Maternity - Postpartum, part 5: Postpartum Hemorrhage, Endometritis, Mastitis, Mental Health Concerns
by Meris Shuwarger BSN, RN, CEN, TCRN November 30, 2021 Updated: June 16, 2022 12 min read
Hi, I'm Meris with Level Up RN, and in this video, I'm going to be talking to you about some postpartum complications, including postpartum hemorrhage, endometritis, mastitis, and mental health concerns. I'm going to be following along using our maternity flashcards, which are available on our website, leveluprn.com, if you want to grab a set for yourself. Otherwise, if you already have a set, I would invite you to go ahead and follow along with me. All right. Let's get started. So first up, we are talking about postpartum hemorrhage, which is going to be defined differently based on what type of delivery your patient had. Postpartum hemorrhage for a vaginal delivery is going to be defined greater than 500 mls of blood loss for a C-section greater than 1,000 mls or one liter of blood loss. Now, risk factors. Let's talk about risk factors because they're really important here at helping you identify who could go on to have postpartum hemorrhage, who do I need to watch more closely? So uterine atony, a-tony, right? Means without tone. So atony means like a boggy fundus. If we have good tone in the uterus, that fundus is going to be nice and firm. But if we have atony, then we are going to have a boggy fundus. That is a huge, huge, huge risk factor, so much so that it is in bold red text here. Birth canal trauma, so if they had some sort of a laceration or hematoma. Precipitous delivery, remember, we've talked about that in the past, but that's a delivery that is happening very fast. So things are not going through the normal phases of a delivery; things are happening very rapidly, and now I am at risk for postpartum hemorrhage.
Retained placental fragments, uterus inversion or subinvolution. So if the uterus inverts, meaning, here's your normal uterus, and it actually kind of comes out of itself, it turns inside out - of course, huge risk for postpartum hemorrhage - coagulopathies such as DIC, disseminated intravascular coagulation, or ITP, immune thrombocytopenic purpura, those, of course, are going to put me at risk for postpartum hemorrhage because it's a problem with my clotting, right? Multipolarity, so patients who have had multiple pregnancies. And also, multiple births. So if we have a patient who gave birth to twins or triplets, they are more at risk as well. And then fetal macrosomia, so a bigger baby means the uterus had to be bigger, which means I have more to contract down higher risk for postpartum hemorrhage. So signs and symptoms, got to know that too. Saturating a pad in less than or equal to 15 minutes, that's our biggest sign. We can see the blood coming out, right, and we are saying it's happening too fast, too rapidly. There is too much of it, soft or boggy fundus, large blood clot. So if we're passing these huge blood clots, that should be a big red flag for you as well.
A constant flow of blood from the vagina. Yeah, we're going to trickle blood out. But if I am just seeing blood coming out of the vagina, that's not normal, right? That is a hemorrhage. And then signs and symptoms of hypovolemic shock. So tachycardia, hypotension, tachypnea, cooling clammy skin. All of those sorts of things are going to be, "Something's wrong. We don't have enough blood volume here." Now, for labs, you will see a decrease in hemoglobin and hematocrit, of course, and that may tell us that we need to give blood to replace the blood that has been lost. So the treatment, though, is very important because it's different than what we would do for someone who had a trauma, like a car accident, and is bleeding out, right? So a big one here is going to be uterine stimulants. If we can stimulate the uterus to contract down, that's going to cut off those bleeding vessels, right? It's going to help to kind of tamponade the bleed itself from inside. So big ones here would be oxytocin. We talked about that before in a previous video. It's given very routinely to all postpartum patients nowadays to just help that uterus contract back down. Methylergonovine, which is also called Methergin, that is another one that is given for postpartum hemorrhage. Misoprostol and Carboprost. Carboprost is also sometimes called Hemabate. I think Hemabate is a great name because it literally means blood stop. So it's a great name.
So anyway, those would be your biggest uterine stimulants here. We can also do bimanual compression. And by we, I mean the provider, so that would involve one hand being inserted into the patient's vagina and the other one being used to massage that uterus. So it's going to be bimanual, meaning two hands. Other things that we can do here would be uterine packing - again, not us, but the provider - and surgical intervention. If we've tried all of these things and they're not working and our patients are still hemorrhaging, we need to emergently be going to the OR to see if we can locate the source of the bleed. And in some cases, we may actually have to do a hysterectomy for this patient. That is always our last resort. It is not something that we just jump to doing, but we would rather our patient lose their uterus than lose their life, right? So nursing care would be firmly massaging the fundus, administering oxygen and IV fluids and blood products per ordered, and then elevating the patient's legs, again, to help get that blood flow back to their heart, their lungs, their brain, right? So all of those things are going to be vitally important.
