Nursing care of a Family

Experiencing a Postpartum
Complication

Prepared By: Analisa L. Pepito RN,MN

 • The postpartal period is a
time when women are very
Nursing Care susceptible to hemorrhage
and thrombophlebitis and,
when these complications
Planning develop, women may
choose not to breastfeed

Based on because of them. The 2020

National Health Goals that
speak to this include:
2020 • Reduce the maternal
National mortality rate to no
more than 11.4 per
100,000 live births
Health Goals from a baseline of
12.7 per 100,000.
• Increase the
Nurses can help the nation proportion of infants
achieve these goals by who are breastfed to
at least 81.9% from a
carefully monitoring uterine baseline of 74%.
involution in the postpartal • Increase the
proportion of infants
period and by encouraging who are breastfed at
6 months from a
women to breastfeed even baseline of 43.5% to
in the face of a postpartal 60.6%

complication.
 Nursing Care Planning using Assessment

NURSING
PROCESS
OVERVIEW
For a Woman
Experiencing a
Postpartum
Complication.
ASSESSMENT
Assess each woman holistically to determine how the
health problem a woman is experiencing is impacting her
and her family.

Assessment findings associated with a postpartum

complication may be subtle, such as tenderness in the calf
of a leg, an increase in uterine or perineal pain, a slight
elevation in temperature, or a small increase in the amount
of lochia flow.

Do not rely solely on a woman’s report of perineal

healing or amount of lochia flow; always inspect her
perineum and lochia yourself because the report of “I feel
fine” or “my bleeding was just a small amount” may be
deceptive if she has no familiarity with normal lochia,
perineal healing, or fundal height against which to
accurately compare her own condition.
NURSING DIAGNOSIS

Nursing diagnoses during this time vary depending on the

postpartal complication.

• Deficient fluid volume related to blood loss

• Ineffective breastfeeding related to the development of mastitis
• Risk for impaired parenting related to postpartum depression
• Risk for injury to self and newborn related to postpartal psychosis
• Acute pain related to a collection of blood in traumatized tissue
(hematoma)secondary to birth trauma
• Situational low self-esteem related to inability to perform regular tasks
• Social isolation related to precautions necessary to protect infant and
others from infection transmission
• Ineffective peripheral tissue perfusion related to interference with
circulation secondary to development of thrombophlebitis (blood clot)
• Risk for infection related to microorganism invasion of episiotomy,
surgical incision site, or migration of microorganisms from the vagina to
the uterus
OUTCOME IDENTIFICATION
AND PLANNING

• Outcome identification for a woman with a

postpartum complication may be particularly
difficult, because although a woman wants to do
everything necessary to return to health, she also
does not want anything to interfere with her ability
to bond with and take care of her new child.
• As a rule, however, never underestimate how
much a woman will endure to enable herself to
“mother her new child. This ability of a mother to
overcome challenges to meet her child’s needs is the
essence of motherhood

• Provide for measures that will restore the woman

most quickly to health and promote contact among
her, her child and her primary support person. If
physical contact between a mother and her newborn
is not possible, give her mother frequent reports of
her infant’s condition and include her in planning
care for her newborn.

• If the infant is being cared for in another facility,

ask them to provide photographs of the infant. His
provides something tangible to which a new mother
can connect with her newborn.
Postpartum Hemorrhage
▪Refers to excessive blood loss during or after the third stage of labor.
▪Defined as blood loss of 500 ml or more following vaginal birth(occurs
occasionally as many as 5-15% of postpartal women.(Dahlke, Menez-
Figueroa, Maggio et al.,2015).
▪Ceasarean Birth Hemorrhage is present when there is 1000 ml blood loss
or a 10% decrease in the hematocrit level. (Pratts & Henderson, 2015).
▪Leading cause of maternal mortality
Incidence:
➢3-6% overall incidence
➢3.9% in vaginal deliveries
➢6.4% in cesarean deliveries
➢1-2% in delayed postpartum
hemorrhage
Types of Postpartum Hemorrhage
1. Early postpartum hemorrhage
occurs during the first 24 hours after delivery
Common causes:
▪ Uterine atony
▪ Laceration of the birth canal(cervix, vagina &perineum)
▪ Inversion of the uterus, uterine rupr
DIC

2. Late postpartum hemorrhage

occurs from 24 hours after birth to 6 weeks postpartum.
Common causes:
▪ Retained placental fragments
▪ Sub involution of the uterus
▪ Infection
CONDITIONS THAT INCREASE A WOMAN’S RISK FOR A
POSTPARTAL HEMORRHAGE.

