Nursing Care of Women with Complications After Birth

Postpartum hemorrhage is traditionally defined as blood loss greater than 500 mL after vaginal birth or 1000 mL after cesarean birth, resulting in signs or symptoms of hypovolemia. Because the average-sized woman has 1 to 2 L of added blood volume from pregnancy, she can tolerate up to these amounts of blood loss better than would otherwise be expected.

Most cases of hemorrhage occur immediately after birth, but some are delayed up to several weeks. Early (primary) postpartum hemorrhage occurs within 24 hours of birth. Late postpartum hemorrhage occurs after 24 hours and within 6 weeks after birth.

The major risk of hemorrhage is hypovolemic (low-volume) shock, which interrupts blood flow to body cells. This prevents normal oxygenation, nutrient delivery, and waste removal at the cellular level. Although a less dramatic problem, anemia is likely to occur after hemorrhage. Postpartum hemorrhage is a leading cause of postpartum death around the world.

Hypovolemic Shock

Hypovolemic shock occurs when the volume of blood is depleted and cannot fill the circulatory system. The woman can die if blood loss does not stop and if the blood volume is not corrected.

Body’s Response to Hypovolemia

The body initially responds to a reduction in blood volume with increased heart and respiratory rates. These reactions increase the oxygen content of each erythrocyte (red blood cell) and cause faster circulation of the remaining blood. Tachycardia (a rapid heart rate) is usually the first sign of inadequate blood volume (hypovolemia). The first blood pressure change is a narrow pulse pressure (a falling systolic pressure and a rising diastolic pressure). The blood pressure continues falling and eventually cannot be detected.

Blood flow to nonessential organs gradually stops, to make more blood available for vital organs, specifically the heart and brain. This change causes the woman’s skin and mucous membranes to become pale, cold, and clammy (moist). As blood loss continues, flow to the brain decreases, resulting in mental changes, such as anxiety, confusion, restlessness, and lethargy. As blood flow to the kidneys decreases, they respond by conserving fluid. Urine output decreases and eventually stops.

Safety Alert!

Because postpartum women often have a slow pulse rate, the caregiver should suspect hypovolemic shock or infection if the pulse rate is greater than 100 beats/min.

Medical Management

Medical management of hypovolemic shock resulting from hemorrhage may include any of the following actions:

• Stopping the blood loss
• Giving intravenous (IV) fluids to maintain the circulating volume and to replace fluids
• Giving blood transfusions to replace lost erythrocytes
• Giving oxygen to increase the saturation of remaining blood cells; a pulse oximeter is used to assess oxygen saturation of the blood
• Placing an indwelling (Foley) catheter to assess urine output, which reflects kidney function
• Uterine massage and administration of drugs to contract the uterus (e.g., oxytocin)

Nursing Care

Routine postpartum care involves assessing vital signs every 15 minutes until stable so that the signs of postpartum hemorrhage are identified as early as possible. The woman should be observed closely for early signs of shock, such as tachycardia, pallor, cold and clammy hands, and decreased urine output. Decreased blood pressure may be a late sign of hypovolemic shock.

Routine frequent assessment of lochia in the fourth stage of labor helps identify early postpartum hemorrhage. When the amount and character of the lochia are normal and the uterus is firm, but signs of hypovolemia are still evident, the cause may be a large hematoma. Excessive bright red bleeding despite a firm fundus may indicate a cervical or vaginal laceration. The occurrence of petechiae, bleeding from venipuncture sites, or oliguria may indicate a blood clotting problem. In the first hours postpartum, the perineal pad should be weighed to determine the output amount: 1 g equals 1 mL (see Chapter 9). Intake and output should be recorded and IV therapy monitored. Oxygen saturation levels are also monitored in early postpartum hemorrhage.

Safety Alert!

Saturation of a perineal pad within 15 minutes to 1 hour after delivery must be promptly reported.

Careful explanations to the mother and family are essential, and providing emotional support and maintaining the integrity of the woman’s support system are key nursing roles. Even if the mother is separated from her infant, information concerning the infant’s condition should be readily accessible. Rooming-in should be established as soon as the woman’s condition permits.

Intensive care may be required to allow invasive hemodynamic monitoring of the woman’s circulatory status. Nursing Care Plan 10.1 specifies interventions for the woman at high risk for altered tissue perfusion related to hemorrhage.

Nursing Care Plan 10.1

The Woman with Postpartum Hemorrhage

Patient Data

A woman is admitted to the postpartum unit. She appears anxious and frightened, and her lochia has saturated three perineal pads in the past hour.

