OB (Finals) instructional program on Anatomical Changes and Clinical

Manifestations in the Postpartum Woman before reading

POST PARTUM CARE this program.

Introduction INVOLUTIONAL CHANGES

The postpartum period, also known as puerperium, refers to This section deals with the care of the newly-delivered
the first six to eight weeks after delivery during which time woman as her body goes through the various involutional
the reproductive return to their prepregnant state, a process changes, using the following goals of physical postpartum
called involution. care as guidelines:

This self-instructional program is all about the different 1. Promotion of healing and return to normal of the
aspects of care regarding involutional changes that newly- perineum and pelvic structures
delivered women experience and the possible complications 2. Prevention of infection of the Bladder the breasts,
that may hamper normal recovery. the uterus and other body parts
3. Establishment of successful lactation the mother so
Objectives
desires
Upon completion of this program, the user should be able to: 4. Provision of emotion support

1. Distinguish the following terms: Changes during involution may relate to the circulatory
a. Postpartum or puerperium and renal systems, gastrointestinal adaptation, nutritional
b. Involution demands, genital and breast modifications, alterations in
c. Lochia vital signs, emotional concerns, and physical tolerance.
d. Afterpains
A. CIRCULATORY EFFECTS
e. Engorgement
f. Postpartum blues Several important circulatory changes should be taken into
g. Hemorrhage account:
h. Uterine atony
i. Lacerations 1. The first 5-10 minutes after placental delivery is critical
j. Hypofibrinoginemia because it is during this time that the 30%-50% increase
k. Mastitis in total cardiac volume during pregnancy is reabsorbed
l. Endometritis into the general circulation. This implies a sudden
m. Thrombophlebitis increase in cardiac workload and would, therefore,
necessitate close monitoring of the mother's vital signs,
2. Enumerate the goals of physical postpartum care. Consequently, a rapid reduction in total cardiac volume
takes place so that by the end of the third week
3. Give relevant data/specific situations: postpartum, the blood volume has already returned to its
a. Identify the different physiological prepregnant level. If the mother had a low serum
characteristics which take place during hemoglobin count during pregnancy, it can be expected
puerperium to continue until puerperium, in which case,
b. Distinguish the psychological phases of supplemental iron is usually prescribed or continued to
puerperium. be taken.
c. State the appropriate nursing interventions for
the different aspects of involution. 2. The usual high level of circulating fibrinogen during the
d. Give the leading causes of maternal morbidity pregnancy continues to be so during the first postpartum
and mortality. week. This is a protective measure against hemorrhage;
e. Identify the clinical manifestations of however this same condition encourages
postpartum complications. thromboembolization an inflammation of the lining of
f. Specify the management for the different post- the blood vessels with formation of clots To avoid
partum complications. thromboembolism, it is necessary to consider the
following:
Recommended Preparation
a. Ambulation. The postpartum woman should be
This program is intended primarily for nursing
advised to ambulate early (after 4-6 hours in
students who already have background knowledge in caring
normal vaginal delivery or after 24 hours in
for the pregnant woman and the woman in labor and
Caesarean. section). The woman can expect to feel
delivery. It may also be used by graduate nurses and other
dizzy and wobbly the first time that she is out of
health workers who may find the subject matter relevant in
bed. This can be remedied if she dangles her feet
thier work. The reader is advised to read the self-
 for a short time in bed before actually getting up,
then walk a few steps and sit for a brief period. The
nurse who assists the patient to for the first time
should hold on to the patient's arm so that she can
give immediate support should the patient suddenly
feel faint.
b. Exercises. Exercise should be encouraged. Post-
partum exercises help strengthen the abdominal
muscles, promote involution and a general sense of
well-being. With the doctor's advice, these
exercises should be continued until the end of
puerperium in order to derive maximum benefit
from them.
Certain postpartum exercises, however, may not be
advisable if the mother underwent caesarean section or any
extensive perineal repair. It is, there- fore wise to consult a
physician first before exercises are done. Exercises
prescribed during this period should not be strenuous. They
should be practiced slowly and rhythmically only a few
times at first and gradually increased from day to day.
Following are recommended exercises.
i. Abdominal breathing. This exercise may be started
on the first postpartum day 1ying flat on her back;
the woman should breathe slowly and deeply in and
out for 5 times using her abdominal muscle. This
helps the abdominal muscles regain the tone easily.
ii. Chin-to chest. On the second day postpartum, flat
on her back without pillows, the woman raises her
head and bends her chin forward on her chest
without moving any other part of her body.
