Chapter 22 – Nursing Management of the Postpartum Patient at Risk

Overview of Common Postpartum Disorders

• The postpartum period carries four primary risk categories:
  • Hemorrhage
  • Infection
  • Thromboembolic disease
  • Postpartum affective disorders (baby blues, depression, psychosis)

Hemorrhagic Shock – Clinical Manifestations

• Shock severity correlates with percentage of total blood-volume loss:
  • Mild 15\%\text{–}25\% loss
    • Diaphoresis
    • Weakness
    • Tachycardia
    • Slight fall in blood pressure
  • Moderate 25\%\text{–}35\% loss
    • Pallor
    • Restlessness
    • Oliguria
    • Moderate fall in blood pressure
  • Severe 35\%\text{–}50\% loss
    • Marked hypotension
    • Agitation / confusion
    • Hemodynamic instability
    • Anuria
• Rapid identification is crucial to prevent organ failure and death.

Definition & Diagnostic Criteria for Postpartum Hemorrhage (PPH)

• Quantitative thresholds
  • Vaginal birth: >500\,\text{mL} blood loss
  • Cesarean birth: >1{,}000\,\text{mL} blood loss
• ANY blood loss that pushes the birthing parent toward hemodynamic compromise also qualifies, irrespective of volume.

Etiology / Causes of PPH

• Uterine atony (most common)
• Genital-tract lacerations (vagina, cervix, perineum)
• Episiotomy extension
• Retained placental fragments
• Uterine inversion
• Coagulation disorders (pre-existing or acquired)
• Hematomas (vulvar, vaginal, sub-peritoneal)

Pathophysiology: The “Four Ts” Framework

1. Tone – uterine atony, distended bladder
2. Tissue – retained placenta, blood clots
3. Trauma – lacerations or uterine/ cervical injury
4. Thrombin – coagulopathy leading to poor clot formation

Therapeutic Management of PPH

• Treat the underlying cause—interventions are not one-size-fits-all.
• Core strategies
  • Bimanual uterine massage to restore uterine tone
  • Manual/ surgical removal of retained placental tissue
  • Suture repair of lacerations / episiotomy
  • Broad-spectrum antibiotics if infection suspected
  • Administration of uterotonics (see Drug Guide 22.1): oxytocin, methylergonovine, carboprost, misoprostol
  • Large-bore IV access for crystalloid/ colloid resuscitation
  • Blood product transfusion guided by lab results and clinical status
  • Emergent management of Disseminated Intravascular Coagulation (DIC) if present

Nursing Assessment & Management for PPH

• Ongoing risk-factor review: grand multiparity, prolonged labor, chorioamnionitis, retained placenta, etc.
• Physical checks
  • Fundal firmness, height, and position
  • Vaginal bleeding – quantify via pad count / gravimetrics (Nursing Procedure 22.1)
• Interventions
  • Continuous fundal massage until tone sustained
  • Administer ordered uterotonics promptly
  • Ensure bladder emptying; catheterize if needed
  • Maintain warmed IV fluids; titrate based on vitals & urine output
  • Monitor classic shock indicators (tachycardia, narrowed pulse pressure, cool clammy skin)
  • Prepare for rapid-response measures if vital signs deteriorate

Subinvolution

• Definition: incomplete return of the uterus to pre-pregnancy size/position.
• Causes
  • Retained placental fragments
  • Distended bladder compressing fundus
  • Uterine fibroids (myomas)
  • Endometritis or other infections
• Complications
  • Secondary PPH
  • Pelvic peritonitis
  • Salpingitis
  • Abscess formation

Thromboembolic Conditions

Types & Locations

• Superficial venous thrombosis (SVT) – usually saphenous vein of lower leg
• Deep vein thrombosis (DVT) – can progress to pulmonary embolism (PE)

Triad Pathophysiology

1. Venous stasis (e.g., immobility, compression of pelvic veins)
2. Endothelial injury (trauma during birth or surgery)
3. Hypercoagulability (pregnancy-induced clotting cascade elevation)

Nursing Assessment

• Risk factors: cesarean birth, obesity, smoking, varicosities, anemia, prolonged bed rest, previous VTE, thrombophilias.
• SVT S/S: localized warmth, redness, tenderness, palpable cord.
• DVT S/S: unilateral leg pain, edema, temperature change, +Homan sign (controversial), diminished peripheral pulses.
• PE red flags: sudden dyspnea, chest pain, hemoptysis, sense of doom.

