prof. saadya hadi

1. Nursing Care of Women with
Complications After Birth
Prof.Saadya Hadi Humade

2. KEY TERMS:
atony (ĂT-ŏ-nē,):
curettage (KYŪ-rĕ-tăhzh:
endometritis (ĕn-dō-mē-TRĪ-tĭs,)
hematoma (hē-mă-TŌ-mă)
hypovolemic shock (hī-pō-vō-LĒ-mĭk shŏk,)
involution (ĭn-vō-LŪ-shŭn,)
mania (MĀ-nē-ă,)
mastitis (măs-TĪ-tĭs,)
mood)
psychosis (sī-KŌ-sĭs,
puerperal sepsis (pū-ĔR-pŭr-ăl SĔP-sĭs,
subinvolution (sŭb-ĭn-vō-LŪ-shŭn,

3. A woman can have any medical problem after a birth, but most
complications related to childbirth fall into one of six categories:
1. Shock
2. Hemorrhage
3. Thromboembolic disorders
4. Puerperal infections
5. Subinvolution of the uterus
6. Mood disorders

4. Shock Shock is defined as a condition in which the cardiovascular
system fails to provide essential oxygen and nutrients to the cells.
Postpartum shock related to childbearing includes the following:
• Cardiogenic shock: Caused by pulmonary embolism, anemia,
hypertension, or cardiac disorders
• Hypovolemic shock: Caused by postpartum hemorrhage or blood
clotting disorders
• Anaphylactic shock: Caused by allergic responses to drugs
administered
• Septic shock: Caused by puerperal infection The inherent danger of
obstetric shock is that body compensation can mask the signs until the
condition becomes life-threatening.
The vigilance of the nurse can enable detection of early signs and then
prompt intervention.

5. Hemorrhage:
• Postpartum hemorrhage is traditionally defined as blood loss greater than
500 mL after vaginal birth or 1000 mL after cesarean birth, resulting in
signs or symptoms of hypovolemia.
• Because the average-sized woman has 1 to 2 liters of added blood volume from
pregnancy, she can tolerate up to these amounts of blood loss better than would
otherwise be expected.
• Most cases of hemorrhage occur immediately after birth, but some are delayed
up to several weeks.
• Early (primary) postpartum hemorrhage occurs within 24 hours of birth.
• Late postpartum hemorrhage occurs after 24 hours and within 6 weeks
after birth.
• The major risk of hemorrhage is hypovolemic (low-volume) shock, which
interrupts blood flow to body cells.
• This prevents normal oxygenation, nutrient delivery, and waste removal at the
cellular level.
• Although a less dramatic problem, anemia is likely to occur after hemorrhage.
• Postpartum hemorrhage is a leading cause of postpartum death around the world.
• Hypovolemic shock Hypovolemic shock occurs when the volume of blood is
depleted and cannot fill the circulatory system.
• The woman can die if blood loss does not stop and if the blood volume is not
corrected.

6. Body’s Response to Hypovolemia :
• The body initially responds to a reduction in blood volume with increased
heart and respiratory rates.
• These reactions increase the oxygen content of each erythrocyte (red blood
cell) and cause faster circulation of the remaining blood.
• Tachycardia (a rapid heart rate) is usually the first sign of inadequate blood
volume (hypovolemia).
• The first blood pressure change is a narrow pulse pressure (a falling systolic
pressure and a rising diastolic pressure).
• The blood pressure continues falling and eventually cannot be detected.
• Blood flow to nonessential organs gradually stops, to make more blood
available for vital organs, specifically the heart and brain.
• This change causes the woman’s skin and mucous membranes to become
pale, cold, and clammy (moist).
• As blood loss continues, flow to the brain decreases, resulting in mental
changes, such as anxiety, confusion, restlessness, and lethargy.
• As blood flow to the kidneys decreases, they respond by conserving fluid.
• Urine output decreases and eventually stops.

