Chapter 14: Postpartum Complications

• Postpartum complications is the subject of chapter 14

Learning Objectives

• Identify the causes, nursing actions, and medical care that relate to postpartum hemorrhage (PPH)
• Identify the postpartum infections and their related nursing actions and medical care
• Identify the postpartum psychological complications and related nursing and medical care
• Identify the postpartum cardiovascular complications and their related nursing and medical care
• Determine how social determinants of health affect maternal outcomes

Postpartum Hemorrhage (PPH)

• PPH includes cumulative blood loss >1000 cc or blood loss with hypovolemia symptoms
• Hypovolemia symptoms may include; tachycardia, cool clammy skin, tachypnea, hypotension, low O2 saturation [<95%], pallor, oliguria, confusion and restlessness
• Symptoms of hypotension, dizziness, pallor, and oliguria may not present until there is substantial blood loss
• PPH is classified as primary or secondary hemorrhage
• Primary occurs within the first 24 hours, caused by uterine atony, lacerations, or hematomas
• Secondary occurs 24 hours to 6 weeks, caused by hematomas, retained placenta, or subinvolution

Risk Factors of PPH

• Pre-existing risk factors include; high parity, a previous history of PPH, previous uterine surgery, or medical of thrombophilia disorders
• Current pregnancy risk factors include; excessive uterine distention (macrosomia, multiple gestation, etc), a history of antepartum hemorrhage, chorioamnionitis, placental abnormalities (accreta, previa, abruptio), or fetal death
• Labor and delivery risk factors include; labor dystocia or precipitous labor and delivery, use of tocolytic medication, large episiotomy, operative vaginal birth, Cesarean section, abnormal location of placenta, attached placenta, or uterine inversion

Primary Causes of PPH

• Four T's can cause PPH:
  • Tone; Uterine Atony which causes slow or profuse bleeding, passage of large clots, and a boggy uterus
    • Nursing inventions need to assess for displaced uterus, uterine massage and reassessment every 5-15 mins, administer meds, weigh peripads, administer IV fluids of normals saline or lactated ringer, review labs and start blood transfusions, and provide oxygen
  • Tissue : Retained placenta can result in the uterus not responding to interventions, a large uterus, and possible visible tissue with bleeding occurring suddenly after the first postpartum week or a subinvolution
    • Nursing interventions require calling a provider to assess, possible surgery, monitoring shock and providing oxygen
  • Trauma: Lacerations, genital trauma or hematoma- Bleeding from lacerations can be unclotted and bright red, uterus is firm.
    • Nursing interventions include assessing vitals, monitoring lochia, weighing pads, and notifying a provider to assess the client
    • Bleeding from hematoma can be evidenced from sudden perineal pressure, a bulging area, difficulty voiding or sitting and rectal pressure
    • Nursing Interventions include calling the provider to assess, considering a foley catheter, providing pain management, icing the perineal area for the first 24 hours, assessing for hematoma and anticipating possible I&D is the hematoma is >3 cm
  • Thrombin Disorder: Disseminated intravascular coagulopathy presents with nosebleeds, bleeding from IV sites, petechiae, bleeding gums, hypotension, and abnormal blood clotting levels
    • Nursing interventions require confirming blood loss estimates, monitoring lab results, vitals, I/O, initiation of volume replacement, platelets, and oxygen

Medications for PPH

• Oxytocin is a high alert uterotonic drug given intramuscularly or by IV drip that stimulates smooth muscle to produce intermittent contractions
• Methergine, an ergot alkaloid drug given PO/IM/IV (emergencies only), stimulates smooth and vascular smooth muscles causing contractions and is contraindicated for patients with hypertension
• Hemabate is a prostaglandin drug administer IM for contraction of the uterine muscle
• Cytotec is a is prostaglandin drug administered PO or rectally for uterine contraction
• Tranexamic Acid (TXA) is an antifibrinolytic drug, given IV or PO

