Midwife Licensure Exam High-Risk Pregnancy & Complications (Recognize & Refer) — Postpartum ComplicationsRevision Notes

Exam Tips

• NLE loves to ask: 'The fundus is firm but deviated to the right — what is the nurse's first action?' Answer: Have the patient void (or catheterize if unable).
• Memorize the lochia sequence with the mnemonic RSA — Rubra → Serosa → Alba.
• If the question describes lochia returning to bright red after it had become pinkish-brown, think subinvolution or retained placental fragments.
• Day 10 is the key landmark: fundus non-palpable, lochia transitioning from serosa to alba.

Key Points

• Involution is the return of the uterus to its pre-pregnant state, beginning immediately after delivery of the placenta.
• Immediately after birth: the fundus is firm, midline, at or just below the umbilicus (at the level of the umbilicus or 1 cm above).
• Fundal height descends approximately 1 fingerbreadth (1 cm) per day — by day 10, the fundus is no longer palpable abdominally.
• A fundus that is high (fails to descend), boggy (soft), or displaced laterally (usually to the right) signals a complication.
• Lochia progresses in three stages: RUBRA (days 1–3, dark red, menstrual-like), SEROSA (days 4–10, pinkish-brown, serosanguineous), ALBA (day 10 to up to 6 weeks, yellowish-white).
• ABNORMAL lochia findings: foul odor (infection), return to bright red after serosa/alba (subinvolution or retained fragments), heavy saturation of one pad in less than one hour (hemorrhage), large clots.
• Normal afterpains (uterine contractions during involution) are expected, especially in multiparous mothers and breastfeeding mothers — distinguish from abnormal tenderness.
• Breastfeeding accelerates involution due to oxytocin release — this is a physiologic benefit to emphasize in health teaching.
• A full bladder is the most common cause of fundal displacement and boggy uterus — always assess bladder distension before diagnosing atony.
• Teach every mother BEFORE discharge to report: saturating a pad in 1 hour, foul-smelling lochia, fever above 38°C, leg pain/swelling, breast redness/hardness, and any mood changes including thoughts of self-harm or harming the baby.

Definitions

Section Title

Normal Involution — Your Baseline for Detecting Complications

Common Mistakes

• Confusing the normal fundal height timeline — remembering 'one fingerbreadth per day' helps; if a student says the fundus should be at the umbilicus on day 5, that is wrong.
• Forgetting that a fundus deviated to the right is due to a full bladder — the intervention is voiding/catheterization, NOT just massaging the fundus.
• Mistaking breastfeeding-associated afterpains as a sign of infection — afterpains with breastfeeding are physiologic.
• Describing lochia serosa as bright red — serosa is pinkish-brown. Bright red lochia after day 3 is abnormal.

Formulas

Exam Tips

• The NLE question stem will say 'boggy uterus' — the FIRST nursing action is FUNDAL MASSAGE, not medication.
• If the question adds 'fundus deviated to the right (or side),' the first action becomes VOIDING or CATHETERIZATION to empty the bladder.
• Memorize the 4 Ts: Tone, Trauma, Tissue, Thrombin — NLE may give a scenario and ask you to identify the cause.
• Bright red steady bleeding + firm uterus = TRAUMA (laceration) — this differentiates from atony.
• Drug contraindication pairs to memorize: Methylergonovine = NO in hypertension; Carboprost = NO in asthma.
• For shock positioning: elevate legs (modified Trendelenburg) to improve venous return — flat with legs up, NOT head down.
• Oxytocin is always the first-line drug — methylergonovine and carboprost are second-line.

