NCM 109 – CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC)

S.Y. 2022-2023 | 2nd Semester | Preliminary Term

Module 5: Nursing Care of the High-risk Client during Postpartum Period

Description
Although the postpartum is usually a period of health, complications can occur. When they do,
immediate intervention is essential to prevent long-term disability and interference with parent–child
relationships. This module adds information about how to care for a woman and her family when there
is a complication during this time.
Learning Outcomes
LO1 Integrate concepts, theories and principles of sciences and humanities in the formulation and
application of appropriate nursing care to mothers with complications during pregnancy to achieve
quality maternal and child nursing care.
LO2 Apply maternal and child nursing concepts and principles in the prevention of complications during
postpartum period
LO3 Assess mothers who is experiencing complications during postpartum period with the use of
specific methods and tools to address existing health needs.
LO4 Formulate nursing diagnoses to address needs / problems of mothers and her family experiencing
complications during postpartum period.
LO5 Implement safe and quality nursing interventions to meet the needs and promote optimal
outcomes for mothers and her family during a postpartum complication.
LO7 Evaluate with mothers and family the expected outcomes for the effectiveness and achievement of
care.
LO8 Institute appropriate corrective actions to prevent or minimize complications during postpartum
period.

Module Outline
I. Postpartum Hemorrhage
A. Uterine atony
B. Laceration
C. Retained placental fragments
D. Uterine inversion
E. Disseminated Intravascular Coagulation
F. Subinvolution

Module 5: Postpartum Complications 1

 G. Perineal Hematoma
II. Puerperal Infection
A. Mastitis
B. Endometritis
III. Emotional and Psychological Complications
A. Postpartum

Module
Postpartum complications are always potentially serious because they can impact so many people.
A complication may be so serious it could cause a personal injury, leave a woman with her future fertility
impaired, or even result in death. Any complication that affects the health of the mother can also affect
her interactions with her newborn, such as causing her to discontinue breastfeeding. Her family can be
disrupted because of an extended hospital stay or impairment that prevents her from performing her
normal family responsibilities. Financial difficulties may arise because of her inability to maintain
employment and need for additional child and health care. Fortunately, most postpartal complications
are preventable, and if they do occur, the majority can be treated effectively without long-term
complications.
I. Postpartum hemorrhage
Hemorrhage, one of the primary causes of maternal mortality associated with childbearing, is a major
threat during pregnancy, throughout labor, and continuing into the postpartum period.
Postpartum hemorrhage is bleeding of 500 mL or more after delivery which can occur early (primary
postpartum hemorrhage) during the first 24 hours after delivery, or later (secondary postpartum
hemorrhage) after the first 24 hours following delivery
The four main reasons for postpartum hemorrhage are (Fig 1):
A. Uterine atony
B. Trauma (lacerations, hematomas, uterine inversion, uterine rupture)
C. Retained placental fragments
D. Disseminated intravascular coagulation (DIC)
These causes are generally referred to as the four T’s of postpartum: tone, trauma, tissue and thrombin.

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 Figure 1. The common causes of postpartal hemorrhage

Consequences of postpartum hemorrhage are:

1. Circulatory collapse leading to shock and death
2. Puerperal anemia and morbidity
3. Damage to the pituitary blood supply - Sheehan's syndrome
4. Fear of further pregnancies
A. Uterine Atony
- Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartal hemorrhage.
- The uterus must remain in a contracted state after birth to keep the open vessels at the
placental site from bleeding.
- Factors that predispose to poor uterine tone or any inability to maintain a contracted state are
summarized in Table 1.
- When caring for a woman in whom any of these conditions are present, be especially cautious in
your observations and be on guard for signs of uterine bleeding. This is especially important
because many postpartal women are discharged within 48 hours after birth.

