ELO A: Complications During the Postpartum Period Complications After Birth

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Questions and Answers

What is the primary cause of cardiogenic shock in the postpartum period?

Infection from surgical site

Pulmonary embolism (correct)

Postpartum hemorrhage

Moderate blood loss from anemia

Which type of postpartum hemorrhage occurs after 24 hours but within 6 weeks of childbirth?

Delayed postpartum hemorrhage

Primary postpartum hemorrhage

Hypovolemic postpartum hemorrhage

Secondary postpartum hemorrhage (correct)

What is a major risk associated with postpartum hemorrhage?

Cardiogenic shock

Hypovolemic shock (correct)

Uterine subinvolution

Anemia without blood loss

What type of shock is directly caused by allergic reactions to medications administered during childbirth?

Anaphylactic shock Signup and view all the answers

What is the traditional threshold for defining postpartum hemorrhage after a vaginal birth?

500 mL of blood loss Signup and view all the answers

What is the initial body response to a reduction in blood volume?

Increased heart and respiratory rates Signup and view all the answers

Which of the following conditions is NOT a cause of early postpartum hemorrhage?

Placental abruption Signup and view all the answers

What is a common sign of hypovolemic shock as blood flow to the brain decreases?

Anxiety and confusion Signup and view all the answers

What nursing action is critical for detecting early signs of postpartum hemorrhage?

Assessing vital signs every 15 minutes Signup and view all the answers

What is the main cause of puerperal sepsis following childbirth?

Tissue trauma during labor Signup and view all the answers

Which symptom is most indicative of a postpartum infection?

A pulse rate higher than expected Signup and view all the answers

What nursing intervention is appropriate to monitor kidney function in a woman experiencing hypovolemic shock?

Placing an indwelling Foley catheter Signup and view all the answers

What is a critical nursing intervention to prevent uterine infections in postpartum women?

Teaching proper perineal hygiene Signup and view all the answers

What characterizes uterine atony in relation to postpartum hemorrhage?

Soft and flaccid uterus allowing for bleeding Signup and view all the answers

Which laboratory test should be prioritized for a woman experiencing urinary symptoms three days postpartum?

Clean-catch urine specimen Signup and view all the answers

What dietary element is crucial in helping postpartum women recover from infection?

Foods high in protein and vitamin C Signup and view all the answers

What are two common risk factors for thrombosis in pregnancy?

Venous stasis and hypercoagulability Signup and view all the answers

What is a key characteristic of superficial venous thrombosis (SVT)?

Hard, reddened, and warm saphenous vein Signup and view all the answers

Which treatment is recommended for deep venous thrombosis (DVT)?

Subcutaneous or IV anticoagulation drugs Signup and view all the answers

What should a postpartum woman be advised to avoid to reduce the risk of thrombus formation?

All of the above Signup and view all the answers

What is a notable symptom of pulmonary embolism (PE)?

Sudden chest pain and difficulty breathing Signup and view all the answers

What preventative measure is recommended for women on prolonged bed rest after cesarean delivery?

Use of pneumatic compression devices Signup and view all the answers

Which factor does NOT contribute to a woman's state of hypercoagulability during pregnancy?

Reduced platelet count Signup and view all the answers

What nursing intervention is crucial for a postpartum woman to help prevent thrombi?

Encourage early ambulation and range-of-motion exercises Signup and view all the answers

When teaching a woman about anticoagulant therapy at home, which sign of excess anticoagulation should she be specifically instructed to watch for?

Prolonged bleeding from minor injuries Signup and view all the answers

What condition occurs when a blood clot obstructs the pulmonary artery?

Pulmonary embolism Signup and view all the answers

How should the fundus of the uterus be positioned immediately after the placenta is expelled?

At the level of the umbilicus Signup and view all the answers

What is a common characteristic of uterine atony?

The fundal height is above the umbilicus Signup and view all the answers

What should be done if the uterus is found to be boggy?

Massage until firm without excessive stimulation Signup and view all the answers

What kind of bleeding is typically associated with lacerations of the reproductive tract?

Bright red and continuous trickle Signup and view all the answers

Which drug is commonly ordered to control uterine atony?