Key Points

• PPH is defined as blood loss greater than 500 mL after a vaginal birth or greater than 1,000 mL after a cesarean section, OR any amount causing hemodynamic instability.
• PPH is a leading cause of maternal mortality in the Philippines and globally.
• EARLY (Primary) PPH: occurs within the first 24 hours postpartum — most often caused by uterine atony.
• LATE (Secondary) PPH: occurs from 24 hours to 6–12 weeks postpartum — most often caused by retained placental fragments or subinvolution.
• The '4 Ts' framework identifies all causes: Tone (atony), Trauma (lacerations/hematoma), Tissue (retained placenta), Thrombin (coagulopathy/DIC).
• UTERINE ATONY is the NUMBER ONE cause of PPH — characterized by a boggy (soft, poorly contracted) uterus and heavy dark red lochia.
• TRAUMA (lacerations): suspect when bleeding is BRIGHT RED and STEADY despite a FIRM fundus — this is a key differentiating sign on the NLE.
• RETAINED PLACENTA/TISSUE: prevents uterine contraction; confirmed by manual exploration or ultrasound.
• DIC (Disseminated Intravascular Coagulation): a coagulation failure — blood does not clot; associated with severe preeclampsia, abruptio placentae, and sepsis.
• Signs of shock appear in order: restlessness and tachycardia FIRST (early shock), THEN hypotension (late/decompensated shock) — hypotension is a LATE sign.
• PRIORITY NURSING INTERVENTIONS for boggy uterus: (1) Massage the fundus, (2) Empty the bladder, (3) Administer uterotonics as ordered, (4) Establish IV access and give fluids/blood, (5) Monitor vitals and output frequently.
• OXYTOCIN is the first-line uterotonic drug: 10–40 units in 1 L IV fluid by infusion OR 10 units IM.
• METHYLERGONOVINE 0.2 mg IM: highly effective but CONTRAINDICATED in hypertension/preeclampsia because it causes vasoconstriction and raises BP — always check BP before giving.
• CARBOPROST 250 mcg IM (prostaglandin PGF2-alpha): CONTRAINDICATED in ASTHMA due to bronchospasm; side effects include diarrhea, fever, and flushing.
• MISOPROSTOL 600–1,000 mcg rectally or orally: a prostaglandin E1 analogue; useful in low-resource settings where refrigeration is limited; side effect is fever/shivering.
• Pad weighing quantifies blood loss: 1 gram weight gain = approximately 1 mL blood loss.
• If uterotonics fail: bimanual compression, uterine balloon tamponade, surgical options up to hysterectomy.
• Supportive care: supplemental oxygen, large-bore IV access (at least 18G), Trendelenburg or modified Trendelenburg positioning (legs elevated), warm blankets, blood type and crossmatch, CBC, coagulation studies.

Definitions

Section Title

Postpartum Hemorrhage (PPH)

Common Mistakes

• Thinking hypotension is an early sign of shock — tachycardia and restlessness come FIRST; hypotension is a LATE and dangerous sign.
• Administering methylergonovine to a hypertensive patient — always check BP before giving; this is contraindicated.
• Giving carboprost to an asthmatic patient — it causes bronchospasm and is contraindicated in asthma.
• Starting with IV fluids before massaging the fundus — fundal massage is the FIRST action for a boggy uterus.
• Not checking for bladder distension — a full bladder prevents uterine contraction and is a reversible cause of atony.
• Confusing bright-red bleeding with a firm fundus as atony — this indicates trauma/laceration, not atony.
• Forgetting that late PPH (after 24 hours) is usually from retained placental fragments, not atony.

Exam Tips

• NLE will test the fever definition — memorize: '38°C or higher, on any 2 of the first 10 postpartum days, EXCLUDING the first 24 hours.'
• Foul-smelling lochia is the MOST SPECIFIC sign of endometritis — if the question mentions foul odor, think endometritis.
• Semi-Fowler's is the therapeutic position for puerperal infection — promotes gravity drainage of infected lochia.
• Drug sequence: cultures FIRST, then antibiotics — never give antibiotics before cultures in infection management questions.
• Clindamycin + Gentamicin = the classic combination for endometritis; memorize this pair.
• REEDA — use this mnemonic to assess wound healing at episiotomy and cesarean incision sites.

