Postpartum Complications- Maternal (OB) Nursing

by | Jul 26, 2020 | Maternal Nursing

Postpartum Complications- Maternal (OB) Nursing

This is a review for nursing students that will cover the most common postpartum complications. For each complication the signs and symptoms, treatment, and nursing considerations will be explored. This is the perfect study guide for nursing students who are in their Maternal (OB) rotation.

Once you read through all the information in this post, be sure to download this PDF cheat sheet that highlights all the important information that you need to know in nursing school.

You can also check out this other Maternal (OB) Nursing info (downloadable PDF cheat sheets available for each of these topics, as well):

Post-partum hemorrhage

More than 500 mL of blood loss after vaginal birth

More than 1000 mL of blood loss after a c-section

Most commonly caused by uterine atony

Uterine atony

Uterus does not contract leading to a soft or boggy fundus

Trauma to birth canal, hematoma, retained placenta, abnormal coagulation, DIC, placenta previa, placenta accreta

Risk factors included overdistended uterus, multiparity, precipitate or prolonged labor, augmentation with oxytocin

Signs/symptoms:

  • Uterine fundus difficult to locate
  • Soft or “boggy” fundus
  • Uterus becomes firm when massaged, but becomes boggy when massage stops
  • Fundus above expected level
  • Excessive lochia (saturates pad in one hour)- bright red
  • Excessive clots
  • Slow trickle of blood or large quantities/gushes of blood

Nursing interventions:

  • Massage uterus if not firm
  • Express clots
  • **Do not push on uterus if it is not firm. Excess pressure on a boggy uterus can cause an inverted fundus and result in massive hemorrhage and shock**
  • Assess for a distended bladder. Assist patient with urination- may require a foley catheter
  • Administer prescribed medications that help contract uterus
    • Methylergometrine (Methergine) IM- DO NOT give to patient with hypertension
    • IV oxytocin (Pitocin)
    • Carborprost Tromethamine IM
  • Bimanual compression if massage and medications do not work
  • Administer prescribed Lactated Ringers, blood, or blood products to prevent hypovolemic shock or hypovolemia
  • Nurse may need to assist with insertion of balloon into uterus, insertion of uterine packing, prepare patient for laparotomy to identify source of bleeding, prepare patient for uterine compression sutures, or prepare patient for a hysterectomy as a last resort.

Trauma of the birth canal

Vaginal, cervical, or perineal lacerations; hematomas

May be associated with precipitous birth, macrosomia, use of vacuum extractor or forceps

  • If fundus is firm and bleeding is still occurring, then birth canal lacerations should be suspected

Hematomas- discolored bulging mass; causes deep, severe, unrelieved pain and feelings of pressure

  • If fundus is firm and lochia is within normal limits, then hematoma should be suspected. Patient may also have an increase heart rate and decreased blood pressure with a hematoma

Treatment- surgical repair of laceration or hematoma

Nursing interventions

  • Assess an episiotomy for extension into a third or fourth degree laceration
  • Assess firmness of fundus
  • Evaluate amount lochia
  • Use ice packs to treat small hematomas
  • Encourage sitz baths and frequent perineal hygiene

Retained placenta

Failure of placental delivery within 60 minutes of the fetus

May be caused by adherence of placenta to uterine wall

  • Placenta acreta- abnormally adherent; may cause immediate or delayed hemorrhage
  • Placenta increta- placenta penetrates the uterine muscle itself
  • Placenta percreta- penetrates all the way through the uterus

Nursing interventions

  • Monitor the uterus for fundal height, consistency, and position
  • Monitor lochia for color, amount, consistency, and odor
  • Provide oxygen at 2-3 L/min per nasal cannula
  • Administer oxytocin as prescribed to expel retained fragments of the placenta
  • Monitor for hemorrhage and shock
  • Assist with manual removal of placenta
  • Prepare patient for surgical removal of placenta if manual removal is unsuccessful
  • Prepare patient for hysterectomy as a last resort

Thromboembolic disease

Most common thromboembolic disorders

  • Superficial venous thrombophlebitis (SVT)
  • Deep vein thrombosis (DVT)
  • Pulmonary embolism (PE)

Superficial venous thrombosis

Signs/symptoms:

  • Swelling of affected extremity
  • Redness
  • Tenderness
  • Warmth

Nursing interventions

  • Administer analgesics for discomfort
  • Promote rest and elevate the lower extremity if affected
  • Apply elastic support/support hose
  • Apply heat to promote healing
  • Teach patient that there is no need for anticoagulants but that they may be given an anti- inflammatory
  • Teach patient to avoid standing for long periods of time after recovery

Deep Venous Thrombosis

Signs/symptoms:

  • Erythema
  • Warmth
  • Enlarged hardened vein
  • Unilateral leg pain/swelling
  • Calf tenderness
  • Swelling

Treatment

  • Prophylactic heparin for high risk women during pregnancy
    • Discontinued during labor and delivery and resumed 6-12 hours after an uncomplicated birth
  • IV heparin or SQ low molecular weight heparin (LMHP) can be used to treat a DVT
  • Warfarin is contraindicated during pregnancy due to its teratogenic effects but can be used after birth for women who develop a DVT. Warfarin is safe for lactating mothers.     
    • Patient will stay on warfarin for at least 6 weeks

Nursing interventions

  • Promote prevention by encouraging fluids, leg exercises every 1-2 hours, early ambulation. Teach the patient how to apply graduate compression stockings and encourage the use of sequential compression stockings when in bed.
  • Administer prescribed anticoagulants and teach patient about administered medications
  • Check PT, PTT, and INR lab values
  • Apply antiembolic hose when ambulation is allowed
  • Encourage bed rest
  • Assess affected area frequently
    • Check peripheral pulses
    • Measure leg circumferences
  • Monitor for signs of pulmonary embolism which women who have a DVT are at high risk of developing

