Nursing Care for the Women & Family Experiencing Postpartal Complications
Usually a period of health but complications do occur.
Woman at risk in three points of view:
 Her own health
 Her future childbearing potential
 Her ability to bond with her new infant
 Family is disrupted, hospital stay is longer, increased cost, difficult to cope.
 Most complications are preventable, and if they do occur they can be treated.
Postpartal Complications
 Hemorrhage
 Infection
 Thrombophlebitis
 Urinary System Disorders
 Cardiovascular System Disorders
 Reproductive System Disorders
 Emotional and Psychological Complications
Postpartal Complications
 Assessment findings may be extremely subtle.
 Tenderness in calf of leg
 Slight increase in pain
 Slight elevation in temperature (serious 1st 24 hours)
 Slight increase in lochia
 Things that are more than usual
 Do not rely on the mother’s report, she wants to go home
Postpartal Complications
 Provide for measures that restore the woman quickly to health, and promote
contact with her child and support person.
 If she can not see the baby she needs contact by phone with the nursery. A
photo of the infant, a note written about the progress as if from the baby.
 1 in 500 develop depression and even psychosis.
 Reinforcement is needed, support and remind that it is a temporary situation.
Postpartal Hemorrhage
 Any blood loss from the uterus greater than 500 mL. within a 24 hour period.
 Can occur early, within 24 hours or late, anytime after the first 24 hours
during the remaining days of the 6 week puerperium.
 4 main causes:
 Uterine atony
 Lacerations
 Retained placental fragments
 DIC disceminated intravascular coagulation
Postpartal Hemorrhage
 Uterine Atony:
 Relaxation of the uterus
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Most frequent cause of hemorrhage
 Uterus must remain in a contracted state to allow open vessels at the
placental site to seal.
 Box 25.1 p. 695 list some factors.
 Multiple gestation, hydraminios, lg baby, myomas
Postpartal Hemorrhage
 Assessment:
 Abrupt gush of blood from placental site
 Lg. amount of vaginal bleeding
 Symptoms of shock and blood loss
 A saturated pad can hold 25 to 50 mL.
 Count pads to estimate blood loss(q 30 min)
 Weigh pads the subtract the difference (1 g weight equals 1 mL volume of
blood.
 Turn woman on side to inspect for pooling beneath her.
Postpartal Hemorrhage
 Box 25.2 p. 696 outcomes and interventions
 Palpate uterus; keep contracted, detecting relaxation is 1st and most
important assessment.
 Lochia
 VS
 Treatment:
 Uterine massage to encourage contraction
 IV oxytocin – maintain uterine tone (10 to 40 U per 1000 mL of 5% dextrose)
(1 hr.)
 IM Methergine

Postpartal Hemorrhage
 Bimanual Massage:
 One hand in vagina while pushing against fundus through the abdominal wall
with the other hand. (painful)
 Sonogram to detect placental fragments
 Examine manually and insert packing.
 Prostaglandin Administration:
 Prostaglandin F IM to initiate contractions
 Watch for nausea, diarrhea, tachycardia, and hypertension.
Postpartal Hemorrhage
 Blood Replacement:
 Type and cross match
 Some may donate during pregnancy.
Hysterectomy:
 Ligation of uterine or hysterectomy as last resort.
 Comfort and support.
 “Why me”, grief, anger, glad to be alive.
Postpartal Hemorrhage
 Nursing interventions:
 Observe fundal height, consistency, and lochia for 4 hours.
 Offer bedpan or ambulate to BR q 4 hours or catheter may be ordered.
 O2 4 L/minute by face mask.
 Supine
 VS increase pulse, decrease B/P
 Fatigue- needs rest
 May need iron therapy, help at home.
 Monitor for infection
Postpartal Hemorrhage
 Lacerations:
 Small tears or lacerations of the birth canal are common. Large lacerations are
complications.
 Occur:
 With difficult or precipitate births
 In primigravidas
 With birth of a large infant >9 lbs.
 With the use of a lithotomy position and instruments.