Selected Nursing Diagnosis

Risk for hypovolemic shock related to excessive blood loss

Goals	Nursing Interventions	Rationales
The woman’s blood pressure and pulse rate will be within 10% of her values when she was admitted.	Identify whether the woman has added risk factors for postpartum hemorrhage.	Women who have risk factors should be assessed more often than those who do not.
	Observe the following:
	• Fundus for height, firmness, and position	The fundus must be firm to compress bleeding vessels at the placenta site. Bladder distention interferes with uterine contraction and causes the fundus to be high and displaced to one side.
	• Lochia for color, quantity, and clots; count pads and degree of saturation (weigh pads for greater accuracy); check blood pressure, pulse rate, and respiratory rate per hospital protocol	Observing lochia provides an estimate of actual blood loss. A rising pulse rate is often the first sign of inadequate blood volume. A rising pulse rate and falling blood pressure reading also occur. Most blood lost after birth is visible rather than concealed.
	Observe for less obvious signs of bleeding: • Constant trickle of brighter red blood with a firm fundus • Severe, poorly relieved pain, especially if accompanied by changes in the vital signs or shock signs and symptoms	Most postpartum hemorrhage is caused by uterine atony, which often produces dramatic blood loss. However, blood loss from a laceration or hematoma can be significant, even though it is less obvious.
The woman will not have signs or symptoms of hypovolemic shock.	Observe for other signs and symptoms of hypovolemic shock.	Excessive blood loss can result in hypovolemic shock.
	If signs of hemorrhage are noted, take appropriate actions according to the probable cause of the hemorrhage: • Uterine atony: Massage uterus until firm—do not overmassage; expel blood from uterine cavity when uterus is firm; have breastfeeding woman nurse infant; notify registered nurse and/or health care provider for orders and medication if uterus does not become firm and stay firm. • Lacerations: Notify registered nurse and/or health care provider to examine woman. • Hematomas on the vulva: Place cold pack on the area.	Hemorrhage can cause the death of a new mother if not promptly corrected. Most minor episodes of uterine atony are easily corrected with fundal massage and infant suckling. If the uterus does not remain firm, the health care provider examines the woman to identify and correct the cause of bleeding. Oxytocin (Pitocin) infusions are often ordered to contract the uterus. Other drugs, such as methylergonovine (Methergine) or prostaglandin, may be needed. Excessive massage of the uterus can tire it, possibly resulting in inability to contract. Trauma, such as a laceration or hematoma, may necessitate repair by the health care provider. Small hematomas on the vulva can be limited by cold applications, because these applications reduce blood flow to the area; cold also numbs the area and makes the woman more comfortable.

Selected Nursing Diagnosis

Fear, related to unexpected complication

Goals	Nursing Interventions	Rationales
The woman will be able to cope with the unexpected complication.	Identify the woman’s reaction to the unexpected complication and correct misconceptions, exaggerations of fact, or myth.	Supplying factual information reduces fear. Identifying the reaction establishes a basis for intervention.
Anxiety will be at a manageable level.	Be calm and reassuring when in contact with the woman.	Anxiety can be transferred by voice or body language.
	Encourage the woman to verbalize her fears and perceptions.	This helps establish a basis for patient teaching and identification of fears.
	Stay with the woman and her partner.	Having a professional person present promotes a feeling of security.

Critical Thinking Question

1. A woman is admitted to the postpartum unit after delivery of an infant weighing 9 lb, 12 oz. She voids 600 mL. The fundus is difficult to locate, and lochia is heavy. What are the priority nursing actions?

Early (Primary) Postpartum Hemorrhage

Early postpartum hemorrhage results from one of three causes:

• Uterine atony (the most common cause)
• Lacerations (tears) of the reproductive tract
• Hematomas in the reproductive tract

Table 10.1 summarizes the types of early postpartum hemorrhage.

Table 10.1

Types of Early Postpartum Hemorrhage
Uterine atony	Lacerations	Hematoma
Characteristics
Soft, high uterine fundus that is difficult to feel through woman’s abdominal wall Heavy lochia, often with large clots or sometimes a persistent moderate flow Bladder distention that causes uterus to be high and usually displaces it to one side Possible signs of hypovolemic shock	Continuous trickle of blood that is brighter than normal lochia Fundus that is usually firm Onset of hypovolemic shock that may be gradual and easily overlooked	If visible, appears as blue or purplish mass on vulva Severe and poorly relieved pain and/or pressure in vulva, pelvis, or rectum Large amount of blood lost into tissues, which causes signs and symptoms of hypovolemic shock Lochia that is normal in amount and color
Contributing Factors
Bladder distention Abnormal or prolonged labor Overdistended uterus Multiparity (five or more births) Use of oxytocin during labor Medications that relax uterus Operative birth Low placental implantation	Rapid labor Use of instruments such as forceps or vacuum extractor during birth	Prolonged or rapid labor Large infant Use of forceps or vacuum extractor

Uterine Atony

Atony describes a lack of normal muscle tone. The postpartum uterus is a large, hollow organ with three layers of muscle. The middle layer includes interlacing figure-eight fibers. The uterine blood supply passes through this network of muscle fibers to supply the placenta.

After the placenta detaches, the uterus normally contracts and the muscle fibers compress bleeding vessels. If the uterus is atonic, however, these muscle fibers are flaccid and do not compress the vessels. Uterine atony allows the blood vessels at the placenta site to bleed freely and usually massively. Uterine overdistention, retained placental fragments, prolonged labor, or the use of drugs during labor that relax the uterus may cause atony.

Normal Postpartum Changes

After a full-term birth, the uterus should easily be felt through the abdominal wall as a firm mass about the size of a grapefruit. After the placenta is expelled, the fundus of the uterus is at the umbilicus level and then begins descending at a rate of about 1 finger’s width (1 cm) each day.

