Chapter 10: Postpartum Complications & Nursing Care

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Welcome back to the Deep Dive.

Today, we are, uh, we're trying something a little different, and frankly, I'm really excited about it.

Me too.

Usually we take a pretty broad topic and sort of swim around the edges, you know, exploring the general concepts.

But today.

Today we're going deep.

We are going straight to the bottom.

We're positioning this session as a dedicated deep dive study companion specifically designed for our Last Minute Lecture series.

That's exactly right.

This isn't just edutainment today.

We are really, um, targeting nursing students, NCLEX preppers, and, you know, active health care professionals who need a high level, rigorous refresh.

And we have our source material right in front of us.

We do.

We are breaking down chapter 10 of LIFER's introduction to maternity and pediatric nursing in Canada.

The mission is specific.

We are decoding nursing care of women with complications after birth.

It sounds broad, but we're really looking at the big four, the four main categories that can turn a really happy occasion into a medical emergency.

That's the goal.

Yeah.

The goal is to walk through the chapter, basically page by page, and translate that, you know, that textbook density into clear, actionable nursing knowledge.

Exactly.

Because in the obstetrics world, things can turn on a dime.

I mean, you have a stable patient one minute, and the next you're calling a critical response team.

Right.

So we're organizing this dive around those four pillars.

The first is postpartum hemorrhage, or PPH.

Okay.

Then thromboembolic disorders, which are, you know, blood clots.

Right, clots.

Third is puerperal infections.

And fourth, mood disorders.

And just a quick note for our listeners.

Since we are pulling from the Canadian edition of LIFER, we will be referencing SOGC guidelines.

Yes.

That's the Society of Obstetricians and Gynecologists of Canada.

So if you're listening from somewhere else, say the US or the UK, the physiology is obviously the same, but the protocols or the specific names of organizations might have some slight regional variations.

Precisely.

The standards of care, especially around measurements and screening, are tailored to that Canadian context.

It's just something to keep in mind.

Okay.

Let's unpack this.

We have to start with the single most dangerous complication in that immediate postpartum period.

The heavyweight champion of risks,

postpartum hemorrhage, PPH.

Right.

Now, historically, or traditionally, we had very specific volume metrics for this.

If you looked at older textbooks, PTH was defined strictly by the numbers.

Just how much blood was lost.

Exactly.

Blood loss greater than 500 milliliter after a vaginal birth or 1 ,000 milliliter after a cesarean birth.

That seems pretty straightforward.

500 for vaginal, 1 ,000 for a C -section.

But the text mentions a newer clinical definition for the SOGC back in 2014.

Why the change?

Well, the change is really about clinical impact.

The old definition was purely, well, it was just based on volume.

The problem is visual estimation of blood loss is notoriously inaccurate.

I mean, we often underestimate it by like half.

Wow, by half.

At least.

So the new clinical definition is more functional.

PPH is now defined as any blood loss that has the potential to produce hemodynamic instability.

Hemodynamic instability.

So we're looking at how the patient is actually handling the loss, not just how much is in the bucket.

That's the perfect way to put it.

It's about the patient's response.

But this brings up a physiological puzzle.

A pregnant woman has way more blood than a non -pregnant woman.

So how does that buffer affect what we see on the monitor?

That is the hypervolemia of pregnancy.

It's a critical concept.

You have to remember that during those nine months, a woman's body adds roughly one to two liters of extra blood volume.

One to two liters.

That's a huge amount.

It's a massive amount of extra fluid.

It's a survival mechanism, right?

It absolutely is.

Biologically it's there for this exact moment.

It allows her to tolerate blood loss much, much better than you or I could.

So she can lose a fair bit before anything looks wrong.

She can lose a significant amount before her vital signs even begin to flicker.

And that's why the new clinical definition is so important, because by the time she shows instability,

she might have lost a lot more than that 500 milliliter baseline.

That is a double -edged sword for the nurse, then.

She compensates incredibly well.

Until she doesn't.

And when she crashes, she crashes hard.

Exactly.

It means if you're waiting for the crash, you've waited way too long.

Now the text breaks PPH down by timeline.

We have early and late.

Correct.

Early PPH is by far the most common.

This is hemorrhage occurring within the first 24 hours after birth.

So if you're a nurse on the postpartum unit, this is your primary vigilance window.

