Week 4: Nursing Care of Clients with Postpartum carefully, including fundal height and

Complications consistency and lochia, for the next 4 hours.

 You can also put iced pack in the fundus of
Post-Partum Hemorrhage – one of the most
the patient.
important causes of maternal mortality associated with
 If the uterus cannot remain contracted, her
childbearing, poses a possible threat throughout
physician or nurse-midwife probably will
pregnancy and also a major potential danger in the
order a dilute intravenous infusion of
immediate post partal period.
oxytocin (Pitocin) to help the uterus
 For normal delivery, the normal blood lost is maintain tone.
300ml. PS: Oxytocin should always be incorporated
 For CS delivery, the normal blood lost is in 1,000ml of IV fluid
1,000ml. PPS: 10 – 40 U is the usual dosage of
 The greatest danger of hemorrhage is in the oxytocin
first 24 hours because of the grossly denuded  Carboprost tromethamine (Hemabate),
and unprotected uterine area left after aprostaglandin F2a derivative, or
detachment of the placenta. methylergonovine maleate (Methergine),
anergot compound, given intramuscularly,
Main Causes for Post Partal Hemorrhage are second possibilities. Rectal misoprostol,
1. Uterine Atony – Uterine atony, or relaxation of a prostaglandin E1 analogue, may be
the uterus, is the most frequent cause of post repeated every 15 to 90 minutes up to 8
partal hemorrhage. The uterus must remain in a doses; methylergonovine may be repeated
contracted state after birth to keep the open every 2 to 4 hours up to 5 doses. All these
vessels at the placental site from bleeding. (The drugs should be readily available for use on
uterus is not contracted) a hospital unit in the event of postpartal
 Once the placenta is delivered the site of hemorrhage. Because prostaglandins tend to
detachment is an open blood vessel hence it cause diarrhea as a side effect, assess for this
will continue to bleed until uterine is frequently.
contracted. Contraction can lead to  You can’t give carboprost to a
vasoconstriction that can sealed the blood asthmatic patient. While
vessel site. Methylergonovine is
contraindicated to patients
Therapeutic Management with hypertension.
 in the event of uterine atony, the first step in  Offer a bedpan or assist the
controlling hemorrhage is to attempt uterine woman with ambulating to the
massage to encourage contraction. Unless the bathroom at least every 4
uterus is extremely lacking in tone, this hours to be certain her bladder
procedure is usually effective in causing is empty. A full bladder pushes
contraction, and after a few seconds, the an uncontracted uterus into an
uterus assumes its healthy, grapefruit-like even more uncontracted state.
feel. (Palpate the fundus first to know if the To reduce bladder pressure,
uterine is contracted or not. The uterus should insertion of a urinary catheter
be hard as the head.) may be ordered.
 With uterine atony, even if the uterus  If a woman is experiencing
responds well to massage, the problem may respiratory distress from
not be completely resolved. After you decreasing blood volume,
remove your hand from the fundus, the administer oxygen by face
uterus may relax and lethal seepage may mask at a rate of about
begin again. (It means the uterus might relax 4L/min. Position her supine to
again which will result into more bleeding) allow adequate blood flow to
Therefore, remain with the woman after her brain and kidneys.
massaging her fundus, to be certain the  Obtain vital signs frequently
uterus is not relaxing again. Observe and make sure to interpret the
accurately, looking for trends.
 For examples, a continuously  Assure her about her baby’s condition and
rising pulse rate is an ominous inform her about the need to stay in the
pattern. birthing room a little longer than expected
while the physician or nurse-midwife places
additional sutures. Remember that the
protective attitude a woman has felt toward her
body all during pregnancy is now turned
Summary of the management for Uterine Atony toward her baby, so she usually is relieved to
learn that any problem that may be occurring
 Bimanual massage
is hers, not her infant’s.
