Ø Lacerations of birth canal, or

POSTPARTUM COMPLICATIONS perineum can also lead to postpartum

POSTPARTUM HEMORRHAGE
• Any blood loss from the uterus that
exceeds 500mL during after delivery
• Is the main cause of maternal
mortality
• In vaginal delivery blood loss
• of 500 ml is acceptable
• In C/S blood loss of 1000- 1500 ml is
acceptable
• Danger of postpartum hemorrhage is
greatest during the first hour after
birth
Risk Factors:
A patient who has a birth complicated by any
of these factors should be observed for the
possibility of developing a postpartum
hemorrhage:
Ø Abruptio placentae
Ø Missed abortion
Ø Placenta previa
Ø Uterine infection
Ø Uterine inversion
Ø Severe preeclampsia
Ø Amniotic fluid embolism
Ø Intrauterine fetal death
Types of Postpartum Hemorrhage
1. Early Postpartum Hemorrhage
- is blood loss in excess of 500ml
that occurs during the first 24
hours postpartum
2. Late Postpartum Hemorrhage
- is uterine blood loss in excess of
500ml that occurs during the
remaining 6-week postpartum
period but after the first 24 hour
Causes
Ø uterine atony- primary cause
Ø laceration of the cervix (occurs
immediately after delivery of the
placenta)
hemorrhage.
Ø retained placental fragments
Ø DIC
Assessment Findings
Ø Oozing of blood
Ø More frequent saturated pads
Ø Uterine atony, the uterus is soft and
relaxed
Ø Laceration, bright-red blood with
clots oozing continuously from the
site and a uterus that remains firm
Signs and Symptoms of Postpartum
Hemorrhage
Ø restlessness, lightheadedness, and
dizziness as cerebral perfusion
decreases
Ø pale skin, decreased sensorium, and
rapid, shallow respirations.
Ø Urine output less 25ml/hr
Ø Cold clammy skin
Ø Capillary refill is delayed 3 to 5 sec
Diagnostic Test Findings
Ø Decreased hemoglobin and
hematocrit levels
Ø elevated serum hCG level
Ø platelet and fibrinogen levels are
decreased
Ø clotting times are prolonged.
Medical Management
Ø oxytocin or methylergonovine may be
given IV or IM; . Prostaglandins
Ø cold therapy, ligation of the bleeding
vessel, or evacuation of the hematoma
Ø D&C
Ø HYSTERECTOMY
Ø Blood transfusion, IV replacement
Nursing Intervention
Ø Assess the fundus and lochia
Ø Stay with the patient

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 Ø Weigh perineal pads
Ø Turn patient to her side and inspect
the buttocks for pooling of blood.
Ø Monitor vital signs and I&O

SUBINVOLUTION
- Delayed return of the enlarged
uterus to normal size and
function.

Etiology
Subinvolution results from:
• Retained placental fragments and
membranes.
• Endometritis or uterine fibroid tumor
• Treatment depends on the cause.

Pathophysiology
• Uterine atony or placental fragments
prevent the uterus from contracting
effectively.

Assessment Findings
Clinical manifestations include:
1. Prolonged lochial discharge
2. Irregular or excessive bleeding
3. Larger than normal uterus
4. Boggy uterus (occasionally)

Nursing Management
1. Prevent excessive blood loss,
infection, and other complications.
a. Massage uterus, facilitate
voiding, and report blood loss.
b. Monitor blood pressure and pulse
rate.
c. Administer prescribed
medications.
d. Be prepared for possible D&C
2. Assist the client and family to deal
with physical and emotional stresses
of postpartum complications.