The first day.

The first day.

Late PPH is anything that happens from 24 hours all the way up to 12 weeks postpartum.

Up to 12 weeks.

Wow.

I think most people assume once you're home, you're in the clear.

Not necessarily.

It's pretty rare, but it happens.

It's usually due to something like retained tissue or an infection that's preventing the uterus from healing properly.

But for early PPH, we use a mnemonic that, honestly, every nursing student needs to tattoo on their brain.

It's the four T's.

I love a good mnemonic.

Let's run through them.

It's tone, trauma, tissue, and thrombin.

Perfect.

Tone refers to uterine atony.

The muscle just isn't squeezing.

Trauma covers things like lacerations, hematomas, or uterine rupture.

Tissue means there are retained placental fragments preventing the uterus from clamping down.

And the last one.

And thrombin refers to coagulopathy.

So issues with the blood clotting mechanism itself.

We are going to break down each of those T's in detail, but before we do, we need to talk about the consequence of all this.

The consequence of hemorrhage.

Hypovolemic shock.

Yes.

This is the so -what of bleeding.

What happens when the tank runs dry?

Well, this is basically a mechanical failure.

When that blood volume gets depleted, the body goes into like an emergency mode.

It stops sending blood to non -essential organs.

Like the skin.

Like the skin and the kidneys.

It does this to preserve blood flow to the heart and the brain.

It's prioritizing survival.

Exactly.

And as a nurse, you are looking for the clues of this prioritization.

And here is where it gets really interesting and where students often get tripped up.

The very first sign of hypovolemia is not low blood pressure.

It's not.

I think that's what most people would guess.

No.

The first sign is tachycardia, a rapid heart rate.

The heart starts beating faster to try and circulate the remaining red blood cells to keep oxygen levels up.

The text explicitly says a pulse greater than a hundred beats per minute.

That's a major aha moment.

So if you are waiting for the blood pressure to drop.

You are waiting way too long.

You missed the first warning sign.

Correct.

Falling blood pressure is a late sign.

A very late sign.

By the time the BP crashes, the woman has lost a significant percentage of her volume.

So what comes before that?

You'll see a narrow pulse pressure first.

The systolic falls and the diastolic rises.

But that tachycardia is your early warning system.

So a pulse over a hundred, you investigate immediately.

Immediately.

What else are we seeing?

The respiratory rate goes up?

Again, trying to get more oxygen.

Right.

The skin becomes pale, cold, and clammy because blood is being shunted away from the periphery.

And the patient herself.

The woman might get anxious or confused because the brain is getting slightly less oxygen.

And the kidneys, they just stop making urine to conserve fluid.

Okay, so we see these signs.

We have a patient going into shock.

What is the medical management?

What's the nursing care?

Priority one, stop the blood loss.

That's your number one job.

That might mean uterine massage, giving medications,

or even surgical intervention.

And priority two.

Replace what was lost, 5E fluids, blood transfusions.

You're also giving oxygen to saturate the red blood cells she has left.

And you're inserting a Foley catheter.

Why the catheter?

Is that just to keep her comfortable?

No, no.

It's a diagnostic tool.

We need to monitor her kidney function.

If the kidneys aren't producing urine, it means they aren't getting blood perfusion.

It tells us how severe the shock is.

Got it.

And in terms of assessment, how often are we checking her?

Every 15 minutes.

Vital signs every 15 minutes until she is stable.

And we have to be accurate about the blood loss.

Absolutely.

No more guessing.

The text gives us a great conversion.

One gram of weight equals one LAL of blood loss.

So you're literally weighing the pads.

Literally weighing them.

You weigh a dry pad, you weigh the soaked pad, and you subtract the difference.

That gives you the exact volume.

And there's a safety alert here.

Yes.

If a woman saturates a peripad within 15 minutes to an hour, that is a huge red flag.

You report it immediately.

Okay.

Let's move into the specific causes, starting with that first T -tone.

Or more specifically, the lack of it, uterine atony.

This is the big one.

It accounts for something like 70 to 80 % of all PPH cases.

So this is the most common cause by a long shot.

By far.

Ideally, the uterus has these interlacing muscle fibers that act like a living tourniquet.

After the placenta detaches, these muscles contract and they literally crimp the open blood vessel shut.

So atony is when that doesn't happen?

