•POSTPARTAL COMPLICATIONS

•By:
•Maribeth G. Orio RN MN

•POSTPARTAL HEMORRHAGE

Definition: Bleeding of 500 ml or more following delivery

Types:
•Early –in the first 24 hours after delivery; uterine atony is the
most common cause
•Late – between day 2 up to 6 weeks

Predisposing/Precipitating Factors
a. Uterine Atony
–Overdistention
•Multiple pregnancy
•Diabetic pregnancy
•Polyhydramnios
–Effect of Anesthesia – general anesthesia causes uterus to be
atonic; cesarean section
–Multiparity
–Prolonged difficult labor
–Placenta Previa (lower uterine segment is not as contractile
as the upper fundal portion)
–Abruptio Placenta (couvelaire uterus may prevent Norman
uterine contractility)

b. Lacerations
–Operative obstetrics – forceps
–Poor management of the second stage of labor
–Large size of the fetus
–Precipitate labor
–Abnormal positions

c. Retained Placental Membranes

•-Injudicious third stage of labor
d. Subinvolution: delayed return of uterus to normal size,
shape, position

Assessment Findings
–Copious vaginal bleeding
–Soft, boggy, non palpable uterus indicating uterine atony (the
number one cause of early postpartal bleeding)
–Incomplete placenta
–Obvious lacerations; bleeding from wound
–Signs of maternal shock

Complications
*Maternal mortality (postpartal hemorrhage is the leading
cause)

Nursing Implementation
Stay with the client
Massage fundus until firm. This is the first nursing action for
uterine atony. Take care not to overmassage as this can tire
the muscles causing relaxation
Check VS and fundus every 5-15 minutes
Assess and estimate blood loss frequently
Notify physician for repair of lacerations or D & C for
management of laceration and retained membranes,
respectively
Maintain asepsis since hemorrhage predisposes a mother to
infection

Monitor I & O, fluid and blood replacement and O2

administration. Be alert for blood reactions.
Ice cap on fundus and regular bladder emptying to keep the
uterus contracted
Provide psychological support: explain tests, procedures,
situation (but omitting details) to allay anxiety
Teach the need to increase iron in the diet and to adhere to
follow-up care schedule
Explain that lacerated wounds would take longer time to
heal

•PUERPERAL SEPSIS

Definition:Any infection of the reproductive organs that occurs

within 28 days of delivery and abortion; usually localized in the
endometrium.

Etiology
•Bacterial causative agents: aerobic and anaerobic bacteria
with the most common – anaerobic streptococci
•E. coli

Predisposing/Precipitating Factors
•Invasive procedures in labor – excessive vaginal examinations
•PROM
•Weakened resistance due to dystocia and dehydration
•Hemorrhage, anemia’
•Trauma and operative obstetrics
•Retained placental fragments
•Break in asepsis by hospital personnel – most common cause
Criteria: Elevate temperature; 38 C or more for two
consecutive days or more starting on day 2.

Assessment Findings
fever and chills
foul smelling lochia
painful boggy uterus; abdominal pain and tenderness
body malaise, anorexia, headache
tachycardia
dysuria, burning sensation on urination
delayed uterine involution

Complications
PID
Pelvic cellulites
Generalized peritonitis
One of the leading cause of mortality

Prognosis: Improved with early detection and appropriate

medical and nursing management

Nursing Intervention
PREVENTION
prevention and early treatment of antepartal anemia
strict asepsis in handling labor and delivery
prevention of lacerations
good management of the third stage to prevent retained
membranes
perineal cleanliness
adequate treatment of dystocia and PROM with antibiotics,
intravenous fluid containing calories and electrolytes, and
cesearean section when appropriate
Hygiene and proper attire of personnel