1.Conditions that distend the uterus beyond average capacity:

a. Multiple gestation
b. Polyhydramnios (Excessive amount of amniotic fluid)
c. A large baby (>9 lb)
d. presence of uterine myomas(fibroid tumors)

2. Conditions that would have caused cervical or uterine lacerations:

a. an operative birth
b. a rapid birth

3. Conditions with varied placental site or attachment:

a. Placenta previa
b. Placenta accreta
c. Premature separation of the placenta
d. Retained placental fragments
4. Conditions that leave the uterus unable to contract readily:

a. Deep anesthesia or analgesia

b. Labor initiated or assisted with Oxytocin agent
c. High parity or maternal age over 35 years of age
d. Previous uterine surgery
e. Prolonged or difficult labor
f. Chorioamnionitis or endometritis
g. Secondary maternal illness such as anemia
h. Prior history of postpartum hemorrhage
i. Prolonged use of magnesium sulfate or other tocolytic
therapy.

5. Conditions that lead to inadequate blood coagulation:

a. Fetal death
b. Disseminated Intravascular Coagulation (DIC).
 Four Main Reasons for Postpartum
Hemorrhage

1. Uterine Atony
2. Trauma (Lacerations, hematoma, uterine inversion, or uterine rupture)
3. Retained placental fragments
4. Development of Disseminated Intravascular Coagulation (DIC).

These causes are generally referred to as:

The Four T’s of Postpartum Hemorrhage (mnemonic)

1. Tone
2. Trauma
3. Tissue
4. Thrombin
CAUSES: 4 T’s

1.Tone

UTERINE ATONY or relaxation of the uterus, is the most frequent cause of

postpartum hemorrhage, it tends to occur most often in Asian, Hispanic, and
Black woman (Grobman, Bailit, Rice, et al., 2015).

If the uterus suddenly relaxes, there will be an abrupt gush of blood vaginally
from the placental site.

The best safeguard against uterine atony is to palpate a woman’s fundus

at frequent intervals to be assured her uterus is remaining contracted.

Frequent assessments of lochia(to be certain the amount of the flow is under

a saturated pad per hour and that any clots are small), as well as vital signs,
particularly pulse and blood pressure, are equally important determinants.
THERAPEUTIC MANAGEMENT FOR UTERINE ATONY

1. Fundal massage
2. If a woman’s uterus does not remain contracted, contact her primary care provider
so interventions to increase contraction will be given.

Important drugs readily available for use on a hospital unit in the event of
Postpartum hemorrhage.

a. Oxytocin (Pitocin) – Incorporation, IV, IM

b. Methylergonovine maleate (Methergine) – IM , maybe repeated every 2 to 4
hours up to 5 doses (0.2 mg), contraindicated with hypertensive patients.
c. Carboprost tromethamine (Hemabate) 250 micrograms- may be repeated
every 15 to 90 minutes up to 8 doses.
Common side effect: diarrhea and nausea.
d. Misoprostol (Cytotec) 200 mcg – may be administered rectally to decrease
postpartum hemorrhage. A second dose of misoprostol should not be
administered unless a minimum of 2 hours has elapsed.
Nursing alert:
Be aware that all of these medications can increase blood pressure and so must be used cautiously in
women with hypertention. Assess BP prior to administration and about 15 min afterward to detect
potentially dangerous side effect.
ADDITIONAL MEASURES TO COMBAT UTERINE ATONY:

1. Elevate the woman’s lower extremities to improve circulation to essential

organs.
2. Offer bedpan for at least every 4 hours to be certain her bladder is emptying
because a full bladder predisposes a woman to uterine atony. Or insert a urinary
catheter to reduce possibility of bladder pressure.
3. Administer Oxygen by face mask at a rate of about 10 to 12 L/min if the woman
is experiencing respiratory distress from decreasing blood volume. Position her
supine (flat) to allow adequate blood flow to her brain and kidneys.
4. Obtain vital signs frequently and assess them for trends such as a continually
decreasing blood pressure with a continuously rising pulse rate.

NOTE:
Explain that these measures are disturbing, but that they are important for her
and welfare. Obtain measurements as quickly and gently as possible to cause a
minimum of discomfort and disruption, allowing the woman to rest from
exhaustion of labor and blood loss.
• If fundal massage and administration of uterotonics(drugs to contract the uterus) are
not effective at stopping uterine bleeding, a sonogram may be done to detect possible
retained placental fragments.

The primary care provider may attempt to do:

1. Bimanual compression
2. Blood replacement to replace blood loss with postpartal hemorrhage.
3. Hysterectomy or suturing – this is the last resort, ligation of the uterine arteries or a
removal of the uterus.
2. Trauma: 20% of postpartum hemorrhage cases.