 Prostaglandin Administration
 Blood replacement Vaginal Laceration – Although they are rare,
 Hysterectomy or suturing lacerations can also occur in he vaginal. They are
2. Lacerations - Small lacerations or tears of the easier to assess than cervical lacerations, because they
birth canal are common and may be considered a are easier to view.
normal consequence of childbearing. Large
Therapeutic Management
lacerations, however, can cause complications.
They occur most often:  Because vaginal tissue is friable, vaginal
 With difficult or precipitate births in lacerations are also hard to repair. Some
primigravidas oozing often occurs after a repair, so the
 With the birth of a large infant (9lb) vagina may be packed to maintain pressure on
 With the use of a lithotomy position and the sutures line. An indwelling urinary catheter
instruments (Foley catheter) may be placed at the same
 Episiotomy – the perinium was cut a scissor time, because the packing causes pressure on
to open the perinium to give way to the the urethra and can interfere with voiding.
head.  If packing is inserted, a document in a
 Lacerations – normal cut because of tearing woman’s nursing care plan when and where it
was placed, so you can be certain it will be
Cervical Laceration – lacerations of the cervix are removed after 24 to 48 hours or before
usually found on the sides of the cervix, near the discharge. Packing that is left in place too long
branches of the uterine artery. If the artery is torn, the leads to stasis and infection similar to toxic
blood loss may be so great that blood gushes from shock syndrome, a form of septic shock.
vaginal opening. Because this is arterial bleeding, it is
brighter red than the venous blood lost with uterine Perineal Laceration – lacerations of the perineum
atony. Fortunately, this bleeding ordinarily occurs usually occur when a woman is placed in a lithotomy
immediately after delivery of the placenta when the position for birth, because this position increases
physician or nurse-midwife is still in attendance. tension on the perineum. Perineal lacerations are
classified by four categories, depending on the extent
Therapeutic Management and depth of the tissue involved.
 Repair of a cervical laceration is difficult, Classification of Perineal Lacerations
because the bleeding can be so intense that it
obstructs visualization of the area. Be certain  First degree – vaginal mucous membrane and
that a physician or nurse-midwife has adequate skin of the perineum to the fourchette
space to work, adequate sponges and suture  Second degree – Vagina, perineal skin, fascia,
supplies, and a good light source. The woman levator ani muscle, and perineal body.
is not always aware of what is happening at  Third degree – Entire perineum, extending to
this point, but she senses quickly that reach the external sphincter of the rectum.
something is seriously wrong.  Fourth degree – entire perineum, rectal
 Try to maintain an air of calm and if possible, sphincter, and some of the mucous membrane
stand beside the woman, at the head of the of the rectum.
table. She may be worried that the extra  A woman who has a third or fourth degree
activity in the room has something to do with laceration should not have an enema or rectal
her baby. suppository prescribed or have her
 temperature taken rectally, because the hard a large amount of blood. On
tips of equipment could open sutures near to examination, usually the uterus is not
or including those of the rectal sphincter. Be fully contracted.
sure that ancillary care givers such as nurses’
Therapeutic Management
aides are informed of this, so that they
understand these measures. Although fourth  Removal of the retained placental
degree lacerations can lead to long term fragment is necessary to stop the
dyspareunia, rectal incontinence, or sexual bleeding. Usually, a dilatation and
dissatisfaction, they usually heal without curettage (D&C) is performed to remove
further complications. the placental fragments. In some
instances, placenta accreta is so deeply
Therapeutic Management
attached that it cannot be surgically
 Perineal lacerations are sutured and treated as removed. Balloon occlusion and
an episiotomy repair. Make certain that the embolization of the internal iliac arteries
degree of the laceration is documented, may minimize blood loss. Methotrexate
because women with fourth-degree may be prescribed to destroy the
lacerations need extra precautions to avoid retained placental tissue.
