NCM 109: CARE OF MOTHER AND CHILD AT RISK (ACUTE & CHRONIC)

MODULE 3M: POSTPARTAL COMPLICATIONS

NURSING PROBLEMS o Subinvolution of the uterus
- Ultrasonography – detecting the bits of
1. Tissue Perfusion placenta inside the uterine cavity
a. Thrombophlebitis
2. Acute Pain SIGNS AND SYMPTOMS
a. DVT - Irregular cramps
3. Fluid Volume Deficit - Abnormal lochial discharge
a. Bleeding - Excessive uterine bleeding
4. Excess Volume - It is possible that Subinvolution of uterus
a. Edema shows no physical symptoms and still is
5. Sexual Function present in a patient.
a. Sheehan’s
i. Endocrine disorder MANAGEMENT
6. Psychological/Mental Problem -
1. Medical
Parenting, Anxiety
a. Conservative medical therapy – a
a. Postpartum blues
type of medical treatment defined by
b. Depression
the avoidance of invasive measures
c. Psychosis
such as surgery or other invasive
SUB-INVOLUTION OF THE UTERUS procedures, usually with the intent to
DEFINITION preserve function or body parts
b. Fertility-sparing percutaneous
- The incomplete return of the uterus to its pre- embolotherapy – the use of any type
pregnancy size and shape of embolic material
- It is the delayed return of the enlarged uterus i. Autologous thrombus, muscle
to normal size and function. fragment, or foreign body for
- With subinvolution, at a 4–6-week therapeutic occlusion of a
postpartum visit: the uterus is still enlarged blood vessel
and soft, presence of lochial discharge 2. Pharmacologic
- Soft and flabby leads to bleeding a. Oral antibiotic
ETIOLOGY/CAUSE i. Prescribed when the uterus
feels tender to palpation,
- Uterine atony or placental fragments prevent suggesting endometritis is
the uterus from contracting effectively present
- Subinvolution may result from: b. Methylergonovine
o Small retained placental fragment c. Oxytocin
o Mild endometritis d. Carboprost Tromethamine
o Uterine myoma (interferes with
complete contraction) Classificatio Used for Selected
o Treatment depends on the cause ns Interventions
- Grand multiparity o Blocks o Heparin IV
- Overdistension of uterus as in twins and the should be
hydramnios conversio administered
- Ill maternal health n of as a “piggy
prothrom back”
- Caesarean section
bin to infusion
- Uterine prolapse
thrombin o Heparin SQ
- Uterine fibroid and is given deep
Anticoagula
- Persistent lochia/fresh bleeding fibrinoge into the site
- Long labor nts
n to fibrin (abdomen),
- Precipitate labor thus site are
- Anesthesia Heparin
decreasi rotated, do
- Full bladder sodium
ng not aspirate,
- Difficult delivery injection
clotting apply
- Retained placenta (Hepalean) ability pressure (do
- Maternal infection/uterine sepsis Lovenox o Inhibits not massage)
thrombus o Used to
ASSESSMENT FINDINGS and clot prevent and
formation treat
- Clinical manifestations include:
pulmonary
o Prolonged lochial discharge
embolism
o Irregular or excessive bleeding and
o Larger than normal uterus thrombosis
o Boggy uterus (occasionally) o Interferes o Women on
DIAGNOSTIC TEST FINDINGS Warfarin with anticoagulop
sodium hepatic athy therapy
- Internal examination synthesis should not be
(Coumadin,
o Massive bleeding of vitamin given
Warfione)
o Evidence of sepsis (white fluid show K – estrogen or
presence of pus) depende aspirin
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MODULE 3M: POSTPARTAL COMPLICATIONS

nt clotting o Obtain contracti o Assess for

factors baseline on numb fingers
(II, VII, IX, coagulation o Used for and toes,
X) studies preventio cold, chest
o Obtain serial n and pain, nausea,
coagulation treatment vomiting,
studies while of muscle pain,
the client is postpartu and
on therapy m or weakness
o Keep postabort o May cause
protamine ion decreased
sulfate hemorrha serum
readily ge prolactin
available in caused o IV
case of by uterine administratio
heparin atony or n is used for
overdose subinvolu emergency
o Assess client tion dosage only
for bleeding o Administer at
from nose, a rate of
gums, 0.2mg over at
hematuria, least 1
and blood in minutes
stool o Do not mix
o Observe this drug with
color and any other
amount of drug
lochia. o Use solution
Institute pad only if it is
count clear and
o Avoid IM colorless,
injections to with no
avoid precipitate.
formation of May store at
hematomas room
o Inform the temperature
client that this for 60 days.
drug does not The drug
pass into deteriorates
breast milk with age.
o Monitor for
the following 3. Surgical
side effects; a. Hysterectomy – the removal of the
hemorrhage, uterus
bruising b. Dilation and Curettage (D & C) – to
urticaria, and manually remove retained placental
thrombocyto tissues that may have caused the
penia
complication.
o Women on
anticoagulant NURSING INTERVENTIONS
therapy
should not be Therapeutic Management
given
1. Oral administration of methylergonovine
estrogen or
aspirin a. 0.2 mg four times daily
o Keep b. Usual prescription to improve uterine
AquaMEPHY tone and complete involution
TON (vitamin c. Improve uterine tone
K) on hand in 2. Prevent excessive blood loss, infection, and
case of other complications.
Coumadin a. Massage uterus, facilitate voiding,
overdose and report blood loss.
o Directly o Obtain a b. Monitor blood pressure and pulse
stimulate baseline rate
Oxytoxic s uterine calcium level c. Administer prescribed medications.
and o Advise the d. Be prepared for possible D&C.
methylergono vascular client that this 3. Assist the client and family to deal with
vine maleate smooth medication physical and emotional stresses of
(maleate) muscle will cause postpartum complications.
o Promotes menstrual-
uterine like cramps
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MODULE 3M: POSTPARTAL COMPLICATIONS

4. Before hospital discharge, instruct client how MANAGEMENT

to recognize the normal process of involution
and lochial discharge. 1. Medical
a. To identify subinvolution and seek a. Uterine massage
early care if it occurs i. Cup position
b. A chronic loss of blood from ii. Massage in a circle
subinvolution causes anemia and
lack of energy
NURSING DIAGNOSES
- Fluid Volume Deficit: lochia rubia of 650ml in
the first 24 hours post-deliver y, and
lightheaded ness r/t blood volume loss b. Bimanual uterine compression
secondary to postpartum hemorrhage c. Blood transfusion
d. Tamponade techniques
UTERINE ATONY 2. Dietary
DEFINITION a. Balanced diet with high fiber
- Relaxation of the uterus, most frequent b. Enough fluid intake
cause of postpartum hemorrhage c. Iron supplement
- Poor uterine tone 3. Pharmacologic
o Inability of her uterus to maintain a a. Uterotonic drugs – 22 units
contracted state b. Oxytocin IV
- If the uterus suddenly relaxes, there will be c. Methergine IM
an abrupt gush of blood vaginally from the d. Hemabate IM
placental site e. Prostaglandins
- Occurs on the first postpartum hour, f. Ergot alkaloids
4. Surgical
immediately after birth
- Soft and flabby leads to bleeding a. Hysterectomy
- FUNDAL HEIGHT b. B-Lynch
o 1 cm - day after c. Hayman uterine compression sutures
d. Bilateral closure of the ascending
o 2 cm under – next 2 days
branches of the uterine arteries
o 10-14 days - non palpable
o 6 weeks - normal NURSING INTERVENTIONS
ETIOLOGY/CAUSE 1. Monitor BP and pulse slowly
2. Palpate uterus and massage
- Risk Factors:
3. Save all perineal pads
o Uterine overdistention
4. Assess lochia frequently
o Multiple gestation
5. Positioning
o Fetal macrosomia
o Prolonged oxytocin Therapeutic Management
- The inability of the myometrium to contract
sufficiently in response to oxytocin 1. U - uterine fundal massage
a. First step in controlling hemorrhage
COMPLICATIONS b. To encourage contractions
c. Continue to assess carefully for the
- Extreme blood leads symptoms of
next 4 hours
Hypovolemic Shock:
2. T - The medications
o Decreased blood pressure
a. If a woman’s uterus does not remain
o Increased pulse rate (rapid, weak or
contracted, she is given:
thready)
i. Oxytocin (Pitocin) bolus/
o Increased shallow respirations
dilute infusion
o Pale clammy skin
1. Bolus/ diluted
o Increased anxiety
intravenous infusion
PROCEDURES 2. Increase contractions,
prescribed to maintain
- Pelvic exam uterine tone
- Physical exam 3. Short duration of
SIGNS AND SYMPTOMS action: approximately
1 hour so symptoms of
- Uncontrolled postpartum hemorrhage or uterine atony can
excessive blood loss after delivery recur quickly if it is
o Drop in arterial blood pressure administered as a
(Hypotension) single dose.
o Increase heart rate (Tachycardia) ii. Carboprost tromethamine
- Pain in the lower back (Hemabate)
- Delayed capillary refill 1. If oxytocin is not
effective
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MODULE 3M: POSTPARTAL COMPLICATIONS