Lochia rubra should be dark red. The amount of lochia during the first few hours should be no more than one saturated perineal pad per hour. A few small clots may appear in the drainage, but large clots are not normal.

Nursing Tip

Perineal pads containing cold packs absorb less than regular perineal pads.

Nursing Tip

To best determine blood loss, weigh perineal pads before and after applying them: 1 g in weight equals about 1 mL in volume of blood lost.

Characteristics of Uterine Atony

When uterine atony occurs, the woman’s uterus is difficult to feel and, when found, feels boggy (soft). The fundal height is high, often above the umbilicus. If the bladder is full, the uterus is higher and pushed to one side rather than located in the midline of the abdomen (Fig. 10.1). The uterus may or may not be soft if the bladder is full. A full bladder interferes with the ability of the uterus to contract and, if not corrected, eventually leads to uterine atony.

Illustration of woman shows a curved line on the abdomen marked fundus and swelled bladder. — Fig. 10.1 A distended bladder pushes the uterus upward and usually to one side of the abdomen. The fundus may be boggy or firm. If not emptied, a distended bladder can result in uterine atony and hemorrhage because it interferes with normal contraction of the uterus. (From McKinney ES, James SR, Murray SS, et al: *Maternal-child nursing*, ed 5, St Louis, 2018, Saunders.)

Lochia is increased and may contain large clots. The bleeding may be dramatic but may also simply be slightly above normal for a long time. Some lochia will be retained in the relaxed uterus because the cavity is enlarged; thus the true amount of blood loss may not be immediately apparent. Collection of blood in the uterus further interferes with contraction and worsens uterine atony and postpartum hemorrhage. A woman who has risk factors for postpartum hemorrhage (see Table 10.1) should have more frequent postpartum assessments of the uterus, lochia, and vital signs.

Medical Management and Nursing Care

Care of the woman with uterine atony combines nursing and medical measures. When the uterus is boggy, it should be massaged until firm (see Chapter 9), but it should not be overly massaged. Because the uterus is a muscle, excessive stimulation to contract it will tire it and can actually worsen uterine atony. If the uterus is firmly contracted, it should be left alone.

Bladder distention is an easily corrected cause of uterine atony. The nurse should catheterize the woman if she cannot urinate on the toilet or in a bedpan. Pressing toward the vagina should expel any clots or blood pooled in the vagina after the uterus is firm. Most health care providers include an order for catheterization to prevent delaying this corrective measure. First the uterus is massaged to firmness, and then the bladder is emptied to keep the uterus firm.

The infant suckling at the breast stimulates the woman’s posterior pituitary gland to secrete oxytocin, which causes uterine contraction. A dilute oxytocin (Pitocin) IV infusion is the most common drug ordered to control uterine atony. Other drugs to increase uterine tone include methylergonovine (Methergine) and prostaglandins (e.g., Hemabate or Cytotec). Methylergonovine increases blood pressure and should not be given to a woman with hypertension. Excessive bleeding may also be managed by providing a uterine tamponade (packing), using an intrauterine balloon, selective arterial embolization, or surgical ligation of the artery. Intravenous calcium gluconate may be used to counteract a tocolytic drug that may have been administered to relax the uterus during labor.

The health care provider may examine the woman in the delivery or operating room to determine the source of her bleeding and to correct it. Rarely, a hysterectomy is needed to remove the bleeding uterus that does not respond to any other measures. The woman should have nothing by mouth (NPO) until her bleeding is controlled.

Safety Alert!

The woman who develops a hemorrhagic complication should be kept on NPO status until the health care provider evaluates her condition because she may need general anesthesia for correction of the problem.

Lacerations of the Reproductive Tract

Lacerations of the perineum, vagina, cervix, or area around the urethra (periurethral lacerations) can cause postpartum bleeding. The vascular beds are engorged during pregnancy, and bleeding can be profuse. Trauma is more likely to occur if the woman has a rapid labor or if forceps or a vacuum extractor is used. Blood lost in lacerations is usually a brighter red than lochia and flows in a continuous trickle. Typically, the uterus is firm.

Treatment

The health care provider should be notified if the woman has signs of a laceration, such as bleeding with a firmly contracted uterus. The injury is usually sutured in the delivery or operating room.

Nursing Care

Signs and symptoms of a bleeding laceration should be reported. A continuous trickle of blood can result in as much or more blood loss than the dramatic bleeding associated with uterine atony. The woman should be kept on NPO status until further orders are received, because she may need a general anesthetic for repair of the laceration. Genital trauma can cause long-term effects, such as cystocele, a prolapsed uterus, or urinary incontinence (Cooper & Gosnell, 2019).

Hematomas of the Reproductive Tract

A hematoma is a collection of blood within the tissues. Hematomas resulting from birth trauma are usually on the vulva or inside the vagina. They may be easily seen as a bulging bluish or purplish mass. Hematomas deep within the vagina are not visible from the outside.

Discomfort after childbirth is normally minimal and easily relieved with mild analgesics. The woman with a hematoma usually has severe, unrelenting pain that analgesics do not relieve. Depending on the amount of blood in the tissues, she also may describe pressure in the vulva, pelvis, or rectum. She may be unable to urinate because of the pressure.