Oxytocin (Pitocin) Signup and view all the answers

What is a potential long-term effect of genital trauma during childbirth?

Prolapsed uterus Signup and view all the answers

What is typically an indication of a hematoma after childbirth?

Unrelenting severe pain not relieved by analgesics Signup and view all the answers

Which measure is often used to help correct uterine atony related to bladder distention?

Catheterization Signup and view all the answers

What is the primary purpose of administering tranexamic acid in postpartum care?

To inhibit the breakup of blood clots Signup and view all the answers

What indicates late postpartum hemorrhage?

Retention of placental fragments Signup and view all the answers

What is the expected rate of uterine descent after delivery?

1 cm per day Signup and view all the answers

What symptom should the nurse monitor for indicating a potential complication after birth?

Persistent bright red bleeding Signup and view all the answers

Which medication is NOT typically used to promote uterine contraction following childbirth?

Tranexamic acid Signup and view all the answers

What signs of subinvolution should a nurse evaluate in a postpartum patient?

Pelvic pain and heaviness Signup and view all the answers

What type of bleeding indicates a potential issue when it returns after changing to a lighter color?

Late postpartum hemorrhage Signup and view all the answers

What is the purpose of curettage in the management of retained placental fragments?

To remove small blood clots and fragments Signup and view all the answers

Which of these statements about the changes in lochia after childbirth is accurate?

Lochia should progress from red to pinkish and then to white Signup and view all the answers

What is a common sign of retained placental fragments that a nurse should monitor?

Foul-smelling vaginal discharge Signup and view all the answers

Study Notes

Postpartum Complications

Most women recover uneventfully from childbirth, however some experience complications.
Most complications related to childbirth fall into six categories: shock, hemorrhage, thromboembolic disorders, puerperal infections, subinvolution of the uterus, and mood disorders.

Shock

Shock is a serious condition where the cardiovascular system fails to provide essential oxygen and nutrients to the cells.
Postpartum shock can be caused by various factors:
- Cardiogenic shock: Pulmonary embolism, anemia, hypertension, or cardiac disorders.
- Hypovolemic shock: Postpartum hemorrhage or blood clotting disorders.
- Anaphylactic shock: Allergic responses to administered drugs.
- Septic shock: Puerperal infection.
Early detection of shock is crucial as body compensation can mask signs until the condition becomes life-threatening.

Postpartum Hemorrhage

Postpartum hemorrhage is defined as blood loss exceeding 500 mL after vaginal birth or 1000 mL after Cesarean birth, leading to hypovolemia.
Most cases of hemorrhage occur immediately after birth, but some are delayed.
- Early (primary) hemorrhage: Occurs within 24 hours of birth.
- Late hemorrhage: Occurs between 24 hours and 6 weeks after birth.
The major risk of hemorrhage is hypovolemic shock, which disrupts blood flow to body cells.
Postpartum hemorrhage is a leading cause of postpartum death worldwide.

Hypovolemic Shock

Hypovolemic shock is a condition caused by depletion of blood volume, making it impossible to fill the circulatory system.
The body initially responds to reduced blood volume by increasing heart and respiratory rates.
Signs and symptoms of hypovolemic shock:
- Tachycardia (rapid heart rate).
- Narrowed pulse pressure (falling systolic pressure and rising diastolic pressure).
- Pale, cold, and clammy skin and mucous membranes.
- Anxiety, confusion, restlessness, and lethargy.
- Decreased urine output.

Medical Management of Hypovolemic Shock

Actions to manage hypovolemic shock include:
- Stopping the blood loss.
- Intravenous (IV) fluids to maintain circulating volume.
- Blood transfusions to replace lost erythrocytes.
- Oxygen administration to increase saturation of remaining blood cells.
- Indwelling (Foley) catheter to assess urine output.
- Uterine massage and administration of drugs (e.g., oxytocin).

Nursing Care for Hypovolemic Shock

Routine postpartum care involves monitoring vital signs every 15 minutes until stable.
Observe for early signs of shock: tachycardia, pallor, cold and clammy hands, and decreased urine output.
Frequent assessment of lochia helps identify early postpartum hemorrhage.
Weigh perineal pads to determine output amount (1 g equals 1 mL).
Monitor IV therapy and oxygen saturation levels.
Provide emotional support and maintain the integrity of the woman's support system.

