Loss of more than 500mL of blood following vaginal childbirth or loss of more than 1000mL following cesarean birth

Early postpartum hemorrhage >500 ml in first 24 hrs (blood loss often underestimated)

Late or delayed >500 cc after first 24 hrs.

Decrease in hematocrit of 10% or more since admission pr the need for blood transfusion

Etiology:

Early postpartum hemorrhage:

Uterine Atony

Trauma to the birth canal

Late postpartum hemorrhage

Retained placental fragments

Subinvolution or infection

Predisposing Factors

Early postpartum hemorrhage: 4 main causes:

Uterine Atony

Lacerations

Retained placental fragments

Disseminated intravascular coagulation

Late postpartum hemorrhage

Subinvolution

Perineal Hematomas

Puerperal Infection

Thrombophlebitis

Mastitis

Urinary System Disorders

Psychological complications of Puerperium

Relaxation of the uterusFailure of the uterus to stay firmly contractedSlow, steady or massive hemorrhage, sometimes underestimated or hidden behind a clotVS may not change immediately

Clinical Signs

Fundus that is soft, “boggy”, or difficult to locate

Uterus does not remain firm when massage is stopped

Fundus located above the expected level or displaced from the midline

Excessive lochia (bright red)

Excessive clots

Tachycardia

Tachypnea

Falling blood pressure

Skin cool and pale

History of predisposing factors Location and firmness of fundus

(+)excessive bleeding firm fundus cervical or vaginal laceration

Assess blood loss; weigh pads, bed liners and linen (1 g = 1 mL) Examine for perineum:

Discoloration Bulging or tender area hematoma Deep unrelieved pelvic pain vaginal or retroperitoneal hematoma

Measure vital signs every 15 minutes (+) tachycardia and pulse pressure sign of hypovolemia BP remain normal vasoconstriction shunts blood to the vital organs during initial phase Evaluate bladder

Distended bladder hinders effective uterine contraction Urinary output less than 30 mL/hr inadequate vascular volume

Analyze laboratory reports hct and hgb blood loss

Nursing Assessments

Uterine massage encourage contraction Insert indwelling catheter to empty bladder allow accurate measurement output Place woman in supine position

Avoid Trendelenburg position interfere with respiratory and cardiac function

(Prescribed by physician) Dilute IV infusion of oxytocin to help the uterus maintain tone Administer IV fluids, volume expander, and blood as directed Draw blood (per protocol) for hgb, hct, type and crossmatch, platelets, prothrombin time, aPTT, fibrinogen degradation products, and fibrin split products Prostaglandin administration

Promote strong, sustained uterine contraction Blood replacement

To replace blood loss with postpartal hemorrhage Hysterectomy effective in halting bleeding

Therapeutic Mangement

LacerationsLacerationsLacerationsLacerationsLacerationsLacerationsLacerationsLacerationsLacerationsLacerationsLacerationsLacerationsLacerationsLacerationsLacerationsLacerationsLacerationsLacerationsLacerationsLacerationsLacerations

Predisposing factors Difficult or precipitate birth Primigravidas With birth of a large infant ( over 9 lb) With the use of lithotomy position and instruments

Types of lacerations Cervical laceration Vagina laceration Perineal laceration

Found on the sides of the cervix near the branches of the uterine artery

Torn artery great blood loss blood gushes from the vaginal opening

Vaginal bleeding brighter red arterial bleeding

Occurs after delivery of the placenta

Therapeutic ManagementBe certain that the physician or midwife has:

Adequate work spaceAdequate sponges and suture suppliesGood light source

Maintain a calm air and stay beside the woman at the head of the tableReassure to her about the baby’s conditionInform her about the need to stay in birthing room a little longer(+)difficult laceration repair given regional anesthetic relax uterine muscle and prevent pain

Vaginal Laceration

•Vaginal tissue is friable, and harder to repair

Management

•Oozing to repair vagina may be packed maintain pressure on the suture line•Foley catheter packing causes pressure on the urethra•Document time of packing insertion•Packing should be removed after 24 to 48 hours•Packing placed too long stasis and infection toxic syndrome shock

