Complication of

Postpartum Period
Postpartum Hemorrhage, Uterine Atony,
Lacerations, Hematomas, Retained Placental
Fragments, Subinvolution of the Uterus,
Sheehan’s Syndrome. Puerperial Infection,
Postpartum Thromboembolic Disorder,
Postpartum Thyroiditis, Postpartum
Psychiatric Disorders.
 Postpartum Hemorrhage
• Refers to the excessive blood loss during or after the
third stage of labor.
• The accepted normal blood loss is 500 ml at vaginal
delivery and 1000ml at CS. In excess of this amount is
considered hemorrhage.
• In addition, the actual amount of blood lost during
delivery would be difficult to assess.
• A newer and more objective criterion for diagnosis of
postpartum hemorrhage is; a 10% decrease of
hematocrit level between admission and the postpartum
period or the need for transfusion after delivery
secondary to blood loss.
• Postpartum hemorrhage is the leading cause of
maternal mortality. The most dangerous time at which
hemorrhage is likely to occur is during the first hour
postpartum.
 Types of Postpartum Hemorrhage
1. Early postpartum
hemorrhage: Occurs
during the first 24 hours
after delivery. The common
causes are:
• Uterine atony
• Laceration of the birth canal
• Inversion of the uterus
2. Late postpartum
hemorrhage: Occurs from
24 hours after birth to 4
weeks postpartum. The
common causes are:
• Retained placental
fragments
• Subinvolution of the uterus
• Infection
Causes
The causes of postpartum hemorrhage can be
remembered easily using the mnemonic “4 T’s”
1. Tone: This refers to the failure of the uterine
myometrial muscle fibers to contract and retract which
can caused by the following conditions:
• Overdistention: macrosomia, hydramnios, multiple
pregnancy
• Fatigue: prolonged labor, precipitate labor, oxytocin
drugs
• Inhibition of contractions by drugs: anesthesia agents,
nitrates NAIDS, MgSO4, beta-sympathomimetics,
nifedipine
• Infection: chorioamnionitis, endomyometritis,
septicemia
• Uterine structural abnormality
• Hypoxia due to hypoperfusion or Couvelaire uterus
• Placental site in the lower uterine segment
• Distension with blood before or after placental delivery
2. Tissue: Presence retained placental tissues prevents
full uterine contractions resulting in failure to seal off
bleeding vessels which can caused by:
• Presence of a succenturiate or accessory lobe
• Preterm gestation especially in less than 24 weeks
gestation
• Abnormal adhesions such as accrete, increta and
percreta
3. Trauma: 20% of postpartum hemorrhage is due to
trauma anywhere in the genital tract which may be
caused by:
• Laceration and episiotomy
• Hematoma
• Cesarean section
• Uterine rupture and uterine inversion
• Uterine perforation during forceps application or
curettage
4. Thrombosis: Clot formation and fibrin deposition on the
placental site stop the oozing of blood from the blood vessels
of the uterus. Disorders of the coagulation system and
platelets, whether preexistent or acquired, can result in
bleeding or aggravate bleeding.
• Preexistent coagulation disorder: thrombocytopenic purpura.
• Acquired disorder: HELLP syndrome (hemolysis, elevated liver
enzymes, and low platelet count), DIC
• Dilutional coagulopathy, in which clotting factors are
significantly reduced with aggressive transfusion of cystalloid
and packed red blood cells
Assessment of Blood Loss and Hemorrhage

