Nursing Care of a family experiencing a postpartal complication

Postpartal hemorrhage
- Any blood loss from the uterus greater than 500 mL within a 24 hr period
- May occur either within first 24 hrs or anytime after the first 24 hrs
- Greatest danger is in the first 24 hrs
Conditions that increase womans risk for postpartal hemorrhage:

Conditions that distend the uterus

beyond average capacity :

Multiple gestation
Hydramnios
Large baby (>9lb)
Presence of uterine myomas /fibroid tumors

Conditions that could have caused

cervical or uterine lacerations

Operative birth
Rapid birth

Conditions that varied placental

site or attachment

Placenta previa
Placenta accreta
Abruptio placenta
Retained placental fragments

Conditions that leave the uterus

unable to contract readily

Deep anesthesia or analgesia

Labor initiated or assisted w/ an oxytocic agent
Maternal age greater than 35 yrs
High parity
Previous uterine surgery
Prolonged and difficult labor
Possible chorioamnionitis
Secondary maternal illness
Prior history of postpartum hemorrhage
Endometritis
> Prolonged use of magnesium sulfate or other tocolytic therapy

Conditions that lead to inadequate

blood coagulation

Fetal death
Disseminated intravascular coagulation

Five Main Causes :

I. Uterine atony

Definition

Relaxation of the uterus

Most frequent cause of postpartal hemorrhage
Uterus must remain in a contracted state after birth to keep the open vessels at the placental site from bleeding

Therapeutic management

First step in controlling hemorrhage is to attempt uterine massage to encourage contraction

Massage should be done only when uterus is not firm, otherwise muscle fatigue and uterine relaxation may occur , aggressive
massage may lead to partial/complete uterine prolapse
Remain w/ the woman after massaging her fundus to be certain the uterus is not relaxing again
Observe carefully the fundal height and consistency and lochia over the next 4 hrs
If uterus cannot remain contracted , physician will order a dilute IV infusion of oxytocin
Usual dosage of oxytocin is 10 to 40 U per 1000 mL of Ringers lactated solution , when given IV .. its action is immediate but has a
short duration of action app. 1 hr .. so symptoms of uterine atony can recur quickly after administration of only a single dose
Second possibilities :
o Carboprost tromethamine (Hemabate) may be repeated q 15 to 90 min. up to 8 doses
o Prostaglandin F2a derivative tend to cause diarrhea as side effect
o Methylergonovine maleate (Methergine) may be repeated q 2 to 4 hrs up to 5 doses ; contraindicated w/ hypertensive pt
o Rectal misoprostol

Addtnl measures:
Be certain that the womans bladder is empty ; A full bladder pushes an uncontracted uterus into an even more uncontracted state
o Offer bedpan

o Assist the woman w/ ambulating to the bathroom at least q 4 hrs

o Insertion of urinary catheter
- If woman is experiencing respiratory distress from decreasing blood volume
o Administer O2 by face mask (4L/min)
o Position her supine
Obtain V/S frequently , make sure to interpret them accurately , looking for trends (e.g., continuously rising pulse rate is an
ominous pattern)
When planning continuing care after sudden blood loss, understand that the woman may be so exhausted that she resents uterine
and BP assessments
o Explain that these measures although disturbing are important for her welfare
o Obtain V/S as quickly and gently as possible
Signs of Shock
o Increased, thread and weak pulse
o Decreased BP
o Increased and shallow Respiration
o Pale , clammy skin
o Increasing anxiety
Bimanual massage/compression
If fundal massage and administration of oxytocin and others are not effective in stopping uterine bleeding , a Sonogram may be
done to detect possible retained placental fragments
Physician inserts one hand into a womans vagina while pushing against the fundus through abdominal wall w/ the other hand
Woman may be returned to the delivery room so to explore her uterine cavity manually
Uterine packing may be inserted during this procedure to help halt bleeding
Painful .. so anticipate the need for analgesia or anesthesia
If uterine packing is used, be certain to document it on chart ; Retained packing serves a growth medium for microbe invasion that
could lead to postpartal infection

Prostaglandin administration
Promote strong, sustained uterine contractions
IM injection of Prostaglandin F22
Possible adverse effects
o Nausea
o Diarrhea
o Tachycardia
o Hypertension