7. Medical Management :
Medical management of hypovolemic shock resulting from hemorrhage
may include any of the following actions:
• Stopping the blood loss
• Giving intravenous (IV) fluids to maintain the circulating volume and
to replace fluids
• Giving blood transfusions to replace lost erythrocytes
• Giving oxygen to increase the saturation of remaining blood cells; a
pulse oximeter is used to assess oxygen saturation of the blood
• Placing an indwelling (Foley) catheter to assess urine output, which
reflects kidney function
• Uterine massage and administration of drugs to contract the uterus
(e.g., oxytocin)

8. Nursing care:
1. Routine postpartum care involves assessing vital signs every 15 minutes
until stable so that the signs of postpartum hemorrhage are identified as
early as possible.
2. The woman should be observed closely for early signs of shock, such as
tachycardia, pallor, cold and clammy hands, and decreased urine output.
Decreased blood pressure may be a late sign of hypovolemic shock.
3. Routine frequent assessment of lochia in the fourth stage of labor helps
identify early postpartum hemorrhage.
4. When the amount and character of the lochia are normal and the uterus is
firm, but signs of hypovolemia are still evident, the cause may be a large
hematoma.
5. Excessive bright red bleeding despite a firm fundus may indicate a cervical
or vaginal laceration.
6. The occurrence of petechiae, bleeding from venipuncture sites, or oliguria
may indicate a blood clotting problem. In the first hours postpartum, the
perineal pad should be weighed to determine the output amount:
7. 1 g equals 1 mL .
8. Intake and output should be recorded and IV therapy monitored.
9. Oxygen saturation levels are also monitored in early postpartum
hemorrhage.

9. Safety Alert! :
1. Saturation of a peripad within 15 minutes to 1 hour after
delivery must be promptly reported.
2. Careful explanations to the mother and family are essential,
and providing emotional support and maintaining the integrity
of the woman’s support system are key nursing roles.
3. Even if the mother is separated from her infant, information
concerning the infant’s condition should be readily accessible.
Rooming-in should be established as soon as the woman’s
condition permits.
4. Intensive care may be required to allow invasive
hemodynamic monitoring of the woman’s circulatory status.

10. Nursing Care Plan :’
• The Woman with Postpartum Hemorrhage Patient data A woman is
admitted to the postpartum unit.
• She appears anxious and frightened, and her lochia has saturated three
perineal pads in the past hour.
• Selected Nursing Diagnosis Risk for hypovolemic shock related to
excessive blood loss

11. Early (primary) postpartum hemorrhage Early postpartum
hemorrhage results from one of three causes:
• Uterine atony (the most common cause)
• Lacerations (tears) of the reproductive tract
• Hematomas in the reproductive tract

13. Uterine Atony :
• Atony describes a lack of normal muscle tone.
• The postpartum uterus is a large, hollow organ with three layers of muscle.
• The middle layer includes interlacing figure-eight fibers.
• The uterine blood supply passes through this network of muscle fibers to
supply the placenta.
• After the placenta detaches, the uterus normally contracts and the muscle
fibers compress bleeding vessels.
• If the uterus is atonic, however, these muscle fibers are flaccid and do not
compress the vessels.
• Uterine atony allows the blood vessels at the placenta site to bleed freely
and usually massively.
• Uterine overdistention, retained placental fragments, prolonged labor, or
the use of drugs during labor that relax the uterus may cause atony.

15. • Normal postpartum changes After a full-term birth, the uterus should easily
be felt through the abdominal wall as a firm mass about the size of a grapefruit.
• After the placenta is expelled, the fundus of the uterus is at the umbilicus level
and then begins descending at a rate of about 1 finger’s width (1 cm) each day.
Lochia rubra should be dark red.
• The amount of lochia during the first few hours should be no more than one
saturated perineal pad per hour.
• A few small clots may appear in the drainage, but large clots are not normal.

16. Characteristics of uterine atony :
• When uterine atony occurs, the woman’s uterus is difficult to feel and,
when found, feels boggy (soft).
• The fundal height is high, often above the umbilicus.
• If the bladder is full, the uterus is higher and pushed to one side rather
than located in the midline of the abdomen .
• The uterus may or may not be soft if the bladder is full. A full bladder
interferes with the ability of the uterus to contract and, if not corrected,
eventually leads to uterine atony.
• Lochia is increased and may contain large clots.
• The bleeding may be dramatic but may also simply be slightly above
normal for a long time.
• Some lochia will be retained in the relaxed uterus, because the cavity is
enlarged; thus, the true amount of blood loss may not be immediately
apparent.

17. • Collection of blood in the uterus further interferes with contraction and
worsens uterine atony and postpartum hemorrhage
• A woman who has risk factors for postpartum hemorrhage should have
more frequent postpartum assessments of the uterus, lochia, and vital
signs.

