POSTPARTUM

COMPLICATIONS
DONALD G. CAMATURA, RN

Too many mothers and newborns
are dying every year
At current rate of decline, the Philippines is
unlikely to reach MDG 5 target for MMR by 2015
3
Most maternal deaths occur during labor, delivery
and the immediate post-partum period
4


0-1 day 2-7 days 8-14 days 15-21 days 22-30 days 31-42 days

Day of maternal death after delivery


Source: X. F. Li et al., International Joumal of Gynecology & Obstetrics 54 (1996): 1-10
P
e
r
c
e
n
t

o
f

m
a
t
e
r
n
a
l

d
e
a
t
h
s

i
n

d
e
v
e
l
o
p
i
n
g

c
o
u
n
t
r
i
e
s

Causes of Maternal Mortality
41%
12%
22%
15%
10%
Hemorrhage
Unsafe
Abortion
Hypertension
Other
Infection
WHO, 2010
TOPIC OUTLINE:
Postpartum Infection
Postpartum Hemorrhage
Mastitis
Postpartum Hematoma
Subinvolution
Postpartum UTI
Postpartum Psychosis
Postpartum Infection
Puerperal Infection
Term used to describe bacterial infections after childbirth
A fever of 38 C ( 100.4 F ) or higher after the first 24 hrs. after childbirth
occuring on at least 3 of the first 10 days after the first 24 hrs.
During the first 24 hrs. a slight elevation may occur because of
dehydration or the exertion of labor
Organisms can move from the vagina, cervix, uterus and out of the
fallopian tube to infect the ovaries and the peritoneal cavity. Blood
vessels or lymphatics can carry infection to the rest of the body.-
Septicemia
Causative organisms can be Staphylococcus aureus,
gonococci, coliform bacteria, and rarely by Clostridia


Postpartum Infection
Types of Infection:
Endometritis
Parametritis
Peritonitis
Pyelonephritis
Cystitis
Thrombophlebitis
Mastitis, abcess


Postpartum Infection
Risk or Predisposing Factors:
Antenatal:
poor nutrition
low SES
Hx of Infections ( UTI, mastitis thrombophlebitis)
Anemia
Immunodeficiency
Poor general health( fatigue, anemia, frequent minor illness)
Poor hygiene
Medical conditions such as DM


Postpartum Infection
Risk or Predisposing Factors:
Intrapartal:
Prolonged labor
PROM
Poor aseptic technique
Birth trauma
Multiple exams
Internal monitoring
Episiotomy
C section


Postpartum Infection
Risk or Predisposing Factors:
Postpartum:
Manual removal of placenta
Hemorrhage
Retained secundines
Colonization of the vagina with pathogenic organisms



Postpartum Infection
Causative Organism:


B hemolytic streptococcus
Escherichia coli
Klebsiella
Proteus
Pseudomonas
Staphylococcus
Aerobic
30%
Bacteriodes
Peptococcus
C. perfringes
Anaerobic
70%
Postpartum Infection
Signs and Symptoms:
Fever and chills
Pain and redness of wounds
Purulent wound drainage or wound edges not approximating
Tachycardia
Uterine Subinvolution
Abnormal duration of lochia or foul odor
Elevated white blood cell count
Frequency or urgency of urination, dysuria or hematuria
Suprapubic pain
Localized area of warmth, redness or tenderness in the breast
Body aches, general malaise
Endometritis
Infection of the endometrium
placental site
decidua
cervix
Symptoms--discharge (scant to profuse), bloody, foul smelling
uterine tenderness
jagged, irregular temp elevations
tachycardia, chills, subinvolution
Salpingitis, Oopheritis
May be caused by gonorrhea, chlamydia
unilateral or bilateral abdominal pain
chills, fever
mass
tachycardia
may lead to sterility
Pelvic Cellulitis, (parametritis)
Infection of the connective tissue of pelvis
frequently infecting the broad ligament and causing severe pain.
May ascend from cervical lacerations
Parametritis symptoms
Spiking temp to 104
chills, flushing, sweating
tachycardia, tachypnea
uterine tenderness, cramping
change in LOC/agitation,delerium, disorientation
change in lochia
cervical or uterine tenderness on vag exam
WBC elevation
Peritonitis
Life threatening infection of the peritoneum
Abcesses on the uterine ligaments, in the cul de sac, and/or in the
subdiaphragmatic space
May result from pelvic thrombophlebitis
Symptoms of Peritonitis
High temp
chills
malaise
lethargy
pain
subinvolution
Tachycardia
local or referred
pain
rebound tenderness
thirst
distension
nausea and
vomiting
Cystitis
Bladder infection
urgency
frequency
burning
dysuria
suprapubic pain
hematuria
Pyelonephritis
Kidney infection, usually of the R. kidney.Ascends from bladder.
Spiking temp
Shaking chills
Flank pain, CVA pain
Nausea and vomiting
Hx of asymptomatic bacteruria or pyelonephritis
Urgency, frequency, dysuria
Back pain
Prevention and treatment
Force fluids
Insure complete emptying of bladder
Sterile technique for cath
Good perineal care
Antibiotics
Thrombophlebitis Blood clot
associated with bacterial infection