having repair sutures loosened or infected.  Because the hemorrhage from retained
 Both lacerations and episiotomy incisions fragments may be delayed until after a
tend to heal in the same length of time. A diet woman is at home, be certain a woman
high in fluid and a stool softener may be knows to continue to observe the color
prescribes for the first week after birth to of lochia discharge and to report any
prevent constipation and hard stools, which tendency for the discharge to change
could break the sutures. from lochia serosa or alba black to
3. Retained Placental Fragments – Occasionally, rubra.
a placenta does not deliver in its entirely; 4. Disseminated Intravascular Coagulation –
fragments of it separate and are left behind. Disseminated intravascular coagulation (DIC) is
Because the portion retained keeps the uterus a deficiency in clotting ability caused by
from contracting fully, uterine bleeding occurs. vascular injury. It may occur in any woman in
Although this is most likely to happen with a the post partal period, but it is usually associated
succenturiate placenta (a placenta with an with premature separation of the placenta, a
accessory lobe) missed early miscarriage, or fetal death in utero.
 To detect the complication of retained  DIC is an acquired disorder of blood
placenta, every placenta should be clotting in which the fibrinogen level
inspected carefully after birth to see that falls to below effective limits. Early
it is complete. Retained placental symptoms include easy bruising or
fragments may also be detected by bleeding from an intravenous site.
ultrasound. A blood serum sample that Conditions such as premature
contains human chorionic gonadotropin separations of the placenta, pregnancy-
hormone (hCG) also reveals that part of induced hypertension, amniotic fluid
a placenta is still present. (24 hours after embolism, placental retention, septic
delivery the mother should have abortion, and retention of a dead fetus
negative hCG) are all associated with its development.
 Normally, platelets quickly form a seal
Assessment
over a point of bleeding to prevent
 If an undetected retained fragment is further loss of blood. Intrinsic and
large, bleeding will be apparent in the extrinsic clotting pathways then activate
immediate post partal period, because and strengthen this plug by fibrin
the uterus cannot contract with the threads to produce a firm, fixed
fragment in place. If the fragment is structure. To prevent too much clotting
small, bleeding may not be detected from occurring at the same time the clot
until post partum day 6 to 10, when the is being formed, thrombin activates
woman notices an abrupt discharge, and fibronolysin, a proteolytic enzyme, to
 begin to digest excess fibrin threads so that coagulation factors can be freed
(anticoagulation). This lysis results in and normal clotting function can be
the release of fibrin degradation restored.
products.  This is accomplished by the intravenous
 Pathophysiology: DIC occurs when administration of heparin to halt the
there is such extreme bleeding and so clotting cascade. Heparin must be given
many platelets and fibrin from the cautiously close to birth or postpartum
general circulation rush to the site that hemorrhage could occur from poor
not enough are left in the rest of the clotting after delivery of the placenta. If
body. This results in a paradox: at one bleeding during pregnancy was the
point in the circulatory system, the stimulus for DIC, a blood or platelet
person has increased coagulation, but transfusion may be necessary to replace
throughout the rest of the system, a blood or platelet loss.
bleeding defect exists. DIC is an  This administration may be delayed,
emergency because it can result in however, until after heparin therapy so
extreme blood loss. Goals should reflect the new blood factors are also not
the presence of the emergency. consumed by the coagulation process.
Antithrombin III factor, fibrinogen, or
Assessment
cryoprecipitate (which contains
 Testing clotting time can be done by fibrinogen) can all be used to restore
placing a small amount of blood in a test blood clotting. If these are not available,
tube. After 30 minutes, a clot should not fresh frozen plasma or platelets can also
only form but retract and the volume of aid in restoring clotting function.
serum in the tube should exceed the size
Subinvolution – is incomplete return of the uterus to
of the clot. If this does not occur, a low
its prepregnant size and shape. With subinvolution, at a
fibrinogen level is suggested.