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Table 1. Conditions that increase a Woman’s Risk for a Postpartal Hemorrhage
Conditions that distend the uterus beyond Multiple gestation
average capacity Polyhydramnios
A large baby (>9 lb)
Uterine myomas (fibroid tumors
Conditions that could have caused cervical or An operative birth
uterine lacerations Rapid birth
Conditions with varied placental site or Placenta previa
attachment Placenta accreta
Premature separation of the placenta
Retained placental fragments
Conditions that leave the uterus unable to Deep anesthesia or analgesia
contract readily Labor initiated or assisted with an oxytocin agent
High parity or maternal age over 35 years of age
Previous uterine surgery
Prolonged and difficult labor
Chorioamnionitis or endometritis
Secondary maternal illness such as anemia
Prior history of postpartum hemorrhage
Prolonged use of magnesium sulfate or other
tocolytic therapy
Conditions that lead to inadequate blood Fetal death
coagulation Disseminated intravascular coagulation

- Assessment
1. A soft (boggy) uterus noted on palpation of the uterine fundus.
2. Signs of Shock and Hypovolemia
a. Persistent significant bleeding: Perineal pad is soaked within 15 minutes.
b. Restlessness, increased pulse rate, decrease in blood pressure, cool and clammy skin,
ashen or grayish color
c. Complaints of weakness, lightheadedness, dyspnea

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 - Interventions
1. Massage the uterus until firm (Fig. 2)
2. Empty the woman’s bladder (by voiding or catheterization) if that is contributing to the
uterine atony.
3. Elevate woman’s extremities
4. Oxygen by mask = 10-12lpm
5. Position flat
6. Monitor VS
7. Notify the health care provider (HCP) if interventions do not resolve the atony, because this
could be an indication of hemorrhage.
8. Administer medications
a. Oxytocin bolus or dilute IV
b. Carbopost tromethamine (Hemabate) q 15 – 90 minutes x 8 doses
c. Methylergonovine maleate (Methergine) q 2-4 hours x 5 doses
d. Misoprostol (Cytotec) x 2 doses
9. Bimanual massage
The doctor inserts one hand into the woman’s vagina while pushing against the fundus
through the abdominal wall with the other hand.
10. Blood transfusion
11. Hysterectomy

A
B

Figure 2. Technique for fundal massage. (A). The other hand is cupped to massage and gently
compress the fundus toward the lower uterine segment. (B). One hand remains cupped against the uterus at the
level of the symphysis pubis to support the uterus.

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B. Laceration
- Small lacerations or tears of the birth canal are common and may be considered a normal
consequence of childbearing.
- Large lacerations, however, can cause complications.
- Causes
a. Difficult or precipitate births
b. Primigravidas
c. Birth of a large infant (>9 lb)
d. Use of a lithotomy position and instruments during the stage 2 of labor
- Either cervical, vaginal, or perineal lacerations may occur.
- After birth, any time a uterus feels firm, but bleeding persists, suspect a laceration of one of
these three sites.
- Types of lacerations
1. Cervical Lacerations
Lacerations of the cervix are usually found on the sides of the cervix, near the branches of the
uterine artery. If the artery is torn, the blood loss may be so great that blood gushes from the
vaginal opening. Because this is arterial bleeding, it is brighter red than the venous blood lost
with uterine atony. Fortunately, this bleeding ordinarily occurs immediately after delivery of the
placenta, when the physician or nurse midwife
is still in attendance.
2. Vaginal Lacerations
Vaginal lacerations are easier to locate and assess than cervical lacerations because they are
much easier to view.
3. Perineal lacerations
Lacerations of the perineum are apt to occur when a woman is placed in a lithotomy position for
birth rather than a supine position because a lithotomy position increases tension on the
perineum. Perineal lacerations are classified by four categories, depending on the extent and
depth of the tissue involved (Table2).

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 Table 2 Classification of perineal lacerations
Classification Description
First degree Vaginal mucous membrane and skin of the perineum to the fourchette
Second degree Vagina, perineal skin, fascia, levator ani muscle, and perineal body
Third degree Entire perineum, extending to reach the external sphincter of the rectum
Fourth degree Entire perineum, rectal sphincter, some mucous membrane of the rectum

- Interventions
1. Document the degree of laceration
2. Repair of the laceration with regional anesthesia to relax uterine muscle for cervical
laceration
3. Diet high in fluid and stool softener to prevent constipation
4. Avoid enema or rectal suppositories