Etiologies
blood clotting factors
postpartal thrombocytosis (platelets)
thromboplastin release (placenta, amnion)
fibrinolysin and fibrinogen inhibitors
Superficial
Tenderness
heat
redness
low grade fever
+ homans sign
tachycardia
Treatment
elevation
heat
analgesic
bedrest
Antibiotics
Thrombophlebitis Blood clot
associated with bacterial infection

Etiologies
blood clotting factors
postpartal thrombocytosis (platelets)
thromboplastin release (placenta, amnion)
fibrinolysin and fibrinogen inhibitors
Management of Puerperal
Infection:
Detailed history regarding onset, severity and associated symptoms
Complete physical examination including general, systemic and
local examination
Manage according to the underlying cause
Blood & urine for routine & microscopic investigation
Encourage increased oral fluid intake
Cold sponging to help decrease temperature
Antibiotics
Treat the cause
Refer if required

Management of Puerperal
Infection:
If the general condition of the woman is non toxic i.e., low grade fever
& pulse not rapid, give her a combination of oral antibiotics
Ampicillin 500 mg. QDS PLUS
Tab Metronidazole 400mg. TDS PLUS
Inj Gentamicin 80 mg. TDS
Rule out presence of retained placental bits
Monitor vitals every 2 hrly.
Watch for 24 hrs
If vital signs improving, then complete the course of
Antibiotic

Management of Puerperal
Infection:
If fever persists after 72 hours of initiating antibiotics:
Re-evaluate and consider other causes of fever
Consider if antibiotic cover sufficient; and
REFER

Management of Puerperal
Infection:
If the general condition of the woman is toxic i.e.,
with high grade fever & rapid pulse
Start her on intravenous fluids and
Give her the first dose of IV antibiotics:
Ampicillin 1 gm IV PLUS
Tab Metronidazole 500mg PLUS
Inj Gentamicin 80 mg IM
Rule out presence of retained placental bits
Refer the woman
Prevention of Puerperal Infection:
Puerperal sepsis is to a great extent preventable;
Measures to be taken in
Antenatal Period:
Improve Hb level to > 11 gms %
Treat any septic focus (skin, throat etc.)
Intranatal Period:
Asepsis during delivery
Postpartum Period:
Maintain perineal hygiene
Use of clean sanitary pad
Remember!
Puerperal sepsis is important cause of maternal mortality and
morbidity
It is, to a great extent, preventable
Early detection and treatment helps complete recovery
Serious cases require referral

TOPIC OUTLINE:
Postpartum Infection
Postpartum Hemorrhage
Mastitis
Postpartum Hematoma
Subinvolution
Postpartum UTI
Postpartum Psychosis
Postpartum Hemorrhage

Early postpartum hemmorhage
>500 ml in first 24 hrs (blood loss often underestimated)

Late or delayed
>500 cc after first 24 hrs.
Why do we care?
Major obstetric haemorrhage more than 1000ml


Very rapidly lead to maternal death


Predisposing Factors:
Uterine overdistension--large infant,etc.
Grand multiparity
Anesthesia or MgSO
4

Trauma
Abnormal labor pattern--hypo or hypertonia
Oxytocin during labor
Prolonged labor
Hx of maternal anemia, hemorrhage
Placenta previa
Polyhydramnios

Prevention
Risk assessment - may present antenatally or intrapartum
Inspect placenta
Explore uterus
Avoid overmanipulation of uterus
If at risk type and Crossmatch and start IV
Treat anemia antenatally
Active management of the 3
rd
stage
Prophylactic oxytocics reduce the risk of PPH by 60% (oxytocin or
oxytocin & ergometrine)
5IU IM for vaginal delivery
5IU IV for LSCS
Consider oxytocin infusions