4 or 6 week post partal visit, the uterus is still enlarged
 For definite diagnosis, blood needs to be
and soft. Lochial discharge usually is still present.
drawn for platelets (will e decreased to
Subinvolution may result from a small retained
100,000/L), prothrombin (will be low
placental fragment, a mild endometritis (infection of
because it depends on the conversion of
the endometrium), or an accompanying problem such
fibrinogen to fibrin), thrombin time (will
as a uterine myoma that is interfering with complete
be elevated because it measures the time
contraction.
necessary for conversion of fibrinogen
to fibrin), fibrinogen (will be decreased Therapeutic Management
to 150mg/Dl because fibrinogen has
 Oral administration of methylergonovine,
been used up), and fibrin split products
0.2mg four times daily, usually is prescribed to
(will be 40g/mL reflecting the
improve uterine tone and complete involution.
destruction of fibrinogen or fibrin).
If the uterus is tender to palpation, suggesting
 A D-dimer is a specific for fibrin (not
endometritis, an oral antibiotic also will be
fibrinogen) degradation products and
prescribed. Being certain that women are able
will be abnormal in 90% of patients with
to recognize the normal process of involution
DIC.
and lochial discharge before hospital discharge
Therapeutic Management helps women to be able to identify
subinvolution and seek early health care if it
 To stop the process of DIC, the
occurs. A chronic loss of blood from
underlying insult that began the
subinvolution sill result in infection or anemia
phenomenon must be halted. When the
and lack of energy, condition that possibly
insult was a complication of pregnancy
could interfere with infant bonding
such as premature separation of the
placenta, ending the pregnancy by Perineal Hematoma – a collection of blood in the
birthing the fetus and delivering the subcutaneous layer of tissue of the perineum. The
placenta is a part of the solution. Next, overlying skin, as a rule, is intact with no noticeable
the marked coagulation must be stopped trauma. Such blood collections can be caused by injury
to blood vessels in the perineum during birth. They are may be left open and packed with gauze rather
most likely to occur after rapid, spontaneous births and than resutured. Packing is usually removed
in women who have perineal varicosities. They may within 24 to 48 hours.
occur at the site of an episiotomy or laceration repair if  Be certain to record that this packing was
a vein was punctured during repair. Although they can placed, so it can be removed before discharge
cause woman acute discomfort and concern, they or when the woman returns to an ambulatory
usually represent only minor bleeding. setting. A suture line opened in this way heals
by tertiary intention, more slowly than a first
Assessment
degree intention suture line. Be certain the
 Perineal sutures almost always give a post woman has clear instructions before discharge
partal woman some discomfort. If a woman regarding necessary suture line care that she
reports severe pain in the perineal area or a needs to do at home such as keeping it clean
feeling of pressure between her legs, inspect and dry and perhaps using a sitz bath once or
the perineal area for a hematoma. If one is twice a day.
present, it appears as an area of purplish
Puerperal Infection
discoloration with obvious swelling. It may be
as small as 2cm or as large as 8cm in diameter.  Infection that happens after giving birth.
The area is tender to palpation. At first it may  Theoretically, the uterus is sterile during
feel fluctuant, but as seepage into the area pregnancy and until the membranes rupture.
continues and tissue is drawn taut, it palpates After rupture, pathogens can invade. The risk
as firm globe. of infection is even greater if tissue edema and
 Observe if hematoma is getting larger. trauma are present. If infection occurs, the
prognosis for complete recovery depends on:
Therapeutic Management
 Virulence of the invading
 Report the presence of a hematoma, its size, organism
and the degree of the woman’s discomfort to  The woman’s general health
her primary care provider. Assess the size by  Portal of entry
measuring it in centimeters with each  Degree of uterine involution at
inspection. Describing a hematoma as “large” the time of the microorganism
or “small” gives little information about the invasion
actual size. Describing a lesion as 5cm across  Presence of lacerations in the
or the size of a quarter or a half dollar is more reproductive tract
meaningful because it establishes a basis for
comparison. Endometritis – is an infection of the endometrium, the
 Administer a mild analgesic as ordered for lining of the uterus. Bacteria gain access to the uterus
pain relief. Applying an ice pack (covered with through the vagina and enter the uterus either at the
a towel to prevent thermal injury to the skin) time of birth or during the postpartal period. This may
may prevent further bleeding. Usually the occur with any birth, but the infection is usually
hematoma is absorbed over the next 3 or 4 associated with chorioamnionitis and cesarean birth.