2. Repeated q15 o Development of DIC

3. 90 minutes up to 8 - FOUR T’s of postpartum hemorrhage:
doses o TONE
iii. Methylergonovine maleate o TRAUMA
(Methergine) o TISSUE
1. Ergot compound, IM o THROMBIN
2. May be repeated - Predisposing factors:
every 2 to 4 hours up o Hypotonic contractions
to 5 doses o Overdistended uterus
iv. Misoprostol (Cytotec) o Multiparity
1. Administered rectally o Large newborn
to decrease o Forceps delivery
postpartum o Cesarean delivery
hemorrhage o Risk Factors:
2. Repeated q2-4 hrs up o A patient who has a birth complicated by
to 5 doses any of these factors should be observed
3. A 2nd dose should not for the possibility of developing a
be administered postpartum hemorrhage:
unless a minimum of 2  Abruptio placentae
hours has elapsed  Missed Abortion
4. After administration,  Placenta previa
assess for nausea  Uterine infection
and diarrhea for  Uterine inversion
 Severe preeclampsia
these are
 Amniotic fluid embolism
prostaglandin’s
 Intrauterine fetal death
effects.
- Uterine Atony - primary cause
5. Prostaglandin E1
- Laceration of the cervix (occurs immediately
analogue
after delivery of the placenta)
3. E - Elevate woman’s lower extremities
- Lacerations of birth canal, or perineum can
and Empty Bladder
also lead to postpartum hemorrhage
4. R - Rate: 10-12 L/ min oxygen
- Retained placental fragments
administration by face mask
- DIC
a. Reposition patient to SUPINE to
- Oozing of blood
allow adequate blood flow to brain
- More frequent saturated pads
and kidneys
- Uterine atony, the uterus is soft and relaxed
5. I - insert 1 hand into a woman’s vagina
- Laceration, bright red blood with clots oozing
while pushing against the fundus through
continuously from the site and a uterus that
abdominal wall
remains firm
a. BIMANUAL COMPRESSION
6. N - Necessary: Blood transfusion ASSESSMENT AND DIAGNOSTIC TEST
7. E - Evaluation of Nursing Interventions FINDINGS
by:
a. Weigh perineal pads - Decreased hemoglobin and hematocrit
b. Assess vital signs levels
Elevated serum hCG level
NURSING DIAGNOSES - Platelet and fibrinogen levels are decreased
- Risk for Infection r/t uterine atony as - Clotting times are prolonged
evidenced by statis of body fluids (lochia) TYPES
HEMORRHAGE 1. Primary or Early postpartum hemorrhage
DEFINITION – occurs within the first 24 hours after
- Defined as blood loss of 500 ml or more delivery
following a vaginal birth a. Blood loss in excess of 500mL that
- Blood loss of 1000 ml following a cesarean occurs during the first 24h
birth or 10% decrease in hematocrit level postpartum
- Is the main cause of maternal mortality 2. Secondary or Late postpartum
- First 24 hours as greatest danger: hemorrhage – occurs 24 hours to 12 weeks
o Grossly denuded and unprotected postpartum
uterine area left after detachment of a. Uterine blood loss in excess of
placenta 500mL that occurs during the
remaining 6-week postpartum period
ETIOLOGY/CAUSE but after 24hours
- 4 main reasons of placenta hemorrhage: SIGNS AND SYMPTOMS
o Uterine atony
o Trauma (lacerations, Hematomas, - Uncontrolled bleeding
uterine inversion or uterine rupture) - Decreased blood pressure
o Retained placental fragments - Increased heart rate
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MODULE 3M: POSTPARTAL COMPLICATIONS

- Decrease in the red blood cell count 5. Assess lochia frequently to determine if the
- Swelling and pain in the vagina and nearby amount discharged is still within the normal
area if bleeding is from a hematoma limits.
- restlessness, lightheadedness, and 6. Assess vital signs, especially the blood
dizziness as cerebral perfusion decreases pressure
- Pale skin, decreased sensorium, and rapid, 7. Assess for signs of shock
shallow respirations 8. Assess the fundus and lochia
- Urine output less 25mL/hr. 9. Stay with the patient
- Cold clammy skin
NURSING DIAGNOSES
- Capillary refill is delayed 3-5secs
- Deficient fluid volume related to excessive
MANAGEMENT
postpartum vaginal bleeding as evidenced
1. Medical by a sudden decrease of blood pressure.
a. Blood transfusion and IV
RETAINED PLACENTAL FRAGMENTS
replacement
DEFINITION
i. Cross matching and blood
typing is necessary to replace - Fragments of placenta separate and some
the blood loss are left still attached to the uterus
b. Administration of Oxygen - Rare complication affecting only about 2 to 3
i. If the woman is experiencing percent of all deliveries that occurs when all
respiratory distress, or a portion of the placenta is left inside the
administration of oxygen at uterus after baby's birth.
4L/min via face mask could be - Retained placental fragments keeps the
prescribed by the physician. uterus from contracting -> uterine bleeding
c. Cold therapy, ligation of the bleeding occurs
vessel, or evacuation of the
hematoma ETIOLOGY/CAUSE
2. Pharmacologic - The uterus not contracting properly after the
a. Oxytocin or methylergonovine baby is born
may be given IV or IM; - The umbilical cord snapping (this isn’t very
b. Pitocin common and will not hurt your baby if
i. maintain the tone of the managed quickly – your midwife will simply
uterus if it is unable to clamp the cord to prevent any bleeding)
contract - The placenta attaching abnormally deeply
c. Carboprost tromethamine into the wall of the uterus – this is rare.
i. a prostaglandin derivative
that could help promote ASSESSMENT AND DIAGNOSTIC TEST
sustained uterine FINDINGS
contractions
- Ways to identify the complication of a
3. Surgical retained placenta:
a. D&C (Dilatation & Curettage)
o After birth, every placenta should be
b. Hysterectomy inspected carefully to be certain it is
i. In a worst-case scenario, the complete.
uterus needs to be surgically o A blood sample that contains HCG
removed to save the life of the reveals that part of the placenta is still
mother. present.
c. Suturing is necessary for extreme o May be detected by ultrasound
uterine atony to stop the bleeding.
TYPES
NURSING INTERVENTIONS
1. Placenta Adherens
1. Estimate the amount of blood loss by a. It is the most common type of
counting the number of perineal pads retained placenta. It occurs when the
saturated in a given time. uterus, or womb, fails to contract
2. To measure vaginal discharge, weigh enough to expel the placenta.
perineal pads before and after use and then Instead, the placenta remains loosely
subtract the difference. attached to the uterine wall.
a. Save all perineal pads used during 2. Trapped Placenta
bleeding and weigh them to a. A trapped placenta occurs when the
determine the amount of blood loss. placenta detaches from the uterus
3. To inspect for blood loss, make sure to turn but doesn’t leave the body. This often
a woman on her side to be certain that blood occurs because the cervix starts to
is not pooling underneath beneath her. close before the placenta is removed,
a. Place the woman in a side lying causing the placenta to become
position to make sure that no blood is trapped behind it.
pooling underneath her.
4. Assess vital signs: pulse and blood pressure
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3. Placenta Accreta NURSING DIAGNOSES

a. This the placenta to attach to the
muscular layer of the uterine wall - Risk for bleeding related to retained placental
rather than the uterine lining. This fragments evidenced by inadequate
often makes delivery more difficult contractions
and causes severe bleeding. If the DISSEMINATED INTRAVASCULAR
bleeding can’t be stopped, blood COAGULATION
transfusions or a hysterectomy may DEFINITION
be required.
- AKA Consumption Coagulopathy
PROCEDURES - A serious and rare condition that leads to
- Dilatation and Curettage (D&C) abnormal blood clotting throughout the
- Hysterectomy body’s blood vessels, therefore,
compromising proper blood flow.
SIGNS AND SYMPTOMS - It is characterized by systemic activation of
blood coagulation that results in the
- Failure of all or part of the placenta to
generation and deposition of fibrin which
leave the body within an hour after
results in microvascular thrombi in various
delivery.
organs and highly contributes to multiple
- Symptoms of a retained placenta the day
organ failure.
after delivery can include: - Increased production of prothrombin,
o A fever platelets and other coagulation factors that
o A foul-smelling discharge from the lead to widespread thrombi formation thru
vagina that contains large pieces of
out the body.
tissue
- Ultimately, the body’s clotting factors are
o Heavy bleeding that persists expended leading to hemorrhage
o Severe pain that persists - Acquired disorder of blood clotting in w/c the
MANAGEMENT fibrinogen levels fall to below the effective
limits
1. Pharmacologic o NORMAL: platelets create a seal to
a. Antibiotic prophylaxis (gentamicin, prevent bleeding; activation of
ampicilin, clindamycin). intrinsic & extrinsic clotting pathways
b. Oxytocin (Pitocin) strengthen plug with fibrin threads
2. Medical and Surgical - DIC occurs: during extreme bleeding when
a. Removal of the retained placental many platelets and fibrin from general
fragments: (to stop bleeding) circulation rush to the site that there is none
b. Dilatation and Curettage (D&C) left for the rest of the body
i. Widening of the cervix and - DIC, an EMERGENCY, results to EXTREME
surgical removal of part of the BLOOD LOSS
lining of the uterus and/or o FIBRINOLYSIN - activated by
contents of the uterus (often a thrombin, a proteolytic enzyme which
fetal body) by scraping and begins digestion of excess fibrin
scooping threads; lysis results in release of
c. Methotrexate fibrin degradation products
i. If it cannot be removed by
D&C, it is prescribed to ETIOLOGY/CAUSE
destroy the retained - Release of procoagulants into the
fragments
bloodstream
d. Hysterectomy
- Systemic inflammatory response
NURSING INTERVENTIONS - Obstetrical complications that lead to DIC:
o Placental abruption (Premature
1. Instruct clients to report any changes of separation of placenta)
lochial discharge (e.g., from lochia serosa or o Hemolysis
alba back to rubra). o Elevated liver enzyme
a. Rationale: Hemorrhage from o Low platelet count (HELLP
retained fragments may be delayed syndrome)
until after a woman is at home. o Amniotic fluid embolism
2. Uterine exploration and removal under o Dead fetus & placental retention
anesthesia is the final therapy of retained o Septic abortion
placenta. - Predisposing Factors
a. Uterine exploration can be done o Abruptio placenta
manually or under ultrasound o Intrauterine fetal death
guidance with curettage. These o Amniotic fluid embolism
patients are often young and
healthy, with few comorbid medical ASSESSMENT AND DIAGNOSTIC TEST
conditions. FINDINGS
- Blood is drawn:
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MODULE 3M: POSTPARTAL COMPLICATIONS

o Platelet count: decreased to <>40 - Implications

mcg/ml o Maternal implications: death if hypo-
o Prothrombin: Low fibrinogen does not reverse
o Thrombin time: elevated o Fetal/Neonate implications: fetus not
o Fibrinogen: decreased to <>40 directly affected; however, at risk
mcg/ml from maternal sepsis, acidosis, and
o Fibrin split products: <>40 mcg/ml hypotension. Major risk to
o D-dimer analysis: specific for fibrin fetus/neonate hypoxia
degradation products, abnormal in
90% of patients with DIC MANAGEMENT