Blood replacement
Be certain that blood typing and cross-matching were done when the woman was admitted and that blood is available
Iron therapy may be prescribed to ensure good hemoglobin formation
Extensive blood loss is one of the precursors of postpartal infection

Hysterectomy / Suturing
In the rare of instance of extreme uterine atony:
o Sutures or balloon compression may be used to halt bleeding
o Embolization of pelvic and uterine vessels by angiographic techniques may be successful
o Hysterectomy or Ligation of uterine arteries may be necessary
After a hysterectomy, a woman needs to discuss her feelings

II. Lacerations
Definition

Cervical lacerations

Occur most often

o w/ difficult or precipitate births
o In primigravidas
o w/ birth of a large infant (>9lb)
o w/ the use of a lithotomy position and instruments
After birth, any time a uterus may feel firm but bleeding persists .. suspect laceration

Usually found on the sides of the cervix, near the branches of uterine artery
If artery is torn, blood loss may be so great that blood gushes from vaginal opening
Because of arterial bleeding .. it is brighter red than the venous blood lost w/ uterine atony

Management

Repair of a cervical laceration is difficult because the bleeding can be so intense that it obstructs visualization of the area

Be certain that physician has adequate space to work, adequate sponges, and suture supplies and a good source of light

Regional anesthetic may be necessary if cervical laceration appears to be extensive or difficult to repair , to relax uterine

muscle and to prevent pain

Vaginal lacerations

Easier to assess than cervical lacerations

Management

Also hard to repair because vaginal tissue is friable

Some oozing often occurs after a repair so vagina may be packed to maintain pressure on the suture line

An indwelling catheter may be placed at the same time, because packing causes pressure on the urethra and can interfere w/
voiding

If packing is inserted , document it on the chart , packing that is left in place too long ..leads to stasis and infection similar to
toxic shock syndrome
Perineal lacerations

Usually occur when a woman is placed in a lithotomy position , because this position increases tension on the perineum
Can lead to
o Long term dyspareunia
o Rectal incontinence
o Sexual dissatisfaction
Usually heal w/o further complications

4 Categories
1st degree
Vaginal mucous membrane
Skin of the perineum to the fourchette
2nd degree
Vagina
Perineal skin
Fascia
Levator ani muscle
Perineal body
3rd degree
Entire perineum
External sphincter of the rectum
4th degree
Entire perineum
Rectal sphincter
Some of the mucous membrane of the rectum
Management
Sutured and treated as an episiotomy repair
Be certain that the degree of laceration is documented
Women w/ 4th degree need extra precautions to avoid having repair sutures loosened or infected , they should not have enema
or a rectal suppository prescribed
A diet high in fluid and stool softener may be prescribed for the first week after birth to prevent constipation and hard stools

III. Retained Placental fragments

Definition

Assessment

Therapeutic management

Portion retained keeps the uterus from contracting fully

Most likely to happen w/
o
Succenturiate placenta (placenta w/ an accessory lobe)
o
Placenta accreta ( placenta that fuses w/ myometrium because of an abnormal deciduas basalis layer
Every placenta should be inspected carefully after birth to see that its complete
May also be detected by
o
UTZ
o
A blood serum sample that contains hCG
If an undetected retained fragment is large , bleeding will be apparent in immediate postpartum
If fragment is small, bleeding may not be detected until postpartum day 6 to 10 , when woman notices an abrupt discharge and a
large amt. of blood
On examination, usually .. uterus is not fully contracted
Removal usually by D&C
Balloon occlusion
Embolization of internal iliac arteries
Methotrexate to destroy retained placental tissue
Be certain a woman knows to continue to observe color of lochia discharge and report any tendency for discharge to change from
lochia serosa or alba back to rubra

IV. Uterine inversion

Prolapse of the fundus of the uterus through the cervix so that the uterus turns inside out
Usually occurs immediately after birth

V. Disseminated intravascular coagulation

o
o
o

Deficiency in clotting ability caused by vascular injury

Usually associated w/
Abruptio placenta
Missed early miscarriage
Fetal death in utero

Subinvolution

Definition

Therapeutic management

Incomplete return of uterus to its prepregnant shape and size

At 4- or 6-week postpartal visit
o
Uterus will still enlarged and soft
o
Lochial discharge usually is still present
May result from
o
Small retained placental fragment
o
Mild Endometritis
o
Accompanying problem (e.g., uterine myoma) that interfering w/ contraction