Perineal Laceration

•Occurs when placed in lithotomy position for birth tension on perineum

Four Classifications•First degree – vaginal mucous membrane and skin of the perineum to the fourchette•Second degree – vagina, perineal skin, fascia, levator ani muscle, and perineal body•Third degree – entire perineum, and reaches the external sphincter of the rectum•Fourth degree – entire perineum, rectal sphincter, and some of the mucous membrane of the rectum

Management•Episiotomy repair by physician

•Document degree of laceration

•Laceration heals slowly suture line are ragged

•1st week diet high in fluid and stool softener prevent constipation

•Be aware of the extent laceration

•Do not give enema or rectal suppository

•Avoid taking rectal thermometer could open suture

•Avoid sex for 6 months

Retained Placental Fragments

•Placenta does not deliver entirely•Fragments of it separate and are left behind•Commonly with:

Succenturiate placenta - a placenta with an accessory lobePlacenta Accreta – placenta that fuses with the myometrium abnormal deciduas basalis retained placenta

Assessment

Undetected retained fragment large bleeding uterus cannot contractSmall fragment bleeding 6th or 10th day postpartumAbrupt discharge of large amount of bloodOn examination not contracted uterus(+) placental tissue elevated hcGSonogram retained placental fragment

Therapeutic Management

Removal of the fragments D&CMethotrexate therapy destroy retained placental tissueAt home: observe color of the lochiaReport changes from lochia serosa or alba to rubra

Signs and Symptoms protime fibrinogen•thrombocytopenia•bleeding from gums•bleeding from puncture sites•ecchymosis hemorrhage into the skin and subcutaneous tissue

Management•Delivery of the fetus and placenta stop production of thromboplastin•Blood transfusion ( whole blood, packed RBC, plasma, cryoprecipitate)•Monitor vital signs hypovolemia•Document location and severity of bleeding

Late postpartum hemorrhageLate postpartum hemorrhageLate postpartum hemorrhage

Clinical Signs and Symptoms

Prolonged lochial discharge

Irregular or excessive uterine bleeding

Pelvic pain or feelings of pelvic heaviness

Backache, fatigue, persistent malaise

Uterus feels larger, and softer than expected

Therapeutic Management

Methylergonovine maleate (Methergine) 24 to 48 hrs. improve uterine tone and complete involution

Antimicrobial therapy infection

Explain to the mother:

Normal process of involution

Normal lochial discharge

Chronic loss of blood anemia, lack of energy

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Assessment

•Discomfort in perineal sutures•Mass felt on vaginal exam•Difficulty voiding•Abdominal distention•Woman report :

severe perineal painPressure bet. Legs

•Inspect perineal area for hematoma(+) hematoma purplish discoloration swelling 2 to 8 cm in diameter

•Area is tender on palpation•May feel fluctuant seepage into the area continues tissue drawn taut palpates as firm globe

Therapeutic Management

•(+) hematoma report: size, degree of discomfort•Describing as “large” or “small” actual size•Describing size of lesion•Administer mild analgesic pain relief•Ice pack prevent further bleeding•Hematoma absorbed over the next 6 weeks•Opening episiotomy incision line to drain hematoma packed with gauze•Packing removed 24 to 48 hrs•Be certain to clear instruction before discharge

Predisposing Factors

•History of previous infection•Colonization of lower genital tract by pathogenic organisms•Cesarean birth•Trauma•PROM•Prolonged labor•Catheterization•Excessive number of vaginal exams•Retained placental fragments•Hemorrhage•Poor general health (anemia, excessive fatigue, frequent illness)•Poor nutrition•Poor hygiene•Medical conditions (DM)•Low socioeconomic status

Causative OrganismsAerobic 30%•B hemolitc strep•E.coli •Klebsiella •Proteus•Pseudomonas•Staphylococcus toxic shock syndrome death and morbidity

Anerobic 70%•Bacteriodes •Peptococcus •C. perfringes

Types of Infections

1.Endometritis 2.Parametritis 3.Infection of the Perineum4.Peritonitis5.Pyelonephritis 6.Thrombophlebitis 7.Mastitis, abcess