COMPLICATIONS 1. Medical
a. Blood and fibrinogen transfusions
- Typically occurs as an acute complication to b. Treatment of underlying conditions
patients with underlying life-threatening c. Immediate delivery
illnesses such as: 2. Pharmacologic
o Placental abruption a. Heparin
o Severe trauma i. Non-symptomatic type of
o Severe sepsis DIC.
o Hematologic malignancies b. Synthetic protease inhibitors and
- Paradox Result: increase coagulation in the Antifibrinolytic therapy
site BUT a bleeding defect exists in the rest i. With the bleeding and
of the system massive bleeding types of
DIC.
TYPES c. Natural protease inhibitors
1. Acute Disseminated Intravascular i. With the organ failure type of
Coagulation DIC, while antifibrinolytic
a. More severe and develops quickly treatment is not.
over hours or days. NURSING INTERVENTIONS
b. The first sign may be bleeding.
2. Chronic Disseminated Intravascular 1. Halt underlying result: premature placenta ->
Coagulation end pregnancy with delivery of fetus and
a. Happens more slowly and sometimes placenta
has no signs or symptoms especially 2. Administration of heparin:
when it originates from cancer. a. IV then Subq, to halt clotting cascade,
stop marked coagulation, cautiously
SIGNS AND SYMPTOMS given after birth
- Early s/s: 3. Assess the client’s breath sounds.
o Easy bruising 4. Assess cough for signs of bloody sputum.
o Bleeding from IV site 5. Assess for tachycardia, shortness of breath,
- Bruising - often in various areas as small dots and use of accessory muscles.
or larger patches (Petechia and purpura) NURSING DIAGNOSES
- Bleeding
o At the site of wounds from surgical - Risk for bleeding related to abnormal blood
cuts or from placement of a needle profile
o From the nose, gums, or mouth,
LACERATION AND TYPES
including when you brush your teeth
- Pain, redness, warmth, and swelling in the DEFINITION
lower leg - Tears in perineum, vagina, or cervix due to
- Blood in the stools from bleeding in the stretching of tissues during childbirth
intestines or stomach. - Small lacerations are normal in
o Stools may appear dark red or like childbearing. However, large lacerations
tar. can be sources of infection or hemorrhage.
- Blood in the urine - Lacerations in the birth canal quite commonly
- Unusually heavy periods occur as the delivery process goes on. These
- Low blood pressure are simply considered to be a normal
- Chest pain consequence of childbearing.
- Trouble breathing and shortness of breath - They occur in the cervix, vagina, and
- Headaches perineum. After birth, anytime a uterus feels
- Confusion, speech changes or trouble firm but bleeding persists, suspect a
speaking, dizziness, or seizures laceration at one of these three sites
- Clinical Manifestation - Nursing Problems for laceration
o Thrombocytopenia o Impaired tissue integrity
o Decreased fibrinogen and platelet - Nursing problems of Hematoma
count o Bleeding
o Increased prothrombin time and - Prone to laceration
partial thromboplastin time o Primigravida mothers
o Macrosomic babies
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MODULE 3M: POSTPARTAL COMPLICATIONS

ETIOLOGY/CAUSE diagonal incision across

the midline between the
- Predisposing risk factors: vagina and anus.
o Difficult or precipitate births  Advantages:
o Primigravidas
 Low risk for anal
o Birth of a large infant (>9lb)
muscle tear
o Use of a lithotomy position and
 Disadvantages:
instruments (Forceps, Vacuum
 increased blood
extraction)
loss
TYPES  more severe pain
 difificult to repair
1. Cervical Lacerations – Found on the sides
 discomfort, during
of the cervix, near the branches of the uterine
sexual intercourse
artery. Arterial bleeding -> bright red
o Median Incision
blood loss. This bleeding ordinarily occurs
 Midline incision along a
immediately after the detachment of the
straight line from the
placenta
lowest edge of the vaginal
2. Vaginal Lacerations – Easier to locate,
opening to toward the
assess and view than cervical lacerations
anus
3. Perineal Laceration – Likely to occur when
 Advantages:
a woman is placed in a little position for birth
 Easy to prepare
rather than a supine position Rationale:
and improve
lithotomy position increases tension on the
healing
perineum
 Less painful
Perineal  Less blood loss
Lacerations Description  Disadvantages:
Classification  Increased the risk
Vaginal mucous membrane, of tearing leading to
FIRST degree
Skin of perineum to fourchette injury to fecal
SECOND Vagina, perineal skin, fascia, incontinence,
degree levator ani, perineal body inability to control
Entire perineum, extending to bowel movements
THIRD
reach the external sphincter of  May experience
degree
the rectum pain during sexual
Entire perineum, rectal intercourse
FOURTH o Classifications: episiotomy is classified
sphincter, and some of the
degree by degrees based on the severity or
mucous membrane of the rectum
extent of the tear
PROCEDURES – First Degree: A first degree episiotomy
consists of a small tear that only extends
- Episiotomy through the lining of the vagina. It doesn’t
o An incision made into the perineum to involve the underlying tissues
facilitate delivery and prevent – Second Degree: This is the most
lacerations and overstretching of the common type of episiotomy. It extends
pelvic floor through the vaginal lining as well as the
o Incision types: median and vaginal tissue. However, it doesn’t
mediolateral involve the rectal lining or anal sphincter.
o Indications: – Third Degree: A third-degree tear
 Rapid labor and delivery involves the vaginal lining, the vaginal
 Large baby tissues, and part of the anal sphincter.
 Malposition of the fetus o As the degree of the episiotomy increases,
 Facilitate repair of the laceration there is more potential for infection, pain, and
& promote healing other problems after the procedure.
 Spare the infant’s head from – Fourth Degree: The most severe type of
prolonged pressure & pushing episiotomy includes the vaginal lining,
against the perineum which may vaginal tissues, anal sphincter, and rectal
result in brain damage especially lining.
the premature infants  After having an episiotomy, it is
 Shorten the second stage of labor normal to feel pain around the
o Prognosis incision site for two to three
 Generally heals within 2-4weeks weeks.
following delivery  Women who have third- or fourth-
 May cause mild to moderate degree episiotomies are more
discomfort in the perineum likely to experience discomfort for
o Mediolateral incision a longer period of time.
 the episiotomy is
performed by making a
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MODULE 3M: POSTPARTAL COMPLICATIONS

 The pain may become more VAGINAL Therapeutic Management

noticeable while walking or
sitting. 1. Balloon tapenade - effective if suturing does
 Urinating can also cause the cut not achieve hemostasis
to sting. 2. Pack vagina to maintain pressure on the
o To help ease the pain: suture line.
– apply cold packs on the perineum
a. Some oozing occurs after vaginal
– use personal lubricant when having
repair
sexual intercourse b. Document when and where packing
– take pain-relieving medications
was placed so the nurse.
– use a squirt bottle instead of toilet paper
c. Remove packing after 24 - 48 hours
to clean after using the toilet 3. Place an indwelling urinary catheter after the
– the incision should be completely healed
repair.
within four to six weeks after delivery. a. Rationale: Packing causes pressure
– the recovery time may be slightly longer
on the urethra that it can interfere with
for third- or fourth-degree episiotomy. voiding
o Assessment PERINEAL Therapeutic Management
– REEDA
– Redness 1. Perineal lacerations are sutured and treated
– Edema like episiotomy repair.
– Ecchymosis 2. Encourage a diet high in fluid or
– Discharge or drainage (bleeding) administration of stool softener. Rationale: to
– Approximation of wound edges prevent breakage of new sutures
– Infection 3. With 4th degree lacerations: extra precaution
– Hematoma Formation to avoid loosening the sutures or infecting
– Note: during the recovery period. them. 4th degree can lead to long-term
Episiotomy should be evaluated every dyspareunia, rectal incontinence or sexual
12minutes and then 3 times a day after dissatisfaction.
4. Enema, rectal suppository, rectal
SIGNS AND SYMPTOMS thermometer is contraindicated to 3rd/4th
- Pain degree lacerations.
- Bleeding occurs NURSING DIAGNOSES
MANAGEMENT - Deficient Fluid Volume: bleeding r/t perineal
1. Surgical laceration
a. Episiorrhaphy VULVAR HEMATOMA
i. Suturing of perineum DEFINITION
NURSING INTERVENTIONS - It is the collection of blood in the vulva
1. Support the patient and inform her about the - Hematoma occurs as a result of damage to
baby’s condition. one of the larger blood vessels in the body
2. Maintain that the setting of the room stays specifically in the vulva or perineum.
calm and if possible, stand beside the o Already clotted
woman. - A vulvar hematoma can develop in non-
3. Use of warm or cold pads to help with pain. obstetric settings as well, despite being a
4. An indwelling urinary catheter can be put to common obstetric complication.
help with the pressure of the urethra. ETIOLOGY/CAUSE
5. Promote healing (per doctor’s order)
a. Hot sitz bath - Direct injury of the soft tissue (episiotomy,
b. High in protein vaginal lacerations, etc.)
c. REEDA - Indirect injury of the soft tissue (extensive
stretching of birth canal)
CERVICAL Therapeutic Management - Surgery of vulva
1. Sutures – repair lacerations - Spontaneous vessel rupture
2. Maintain a calm air or environment - Prolonged second stage of labor
3. assure her of her baby’s condition and inform - Macrosomia
her about the need to stay in the birthing - Vulvovaginal varicosity
room a little longer than expected - Primiparity
4. Administer regional anesthetic to relax the SIGNS AND SYMPTOMS
uterine muscle and to prevent pain.
5. Explain the need for an anesthetic and the - Pain and swelling
procedures being carried out. - Painful or difficult urination
6. Assist the primary care provider with - Bulging tissue
adequate space to work, adequate sponges
& suture supplies and a good light source
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MANAGEMENT - Mild to severe pain, depending on the size