The woman does not have unusual amounts of lochia, but she may develop signs of concealed blood loss if the hematoma is large. Her pulse and respiratory rates rise, and her blood pressure falls. She may develop other signs of hypovolemic shock if blood loss into the tissues is substantial. See Table 10.1 for risk factors for the development of a hematoma.

Treatment

Small hematomas usually resolve without treatment. Larger ones may require incision and drainage of the clots. The bleeding vessel is ligated or the area packed with a hemostatic material to stop the bleeding.

Nursing Care

An ice pack to the perineum is sufficient for most small perineal hematomas and requires no physician prescription. The nurse should observe for and report the classic symptom—excessive, poorly relieved pain. Signs of concealed blood loss accompanied by maternal complaints of severe pain, perineal or vaginal pressure, or inability to void should be reported. The woman is kept NPO until the health care provider examines her and prescribes treatment.

Medication to Support Clot Formation

In addition to the specific interventions for specific causes of postpartum hemorrhage, the medication tranexamic acid can be used to inhibit the breakup of clots that form; this supports the developing blood clot that is necessary to control hemorrhage. However, the drug must be administered within 3 hours of delivery (Francois and Foley, 2020).

Late Postpartum Hemorrhage

Late postpartum hemorrhage (bleeding that occurs 24 hours to 6 weeks after childbirth) usually occurs after discharge from the hospital and usually results from the following:

• Retention of placental fragments
• Subinvolution of the uterus

Placental fragments are more likely to be retained if the placenta does not separate cleanly from its implantation site after birth or if there is disruption of the placental scab. Clots form around these retained fragments and slough several days later, sometimes carrying the retained fragments with them. Retention of placental fragments is more likely to occur if the placenta is manually removed (removed by hand rather than being pushed away from the uterine wall spontaneously as the uterus contracts). These placental fragments are also more likely to exist if the placenta grows more deeply into the uterine muscle than is normal.

Treatment

Treatment consists of the administration of drugs such as oxytocin, methylergonovine, or prostaglandins (e.g., carboprost) to contract the uterus. Firm uterine contraction often expels the retained fragments, and no other treatment is needed. Ultrasonography may be used to identify remaining fragments. If bleeding continues, curettage (scraping or vacuuming of the inner surface of the uterus) is performed to remove small blood clots and placental fragments. This procedure is known as dilation and curettage (D&C) or dilation and evacuation (D&E). Antibiotics are prescribed if infection is suspected.

Nursing Care

The nurse should teach each postpartum woman what to expect about changes in the lochia (see Chapter 9). The woman should be instructed to report the following signs of late postpartum hemorrhage to her health care provider:

• Persistent bright red bleeding
• Return of red bleeding after it has changed to pinkish or white

If a late postpartum hemorrhage occurs, the nurse assists in implementing pharmacological and surgical treatment.

Subinvolution of the Uterus

Involution is the return of the uterus to its nonpregnant condition after birth. The muscles of the uterus contract and constrict the blood vessels at the placental site, stopping the bleeding. Normally the uterus descends at the rate of 1 cm (one finger’s width) per day and is no longer palpable by 12 days postpartum. The placental site heals by 6 weeks postpartum. Subinvolution is a slower than expected return of the uterus to its nonpregnant condition. Infection and retained fragments of the placenta are the most common causes. Typical signs of subinvolution include the following:

• Fundal height greater than expected for the amount of time since birth
• Persistence of lochia rubra or a slowed progression through the three phases
• Pelvic pain, heaviness, fatigue

Treatment

Medical treatment is selected to correct the cause of the subinvolution. It may include the following:

• Methylergonovine (Methergine) to maintain firm uterine contraction
• Antibiotics for infection
• Dilation of the cervix and curettage to remove fragments of the placenta from the uterine wall

Nursing Care

The mother will almost always have been discharged when subinvolution of the uterus occurs. All new mothers should be taught about the normal changes to expect so they can recognize a departure from the normal pattern. Women should report fever, persistent pain, persistent red lochia (or return of bleeding after it has changed), or foul-smelling vaginal discharge. The woman should be taught how to palpate the fundus and what normal changes to expect.

The woman may be admitted to the hospital on the gynecology unit. Nursing care involves assisting with medical therapy and providing analgesics and other comfort measures. Specific nursing care depends on whether the subinvolution results from infection or another cause.

Thromboembolic Disorders

A venous thrombosis is a blood clot within a vein. It occurs in 1 in 1500 pregnancies (Merriam and Pettker, 2020). The size of the clot can increase as circulating blood passes over it and deposits more platelets, fibrin, and cells. It often causes an inflammation of the vessel wall. The pregnant woman is at increased risk for venous thrombosis because of the venous stasis that can occur from compression of the blood vessels by the heavy uterus or by pressure behind the knees when the legs are placed in stirrup leg supports for episiotomy repair. Blood vessel injury during cesarean section can also cause a thrombus.

The levels of fibrinogen and other clotting factors normally increase during pregnancy, whereas levels of clot-dissolving factors (e.g., plasminogen activator and antithrombin III) are normally decreased, resulting in a state of hypercoagulability (an increased susceptibility to developing blood clots). If the woman has varicose veins or remains on bed rest, her state of hypercoagulability places her at increased risk for thrombus formation.