C. Retained Placental Fragments

Occasionally, a placenta does not deliver in its entirety; fragments of it separate and are left behind.
Because the portion retained keeps the uterus from contracting fully, uterine bleeding occurs.
- Risk factors:
1. Succenturiate placenta—a placenta with an accessory lobe.
2. Placenta accreta—a placenta that fuses with the myometrium because of an abnormal
decidua basalis layer
3. Previous cesarean birth
4. In vitro fertilization
- Assessment
1. Detection of retained placental fragments thru:
a. Ultrasound
b. Inspection of placenta carefully after birth
c. Blood serum sample contains gonadotropin hormone
2. Bleeding occurs because the uterus cannot contract with the large fragment in place.
3. Bleeding may not be detected until postpartum day 6 to 10, if the fragment is small.
4. Uterus not fully contracted

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 - Intervention
1. Removal of the retained placental fragment by dilatation and curettage (D&C).
2. Observe lochia and report reversal of pattern.
3. Balloon occlusion and embolization for placenta accrete.
4. Hysterectomy as last resort.
D. Uterine Inversion
Uterine inversion is a prolapse of the fundus of the uterus through the cervix so that the uterus
turns inside out with either birth of the fetus or delivery of the placenta.
- Risk factors
1. Traction is applied to the umbilical cord to remove the placenta
2. Pressure is applied to the uterine fundus when the uterus is not contracted.
3. Placenta is attached at the fundus so that, during birth, the passage of the fetus pulls the
fundus down.
- Assessment
1. Blood suddenly gushes from the vagina
2. Fundus, uterus protrudes from the vagina
3. Fundus not palpable in the abdomen
4. Signs of shock: hypotension, dizziness, paleness, or diaphoresis
- Intervention
1. Never attempt to replace an inversion because handling of the uterus may increase the
bleeding.
2. Never attempt to remove the placenta if it is still attached, because this only creates a larger
surface area for bleeding.
3. IV fluid line needs to be started, if one is not already present (use a large-gauge needle,
because blood will need to be replaced).
4. Administer oxygen by mask and assess vital signs.
5. Be prepared to perform cardiopulmonary resuscitation (CPR) if the woman’s heart should
fail from the sudden blood loss.
6. The woman will immediately be given general anesthesia or possibly nitroglycerin or a
tocolytic drug intravenously, to relax the uterus.
7. The physician or nurse midwife then replaces the fundus manually.

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 8. Administration of oxytocin after manual replacement helps the uterus to contract and
remain in its natural place.
9. Because the uterine endometrium was exposed, a woman will need antibiotic therapy to
prevent infection.
10. She needs to be informed that cesarean birth will probably be necessary in any future
pregnancy, to prevent the possibility of repeat inversion.
E. Disseminated Intravascular Coagulation
Disseminated intravascular coagulation (DIC) is a deficiency in clotting ability caused by vascular
injury. It may occur in any woman in the postpartal period, but it is usually associated with
premature separation of the placenta, a missed early miscarriage, or fetal death in utero. DIC is
discussed in Module 2 (Bleeding in Pregnancy)
F. Subinvolution
Subinvolution is incomplete return of the uterus to its prepregnant size and shape. With
subinvolution, at a 4- or 6- week postpartal visit, the uterus is still enlarged and soft. Lochial
discharge usually is still present. Subinvolution may result from:
a. a small retained placental fragment,
b. mild endometritis (infection of the endometrium),
c. uterine myoma/fibroids
- Assessment
1. Prolonged lochial discharge
2. Irregular or excessive bleeding
3. Larger than normal uterus
4. Boggy uterus
- Interventions
1. Prevent excessive blood loss, infection, other complications
a. Massage uterus
b. Monitor BP and pulse rate
c. Administer medications
d. Prepare for possible D & C
2. Assist the client and family deal with physical and emotional stress of postpartum
complications

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G. Perineal Hematomas
- A perineal hematoma is a collection of blood in the subcutaneous layer of tissue of the
perineum.
- The overlying skin, as a rule, is intact with no noticeable trauma.
- Such blood collections can be caused by injury to blood vessels in the perineum during birth.
- They are most likely to occur after rapid, spontaneous births and in women who have
perineal varicosities.
- They may occur at the site of an episiotomy or laceration repair if a vein was punctured
during repair.
- They can cause a woman acute discomfort and concern and they usually represent only
minor bleeding.
- Assessment
1. Severe pain in the perineal area or a feeling of pressure between the mother’s legs
2. Appears as an area of purplish discoloration with obvious swelling.
3. The area is tender to palpation.
4. At first it may feel fluctuant, but as seepage into the area continues and tissue is drawn
taut, it palpates as a firm globe.
- Interventions
1. Report the presence of a hematoma, its size, and the degree of the woman’s discomfort
to her primary care provider.
2. Assess the size by measuring it in centimeters with each inspection.
3. Administer a mild analgesic as ordered for pain relief.
4. Applying an ice pack (covered with a towel to prevent thermal injury to the skin) may
prevent further bleeding.
5. Usually, the hematoma is absorbed over the next 3 or 4 days.
6. If the hematoma is large when discovered or continues to increase in size, the woman
may have to be returned to the delivery or birthing room to have the site incised and
the bleeding vessel ligated under local anesthesia.
II. Puerperal Infection
Any infection of the reproductive organs that occurs within 28 days of delivery or abortion.
Requires a complete physical examination and examination of urine specimen, throat swab or