•Infection of the lining of the endometrium or inner lining of the uterus•Metritis infection involves surrounding the tissues•Portal of entry: bacteria gain access in the vagina enter uterus time of birth postpartum period

Signs and Symptoms

•Fever•Chills•Malaise, lethargy, anorexia•Abdominal pain, cramping and uterine tenderness•Purulent, foul-smelling lochia (depending on the responsible organism)•Tachycardia•Subinvolution

•Infection of the connective tissue of pelvisFrequently infecting the broad ligament and causing severe pain. May ascend from cervical lacerations

Signs and Symptoms

•Spiking temp to 104

•chills, flushing, sweating

•tachycardia, tachypnea

•uterine tenderness, cramping

•change in LOC/agitation,delerium, disorientation

•change in lochia

•cervical or uterine tenderness on vag exam

•WBC elevation

•Infection on the suture line from episiotomy or laceration on the perineum

•Portal of entry: episiotomy or laceration bacterial invasion

Assessment

•Suture line infection pain, heat, and feeling of pressure

•Elevated temperature

•Inflamed suture line

•One or two suture line sloughed away with (+) purulent drainage

Therapeutic Management

•Physician remove the sutures allow drainage•Iodoform gauze placed in open lesion to keep open allow drainage•Inform client about the packing prevent dislodge when changing pads•Systemic or topical antibiotis (as ordered)•Analgesic alleviate discomfort•Sitz bath or warm compress hasten drainage and cleanse the area•Remind client to change pad frequently prevent vaginal contamination

For discharge:•Encourage mother to ambulate frequently •Ask for analgesia as needed for pain management

Peritonitis

Infection of the peritoneal cavity Usually an extension of endometritisOne of the gravest complication of childbearingMajor cause of death from puerperal infectionAbcesses on the uterine ligaments form in cul-de-sac of DouglasMay result from pelvic thrombophlebitis

Signs and Symptoms•High temp•chills•malaise•lethargy•pain•subinvolution •Tachycardia•local or referred pain•rebound tenderness•thirst•distension•nausea and vomiting

Therapeutic Management

•Nasogastric tube prevent vomiting and rest the bowel•IVF or total parenteral nutrition client is unable to eat orally intestinal paralysis•Analgesics relief of pain•Large dose of Antibiotic treat infection•May interfere future fertility scarring and adhesions in the peritoneum

•Phlebitis inflammation of the lining of a blood vessel•Thrombophlebitis inflammation of the lining of a blood vessel with the formation of blood clots•(+)postpartum extension of an endometrial infection•Classified as superficial vein disease (SVD) or deep vein thrombosis (DVT)

Etiologies• blood clotting factors•postpartal thrombocytosis (platelets)•thromboplastin release (placenta, amnion)•fibrinolysin and fibrinogen inhibitors

Risk factors:

Women with:•Varicose veins•Obese•Previous thrombophlebitis•Women over 30 years of age with parity•Family history of thrombophlebitis•DM•Prolonged bed rest•Smoking•Cesarean birth•Parity greater than 3

Three Most Common Thromboembolic Disorders

•Femoral thrombophlebitis•Pelvic Thrombophlebitis•Pulmonary Embolus

Assessment

•(+)thrombophlebitis 10th day after birth•Elevated temperature•Chills, pain and redness in the affected leg•(+) Homan’s sign pain in calf on dorsiflexion of the foot

Therapeutic Management

•Bed rest affected leg elevated keep pressure of the bedclothes off to the leg improve circulation

•Anticoagulant administration (Heparin) dissolve clot by activating fibrinolytic precursors prevent further clot formation

•Application of moist heat inflammation

•Never massage the affected area loosen the clot pulmonary or cerebral embolism

•Analgesic relief of pain

Assessment•extremely ill•high fever•chills and general malaise•severe infection necroses the vein pelvic abscess•can become systemic lung, kidney or heart valve abscess•long course of 6 to 8 weeks

Therapeutic Management•total bedrest•administer antibiotics•anticoagulants administration•inflammation tubal scarring interfere future fertility

an infection of the lactating breastusually affects only one breastoccurs in the 2nd or 3rd weeks following birthif untreated breast abscess

