Postpartum complications: Nursing

The postpartum period, also known as the fourth stage of labor, begins after delivery of the fetus and placenta, and it extends through the first six weeks after birth. Several complications can arise during the postpartum period, including postpartum hemorrhage, thromboembolic disorders, and infection. 

Now, postpartum hemorrhage is defined as cumulative blood loss of 1,000 mL or more, or blood loss that’s accompanied by signs or symptoms of hypovolemia within 24 hours after birth. Common causes can be remembered by the four Ts, including tone for uterine atony, or weak uterine muscle tone, which includes subinvolution, meaning the return of the uterus to its nonpregnant state is impaired; trauma to the birth canal, such as lacerations or hematomas; tissue, meaning retention of placental fragments; and thrombin, representing coagulation deficiencies, like von Willebrand disease. Other causes include placenta previa, or when the placenta is abnormally implanted over the cervix; and placenta accreta or abnormal placental adherence to the uterine wall.  

Signs and symptoms of hemorrhage may include a soft or displaced uterus and saturating one or more peri-pads per hour. If the hemorrhage is concealed within a hematoma, there could be severe perineal pain or rectal pain; a discolored bulging mass in the perineum; and abnormal vital signs like tachycardia.  

Treatment depends on the cause and may include fundal massage; bimanual compression of the uterus; uterotonic, antifibrinolytic, and analgesic medications; IV fluid and blood product administration; or surgery, like uterine artery ligation, hematoma repair, or hysterectomy.  

When caring for your patient with postpartum hemorrhage, closely monitor their vital signs, pain, skin color and temperature, and urine output. Assess their uterine tone and perform fundal massage to keep the uterus firmly contracted. Monitor the color and amount of lochia, or vaginal discharge, and weigh all blood-soaked pads and linens to quantify blood loss, remembering that one gram of weight equals one milliliter of volume. Also monitor their urine output to prevent a full bladder that can interfere with uterine involution.  

As prescribed, administer medications, IV fluids, blood products, and supplemental oxygen; insert an indwelling urinary catheter, and collect laboratory specimens, like CBC, coagulation panel, and blood type and crossmatch. Also, maintain bed rest and elevate your patient’s legs to increase blood return, and provide emotional support and reassurance.  
 Thromboembolic disorders include deep vein thrombosis, or DVT, where a thrombus, or clot, forms in a major vein, most commonly in the lower extremities; and pulmonary embolism, or PE which can happen when the thrombus dislodges and is carried to the pulmonary artery where it obstructs blood flow in the lungs. Now, keep in mind, all postpartum patients are at increased risk of excessive clotting because, during pregnancy, there’s an increase in clotting factors and suppression of the fibrinolytic system.