COMPLICATIONS OF

THE POSTPARTUM
PERIOD
13th January, 2020
POSTPARTUM COMPLICATIONS
 Postpartum hemorrhage
 Postpartum psychiatric disorders
 Puerperal infection
 Mastitis
 Deep vein thrombosis
Postpartum Hemorrhage
 PPH is any blood loss from the uterus that exceeds 500ml
during a 24 hour period
 Early postpartum hemorrhage ; during the first 24 hours
 Late postpartum hemorrhage: after the first 24 hours , during
the remaining 6 weeks
 PPH any amount of bleeding that places the mother in
hemodynamic jeopardy
 After vaginal birth : 500ml
 After cesarean birth: 1000 and 1200ml is the acceptable range
 ***uterine atony ; pauses greatest danger for PPH
Risk Factors
 Abruptio placentae
 Missed abortion
 Placenta previa
 Uterine infection
 Placenta accreta
 Uterine inversion
 Severe preeclampsia
 Amniotic fluid embolism
 Intrauterine fetal death
 Precipitous labour
 Macrosomia
 Multiple gestation
 Prolonged labor
 Multiparity
 Prolonged 3rd stage of labor >30 minutes
Causes of PPH
 Uterine atony/uterine relaxation
 Lacerarions
 Retained placenta or placental fragments
 Disseminated intravascular coagulation (DIC)
 5 Ts
 Tone; uterine atony, distended bladder
 Tissue: retained placenta and clots
 Trauma: vaginal, cervical or uterine injury
 Thrombin: coagulopathy (preexisting or acquired)
 Traction : causing uterine inversion
Causes cont..
 Uterine atony; failure of the uterus to contract and retract after
birth- soft and boggy
 Risk factors include;
 Polyhydramnios
 Delivery of macrosomic neonate
 Use of magnesium sulfate during labor
 Multiple gestation
 Delivery that was rapid or required operative techniques
 Injury to the cervix or birth canal
 Use of oxytocin to initiate labor or prolonged use of tocolytic agents
 Dystocia / dysfunctional labor
 Previous history of PPH
 Use of deep analgesia or anesthesia
Clinical manifestations of shock due
to blood loss
Degree of shock Blood loss Signs and symptoms
Mild <20% Diaphoresis
Increased capillary refilling
Cool extremities
Maternal anxiety
Moderate 20-40% Tachycardia
Postural hypotension
Oliguria
Severe >40% Hypotension
Agitation or confusion
Hemodynamic instability
Diagnostic tests
 Hemoglobin level and hematocrit decreases
 Elevated HCG levels if patient has retained placental
fragments
 Platelet and fibrinogen levels are decreased in DIC
 Clotting times PT& PTT are prolonged
 Blood tests – decreased fibrinogen levels and fragmented
RBCs
Therapeutic management
 Focuses on the underlying cause
 Massage the uterus to treat uterine atony, empty the bladder and
administer methylergonovine (methergine) or oxytocin(pitocin)
 Manually separate or evacuate the uterus in retained placental
fragments
 Administer a uterine stimulant to expel fragments
 Lacerations are sutured or repaired
 Manage DIC, active bleeding require administration of blood, fresh
frozen plasma, platelets or packed RBCs to support hemostasis
 IVFs lactated ringers solution , plasma expanders until whole
blood is available
Other steps in management of PPH
 Asses the patient fundus and lochia every 15 minutes for 1 hour
after birth to detect changes. Notify the doctor if lochia increases or
fundus not contacted
 Fundal massage
 If you suspect PPH, weigh perineal pads to estimate blood loss
 Turn the patient to her side and inspect under buttocks for pooling
of blood
 Inspect the perineal area closely for oozing for possible lacerations
 Monitor vital signs for changes
 Monitor input and output an report output less than 30ml/hour
encourage patient to void frequently
Steps if patient develops signs and
symptoms of hypovolemic shock
 Begin an iv infusion of lactated ringers solution
 Administer colloids and blood products as ordered
 Monitor the patient for fluid overload
 Monitor for signs and symptoms of infection
 Record vital signs every 15 minutes until stable
 Monitor cardiac rhythm continously
 Assess skin color and temperature and note changes
 Monitor capillary refill and skin turgor
 Watch for signs of impending coagulopathy, such as petechiae, bruising and bleeding
or oozing from gums or venipuncture sites
 Anticipate the need for fluid replacement and blood component therapy if ordered
 Obtain arterial blood samples to measure ABG levels
 Obtain venous blood specimens as ordered for CBC, electrolyte measurements, typing
and crossmatching and coagulation studies
Postpartum psychiatric disorders
 Postpartum blues(baby blues)
 Postpartum depression
 Postpartum psychosis
Postpartum blues
 Most common and least severe, self limiting
 Occur within 3 to 5 days after birth but may last up to 1 week
or more, though rarely persisting longer than 48 hours.