Four Ts
Tone

Tissue

Thrombin

Trauma

Tone

Previous PPH
Prolonged labour
Age > 40 years
Big baby
Multiple pregnancy
Placenta previa
Obesity
Asian ethnicity

Tissue

Retained placenta/
membrane/clot

Thrombin

Abruption
PET
Pyrexia
Intrauterine death
Amniotic fluid embolism


DIC

Trauma

Caesarean section
(emergency > elective)
Perineal trauma
Episiotomy
Operative delivery
Vaginal and cervical tears
Uterine rupture
Uterine Inversion
Hematoma
Signs of Impending Hemorrhage:
Excessive bleeding (>2pads/30min-1hr)
Light headedness, nausea, visual disturbances
Anxiety, pale/ashen color, clammy skin
Increasing P and R, BP same or lower

Action to take:
Summon help
Check uterine tone, massage, assess effect
Elevate legs, lower head
Increase or begin O
2

Increase or begin IV

Early Postpartum Hemorrhage
Within the first 24 hrs
Causes
uterine atony
lacerations
retained secundines
coagulation problems

Uterine Atony
Failure of the uterus to stay firmly contracted
Slow, steady or massive hemorrhage, sometimes underestimated or
hidden behind a clot
VS may not change immediately
Treatment
bimanual massage
oxytoxics
curretage
surgery iliac ligation or hysterectomy


Retained Placental Fragments
Partial separation caused by:
pulling on the cord
uterine massage prior to separation
placenta accreta
Treatment:
massage
manual removal
oxytoxics
D & E

Late Postpartum Hemorrhage
Hemorrhage occurring after 24 hrs
retained placenta--necrosed, fibrin deposits, placental polyps,
sloughingbleeding

Symptoms
excessive or bright red bleeding
boggy fundus
large clots
backache
T-P-R, BP



Late Postpartum Hemorrhage
Treatment, massage, IV oxytocin, D&E



Management:
Has the placenta been delivered and is it complete?

Is the uterus well-contracted?

Is the bleeding due to trauma?
Management
A & B 10 -15l/min O2 by facemask
C - crossmatch 4 units
2 litres of crystalloid rapidly transfuse as soon as possible
consider O blood if any delays.

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


Nursing Assessment:
1. Assess for hypotension, tachycardia, change in respiratory rate,
decrease in urine output, and change in mental statusmay
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


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

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.


Nursing Interventions:
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.


Nursing Interventions:
C. Prevention 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.


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.


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



TOPIC OUTLINE:
Postpartum Infection
Postpartum Hemorrhage
Mastitis
Postpartum Hematoma
Subinvolution
Postpartum UTI
Postpartum Psychosis
Mastitis
It is an inflammation of the mammary gland (parenchyma) .
Incidence: 2 - 3% of lactating women
More common at 2 - 6 weeks post-partum, but can occur at any
time
More common in primiparas, but probably due to bias
Risk factors: milk stasis, age > 30, stress, fatigue, professional
employment of mother or father

Mastitis
Etiology:
50% or more: S. Aureus
Other organisms: E. Coli, S. pyogenes
Source: infant nasopharynx
Mechanism: via milk ducts or nipple fissure, carried on hands of
mom. Enters nipple thru crack or blister.

Mastitis:
Risk Factors:
Primiparity
incomplete emptying of the breast
improper nursing technique.

Mastitis:
Signs and Symptoms:
Fever
Chills
Malaise
localized erythema
tenderness of breast tissue.
Mastitis:
Treatment:
Warm soaks to both breasts as needed; pumping; put baby on breast
more often.
Analgesics; ABs - Amoxicillan 250mg.po TID.
Milk stasis can be treated with moist heat, massage, fluids, rest, proper
positioning of the infant during lactation, manual expression of milk, and
analgesics.
Penicillinase-resistant penicillins and cephalosporins, such as dicloxacillin or
cephalexin, are the drugs of choice.
Erythromycin, clindamycin, and vancomycin may be used for patients who are
resistant to penicillin.
Resolution usually occurs 48 hours after the onset of antimicrobial therapy.