Early Postpartum Hemorrhage

Early postpartum hemorrhage is caused by three main factors:
- Uterine atony: The most common cause.
- Lacerations: Tears in the reproductive tract.
- Hematoma: Collection of blood in the reproductive tract.

Types of Early Postpartum Hemorrhage

Uterine Atony:
- Characteristics: Soft, high uterine fundus, heavy lochia with large clots or persistent moderate flow, and potential signs of hypovolemic shock.
- Contributing Factors: Bladder distention, abnormal or prolonged labor, overdistended uterus, multiparity, use of oxytocin during labor, medications that relax the uterus, operative birth, low placental implantation, rapid labor, and use of instruments (forceps or vacuum extractor).
Lacerations:
- Characteristics: Continuous trickle of blood brighter than normal lochia, usually firm fundus, and gradual onset of hypovolemic shock.
- Contributing Factors: Rapid labor, use of instruments, prolonged or rapid labor, and large infant.
Hematoma:
- Characteristics: Visible blue or purplish mass on vulva, severe and poorly relieved pain, and potential hypovolemic shock.
- Contributing Factors: Prolonged or rapid labor, large infant, and use of forceps or vacuum extractor.

Uterine Atony

Atony is the lack of normal muscle tone.
After the placenta detaches, the uterus usually contracts to compress bleeding vessels.
Atonic uterus fails to contract, allowing blood vessels at the placental site to bleed freely.
Contributing factors to uterine atony: overdistention, retained placental fragments, prolonged labor, or drugs that relax the uterus.

Medical Management and Nursing Care for Uterine Atony

Nursing care: Massage the uterus until firm, but avoid excessive massage. Ensure bladder is emptied to prevent uterine atony. Encourage infant suckling to stimulate oxytocin release.
Medical management: IV oxytocin infusion, methylergonovine, prostaglandins, uterine packing, intrauterine balloon, selective arterial embolization, surgical ligation of the artery, and IV calcium gluconate.
Rarely: Hysterectomy may be necessary for unresponsive cases.

Lacerations of the Reproductive Tract

Tears in the perineum, vagina, cervix, or urethra can cause postpartum bleeding due to engorged vascular beds during pregnancy.
Contributing factors: Rapid labor and use of instruments.
Signs and symptoms: Bleeding with a firmly contracted uterus, bright red blood in a continuous trickle.

Treatment and Nursing Care for Lacerations

Treatment: Suturing in the delivery or operating room.
Nursing care: Report signs and symptoms, keep woman NPO until further orders.

Hematomas of the Reproductive Tract

Hematoma is a collection of blood within the tissues.
Signs and symptoms: Severe, unrelenting pain, vulvar, pelvic, or rectal pressure, inability to urinate, and potential signs of hypovolemic shock.
Treatment: Small hematomas resolve without treatment, while larger ones may require incision and drainage.

Nursing Care for Hematomas

Nursing care: Ice pack to the perineum for small hematomas, report excessive pain, signs of concealed blood loss, and inability to void. Keep woman NPO until treatment.

Medication for Postpartum Hemorrhage

Tranexamic acid can be administered within 3 hours of delivery to inhibit clot breakup and support clot formation.

Late Postpartum Hemorrhage

Bleeding occurring 24 hours to 6 weeks after childbirth.
Causes: Retention of placental fragments or subinvolution of the uterus.
Treatment: Administration of oxytocin, methylergonovine, or prostaglandins, ultrasonography, curettage, dilation and curettage (D&C) or dilation and evacuation (D&E), antibiotics.

Nursing Care for Late Postpartum Hemorrhage

Nursing care: Educate postpartum women about normal lochia changes, report persistent bright red bleeding or return of red bleeding after color change. Assist with pharmacological and surgical treatment.

Subinvolution of the Uterus

Slower than expected return of the uterus to its nonpregnant condition.
Causes: Infection and retained placental fragments.
Signs and symptoms: Fundal height greater than expected, persistent lochia rubra, pelvic pain, heaviness, and fatigue.
Treatment: Methylergonovine, antibiotics, dilation and curettage.