Etiology•Staphylococcus Aureus injured area of the nipple infant’s mouth, hands of the mother or medical or nursing staff•Engorgement or stasis of frequently precede mastitis

Signs and Symptoms•Localized area of pain, redness and inflammation•Fatigue, malaise, aching muscles•Fever, chills, headache

Therapeutic Management•Antibiotics•Analgesics•Moist heat or ice packs, breast support•Empty breast by breastfeeding or breast pump•Bed rest•Surgical drainage for breast abscess

Nursing Consideration•Demonstrate proper position of the baby for breastfeeding•Encourage breastfeeding at least 2 to 3 hours•Recommend that the woman avoid formula supplements•Avoid cont. pressure on the breast from light bras •Drink 2500 to 3000 mL of fluid each day•Discourage weaning cause engorgement breast abscess

Urinary System Disorders

Assessment•Overdistention of the bladder•Voiding is frequent •Urine output is inadequate•Less than 100 mL urine output•(+) Vulvar edema often distorts the position and appearance of urinary meatus

Therapeutic Management•Foley catheterization to catheterize the residual urine

Signs and Symptoms

•Dysuria•Urgency, frequency of urination•Suprapubic pain•Low-grade fever•Signs of phylonephritis•Chills•Spiking fever•Costovertebral angle tenderness•Flank pain•Nausea and vomiting

Therapeutic Management

•Oral or IV antibiotics

•Explain the need for 2500 to 3000 mL fluid daily

•Suggests to drink apricot, plum, or cranberry juices low acidity

•Avoid carbonated drinks

•Explain perineal care and the need to urinate frequently

•A dead, dying, or severely handicapped infant leads to the problems of grief and grief resolution for the postpartum mother

•initial task faced by the mother is the realization that her child is dead, dying, or severely handicapped

•Parents feel devastated and inadequate and are mourning the loss of the fantasized perfect baby

Nursing Management

•Be able to cope constructively with her own response to loss and grief to meet the woman's needs•Provide emotional support for the mother and her family•Do not avoid talking about the baby•Place the parents and the baby in a private room•Encourage infant bonding•Acknowledge the father as an equal, grieving parent•Encourage and provide an opportunity for the parents to hold the infant•Provide the parents with a collection of concrete memories•Make sure the mother is allowed to attend the funeral and to help with the arrangements•Educate the mother and father on the grieving process and what to expect•Refer/consult with the appropriate health care team members (clergy, social work) to initiate follow-up support

•The so called “baby blues” •A common transient, self limited, mild depression•Usually begins in the 1st week following childbirth and usually lasts no longer than 2 weeks•Possible etiology: probable hormonal changes, stress of life changes

Signs and Symptoms

•Insomnia•Irritability•Fatigue•Tearfulness•Mood instability•Anxiety•Sadness

Nursing Considerations•Offering compassion and understanding•Acknowledge feelings and other support•Explain that what the woman is experiencing is normal•Reassure her that the feeling will abate in less than 2 weeks•Encourage rest and time for herself•Distinguish between blues and postpartum depression or psychosis

•1 to 12 months after birth•Possible etiology: history of previous depression, hormonal response, lack of social support

•Predisposing Factors

Previous PPD or depression during pregnancyHormonal fluctuationsMedical problems (preeclampsia, M, anemia, thyroid dysfunction) during or after pregnancyHistory of depression, mental illness, alcoholismFamily historyImmaturity or low self-esteemMarital dysfunctionAnger or ambivalence about the pregnancyFeelings of isolation, lack of social supportFatigue, sleep deprivation, financial worriesBirth of an infant with illness or anomaliesMultiple pregnancy

Signs and Symptoms•anxiety•feeling of loss•sadness

Therapy•counselingNursing role•referring to counseling

•Within first month after birth

•Symptoms: Delusions or Hallucinations to harm infant and herself

•Possible etiology: possible activation of previous mental illness, hormonal changes, family history of bipolar disorder

•Therapy: psychotherapy, drug therapy

•Nursing role: referring to counseling, safe guarding mother from injury to self or to newborn