18. Medical management and nursing care :
Care of the woman with uterine atony .
• When the uterus is boggy, it should be massaged until firm but it should not be
overly massaged.
• Because the uterus is a muscle, excessive stimulation to contract it will tire it
and can actually worsen uterine atony.
• If the uterus is firmly contracted, it should be left alone.
• Bladder distention is an easily corrected cause of uterine atony.
• The nurse should catheterize the woman if she cannot urinate on the toilet or in
a bedpan.
• Pressing toward the vagina should expel any clots or blood pooled in the
vagina after the uterus is firm.
• Most health care providers include an order for catheterization to prevent
delaying this corrective measure.
• First the uterus is massaged to firmness, and then the bladder is emptied to
keep the uterus firm.
• The infant suckling at the breast stimulates the woman’s posterior pituitary
gland to secrete oxytocin, which causes uterine contraction.
• A dilute oxytocin (Pitocin) IV infusion is the most common drug ordered to
control uterine atony.

19. • Other drugs to increase uterine tone include methylergonovine
(Methergine) and prostaglandins (e.g., Hemabate or Cytotec).
• Methylergonovine increases blood pressure and should not be given to a
woman with hypertension.
• Excessive bleeding may also be managed by providing a uterine tamponade
(packing), using an intrauterine balloon, selective arterial embolization, or
surgical ligation of the artery.
• Intravenous calcium gluconate may be used to counteract a tocolytic drug
that may have been administered to relax the uterus during labor.
• The health care provider may examine the woman in the delivery or
operating room to determine the source of her bleeding and to correct it.
• Rarely, a hysterectomy is needed to remove the bleeding uterus that does
not respond to any other measures.
• The woman should have nothing by mouth (NPO) until her bleeding is
controlled.

20. Safety Alert! :
• The woman who develops a hemorrhagic complication should be kept on
NPO status until the health care provider evaluates her condition, because
she may need general anesthesia for correction of the problem.
• Lacerations of the Reproductive:
• Tract Lacerations of the perineum, vagina, cervix, or area around the
urethra (periurethral lacerations) can cause postpartum bleeding.
• The vascular beds are engorged during pregnancy, and bleeding can be
profuse. Trauma is more likely to occur if the woman has a rapid labor or
if forceps or a vacuum extractor is used.
• Blood lost in lacerations is usually a brighter red than lochia and flows in
a continuous trickle. Typically, the uterus is firm.
• Treatment The health care provider should be notified if the woman has
signs of a laceration, such as bleeding with a firmly contracted uterus.
• The injury is usually sutured in the delivery or operating room.

21. • Nursing care Signs and symptoms of a bleeding laceration should be
reported. A continuous trickle of blood can result in as much or more
blood loss than the dramatic bleeding associated with uterine atony.
• The woman should be kept on NPO status until further orders are
received, because she may need a general anesthetic for repair of the
laceration.
• Genital trauma can cause long-term effects, such as cystocele, a
prolapsed uterus, or urinary incontinence .

22. Hematomas of the Reproductive Tract :
• A hematoma is a collection of blood within the tissues.
• Hematomas resulting from birth trauma are usually on the vulva or inside the
vagina.
• They may be easily seen as a bulging bluish or purplish mass.
• Hematomas deep within the vagina are not visible from the outside.
• Discomfort after childbirth is normally minimal and easily relieved with mild
analgesics.
• The woman with a hematoma usually has severe, unrelenting pain that analgesics
do not relieve.
• Depending on the amount of blood in the tissues, she also may describe pressure in
the vulva, pelvis, or rectum.
• She may be unable to urinate because of the pressure.
• The woman does not have unusual amounts of lochia, but she may develop signs
of concealed blood loss if the hematoma is large.
• Her pulse and respiratory rates rise, and her blood pressure falls.

23. • She may develop other signs of hypovolemic shock if blood loss into the tissues
is substantial.
• for risk factors for the development of a hematoma. Treatment Small hematomas
usually resolve without treatment. Larger ones may require incision and
drainage of the clots.
• The bleeding vessel is ligated or the area packed with a hemostatic material to
stop the bleeding.
Nursing care :
• An ice pack to the perineum is sufficient for most small perineal hematomas and
requires no physician prescription.
• The nurse should observe for and report the classic symptom – excessive, poorly
relieved pain.
• Signs of concealed blood loss accompanied by maternal complaints of severe
pain, perineal or vaginal pressure, or inability to void should be reported.
• The woman is kept NPO until the health care provider examines her and
prescribes treatment.
• Medication to support clot formation In addition to the specific interventions for
specific causes of postpartum hemorrhage, the medication tranexamic acid can
be used to inhibit the breakup of clots that form; this supports the developing
blood clot that is necessary to control hemorrhage. However, the drug must be
administered within 3 hours of delivery .

