Module 3 Postpartum Complications

I. CYSTITIS
- An infection on the bladder

ASSESSMENT

1. Burning and pain on urination

2. Lower abdominal pain
3. Increased frequency of urination
4. Costovertebral angle tenderness (is pain that results from touching the region inside of
the costovertebral angle. The CVA is formed by the 12th rib and the spine. Assessing for
CVA tenderness is part of the abdominal exam, and CVA tenderness often indicates kidney
pathology.

5. Fever
6. Proteinuria, hematuria, bacteriuria, white blood cells in the urine

 INTERVENTIONS
1. Palpate bladder for distention.
2. Palpate fundus.
3. Obtain urine specimen for culture and sensitivity if prescribed.
4. Institute measures to assist the client to void. Encourage frequent and complete
emptying of the bladder.
5. Encourage frequent and complete emptying of the bladder.
6. Force fluids to 3000 mL per day.
7. Administer antibiotics as prescribed after the urine culture is obtained.
8. Instruct the client in the methods of prevention and treatment of cystitis.

II. HEMATOMA
1. Hematoma is a localized collection of blood into the tissues of the reproductive sac
after the delivery.
2. Predisposing conditions include operative delivery with forceps and injury to a
blood vessel.
- The use of an epidural anesthesia, prolonged second stage of labor, and forceps
delivery are predisposing factors for hematoma formation, and a collection of up
to 500 ml of blood can occur in the vaginal area. Immediate action for such
condition is- surgery to stop the bleeding.
3. Hematoma can be a life-threatening condition.

ASSESSMENT

1. Abnormal severe pain

2. Pressure in the perineal area
3. Sensitive, bulging mass in the perineal area with discolored skin.
4. Inability to void.
5. Decreased hemoglobin and hematocrit levels.
6. Signs of shock, such as pallor, tachycardia, and hypotension, if significant blood
loss has occurred.
Other signs and symptoms of shock includes:
- Rapid breathing and hyperventilation
- Decreased urine output
- Cold, moist skin. Hands and feet may be blue or pale.

INTERVENTIONS

1. Monitor vital signs, (unusual changes may indicate the presence of hematoma).
2. Monitor client for abdominal pain, especially when forceps delivery has occurred.
3. Place ice at the hematoma site.
4. Administer analgesic as prescribed.
5. Monitor intake and output.
6. Encourage fluid and voiding.
7. Prepare for urinary catheterization if the client is unable to void.
8. Administer blood products as prescribed.
9. Monitor for signs and infection, such as increased temperature, pulse rate, and
white blood cell count.
10. Administer antibiotics as prescribed because infection is common following
hematoma formation.
11. Prepare for incision and evacuation of hematoma if necessary.

III. HEMORRHAGE
- Bleeding of 500 mL or more following delivery.

ASSESSMENT

1. Early
a. Hemorrhage occurs during the first 24 hours after delivery.
- It may lead to hypovolemia; IMMEDIATE NSG ACTIONS would be: Assess for
hypovolemia and notify the physician.
- S/Sx of hypovolemia include cool, clammy skin, pale skin, sensation of anxiety or
impending doom, restlessness, and thirst. WHEN THESE SYMPTOMS are
present, the nurse should further assess for hypervolemia and notify the health
care provider
b. hemorrhage is caused by uterine atony, lacerations, or inversion of the uterus.

2. Late
a. Hemorrhage occurs after the first 24 hours following delivery.
b. hemorrhage is caused by retained placental fragments.

INTERVENTIONS

1. Massage fundus, with care not to over massage.

- If the uterus is not contracted firmly, the first intervention is to massage the
fundus until it is firm and to express clots that may have accumulated in the
uterus.
2. Notify physician or health care provider if hemorrhage occurs.
- The saturation of more than one perineal pad per hour may indicate
complication.
 NOTE:

- In assessing the client in the fourth stage of labor: if the fundus is firm but that
bleeding is excessive, THE INITIAL NSG ACTION is to notify the physician.

