Postpartum Adaptation & Complications of Postpartum

Week 6

What is Tranexamic acid used for in PP?

Tranexamic acid is used in postpartum care to reduce excessive bleeding by inhibiting fibrinolysis, thus helping to stabilize blood clots.

what vitals suggest pre-eclampsia?

Increased BP, constant headache, and visual disturbances such as spots or flashing lights.

What manifestations suggest hemorrhage?

• Decreased blood pressure,

• Increased heart rate,

• tachypnea

• Pale, cool, and clammy skin,

• delayed capillary refill,

• dizziness, restlessness,

• >500 vag birth, >1000 c section

• decreased urine output.

What can you have the patient do to prevent the uterus being over distended?

Urinate. A full bladder can contribute to PPH from the uterus being over-distended.

What can places patient at risk for PPH?

• Prolonged labor

• Infection (chorioamnionitis)

• Uterine overdistention

How can we prevent possible PP neropathy?

Changing positions frequently

How do you determine whether a patient is experiencing a spinal headache vs preeclampsia?

Spinal headaches typically occur after a spinal anesthesia or epidural, characterized by a severe headache that worsens when sitting or standing.

In contrast, preeclampsia presents with high blood pressure and symptoms like visual changes or abdominal pain.

What are “after pains” characterized as?

"After pains" are characterized as uterine contractions that occur post-delivery as the uterus shrinks back to its pre-pregnancy size, often leading to discomfort or cramping. These contractions can be more intense during breastfeeding due to the release of oxytocin, which stimulates uterine activity.

Why does insulin decrease PP?

HgL is no longer being produced.

What cardiovascular changes occur immediately postpartum?

↑ Cardiac output, ↑ stroke volume, ↑ heart rate initially; returns toward baseline within hours to weeks.

What postpartum cardiovascular finding requires evaluation?

Blood pressure that does not return toward baseline or significant deviations from expected values.

What fluid shift changes are expected postpartum?

• Orthostatic hypotension is common

• Change positions slowly

• Diaphoresis and diuresis help eliminate excess pregnancy fluid

• Postpartum shaking/chills can occur and are usually normal

What hematologic changes occur immediately postpartum?

• Blood volume rapidly decreases.

• Hemodilution temporarily lowers Hgb/Hct.

• WBC count may increase to 25,000/mm³ due to labor stress (normal finding).

Why is the WBC count elevated after delivery?

It is an expected physiologic response to labor stress, not necessarily infection.

How long do fibrinogen and clotting factors remain elevated postpartum?

They remain elevated for several weeks postpartum, increasing the risk for venous thromboembolism (DVT/VTE).

Which postpartum hematologic findings require nursing intervention?

• Signs of postpartum hemorrhage

• Symptoms of DVT (unilateral leg pain, warmth, redness, swelling)

• Abnormal or persistent decreases in Hgb/Hct with excessive bleeding

What respiratory complication is postpartum clients at increased risk for?

Pulmonary edema due to fluid shifts and preeclampsia; assess for dyspnea, crackles, decreased oxygen saturation, and increased work of breathing.

What respiratory assessment finding requires immediate attention postpartum?

Respiratory rate <12 breaths/min, especially in a client receiving magnesium sulfate, because it may indicate respiratory depression.

What respiratory change occurs after birth?

The diaphragm descends after delivery, allowing lung expansion to improve and respiratory rate to return toward baseline.

How can postpartum constipation be prevented?

• Increase hydration

• Eat a high-fiber diet

• Use stool softeners or laxatives as prescribed

• Encourage early ambulation

What is OASIS?

Obstetric Anal Sphincter Injury (OASIS) is a severe perineal laceration involving the anal sphincter that increases the risk of anal incontinence.

What rectal medications should be avoided postpartum?

Do not administer enemas, harsh suppositories, or rectal medications to clients with 3rd- or 4th-degree perineal lacerations.

When does postpartum diuresis begin, and how much urine output is expected?