Now, moving on to a different postpartum complication called endometritis. I know it sounds similar to a condition called endometriosis, but it's not. Very different conditions. Endometritis means infection or inflammation of the endometrium, the lining of the uterus. So we now have an infection of the lining of the uterus. And I will tell you, I had this with both of my children. It is very painful, very distressing. It was awful. It was the worst part of having a baby for me. So infection and inflammation inside of the uterus. And risk factors here, think about who's more at risk, right? Your patient who had a vaginal delivery or a C-section? Either one can get it. But a C-section where we have actually cut the patient open and exposed the uterus to the outside, we are more at risk for endometritis. A patient who has had chorioamnionitis, so a different type of infection inside the uterus, is at risk. Retained placental fragments, we don't want to retain anything inside the uterus. Puts us at risk for hemorrhage and for infection. A patient who had a premature rupture of membranes so they had prolonged membrane rupture puts them at risk for infection, prolonged labor. Internal fetal monitoring. Again, think about this. Remember, internal fetal monitoring is an invasive procedure where something from the outside is introduced into the uterine environment to keep an eye on the baby. It puts us at risk for infection.
In the multiple cervical examinations, yes, we wear sterile gloves when doing cervical exams, but there is still the risk for introducing pathogens. And the more we do these exams, the more we are putting our patients at risk. So signs and symptoms, the biggest one is going to be fever. A fever is going to alert us that there's some sort of systemic reaction here going on. Suprapubic pain and tenderness, excessive and malodorous lochia. Remember, we don't want the discharge from the vagina to smell foul. If it smells foul, we are concerned for infection. Tachycardia and hypertension, those can be suggestive of the systemic inflammatory response syndrome, or SIRS, which is very bad. So for me in particular, it was probably day three, four, or five postpartum. I can't remember exactly, but I felt terrible. I was in excruciating pain, and I thought this seems like more pain than I was in. I was in so much pain. I was having fevers and chills and night sweats and all of that sort of thing. And the reason I finally called my doctor was malodorous lochia. I thought something is wrong. Sure enough, I had endometritis, and I needed to be treated. So let's talk about treatment. Treatment is going to be with IV or oral antibiotics. Depending on how far progressed it is, you may need to be hospitalized and receive IV antibiotics. If you catch it early enough, you may be able to do oral antibiotics. And then, of course, analgesics, because we are really concerned about the pain for this patient as well. So we're going to monitor these patients for any sort of complications. But, in general, we're going to expect to see that once they begin on antibiotics, their symptoms should start to resolve somewhat.
Now, let's talk about a different kind of infection, mastitis. So mastitis is going to be an infection and inflammation of the breast. And this is very common with breastfeeding patients who are not able to fully drain the breast. Maybe they have inadequate drainage of milk, and that can lead to bacterial contamination and infection. Now, risk factors would be infrequent feeding. So if we are not feeding very frequently or maybe we're only feeding on one side, because the other one doesn't produce as much or the baby doesn't latch as well, that other side that doesn't get used as much is at risk for developing mastitis. A clogged milk duct is going to prevent milk from coming through, putting us at risk for mastitis. Nipple damage, if we have an improper latch, which is causing nipple damage, now we are at risk for introducing bacteria into that environment. And then poor hand hygiene. Remember, I said in a previous video, prior to breastfeeding, we wash our hands, and that is going to help to prevent mastitis and also infections for the newborn. Signs and symptoms are classic. Your patients are going to report flu-like symptoms, so malaise, fatigue, body aches, fever. Again, infection and fever go hand in hand. And then in terms of more localized symptoms, we're going to have unilateral pain, swelling, and erythema of the breast. That is very common. It is possible to get mastitis on both, but typically, it's going to present just on the one side. So antibiotics and analgesics are going to be indicated. Mastitis is very painful, so your patients should be receiving some form of analgesia.
And then for patient teaching, a lot of it is going to have to do with prevention, right? Good hand hygiene, proper latch, feed from both breasts, that sort of a thing. Apply heat prior to breastfeeding is going to help to dilate those ducts and also improve circulation. And then we want to ensure that the patients are fully emptying their breasts, which may also require manual expression of milk or pumping milk. Now, this is awful but when you have mastitis, you are still supposed to try to pump from that breast because it is going to-- it's going to be very painful, but it's going to help. It's going to move that milk out, ensure that we have good circulation and milk flow. But it's very painful, so we're going to teach our patients to do it just as much as they can tolerate, and maybe even do manual expression, expressing milk with the hands rather than a pump at first.