 Normal hormonally generated postpartum occurrence
 Premature delivery and mothers who have an infant in the
NICU are at high risk
Pospartum blues
 The main features are mild and may include:
 a state whereby the woman experiences labile emotions
(e.g. tearfulness, despair, irritability to euphoria and laughter)
 • a state whereby the woman feels overwhelmed by the
sudden realization of the relentless responsibility of the
baby’s 24-hour dependency and vulnerability
Postpartum blues
 The actual aetiology is unclear but hormonal influences
(e.g. changes in oestrogen, progesterone and prolactin
levels) seem to be implicated as the period of increased
emotionality appears to coincide with the production of
milk in the breasts
 self-limiting and will resolve spontaneously, assisted by
support from loved ones
Postpartum depression
 It’s a mood disorder
 Exact cause is unknown, previous risk of depression or
psychiatric illness before or during the pregnancy
 Anxiety during pregnancy
 Teenage pregnancy
 Multiple births
 Lack of social support
 Stressful life situations
 Socioeconomic status of the mother
 Obstetric complications minor risk factors
Signs and symptoms of postpartum
depression
 Feeling sad or down
 Decreased interest in normal activities
 Appetite problems and weight changes
 Anxiety and agitation
 Difficulty sleeping
 Fatigue and reduce energy
 Feeling guilty or worthless
 Feelings of suicide or thoughts of harming the infant
Management
 Outpatient basis
 Selective serotonin reuptake inhibitors such as paroxetine,
fluoxetine and sertraline
 Safe for breastfeeding women
Nursing management
 Teach the postpartum patient about warning signs
 Include teaching about postpartum depression as part of the patient
discharge plan
 Encourage the woman to verbalize her feelings about the pregnancy
 Help the woman understand that it is normal to feel sadness or a lack
of enthusiasm about motherhood
 Instruct the woman and her family that postpartum depression can
occur at any time after delivery
 Advise the family of the warning signs of postpartum depression and
report immediately to the practitioner
 Assist the woman in contacting a support group that can help alleviate
her feelings of isolation
Postpartum psychosis
 Appears within 2 to 3 weeks after birth but can occur as early as
the first or second day
 Its an emergency situation and requires immediate intervention
 Most severe form of postpartum affective (mood) disorder
 Cause is unknown
 Predisposing factors
 Changing hormone levels
 Lack of support systems
 Low sense of self esteem
 Financial difficulties
 Major life changes
Signs and symptoms of postpartum
psychosis
 Feelings that her baby is dead or defective
 Hallucinations that may include voices telling her to harm the
baby or herself
 Severe agitation, irritability or restlessness
 Poor judgment and confusion
 Feelings of wothlessness, guilt, isolation or overconcern with
the baby’s health
 Sleep disturbances
 Euphoria, hyperactivity, or little concern for self or infant
Signs and symptoms cont..
 pressure of speech and flight of ideas
 there is often a mixture of grandiosity, elation and certain
conviction alternating with states of fearful tearfulness, guilt
and a sense of foreboding
 The sufferers are usually restless and agitated, resistive,
seeking senselessly to escape and difficult to reassure
 However, they are usually calmer in the presence of familiar
relatives
 Her concentration is usually grossly impaired and she is
distractible and unable to initiate and complete tasks
Relationship with the baby
 Some women are so disturbed, distractible and their
concentration so impaired that they do not seem to be aware of
their recently born baby.