Oral administration of Methylergonovine 0.2 mg 4x daily

If uterus is tender to palpation, suggest Endometritis
Oral antibiotic will also be prescribed
Chronic loss of blood will result in
o
Infection
o
Anemia
o
Lack of energy

Collection of blood in the subcutaneous layer of tissue of perineum

Overlying skin is intact w/ no noticeable trauma
Can be caused by injury to blood vessels in the perineum during birth
Most likely to occur
o After rapid , spontaneous birth
o In women who have perineal varicosities
May occur at the site of an episiotomy or laceration repair if a vein was punctured during repair
Usually represent only minor bleeding
Can cause a woman acute discomfort

Perineal Hematoma

Definition

Assessment

Therapeutic management

Suspect hematoma if there is

o Severe pain in the perineal area
o Feeling of pressure bet. her legs
Appears as an area of purplish discoloration w/ obvious swelling
May be as small as 2 cm or as large as 8cm in diameter
The area is tender to palpation
At first it may feel fluctuant .. but as seepage into area continues and tissue is drawn traut , it palpates as firm globe

Report presence and size of hematoma and degree of womans discomfort

Administer analgesic
Applying icepack (covered w/ towel to prevent thermal injury) may prevent further bleeding
Hematoma usually is absorbed over the next 3 or 4 days
If hematoma is large .. or continues to increase in size .. woman may have to be returned to the delivery room to have the site
incised and bleeding vessel ligated under local anesthesia
If an episiotomy incision line is opened to drain hematoma, it may be left open and packed w/ gauze rather than restored ,
packing is usually removed w/in 24 to 48 hrs (tertiary intention/healing by 3 rd intention)

Puerperal infection

Definition

Theoretically , uterus is sterile during pregnancy until membranes rupture

Risk of infection is even greater if tissue edema and trauma are present
Prognosis depends on
o Virulence of invading organism
o Womans gen. health
o Portal of entry
o Degree of uterine involution at the time of microorganism invasion
o Presence of lacerations in the reproductive tract
Usually begins as only a local infection but can spread to involve the peritoneum (peritonitis) or the circulatory system
(septicemia)
Organisms commonly cultured postpartally :
o Group B streptococci
o Aerobic gram negative bacilli (e.g. E coli)
Staphylococcal infections are the cause of toxic shock syndrome, infection similar to puerperal infection

Therapeutic management

Use of an appropriate antibiotic after culture and sensitivity testing of the isolated organism
Proper perineal care
Hand washing
Any articles that are introduced into the birth canal should be sterile
Adherence to standard infection precautions
No sharing of Perineal supplies

Conditions that increase a

womans risk for postpartal
infection

Rupture of membranes more than 24 hrs before birth

Placental fragments retained w/in uterus
Postpartal hemorrhage
Pre-existing anemia
Prolonged and difficult labor, particularly instrument births (trauma to tissue may leave lacerations for easy portals of entry for
infection)
Internal fetal heart monitoring
Local vaginal infection was present at the time of birth
Exploration

Common Guidelines for

woman w/ a postpartal
infection

Woman w/ an increased temp (38 degree C) for 2 consecutive 24 hr periods exclusive of the first 24 hrs is kept in an isolation
nursery until the cause of infection is determined

If the cause of fever is found to be related to childbirth but involves a closed infection .. w/ no danger of the baby contracting
the disease .. woman may care for her child as long as she maintains bed rest in the prescribed position while doing so

If infection involves drainage , newborn visiting may be contraindicated . If rooming in is continued, mother should wash her
hands thoroughly before holding her infant and she should never place her infant on the bottom bed sheet

Most hospitals are reluctant to return a baby to a central nursery after baby has visited in a room where there is infection .. the
hospital should provide a small nursery that may be used as an isolation nursery for these situations

If she is receiving an antibiotic that is passed in breastmilk and would be harmful to the baby , infant should be fed by a
supplementary milk formula
Womans breast milk can be manually expressed or pumped to maintain production of milk so it will be available when she is again
able to nurse
If it appears that the course of infection will be long , woman may choose to discontinue breastfeeding

If woman is going to be hospitalized beyond the usual time , she may have to make arrangements for the discharge and care of
her baby

