NUR 254 | Exam 2 Study Manual | Chapter 2
NUR 254 Exam 2 Study Manual
Chapter 2: Postpartum Complications
Hemorrhage • Shock • Thromboembolism • Infection • Psychiatric Disorders
Source basis: Unit 4 Postpartum Complications PowerPoint and Maternal Child Nursing Care, 7th ed., Chapter 21.
Chapter at a Glance
• Postpartum hemorrhage can develop with little warning; early recognition and rapid intervention are essential.
• A boggy uterus points toward uterine atony; a firm uterus with persistent bright-red bleeding suggests trauma.
• Venous thromboembolism, postpartum infection, and postpartum psychiatric disorders require focused
screening and urgent escalation when warning signs appear.
Learning Objectives
Differentiate early and late postpartum hemorrhage and identify likely causes.
Recognize uterine atony, genital tract trauma, hematomas, retained tissue, uterine inversion, subinvolution, and
coagulopathy.
Prioritize nursing actions for excessive bleeding and hypovolemic shock.
Recognize venous thromboembolism, postpartum infection, and psychiatric emergencies.
Apply medication precautions and discharge teaching emphasized in the assigned course materials.
1. Postpartum Hemorrhage (PPH)
Postpartum hemorrhage is an obstetric emergency. The textbook describes it as a major cause of maternal
mortality that may occur with little warning and may not be recognized until substantial blood loss has occurred. The
course materials classify PPH by timing: early PPH occurs within 24 hours after birth, whereas late PPH occurs more
than 24 hours and up to 12 weeks after birth.
Type Timing Common Course Emphasis Assessment Clue
Early / primary PPH Within 24 hours Uterine atony is the most Boggy, enlarged uterus with
common cause. excessive bleeding.
Late / secondary PPH More than 24 hours to 12 Retained placental tissue, Prolonged lochia, irregular or
weeks subinvolution, or infection. excessive bleeding, enlarged or
boggy uterus.
The 4 Ts: A Framework for Causes
The PowerPoint groups common causes of PPH into four categories: Tone, Trauma, Tissue, and Thrombin.
This framework helps the nurse connect the assessment finding to the likely source of bleeding.
Cause Examples Typical Finding Nursing Focus
Tone Uterine atony; overdistended Boggy or hypotonic fundus; Firm fundal massage; empty
uterus increased lochia bladder; uterotonics and fluids
as ordered.
Trauma Cervical, vaginal, or perineal Persistent bright-red bleeding Inspect birth canal/perineum;
laceration; hematoma with a firm uterus; pain or notify provider; prepare for
pressure with hematoma repair or evacuation.
Tissue Retained placenta or placental Subinvolution; prolonged or Provider evaluation; possible
fragments recurrent bleeding; placental removal of retained tissue or
fragments in lochia D&C.
Thrombin HELLP syndrome, DIC, Continuous bleeding without an Rapid laboratory assessment
inherited/acquired coagulopathy obvious source; abnormal and replacement of blood
coagulation studies products/clotting factors.
1
, NUR 254 | Exam 2 Study Manual | Chapter 2
Risk Factors Emphasized in the Course Materials
Uterine overdistention: macrosomia, multiple gestation, and polyhydramnios.
Prolonged labor, oxytocin-induced labor, or failure to progress.
Chorioamnionitis.
Magnesium sulfate administration during labor or postpartum.
High parity or previous uterine atony.
Operative vaginal birth, cesarean birth, lacerations, uterine rupture, or uterine inversion.
Retained placental fragments, placenta previa/accreta syndrome, placental abruption, or coagulation disorders.
Exam Alert: Fundus + Bleeding Pattern
• Boggy uterus + heavy bleeding = think uterine atony first.
• Firm uterus + continued bright-red bleeding = think laceration or other trauma.
• Severe perineal or rectal pressure with little visible bleeding = suspect a hematoma.
2. Assessment and Immediate Nursing Response
When bleeding appears excessive, the first assessment is uterine contractility. The nurse evaluates fundal
tone and position, quantifies blood loss, assesses the perineum and lochia, obtains vital signs, and watches for signs
of shock. The textbook also emphasizes laboratory evaluation such as CBC, hemoglobin/hematocrit, platelet count,
blood typing/crossmatch, and coagulation studies.