 Either cervical, vaginal, or perineal.

Postpartal Hemorrhage
 If uterus is firm but bleeding persists, suspect a laceration.
 Cervical Laceration:
 Found on the sides of cervix near branches of uterine artery.
 May gush, bright red, immediately after delivery of the placenta.
 Treatment:
 Repair laceration (difficult to see)
 Reassure, may need anesthetic for pain.
Postpartal Hemorrhage
 Vaginal Lacerations:
 Harder to repair, some oozing, may need packing. Remove in 24 to 48 hours.
 Foley catheter inserted due to pressure on urethra.
 Packing left to long causes stasis, infection similar to toxic shock syndrome.
 Perineal Laceration:
 Occur when in lithotomy position for birth, which increases tension on
perineum.
Postpartal Hemorrhage
 Four categories:
 From vaginal mucous membranes to rectum
 Treatment:
 Sutured and treated same as episiotomy repair.
 Document the degree.
 Heal slower due to tearing and ragged edges
 Diet high in fluids, stool softener, no rectal temps, suppositories or enemas.
Postpartal Hemorrhage
 Retained Placental Fragments:
 Portions retained keep uterus from contracting fully, uterine bleeding occurs.
 Happens with a succenturiate placenta ( an accessory lobe), placenta accreta
(fused with myometrium because of abnormal decidua basalis layer.
 May need surgically removed.
 Inspect placenta carefully after birth to see if it is complete.
Postpartal Hemorrhage
 Assessment:
 Lg. Fragment, bleeding, uterus can not contract.
 Sm.fragment, bleeding at day 6 to 10 postpartum. Woman notices an abrupt
discharge of blood.
 If placental tissue is present; elevated serum HCG present.
 Sonogram.
 Treatment:
Postpartal Hemorrhage
 Removal of fragments (D&C)
 Methotrexate to destroy retained placental tissue.
 Teach woman to monitor color of lochia
 Disseminated Intravascular Coagualtion:
 Deficiency in clotting ability caused by vascular injury.
 Subinvolution:
 Incomplete return of uterus to its prepregnant size and shape.
Postpartal Hemorrhage
 Postpartal visit in 4 to 6 weeks, the uterus is still enlarged and soft.
 Lochial discharge still present.
 Results from-sm. placental fragments, mild endometritis, or myoma.
 Management:
 Methergine 0.2 mg four times a day.
 Oral antibiotic (endometritis)
 Anemia
 Teach normal process of involution at D/C
Postpartal Hemorrhage
 Perineal Hematomas:
 Collection of blood in the subcutaneous layer of tissue of perineum.
 Injury to blood vessels during birth.
 Assessment:
 Woman reports severe pain in perineal area or feeling pressure between her
legs. Check for hematoma.
 Purplish color and swelling. (2 cm to 8 cm)
 Tender and palpates as firm globe.
Postpartal Hemorrhage
 Management:
 Report presence, size, degree of discomfort.
 Analgesic, ice, may absorb in 3 to 4 days or may need incised.
 Puerperal Infection
 Uterus is sterile during pregnancy and until membranes rupture.
 Greater risk if tissue edema and trauma are present.
 Pathogens invade.
Infection
 Prognosis for recovery depends on:
 Virulence of the invading organism
 General health of the woman
 Port of entry
 Degree of uterine involution
 Presence of lacerations in the reproductive tract.
 Always serious, it can spread to peritonitis or septicemia. Can be fatal.
Infection
 Management
 Antibiotic after C&S
 Ampicillin, Gentamicin, Suprax
 Use gloves and sterile instruments.
 Proper perineal care
 May need isolation
 Pump breasts if breast feeding
 Give support
Infection
 Endometritis:
 Infection of endometrium, lining of uterus.
 Assessment:
 Temperature elevation, usually on 3rd to 4th day postpartum > 100.4 for 2
days.
 Normal WBC 20,000 to 30,000
 Chills, loss of appetite, general malaise.
 Sonogram for infected placental fragments.
Management:
 Cleocin, oxytocic agent, fluids, analgesic.