1. During the immediate postpartum period, blood loss

should be monitored closely and continuously by
assessing the fundus, vital signs (BP and PR), vaginal
bleeding, Hgb and Hct.
 Assessment Findings in Obstetric Hemorrhage
Blood Volume Blood Pressure Symptoms and Degree of Shock
Loss (systolic) Signs
500-1000 (10-15%) Normal Palpitations, Compensated
tachycardia,
dizziness
1000-1500 ml(15- Slight fall (80-100 Weakness, Mild
25%) mmHg) tachycardia,
sweating
1500-2000 (25- Moderate fall (70- Restlessness, Moderate
35%) 80mmHg) pallor, oliguria
2000-3000ml (35- Marked fall (50- Collapse, air Severe
50%) 70mmHg) hunger, anuria
2. Palpate the fundus and determine its consistency, size and position
3. Inspect the vagina and perineal area for continuous oozing of blood
and hematoma formation.
4. Monitor blood loss per vagina: Weigh perineal pad before and after
use to measure accurately the amount of blood loss per vagina.
Check under hips where blood tends to pool.
5. Monitor vitals signs particularly pulse rate and BP. Tachycardia
(pulse rate more than 100) and hypotension are the most significant
vital signs changes in hemorrhage.
6. Monitor urine output: The kidney is very sensitive to circulating
blood volume changes. As blood volume decreases, so does the
blood supply to the kidney and the amount of urine formation. A
decreasing urine output signifies declining blood supply to the vital
organs due to decreased circulating blood volume.
7. Monitor tissue perfusion: Pulse oximetry is useful for assessing
tissue perfusion and oxygen saturation.
8. Auscultation of the lung fields helps detect pulmonary edema or the
development of adult respiratory distress syndrome. Presence of
crackles and dyspnea indicate presence of fluids in the lungs.
9. Assess level of consciousness: Altered level of consciousness that
occurs with shock is due to decreaed blood supply to the brain.
10.Lab work:
• The CBC is relied upon when determining the need for blood
transfusion
11.Ultrasound is performed to detect causes of hemorrhage such as
retained placental fragments and occult hematoma
12. Angiography is done when embolization of bleeding vessels is to be
performed. Assess the patient for allergy to the contrast medium to be
used.
13.Upon diagnosis or admission of a patient with postpartum
hemorrhage:
a. Raise the legs to trendelenburg to improve venous return
b. Keep the patient warm by providing extra blanket
c. Administer oxygen
d. Two IV line is usually ordered. One is for fluids and drugs
that must be administered by IV and the other for possible
blood transfusion.
e. Blood transfusion- Blood transfusion is often required
if estimated blood loss is over 2000 ml.
• Warm blood before transfusion
• Monitor patient for transfusion reactions and slow
down or discontinue transfusion as necessary
 Uterine Atony
• Uterine atony refers to the failure of the uterus to contract
continuously after delivery. It is the most common cause of PPH
and often occurs following delivery of the baby, and up to 24 hours
after the delivery of the placenta.
• Incidence: 1 for every 2o deliveries or 5%
Causes
• Overdistention: Hydramnios, multiple pregnancy,
macrosomia
• Complication of the labor: precipitate of labor,
prolonged labor
• Uterine relaxing agents: anesthesia, analgesia,
terbutaline, magnesium sulfate, nitroglycerine
• Oxytocin given during labor
• High parity and advance maternal age
• Infection: amnionitis and chorioamnionitis
• Presence of fibroid tumors that interfere with uterine
contractions
• Overmassage of the uterus that results in very strong uterine
contractions and eventual fatigue
• Retained placental fragments
• Prolonged stage of labor: more than 30 minutes is associated
with uterine atony in the immediate postpartum period
Management
1. The first action to take when a relaxed and boggy uterus is
palpated is to massage the uterine fundus to stimulate uterine
contractions and to express clots that have accumulated in
the uterus or vagina. Avoid forceful massage as it causes very
strong uterine contractions which are too painful for the
patient and can cause uterine fatigue with the uterus
eventually loosing its ability to contract.
2. Keep the bladder empty since a full bladder interferes with
effective uterine contractions. Make the newly delivered
woman void every two hours. If the woman cannot void
normally, as a result of trauma and reduce tone of the
bladder, catheterized patient with doctor’s order.
3. By manual compression and massage: done to stimulate
and sustain uterine contractions in an atonic uterus. It is
performed by massaging the posterior aspect of the uterus
through the abdomen with one hand while the other hand
massages the anterior fornix through the vagina.
4. Manual exploration of the uterine cavity may be
performed if the uterus continuous to relax despite
administration of uterotonics and by manual compression.
The patient is placed under anesthesia or analgesia and
with fluid or blood replacement already being instituted.