 preoccupied with the baby, reluctant to let it out of their sight
and forever checking on its presence and condition
 delusional ideas of infant ill health or changed identity
 Rarely hostile to their baby and for their behaviour to be
aggressive or punitive
 The risk to their baby lies more from an inability to organize and
complete tasks, and to inappropriate handling and tasks being
impaired by their mental state
Postpartum depression screening
scale
 PDSS is a 35 item self report scale Likert type scale with a range of 1
(strongly disagree) to 5( strongly agree) that the woman complete in 5
to 10 minutes
 The instrument gives a total score that determines the degree of
severity of postpartum depression symptoms
 Total score range 35-59 normal adjustment
 Total score range 60-69: significant symptoms of postpartum
depression
 Total score> 80: major postpartum depression
 The scale assess the following areas:
 Eating or sleeping disturbances
 Anxiety or insecurity
 Emotional lability
 Mental confusion
 Loss of self
 Guilt or shame
 Suicidal thoughts
Prognosis
 resolve relatively quickly over 2–4 weeks
 initial recovery is often fragile and relapses are common in
the first few weeks
 As the psychosis resolves, it is common for women to pass
through a phase of depression and anxiety and
preoccupation with their past experiences and the
implications of these memories for their future mental health
and their role as a mother
 Sensitive and expert help is required to assist women
through this phase
 complete recovery by 3–6 months postpartum
 50% risk of a recurrence should they have another child
 Some may have bipolar later in their lives
Treatment
 Immediate hospitalization
 Antipsychotics and antidepressants are used
 Nursing management
 Teach the postpartum patient about the warning signs of postpartum
depression and psychosis
 Include teaching about postpartum depression and psychosis as part
of discharge teaching plan
 Instruct the woman and the family that it can occur at any time after
delivery
 Advise the family of the warning signs of postpartum depression and
psychosis and urge them to report them immediately to the
practitioner
Peurperal infection
 Infection during the peurperal period (immediately following
childbirth
 Causes
 A,B,G hemolytic streptococcus
 Gardenerella vaginallis
 Chlamydia trachomatis
 Coagulase negative staphyloccocci
Predisposing factors
 Prolonged(>24 hours) or premature rupture of membranes
 Prolonged(>24 hours) or difficult labor
 Frequent or unsterile vaginal examinations or unsterile
delivery
 Delivery requiring the use of instruments, which may
traumatize the tissue, providing an entry portal for
microorganisms
 Internal fetal monitoring , which may introduce organisms
when electrodes are placed
Predisposing factors cont…
 Retained products of conception which cause tissue necrosis and
provide an excellent medium for bacterial growth
 Hemorrhage which weakens the patient’s overall defenses
 Maternal conditions such as anemia, DM, immunosuppression
 Cesarean birth 30-50% risk
 Existence of localized vaginal infection or other type of infection at
delivery, which allows direct transmission of infection
 Bladder catheterization
 Episiotomy or lacerations
 Pneumonia
 Venous thrombosis
Clinical manifestations
 Fever >380 C that occurs during the first 10
days postpartum and lasts for 2
consecutive days
 Chills
 Headache
 Malaise
 Restlessness
 Anxiety
Accompanying signs and symptoms
 Localized perineal infection
 Endometritis
 Prametritis(pelvic cellulitis)- vaginal tenderness and
abdominal pain and tenderness
 Septic pelvic thrombophlebitis
 Peritonitis wide spread inflammation
may cause these
conditions
Diagnostic tests
 Physical assessment : fever and uterine tenderness
 Blood culture
 Elevated WBCs
 Elevated ESR
Treatment
 IV infusion of broad spectrum antibiotics
 Analgesics
 Antiemetics for nausea and vomiting from peritonitis
 Antiseptics for local lesions
 Supportive care;
 Bed rest
 Adequate fluid intake
 IV fluids when necessary
 Measures to reduce fever
 Heparin and broad spectrum antibiotics for septic pelvic
thrombophlebitis
BREAST COMPLICATIONS
Expressing Breast Milk
 Expression is appropriate in the following situations, if:
 • there is concern about the interval between feeds in the
early perinatal period (expressed colostrum should always
be given in preference to formula milk to healthy term
babies)
 • there are difficulties in attaching the baby to the breast
 • the baby is separated from the mother, due to prematurity
or illness
Expressing Breast milk cont..
 there is concern about the baby’s rate of growth, or the
mother’s milk supply (expressing to top up with the mother’s
own milk may be necessary in the short term while the cause
of the problem is resolved)
 • the mother needs to be separated from her baby for periods
(occasionally or regularly), as the baby gets older
Expressing breast milk cont..
Manual expression
 Manual expression has several advantages over mechanical
pumping and should be taught to all mothers.
 It is usually the most efficient method of obtaining colostrum
Expressing with a breast pump
 If it is possible and practical, the mother should be able to
experiment with a variety of breast pumps to discover what
will suit her best (Auerbach and Walker 1994) as not all
pumps work well for every woman
 Manually operated pumps
 Most manually operated pumps are not efficient enough to
allow initiation of full lactation
 They can be useful when expressing is required once
lactation is established
 It is helpful for midwives to explain to mothers that these
pumps function most efficiently if the vacuum phase is
considerably longer than the release phase
 Electrically controlled pumps
 Some electrically controlled pumps provide a regular vacuum
and release cycle, with variability in the strength of the
suction and others also vary the frequency of the cycle

 Double pumping is possible with most models, and this has

repeatedly been shown to be of benefit, either reducing the
time for which the mother needs to use the pump at each
session to obtain the available milk
 Storage of breastmilk
 NICE (2008) advises that expressed milk can be stored for
up to:
 • 5 days in the main part of a fridge, at 4 °C or lower
 • 2 weeks in the freezer compartment of a refrigerator
 • 6 months in a domestic freezer, at −18 °C or lower.
