Sunday, December 26, 2010

Postpartum Complications

Despite the normalcy of childbirth, complications may arise that will have detrimental effects on the postpartum client. These include postpartum hemorrhage, thrombophlebitis, infections (including mastitis, endometritis, and urinary tract infections), and postpartum depression. Healthcare providers working with postpartum clients must have a clear understanding of these complications, including the symptoms, nursing interventions, and treatment.

Postpartum Hemorrhage (PPH)
Postpartum hemorrhage is one of the leading causes of death among postpartum clients. Postpartum hemorrhage refers to a blood loss of more than 500 mL after a vaginal birth and more than 1000 mL after a C-section. Postpartum hemorrhage is categorized as early or late. Early refers to a hemorrhage occurring within the first 24 hours after birth, while late refers to a hemorrhage occurring after 24 hours.

Every postpartum client has the potential to hemorrhage after delivery. However, some clients have attributes that place them at higher risk for postpartum hemorrhage. These risk factors include:

  • Multiple parity
  • Multi-fetal pregnancy
  • Macrosomia
  • Prolonged or precipitous labor
  • Labor induction
  • Vacuum or forceps delivery
  • Lacerations
  • Stillbirth
  • Placenta previa
  • Use of certain medications (eg, magnesium sulfate)
  • Mechanical factors, such as a full bladder

Early postpartum hemorrhage is often caused by uterine atony. With uterine atony, there is a failure of the uterine muscles to contract properly, thereby inhibiting the healing of blood vessels at the site of placental attachment. The blood vessels continue to bleed until the uterine muscles contract. Signs of uterine atony include a boggy uterus, a fundus that is higher than expected upon palpation, and excessive lochia.

If the fundus is not firm (boggy), there are several nursing interventions that can alleviate the problem:

  • Massage the uterine fundus.
  • Express blood clots only if the uterus is firmly contracted, otherwise, uterine inversion and severe hemorrhage can occur.
  • Encourage the client to void, or catheterize as needed.
  • Administer prescribed medications, such as Pitocin, Ergonovine, Methergine, or Hemabate to assist the uterus in contracting. (Methergine can cause an elevation in blood pressure and should not be used with hypertensive clients.)

The nurse must report a PPH immediately and prepare for the insertion of a large-bore intravenous catheter, if one is not already present, and the administration of intravenous fluids and oxygen. A large-bore intravenous catheter is inserted to allow possible administration of blood products. The nurse should assess continually for bleeding, changes in vital signs, and oxygen saturation. The client's legs may also be elevated "to a 20° to 30° angle to increase venous return" (Leifer, 2005). Clients and their families will need nursing support during a PPH as it can be quite a disconcerting experience.

Early postpartum hemorrhage can also be caused by damage to the birth canal during labor and birth. If an early PPH is due to trauma to the birth canal, such as a hematoma, an extension of a perineal incision, or an improperly sutured laceration, clients may exhibit one or more of the following symptoms: a contracted uterus with excessive lochia, bright red lochia, a constant trickle of blood from the vagina, severe pain (possibly from a hematoma), or shock.

In the case of an early PPH caused by damage to the birth canal, surgical repair is usually necessary. In the case of hematoma formation, surgical incision, evacuation of blood clots, and ligation of the bleeding blood vessel may be necessary. However, in the case of a small hematoma, observation and application of ice or alternating hot and cold applications may be all that is necessary (Leifer, 2005).

Late postpartum hemorrhage is often caused by subinvolution of the uterus or by retained placental fragments that prevent the uterus from contracting. In the case of retained placental fragments, clots develop around the retained fragments and hemorrhaging can occur days later when the clots are shed. The certified nurse-midwife or physician is responsible for examining the placenta after delivery and ensuring that it is intact; therefore, a late PPH is usually preventable. Clients with placenta accreta (an abnormally deep attachment of the placenta) or when providers attempt to extract the placenta prior to uterine wall separation are at higher risk for a late PPH.

Assessment and manual expression of placental fragments by the physician or nurse-midwife can often alleviate the problem; however, surgical intervention, such as a dilation and evacuation (D&E) may be necessary. With subinvolution and a late PPH, fundal massage, in addition to medications (Pitocin, Ergonovine) and the previously mentioned interventions for early PPH, may be used to minimize bleeding.

