Nursing Care of Clients with Postpartum Complications PDF

Nursing Care of Clients with Postpartum Complications Ryann A. De Silva R.N., M.A.N., CLDP Learning Objectives: Identify and differentiate the causes of Explain the pathophysiology of each 01 postpartum hemorrhage, including uterine atony, lacerations, retained placental...

Nursing Care of Clients with Postpartum Complications Ryann A. De Silva R.N., M.A.N., CLDP Learning Objectives: Identify and differentiate the causes of Explain the pathophysiology of each 01 postpartum hemorrhage, including uterine atony, lacerations, retained placental 02 cause and describe how it contributes to excessive bleeding in the fragments, disseminated intravascular postpartum period. coagulation (DIC), subinvolution, and hematomas. Demonstrate appropriate nursing Educate postpartum patients and 03 interventions for managing postpartum 04 their families on recognizing early hemorrhage, including assessment warning signs of hemorrhage and techniques, emergency response, and when to seek medical attention. pharmacological treatments. Postpartal Hemorrhage Uterine Atony Uterine atony is the failure of the uterus to contract effectively after childbirth, leading to postpartum hemorrhage (PPH). It is the most common cause of excessive postpartum bleeding. Causes: Overdistended uterus (multiple gestation, polyhydramnios, macrosomia) Prolonged or rapid labor Use of uterine relaxants (e.g., magnesium sulfate, anesthesia) Grand multiparity (≥5 births) Retained placental fragments Chorioamnionitis (infection of the amniotic sac) Uterine Atony Signs and Symptoms: Soft, boggy uterus upon palpation Heavy vaginal bleeding Hypotension and tachycardia (signs of hypovolemic shock) Pallor, dizziness, or weakness Increased fundal height due to blood accumulation Medical or Pharmacological Management: Uterotonic agents: Oxytocin (Pitocin), Methylergonovine (Methergine), Carboprost (Hemabate), Misoprostol (Cytotec) Bimanual uterine massage IV fluid resuscitation and blood transfusion if needed Uterine tamponade with a balloon catheter (Bakri balloon) Surgical interventions (uterine artery ligation, hysterectomy in severe cases) Uterine Atony Nursing Management: Monitor vital signs and assess for signs of shock Fundal massage to stimulate contractions Administer prescribed uterotonic drugs Maintain IV access for fluid and blood transfusion Monitor urine output to assess kidney perfusion Educate the mother on recognizing excessive bleeding Possible Nursing Diagnosis: Risk for deficient fluid volume related to excessive blood loss Ineffective tissue perfusion related to hypovolemic shock Risk for infection related to prolonged uterine atony Lacerations Lacerations refer to tears in the cervix, vagina, perineum, or surrounding structures that occur during childbirth. Causes: Rapid or forceful delivery Large fetal head Use of forceps or vacuum extraction Insufficient stretching of the perineum Episiotomy extension Lacerations Signs and Symptoms: Continuous bright red vaginal bleeding despite a firm uterus Pain and tenderness at the site Swelling or bruising Difficulty urinating or defecating (depending on location) Medical or Pharmacological Management: Surgical repair (suturing under anesthesia) Pain management (NSAIDs, ice packs) Antibiotics to prevent infection if indicated Laceration Nursing Management: Assess bleeding and wound healing Apply ice packs for the first 24 hours Administer pain medications as prescribed Encourage perineal hygiene and proper wound care Educate on signs of infection (redness, pus, increased pain) Possible Nursing Diagnosis: Acute pain related to tissue injury Risk for infection related to open wound Impaired skin integrity related to perineal trauma Retained Placental Fragments Retention of placental tissue in the uterus after delivery, leading to postpartum hemorrhage and infection risk. Causes: Incomplete placental separation Abnormal placental attachment (placenta accreta, increta, percreta) Uterine atony preventing expulsion Retained Placental Fragments Signs and Symptoms: Prolonged or excessive postpartum bleeding Uterine subinvolution (failure to return to normal size) Persistent lower abdominal pain Foul-smelling lochia (suggestive of infection) Medical or Pharmacological Management: Manual removal of retained fragments Uterotonics to contract the uterus Dilation and Curettage (D&C) if manual removal fails Antibiotics if infection is suspected Retained Placental Fragments Nursing Management: Monitor bleeding and fundal height Prepare for potential surgical removal Educate the mother on normal vs. abnormal lochia patterns Ensure adherence to prescribed