Initially, she will repeat this for 5 times and then
increase the frequency to 10-15 times in
succession. Done 3 to 4 times a day, this will also
help the abdominal and respiratory muscles regain
their tone.
iii. Kegal. An isometric exercise which consists of
contracting and relaxing the perineal muscles 5
times in succession, as if trying to stop voiding.
This is done 3-4 times a day to improve circulation
in the perineum, thus decrease edema and minimize
perineal discomfort.
iv. Arm-raising. To help both the breast and abdomen
return to good tone, arm-raising exercise is added
on the fourth postpartum day. They woman lies flat
on her back with arms at her sides until they are
perpendicular to her body. She then raises them
over her body until her hands touch and then
lowers them slowly to her sides. This is repeated 5
times with brief rest periods in between.
v. Knee-to-abdomen. The woman should wait until
the perineum has healed before doing this exercise.
Flat on her back, she bends one leg at a time at the
knee and brings it up to touch her abdomen. She
then lowers her foot to touch her buttocks
straightens her leg and lowers it This helps
strengthen the abdominal and gluteal muscles.
c. Massage. Massage is never done immediately after
delivery because blood clots may be dislodged and
settle in the heart, the lungs, or the brain.
3. While the high level of circulating fibrinogen is at
protective measure against hemorrhage, there is also a
defense mechanism against infection as well as an aid in
prompt healing. This is brought about by an increase in
the white blood cells count up to 30,000 per mm3
(normal count is 5.000- 10,000). In view of this finding,
the WBC count, therefore, cannot be considered as an
indication of postpartum infection because with or
without infection, the WBC count of all newly-
delivered women is normally high.
4. All blood values of newly-delivered women are back to
their prepregnant levels by the third or fourth post-
partum week
B. RENAL CHANGES
Nursing care is centered on the following renal changes
during puerperium:
1. The increase in urine volume of about 3000 ml/day
(normal is 1.500 ml/day), known as diuresis, is
characteristically observed from the second to the fifth
day postpartum and is due to the rapid return of the
blood volume to the pre- pregnant level. This marked
increase in urine production causes the bladder to fill
rapidly. Some newly-delivered women may experience
voiding frequently in small amounts, which indicates
retention of urine with overflow because of impaired
muscle tone. Some newly-delivered women, on the
other hand, may have no urge to void despite the rapid
filling up of the bladder. This is true especially in
vaginal deliveries because the fetal head exerts a great
deal of pressure on the bladder, thus resulting in
transient loss of tone due to injury to the trigone of the
bladder. Nursing management would depend on the
particular situation:
a. The nurse should offer the woman a bedpan at
intervals of 2-3 hours. She should measure the
amount of urine at each voiding during the first day
or until it has been established that she is emptying
her bladder completely. It is considered satisfactory
if the mother excretes 100 cc. of urine per voiding.
Perineal care, of course, should be done after each
voiding in order to prevent infection.
b. If the mother is unable to void and the bladder is
distended, the usual measures for initiating voiding.
ie, alternately pouring warm and cold water over
the perineum, helping the woman use the toilet
seat, making her hear the sound of running water,
should be carried out. If efforts to encourage the
mother to void fail, catherization, on doctor's order,
 is done as a last resort. The basic principles of
asepsis should be observed in the process.
Specifically for women who delivered vaginally,
the nurse should proceed with extreme gentleness
because the genitalia feels sore and tender. Case
should also be observed in separating the labia to
expose the vestibule in order to prevent pulling on
the sutures, if there are any. A good light is
necessary because the urinary meatus may be
difficult to locate due to the ederna and distortion
of the tissues.
2. During the postpartum period, urine tends to contain
more lactose, nitrogen, and albumin, probably because
of the woman's increased muscle activity during labor
and the corresponding protein breakdown.
C. GASTROINTESTINAL ADAPTATION
There is delayed bowel evacuation during the immediate
post-partum period because of the following reasons:
1. Decreased muscle tone of the abdomen and
intestines
2. Lack of food during labor and delivery
3. Enema administration during the first stage of labor
4. Dehydrating effects of labor and delivery
5. Fear of pain due to perineal tenderness
The management for delayed bowel evacuation consists of
encouraging the woman to ambulate early and do post-
partum exercises and to increase fluids and roughage in her
diet.