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 sputum, high vaginal swab and in some cases blood culture. Factors that predispose women to
infection in the postpartal period are shown in Table 3. When caring for a woman who has any of
these circumstances, be aware that the risk for postpartal infection is greatly increased.
Table 3. Conditions that increase a Woman’s Risk for Postpartal Infection
Risk Factor Basis for Risk
Rupture of membranes more than 24 hours Bacteria may have started to invade the uterus
before birth while the fetus was still in utero.
Retained placental fragments within the uterus The tissue necroses an serves as an excellent for
bacterial growth
Postpartal hemorrhage The woman’s general condition is weakened
Preexisting Anemia The woman’s general condition is weakened
Prolonged and difficult labor, particularly with Trauma to the tissue may leave lacerations or
instrument births fissures for easy portals of entry for infection
Internal fetal heart monitoring electrode Contamination may have been introduced with
placement of the scalp electrodes.
Local vaginal infection present at the time of A direct spread of infection has occurred.
birth

Theoretically, the uterus is sterile during pregnancy and until the membranes rupture. After rupture,
pathogens can invade. The risk of infection is even greater if tissue edema and trauma are present. If
infection occurs, the prognosis for complete recovery depends on:
- Virulence of the invading organism
- The woman’s general health
- Portal of entry
- Degree of uterine involution at the time of the microorganism invasion
- Presence of lacerations in the reproductive tract
A puerperal infection is always potentially serious, because, although it usually begins as only a local
infection, it can spread to involve the peritoneum (peritonitis) or the circulatory system (septicemia).
These conditions can be fatal in a woman whose body is already stressed from childbirth.

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Organisms commonly cultured postpartally include group B streptococci and aerobic gram-negative
bacilli such as Escherichia coli. Staphylococcal infections
also are becoming more common.
- Assessment
1. Fever
2. Localized vaginal, vulvar, perineal infections
3. Manifestations of endometritis
4. Parametritis
5. Signs and symptoms of peritonitis
- Intervention
1. Use of an appropriate antibiotic after culture and sensitivity testing of the isolated organism.
2. Provide client of the family teaching especially prevention for future pregnancies
a. During pregnancy
- Correct all anemia states
- Avoid sexual intercourse
- Douching during the last 2 months of pregnancy
b. During labor
- Strict aseptic technique – wearing of cap, mask, gown
- Keep perineal and vaginal laceration in minimum
- Avoid contact with person with URTI
- Replace blood loss
c. During puerperium
- Use of clean/sterile perineal pads always
- Perineal flushing every after urination and bowel elimination
A. Mastitis
It is an infection of the breast, usually unilateral, frequently caused by cracked nipples in the
nursing mother. The causative organism usually hemolytic S. Aureus. If untreated, may result in
breast abscess. Mastitis occurs primarily in breast-feeding mothers 2 to 3 weeks after delivery,
but may occur at any time during lactation.
- Assessment
1. Redness, tenderness or hardened are in the breast