medications Possible Nursing Diagnosis: Risk for deficient fluid volume related to prolonged bleeding Risk for infection related to retained placental tissue Disseminated Intravascular Coagulation (DIC) DIC is a life-threatening condition where widespread clotting and bleeding occur simultaneously due to excessive activation of the coagulation system. Causes: Obstetric complications: Placental abruption, preeclampsia, HELLP syndrome, amniotic fluid embolism Infections: Sepsis, chorioamnionitis Severe hemorrhage Disseminated Intravascular Coagulation (DIC) Signs and Symptoms: Uncontrolled bleeding (from IV sites, gums, nose, surgical wounds) Petechiae, ecchymosis, or purpura Hypotension, tachycardia Organ dysfunction (kidneys, liver, lungs) Medical or Pharmacological Management: Treat underlying cause (e.g., sepsis, abruption) Blood transfusions (packed RBCs, fresh frozen plasma, platelets) Anticoagulants (in early stages to prevent clotting) Disseminated Intravascular Coagulation (DIC) Nursing Management: Frequent monitoring of vital signs and bleeding Prepare for blood transfusion Maintain strict fluid balance Monitor coagulation studies (PT, PTT, INR, fibrinogen) Possible Nursing Diagnosis: Risk for bleeding related to coagulation abnormalities Risk for impaired tissue perfusion Subinvolution Subinvolution is the delayed return of the uterus to its pre-pregnancy size and condition. Causes: Retained placental fragments Uterine infection Uterine atony Subinvolution Signs and Symptoms: Prolonged lochia discharge (rubra lasting longer than expected) Larger-than-normal uterus on palpation Intermittent postpartum bleeding Medical or Pharmacological Management: Uterotonics (oxytocin, methylergonovine) Antibiotics if infection is present D&C for retained tissue Subinvolution Nursing Management: Monitor lochia patterns Encourage breastfeeding (natural oxytocin release) Educate on the importance of follow-up check-ups Possible Nursing Diagnosis: Risk for bleeding related to subinvolution Risk for infection Hematomas Hematomas are localized collections of blood in tissues, usually occurring in the perineum, vagina, or pelvis after childbirth. Causes: Birth trauma Use of forceps or vacuum extraction Prolonged second stage of labor Hematomas Signs and Symptoms: Severe perineal or vaginal pain Swelling or discoloration at the site Pressure sensation Signs of hypovolemic shock (if large) Medical or Pharmacological Management: Small hematomas: Conservative management (ice packs, analgesia) Large hematomas: Incision and drainage Blood transfusion if severe blood loss occurs Hematomas Nursing Management: Assess for hidden bleeding Apply cold compresses for the first 24 hours Monitor vital signs for signs of hypovolemia Educate on signs of worsening hematoma Possible Nursing Diagnosis: Acute pain related to tissue injury Risk for bleeding related to vascular damage Puerperal Infection Endometritis Endometritis is an infection of the uterine lining (endometrium), typically occurring after childbirth, miscarriage, or gynecologic procedures. It is a common postpartum infection, particularly after cesarean delivery. Causes: Cesarean section (most significant risk factor) Prolonged labor or prolonged rupture of membranes (>18 hours) Retained placental fragments Multiple vaginal examinations during labor Chorioamnionitis (infection of the amniotic sac) Poor perineal hygiene Intrauterine devices (IUDs) Endometritis Signs and Symptoms: Fever (≥38°C or 100.4°F) within the first 24–48 hours postpartum Lower abdominal pain and uterine tenderness Foul-smelling, purulent lochia Tachycardia Chills, malaise, or general fatigue Medical or Pharmacological Management: Broad-spectrum IV antibiotics (e.g., clindamycin + gentamicin) Antipyretics (acetaminophen) for fever management Uterotonic agents (oxytocin) to help expel infected material if necessary D&C (Dilation and Curettage) if retained products of conception are present Endometritis Nursing Management: Monitor vital signs, especially temperature and heart rate Assess for uterine tenderness and abnormal lochia Maintain IV access for antibiotic administration Encourage hydration and ambulation to promote healing Educate the patient on proper perineal hygiene and signs of worsening infection Possible Nursing Diagnosis: Risk for infection related to postpartum uterine changes Acute pain related to uterine inflammation Hyperthermia related to systemic infection Perineal Infection Perineal infection is an infection of the perineal area, often occurring after childbirth due to episiotomy, lacerations, or poor hygiene. Causes: Perineal tears or episiotomy wounds Poor perineal hygiene Prolonged rupture