D. NUTRITIONAL DEMANDS
Proper nutrition is a very important aspect of care
during the postpartum period. Diet on the first day consists
chiefly of liquids, not only because the mother is more tired
than hungry but also because the body has to replace the
fluids lost during labor and delivery. By the second post-
partum day, she may have a full diet. Some newly-delivered
women prefer to have a full diet immediately after delivery;
there is no contra- indication to this, provided she is not
nauseated
Ideally, a postpartum diet should contain 2500 to
2600 calories per day and should be high in proteins,
vitamins and minerals needed for good tissue repair. Table I
lists the quantities of food that will supply the calories and
nutrients recommended for the postpartum mother. The
nurse should be conscious of the available local sources.
The woman who is breastfeeding would need an
additional 500 calories and additional 500 ml. of fluid in her
diet to encourage production of breast milk. It should be a
diet high in proteins, calcium, iron and Vitamins A, B and
C.
Table 1. Recommended Diet for Postpartum Women
FOOD GROUP FOOD QUANTITY
3-4 servings of meat, fowl or
Meat
fish daily; 1 egg daily
Vegetables: dark green or
1 serving daily
deep yellow
Other vegetables 2-3 servings daily
Fruits: citrus, melon or
2 or more servings daily
tomatoes
Other fruits 1 serving daily
Bread and cereals 4 servings daily
1 quart daily (4-8 oz of
Milk or its substitutes
water)
Additional fluid At least 2 glasses daily
Newly-delivered mothers, specially those who
breastfeed usually have good appetites and become hungry
between meals. For this reason, a nourishing snack three
times a day is advisable.
If all the nutritional requirements are provided for,
the woman's convalescence will be more rapid her strength
will be regained more quickly, the quantity and quality of
milk of women will be better, and she will be more able to
resist infection.
E. GENITAL INVOLUTION
The most dramatic changes during the postpartum period are
observed in the genital organs.
1. Uterus. Aside from the reduction in the size of the
uterus, there are other aspects to be noted
a. Uterine involution is measured be fingerbreadths.
On the first day postpartum the fundus is one
finger-breadth (1 cm) below the umbilicus, on the
second day, 2 fingerbreadths (2 cm) below the
umbilicus, on the third, three fingerbreadths (3 cm)
below the umbilicus and so on and so forth until on
the tenth postpartum day it can no longer be
palpated because it is already behind the symphysis
pubis. A sub-involuted uterus implied the presence
of blood clots, which are good culture media for
bacteria. This is a sign of puerperal sepsis.
 To encourage uterine involution, the
woman is advised to lie prone or assume
knee-chest position (if episiorrhaphy has
already healed) in order to tip the uterus to
its natural anteflexed position.
b. Immediately after delivery, the uterus casts off
fragments of the decidua basalis, white blood cells,
mucus and blood and becomes fully cleansed by
this sloughing process. This uterine flow is called
lochia. Lochia has the following characteristics
1) The pattern of lochial discharges should
not reverse, ie, during the first three days
post partum the discharge consists mostly
of blood. with small particles of decidua
and mucus and because of its red color, is
 called lochia rubra. On the fourth to the
ninth day postpartum, the flow diminishes
and becomes pinkish or brownish in color
and is now termed lochia serosa. On the
tenth day up to the third or sixth week
postpartum, it is called lochia alba
because of its whitish color and minimal
amount.
2) It should approximate menstrual flow in
amount. Lochia increases with activity,
specially during the first time that the
woman ambulates. and decreases with
breastfeeding because of good uterine
contractions. This results from the
influence of oxytocin which is the infant
sucks the breast.
3) It should not contain large clots. Large
clots imply an infectious process.
4) It should not have any offensive odor.
Lochia has the same fleshy odor of
menstrual blood. An offensive odor also
signifies infection.
5) It should never be absent, regardless of the
method of delivery. Even women who
delivered by Caesarean section have
lochia, in the same pattern and amount.
c. The area where the placenta used to be implanted is
sealed off, which is accomplished by rapid
contraction of the uterus following placental
delivery. These uterine contractions cause
cramplike pains which are called afterpains.
Afterpains occur more frequently in multiparas and
in those who delivered large babies and twins
because of the overdistention of the uterus. It is
also common among breastfeeding women because
of the release of oxytocin when the infant sucks. It
is necessary for the nurse to explain that afterpains
are normal and rarely last for more than 3 days.