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 2. Maternal chills, malaise
3. Elevated vital signs, especially temperature and pulse
- Interventions
1. Teach/ stress importance of hand washing to nursing mother and wash own hands
before touching client’s breast
2. Apply ice if ordered between feedings
3. Empty breast regularly: baby may continue to nurse or have mother use hospital-grade
pump
4. Wear supportive bra; avoid wearing an underwire bra
5. Maintain lactation in breast feeding mothers
6. Administer antibiotic and analgesic as prescribed
B. Endometritis
Endometritis is an infection of the lining of the uterus occurring in the postpartum period and
caused by bacteria that invade the uterus at the placental site. The infection may spread and
involve the entire endometrium and cause peritonitis or pelvic thrombophlebitis.
- Assessment
1. Chills and fever
2. Increased pulse
3. Decreased appetite
4. Headache
5. Backache
6. Prolonged, severe afterpains
7. Tender, large uterus
8. Foul odor to lochia or reddish brown lochia
9. Ileus
10. Elevated white blood cell count
- Interventions
1. Monitor vital signs.
2. Position the client in Fowler’s position to facilitate drainage of lochia.
3. Provide a private room for the mother; inform the mother that isolation of the newborn
from the mother is unnecessary.

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 4. Instruct the mother in proper hand-washing techniques.
5. Initiate contact precautions as necessary.
6. Monitor intake and output and encourage fluid intake.
7. Administer antibiotics as prescribed.
8. Administer comfort measures such as back rubs and position changes and pain
medications as prescribed.
9. Administer oxytocic medications as prescribed to improve uterine tone.
10. Provide psychological support.
III. Thrombophlebitis
- Phlebitis is inflammation of the lining of a blood vessel.

- Thrombophlebitis is inflammation with the formation of blood clots. When thrombophlebitis occurs in

the postpartal period, it is usually an extension of an endometrial infection. It tends to occur because:

1. A woman’s fibrinogen level is still elevated from pregnancy, leading to increased blood

clotting.

2. Dilatation of lower extremity veins is still present as a result of pressure of the fetal head
during pregnancy and birth.
- It tends to occur most often in women who:
a. Are relatively inactive in labor and during the early puerperium because of this increases the
risk of blood clot formation.
b. Have spent prolonged time in delivery or birthing room with their legs positioned in stirrups
c. Have preexisting obesity and pregnancy weight gain greater than the recommended weight
gain, which can lead to inactivity and lack of exercise
d. Have preexisting varicose veins
e. Develop postpartal infection
f. Have history of a previous thrombophlebitis
g. Are older than age of 35 years or have increased parity
h. Have a high incidence of thrombophlebitis in their family
i. Smoke cigarettes because nicotine causes vasoconstriction and reduces blood flow

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- A clot forms in a vessel wall as a result of inflammation of the vessel wall. A partial obstruction of the
vessel can occur. Increased blood-clotting factors in the postpartum period place the client at risk.
- Types
1. Superficial thrombophlebitis
2. Femoral thrombophlebitis
3. Pelvic thrombophlebitis
- Assessment
1. Superficial
a. Palpable thrombus that feels bumpy and hard
b. Tenderness and pain in affected lower extremity
c. Warm and pinkish red color over the thrombus area
2. Femoral
a. Malaise
b. Chills and fever
c. Diminished peripheral pulses
d. Shiny white skin over affected area
e. Pain, stiffness, and swelling of affected leg
3. Pelvic
a. Severe chills
b. Dramatic body temperature changes
c. Pulmonary embolism may be the first sign
- Interventions
1. Specific therapies may depend on the location of thrombophlebitis.
2. Assess the lower extremities for edema, tenderness, varices, and increased skin
temperature.
3. Maintain bed rest.
4. Elevate the affected leg.
5. Apply a bed cradle and keep bedclothes off the affected leg.
6. Never massage the leg.
7. Monitor for manifestations of pulmonary embolism.
8. Apply hot packs or moist heat to the affected site as prescribed to alleviate discomfort.