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PUEPERAL INFECTION
- Puerperal infection affects the
uterus and structures above it with
a characteristic fever pattern
Several types of puerperal infection
including:
• Endometritis – an infection of the
uterine lining
• Myometritis – an infection of the
uterine muscle
• Parametritis – an infection of the
areas around the uterus
Pathophysiology
• group A, B, or G hemolytic
streptococcus, gardnerella vaginalis,
Chlamydia trachomatis, and
coagulase-negative staphylococci
• Less common causative agents are:
clostridium perfringens, bacteroides
fragilis, klebsiella, proteus mirabilis,
pseudomonas, staphylococcus
aureus, and Escherichia coli
Predisposing Factors
Ø Prolonged or premature rupture of
membranes
Ø Prolonged or difficult labor
Ø Frequent or unsterile vaginal
examinations or unsterile delivery
Ø Delivery requiring the use of
instruments, which can traumatize the
tissue, providing an entry portal for
microorganisms
Ø Internal monitoring
Ø Retained products of conception
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Ø Hemorrhage
Ø Maternal conditions, such as anemia,
DM, immunosuppression, or
debilitation from malnutrition
Ø Cesarean birth
Assessment Findings
Ø fever at least 100.4˚F (38˚C)
Ø chills, headache, malaise,
restlessness, and anxiety
Ø pain in the lower abdomen or pelvis
caused by a swollen uterus
Ø foul-smelling vaginal discharge
Ø loss of appetite increased heart rate
Ø Localized perineal infection
o pain, elevated temperature,
edema, redness, firmness, and
tenderness at the wound site;
o sensation of heat; burning on
urination; discharge from the
wound;
o or separation of the wound
Ø Endometritis
o heavy, sometimes foul- smelling
lochia;
o tender, enlarged uterus; backache;
o severe uterine contractions
persisting after childbirth;
o fever greater than 100.4˚F; chills;
o and increased pulse rate
Ø Parametritis
o vaginal tenderness and abdominal
pain and tenderness
Diagnostic Findings
Ø A culture and sensitivity
Ø A sudden increase of 30% above the
baseline WBC
Medical Management
Ø broad-spectrum antibiotic
Ø contagious disease is usually placed
in a private room and should be
isolated, even from her neonate
Ø bed rest, adequate fluid intake, IV
fluids
Nursing Management
1. Monitor vital signs every 4 hours
2. Place her in a high Fowler’s to semi-
Fowler’s position
3. Assess capillary refill and skin turgor
as well as mucous membranes
4. Assess intake and output
5. Enforce strict bed rest
6. Provide a high-calorie, high protein
diet
7. Provide fluid (3,000 to 4,000ml)
8. Encourage the patient to void Assessment Findings:
frequently 1. Femoral DVT
9. Inspect the perineum often o malaise; chills; and pain, stiffness,
10. Encourage the patient to change or swelling in a leg or in the groin
perineal pads frequently, o calf pain
11. Administer antibiotics and o a positive RIELANDER’S SIGN /
analgesics, antiemetics PAYR’S SIGN
12. Provide sitz baths or warm or cool
compress
13. Change bed linens, perineal pads, and
underpads frequently

THROMBOPHLEBITIS OR DEEP
VEIN THROMBOS
- is an inflammation of the lining of
a blood vessel that occurs in
conjunction with clot formation
2. Pelvic DVT
o high fever, severe repeated
chills, and general malaise
o lower abdominal or flank pain

Risk Factors Diagnostic Test Findings

• History of varicose veins • DOPPLER ULTRASOUND
• Obesity • PLETYSMOGRAPHY
• Previous DVT Multiple gestations • VENOGRAPHY
• Increased age
• Family history of DVT Smoking Medical Management
• Cesarean birth • bed rest, with elevation of the
• Multiparity affected arm or leg;
• application of warm, moist
Ø DVT can affect small veins, such as compresses;
the lesser saphenous, or large veins, • administration of analgesics,
such as the iliac, femoral, pelvic, and antibiotics, and anticoagulants.
popliteal veins and the vena cava. • after the acute episode subsides, the
patient may begin to ambulate while
wearing antiembolism stockings
(applied before she gets out of bed)