- Bloody stools
1. Pharmacologic
a. Prescribe mild analgesic for pain MANAGEMENT
relief
2. Surgical 1. Pharmacologic
a. Incision of the site a. Rx mild analgesic for pain relief
2. Surgical
b. Vessel ligation under anesthesia
c. If episiotomy incision; may be left a. Incision of the site
open and packed with gauze rather b. Vessel ligation under anesthesia
than resutured. c. If episiotomy incision; may be left
d. Remove gauze packing in 24 to 48 open and packed with gauze rather
than resutured.
hours.
d. Remove gauze packing in 24 to 48
NURSING INTERVENTIONS hours.
1. Report presence of hematoma: NURSING INTERVENTIONS
a. Size
b. Degree of discomfort. 1. Report presence of hematoma: a
2. Report a definite size (5 cm) rather than a. Size
b. Degree of discomfort.
“large or small”
3. Apply ice pack (covered with towel) 2. Report a definite size (5 cm) rather than
4. Patient teaching: Keep site clean and dry “large or small” 4
3. Apply ice pack (covered with towel)
NURSING DIAGNOSES 4. Patient teaching: Keep site clean and dry
- Risk for Maternal Injury r/t vulvar hematoma NURSING DIAGNOSES
PERINEAL HEMATOMA - Risk for Maternal Injury r/t perineal
DEFINITION hematoma
- Collection of blood in the subcutaneous layer EDEMA
of tissue of the perineum. DEFINITION
- Overlying skin = Intact w/ no noticeable
trauma - Postpartum edema, or postpartum swelling
- Blood accumulates underneath - It is caused by an excess amount of fluid
- Hematomas are most likely to occur after remaining in the body tissue after childbirth.
rapid, spontaneous births and in women who - Swelling can lead to the skin looking
have perineal varicosities stretched and inflamed, and sometimes will
- May occur at the site of episiotomy or cause the outer layer of the skin to look puffy
laceration repair if a vein was punctured or shiny
during suturing. ETIOLOGY/CAUSE
- Usually only represent minor bleeding
- During pregnancy, hormones cause her
ETIOLOGY/CAUSE body to retain fluid.
- Ruptured or leaking vein - Risk Problems (pre eclampsia, eclampsia,
- Direct injury of the soft tissue (episiotomy, dietary lifestyle)
vaginal lacerations, etc.) TYPES
- Indirect injury of the soft tissue (extensive
stretching of birth canal) 1. Breast engorgement – This happens when
- Surgery of vulva your breasts swell because they are full of
- Spontaneous vessel rupture milk. It most commonly happens a few days
- Prolonged second stage of labor after delivery. Your breasts may also feel
- Macrosomia tender and sore. The discomfort will go away
- Vulvovaginal varicosity once you start breastfeeding regularly.
- Primiparity 2. Hemorrhoids – You may develop painful
swelling of a vein in the rectum during your
ASSESSMENT FINDINGS pregnancy. If not, you may get them from the
1. Severe pain strain and pushing during delivery.
2. Feeling of pressure (inspect perineum for Hemorrhoids are painful and may bleed after
hematoma) a bowel movement. Sometimes they itch too.
3. Appears as purplish discoloration with Applying cold witch hazel may help relieve
obvious swelling hemorrhoid pain. They should shrink over
4. As small as 2 cm or as large as 8 cm in time, but if they don’t, contact your doctor.
diameter. 3. Water retention – Also known as
5. May feel fluctuant at first; palpates as a firm postpartum edema (swelling). After giving
globe and feels tender birth, your body will continue to hold on to
water because of an increase in
SIGNS AND SYMPTOMS progesterone. You may notice the swelling in
your hands, arms, feet, ankles, and legs.
- Bubbling or bulging skin near the anus
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Edema shouldn’t last much longer than a - Organism comes from the oral cavity of the
week after delivery. If it does or if it gets infant.
worse over time, consult your doctor o Staphylococcus aureus
o MRSA (Methicillin Resistant Staph.
SIGNS AND SYMPTOMS Aur.)
- Swollen extremities (hands, feet, and ankles) o Sucking introduces the organsim to
o Swelling or puffiness under the skin in the nipple.
your feet and ankles o EPIDEMIC MASTITIS or EPIDEMIC
- Weight gain BREAST ABSCESS
o Quick weight gain over a period of a  Because it spreads from one
few days person to another.
- Skin that looks stretched - Risk Factors:
- Indentations when you press down on your o Previous bout of mastitis while
skin for a few seconds breast-feeding
o Sore or cracked nipples – although
MANAGEMENT mastitis can develop without broken
1. Pharmacologic skin
a. Drug: Diuretic drugs (Furosemide) o Wearing a tightfitting bra or putting
b. Over-the-counter creams, ointments, pressure on your breast when using
suppositories or pads a seatbelt or carrying a heavy bag,
i. Contain ingredients such as which may restrict milk flow
witch hazel, or hydrocortisone o Improper nursing techniques
and lidocaine o Becoming overtly tired or stressed
2. Medical o Poor nutrition
a. Closed hemorrhoidectomy – treat o Smoking
internal hemorrhoids ASSESSMENT FINDINGS
NURSING INTERVENTIONS - Usually unilateral (one sided)
1. During the first 24 hours after the surgery, - Epidemic mastitis (bilateral)
place an icepack over the surgical site. This - Pain in affected breast
can help reduce swelling and pain. - Swollen and reddened.
2. A warm pack can also be helpful during the - Fever accompanies first symptoms
recovery period. Hemorrhoid surgery is - Scant breast milk
predictably painful DIAGNOSTIC TEST FINDINGS
3. Patient teachings:
a. Apply an over-the-counter - Sonogram – to determine presence of breast
hemorrhoid cream or use pads abscess.
containing witch hazel or a numbing
SIGNS AND SYMPTOMS
agent.
b. Soak regularly in a warm bath or sitz - Breast tenderness or warmth to the touch
bath. Soak your anal area in plain - Breast swelling
warm water for 10 to 15 minutes two - Thickening of breast tissue, or a breast lump
to three times a day. - Pain or a burning sensation continuously or
c. Limited fluid and sodium intake while breast-feeding
- Skin redness, often in a wedge-shaped
NURSING DIAGNOSES
pattern
- Risk of pain related to rectal swelling and - Generally feeling ill
prolapse (Postpartum Hemorrhoids) as - Fever of 101 F (38.3 C) or greater
manifested by small distended veins, pain
MANAGEMENT
scale of 7/10 and facial mask of pain
1. Pharmacologic
MASTITIS
a. Antibiotics effective against penicillin
DEFINITION
resistant staph.
- Infection of the breast i. a 10-day course of antibiotics
- Inflammation of the breast tissue that is is usually needed.
usually caused by infection or by stasis of ii. Dicloxacillin
milk in the ducts iii. Cephalosphorin
- May occur as early as the 7th postpartal day b. Pain relievers
or not until the baby is weeks or months old. i. Over-the-counter pain
- Organism usually enters through cracked reliever, such as:
and fissured nipples. 1. Acetaminophen
(Tylenol, others)
ETIOLOGY/CAUSE 2. Ibuprofen (Advil,
- Injury to breast – overdistention, stasis Motrin IB, others)
(missed feedings, a bra that is too tight or 3. Analgesics
impaired infant sucking)
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2. Surgical NURSING DIAGNOSES

a. It requires surgical drainage in the
operating room - Acute pain r/t inflammation of breast tissue
b. Excisional biopsy PUERPERAL INFECTION
c. Partial mastectomy DEFINITION
NURSING INTERVENTIONS - Reproductive tract infection in the postpartal
1. PREVENTION period, another major cause of maternal
a. Position the baby correctly and mortality
grasps nipple properly including both - Uterus is sterile during pregnancy until the
the nipple and areola. membranes rupture. After rupture,
b. Help the baby release a grasp on the pathogens begin to invade.
nipple before removing the baby from - A local infection that can spread to the
the breast. peritoneum (peritonitis), circulatory system
c. Wash hands between handling (septicemia)
perineal pads and touching breasts o Commonly postpartally cultured
d. Expose nipple to air for at least part organisms: B streptococci,
of everyday staphylococcus, aerobic gram-
e. Use vitamin E ointment daily to soften negative (Escherichia coli)
nipples - Prolong - possible bleeding
f. Encourage women to begin - Foul odor of lochia - infection (endometritis,
breastfeeding on an unaffected peritonitis)
nipple. ETIOLOGY/CAUSE
2. Apply warm, moist compresses to the
affected breast every few hours or take a - Group A, B, or G hemolytic streptococcus,
warm shower. Gardnerella vaginalis, Chlamydia
3. Breastfeed every two hours or more often to trachomatis, and coagulase-negative
keep milk flowing through the milk ducts. staphylococci
a. Before breast-feeding, avoid - Less common causative agents are:
overfilling your breasts with milk for clostridium perfringens, Bacteroides fragilis,
an extended period of time. klebsiella, proteus mirabilis, pseudomonas,
b. Varying your breast-feeding staphylococcus aureus, and E.coli
positions. - Conditions that increase a woman’s Risk
c. Expressing a small amount of milk by to Postpartal Infection
hand before breast-feeding might o Rupture of membranes more than 24
help. hours
4. Drink plenty of fluids and rest when possible.  Bacteria may have started to
5. Massage the area using a gentle circular invade the uterus while the
motion starting at the outside of the affected fetus was in the utero
area and working in toward the nipple. o Retained Placental Fragments w/in
6. Administer antibiotics and complete the uterus
antibiotic regimen  The tissue necrosis and
7. Offer comfort measures such as: serves as an excellent bed for
a. Suggest supportive bra bacterial growth.
b. Apply cold or hear application over o Postpartal hemorrhage
localized abscess  The woman’s general
8. Reinforce meticulous handwashing condition is weakened.
9. Breastfeed frequently o Prolonged, & difficult labor,
10. Perform adequate breast and nipple care particularly with instrument births
a. Adequate round-the-clock non-  Trauma to the tissue may
constrictive support of the breasts leave lacerations or fissures
b. Gentleness during care for easy portals of entry for
c. Avoidance of harsh cleansing agents infection.
and decrusting the nipple o Internal fetal heart monitoring
d. Frequent breast pad changes electrode
e. Intermittent exposure of nipples to the  Contamination may have
air been introduced with the
11. Observe for signs of infection and pain placement of the scalp
a. Elevated temperature, chills, electrodes
tachycardia, headache, pain and o Local vaginal infection present at the
tenderness, firmness, and redness of time of birth
the breast  A direct spread of infection
b. Use OLDCART for assessment has occurred.
12. Health Teachings: o Uterus exploded after birth for a
a. Do warm shows retained placenta of abnormal
b. Wear lose bras bleeding site.
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 The infection was introduced - Pale skin, which can be a sign of large
with exploration. volume blood loss
o Maternal conditions, such as anemia, - Chills
DM, immunosuppression, or - Feelings of discomfort or illness
debilitation from malnutrition - Headache
o CS birth - Loss of appetite
- Increased heart rate
ASSESSMENT FINDINGS
MANAGEMENT
- Fever at least 100.4 F (38 C)
- Chills, headache, malaise, restlessness, and 1. Medical
anxiety a. Blood tests
- Pain the lower abdomen or pelvis caused by i. Check for a high white blood
a swollen uterus count to check for bacterial
- Foul-smelling vaginal discharge infection.
- Loss of appetite b. Imaging tests
- Increased HR i. Use an X-ray to check for
holes or other perforations in
Localized Perineal Infection: Assessment the gastrointestinal tract.
Findings Ultrasound also may be used.
- Pain, elevated temperature, edema, c. Broad-spectrum antibiotic
redness, firmness, and tenderness, at the d. Contagious disease is usually placed
wound site; in a private room and should be
- Sensation of heat; burning on urination; isolated, even from her neonate
discharge from the wound e. Bed rest, adequate fluid intake, IV
- Or separation of the wound fluids
2. Pharmacological
Endometritis: Assessment Findings a. Analgesics
i. Relieve pain
- Heavy, sometimes foul-smelling lochia
b. Antibiotic therapy
- Tender, enlarged uterus; back ache
i. Early treatment of peritonitis
- Severe uterine contractions persisting after
c. Antiemetics
childbirth
i. Relieve and prevent nausea
- Fever >100 F; chills;
and vomiting
- Increased PR
3. Surgery
Parametritis: Assessment Findings
a. Clot removal or by-pass
- Vaginal tenderness and abdominal pain and 4. Prognosis for complete recovery
tenderness depends on:
a. Woman’s general health
DIAGNOSTIC TEST FINDINGS b. Virulence of invading organism
- Culture and sensitivity c. Portal of entry
- A sudden increase of 30% above the d. Degree of uterine involution at time of
baseline WBC invasion
e. Presence of lacerations in
TYPES reproductive tract