24. Late postpartum hemorrhage:
• Late postpartum hemorrhage (bleeding that occurs 24 hours to 6 weeks
after childbirth) usually occurs after discharge from the hospital and usually
results from the following:
• • Retention of placental fragments
• • Subinvolution of the uterus Placental fragments are more likely to be
retained if the placenta does not separate cleanly from its implantation site
after birth or if there is disruption of the placental scab.
• Clots form around these retained fragments and slough several days later,
sometimes carrying the retained fragments with them.
• Retention of placental fragments is more likely to occur if the placenta is
manually removed (removed by hand rather than being pushed away from
the uterine wall spontaneously as the uterus contracts).
• These placental fragments are also more likely to exist if the placenta grows
more deeply into the uterine muscle than is normal.

25. Treatment :
1. Treatment consists of the administration of drugs such as oxytocin,
methylergonovine, or prostaglandins (e.g., carboprost) to contract the
uterus.
2. Firm uterine contraction often expels the retained fragments, and no other
treatment is needed.
3. Ultrasonography may be used to identify remaining fragments.
4. If bleeding continues, curettage (scraping or vacuuming of the inner
surface of the uterus) is performed to remove small blood clots and
placental fragments.
5. This procedure is known as dilation and curettage (D&C) or dilation and
evacuation (D&E). Antibiotics are prescribed if infection is suspected.

26. Nursing care :
The nurse should teach each postpartum woman what to expect about
changes in the lochia .
The woman should be instructed to report the following signs of late
postpartum hemorrhage to her health care provider:
• Persistent bright red bleeding
• Return of red bleeding after it has changed to pinkish or white If a late
postpartum hemorrhage occurs, the nurse assists in implementing
pharmacological and surgical treatment.

27. Subinvolution of the uterus Involution is the return of the uterus
to its nonpregnant condition after birth.
• The muscles of the uterus contract and constrict the blood
vessels at the placental site, stopping the bleeding.
• Normally the uterus descends at the rate of 1 cm (1 finger’s
width) per day and is no longer palpable by 12 days postpartum.
• The placental site heals by 6 weeks postpartum.
• Subinvolution is a slower than expected return of the uterus to
its nonpregnant condition.
• Infection and retained fragments of the placenta are the most
common causes.

28. Typical signs of subinvolution include the following:
• Fundal height greater than expected for the amount of time since birth
• Persistence of lochia rubra or a slowed progression through the three
phases
• Pelvic pain, heaviness, fatigue Treatment Medical treatment is selected
to correct the cause of the subinvolution.
It may include the following:
• Methylergonovine (Methergine) to maintain firm uterine contraction
• Antibiotics for infection
• Dilation of the cervix and curettage to remove fragments of the placenta
from the uterine wall

29. Nursing care :
1. The mother will almost always have been discharged when subinvolution
of the uterus occurs.
2. All new mothers should be taught about the normal changes to expect so
they can recognize a departure from the normal pattern.
3. Women should report fever, persistent pain, persistent red lochia (or return
of bleeding after it has changed), or foul-smelling vaginal discharge.
4. The woman should be taught how to palpate the fundus and what normal
changes to expect.
5. The woman may be admitted to the hospital on the gynecology unit.
6. Nursing care involves assisting with medical therapy and providing
analgesics and other comfort measures.
7. Specific nursing care depends on whether the subinvolution results from
infection or another cause.