TOPIC OUTLINE:
Postpartum Infection
Postpartum Hemorrhage
Mastitis
Postpartum Hematoma
Subinvolution
Postpartum UTI
Postpartum Psychosis
Postpartum Hematoma
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.
Result from injury to a blood vessel, usually in vagina or vulva, may
extend upward into broad ligament or other pelvic structures
develop rapidly
may contain 300-500ml blood

Etiology:
1. Trauma during spontaneous labor
2. Trauma during forceps application or delivery
3. Inadequate suturing of an episiotomy


Signs and symptoms:
Severe pain
Difficulty voiding
Mass felt on vaginal exam
(Discolored skin that is tight, full feeling,
and painful to touch)
Flank pain
Abdominal distension
Shock (Decrease BP, tachycardia)



Complications:
1. Hypovolemia and shock from extreme blood loss
2. Anemia, infection
3. Increased length of postpartum recovery period


Treatment:
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. (Incision and Drainage)
3. Analgesics and antibiotics may be ordered (due to increased
chance of infection).



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.
Nursing Interventions/
Patient Education
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.


TOPIC OUTLINE:
Postpartum Infection
Postpartum Hemorrhage
Mastitis
Postpartum Hematoma
Subinvolution
Postpartum UTI
Postpartum Psychosis
Subinvolution
Uterus remains large, does not involute

CAUSES:
Aggravating factors:
Retained products of conception
Uterine sepsis, endometritis

Subinvolution
Predisposing factors
grand multiparity
overdistension of uterus as in twins and hydramnios
ill maternal health
caesarean section
uterine prolapse
retroversion after the uterus becomes pelvic organ
uterine fibroid
Subinvolution
Symptoms:
The condition may be asymptomatic. The predominant symptoms
are:
Abnormal lochial discharge either excessive or prolonged
Irregular or at times excessive uterine bleeding
Irregular cramp like pain is cases of retained products or rise of
temperature in sepsis
Signs:
The uterine height is greater than the normal for the particular day
of puerperium. Normal puerperal uterus may be displaced by a full
bladder or a loaded rectum. It feels boggy and softer upon
palpation.
Subinvolution
Treatment:
Antibiotics in endometritis
Exploration of the uterus in retained products/curretage
Ergometrine (methergine) to enhance the involution process by
reducing the blood flow of the uterus is of no value in prophylaxis.


TOPIC OUTLINE:
Postpartum Infection
Postpartum Hemorrhage
Mastitis
Postpartum Hematoma
Subinvolution
Postpartum UTI
Postpartum Psychosis
Postpartum UTI

A urinary tract infection (UTI) is defined as a bacterial inflammation
of the bladder or urethra.
Greater than 105 colony-forming units from a clean-catch urine
specimen or greater than 10,000 colony-forming units on a
catheterized specimen is considered diagnostic of a UTI.
~ 2-4 % develop UTI postpartum.
The most common pathogen is E coli. In pregnancy
-Risk factors Cesarean delivery, forceps delivery, vacum delivery,
induction of labor, maternal renal disease, preeclampsia,
eclampsia, epidural anesthesia, bladder catheterization, length of
hospital stay, and previous UTI during pregnancy.
Postpartum UTI
Diagnosis
History (frequency, urgency, dysuria, hematuria)
Physical examination (febrile patient, Suprapubic tenderness)
Laboratory tests (urinalysis, urine culture and CBC)

Signs/Symptoms:
Dysuria
low grade fever
Urgency
Frequency
Elevated temperature



Treatment:
Empirical culture selective (3-7 Days)
trimethoprim/sulfamethoxazole, ciprofloxacin, and norfloxacin.
Amoxicillin is often still used,
quinolones are very effective but are considerably more expensive than
amoxicillin and trimethoprim/sulfamethoxazole and should not be used
in breastfeeding mothers.


Nursing Care:
1. Teach about increase Fluid Intake
2. Perineal Care
3. Antibiotic therapy
4. Taking of Fresh fruits rich in Vit. C.



TOPIC OUTLINE:
Postpartum Infection
Postpartum Hemorrhage
Mastitis
Postpartum Hematoma
Subinvolution
Postpartum UTI
Postpartum Psychosis
Psychiatric Disorders

1- Postpartum blues - 50-70%
Mild, self limited, arises during the first 2 weeks PP
TTT: Support & education
2- Postpartum depression (PPD) - 10-15%.
More prolonged (3-6 months)
TTT: Supportive care and reassurance, SSRI
3- Postpartum psychosis- 0.14-0.26%.
Generally lasts only 2-3 months. Need psychiatrist.
Better prognosis than nonpuerperal psychosis.

Postpartum Psychosis
described as a period when a woman loses touch with reality, the
disorder occurs in women who have recently given birth. It affects
between one and two women per 1,000 women who have given
birth.
Postpartum psychosis has a 5% suicide rate and a 4% infanticide
rate.
onset of symptoms can occur at anytime within the first three
months after giving birth, women who have postpartum psychosis
usually develop symptoms within the first two to three weeks after
delivery.