1. Endometritis – It is an infection of the NURSING INTERVENTIONS

uterine lining.
1. Appropriate antibiotics after culture and
a. Inflammation and infection of the sensitivity testing of isolated organism
endometrium (the lining of the uterus)
a. Administer prescribed antibiotics or
2. Myometritis – This is a type of postpartum
medications; document the client’s
infection of the uterine muscle caused by
response.
placental fragments remaining in the uterus.
2. Instruct proper perineal care: wiping front to
Excessive bleeding can occur as a result of
back
severe myo metritis.
a. Rationale: to prevent E. coli
3. Parametritis – This is also known as pelvic
organisms to forward from rectum
cellulitis, which is an infection that affects the
3. Encourage proper handwashing.
surrounding area of the uterus
4. Encourage client to have her own set of
SIGNS AND SYMPTOMS perineal supplies.
5. Intravenous antibiotics - prescribed for
- Fever postpartal infections.
- Pain in the lower abdomen or pelvis caused 6. Frequently used antibiotics: ampicillin,
by a swollen uterus gentamicin, 3rd gen. Cephalosporins:
- Foul-smelling vaginal discharge cefixime (Suprax)
o This is caused by an infection known 7. Make sure woman who are breastfeeding are
as bacteria vaginosis (BV), which not prescribed antibiotics incompatible with
occurs when a specific bacteria breastfeeding.
accumulates in the vagina 8. Assess infant for:
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a. White plaques, thrush (oral o Foreign – body cystitis – long –

candidiasis). This happens when a term use of catheter that leads to
portion of maternal antibiotic passes infection
into the breastmilk and causes o Drug – induced cystitis –
overgrowth of fungal organisms. chemotherapy drugs such as
b. Easy bruising; insufficient Vit. K ifosfamide and cyclophosphamide
formation, decreased blood clotting that causes inflammation because
ability when antibiotic is passed on broken – down substances irritate the
breastmilk lining of the bladder
9. Inspect the perineum twice daily for redness, o Chemical cystitis – inflammation
edema, ecchymosis, and discharge. caused by certain products used by
10. Evaluate for abdominal pain, fever, malaise, women who are hypersensitive to
tachycardia, and foul-smelling lochia. chemicals
11. Obtain specimens for laboratory analysis; o Radiation cystitis – radiation
report the findings. treatment of the pelvic area causes
12. Offer a balanced diet, frequent fluids, and inflammation
early ambulation. o Cystitis associated with other
13. Monitor v/s every 4h conditions – secondary effect of
14. Place in a high Fowler’s to Semi-Fowler’s various conditions such as diabetes,
position kidney stones, enlarged prostate, or
15. Assess capillary refill and skin turgor as well spinal cord injury
as mucous membranes
16. Assess I&O SIGNS AND SYMPTOMS
17. Enforce strict bed rest
18. Provide high-calorie, high protein diet  Strong, persistent urge to urinate
19. Provide fluids (3000-4000mL)  Burning sensation when urinating
20. Encourage patient to void frequently  Passing frequent, small amounts of urine
21. Inspect perineum often  Blood in the urine (hematuria)\
22. Encourage the patient to change perineal  Passing cloudy or strong – smelling urine
pads frequently  Pelvic discomfort
23. Administer antibiotics and analgesics,  Pressure in the lower abdomen
antiemetics  Low grade fever
24. Provide sitz baths or warm or cool compress
25. Change bed linens, perineal pads, and MANAGEMENT
underpads frequently  MEDICAL
NURSING DIAGNOSES o Microscopic urinalysis: to detect
urinary tract cells, blood cells,
- Greater Risk of infection: presence of tissue crystals, germs, parasites, and tumor
edema and trauma cells
- Altered thermoregulation: increase in body o Urine culture: to diagnose a UTI and
temperature r/t body response to infective identify what kinds of bacteria are
agent causing it
CYSTITIS  PHARMACOLOGICAL
o Trimethoprim – sulfamethoxazole
DEFINITON (TMP-SMX): Sulfamethoxazole and
- Inflammation of the bladder that is painful trimethoprim are combined. Treats
and irritating and can be a serious health wide range of bacterial illness
problem when the infection spreads to the o Nitrofurantoin: to treat or prevent
kidney certain UTI. This works by stopping
the growth of bacteria
ETIOLOGY/CAUSE o Fluoroquinolones: to treat and
prevent bacterial infections
- Caused by a typed of Escherichia coli (E.
o Cephalosporins – Beta-lactam
coli) bacteria
antimicrobials: to treat wide
- When the bacteria enter the bladder or
spectrum of gram positive and gram-
urethra and multiply
negative bacterial illness
TYPES  SURGICAL
o Cystoscopy with hydrodistention
 Bacterial cystitis – infection that results in
women due to as a result of sexual NURSING INTERVENTIONS
intercourse - Encourage the patient to drink plenty of water
 Noninfectious cystitis (at least eight glasses per day) and
o Interstitial cystitis – painful bladder emphasize the importance of maintaining a
syndrome. A chronic bladder constant fluid intake of 2L per day.
inflammation that is unclear and has - Instruct the patient how to thoroughly clean
no treatment the perineum and keep the labia separated
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while voiding because a non-contaminated o Uterus is not well contracted and

midstream sample is required for appropriate painful to touch
diagnosis.  Fever >100 F on 3rd or 4th postpartal day;
- Advise the patient to have a warm sitz bath chills;
to relieve perineal discomfort, or apply heat  Increased PR
gently to the perineum while being careful not
to burn the patient. DIAGNOSTIC TEST FINDINGS
- Educate the patient with the nature and  Culture and sensitivity
purpose of antibiotic therapy upon  A sudden increase of 30% above the
administration, emphasizing the need of baseline WBC
finishing the specified course of medication
or, in the case of long-term prophylaxis, COMPLICATIONS
strictly sticking to the ordered dosage.
 Tubal scarring
NURSING DIAGNOSIS  Interference with future fertility
- Acute pain: facial grimace related to MANAGEMENT
inflammation and infection of the urinary tract
 MEDICAL
ENDOMETRITIS o Blood testing: to identify signs of
infections or inflammation
DEFINITON
o Cervical cultures: taking a swab
- Infection of the endometrium; lining of the from the cervix to look for chlamydia,
uterus gonorrhea or other bacteria
- Associated with chorioamnionitis and  PHARMACOLOGICAL
cesarean birth o Administer of an appropriate
antibiotic such as clindamycin
ETIOLOGY/CAUSE & PATHOPHYSIOLOGY (Cleocin) as determined by a culture
- Bacteria gain access to the uterus through of the lochia
the vagina and enter the uterus either at the  Obtain the culture from the
time of birth or during the postpartal period vagina, using a sterile swab
- Group A, B, or G hemolytic streptococcus, rather than from a perineal
Gardnerella vaginalis, Chlamydia pad, to ensure that you are
trachomatis, and coagulase-negative culturing the endometrial
staphylococci infectious organism and not
- Less common causative agents are: an unrelated one from the pad
clostridium perfringens, Bacteroides fragilis, o Oxytocic agents such as
klebsiella, proteus mirabilis, pseudomonas, methylergonovine may be
staphylococcus aureus, and E. coli prescribed to encourage uterine
contractions
PREDISPOSING FACTORS:
NURSING INTERVENTIONS
 Prolonged or premature rupture of
membranes - Urge mother to drink additional fluids to
 Prolonged or difficult labor combat the fever
- If strong afterpains and abdominal discomfort
 Frequent or unsterile vaginal examinations or
are present, administer analgesic for pain
unsterile delivery
relief
 Delivery requiring the use of instruments,
- Assume woman in sitting Fowler’s position or
which can traumatize the tissue, providing an
encourage mother in walking as it
entry portal for microorganisms
encourages lochia drainage by gravity and
 Internal monitoring
helps prevent pooling of infected secretions
 Retained products of conception
- Monitor the v/s every 4H and fluid I&O
 Hemorrhage - If infection is limited to the endometrium, the
 Maternal conditions, such as anemia, DM, course of infection is about 7 to 10 days
immunosuppression, or debilitation from
malnutrition NURSING DIAGNOSIS
 CS birth
- Acute pain: pain in the lower abdomen with
ASSESSMENT FINDINGS (S/S) guarding and abnormal lochia discharge r/t
presence of vaginal bacteria in the uterus
 Heavy, sometimes foul-smelling lochia
o Lochia discharge is dark brown and PERITONITIS
foul odor but if accompanied by high DEFINITON
fever: lochia may be scant or
absent - Infection of the peritoneal cavity, usually
 Tender, enlarged uterus; back ache occurs as an extension of endometritis
 Severe uterine contractions persisting after - Usually caused by infection or fungi
childbirth
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- If left untreated, it can rapidly spread into the 