During manual exploration, placenta or parts of it left in
the uterus may be removed and uterine inversion may be
corrected. Right after exploration, uterine compression
and massage is performed and oxytocin is administered to
stimulate uterine contractions.
5. Administer uterotonics to stimulate uterine contractions:
a. Oxytocin (Pitocin, Syntocinon) is the first drug of
choice
for postpartum uterine atony.
b. Methylergonovine maleate (Methergine)
c. Carboprost (Hermabate): This drug is prostaglandin that
is similar to F2-alpha (dinoprost) but it has a longer duration
of action and produces uterine contractions that induce
hemostasis at placental site, which reduces post partum
bleeding. This is administered if oxytocin is ineffective and
ergotrate is contraindicated to the patient.
6. Uterine packing: the uterus and vagina is tightly packed with
continuous, layered, 2 or 4 inches gauze under direct visualization using
a speculum and/or retractors or a purpose built uterine packer. The
packing is removed after 24 to 36 hours. Packing prevents bleeding by
tamponade effect and is useful as a primary intervention to control
bleeding and to help stabilize the patient until the surgical procedure is
arranged.
Nursing Implications:
• Monitor concealed hemorrhage: Patient develops hypotension and
tachycardia without evidence of excessive external bleeding.
• Monitor for possible infection: Manifested by fever and foul vaginal
discharge. Be sure to remove packing after 24 hours.
7. Laparotomy may also be performed for hemorrhage after
vaginal delivery for the following purposes:
• To removed blood clots
• To inspect the uterus and surrounding tissues for signs of rapture
or hematoma and to repair if found
• To perform direct by manual massage and compression if uterine
atony is found to be the sole caused of bleeding
• To perform direct injection of oxytocin, carboprost, and/or
ergonovine in the uterine muscles
• To perform ovarian artery, inter iliac artery and uterine artery
ligation to control bleeding
• To perform direct injection or compression with warm saline
packs after artery ligation
8. If the patient is bleeding but the uterus is firm, inspect for
presence of lacerations and developing hematoma.
 Lacerations
When bright red bloods continue to ooze from the vagina
despite a firmly contracted uterus, lacerations of the birth
canal are usually the cause of bleeding. Lacerations can occur
anywhere in the cervix, vagina and perineum.
Causes of Lacerations Complications
1. Primygravidas 1. Chronic perineal pain
2. Operative delivery; forceps, 2. Dyspareunia
vacuum extractions,
episiotomy
3. Urinary incontinence
3. Precipitate delivery 4. Fecal incontinence
4. Large infant weighing over 9
pounds
5. Multiple pregnancy
6. Abnormal fetal presentation
and position
Management
1. Failure to repair first and second degree lacerations may
not result in excessive bleeding but it has been associated
with prolong wound healing extending past 6 weeks after
delivery. Larger lacerations of the third and fourth degree
can cause hemorrhage and shock.
• After suturing is completed, vaginal packing may be
applied to help stop bleeding and maintain placement of the
suture.
 2. When a woman has sustained third and fourth degree
lacerations, she should not be given an enema or rectal suppository,
constipation should be avoided and no rectal temperature should be
taken.
• Vaginal packing: this may be done after repair of third and fourth
degree laceration to maintain pressure on suture line. Be sure to
remove packing after 24 to 48 hours to prevent infection.
• Assess bladder distention in women with larger lacerations and
episiotomy.
• Constipation is common during the postpartum period.
Provide stool softeners to reduce stress on sutures.
• Relieve discomfort by administering analgesic or anesthetic
sprays. Apply ice compress during the first 24 hours
postpartum.
• Promote perennial healing by heat application using sitz
bath and perilight. Apply heat only after 24 hours.
 Hematomas
Injury to blood vessels during instrumental delivery or during
repair of episiotomy by needle prick can result in blood
escaping into connective tissue with the overlying skin
appearing intact, this collection of blood under the skin is
called hematoma. When bleeding is by hematoma, blood loss
occurs slower and the signs and symptoms of hypovolemia
may develop over a longer time frame.
Risk Factors
1. Vulvar varicosities
2. Precipitate labor
3. Inadequate suturing of episiotomy or lacerations
4. Pudendal anesthesia
5. Primipara
6. Prolonged second stage labor
7. Large Infant
8. Forceps or vacuum assisted birth
Signs and Symptoms
1. Lower genital tract hematomas is generally associated with:
• Intense pain that is out of proportion to what seems apparent
• Localized tenderness being painful to touch
• Swelling
• Discoloration of skin over the swollen area
• Feeling of pressure over the vagina which may cause
difficulty voiding
• If in posterior vagina may cause sensation of rectal pressure