Cause:
✓Lacerations and episiotomy
✓Hematoma
✓Cesarean section
✓Uterine rupture and uterine inversion
✓Uterine perforation during forceps application or
curettage
Trauma
1. LACERATIONS(Cervix, vagina or perineum)
Small lacerations or tears of the birth canal are common and maybe
considered normal consequence of childbearing, however, large lacerations
can be sources of infection or hemorrhage.

A. Cervical laceration – usually found on the sides of the cervix, near the
branches of the uterine artery. If the artery is torn, blood loss may be so great
that blood gushes from the vaginal opening and is brighter red than the
venous blood lost with uterine atony.

Therapeutic management:
The repair of a cervical laceration, usually requires sutures and can be
difficult because if bleeding is intense this obstructs visualization of the area.
May require regional anesthetics to relax the uterine muscle and to prevent
pain. Explain for the need of anesthetic and the procedures being carried out.
Be certain the primary care provider has the adequate space to work,
adequate sponges and suture supplies, and a good light source.
Trauma

B. Vaginal lacerations are easier to locate

and assess than cervical laceration because they are much easier to view.

Therapeutic Management:

Vaginal tissue is friable making it difficult to suture. Some oozing often

occurs after vaginal repair, so the vagina maybe packed to maintain
pressure on the suture line. An indwelling urinary cath may be placed
following the repair because the packing causes such pressure on the
urethra that it can interfere with voiding.

Document when and where packing was placed so you can be certain it
is removed after 24 to 48 hours or before hospital discharge to prevent
infection.
Trauma

C. Perineal lacerations –are more apt to

occur when the woman is placed in
lithotomy position for birth rather than a
supine position because a lithotomy
position increases tension on the perineum.

CLASSIFICATION OF PERINEAL
LACERATIONS

1. First degree – Vaginal mucous membrane and the skin of the perineum to the
fourchette.
2. Second degree – vagina, perineal skin, fascia,
levator ani muscle, and perineal body.
3. Third degree – entire perineum, extending to
reach the anal sphincter.
4. Fourth degree – entire perineum, rectal sphincter, and some of the mucous membrane
of the rectum and some of the mucous membrane of
rectum.
TRAUMA

2. PERINEAL HEMATOMA is a collection of blood

in the subcutaneous layer of tissue of the perineum.

AS A RULE: the overlying skin is intact with no

noticeable trauma.

Hematomas are most likely to occur after rapid,

spontaneous births and in women who have
Perineal varicosities. Injury to the vagina and the
perineum during delivery may cause swelling,
Bruising or a collection of blood under the skin.

Small hematomas usually go away without treatment..

Painful large hematomas may need drainage of the
blood that collects in them.
THERAPEUTIC MANAGEMENT FOR PERINEAL
HEMATOMA

1. Administer a mild analgesic a s prescribed for pain relief.

2. Applying ice pack(covered with a towel to prevent thermal
injury to the skin) may prevent bleeding. Usually, a hematoma is
absorbed over the next 3-4 days.
If hematoma is large or continues to increase in size, the
woman may have to be returned to the birthing room to have the site incised and
the bleeding vessel ligated under local anesthesia.

You can assure the woman that even though the hematoma is causing him
considerable discomfort, it is not a serious complication and will slowly reabsorb
over the next 6 weeks causing no further difficulty.

If an episiotomy incision was opened to drain a hematoma, it may be left open

and packed with gauze rather than resutured. Be certain to record the packing
was placed so it can be removed in 24-48 hours. Healing will occur more slowly
than a usual intention suture line.
TRAUMA

3. UTERINE INVERSION - is a prolapse

of the fundus of the uterus through the
cervix so that the uterus turns inside out.
Usually occurs right after birth of the fetus
or delivery of the placenta.

A rare phenomenon occurring in about 1 in

20,000 births(Furukawa & Sameshima, 2015)

Causes:
1. May occur if traction is applied to the umbilical cord to remove the
placenta or if pressure is applied to the uterine fundus when the uterus
is not contracted.
2. May also occur if the placenta is attached at the fundus so that during
birth, the passage of the fetus pulls the fundus downward(Choubey &
Werner, 2015)
TRAUMA :

UTERINE INVERSION

When an inversion occurs:

a. A large amount of blood suddenly gushes from the vagina
b. The fundus is no longer palpable in the abdomen
c. The woman begins to show signs of blood loss: hypotension, dizziness, paleness
or diaphoresis
d. The uterus is not able to contract in this position, bleeding can’t be halted or will
continue to such an extent exsanguination could occur within 10min.