Nursing Management

• Prevention
  • Early ambulation, leg exercises
  • Adequate hydration
  • Graduated compression stockings / sequential compression devices
• Treatment
  • Heparin (unfractionated or LMWH) for DVT – prevents extension & embolization
  • NSAIDs for pain/inflammation in SVT
  • Strict bed rest with limb elevation until anticoagulation established
  • Teach signs of bleeding, need for follow-up labs (PTT), and medication adherence
• Emergency PE – oxygen, call rapid response, prepare for thrombolytics or surgical embolectomy.

Postpartum Infections

Diagnostic Cut-Off

• Fever >38^\circ\text{C} (or >100.4^\circ\text{F}) on any two days after the first 24 h postpartum.

Common Infection Sites & Terms

• Metritis – infection of endometrium, decidua, and adjacent myometrium
• Wound infections – episiotomy or cesarean incision
• Urinary-tract infection (UTI)
• Mastitis – breast tissue inflammation, often Staphylococcus aureus

Therapeutic Management

• Metritis: broad-spectrum IV antibiotics (e.g., clindamycin + gentamicin)
• Wound: opening/draining, culture, targeted antibiotics, sterile dressing changes
• UTI: fluids, culture-specific antibiotics, bladder emptying
• Mastitis: continued breastfeeding/ pumping for milk removal, warm compresses, analgesics, antibiotics

Nursing Assessment

• Review risk factors (see Box 22.1) – prolonged ROM, multiple vaginal exams, operative birth, anemia
• Note REEDA findings at perineal site; monitor lochia odor/character.
• Systemic S/S: chills, malaise, uterine tenderness, flank pain, localized breast pain with erythema.

Nursing Management & Teaching

• Strict hand hygiene, sterile technique for catheter or wound care.
• Encourage balanced nutrition, hydration, rest to boost immunity.
• Educate on:
  • Correct perineal cleansing (front-to-back)
  • Breastfeeding positions and complete emptying
  • Early reporting of fever or incision changes

REEDA Method for Perineal/Incision Assessment

• Five parameters scored 0\text{–}3 each (higher = worse healing):
  1. Redness
     • 0: none • 1: \le 0.25\,\text{cm} • 2: \le 0.5\,\text{cm} • 3: >0.5\,\text{cm} bilaterally
  2. Edema – distance swelling extends from incision
  3. Ecchymosis – bruising pattern/size
  4. Discharge – none → purulent
  5. Approximation of skin edges – fully closed to full fascial separation
• Total possible score: 15 – guides healing progress and need for intervention.

Postpartum Affective Disorders Continuum

Baby Blues

• Transient emotional lability, irritability, insomnia
• Onset day 3–4; resolves by postpartum day 10 (within \approx 2\,\text{weeks})
• Self-limiting; supportive care and rest usually adequate.

Postpartum Depression (PPD)

• Major depressive episode linked to childbirth
• Symptoms persist >6\,\text{weeks} and often worsen if untreated
• S/S: persistent sadness, anhedonia, guilt, changes in appetite/sleep, intrusive thoughts of harm.

Postpartum Psychosis

• Rarest, most severe category—psychiatric emergency
• Onset typically within 3\,\text{weeks} postpartum
• Hallmarks: sleep disturbance, fatigue, depression mixed with hypomania, delusions, hallucinations, disorganized behavior
• Risk of suicide or infanticide mandates immediate hospitalization.

Nursing Assessment & Management for Affective Disorders

• Screen using EPDS (Edinburgh Postnatal Depression Scale) or similar tools (Evidence-Based Practice 22.2).
• Identify risk factors: prior mood disorders, poor social support, stressful life events, hormonal fluctuation.
• Interventions
  • Offer empathetic listening; validate feelings
  • Teach coping strategies, sleep hygiene, nutrition
  • Facilitate referrals: social worker, lactation consultant, psychiatrist
  • Coordinate pharmacologic therapy if prescribed (SSRIs, antipsychotics, mood stabilizers) while discussing breastfeeding implications.

Sample NCLEX-Style Questions (Lecture Highlights)

• Q#1: True/False – Uterine atony is the most common cause of PPH.
  • Answer: True.
• Q#2: Which drug for DVT postpartum?
  • Answer: Heparin – prevents clot propagation.
• Q#3: True/False – Postpartum psychosis is the most severe form of postpartum affective disorder.
  • Answer: True.

Key Take-Home Messages & Clinical Connections

• Timely recognition of abnormal bleeding volumes saves lives; know quantitative benchmarks and hemodynamic cues.
• The "Four Ts" mnemonic streamlines differential diagnosis during obstetric emergencies.
• Vigilance for infection requires both systemic vital-sign monitoring and meticulous wound/perineal assessment using REEDA.
• Early ambulation is a low-tech, high-yield intervention for thromboembolism prevention.
• Because mood disorders can impair bonding and infant safety, mental-health screening is as vital as physical assessment in the postpartum period.