Complications During the Postpartal Period

  1. Disorders affecting fluid-gas transport

    1. Postpartum hemorrhage
      1. Definition - loss of 500 mL of blood or more during first 24 postpartal hr in vaginal birth; 1000 mL in cesarean birth.
      2. Pathophysiology - excessive loss of blood secondary to trauma, decreased uterine contractility; results in hypovolemia.
      3. Etiology (in order of frequency):
        1. Uterine atony
          1. Uterine overdistention (multipregnancy, polyhydramnios, fetal macrosomia).
          2. Multiparity.
          1. Prolonged or precipitous labor.
          2. Anesthesia - deep inhalation or regional (particularly saddle block).
          3. Myomata (fibroids).
          4. Oxytocin induction of labor.
          5. Overmassage of uterus in postpartum.
          6. Distended bladder.
        3. Lacerations - cervix, vagina, perineum.
        4. Retained placental fragments - usually delayed postpartum hemorrhage.
        5. Hematoma - deep pelvic, vaginal, or episiotomy sit.
        6. Assessment:
          1. Uterus - boggy, flaccid; excessive vaginal bleeding (dark; seepage, large clots) - due to uterine atony, retained placental fragments.
          2. Late signs of shock - air hunger; anxiety/apprehension, tachycardia, tachypnea, hypotension.
          3. Blood values (admission and postpartal) - hemoglobin (Hgb), hematocrit (Het), clotting time.
          4. Estimated blood loss: during labor/birth; in early postpartum.
          5. Pain: vulvar, vaginal, perineal.
          6. Perineum: distended - due to edema; discoloration - due to hematom May complain of rectal pressure.
          7. Lacerations - bright red vaginal bleeding with firm fundus.
        7. Analysis/nursing diagnosis:
          1. Fluid volume deficit related to excessive blood loss secondary to uterine atony, retained placental fragments.
          2. Anxiety/fear related to unexpected complication.
          3. Altered tissue perfusion related to decreased oxygenation secondary to blood loss.
          4. Activity intolerance related to fatigue.
        8. Nursing care plan/implementation:
          1. Medical management:
            1. IV oxytocin infusion; IV or oral ergot preparations (ergonovine [Ergotrate maleate]; methylergonovine [Methergine]; carboprost (Prostin/ M15), an oxytocic; prostaglandin.
            2. Order blood work: clotting time, platelet count, fibrinogen level, Hgb, Het, CB.
            3. Type and crossmatch for blood replacement.
            4. Surgical:
              1. Repair of lacerations.
              2. Evacuation, ligation of hematoma.
              3. Curettage-retained   placental fragments.
          2. Nursing management:
            1. Goal: minimize blood loss.
              1. Notify physician promptly of abnormal assessment findings.
              2. Order lab work stat, as directed-to determine blood loss and etiology.
              3. Fundal massage.
                1. Administer medications to stimulate uterine ton For ergot products and carboplast, monitor blood pressure (contraindicated in PIH).
                2. Goal: stabilize status.
                  1. Establish IV line-to enable administration of medications and rapid absorption/action. Administer whole blood (with larger catheter).
                  2. Administer medications, as ordered to control bleeding, combat shock.
                  3. Prepare for surgery, as ordered.
                3. Goal: prevent infection. Strict aseptic technique.
                4. Goal: continual monitoring. Vital signs, bleeding (do pad count or weigh pads), fundal status.
                5. Goal: prevent sequelae (Sheehans syndrome).
                6. Goal: health teaching -after episode: Reinforce appropriate perineal care and handwashing techniques.
        9. Evaluation/outcome criteria:
          1. Maternal vital signs stable.
          2. Bleeding diminished or absent.
          3. Assessment findings within normal limits.
        10. Subinvolution-delayed return of uterus to normal size, shape, position.
          1. Pathophysiology-inability of inflamed uterus (endometritis) to contract effectively -> incomplete uterine involution; failure of contractions to effect closure of vessels in site of placental attachment -> bleeding.