I. Endometritis

Definition

Infection of the endometrium

Bacteria gain access to the uterus through the vagina and enter the uterus either at the time of birth or during the postpartal
period
Usually associated w/
o Chorioamnionitis
o CS birth
If infection is limited to the endometrium , course of infection is about 7 to 10 days
Can lead to
o Tubal scarring
o Interference w/ future fertility
If woman desires more children, She may need a fertility assessment including a hysterosalpingogram to determine tubal

patency
Assessment

Therapeutic management

Benign temp. elevation may occur on the postpartal day , particularly if woman is not drinking enough fluid
Fever of Endometritis usually manifests on the 3 rd or 4th day , suggesting much of the invasion occurred during labor or birth
(consistent w/ the time it takes for infectious organisms to grow)
Elevated WBC is not of great value in puerperium
Febrile condition suggesting infection : Increase in temp. to more than 38 degree C for 2 consecutive 24 hr periods excluding
the first 24-hr period after birth
Depending on severity of infection , woman may have :
o Chills
o Loss of appetite
o Gen. malaise
o Uterus is usually not well contracted and is painful to touch
o Strong afterpains
o Lochia is usually dark brown and has a foul odor , increased in amt. due to poor uterine involution
o If infection is accompanied by high fever , lochia may be scant or absent
UTZ may be ordered to confirm presence of placental fragments that are possible cause of infection
Administration of appropriate antibiotic as determined by a culture of lochia
Using a sterile swab rather than from perineal pad to ensuring culturing endometrial infectious organism and not an unrelated
one from the pad
AN oxytocic agent may be prescribed to encourage uterine contraction
Additional fluid to combat fever
Analgesics for strong afterpains and abdominal discomfort
Sitting in fowlers position or walking encourages lochia drainage
Be certain to wear gloves when helping a woman change her perineal pads

II. Infection of the Perineum

Definition

If woman has suture line on her perineum from an episiotomy or a laceration repair , a portal of entry exists for bacterial
invasion

Assessment

Infection of perineum usually remain localized

Revealed by symptoms similar to those of any suture-line infection (pain, heat, feeling of pressure)
Woman may or may not have an elevated temp.
Inspection of suture line reveal inflammation
o One or two stitches may be sloughed away
o Area of suture line may be open w/ purulent drainage
Notify physician of the localized symptoms and culture the discharge

Therapeutic management

Physician may choose to remove perineal sutures to open area and allow for drainage
Packing such as iodoform gauze , may be placed in the open lesion to keep it open and allow drainage , be sure woman is aware
that packing is in place
Systemic or topical antibiotic is ordered even before culture report is returned
Analgesic may be prescribed
Sitz bath , moist warm compresses or Hubbard tank treatments may be ordered to hasten drainage and cleanse the area
Remind woman to change perineal pads frequently because they are contaminated by drainage
Be certain that woman wipes front to back after a bowel movement
Woman is usually discharged w/ a referral for home care follow up because incision site once opened, must heal by tertiary
rather than primary intention
Because infection is localized, there is no need to restrict woman from caring for her infant as long as she washes her hands
well before handling her newborn
Be certain not to place the infant on the bottom bed sheet
Encourage woman to ambulate

III. Peritonitis
Definition

Infection of the peritoneal cavity

Usually occurs as an extension of Endometritis
One of the gravest complications of childbearing and major cause of death from puerperal infection
Infection spreads through the lymphatic system or directly through the fallopian tubes or uterine wall to the peritoneal cavity
An abscess may form in the cul-de-sac of Douglas because this is the lowest point of peritoneal cavity and gravity causes
infected material to localize there
Often accompanied by paralytic ileus (blockage of inflamed intestines)
Can interfere w/ future fertility because it leaves scarring and adhesion in the peritoneum ; Adhesions form this way may
separate fallopian tubes from ovaries

Assessment

Rigid abdomen
Abdominal pain
High fever
Rapid pulse
Vomiting

Therapeutic management

Requires NGT to prevent vomiting and rest the bowel

IV fluid or total parenteral nutrition
Analgesics
Antibiotics

Thrombophlebitis

Phlebitis
Inflammation of the lining of a blood vessel
Thrombophlebitis
Inflammation w/ the formation of blood clots
When occurs in postpartal period, it is usually an extension of an endometrial infection
Tends to occur because :
o Womans fibrinogen level is still elevated from pregnancy leading to increased blood clotting
o Dilatation of lower extremity veins is still present as a result of pressure of the fetal head during pregnancy
o Prolonged time spent in birthing room stirrups leads to pooling, stasis and clotting of blood in the lower extremities
o Obesity leads to inactivity and lack of exercise
o Woman smokes cigarettes
Women most prone are those :
o Who have had a previous Thrombophlebitis
o Older than 35 yrs of age w/ increased parity
o Have high incidence of Thrombophlebitis in their family

