NURSING CARE OF

THE HIGH RISK POST

PARTAL CLIENT
Nursing Care Planning Based on 2020 National Health Goals

The postpartal period is a time when women are very

susceptible to hemorrhage and thrombophlebitis and, when
these complications develop, women may choose not to
breastfeed because of them. The 2020 National Health Goals
that speak to this include:

A. Reduce the maternal mortality rate to no more than 11.4

per 100,000 live births from a baseline of 12.7 per 100,000.
B. Increase the proportion of infants who are breastfed to at
least 81.9% from a baseline of 74%.
C. Increase the proportion of infants who are breastfed at 6
months from a baseline of 43.5% to 60.6%
Nursing Process Overview
FOR A WOMAN EXPERIENCING A POSTPARTUM COMPLICATION

ASSESSMENT
NURSING DIAGNOSIS
Nursing diagnoses during this time vary depending on the postpartal
complication.

• Deficient fluid volume related to blood loss

• Ineffective breastfeeding related to the development of mastitis
• Risk for impaired parenting related to postpartum depression
• Risk for injury to self and newborn related to postpartal psychosis
• Acute pain related to a collection of blood in traumatized tissue
(hematoma)secondary to birth trauma
• Situational low self-esteem related to inability to perform regular tasks
• Social isolation related to precautions necessary to protect infant and
others from infection transmission
• Ineffective peripheral tissue perfusion related to interference with
circulation secondary to development of thrombophlebitis (blood clot)
• Risk for infection related to microorganism invasion of episiotomy,
surgical incision site, or migration of microorganisms from the vagina to
the uterus
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 anything to
interfere with her ability to bond with and take care of 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
IMPLEMENTATION

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.
OUTCOME EVALUATION
Examples of expected outcomes include:

A. Lochia is free of foul odor.

B. Fundus remains firm and midline with progressive descent.
C. Patient maintains a urinary output greater than 30 ml/hr.
D. Lochia discharge amount is 6 in. or less on a perineal pad in 1
hour.
E. Patient maintains vital signs and oxygen saturation within
defined normal limits.
F. Patient identifies signs and symptoms that should be reported.
G. Patient demonstrates attachment behaviors with infant despite
separation or activity restrictions.
 Postpartum Hemorrhage
▪ Refers to excessive blood loss during or
after the third stage of labor
▪ Leading cause of maternal mortality
 Incidence:
➢3-6% overall incidence
➢3.9% in vaginal deliveries
➢6.4% in cesarean deliveries
➢1-2% in delayed postpartum
hemorrhage
 Types of Postpartum Hemorrhage
1. Early postpartum hemorrhage
occurs during the first 24 hours after delivery
Common cause:
▪ Uterine atony
▪ Laceration of the birth canal
▪ Inversion of the uterus

2. Late postpartum hemorrhage

occurs from 24 hours after birth to 4 weeks
postpartum.
Common cause:
▪ Retained placental fragments
▪ Sub involution of the uterus
▪ Infection
 CAUSES: 4 T’s
1.Tone- refers to failure of the uterine myometrial muscle
fibers to contract and retract which can cause by the
following condition:
✓Over distention; macrosomia, hydramnios, multiple
pregnancy
✓Fatigue: prolonged labor, precipitate labor, oxytocic
drugs
✓Inhibition of contraction by drugs: anesthetic agents,
nitrates, NAIDS, MgSO4, beta-sympathomimetics,
nifedipine
✓Uterine structural abnormality
✓Infection: chorioamnionitis, endomyometritia, septicemia
✓Hypoxia due to hypoperfusion or Couvelaire uterus
✓Placental site in the lower uterine segment
✓Distention with blood before or after placental delivery.
 2. Tissue: presence of retained placental
tissues prevents full uterine contractions
resulting in failure to seal off bleeding vessels.

Cause:
✓ Presence of succenturiate or accessory lobe
✓ Preterm gestation especially in less than 24
weeks gestation
✓ Abnormal adhesions such as accreta,
increta and percreta
3. Trauma: 20% of postpartum hemorrhage
cases.

Cause:
✓Lacerations and episiotomy
✓Hematoma
✓Cesarean section
✓Uterine rupture and uterine inversion
✓Uterine perforation during forceps
application or curettage
 4. Thrombosis, clot formation and fibrin
deposition on the placental site stop the oozing of
blood from the blood vessels of the uterus.