Heat should never be applied on the abdomen of a
woman who complains of afterpains because
vasodilatation will cause the uterus to relax and
result in undue bleeding. An analgesic may be
given if the doctor so prescribes.
d. If the postpartum woman is not breastfeeding.
menstrual flow may return within 8 weeks after
delivery. If she is breastfeeding, menstrual flow
may return in 3-4 months time or, in some women,
may take the entire lactation period before
menstruation. resumes. The absence of
menstruation, though is not a guarantee that she is
not capable of getting pregnant because although
she is not menstruating she may be ovulating the
absence of menstruation may be her body's own
way of conserving fluid for lactation. Breastfeeding
women, therefore, should be protected against a
subsequent pregnancy by contraceptive methods
other than the pill.
e. Immediately after delivery, the cervix is soft and
malleable and both internal and external os are
open. After 7 days, the external os becomes narrow
and the cervix feels firm again. The internal os will
close as before but the external os will usually
remain slightly open after vaginal delivery.
2. Perineum. Just like the cervix, the vagina is soft and its
diameter is considerably greater than usual immediately
after delivery. The outlet remains slightly distended
than before. This is true in vaginal deliveries. It takes
the entire postpartum period for it to involute by
contraction. The labia majora and labia minora remain
atrophic and softened in a woman who has delivered a
child.
Nursing care regarding genital involution consists of the
following:
a. Perineal care. The perineum seems to be the major
focus of care during the early postpartum period and
this is because of the following reasons:
1) Lochia which is allowed to dry and harden on the
vulva not only furnishes a bed for bacterial growth
and cause infection, but also results in discomfort
and emits a foul odor.
2) In mothers who delivered vaginally the perineum
is the area which was subjected to a great deal of
pressure. This resulted in edema and generalized
tenderness and some portions may even show
ecchymosis because of rupture of surface
capillaries.
3) Perineal stitches at the episiotomy site cause much
discomfort since perineal muscles are involved in
many activities such as sitting, walk- ing, standing,
squatting, bending, voiding, and defecating
Perineal care should be done after each voiding or
bowel movement and as part of the daily bath, or as often as
the mother wishes for her own comfort. In cleansing the
perineal area, warm water is poured gently over the
perineum while cleansing the labia with a clean gauze
square or very soft wash cloth (cotton balls are not used
because they might stick to the public hair and leave
particles behind to invite lochia buildup) always washing
from front to back (from the pubis to rectum). In doing
perineal care during the postpartum period, the labia should
not be extremely separated as this can cause the solution to
enter the vagina and could be a source of contamination.
After having dried the perineal area, the anal region is
washed separately by turning the mother onto her side. If the
patient does the perineal care herself, she should be told to
wash her hands before cleansing the perineum.
b. Care of the episorrhaphy. The newly delivered woman
needs to be informed that the perineal discomfort
caused by pressure during vaginal delivery is normal. It
lasts only for about 5-7 days because the perineal area
heals rapidly due to its abundant blood supply. This
perineal discomfort, when aggravated by the presence
of sutures from the episiorrhaphy causes tugging sharp
pain which may interfere with rest and sleep, eating,
and even in caring for the new- born. Several nursing
measures may be utilized to relieve pain and discomfort
due to perineal edema, hemorrhoids and/or
episiorrhaphy and hasten or promote rapid healing:
1) An ice bag applied to the perineum for the first 24
hours after delivery does a great deal to reduce
edema by means of vasoconstriction and thus
decrease tension on the suture line.
2) Exposing the perineum to a heat lamp after the
first postpartum day helps reduce edema by
vasodilatation, promoting healing and providing
comfort. With the woman supine on bed (in dorsal
recumbent position) with knees flexed and
properly covered with a blanket, the perineal lamp,
or perilamp, is placed between her legs, about 12-
16 inches away from the perineum, and left in
place for 20 minutes. This is done 3-4 times a day
until healing has taken place.
3) Some patients get relief from perineal discomfort
by using foam rubber rings to sit on.
4) Lying on Sim's position is said to minimize
perineal discomfort because it reduces tension on
the suture line.