Classified as Superficial vein disease (SVD) or Deep vein thrombosis (DVT)

Preventing Thrombophlebitis
o Prevention of endometritis by use of good aseptic technique during birth
o Asking for any alternative position rather than lithotomy
o If using lithotomy, ask for padding on the stirrups to prevent calf pressure
o Limiting the time a woman remains in obstetric stirrups
o Ambulation
o Wearing support stockings , be certain to put these on before ambulating in the morning , remove 2x daily
o Drink adequate fluids
o Do not sit w/ your knees bend sharply
o Avoid wearing constricting clothing
o When resting in bed, wiggles your toes or do leg lifts
o Quit smoking

I. Femoral Thrombophlebitis

Definition

Assessment

Femoral, Saphenous, Popliteal veins are involved

Also an accompanying arterial spasm often occurs , diminishing arterial circulation to a leg as well
The decreased circulation along w/ edema gives the leg a white or drained appearance
It was formerly believed that breast milk drained into the leg , giving it its white appearance , therefore the condition was
formerly called milk leg or phlegmasia alba dolens (white inflammation)
Acute symptoms last only a few days ; Full course takes 4 to 6 weeks
Affected leg may never return to its former size and may always cause discomfort after long periods of standing

Woman notices :
Elevated temp
Chills
Pain
Redness in affected leg about 10 days after birth
Leg begins to swell below the lesion at the point at w/c venous circulation is blocked
Skin becomes so stretched from swelling that it appears shiny and white
Homans sign pain in the calf of the leg on dorsiflexion of the foot may be positive
Diameter of the leg at thigh or calf level may be increased compared w/ the other leg
Doppler UTZ or Contrast venography usually is ordered to confirm the diagnosis

Therapeutic management

Bed rest w/ the affected leg elevated

Administration of anticoagulants
o Blood coagulation levels to determine effectiveness of drug therapy are measured daily before administration of the
anticoagulant
o Depending on drug prescribed, a baseline activated partial thromboplastin (aPTT) or prothrombin time (PT) is obtained
o Lochia usually increases in amount in a woman who is receiving an anticoagulant
o Woman taking anticoagulant are not normally prescribed salicylic acid (aspirin) for pain because it prevents blood clotting
by preventing platelet aggregation and clot formation , however some women may be prescribed aspirin q 4hrs as
preventive measures if they are at high risk for recurrent Thrombophlebitis
o May be continued for 3 to 6 mos.
o Heparin
Can be administered by continuous IV infusion or intermittently by IV or subcutaneous injection
Antagonist : Protamine sulfate should be readily available any time heparin is administered
Woman can continue to breastfeed
o Warfarin
An oral coumarin derivative
Antidote : Vit K
Woman has to discontinue breastfeeding because coumarin-derived anticoagulants are passed in breastmilk
Application of moist heat/warm compress can help decrease inflammation
o Compresses and water used in this way do not have to be sterile because there is no break in the skin
o Be certain it is not too warm , because edema decreases sensation in a womans leg , she can burn easily
o Always cover wet, warm dressings w/ a plastic pad to hold in heat and moisture
o Be certain the weight of a hot pack or pad does not rest on the leg causing an obstruction to flow of blood
o Check womans bed frequently to be certain mattress does not become wet from seeping water
o For soaks to stay in place , she must keep her leg fairly immobile
A bed cradle keeps pressure of the bedclothes off the affected leg , both to decrease sensitivity of leg and improve circulation
Check for bed wrinkles so that a woman does not develop secondary problem of a pressure ulcer while on bed rest
Never massage skin over the clot; this could loosen the clot causing a pulmonary or cerebral embolism
Administration of analgesics because pain is usually severe
Administration of appropriate antibiotic to reduce initial infection
Assess for other possible signs of bleeding