2. Broad ligament hematomas may be palpated as enlarging

masses next to the uterus
Management
1. Prevention:
• Proper suturing of lacerations and episiotomies
• Decrease risk of developing hematoma by applying ice
pack first hour after delivery, then intermittently for 8 to 12
hours after birth.
2. If patient persistently complains perennial pain, do not
assume that it is due to episiotomy. Assess the perineum
carefully.
3. Small hematomas less than 5cm usually do not need
treatment because they are resorbed spontaneously within
3 to 4 days. Prevent further bleeding and enlargement of
small hematomas by:
• Apply ice pack during the first 24 hours after delivery on
the perineum to prevent further bleeding and congestion.
Then warm compress after 24 hours to promote blood flow
and absorption.
• Provide pain medications.
4. Large hematomas are potentially dangerous because they may
rupture and cause severe bleeding and infection. Woman is
brought back to the DR for incision, evacuation and ligation of
the bleeding vessels.
5. Arterial embolization: alternative to laparotomy when suture and
packing fail.
6. Broad spectrum antibiotics to prevent or treat infections because
hematomas are good medium of bacterial growth.
7. Blood transfusion to combat hypovolemia if severe bleeding
occurs.
 Retained Placental Fragments

The most common cause of late postpartum hemorrhage.

Women with the history of retained placenta have an
increased risk of recurrence of retained placenta in
subsequent deliveries. It has been associated with pregnancy
complications that probably caused abnormal developments
of tissues between the decidua and the placenta.
 Causes
1. Partial separation of a normal placenta.
2. Manual removal of placenta.
3. Entrapment of placenta in the uterus.
4. Abnormal adherent placenta-accrete, increta, and percreta.
5. Abnormal placental adhesion is most likely in:
• Previous peripartum curettage
• Previous cesarian
• Placenta previa
• High parity
 Complications
1. Infection
2. May interfere with adequate production in breastfeeding mothers
as it may continue to produce hormones like estrogen that inhibit
prolactin secretions.