Atony is when the uterus is flaccid.

It's like a tired rubber band.

It just won't snap back.

And when you palpate it, what does that feel like?

The text uses a very specific word.

Boggy.

It feels soft, mushy, and it's often really hard to even find in the abdomen.

And its position.

Usually, the fundus, that's the top of the uterus, is high, well above the umbilicus.

And because it's not squeezing, the lochia, the vaginal discharge, is heavy, often with large clots.

Now, there is a diagram in the chapter, figure 10 .1, that shows a very specific cause for this.

It shows the uterus being pushed out of place.

Yes, the full bladder.

This is a classic nursing catch, a classic.

If the bladder is distended, it physically pushes the uterus up into the side, usually to the right side.

So if I'm palpating a patient's abdomen, and I feel the uterus way over on the right, I should be thinking full bladder.

Absolutely.

And a displaced uterus cannot contract effectively, it just can't clamp down, so the intervention is simple.

Empty the bladder.

Empty the bladder.

What are some other factors that cause this tired uterus?

Well, anything that overstretched it, so twins or triplets, a very large baby.

Or if the labor was extremely long, the muscle is just exhausted.

Paradoxically, a very rapid labor can do it too.

And the use of oxytocin during labor can sometimes make the uterus less responsive postpartum.

The receptors get a bit saturated.

So we have a boggy uterus.

What do we do?

What's the first line of defense?

Massage.

You put one hand to continuously support the lower segment, just above the symphysis pubis, and with the other hand, you massage the fundus until it firms up.

But there's a warning here.

Do not overmassage.

Why is that?

Right.

It's a muscle.

If you work it too hard, it just gets more fatigued.

So you massage until it's firm, then you stop.

Also, and this is critical, do not try to express clots, you know, pushing down to squirt blood out until the uterus is firm.

Why not?

If you push on a boggy uterus, you could actually invert it, turn it inside out, which is a catastrophic medical emergency.

That is a vivid and terrifying image.

Okay, so massage helps.

Emptying the bladder helps.

What about drugs?

We have an arsenal.

Oxytocin is the standard, usually a dilute, high V infusion to keep the muscle contracted.

And if it doesn't work?

If that doesn't work, we might use methylurganavine.

But huge caution here.

Methylurganavine raises blood pressure.

So if the mom has preeclampsia or hypertension?

You cannot give it.

Absolutely contraindicated, you could cause a stroke.

Got it.

What's next?

Then we have prostaglandins, like carboprost or mesoprostol, and there is a newer emphasis on something called tranexamic acid.

Right, I've seen this mentioned more and more recently.

It works differently, right?

It's not about the muscle.

It does.

It's not about squeezing the muscle.

It's about stopping the clot from breaking down.

It inhibits fibrolysis.

But the study that's cited, the woman trial, says it must be given within three hours of birth to be effective.

So time is of the essence with that one.

Very much so.

One final safety alert for this section.

The text says, to keep the woman NPO.

Nothing by mouth.

Why?

Because if the massage and the meds don't work, she might need surgical intervention.

She might need a DNC or worse.

If she needs general anesthesia, having food in her stomach is a major aspiration risk.

So no water, no snacks until she is stable.

Okay, that covers tone.

Now let's move to the second T -trauma.

This includes lacerations and hematomas.

How do we distinguish this from atony?

This is the trickle versus gush distinction, but with a twist.

With trauma,

specifically lacerations of the cervix or vagina, the uterus is firm.

Okay, so you do your assessment.

The fundus feels like a hard grapefruit, firm and solid, but she is still bleeding.

Exactly.

A continuous trickle of bright red blood despite a firm fundus.

That screams laceration.

It means the bleeding isn't coming from the placental site.

It's coming from a tear in the tissue somewhere else.

What are the risk factors for that?

Rapid labor or an operative berzo, forceps or vacuum extraction.

Those instruments can nick the tissue.

And the management is surgical repair.

The doctor just needs to find the tear and suture it up.

Now what about hematomas?

These sound sneakier.

They are the silent threat.

A hematoma is blood collecting inside the tissue like a massive internal bruise.

It can happen on the vulva, which you can see, a blue or purple bulging mass.

But it can also happen deep inside the vagina where you can't see it at all.

So if you can't see it, how do you know it's there?

Pain.

