply heat applications such as heat lamp or
moist, warm compress as prescribed.
□ Obtain a record of lochia and weigh perineal pads
to assess bleeding if the client is on anticoagulant
therapy.
□ Assess for other possible bleeding signs, such as
bleeding gums, ecchymotic spots on the skin, or
oozing from an episiotomy suture line.
□ Reassure the client receiving heparin that she may
continue to breast-feed as this medication will not
be present in breast milk.
□ Be prepared to administer protamine sulfate as an
antagonist for heparin.
□ Prepare the client with pelvic thrombophlebitis
for surgery.

EMOTIONAL AND PSYCHOLOGICAL

COMPLICATIONS OF THE PUERPERIUM
Comparing Postpartum Blues, Depression
and Psychosis

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