Chapter 21: Postpartum Complications

What PPH conditions are considered medical emergencies that require immediate treatment? a. Inversion of the uterus and hypovolemic shock b. Hypotonic uterus and coagulopathies c. Subinvolution of the uterus and idiopathic thrombocytopenic purpura d. Uterine atony and disseminated intravascular coagulation

ANS: A Inversion of the uterus and hypovolemic shock are considered medical emergencies. Although hypotonic uterus and coagulopathies, subinvolution of the uterus and idiopathic thrombocytopenic purpura, and uterine atony and disseminated intravascular coagulation are serious conditions, they are not necessarily medical emergencies that require immediate treatment.

The perinatal nurse caring for the after birth woman understands that late postpartum hemorrhage (PPH) is most likely caused by: a. subinvolution of the placental site. b. defective vascularity of the decidua. c. cervical lacerations. d. coagulation disorders.

ANS: A Late PPH may be the result of subinvolution of the uterus, pelvic infection, or retained placental fragments. Late PPH is not typically a result of defective vascularity of the decidua, cervical lacerations, or coagulation disorders.

Early after birth hemorrhage is defined as a blood loss greater than: a. 500 mL in the first 24 hours after vaginal delivery. b. 750 mL in the first 24 hours after vaginal delivery. c. 1000 mL in the first 48 hours after cesarean delivery. d. 1500 mL in the first 48 hours after cesarean delivery.

ANS: A The average amount of bleeding after a vaginal birth is 500 mL. Blood loss after a cesarean birth averages 1000 mL. Early after birth hemorrhage occurs in the first 24 hours, not 48 hours. Late after birth hemorrhage is 48 hours and later.

The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is: a. uterine atony. b. uterine inversion. c. vaginal hematoma. d. vaginal laceration.

ANS: A Uterine atony is marked hypotonia of the uterus. It is the leading cause of after birth hemorrhage. Uterine inversion may lead to hemorrhage, but it is not the most likely source of this patient's bleeding. Furthermore, if the woman is experiencing a uterine inversion, it would be evidenced by the presence of a large, red, rounded mass protruding from the introitus. A vaginal hematoma may be associated with hemorrhage. However, the most likely clinical finding would be pain, not the presence of profuse bleeding. A vaginal laceration may cause hemorrhage, but it is more likely that profuse bleeding would result from uterine atony. A vaginal laceration should be suspected if vaginal bleeding continues in the presence of a firm, contracted uterine fundus.

Medications used to manage postpartum hemorrhage (PPH) include: (Select all that apply.) a. Pitocin. b. Methergine. c. Terbutaline. d. Hemabate. e. magnesium sulfate.

ANS: A, B, D Pitocin, Methergine, and Hemabate are all used to manage PPH. Terbutaline and magnesium sulfate are tocolytics; relaxation of the uterus causes or worsens PPH.

Which instruction should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications? a. Palpate the fundus daily to ensure that it is soft. b. Notify the physician of any increase in the amount of lochia or a return to bright red bleeding. c. Report any decrease in the amount of brownish red lochia. d. The passage of clots as large as an orange can be expected

ANS: B An increase in lochia or a return to bright red bleeding after the lochia has become pink indicates a complication. The fundus should stay firm. The lochia should decrease in amount over time. Large clots after discharge are a sign of complications and should be reported.

A woman delivered a 9-lb, 10-ounce baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action? a. Call for help. b. Assess the fundus for firmness. c. Take her blood pressure. d. Check the perineum for lacerations.

ANS: B Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first assess for firmness and massage the fundus as indicated. Assessing blood pressure is an important assessment with a bleeding patient; however, the top priority is to control the bleeding. If bleeding continues in the presence of a firm fundus, lacerations may be the cause.

Which woman is at greatest risk for early postpartum hemorrhage (PPH)? a. A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress. b. A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced. c. A multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor. d. A primigravida in spontaneous labor with preterm twins.

ANS: B Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony. Although many causes and risk factors are associated with PPH, the primiparous woman being prepared for an emergency C-section, the multiparous woman with 8-hour labor, and the primigravida in spontaneous labor do not pose risk factors or causes of early PPH.

A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to: a. establish venous access. b. perform fundal massage. c. prepare the woman for surgical intervention. d. catheterize the bladder.

ANS: B The initial management of excessive after birth bleeding is firm massage of the uterine fundus. Although establishing venous access may be a necessary intervention, the initial intervention would be fundal massage. The woman may need surgical intervention to treat her after birth hemorrhage, but the initial nursing intervention would be to assess the uterus. After uterine massage the nurse may want to catheterize the patient to eliminate any bladder distention that may be preventing the uterus from contracting properly.

A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests: a. uterine atony. b. lacerations of the genital tract. c. perineal hematoma. d. infection of the uterus.

ANS: B Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction. The fundus is not firm in the presence of uterine atony. A hematoma would develop internally. Swelling and discoloration would be noticeable; however, bright bleeding would not be. With an infection of the uterus there would be an odor to the lochia and systemic symptoms such as fever and malaise.