Infection
 Fowlers position or ambulate.
 Lasts 7 to 10 days. May be discharged on IV antibiotic at home.
 Can lead to tubal scarring and infertility.
 Infection of the Perineum
 Assessment:
 Suture line, or laceration is port for entry of bacteria.
 Generally remain localized.
 SS-pain, heat, feeling of pressure, inflammation at suture line.

Infection
 Culture any drainage
 Management:
 Remove perineal sutures to open area and allow to drain.
 Packing (iodoform gauze) to keep open.
 Antibiotic, analgesic, sitz bath or warm compresses, change peri pads
frequently.
 Heals by tertiary intention.
 Monitor infant for thrush, bruising, decreased vitamin K > poor clotting.
Infection
 Peritonitis
 Infection of the peritoneal cavity.
 Major cause of death from puerperal infection
 Spreads through lymphatic system or fallopian tubes or uterine wall.
 May settle in cul-de-sac of Douglas.
 Assessment:
 SS-(guarding) rigid abdomen, abdominal pain, high fever, rapid pulse,
vomiting, appears ill.
Infection
 Management:
 Often accompanied by paralytic ileus. Insert NG tube to prevent vomiting and
rest the bowel.
 IV or TPN
 Analgesic, antibiotic.
 May have infertility due to scarring and adhesions in peritoneum.
Thrombophlebitis
 Inflammation of the lining of a blood vessel with the formation of blood clots.
 Usually an extension of endometrial infection.
 Causes:
 Increased fibrinogen level that is still elevated from pregnancy leading to
clotting.
Dilation of lower extremity veins due to pressure of fetal head during
pregnancy and birth.
 Inactivity or prolonged time in stirrups.
Thrombophlebitis
 Classified as SVD or DVT.
 Prone women:
 With varicose veins
 Obese
 Previous thrombophlebitis
 Over 30 yrs. of age with increased parity
 Family history.
 Prevention:
 Prevent endometritis
 Ambulation

Thrombophlebitis
 Limit time in stirrups
 Exam tables well padded
 Support stockings
 Femoral Thrombophlebitis
 Femoral, saphenous, or popliteal veins involved.
 Arterial spasm often diminishes arterial circulation to the leg. This plus edema
give the leg a white appearance.
 Assessment:
Thrombophlebitis
 10th day after birth; elevated temperature, chills, pain, redness in leg.
 Leg swells below the lesion, appears shiny and white. Homans’ sign positive,
diameter of leg increased.
 Doppler US or contrast venography to confirm diagnosis.
 Management:
 Bedrest, elevate leg, anticoagulants and moist heat, analgesic, antibiotic.
 APTT, PT
Thrombophlebitis
 Coumarin, streptokinase or urokinase, Heparin. Later may be placed on
aspirin.
 With treatment will last a few days but it takes 4 to 6 weeks to resolve.
 Pelvic Thrombophlebitis
 Involves the ovarian, uterine, or hypogastric veins.
 Follows mild endometritis
 Occurs on day 14 or 15.
Assessment:
 Suddenly extremely ill, high fever, chills,
Thrombophlebitis
 General malaise.
 Necroses the vein and results in a pelvic abscess. Can become systemic and
result in lung, kidney or heart valve abscess.
 Management:
 Bedrest, antibiotics, and anticoagulants.
 Disease lasts 6 to 8 weeks.
 May need incised by laparotomy
 Tubal scarring > infertility.
 Teach preventive measures.
Pulmonary Embolus
 Obstruction of pulmonary artery with a blood clot.
 Emergency
 Sudden sharp chest pain, tachypnea, tachycardia, orthopnea, cyanosis.
 O2
 ICU
 Mastitis
 Infection of the breast. Occurs on 7th day to weeks or month.
Mastitis
 Organism enters through cracked and fissured nipples.
 Preventive measures:
 Position baby correctly and grasps nipple properly.
 Release baby’s grasp on nipple before removing from the breast.
 Wash hands
 Expose nipples to air for part of day.