A sequela of PPH is hypovolemic shock. Under normal circumstances, postpartal clients are able to withstand blood loss during the postpartum period as a result of increased blood volume during pregnancy. However, in the presence of a PPH, hypovolemic shock can occur and cause severe organ damage and even death if untreated. Often tachycardia is the first sign of hypovolemic shock. The blood pressure usually decreases and the respiratory rate increases. The skin becomes cool and pale initially and then cold and clammy. Clients may also become anxious, agitated, and restless as blood loss starts to affect the brain. Hypovolemic shock can be stopped by stopping blood loss. These clients will also require oxygen (usually 8–10 mL via face mask), IV fluids, and possibly blood products. This is a very serious situation and nurses must be prepared to assist in this life-threatening emergency.

Clients can suffer from thrombophlebitis as a result of venous stasis and the normal hypercoagulability state of the postpartum period. Thrombophlebitis is an inflammation of the blood vessel wall in which a blood clot forms and causes problems in the superficial or deep veins of the lower extremities or pelvis. All postpartum clients are at risk. However, certain risk factors predispose some clients to developing thrombophlebitis. These risk factors include varicose veins, clotting disorders, delivering via C-section, diabetes mellitus, smoking, obesity, prolonged sitting or standing, and advanced maternal age.

The blood clot that develops in thrombophlebitis can lead to a life-threatening pulmonary embolism as a result of the clot detaching from the vein wall and blocking the pulmonary artery. The major signs of pulmonary embolism include dyspnea and chest pain.In monitoring postpartum clients for the development or presence of thrombophlebitis, nurses should assess for the presence of hot, red, painful, or edematous areas on the lower extremities or groin area. An elevated temperature may also be present. As previously mentioned, it is currently contraindicated to assess for a thrombophlebitis by eliciting a Homan's sign.

Interventions to treat thrombophlebitis depend on the severity of the thrombosis. Usually, for superficial thrombosis, analgesics, bed rest, and elevation of the affected limb is enough to alleviate the problem. However, in the presence of a DVT, anticoagulants may be necessary. In addition to use of compression stockings and warm, moist heat applications, clients should be instructed to keep their legs elevated and uncrossed. These clients are typically allowed to ambulate only after symptoms subside.

Postpartum infections are infections accompanied by a temperature of 38° C or higher on two separate occasions where no other explanation is responsible for the elevation in temperature. Postpartum clients should be carefully monitored for signs and symptoms of infection during this period. Common infections that may occur during the postpartum period include mastitis, endometritis, wound infections, and urinary tract infections.

Mastitis is a breast infection caused by Staphylococcus aureus. S. aureus is found on the hands and can also be in the mouths of infants. Bacteria can enter through cracked nipples caused by improper latch-on during breastfeeding. Mastitis can develop due to blocked milk ducts and milk stasis in the breastfeeding clients. Blocked milk ducts and milk stasis occurs as a result of improper latching and inadequate breast emptying.
It is crucial that postpartum nurses teach breastfeeding clients proper latch techniques. Additionally, nurses must stress that clients feed infants regularly and allow the breast to empty completely. Breastfeeding clients should also be encouraged to avoid missing feedings and allowing the breast to become engorged.The classic symptom of mastitis is a unilateral mass in the breast accompanied by pain and redness. Often these clients experience a low-grade fever, chills, and general malaise. If untreated, a breast abscess may develop. Treatment for mastitis typically involves antibiotic therapy and regular breastfeeding or pumping the breast. Nurses can encourage these clients to apply cold or warm compresses to ease discomfort and to take analgesics as needed. Mastitis usually resolves quickly as long as clients continue to breastfeed or pump regularly.

Endometritis is an infection of the uterus characterized by uterine subinvolution, infection, abdominal cramps, and purulent, foul-smelling lochia. It is caused by the bacteria normally present in the uterus and cervix, such as E. coli and group B streptococcus. Manual removal of the placenta, multiple vaginal examinations during labor, C-sections, premature rupture of members, and internal fetal and/or uterine monitoring predispose clients to developing endometritis.
In addition to cramping and foul-smelling lochia, clients with endometritis typically have a fever, chills, general malaise, and may exhibit tachycardia. Blood cultures to identify the causative organism are typically done and white blood cell (WBC) counts are monitored. However, it is important to remember that the white blood cell count is normally elevated after delivery for a short period; continued monitoring of the WBC count is required in identifying endometritis. Endometritis is usually treated with intravenous antibiotics and rest.