Pulmonary Embolism

Signs/symptoms:

  • Dyspnea
  • Chest pain
  • Tachypnea
  • Apprehension; impending doom
  • Cough
  • Tachycardia
  • Decreased oxygen saturation

Treatment:

  • Goal of treatment is to dissolve clot
    • Heparin/warfarin therapy
    • Embolectomy
    • Thrombolytic drugs

Nursing interventions

  • Frequently monitor respiratory status- monitor for air hunger, dyspnea, tachycardia, pallor, cyanosis
    • Administer oxygen 8-10 L/min via face mask
    • Position mother on her side
    • Administer narcotic analgesics as prescribed to relieve apprehension
    • Administer continuous IV heparin
    • Teach patient that they will be on oral anticoagulant therapy for 6 months
    • Encourage bed rest, keep HOB elevated

Post-partum (puerperal) infections

Bacterial infection after childbirth

Temp >100.4 within 2-10 days after childbirth

C-section is a major predisposing factor

Risk factors include c-section, prolonged labor, prolonged rupture of membranes, poor hygiene, infrequent voiding, excessive vaginal exams, etc

Endometritis


Most infections are polymicrobial

Typically occurs within 36 hours of delivery

Signs/symptoms:

  • Fever of 100.4 or greater
  • Chills
  • Malaise
  • Abdominal pain and cramping
  • Uterine tenderness
  • Purulent, foul-smelling drainage
  • Leukocytosis

Treatment:

  • Prophylactic antibiotics for all women having a c-section
  • IV antibiotics
    • Broad spectrum- cephalosporins, clindamycin + gentamicin, ampicillin + aminoglycosides, metronidazole + penicillin

Nursing interventions:

  • Assess vital signs every 2 hours while fever is present and every 4 hours once afebrile
  • Administer prescribed antipyretics and analgesics when indicated
  • Administer IV fluids or encourage consumption of fluids to ensure hydration
  • Position patient in Fowler’s position to help gravity keep drainage going

Wound Infection

  • Surgical incisions
  • Episiotomies
  • Lacerations

Signs/symptoms:

  • Edema
  • Warmth
  • Redness
  • Tenderness
  • Pain

Treatment:

  • Incision and drainage (I&D) may be needed
    • Obtain culture from drainage
  • Analgesics for discomfort

Urinary Tract Infections (UTI)

Signs/symptoms:

  • Dysuria
  • Urgency
  • Frequency
  • Suprapubic pain
  • Low grade fever
  • Possible pyelonephritis- chills, N/V, flank pain

Treatment:

  • Oral or IV antibiotics
  • Fluid intake 2500-3000 mL/ day to ensure adequate hydration

Nursing interventions

  • Obtain either a random or clean-catch urine sample
  • Administer prescribed antibiotics
  • Teach the client proper perineal hygiene
  • Encourage the patient to increase her fluid intake to 3000 mL/day to dilute bacteria and flush her bladder
  • Recommend that the patient drink cranberry and prune juice to promote urine acidification
  • Teach patient to avoid grapefruit and soft drinks as they change the pH of urine to alkaline

Mastitis

Infection of the breast

Usually affects one breast; 2-4 weeks after birth

Signs/symptoms

  • Painful or tender, localized hard mass, and reddened area usually on one breast
  • Chills
  • Fatigue
  • Flu-like symptoms
  • Enlarged axillary lymph nodes

Treatment:

  • May turn into an abscess if left untreated
  • Antibiotics for 10-14 days
  • Analgesics for pain relief

Nursing interventions

  • Teach patients about prevention
    • Thoroughly wash hands prior to breastfeeding
    • Maintain cleanliness of breasts with frequent changes of breast pads
    • Encourage allowing nipples to air-dry
    • Avoid nipple trauma and milk stasis
  • Encourage using ice packs or warm packs on affected breasts for discomfort
  • Instruct the patient to begin breastfeeding from the unaffected breast first to initiate the letdown reflex in the affected breast
  • Encourage the patient to wear a well-fitting bra
  • Administer prescribed antibiotics; teach patient about importance of taking prescribed antibiotics until all pills have been taken
  • Encourage patient to drink 2500-3000 mL of fluid per day

Affective Disorders

Postpartum mothers are at increased risk for mood disorders including postpartum blues, depression, and psychoses

Defined as a disturbance in thought processes, affect, and function

Postpartum blues

  • “Baby blues” is a mild depression that affects about 70-80% of mothers
  • The “baby blues” should not last longer than 2 weeks. The mother should contact her physician if the sad feelings last for longer than 2 weeks.
  • Mothers may experience insomnia, irritability, fatigue, anxiety, and mood instability
  • Must be distinguished from postpartum depression or postpartum psychoses

Postpartum Depression

Depression begins any time after childbirth and lasts at least 2 weeks

Signs/symptoms:

  • Persistent depressed mood
  • Loss of interest in normal activities
  • Unable to feel pleasure or love
  • Feels inept at being a mother
  • Anxiety
  • Loss of self
  • Generalized fatigue

Treatment:

Combination of psychotherapy, social support, and medication

SSRIs and tricyclic antidepressants

  • May take up to 4 weeks to see improvement

Electroconvulsive therapy may be needed for suicidal women

Postpartum Psychosis

Classified as depressed or manic

Psychiatric emergency that often requires hospitalization

Signs/symptoms:

  • Agitation
  • Irritability
  • Disorientation
  • Delusions or hallucinations

Treatment:

  • Hospitalization
  • Medications
  • Referral to specialist for psychiatric care

That wraps up this information. I hope it was useful to you.

Please feel free to reach out to me if you have any questions or just want to chat.

Happy Nursing!