However, complications can develop due to a wide range of factors, such as blood loss, trauma, infection, or fatigue. Some common postpartum complications include postpartum hemorrhage, postpartum psychiatric disorders, puerperal infection, mastitis, and deep vein thrombosis (DVT). Your keen nursing skills can help to prevent problems or detect them early before they cause more stress or seriously interfere with the parent-child relationship.

A patient who has a birth complicated by any of these factors should be observed for the possibility of developing a postpartum hemorrhage:

Postpartum hemorrhage is classified as early or late, depending on when it occurs. Early postpartum hemorrhage refers to blood loss in excess of 500 ml that occurs during the first 24-hours postpartum. Late postpartum hemorrhage refers to uterine blood loss in excess of 500 ml that occurs during the remaining 6-week postpartum period but after the first 24 hours.

The primary cause of postpartum hemorrhage, especially early postpartum hemorrhage, is uterine atony (uterine relaxation). When the uterus doesn’t contract properly, vessels at the placental site remain open, allowing blood loss. Any condition that interferes with the ability of the uterus to contract can lead to uterine atony and, subsequently, postpartum hemorrhage. (See Relaxation is risky.)

Lacerations of the cervix, birth canal, or perineum can also lead to postpartum hemorrhage. Cervical lacerations may result in profuse bleeding if the uterine artery is torn. This type of hemorrhage usually occurs immediately after delivery of the placenta while the patient is still in the delivery area. Suspect lacerations when bleeding persists but the uterus is firm.

Entrapment of a partially or completely separated placenta by an hourglass-shaped uterine constriction ring (a condition that prevents the entire placenta from expelling) can cause placental fragments to be retained in the uterus. Poor separation of the placenta is common in preterm births of 20 to 24 weeks’ gestation.

The reason for abnormal adherence is unknown, but it may result from the implantation of the zygote in an area of defective endometrium. This abnormal implantation leaves a zone of separation between the placenta and the decidua. If the fragment is large, bleeding may be apparent in the early postpartum period. If the fragment is small, however, bleeding may go unnoticed for several days, after which time, the woman suddenly has a large amount of bloody vaginal discharge.

DIC is a fourth cause of postpartum hemorrhage. Any woman is at risk for DIC after childbirth. However, it’s more common in women with abruptio placentae, missed abortion, placenta previa, uterine infection, placenta accreta, uterine inversion, severe preeclampsia, amniotic fluid embolism, or intrauterine fetal death.

When uterine atony is the cause, the uterus feels soft and relaxed. The bladder may be distended, displacing the uterus to the right or left side of midline and preventing it from contracting properly. The fundus may also be pushed upward.

When a laceration is the cause of postpartum hemorrhage, you may notice bright red blood with clots oozing continuously from the site and a uterus that remains firm.

Bleeding caused by a retained placenta or placental fragments usually starts as a slow trickle, oozing, or frank hemorrhage. In the case of retained placental fragments, also expect to find the uterus soft and noncontracting.

When the patient’s bleeding is continuous and uterine atony, lacerations, and retained placenta or fragments have been ruled out, coagulation problems may be the cause of the bleeding.

If blood loss is sufficient, the patient exhibits signs and symptoms of hypovolemic shock, such as increasing restlessness, lightheadedness, and dizziness as cerebral tissue perfusion decreases. Inspection may also reveal pale skin, decreased sensorium, increased pulse rate, and rapid, shallow respirations. Urine output usually falls below 25 ml/hour. Palpation may disclose rapid, thready peripheral pulses and cool skin that becomes cold and clammy.

Auscultation of blood pressure usually detects a mean arterial pressure below 60 mm Hg and a narrowing pulse pressure. Capillary refill at the nail beds is delayed 3 to 5 seconds.

When DIC is the cause of postpartum hemorrhage, platelet and fibrinogen levels are decreased and clotting times (prothrombin time [PT] and partial thromboplastin time [PTT]) are prolonged. Blood tests also reveal decreased fibrinogen levels and fragmented red blood cells (RBCs). Fibrinolysis increases and then decreases. Coagulation factors are decreased, with decreased antithrombin III, an increased D-dimer test, and a normal or prolonged euglobulin lysis time.

For the patient with uterine atony, initiate uterine massage. The goal is to increase uterine tone and contractility to minimize blood loss. If clots are present, they should be expressed. If the patient’s bladder is distended, she should try to empty her bladder because a distended bladder prevents the uterus from fully contracting. If these efforts are ineffective or fail to maintain the uterus in a contracted state, oxytocin (Pitocin) or methylergonovine (Methergine) may be given I.M. or I.V. to produce sustained uterine contractions. Prostaglandins (carboprost tromethamine) can also be given I.M. to promote strong, sustained uterine contractions.

If the uterus is firm and contracted and the bladder isn’t distended, the source of the bleeding must still be identified. Perform visual or manual inspection of the perineum, vagina, uterus, cervix, and rectum. A laceration requires sutures. If a hematoma is found, treatment may involve observation, cold therapy, ligation of the bleeding vessel, or evacuation of the hematoma. Depending on the extent of fluid loss, replacement therapy may be indicated.

Retained placental fragments typically are removed manually or, if manual extraction is unsuccessful, via dilatation and curettage (D&C). If the placenta is adhered to the uterine wall or has implanted into the myometrium, a hysterectomy may need to be performed to stop uterine bleeding.

Successful management of DIC requires prompt recognition and adequate treatment of the underlying disorder. Treatment may be supportive (for example, when the underlying disorder is self-limiting) or highly specific. If the patient isn’t actively bleeding, supportive care alone may reverse DIC. Active bleeding may require administration of blood, fresh frozen plasma, platelets, or packed RBCs to support hemostasis.

Heparin (Hep-loc) therapy for DIC is controversial. It may be used early in the disease to prevent microclotting but may be considered a last resort in the patient who’s actively bleeding. If thrombosis occurs, heparin therapy is usually mandatory. In most cases, it’s administered in combination with transfusion therapy.

Emergency treatment relies on prompt and adequate blood and fluid replacement to restore intravascular volume and to raise blood pressure and maintain it above 60 mm Hg. Rapid infusion of lactated Ringer solution and, possibly, albumin or other plasma expanders may be needed to expand volume adequately until whole blood can be matched.

Here are the steps you should take if the patient develops signs and symptoms of hypovolemic shock:

Baby blues are the most common of the postpartum psychiatric disorders and the least severe. Approximately 50% of all postpartum women experience some form of baby blues. Baby blues usually occur within 3 to 5 days after birth. They are a normal, hormonally generated postpartum occurrence that is thought to foster maternal-neonatal attachment. Mothers who have delivered prematurely and those who have an infant in the newborn intensive care unit are at particularly high risk.

Postpartum depression and postpartum psychosis are mood disorders recognized by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). Approximately 400,000 women a year (10% to 20% of postpartum women) develop postpartum depression or postpartum psychosis.

A major risk factor for developing postpartum depression is a previous history of depression or a psychiatric illness before or during the pregnancy. Anxiety during the pregnancy, a teenage pregnancy, multiple births, lack of social support, stressful life situations other than the pregnancy, and conflict with a spouse or significant other during the pregnancy can also be major risk factors.

Some minor risk factors include the socioeconomic status of the mother and obstetric complications.

Untreated depression during pregnancy can lead to poor self-care; noncompliance with prenatal care; a negative effect on maternalinfant bonding; a higher risk of obstetric complications; drug, tobacco, or alcohol abuse; termination of the pregnancy; and suicide.