Preventive measures include the use of pneumatic compression devices on the lower extremities or prophylactic heparin for women undergoing cesarean sections or who are on prolonged bed rest (Merriam and Pettker, 2020).

There are three types of thromboembolic disorders:

1. Superficial venous thrombosis (SVT) involves the saphenous vein of the lower leg and is characterized by a painful, hard, reddened, warm vein that is easily seen.
2. Deep venous thrombosis (DVT) can involve veins from the feet to the femoral area and is characterized by pain, calf tenderness, leg edema, color changes, pain when walking, and sometimes a positive Homans’ sign (pain when the foot is dorsiflexed), although the Homans’ sign is not always reliable during the postpartum period because it is not specific to blood clots postpartum. An increase in leg circumference greater than 2 cm accompanied by redness, tenderness, and edema should be promptly reported. The diagnosis is confirmed by ultrasound, with or without Doppler assistance (Merriam and Pettker, 2020).
3. Pulmonary embolism (PE) occurs when the pulmonary artery is obstructed by a blood clot that breaks off (embolizes) and lodges in the lungs. It may have dramatic signs and symptoms, such as sudden chest pain, cough, dyspnea (difficulty breathing), a decreased level of consciousness, and signs of heart failure. A small PE may have nonspecific signs and symptoms, such as shortness of breath, palpitations, hemoptysis (bloody sputum), faintness, and a low-grade fever.

Treatment

SVT is treated with administration of analgesics, local application of heat, and elevation of the legs to promote venous drainage. DVT is treated similarly, with the addition of subcutaneous or IV anticoagulation drugs, such as heparin. Low-molecular-weight heparin (LMWH), such as Lovenox, may be used, because it is long acting and requires less frequent doses and lab testing. LMWH anticoagulants are contraindicated with regional anesthesia.

Medication Safety Alert!

The antidote for a warfarin overdose is vitamin K.

Nursing Care

The woman should be observed before and after birth for signs and symptoms that suggest venous thrombosis. Dyspnea, coughing, and chest pain suggest PE and must be reported immediately.

Prevention of thrombi is most important. Pregnant women should not cross their legs because this impedes venous blood flow. When the legs are elevated, there should not be sharp flexion at the groin or pressure in the popliteal space behind the knee, which would restrict venous flow. Measures to promote venous flow should be continued during and after birth because levels of clotting factors remain high for several weeks.

Early ambulation or range-of-motion exercises are valuable aids to preventing thrombus formation in the postpartum woman. Antiembolic stockings may be used if varicose veins are present. The nurse should teach the woman how to put on the stockings properly because rolling or kinking of the stocking can further impede blood flow. If stirrups are used during birth or episiotomy repair, they should be padded to prevent pressure at the popliteal angle.

The woman who will be undergoing anticoagulant therapy at home should be taught how to give herself the drug and about signs of excess anticoagulation (prolonged bleeding from minor injuries, bleeding gums, nosebleeds, unexplained bruising). She should use a soft toothbrush and avoid minor trauma that can cause prolonged bleeding or a large hematoma. Home nursing visits are often prescribed to obtain blood for laboratory clotting studies and to help the woman cope with therapy.

Infections

Puerperal Sepsis

Puerperal sepsis is an infection or septicemia after childbirth and is one of the five leading causes of maternal mortality in the United States (Hovert, 2021). Tissue trauma during labor, the open wound of the placental insertion site, surgical incisions, cracks in the nipples of the breasts, and the increased pH of the vagina after birth are all risk factors for the postpartum woman.

The fever is most often caused by endometritis, an inflammation of the inner lining of the uterus. Blockage of the lochial flow because of retained placenta or clots increases susceptibility to infection.

The danger of postpartum infection is that a localized infection of the perineum, vagina, or cervix can ascend the reproductive tract and spread to the uterus, fallopian tubes, and peritoneum, causing peritonitis, which is a life-threatening condition. Table 10.2 lists characteristics, medical treatment, and nursing care for these infections. Regardless of their location or the causative organism, postpartum infections have several common features.

Table 10.2

Postpartum Infections
Wound Infections	Endometritis (Uterus)	Urinary Tract Infections	Mastitis (Breast)
Characteristics
Signs of inflammation (redness, edema, heat, pain) Separation of suture line Purulent drainage	Tender, enlarged uterus Prolonged, severe cramping Foul-smelling lochia Fever and other systemic signs of infection Signs of uterine subinvolution	Cystitis (bladder) Low-grade fever Burning, urgency, and frequency of urination Pyelonephritis (kidneys) High fever with pattern of spikes Chills Pain in costovertebral angle or flank Nausea and vomiting	Reddened, tender, hot area of breast Edema and feeling of heaviness in breast Purulent drainage (may occur if an abscess forms)
Medical Management
Culture and sensitivity of wound exudate Antibiotics	Culture and sensitivity test of uterine cavity Antibiotics by intravenous (IV) route initially	Clean-catch or catheterized urine specimen for culture and sensitivity testing Antibiotics (initially by IV route for pyelonephritis)	Antibiotics (usually oral, although may be IV initially if woman has abscess) Incision and drainage of abscess
Nursing Care
Use aseptic or sterile technique for all wound care as indicated Teach proper perineal hygiene to reduce fecal contamination Use sitz baths for perineal wound infections	Teach woman usual progression of lochia because infection often occurs after discharge Use Fowler’s position to facilitate drainage of infected lochia Administer analgesics Observe for absent bowel sounds, abdominal distention, and nausea or vomiting, which suggest spread of infection	Teach perineal hygiene Encourage fluid intake of 3 L/day Teach which foods increase acidity of urine, such as apricots, cranberry juice, plums, and prunes	Teach effective breastfeeding techniques Encourage moist heat applications with warm pack Use warm shower before nursing to start milk flow Massage affected area to reduce congestion and start milk flow Encourage regular and frequent nursing or pumping to keep breasts empty