NEVER ATTEMPT TO REPLACE AN INVERSION because handling the uterus

could increase the bleeding.

NEVER ATTEMPT to remove the placenta if it is still attached because this would
create a larger surface area for bleeding.

Oxytocin, if being used, should be discontinued because it will make the uterus
more intense and difficult to replace.
INVERSION OF THE UTERUS MANAGEMENT

a. An IVF line is inserted if one is not already present, open for restoration of fluid.
b. Use a large-gauge needle because blood will need to be replaced.
c. Administer oxygen by mask.
d. Assess vital signs especially BP and pulse.
e. Be prepared to perform cardiopulmonary resuscitation (CPR) if the heart should
fail from the sudden blood loss.
f. The woman will immediately be given general anesthesia or possibly nitroglycerin
or tocolytic drug by IV to relax the uterus.
g. The primary care provider then replaces the fundus manually.
h. Administer Oxytocin after manual replacement helps the uterus to contract and
remain in its natural place.
i. The woman will need antibiotic therapy to prevent infection because the uterine
endometrium was exposed.
j. Inform the client that cesarean birth will probably be necessary in any future
pregnancy to prevent the possibility of repeat inversion.
3. Tissue: presence of retained placental tissues prevents full
uterine contractions resulting in failure to seal off bleeding vessels.

Cause:
✓Presence of succenturiate or accessory lobe
✓Preterm gestation especially in less than 24 weeks gestation
✓Abnormal adhesions such as accreta, increta and percreta.

To identify the complication of a retained placenta (severe

postpartal hemorrhage), every placenta should be inspected
carefully after birth to be certain it is complete.

How to detect retained placental fragments?

1. Ultrasound
2. Blood serum sample for presence of HCG(Human Chorionic
Gonadotropin) reveals that part of the placenta is still present.
Therapeutic Management Retained
Placental Fragments

1. Dilatation and Curettage (D & C) – removal of the retained

placental fragment is necessary to stop the bleeding.
2. If it cannot be removed, Methotrexate may be prescribed to
destroy the retained placental fragment.
3. Balloon occlusion and embolization of the internal iliac
arteries may be necessary to minimize blood loss in some
instances of placenta accreta which is so deeply attached to the
myometrium.
4. In others, Hysterectomy(removal of the uterus) must be
performed. (Silver, 2015).
4. Thrombin: Coagulopathy

Cause:
✓Prexistent coagulation disorder: thombocytopenic
purpura
✓Acquired disorder: Preeclampsia and HELLP
syndrome( hemolysis, elevated liver enzymes, and low
platelet count). DIC
✓Dilutional coagulopathy in which clotting factors are
significantly reduced with aggressive transfusion of
crystalloid and packed red blood cells (PRBCs).
DISSEMINATED INTRAVASCULAR COAGULATION

DIC – is a deficiency in clotting ability caused by vascular injury. It is an

acquired disorder of blood clotting in which the fibrinogen level falls to
below effective limits (Cunningham & Nelson, 2015)
DIC occurs when there is such extreme bleeding and so many platelets and
fibrin from the general circulation rush to the site that there is not enough
left in the rest of the body. This is an emergency because it can result in
extreme blood loss.
 Predisposing Factors

• Abruptio placenta.
• Amniotic fluid embolism.
• Endotoxic shock.
• Eclampsia and pre-eclampsia.
• Hydatidiform mole.
• IUFD and missed abortion.
• Incompatible blood transfusion or
• Prolonged shock of whatever the cause.
• Placenta accreta.
• Rupture of uterus.
 Clinical Features
Unexplained spontaneous bleeding from any
site e.g.
• oozing of blood
• bruising
• epistaxis
• hematuria
• hematoma formation especially at wound
and venepuncture site
• postpartum hemorrhage.
 Management
• Elimination of the underlying cause.
• Fresh blood transfusion- contains clotting
factors esp F II, V and VIII.
• Fresh frozen plasma contains 3 gm
fibrinogen/L in addition to F V and VIII.
• Fibrinogen
• Heparin
• Antifibrinolytic
LATE POSTPARTAL HEMORRHAGE

SUBINVOLUTION

• It is the incomplete return of the uterus to its

pre-pregnant size and shape.

• With subinvolution, at 4 or 6 week postpartal

visit, the uterus is still enlarged and soft.
Lochial discharge is still present.