days. If the hematoma is large when  Slight fever after giving birth is normal
discovered or continues to increase in size, the because of dehydration.
woman may have to be returned to the
delivery or birthing room to have the site Assessment
incised and the bleeding vessel ligated under
 A benign temperature elevation may occur on
local anesthesia.
the first postpartal day, particularly if a woman
 You can reassure a woman that, even though
is not drinking enough fluid. The fever of
the hematoma is causing her considerable
endometritis usually manifests on the third or
discomfort, her hospital stay probably will not
fourth postpartal day, suggesting that much of
be lengthened by its occurrence (unless it is
the invasion occurred during labor or birth
extremely extensive). In most women,
(consistent with the time it takes for infectious
hematomas absorb over the next 6 weeks,
organisms to grow)
causing no further difficulty. If an episiotomy
incision line is opened to drain a hematoma, it
Therapeutic Management a woman should be forewarned that it could
occur.
 Administration of an appropriate antibiotic,
such as clindamycin (Cleocin), as determined Infection of the Perineum – if a woman has a suture
by a culture from the vagina, using a sterile line on her perineum from an episiotomy or a
swab, rather than from a perineal pad, to laceration repair, a portal of entry exists for bacterial
ensure that you are culturing the endometrial invasion.
infectious organism and not an unrelated one
 Infection of the perineum usually remain
from the pad. An oxytocin agent such as
localized. They are revealed by symptoms
methylergonovine, may be prescribed to
similar to those of any suture-line infection,
encourage uterine contraction. The woman
such as pain, heat, and a feeling of pressure.
requires additional fluid to combat the fever. If
The woman may or may not have an elevated
strong afterpains and abdominal discomfort
temperature, depending on the systemic effect
are present, she needs an analgesic for pain
and spread of the infection.
relief.
 Sitting in fowler’s position or walking Assessment
encourages lochia drainage by gravity and
helps prevent pooling or infected secretions.  Inspection of the suture line reveals the
Because this drainage is contaminated, be inflammation. One or two stiches may be
certain to wear gloves when helping a woman sloughed away, or an area of suture line may
change her perineal pads. In addition, both of be open with purulent drainage present. Notify
you and the woman must use good the woman’s physician or nurse-midwife of
handwashing techniques before and after the localized symptoms, and culture the
handling these pads. discharge using a sterile cotton-tipped
 As with any infection, endometritis can be applicator touched to the secretions.
controlled best if it is discovered early. If you Therapeutic Management
can interpret the normal color, quantity, and
odor of lochia discharge and the size,  A woman’s physician or nurse-midwife may
consistency, and tenderness of a normal choose to remove perineal sutures, to open the
postpartal uterus, you may be at home when area and allow for drainage. Packing, such as
signs of infection occur, teaching about the iodoform gauze, may be placed in the open
signs and symptoms of endometritis is lesion to keep it open and allow drainage. B
essential. In addition, follow-up by a home sure the woman is aware that the packing is in
care nurse can help with early detection. (You place, so she knows not to dislodge it as she
should not saturate a perineal pad in 1or 2 changes her perineal pad.