30. Thromboembolic disorders :
• A venous thrombosis is a blood clot within a vein. It occurs in 1 in 1500
pregnancies .
• The size of the clot can increase as circulating blood passes over it and
deposits more platelets, fibrin, and cells. It often causes an inflammation of the
vessel wall.
• The pregnant woman is at increased risk for venous thrombosis because of the
venous stasis that can occur from compression of the blood vessels by the
heavy uterus or by pressure behind the knees when the legs are placed in
stirrup leg supports for episiotomy repair.
• Blood vessel injury during cesarean section can also cause a thrombus.
• The levels of fibrinogen and other clotting factors normally increase during
pregnancy, whereas levels of clot-dissolving factors (e.g., plasminogen
activator and antithrombin III) are normally decreased, resulting in a state of
hypercoagulability (an increased susceptibility to developing blood clots).
• If the woman has varicose veins or remains on bed rest, her state of
hypercoagulability places her at increased risk for thrombus formation.
• Preventive measures include the use of pneumatic compression devices on the
lower extremities or prophylactic heparin for women undergoing cesarean
sections or who are on prolonged bed rest

31. There are three types of thromboembolic disorders:
1. Superficial venous thrombosis (SVT) involves the saphenous vein of the
lower leg and is characterized by a painful, hard, reddened, warm vein that is
easily seen.
2. Deep venous thrombosis (DVT) can involve veins from the feet to the femoral
area and is characterized by pain, calf tenderness, leg edema, color changes, pain
when walking, and sometimes a positive Homans’ sign (pain when the foot is
dorsiflexed), although the Homans’ sign is not always reliable during the
postpartum period because it is not specific to blood clots postpartum.
An increase in leg circumference greater than 2 cm accompanied by redness,
tenderness, and edema should be promptly reported.
The diagnosis is confirmed by ultrasound, with or without Doppler assistance.
3. Pulmonary embolism (PE) occurs when the pulmonary artery is obstructed by
a blood clot that breaks off (embolizes) and lodges in the lungs.
• It may have dramatic signs and symptoms, such as sudden chest pain, cough,
dyspnea (difficulty breathing), a decreased level of consciousness, and signs
of heart failure.
• A small pulmonary embolism may have nonspecific signs and symptoms,
such as shortness of breath, palpitations, hemoptysis (bloody sputum),
faintness, and a low-grade fever.

32. Treatment:
• Superficial venous thrombosis is treated with administration of analgesics,
local application of heat, and elevation of the legs to promote venous
drainage.
• Deep venous thrombosis is treated similarly, with the addition of
subcutaneous or IV anticoagulation drugs, such as heparin. Low-
molecularweight heparin (LMWH), such as Lovenox, may be used, because it
is long acting and requires less frequent doses and lab testing.
• LMWH anticoagulants are contraindicated with regional anesthesia.
• Medication Safety Alert! :
• The antidote for a warfarin overdose is vitamin K.

33. Nursing care :
• The woman should be observed before and after birth for signs and
symptoms that suggest venous thrombosis.
• Dyspnea, coughing, and chest pain suggest PE and must be reported
immediately. Prevention of thrombi is most important.
• Pregnant women should not cross their legs, because this impedes
venous blood flow.
• When the legs are elevated, there should not be sharp flexion at the
groin or pressure in the popliteal space behind the knee, which would
restrict venous flow.
• Measures to promote venous flow should be continued during and after
birth, because levels of clotting factors remain high for several weeks.
• Early ambulation or range-of-motion exercises are valuable aids to
preventing thrombus formation in the postpartum woman.
• Antiembolic stockings may be used if varicose veins are present.

34. • The nurse should teach the woman how to put on the stockings properly,
because rolling or kinking of the stocking can further impede blood flow.
• If stirrups are used during birth or episiotomy repair, they should be
padded to prevent pressure at the popliteal angle.
• The woman who will be undergoing anticoagulant therapy at home should
be taught how to give herself the drug and about signs of excess
anticoagulation (prolonged bleeding from minor injuries, bleeding gums,
nosebleeds, unexplained bruising).
• She should use a soft toothbrush and avoid minor trauma that can cause
prolonged bleeding or a large hematoma.
• Home nursing visits are often prescribed to obtain blood for laboratory
clotting studies and to help the woman cope with therapy.

35. Infections:
• Puerperal sepsis Puerperal sepsis is an infection or septicemia after
childbirth and is the fourth leading cause of maternal mortality.
• Tissue trauma during labor, the open wound of the placental insertion site,
surgical incisions, cracks in the nipples of the breasts, and the increased pH
of the vagina after birth are all risk factors for the postpartum woman.
• The fever is most often caused by endometritis, an inflammation of the
inner lining of the uterus.
• Blockage of the lochial flow because of retained placenta or clots increases
susceptibility to infection.
• The danger of postpartum infection is that a localized infection of the
perineum, vagina, or cervix can ascend the reproductive tract and spread to
the uterus, fallopian tubes, and peritoneum, causing peritonitis, which is a
life-threatening condition.
• Table 10.2 lists characteristics, medical treatment, and nursing care for
these infections. Regardless of their location or the causative organism,
postpartum infections have several common features.