Management
1.Start with ordered antibiotics stat ( after appropriate
specimen is obtained)
2.Maintain bedrest; isolate from newborn
3.Maintain asepsis
4.Monitor vital signs every four hours
5.Monitor I & O; force fluids-3000 to 4000 ml if not
contraindicated and encourage frequent voiding
6.Promote drainage of secretions – proper position: Fowler’s or
semi-Fowler’s
7. Give teachings regarding perineal hygiene:
a. Handwashing before and after touching the perineum
b. Front to back removal of sanitary napkins
c. Frequent changing of pads
8. Provide nutritious, high calorie, high protein, high iron diet
9. Promote client’s comfort
a.Position for comfort
b.Warm if chilled
c.Use heat or cold as indicated to relieve localized pain
d.Administer analgesic as ordered
e.Prevent and/or relieve common discomforts of puerperium
f.Provide a restful environment

•MASTITIS

Definition: Inflammation of the breasts as a result of infection

Etiology
a. Bacteria – Staphylococcus aureus and Streptococcus
hemolyticus mainly seen in breast-feeding mothers from the
infant’s nasopharynx and oropharynx
b. Cracked or fissured nipples
c. Milk stasis/clogged milk ducts/overdistention
d. Unclean hands
e. Erosion of the areola

Assessment Findings
a. Breasts hard, painful, tender, REDDENED, hot with “moth
ball” lump
b. Engorgement
*Reddened breasts differentiates engorgement from mastitis
c. Fever and chills
d. Tachycardia
e. Axillary lymphadenopathy
f. Malaise, flu-like symptoms

Nursing Interventions
PREVENTION
1.Good handwashing before handling the breasts
2.Practice of good breastfeeding techniques to prevent
fissures
a. Proper support of infant at breasts
b. Proper removal of nipple from the infant’s mouth: press the
cheeks and depress the lower jaw to avoid trauma to the
nipple or lift the outer border of the upper lip to break the
suction. Holding the nostrils is unkind.
c. “Fix” the baby properly to avoid bruising the nipple with his
gums

3. Provide meticulous oral hygiene for the infant

4. Observe cleanliness of the breasts: wash with WARM
WATER. NO NEED FOR STERILE WATER AS THE MOUTH OF THE
INFANT IS NOT STERILE. Do not use anything that dries and
removes protective covering of the nipples (alcohol, soap).

•THROMBOPHLEBITIS

Definition: inflammation of the vein resulting to vascular

occlusion o vessels of pelvis or lower extremeties
Etiology
a. Infection from uterine cavity (placental site) into pelvic and
femoral veins
b. Circulatory stasis
c. Increased post delivery coagulability of blood from:
1.progesterone effect
2.trauma of childbirth
3.lack of activity
d. clot formation in pelvic veins following CS
e. clot formation in calf of leg due to poor circulation

Predisposing/Precipitating Factors
bedrest
operative CS
multiparity, advanced age: over 30
obesity
women on estrogen therapy for suppression
previous history of thrombophlebitis
•

Assessment Findings
•Calf – positive Homan’s sign (pain in the calf as the foot is
flexed while the knee is extended)
•Pelvic – abdominal or pelvic discomfort and tenderness
•Femoral – edema and swelling in the leg
Pain in the leg
Fever and chills

Complications: Pulmonary Embolism

Nursing Implementation
Maintain bedrest
Use bed cradle to support linens/bedding
Elevate affected leg/hip
Use of support bandage pr stockings
Administer antibiotic and anticoagulant as ordered
Apply heat or warm compress, as ordered for 15-20 minutes
for comfort
Analgesics for pain but NOT ASPIRIN as it alters clotting and
causes bleeding -- clot dislodgement and pulmonary
embolism
 Caution mother NOT TO MASSAGE the leg
Allow client to express fears and concerns; provide support
Monitor for signs of complications
Pulmonary embolism: sudden, intense chest pains, severe
dyspnea, pallor or cyanosis, hemptysis; syncope,
apprehension; irregular thready pulse; signs of shock
Excessive bleeding: The use of HEPARIN may predispose the
mother to excessive bleeding. Be ready with the ANTIDOTE:
PROTAMINE SULFATE AND VITAMIN K to counteract toxic
effects.

