Section III. COMPLICATIONS OF POSTPARTUM 6-12.

POSTPARTAL HEMORRHAGE Postpartal hemorrhage is the postpartum loss of blood totaling 500 ml or more within a twentyfour hour period. After bladder distention is ruled out, the three main causes of postpartal hemorrhage are uterine atony, lacerations, and retained placental fragments in the uterus. a. Uterine Atony. This is the inability of the myometrium to contract and constrict the blood vessels within the muscle fibers, resulting in open sinuses at the site of placental separation. Decreased muscle tone causes slow, insidious loss of blood. (1) Factors usually leading to uterine atony. (a) Conditions which result on overextension of uterine musculature (multiple pregnancy - two or more fetuses and hydramnios - excessive amniotic fluid). (b) Conditions resulting in exhaustion of the uterine musculature are large fetuses, prolonged or difficult labor, Pitocin induced or augmented labor (this may result in decreased response to postpartal administration of pitocin) and precipitous or forceful delivery. (2) Situations resulting in drug related relaxation of uterine musculature are the use of MgSO4 for preeclampsia and the use of general anesthesia for cesarean delivery. Conditions resulting in abnormal bleeding or uterine tissue damage are cesarean section, placenta previa, abruptio placenta, uterine rupture, and retained placental fragments. (3) Signs and symptoms of uterine atony. (a) Signs of shock--decreased blood pressure, increased pulse, and increased and anxiety and irritability. (b) Bleeding-usually dark with clots present. (c) Noncontracted, boggy uterine fundus. (4) Medical treatment. (a) Intervenously fluids administered to increase fluid and blood volume. (b) Oxytocin administration. (c) Methergine/prostin may be administered to stimulate uterine contractions when oxytocin is ineffective. (d) Blood transfusion if the patient's hematocrit drops too low and/or if she is symptomatic. (5) Nursing interventions. (a) Palpate the fundus frequently to determine continued muscle tone. (b) Massage the fundus, if boggy, until firm (do not over massage, this fatigues the muscle).

(c) Monitor patient's vital signs every 15 minutes until stable. (d) Prevent bladder distention. Bladder distention displaces the uterus and prevents effective uterine contractions. b. Lacerations. (1) Common sites. Sites of lacerations are the vaginal side wall, the cervix, the lower uterine segment, and the perineum. (2) Degrees of perineal lacerations. (a) First degree-tear of the vaginal and perineal mucous membranes. (b) Second degree-tear of the vaginal and perineal mucous membrane and the perineal muscles. (c) Third degree-tear of the vaginal and perineal mucous membrane, the perineal muscles, and the capsule of the rectal sphincter. (d) Fourth degree-tear of the vaginal and perineal mucous membrane, the perineal muscles, and through the rectal sphincter and anterior wall of the rectum. (3) Possible causes. (a) Rapid descent of the fetus. (b) Pushing prior to complete cervical effacement and dilatation. (c) Large fetus. (d) Forceps application. (e) Uncontrolled, forceful extension of the fetal head. (4) Signs and symptoms. (a) Obvious body injury after delivery of the infant--if perineal laceration. (b) Bright red bleeding despite a well toned fundus-if vaginal or cervical laceration and not detected at time of delivery. (c) Signs of shock-rapid, thready pulse, falling blood pressure, increasing anxiety of the patient. (5) Medical treatment. (a) Suturing of the laceration. (b) Vaginal packing. (c) Blood transfusions if the patient's hematocrit is low and the patient is symptomatic.

(6) Nursing interventions. (a) Observe closely for continued vaginal bleeding. (b) Monitor the patient's vital signs. (c) Flag the patient's chart for vaginal packing in place. This is helpful to the nurse who is checking for vaginal bleeding doesn't mistake a lack of obvious signs of blood for no bleeding. The vaginal packing could "hide" a hemorrhagic episode of bleeding. c. Retained Placental Fragments in the Uterus. These fragments are the major cause of late postpartum hemorrhage. (1) Signs and symptoms. (a) Large amount of bright red bleeding or persistent trickle type bleeding. (b) Uterus may be boggy due to its inability to contract properly. (c) Signs of shock. (d) Sudden rise in uterine fundal height indicating the formation of clots inside the uterine cavity. (2) Medical treatment. (a) Manual removal of the remaining placenta is done by the physician, if it is a result of incomplete separations of the placenta with increased vaginal bleeding. (b) A D&C is performed, if it is retained fragments. (c) Intravenous fluids are administered. (d) Oxytocic drugs are given immediately after either procedure. (3) Nursing interventions. (a) Check the uterine fundus tone frequently (every 15 minutes the first hour, then every 30 minutes for 2 hours, and every hour until stable). (b) Check the nature and amount of lochia flow (every 15 minutes the first hour, then every 30 minutes for 2 hours, and every hour until stable). (c) Keep accurate count of perineal pads used. (d) Monitor the patient's vital signs and blood pressure every 15 minutes or more frequently as necessary. (e) Observe for signs of shock. (f) Turn the patient on her side to prevent pooling of blood under her.