Signs and Symptoms

1. Passage of large clots
2. Heavy bleeding
3. Presence of tears or missing cotyledons on inspection of placenta.
 Management
1. Confirmation is done by:
• Manual uterine exploration
• Ultrasound: ultrasound can show residual trophoblastic tissue,
blood clots, and decidua in the uterus
3. D and C to remove adherent placenta
4. Hysterectomy if manual removal, D and C if not successful
or will result with grave complications such as severe
hemorrhage, DIC and perforation of the uterus.
 Subinvolution of the uterus
Subinvolution of the uterus occurs when there is a delay
in the return of the uterus to its prepregnant size, shape
and function.
 Signs and Symptoms
Causes
1. Enlarged and boggy uterus
1. Retained placental
fragments 2. Prolonged or reversal
pattern in lochial discharge
2. Infection-Endometritis
3. Foil odor in lochia if
3. Uterine tumors caused by infection
4. Backache
 Management
1. Initially, the physician may order Ergonovine maleate .2
mg to stimulate uterine contractions for 2 weeks. If
bleeding continues after 2 weeks, D and C is performed.
2. Treating the cause:
• Removal of uterine tumors and antibiotics for infection.
• Evacuation of the retained placental fragments by D and
C.
 Sheehan’s Syndrome
• Occur with severe hemorrhage during labor and
delivery. Severe blood loss results in poor blood supply
to the pituitary gland causing tissue death that
eventually cause hypopituitarism.
• This disorder is also known as postpartum
hypopituitarism, postpartum pituitary insufficiency and
hypopituitarism syndrome.
Signs and Symptoms
• The pituitary gland is the source of hormones that stimulate
breast milk production(prolactin), growth, reproductive
functions (FSH and LH), the thyroid (TSH), and the adrenal
glands.
• Sheehans’s syndrome is characterized by the lose of the ability
of the pituitary to produce these hormones resulting in variety
of symptoms that include:
1. Inability to breast-feed(milk never “comes in”)
2. Fatigue
3. Loss of pubic and axillary hair
4. Amenorrhea, or lack of menstrual bleeding
5. Low blood pressure
6. Blood tests are performed to measure serum hormone
levels
7. CT scan of the head may be recommended to rule out
other abnormalities of the pituitary such as tumor.
 Puerperial Infection
Puerperial fever or infection (also known as childbed fever) is a
general term used to describe infection of the genital tract after
delivery.
Infecting Organisms
1. The causative agents are those that normally inhibit the colon,
vagina and cervix (anaerobic streptococci) and those that are part
of the normal flora of the woman’s body (Escherichia coli)
2. The causative agent may be introduced during labor and delivery
by the hospital personnel through droplet infection.
 Predisposing Factors
• Premature rupture of the membrane
• Prolonged labor
• Postpartum hemorrhage
• Anemia
• Malnutrition
• Retained placental fragments
• Instrumental deliveries, cesarean
section
• Intrauterine manipulation such as
manual exploration of the uterus
• Excessive vaginal manipulation
(IE) during labor
• Presence of infection elsewhere in
the body or genital tract during
labor, delivery and puerperium
• Sexual intercourse near labor or
after membranes ruptured
• Low socio-economic status
Signs and Symptoms
1. Fever: Elevation of temperature (100.4F and above) for 2
consecutive days or more after the first 24 hours postpartum is the
most characteristic of postpartum infection.
Due to physiologic changes associated with pregnancy, the
leukocyte count and segmented neutrophil percentage are normally
elevated after the first few days of delivery and therefore cannot be
used to indicate presence of infection.
However leukocyte count is considered if there is a 30% increase
within 6 hours period.
2. Foul smelling lochia or vaginal discharge
3. Rapid pulse, chills
4. Abdominal pain and tenderness
5. Body malaise
6. Lack of appetite
7. Perineal discomfort
8. Nausea and vomiting
Infection of the Perineum,Vulva and Cervix
Signs and Symptoms
• Pain sensation of heat or feeling of pressure on the
affected area
• Presence of pus
• Redness, swelling, one or two stitches may be sloughed
off with infected episiotomy wound
• Dysuria
 Management
1. For prevention, instruct the mother to:
• Observe good perineal hygiene
• Change pad frequently to avoid contamination and reinfection
• Wash hands before and after changing perineal pads
• Wipe perineal area from front to back
2. Perineal heat lamp, sitz bath and warm compress to promote healing
and comfort.
3. If infection with purulent discharge is noted, sutures are removed to
open the area and to establish drainage.
• This is done to prevent extension of infection to surrounding tissues.
The wound is repair when no more pus is draining and infection has
subsided.
4. The mother is encouraged to care and feed her baby as the infection
is localized and the risk of infecting the baby can be avoided:
• Instruct the mother to wash hands before handling baby
• The mother can breastfeed the infant if the antibiotics does not cross
breast milk
• If the mother cannot nurse her baby, the infant should be
fed by milk formula. Breastmilk should be expressed
manually or by breast pump to maintain production. It is
normal for milk supply to decrease in the presence of high
fever.
• If it is contraindicated for the mother to care for the infant,
keep the mother informed of the day to day progress of her
baby to allay anxiety.
5. Analgesics are prescribed for pain and antibiotics to
combat infection.
 Endometritis
Endometritis is the infection of the lining of the uterus,
the endometrium. It is often an ascending polymicrobial
infection which occurs when vaginal organisms invade
the endometrial cavity during labor and birth. It is the
most common uterine puerpereal infection.
 Causative Agents
1. Microorganisms of the vaginal flora are the most common etiologic
agents: Escherichia coli, Klebsiella pneumonia, and proteus species.
2. Endometritis occurring on postpartum day 1 or 2 most frequently is
caused by group A streptococci.
3. If the infection develops on day 3 or 4, the causative organism is
frequently enteric bacteria, most common E coli, or anaerobic
bacteria.
4. Endometritis tha develop more than 7 days after delivery is most
frequently caused by Chlamydia trachomitis.
5. Endometritis following cesarean delivery is most frequently caused
by anerobic gram-negative bacilli, specially Bacteroids species.
Risk Factors
1. Cesarean Section is the common risk factors. Prophylactic antibiotic
decreases the risk. Classic signs of endometritis after CS:
• Redness
• Warmth
• Edema
• Purulent drainage
• Gaping of wound
• Local pain
2. Premature rupture Of memmbranes
3. Prolonged labor
4. Multiple vaginal examinations
5. Placement of an intrauterine catheter
6. Manual removal of the placenta
7. Manual exploration of the uterus
8. Preexisting infection or colonization of the lower genital tract
9. Twin delivery
10. Chorioamnionitis
11. Forceps or vacuum assisted delivery
Complications of Endometritis