Care of the breasts

 Daily washing is all that is necessary for breast hygiene.

 Brassieres may be worn in order to provide comfortable
support and are useful if the breasts leak and breast pads (or
breast shells) are used
 Breast problems
 Sore and damaged nipples
 The cause is almost always trauma from the baby’s mouth and tongue, which results
from incorrect attachment of the baby to the breast.
 Correcting this will provide immediate relief from pain and allow rapid healing to take
place.
 Epithelial growth factor, contained in fresh human milk and saliva, may aid this process.
 Resting the nipple enables healing to take place but makes the continuation of lactation
much more complicated because it is necessary to express the milk and to use some
other means of feeding it to the baby.
 Nipple shields should be used with caution, and never before the mother has begun to
lactate, as the baby is unlikely to extract colostrum via a shield.
 They may make feeding less painful, but often they do not.
 Their use does not enable the mother to learn how to feed her baby correctly, and their
longer-term use may result in reduced milk transfer from mother to baby.
 This in turn may result in mastitis in the mother (reduced milk removal), slow weight
gain or prolonged feeds in the baby (reduced milk transfer), or both
Breast problems cont..
 Other causes of soreness
 Infection with Candida albicans (thrush) can occur, although it is
not common during the first week following the baby’s birth
 Sudden development of pain after a period of trouble-free
feeding is suggestive of thrush
 The nipple and areola are inflamed and shiny, and pain typically
persists throughout the feed.
 The baby may show signs of oral or anal thrush
 Both mother and baby should receive concurrent fungicidal
treatment, such as miconazole, and it may take several days for
the pain in the nipple to disappear
Anatomical variations
 Short nipples
 Short nipples should not cause problems as the baby is able
to form a teat from both the breast and nipple.
Long nipples
 Long nipples can lead to poor feeding because although the
baby is able to latch on to the nipple, he is unable to draw any
breast tissue into his mouth, due to the length of the nipple.
Abnormally large nipples
 If the baby is small, his mouth may not be able to get beyond
the nipple and onto the breast
 Lactation can be initiated by expressing, by hand or by pump,
provided the nipple fits into the breastshield
 As the baby grows and the breast and nipple become more
protractile, breastfeeding may become possible
Anatomical Variations
Inverted and flat nipples
 If the nipple is deeply inverted it may be necessary to initiate
lactation by expressing and delay attempting to attach the
baby to the breast until lactation is established and the
breasts have become soft and the breast tissue more elastic
Difficulties with breastfeeding
 Engorgement
 This condition occurs around the 3rd or 4th day following the
baby’s birth
 The breasts become hard, often oedematous, painful and
sometimes appear flushed.
 The mother may be pyrexial
 Engorgement is usually an indication that the baby is not
keeping pace with the stage of lactation
 Engorgement may occur if feeds are delayed or restricted or if
the baby is unable to feed efficiently because he is not correctly
attached to the breast
Engorgement
 Management should be aimed at enabling the baby to
 feed well
 In severe cases the only solution will be the gentle use of a
pump.
 This will reduce the tension in the breast and will not cause
excessive milk production
 Deep breast pain
 In most cases, deep breast pain responds to improvement in
breastfeeding technique and is likely to be due to raised
intra-ductal pressure caused by inefficient milk removal
 Although it may occur during the feed, it typically occurs
afterwards
 This distinguishes it from the sensation of the let-down
reflex, which some mothers experience as a fleeting pain
 Very rarely, deep breast pain may be the result of ductal
thrush infection
Mastitis
 Parenchymatous inflammation of the mammary
glands that disrupts normal lactation
 Causes
 Trauma due to incorrect latching or removal from
the breast allows introduction of organisms from
the neonate nose or pharynx into maternal breast
 Staphylococcus aureus is the most common
causing pathogen
Predisposing factors of mastitis
 Fissure or abrasion in the nipple
 Blocked milk ducts; wearing a tight fitting bra or waiting
prolonged intervals between breast feeding
 Incomplete let down reflex due to emotional trauma
Clinical manifestations
 Fever
 Chills
 Malaise
 Flu-like symptoms
 Redness, swelling, warmth, hardness tenderness, nipple
cracks or fissures and enlarged axillary lymph nodes

Unless treated, it may progress to breast abscess

Laboratory tests and treatment
 Cultures of expressed breast milk/ breast skin
 Analgesics for pain

 Antibiotic therapy
 Oral cephalosporins or penicillins
 Cloxacillin or dicloxacillin
 Azithromycin or vancomycin for patients allergic to penicilin’
Prevention
 Wash your hands after using the bathroom, before touching your
breasts and before and after every breastfeeding
 To facilitate milk flow, take a warm shower or apply a warm
compress
 Position the neonate properly
 Empty your breasts as completely as possible after each feeding
 Air dry your nipples
 Alternate feeding positions
 Drink plenty of fluids
 Don’t wait too long between feedings or wean the infant abruptly
Breast abscess
 A fluctuant swelling develops in a previously inflamed area: namely a
breast abscess.