of membranes Use of contaminated obstetric instruments Immunocompromised conditions (e.g., diabetes) Perineal Infection Signs and Symptoms: Redness, warmth, and swelling at the perineal site Persistent pain despite pain management Purulent discharge or foul-smelling drainage Fever and malaise Delayed wound healing Medical or Pharmacological Management: Broad-spectrum antibiotics (e.g., cephalexin, clindamycin) Analgesics (NSAIDs or acetaminophen) Incision and drainage if an abscess forms Frequent wound care (sitz baths, wound cleaning) Perineal Infection Nursing Management: Assess perineal wound for signs of infection Educate on perineal hygiene (wiping front to back, changing pads frequently) Encourage warm sitz baths to promote circulation and healing Provide pain management as prescribed Monitor for systemic infection (fever, chills) Possible Nursing Diagnosis: Impaired skin integrity related to perineal trauma Acute pain related to infected perineal wound Risk for infection related to postpartum healing process Thrombophlebitis Thrombophlebitis is the inflammation of a vein associated with the formation of a blood clot, often occurring in the legs postpartum. It includes conditions like superficial thrombophlebitis and deep vein thrombosis (DVT). Causes: Venous stasis due to prolonged immobility Hypercoagulability of pregnancy Endothelial injury from delivery or cesarean section Obesity Smoking History of thrombosis Thrombophlebitis Signs and Symptoms: Localized pain, tenderness, and swelling in the affected leg Warmth and redness over the involved vein Positive Homan’s sign (pain in the calf on dorsiflexion of the foot) – Not always reliable Low-grade fever in some cases Medical or Pharmacological Management: Anticoagulants (e.g., heparin, enoxaparin, warfarin) to prevent clot growth Analgesics for pain relief Compression stockings to promote circulation Bed rest with elevation of the affected leg in the acute phase Thrombectomy (surgical removal of the clot) in severe cases Thrombophlebitis Nursing Management: Assess for signs of DVT (pain, swelling, warmth) Monitor for complications such as pulmonary embolism (sudden shortness of breath, chest pain) Educate on leg exercises and early ambulation to prevent clot formation Encourage hydration and avoidance of prolonged immobility Administer prescribed anticoagulants and monitor for bleeding Possible Nursing Diagnosis: Ineffective peripheral tissue perfusion related to venous obstruction Risk for impaired physical mobility related to pain and swelling Risk for bleeding related to anticoagulant therapy Urinary Tract Infection (UTI) A urinary tract infection (UTI) is a bacterial infection affecting any part of the urinary system, commonly the bladder (cystitis) or urethra (urethritis). Causes: Urinary stasis due to postpartum bladder distension Catheterization during labor and delivery Perineal contamination from fecal matter Hormonal changes reducing bladder tone Incomplete bladder emptying postpartum Urinary Tract Infection (UTI) Signs and Symptoms: Dysuria (painful urination) Urinary frequency and urgency Suprapubic pain or discomfort Cloudy, foul-smelling urine Low-grade fever (may progress to pyelonephritis if untreated) Medical or Pharmacological Management: Antibiotics (e.g., nitrofurantoin, trimethoprim-sulfamethoxazole) Increased fluid intake to flush bacteria Urinary analgesics (e.g., phenazopyridine) for pain relief Urinary Tract Infection (UTI) Nursing Management: Encourage increased fluid intake (>2L/day) Monitor urine output and characteristics Teach proper perineal hygiene (wiping front to back) Educate on completing the full course of antibiotics Encourage voiding every 2–3 hours to prevent stasis Possible Nursing Diagnosis: Acute pain related to urinary tract irritation Impaired urinary elimination related to infection Risk for fluid volume deficit related to fever and increased urination  Emotional & Psychological Complications of Puerperium Postpartum Depression (PPD) Postpartum depression (PPD) is a mood disorder that affects women after childbirth, characterized by persistent feelings of sadness, anxiety, and exhaustion. It goes beyond the "baby blues" and can interfere with a mother’s ability to care for herself and her baby. It typically develops within the first few weeks to months after delivery but can occur up to a year postpartum. Causes: Hormonal changes – A rapid drop in estrogen and progesterone levels after childbirth. History of depression or anxiety – Personal or family history increases risk. Stressful life events – Financial struggles, relationship problems, or lack of social support. Sleep deprivation – Lack of sleep worsens