CHAPTER 23

NURSING CARE OF A WOMAN

AND FAMILY EXPERIENCING A
POSTPARTAL COMPLICATION
POSTPARTAL HEMORRHAGE
 Hemorrhage, is one of the most
important causes of maternal mortality
associated with childbearing, poses a
possible threat throughout pregnancy
and is a major potential danger in the
immediate postpartal period.
 Traditionally, postpartal hemorrhage
has been defined as any blood loss
from the uterus greater than 500 mL
within a 24-hour period.
 Hemorrhage may occur either early
(i.e. within the first 24 hours), or late
(anytime after the first 24 hours
during the remaining days of the 6-
weeks puerperium).
 The greatest danger of hemorrhage is
in the first 24 hours because of the
grossly denuded and unprotected
area left after detachment of the
placenta.
 There are four main causes for
postpartal hemorrhage: Uterine Atony,
Lacerations, Retained placental
fragments, and disseminated
intravascular coaguation.
UTERINE ATONY
 Uterine Atony, or relaxation of uterus, is the
most frequent cause of postpartal
hemorrhage.
 The uterus must remain in a contracted state
after birth to allow the open vessels at the
placental site to seal.
 When caring for a client in whom any of these
conditions are present, be especially cautious
in your observations and be on guard for
signs of uterine bleeding. This is especially
important because many postpartal clients are
discharged within 48 hours after birth.
 Conditions That Increase A
Woman’s Risk For Postpartal
Hemorrhage
Conditions That Distend the Uterus
Beyond Average Capacity
 Multiple Gestation
 Hydramnios (excessive amount of
amniotic fluid)
 Large Baby (more than 9 lb)
 Presence of uterine myomas (fibroid
tumors)
Conditions That Could Have Caused
Cervical Or Uterine Lacerations
 Operative Birth
 Rapid Birth
 Conditions with varied placental
site or attachment
 Placenta Previa
 Placenta Accreta
 Premature separation of the placenta
 Retained placental fragments
Conditions that leave the uterus unable
to contract readily
 Deep anesthesia or analgesia
 Labor initiated or assisted with an oxytocin agent
 Maternal age greater than 30 years
 Highly parity
 Previous uterine surgery
 Prolonged and difficult labor
 Possible chorioamniotitis
 Secondary maternal illness (e.g. anemia)
 Prior history of postpartum hemorrhage
 Endometritis
 Prolonged use of magnesium sulfate or other tocolytic
therapy.
Conditions that lead to inadequate
blood coagulation
 Fetal death
 Disseminated intravascular coagulation
 Ifa woman is losing enough blood to
affect her systemic circulation, she
will develop signs of shock, such as
an increased, thready, and weak
pulse rate; decreased blood pressure;
increased and shallow respirations;
pale, clammy skin; and increasing
anxiety.
 Bimanual Massage
 The physician or nurse-midwife inserts one
hand into a woman’s vagina while pushing
against the fundus through the abdominal wall
with the other hand. . If necessary, a sonogram
may be done to detect possible retained
placentaql fragments. The woman may be
returned to the delivery or birthing room so that
her uterine cavity can explored manually.
Uterine packing may be inserted during this
procedure to help halt bleeding. Uterine
manipulation is painful; anticipate the need for
analgesia or anesthesia to provide comfort.
 Prostaglandin Administration
 Prostaglandins promote strong, sustained
uterine contractions. Prostaglandin F may
be injected intramuscularly to initiate
uterine contractions. Watch for nausea,
diarrhea, tachycardia, and hypertension,
all of which are possible adverse effects of
prostaglandin administration.
 Blood Replacement
 Blood transfusion to replace blood loss
with postpartal hemorrhage may be
necessary. Make sure that blood typing
and cross-matching were done when the
client was admitted and that blood is
available. Some women donate blood so
that they can be autotransfused if
hemorrhage should occur postpartly.
 Hysterectomy
 Usually, therapeutic management is
effective in halting bleeding. In the rare
instance of extreme uterine atony, ligation
of the uterine arteries or a hysterectomy
may be necessary.These measures are
done as a last resort only.
LACERATIONS
 Small lacerations or tears of the birth canal
are common and may be considered a
normal consequence of childbearing.
However, large lacerations are
complications. They occur most often in
the following circumstances:
 With difficult or precipitate births
 In primigravidas
 With the birth of a large infant (more than 9 lb)
 With the use of a lithotomy position and
instruments
 Either cervical, vaginal, or perineal
lacerations may occur. After birth, anytime
a uterus feels firm but bleeding persists,
suspect a laceration of one of these three
sites.