•POSTPARTAL CYSTITIS

Definition: Infection of the bladder occurring in the puerperium

Etiology: Coliform Bacteria

Incidence: 5% of all postpartal women

Predisposing/Precipitating Factors
–Bladder trauma during delivery
–Catheterization
–Bladder hypotonia with retention due to intrapartal
anesthesia or trauma

Assessment Findings
Frequency of urination with dysuria, urgency, hematuria
Abnormal urinalysis; pus present in urine, cloudy
Fever (slight) ad chills

Nursing Implementation
Prevention – first principle management
1.Aseptic catheterization techniques
2.Increased fluids
3.Regular voiding

4. facilitating voiding: reduce edema to perineum during the

first hour post-delivery
5. Good perineal hygiene in labor delivery and postpartum
6. Frequent and complete emptying of the bladder
a.Obtain urine specimen for culture and sensitivity
b.Administer antibiotic and analgesic as ordered by the
physician
c.Monitor I & O and characteristics of urine

•UTERINE PROLAPSE

Definition:
A. Prolapse of the uterus – downward and backward sagging or
displacement of the uterus into the vagina or outside bulging
completely (total prolapse)
B. Cystocele: herniation or relaxation of the anterior vaginal
wall allowing the bulging or prolapse of the bladder
C. Rectocele: relaxation of the posterior vaginal wall with
prolapse of the rectum into the vagina

Predisposing Factors
1.pelvic tearing during labor
2.congenital weakness of the vaginal wall
3.multiparity
4.advanced age resulting to vaginal muscle weakness
5.poor bearing down in labor
6.vaginal lacerations causing weakness

Assessment Findings
UTERINE PROLAPSE
–Pelvic pain
–Dragging sensation in the pelvis and back
–Dysmenorrheal

RECTOCELE
•Sensation of pressure
•Constipation
•Hemorrhoids

CYSTOCELE
•Cystitis, retention, incontinence, dribbling, couging or any
activity that increases intraabdominal pressure

Treatment
•Anterior and posterior vaginal repair (colporrhapy)
•Pessary (supportive device) to stabilize the uterus if the
condition of the mother does not warrant surgery
•Vaginal hysterectomy

Nursing Implementation
•Instruct to refrain from activities that increase
intraabdominal pressure like coughing, sneezing, straining or
heavy lifting
•Promote perineal healing
•*Kegel exercise can improve muscle tone around the
reproductive organ.
•c. Instruct on gradual increase in roughage in the diet, need
for regular bowel movement.

a.Prevention
b.Prevention of lacerations of the vagina and perineum
c.Proper and thorough repair of lacerations no matter how
small
d.Correct performance of episiotomy
e.Postpartal perineal exercises to improve the tone of perineal
and vaginal muscles
f.Well-spaced pegnancies

•POSTPARTAL PSYCHOSIS/PSYCHOLOGIC MALADAPTATIONS

Definition: Psychosis occurring within 4-6 weeks after delivery

Predisposing/Precipitating Factors
Stresses of pregnancy/delivery
Prior emotional or mental illness/problems
Physical health problems and stresses of new
responsibilities of parenthood
Separation because of maternal or neonatal problems
Social factors: lack of support system, low socio-economic
status, disturbed family relationships
Surfacing of deepseated feelings about femaleness and self
concept

Assessment Findings
–Depression, withdrawal, blue that persist
–Delusions, hallucinations, paranoia
–May injure self, infant; may have suicidal tendencies
–Clouding of consciousness
–Fear, suspiciousness, hostility
–Maladaptations in attachment, feelings of inadequacy
–Refusal to eat

Nursing Implementation
•Early recognition of problems
•Explore potential resources client or family might use to
reduce stress of parenthood
•Maintain contact with infant; support positive parenting
behaviors; give positive feedback as much as possible

•Administer ordered drugs

1.Mania =sedatives
2.depression = mood elevating medication
3.schizophrenia = phenothiazines
•referrals to other health team members/agencies to improve
resources of client/family

Prognosis:Good; may recur after subsequent pregnancies

END