2. POSTPARTUM HEMORRHAGE
• Postpartum hemorrhage involves a loss of
500 mL or more of blood; it occurs most
frequently in the first hour after delivery.
• Төрсний дараах цус харвалт гэдэг нь
500 мл буюу түүнээс дээш хэмжээний
цус, бөгөөд төрсний дараа эхний нэг
цагт болно.
3. Pathophysiology/Etiology
Early postpartum hemorrhage
1. Uterine atony—relaxation of the uterus secondary to:
a. Multiple pregnancy—causes overdistention of uterus
and a larger placental site
b. Polyhydramnios (excessive amniotic fluid)
c. High parity
d. Prolonged labor with maternal exhaustion
e. Deep anesthesia
f. Fibromyomata—prevents uterus from contracting
g. Retained placental fragments—result from manual
removal of placenta, abnormal adherent placenta
(placenta accreta)
4. Early postpartum hemorrhage
2. Laceration of the vagina, cervix, or
perineum secondary to:
a. Forceps delivery, especially rotation
forceps
b. Large infant
c. Multiple pregnancy
5. Clinical Manifestations
1. With uterine atony uterus is soft or boggy,
often difficult to palpate, and will not remain
contracted; excessive vaginal bleeding
occurs.
2. Lacerations of the vagina, cervix, or
perineum cause bright red, continuous
bleeding even when the fundus is firm.
3. Hemorrhage usually occurs about the tenth
postpartum day with retained placental
fragments.(late postpartum hemorrhage)
6. Management
1. For uterine atony, oxytocin (Pitocin) or
methylergonovine (Methergine) are
prescribed.
2. Pain medication may be needed to
counter uterine contractions.
3. If placental fragments have been retained,
curettage of the uterus is indicated.
4. Lacerations may need to be repaired
7. Nursing Assessment
1. Assess for hypotension, tachycardia, change in
respiratory rate, decrease in urine output, and
change in mental status—may indicate
hypovolemic shock.
2. Assess location and firmness of uterine fundus.
3. Percuss and palpate for bladder distention, which
may interfere with contracting of the uterus.
4. Monitor amount and type of bleeding or lochia
present and the presence of clots.
5. Inspect for intactness of any perineal repair
8. Nursing Diagnoses
A. Anxiety related to unexpected blood loss
and uncertainty of outcome
B. Fluid Volume Deficit related to blood loss
C. Risk for Infection related to blood loss
and vaginal examinations
9. Nursing Interventions
A. Decreasing Anxiety
1. Maintain a quiet and calm atmosphere.
2. Provide information about the situation
and explain everything as it is done;
answer questions that the woman and her
family ask.
3. Encourage the presence of a support
person.
10. B. Maintaining Fluid Volume
1. Maintain or start a large-bore IV line if
vaginal bleeding becomes heavy.
2. Ensure that crossmatched blood is
available.
3. Infuse oxytocin, IV fluids, and blood
products at prescribed rate.
4. Monitor CBC for anemia.
11. C. Preventing Infection
1. Maintain aseptic technique.
2. Evaluate for symptoms of infection,
chilling, and elevated temperature,
changes in white blood cell count, uterine
tenderness, and odor of lochia.
3. Administer antibiotics as prescribed.
12. Patient Education/Health
Maintenance
1. Educate the woman about the cause of the
hemorrhage.
2. Teach the woman the importance of eating a
balanced diet and taking vitamin supplements.
3. Advise the woman that she may feel tired
and fatigued and to schedule daily rest
periods.
4. Advise the woman to notify her health care
provider of increased bleeding or other
changes in her status.
13. Evaluation
A. Verbalizes concerns about her well-being
B. Vital signs stable, urine output adequate,
hematocrit stable
C. Remains afebrile, WBC count within
normal limits
14. POSTPARTUM HEMATOMAS
ТӨРСНИЙ ДАРААХ ЦУС ХУРАЛТ
• Postpartum hematomas are localized
collections of blood in loose connective
tissue beneath the skin that covers the
external genitalia, beneath the vaginal
mucosa, or in the broad ligaments.
17. Clinical Manifestations
1. Complaints of pressure and pain, often
noting that the pain is excruciating
2. Discolored skin that is tight, full feeling,
and painful to touch
3. Possible decrease in blood pressure,
tachycardia
18. Complications
1. Hypovolemia and shock from extreme
blood loss
2. Anemia, infection
3. Increased length of postpartum recovery
period
19. Management
1. Small hematomas are left to resolve on
their own - ice packs may be applied.