• Begins within hours after birth

• Urine output can reach up to 3,000 mL/day

What causes postpartum diuresis?

The drop in estrogen and postpartum fluid shifts promote increased urine output.

Why are postpartum clients at risk for urinary retention?

Decreased bladder sensation after birth or epidural anesthesia increases the risk of urinary retention.

Why does a full bladder increase the risk of postpartum hemorrhage?

A full bladder displaces the uterus, preventing effective uterine contraction (uterine atony), which increases the risk of postpartum hemorrhage.

When should a postpartum client have their first void?

Within 6 hours after delivery or catheter removal.

What teaching should be provided for postpartum urinary incontinence?

Encourage Kegel exercises to strengthen the pelvic floor. Some clients may require pelvic floor physical therapy.

What nursing intervention should be performed if a postpartum client has a boggy uterus?

Assess whether the bladder is full. Assist the client to void or catheterize if needed, then reassess uterine tone because a distended bladder can contribute to uterine atony and postpartum hemorrhage.

How much urine should a postpartum client void each time?

Each void should be at least 150 mL.

What nursing intervention should be performed before catheterizing a postpartum client with urinary retention?

Encourage the client to attempt noninvasive measures first (ambulation, privacy, running water, warm water over the perineum). If unsuccessful, catheterization may be necessary.

What is colostrum?

The first breast milk produced during the first 3 days postpartum that is rich in IgA and IgG, high in protein, and low in carbohydrates.

When does primary breast engorgement typically occur?

Approximately 72 hours postpartum.This condition is characterized by increased blood flow and lymphatic fluid accumulation, leading to swollen breasts.

What factors influence breast milk supply?

Milk production is influenced by hormones and frequent breast stimulation/emptying.

What teaching promotes successful breastfeeding?

• Deep latch

• Feed based on infant feeding cues

  • Empty the breasts frequently

What are the expected breast changes during the first 3 postpartum days?

• First 24 hours: Soft and nontender

• Postpartum day 2: Slightly firm/full but nontender

  • Postpartum day 3: Filling or firm, tender, and warm to the touch

What is primary breast engorgement?

Primary engorgement occurs during the first 72 hours postpartum as milk production begins. It is hormonally (endocrine) controlled.

What is secondary breast engorgement?

Secondary engorgement occurs when milk production exceeds infant intake or milk is not removed adequately from the brea

What are the signs of mastitis?

• Unilateral breast redness

• Firm, painful area of the breast

  • Fever, chills, and fatigue may occur

What findings suggest an improper breastfeeding latch?

• Nipple redness

• Pain or tenderness

  • Cracked nipples

What are the characteristics of a proper breastfeeding latch?

• Baby's mouth opens wide (~140° angle)

• Lips are flanged outward

• Ears, shoulders, and hips are aligned

• Cheeks are rounded

• Nose touches the breast

How often should a breastfeeding client nurse?

Breastfeed on demand, approximately 8–12 times per 24 hours.

What should be used to relieve breast engorgement in a lactating client?

Use warm compresses before breastfeeding to promote milk flow and relieve engorgement.

What should be used to relieve breast engorgement in a non-lactating client?

Use cold compresses or cabbage leaves to decrease pain, swelling, and milk production.

What teaching should be provided to a client who is not breastfeeding?

• Avoid nipple stimulation

• Wear a supportive bra continuously for the first 72 hours

• Use cold compresses as needed

  • Take pain medication if prescribed

What should a breastfeeding client do for sore nipples?

Apply expressed colostrum or breast milk, lanolin cream, or hydrogel pads after feeding.

Why should underwire bras be avoided while breastfeeding?

Underwire bras can compress breast tissue, impede milk flow, and increase the risk of plugged ducts or mastitis

What is uterine involution?

The uterus returns to its prepregnancy size, shape, and location after childbirth.

Where should the fundus be immediately after delivery?

The fundus should be at or near the umbilicus within 1–2 hours postpartum.

How quickly should the postpartum fundus descend?

The fundus descends approximately 1 cm (1 fingerbreadth) per day.

