POSTPARTUM COMPLICATIONS

Despite the normalcy of childbirth, complications may arise that will have detrimental effects on the postpartum patient. In the week after delivery, leading causes of death included high blood pressure, infection, and severe bleeding. About 33% of maternal deaths happen one week to one year postpartum (CDC, 2019b). Healthcare professionals working with postpartum patients must have a clear understanding of these complications, including the signs and symptoms, nursing interventions, and treatment.

Postpartum Hemorrhage (PPH)

Postpartum hemorrhage is one of the leading causes of death among postpartum women. Traditionally, PPH has referred to a blood loss of ≥500 mL after a vaginal birth and ≥1,000 mL after a C-section. In 2017, the American College of Obstetricians and Gynecologists revised their definition to be a cumulative blood loss ≥1,000 mL, or bleeding associated with signs/symptoms of hypovolemia within 24 hours of the birth process (ACOG, 2017).

Postpartum hemorrhage is categorized as early or late. Early refers to a hemorrhage occurring within the first 24 hours after birth, while late refers to a hemorrhage occurring 24 hours to 12 weeks after delivery. PPH affects approximately 3% of deliveries and is on the rise (Belfort, 2022).

CAUSES AND INTERVENTIONS

Late postpartum hemorrhage is often caused by diffuse uterine atony or subinvolution of the uterus (uterus not returning to its normal size) caused by retained placental fragments and/or infection that prevent the uterus from contracting. In the case of retained placental fragments, clots develop around the retained fragments and hemorrhaging can occur days later when the clots are shed. The certified nurse-midwife or physician is responsible for examining the placenta after delivery and ensuring that it is intact; therefore, a late PPH is usually preventable.

Assessment and manual expression of placental fragments by the physician or nurse-midwife can often alleviate the problem; however, surgical intervention, such as a dilation and evacuation (D&E), may be necessary. With subinvolution and a late PPH, fundal massage, in addition to medications may be used to minimize bleeding. (The California Maternal Quality Care Collaborative [CMQCC, 2022] has created the OB Hemorrhage Toolkit to assist providers and clinical staff in recognizing and responding to hemorrhage.)

Thrombophlebitis

Patients can suffer from thrombophlebitis as a result of venous stasis and the normal hypercoagulability state of the postpartum period. Thrombophlebitis is an inflammation of the blood vessel wall in which a blood clot forms and causes problems in the superficial or deep veins of the lower extremities or pelvis.

The blood clot that develops in thrombophlebitis can lead to a life-threatening pulmonary embolism as a result of the clot detaching from the vein wall and blocking the pulmonary artery. The major signs of pulmonary embolism include dyspnea and chest pain.

In monitoring postpartum patients for the development or presence of thrombophlebitis, nurses assess for the presence of hot, red, painful, or edematous areas on the lower extremities or groin area. An elevated temperature may also be present. It is contraindicated to assess for a thrombophlebitis by eliciting a Homan’s sign.

Interventions to treat thrombophlebitis depend on the severity of the thrombosis. Usually, for superficial thrombosis, analgesics, bed rest, and elevation of the affected limb are enough to alleviate the problem. However, in the presence of a DVT, anticoagulants may be necessary. In addition to using compression stockings and applying warm, moist heat, patients are instructed to keep their legs elevated and uncrossed and to ambulate only after symptoms subside.

Infections

Postpartum infections are infections accompanied by a temperature of 38 °C or higher on two separate occasions during the first 10 days postpartum, exclusive of the first 24 hours (when low-grade fever is common and self-limited) (Berens, 2022a). Postpartum patients are carefully monitored for signs and symptoms of infection during this period. Common infections that may occur during the postpartum period include mastitis, endometritis, wound infections, and urinary tract infections.

MASTITIS

Mastitis is a localized, painful infection of the breast, which can progress to an abscess if not treated properly. It typically presents as a red, painful, firm, swollen area of one breast with accompanying fever >38.3 °C. The patient may also complain of myalgia, chills, malaise, and flu-like symptoms (Dixon, 2022).

Mastitis is less likely to occur with complete emptying of the breast and good breastfeeding technique. Thus, it is crucial that postpartum nurses teach breastfeeding patients proper latch-on technique and that they stress regular breastfeeding and allowing the breast to empty completely. Breastfeeding patients are also encouraged to avoid missed feedings and allowing the breast to become engorged.