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Nursing Management
Institute measures to prevent DVT:
Ø Assess the woman for risk factor that
could predispose her to DVT
Ø Teach her about measures to reduce
her risk
Ø Avoid standing in one place for too
long or sitting with knees bent or legs
crossed
Ø Avoid using garters or wearing
constrictive clothing
Ø Wiggle toes and perform leg lifts
while in bed
Ø Ambulate as soon as possible after
delivery
Ø Wear antiembolism or support
stockings as ordered.
Ø Bed rest
Ø Apply warm compresses
Ø Give an analgesic as ordered
Ø Assess uterine involution and note
any changes in fundal consistency
Ø Administer anticoagulant, antibiotic
and antipyretic therapy
Ø Mark, measure, and record the
circumference of the affected
extremity at least daily
Ø Watch for signs and symptoms of
bleeding, such as tarry stools, coffee-
ground vomitus, and ecchymoses.
MASTITIS
- Inflammation of the breast tissue
that is usually caused by infection
or by stasis of milk in the ducts.
Etiology
• Injury to breast - overdistention,
stasis (missed feedings, a bra that is
too tight or impaired infant sucking)
• Staphylococcus aureus derived from
the infant’s nose and throat
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Risk Factors
Ø Previous bout of mastitis while
breast-feeding
Ø Sore or cracked nipples — although
mastitis can develop without broken
skin
Ø Wearing a tightfitting bra or putting
pressure on your breast when using a
seat belt or carrying a heavy bag,
which may restrict milk flow
Ø Improper nursing technique
Ø Becoming overly tired or stressed
Ø Poor nutrition
Ø Smoking
Signs and Symptoms
• Breast tenderness or warmth to the
touch
• Breast swelling
• Thickening of breast tissue, or a
breast lump
• Pain or a burning sensation
continuously or while breast- feeding
• Skin redness, often in a wedge-
shaped pattern
• Generally feeling ill
• Fever of 101 F (38.3 C) or greater
POSTPARTUM MOOD
DISORDERS
3 PHASES
1. Initial/acute period – first 6-12hrs
postpartum
 2. Subacute postpartum period – which Comparison of Postpartum Blues,
lasts 2-6 weeks Depression, Psychosis
3. Delayed postpartum period – which
can last up to 6 months

Physiological Changes
1. Taking-In Phase
- 1 to 2 days after delivery.
- within this period, the woman is
passive.
- dependent on with some of the
daily tasks and decision-making.
- talk about her experiences during
labor and birth
- regain her physical strength and
organize her rambling thoughts
2. Taking-Hold Phase
- starts 2 to 4 days after delivery.
- starts to initiate actions on her
own and making decisions
- begins to actively participate in
newborn care.
- woman still needs positive
Assessment Findings
reinforcements
- Allow the woman to settle in
gradually into her new role
3. Letting-Go Phase
- 10 days to 6 weeks
- the woman finally accepts her
new role
- the phase where postpartum
depression may set in.
- Readjustment of relationship

Postpartum Mood Disorders

1. Postpartum blues Nursing Management
2. Postpartum depression without 1. Identify postpartum mood disorders.
psychotic features o Be aware of signs and
3. Postpartum depression with psychotic symptoms of postpartum
features (postpartum psychosis) mood disorders.
o Teach the client and family
about these disorders
2. Support and treat the client and
family.
o Develop specific therapeutic
goals.

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 o Maintain the prescribed
medication schedule.
o Keep communication open
with the health care providers;
coordinate social services.
o Include family participation
and involvement in plans of
care.
o Make appropriate referrals.
REPRODUCTIVE FUNCTION
DISORDERS
UTERINE DISORDERS
Fibroids
• abnormal growths that develop in or
on a woman’s uterus.
• known as:
* leiomyomas
* myomas
* uterine myomas
* fibromas
Leiomyomas:
• group of benign smooth muscle
tumors commonly present in
premenopausal women
• monoclonal origin which arises from
the smooth muscle of the uterus
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Etiology for Fibroids
• early menarche
• use of oral contraception before the
age of 16 and an increase in body
mass index.
• use of progestin-only contraceptives
multiparity
Pathology
• studies indicate that ovarian steroids,
estradiol, and progesterone, promote
the growth of leiomyomas; and that
the size of fibroids often decline after
menopause
Signs and Symptoms
• heavy bleeding between or during
periods that includes blood clots
• pain in the pelvis or lower back
• increased menstrual cramping
• increased urination
• pain during intercourse
• menstruation that lasts longer than
usual
• pressure or fullness in lower abdomen
• swelling or enlargement of the
abdomen
Diagnostic Exam for Fibroids Risk Factors
• Ultrasound • Imbalance between estrogen and
• Pelvic MRI progesterone
• obesity
Management • nulliparity
o Gonadotropin-Releasing Hormone • other reproductive cancer
(GnRH) agonists: leuprolide • tamoxifen use for breast cancer
(Lupron), will cause estrogen and • family history of diabetes mellitus,
progesterone levels to drop, will hypertension
eventually stop menstruation and
shrink fibroids.

Surgical Management
• Surgery: Myomectomy
• Laparoscopy
Note:
Fibroids might grow back after surgery.

Signs /Symptoms:
UTERINE CANCER
Endometrial cancer : cancer that arises from
the endometrium (the lining of the uterus or
womb).
• result of the abnormal growth of cells
that have the ability to invade or
spread to other parts of the body.
• Bleeding or discharge not related to
periods (menstruation) — over 90
percent of women diagnosed with
endometrial cancer have abnormal
vaginal bleeding.
• Postmenopausal bleeding.
• Difficult or painful urination.
• Pain during intercourse.
• Pain and/or mass in the pelvic area.