5) The woman should be taught to contract the
muscles of the perineal floor before sitting down
or standing up. This way, tissues are prevented
from being pulled apart as the woman sits or
stands.
c. Sexual activity. In order to prevent infection and
trauma to areas that have just healed, sexual activity
should be resumed only when lochia has stopped and
healing of the perineal area has occurred, which is about
4-6 weeks after delivery.
d. Postnatal clinic follow up. The woman should see a
physician or go to a health center or clinic for an
examination 6 weeks after delivery to assure herself that
she is in good health and has no problems from
childbearing. During the postpartal check-up. the
following are examined
1) The abdominal wall for tone.
2) The breasts to see if they returned to their
prepregnant state if she is not breastfeeding. or if
they are unfissured and free of complications if she
is breastfeeding.
3) The genitals, by internal examination, to deter-
mine if involution is complete, if the ligaments and
pelvic muscle supports have returned to good
functional alignment, and if lacerations/
episiorrhaphy have healed.
4) The anal region to see whether hemorrhoids are
present and thus discuss management if needed
5) The general condition to find out if varicosities are
present.
6) The emotional state to determine whether she has
problems regarding childbearing, in particular, and
her family, in general which come in the way of
proper child care.
The newly-delivered woman, however, should be instructed
that she need not wait for six weeks after delivery to see a
doctor if she notices any of the following:
a) An increase in lochial discharge or a reversal in its
pattern. Delayed postpartum hemorrhage is a
possibility, especially if the woman becomes
extremely fatigue.
b) A sudden and sustained increase in temperature
after the first postpartum day may be a sign of
infection.
c) Pain in the calf when the foot is dorsiflexed, a sign
of thrombophlebitis.
F. BREAST MODIFICATIONS
For the first 2 days postpartum, the average woman
notices little change in her breasts from the way they were
during pregnancy. But on the third postpartum day, the
breasts tend to become full, feel tense and hot, with a
throbbing pain. Breast tissues appear reddened, simulating
an acute inflammatory or infectious process. This feeling of
tension in the breasts on the third postpartum day is called
engorgement. Sometimes, body temperature may increase
and this is referred to as milk fever. Nursing interventions
for breast engorgement consist of:
1. Advising use of firm-fitting brassiere or breast
binder for good support of the breasts. The
brassiere or breast binder will not only reduce
discomfort from breast engorgement but also
prevent contamination of the nipples and the
areolae.
2. Cold compress application on the breasts if the
mother does not intend to breastfeed, or warm
compress application if the woman desires to
breastfeed Cold causes vasoconstriction and will,
therefore, inhibit breast milk production; while heat
causes vasodilatation and will, therefore, encourage
breast milk production.
3. Breast massage or the use of the breast pump if the
woman will breastfeed.
G. ALTERATIONS IN VITAL SIGNS
Except for the respiratory rate of newly-delivered women
which undergoes no change at all, the following are to be
expected:
 1. There is a slight increase in body temperature
during the first 24 hours postpartum. This is due to
the loss of fluids during labor and delivery and is
also brought about by diaphoresis as the body rid
itself of the excess fluids which accumulated
during pregnancy. Thus, an increase in body
temperature on the first day postpartum should not
be considered as a sign of infection because it is a
normal physiologic change during this time. The
temperature may again rise during the third or
fourth postpartum day because of the increased
vascular activity involved in breast milk formation.
2. Postpartum women are observed to have a slight
decrease in pulse rate of about 60-70 per minute
during the first 5-7 days postpartum. It is postulated
that this decrease in pulse rate is actually a
compensatory mechanism to reduce the pressure in
the circulatory system.
3. There is, on the other hand, a slight increase in
blood pressure because of the increased amount of
blood being reabsorbed into the general circulation.
By the end of the first week postpartum, however,
the blood pressure would have stabilized.
H. PHYSICAL TOLERANCE
A newly-delivered woman needs abundant rest and
should be encouraged to relax and sleep whenever possible.
At least one rest period a day and a good night's sleep are
required. Heavy work should be avoided for at least the first
month after delivery. There are varying concepts of what
"heavy work" is so the nurse must make sure to give specific
examples (like fetching water, washing or ironing clothes).
I. EMOTIONAL CONCERNS
Psychologically, puerperium may be divided into two
separate phases:
1. Taking-in phase. The first 2 or 3 days following
delivery is a time of reflection for the woman. She
is so passive that she relies on the nurse to do
things for her, even make decisions for her rather
than doing things for herself. The mother focuses
upon her own needs rather than the baby's and her
verbalizations center on her reactions to the recent
delivery in an effort to integrate the experience into
herself
2. Taking-hold phase. The next days following the
first phase find the woman beginning to do things
for herself and make decisions on her own. This is
about the time when she begins to develop strong
interest in caring for her baby. Some women
become overly concerned with their bodily
functions, such as bladder and bowel control, since
these are necessary for independence. Health
teachings regarding self-care, newborn care and
family planning can be discussed with the mother
at this time. However, this may also be the time
when the newly- delivered woman may experience
an overwhelming feeling of sadness that cannot be
accounted for. This is called postpartum blues.