 Pus may be discharged from the nipple
 Simple needle aspiration may be effective, or incision and drainage
may be necessary (Dixon 1988).
 It may not be possible for the baby to feed from the affected
 breast for a few days, however milk removal should continue by
expression with breastfeeding recommencing as soon as practicable
as this would reduce the chances of further abscess formation (WHO
2000).
 A sinus that drains milk may form, but it is likely to heal in time
Blocked Ducts
 Lumpy areas in the breast are not uncommon, due to distended
glandular tissue. If such lumps become very firm and tender and
sometimes flushed, they are often described as blocked ducts.
 This description carries with it the image of a physical obstruction within
the lumen of the duct. However, this is very rarely the cause of the
symptoms.
 It is much more likely that milk drainage has been somewhat uneven
due to less than optimal attachment and that secreted milk is trying to
occupy more space than is actually available, causing the alveoli to
distend.
 Milk may subsequently be forced out into the connective tissue of the
breast where it causes inflammation.
 The inflammatory process narrows the lumen of the duct by exerting
pressure on it from the outside as the tissue swells, resulting in mastitis
or incipient mastitis.
 to improve milk drainage by improved attachment, with possibly milk
expression, and to treat the accompanying pain and inflammation.
 White spots/epithelial overgrowth
 Very occasionally, a ductal opening in the tip of the nipple may
become obstructed by epithelial overgrowth.
 A white blister is evident on the surface of the nipple, effectively
causing a physical obstruction closing off the exit points from one or
more milk-producing sections of the breast.
 This may sometimes be resolved by the baby feeding
 Alternatively, after the baby has fed and the skin is softened, the
blister may be removed with a clean fingernail, a rough flannel, or a
sterile needle.
 True blockages of this sort tend to recur, but once the woman
understands how to deal with them, the progression to mastitis can be
avoided.p9/
1/20/2020

THROMBOEMBOLIC DISORDERS
Thromboembolic Disorders
 A thrombus is a collection of blood factors, primarily
platelets and fibrin, on a vessel wall.
 Thrombophlebitis occurs when the vessel wall develops an
inflammatory response to the thrombus
 An embolus is a mass that may be composed of a
 thrombus or amniotic fluid released into the bloodstream that
may cause obstruction of capillary beds in another part of the
body, frequently the lungs.
 Pulmonary embolus is a potentially fatal complication that
occurs when the pulmonary artery is obstructed by a blood
clot that was swept into circulation from a vein or by amniotic
fluid
 The three most common thromboembolic disorders
encountered during pregnancy and the postpartum period
are :
 superficial venous thrombophlebitis (SVT),
 deep vein thrombosis (DVT), and occasionally
 pulmonary embolism (PE
 SVT generally involves the saphenous venous system and is
confined to the lower leg.
 DVT can involve veins from the foot to the iliofemoral region
 It is a major concern because it predisposes to PE.
Incidence and etiology
 The incidence of venous thromboembolism is about 1 in
1500 pregnancies; however, it is a leading cause of maternal
mortality
 Thrombi can form whenever the flow of blood is impeded.
 Once started, the thrombus can enlarge with successive
layering of platelets, fibrin, and blood cells as the blood flows
past the clot.
 Thrombus formation is often associated with
thrombophlebitis.
Incidence and etiology cont..
 The three major causes of thrombosis are venous stasis,
hypercoagulable blood, and injury to the endothelial surface
(the innermost layer) of the blood vessel
 Two of these conditions—venous stasis and hypercoagulable
blood—are present in all pregnancies; the third, blood vessel
injury, is likely to occur during birth.
Venous stasis
 During pregnancy, compression of the large vessels of the
legs and pelvis by the enlarging uterus causes venous
stasis.
 Stasis is most pronounced when the pregnant woman stands
for prolonged periods of time
 It results in dilated vessels that increase the potential for
continued pooling of blood postpartum.
 Relative inactivity during pregnancy and activity restriction
due to complications during pregnancy lead to venous
pooling and stasis of blood in the lower extremities
Venous Stasis
 Prolonged time in stirrups for delivery and repair of the
episiotomy also may promote venous stasis and increase the
risk of thrombus formation
hypercoagulation
 Pregnancy is characterized by changes in the coagulation and
fibrinolytic systems that persist into the postpartum period
 During pregnancy the levels of many coagulation factors are
elevated.
 In addition, the fibrinolytic system, which causes clots to
disintegrate (lyse), is suppressed.