• Subinvolution may result in small retained

placental fragments, a mild
endometritis(infection of the endometrium), or
an accompanying problem such as a uterine
myoma that is interfering with complete
contraction.
 THERAPEUTIC MANAGEMENT FOR
SUBINVOLUTION

1. Oral administration of Methylergonovine, 0.2 mg 4x a daily, is the

usual prescription to improve uterine tone and complete involution.
2. Oral antibiotic, if uterus feels tender upon palpation suggesting
endometritis.
3. Be certain the women are able to recognize the normal process of
involution and lochial discharge, this helps the women identify
subinvolution and seek early care if it occurs.

A chronic loss of blood from subinvolution will result in anemia and a

lack of energy, conditions that possibly could interfere with infant bonding
or lead to infection.
PUERPERAL INFECTION
 PUERPERAL INFECTION
• A term used to describe bacterial infections after childbirth. Infection occurs
in 3% of all women who had vaginal births and is 5 to 10 times more frequent
in those who had Cesarean births (Gibbs, Sweet, & Duff, 20040.

• Infection of the reproductive tract in the postpartal period is another major

cause of maternal mortality (Galvao, Braga, Goncalves, et al, 2016)

Theoretically, the uterus is sterile during pregnancy and up until the

membranes rupture. Pathogens can begin to invade; the risk of infection grows
even greater if tissue edema are present.

A puerperal infection is always potentially serious, because although it usually

begins as only local infection, it has the potential to spread to the
peritoneum(peritonitis) or the circulatory system (septicemia), conditions
that can be fatal in a woman whose body is already stressed from childbirth.
 Organisms commonly The management for
cultured postpartally include puerperal infection focuses
the group B streptococci, on the use of an appropriate
staphyloccoci, and aerobic antibiotic after culture and
gram-negative bacilli such as sensitivity testing of the
Escherichia coli. isolated organism.
 CONDITIONS THAT INCREASE A WOMAN’S RISK
FOR POSTPARTAL INFECTION
RISK FACTOR BASIS FOR RISK
1. Rupture of the membranes more than 24 1. Bacteria may have started to invade the
hours before birth. uterus while the fetus is still in utero.
2. The tissue necroses and serves as an
2. Retained placental fragments. excellent bed for bacterial growth.
3. The woman’s general condition is
weakened.
3. Postpartal hemorrhage
4. The woman’s general condition is
4. Preexisting anemia weakened.
5. Prolonged and difficult labor, particularly 5. Trauma to the tissue may lead lacerations
with instrument births. or fissures for easy portals of entry for
infection.
6. Internal fetal heart monitoring electrodes. 6. Contamination may have been introduced
with placement of scalp electrodes.
7. Local vaginal infection present at the time
of birth. 7. A direct spread of infection has occurred.
8. Uterus explored after birth for a retained 8. The infection was introduced with
placenta or abnormal bleeding site. exploration.
PUERPERAL INFECTION
Defined as a fever of 38 ℃ (100.4 ℉) or higher after the first 24 hours
and occurring on at least 2 days during the first 10 days after childbirth.
Although a slight elevation of temperature may occur during the first 24 hours
because of dehydration or exertion of labor, any mother with fever should be
assessed for other signs of infection.

Other Risk Factors:

1. Cesarean birth is a major predisposing factor because of the tissue trauma

that occurs in surgery, the incision that provides an entrance for bacteria, the
possibility of contamination during surgery, and the foreign bodies such as
sutures that can promote infection.
2. Any trauma to maternal tissues increases the hazard of infection. (rapid
delivery, birth of large infants, use of vacuum extractor or forceps, manual
delivery of placenta, lacerations, episiotomies, catheterizations and excessive
number of vaginal examinations). Every vaginal examination increases the
possibility of contamination from gloves or from organisms in the vagina
that are pushed through the open cervix.
3. Lack of knowledge of hygiene or lack of access to facilities that permit
adequate hygiene increases the risk of postpartum infection.
 EFFECT OF NORMAL ANATOMY AND PHYSIOLOGY ON INFECTION

• To understand the seriousness of infection of the reproductive tract, consider the

anatomy of the region. Every part of the reproductive tract is connected to every
other part, and organisms can move from vagina, through the cervix, into the
uterus, and through the fallopian tubes to infect the ovaries and the peritoneal
cavity.
• The entire reproductive tract is particularly well supplied with blood vessels during
pregnancy and after childbirth. Bacteria that invade or are picked up by the blood
vessels or lymphatics can carry the infection to the rest of the body, which can
result in life-threatening septicemia.