Manifestations

Puerperal (postpartum) fever is defined as a temperature of 38°C (100.4 °F) or higher after the first 24 hours and for at least 2 days during the first 10 days after birth. Slight temperature elevations with no other signs of infection often occur during the first 24 hours because of dehydration. The nurse should look for other signs of infection if the woman’s temperature is elevated, regardless of the time since delivery. A pulse rate that is higher than expected and an elevated temperature often occur when the woman has an infection. Other signs and symptoms of infection may be localized (in a small area of the body) or systemic (throughout the body).

The assessment of any cesarean section wound or episiotomy wound using the REEDA criteria (redness, edema, ecchymosis, discharge, approximation), or hardening of the operative area, should be promptly reported and documented. Fever, pain, a foul odor, or abnormal findings on routine postpartum assessment must be reported to the health care provider.

White blood cells (leukocytes) are normally elevated during the early postpartum period to about 20,000 to 30,000 cells/mm³, which limits the usefulness of the blood count to identify infection. Leukocyte counts in the upper limits are more likely to be associated with infection than lower counts.

Safety Alert!

Proper hand hygiene is the primary method to prevent the spread of infectious organisms. Gloves should be worn when in contact with any blood or body fluid or any other potentially infectious materials.

Treatment

The goals of medical treatment are to limit the spread of infection, to prevent it from reaching the blood and other organs, and to eliminate the infection. A culture and sensitivity sample from the suspected site of infection is taken to determine the antibiotics that will be most effective. IV antibiotics may be ordered, and the woman may be placed on bed rest.

Nursing Care

Nursing care objectives focus on preventing infection and, if an infection occurs, on facilitating medical treatment. To achieve these goals, the nurse should do the following:

• Use and teach hygienic measures to reduce the number of organisms that can cause infection (e.g., hand hygiene, perineal care).
• Promote adequate rest and nutrition for healing.
• Observe for signs of infection.
• Teach signs of infection that the woman should report after discharge.
• Teach the woman to take all of the antibiotics prescribed rather than stopping them after her symptoms are eliminated.
• Teach the woman how to apply perineal pads (front to back).

Women should be taught to wash their hands before and after performing self-care that may involve contact with secretions. The nurse should explore ways to help the woman get enough rest.

Ultimately, a woman’s own body must overcome infection and heal any wound. Nutrition is an essential component of her body’s defenses. The nurse, and sometimes a dietitian, should teach her about foods that are high in protein (meats, cheese, milk, legumes) and vitamin C (citrus fruits and juices, strawberries, cantaloupe), because these nutrients are especially important for healing. Foods high in iron, to correct anemia, include meats, enriched cereals and breads, and dark green, leafy vegetables.

Mastitis and Breastfeeding

Mastitis is an infection of the breast. It usually occurs about 2 or 3 weeks after giving birth (Fig. 10.2). Mastitis occurs when organisms from the skin or the infant’s mouth enter small cracks in the nipples or areolae. These cracks may be microscopic. Breast engorgement and inadequate emptying of milk are associated with mastitis. Mastitis often involves only one breast.

Close-up of breast shows inflammation of tissue and redness near areola. — Fig. 10.2 Mastitis typically occurs several weeks after birth in the woman who is breastfeeding. Bacteria usually enter the breast through small cracks in the nipples. Breast engorgement and milk stasis increase the risk for mastitis. (From Swartz MH: *Textbook of physical diagnosis: history and examination*, ed 8, Philadelphia, 2021, Saunders.)

Signs and symptoms of mastitis include the following:

• Redness and heat in the breast
• Tenderness
• Edema and a heaviness in the breast
• Purulent drainage (may or may not be present)

The woman usually has fever, chills, and other systemic signs and symptoms. If not treated, the infected area becomes encapsulated (walled off) and an abscess forms. The infection is usually outside the ducts of the breast, and the milk is not contaminated.

Treatment

Antibiotics and the continued removal of milk from the breast are the primary treatments for mastitis. Mild analgesics make the woman more comfortable. The woman may need an incision and drainage of the infected area and IV antibiotics if an abscess forms. The mother can usually continue to breastfeed. If she should stop nursing for any reason, she should pump her breasts. She should not wean her infant when she has mastitis because weaning leads to engorgement and stasis of milk, which worsens the mastitis.