Cause:
✓Prexistent coagulation disorder:thombocytopenic
purpura
✓Acquired disorder: HELLP ( hemolysis, elevated
liver enzymes, and low platelet count). DIC
✓Dilutional coagulopathy in which clotting factors
are significantly reduced with aggressive transfusion
of crystalloid and packed red blood cells (PRBCs).
 Post Partal Hemorrhage
Primary/Early Secondary/Late
Postpartal Postpartal
Hemorrhage Hemorrhage
⦿Bleeding occurs ⦿Bleeding occurs
during the 3rd after the first 24
stage or within 24 hours until 6 weeks
hours after ( the end of
childbirth. It is puerperium).
more common.
 Etiology
⦿ Placental site hemorrhage
• Atony of the uterus Infection:
⦿ Fibroid polyp: necrosis
• Retained placenta.
and sloughing of its tip.
• Disseminated ⦿ Subinvolution of the
intravascular uterus.
coagulation (DIC). ⦿ Local gynecological
⦿ Traumatic hemorrhage lesions
• Rupture uterus, cervical, ⦿ Choriocarcinoma.
⦿ Puerperal inversion of the
vaginal , vulval or
uterus.
perineal lacerations. ⦿ Estrogen withdrawal
bleeding
 Management of Primary
Hemorrhage
During pregnancy:
⦿ 1.Detection and correction of anemia.
⦿ 2. Hospital delivery with ready cross-matched blood
for high risk patients
During labor:
⦿ Avoid prolonged labor
⦿ Avoid lacerations

Postpartum:
⦿ Exploration of the birth canal after difficult or
instrumental delivery as well as precipitate labor.
⦿ Careful observation in the fourth stage of labor (1-2
hours postpartum).
 Treatment of Secondary
Hemorrhage
Depends on the cause:
⦿Retained parts:
• with minimal bleeding can be
spontaneously expelled using:
Ergometrine and antibiotics.
• with severe bleeding :
●vaginal evacuation
⦿ Infection : antibiotics.
⦿Other causes : treatment of the cause.
Classification of Hemorrhage
Class Blood Clinical Picture
Loss%

I 15-20% Normal pulse & blood pressure.

II 20-25% Tachycardia. - Tachypnea.

Pulse pressure (<30mmHg).
Low systolic pressure.
Delayed capillary filling.
 Continuation
Class Blood Loss Clinical Picture

III 30%-35% Skin: cold, clammy and pale.

Severe drop in blood pressure.
Restlessness.
Oliguria (<30 ml/hour).
Metabolic acidosis (blood pH <7.5).

IV 40%-45% Profound hypotension.

The carotid pulse is the only felt one.
Irreversible shock.
Coagulation Defects in Pregnancy
 

Disseminated Intravascular Coagulation
 Predisposing Factors
■Abruptio placenta.

■Amniotic fluid embolism.

■Endotoxic shock.

■Eclampsia and pre-eclampsia.

■Hydatidiform mole.

■IUFD and missed abortion.

■Intra amniotic hypertonic saline or urea for

induction of abortion.

■Incompatible blood transfusion or

■Prolonged shock of whatever the cause.

■Placenta accreta.

■Rupture uterus.
 REMEMBER: TEAR

●Toxemia of pregnancy
●Emboli (amniotic
fluid)
●Abruptio placenta
●Retain fetus products
 Clinical Features
Unexplained spontaneous bleeding from
any site e.g.

■ oozing of blood,

■ bruising,

■ epistaxis,

■ hematuria,

■ hematoma formation especially at

wound and venepuncture site,

■ postpartum hemorrhage.
 Management
■Elimination of the underlying
cause.

■Fresh blood transfusion

■Fresh frozen plasma

■Fibrinogen

■Heparin

■Antifibrinolytic
Deep Vein Thrombosis
 Predisposing Factors
■ Increased clotting factors

■ Reduced fibrinolytic activity.

■ Pressure of the gravid uterus on pelvic

veins.

■ Antenatal rest, prolonged labor,

dehydration, excessive blood loss,
pressure on calf muscles during delivery,
delay in mobilization, trauma and pelvic
infection.

■ Estrogen for postpartum suppression

of lactation.
 Clinical Picture Management

⦿ Pain and tenderness in ⦿ Elastic bandage

calf muscles and elevation of
⦿ Edema of the affected the affected leg
leg
⦿ Hotness and cyanosis of ⦿ Heparin
the leg.
⦿ Positive Homan’s sign
⦿ Fever.
 REMEMBER: DVT Diagnosis

●Dilated superficial veins/

Discoloration/Doppler
Ultrasound
●Venography is gold standard
●Tenderness of Thigh and calf
Pulmonary Embolism
 Factors: TOM SCHREPFER
■ T- Trauma