II. Pelvic Thrombophlebitis

Definition

Assessment

Therapeutic management

Involves ovarian , uterine or hypo gastric veins

Usually follows a mild endometritis
Occurs later than femoral thrombophlebitis often around 14th or 15th day of puerperium
Risk factors are the same as for femoral thrm.
Runs a long course of 6 to 8 weeks
Formation of an abscess is associated w/ high mortality rate , inflammation of this extent may leave tubal scarring and
interfere w/ future fertility
Woman may need surgery to remove affected vessel before she attempts to become pregnant again

Woman suddenly becomes extremely ill w/

o High fever
o Chills
o Gen. malaise
Infection can become systemic and result in a lung, kidney or heart valve abscess

Total bed rest

Administration of antibiotics and anticoagulants
If an abscess forms, it can be located by sonogram and incised by laparatomy if necessary

III. Pulmonary Embolus

Obstruction of pulmonary artery by a blood clot

Usually occurs as a complication of thrombophlebitis
Signs :
o Sudden ,sharp chest pain
o Tachypnea
o Tachycardia
o Orthopnea /inability breathe except in an upright position
o Cyanosis / blood clot is obstructing pulmonary artery ,blocking blood flow to the lungs and return to
heart
An emergency
Woman needs O2 administered immediately
At high risk for Cardiopulmonary arrest
Woman is commonly transferred to an ICU

Mastitis

Definition

Infection of the breast

May occur as 7th postpartal day or not until the baby is weeks or months old
Organism causing infection :
o
Usually enters through cracked and fissured nipples
o
Occasionally comes from nasal-oral cavity of the infant
o
Infant has usually acquired Staphylococcus aureus while in the hospital
o
By sucking on nipple, infant introduces the organisms into the milk ducts where they proliferate
Breastmilk is an excellent medium for bacterial growth
Runs a short course of about 2 to 3 days , if left untreated .. a breast infection can become a localized abscess (May
involve large portion of breast and rupture through the skin w/ thick, purulent drainage .. necessitating incision and
drainage of the abscess )
Leaves any no permanent breast disease , not associated w/ development of cancer and does not interfere w/
breastfeeding potential

Measures to prevent cracked and fissured nipples :

Making certain that the baby is positioned correctly, grasps the nipple properly , including both nipple and areola

Releasing a babys grasp on the nipple before removing the baby from breast

Washing hands bet. handling perineal pads and touching breasts

Exposing nipples to air for at least part of everyday

Using a vit. E ointment to soften nipples daily

If a woman has one cracked and one well nipple, encourage her to begin breastfeeding on the unaffected nipple
Assessment

Therapeutic
management

Is usually unilateral, but may be bilateral

Affected breast is
o Painful
o Swollen
o Reddened
Fever accompanies these first symptoms w/in hrs
Breast milk becomes scant

Antibiotics that are effective against penicillin-resistant staphylococci (e.g., dicloxacillin , cephalosporin )
Breastfeeding is continued because keeping the breast emptied of milk helps to prevent growth of bacteria
Cold or ice compress for pain relief
Good supportive bra
Warm, wet compresses to reduce inflammation and edema
If an abscess forms , breastfeeding on that affected breast is discontinued
- A woman is encourage to pump breast milk until the abscess has resolved to preserve breastfeeding

Urinary System disorders

- Can occur because a womans bladder is compressed by the infants head during birth
I. Urinary Retention

Definition

Occurs as a result of inadequate bladder emptying

Associated w/ the use of anesthesia esp. epidural anesthesia
After childbirth, bladder sensation for voiding is decreased because of bladder edema caused by pressure of birth
Unable to empty , bladder feels overdistention
Retention w/ overflow : when woman void, instead of emptying completely.. bladder empties only a small portion of its contents
If allowed to continue , permanent damage may occur from lost of bladder tone leading to permanent incontinence
Always measure the amt. of womans first voiding after birth , if this voiding is less than 100 mL .. suspect urinary retention
Difficulty w/ bladder function after childbirth is becoming less of a problem as less anesthesia and fewer forceps are used at birth
.. decreasing bladder and vulvar pressure