(g) Provide emotional support to the patient and family. 6-13. HEMATOMAS Vulvar hematoma is a localized collection of blood in the connective tissue beneath the skin covering the external genitalia or vaginal mucosa. It generally forms as a result of injury to the perineal blood vessels during the delivery process. a. Causes of Hematomas. (1) Rapid, spontaneous delivery. (2) Perineal varicosities. (3) Episiotomy repairs. (4) Laceration of perineal tissues. b. Signs and Symptoms. (1) Severe, sharp perineal pain. (2) Appearance of a tense, sensitive mass of varying size covered by discolored skin. (3) Swelling in the perineal wall. (4) Often seen on the opposite side of the episiotomy. (5) Inability to void due to pressure/edema on or around the urethra. (6) Complaint of fullness or pressure in the vagina. c. Medical Treatment. This is consists of analgesics given for discomfort, opening the hematoma so blood clots can be evacuated and the bleeders can be ligated, and packing for pressure. d. Nursing Interventions. (1) Apply ice to area of hematoma. (2) Observe for evidence of enlarged hematoma. (3) Flag the patient's chart if packing was inserted. 6-14. UTERINE SUBINVOLUTION Uterine subinvolution is a slowing of the process of involution or shrinking of the uterus. a. Causes. Endometritis, retained placental fragments, pelvic infection, and uterine fibroids may cause uterine subinvolution. b. Signs and Symptoms.

(1) Prolonged lochial flow. (2) Profuse vaginal bleeding. (3) Large, flabby uterus. c. Medical Treatment. (1) Administration of oxytocic medication to improve uterine muscle tone. Oxytocic medication includes (a) Methergine-a drug of choice since it can be given by mouth. (b) Pitocin. (c) Ergotrate. (2) Dilation and curettage (D&C) to remove any placental fragments. (3) Antimicrobial therapy for endometritis. d. Nursing Interventions. (1) Early ambulation postpartum. (2) Daily evaluation of fundal height to document involution. 6-15. PUERPERAL INFECTION Puerperal infection is a term used to describe any infection of the reproductive tract during the first six weeks of postpartum.

a. Pathology. When the third stage of labor is completed, the placental attachment site is raw, elevated, and dark red. The surface is nodular, owing to the numerous veins, and offers an excellent portal of entry for microorganisms. The uterine decidua is very thin and has many small openings that offer a portal for pathogens. In addition, small cervical, vaginal and perineal lacerations, as well as the episiotomy site, provide entry ports for pathogens. The resultant inflammation and infection can remain localized or can extend via blood or lymph vessels to other tissues. b. Organisms. Those organisms recognized as the common causative agents are normally seen in the lower bowel and lower genital tract. (1) Anaerobic staphylococci. (2) Anaerobic streptococci. (3) Clostridium perfringens.

(4) Neisseria gonorrhea. c. Predisposing Factors. (1) Prolonged rupture of uterine membranes provides increased opportunity for infection to develop prior to delivery. (2) Retained placental fragments-provides additional medium for infectious growth. (3) Postpartal hemorrhage-causes decreased resistance to pathogens. (4) Preexisting anemia-low resistance to infection. (5) A prolonged and difficult labor, especially with the involvement of instruments (forceps). (6) Intrauterine manipulations for fetal delivery or manual expulsion of placenta. d. Spread of Infectious Microorganisms. This may be the result of the spread of infectious microorganisms in the hospital setting. e. Means to Prevent the Spread of Puerperal Infection in Hospitals. (1) Restrict personnel with respiratory infections from working with patients. (2) Use caps, mask, gowns, and gloves when working in delivery rooms. (3) Use sterilized equipment within control dates. (4) Wash hands meticulously (staff). (5) Correct breaks in sterile techniques immediately. (6) Instruct the patient on hand washing and cleansing her perineum from front to back. (7) Limit unnecessary vaginal exams during labor which increases the chances of introducing organisms from the rectum and vagina into the uterus.