 Vitamin E daily
Mastitis
 May come from oral-nasal cavity of the infant.
 Assessment:
 Usually unilateral, pain, swelling, redness, fever and scant breast milk.
 Management:
 Broad spectrum antibiotic
 Continue breast feeding
 Cold or ice compresses
 Support bra
Mastitis
 Warm, wet compresses
 Lasts 2 to 3 days
 May abscess
 Urinary System Disorders
 Urinary Retention:
 Inadequate bladder emptying.

Bladder sensation is decreased due to edema from the pressure of birth.
 Permanent damage may occur from loss of muscle tone.
Urinary System Disorders
 Assessment:
 Associated with use of anesthesia and forceps.
 Percussion or palpation
 Voiding is frequent, sm. And inadequate.
 Always measure 1st voiding after birth. If < 100 mL suspect retension.
 Catheterize after voiding, if > 100mL it is retention.
 Leave Foley in place
Urinary System Disorders
 Management:
 Catheterization
 After 24 hours clamp then remove.
 Fluids, analgesics,
 Void within 8 hours.
 Present for no longer than 48 hours.
 Urinary Tract Infection
 Bacteria may be introduced into bladder.
 Assessment:
 Burning on urination, blood, feeling of

Urinary System Disorders
 Frequency, pain, low grade fever and discomfort from lower abdominal pain.
 Clean catch urine specimen
 Management:
 Sulfa drugs contraindicated for breast feeding.
 Antibiotic-ampicillin
 Fliuds -1 glass /hour
 Analgesics
 5 to 7 days to eradicate completely.
Cardiovascular System Disorders
 Postpartal Pregnancy-Induced Hypertension
 PIH
 May have a preexisting hypertension.
 SS- proteinuria, edema, hypertension.
 Tx.- bedrest, quiet atmosphere, VS, urine output and Magnesium sulfate or
antihypertensive medication.
 Usually some placenta is still present.
 Once a D&C is completed B/P decreases.
 Seizures occur 6 to 24 hours after birth.
Reproductive System Disorders
 Reproductive Tract Displacement:
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Ligaments may no longer be able to maintain the uterus in its usual position or
level after pregnancy.
Problem: retroflexion, anteflexion, retroversion, anteversion or prolapse.
May interfere with fertility, may cause continued pain in lower abdomen.
Cystocele, rectocele, stress incontinence
High parity
Reproductive System Disorders
 Separation of the Symphysis Pubis:
 Ligaments may be stretched by birth and tear.
 Woman feels acute pain on turning or walking. Legs rotate externally (waddle)
 Defect over symphysis pubis, area is swollen and tender.
 Tx. – bedrest, binder, avoid heavy lifting
 4 to 6 weeks to heal
 May need cesarean birth for future.
Emotional Complications
 Difficult bonding with infant.
 Child Born with an Illness:
 Sex of child
 Anger, hurt, disappointment, grief
 Loss of self esteem
 Feelings that child is not real
 Shock to the couple
 ICU visits
 Open lines of communication
Complications
 Woman Whose Child Has Died:
 Questions about what happened.
 Bewildered, bitter, resentful, “Why me”
 Clean the baby and wrap in blanket and let the parents see the baby.
 Stay with them, complete forms, provide a private room.
 Postpartal Depression:
 Almost every woman has some feelings of sadness in 1 to 10 days after
childbirth.
Complications
 Response to anticlimatic feelings after birth.
 Related to hormonal shifts-estrogen, progesterone, corticotropin releasing
hormone levels decline.
 Extreme fatigue, inability to stop crying, increased anxiety about health,
insecurity, psychosomatic symproms (N/V) and depressed or manic mood
fluctuations.
 May need counseling and/or antidepressant therapy.
Complications
 Postpartal Psychosis:
 1 woman in 500
 Response to the crisis of childbearing.
 May previously had mental illness
 Lost contact with reality, may deny she had a child.
 Mat respond as threatening, anger
 Do not leave alone because the distorted perception might lead her to harm
herself.