Postpartum Complications
Most common: Hemorrhage and Infection
Postpartum Hemorrhage
Defined as loss of more than 500 mls of blood in the 24 hours period following the third stage of labor or
1000 mls following surgical delivery and does not include blood loss during the delivery.
Slow and subtle- more dangerous because may not notice
Sudden and profuse
Pad count- each additional gm of weight of pad= 1 mL of blood lost
Concealed bleeding with hematomas
No relief from pain meds= hematoma
Early: Occurs in the first 24 hours
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Causes:
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Uterine atony
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Lacerations
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Retained placental fragments
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Hematomas
 Distended bladder
Late: Occurs after first 24 hours
Causes:
Retained placental fragments
Sub-involution
Infection
Bleeding disorders
Risk factors: episiotomy, lacerations, forceps delivery, multiparity over 5, prolonged labor, excessive
massaging of the fundus
Uterine Atony
Atony is the most common cause of early postpartum hemorrhage
Atony refers to lack of muscle tone
Uterus is difficult to feel, and when found, it feels soft or boggy
Fundal height may be high
Lochia is increased and may contain large clots
Bleeding vessels are not contracting
When the uterus is boggy, the nurse should massage it until it is firm while other nurse calls the doctor.
Massage only until firm and then stop.
Pitocin
Hysterectomy
Cervical Lacerations
If fundus is firm and can’t get Mom to stop bleeding suspect cervical tear/laceration
Suspect with bright red bleeding in spite of tightly contracted uterus
Cause: Mom pushes before she is dilated complete 10 cm.
Other causes: Forceps delivery, macrosomia, precipitous delivery
Perineal Lacerations
First degree: tear of skin and MM of the posterior connection of the labia minora and outer vagina
Second degree: Plus muscles and fascia up to the anal sphincter
Third degree: Plus anal sphincter
Fourth degree: Plus extension through the rectal wall
Hematomas
Trauma during delivery
Excessive pain and pressure in the perineal or rectal area- feels warm and may bulge out of vaginal wall
Cold packs to perineum after delivery
Restless
If epidural is working may go straight into shock
Small or size of baseball containing 250-500 mL of blood
Infections
Cystitis- epidural and urinary retention- catheterizations
Watch for signs and symptoms of infection
Mastitis- inflammation or infection of the breast tissue
Inflammation due to blocked milk ducts
Infection from cracks on nipples and bacteria from the mouth of the baby
Swollen engorged breasts
Painful breasts
Reddened and hot to the touch
Fever
Malaise
Goal: get milk flowing freely again
Express milk manually or use a breast pump every 4 hours
Warm heat
Cabbage
Analgesics and antibiotics
Wash nipples and air dry and coat with milk- nurse until abscess
Pitocin Reminder
Given at any time can cause water intoxication
Stimulates contraction
Promotes fluid retention
Monitor I&O
Peurperal Infection
Report temp > 100.4F 24 hours after delivery and/or 2 of the first 10 postpartum days
Normal elevated temp for first 24 hours due to blood loss, dehydration, etc.
Chills, anorexia, vomiting, lower abdominal tenderness, purulent or malodorous Lochia
Treatment
Fowler’s position for drainage
Assess Lochia
Cultures/sensitivities
IV antibiotics
Isolation
Suppress milk and discard
Amniotic Fluid Embolism
Occurs when amniotic fluid, with its particles such as vernix, fetal hair, and sometimes meconium, enter
the woman’s circulation and typically obstructs small blood vessels in her lungs
Characterized by abrupt onset of hypotension, respiratory distress, and coagulation abnormalities
Thrombophlebitis
Treatment
Measure calf
Bed rest with elevation of affected leg
Application of heat
Heparin or Lovenox
Oral anticoagulants for 6 weeks
Avoid crossing legs, constriction, etc.
Postpartum Depression
Hormonal changes in the postpartum period contribute to the mood swings and depression
Postpartum blues- appears within 3-10 days and disappears within 2 weeks
Crying, sadness, irritability
20% of new mothers
True Depression
Sadness doesn’t go away in 2 weeks
Anger 1 month after delivery
Changes in appetite or sleep
Panic attacks
Lack of interest in surroundings or baby
Appears 2 weeks after delivery to 1 year postpartum
More intense symptoms
Alterations in family
Ineffective coping
Babies may fail to thrive
Postpartum Psychosis
Delusions
Hallucinations
Confusion
Desire to harm baby
Immediate care by obstetrician and psychiatrist