Wound infections are infections that occur at wound sites. Commonly affected wound sites during the postpartum period include the perineum, where lacerations and episiotomies occur, and C-section incisions. As with all infections, every client is at risk.
Postpartum clients with wound infections typically have wounds that exhibit redness, warmth, poor wound approximation, tenderness, and pain. If untreated, these clients may develop a fever and other symptoms of an infection, such as malaise. As with endometritis, blood cultures may be obtained to isolate the causative organism. Antibiotics will typically be administered and drainage of the wound may be necessary.
Dressing changes using normal saline will aid in the healing process. Clients should be taught about proper handwashing and encouraged to maintain adequate fluid intake and increase protein intake to assist in wound healing. Wound infections can be intensely painful, especially in the perineum. Therefore, the nurse should assist these clients in managing pain through the use of analgesics and positioning.

Urinary tract infections are common during the postpartum period. The client's urethra and bladder is often traumatized during labor and birth due to intermittent catheterizations and the pressure of the infant as it passes through the birth canal. Additionally, the bladder and urethra loose tone after delivery, making the retention of urine and urinary stasis common. The risk of developing a UTI is high. Clients may also develop a UTI due to frequent catheterization while in labor or the placement of a Foley catheter, which frequently remains in place for several hours or days after delivery.
Clients with urinary tract infections often complain of frequent and/or painful urination as well as flank pain. A low-grade fever and hematuria may also be present. Urinary tract infections are treated with antibiotics, but it is important that these clients drink adequate fluids to flush bacteria out of the system. (Additionally, it has been suggested that cranberry juice is useful in preventing urinary tract infections due to acidifying the urine and preventing bacteria from attaching to the bladder walls; however, there is great debate over this issue.)

Postpartum Depression
Postpartum depression is a serious and debilitating depression that affects many women throughout the world. According to Blum (2007), "There are no specific, generally accepted criteria for time after delivery for a depression to be considered a postpartum depression, but typically these depressions occur within the first nine months after the baby's birth, often within the initial weeks or months." Symptoms typically include sadness, crying, insomnia, decreased appetite, withdrawal, and sometimes suicidal ideation or the desire to harm the infant. Additionally, clients may present with somatic symptoms, such as "headaches, diarrhea, constipation, severe anxiety, feeling as though they are jumping out of their skin, and/or just not feeling like themselves" (Driscoll, 2006).
It is the responsibility of nurses to assess postpartum clients for signs and symptoms of postpartum depression. Various assessment tools are available, including the Edinburgh Postnatal Depression Scale (EPDS) and the Postpartum Depression Screening Scale (PDSS). These tools are quick and provide a simple way to assess clients while at the hospital, at home during postpartum home visits, and during postpartum follow-up visits. These tools can also be used to assess maternal clients at pediatric follow-up visits.
After screening and assessment, clients who are at risk for developing (or who are suffering from) postpartum depression can be referred to the appropriate healthcare provider for follow-up and treatment. According to Lowdermilk and Perry (2006), symptoms of postpartum depression rarely disappear without outside help; therefore, it is imperative to appropriately assess and refer clients suffering from this type of depression.
Postpartum depression is usually treated with counseling and medication. Nurses can support these clients in the healing process at follow-up appointments and during home visits. Driscoll (2006) recommends that nurses help clients and their families understand postpartum depression and assist them in exploring the spiritual aspects of their suffering as an aid in the healing process. Additionally, nurses should encourage these clients to get adequate nutrition, rest, relaxation, and exercise (Driscoll, 2006).

Postpartum clients and their families should be instructed to call the healthcare provider if the client has any of the following:

  • Fever
  • Foul-smelling lochia
  • Large blood clots or bleeding that saturates a pad in one hour
  • Discharge or severe pain from incisions
  • Hot, red, painful areas on the breasts or legs
  • Bleeding and/or severe pain in the nipples
  • Severe headaches and/or blurred vision
  • Chest pain and/or dyspnea without exertion
  • Frequent, painful urination
  • Signs of depression


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