1. Wound infections of abdominal incisions following

CS
2. Peritonitis when it extends to the abdominal cavity via
lymphatics.
3. Adnexal Infections when infection extends to the
fallopian tubes
4. Parametrial Phlegmon: A phlegmon is an area of
induration that develops usually within the leaves of
the broad ligaments.
 Managements
1. If a post-CS patient develops endometritis that results in infection of the CS:
• The sutures are removed and the wound is left open to drain
• When free of drainage and tissue granulation is seen, wound is resutured.
2. Antibiotic therapy to combat infection
a. IV antibiotic therapy until patient is afebrile for 24 hours followed by oral
antibiotics
b. Drugs of choice are combination od gentamycin and clindamycin in which a cure
rate of approximately 90% is observed in most patients.
c. If the cause is Enterococcus faecalis, ampicillin is added to the regimen of
gentamycin and clindamycin. Vacanmycin is the alternative if patient is penicillin
allergic.
d. Nursing implications:
• Instruct patient to take medication consistently until the
antibiotic therapy is completed even if signs and symptoms
have already disappeared.
• Stopping antibiotic intake before the completion of therapy can
results in reappearance of signs and symptoms and emergence
of more resistant strains of microorganisms that would be more
difficult to treat.
3. Instruct the patient to observe good perineal hygiene: change
pads frequently, wash hands, wipe perineum front to back and etc.
4. Isolate woman with infection to prevent spread of infection
to other patients. Perform hand washing before providing
nursing care to other patients.
5. Place in semi-fowler’s position to promote drainage
6. Provide analgesics for pain
7. Administer oxytocics as ordered to promote involution
8. Increase fluid intake
 Parametritis
Parametritis or pelvic cellulitis is the infection of the pelvic connective
tissue including blood vessels and lymphatics. It is often a result of an
extension of infection from the endometrium, cervix, vagina and
perineum.
Signs and Symptoms
1. Body malaise, chills, unilateral and bilateral lower abdominal pain
2. Tachycardia
3. Tenderness of the uterus especially on palpation
4. Uterus may appear large
Management

1. Antibiotic therapy to treat infection

2. Analgesics for pain
3. Comfort measures: sponge bath, change perineal pad
frequently
 Wound Infections
Postpartum wound infections are infections that develop
in the perineum at the site of episiotomy and at the
abdominal incision of CS.
It is characterized by redness, warmth and pain on the
area with induration and purulent drainage that is often
foul smelling.
The management is the same as in endometritis and
infection of the perineum.
• Perineal infections: Usually occur on the 3rd and 4th day after
giving birth. The most common causes are infected lochia
(endometritis) fecal contamination of the wound, and poor
hygiene. The causative agents are microorganism that
normally inhibit vagina.
• Abdominal wound infections: This type of infection often
results from contamination of CS incision by microorganism
of the vaginal flora. The most common risk factors in the
development of the abdominal wound infection are: diabetes,
hypertension, and obesity, treatment with corticosteroids,
immunosuppression, anemia, and development of hematoma,
chorioamnionitis, prolonged labor, and prolonged rupture of
membranes, prolonged operating time, abdominal twin
delivery, and excessive blood loss.
 Urinary Tract Infection(UTI)
UTI is defined as a bacterial inflammation of the bladder or urethra that
is confirmed when greater than 105 colony-forming units from a clean-
catch urine specimen or greater than 10,000 colony-forming units on a
catheterized specimen is revealed.
UTI are common during puerperium because of trauma to the bladder
after delivery, urinary retention and overdistention of the bladder due to
anesthesia.
Infection may also be introduced during catheterization.
Infecting Organisms: The causative agents are usually coliform
bacteria coli, kleibsella pneumonia and enterococci.
Risk Factors
1. Cesarean delivery
2. Forceps and vacuum delivery
3. Tocolysis
4. Induction of labor
5. Maternal renal disease
6. Preeclampsia and eclampsia
7. Epidural anesthesia
8. Prolonged hospital stay
9. Previous UTI during pregnancy
Signs and Symptoms
1. Painful urination
2. Frequency and urgency of urination
3. Suprapubic pain, flank pain
4. Fever
5. Hematuria
6. Some patients exhibit no symptoms at
all
7. On abdominal examination, patient
may complain of suprapubic
tenderness
 Management
1. Increase fluid intake (3,000 cc/day) to flush away infection
from the bladder.
2. Regular emptying of the bladder to prevent stasis of urine
3. Analgesic for pain and antibiotics for infection
4. Advice cranberry, plum, apricot, prune juices, take vitamin
C, avoid carbonated
5. Antibiotic therapy
 Mastitis
Mastitis or infection of breast tissue occurs most commonly in
breastfeeding mothers. It usually appears during the 2nd and 3rd week
postpartum when milk supply is already established. In the process of
the vigorous pull and tug of the infant during breastfeeding, especially
if the mouth of the baby is not properly positioned over the areola, the
nipples may become sore, cracked or abraded. This tiny skin cracks
enable bacteria from the infant’s mouth to enter the breast tissue.
Microorganisms that gain access to breastmilk multiple rapidly as milk
is rich in sugar, fats and protein, providing excellent medium for
bacterial growth.
Infecting Organisms
1. Staphylococcus aureus from the oral-nasal cavity of the infant is the most
common causative agent
2. Coagulase-negative streptococci-Veridans streptococci
Signs and Symptoms
3. Usually, only one breast is involved
4. Engorgement and swelling of affected breast and chills are usually the first
signs. The breast feels hard and appears reddened.
5. Fever, tachycardia, body malaise
6. Reduced milk supply occurs as edema and engorgement obstruct milk flow
5. Breast abscess: About 10% of women with mastitis develop breast
abscess. An abscess is a collection of pus within the breast.
6. Accurate diagnosis involves obtaining a sample of breast milk from
the infected breast. The milk is cultured to allow colonies of
bacteria to grow and to enable identification of the causative agent
by examination of the culture under microscope. It is important to
identify causative agents in infection in order to determine the most
appropriate antibiotic that would be effective in destroying the
microorganisms.
 Management
1. Prevention
a. Prevent nipple cracks and fissures by correct placement infant’s
mouth on the nipple, not feeding too long, using correct technique
when releasing the baby from the nipple after feeding, proper breast
care
b. Apply warm compress before nursing
c. Express excess milk after feeding the baby to prevent milk stasis
which is good a medium of bacterial growth.
d. Isolation of the infants with cord or skin infection
e. Person with known or suspected staphylococci infections should not
be allowed to care for newborn in the nursery.
f. Proper hand washing technique in between handling of newborns.
Observance of strict aseptic technique.
g. Instruct to wash hands before and after changing perineal pads and to
practice good personal hygiene
h. To treat and prevent blocked duct:
• Rotate infant positions each feeding
• Manually express excess milk after feeding
• Massage caked area toward nipple while breastfeeding
2. Comfort measure:
• Instruct the mother to wear supportive brassiere
• Application of ice to the breast to promote comfort and
relieve engorgement.
• Discontinue breastfeeding from the affected breast. Express
milk every 4 hour to maintain lactation and prevent abscess
formation
• Acetaminophen PRN for pain
3. Bed rest for 24 hours
4. Antibiotic therapy to fight infection:
• Antibiotics of choice are dicloxacillin and
erythromycin. Women taking these drugs can continue
breastfeeding.
• Resolution usually occurs within 24 hours after
initiation of antibiotic therapy
• Other antibiotic used are clindamycin and vancomycin.
5. If abscess develops, the affected area is incised and
drained.
 Postpartum Thromboembolic Disorders
Thrombi or blood clots are formed when there is stasis of
circulation or repair of damaged tissue. The postpartum
woman is especially susceptible to the formation of
thrombi because of increased fibrinogen and prothrombin
levels which increases blood coagulability. Thrombi have
a tendency to occlude circulation and are a good medium
of bacterial growth.
The two major complications associated with the hypercoagulable
state brought by pregnancy:
1. Thrombophlebitis: Infection of the lining of the vein with
formation of thrombi (thrombo for the presence of clots and
phlebitis meaning inflammation of the lining of blood vessels). If
the inflammation is minor and involves only the superficial veins
of the extremities, the disease is usually called venous thrombosis
or phlebothrombosis. If the inflammation involves the deep veins,
it is often referred to as thrombophlebitis.
2. Pulmonary embolism may occur when these thrombi formed in the
deep leg veins are by circulation to the pulmonary artery, and
obstruct blood flow to the lungs. Pulmonary embolism is rare but
when it happens, it is life threatening.
Incidence
3. Deep vein thrombosis occur in 3:1000
4. Pulmonary embolism occur in 2700 to 7000
Predisposing Factors

