Postpartum Complications: Nursing Care

• Postpartum complications can hinder parent-child relationships and cause long-term disabilities
• Module focuses on nursing care for women and families experiencing complications during the postpartum period

Learning Outcomes

• Merge science and humanities to provide quality nursing care for mothers facing complications in pregnancy
• Use maternal and child nursing concepts to prevent postpartum complications
• Assess mothers experiencing postpartum complications using specific tools
• Create nursing diagnoses that address the needs of mothers and families during postpartum complications
• Provide safe nursing interventions to promote optimal outcomes during a postpartum complication
• Evaluate the effectiveness of care with mothers and their families
• Apply corrective measures to minimize complications during postpartum

Module Outline

• Postpartum Hemorrhage
• Puerperal Infection
• Emotional and Psychological Complications

Postpartum Complications

• They are potentially serious and can lead to personal injury, impaired fertility, or death
• Can disrupt the mother-newborn relationship, potentially stopping breastfeeding
• Can cause extended hospital stays and inability to perform family duties, leading to financial issues

Postpartum Hemorrhage

• Hemorrhage is a major cause of maternal mortality related to childbearing
• Postpartum hemorrhage is defined as bleeding of 500 mL or more after delivery
• Early (primary) postpartum hemorrhage occurs within the first 24 hours
• Late (secondary) postpartum hemorrhage occurs after the first 24 hours
• Four main causes are uterine atony, trauma, retained placental fragments, and disseminated intravascular coagulation (DIC)
• These causes are known as the four Ts: tone, trauma, tissue, and thrombin.
• Consequences include circulatory collapse leading to shock and death and puerperal anemia and morbidity
• It can also cause damage to the pituitary blood supply (Sheehan's syndrome) and fear of future pregnancies

Uterine Atony

• Uterine atony, or uterus relaxation, is the most common cause of postpartum hemorrhage
• After birth, the uterus must stay contracted to close blood vessels at the placental site
• Assessment involve noting a soft (boggy) uterus during palpation of the uterine fundus and by observing signs of shock and hypovolemia
• Interventions include massaging the uterus, emptying the bladder, elevating the woman's extremities
• Provide oxygen, maintain a flat position, and monitor vital signs
• Notify the health care provider if atony persists, and administer medications (oxytocin, carboprost tromethamine, methylergonovine maleate, or misoprostol)
• Other interventions include performing bimanual massage, blood transfusions and hysterectomy

Laceration

• Small tears in the birth canal are normal after giving birth
• Large lacerations may cause complications like difficult or precipitate births, primigravidas, large infants, a lithotomy position
• Cervical lacerations are often near the uterine artery
• Arterial bleeding from cervical lacerations is bright red
• Vaginal lacerations easier to locate than cervical lacerations
• Perineal lacerations occur more frequently in the lithotomy position
• Lacerations classified by extent and depth of tissue involved

Retained Placental Fragments

• Placenta fragments keep the uterus from contracting, leading to uterine bleeding
• Risk factors include succenturiate placenta, placenta accreta, previous cesarean birth, and in vitro fertilization
• Diagnoses include: ultrasound, placenta inspection, and blood serum samples containing gonadotropin hormone.
• Bleeding occurs when the uterus cannot contract
• Fragment retained may not be detected until postpartum day 6 to 10
• Interventions include removal via dilatation and curettage (D&C), observing lochia, and balloon occlusion for placenta accreta

Uterine Inversion

• Uterine inversion involves the fundus prolapsing through the cervix, turning the uterus inside out
• Risk factors include traction on the umbilical cord, pressure on the uterine fundus when the uterus is not contracted
• Risk also caused by placental attachment at the fundus
• Blood will flow suddenly and profusely from the vagina and the fundus and uterus protrude from the vagina are key signs
• Fundus is not palpable in the abdomen and there are signs of shock
• Interventions include not attempting to replace an inversion
• Do not attempt to remove the placenta, start an IV fluid line, administer oxygen, and prepare for CPR
• General anesthesia or nitroglycerin may be needed to relax the uterus, followed by manual fundus replacement
• Administer oxytocin and antibiotics
• Cesarean birth is needed to prevent repeat inversion

Disseminated Intravascular Coagulation (DIC)

• DIC involves deficient clotting due to vascular injury
• It is associated with premature placenta separation, early miscarriage, or fetal death