2. Large hematomas may require
evacuation of the blood and ligation of the
bleeding vessel.
3. Analgesics and antibiotics may be
ordered (due to increased chance of
infection).
20. Nursing Interventions/Patient
Education
1. Inspect perineal and vulva area for signs of a hematoma when
woman complains of pain or pressure after delivery.
2. Inspect the vaginal area for signs of a hematoma if woman is unable
to void after anesthesia has worn off.
3. Monitor vital signs at least every 10 to 15 minutes and evaluate for
signs of shock.
4. Relieve pain of a hematoma by applying an ice bag to perineal area,
medicating with mild analgesics, and positioning for comfort to
decrease pressure on the affected area.
5. Help relieve voiding problems by assisting to bathroom to void if able
to ambulate.
6. If she is unable to void, catheterize.
7. Teach the woman the importance of eating a balanced diet and to
include food high in iron.
8. Encourage the woman to take vitamin supplements and to take
medications as ordered.
21. PUERPERAL INFECTION
• Puerperal infection is a postpartum
infection of the genital tract, usually of the
endometrium, that may remain localized or
may extend to various parts of the body.
22. Pathophysiology/Etiology
• Bacterial organisms either are introduced from external sources or
are normally present in the genital tract and are carried to the uterus.
• Predisposing factors include:
1. Prolonged labor or rupture of membranes (PROM)
2. Number of vaginal examinations
3. Infection elsewhere in the body
4. Anemia, malnutrition
5. Size and number of perineal lacerations
6. Intrauterine manipulation
7. Retained placental fragments of membranes
8. Lapse in aseptic technique
9. Poor perineal hygiene
10. Cesarean section
23. Clinical Manifestations
• Diagnosis is made by sustained fever of
38°C (100.4°F) or higher occurring on any
two of the first 10 days postpartum,
excluding the first 24 hours. Symptoms
depend on site and extension of infection.
25. Endometritis
A. Endometritis Postpartum infection involving
the endometrium
1. Uterus usually larger than expected for
postdelivery day.
2. Lochia may be profuse, bloody, and foul
smelling.
3. Chills and fever occur if lochial discharge is
obstructed by clots.
4. Infection may spread to myometrium,
parametrium, uterine (fallopian) tubes,
peritoneum, and blood.
26. B. Parametritis
• B. Parametritis (Pelvic Cellulitis) Infection of the pelvic
(connective tissue spread by the lymphatic system
within the uterine wall. Often a result of an infected
wound in the cervix, vagina, perineum, or lower uterine
segment
1. Chills, fever (38.8°-40.0°C; 102°-104°F), tachycardia
2. Severe unilateral or bilateral pain in lower abdomen
3. Enlarged and tender uterus
4. Uterine position may become fixed as it is displaced
by the exudate along the broad ligament.
28. Management
1. Aseptic technique, avoid cross infection
Hand wash medical personal.
2. Antibiotic therapy is instituted after cultures are
obtained and causative agent identified.
3. Supportive therapy is used to control pain and to
maintain hydration and nutritional status.
4. Drainage is indicated for abscess development.
29. Complications
• Thrombophlebitis may result from puerperal infection spread
along the veins.
1. Femoral thrombophlebitis—appears 10 to 20 days after
delivery as pain in calf, positive Homan's sign, fever, edema
2. Pelvic thrombophlebitis
a. Infection of the veins of uterine wall and broad ligament
usually caused by anaerobic streptococci
b. Severe repeated chills and wide range of temperature
changes occur about 2 weeks after delivery.
3. Strict bed rest, anticoagulants, and antibiotics are indicated.
31. Nursing Interventions/Patient
Education
1. Perform postpartum assessment, noting uterine
tenderness on palpation and the color, amount,
and odor of lochia.
2. Monitor vital signs for signs of infection.
3. Assess knowledge and skill of perineal hygiene;
teach proper technique and assist, if necessary.
4. Provide for adequate rest periods.
5. Position in high Fowler's position to promote
drainage.
6. Administer antibiotics and analgesics, as ordered.
32. Nursing Interventions/Patient
Education
7. Explain the benefit of perineal washing or sitz baths
and demonstrate setup.