Nursing Care

The nursing mother should be taught proper breastfeeding techniques to reduce the risk for mastitis (see Chapter 9). Nursing care for mastitis centers on relieving pain and on maintaining lactation. Heat promotes blood flow to the area, comfort, and complete emptying of the breast. Moist heat can be applied with chemical packs. Placing a warm, wet cloth in a plastic bag and applying it to the breasts can create an inexpensive warm pack. A warm shower taken just before nursing provides warmth and cleanliness and stimulates the flow of milk.

Both breasts should be emptied regularly to reduce milk stasis, which increases the risk for abscess formation. If the affected breast is too painful for the mother to breastfeed, she can use a breast pump to empty it. She can massage the area of inflammation to improve milk flow and reduce stasis. Nursing first on the unaffected side starts the milk flow in both breasts and can improve emptying with less pain. Other nursing measures include the following:

• Encouraging fluid intake
• Advising the woman to wear a good support bra to support the breasts and to limit movement of the painful breast; the bra should not be too tight or it will cause milk stasis
• Supporting the woman emotionally and reassuring her that she can continue to breastfeed

Mood Disorders

A mood is a pervasive and sustained emotion that can color one’s view of life. “Postpartum blues” or “baby blues” is common after birth. The woman has periods when she feels let down, but overall she finds pleasure in life and in her new role as a mother. Her rollercoaster emotions are usually self-limiting as she adapts to the changes in her life.

A psychosis involves serious impairment of one’s perception of reality. Postpartum depression and postpartum psychosis are disorders that are more serious than “postpartum blues.” Postpartum blues, also known as an adjustment reaction, occurs in about 70% of women, appearing on day 5 and disappearing by day 10 (Isley, 2020). After childbirth, estrogen and progesterone levels decrease rapidly, which leads to increased brain levels of monoamine oxidase-A (MAO-A), which is related to the onset of postpartum depression. The presence of a thyroid disorder often presents with symptoms of postpartum dysphoria, and referral for follow-up care is indicated. Research has shown that it is possible a nutritional supplement of tryptophan, tyrosine, and blueberry juice counters the effects of increased MAO-A levels and may prevent the development of postpartum depression (Dawlati et al., 2017). Research is ongoing.

Postpartum Depression

According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), which is published by the American Psychiatric Association, there are three types of postpartum depression:

• Adjustment disorder, also called the baby blues
• Postpartum mood disorders
• Postpartum depression

Postpartum depression is a depressive illness that is usually manifested within 2 to 4 weeks after delivery. The onset of depression during this time may interfere with the mother’s ability to respond to her infant’s cues and interferes with the developing maternal-infant bonding. Formal postpartum screening for depression is not standard practice in the United States, which places the responsibility on the nurse to detect and refer problems to prevent progression to chronic depression. The nurse can promote the behaviors that improve mental health. Risk factors for postpartum depression include inadequate social support, a poor relationship with the partner, life and childcare stress, low self-esteem, and an unplanned pregnancy. Those having close contact with the woman notice the depression. Signs and symptoms may include the following:

• Lack of enjoyment in life
• Disinterest in others; loss of normal give-and-take in relationships
• Intense feelings of inadequacy, unworthiness, guilt, inability to cope
• Loss of mental concentration; inability to make decisions
• Disturbed sleep or appetite
• Constant fatigue and feelings of ill health

Postpartum depression strains the coping mechanisms of the entire family at a time when all are adapting to the birth of a child. As a result of the strained relationships, communication is often impaired, and the depressed woman may withdraw further, which distances her even further from her support system. The woman usually remains in touch with reality. The nurse should observe for signs and symptoms during clinic visits.

Nursing Tip

If a postpartum woman seems depressed, the nurse should not assume that she has the common “baby blues” or that she will “snap out of it.” Explore her feelings to determine whether they are persistent and pervasive.

Treatment

A combination of psychotherapy and antidepressants is often the course of therapy, either in an outpatient or inpatient setting. Screening tools are available. The nurse provides support and observation of behavior and is alert to the possibility of self-harm by the woman. Light therapy (phototherapy) and exercise are complementary and alternative medicine (CAM) treatment strategies that may help in the management of postpartum depression (see Chapter 34 for other types of CAM therapy). The influence of hormones on mood changes before, during, and after menstruation supports the theory that fluctuating hormone levels postpartum may also have an effect on the woman’s mood. Referral for follow-up to available community mental health support services and facilities is a nursing responsibility, to assure ongoing care and support. Counseling should include the woman’s partner and family.

Postpartum Psychosis

Women experiencing a postpartum psychosis have an impaired sense of reality. Psychosis is much less common than postpartum depression. A woman may have any psychiatric disorder, but two are most often encountered:

• Bipolar disorder: a disorder characterized by episodes of mania (hyperactivity, excitability, euphoria, and a feeling of being invulnerable) and depression
• Major depression: a disorder characterized by deep feelings of worthlessness and guilt, serious sleep and appetite disturbances, and sometimes delusions about the infant being dead

Postpartum psychosis can be fatal for both mother and infant. The mother may endanger herself and her infant during manic episodes because she uses poor judgment and has a sense of being invulnerable. Suicide and infanticide are possible, especially during depressive episodes.