When should the uterus no longer be palpable abdominally?

Definition

The uterus should no longer be palpable abdominally by approximately 2 weeks postpartum, as it has typically returned to the pelvis.

Which medications may be administered for uterine atony or postpartum hemorrhage?

• Oxytocin (Pitocin)

• Misoprostol (Cytotec)

• Methylergonovine (Methergine)

  • Carboprost (Hemabate)

What is the normal progression of lochia?

Rubra → Serosa → Alba

Lochia should only progress in this order.

What is lochia rubra?

• Birth through postpartum day 3

• Dark red blood

• Small clots may be present

  • Fleshy odor

What is lochia serosa?

• Postpartum days 4–10

• Pink or brown

• Small clots may be present

• Fleshy odor

---

What is lochia alba?

• Day 10 through about 6 weeks postpartum

• Yellow-white discharge

• No blood or clots

  • Little to no odor

When should the MMR vaccine be given postpartum?

Administer postpartum if the client is nonimmune because MMR is contraindicated during pregnancy.

How long should a client wait to become pregnant after receiving the MMR vaccine?

Wait at least 28 days before becoming pregnant.

How is the varicella vaccine administered postpartum?

If the client is nonimmune:

• Give the first dose before discharge

  • Give the second dose 4–8 weeks later

When should Tdap be administered postpartum?

Administer postpartum if it was not received during pregnancy.

Who should receive the Tdap vaccine to protect a newborn?

Anyone in close contact with the newborn should be up to date on Tdap vaccination.

Who should receive Rho(D) immune globulin (RhoGAM)?

An Rh-negative client carrying an Rh-positive fetus/newborn.

When is Rho(D) immune globulin (RhoGAM) administered?

• Around 28 weeks' gestation

  • Again within 72 hours postpartum if the newborn is Rh-positive

What is the first step in initiating breastfeeding?

Begin with skin-to-skin contact immediately after birth.

What are the early feeding cues of a newborn?

• Rooting

• Mouth movements

• Lip smacking

• Hand-to-mouth movements

Crying is a late feeding cue.

What blood loss defines postpartum hemorrhage (PPH)

• ≥500 mL after a vaginal birth

• ≥1,000 mL after a cesarean birth

  • OR any blood loss accompanied by signs of hypovolemia`

What are the Four Ts that cause postpartum hemorrhage?

• Tone – uterine atony (most common)

• Trauma – lacerations, hematomas, uterine inversion/rupture

• Tissue – retained placental fragments

  • Thrombin – coagulation disorders

What causes secondary postpartum hemorrhage?

• Subinvolution of the uterus

• Retained placental tissue

• Hematomas

What are the signs of secondary postpartum hemorrhage?

• Excessive vaginal bleeding

• Delayed uterine involution

  • Return to bright red bleeding after lochia has lightened

What is the priority nursing intervention for postpartum hemorrhage caused by uterine atony?

Massage the fundus immediately while calling for assistance and preparing uterotonic medications.

What assessment findings suggest postpartum hemorrhage caused by genital tract lacerations?

• Firm, midline uterus

• Heavy, steady bright red bleeding

• Tachycardia

• Hypotension

• Pain

• Few or no clots

What assessment findings suggest a postpartum hematoma?

• Severe localized perineal pain

• Unilateral swelling

• Visible vulvar mass

• Intermittent bleeding

• Difficulty voiding or urinary retention

How are small postpartum hematomas managed?

• Ice packs

• Compression

• Bed rest

• Analgesics

• Monitor and educate the client on self-care

What assessment findings suggest retained placental tissue?

• Delayed uterine involution (subinvolution)

• Excessive postpartum bleeding (hemorrhage)

• Return of lochia rubra after it has progressed

• Signs of hypovolemia if bleeding is severe

---

How is retained placental tissue managed?

• Dilation and curettage (D&C) to remove retained tissue

  • Treat infection if present

What is disseminated intravascular coagulation (DIC)?