Coagulation Complications

• Disseminated Intravascular Coagulation (DIC): Is a syndrome in which the body breaks down clots faster than they can form, causing coagulation factors to be depleted and can lead to hemorrhage and death
• DIC is Disseminated (all over) –Intravascular (within blood vessels) – Coagulation (blood clots)
• DIC can present as hemorrhage or thrombosis
• Four types of DIC dependent on the severity of hypercoagulation and hyperfibrinolysis
  • Asymptomatic (limited coagulation and fibrinolysis), Bleeding (fibrinolysis dominant), Massive bleeding (hypercoagulation and hyperfibrinolysis), or Organ failure (hypercoagulation dominant)
  • Findings include prolonged, uncontrolled bleeding, bleeding from IV sites, gums, bladder, incision, abnormal low aPTT, low platelets, increased anxiety, and S/S of shock
    • Nursing interventions: IV hydration, O2, review labs, start blood transfusion (platelets, blood, FFP etc), facilitate transfer to ICU
    • Early intervention is key to survival
    • Reduce risk of DIC by identifying risk factors, monitor frequently for those that are at risk, and reporting abnormal findings immediately
    • Predispositions include abruption, preeclampsia, HELLP, AFE, massive obstetric hemorrhage, sepsis, IUFD
  • Amniotic Fluid Embolism (AFE): Also known as Anaphylactoid Syndrome of Pregnancy
    • Occurs when amniotic fluid enters the maternal circulation, causing an anaphylactoid reaction
    • Unpreventable and unpredictable
      • Signs and symptoms include rapid onset of respiratory distress that occurs during labor, delivery, or 1st 24 hrs postpartum with severe hypoxia, hypotension, or cyanosis
      • Other signs and symptoms may include, loss of consciousness; foaming at the mouth; pulmonary edema; or uncontrolled bleeding from the uterus, IV sites, or any other incisions due to coagulopathy, seizures, or cardiac arrest.
      • Nursing interventions require activating the code team for ACLS
  • Venous Thromboembolic Disease (VTE):
    • Is a blood clot
    • The two types include deep vein thrombosis (DVT) or pulmonary embolism (PE)
    • Nursing inventions: Apply a supportive bandage or antiembolic support stockings, compare pulses in both extremities
    • Heparin anticoagulation therapy may be ordered
    • Bedrest with elevation of the involved extremity until swelling is reduced and anticoagulation therapy are effective; promotes venous return and decrease edema
    • Encourage ambulation as soon as patient is able
    • Assess for unusual bleeding; heavy vaginal bleeding, generalized petechiae, bleeding from the mucous membranes, hematuria, or oozing from venipuncture sites should be reported to the physician

Postpartum Infections

• Risk factors include; history of Cesarean delivery, premature ROM, frequent cervical exam, sterile gloves, internal fetal monitoring, preexisting pelvic infections, diabetes, nutritional status and obesity
• Endometritis is an infection of the uterine lining
  • Risk factors include; Cesarean birth, prolonged labor or ROM, use of invasive procedures: Internal monitoring, amnioinfusion, poor nutrition, smoking, anemia, multiple cervical examinations during labor, pyelonephritis or diabetes.
  • Signs and symptoms include a Temp greater than 100.4 F with or without chills, lower abdominal pain, uterine tenderness, tachycardia, subinvolution, malaise, headache, or foul smelling lochia
• Urinary Tract Infections has risk factors; epidural anesthesia, overdistended bladder, operative vaginal deliveries, intrapartum vaginal exams, catheter insertions, and C/S
  • Signs and symptoms include burring on urination, frequency, urgency, voiding less than 150 cc, low grade fever, and suprapubic pain
  • Nursing interventions: Encourage voiding after delivery, catheterize if unable to void after 2-3 hours post delivery, good peri-care, encourage hydration encourage foods that increase urine acidity
• Mastitis and wound infection are also considered

Pregnancy Complications Postpartum

• Hypertension in BP >160/110 requires urgent antihypertensive therapy to reduce the risk of stroke, seizure or death
  • First-line medications include IV labetalol and hydralazine
  • Oral labetalol can be used if IV is not available
  • IV labetalol may cause neonatal bradycardia so prevent use in women with asthma, heart disease or CHF
  • IV hydralazine increases the risk of hypotension
• Gestational diabetes usually resolves postpartum but can develop type 2 diabetes later in life
  • Nursing interventions: Education on diet, exercise, promote breastfeeding, encourage follow-up

Psychological Complications

• Postpartum Blues
  • Symptoms disappear without intervention
  • Onsets within 2 weeks post delivery
  • The mother is able to safely take care of herself and baby
• Postpartum Depression
  • Psychological intervention
  • Onsets occurs within 12 months post delivery
  • The mother is unable to take care of self and baby
  • Defined as a depressed mood or loss of pleasure or interest for at least 2 weeks PLUS a number of other possible additional symptoms
    • Significant weight loss or gain with a change of more than 5% of body weight in a month
    • Insomnia or hypersomnia
    • Changes in psychomotor activity: agitation or retardation
    • Decreased energy or fatigue
    • Feelings of worthlessness or guilt
    • Decreased ability to concentrate and or an inability to make decisions
    • Decreased interest in normal activities
  • Risk factors for PPD: History of depression or anxiety before or during pregnancy, inadequate social support, poor relationship with partner, low socioeconomic status, complications of pregnancy or birth, low support from mother, life or childcare stresses, domestic abuse, and a history of child sexual abuse
    • Nursing interventions: Review records for risk factors, Monitor interactions between mom and baby, Educate on signs and symptoms of PPD with mom and partner, Provide community resources and support groups, Provide alternative approaches to treatment (non-pharmaceutical) and Supportive and encouraging interactions.
  • Postpartum Psychosis
    • Characterized by rapid onset- within 2-3 days post delivery- and one or more of the following delusions, hallucinations, disorganized speech, catatonic behavior
    • Risk factors: history of bipolar, family history of bipolar or affective disorder.
    • Signs/symptoms: Paranoia, extreme agitation, delusions associated with baby, mood swings, depressed or elated moods, distraught feelings about enjoying infant, confused feelings, disorganized behavior, strange beliefs about dying (either mother and/or baby).
    • Nursing interventions: early detection and intervention is key, educate on s/s and when to call provider, provide information on effective therapies (pharmaceuticals, psych evals, hospitalization, psychotherapy, and ECT)