 CERVICAL LACERATIONS
 Usually found on the sides of the cervix, near
the branches of the uterine artery. If the
artery is torn, The blood loss may be so great
that blood gushes from the vaginal opening.
Because this is arterial bleeding, it is brighter
red than the venous blood lost with uterine
atony. Fortunately, this bleeding ordinarily
occurs immediately after delivery of the
placenta, when the physician or nurse-
midwife is still in attendance
 VAGINAL LACERATIONS
 Although they are rare, lacerations can
also occur in the vagina. They are easier
to assess than cervical lacerations,
because they are easier to view.
 PERINEAL LACERATIONS
 Lacerations of the perineum usually occur
when a woman is placed in a lithotomy
position for birth, because this position
increases tension on the perineum.
Perineal lacerations are classified by four
categories, depending on the extent and
depth of the tissue involved.
 CLASSIFICATION OF PERINEAL
LACERATIONS
CLASSIFICATIONDESCRIPTION OF
 First Degree INVOLVEMENT
 Vaginal mucous membrane
and skin of the perineum to
the fourchette.
 Second Degree
 Vagina, perineal skin, fascia,
levator ani muscle, and
 Third Degree perineal body.
 Entire perineum, and reaches
 Fourth Degree the external sphincter of the
rectum.
 RETAINED PLACENTAL
FRAGMENTS
 Occasionally, a placenta does not deliver
in its entirety; fragments of it separate and
are left behind. Because the portion
retained keeps the uterus from contracting
fully, uterine bleeding occurs. Although it is
most likely to happen with a succenturiate
placenta– a placenta with an accessory
lobe– it can happen in any instance.
 Placenta accreta– a placenta that fuses
with the myometrium because of an
abnormal decidua basalis layer– may also
be retained. To detect the complication of
retained placenta, every placenta should
be inspected carefully after birth to see
that it is conmplete. A blood serum sample
that contains human chorionic
gonadotropin hormone (HCG) also reveals
that part of a placenta is still present.
DISSEMINATED INTRAVASCULAR
COAGULATION
 Disseminated intravascuylar coagulation
(DIC) is a deficiency in clotting ability
caused by vascular injury. It may occur in
any woman in the postpartal period, but it
is usually associated with premature
separation of the placenta, a missed early
miscarriage, or fetal death in utero.
Submitted by: Mary Rose Torcita
BSN-3B
 SUBINVOLUTUION
 Is incomplete return of the uterus to its
prepregnant size and shape. With
subinvolutiuon, at a 4- or 6-week
postpartal visit, the uterus is still enlarged
and soft. Lochial discharge usually is still
present. Subinvolution may result from a
small retained placental fragment, a mild
endometritis, or an accompanying problem
(e.g. myoma) that is interfering with
complete contraction.
 PERINEAL HEMATOMAS
 A collection of blood in the subcutaneous
layer of the tissue of the perineum.
 They are most likely to occur after rapid,
spontaneous births and in women who
have perineal varicosities.
 Occur in the site of an episiotomy or
laceration repair if a vein was punctured
during repair.
 Puerperal Infection
 Infection of the reproductive tract is
another leading cause of maternal
mortality. Factors that predispose women
to infection is the postpartal period.
 Ifinfection occurs, the prognosis for
complete recovery depends on many
factors, including the following:
 Virulence of the invading organism
 Women’s general health
 Portal entry
 Degree of uterine involution
 Presence of laceration in the
reproductive tract
 Endometritis
 Itis an infection of the endometrium,
the lining of the uterus. Bacteria gain
access to the uterus through the
vagina and enter the uterus either the
time of birth or during the postpartal
period. This may occur with any birth,
but it is associated with chorionionitis
and cesarean birth.
 Infection of the Perineum
 Ifa woman has a suture line on her
perineum from an episiotomy or a
laceration repair, a portal of entry
exist for bacterial invasion.
 Infections of the perineum usually
remains localized. They are
manifested with symptoms similar to
those of any suture line infection,
such as pain, heat, and feeling of
pressure.
 Peritonitis
 Itis the infection of the peritoneal
cavity and usually an extension of
endometritis. It is one of the gravest
complications of child bearing and the
major cause of death from puerperal
infection. The infections spreads
through the lymphatic system or
directly to the fallopian tubes.
 Assessment
 Symptoms are the same as those of a
surgical patient in whom peritoneal
infection develops: rigid abdomen,
abdominal pain, rapid pulse, vomiting and
the appearance of being acutely ill.