3. Monitor vital signs and fundus every 5 to 15 minutes.

NOTE:
- During the fourth stage of labor, the maternal blood pressure, pulse, and
respiration should be checked every 15 minutes during the first hour.
- A rising pulse is an early sign of excessive blood loss because the heart pumps
faster to compensate for reduced blood volume.
- The blood pressure will fall as the blood volume diminishes, but a decreased
blood pressure would not be the earliest sign of hemorrhage.
- A slight rise in temperature is normal.
- The respiratory rate is slightly increased.
4. Remain with the client.
5. Assess and estimate blood loss by pad count.
6. Assess level of consciousness.
7. Administer fluids and monitor intake and output.
8. Monitor hemoglobin and hematocrit levels.
9. Maintain asepsis because hemorrhage predisposes to infection.
10. Prepare for the administration of oxytocin(Pitocin) if prescribed.
11. Prepare for the administration of blood transfusion if prescribed.

IV. INFECTION
- Any infection of the reproductive organs that occurs within 28 days of delivery
or abortion.

ASSESSMENT

1. Fever
2. Chills
3. Anorexia
4. Pelvic discomfort or pain
5. Vaginal discharge
6. Elevated white blood cell count.

INTERVENTION
1. Monitor vital signs and temperature every 2 to 4 hours.
2. Make the mother as comfortable as possible; position the mother for comfort and to
promote drainage.
3. Keep the mother warmed if chilled.
4. Isolate the baby from the mother only if the mother can infect the baby.
5. Provide nutritious, high-calorie, protein diet.
6. Encourage fluids to 3000 to 4000 mL per day, if not contraindicated.
7. Encourage frequent voiding and monitor intake and output.
8. Monitor culture results if cultures were prescribed.
9. Administer antibiotics according to organism, as prescribed.

V. PULMONARY EMBOLISM

- The passage of thrombus, often originating in one of the uterine or

other pelvic veins, into the lungs, where it disrupts the circulation of
the blood.

ASSESSMENT

1. Dyspnea, tachypnea, and tachycardia

2. Cough and rales
3. Hemoptysis
4. Pleuritic chest pain
5. Feeling of impending doom
INTERVENTIONS

1. Administer oxygen as prescribed.

- If pulmonary embolism is suspected, the initial action is to
administer oxygen at 8 to 10L/min by face mask to decrease hypoxia.
2. Position client with the head of the bed elevated to promote comfort
and reduce dyspnea.
3. Monitor vital signs frequently.
 4. Frequently assess respiratory rate and breath sounds.
5. Monitor for signs of respiratory distress and for signs of increasing
hypoxemia.
6. Administer intravenous fluids as prescribed.
7. Administer anticoagulants as prescribed.
8. Prepare to assist physicians to administer streptokinase (Streptase) to
dissolve the clot if prescribed.

VI. SUBINVOLUTION

- Incomplete involution or failure of the uterus to return to its normal

size and condition.
ASSESSMENT

1. Uterine pain on palpation

2. Uterus is larger than expected.
3. Greater than normal vaginal bleeding
INTERVENTIONS

1. Assess vital signs.

2. Assess uterus and fundus.
3. Monitor for vaginal bleeding.
4. Elevate the legs to promote return.
5. Encourage frequent voiding.
6. Monitor hemoglobin and hematocrit.
7. Prepare to administer methylergonovine maleate (Methergine) as
prescribed.

VII. THROMBOPHLEBITIS

1. Thrombophlebitis is a condition in which a clot form in a vessel wall as

a result of the inflammation of the vessel wall.
2. A partial obstruction of the vessel can occur.
 3. Increased blood-clotting factor in the postpartum period place the client
at risk.