That is the key symptom.

Severe, unrelenting pain or pressure.

A woman might say, I feel like I have to have a bowel movement or there's just so much pressure on my rectum.

And standard pain meds don't touch it.

So if a patient is complaining extreme pain, out of proportion to what you'd expect, but her lochia looks normal.

You have to suspect a hematoma.

The blood is concealed in the tissue.

She could be going into hypovolemic shock high pulse, low BP, but you won't see the external bleeding because it's all trapped inside.

That is incredibly dangerous.

So what's the nursing care?

For small, visible ones, ice packs can help stop the bleeding and numb the area.

But for large ones or concealed ones, she needs to go to surgery to have it drain and the vessel tied off.

Okay.

Moving to the third T tissue.

This usually refers to the placenta, right?

Yes.

Retained placental fragments.

The placenta is supposed to detach cleanly, you know, like a sticker coming off a backing, but sometimes pieces break off and stay stuck to the uterine wall.

And if something is stuck there, the muscle can't clamp down.

Exactly.

It physically prevents contraction and that leads to hemorrhage.

This is often a cause of late PPH bleeding that happens days or even weeks later.

This connects to the concept of sub involution.

Can you define that for us?

Sure.

So involution is the process of the uterus shrinking back to its pre -pregnancy size.

Sub involution is when that process stalls or is slower than expected.

How slow is too slow?

Normally, the uterus descends about one centimeter per day.

By about two weeks, you shouldn't be able to feel it in the abdomen anymore.

If a woman comes in at one week postpartum and her fundus is still high and she's still having bright red bleeding, lochiarubra, that's sub involution.

And the patient teaching here is vital because she's usually at home when this happens.

Right.

You have to tell her.

If your bleeding stays bright red if it smells foul or if you have pelvic pain, you need to call the doctor.

Treatment usually involves a DNC dilation and curatage to scrape out those retained fragments.

The final T is thrombin.

This is all about the blood's ability to clot.

Right.

So we are talking about coagulopathies, things like von Willebrand disease or ITP, which are pre -existing conditions.

But the really scary one in the obstetrics world is DIC.

DIC, disseminated intravascular coagulation.

That's the condition where you kind of you clot and bleed at the same time.

It's a paradox.

Exactly.

The body's clotting factors go into overdrive and they get all used up in tiny clots throughout the body.

Once those clotting factors are consumed, the patient bleeds freely from everywhere.

Everywhere.

IV sites, gums, nose, anywhere.

That sounds horrific.

What triggers it?

Usually a major trauma or shock event, a dead fetus that's been retained in the uterus, a severe infection or a big placental abruption.

The management is just treating the underlying cause.

If you treat the infection or deliver the fetus, the DIC often resolves, but you need to support her with a lot of blood products in the meantime.

Okay, that wraps up the four Ts of hemorrhage.

That's a huge topic.

Now let's pivot to the second major category of complications.

Thromboembolic disorders.

This creates a bit of a physiological paradox, actually.

We just said the body ramps up clotting factors during pregnancy to prevent hemorrhage.

That is a survival mechanism.

But that same mechanism makes her more prone to blood clots.

Exactly.

It's a state of hypercoagulability.

Fibrinogen levels are up.

The factors that dissolve clots are down.

You add in venous stasis, pressure on the leg veins from the heavy uterus, and you have a recipe for venous thromboembolism, or VTE.

We break VTE down into two main types, DVTE and PE.

Right.

DVTE is deep vein thrombosis, a clot in the leg veins.

The signs.

You're looking for pain, calf tenderness, and edema, or swelling.

Often one leg will be noticeably more swollen than the other.

A difference of more than two centimeters in circumference is significant.

And PE is pulmonary embolism.

And that is the medical emergency.

That's when a piece of the clot breaks off the leg, travels up to the heart, and then gets pumped into the lungs, where it blocks the circulation.

What are the signs of a PE?

Sudden sharp chest pain, dyspnea, where she's fighting for air, and coughing up blood, which is called hemoptysis.

If a postpartum woman suddenly grabs her chest and says she can't breathe, you act fast.

What are the risk factors we should be looking for?

The text has them in box 10 .1.

Yeah, obesity is a big one.

A BMI over 30, smoking,

varicose veins being over the age of 35, and specifically having a C -section, which basically doubles the risk because of the vessel damage during surgery.

