• PIH
• DM
• Cardiac disease
• Cesarean birth
• Overdistention of uterus
• Precipitous labor
• Prolonged labor
• Difficult birth/ pushing

1. Postpartum hemorrhage (PPH)
2. Thromboembolitic disease
3. Postpartum infections

• Loss of:
• >500 mL blood after vaginal birth
• >1000 mL blood after cesarean birth
• 10% decrease in hematocrit b/w admission for labor and PP
• Need for erythrocyte transfusion
• Occurs in 18% of women

• Occurs in first 24 hours PP
• Causes:
• Uterine atony
• Lacerations of vaginal & cervical areas
• Retained placental fragments
• Vulvar, vaginal, or pelvic hematomas
• Uterine inversion

• Occurs from 24 hours to 6 weeks PP
• Causes:
• Subinvolution of placental site
• Endometritis
• Retention of placental fragments

• Make sure no placental fragments are retained
• Observe for uterine atony
• Observe for lacerations w/ significant bleeding
• If uterus boggy--> massage vigorously, let mom nurse NB if possible
• Bimanual compression (one hand in vagina and one on abdomen) to stop bleeding
• Adminster meds (pitocin, methergine, etc.)
• Bleeding not stopped--> uterine atony embolization or emergency hysterectomy

• Leading cause of PPH
• Marked hypotonia of uterus, occurs in 1/20 births
• Causes:
• Multipara, hydramnios, macrosomia, multi-gestation (uterus is over-stretched)
• Traumatic birth, magnesium sulfat, rapid/prolonged labor, chorioamniotis, placenta previa, and placenta abruption

• Common cause of PPH
• Bleeding based on laceration site:
• Cervix: cut shalow, bleeding minimal
• Vagina: vaginal hematomas
• Perineum: most common bleeding cause
• Classified by degree

• 1st degree: through skin and superficial structures; up to muscle
• 2nd degree: through the muscle of the perineal body
• 3rd degree: through the anal sphincter
• 4th degree: into the anal rectal wall

• No enemas, no rectal temps
• Encourage fluids and use stool softeners
• Document degree of laceration
• Evaluate site
• Lacerations should heal w/o interventions

• Collection of blood in the subcutaneous tissue of the perineum
• Cause of severe pain
• S/S:
• Purplish discoloration, obvious swelling, tender to palpation

• Document size and degree of discomfort
• Administer mild analgesic (as ordered)
• Place ice pack on affected site
• If severe, site may be incised and vessel ligated 

• Poor placental separation (may still be attached to endometrial tissue, but normal implantation
• Managed by manual separation and removal

• Abnormal attachment of the placenta into the layers of uterine organ
• Three types: accreta, increta, and percreta
• Delivery of the placenta will be unsuccessful and bleeding will be profuse when attempted

• Part of the placenta is retained in the uterus after delivery
• Cause of PPH; immediate if large amount retained, up to 10 days PP if small amount retained
• Uterine not fully contracted
• Elevated hCG if bloodwork done

• Causes:
• Retained placental fragments
• Pelvis infection
• S/S:
• Prolonged lochial discharge
• Irregular or excessive bleeding

• Administer meds to stimulate contractions & O2
• IV replacement of blood and/or fluids
• Fundal massage
• Removal of retained placental pieces
• Packing uterus with sponges and sterile materials
• Tying-off of bleeding blood vessels
• Laparotomy (find cause of bleeding)
• Hysterectomy (last resort)

• Excessive or bright-red bleeding
• Boggy fundus, unresponsive to massage
• Abnormal clot from vaginal vault
• Unsual pelvic discomfort or backache
• Persistent bleeding w/ firm fundus
• Rise in fundal heigh
• Increased pulse or decreased BP
• Decrease in Hct
• Hematoma formation or bulging, shiny skin in perineal area

• Massage soft & boggy uterus
• Weigh perineal pads
• Maintain vascular access
• Observe for signs of anemia
• Monitor urinary output
• Allow adequate rest
• Administer meds (uterine stimulants, analgesics)
• Teach self-care

Emergency situation

Hypovolemic shock

Perfusion of organs may become severely compromised

Possibly fatal

• Respirations rapid and shallow
• Pulse rapid, weak, and irregular
• BP decreasing (late sign)
• Skin cool, pale, and clammy
• Urinary output decreases
• LOC decreases, from lethargy to coma
• Becomes anxious
• Central venous pressure decreases

• Summon assistance and equipment
• Start IV fluids and/or blood (per standing orders)
• Ensure patient airway
• Administer O2
• Continue to monitor status

• Blood clot or clots inside a blood vessel
• Caused by inflammation or partial obstruction of vessel
• Part of the blood clot disloges--> carried to the pulmonary artery--> occludes the vessel and obstructs blood flow to the lungs

• Type of thromboembolic disease
• Most frequent form of PP thrombophlebitis
• Pain and tenderness in the lower extremity
• Physical exam:
• Warmth, redness, and an enlarged, hardened vein over the site of the thrombosis

• Type of thromboembolic disease
• Can extend from the foot to the iliofemoral region
• Will have unilateral leg pain, calf tenderness, and swelling
• Physical exam:
• Redness and warmth
• Homan's sign may be positive

Indicator of deep venous thrombosis

Present if pain in the calf is produced by passive dorsiflexion of the foot

• Rare
• Dyspnea and tachypnea
• Apprehension, cough, tachycardia, elevated temperature, and chest pain

Obstruction of the pulmonary artery with a blood clot

Usually a complication of thrombophlebitis

Emergency !

• Sudden, sharp chest pain
• Tachypnea
• Tachycardia
• Orthopnea
• Cyanosis

• Administer O2
• ICU transfer
• CPR if indicated

• Analgesia
• Rest w/ affected leg elevated
• Compression hose
• Local application of heat

• Initially give anticoagulant (usually IV heparin, continuously for 5-7 days)
• Oral anticoagulant therapy (warfarin) started w/ heparin, continue use for 3 months
• Bed rest w/ affected leg elevated
• Analgesia
• After symptoms decrease, compression hose when ambulating 

• Continuous IV heparin until symptoms resolve
• Intermittent SQ heparin or oral anticoagulants for 6 months

• Heparin:
• Administer proatmine sulfate
• Warfarin:
• Administer vitamin K

• Most common cause of PP infection
• Usually begins at placental site
• Incident is higher after c-section

• Fever (usually on 3rd or 4th day PP), chills
• Increased WBCs 
• Increased pulse
• Anorexia, nausea
• Fatigue and lethargy
• pelvic pain
• uterine tenderness
• Foul-smelling, profuse lochia
• Positive blood cultures or utracervical or itnrauterine bacterial cultures

• Vaginal culture
• Antibiotics and/or excission of perineal sutures
• Encourage fluids
• Fowler's position or ambulation
• Document color, consistency, odor of discharge

• Often develop after women go home
• Sites:
• C-section site
• Episiotomy site
• Repaired laceration site

• Urinary catheterization
• Frequent pelvic exams
• Epidural anesthesia
• Genital tract injury
• History of UTI
• C-section birth

• Infection of breast
• Unilateral
• Mostly in first-time moms who are breastfeeding
• Develops after flow of milk is established
• Starts with nipple fissure--> ductal system--> milk flow blocked
• May lead to breast abscess

• Rigid abdomen
• Abdominal pain
• High fever
• Tachycardia
• Vomiting

• If paralytic ileus presents--> NG tube
• IVF or TPN
• Antibiotics