Analgesics - Analgesics are
blood (sepsis) and to other organs, resulting prescribed for pain.
in multiple organ failure and death  Intubation and suction -
Intestinal intubation and
ETIOLOGY/CAUSE suction assist in relieving
- In most cases, peritonitis happens in a abdominal distention and in
rupture (perforation) within the abdominal promoting intestinal function
wall  PHARMACOLOGICAL
- In rare cases it can develop w/out an o Analgesics - to relieve pain for acute
abdominal rupture pain
- Peritoneal dialysis o Antibiotic therapy – for early
- Ruptured appendix, stomach ulcer or treatment of peritonitis
perforated o Antiemetics – to relieve and prevent
- Pancreatic, diverticulitis or trauma nausea and vomiting
o Oxygen therapy - by nasal cannula
TYPES or mask generally promotes
 Spontaneous bacterial peritonitis adequate oxygenation
(Primary): develops as a complication of  SURGICAL
liver disease such as cirrhosis or kidney o Surgeries that involve in removing the
disease. An infection w/out an apparent infected tissue and correcting the
source of ascitic fluid cause
 Secondary peritonitis: an escape of pus NURSING INTERVENTIONS
from an infected abdominal organ. These
includes - Monitor Vital signs, note the presence of
o Perforated ulcer/bowel/gallbladder hypotension, tachycardia, tachypnea and
o Burst appendix fever
o Pancreatitis - Observe skin or mucous membrane dryness,
o Ectopic pregnancy turgor (dehydration for poor skin turgor).
o Salpingitis - Move patient slowly avoiding the painful area
o Abdominal surgery NURSING DIAGNOSIS
o Blood infection
o Dialysis - Deficient Fluid Volume: diminished urinary
o Stab wound output r/t fluid shifts from extracellular,
 Tertiary peritonitis: caused by the bacteria intravascular, and interstitial compartments
caused by the bacteria mycobacterium into intestines and/or peritoneal space
tuberculosis (TB), and is referred to as
PARAMETRITIS
tuberculosis peritonitis
 Chemical peritonitis (sterile): leakage of DEFINITON
sterile fluid that are irritants to the peritoneum
- AKA: pelvic inflammatory disease (PID)
SIGNS AND SYMPTOMS - An infection of the female reproductive
organs
 Swollen abdomen when your belly area is - Occurs most often when sexually transmitted
bigger than usual bacteria spread from the vagina to the
 Abdominal pain uterus, fallopian tubes or ovaries
 Diarrhea - Infection of the areas around the uterus
 Loss of appetite
 Fever
 Fatigue ETIOLOGY/CAUSE & PATHOPHYSIOLOGY
 Confusion - Many types of bacteria can cause PID, but
 Low urine output gonorrhea or chlamydia infections are the
 Nausea most common. And these bacteria are
 Thirst usually acquired during unprotected sex
 Inability to pass stool or gas - Less commonly bacteria that can enter the
 Vomiting reproductive tract anytime the normal barrier
created by the cervix is disturbed
Note: There may be signs of shock o This can happen during menstruation
MANAGEMENT and after childbirth, miscarriage or
abortion
 MEDICAL - Rarely, bacteria can also enter the
o Fluid, colloid, and electrolyte reproductive tract during the insertion of an
replacement is the major focus of IUD or any medical procedure that involves
medical management. inserting instruments into the uterus
 Fluid - The administration of
several liters of an isotonic PREDISPOSING FACTORS  similar with
solution is prescribed. Endometritis
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ASSESSMENT FINDINGS - Cold press and semi - Fowler’s position for

pelvic comfort and drainage
- Vaginal tenderness
- Heat lamp or sitz bath as indicated
- Abdominal pain and tenderness
- Change bed linens, perineal pads, and
DIAGNOSTIC TEST FINDINGS underpads frequently

- Culture and sensitivity NURSING DIAGNOSIS

- A sudden increase of 30% above the
- Risk for infection r/t puerperal infections can
baseline WBC
be brought by poor sterile strategy and
TYPES invasive procedure

 Acute parametritis: diagnosed by the THROMBO – EMBOLITIC DISEASE

symptoms of elevated temperature and pulse SVT: SUPERFICIAL VEIN THROMBOSIS
as well as slightly comfortability
 Chronic parametritis: symptoms of the DEFINITON
disease are more intense and serious than
- A thrombosis and inflammation of the
the acute parametritis that also tend to cause
superficial vein, characterized by painful,
other underlying problems like gonorrhea
warm, erythematous, tender, and palpable
SIGNS AND SYMPTOMS cord – like structure along the course of a
superficial vein, usually in the lower
The signs and symptoms of pelvic inflammatory extremities but potentially affecting any
disease might be mild and difficult to recognize. superficial vein in the body
Some women don't have any signs or symptoms.
When signs and symptoms of PID are present, they ETIOLOGY/CAUSE
most often include:
 Main primary cause is blood clot.
 Pain — ranging from mild to severe — in your
Some factors leading to blood clotting are:
lower abdomen and pelvis
 Abnormal or heavy vaginal discharge that  Inherited blood-clotting disorder
may have an unpleasant odor  An injury to a vein
 Abnormal uterine bleeding, especially during  Long period of immobility (such as during
or after intercourse, or between menstrual hospital stays or bed ridden)
cycles
 Pain during intercourse TYPES
 Fever, sometimes with chills CLASSIFIED BY ABSENCE OR PRESENCE OF
 Painful, frequent or difficult urination VARICOSE VEINS:
MANAGEMENT  Varicose Vein (V) – SVT
 MEDICAL o thrombosis in varicose vein
o Check blood culture for infection associated with sterile inflammation
o Perform physical infection for of vein wall
tenderness using palpation o occurs in great saphenous vein, small
o Ultrasound saphenous vein, or collateral
 PHARMACOLOGICAL varicose veins
o Broad spectrum antibiotic drug o pathogenesis includes stasis of blood
o Intravenous infusion of calcium flow and vessel wall damage
chloride and 150 mL of 3%  Non – varicose Vein (NV) – SVT
solution: if festering abscess is o miscellaneous causes
opened through the posterior vaginal o occurs in any superficial vein
vault or from the anterior abdominal o either thrombosis or inflammation
wall (extraperitoneal) may predominate
o In the case of chronic process, daily o pathogenesis includes stasis of blood
prednisolone dose of 20mg for 10 flow, vessel wall damage, and/or
days followed by NSAIDs hypercoagulability
(Indomethacin) with normalization of CLASSIFIED BY PATHOPHYSIOLOGY:
blood parameters
 SURGICAL  Primary SVT
o Deep Incisional SSI: since infection o Inflammation affects only the vein
involves deep soft tissue, purulent wall and surrounding tissues
drainage from deep incision  Secondary SVT
o inflammation of vein wall is
NURSING INTERVENTIONS associated with a chronic
- Observe possible symptoms such as fever, inflammatory process or systemic
vague abdominal pain or pelvic fullness disease including: thromboangiitis
- REEDA scale – perineum/ incision for other obliterans (Buerger disease), Behcet
signs of infection disease, antiphospholipid syndrome,
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systemic lupus erythematosus (SLE), - Can affect small vein, such as the lesser
malignancy saphenous or large veins such as the iliac,
femoral, pelvic and popliteal veins and the
SIGNS AND SYMPTOMS
vena cava
If a vein close to the surface of your skin is affected,
ETIOLOGY/CAUSE
there may be a red, hard cord visible just under
the skin. If it’s a deep vein in the leg, your leg may - Narrowing or occlusion of the vessels in an
be tender, painful and swollen. extremity. If caused by plaque (cholesterol
and other substances)
Common symptoms of superficial vein thrombosis
- This could be from poor diet, lack of exercise,
include:
or genetics. However, blood stasis can cause
 Redness or inflammation of the skin aggregation of platelets and other blood
 Warm skin products forming a clot that travels to the
 Tenderness or pain extremity (or heart, lungs or brain).
 Vein hardening - The most common cause of blood pooling
(stasis) is Atrial Fibrillation (AFib).
MANAGEMENT - Increased level of fibrinogen leading to
increased blood clotting
 MEDICAL
o Conduct physical assessment on the RISK FACTORS
condition present to help diagnose
and overall treatment and  Prolonged bed rest, such as during a long
understanding of the condition hospital stay, or paralysis
o Doppler ultrasound to help in the  Injury or surgery.
diagnosis of blood clots, blocked  Pregnancy.
artery, poor blood circulation, and  Birth control pills (oral contraceptives) or
many more hormone replacement therapy
o Venography to find blood clots  Being overweight or obese.
 PHARMACOLOGICAL  Smoking.
o Anti-inflammatory pain  Cancer.
medications: to alleviate pain and
inflammation around the affected TYPES
area  Venous Thrombosis: when a blood clot
o Oral anticoagulants or blood blocks a vein.
thinning medications: to prevent o Veins carry blood from the body back
blood clots from spreading or growing into the heart
 SURGICAL  Arterial Thrombosis: when a blood clot
o Sclerotherapy: to eliminate varicose blocks an artery
veins and spider veins o Arteries carry oxygen-rich blood
NURSING INTERVENTIONS away from the heart to the body

- Apply or advise warm compress around SIGNS AND SYMPTOMS

the affected area. Allow compression for  Swelling
about 10 minutes with a repetition of 4 times
 Pain
each day. This will help in decreasing the
 Redness
swelling and pain around the area.
 Warmth to the touch
- Elevate the client's legs when resting such
as stacking a few pillows to support the legs  Worsening leg pain when bending the foot
in an elevated yet comfortable manner. This  Leg cramps (especially at night and/or in the
will aid in blood circulation and decrease both calf)
pain and swelling.  Discoloration of skin
- Advice the client to wear pressure
stockings if directed. The use of pressure
stockings can improve blood circulation and
help decrease pain and swelling. Aside from
MANAGEMENT
that, these can help in decreasing the risk of
blood clots on the lower extremities where  MEDICAL
most superficial vein thrombosis occurs. o Oral anticoagulant therapy
o Blood test
DVT: DEEP VEIN THROMBOSIS
o Venography
DEFINITON o D – dimer Test: the presence of a
substance released when a blood clot
- A blood clot that forms in a vein deep in the breaks apart is measured
body  PHARMACOLOGICAL
- Most deep vein clots occur in the lower leg or o Blood thinners – to decrease
thigh blood’s ability to clot
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 Heparin – IV SIGNS AND SYMPTOMS