So prevention is really the name of the game here.

What is the nurse doing?

Ambulation.

Get her up, get her walking.

Early ambulation is the single most effective preventative measure.

The muscles pumping in the legs keeps the blood moving.

What about when she's sitting or in bed?

Don't cross your legs.

Simple, but it cuts off flow.

And we use anti -embolic stockings, but you have to teach her how to use them properly.

How so?

You can't let the top roll down.

If it rolls, it acts like a rubber band and actually cuts off circulation, which is the opposite of what you want.

And for treatment, if a clot does form...

Analgesics for the pain, heat, and leg elevation.

For medication, we use anticoagulants.

Okay.

Heparin or low -molecular -weight heparin, LMWH, are safe during pregnancy.

Warfarin or Coumadin is used, but only postpartum.

Why only postpartum?

Warfarin crosses the placenta and can harm the fetus, but after birth, it's okay.

However,

and this is a medication safety alert, the antidote for warfarin overdose is vitamin K.

You need to know that in case her levels get too high and she starts bleeding.

Okay.

Hemorrhage?

Check.

Clots?

Check.

Number three on our big four list.

Infection?

Purple sepsis.

Right.

This is technically defined as a fever of 38 degrees Celsius or higher after the first 24 hours.

Why after the first 24 hours?

That seems specific.

Because a mild temp elevation in the first day is often just dehydration from the labor.

You give her fluids, it usually drops right back down.

If it spikes after that 24 -hour mark, it's much more likely to be an infection.

And the text highlights endometritis.

Which is an inflammation of the inner lining of the uterus, the endometrium.

It's usually caused by bacteria ascending up from the vagina.

What are the signs?

The signs are distinct.

A tender, enlarged uterus.

And the lochia smells foul, purulent.

It's not the normal fleshy smell of blood, it's the smell of infection.

And then we have wound infections, C -section incisions, or episiotomies.

We have another great mnemonic for assessment here.

RETA.

R -E -E -D -A.

Redness.

Edema, which is swelling.

Echemosis, which is bruising.

Discharge, like pus or drainage.

And approximation, which means are the edges of the wound closed together nicely.

So if the edges are pulling apart or there is pus coming out, that's a fail on the assessment.

Correct.

And remember, a high pulse rate often accompanies infection too.

The body is revving up to fight the bacteria, so the heart rate increases.

Prevention.

Hand hygiene.

It sounds so basic, but it is the primary method.

Using gloves when touching body fluids, and teaching the mom to wipe from front to back.

The text also touches on nutrition for healing.

Yeah.

You want to encourage a diet high in protein for tissue repair, some secneys, cheese, vitamin C, citrus, strawberries for college information, and iron to help replace the red blood cells lost during birth.

There's a table here, table 10 .2, that breaks down the difference between endometritis and a UTI.

Right.

UTIs, urinary tract infections, can also cause fever, but the key symptoms there are urinary.

Frequency, urgency, and dysuria, or painful urination.

Endometritis is more about the uterus itself being tender and that foul discharge.

Okay.

Zooming in on a very specific type of infection, mastitis.

Infection of the breast.

Yes.

And let's clear up a misconception here.

It is an infection of the breast tissue, and it usually enters through cracked nipples.

It typically happens two to three weeks postpartum, so she's often at home when it hits.

What are the symptoms?

It's usually unilateral, so just on one side, you'll see redness, heat, a heavy hard feeling in the breast,

and systemically she'll have a fever and chills.

The mom often feels like she has the flu.

Now the biggest question moms have is, can I keep breastfeeding?

And the answer is an emphatic yes.

In fact, she must keep emptying the breast.

She has to.

She has to.

If the milk stays in there, that's called stasis, it can lead to an abscess, which is much, much worse.

But it hurts.

It hurts a lot.

So here's a nursing tip.

Apply moist heat or take a warm shower before feeding to help the milk flow.

Start the baby on the unaffected side first to get the letdown reflux going, then switch to the infected side.

And if it's just too painful?

If it is absolutely too painful to nurse, she must pump.

The breast must be emptied one way or another.

And antibiotics are standard treatment here, I assume?

Yes, usually oral antibiotics.

But don't stop feeding.

Okay, moving to our final pillar of the big four, mood disorders.

