Postpartum Complications
CH 21
Julie Vavrek MSN, BA, RN, CPNP
Postpartum Hemorrhage
Leading cause of maternal death worldwide
PPH traditionally defined as loss of more than:
•500 ml of blood after vaginal birth
•1000 ml after cesarean birth
Life-threatening with little warning
Often unrecognized until profound symptoms
Etiology and Risk Factors
Uterine atony
•Marked hypotonia of uterus
Lacerations of genital tract
Hematomas
Retained placenta
•Nonadherent retained placenta
•Adherent retained placenta
Inversion and Subinvolution
Inversion of uterus
•Turning inside out of uterus
•Potentially life threatening
•1 in 3000 births
Subinvolution of uterus
•Late postpartum bleeding
•Retained placental fragment and pelvic infection
Medical Management
Early recognition is critical
•Evaluate of contractility of uterus
Firm massage of fundus
Management is directed toward increasing contractility and minimizing blood loss
Medications
Nursing interventions
Hemorrhagic (Hypovolemic) Shock
Medical management
Nursing interventions
Fluid or blood replacement therapy
*Legal– standard of care for bleeding emergencies allows for provisions to
be made for nurses to initiate actions independently
Coagulopathies
Idiopathic thrombocytopenic purpura (ITP)
von Willebrand disease—type of hemophilia
Disseminated intravascular coagulation
-Consumptive coagulopathy
-Consumes large amounts of clotting factors
-Widespread external bleeding, internal bleeding, or both
Thromboembolic Disorders
Results from blood clot caused by inflammation or partial obstruction of
vessel
Superficial venous thrombosis
Deep venous thrombosis
Pulmonary embolism
Incidence and etiology
Clinical manifestations
Medical management
Nursing interventions
Postpartum Infections
Puerperal infection: any infection of genital tract within 28 days after
miscarriage, induced abortion, or birth
Most common infecting agents are numerous streptococcal and anaerobic
organisms
Endometritis
Wound infections
Urinary tract infections
Mastitis
Perinatal Mood Disorders
A set of mood disorders that occur any time during pregnancy or the first
year postpartum
•Depression
•Anxiety
•OCD
•PTSD
•Postpartum psychosis
Depression
Depression during pregnancy is a major risk factor for PPD
Maternal suicide
•20% of postpartum deaths
Negatively affects infant’s cognitive, neurologic, and motor skill
development
Affect the well-being of the mother, baby, and family
Can interfere with attachment
Baby Blues
Up to 85% of women experience a ”mild depression”
Functioning is not impaired
Mood swings, sadness, crying, difficulty sleeping, loss of appetite
Symptoms resolve in a few days
Postpartum Depression
Onset in pregnancy or within 4 weeks of birth
Hormone fluctuations, nutritional deficiencies (folate, B12)
Risks
•History of anxiety or depression
•Younger age
•Unintended pregnancy
•Family history
•Unmarried, lack of social support
•Lower education
Paternal Postpartum Depression
10-50% of fathers experience PPD as well
Partner with PPD major risk factor
Fatigue, frustration, anger irritable withdrawn
Treatment
Early recognition of symptoms
Education
Screening
Referrals
Provide safety
Psychiatric hospitalization
Medications
Medications for non-lactating
•TCAs, SSRIs, SNRIs, MAOIs, mood stabilizers, antipsychotics
•Educate about side effects
•Lithium is not used with breastfeeding
Medications for lactating
•Benefits outweigh risks
•Avoid feeding during peak medication times
•SSRIs used most commonly – Paxil, Zoloft, Pamelor
•Do pass through milk but no untoward effects to baby
Monitor infant for irritability, poor feeding, altered sleep
Loss and Grief
Situational life crises superimposed on childbearing
•Infertility
•Premature labor or birth
•Cesarean birth
•Gender of infant not desired
•Birth of child with handicap
•Maternal death
• Fetal or neonatal death