In some cases, social workers within the community may refer the woman for counseling. In other cases, an inpatient psychiatric treatment center is the appropriate environment for treatment.

The Homeless Mother and Newborn

Homelessness is defined as a lack of a permanent home and is not limited to women who must live on the street. Some women live in single-room hotels, and others stay with friends or extended family. Homeless women often have difficulty accessing care, receive care from different health care providers at different sites, and have incomplete medical records. Follow-up is difficult. Before a mother is discharged with her newborn infant, it is essential to determine that she has a place to go and has a way of accessing help for herself or her newborn. The nurse can be a key link in facilitating referrals to outreach programs, support services, counseling, shelters, and follow-up medical care.

Unfolding Case Study

Tess and Luis were introduced to the reader in Chapter 4, and Tess’s pregnancy experience has unfolded in each chapter. Tess has delivered twins and has transferred to the postpartum unit with one twin infant, while her husband, Luis, stays with the other twin infant in the NICU.

Tess has been resting in the postpartum unit for 4 hours with the infant at her bedside. She states that she is worried that her lochia is heavy and still red, and she believes she may be bleeding too heavily. She has not ambulated at all, because she says she is too tired.

Questions

1. What factors during delivery may contribute to postpartum hemorrhage for Tess?
2. What assessments would the nurse make to determine whether her lochia is excessive?
3. Because Tess has not yet ambulated to the bathroom, what safety precautions need to be initiated for her?
4. What safety precautions need to be initiated for the baby?
5. What teaching would the nurse offer?

Get Ready for the Next-Generation NCLEX® Examination!

Key Points

• The nurse must be aware of women who are at higher risk for postpartum hemorrhage and assess them more often.
• A constant small trickle of blood can result in significant blood loss, as can a larger one-time hemorrhage.
• Pain that is persistent and more severe than expected is characteristic of a hematoma in the reproductive tract.
• It is essential to identify and limit a local infection before it spreads to the blood or other organs.
• The nurse should teach new mothers about normal postpartum changes and indications of problems that should be reported.
• Early ambulation can prevent thrombosis formation.
• Types of obstetric shock include cardiogenic (from anemia or cardiac disorders), hypovolemic (from hemorrhage), anaphylactic (from a drug response), and septic (caused by puerperal infection).
• Careful listening and observation can help the nurse identify a new mother who is suffering from postpartum depression.
• Postpartum psychoses are serious disorders that are potentially life-threatening to the woman and others, including her infant.

Additional Learning Resources

Go to your Study Guide for additional learning activities to help you master this chapter content.

Go to your Evolve website (http://evolve.elsevier.com/Leifer) for the following learning resources:

• Animations
• Answer Guidelines for Critical Thinking Questions
• Answers and Rationales for Review Questions for the NCLEX® Examination
• Glossary with English and Spanish pronunciations
• Interactive Review Questions for the NCLEX® Examination
• Patient Teaching Plans in English and Spanish
• Skills Performance Checklists
• Video clips and more!

Online Resources

Clinical Judgment and Next-Generation NCLEX® Examination-Style Questions

1. During the postpartum period the white blood cell (leukocyte) count is normally:
2. A woman delivered her newborn several hours previously, and her uterus remains soft and boggy. Which of the following should the nurse anticipate that the health care provider would prescribe to increase uterine tone and firm the uterus? (Select all that apply.)

3. Identify the possible postpartum complications that may be indicated by the nursing observations listed.

Observation	Complication
1. Blood loss of 800 mL after vaginal birth	Hypovolemic shock
2. Tachycardia and narrow pulse pressure	Subinvolution of the uterus
3. Persistence of lochia rubra at 4 weeks postpartum	Puerperal sepsis
4. Sudden chest pain and dyspnea	Hemorrhage
5. Foul-smelling lochia and fever	Mood disorders
6. Prolonged bouts of crying and refusal to hold the baby	Thromboembolic disorders

4. Place an X in the appropriate column to identify the following characteristics as evidence of either uterine atony, laceration, or hematoma.

Characteristic	Uterine Atony	Laceration	Hematoma
Heavy lochia with large clots
Purplish mass on vulva
Pain and pressure in rectum
Continuous trickle of bright blood
Bladder distention
Soft, high fundus

5. A postpartum mother who is breastfeeding has developed mastitis. She states that she does not think it is good for her infant to drink milk from her infected breast. Which of the following would be appropriate responses from the nurse? (Select all that apply.)
6. Complete the nursing actions from the choices below to fill in each blank in the following sentence.

A 29-year-old multipara has vaginally delivered her second child 60 minutes ago. Breastfeeding was initiated in delivery room. The placenta was delivered spontaneously and intact. At 60 minutes postdelivery, the patient’s uterus is palpated at one fingerbreadth below the umbilicus and is “boggy.” Pad saturation was estimated to be between 10 to 15 mL of bloody lochia. Vital signs all within normal limits. The diagnosis of uterine atony is made by the attending obstetrician.
Considering the diagnosis and patient condition, the nurse should expect the prioritizing of ___________ and then ___________.
Nursing actions
Uterine massage
Breastfeeding
Facilitating patient urination
Administering methylergonovine