Assessment

Urinary retention w/ overflow

o More difficult to detect
o Woman is able to void
o Voiding is very frequent , and in small amt.
o Her overall output is inadequate
Primary overdistention
o Woman does not void at all
o Longer than usual time (>8 hrs) passes after the birth or bet. voids
o Assessment by percussion or palpation of bladder reveals bladder distention
Confirmed by catheterizing a woman immediately after she voids
o If amt. of urine left in the bladder after voiding is greater than 100 mL , woman has retention of more than normal amt.
(residual)
o Physician writes an order such as Catheterize for residual urine .. if >100 mL , leave indwelling catheter in place

o
o
o
o

Therapeutic
management

Always use aseptic technique to prevent introducing pathogenic bacteria into the sterile urinary tract
Always use indwelling (Foley) catheter rather than a temporary one or straight catheter for residual urine.. this helps
minimize risk of introducing pathogens w/ a second catheterization should an indwelling catheter be needed
Can be difficult during early postpartal period because vulvar edema often distorts the position and appearance of urinary
meatus
Use gentle technique , because womans perineum is apt to feel tender to touch

Amt. of urine to remove from an overdistended bladder is controversial

o
There is a suggestion that removing > 750 to 1000 mL of urine at any one time may create extreme pressure changes in
bladder and lower abdomen
o
Decreased pressure may cause blood to flow into the area , creating a supine hypotension
Follow your healthcare agencys policy concerning how much urine to remove from a full bladder at catheterization
Because pain sensation of edematous tissue is decreased .. a woman w/ extreme vulvar edema may experience only slight
discomfort in catheterization procedure
After 24 hrs , physician may order the indwelling catheter to be clamped for a short time and then removed
Encourage woman to void by the end of 6 hrs after removal of catheter by
o
Offering fluid
o
Administering an analgesic so she can relax
o
Assisting her to the bathroom
o
Trying time-tested solutions such as running water at the skin or letting her hold her hand under warm running water
If woman has not voided by 8 hrs after catheter removal .. physician may order reinsertion of the indwelling catheter for an
addtnl 24 hrs

II. Urinary Tract Infection

Definition

Assessment

Woman who is catheterized at the time of childbirth or during postpartal period is prone to the development of a UTI because
bacteria may be introduced into the bladder at the time of catheterization

o
o
o
o
o
o

Therapeutic management

Symptoms :
Burning sensation
Hematuria
Feeling of frequency to void
Pain is so sharp in voiding
Low grade fever
Discomfort from lower abdominal pain
Obtain a clean-catch urine specimen from any woman w/ symptoms of UTI
So that lochial discharge does not contaminate the specimen , provide a sterile cotton ball for the woman to tuck into her vagina
after perineal cleansing , be certain to ask if she remove the cotton after the procedure otherwise, it could cause stasis of vaginal
secretions and increase the possibility of Endometritis
Mark the specimen possibly contaminated by lochia so that any blood in the specimen will not overly interpreted by laboratory
technician
Sulfa drugs are normally prescribed but are contraindicated for breastfeeding women because they can cause neonatal jaundice
Broad-spectrum antibiotic (e.g amoxicillin , ampicillin
If an antibiotic contraindicated by breastfeeding is prescribed , check the womans physician about possibly changing the
antibiotic
Encourage woman to drink large amt. of fluid to help flush the infection from her bladder
Oral analgesic (e.g acetaminophen [Tylenol]) to reduce the pain of urination
Be certain that woman understands the importance of continuing to take the prescribed antibiotic for the full 5 to 7 days to
eradicate infection completely

Cardiovascular system disorders

- Because pregnancy requires major changes in volume of blood and blood pressure, some excess volume and pressure can still be present in postpartal period
I. Postpartal Pregnancy-Induced Hypertension

Mild pre-existing hypertension may increase in severity during the first few hrs or days after birth
Cardinal symptoms are the same as those prenatal PIH : proteinuria, edema, and hypertension
Treatment measures are also the same for antepartal PIH
o
Bed rest
o
Quiet atmosphere
o
Frequent monitoring of v/s and urine output
o
Administration of magnesium sulfate or antihypertensive agent (can be administered in higher doses than during
pregnancy)
Usually occurs because of retention of some placental material
o
Woman may be taken to surgery to have D & C to be certain that all placental fragments have been removed
Seizures
o
Develop 6 to 24 hrs after birth (Symptom of PIH)
o
Occurring more than 72 hrs after birth (Not result of PIH )
Women w/ chronic hypertension need frequent monitoring during a future pregnancy to prevent PIH symptoms from occurring
again

Reproductive System Disorders

- Pregnancy may leave reproductive system organs weakened or displaced
I. Reproductive Tract Displacement