Priority Sequence for Suspected Uterine Atony
1. Firmly massage the uterine fundus.
2. Assess for and help eliminate bladder distention.
3. Assess the amount and type of bleeding; weigh blood-soaked materials when quantitative blood loss is used.
4. Notify the health care provider and activate the facility PPH protocol or emergency team when indicated.
5. Verify or establish large-bore venous access; administer prescribed IV fluids, uterotonics, and blood products.
6. Monitor vital signs, oxygen saturation, level of consciousness, urine output, laboratory values, and response to
treatment.
Specific Hemorrhage Patterns
Uterine atony
The uterus fails to contract effectively and remains soft or boggy. Fundal massage, expression of clots when
directed, bladder emptying, oxytocin, other uterotonics, rapid fluid replacement, and ongoing reassessment are
emphasized in the textbook and PowerPoint.
Lacerations
Deep cervical or vaginal lacerations can cause persistent bright-red bleeding even when the uterus is firm.
Management focuses on identifying and repairing the laceration, controlling bleeding, supporting circulation, and
providing comfort and bowel-care teaching during recovery.
Hematomas
Key findings include discoloration, edema, severe perineal pain, vaginal or rectal pressure, and sometimes minimal
visible blood loss. Some hematomas require surgical evacuation. Nursing care includes pain control, bleeding
assessment, fluid replacement, and review of hemoglobin and hematocrit.
Uterine inversion
Uterine inversion is rare but life-threatening. Sudden hemorrhage, shock, severe pain, inability to palpate the uterus
abdominally, or a red mass at the introitus are major clues. Immediate fluid resuscitation and replacement of the
uterus are required. After manual replacement, aggressive fundal massage is avoided.
Subinvolution
Subinvolution is delayed return of the uterus to nonpregnant size and function. Retained placental fragments and
pelvic infection are recognized causes. Findings include prolonged lochia, irregular or excessive bleeding, and an
enlarged, possibly boggy uterus. Treatment depends on the cause and may include methylergonovine, D&C, or
antibiotics.
2
NUR 254 Exam 2 Study Manual
Chapter 2: Postpartum Complications
Hemorrhage • Shock • Thromboembolism • Infection • Psychiatric Disorders
Source basis: Unit 4 Postpartum Complications PowerPoint and Maternal Child Nursing Care, 7th ed., Chapter 21.
Chapter at a Glance
• Postpartum hemorrhage can develop with little warning; early recognition and rapid intervention are essential.
• A boggy uterus points toward uterine atony; a firm uterus with persistent bright-red bleeding suggests trauma.
• Venous thromboembolism, postpartum infection, and postpartum psychiatric disorders require focused
screening and urgent escalation when warning signs appear.
Learning Objectives
Differentiate early and late postpartum hemorrhage and identify likely causes.
Recognize uterine atony, genital tract trauma, hematomas, retained tissue, uterine inversion, subinvolution, and
coagulopathy.
Prioritize nursing actions for excessive bleeding and hypovolemic shock.
Recognize venous thromboembolism, postpartum infection, and psychiatric emergencies.
Apply medication precautions and discharge teaching emphasized in the assigned course materials.
1. Postpartum Hemorrhage (PPH)
Postpartum hemorrhage is an obstetric emergency. The textbook describes it as a major cause of maternal
mortality that may occur with little warning and may not be recognized until substantial blood loss has occurred. The
course materials classify PPH by timing: early PPH occurs within 24 hours after birth, whereas late PPH occurs more
than 24 hours and up to 12 weeks after birth.
Type Timing Common Course Emphasis Assessment Clue
Early / primary PPH Within 24 hours Uterine atony is the most Boggy, enlarged uterus with
common cause. excessive bleeding.
Late / secondary PPH More than 24 hours to 12 Retained placental tissue, Prolonged lochia, irregular or
weeks subinvolution, or infection. excessive bleeding, enlarged or
boggy uterus.
The 4 Ts: A Framework for Causes
The PowerPoint groups common causes of PPH into four categories: Tone, Trauma, Tissue, and Thrombin.