 Warfarin (Coumadin) – Pill
o Antipyretics (Acetaminophen)  Sudden sharp, sharp chest pain
 SURGICAL  Tachypnea
o Thrombectomy  Tachycardia
o Thrombolysis  Orthopnea (inability to breathe except
upright position)
NURSING INTERVENTIONS  Cyanosis (the blood clot is blocking both
- Monitor v/s blood flow to the lungs and return to the
- Bed rest during acute phase heart).
- Change position frequently and elevate MANAGEMENT
affected extremity
o When a patient has been sitting for a  MEDICAL
long time, encourage them to move o Pneumatic compression: uses
their legs. This aids in the circulation thigh-high or cuff-high cuffs that
of their blood. After being on bed rest, automatically inflate with air and
walking around can help prevent deflate every few minutes to
blood clots from developing. massage and squeeze veins in the
- Apply warm compress to affected leg legs and improve blood flow
- To avoid DVT and ease discomfort and o Anticoagulation therapy
swelling, compression stockings (AKA: o Thrombolytic therapy
graduated compression stockings) are often  PHARMACOLOGICAL
prescribed. Inform patients that after DVT, o Anticoagulant medication
they may need to be worn for up to two years.  Rivaroxaban
- Ascertain that the patient takes the  Heparin
medication as prescribed on time.  Warfarin
- While the patient is sitting, tell them to extend o Thrombolytic medication
their legs and feet. This maintains a steady  Alteplase
flow of blood in their calves. Recommend  Reteplase
that they avoid wearing clothing that restricts  SURGICAL
blood flow. o Surgical embolectomy: the removal
of the actual clot and must be
PULMONARY EMBOLUS performed by a cardiovascular
DEFINITON surgical team with the patient on
cardiopulmonary bypass
- An obstruction of the pulmonary artery by a o Transvenous catheter
blood clot embolectomy: a technique in which
- Usually occurs as a complication of vacuum – cupped catheter is
thrombophlebitis when a blood clot from a leg introduced transvenously into the
vein to the pulmonary artery affected pulmonary artery
o Interrupting the vena cava: an
ETIOLOGY/CAUSE
approach that prevents dislodged
- Occurs when a clump of material most often thrombi from being swept into the
a blood clot gets wedged into an artery in the lungs while allowing adequate blood
lungs. These blood clots most commonly flow
come from the deep veins in the legs called
NURSING INTERVENTIONS
DVT
- Ambulation and active and passive leg
Link to a lot of causes and these are the most
exercises to prevent venous stasis
common:
- Monitor thrombolytic and anticoagulant
 Trauma: trauma anywhere in the body could therapy through INR or PTT
cause it especially if clot is released from the - Turn and reposition to improve ventilation-
venous system perfusion ratio
 Surgery: certain surgical procedures such - Assess for signs of hypoxemia and monitor
as orthopedic, major abdominal, pelvic, and pulse oximetry values
gynecologic surgeries NURSING DIAGNOSIS OF THROMBO –
 Hypercoagulable states: a patient with EMBOLITIC DISEASE
hypercoagulability disorders would most
likely develop a clot that could result in - Ineffective tissue perfusion: edema and
pulmonary embolism tenderness in the affected area r/t
 Prolonged immobility: being unable to interruption of venous flow
move for a prolonged time predisposes a
person in PE
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THROMBOPHLEBITIS FEMORAL DVT:

DEFINITON  Malaise; chills; pain, stiffness, or swelling in
a leg or in the groin
- Inflammatory process that causes a blood
 Calf pain
clot to form and block one or more veins
which slows the blood flow in the veins  Positive Rielander’s Sign/Payr’s Sign
- Thrombo means clot DIAGNOSTIC TEST FINDINGS
- Phlebitis means inflammation in a vein
 Doppler Ultrasound
ETIOLOGY/CAUSE  Plethysmography
Tends to occur because:  Venography

 A woman’s fibrinogen level is still elevated TYPES

from pregnancy leading to increased blood  Superficial Vein Disease (SVD)
clotting o Vein that has a clot just under the skin
o During pregnancy, the level of the o Type of clot does not usually travel to
blood – clotting protein increases the lungs unless it reaches the deep
while anti-clotting protein levels get veins but this can be painful and
lower (hypercoagulable condition). treatment may be needed
This is because nature wisely wants  Deep Vein Thrombosis (DVT)
to limit bleeding at childbirth and o Blood clot in a vein deep in the body
prevent hemorrhage during placental o Mostly happens in the lower leg or
separation causing the increase of thigh
the blood’s clotting ability around o Clot like this can get loose and travel
birth, occasionally too much. through the bloodstream
 Dilatation of lower extremity veins is still
present as a result of pressure of the fetal Others:
head during pregnancy and birth so blood
 Migratory Thrombophlebitis
circulation is sluggish
o AKA: Trousseau’s Syndrome or
It tends to occur most often in women who: Thrombophlebitis migrans
o When the clot comes back in a
 Are relatively inactive in labor and during the different part of the body
early puerperium because this increased the o Often goes from 1 leg to other and is
risk of blood clot formation often linked to cancer (esp. pancreas
 Have spent prolonged time in a birthing room or lung)
with their legs positioned in stirrups  Femoral Thrombophlebitis
 Have preexistent obesity and a pregnancy o The femoral, saphenous, or popliteal
weight gain greater than the recommended veins are involved.
weight gain, which can lead to inactivity and o Although the inflammation site in
lack of exercise thrombophlebitis is a vein, an
 Have preexisting varicose veins accompanying arterial spasm often
 Develop a postpartal infection occurs, diminishing arterial
 Have a history of a previous thrombophlebitis circulation to the leg as well.
 Are older than age 35 years or have o This decreased circulation, along
increased parity with edema, gives the leg a white or
 Have a high incidence of thrombophlebitis in drained appearance.
their family o It was formerly believed that breast
 Smoke cigarettes because nicotine causes milk drained into the leg, giving it its
vasoconstriction and reduces blood flow white appearance. The condition
was, therefore, formerly called milk
RISK FACTORS leg or phlegmasia alba dolens
 History of varicose veins (white inflammation).
 Obesity  Pelvic Thrombophlebitis
 Previous DVT o Involves the ovarian, uterine, or
 Multiple gestations hypogastric veins
 Increased age o Usually follows a mild endometritis
and occurs later than femoral
 Family history of DVT
thrombophlebitis, often around the
 Smoking
14th or 15th day of puerperium.
 CS birth
o Inflammation of the blood vessels in
 Multiparity the pelvic area causes a partial
ASSESSMENT FINDINGS obstruction, which leads to slowed
blood flow and clots in the stagnant
 High fever, severe repeated chills, and blood in the vessel.
general malaise
 Lower abdominal or flank pain
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 Pulmonary Embolus - Place a bed cradle over the legs to lift the
o Obstruction of the pulmonary artery pressure of the bed linens off the affected
by a blood clot leg. This helps decrease the sensitivity of the
o Usually occurs as a complication of legs and improve circulation.
thrombophlebitis when a blood clot - Never massage the skin over the clotted
moves from a leg vein to the area. This could loosen the clot and can
pulmonary artery possibly cause pulmonary or cerebral
embolism.
SIGNS AND SYMPTOMS - Teach client preventive measures such as
The symptoms of thrombophlebitis depend partly on wearing non constricting clothing, resting
the type. The following are symptoms you may with feet elevated, and ambulating daily
experience near the affected area: NURSING DIAGNOSIS
 Pain - Ineffective Tissue Perfusion: discoloration in
 Warmth left lower extremity r/t thrombophlebitis
 Tenderness
 Swelling CHIARRI – FROMMEL SYNDROME
 Redness DEFINITON
 Affected vein may be visibly engorged and
red - Rare endocrine disorder that affects women
 Pain when flexing the ankle who have recently given birth
- Characterized by the over – production of
MANAGEMENT breast milk (galactorrhea), lack of ovulation
 PHARMACOLOGICAL (anovulation) and the absence of regular
o Anticoagulants: such as menstrual periods (amenorrhea) which
unfractionated Heparin (given IV) or continues for an abnormal length of time
- Symptoms persist long (for more than 6
low molecular weight Heparin (given
month) after childbirth
SubQ)
o Thrombolytics: should be initiated - Due to absence of normal hormonal cycles,
within the first 24 hours the reduced size of the uterus (atrophy) may
 SURGICAL occur
o Filters: will prevent clots that can - Some cases resolve completely w/out
treatment (spontaneously); hormone levels
break loose in the legs and travel to
the lungs. and reproductive function return to normal
o Varicose Vein Stripping: The ETIOLOGY/CAUSE
procedure involves removing a long
vein through small incisions. - Exact cause is not fully understood but may
Removing the vein won't affect blood be related to an abnormality of the
flow in your leg because veins deeper hypothalamus and/or pituitary glands
in the leg take care of the increased - Some researches suggests that microscopic
volumes of blood. tumors of the pituitary gland
o Clot removal or bypass: The doctor (microadenomas), stimulated by the
will place a small wire mesh tube to hormones associated with pregnancy (e.g.,
keep the vein open. This is a similar prolactin, stimulator of lactation) are
procedure as placing a stint in a heart responsible
attack patient. - When such microtumors grow, they may be
detected by imaging techniques. Approx.
NURSING INTERVENTIONS 50% of affected women eventually resume
- Assess and monitor v/s normal menstruation over a period of months
- Assess extremities for signs of inflammation, or years
swelling and the presence of Homan’s sign - The cause of the abnormal hormonal
relationship between the pituitary and
o To assess Homan’s sign:
hypothalamus gland associated with Chiari –
 The knee is extended by the
Frommel Syndrome is not known
examiner and then the
straight leg is raised to 10 - Some studies suggest that microscopic
degrees, then the foot is lesions of the hypothalamus may also cause
passively and abruptly - An association with the use of oral
contraceptives has also been suggested
dorsiflexed and the calf is
squeezed by the other hand SIGNS AND SYMPTOMS
- Observe for signs of bleeding and allergic
reactions - Symptoms occur even though the mother is
- Apply moist heat on the affected area. This is not nursing the baby.
done to help decrease inflammation Other symptoms may include:
- Recommend bed rest with the affected leg
elevated  Emotional distress
 Anxiety
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MODULE 3M: POSTPARTAL COMPLICATIONS