Module 5: Postpartum Complications 15

 9. Apply elastic stockings (support hose) if prescribed.
10. Administer analgesics and antibiotics as prescribed.
11. Heparin sodium intravenously may be prescribed for femoral or pelvic thrombophlebitis
to prevent further thrombus formation.
IV. Emotional and Psychological Complications of the Puerperium
Any woman who is extremely stressed or who gives birth to an infant who in any way does
not meet her expectations such as being the wrong sex, being physically or cognitively
challenged, or being ill may have difficulty bonding with her infant. Inability to bond is a
postpartal complication with far-reaching implications, possibly affecting the future health of
the entire family.
A. Postpartal Depression
Almost every woman notices some immediate (1 to 10 days postpartum) feelings of sadness
(postpartal “blues”) after childbirth. This probably occurs as a response to the anticlimactic
feeling after birth and also probably is related to hormonal shifts as the levels of estrogen,
progesterone, and gonadotropin-releasing hormone in her body decline or rise.
In as many as 20% of women, however, especially in women who are disappointed in some
aspect of the newborn or who have poor family support, these normal feelings continue
beyond the immediate postpartal period (possibly as long as 1 year) or reflect a more
serious problem than usual “baby blues”. They become postpartum depression (Table 4).
Depression of this type, manifested by overwhelming sadness, can occur in both new
mother and fathers. The syndrome can interfere with breastfeeding, childcare, and
returning to a career. Both women and men may notice extreme fatigue, an inability to stop
crying, increased anxiety about their own or their infant’s health, insecurity (unwillingness
to be left alone or inability to make decisions), psychosomatic symptoms (nausea and
vomiting, diarrhea), and either depressive or extreme mood fluctuations.
Risk factors
1. History of depression
2. Troubled childhood
3. Low self-esteem
4. Stress in the home or at work
5. Lack of effective support

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 6. Different expectations between partners (e.g. if a woman wants a child and her partner
does not)
7. Disappointment in the child (e.g. a boy instead of a girl)
Table 4. Comparing Postpartal Blues, Depression, and Psychosis
POSTPARTAL BLUES POSTPARTAL DEPRSSION POSTPARTAL PSYCHOSIS
ONSET 1-10 days after birth 1-12 months after birth Within first year after birth
SYMPTOMS Sadness, tears Anxiety, feelings of loss, Delusion or hallucinations of
sadness harming infant or self
Incidence 70% of all births 10% of all births 1% - 2% of all births
Etiology Probable hormonal History of previous Possible activation of
changes, stress of life depression, hormonal previous mental illness,
changes response, lack of social hormonal changes, family
support history of bipolar disorder
Therapy Support, empathy Counseling, possibly drug Psychotherapy, drug therapy
therapy
Nursing role Offer compassion and Screen for depression and Refer to psychiatric care,
understanding refer to counseling safeguarding mother form
injury to self and newborn

B. Postpartal Psychosis
When the illness coincides with the postpartal period, it is called postpartal psychosis. Rather
than being a response to the physical aspects of childbearing, however, it is probably a response to the
crisis of childbearing. The majority of these women have had symptoms of mental illness before
pregnancy. If the pregnancy had not precipitated the illness, a death in the family, loss of a job or
income, divorce, or some other major life crisis would probably have precipitated the same recurrence.
A woman with postpartal psychosis usually appears exceptionally sad. By definition, psychosis exists
when a person has lost contact with reality. Because of this break with reality, the woman may deny
that she has had a child and, when the child is brought to her, insist that she was never pregnant. She
may voice thoughts of infanticide or that her infant is possessed. If observation tells you that a woman is
not functioning in reality, you cannot improve her concept of reality by a simple measure such as

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explaining what a correct perception is. Her sensory input is too disturbed to comprehend this. In
addition, she may interpret your attempt as threatening. She may respond with anger or become
equally threatening. A psychosis is a severe mental illness that requires referral to a professional
psychiatric counselor and antipsychotic medication.
- Interventions
1. Do not leave woman alone
2. Do not leave her alone with her infant
3. Refer to psychiatric counselor and antipsychotic medication
V. Nursing Process for a Woman experiencing Postpartum Complication
A. Assessment
Women who assume that they will immediately return to an active lifestyle after birth of their
child may view hospitalization for a postpartum complication as more upsetting than do women
who view the postpartum period as one in which they are expected to rest. Assess each woman
holistically, therefore, to determine how the health problem a woman is experiencing is
impacting her and her family.
Assessment findings associated with a postpartum complication may be extremely subtle, such
as tenderness in the calf of a leg, a slight increase in uterine or perineal pain, a slight elevation in
temperature, or a slight increase in the amount of lochia flow. Because the average woman
usually has no postpartum complications and the length of stay in a hospital is short, it is easy to
overlook these subtle signs. It is important to be alert to any findings that are “different from
usual,” because they may be the beginning of a serious. To be certain, do not rely solely on a
woman’s report of perineal healing or amount of lochia. Always inspect her perineum yourself,
because the report of “I feel fine” or “my bleeding was just a small amount” may be deceptive if
she no familiarity with “normal” lochia, perineal healing, or fundal height against which to
accurately compare her own condition.
An increased temperature during the first 24 hours after birth is an extremely serious
finding. Women may try to “explain away” an increased temperature, because they know that if
they have an elevated temperature, they not be tempted to rationalize such a finding with
explanations such as, “The room was warm,” or “She just drank some hot coffee.” Although
these factors may make a slight difference (part of 1°) in temperature level, they do not affect it
enough to account for an oral temperature greater than 100.4° F (38.0° C).