 The result is that factors that promote clot formation are
increased and factors that prevent clot formation are decreased
to prevent maternal hemorrhage, resulting in a higher risk for
thrombus formation during pregnancy and the postpartum period
Blood Vessel Injury
 Injury to the endothelium of the blood vessels may occur
during pregnancy, especially at birth.
 Lower extremity trauma, operative delivery and prolonged
labor can cause vascular damage
 Cesarean birth significantly increases the risk for
thromboembolic disease
Superficial Venous Thrombosis
Clinical Manifestations
 Superficial thrombophlebitis is most often associated with
varicose veins and limited to the calf area.
 It can also occur in the arms as a result of IV therapy.
 Signs and symptoms include swelling of the involved
extremity and redness, tenderness, and warmth.
 It may be possible to palpate an enlarged, hardened, cordlike
vein
 The woman may experience pain when she walks, but some
women have no signs
Therapeutic Management
 Treatment includes analgesics, rest, and elastic support.
 Elevation of the lower extremity improves venous return. Warm packs
may be applied to the affected area.
 Anticoagulants are not needed but antiinflammatory medications may
be used.
 After a period of bed rest with the leg elevated, the woman may
ambulate gradually if symptoms have disappeared.
 She should avoid standing for long periods and should
 continue to wear support hose to help prevent venous stasis and a
subsequent episode of superficial thrombosis.
 Little chance of PE exists if the thrombosis remains in the superficial
veins of the lower leg
Deep vein thrombosis
 DVT , also called deep vein thrombophlebitis, is an
inflammation of the lining of a blood vessel that occurs in
conjunction with clot formation
 Occurs at valve cusps because venous stasis encourages
the accumulation and adherence of platelets and fibrin
 Starts with localized inflammation(phlebitis), but rapidly
provokes thrombus formation
 Rarely, venous thrombosis develops without associated
inflammation of the vein (phlebothrombosis)
Causes
 Idiopathic occur along with certain diseases, treatments, injuries or other factors
 In the postpartum woman, DVT most commonly results from an extension of
endometritis
 Risk factors for developing DVT in the postpartum period include:
 History of varicose veins
 Obesity
 Previous DVT
 Multiple gestations
 Increased age (older than age 30)
 Family history of DVT
 Smoking
 Ceserean birth
 Multiparity
Compounding the risk of DVT
 Blood clotting increases post-partally as a result of fibrinogen
levels
 Pressure from the fetal head during pregnancy and delivery
causes veins in the lower extremities to dilate, leading to
venous stasis
 Lying in the lithotomy position for a long time with the lower
extremities in stirrups promotes venous pooling and stasis
Signs and symptoms
 Femoral DVT
 Patient’s temperature increases around the 10th day postpartum
 Malaise, chills and pain , stiffness or swelling in a leg or in the
groin
 Affected extremity appears reddened or inflamed, edematous
below the level of obstruction and possibly shiny and white
 Diminished peripheral pulses
 Positive Homan’s sign
Signs and symptoms
 Pelvic DVT
 The patient looks acutely ill with a sudden onset of high fever,
severe repeated chills and general malaise
 Approximately postpartum days 14 to 15
 Tachycardia
 Chills
 General malaise
 Possible pelvic abscess
 Abdominal and flank pain
Treatment
 Femoral DVT
 Bed rest
 Elevation of affected extremity
 Never massaging affected area
 Anticoagulants
 Moist heat applications
 Analgesics
Treatment
 Pelvic DVT
 Complete bed rest
 Anticoagulants
 Antibiotics
 Incision and drainage if abscess develops
Prevention
 Incorporate these instructions in your teaching plan to reduce a woman’s
risk of developing DVT
 Check with your practitioner about using a side-lying or back-lying position
for birth instead of the lithotomy position
 Change positions frequently if on bed rest
 Avoid deeply flexing your legs at the groin or sharply flexing your knees
 Don’t stand in one place for too long or sit with your knees bent or legs
crossed , elevate your legs slightly t improve venous return
 Don’t wear constrictive clothing
 Wiggle your toes and perform leg lifts while in bed to minimize venous
pooling and help increase venous return
 Walk as soon as possible after birth
 Use a sequential compression device or wear thigh high stockings during
and after cesarean birth until you are ambulating
 Wear anti-embolism stockings as ordered
 Use padded stirrups in lithotomy position to put less pressure on the calves
 Preventing Thrombus Formation. Women who have had a
previous DVT or PE are at risk for another.
 These women and others at high risk may receive prophylactic
heparin, which does not cross the placenta.
 Either standard unfractionated heparin (UH) or a lowmolecular-
weight heparin (LMWH) such as enoxaparin (Lovenox) or
 tinzaparin (Innohep) may be used.