■ O-Obesity

■ M-Malignacy

■ S-Surgery

■ C-Cardiac Disease

■ H-Hospitalization

■ R-Rest (Bed Ridden)

■ E-Elderly

■ P-Past History

■ F-Fracture

■ E-Estrogen (Pregnancy, Post partum)

■ R-Road Trip
Symptoms Signs
⦿ Dyspnea, ⦿ Mild pyrexia,
⦿ Chest pain, ⦿ Tachycardia,
⦿ Cough, ⦿ Tachypnea,
⦿ Frothy blood stained ⦿ Cyanosis,
sputum, ⦿ Raised jugular venous
⦿ Hemoptysis, pressure,
⦿ Nausea, vomiting and ⦿ Pleural friction rub,
sudden desire to defecate. ⦿ Pleural effusion,
⦿ Right ventricular failure.
 Treatment
Prophylaxis:
■Subcutaneous heparin

■Dextran

Curative:
■ Heparin

■ Defibrinating drugs: as streptokinase

■ Oxygen..

■ Analgesic

■ Digoxin

■ Aminophylline

■ Pulmonary embolectomy
Post partum Infection
 Puerperal Pyrexia
Definition:
■It is a rise of temperature reaching 38oC or more and
lasting for 24 hours or more during the first 3 weeks of
puerperium.

Causes:
■ Puerperal infection (sepsis).

■ Urinary tract infection.

■ Breast infection.

■ Respiratory infection.

■ Intercurrent febrile illness.

■ Complicated pelvic tumurs as infected ovarian cyst

or red degeneration of myoma.
 

Puerperal Sepsis
Definition:
■It is a genital tract infection resulted from
bacterial invasion during or after labor.

Mode of Infection:
■ Endogenous origin: It may be present in the
genital tract as anaerobic streptococci

–It may be outside the genital tract as in the

gastrointestinal tract, perineum or in a distant
part as tonsils where it is transmitted by blood
stream.
■Exogenous origin: from infected attendants,
dust, instruments...etc.
 Primary sites: UTERUS
Localised or Putrid Generalised or Septic

Type of infection is mild. is severe.

Organism virulence is low as anaerobic Virulent organism as

streptococci. haemolytic streptococci.

Resistance of the patient is good is low.

Uterus Subinvoluted and soft. Well involuted.

Uterine cavity Offensive retained necrotic Empty but lined with

parts. purulent membrane.
Lochia is excessive and offensive Scanty and not offensive.

Clinical picture 4 days after delivery there is 1-2 days after delivery with
fever, tachycardia, rigors and more severe manifestations.
malaise.
 Other Common Sites
■ Infected lacerations- The wound edges are
red, edematous and extruding greenish or
yellowish offensive pus.

■ Parametritis and pelvic cellulitis

■ Salpingo-ophritis

■ Peritonitis

■ Thrombophlebitis

■ Septicemia
Prevention
 Antenatal

■ Proper diet , vitamins and minerals.

■ Anemia and diabetes should be treated.

■ Local or distant infection should be treated.

■ Avoid sexual intercourse late in pregnancy.

 Intranatal
■ Strict aseptic and antiseptic measures for the
patient, attendants and instruments.

■ Minimize vaginal examinations.

■ Avoid bleeding and excessive blood loss should

be replaced.

■ Lacerations should be properly sutured

immediately.

■ Prophylactic antibiotics in PROM and prolonged

or instrumental delivery.
 Postnatal
■ Maintenance of aseptic precautions.

■ Care of the perineal or abdominal wounds.

■ Minimize visitors and keep whom are

infected away.

■ Early isolation of cases of puerperal

sepsis.
Treatment
 General Treatment
■Isolation in a separate room

■Diet: light diet rich in vitamins and minerals with plenty

of fluids.

■Supportive treatment: restoration of fluid and electrolyte

balance

■ Symptomatic treatment:

– - Analgesics,

■Observations : pulse, temperature, blood pressure,

vaginal bleeding, lochia , manifestations of DVT.
Breast Disorders in
Puerperium
 Breast Engorgement
■Usually occurs in the 3rd day after
delivery when secretion of milk begins.

Clinical picture:
■- Breasts are over distended with
visible dilated veins.

■- Breasts are painful and tender.

■- Pyrexia may develop.

 Treatment
■ Breast evacuation: in early stage
baby suckling can be sufficient

■ Cold fomentations may

occasionally needed and there is
no risk of suppressing lactation.

■ Analgesics -antipyretics.
 Deficient Lactation
Causes:
■ Constitutional.        

■ Bad general condition and

malnutrition.

■ Infrequent or irregular suckling.

Treatment:
■ Regular breast feeding.     