• The normal physiologic changes of childbirth increase the risk of infection. During
labor the acidity of the vagina is reduced by the amniotic fluid, blood and lochia,
which are alkaline. An alkaline environment encourages growth of bacteria.
• Necrosis of the endometrial lining and the presence of lochia provide a favorable
environment for the growth of anaeorobic bacteria. Many small lacerations, some
microscopic, occur in the endometrium, cervix and vagina during birth and allow
bacteria to enter the tissue.
• Scrupulous aseptic technique during labor and birth and careful handwashing
during the postpartum period are also major preventive factors.
•MOST COMMON POSTPARTUM INFECTIONS

1. Metritis (Inflammation of the uterus, endometritis, endomyometritis,

endoparametritis). It involves infection of the, endometrium, muscles,
inner lining and surrounding tissues of the uterus.
2. Wound infections- most common types of puerperal infection because any
break in the skin or mucous membrane provides a portal of entry for
bacteria.
3. Urinary tract infections –a woman who was catheterized at the time of the
childbirth or during the postpartal period is prone to the development of
infection because bacteria may be introduced into the bladder at the time
of catheterization. Pushing with labor may also have allowed some
secretions to enter the urinary urethra.
4. Mastitis - infection of the lactating breasts.
5. Pelvic thrombophlebitis – involves the ovarian, uterine or hypogastric
veins. Inflammation of the blood vessels in the pelvic area causes partial
obstruction of , which leads to slowed blood flow and clots in the stagnant
blood in the vessels.
 ENDOMETRITIS
• It is an inflammation of the endometrium, the lining of the uterus
(Pratts & Henderson, 2015).

• Bacteria gain access to the uterus through the vagina and enter the uterus
either at the time of birth or during the postpartal period. This may occur
with any birth, but the infection is usually associated with
chorioamnionitis and a cesarean birth (Shanks, Mehra Gross, et, at, 2016).

• The fever of endometritis usually manifest itself on the 3rd or 4th day,
suggesting that much of the invasion occurred during labor or birth
(consistent with the time it takes for infectious organisms to grow). A rise
in temperature that occurs on the 3rd or 4th postpartum day occurs
coincidentally at the same time as breast filling occurs. Do not be led
astray, suspect fever on the 3rd or 4th day postpartum as possible
endometritis until proven otherwise.
• ENDOMETRITIS

Depending on the severity of the infection, a woman may

have accompanying :
> Chills, loss of appetite, and general malaise.
> Usually uterus is not well contracted
> Painful to touch
> She may feel strong afterpains
> Lochia is usually brown and has a foul odor and
may be increased in amount because of poor uterine
involution.
THERAPEUTIC MANAGEMENT FOR ENDOMETRITIS
1. Antibiotic such as Clindamycin (Cleocin), as determined in culture.
2. Oxytoxic agent such as methylergonovine may also be prescribed to
encourage uterine contraction.
3. Urge the woman to drink additional fluid to combat the fever.
4. Analgesic for strong uterine contractions may be given if there is strong
afterpains and abdominal discomfort.

Be certain you have taught the woman about the signs and symptoms of
endometritis before healthcare agency discharge.

An added danger of endometritis is that it can lead to tubal scarring and

interference with future fertility.
 PHLEBITIS is
THROMBOPHLEBITIS inflammation of the
lining of a blood vessel.

THROMBOPHLEBIT
IS is
inflammation with the
formation of
blood clots.

It is classified as either
superficial
vein disease(SVD) or
Deep vein thrombosis
(DVT).
• THROMBOPHLEBITIS occurs in the postpartum period
because:

1. A woman’s fibrinogen level is still elevated from pregnancy, leading to increased

blood clotting.
2. Dilatation of lower extremity veins is still present as a result of pressure of the fetal
head during pregnancy and birth so blood circulation is sluggish.
3. It tends to occur most often in women who: are relatively inactive in labor and
during the early puerperium because this increases the risk of clot formation.
4. Have spent prolonged time in a birthing room with their legs positioned in stirrups.
5. Have preexistent obesity and a pregnancy weight gain, which can lead to inactivity
and lack of exercises.
6. Have preexisting varicose veins
7. Develop a postpartal infection
8. Have a history of previous thrombophlebitis.
9. Are older than age 35 years or have increased parity.
10.Have a high incidence of thrombophlebitis in their family.
11.Smoke cigarettes because nicotine causes vasoconstriction and reduces
blood flow.
 Types of Thromboembolitic Disorders

1. Superficial thrombophlebitis (more common in postpartum)

2. Deep Vein thrombosis (DVT)
a. More frequently seen in women with history of thrombosis.
b. Increased incidence in women with obstetrics complications such as
hydramnios, preeclampsia, and operative birth.
3. Septic pelvic thrombophlebitis (ovarian, uterine or hypogastric veins)
a. A complication that develops in conjunction with infections of the reproductive
tract.
b. More common in women with a cesarean birth, incidence is 1 in 800 deliveries.
c. DVT and septic pelvic thromboemboli predispose clients to pulmonary
embolism.
4. Pulmonary Embolism
a. A catastrophic event with high mortality rate: most fatalities occur within 30 min
b. Occurs most commonly in postpartum.
• FEMORAL THROMBOPHLEBITIS – the femoral,
saphenous, or popliteal veins are involved.