We are talking about the mental and emotional complications after birth.

This is an area that is thankfully getting much more attention.

We really need to distinguish between the blues and true disorders.

Let's start with postpartum blues or baby blues.

Is this pathological?

Is it a disease?

No, it is considered a normal adjustment reaction.

It affects like 50 to 80 percent of women.

It's that roller coaster of emotions, crying for no reason, feeling let down.

It usually hits a few days after birth and it disappears by day 14.

Day 14 is the cutoff.

Roughly, yes.

It's self -limiting.

The key is that it goes away on its own as the hormones level out.

But perinatal mood disorders or PMD are different.

Yes.

PMD is an umbrella term that includes anxiety, depression, and psychosis.

These are not normal and they absolutely require treatment.

And they can happen during pregnancy, that's the perinatal part, or after.

Let's look at perinatal anxiety first.

What's the key diagnostic clue that the text offers?

The inability to sleep, even when the infant is asleep, that's the tell.

If the baby is finally down and mom is lying there staring at the ceiling, consumed by irrational fear or tension, that is anxiety.

And perinatal depression.

This usually manifests about two to four weeks postpartum.

It's a deeper darkness, a lack of enjoyment in things, disinterest in the infant, intense feelings of guilt and just crushing fatigue.

The text mentions a screening tool for this.

Yes.

The EPDES, the Edinburgh Postnatal Depression Scale, the RNAO, the Registered Nurses Association of Ontario, recommends routine screening.

You can't just look at a mom and know if she's depressed.

You have to ask the questions.

What are the risk factors?

They're listed in box 10 .2.

A personal history of mental health issues is the strongest predictor.

Also low social support, recent stressful life events like a move or intimate partner violence.

Finally, perinatal psychosis.

This is the extreme end of the spectrum.

It is a medical emergency.

It's rare, only about 0 .1 to 0 .5 percent of births.

But it is incredibly dangerous.

The woman has an impaired sense of reality.

She's having delusions, hallucinations, rapid mood swings.

And there's a strong link to bipolar disorder here.

Yes.

And the safety risk is extremely high risk of suicide or infanticide.

This woman needs inpatient psychiatric care immediately.

You do not leave her alone with the baby if you suspect psychosis.

Heavy but so important.

To wrap this all up, the chapter offers an unfolding case study about a patient named Tess.

Let's walk through it to apply what we've just learned.

OK, sounds good.

So Tess gave birth to twins.

She is four hours postpartum.

She has heavy red lochia and she hasn't gotten out of bed yet.

OK, step one, assess the risk.

Why is Tess high risk for complications?

Twins.

Her uterus was over distended.

It was stretched to the max.

That makes her a very high risk for uterine adenine.

The muscle is just plain tired.

Step two, assessment.

She says the lochia is heavy.

What do you do?

You need to get your hands on her belly.

Palpate the fundus.

Is it boggy?

Is it displaced?

If it's over to the right, you need to check her bladder and you need to weigh her pads.

If you're unsure of the volume, quantify it.

Step three, safety.

She hasn't walked yet.

She's lost blood.

She's been in bed for hours.

She is a major fall risk due to orthostatic hypotension.

That's when your blood pressure drops when you stand up.

So you don't let her walk to the bathroom alone.

Absolutely not.

You assist her.

And a crucial point, you do not leave the baby alone on the bed while you are helping her.

Baby safety is paramount.

It really brings it all together.

The mechanics, the assessment, the safety checks.

It really does.

It shows how you have to think through all these layers at once.

So what does this all mean for the learner listening right now?

What's the big takeaway?

It means that postpartum care is a high stakes vigilance game.

You are the safety net.

You are constantly watching for the four T's of hemorrhage.

You're watching for that calf pain of a DBT.

You're smelling the lochia for signs of infection.

You're listening to her talk about her sleep patterns to screen for anxiety.

And you are remembering that a pulse over 100 is your first clue for shock and that one gram equals one ml.

These tiny details, they save lives.

That's the bottom line.

That is a wrap on Chapter 10.

We hope this deep dive helps you crush your exam or just be a better, safer clinician.

Remember to review those charts, especially the four T's and that read a mnemonic for wounds.

And remember, knowledge is safety.

A huge thank you from the last minute lecture team.

Good luck with your studies and we will see you on the next deep dive.