Subinvolution

• Subinvolution is uterus failing to return to its pre-pregnancy size
• At 4-6 weeks postpartal, the uterus is still enlarged and soft, with lochial discharge
• Results from retained placental fragment, mild endometritis, or uterine myoma/fibroids
• Assessment include prolonged lochial discharge, irregular bleeding, a larger than normal uterus
• Interventions include preventing excessive blood loss and managing infection
• Nurse should massage the uterus and monitor vital signs

Perineal Hematomas

• Hematomes are blood collections in the subcutaneous layer of the perineum
• The skin remains intact with no noticeable trauma
• It mostly occurs after rapid births and in women with perineal varicosities
• Can cause acute discomfort and is represented with minor bleeding
• Assessment find severe pain in the perineal area or pressure
• Nurse observe purplish discoloration with swelling and tenderness and palpate a firm globe area
• Interventions include reporting the hematoma, assessing its size, administering analgesics, and applying ice packs

Puerperal Infection

• Puerperal infection: any reproductive organ infection within 28 days of delivery or abortion
• Risks: membrane rupture over 24 hours before birth, retained placental fragments, postpartal hemorrhage, anemia, difficult labor
• Other risks: internal fetal heart monitoring electrode, local vaginal infection
• After rupture, pathogens can invade
• Infection risk is high if there is tissue edema
• Assessment: fever, vaginal/vulvar/perineal infections, endometritis, parametritis, peritonitis signs
• Intervention: use appropriate antibiotics after culture
• Educate client on preventing future pregnancies and ensure aseptic techniques during labor and delivery

Mastitis

• Infection of the breast, often unilateral, is mostly found in nursing mothers
• The causative organism is S. aureus
• It mostly occurs 2 to 3 weeks after delivery
• Assessment reveals redness, tenderness, or hardened breast and maternal chills, malaise
• Interventions: teach hand washing, apply ice between feedings, empty the breast regularly, and administer antibiotics and analgesics

Endometritis

• Infection of the uterine lining, caused by bacteria invading the uterus at the placental site
• Assessment: chills/fever, increased pulse, appetite decrease, headache, backache and tenderness in the uterus
• Can be determined via foul odor on the lochia and elevated white blood cell count. Interventions include monitoring vital signs

Thrombophlebitis

• Phlebitis is inflammation of the lining of a vessel
• Thrombophlebitis is inflammation of a vessel with a blood clot
• Most postpartal extensions stem from the endometrium
• High fibrinogen levels lead to increased blood clotting
• It is common with dilations of lower extremity veins and if a woman has immobility within labor.
• The condition is high risk if the woman is obese or has previous vascular conditions.
• Types include superficial, femoral, and pelvic thrombophlebitis
• Assessment includes a palpable thrombus, tenderness, and warm skin
• Diminished peripheral pulses, shiny skin, and leg swelling are factors
• Interventions include specific therapies based on the location and assess extremities
• Do not massage the leg and apply hot packs

Emotional and Psychological Complications of the Puerperium

• Inability to bond can have implications for the entire family
• Postpartal depression occurs in almost every woman where they feel sadness after childbirth
• Can be correlated with the hormonal and anticlimactic feelings

Postpartal Blues

• 1-10 days after birth
• Sadness, Tears
• Occurs in 70% of all births

Postpartal Depression

• 1-12 months after birth
• Anxiety, feelings of loss, sadness
• Occurs in 10% of all births

Postpartal Psychosis

• Within first year after birth
• Delusions or hallucinations of harming infact or self
• Occurs in 1-2% of all births

Etiology

• Psychosis: probable hormonal changes, stress of life changes
• Depression: history of previous depression, hormonal response, lack of social
• Support: family history of bipolar disorder
• Interventions include therapy and compassion

Postpartal Psychosis

• May be a response to crisis of childbearing.
• Occurs if woman loses touch with reality.
• Cannot be fixed with a simple solution.
• Interventions: do not leave the woman alone and refer psychiatric help

Nursing Process for a Woman experiencing Postpartum Complication

• Each health problem impacts the family and mother. Subtle findings could lead to beginning of a serious problem
• increased temp after 24 hours is a major issue.
• Review for postpartal depression
• Interventions: Instruction for self and child care because it reinforces the idea that she will get better to care for self and child