• Although the inflammation site in thrombophlebitis is a

vein, an accompanying arterial spasm often occurs,
diminishing arterial circulation to the leg as well.

• Ambulation, limiting the time a woman remains in

obstetric stirrups encourages circulation in the lower
extremities, promotes venous return, and decreases the
possibility of clot formation, this helping to prevent
thrombophlebitis.
• THERAPEUTIC MANAGEMENT FOR THROMBOPHLEBITIS

1. Administration of anticoagulants. (Heparin)

2. Application of moist heat ( to decrease inflammation).
3. Bed rest with the affected led elevated.
4. Never massage the skin over the clotted area because this could
loosen the clot, causing a pulmonary or cerebral embolism.
5. Thrombolytics ( medications that dissolve clots)
6. Antibiotics will be given if the underlying cause of the condition is
infection.

With proper treatment, the acute symptoms of femoral thrombophlebitis last

only for few days, but the full course of the disease takes 4 to 6 weeks before
it is fully resolved.
Anticoagulant therapy may need to be continued for as long as 3 to 6
months.
The affected leg may never return to its former size and may always
cause discomfort after long periods of standing.
 PELVIC THROMBOPHLEBITIS
This involves the ovarian, uterine or hypogastric veins. It usually follows a
mild endometritis and occur later than femoral thrombophlebitis, often
around 14th to 15th of the puerperium.

Inflammation of the blood vessels in the pelvic area causes a partial

obstruction which leads to slowed blood flow and clots in the stagnant blood
in the vessel.
Risk factors are the same with femoral thrombophlebitis, the prevention of
endometritis by the use of good aseptic technique during and after birth is
important to help prevent the disorder.
A woman suddenly becomes extremely ill, with a high fever, chills, abdominal
pain, weakness, and general malaise.

Therapy involves total bedrest and the administration of analgesics,

antibiotics and anticoagulants.
 Pulmonary Embolism
• A pulmonary embolus is obstruction of the pulmonary artery by a
blood clot; usually occurs as a complication of thrombophlebitis
when a blood clot moves from the leg vein to the pulmonary artery
(Konkle, 2015).

• SIGNS: sudden, sharp chest pain; tachycardia, tachypnea;

orthopnea(inability to breathe except in an upright position); and
cyanosis (the blood clot is blocking both blood flow to the lungs
and return to the heart).

• This is an emergency. A woman needs oxygen immediately and is

at high risk for cardiopulmonary arrest. Her condition is extremely
guarded until the clot can be lysed or adheres to the pulmonary artery
wall and is reabsorbed. Because of the seriousness of the condition, a
woman with pulmonary embolism commonly is transferred to ICU for
continuing care.
 PREVENTING THROMBOPHLEBITIS
• 1. Ask your primary care provider if you can use a side-lying or back-
lying(supine recumbent) position for the birth rather than a lithotomy
position because a lithotomy position can increase the tendency for pooling
of blood in the lower extremities.
• 2. If you will be using a lithotomy position, ask for padding on the stirrups to
prevent pressure on the calf of your legs.
• 3. Drink adequate fluids to be certain you’re not dehydrated (6 to 8 glasses of
fluid/day)
• 4.Do not sit with your knees crossed or bent sharply and avoid wearing
constricting clothing such as knee-high stockings.
• 5. Ambulate as soon after birth as possible because walking is the best
preventive measure. When resting in bed, wiggle your toes or do leg lifts to
improve venous return.
• 6. Ask your primary care provider if he or she recommends support stockings
in the immediate postpartal period. Be certain to put these on before
ambulating in the morning before leg veins fill.
• 7. Quit smoking because this is associated with the development of
thrombophlebitis.
 MASTITIS
• MASTITIS – infection of the breast, may occur as early as the 7th postpartal
day or not until the baby is weeks or months old (Witt, Bolman, Kredit, et al,
2016)

• The organism causing the infection usually enters through a cracked and
fissured nipples.
• To prevent mastitis, it is important to prevent nipples from cracking through
measures such as:
1. Making sure the baby is positions correctly and grasps the nipple properly,
including both the nipple and areola.
2. Helping a baby release a grasp on the nipple before removing the baby from
the breast.
3. Washing hands between handling perineal pads and touching breasts.
4. Exposing nipples to air for at least part of every day.
5. Possibly using a Vitamin E ointment daily to soften nipples.
6. Encouraging women to begin breastfeeding (when the infant sucks most
forcefully) on an unaffected nipple (if a woman has one cracked nipple and
one well nipple).
 Mastitis
Causative organism:
• Staphylococcus aureus which may reach the
breast from infected baby.