37. Manifestations Puerperal:
1. (postpartum) fever is defined as a temperature of 38° C (100.4° F) or
higher after the first 24 hours and for at least 2 days during the first 10
days after birth.
2. Slight temperature elevations with no other signs of infection often
occur during the first 24 hours because of dehydration.
3. The nurse should look for other signs of infection if the woman’s
temperature is elevated, regardless of the time since delivery.
4. A pulse rate that is higher than expected and an elevated temperature
often occur when the woman has an infection.
5. Other signs and symptoms of infection may be localized (in a small area
of the body) or systemic (throughout the body).
6. The assessment of any C-section wound or episiotomy wound using the
REEDA criteria (redness, edema, ecchymosis, discharge,
approximation), or hardening of the operative area, should be promptly
reported and documented.
7. Fever, pain, a foul odor, or abnormal findings on routine

38. postpartum assessment must be reported to the health care provider.
• White blood cells (leukocytes) are normally elevated during the early
postpartum period to about 20,000 to 30,000 cells/mm3 , which limits the
usefulness of the blood count to identify infection.
• Leukocyte counts in the upper limits are more likely to be associated
with infection than lower counts.

39. Safety Alert!:
• Proper hand hygiene is the primary method to prevent the spread of
infectious organisms.
• Gloves should be worn when in contact with any blood or body fluid or
any other potentially infectious materials.
Treatment :
• The goals of medical treatment are to limit the spread of infection, to
prevent it from reaching the blood and other organs, and to eliminate the
infection.
• A culture and sensitivity sample from the suspected site of infection is
taken to determine the antibiotics that will be most effective.
• IV antibiotics may be ordered, and the woman may be placed on bed rest.

40. Nursing care :
Nursing care objectives focus on preventing infection and, if an infection occurs, on
facilitating medical treatment.
To achieve these goals, the nurse should do the following:
• Use and teach hygienic measures to reduce the number of organisms that can
cause infection (e.g., hand hygiene, perineal care).
• Promote adequate rest and nutrition for healing.
• Observe for signs of infection.
• Teach signs of infection that the woman should report after discharge.
• Teach the woman to take all of the antibiotics prescribed rather than stopping them
after her symptoms are eliminated.
• Teach the woman how to apply perineal pads (front to back).

41. • Women should be taught to wash their hands before and after performing
self-care that may involve contact with secretions.
• The nurse should explore ways to help the woman get enough rest.
• Ultimately, a woman’s own body must overcome infection and heal any
wound
• Nutrition is an essential component of her body’s defenses.
• The nurse, and sometimes a dietitian, should teach her about foods that are
high in protein (meats, cheese, milk, legumes) and vitamin C (citrus fruits
and juices, strawberries, cantaloupe), because these nutrients are especially
important for healing. Foods high in iron, to correct anemia, include meats,
enriched cereals and breads, and dark green, leafy vegetables.
• Mastitis and breastfeeding Mastitis is an infection of the breast.
• It usually occurs about 2 or 3 weeks after giving birth

42. Mastitis:
• and breastfeeding Mastitis is an infection of the breast.
• It usually occurs about 2 or 3 weeks after giving birth .
• Mastitis occurs when organisms from the skin or the infant’s mouth
enter small cracks in the nipples or areolae.
• These cracks may be microscopic.
• Breast engorgement and inadequate emptying of milk are
associated with mastitis.
• Mastitis often involves only one breast.

44. Signs and symptoms of mastitis include the following:
• Redness and heat in the breast
• Tenderness
• Edema and a heaviness in the breast
• Purulent drainage (may or may not be present) The woman usually has fever,
chills, and other systemic signs and symptoms.
• If not treated, the infected area becomes encapsulated (walled off) and an
abscess forms.
• The infection is usually outside the ducts of the breast, and the milk is not
contaminated.
• Treatment Antibiotics and the continued removal of milk from the breast are
the primary treatments for mastitis.
• Mild analgesics make the woman more comfortable.
• The woman may need an incision and drainage of the infected area and IV
antibiotics if an abscess forms.
• The mother can usually continue to breastfeed.
• If she should stop nursing for any reason, she should pump her breasts. She
should not wean her infant when she has mastitis, because weaning leads to
engorgement and stasis of milk, which worsens the mastitis.