Postpartum Psychosis
Rare, occurs in 1 to 2 per 1000 pregnancies
Rapid, dramatic onset within first 2 weeks
Resembles an affective (manic) psychosis
Early signs: sleep disturbance, restlessness
Depressed or elated mood, agitation, delusions, depersonalization
Risk of self-harm and harm to infant

Pathophysiology:
Hormonal factors
Levels of estrogen, progesterone, and cortisol fall dramatically within 48
hours after delivery.
Women with postpartum depression do not differ significantly from
nondepressed women with regard to levels of estrogen, progesterone,
prolactin, and cortisol or in the degree to which these hormone levels
change; however, affected individuals may be abnormally sensitive to
changes in the hormonal milieu and may develop depressive symptoms
when treated with exogenous estrogen or progesterone.
Psychosocial factors
Women who report inadequate social supports, marital discord or
dissatisfaction, or recent negative life events are more likely to
experience postpartum depression.
Biologic vulnerability
Women with prior history of depression or family history of a mood
disorder are at increased risk for postpartum depression.
Women with a prior history of postpartum depression or psychosis have
up to 90% risk of recurrence.

Signs:
Postpartum psychosis symptoms usually appear quite suddenly; in
80% of cases, the psychosis occurs three to 14 days after a
symptom-free period.
Hallucinations
Delusions
Illogical thoughts
Insomnia
Refusing to eat
Extreme feelings of anxiety and agitation
Periods of delirium or mania
Suicidal or homicidal thoughts


Screening for Postpartum Mood
disorder:
The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-
rated questionnaire used extensively for detection of postpartum
depression. A score of 12 or more on EPDS or an affirmative answer
on question 10 (presence of suicidal thoughts) requires more
thorough evaluation. Include EPDS in routine well-baby and
pediatric visits.

Treatment:
Untreated postpartum affective illness places both the mother and infant at
risk and is associated with significant long-term effects on child
development and behavior;
therefore, prompt recognition and treatment of postpartum depression are
essential for both maternal and infant well-being.
supervised by a psychiatrist and should involve hospitalization.




Treatment:
Puerperal psychosis is a psychiatric emergency that typically
requires inpatient treatment.
Most patients with puerperal psychosis suffer from bipolar disorder.
Acute treatment includes a mood stabilizer (eg, lithium, valproic
acid, carbamazepine) in combination with antipsychotic
medications and benzodiazepines.
ECT (often bilateral) is tolerated well and rapidly effective.
Risk of suicide is significant in this population.
Rates of infanticide associated with untreated puerperal psychosis
are as high as 4%.


Special concerns:
Breastfeeding and psychotropic medications
Women who plan to breastfeed must be informed that all
psychotropic medications, including antidepressants, are secreted
into breast milk. Concentrations in breast milk vary widely.
Data on the use of tricyclic antidepressants, fluoxetine, sertraline,
and paroxetine during breastfeeding are encouraging, and serum
antidepressant levels in the nursing infant are either low or
undetectable. Reports of toxicity in nursing infants are rare, although
the long-term effects of exposure to trace amounts of medication
are not known.
Avoid breastfeeding in women treated with lithium because this
agent is secreted at high levels in breast milk and may cause
significant toxicity in the infant.
Avoid breastfeeding in premature infants or in those with hepatic
insufficiency who may have difficulty metabolizing medications
present in breast milk.

Special concerns:
Impact of postpartum depression on child development
A large body of literature suggests that a mother's attitude and
behavior toward her infant significantly affect mother-infant
bonding and infant well being and development. Postpartum
depression may negatively affect these mother-infant interactions.
Mothers with postpartum depression are more likely to express
negative attitudes about their infant and to view their infant as more
demanding or difficult. Depressed mothers exhibit difficulties
engaging the infant, either being more withdrawn or
inappropriately intrusive, and more commonly exhibit negative
facial interactions. These early disruptions in mother-infant bonding
may have a profound impact on child development.
Children of mothers with postpartum depression are more likely than
children of nondepressed mothers to exhibit behavioral problems
(eg, sleep and eating difficulties, temper tantrums, hyperactivity),
delays in cognitive development, emotional and social
dysregulation, and early onset of depressive illness.


Nursing Interventions:
close follow-up,
adequate sleep,

stressors
Family psychoeducation
Separation

from the infant