Despite popular belief, there is a rare type of hemophilia that affects women of childbearing age. von Willebrand disease is the most common of the hereditary bleeding disorders and can affect males and females alike. It results from a factor VIII deficiency and platelet dysfunction. Although factor VIII levels increase naturally during pregnancy, there is an increased risk for after birth hemorrhage from birth until 4 weeks after delivery as levels of von Willebrand factor (vWf) and factor VIII decrease. The treatment that should be considered first for the patient with von Willebrand disease who experiences a after birth hemorrhage is: a. cryoprecipitate. b. factor VIII and vWf. c. desmopressin. d. hemabate.

ANS: C Desmopressin is the primary treatment of choice. This hormone can be administered orally, nasally, and intravenously. This medication promotes the release of factor VIII and vWf from storage. Cryoprecipitate may be used; however, because of the risk of possible donor viruses, other modalities are considered safer. Treatment with plasma products such as factor VIII and vWf is an acceptable option for this patient. Because of the repeated exposure to donor blood products and possible viruses, this is not the initial treatment of choice. Although the administration of this prostaglandin is known to promote contraction of the uterus during after birth hemorrhage, it is not effective for the patient who presents with a bleeding disorder.

Anxiety disorders are the most common mental disorders that affect women. While providing care to the maternity patient, the nurse should be aware that one of these disorders is likely to be triggered by the process of labor and birth. This disorder is: a. phobias. b. panic disorder. c. posttraumatic stress disorder (PTSD). d. obsessive-compulsive disorder (OCD).

ANS: C In PTSD, women perceive childbirth as a traumatic event. They have nightmares and flashbacks about the event, anxiety, and avoidance of reminders of the traumatic event. Phobias are irrational fears that may lead a person to avoid certain objects, events, or situations. Panic disorders include episodes of intense apprehension, fear, and terror. Symptoms may manifest themselves as palpitations, chest pain, choking, or smothering. OCD symptoms include recurrent, persistent, and intrusive thoughts. The mother may repeatedly check and recheck her infant once he or she is born, even though she realizes that this is irrational. OCD is best treated with medications.

What infection is contracted mostly by first-time mothers who are breastfeeding? a. Endometritis b. Wound infections c. Mastitis d. Urinary tract infections

ANS: C Mastitis is infection in a breast, usually confined to a milk duct. Most women who suffer this are primiparas who are breastfeeding.

To provide adequate after birth care, the nurse should be aware that postpartum depression (PPD) without psychotic features: a. means that the woman is experiencing the baby blues. In addition she has a visit with a counselor or psychologist. b. is more common among older, Caucasian women because they have higher expectations. c. is distinguished by irritability, severe anxiety, and panic attacks. d. will disappear on its own without outside help.

ANS: C PPD is also characterized by spontaneous crying long after the usual duration of the baby blues. PPD, even without psychotic features, is more serious and persistent than after birth baby blues. It is more common among younger mothers and African-American mothers. Most women need professional help to get through PPD, including pharmacologic intervention.

A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. The nurse should suspect __________ and should confirm the diagnosis by ___________. a. disseminated intravascular coagulation; asking for laboratory tests b. von Willebrand disease; noting whether bleeding times have been extended c. thrombophlebitis; using real-time and color Doppler ultrasound d. coagulopathies; drawing blood for laboratory analysis

ANS: C Pain and tenderness in the extremities, which show warmth, redness, and hardness, likely indicate thrombophlebitis. Doppler ultrasound is a common noninvasive way to confirm diagnosis.

Complicated bereavement: a. occurs when, in multiple births, one child dies, and the other or others live. b. is a state in which the parents are ambivalent, as with an abortion. c. is an extremely intense grief reaction that persists for a long time. d. is felt by the family of adolescent mothers who lose their babies.

ANS: C Parents showing signs of complicated grief should be referred for counseling. Multiple births in which not all the babies survive creates a complicated parenting situation, but this is not complicated bereavement. Abortion can generate complicated emotional responses, but they do not constitute complicated bereavement. Families of lost adolescent pregnancies may have to deal with complicated issues, but this is not complicated bereavement.

The first and most important nursing intervention when a nurse observes profuse after birth bleeding is to: a. call the woman's primary health care provider. b. administer the standing order for an oxytocic. c. palpate the uterus and massage it if it is boggy. d. assess maternal blood pressure and pulse for signs of hypovolemic shock.

ANS: C The initial management of excessive after birth bleeding is firm massage of the uterine fundus. Although calling the health care provider, administering an oxytocic, and assessing maternal BP are appropriate interventions, the primary intervention should be to assess the uterus. Uterine atony is the leading cause of postpartum hemorrhage (PPH).

When a woman is diagnosed with postpartum depression (PPD) with psychotic features, one of the main concerns is that she may: a. have outbursts of anger. b. neglect her hygiene. c. harm her infant. d. lose interest in her husband.

ANS: C Thoughts of harm to oneself' or the infant are among the most serious symptoms of PPD and require immediate assessment and intervention. Although outbursts of anger, hygiene neglect, and loss of interest in her husband are attributable to PPD, the major concern would be the potential to harm herself or her infant.

Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth? a. After birth depression b. After birth psychosis c. After birth bipolar disorder d. After birth blues

ANS: D After birth blues or "baby blues" is a transient self-limiting disease that is believed to be related to hormonal fluctuations after childbirth. After birth depression is not the normal worries (blues) that many new mothers experience. Many caregivers believe that after birth depression is underdiagnosed and underreported. After birth psychosis is a rare condition that usually surfaces within 3 weeks of delivery. Hospitalization of the woman is usually necessary for treatment of this disorder. Bipolar disorder is one of the two categories of after birth psychosis, characterized by both manic and depressive episodes.

One of the first symptoms of puerperal infection to assess for in the after birth woman is: a. fatigue continuing for longer than 1 week. b. pain with voiding. c. profuse vaginal bleeding with ambulation. d. temperature of 38° C (100.4° F) or higher on two successive days starting 24 hours after birth.

ANS: D After birth or puerperal infection is any clinical infection of the genital canal that occurs within 28 days after miscarriage, induced abortion, or childbirth. The definition used in the United States continues to be the presence of a fever of 38° C (100.4° F) or higher on two successive days of the first 10 after birth days, starting 24 hours after birth. Fatigue would be a late finding associated with infection. Pain with voiding may indicate a urinary tract infection, but it is not typically one of the earlier symptoms of infection. Profuse lochia may be associated with endometritis, but it is not the first symptom associated with infection.

If nonsurgical treatment for late after birth hemorrhage is ineffective, which surgical procedure is appropriate to correct the cause of this condition? a. Hysterectomy b. Laparoscopy c. Laparotomy d. D&C

ANS: D D&C allows examination of the uterine contents and removal of any retained placental fragments or blood clots. Hysterectomy is the removal of the uterus and is not indicated for this condition. A laparoscopy is the insertion of an endoscope through the abdominal wall to examine the peritoneal cavity. It is not the appropriate treatment for this condition. A laparotomy is also not indicated for this condition. A laparotomy is a surgical incision into the peritoneal cavity to explore it.

Nurses need to know the basic definitions and incidence data about postpartum hemorrhage (PPH). For instance: a. PPH is easy to recognize early; after all, the woman is bleeding. b. traditionally it takes more than 1000 mL of blood after vaginal birth and 2500 mL after cesarean birth to define the condition as PPH. c. if anything, nurses and doctors tend to overestimate the amount of blood loss. d. traditionally PPH has been classified as early or late with respect to birth.

ANS: D Early PPH is also known as primary, or acute, PPH; late PPH is known as secondary PPH. Unfortunately PPH can occur with little warning and often is recognized only after the mother has profound symptoms. Traditionally a 500-mL blood loss after a vaginal birth and a 1000-mL blood loss after a cesarean birth constitute PPH. Medical personnel tend to underestimate blood loss by as much as 50% in their subjective observations.

When caring for a after birth woman experiencing hemorrhagic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is: a. absence of cyanosis in the buccal mucosa. b. cool, dry skin. c. diminished restlessness. d. urinary output of at least 30 mL/hr.

ANS: D Hemorrhage may result in hemorrhagic shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion. The assessment of the buccal mucosa for cyanosis can be subjective. The presence of cool, pale, clammy skin would be an indicative finding associated with hemorrhagic shock. Hemorrhagic shock is associated with lethargy, not restlessness.

To provide adequate after birth care, the nurse should be aware that postpartum depression (PPD) with psychotic features: a. is more likely to occur in women with more than two children. b. is rarely delusional and then is usually about someone trying to harm her (the mother). c. although serious, is not likely to need psychiatric hospitalization. d. may include bipolar disorder (formerly called "manic depression").

ANS: D Manic mood swings are possible. PPD is more likely to occur in first-time mothers. Delusions may be present in 50% of women with PPD, usually about something being wrong with the infant. PPD with psychosis is a psychiatric emergency that requires hospitalization.

With shortened hospital stays, new mothers are often discharged before they begin to experience symptoms of the baby blues or after birth depression. As part of the discharge teaching, the nurse can prepare the mother for this adjustment to her new role by instructing her regarding self-care activities to help prevent after birth depression. The most accurate statement as related to these activities is to: a. stay home and avoid outside activities to ensure adequate rest. b. be certain that you are the only caregiver for your baby to facilitate infant attachment. c. keep feelings of sadness and adjustment to your new role to yourself. d. realize that this is a common occurrence that affects many women.

ANS: D Should the new mother experience symptoms of the baby blues, it is important that she be aware that this is nothing to be ashamed of. Up to 80% of women experience this type of mild depression after the birth of their infant. Although it is important for the mother to obtain enough rest, she should not distance herself from family and friends. Her spouse or partner can communicate the best visiting times so the new mother can obtain adequate rest. It is also important that she does not isolate herself at home during this time of role adjustment. Even if breastfeeding, other family members can participate in the infant's care. If depression occurs, the symptoms can often interfere with mothering functions, and this support will be essential. The new mother should share her feelings with someone else. It is also important that she not overcommit herself or think she has to be "superwoman." A telephone call to the hospital warm line may provide reassurance with lactation issues and other infant care questions. Should symptoms continue, a referral to a professional therapist may be necessary.