If the support systems of the uterus are weakened because of pregnancy

o
Ligaments may no longer be able to maintain uterus in its usual position or level after pregnancy
o
Uterine displacement disorders : Retroflexion, Antefelxion, Retroversion, Anteversion , Prolapse of the
uterus
May interfere w/ future childbearing and fertility
May cause continued pain or feeling of lower abdominal heaviness and discomfort
If walls of vagina are weakened
o
cystocele outpouching of bladder into the vaginal wall
o
rectocele outpouching of rectum into the vaginal wall
Predisposing factors :
o
High parity
o
Women after a forceps birth
Surgery may be necessary to repair such conditions
If stress incontinence /involuntary voiding during exertion occurs , Kegel exercise to strengthen perineal muscles may be
helpful

II. Separation of Symphysis Pubis

During pregnancy , many women feel some discomfort at symphysis pubis because of the relaxation of joint
preparatory to birth
Ligaments of symphysis pubis may be so stretched by birth that they actually tear
o
If a fetus is unusually large
o
If Fetal position is not optimal
Woman experiences :
o
Acute pain on turning or walking
o
Legs tend to rotate externally (waddling gait)
o
Area is swollen and tender to touch
Treatment measures :
o
Bed rest
o
Application of snug pelvic binder to immobilize joint
o
Avoid heavy lifting
As w/ all ligament injuries, a 4 to 6 week period is necessary for healing to take place
May advised to consider CS birth for any future pregnancy

Emotional and Psychological complications of the puerperium

I. A woman whose child is born w/ an illness or is physically challenged

They can feel angry, hurt, and disappointed ; May feel loss of self esteem because they have given birth to an imperfect
child and so they see themselves as imperfect
A woman sometimes responds w/ a grief reaction as if her child had died
Physician usually makes it her or his responsibility to tell the parents about the defect
People who are under stress are not good listeners and may need repeated explanations before they completely understand
the problem
If possible, it is important for the parents to care for the child during postpartal period so that they can touch, relate to
and claim the infant in as nearly a normal manner as possible
Open lines of communication bet. parents and hospital staff that allow for free discussion of feelings and fears

II. A woman whose newborn has died

A woman whose newborn dies at birth always questions about happened . She is likely to feel bewildered, perhaps bitter
and resentful that the hospital staff could not save her child
She needs concerned support from health care personnel
Most women are interested in seeing baby , this is generally therapeutic because it helps them begin grieving
o Clean the baby
o Wrap the baby in an infant blanket
o Bring him or her to the parents
o Remain w/ them but give them time to handle and inspect the child as they wish
Parents may want to take a photograph of the baby for a memory book
Other women on the unit tend to stay away from a woman whose child has died as if what happened to her baby was
contagious
Most women want a nurse to approach them and say
o Do u want to talk about whats happened?
o How do u feel?
Be careful not to use trite sympathy phrases such as
o God must have another purpose for you
o One door closes , another one opens
Do not place a woman whose child has died in a hospital room w/ a woman who has a healthy baby
Provide a private room to allow woman an opportunity to grieve
Allow her family to visit freely

III. Postpartal Blues

Onset : 1-10 days after birth

Incidence : 70 % of all births
Etiology

Response to the anticlimactic feeling after birth

Hormonal changes

Stress of life changes

Symptoms

Overall feeling of sadness

Tears
Therapy

Support

Empathy
Nursing Role

Offer compassion and understanding

IV. Postpartal Depression

Onset: 1-12 mos. After birth

Incidence : 10 % of all births
Etiology/ Risk factors

History of previous depression

Lack of social support

Hormonal response

Troubled childhood

Low self esteem

Stress in home or work

Symptoms

Extreme fatigue

Inability to stop crying

Increased anxiety

Insecurity

Psychosomatic symptoms (N/V , diarrhea)

Depressive or manic mood fluctuations

Therapy

Counseling

Drug therapy
Nursing Role

Refer to counseling
V. Postpartal Psychosis

Onset: Within 1st yr after birth

Incidence : 1 % to 2 % of all births
Etiology/ Risk factors

Family history of bipolar disorder

Hormonal changes

Possible activation of previous mental illness

Major life crisis

Symptoms

Delusion or hallucinations of harming infant or self

Therapy

Psychotherapy

Drug therapy
Nursing Role

Refer to Psychiatric care

Safeguarding mother from injury to self or to newborn