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Diagnostic Examination OVARIAN DISORDERS
• examining the pelvis. Incidence
• Using sound waves to create a picture • Inactive ovaries and ovarian cysts .
of uterus. • Incomplete uterine involution,
• Using a scope to examine your endometritis
endometrium: • Major finding of the present study
• Hysteroscopy: inserts a thin, flexible, increased prevalence of polycystic
lighted tube (hysteroscope) through ovaries in patients with borderline
vagina and cervix into uterus. personality disorder
• Removing a sample of tissue for
testing.

Management
• Radiation therapy:
• Radiation from a machine outside the
body.
• Radiation placed inside the body:
Internal radiation (brachytherapy)
• Chemotherapy drugs by pill or IV
• Hormone therapy option in advanced
endometrial cancer that has spread
OVARIAN CANCER
Risk Factors
beyond the uterus.
• Nulliparity
• Targeted drug therapy
• History of infertility
• Supportive (palliative) care
• Family history of ovarian or breast
cancer ( mutations in BRCA1 or
BRCA2 genes have been observed in
families)
• Family history of hereditary
nonpolyposis colorectal cancer (
HNPCC )
• Estrogen Replacement Therapy Age
older than 50 years

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 CERVICAL DISORDERS
Cervical Polyps: growths on the cervical
canal, the passage that connects the uterus to
the vagina.
Causes:
• Cervical infections
• Chronic inflammation
• An abnormal response to hormone
estrogen
Signs/Symptoms • Clogged blood vessels near the cervix
• GI disturbances: abdominal
distention with ascites increasing
abdominal girth
• Urinary frequency and urgency
• Pain and pressure caused by growing
tumors or effects of urinary and bowel
obstruction

Cervical Poylps Signs/Symptoms

• Reddish, purplish, or grayish in color
• Shaped like a finger, bulb, or thin
stem
• hypermenorrhea or intermenstrual,
postmenopausal and postcoital
bleeding

Diagnostic Exam Diagnosis:

• History and physical exam • Pap’s Smear
• Ultrasound • Surgery:
• CT scan surgical removal by ligation or use of polyp
• MRI forceps to gently twist the growth off the
cervix.
• Blood tests
• Barium enema and chest x-ray to
detect metastasis

Management
• Surgery with complete surgical
staging (including dissection of the
pelvic and para- aortic lymph nodes,
omentectomy, peritoneal and
diaphragm biopsies).
• Chemotherapy

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CERVICAL CANCER • Laser- direct beam (heat) to remove
Risk Factors diseased tissue
• presence of HPV strains for 16-18, • Hysterectomy
intraepithelial neoplasia (CIN):
• progress to CA and invasive cervical
cancer
• multiple sexual partners
• early sexual intercourse less than
20yr,
• history of STD
• smoking tobacco immunosuppression

Signs and Symptoms

• abnormal vaginal bleeding after VAGINAL DISORDERS
intercourse Vaginal Fistula
• Metrorrhagia • an abnormal opening that connects
• Postmenopausal bleeding the vagina to another organ.
• polymenorrhea Imperforate Hymen:
• pressure on bowel and bladder § when the hymen covers the whole
• rectal discharge opening of the vagina.
• anemia,
• heavy aching abdominal pain

Etiology/Risk Factors
• older women 50 years old
Management • vaginal lesions- squamous cell
• Irradiation precancerous changes
• Chemotherapy • VAIN (vaginal intraepithelial
• Cold colonization- cone shaped neoplasia)
biopsy • ingestion DES
• Loop electrocautery excision-lesions • STD or infection with herpes virus or
removed by low voltage diathermy HPV
loop (electrical current causing • smoking
burning) • vaginal irritation
• Cryosurgery – freezing of diseased • cervical cancer
cervical tissue

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 Conditions of the Female
Reproductive System:
• Female Urogenital Displacement and
Prolapse - occurs when the pelvic
organs relax and descend into the
vagina.

Risk factors:
• Childbearing, decrease levels of
VAGINAL CANCER estrogen during menopause cause
Signs and Symptoms supporting structures lose their
• foul vaginal discharge elasticity and strength.
• painless vaginal bleeding • Multiparity, childbirth trauma,
• vaginal mass or lesion chronic straining, previous pelvic
• frequency and pain upon urination surgeries, or radiation, abdominal
masses, effects of gravity and age.