8. Explain the need for good handwashing technique and
how contamination of vagina from the rectum occurs.
9. Show how to place perineal pads and medications;
encourage to change pads with each voiding, bowel
movement, or every 4 hours while awake.
10. Encourage minimal separation from the infant and
continuation of breast-feeding, as able.
11. Promote good handwashing technique for the mother
before contact with the infant.
33. AMNIOTIC FLUID EMBOLISM
• Amniotic fluid embolism is the escape of
amniotic fluid containing debris such as
meconium, lanugo, and vernix caseosa into
the maternal circulation,
• usually resulting in deposition of fluid or
debris in the pulmonary arterioles, resulting
rapidly in respiratory distress, shock, and the
possible development of DIC.
• Amniotic fluid embolism is rare and usually
fatal.
34. Pathophysiology/Etiology
1. The exact mechanism causing amniotic fluid
embolism is unclear.
2. It usually occurs in the intrapartum period.
3. Myometrial vessels are exposed, usually at the
placental site and contractions are especially
forceful. A thromboplastin-like substance is found
in amniotic fluid, which causes defibrination
leading to DIC.
4. Predisposing conditions include abruptio
placentae, uterine rupture, intrauterine fetal
demise, and high parity.
35. Clinical Manifestations
1. Sudden dyspnea and chest pain
2. Cyanosis, tachycardia
3. Pulmonary edema
4. Profound shock due to:
a. Anaphylaxis, which causes vascular
collapse
b. Uterine bleeding with development of
hypofibrinogenemia
36. Management
1. Endotracheal intubation
2. Administration of IV crystalloid fluids
3. Administration of blood products and heparin
to combat DIC
4. Establishment of central venous pressure
line
5. Immediate delivery of the fetus
6. Initiation of cardiopulmonary resuscitation if
needed
37. Nursing
Assessment/Interventions
1. Be alert to signs and symptoms of potential amniotic fluid
embolism.
2. Monitor maternal vital signs and fetal heart rate frequently to
assess for signs of shock and fetal/maternal demise.
3. Administer oxygen via face mask to assist respiration status.
4. Alert medical staff immediately and assist with emergency
procedures such as delivery and with the cardiopulmonary
resuscitation as needed.
5. Provide information and comfort to the family or support
persons.
If unable to do this personally due to the emergent needs of the
woman, delegate another member of the staff to stay with the
family or support persons.
38. POSTPARTUM DEPRESSION
• Postpartum depression may occur in the first
2 weeks after delivery
• Etiology: unknown,
- Hormonal theory– decrease estrogen level
As like as menstrual period, menopause
- Psychosocial aspect; lack of support system,
unwanted baby
- Cultural aspect; male dominant, favorable
sex baby
39. • postparum blue : a normal developmental crisis
related to the adjustments that are being made
relative to the new role of parent, along with the
added responsibilities, fatigue, and excitement that
go with the birth.
• If a woman is unable to work through her feelings
within about 2 weeks, and the symptoms continue,
a more serious depression is indicated.
• postpartum depression; social, cultural,
physiologic and psychological factors experienced
may contribute to postpartum
• Postpartum psychosis; a severe form of
depression that occurs in a small percentage of
women giving birth.
40. Clinical Manifestations
1. Exaggerated and prolonged periods of
irritability, moodiness, hostility, fatigue
2. Ineffective coping
3. Withdrawal and inappropriate response to
the infant or family
4. Loss of interest in activities
5. Insomnia
41. Management
• Signs and symptoms may be overlooked,
making the diagnosis of depression difficult.
• Counseling with a mental health professional,
medication, and continuous support from
family and friends may be helpful in
managing the depressed patient.
• If untreated, the woman may not fully recover
and possibly harm the infant or others.
refer to psychologist
42. Nursing Interventions/Patient
Education
1. Listen to the woman regarding her adjustment to role
of mother and observe for any clinical manifestations
suggesting depression.
2. Ask the woman about the infant's behavior. Negative
statements about the infant may suggest that the
woman is having difficulty coping.
3. Provide support and encourage husband, family and
friends to support and assist with the infant and mother.
Physical support as well as emotional support may be
indicated.
5. Educate the woman that treatment may help alleviate
her symptoms and allow her to better care for herself
and infant.