1. Varicosities of the legs 5. History of thromboembolic

2. Obesity disease

3. Over 30 years old 6. Anesthesia, surgery

4. Multiparity 7. Smoking

5. Use of estrogen supplement 8. Trauma to extremities

9. DM
Causes

1. Injury to blood vessels usually occurs during delivery,

indwelling catheterization and infection
2. Increased blood clotting that normally occurs during
pregnancy and after delivery and with the use of oral
contraceptives.
3. Blood stasis that occurs as a result of varicose veins,
bed rest after CS and prolonged activity
 Types According to Veins Affected
1. Femoral Thrombophlebitis: Infection of the vein of the legs
(femoral, saphenous, popliteal veins). Manifestations are:
• Homan’s sign- Calf pain when the foot is dorsiflexed.
• Milk leg or phlegmasia Alba dolens- The legs is shiny white in
appearance because of extreme swelling and lack of circulation.
• Swelling of affected leg, pain and stiffness
• Fever
2. Pelvic Thrombophlebitis: Infection of the ovarian,
uterine and pelvic veins. Manifestations are:
• Fever and chills
• Pain in the lower abdomen or flank
• Palpable parametrial mass in some cases
 Management
1. Prevention
a. Early ambulation after delivery
b. Use of support stocking in women with varicosities to promote circulation and
prevent stasis. Instruct patient to put on stocking before rising from bed in the
morning.
c. Provide adequate hydration
d. Avoid trauma on the extremities (Pad stirrups well, avoid pressure on popliteal
vessels, avoid use of knee gatch on bed
e. If post CS, encourage leg exercises to promote venous return while patient is not
yet able to get out of bed
f. Avoid activities that contribute to venous stasis such as prolonged bed rest, standing
and sitting.
2. Superficial venous thrombosis involving small clots in the absence of infection
usually resolves without anticoagulant treatment. The management is directed
towards relief of pain and resolution of clot which include:
• Application of heat to relieve pain
• Administration of anti-inflammatory drugs to relive pain and prevent inflammation.
But if the woman is receiving heparin, aspirin should never be given to her.
• Inform the mother that it can take from several days to several days to several weeks
for the clot to resolve and the symptoms to completely disappear.
• Instruct the patient to avoid massaging the area.
3. Deep vein thrombosis requires intensive management to prevent
serious complications like pulmonary embolism.
• Hospitalization during the acute phase
• Bed rest until signs and symptoms disappear. Gradual ambulation
after disappearance of s/s and must wear elastic stocking to improve
circulation in the leg and prevent venous stasis
• Leg elevation to prevent venous stasis
• Anticoagulant therapy to prevent further clot formation
• Apply warm wet compress dressings to promote circulation and
comfort
• Administer prescribed antibiotic to combat infection and analgesic to
relieve pain.
• Surgery may be used if the affected vein is likely to present a long
term threat of producing blood clots that will release emboli. The
affected veins are either removed or tied off to prevent the release of
the blot clots. Tying off superficial blood veins is an outpatient
procedure that can be performed with local anesthesia. The patient is
capable of immediately resuming normal activities.
 Postpartum Thyroiditis
• Postpartum thyroiditis(PPT) is a temporary thyroid disorder occurring
during the first 8th to 12th months after delivery. The most common
cause of postpartum thyroid disease is thyroiditis, which is due to an
autoimmune process in which the body produces antibodies against its
own thyroid cells.
• This thyroid antibodies causes inflammatory reaction within the
thyroid gland that results in excess thyroid hormone to be released
into the bloodstream (hyperthyroidism) or destroys so much thyroid
tissue that cause inadequate amount of thyroid hormone
(hypothyroidism to be produced
• Thyrotoxicosis occurs 1-4 months postpartum and is always
self-limited. The condition is caused by increase release of
stored hormone as a result of disruption of the thyroid gland.
• Hypothyroidism arises between the fourth and eight month
postpartum.
Diagnosis is made by assessment of:
• Minimal thyroid enlargement without ophthalmophy
• Serum thyroid hormone shows high T4 & T3and low TSH
Risk Factors
1. History of spontaneous abortion and PPT in previous
pregnancy
2. Positive antithyroid antibody test finding
3. Personal and family history of thyroid and autoimmune
disorders
4. Multiparity
Signs and Symptoms
Hyperthyroidism (Overactive Hypothyroidism (Underactive
thyroid thyroid)
Feeling warm Feeling tired
Experiencing muscle weakness Constipation
Feeling tremulous Loss of memory
Experiencing anxiety Cannot tolerate cold weather
Rapid heartbeat Cramps in the muscles
Loss of concentration Feeling weak
Weight loss Weight gain
Management
1. Majority of patients do not require treatment unless the symptoms are severe.
Often antithyroid drugs, radioactive iodine, and surgery do not need to be
considered because this form of hyperthyroidism is only temporary.
a. Thyrotoxicosis:
• Beta-blocker such as propranolol at 20 mg every 8 hours to treat symptoms such
as palpitations and tremors. Beta-blockers are contraindicated in breastfeeding
women.
b. Hypothyroid phase:
• Thyroxine (T$) replacement which is most often given for 12-18 months, then
gradually withdrawn.
• The starting dose is 0.05-0.07 mg every 4-8 weeks until a therapeutic level is
achieved.
 Postpartum Psychiatric Disorders
Causes
The extract cause of these disorders is currently unknown. It is
accepted, though, that the etiology of psychiatric disorders of the
postpartum period is multifactorial-with many contributory
factors. Current beliefs on the causes on its cause include the
following views:
• Due to the stress of the peripartum period and the
responsibilities of child rearing.
• Sudden hormonal changes that occur during the postpartum
period characterized by sudden decrease in the endorphins,
estrogen and progesterone levels that occur after delivery.
• Low free serum tryptophan levels have observed, which is
consistent with findings in major depression in other
settings.
• Postpartum thyroid dysfunction has also been correlated
with postpartum psychiatric disorders.
 9. Poor relationship with husband or bf
Risk Factors 10. Being part of a family with 6 or
1. Unwanted pregnancy more siblings
2. Feeling unloved by mate 11. Limited parental support
3. Below 20 years old 12. Past or present evidence of
4. Single mother emotional problems – women with a
history of PPD and postpartum
5. Medical indigence psychosis have a 50% chance of
6. Low self-esteem recurrence. Women with a previous
7. Dissatisfaction with extent of education history of depression unrelated to
childbirth have 30% chance of
8. Economic problems with housing or developing PPD.
income
 Differentiation of PPB, PPD, PPP
Characteristi Postpartum Blues Postpartum Depression Postpartum Psychosis
cshildbirth
Incidence 70% to 80% of new 7% to 20% of new mothers 1% to 2% of mothers per 1,000 live
mothers 26% in births
adolescent mothers
Onset Three to five days Usually within 6 months after Usually within 2 to 4 weeks
after childbirth following childbirth
Symptoms Periodic crying Anorexia, weight loss, insomnia, Early symptoms may resemble
spells, sadness, fear of harming the baby, neglect depression and then suddenly
confusion, insomnia, of personal care, self-destructive, escalate to delirium, hallucinations,
and anxiety feeling of worthlessness, guilt, anger towards self and baby, bizarre
fatigue, hypochondria, and low behavior, manifestations of mania,
self-esteem and thoughts of hurting self or baby.
Contact with Maintained Intact but can be disoriented; Loss of touch with reality, severe
reality consistently sense of suicidal thoughts and regressive breakdown, high risk of
depersonalization when severe suicide and/or infanticide
Postpartum Blues
Postpartum blues is a transient disorder that occurs 2-3
days after delivery, peaking on the 5th day and usually
resolves within 10 to 14 days. It is characterized by mild
mood swings that begin to develop after the patient arrives
home from the hospital and tends to be worse in primis.
Cause
Hormonal changes after delivery- After birth, the levels of estrogen and
progesterone drop abruptly. It is proposed that the greater the shift in
hormonal levels between pregnancy and postpartum levels of estrogen
and progesterone, the greater the chance of developing postpartum blues.