These are believed to be the result of hormonal
changes, of a response to dependency or
exhaustion, being away from home or sheer anxiety
over the newly-acquired role. The nurse should
provide privacy at this time and reassure the mother
that this is quite normal and should not be a cause
for alarm. Postpartum blues, however, should not
be confused with postpartum psychosis, the latter
being more or less an indication of an emotionally
unstable, neurotic personality.
3. Letting go. A woman finally redefines her new
role; she gives up the fantasized image of her child
and accepts the real one; she gives up her old role
of being childless or the mother of only 1 or 2. A
woman who has reached this phase is well into her
new role.
POSTPARTUM COMPLICATIONS
The changes brought about by involution are
considered to be normal physiological processes; however,
they border closely between health and illness because the
changes are so marked and rapid that a departure from a
condition of well- ness is highly probable.
This section focuses on two of the three leading
causes of maternal morbidity and mortality, namely,
hemorrhage and infection, and their corresponding
management.
A. HEMORRHAGE
Hemorrhage, defined as uterine blood loss over 500 ml, can
occur at any time during pregnancy but is a major danger
during the immediate postpartum period because of the
grossly denuded and unprotected area left after placental
delivery In modern day obstetrics, hemorrhage is classified
into:
1. Early postpartum hemorrhage if it occurs during the
first 24 hours postpartum. The causes of early
postpartum hemorrhage are
a. Uterine atony. Immediately after placental
delivery, the fundus should be firm in the midline
and a little above the umbilicus. The uterus must
remain in a contracted state after delivery so that
the open vessels at the placental site can be sealed.
Uterine atony, the most frequent cause of early
postpartum hemorrhage, is therefore defined as the
inability of the uterus to maintain a contracted
state. Several factors account for poor uterine tone:
multiple pregnancy, polyhydramnios (amniotic
fluid more than 1500 ml), excessively large baby
(over 9 lbs), operative delivery (CS), placental
accidents (previa and abruptio), prolonged and
 difficult labor, and high parity The nurse should be
especially cautious when caring for patients in
whom any of these conditions were present because
of the danger of uterine atony.
At any time at all that the fundus is boggy, relaxed or non-
contracted, the following nursing interven- tions should be
done:
1) Massage. The initial nursing action to control
hemorrhage due to uterine atony is to massage the
fundus to encourage uterine contraction. The nurse
should put one hand on the patient's symphysis
pubis to give good support to the base of the uterus,
then grasp the fundus with the other hand and
massage gently. The patient's fundus should be
monitored continuously for the next 4 hours,
massaging it as needed.
2) Ice compress. Since cold causes vasoconstriction,
an ice cap over the fundus can help con- tract the
uterus.
3) Oxytocin administration. On order of the doctor,
oxytocin should be administered to help the uterus
maintain its tone.
4) Emptying of the bladder. A full bladder prevents
further contraction of the uterus so the nurse should
offer the bedpan at least every 4 hours to keep the
bladder empty. Catheterization may be resorted to
if other measures fail.
5) Bimanual compression. If uterine bleeding does
not stop despite the above measures, the doctor
may attempt to insert one hand into the vagina,
while the other hand pushes against the fundus
through the abdominal wall. This procedure called
bimanual compression is done by the doctor in the
delivery room in order to explore the patient's
uterine cavity for retained placental fragments that
may be preventing good contraction.
6) Hysterectomy. The surgical removal of the uterus is
carried out only as a last resort.
In any case, the nurse should make sure that vital signs are
taken and recorded frequently and the amount of blood loss
is roughly estimated by noting the number of perineal pads
saturated by the patient in given lengths of time (it is said
that a pad saturated in less than 30 minutes may indicate
bleeding), preparations for possible blood transfusion are
anticipated, and comfort measures and emotional support are
provided.
b. Lacerations. Any time the fundus is well
contracted and there are no retained placental
fragments yet bright red bleeding gushes out of the
vaginal opening, lacerations should be suspected.