 Headaches or after childbirth which can deprive the body

 Backaches of oxygen
 Abdominal pain - Lack of oxygen that causes damage to the
 Impaired vision pituitary gland
 Occasional obesity - Causes the pituitary gland to not produce
enough pituitary hormones (hypopituitarism)
Women who have Chiari – Frommel Syndrome for a - AKA: postpartum hypopituitarism
long time - Rare in industrialized nations, largely
because care during pregnancy and
 Loss of muscle tone in the uterus
childbirth is better than in developing
 Diminished uterine size (atrophy)
countries
Diagnosis of Chiari – Frommel Syndrome
ETIOLOGY/CAUSE
 Increase amount of prolactin simultaneously
- Caused by severe blood loss or extremely
with a general decrease in hormonal
low BP during or after childbirth
background in the body
- These factors can be particularly damaging
 Atrophy of mucous tissues to the pituitary gland, which enlarges during
 Absence of ovulation pregnancy, destroying hormone – producing
 Increase in the Turkish saddle or presence of tissue so that the gland can’t function
tumors in nearby zone normally
MANAGEMENT SIGNS AND SYMPTOMS
 MEDICAL  Absence of lactation (agalactorrhea) –
o CT scan earliest and most common sign
o MRI  Difficulty breastfeeding or inability to
o X – ray breastfeed
 PHARMACOLOGICAL
 Irregular menstrual period or absence of
o Dopamine Agonists
menstrual period
 Bromocriptine: prescribed to
 Low blood pressure
help reduce prolactin levels
 Low blood sugar
 Cabergoline: ergot
 Fatigue
medication that works by
preventing prolactin release  Inability to grow regrow shaved pubic hair
from the pituitary gland. To  Breast shrinkage
treat high prolactin levels  Slowed mental function
 Eluxin or Flutamin MANAGEMENT
 Bromo Ergocryptine
 MEDICAL
NURSING INTERVENTIONS o Blood test: dynamic testing of
- Assess mental and physical influence of pituitary hormone levels
illness or condition on the client’s emotional o CT scan or MRI: to investigate the
state. size and structure of pituitary gland
- Evaluate level of client’s knowledge of and o Hormone Replacement Therapy
anxiety related to situation. Observe o Pituitary Hormone Stimulation Test
emotional changes, which may indicate  PHARMACOLOGICAL
acceptance or non-acceptance of situation. o Corticosteroid: Prednisone or
- Recognize behavior indicative of over Hydrocortisone to replace the
concern with body and its process. adrenal hormones
- Assess client’s current level of adaptation o Levothyroxine: increases the
and progress. amount of hormones the thyroid
- Listen to client’s comments and responses to gland makes
the situation. Different situations are o Estrogen and Progesterone:
upsetting to different people, depending on normalize the menstrual cycle.
individual coping skills and past experiences. Therapy can stop upon reaching the
- Polygraphic monitoring age of menopause
o LSH & FH: stimulates ovulation and
NURSING DIAGNOSIS assists mothers for pregnancy
o Growth hormone: hormones
- Risk for disturbed body image r/t oversupply
of breast milk secondary to obesity needed to maintain

SHEEHANS SYNDROME NURSING INTERVENTIONS

- Educate patients on risks and effects of
DEFINITON
Sheehan’s syndrome. As this could result I
- A condition that affects women who lose a crisis due to the risk of poor imbalance of
life – threatening amount of blood in hormones and due to the lack of the anterior
childbirth or who have severe low BP during pituitary gland
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MODULE 3M: POSTPARTAL COMPLICATIONS

- Encourage follow ups for hormonal  Lack of social or family support

assessment. The damage of the pituitary  Being a young or first-time parent
gland disrupts hormonal balance of  Low socioeconomic status
regulatory hormones.
- Educate self-administration of medicine. ASSESSMENT FINDINGS
Treatment for Sheehan’s syndrome involves - 50%-85% mothers in first 2 weeks
a lifetime therapy, therefore it is important for postpartum
the patient to understand how to self- - Mild and spontaneously remits, not
administer considered psychiatric disorder
- Assess patient history. To assess the
severity of Sheehan’s syndrome and identify SIGNS AND SYMPTOMS
means of slowing down the progression of
 Irritability
the effects by correcting imbalances.
- Cooperate with specialists. Discuss with  Anxiety and worry
interprofessional teams on strategies to  Fluctuating mood/ mood swings
improve care coordination and  Increased emotional reactivity
communication to identify the complication  Sadness
early and improve outcomes.  Bursting into tears
 Feeling on edge or overly sensitive
NURSING DIAGNOSIS  Feeling empty or lonely
- Risk of imbalanced nutrition: less than body  Feeling stressed or overwhelmed
requirements r/t insufficient dietary intake  Confusion about your emotions
 Not being able to cope
POSTPARTUM BLUES  Difficulty sleeping or trouble falling asleep
DEFINITON NOTE: it is important to understand that these are
- Temporary and short – term mental and the limitations or postpartum blues symptoms. If the
emotional health condition that can set in mother is experiencing any other more severe and
immediately after giving birth chronic symptoms, then she may be struggling with
- Not considered by medical health postpartum depression or a more serious
professionals to be a serious or severe postpartum condition
condition, but a normal response to changing - If symptoms persist or worsen after 14 days,
hormone levels, exhaustion and life it is vital that the mother should inform her
changing event of having a new baby physician or mental health professional
- Usually subsides w/in 2 weeks w/out immediately
treatment
- Symptoms of this disease typically starts MANAGEMENT
within first 48 to 72 hours after delivering
 MEDICAL
a baby and generally lasts about 2 weeks
o Antidepressant Therapy
with symptoms tending to peak shortly after
o Counselling
1st week
NURSING INTERVENTIONS
ETIOLOGY/CAUSE
- Educate mothers and partners on the s/s of
- This phenomenon may be caused by
postpartum blues
hormonal changes, particularly the decrease
- Plan for continuity of care for the mother,
in estrogen and progesterone that occurred
newborn, and family
with delivery of the placenta
- Include family participation and involvement
- During pregnancy, women have hormone
in plans of care
levels at 20 to 30 times greater than when not
- Make appropriate referrals
pregnant.
- The physical exertion of childbirth also NURSING DIAGNOSIS
creates a chemical high in the brain. Thus,
sudden and temporary sadness may occur - Disturbed sleep pattern: verbalization of
as your brain’s neurotransmitters adjust your difficulty in falling asleep and mood
body to normal hormone levels after giving alterations r/t non – restorative sleep pattern
birth due to parenting practice
- There is no one specific cause of postpartum POSTPARTUM DEPRESSION
blues, there are factors that can contribute to
its potential development. DEFINITON

Common factors that cause postpartum blues - Feeling of sadness that occurs for more than
include: a year after the postpartum period and
interferes with the normal functions of the
 Sleep deprivation mother
 Fatigue - 13% mothers in 1st year postpartum
 Other pre-existing medical conditions
 Marital problems
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ETIOLOGY/CAUSE & PATHOPHYSIOLOGY - A rare event that occurs in approx. 1 to 2 per

1000 women after childbirth
- Anticlimactic feeling is experienced by the
- Presentation us often dramatic with onset of
woman after birth
symptoms as early as the 48 to 72 hours after
- Hormonal changes in estrogen,
delivery
progesterone, and gonadotropin – releasing
- Majority of women with puerperal psychosis
hormone rises and falls
develop symptoms w/in the first 2 postpartum
RISK FACTORS weeks
- 0.01% mothers in first 3 months postpartum
 History of depression - Severe, considered psychiatric emergency;
 Troubled childhood often necessitates hospitalization
 Low self-esteem
 Stress in the home or at work ETIOLOGY/CAUSE
 Lack of effective or social support - Causes of postpartum psychosis are not well
 Different expectations between partners understood
(e.g., if a woman wants a child and her - Possible that the abrupt shift in hormones
partner does not) after delivery could trigger the condition
 Disappointment in the child (e.g., a boy - Some research suggests that being an older
instead of a girl) mother may increase risk, but a mother who
has diabetes or gave birth to a large baby
SIGNS AND SYMPTOMS
may be protected
The syndrome can interfere with breastfeeding, child
SIGNS AND SYMPTOMS
care, and returning to a career. Both women and
men may notice:  Delusions
 Hallucinations
 Extreme fatigue
 Agitation
 An inability to stop crying
 Heightened energy or sex drive
 Increased anxiety about their own or their
infant’s health  Depression, anxiety, or confusion
 Insecurity (unwillingness to be left alone or  Severe insomnia
inability to make decisions)  Paranoia and suspicious feelings
 Psychosomatic symptoms (nausea and  Constant mood swings
vomiting, diarrhea)  Feeling disconnected from the baby
 Either depressive or extreme mood MANAGEMENT
fluctuations
 MEDICAL
MANAGEMENT o Regular check – ups
 MEDICAL o ECT is suggested if mother does not
o Psychotherapy (Talk Therapy) respond well
o Cognitive – Behavioral Therapy o Psychotherapy
(CBT)  PHARMACOLOGICAL
o Interpersonal Therapy (IPT) o Antipsychotic medication to
o Antidepressant Therapy reduce hallucinations such as
 PHARMACOLOGICAL Risperidone (Risperdal), Olanzapine
o Anti – anxiety or anti – depressant (Zyprexa), Ziprasidone (Geodon) and
medications Aripiprazole (Abilify)
o For severe cases, IV infusion of a o Antidepressants
new medication Brexanolone o Mood stabilizers to reduce manic
episodes such Lithium (Lithobid),
NURSING INTERVENTIONS Carbamazepine (Tegretol),
Lamotrigine (Lamictal) and
- Assess on the mental health needs
Divalproex sodium (Depakote)
- Screen for depression
 SURGICAL
- Conscientious observation and discussion
o Stereotactic surgery
- Refer to counseling
NURSING INTERVENTIONS
NURSING DIAGNOSIS
- Primarily examine the mother's and baby's
- Risk for ineffective individual coping r/t
current care needs, with a focus on the
depression in response to stress associated
mother's and baby's safety.
with childbirth and parenting
- Acquire a multidisciplinary assessment that
POSTPARTUM PSYCHOSIS includes a thorough examination of the
severity of the mental disease as well as any
DEFINITON potential repercussions in other areas of
- Most severe form of postpartum psychiatric functioning.
illness
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MODULE 3M: POSTPARTAL COMPLICATIONS

- Recommend support groups to the woman

so that she has a safe place to vent her
emotions
- Assist the woman in making plans for her
everyday activities, including her diet,
exercise, and sleep.
- Advise the woman to set aside some time
each day for herself so she can take a break
from her daily baby-sitting duties.
- Encourage the woman to maintain contact
with her social circle, as they can serve as a
source of support
NURSING DIAGNOSIS
- Disturbed though process: delusions and
hallucinations r/t increased level of anxiety