A life-threatening disorder in which widespread clotting consumes clotting factors and platelets, leading to severe bleeding.

Which laboratory findings are commonly associated with coagulation disorders?

• ↓ Platelets

• Prolonged PT/INR and aPTT

  • ↓ Fibrinogen (especially in DIC)

What are the early signs of postpartum shock?

• Pallor

• Delayed capillary refill

• Restlessness

• Thirst

• Decreased urine output

  • Tachycardia``

What is the shock index (SI), and how is it calculated?

Shock Index = Heart Rate ÷ Systolic Blood Pressure (HR ÷ SBP)

How is the shock index interpreted?

• >0.9 = Concerning

• >1.1 = Likely needs blood products

• >1.3 = Critical

What are the priority nursing interventions for postpartum shock?

• Call for help and activate the hemorrhage response

• Assess fundal tone and massage if boggy

• Establish or maintain IV access

• Begin rapid IV fluid replacement

  • Continue frequent vital sign monitoring

When are nonpneumatic anti-shock garments (NASG) used?

NASGs may be applied in severe postpartum hemorrhage or shock to improve perfusion until definitive treatment is available.

What is uterine inversion?

A rare but life-threatening obstetric emergency in which the uterus turns inside out after delivery, causing severe postpartum hemorrhage and shock.

What are the clinical manifestations of uterine inversion?

• Sudden severe pelvic pain

• Bearing-down sensation

• Heavy postpartum bleeding

• Signs of hypovolemic shock

  • Uterus may not be palpable in the abdomen

What are the priority nursing interventions for uterine inversion?

• Call the interprofessional team immediately

• Begin rapid IV fluid resuscitation

• Support hemodynamic stability

• Prepare for immediate uterine replacement

---

What is the priority treatment for uterine inversion?

Immediate manual replacement of the uterus by the provider.

What medications are given after the uterus is successfully replaced?

After replacement, administer uterotonic medications (e.g., oxytocin) to maintain uterine tone and reduce bleeding.

What is an amniotic fluid embolism (AFE)?

A rare obstetric emergency in which amniotic fluid or fetal cells enter the maternal circulation, causing an anaphylactoid reaction that leads to cardiopulmonary collapse, DIC, and shock.

What are the manifestations of amniotic fluid embolism?

• Sudden dyspnea

• Hypotension

• Seizures

• Respiratory distress/arrest

• Cardiac arrest

• Disseminated intravascular coagulation (DIC)

What is the priority nursing action for suspected amniotic fluid embolism?

Call for help immediately, support airway and oxygenation, begin CPR if indicated, notify the provider, and prepare for aggressive supportive treatment.

What are the signs of postpartum deep vein thrombosis?

• Unilateral leg edema

• Pain or tenderness

• Warmth

• Redness (commonly calf)

How is postpartum deep vein thrombosis treated?

• Anticoagulation (heparin)

• Bed rest initially

• Elevate the affected leg

---

How can postpartum deep vein thrombosis be prevented?

• Early ambulation

• Compression stockings/SCDs

• Administer prescribed prophylactic anticoagulants

What are the manifestations of postpartum endometritis?

• Fever

• Uterine tenderness

• Foul-smelling lochia

• Tachycardia

• Subinvolution

---

How is postpartum endometritis treated?

Broad-spectrum IV antibiotics. Evaluate for retained placental tissue if symptoms persist.

What are the manifestations of postpartum cystitis?

• Dysuria

• Urinary frequency

• Small frequent voids

• Suprapubic pain

• Fever may occur

How is postpartum cystitis diagnosed and treated?

Urinalysis and urine culture followed by antibiotics.

What nursing interventions help prevent postpartum cystitis?

• Encourage hydration

• Frequent voiding

• Good perineal hygiene

  • Prevent bladder distention

What causes postpartum mastitis?

Milk stasis or poor latch leading to breast infection, most commonly Staphylococcus aureus.

What are the manifestations of mastitis?

• Unilateral breast redness

• Warmth

• Firm painful area

• Fever

• Chills

• Fatigue