hours so that the odor of the lochia is like a  Typically, a systemic or tropical antibiotic is
menstruation) ordered even before the culture report is
 If the infection is limited to the endometrium, returned. An analgesic may be prescribed to
the course of infection is about 7 to 10 days. If alleviate discomfort. Sitz baths, moist warm
this occurs while a woman is hospitalized, she compresses, or Hubbard tank treatments may
may have to make arrangements for her baby’s be ordered to hasten drainage and cleanse the
discharge before her own, or for help with area. Remind the woman to change perineal
newborn care, if her hospital stay is extended pads frequently, because they are contaminated
for a few days. Or, she may be discharged by drainage. If they are left in place too long,
home on intravenous antibiotic therapy with they might cause vaginal contamination or
follow-up by a home care nurse. reinfection. Be certain a woman wipes front to
 An added danger of endometritis is that it can back after bowel movement, to prevent
lead to tubal scarring and interference with bringing feces forward onto the healing area.
future fertility. At a future time, if the woman With a local infection of this nature, a woman
desires more children, she may need fertility is usually discharged with a referral for home
assessment (including a hysterosalpingogram) care follow-up, because the incision site, once
to determine tubal patency. With mild opened, must heal by tertiary rather than
endometritis this is usually not a problem, but primary intention. Infections of this nature are
annoying and painful but fortunately, with
 improved techniques during parturition and Femoral Thrombophlebitis – with femoral
puerperium, perineal infections occur only thrombophlebitis, the femoral, saphenous, or popliteal
rarely. Because they are localized, there is no veins are involved. Although the inflammation site in
need to restrict the woman from caring for her thrombophlebitis is a vein, an accompanying arterial
infant, as long as she washes her hands well spasm often occurs, diminishing arterial circulation,
before holding her newborn. Be certain not to along with edema, gives the leg a white or drained
place the infant on the bottom bed sheet of the appearance. It was formerly believed that breastmilk
woman’s bed, where the baby could contact drained into the leg, giving it its white appearance. The
pathogenic bacteria. Encourage the woman to condition was, therefore, formerly called milk leg or
ambulate and ask for analgesia as needed. phlegmasia alba dolens (white inflammation)
Often the pain from infected suture line is
Assessment
severe, and the woman may decrease
ambulation unless she is urged to continue.  If femoral thrombophlebitis develops, a
 Therapeutic Management Peritonitis is often woman notices an elevated temperature,
accompanied by paralytic ileus (blockage of chills, pain, and redness in the affected leg
inflamed intestines). This requires insertion of about 10 days after birth. Her leg begins to
a nasogastric tube to prevent vomiting and rest swell below the lesion at the point at which
the bowel. Intravenous fluid or total parenteral venous circulation is blocked. Her skin
nutrition may be necessary. A woman will becomes so stretched from swelling that it
need analgesic for pain relief. She will be appears shiny and white. Homans’ sign (pain
administered large doses of antibiotics to treat in the calf of the leg on dorsiflexion of the
the infection. Her hospital stay will be foot) may be positive; however, a negative
extended, but with effective antibiotic therapy, Homans’ sign does not rule out obstruction.
the outcome usually is good. Peritonitis can The diameter of the leg at thigh or calf level
interfere with future fertility, because it leaves may be increased compared with the other
scarring and adhesions in the peritoneum. leg. Doppler ultrasound or contrast
Adhesions formed this way may separate the venography usually is ordered to confirm the
fallopian tubes from the ovaries to the extent diagnosis.
that ova can no longer easily enter the tubes.
Therapeutic Management
Thrombophlebitis – phlebitis is inflammation of the
lining of a blood vessel. Thrombophlebitis is  Never massage the skin over the clot; this
inflammation with the formation of blood clots. When could loosen the clot, causing pulmonary or
thrombophlebitis occurs in the postpartal period, it is cerebral embolism. Heat supplied by a moist,
usually an extension of an endometrial infection. It warm compress can help decrease
tends to occur because: inflammation. Although simple in theory,
unfortunately, this is one of the most
 A woman’s fibrinogen level is still technically difficult treatments to carry out,
elevated from pregnancy, leading to because dressing invariably dry or become
increased blood clotting. cold after only a short time. Compresses and
 Dilation of lower extremity veins is water used in this way do not have to be
still present as a result of pressure of sterile because, with thrombophlebitis, there
the fetal head during pregnancy and is no break in the skin.