Risk Factors
1. History of depression
2. Pre-existing psychosocial impairment
Management
1. PPB is self limiting and has little effect on the woman’s ability to carry out her
normal daily functions in majority of cases. Medication is not required.
2. Supportive care and the education is important:
• Inform woman that her feelings are normal and common in many newly
delivered mothers to provide reassurance.
• Encourage woman to discuss her feelings
• Recommend to seek assistance in baby care and other household chores until the
woman has adjusted well to her new role and responsibilities to ease the feelings
of being overwhelmed and avoid excessive fatigue.
• If symptoms do nor disappear within 10 days or become increasingly severe,
refer for psychiatric evaluation and counseling.
 Postpartum Depression
PPD is more prolonged affective disorders that often
occurs during the first month after delivery and lasts for
weeks to months. PPD generally lasts for 3-6 months,
with 25% of patients still affected at 1 year. The signs
and symptoms are similar other major mood disorders .
Risk Factors
1. Postpartum blues
2. History of postpartum depression
3. History of mood disorder or premenstrual dysphonic disorder
4. Family history of depression, bipolar illness, and/or anxiety
5. Marital dissatisfaction
6. Anxiety/depression during pregnancy
7. Infant-related stressors, such as problematic temperament in the baby
8. Adverse life events or stressors
9. Inadequate support from family or friends
 Management
1. Screening: Edinburgh Postnatal Depression Scale, a 10-item self
report test.
2. Individual counseling: More effective than group sessions when the
mother is experiencing severe symptoms of depression.
3. Group therapy: Effective when the patient is recovering from severe
depression.
4. Therapeutic communication:
• Inform the mother that her depression occurs in many other women
after delivery and in most cases, the signs and symptoms resolves.
This provides reassurance and hope for recovery.
• Provide opportunity to express feeling verbally or by other creative
outlets. Some mothers prefer to express their feelings by writing in
diaries or personal journals.
• Allow to ventilate feelings of guilt and resentment at not being able to
perform her mothering roles and responsibilities to her child. Avoid
being judgmental at this time. Discuss patient’s feelings in an
atmosphere of trust and acceptance.
5. Provide assistance in performing activities of daily living.
Postpartum depression can impair normal function during the acute
phase.
6. Support groups: Beneficial during recovery phase to help reduce
feeling of isolation, anger and guilt. Contact with other mothers who
have recovered from this illness reinforces the belief that the
depression will eventually dissipate and will help to validate their
feelings.
7. Monitor for signs of suicidal tendencies when depression sets in and
when the patient begins to recover from depression. When a woman
with severe postpartum depression becomes suicidal, she may
consider killing her infant and young children, not from anger, but
from a desire not to abandon them
8. Medications:
a. Selective serotonin reuptake inhibitors (SSRIs) or secondary amines.
(Paxil, Celexa, Effexor, Lexapro, Zoloft, Prozac and Trazadone or
Wellbutrin for insomnia). Studies on these drugs show that they can
be used by nursing mothers without adverse effects on the infant.
• Avoid alcohol, barbiturates, and over-the-counter medications (herbal
preparations) during medication because these substance may interact
with the antidepressant medications.
• Instruct patient of the expected side effects and not to discontinue
taking the medication if she experience them.
• Instruct patient not to increase, decrease or discontinue medication
without advice from physician or nurse.
• Tell patient that the medications may take 2-3 weeks before taking
effect and improvement in her mood can be left.
• Instruct to stop breastfeeding when antidepressant drugs are passed
on to breast milk such as doxepin.
• Antidepressant medication is continued until 9-12 months after
remission of signs and symptoms with tapering of dose during the
last 1-2 months.
b. There is no clinical indication for women treated with tricyclic
antidepressant (TCAs), other than doxepin, to stop breast feeding,
Provided the infant is healthy and its progress monitored.
c. Lithium is known to impair thyroid and renal function in adults. In
view of the significant risks to the infant of a breast feeding mother
taking lithium, mother should be encouraged to avoid breast
feeding. If a decision is made to proceed, clos monitoring of the
infant, including serum lithium levels, should be made.
d. Electroconvulsive therapy for patients with severe PPD because it is
one of the most effective treatments available for major depression.
 Postpartum Psychosis
• Postpartum psychosis is the most severe and the rarest postpartum
psychiatric disorder. It is characterized by a group of severe and varied
disorders with mania, depression or schizoaffective disorder that elicit
psychotic symptoms which could endanger the patient or the newborn.
The signs and symptoms are similar to the other psychotic disorders
and typically appear during the first two to four weeks after delivery
that generally lasts for three months. Puerperial psychosis has better
prognosis than other psychotic disorders. Recurrence may occur in
about 10-25% or cases.
Risk Factors
1. Previous puerperal psychosis
2. History of manic depression disorder
3. Obsessive personality
4. Family history of mood disorder
5. Prenatal stressors (lack of partner, low socioeconomic
status)
 Management
1. When a woman exhibits signs of postpartum psychosis such as
hallucinations and delusions, it is medical emergency that requires
hospitalization for immediate psychiatric evaluation and
treatment. This because psychotic women are at risk of
committing suicide and, in very rare cases, of harming their
unborn child or infants. These women need to be hospitalized for
their safety and to safeguard their infants.
2. Removal of infant from the mother for safety considerations
3. Medications: antipsychotic medications, sedatives
4. Electroconvulsive therapy is the last resort if other
treatment fails. ECT is usually instituted if waiting for the
therapeutic medications will endanger the life of the
mother and infant.
5. Psychotherapy: Often long term psychotherapy is
required.