This framework helps the nurse connect the assessment finding to the likely source of bleeding.
Cause Examples Typical Finding Nursing Focus
Tone Uterine atony; overdistended Boggy or hypotonic fundus; Firm fundal massage; empty
uterus increased lochia bladder; uterotonics and fluids
as ordered.
Trauma Cervical, vaginal, or perineal Persistent bright-red bleeding Inspect birth canal/perineum;
laceration; hematoma with a firm uterus; pain or notify provider; prepare for
pressure with hematoma repair or evacuation.
Tissue Retained placenta or placental Subinvolution; prolonged or Provider evaluation; possible
fragments recurrent bleeding; placental removal of retained tissue or
fragments in lochia D&C.
Thrombin HELLP syndrome, DIC, Continuous bleeding without an Rapid laboratory assessment
inherited/acquired coagulopathy obvious source; abnormal and replacement of blood
coagulation studies products/clotting factors.
1
, NUR 254 | Exam 2 Study Manual | Chapter 2
Risk Factors Emphasized in the Course Materials
Uterine overdistention: macrosomia, multiple gestation, and polyhydramnios.
Prolonged labor, oxytocin-induced labor, or failure to progress.
Chorioamnionitis.
Magnesium sulfate administration during labor or postpartum.
High parity or previous uterine atony.
Operative vaginal birth, cesarean birth, lacerations, uterine rupture, or uterine inversion.
Retained placental fragments, placenta previa/accreta syndrome, placental abruption, or coagulation disorders.
Exam Alert: Fundus + Bleeding Pattern
• Boggy uterus + heavy bleeding = think uterine atony first.
• Firm uterus + continued bright-red bleeding = think laceration or other trauma.
• Severe perineal or rectal pressure with little visible bleeding = suspect a hematoma.
2. Assessment and Immediate Nursing Response
When bleeding appears excessive, the first assessment is uterine contractility. The nurse evaluates fundal
tone and position, quantifies blood loss, assesses the perineum and lochia, obtains vital signs, and watches for signs
of shock. The textbook also emphasizes laboratory evaluation such as CBC, hemoglobin/hematocrit, platelet count,
blood typing/crossmatch, and coagulation studies.
Priority Sequence for Suspected Uterine Atony
1. Firmly massage the uterine fundus.
2. Assess for and help eliminate bladder distention.
3. Assess the amount and type of bleeding; weigh blood-soaked materials when quantitative blood loss is used.
4. Notify the health care provider and activate the facility PPH protocol or emergency team when indicated.
5. Verify or establish large-bore venous access; administer prescribed IV fluids, uterotonics, and blood products.
6. Monitor vital signs, oxygen saturation, level of consciousness, urine output, laboratory values, and response to
treatment.
Specific Hemorrhage Patterns
Uterine atony
The uterus fails to contract effectively and remains soft or boggy. Fundal massage, expression of clots when
directed, bladder emptying, oxytocin, other uterotonics, rapid fluid replacement, and ongoing reassessment are
emphasized in the textbook and PowerPoint.
Lacerations
Deep cervical or vaginal lacerations can cause persistent bright-red bleeding even when the uterus is firm.
Management focuses on identifying and repairing the laceration, controlling bleeding, supporting circulation, and
providing comfort and bowel-care teaching during recovery.
Hematomas
Key findings include discoloration, edema, severe perineal pain, vaginal or rectal pressure, and sometimes minimal
visible blood loss. Some hematomas require surgical evacuation. Nursing care includes pain control, bleeding
assessment, fluid replacement, and review of hemoglobin and hematocrit.
Uterine inversion
Uterine inversion is rare but life-threatening. Sudden hemorrhage, shock, severe pain, inability to palpate the uterus
abdominally, or a red mass at the introitus are major clues. Immediate fluid resuscitation and replacement of the
uterus are required. After manual replacement, aggressive fundal massage is avoided.
Subinvolution
Subinvolution is delayed return of the uterus to nonpregnant size and function. Retained placental fragments and
pelvic infection are recognized causes. Findings include prolonged lochia, irregular or excessive bleeding, and an
enlarged, possibly boggy uterus. Treatment depends on the cause and may include methylergonovine, D&C, or
antibiotics.
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