Lacerations are accidental tears of the perineum
which occur when episiotomy had not been done or
as extensions of an episiotomy had not been done
or as extensions of an episiotomy In view of the
ragged edges of lacerations, they take longer to
heal and therefore predispose the woman to
infection. Perineal lacerations are classified
according to the extent and depth of the tissues
involved.
1) First-degree involved the vaginal mucous
membrane and the skin of the perineum to the
fourchette.
2) Second degree involve the vaginal mucous
membrane, perineal skin, fascia, levator and
muscle, and perinial body.
3) Third-degree involve the vaginal mucous
membrane, perineal skin, levator and muscle
and the external sphincter of the rectum, either
partially or completely
4) Fourth-degree involve the entire perineum,
rectal splincter and some of the mucous
membrane of the rectum.
Lacerations are sutured by the doctor and treated as
an episiotomy repair. If vaginal episiorrhaphy has
been done and a vaginal pack was inserted to
provide pressure against the bleeding vessels, it
should be removed after 24-48 hours to prevent
lochial build up and bacterial invasion, thus avoid
infection. Any woman who has had a third or
fourth-degree laceration should not be given
enemas and her temperature should not be taken
rectally to prevent opening up of the sutures.
Sutures could also break because of constipation
and hard stools so the woman should have a diet
high in fluid and stool softeners may be given for
the first week postpartum.
c. Hypofibrinoginemia. A deficiency in the level of
fibrinogen in the blood, which interferes with the
clotting mechanism, hypofibrinoginemia should be
suspected when the usual measures to induce
uterine contractions fail to stop the bleeding. This
condition is associated with abruptio placenta and
missed abortions. The main treatment consists of
increasing the women's blood supply of fibrinogen.
2. Late postpartum hemorrhage if it occurs after the
first 24 hours postpartum. The causes of late postpartum
hemorrhage are:
a. Retained placental fragments. Placentas should
be inspected carefully in the delivery room to see if
they are complete because if any portion is retained
this will prevent the uterus from contracting fully,
thus causing bleeding. This condition is most likely
to occur with a succenturiate placenta, a place with
an accessory lobe, but it can also happen in any
other instance.
Dilatation and curettage (D & C) is done by the doctor
in the delivery room to remove the placental fragments.
Since bleeding from retained fragments is often delayed
until and after the woman has been discharged, she
 must be instructed to observe the color of the lochia and
report any change from serosa or alba to rubra.
b. Hematomas. Hematomas occur as the result of
injury to the perineal blood vessels during delivery
and are more prone to occur in the following
instances: rapid spontaneous deliveries, those with
perineal varicosities, or injury to a vein during
episiorrhaphy. A hematoma is seen as a swollen
area (1 inch to 4 inches in diameter) of purplish
discoloration. Although it results only in minor
bleeding. it can cause acute discomfort and concern
for which the following interventions may be done:
1) Ice compresses to prevent further bleeding.
Absorption of the hematoma will occur over
the next 3-4 days
2) Oral analgesics to relieve pain.
3) The site may be incised and the bleeding vessel
ligated if the hematoma is very large and
continues to grow in size.
B. INFECTION
Because the uterus is a closed vesicle, the most
frequently responsible organisms for postpartum infection
are the anaerobic streptococci, although anaerobic
staphylococci are also becoming more common. The
primary sources of postpartum infection are the endogenous
bacteria in the normal flora which become virulent when
tissues are traumatized. Thus, postpartum hemorrhage
(which weakens the woman's general condition), pre-
existing anemia (which lowers the body's defence against
infection), and prolonged and difficult labor, particularly
instrument deliveries (trauma to the tissues may cause
lacerations which serve as portals of infection) are pre-
disposing factors to postpartum infection.
The secondary exogenous sources are the
pathogens introduced via excessive obstetric manipulations
or a break in aseptic techniques. This is the reason why
hospital personnel in the delivery room are obliged to wear
gowns, masks and gloves. to use only sterile instruments,
and to observe aseptic techniques in carrying out procedures
Other predisposing factors are: prolonged rupture of the
membranes: coitus in late pregnancy: and retained placental
fragments.
The extent and severity of postpartum infection,
though. depends on the virulence of the invading organism
and the ability of the host to resist the invasion.