birth.  Be certain to test water temperature by
 The relative inactivity of the period or dipping your inner wrist in it before soaking a
a prolonged time spent in delivery or dressing, to be sure it is not too warm
birthing room stirrups leads to (because edema decreases sensation in a
pooling, stasis, and clotting of blood woman’s leg, she can burn easily). Always
in the lower extremities. cover wet, warm dressings with the plastic
 Obesity from increased weight before pad to hold in heat and moisture. In addition,
pregnancy and pregnancy weight gain a commercial pad with circulating heating
can lead to relative inactivity and lack coils or chemical hot packs may be positioned
of exercise. over the plastic to ensure that soaks stay
 The woman smokes cigarettes. warm. Be certain the weight of a hot pack or
 pad does not rest on the leg, causing an 8 hours” is far meaningful that “large amount
obstruction to flow of blood. of lochia”. Also assess for other possible signs
 Check a woman’s bed frequently when moist of bleeding, such as bleeding gums,
compresses are used, to be certain the ecchymotic spots on the skin, or oozing from
mattress does nit become wet from seeping an episiotomy suture line.
water. For soaks to stay in a place, a woman  Women taking anticoagulants are not
must keep her leg fairly immobile. However, normally prescribed salicylic acid (aspirin) for
be certain she does not interpret this as pain, because salicylic acid prevents blood
meaning that she cannot turn or move about. clotting by preventing platelet aggregation
Provide her with appropriate activities to and clot formation. However, some women
exercise the other parts of her body and may be prescribed aspirin every 4 hours as a
stimulate her time on bed rest is to offer preventive measure if they are high risk for
reading material about newborns. This recurrent thrombophlebitis. If this is so, be
activity helps her maintain bed rest and also certain you do not interpret aspirin used this
educates her about infant care. way as a PRN analgesic order and withhold it
 The pain of thrombophlebitis is usually severe depending on the woman’s level of pain.
enough to require administration of an  With proper treatment, the acute symptoms of
analgesic. An appropriate antibiotic to reduce femoral thrombophlebitis last only a few
the initial infection is prescribed. Often, an days, but the full course of disease takes 4 to
anticoagulant (coumarin derivative or 6 weeks before it is resolved. Anticoagulants
heparin) or a thrombolytic agent such as therapy may need to be continued for 3 to 6
streptokinase or urokinase is prescribed to months The affected leg may never return to
dissolve the clot through the activation of its former size and may always cause
fibrinolytic precursors and prevent further clot discomfort after long periods of standing.
formation.
Pelvic Thrombophlebitis – involves the ovarian,
 Blood coagulation level to determine the
uterine, or hypogastric veins. It usually follows a mild
effectiveness of the drug therapy are
endometritis and occurs later than femoral
measured daily before administration of the
thrombophlebitis, often around the 14th or 15th day of
anticoagulant. Depending on the drug
the puerperium. Risk factors are the same for femoral
prescribed, a baseline activated partial
thrombophlebitis.
thromboplastin time (aPTT) or prothrombin
time (PT) is obtained. Assessment
 A woman can continue to breastfeed while
receiving heparin. If she does not wish to  With pelvic thrombophlebitis, a woman
breastfeed, she can be switched to warfarin suddenly becomes extremely ill, with high
(an oral coumarin derivative) before hospital fever, chills, and general malaise. Her
discharge. The antidote to warfarin is vitamin infection can be so severe it necroses the vein
K. A woman has to discontinue breastfeeding and results in a pelvic abscess. It can become
during therapy with coumarin, because systemic and result in a lung, kidney, or heart
coumarin-derived anticoagulants are passed in valve abscess.