All right. Changing gears entirely from a physical complication to an emotional or psychological one. Let's talk about mental health concerns in the postpartum patient. So there's a couple of different things here that we need to talk about. There's the baby blues, there's postpartum depression, and then there is postpartum psychosis. So postpartum blues or baby blues would be kind of like mood swings or crying spells that lasts for about one to two weeks following delivery. This is normal. I remember when my daughter was born, I would just start crying just randomly, and my husband would say, "Oh my gosh, are you okay? What's wrong?" And I would be, "Hu, hu, hu,"' and I would say, "I don't know why I'm crying." I truly didn't know why I was crying. And then I would have big mood swings where I would be so happy and, "Oh, look at my perfect baby." And then my husband would pick her up, and I would be like, "That's my baby. Give me my baby." I would just have these really dramatic mood swings. But that was very normal. That's okay. It's expected. We're still going to keep an eye on it, right, make sure everything's okay. But if it resolves within the first two weeks postpartum, we're calling it the baby blues. We're saying it's normal. We're moving on.
Now, postpartum depression or PPD, this is going to occur within one year of delivery. So even if it comes on nine months after the baby is born, it is still considered postpartum depression. This is going to be persistent sadness, intense mood swings. It could involve the rejection of the infant. You could have a flat affect, anxiety, panic attacks, decreased or increased appetite. There's lots of different ways that it could present. It doesn't have to be all of those things. But the important thing to understand here is that it's lasting longer than those two weeks, and it can last for a long time. Now, this is not considered a normal finding. This is something where we actually want to intervene, and we do what's called the Edinburgh Depression Scale, so that's the EDS or EPDS postpartum depression scale, is given to patients typically at their postpartum visit and sometimes even by the pediatrician. I'm going to tell you a story about myself. My dad died 19 days before my daughter was born. And so while I did experience the baby blues, I also experienced severe postpartum depression. And when I went for my postpartum checkup, I already knew something isn't right here, but it's embarrassing and uncomfortable to bring it up. And for some reason, the medical assistant did not provide me with the EPDS. Instead, she said to me, "Do you have any concerns about postpartum depression that you would like to talk about with the doctor?" And I said no because I was nervous and ashamed and embarrassed and scared. And what if they think I'm crazy, right? I wanted help so desperately, but I didn't know how to bring it up.
Fortunately, my daughter's pediatrician gave me the EPDS at her checkups. And at one point he said to me, "Marice, you started off pretty high. Your scores are getting worse and worse and worse." And he actually grabbed me by the shoulders at one visit and said, "You need to get help because if you don't get help, you're not going to be here to take care of your daughter." And that was a big wake-up call for me. And thank goodness for this pediatrician. He's not even my doctor who is looking out for me and my well-being and my mental health because he knew that it impacted the health and well-being of my daughter, right? So it's not enough to just say, "Are you having any concerns about postpartum depression?" We need to routinely screen patients, and we need to let them know that this isn't a judgment call. This isn't a morality call. We're not saying that you're not a good mom or that something's wrong with you. We're saying we want to support you better so you can be there for your infant, right? It's a big difference in the way you approach it, changes how receptive your patient is going to be for that.
Now, let's talk about the extreme of this, which is postpartum psychosis. So this typically occurs within two weeks of delivery. Risk factors include a history of bipolar disorder, but I would say, you should just be watching all of your patients for this, and signs and symptoms here are going to be hallucinations, delusions, confusion, and paranoia. So this is a huge safety risk to the postpartum parent and to the infant. Postpartum psychosis, when I'm having delusions and hallucinations and confusion and all of those sorts of things, my baby is at risk for me having some sort of erratic or unpredictable behavior that could harm them in some way. So we need to get help immediately for this patient, and treatment is going to include things like antipsychotics, mood stabilizers, psychotherapy, and that sort of thing. Again, this is all about keeping the patient and the infant safe. First and foremost, we need to make sure everyone is safe. So if any patient ever says that they are thinking of hurting themselves or their infant, you need to be thinking safety, right? I need to be thinking, "How can I immediately guarantee the safety of my patient and their infant?" I hope this review was helpful for you. Be sure to stay on for a few more moments because I got some quiz questions for you to test your knowledge of some key facts provided in this video.
Okay. So first up, I want you to think about the fact that you're caring for a patient who's experiencing a postpartum hemorrhage. Imagine you're caring for this patient. Should you expect that the patient will receive magnesium or oxytocin as a treatment for postpartum hemorrhage? Okay. Next up, is a patient who had a vaginal birth or a C-section more at risk for developing endometritis. Which one? Next up, what is the treatment for a patient who is experiencing mastitis? What two classes of medications would you expect this patient to receive? And lastly, a patient reports experiencing sadness and mood swings for 12 days following the birth of their child. Does the nurse consider this to be a normal or an abnormal finding? Let me know how you did in the comments. I can't wait to hear. Thanks so much and happy studying.
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