45. Nursing care :
1. The nursing mother should be taught proper breast-feeding techniques to
reduce the risk for mastitis .
2. Nursing care for mastitis centers on relieving pain and on maintaining
lactation.
3. Heat promotes blood flow to the area, comfort, and complete emptying of
the breast. Moist heat can be applied with chemical packs.
4. Placing a warm, wet cloth in a plastic bag and applying it to the breasts can
create an inexpensive warm pack.
5. A warm shower taken just before nursing provides warmth and cleanliness
and stimulates the flow of milk.

46. Patient Teaching Mastitis :
• Wash hands thoroughly before breastfeeding.
• Maintain breast cleanliness with frequent breast pad changes.
• Expose nipple(s) to air when possible.
• Ensure correct newborn latch-on and removal from breast.
• Encourage the newborn to empty the breast, because milk provides a
medium for bacterial growth.
• Frequently breastfeed to encourage milk flow.
• If an area of the breast is distended or tender, breastfeed from the uninfected
side first at each feeding (to initiate let-down reflex in the affected breast).
• Massage distended area as the newborn nurses.
• Report redness and fever to health care provider.
• Apply ice packs or moist heat to relieve discomfort.

47. Both breasts should be emptied regularly to reduce milk stasis, which
increases the risk for abscess formation. If the affected breast is too painful
for the mother to breastfeed, she can use a breast pump to empty it.
She can massage the area of inflammation to improve milk flow and reduce
stasis.
Nursing first on the unaffected side starts the milk flow in both breasts and
can improve emptying with less pain.
Other nursing measures include the following:
• Encouraging fluid intake
• Advising the woman to wear a good support bra to support the breasts and
to limit movement of the painful breast; the bra should not be too tight or it
will cause milk stasis
• Supporting the woman emotionally and reassuring her that she can
continue to breastfeed

48. Mood disorders :
• “Postpartum blues” or “baby blues” are common after birth.
• The woman has periods when she feels let down, but overall, she finds
pleasure in life and in her new role as a mother.
• Her roller-coaster emotions are usually self-limiting as she adapts to the
changes in her life.
• A psychosis involves serious impairment of one’s perception of reality.
• Postpartum depression and postpartum psychosis are disorders that are
more serious than “postpartum blues.” Postpartum blues, also known as
an adjustment reaction, occur in about 75% of women, appearing on
day 5 and disappearing by day 10 .
• After childbirth, estrogen and progesterone levels decrease rapidly,
which leads to increased brain levels of monoamine oxidase-A (MAO-
A), which is related to the onset of postpartum depression.
• Research has shown that it is possible a nutritional supplement of
tryptophan, tyrosine, and blueberry juice counters the effects of
increased MAO-A levels and may prevent the development of
postpartum depression .

49. Postpartum depression:
there are three types of postpartum depression:
• adjustment disorder, also called the baby blues
• postpartum mood disorders
• postpartum depression Postpartum depression is a depressive illness that is
usually manifested within 2 to 4 weeks after delivery.
The onset of depression during this time may interfere with the mother’s ability to
respond to her infant’s cues and interferes with the developing maternal-infant
bonding. The nurse can promote the behaviors that improve mental health.
Risk factors for postpartum :
depression include inadequate social support, a poor relationship with the partner,
life and childcare stress, low self-esteem, and an unplanned pregnancy. Those
having close contact wit

50. Those having close contact with the woman notice the depression.
Signs and symptoms may include the following:
• Lack of enjoyment in life
• Disinterest in others; loss of normal give-and-take in relationships
• Intense feelings of inadequacy, unworthiness, guilt, inability to cope
• Loss of mental concentration; inability to make decisions
• Disturbed sleep or appetite
• Constant fatigue and feelings of ill health Postpartum depression strains the
coping mechanisms of the entire family at a time when all are adapting to the
birth of a child.
As a result of the strained relationships, communication is often impaired,
and the depressed woman may withdraw further, which distances her even
further from her support system.
The woman usually remains in touch with reality. The nurse should observe
for signs and symptoms during clinic visits.