Key Points

• Puerperal infection is defined as a temperature of 38°C (100.4°F) or higher on any 2 of the first 10 postpartum days, EXCLUDING the first 24 hours (the first 24 hours are excluded because of normal post-delivery fever).
• ENDOMETRITIS (infection of the uterine lining/endometrium) is the MOST COMMON form of puerperal infection.
• Cesarean birth is the BIGGEST SINGLE RISK FACTOR for puerperal infection — it increases risk 5–10 times compared to vaginal birth.
• Other risk factors: prolonged rupture of membranes (PROM), prolonged labor, multiple vaginal examinations (breaks the protective barrier), retained placental fragments, anemia, malnutrition, PPH, and low socioeconomic status.
• Key manifestations of endometritis: FEVER and CHILLS, UTERINE TENDERNESS on palpation, FOUL-SMELLING or profuse lochia (this is highly specific), tachycardia, subinvolution of the uterus, malaise, and anorexia.
• Other postpartum infections: urinary tract infection (UTI — dysuria, frequency, urgency, costovertebral angle tenderness), wound infection (cesarean incision or episiotomy — redness, warmth, swelling, discharge from wound), and mastitis (see separate section).
• Management of endometritis: obtain cultures BEFORE starting antibiotics, then initiate BROAD-SPECTRUM IV ANTIBIOTICS — the standard regimen is CLINDAMYCIN plus GENTAMICIN.
• NURSING POSITIONING: semi-Fowler's position (head of bed at 30–45 degrees) promotes DRAINAGE of lochia by gravity, preventing pooling of infected material in the uterus.
• Perineal hygiene teaching: front-to-back perineal wiping after every elimination, frequent pad changes (every 3–4 hours or when soiled), handwashing before and after pad changes.
• Monitor for progression to sepsis: escalating fever, hypotension, tachycardia, altered sensorium — requires ICU-level care.
• Wound infections: typically appear 3–7 days postpartum; monitor episiotomy and cesarean incision for REEDA signs (Redness, Edema, Ecchymosis, Discharge, Approximation).
• UTI postpartum: common due to bladder trauma and catheterization; treat with appropriate antibiotics; encourage 2–3 liters of oral fluids daily.
• Isolation precautions: standard contact precautions; educate family members on handwashing and visitation hygiene.

Definitions

Section Title

Puerperal (Postpartum) Infection

Common Mistakes

• Including the first 24 hours in the fever definition — the definition EXCLUDES the first 24 hours.
• Positioning the patient flat instead of semi-Fowler's — semi-Fowler's promotes lochia drainage and is the correct therapeutic position.
• Starting antibiotics without obtaining cultures first — cultures guide specific therapy; this is the correct sequence.
• Forgetting that cesarean section is the biggest risk factor for puerperal infection (not just PROM or prolonged labor).
• Not distinguishing between normal postpartum fever (first 24 hours, often dehydration/engorgement) and true puerperal infection.

Exam Tips

• The most commonly tested mastitis question: 'What should the nurse tell a breastfeeding mother with mastitis about feeding?' Answer: Continue breastfeeding/pumping.
• Mastitis = Unilateral + Wedge-shaped + Flu-like symptoms + Staphylococcus aureus + Cracked nipple entry.
• Drug pairs to memorize: MSSA mastitis → Dicloxacillin or Cephalexin; MRSA mastitis → Clindamycin or Vancomycin.
• Warm compress BEFORE feeding → promotes milk flow; Cold compress AFTER feeding → reduces inflammation.
• If not treated → Breast Abscess → requires I&D (incision and drainage) — this escalation is important to know.
• Prevention mnemonic: PALE — Proper latch, Alternate breasts/positions, Lanolin for nipple care, Empty the breast frequently.

