Postpartum Complications I
Lecture 11
Prepared by MD, PhD Kuziv I.
Subinvolution
is the failure of the
uterus to return to
a nonpregnant
state. The most
common causes of
subinvolution are
retained placental
fragments and
infection.
LACERATIONS
ETIOLOGY AND PATHOPHYSIOLOGY:
Lacerations of the birth canal are second only to uterine
atony as a major cause of postdelivery hemorrhage.
Predisposing Factors:
1. Spontaneous or Precipitous delivery
2. Size, Presentation, and Position of baby
3. Contracted Pelvis
4. Vulvar, perineal, and vaginal varices
HEMATOMA
Etiology and Pathophysiology:
Bleeding into the tissues of the perineal area can
cause hematoma formation. May have at least
500cc. Pooled in the hematoma. May be around
the episiotomy site.
Signs and Symptoms:
1. Pain – perineal.
More than normal
amount of pain.
Mild analgesics are
not sufficient to
decrease the
amount of pain.
2. Hard, firm, area on
the perineum
Treatment and Nursing Care:
1. I & D – incision and drainage.
May leave in a penrose drain.
2. Dressing changes
3. Replace the blood loss
4. Comfort measures
Sequelae of Childbirth Trauma


Disorders of uterus and vagina related to pelvic
relaxation and urinary incontinence, are often result
of childbearing
Uterine displacement and prolapse



Posterior displacement, or retroversion
Retroflexion and anteflexion
Prolapse a more serious displacement

Cervix and body of uterus protrude through vagina and vagina is
inverted
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Types of Fistulas That May Develop
in Vagina, Uterus, and Rectum
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NEUROLOGIC SYSTEM

Neurologic changes during the puerperium
are those that result from a reversal of
maternal adaptations to pregnancy and
those resulting from trauma during labor and
childbirth.
Pregnancy-induced neurologic
discomforts abate after birth.
Elimination of physiologic edema
through the diuresis that follows
childbirth relieves carpal tunnel
syndrome by easing compression of
the median nerve.
Postpartum Depression


Postpartum depression is a nonpsychotic
depressive episode that begins in the
postpartum period due to decreased estrogen
level
Symptoms: changes in appetite or weight, sleep,
and psychomotor activity; decreased energy;
feeling of worthlessness or guilt; difficulty
thinking, concentrating or making decisions; or
recurrent thoughts of death or suicidal ideation,
plans, or attempts.
Postpartum Psychosis




A very serious type of PPD
illness that can affect new
mothers.
Begin 2-3 weeks post
delivery
Fatigue, restlessness,
insomnia, crying liable
emotions, inability to move,
irrationally statements
incoherence confusion and
obsessive concerns about
the infant’s health
Psychiatric emergency
Postpartum Psychologic
Complications

Mental health disorders in postpartum
period have implications for mother,
newborn, and entire family


Interfere with attachment to newborn and
family integration
May threaten safety and well-being of mother,
newborn, and other children
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Postpartum Psychologic
Complications

Postpartum depression without psychotic
features


PPD: an intense and pervasive sadness with
severe and labile mood swings
Treatment options
Antidepressants, anxiolytic agents, and
electroconvulsive therapy
 Psychotherapy focuses fears and concerns of new
responsibilities and roles, and monitoring for suicidal
or homicidal thoughts

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Postpartum Psychologic
Complications