Nursing Care for Subinvolution

Nursing care: Educate women about normal changes, report fever, persistent pain, red lochia, foul-smelling discharge, and teach self-fundal palpation. Provide nursing care based on cause.

Lochia Rubra

Lochia rubra is red in color, primarily composed of blood, and lasts for about 3 days after birth.

Teaching Points for Discharge

Teach women about normal lochia and advise them to report persistent red bleeding or return of red bleeding after color change.

Key Actions for Suspected Hemorrhage

Report lochia saturation within 15 minutes to 1 hour after delivery.
Assess lochia amount and character.
Observe for early signs of shock, such as tachycardia, pallor, cold and clammy hands, and decreased urine output.
Monitor blood pressure as a late sign of hypovolemic shock.

Thromboembolic Disorders in Pregnancy

Venous Thrombosis: Blood clot within a vein, affecting 1 in 1500 pregnancies.
Risk Factors: Increased during pregnancy due to venous stasis from:
- Compression of blood vessels by the enlarging uterus
- Pressure behind the knees with stirrup leg supports
- Injury during cesarean section
Hypercoagulability: Increased clotting factors and decreased clot-dissolving factors during pregnancy.
Risk Factors: Varicose veins, bed rest, and prolonged immobility.
Prevention: Pneumatic compression devices, prophylactic heparin for cesarean sections or prolonged bed rest.

Types of Thromboembolic Disorders

Superficial Venous Thrombosis (SVT): Involves saphenous vein, characterized by painful, hard, reddened, and warm vein.
Deep Venous Thrombosis (DVT): Involves veins from feet to femoral area, characterized by pain, calf tenderness, edema, color changes, and pain with walking. Positive Homans' sign may be present but is not always reliable postpartum.
Pulmonary Embolism (PE): Pulmonary artery obstruction by a blood clot traveling (embolizes) to the lungs.
- Dramatic signs: Chest pain, cough, dyspnea (difficulty breathing), decreased consciousness, heart failure signs.
- Less severe: Shortness of breath, palpitations, hemoptysis (bloody sputum), faintness, low-grade fever.

Thromboembolic Disorder Treatment

SVT: Analgesics, heat application, and leg elevation.
DVT: Similar to SVT plus subcutaneous or IV anticoagulation (e.g., heparin).
- Low-molecular-weight heparin (LMWH) - long-acting, less frequent dosing, less lab testing, but contraindicated with regional anesthesia.

Nursing Care for Thromboembolic Disorders

Postpartum Assessment: Observe for signs and symptoms of venous thrombosis (e.g., dyspnea, cough, chest pain - indicative of PE).
Prevention:
- Avoid crossing legs.
- Elevate legs without sharp groin flexion or popliteal space pressure.
- Encourage early ambulation and range-of-motion exercises.
- Antiembolic stockings for varicose veins.
- Pad stirrups during birth or episiotomy repair.
Home Care:
- Teach self-administration of anticoagulants.
- Explain signs of excess anticoagulation (prolonged bleeding from minor injuries, bleeding gums, nosebleeds, unexplained bruising).
- Encourage soft toothbrushes and avoidance of trauma that can cause prolonged bleeding or hematomas.

Puerperal Sepsis (Postpartum Infection)

Definition: Infection or septicemia after childbirth, the fourth leading cause of maternal mortality in the U.S.
Risk Factors: Tissue trauma during labor, placental insertion site, surgical incisions, nipple cracks, increased vaginal pH.
Common Cause: Endometritis (inflammation of the uterine lining).
Danger: Localized infection can ascend and spread to uterus, fallopian tubes, and peritoneum, resulting in life-threatening peritonitis.

Manifestations of Puerperal Sepsis

Postpartum Fever: Temperature of 38°C (100.4°F) or higher after the first 24 hours and for at least 2 days during the first 10 days following delivery.
Increased Pulse Rate: Higher than expected.
Localized Signs: Perineum, vagina, or cervix inflammation.
Systemic Signs: Fever, pain, foul odor, abnormal findings on postpartum assessment (REEDA criteria).
Elevated White Blood Cell Count: Usually elevated postpartum, but higher levels are more likely associated with infection.