Clinical picture:
• Breast is painful, tender, red , tense and hot.
• Axillary lymph nodes are enlarged.
• High fever may reach 40.5oC.

Treatment:
• Stop lactation on the affected breast.
• Support the breast: over a pad of cotton wall.
• Antibiotic therapy - penicillin
• Analgesics – antipyretics-
POSTPARTUM PSYCHIATRIC DISORDER
Cause
❑ exact cause is unknown though some
contributing factors are accepted:

✓Due to the stress of peripartum period

characterized by sudden decrease in the
endorphins, estrogen, and progesterone
levels

✓Low free serum tryptophan levels

✓Postpartum thyroid dysfunction

RISK FACTORS:
• Unwanted pregnancy
• Feeling unloved by mate
• Below 20 years old
• Single mother
• Low self-esteem
• Dissatisfaction of extent of education
• Economic problem with housing or income
• Poor relationship with husband or
boyfriend
• Being part of a family with 6 or more
siblings
• Limited parental support
• Past or present evidence of emotional
problem
CLASSIFICATION

1. Postpartum blues
2. Postpartum depression
3. Postpartum psychosis
 • 50-70% incidence.
Post • A transient disorder that occurs 2-3 days
after delivery, peaking on the 5th day and
Partum usually resolves within 10 to 14 days
Blues • Manifestations:
• Mood lability, weeping, depression,
fatigue, anxiety, confusion, difficulty
concentrating, depersonalization.
• Cause:
❑ hormonal changes after delivery
• Risk factor:
1. History of depression
2. Pre-existing psychosocial impairment
MANAGEMENT:

✓PPB is self limiting and has little effect on

the woman’s ability to carry out her normal
daily functions in majority of cases.

✓Supportive care education

✓If symptoms do not disappear within or

become increasingly severe, refer for
psychiatric evaluation and counseling.
POSTPARTUM DEPRESSION
➢More prolonged affective disorder that often
occurs during the first month after delivery and
last for weeks to months.
Risk factors
1. Postpartum blues
2. History of postpartum depression
3. History of mood disorder or premenstrual dysphoric
disorder
4. Family history of depression, bipolar illness, and/or
anxiety.
5. Marital dissatisfaction
6. Anxiety/depression during pregnancy
7. Infant-related stressors
8. Adverse life event stressors
9. Inadequate support from family or friends
Management

✓Screening
✓Individual counseling
✓Group therapy
✓Therapeutic communication
✓Provide assistance in performing activities
of daily living
✓Support groups
✓Monitor for signs of suicidal tendencies
when depression sets in and when the
patient begin to recover
✓Medications
 • Incidence 4-10%.

• Onset within days to weeks following

delivery.
Post • Risk factors: previous depression,
Partum unsupportive home environment

Depression • Presents with vegetative signs of

depression, tear fullness, anxiety, loss of
interest in normal activities, guilt,
inadequacy in coping with the infant
duration, thoughts of suicide.

• Duration > 2 w.

• Consider imipramine, amitryptyline 100-

300 mg qd. (response takes 2-4 w) for 6
months, psychiatric consult. Tends to recur
 Incidence 0.1-0.2 %
• Most severe and the rarest postpartum
psychiatric disorder.
Post • Acute onset 2-3d to 4 w after delivery (manic-
Partum depressive type occurs early, schizophrenic type
later).
Psychosis • Risk factors:
History of psychosis, Previous puerperial
psychosis, History of manic depressive
disorder, Obsessive personality, Family
history of mod disorder, Prenatal stressors
• Manifestations:
Auditory hallucinations, delusions, euphoria,
grandiosity, hyperactivity, inappropriate affect. High
risk of infanticide. 50% chance of developing
psychosis in future.
Management

✓Hospitalization if patients
exhibits hallucinations and
delusions.
✓Removal of infant from the
mother
✓Medications
✓Electroconvulsive therapy, the last
resort if other treatment fails.
✓Psychotherapy
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