Postpartum depression with psychotic
features



Postpartum psychosis: syndrome characterized
by depression, delusions, and thoughts of
harming either infant or herself
Psychiatric emergency, and may require
psychiatric hospitalization
Antipsychotics and mood stabilizers such as
lithium are treatments of choice
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PLACENTA ACCRETA
Etiology and Pathophysiology:
Placenta accreta is a condition that occurs when all or
part of the decidua basalis is absent and the placenta
grows directly onto the uterine muscle. This may be
partial where only a portion abnormally adhered or it
may be complete where all adhered.
PLACENTA ACCRETA
Etiology and Pathophysiology:
Placenta accreta is a condition that occurs when all or
part of the decidua basalis is absent and the placenta
grows directly onto the uterine muscle. This may be
partial where only a portion abnormally adhered or it
may be complete where all adhered.
Signs and Symptoms:
– During the third stage of
labor, the placenta does not
want to separate.
– Attempts to remove the
placenta in the usual manner
are unsuccessful, and
lacerations or perforation of
Treatment:
the uterus may occur
1. If it is only small portions
that are attached, then these
may be removed manually
2. If large portion is
attached--a Hysterectomy is
necessary!
LATE POSTPARTUM
HEMORRHAGE
Etiology and Pathophysiology:
Occasionally, late postpartal hemorrhage
occurs around the fifth to the fifteenth
day after delivery when the woman is
home and recovering. The most
frequent causes are:
1. Retained placental fragments
 2.
Subinvolution – the uterus fails
to follow the normal pattern of
involution and remains enlarged.

Lochia
fails to
progress from
rubra to serosa
to alba.
The uterus is
higher in the
abdomen.
Irregular or
excessive
bleeding.
TREATMENT AND NURSING
CARE:
 Oral administration of
Methergine for 24-48 hours.
D&C
Thromboembolic Conditions



Thrombophlebitis–the formation of a clot in an
inflamed vein.
Risk factors include maternal age over 35, cesarean
birth, prolonged time in stirrups, obesity, smoking,
and history of varicosities or venous thromboses.
Prevention: client needs to ambulate early after
delivery.
Thromboembolic Conditions



Thrombophlebitis–the formation of a clot in an inflamed
vein.
Risk factors include maternal age over 35, cesarean birth,
prolonged time in stirrups, obesity, smoking, and history of
varicosities or venous thromboses.
Prevention: client needs to ambulate early after delivery.
Thromboembolic Conditions



Thrombophlebitis–the formation of a clot in an inflamed
vein.
Risk factors include maternal age over 35, cesarean birth,
prolonged time in stirrups, obesity, smoking, and history of
varicosities or venous thromboses.
Prevention: client needs to ambulate early after delivery.
THROMBOEMBOLIC
DISEASE
Superficial thrombophlebitis is limited to the superficial saphenous veins,
whereas deep thrombophlebitis generally involves most of deep venous
system.
PREDISPOSING
FACTORS:
 Slowing of blood flow in
legs – usually in Moms
who have a Cesarean
delivery.
 Trauma to the vessels
during delivery.

THROMBOEMBOLIC
DISEASE
Superficial thrombophlebitis is limited to the superficial saphenous veins,
whereas deep thrombophlebitis generally involves most of deep venous
system



PREDISPOSING
FACTORS:
Slowing of blood flow in
legs – usually in Moms
who have a Cesarean
delivery.
Trauma to the vessels
during delivery.
Assessment of Edema & Homan’s Sign



Assess legs for presence and degree of
edema; may have dependent edema in feet
and legs.
Assess for Homan’s sign- thromboembolism
should be negative
Press down gently on the patient’s knee
(legs extended flat on bed) ask her to flex
her foot (dorsiflex)
Signs and Symptoms:
Sudden onset of pain,
tenderness of calf, redness
and an increase in skin temp.
Positive Homan’s Sign.
Treatment and Nursing Care:
Heparin – it does not cross into breast milk.
Signs and Symptoms:
Sudden onset of pain,
tenderness of calf, redness
and an increase in skin temp.
Positive Homan’s Sign.
Treatment and Nursing Care:
Heparin – it does not cross into breast milk.
Signs and Symptoms:
Sudden onset of pain,
tenderness of calf, redness
and an increase in skin temp.
Positive Homan’s Sign
Treatment and Nursing Care:
Heparin – it does not cross into breast milk.
Signs and Symptoms:
Sudden onset of pain,
tenderness of calf, redness
and an increase in skin temp.
Positive Homan’s Sign.
Treatment and Nursing Care:
Heparin – it does not cross into breast milk.
Thank you for
attention