emotional well-being. Difficult pregnancy or delivery – Complications can contribute to emotional distress. Thyroid dysfunction – Postpartum thyroid imbalance may play a role. Postpartum Depression (PPD) Signs and Symptoms: Persistent sadness, hopelessness, or emptiness. Loss of interest in activities once enjoyed. Difficulty bonding with the baby. Irritability or anger. Severe fatigue or loss of energy. Sleep disturbances (insomnia or excessive sleeping). Appetite changes (eating too little or too much). Anxiety or panic attacks. Thoughts of self-harm or harming the baby (in severe cases). Medical or Pharmacological Management: Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, or paroxetine are commonly prescribed. Hormone therapy: Estrogen therapy may be used in some cases. Psychotherapy: Cognitive-behavioral therapy (CBT) or interpersonal therapy (IPT) can help. Support groups: Peer support and counseling may be beneficial. Electroconvulsive therapy (ECT): Considered for severe or treatment-resistant cases. Postpartum Depression (PPD) Nursing Management: Assess for signs of PPD – Screen using the Edinburgh Postnatal Depression Scale (EPDS). Provide emotional support – Encourage open communication and offer reassurance. Promote self-care – Encourage proper rest, nutrition, and physical activity. Educate the patient and family – Inform about symptoms, treatment options, and when to seek help. Encourage bonding – Teach techniques like skin-to-skin contact and responsive caregiving. Monitor medication adherence – Educate about antidepressants and possible side effects. Refer to mental health professionals – Ensure timely intervention if symptoms worsen. Possible Nursing Diagnoses: Risk for Impaired Parent-Infant Attachment related to maternal emotional distress. Ineffective Coping related to hormonal changes and psychosocial stressors. Risk for Self-Harm related to severe depressive symptoms. Disturbed Sleep Pattern related to anxiety and fatigue. Social Isolation related to withdrawal from family and friends. Postpartum Psychosis (PPP) Postpartum psychosis (PPP) is a rare but severe psychiatric emergency that occurs within the first two weeks after childbirth. It is characterized by delusions, hallucinations, mood disturbances, and disorganized behavior. Unlike postpartum depression, PPP requires immediate medical intervention due to the high risk of harm to the mother and baby. Causes: Hormonal shifts – Extreme fluctuations in estrogen, progesterone, and other neurotransmitters. History of bipolar disorder or psychosis – Strongly associated with PPP. Genetic predisposition – Family history of psychiatric disorders increases risk. Sleep deprivation – Can exacerbate psychotic symptoms. Extreme stress or trauma during childbirth – May trigger psychotic symptoms. Postpartum Psychosis (PPP) Signs and Symptoms: Sudden onset of confusion or disorientation. Hallucinations (seeing or hearing things that are not there). Delusions (false beliefs, such as thinking the baby is evil or a divine figure). Rapid mood swings (from euphoria to deep depression). Paranoia or extreme suspicion. Agitation, restlessness, or hyperactivity. Incoherent speech or disorganized thoughts. Suicidal thoughts or thoughts of harming the baby. Medical or Pharmacological Management: Hospitalization: Immediate admission to a psychiatric unit for safety. Antipsychotics: Medications such as haloperidol, olanzapine, or risperidone to manage psychotic symptoms. Mood stabilizers: Lithium or valproate for patients with bipolar disorder. Benzodiazepines: For acute agitation or anxiety. Electroconvulsive therapy (ECT): Considered for severe or treatment-resistant cases. Postpartum Psychosis (PPP) Nursing Management: Ensure safety – Supervise the mother closely to prevent harm to herself or the baby. Administer medications as prescribed – Monitor for side effects and therapeutic effects. Provide a calm environment – Reduce external stimuli to minimize agitation. Monitor mood and behavior – Observe for worsening symptoms or suicidal ideation. Facilitate family involvement – Educate the family about the condition and encourage support. Encourage adherence to follow-up care – Support long-term mental health management. Possible Nursing Diagnoses: Risk for Self-Directed Violence related to psychotic symptoms and suicidal ideation. Risk for Other-Directed Violence related to hallucinations or delusions involving the infant. Disturbed Thought Processes related to altered perception and cognition. Impaired Parenting related to altered mental status. Deficient Knowledge related to lack of awareness about postpartum psychosis and its management. Thank you!