Precipitating factors
blood clotting abnormality-increased fibrinogen
dilated veins
pooling (accumulation of blood in the parts of the venous system.)
stasis and clotting of blood in LEG-prolonged in stirrups

TYPES

1. Superficial thrombophlebitis / Deep vein thrombophlebitis

2. Femoral thrombophlebitis
3. Pelvic thrombophlebitis
ASSESSMENT OF THE TYPES OF THROMBOPLHEBITIS

SUPERFICIAL

- Tenderness and pain in the affected lower extremity

- Warm and pinkish red color thrombus area
- Palpable thrombus that feels bumpy and hard

Deep venous thrombophlebitis

- Bleeding ; which is an adverse effect of anticoagulants. This includes

hematuria(blood in the urine), ecchymosis(discoloration of the skin
resulting from bleeding underneath), and epistaxis(nosebleed).
FEMORAL

- Chills and fever

- Malaise
- Pain, stiffness, and swelling of the affected leg
- Shiny, white skin over the affected area - “milk leg” or phlegmasia
alba dolens” (white, inflammation)
- Positive Homans’ sign - discomfort behind the knee upon forced
dorsiflexion of the foot.
 - Diminished peripheral pulses
- Embolism ( a blocked artery caused by a foreign body such as blood
clots or an air bubble)
PELVIC

- Severe chills
- Dramatic body temperature changes
- Occurrence of pulmonary embolism may be the first sign.
INTERVENTION

1. Assess the lower extremities for edema, tenderness, varices, and

increased skin temperature.
2. Evaluate the legs for Homans’ sign by extending the legs with the knees
slightly flexed and dorsiflexing the foot.
3. Maintain bed rest.
4. Elevated the affected leg.
5. Apply a bed cradle and keep bedclothes off affected leg.
6. Never massage the leg.
7. Monitor for manifestation of pulmonary embolism.
8. Superficial thrombophlebitis / Deep venous thrombophlebitis
a. Provide bed rest.
b. Apply hot packs to the affected site as prescribed.
c. Apply elastic stockings.
d. Administer analgesic as prescribed.
e. Elevate the affected extremity.
f. Anticoagulant therapy (The treatment for Deep Venous
Thrombophlebitis)
9. Femoral thrombophlebitis
a. Provide bed rest.
b. Elevate affected leg.
c. Apply moist heat continuously to affected area if prescribed to
alleviate discomfort.
d. Administer analgesic as prescribed.
e. Administer antibiotics if prescribed.
 f. Prepare to administer heparin sodium (anticoagulant) intravenously
to prevent further thrombus formation if prescribed.
- Anticoagulant therapy may be used to prevent the extension of
thrombus by delaying the clotting time of the blood.
NOTE: laboratory results for Activated Partial Thromboplastin
Time should be monitored to determine if an effective and
appropriate dose of the heparin is being delivered, and a heparin
dose should be adjusted to maintain a therapeutic level.

g. If pulmonary embolism is developed, pulmonary circulation is

compromised in the presence of an embolus. The immediate nursing
action would be to initiate cardiorespiratory support by oxygen
administration.

10.Pelvic thrombophlebitis
a. Provide bed rest.
b. Administer analgesic as prescribed.
c. Administer antibiotics if prescribed.
d. Prepare to administer heparin sodium intravenously.

CLIENT EDUCATION OF THROMBOPHLEBITIS

- Avoid pressure behind the knees.

- Avoid prolonged sitting.
- Avoid constrictive clothing.
- Avoid crossing the legs.
- Never massage the leg.
- Know how to apply support hose if prescribed.
- Understand the importance of anticoagulant therapy if prescribed.
- Understand the importance of follow-up with the health care
provider.

VIII. Endometritis
- Inflammation of the lining of the uterus – endometrium,
often at the site of placental implantation.

- Is it caused by an infection in the uterus. It can be due to chlamydia,

gonorrhea, tuberculosis, or a mix of normal vaginal bacteria. It is
more likely to occur after miscarriage or childbirth. It is also more
common after a long labor or C-section.