 LMWH is longer acting and can be given less frequently and
with less laboratory testing.
 It has fewer side effects and is less likely to cause bleeding
Prevention cont…
 If stirrups must be used during the birth, risks of thrombus
development can be reduced by placing the woman’s legs in
stirrups that are padded to prevent prolonged pressure
against the popliteal angle during the second stage of labor.
 If possible, the time in stirrups should be no more than 1 hour.
 All new mothers are encouraged to ambulate frequently and
as early as possible.
 Ambulation prevents stasis of blood in the legs and
decreases the likelihood of thrombus formation.
 If the woman is unable to ambulate, range-of-motion and
gentle leg exercises, such as flexing and straightening the
knee and raising one leg at a time, should begin within 8
hours after childbirth.
Prevention cont..
 Graduated compression stockings or sequential compression
 devices are used for mothers with varicose veins, a history of
thrombosis, or a cesarean birth.
 Sequential compression devices should be applied
preoperatively for a woman undergoing a cesarean birth who
is not on anticoagulant therapy and should be continued until
she begins to ambulate postpartum
How Do I Prevent Thrombosis
(Blood Clots)? Patient teaching
 Methods to improve peripheral circulation will help prevent the
occurrence of thrombophlebitis:
 • Improve your circulation with a regular schedule of activity,
preferably walking.
 • Avoid prolonged standing or sitting in one position.
 • When sitting, elevate your legs and avoid crossing them. This
will increase the return of venous blood from the legs.
 • Maintain a daily fluid intake of 12 or more 8-oz glasses to
prevent dehydration and consequent sluggish circulation.
 • Stop smoking. Smoking is a risk factor for thrombosis and can
cause respiratory problems in you and your newborn.
Application of the nursing process
The Mother with Deep Venous Thrombosis
 Assessment
 Assessment focuses on determining the status of the venous
thrombosis.
 Inspect both legs at the same time so that the affected leg can be
compared with the unaffected leg.
 DVT is most often unilateral, usually affecting the woman’s left side
 Warmth or redness indicates inflammation; coolness or cyanosis
indicates venous obstruction.
 Palpate the pedal pulses, comparing the strengthof the right and
left
 Measure the affected and unaffected legs, comparing the
circumferences to obtain an estimation of the edema that
may be present in the affected leg.
 Record the measurements for ongoing assessment.
 It may be helpful to mark the woman’s legs at the location of
the measurement for consistency in assessments.
 Assess for pain .Pain is caused by tissue hypoxia, and
increasing pain indicates progressive obstruction.
 Evaluate the laboratory reports of clotting studies. In addition
to activated partial thromboplastin time, platelets may be
evaluated when UH is used.
 Thrombocytopenia is a concern when heparin is
administered for a prolonged time.
 The INR is evaluated when the anticoagulant for the
postpartum woman is changed to warfarin
Nursing Diagnosis
 The treatment of DVT includes the administration of
anticoagulants for a prolonged time.
 An appropriate nursing diagnosis for this situation is “Risk for
Bleeding related to lack of understanding of anticoagulant
therapy precautions.”
Planning
 Expected Outcomes
 The woman will:
 • Remain free of bleeding from anticoagulant therapy.
 • Verbalize precautions necessary when taking
anticoagulants.
 • Plan for changes necessary as a result of anticoagulant
therapy
Interventions
 Monitoring for Signs of Bleeding
 At least twice a day, inspect the mother for the appearance of
bruising or petechiae.
 Instruct her to report any signs of bleeding: bruises, bloody
nose, blood in urine or stools, bleeding gums, or increased
vaginal bleeding.
 Be alert for signs of hemorrhage, such as tachycardia,
falling blood pressure, or other signs of shock that may
indicate internal bleeding
Interventions cont..
 Observe for excessive or bright red lochia. If the uterus is boggy,
the cause is uterine atony. Massage the uterus and express clots.
 If the fundus is firm, bleeding may be from trauma or
anticoagulant therapy.
 In either case the physician should be notified.
 Unless frank hemorrhage is present, the usual treatment for
excessive anticoagulation is temporary discontinuation of the
anticoagulant.
 Protamine sulfate, which is the antidote for UH and is partially
effective against LMWH, should be available.
 The antidote for warfarin is vitamin K
Interventions Cont…
 Explaining Continued Therapy
 Teach the woman how to prevent excessive anticoagulation.
 Carefully explain the treatment regimen, including the schedule of
medication.
 Help her develop a method for remembering to take the medication
as directed. Caution her not to “double up” if a dose is missed. If
necessary, teach her and another family member how to inject
heparin or enoxaparin.