■ Good diet and plenty of fluids.

 Cracked Nipples
Causes:
■ Lack of cleanness and dryness of the nipples.

■ Vigorous suckling of a hungry baby in deficient

lactating breasts.

■ Leaving the baby too long at the breast.

■ Repeated taking and leaving the nipple by the baby

to breathe if its nose is obstructed by the breast.

■ Monilial infection.

Treatment:
■ Rest

■ Hot fomentations.

■ Panthenol ointment or flavine in liquid paraffin:

applied locally.
 Acute Mastitis
Causative organism:
■Staphylococcus aureus which may reach the breast from
infected baby.

Clinical picture:
■Breast is painful, tender, red , tense and hot.

■ Axillary lymph nodes are enlarged.

■High fever may reach 40.5oC.

Treatment:
■Stop lactation

■ Support the breast: over a pad of cotton wall.

■Antibiotic therapy

■Analgesics - antipyretics.
POSTPARTUM PSYCHIATRIC DISORDER
 Cause
❑ exact cause is unknown though some
contributing factors are accepted:

✓Due to the stress of peripartum period

characterized by sudden decrease in the
endorphins, estrogen, and progesterone
levels

✓Low free serum tryptophan levels

✓Postpartum thyroid dysfunction

 RISK FACTORS:
• Unwanted pregnancy
• Feeling unloved by mate
• Below 20 years old
• Single mother
• Low self-esteem
• Dissatisfaction of extent of education
• Economic problem with housing or income
• Poor relationship with husband or
boyfriend
• Being part of a family with 6 or more
siblings
• Limited parental support
• Past or present evidence of emotional
problem
 CLASSIFICATION

1. Postpartum blues
2. Postpartum depression
3. Postpartum psychosis
 Post Partum Blues
■50-70% incidence.
■A transient disorder that occurs 2-3 days after delivery, peaking on
the 5th day and usually resolves within 10 to 14 days
■Manifestations:
– Mood lability, weeping, depression, fatigue, anxiety, confusion,
difficulty concentrating, depersonalization.
■ Cause:
❑ hormonal changes after delivery
■ Risk factor:
1. History of depression
2. Pre-existing psychosocial impairment
 MANAGEMENT:

✓PPB is self limiting and has little effect on

the woman’s ability to carry out her normal
daily functions in majority of cases.

✓Supportive care education

✓If symptoms do not disappear within or

become increasingly severe, refer for
psychiatric evaluation and counseling.
 POSTPARTUM DEPRESSION
➢ More prolonged affective disorder that often
occurs during the first month after delivery and
last for weeks to months.
Risk factors
1. Postpartum blues
2. History of postpartum depression
3. History of mood disorder or premenstrual dysphoric
disorder
4. Family history of depression, bipolar illness, and/or
anxiety.
5. Marital dissatisfaction
6. Anxiety/depression during pregnancy
7. Infant-related stressors
8. Adverse life event stressors
9. Inadequate support from family or friends
 Management

✓Screening
✓Individual counseling
✓Group therapy
✓Therapeutic communication
✓Provide assistance in performing
activities of daily living
✓Support groups
✓Monitor for signs of suicidal tendencies
when depression sets in and when the
patient begin to recover
✓Medications
 Post Partum Depression
⦿ Incidence 4-10%.
⦿ Onset within days to weeks following delivery.
⦿ Risk factors: previous depression, unsupportive home
environment
⦿ Presents with vegetative signs of depression, tear fullness,
anxiety, loss of interest in normal activities, guilt, inadequacy
in coping with the infant duration, thoughts of suicide.
⦿ Duration > 2 w.
⦿ Consider imipramine, amitryptyline 100-300 mg qd. (response
takes 2-4 w) for 6 months, psychiatric consult. Tends to recur
 Post Partum Psychosis
Incidence 0.1-0.2 %

■Most severe and the rarest postpartum psychiatric disorder.

■Acute onset 2-3d to 4 w after delivery (manic-depressive type
occurs early, schizophrenic type later).

■ Risk factors:

History of psychosis, Previous puerperial psychosis, History of

manic depressive disorder, Obsessive personality, Family
history of mod disorder, Prenatal stressors
■ Manifestations:
Auditory hallucinations, delusions, euphoria, grandiosity,
hyperactivity, inappropriate affect. High risk of infanticide. 50%
chance of developing psychosis in future.
 Management

✓Hospitalization if patients
exhibits hallucinations and
delusions.
✓Removal of infant from the
mother
✓Medications
✓Electroconvulsive therapy, the
last resort if other treatment fails.
✓Psychotherapy