Treatment for Puerperal Sepsis

Goals: Limit infection spread, prevent systemic infection, and eliminate the infection.
Steps:
- Culture and sensitivity testing from suspected site.
- IV antibiotics.
- Bed rest.

Nursing Care for Puerperal Sepsis

Prevention:
- Promote hygienic measures (hand hygiene, perineal care).
- Encourage adequate rest and nutrition.
Observation: Monitor for signs of infection.
Discharge Education:
- Teach signs of infection to report.
- Educate on taking the full course of antibiotics.
- Explain proper perineal pad application (front to back).
- Stress handwashing before and after self-care involving contact with secretions.

Mastitis (Breast Infection)

Occurrence: Usually 2-3 weeks postpartum.
Cause: Organisms from skin or infant's mouth entering cracks in the nipple or areola.
Contributing Factors: Breast engorgement and inadequate milk emptying.
Manifestations:
- One breast typically affected.
- Redness, heat, tenderness, edema, heaviness, purulent drainage (may or may not be present).
- Fever, chills, and systemic symptoms.

Mastitis Treatment

Primary: Antibiotics and continued milk removal.
Pain Management: Mild analgesics.
Abscess Formation: Incision and drainage, IV antibiotics.
Breastfeeding: Typically safe to continue.
Pumping: If breastfeeding is interrupted, pump breasts.
Weaning: No weaning recommended as it leads to engorgement and milk stasis, worsening mastitis.

Nursing Care for Mastitis

Prevention: Teach proper breastfeeding techniques.
Pain Relief and Lactation Maintenance:
- Apply moist heat (chemical packs, warm cloth in a plastic bag).
- Warm shower before nursing.
- Regular breast emptying.
- Massage inflamed area.
- Nurse from unaffected breast first.
Other Nursing Measures:
- Encourage fluid intake.
- Recommend supportive but not too tight bra (prevent milk stasis).
- Provide emotional support and reassurance about breastfeeding continuation.

Mood Disorders Postpartum

Mood: Pervasive and sustained emotion affecting worldview.
"Postpartum Blues" (Baby Blues): Common, occurs within 5 days of delivery and subsides by day 10.
- Feelings of let-down but overall enjoyment of life and motherhood.
- Fluctuating emotions.
Postpartum Psychosis: Serious reality impairment; less common than postpartum depression.

Postpartum Depression

Definition: Depressive illness, usually within 2-4 weeks of delivery.
Impact: Interferes with responding to infant cues, hinders mother-infant bonding.
Risk Factors: Insufficient social support, poor relationship with partner, life and childcare stress, low self-esteem, unplanned pregnancy.
Manifestations:
- Lack of life enjoyment.
- Disinterest in others, relationship withdrawal.
- Feelings of inadequacy, unworthiness, guilt, inability to cope.
- Impaired concentration, difficulty making decisions.
- Sleep or appetite disturbances.
- Constant fatigue and general ill health.

Treatment for Postpartum Depression

Combined Therapy: Psychotherapy and antidepressants (outpatient or inpatient).
Screening Tools: Available for assessment.
Nursing Role: Support, behavioral observation, awareness of self-harm risk.
Complementary and Alternative Therapies: Light therapy (phototherapy) and exercise.
Referral: Mental health services for ongoing care and support.
Counseling: Include partner and family.

Postpartum Psychosis

Definition: Impaired sense of reality, less common than postpartum depression.

Postpartum Mood Disorders

Two most common psychiatric disorders in postpartum women: Bipolar disorder and Major Depression
Bipolar disorder: characterized by periods of mania and depression
Major Depression: Characterized by feelings of worthlessness, sleep and appetite disturbances, and delusions
Postpartum psychosis is a serious condition that can be fatal to both mother and infant
During manic episodes, mothers may make poor decisions due to a feeling of invincibility, potentially endangering themselves and their infants
Suicide and infanticide are possible during depressive episodes and may require inpatient psychiatric treatment

Types of Postpartum Depression

Three types of postpartum depression:
- Adjustment disorder (baby blues)
- Postpartum mood disorders
- Postpartum depression

Risk Factors for Mother and Infant

Major depression in mothers can result in suicide or infanticide

Hemorrhagic Complications, Thromboembolic Disorders, and Puerperal Sepsis

These are all postpartum complications

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