Assessment:
1. 3rd or 4th day puerperium
2. Chills
3. Loss of appetite
4. WBC: 20,000 – 30,000
5. General body malaise
6. Abdominal tenderness
7. “Boggy” uterus
8. Temperature over 38OC
9. Strong after pains
10. Lochia – dark brown, foul

Treatment: Antibiotics, oxytocin, analgesics

Nursing Management:

1. Send specimen for lochial culture.

2. IV fluids
3. Bed rest
4. good hand washing

Complication tubal scarring – infertility

IX. Peritonitis
 inflammation of the peritoneal cavity- it happens when the
thin layer of tissue inside the abdomen becomes inflamed,
the tissue layer is called the peritoneum. it usually happens
due to an infection from bacteria or funji.
extension of endometritis
1/3 of all post partal deaths
spread thru lymphatic system
abcess formed in the Cul-de-Sac of Douglas – the lowest point
of the peritoneal cavity

Assessment:
Signs/Symptoms:
- rigid abdomen
- abdominal pain
- high fever
- rapid pulse
- nausea and vomiting

Management

1.NGT – if with paralytic ileus(intestinal paralysis)

2.IVF – TPN and meds
3.analgesics for pain relief
4.antibiotics

Complications: Adhesions and scarring – infertility

X. Mastitis
 - inflammation of the breast as result of infection.
- Mastitis primary occurs in breast-feeding mothers 2 to 3 weeks after
delivery but may occur at any time during lactation/ breastfeeding.
- pathologic organisms coming from infant’s nasal-oral
cavity(staphylococcal/streptococcal) enter cracked nipples (tissues)
milk good culture media
- S/S: scanty BM, high fever, mastitis (unilateral)

ASSESSMENT

1. Localized heat and swelling

2. Pain
3. Elevated temperature
4. Complaints of flulike symptoms

Management:

1. Instruct the mother in good handwashing and breast hygiene

techniques.
2. Promote comfort.
- Apply heat or cold site as prescribed.
3. Maintain lactation in breast-feeding mothers.
4. Encourage manual expression of breast milk or use of breast pump
every 4 hours.
5. Encourage mother to support breasts by wearing a supportive bra.
6. To prevent fissures(line of breakage or crack)
- utilize Proper Breast-feeding techniques.

Not leaving baby too long at breast

Be certain baby sucks the areola not the nipple only
Release infants grasp at nipple 1st before removing infant from
breast
1.wash hands between handling perineal pads and breast
2.expose nipple at least a part of the day
3.wash the nipples with water
4.instruct the mother to avoid the use of soap on the nipples- Soap is drying
and could lead to cracking of the nipples
 5.teach the mother the importance of handwashing and that she should
breast-feed every 2-3 hours
6.use Vit. E or lanolin – based ointment or A and D cream to soften the
nipple daily

8. Broad spectrum antibiotics as prescribed.

9. Breastfeeding can be continued if the breasts are not too sore. (other
breast and keep other breast empty to prevent bacterial growth),.

10. Manual expression of milk 2 – 3 days

11. Warm wet compresses

12. I and D for localized abscess

13. Assure client that this is not breast cancer a permanent disease;

she can still breastfeed after

XI. Salpingitis
- inflammation of the fallopian tubes.
- Is a common cause of female infertility because it can
damage the fallopian tube.

Common causes includes:

- sexually transmitted diseases such as gonorrhea and
chlamydia.
3 types:
1.Acute
 gonococci; both tubes can lead to local peritonitis
2.Chronic
Sequel gonococcal infection
Severe scarring of FT
 Adhesions
Tubo-ovarian abscess may form
Cause sterility; tubal pregnancy
3.tuberculosis
PTB from TB of lungs
TB endometritis

Assessment:
1.Sudden abdomino-pelvic pain; tenderness, pressure
2. vaginal discharges
3.fever; malaise
Diagnostic:
I.Gram staining or secretions from endocervix or cul-de-sac
II.Ultrasound
III.Culdocentesis

Treatment and management:

Antibiotics – penicillin or tetracycline
Bedrest
Analgesics
IV therapy
Culdotomy
TAHBSO in complicated type
AntiTB therapy in Type 3

Dystocia
Difficult labor(placenta, cord, membranes, and amniotic fluid)
Refers to any labor which does not advance normally