Treatment for mastitis typically involves antibiotic therapy and regular breastfeeding or pumping the breast. Nurses can encourage these patients to apply cold or warm compresses to ease discomfort and to take analgesics as needed. Mastitis usually resolves quickly as long as patients continue to breastfeed or pump regularly.

ENDOMETRITIS

Endometritis is an infection of the uterus characterized by postpartum fever, midline lower abdominal pain, and uterine tenderness. Purulent lochia, chills, headache, malaise, and/or anorexia may also be present (Chen, 2022).

Endometritis is usually treated with broad-spectrum intravenous antibiotics and rest. Blood cultures to identify the causative organism of endometritis are performed if the patient does not respond to empiric therapy. White blood cell (WBC) counts are monitored. However, it is important to remember that the white blood cell count is normally elevated after delivery for a short period; continued monitoring of the WBC count is required in identifying endometritis and is likely to show a left shift and increasing number of neutrophils.

WOUND INFECTIONS

Commonly affected wound sites during the postpartum period include the perineum due to lacerations and episiotomies, and C-section incisions. As with all infections, every patient is at risk.

Wound infections typically exhibit redness, warmth, poor wound approximation, tenderness, and pain. If untreated, these patients may develop a fever and other symptoms of an infection, such as malaise. Blood cultures may be obtained to isolate the causative organism. Antibiotics will typically be administered, and drainage of the wound may be necessary.

Patients are taught proper handwashing and encouraged to maintain adequate fluid intake and increased protein intake to assist in wound healing. Wound infections can be intensely painful, especially in the perineum. Therefore, the nurse assists these patients in managing pain through the use of analgesics and positioning.

URINARY TRACT INFECTIONS (UTIs)

The risk of developing a UTI is high during the postpartum period. A woman’s urethra and bladder are often traumatized during labor and birth due to intermittent or continuous catheterizations and the pressure of the infant as it passes through the birth canal. Additionally, the bladder and urethra lose tone after delivery, making the retention of urine and urinary stasis common. Women may also develop a UTI due to epidural anesthesia or vaginal procedures (Berens, 2022a).

Patients with urinary tract infections often complain of frequent, urgent, and/or painful urination with suprapubic pain. A low-grade fever and hematuria may also be present. Urinary tract infections are treated with antibiotics, and it is important that these patients drink adequate fluids to flush bacteria out of the system.

Postpartum Depression

Postpartum depression is a serious and debilitating depression that affects many women throughout the world. Postpartum depression occurs in approximately 9% of women after delivery.

Symptoms are generally noted within the first three months but may occur up to a year after delivery. They typically include changes in sleep, energy, appetite, weight, and libido. Other symptoms include lack of energy to the point of not getting out of bed for hours; but this should be distinguished from the normal lack of energy that results from sleep deprivation of caring for an infant. Additional symptoms include anxiety and panic attacks; irritability and anger; feeling inadequate, overwhelmed, or unable to care for the baby; and feelings of shame, guilt, and having failed as a mother (Viguera, 2022).

Adverse outcomes of postpartum depression can include impaired bonding, impaired infant and child development, interference in the relationship with one’s partner, suicidal ideation, and infanticide (Viguera, 2022).

It is the responsibility of nurses to assess postpartum patients for signs and symptoms of postpartum depression. Various assessment tools are available, including the Edinburgh Postnatal Depression Scale (EPDS). This tool is quick and provides a simple means to assess patients while at the hospital, during postpartum home visits, and during postpartum follow-up clinic visits. This tool can also be used to assess mothers at pediatric follow-up visits. (See “Resources” at the end of this course.)

After screening and assessment, women who are at risk for developing (or who are suffering from) postpartum depression can be referred to the appropriate healthcare professional for follow-up and treatment. Treatment may include a combination of psychotherapy, social support, and medication. Nurses can support these patients in the healing process at follow-up appointments and during home visits, including encouraging adequate nutrition, rest, relaxation, and exercise.

Hypertension

Postpartum hypertension has been seen in as many as 20% of all postpartum individuals. It can be prolonged gestational hypertension/preeclampsia or new onset (August, 2022). Postpartum treatment is similar to treatment during pregnancy with the use of antihypertensives and/or magnesium sulfate (in the setting of preeclampsia). Additionally, furosemide may be used.

Postpartum patients must be educated on the signs and symptoms of hypertension/preeclampsia including headaches and visual changes.