 Explain the need for repeated laboratory testing to regulate the dose
of the anticoagulant. Emphasize the importance of careful attention
to dosage changes to keep the medication at the appropriate blood
levels
 drug interactions; emphasize the importance of keeping the
health care provider informed about any medications she
takes.
 Caution the woman that common over-the-counter
medications, such as aspirin and other nonsteroidal anti-
inflammatory drugs, increase the risk of hemorrhage
 Explain that many herbs and dietary supplements may affect
the potency of anticoagulants,
 Instruct the woman taking warfarin that eating large amounts
of vitamin K–containing foods may interfere with
anticoagulation.
 These foods include broccoli, cabbage, lettuce, spinach, and
lentils.
 Caution her against drinking alcohol, which inhibits the
metabolism of oral anticoagulants.
 The woman should use effective contraception as long as
she is taking warfarin because the drug can cause fetal
defects
 Suggest that the mother use a soft toothbrush and floss her
teeth gently to prevent bleeding from the gums
Evaluation
 The mother demonstrates no signs of unusual bleeding or
other side effects of the medication.
 • The woman discusses precautions she has taken to
prevent hemorrhage.
 • Necessary changes have been made in the home.
Pulmonary Embolism
 Pathophysiology
 Pulmonary embolism (PE) is a serious complication of DVT
and a leading cause of maternal mortality.
 Approximately 70% of patients with PE also have symptoms
of DVT
 PE occurs when fragments of a blood clot dislodge and are
carried to the lungs.
 An embolus can also consist of amniotic fluid and its debris,
a condition called anaphylactoid syndrome
 The embolus lodges in a vessel and partially or completely
obstructs the flow of blood into the lungs.
 If pulmonary circulation is severely compromised, death may
occur within a few minutes
 If the embolus is small, adequate pulmonary circulation may
be maintained until treatment can be initiated
Clinical Manifestations
 Clinical signs and symptoms depend on how much the flow of blood
is obstructed
 Dyspnea, chest pain, tachycardia, and tachypnea are the most
common signs
 Syncope (fainting) is uncommon and may indicate massive emboli
 Pulmonary rales, cough, hemoptysis (expectoration of blood or
bloody sputum), abdominal pain, and low-grade fever may also occur
 Pulse oximetry shows decreased oxygen saturation.
 Arterial blood gas determinations show decreased partial pressure of
oxygen, and chest radiography reveals areas of atelectasis and
pleural effusion
Therapeutic Management
 Treatment of PE is aimed at dissolving the clot and
maintaining pulmonary circulation.
 Oxygen is used to decrease hypoxia, and narcotic
analgesics are given to reduce pain and apprehension.
 Bed rest with the head of the bed elevated is used to help
reduce dyspnea.
 The level of care, including support of ventilation, depends
on her pulmonary status.
Therapeutic Management
 Pulse oximetry and arterial blood gases are evaluated.
 Heparin therapy is initiated and is continued throughout
pregnancy if the embolism occurs prior to birth.
 Therapy may be continued with warfarin for months after
birth to prevent further emboli.
Therapeutic Management
 Emergency medications, such as dopamine, may be used to
support falling blood pressure.
 Thrombolytic drugs, such as streptokinase, urokinase, or
tissue-type plasminogen activator, may be used for
lifethreatening pulmonary emboli but are associated with
bleeding.
 Embolectomy (surgical removal of the embolus) is rare;
limited evidence exists regarding its use in the obstetric
population
Nursing considerations
 Monitoring for Signs. When caring for a woman with DVT,
nurses must be aware of the danger of pulmonary embolism
and focus the assessment for early signs and symptoms
 This includes frequent assessment of respiratory rate and
thorough and frequent auscultation of breath sounds.
 Abnormalities, such as diminished or unequal breathsounds,
or coughing should be reported immediately to the health
care provider.
 Additional signs that require immediate attention include air
hunger, dyspnea, tachycardia, pallor, and cyanosis.
Nursing considerations cont..
 Facilitating Oxygenation. Oxygen should be administered
at 8 to 10 L/min by tight face mask.
 The nurse should remain with the mother to allay fear and
apprehension.
 The head of the bed should be raised to facilitate breathing.
 Narcotic analgesics, such as morphine, may be used to
relieve pain.
 Sedatives may be given to help control anxiety.
Nursing considerations cont..
 Seeking Assistance. The woman’s condition is precarious
until the clot is lysed or until it adheres to the pulmonary artery
wall and is reabsorbed.
 The primary nurse should call for assistance to initiate
interventions.
 These include continuous assessment of vital signs and
administration of IV heparin and emergency drugs that may be
needed.
 The woman who has pulmonary embolism requires critical
care nursing skills and is usually transferred to an intensive
care unit
End
Quiz
Quiz number 2
Quiz number 3
Question number 4
Question 5
End