          2. Etiology:
            1. PROM with secondary amnionitis, endometritis.
            2. Retained placental fragments.
            3. Oxytocin stimulation or augmentation of labor of overdistended uterine muscle may interfere with involution.
          3. Assessment:
            1. Uterus: large, boggy; lack of uterine tone; failure to shrink progressively.
            2. Discharge: persistent lochia; painless fresh bleeding, hemorrhagic episodes.
          4. Analysis/nursing diagnosis:
            1. Pain related to tender, inflamed uterus secondary to endometritis.
            2. Anxiety/fear related to change in physical status.
            3. Knowledge deficit related to diagnosis, treatment, prognosis.
            4. High risk for injury related to infection.
            5. Fluid volume deficit related to excessive bleeding.
          5. Nursing care plan/implementation:
            1. Medical management:
              1. Have woman void or catheterize; massage.
              2. Surgical (curettage)-to remove placental fragments.
              3. Antibiotic therapy-to treat intrauterine infection.
              4. Oxytocics-to stimulate/enhance uterine contractions.
            2. Nursing management:
              1. Explain condition and treatment.
              2. Describe, demonstrate perineal care, pad change, handwashing.
                1. Goal: health teaching.
                2. Goal: emotional support. Encourage verbalization of anxiety regarding recovery, separation from newborn.
                3. Goal: promote healing.
                  1. Encourage rest, compliance with medical/nursing regimen.
                  2. Administer oxytocics, antibiotics, as ordered.
          6. Evaluation/outcome criteria:
            1. Verbalizes understanding of condition and treatment.
            2. Complies with medical/nursing regimen.
            3. Demonstrates normal involutional progress.
            4. All assessment findings (vital signs, fundal height, consistency, lochial discharge) within normal limits.
            5. Expresses satisfaction with care.
        11. Hypofibrinogenemia
          1. Pathophysiology- decreased clotting factors, fibrinogen; may be accompanied by DIC.
          2. Etiology:
            1. Missed abortion (retained dead fetus syndrome).
            2. Fetal death, delayed emptying of uterine contents.
            3. Abruptio placentae; Couvelaire uterus.
            4. Amniotic fluid embolism.
            5. Hypertension.
          3. Assessment:
            1. Observe for bleeding from injection sites, epistaxis, purpura.
            2. DIC assessment.
            3. Maternal vital signs, color.
            4. I&O.
            5. Medical evaluation-procedures.
              1. Thrombin clot test-important: size and persistence of clot.
              2. Prothrombin time-prolonged.
              3. Bleeding time-prolonged.
              4. Platelet count-decreased.
              5. Activated partial thromboplastin time-prolonged.
              6. Fibrinogen (factor I concentration)-decreased.
              7. Fibrin degradation products-present.
          4. Analysis/nursing diagnosis:
            1. Fluid volume deficit related to uncontrolled bleeding secondary to coagulopathy.
            2. Anxiety/fear related to unexpected critical emergency.
            3. Altered tissue perfusion related to decreased oxygenation secondary to blood loss.
          5. Nursing care plan/implementation:
            1. Medical management:
              1. Replace platelets.
              2. Replace blood loss.
              3. IV heparin-to inhibit conversion of fibrinogen to fibrin.
            2. Nursing management:
              1. Goal: continuous monitoring.
                1. Vital signs.
                2. I&O hourly.
                3. Skin: color, emergence of petechia.
                4. Note, measure (as possible), record, and report blood loss.
              2. Goal: control blood loss.
                1. Establish IV line, administer fluids or blood products as ordered.
                2. Position: side-lying-to maintain blood supply to vital organs.
              3. Goal: emotional support.
                1. Encourage verbalization of anxiety, fear, concerns.
                2. Explain all procedures.
                3. Remain with woman continuously.
                4. Keep woman and family informed.
          6. Evaluation/outcome criteria:
            1. Bleeding controlled.
            2. Laboratory studies-returning to normal values.
            3. Status stable.