1. Infection of the Perineum. This condition usually
refers to infection of the suture line and is often
localized, so the woman may or may not have elevated
body temperature. Specifically, the symptoms of suture
line infection are:
a. Pain, heat and a feeling of pressure in the perineum
b. Inflammation of the suture line with pus
c. One or two stitches may be sloughed away, or area
may be open.
Management of infection of the perineum consists of:
a. Antibiotic and/or analgesic administration
b. Sitz baths or warm compresses to haste drainage
and cleanse the area
c. Removal of the perineal sutures to open the area for
drainage
d. Frequent change of perineal pads to avoid further
infection.
2. Mastitis. Infection of the breasts may occur as early as
the seventh postpartum day or even at the end of
lactation and usually through cracked or some nipples
or occasionally, from the nasaloral cavity of the
breastfeeding infant. It may be unilateral or bilateral (in
epidemic mastitis, because it originates from the infant
who acquired the infection while in the nursery). The
affected breast shows localized pain, swelling, and
redness and feels doughy and tough. Fever is present
and breast milk becomes scanty because of stagnation
of milk in the acinar ducts. Treatment of mastitis
consists of ice compresses and good bra support for
relief of pain and the administration of antibiotics.
Breastfeeding will have to be discontinued if the
infection is bilateral.
3. Endometritis. Endometritis is an infection of the lining
of the uterus and is usually manifested on the third or
fourth day postpartum. Depending on the severity of the
infection, the woman may have fever, chills, loss of
appetite and general malaise. Some abdominal
tenderness may be experienced and the uterus is
generally not well contracted and is painful to touch.
Lochia will usually be dark brown and have a foul odor.
Treatment consists of antibiotic and analgesic
administration, giving oxytocins to encourage uterine
contraction and putting the woman on Fowler's position
to drain out the dark brown, foul-smelling lochia.
4. Thrombophlebitis. Thrombophlebitis is infection of
the lining of a blood vessel with formation of blood
clots and is usually an extension of endometritis. These
are two types of thrombophlebitis:
a. Pelvic thrombophlebitis in which the ovarian,
uterine, and hypogastric veins are involved. The
woman is suddenly ill, with high fever, chills, and
general malaise. Because major veins are involved,
the infection can become systemic and result in
pulmonary abscess, pelvic cellulitis or generalized
peritonitis, the latter being one of the gravest
complications of childbearing. To prevent such
complications, the woman will have to be
readmitted for total bed rest and treated with
antibiotics and anticoagulants.
 b. Femoral thrombophlebitis in which the femoral,
saphenous or popliteal veins are involved. About
the tenth day postpartum, the woman manifests the
following symptoms:
1) Elevated temperature, chills, and general
malaise
2) Stiffness, pain and redness in the affected part
3) Swelling of the leg below the affected part
because of the blockage of venous circulation
by the blood clot, causing the skin to be
stretched to a point of shiny whiteness ("milk
leg" or phlegmasia alba dolens)
4) Pain in the calf when the foot of the affected
leg is dorsiflexed (positive Homan's sign).

Treatment consists of:

1) Bed rest with the affected leg elevated to improve

circulation. Bed cradles may be used to keep the
pressure of the bed sheets off the affected leg, thus
minimize pain.
2) Antibiotics and analgesics to arrest the infection
and reduce pain. Aspirin, however, is never given
to patients with thrombophlebitis because it tends
to increase coagulation time.
3) Avoiding rubbing or massaging the affected leg as
this can cause the clot to move and become a
pulmonary embolus, a possibly fatal complication.
4) Administration of anticoagulants, e.g., Dicumarol
or Heparin, to prevent extension of a thrombus or
further formation of clots. Several important
considerations have to be kept in mind when caring
for patients receiving anti- coagulants:
a) They can cause hematuria and increase lochial
discharge.
b) Daily prothrombin level or clotting time
determination will have to be done before drug
administration.
c) Breastfeeding will have to be discontinued
since the drug can be transmitted through
breast milk. If the woman desires to reinstate
breastfeeding after the course of anticoagulant
therapy (about 10 days her breast milk should
be expressed manually at the time of usual
feedings to maintain continuous milk supply.
d) Protamine sulfate or Vitamin K should always
be at the bedside of the patient to counteract
the toxic effects of Dicamarol or Heparin.

These postpartum complications are no doubt

frightening so that many women become anxious of
childbearing The nurse, however, should not fail to stress
the fact that majority of these complications are preventable
and it takes only a little more awareness, vigilance, and
correct practice to avoid them.