breast milk. If the thrombophlebitis does not Therapeutic Management
seem to be severe and the woman wants to
restart breastfeeding after the course of  As with femoral thrombophlebitis, therapy
anticoagulant (about 10 days), encourage her involves total bed rest and administration of
to manually express breast milk at the time of antibiotics and anticoagulants. The disease
normal feedings, to maintain a good milk runs a long course of 6 to 8 weeks. If an
supply. abscess forms, it can be located by sonogram
 Lochia usually increases in amount in a and incised by laparotomy, if necessary.
woman who is receiving an anticoagulant. Be Formation of an abscess is associated with
sure to keep a meaningful record of the high mortality rate. An inflammation of this
amount of this discharge so that it can be extent may leave tubal scarring and interfere
estimated. “Lochia serosa with scattered with future fertility. A woman may need
pinpoint clots; three perineal pads saturated in
 surgery to remove the affected vessel before will be prescribed to treat a postpartal urinary
she attempts to become pregnant again. tract infection. If an antibiotic contraindicated
 Regardless of the type of thrombophlebitis, by breastfeeding is prescribed, check with a
teach women preventive measures to reduce woman’s physician about possibly changing
the risk of recurrence with future pregnancies. the antibiotic to one that is safe for
These measures include not wearing breastfeeding. Otherwise, once she is home,
constricting clothing such as garters or tight the woman may decide to breastfeed and not
stockings on the lower extremities, resting take the prescribed antibiotic.
with the feet elevated, and ambulating daily  Encourage woman to drink large amount of
during pregnancy. Caution a woman to tell her fluid (a glass every hour) to help flush the
physician or nurse-midwife before her next infection from her bladder. She may need an
pregnancy of the difficulty she experienced oral analgesic, such as acetaminophen
this time, so that extra prophylactic (Tylenol), to reduce the paint of urination for
precautions can be taken to prevent the next few times she voids until antibiotics
thrombophlebitis. begins to have an effect, and the burning
sensation disappears. Otherwise, because
Urinary Tract Infection – A woman who is
voiding is painful, she may not drink the fluid
catheterized at the time of childbirth or during the post
you suggest, knowing that it will increase the
partal period is prone to develop urinary tract
number of times she needs to void.
infection, because bacteria may be introduced into the
 Although symptoms of urinary tract infection
bladder at the time of catheterization.
decrease quickly, be certain a woman
Assessment understand the importance of continuing to
take the prescribed antibiotic for the full 5 to 7
 If urinary tract infection develops, a woman days to eradicate the infection completely.
notices symptoms of burning on urination, Women often stop taking medicine after
possibly blood in the urine (hematuria), and a symptoms disappears, especially if they are
feeling of frequency or that she always has to busy – and women at home with new babies
void. The pain is so sharp on voiding that she are busy. Make a chart for a woman to post on
may resist voiding, further compounding the her refrigerator door as a reminder to continue
problem of urinary stasis. She may also have a to take the medication. If she stops the
low-grade fever and discomfort from lower antibiotic, bacteria in the urine will begin to
abdominal pain. multiply again, and in another week symptoms
 Obtain a clean-catch urine specimen from any and the active infection will recur. Be certain a
woman with symptoms of urinary tract woman is aware of common methods all
infection. This can be done as an independent women should use to prevent urinary tract
nursing action. So that lochial discharge does infection.
not contaminate the specimen, provide a sterile
cotton ball for the woman to tuck into her
vagina after perineal cleansing. Be certain to
ask if she removed the cotton ball after the
procedure; otherwise, it could cause stasis of
endometritis. Mark the specimen “possibly
contaminated by lochia”, so that any blood in
the specimen will not be overly interpreted by
the laboratory technician.
Therapeutic Management
 Although sulfa drugs are normally prescribed
for urinary tract infection, they are
contraindicated for breastfeeding women
because they can cause neonatal jaundice.
Typically, therefore, a broad-spectrum
antibiotic such as amoxicillin or ampicillin