51. Nursing Tip:
• If a postpartum woman seems depressed, the nurse should not assume
that she has the common “baby blues” or that she will “snap out of it.”
• Explore her feelings to determine if they are persistent and pervasive.
Treatment
• A combination of psychotherapy and antidepressants is often the course
of therapy, either in an outpatient or inpatient setting.
• Screening tools are available.
• The nurse provides support and observation of behavior, and is alert to
the possibility of self-harm by the woman.
• Light therapy (phototherapy) and exercise are complementary and
alternative (CAM) treatment strategies that may help in the management
of postpartum depression .
• The influence of hormones on mood changes before, during, and after
menstruation supports the theory that fluctuating hormone levels
postpartum may also have an effect on the woman’s mood.
• Referral for follow-up to available community mental health support
services and facilities is a nursing responsibility, to assure ongoing care
and support.

52. Postpartum psychosis Women experiencing a postpartum psychosis have an
impaired sense of reality.
Psychosis is much less common than postpartum depression.
A woman may have any psychiatric disorder, but two are most often
encountered: • Bipolar disorder: A disorder characterized by episodes of
mania (hyperactivity, excitability, euphoria, and a feeling of being
invulnerable) and depression
• • Major depression: A disorder characterized by deep feelings of
worthlessness and guilt, serious sleep and appetite disturbances, and
sometimes delusions about the infant being dead Postpartum psychosis
can be fatal for both mother and infant. The mother may endanger herself
and her infant during manic episodes, because she uses poor judgment
and has a sense of being invulnerable.
• Suicide and infanticide are possible, especially during depressive
episodes.
• In some cases, social workers within the community may refer the
woman for counseling.
• In other cases, an inpatient psychiatric treatment center is the appropriate
environment for treatment.

53. Get Ready for the NCLEX® Examination! Key Points •
The nurse must be aware of women who are at higher risk for postpartum
hemorrhage and assess them more often.
• A constant small trickle of blood can result in significant blood loss, as can
a larger one-time hemorrhage.
• Pain that is persistent and more severe than expected is characteristic of a
hematoma in the reproductive tract.
• It is essential to identify and limit a local infection before it spreads to the
blood or other organs.
• The nurse should teach new mothers about normal postpartum changes
and indications of problems that should be reported.
• Early ambulation can prevent thrombosis formation.
• Types of obstetric shock include cardiogenic (from anemia or cardiac
disorders), hypovolemic (from hemorrhage), anaphylactic (from a drug
response), and septic (caused by puerperal infection).
• Careful listening and observation can help the nurse identify a new
mother who is suffering from postpartum depression.
• Postpartum psychoses are serious disorders that are potentially life-
threatening to the woman and others, including her infant.

54. Review Questions for the NCLEX® Examination
1. The earliest finding in postpartum hypovolemic shock is usually:
1. low blood pressure.
2. rapid pulse rate.
3. pale skin color.
4. soft uterus.
2. A bleeding laceration is typically manifested by:
1. a soft uterus that is difficult to locate.
2. low pulse rate and blood pressure.
3. bright red bleeding and a firm uterus.
4. profuse dark red bleeding and large clots.
3. During the postpartum period the white blood cell (leukocyte) count is
normally: 1. higher than normal.
2. lower than normal.
3. unchanged.
4. unimportant.

55. 4. A postpartum mother who is breastfeeding has developed mastitis. She states
that she does not think it is good for her infant to drink milk from her infected
breast. The best response from the nurse would be to:
1. instruct her to nurse the infant from only the unaffected breast until the
infection clears up.
2. suggest that she discontinue breastfeeding and start the infant on formula.
3. encourage breastfeeding the infant to prevent engorgement.
4. apply a tight breast binder to the infected breast until the infection subsides.
5. A woman delivered her newborn several hours previously, and her uterus
remains soft and boggy. Which of the following medications should the nurse
anticipate that the health care provider would prescribe to increase uterine tone
and firm the uterus? (Select all that apply.)
1. Methylergonovine (Methergine)
2. Carboprost (Hemabate)
3. Magnesium sulfate
4. Oxytoxin (Pitocin)

56. 6. The nurse should be alert to subinvolution of the uterus as a cause of
late postpartum bleeding. Signs to report and document include (select all
that apply): a. fundal height higher than expected for date
b. persistence of lochia rubra
c. low blood pressure
d. persistence of lochia alba
1. c and d
2. a and d
3. a and b
4. b and c

57. thanks