FEMALE UROGENITAL
DISPLACEMENT AND PROLAPSE
S/S
• Cystocele: descent of bladder into
vagina
• Rectocele: protrusion of rectum into
the vagina
• Vaginal or uterine prolapse descent of
uterus in the vagina.
Diagnostic Exam: • S/S: complete-cervix
• Cytologic examination protrudes into vagina
• Colposcopy and vagina becomes
Management: inverted
• External or intravaginal radiation Management: surgical repair, hysterectomy
therapy
• Chemotherapy Nursing Diagnosis
• Surgical: radical hysterectomy Hysterectomy
• Lymphadenectomy Potential Nursing Diagnosis
• Vaginectomy for Hysterectomy
• Pelvic exenteration in more advanced 1. Situational low, self-esteem
if bladder or rectum is involved. 2. Impaired urinary elimination
3. Impaired urinary retention (acute)
4. Risk for constipation or diarrhea
5. Risk for ineffective tissue perfusion
6. Risk for sexual dysfunction
7. Dysfunctional grieving
8. Knowledge deficient regarding
condition, prognosis, treatment, self-
care, and discharge needs.

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BREAST DISORDERS • Referral and biopsy indicated for
Normal Female Breast definitive diagnosis, especially for
first mass.

Fibroadenoma (Benign Breast Lump)

Physical Assessment/Inspection:
• Occurs as a asingle mass in women
aged 15-35 years
• Non tender round or lobular, firm,
mobile, not fixed to breast tissue or
Breast Assessment/Inspection chest wall
Assessment: • No premenstrual changes
1. History • Referral and biopsy indicated for
2. Inspection: definitive diagnosis
Retraction Signs:
• appear only with position changes or
with breast palpation
• skin dimpling,
• creasing, or changes in the contour of
the breast or nipple secondary to
fibrosis or scar tissue formation in the
breast

Breast Cyst (Benign Mass)

Physical Assessment/Inspection:
• Occur as single or multiple lumps in
one or both breasts
• Usually tender (omitting caffeine
reduces tenderness);
• tenderness increases during
premenstrual period
• Round shape, soft or firm, mobile

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 Breast Cancer Mass (Malignant)
Physical Assessment/Inspection:
• occurs as a single mass (lump) in one
breast, firm, hard, embedded in
surrounding tissue
• Referral and biopsy indicated for
definitive diagnosis
• Usually non tender
• Irregular shape
• Unilateral localized increase in
venous pattern associated with
malignant tumors
• Peau d’Orange (edema) associated
with breast cancer
• Caused by interference with
BREAST CANCER lymphatic drainage
Risk Factors • Breast skin has orange peel
• Female gender appeearance
• Increasing age
• Personal history of breast cancer
• Family history of breast cancer
• Genetic mutations (BRCA-1 and
BRCA-2 mutations are responsible
for majority of inherited breast cancer
cases)
• Late menopause
• Nulliparity
• Hormonal factors
• Early menarche
• First child after 30 years of age
• Hormone therapy (HT)
• Exposure to ionizing radiation during
adolescence and early adulthood
• History of benign proliferative breast
disease
• Obesity
• High-fat diet (controversial)
• Alcohol intake Pagets Disease
Physical Assessment/Inspection:
Paget Disease (Malignancy of Mammary
Ducts)
1. Early signs: erythema of nipple and
areola
2. Late signs: thickening, scaling, and
erosion of the nipple and areola

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Diagnostic Evaluation
Ø Breast Self-Examination (BSE)
• Done on day 5-7 of menstrual
cycle (some changes in breast
occur due to hormones around
menstruation)
• Breast examination with
woman in a supine position
• The entire surface of the
breast is palpated from the
outer edge of the breast to the
nipple.
• Alternative palpation patterns
are circular or clockwise,
wedge, and vertical strip.
Ø Mammography
• Detect nonpalpable lesions
and assist in diagnosing
palpable masses
• Recommended to be done
every year beginning at 40
years of age (women with
family history, start at
younger age)
• Mammography may detect a
breast tumor before it is
clinically palpable (i.e..
smaller than 1cm)
Ø Magnetic Resonance Imaging (MRI)
Ø Procedure for Tissue Analysis
• Percutaneous biopsy
• Fine-needle aspiration
• Surgical biopsy
• Excisional biopsy
• Incisional biopsy

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