Module 5: Postpartum Complications 18

B. Nursing Diagnosis
Nursing diagnoses during this time vary depending on the postpartal complication. Some
examples are:
1. Deficient fluid volume related to increased lochia flow
2. Ineffective breastfeeding related to development of mastitis
3. Acute pain related to a collection of blood in traumatized tissue (hematoma) secondary
to birth trauma
4. Situational low self-esteem related to inability to perform regular tasks
5. Social isolation related to precautions necessary to protect infant and others from
infection transmission Risk for impaired parenting related to postpartum depression
6. Ineffective peripheral tissue perfusion related to interference with circulation from
thrombophlebitis
7. Risk for infection related to microorganism invasion of episiotomy, surgical incision site,
or migration of microorganism from the vagina to the uterus
C. Outcome Identification and Planning
Outcome identification for a woman with a postpartum complication may be particularly
difficult because, although a woman wants to do everything necessary to return to health,
she also does not want to allow anything to interfere with her ability to bond with her new
child. As a rule, however, never underestimate how much a woman will endure to enable
herself to “mother” her new child. This ability of a mother to overcome challenges to meet
her child’s needs is the essence of motherhood.
When planning for a postpartum family, provide for measures that will restore the woman
most quickly to health and promote contact among her, her child, and her
primary support person. If physical contact between a mother and her newborn is not
possible, give the mother frequent reports of her infant’s health and preferences. During
her taking-in phase, ask the nursery staff to contact the mother at least once every nursing
shift to update her on the infant’s status; during her taking-hold phase, encourage her to
contact the nursery. If the infant is being cared
for in another facility, ask them to fax or e-mail photographs of the infant. This provides
something concrete to which a new mother can relate
D. Implementation

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 Interventions for a woman with a postpartum complication should include instruction for
both self-care and child care (if appropriate) because continuing to review these measures
helps a woman accept her situation as temporary, thus reinforcing the idea she will be able
to care for herself and her infant when she is healthy again.
E. Outcome Evaluation
An evaluation of a woman with a postpartum complication should address both her and her
family’s health as well as her family’s ability to integrate the new child into the family. The
evaluation may suggest the need for home care follow-up to assist a
woman in coping with both old and new responsibilities in the face of reduce energy form
illness
Examples of expected outcomes might include:
1. Lochia is free of foul odor.
2. Fundus remains firm and midline with progressive descent.
3. Patient maintains a urinary output greater than 30 ml/hr
4. Lochia discharge amount is 6 in or less on a perineal pad in 1 hour
5. Patient maintains vital signs and oxygen saturation within defined normal limits
Integrative Activity
Watch the following videos:
1. Postpartum hemorrhage: https://www.youtube.com/watch?v=ZSLMm5KNGEc
2. Uterine Atony: https://www.youtube.com/watch?v=GIDL3AONCys
3. Postpartum depression: https://www.youtube.com/watch?v=2ocA-zS3SoI

References
Flagg, J. (2018). Maternal and child health nursing: Care of the childbearing and childbearing
family (8thed.). Philadelphia, PA: WoltersKluwer.
Murray S, (2014) Foundations of maternal-newborn and women’s health nursing
(6thed). St. Louis, Missouri: Elsevier Saunders.

Credits and Quality Assurance

Prepared by: Noriel P. Calaguas, MSHSA, RN

Assistant Professor & Chairperson, Nursing
MELANIE C. TAPNIO, MAN, RN Program
Assistant Professor
Reviewed by:
Recommending Approval:
JENNY ROSE LEYNES-IGNACIO, EdD, MAN, RN

Module 5: Postpartum Complications 20

Assistant Professor & OBE Facilitator

Approved by:
PRECIOUS JEAN M. MARQUEZ, PhD, MSN, RN
OIC Dean
School of Nursing and Allied Medical Science

Module 5: Postpartum Complications 21