Key Points

• Mastitis is inflammation and infection of the breast tissue, most commonly occurring in LACTATING mothers, typically 2–4 weeks postpartum (but can occur anytime during lactation).
• The causative organism is almost always STAPHYLOCOCCUS AUREUS, which enters through a cracked or fissured nipple.
• MILK STASIS is the predisposing condition: missed or infrequent feedings, poor infant latch, engorgement, and abrupt weaning all allow milk to pool and create a culture medium for bacteria.
• MASTITIS IS CLASSICALLY UNILATERAL — one breast, one wedge-shaped area of involvement (follows the affected lobe/duct).
• Cardinal signs: a unilateral, red, warm, hard, tender, wedge-shaped area of the breast, accompanied by SYSTEMIC FLU-LIKE SYMPTOMS (fever, chills, myalgia/body aches, fatigue) — the flu-like symptoms differentiate mastitis from simple engorgement.
• CRITICAL MANAGEMENT PRINCIPLE: CONTINUE BREASTFEEDING or PUMPING — emptying the breast is THERAPEUTIC. Stopping breastfeeding worsens milk stasis and increases the risk of abscess formation.
• Milk from the affected breast is SAFE for the infant — the infection is in the breast tissue, not in the milk itself.
• ANTIBIOTICS: give anti-staphylococcal antibiotics for a FULL 10–14 day course — DICLOXACILLIN or CEPHALEXIN (first-generation cephalosporin) are first-line.
• For MRSA (methicillin-resistant S. aureus): use CLINDAMYCIN or VANCOMYCIN.
• Comfort measures: warm compresses BEFORE feedings (to promote milk flow and drainage), cold compresses AFTER feedings (to reduce pain and inflammation), analgesics (ibuprofen is preferred — anti-inflammatory and analgesic), rest, and adequate hydration.
• If untreated, mastitis can progress to BREAST ABSCESS — a localized collection of pus requiring surgical incision and drainage (I&D); breastfeeding must be suspended from the affected breast if an abscess develops.
• PREVENTION — key health teaching: proper infant latch and positioning, frequent/complete emptying of the breast, alternating breasts and feeding positions, avoiding tight-fitting bras (which compress ducts), and meticulous nipple care to prevent cracking (air dry nipples, use lanolin cream).
• Distinguish mastitis from engorgement: engorgement is BILATERAL, diffuse, without fever or flu-like symptoms, occurs in days 2–4 postpartum, and resolves with frequent feeding/pumping.

Definitions

Section Title

Mastitis

Common Mistakes

• Telling the mother to STOP breastfeeding — this is WRONG and dangerous; it worsens stasis and promotes abscess formation.
• Confusing mastitis with engorgement — engorgement is bilateral and without systemic symptoms; mastitis is unilateral with fever and flu-like symptoms.
• Not completing the full antibiotic course — incomplete treatment leads to relapse and abscess formation.
• Applying only warm compresses — warm is for BEFORE feeding; cold is for AFTER feeding. The NLE may test which is appropriate at which time.
• Forgetting that mastitis is usually Staphylococcus aureus via a cracked nipple.

Exam Tips

• NLE trigger phrase for 'do NOT massage': 'The patient has calf pain, warmth, and swelling in one leg' — the answer is NEVER massage; elevate, apply warm compresses, anticoagulate.
• Sudden dyspnea + pleuritic chest pain + tachycardia postpartum = PULMONARY EMBOLISM — treat as an emergency.
• Drug safety memory aid: Heparin and LMWH = SAFE in pregnancy and lactation (do not cross placenta significantly). Warfarin = TERATOGENIC = avoid in pregnancy.
• Antidote pairs: Heparin → Protamine Sulfate; Warfarin → Vitamin K. This is a standard NLE pharmacology question.
• Monitor pairs: Heparin → aPTT; Warfarin → INR (or PT).
• Prevention = Early ambulation + leg exercises + hydration + compression stockings — if asked about priority prevention, EARLY AMBULATION is the answer.

Key Points

• Pregnancy and the postpartum period create a HYPERCOAGULABLE STATE — elevated clotting factors (fibrinogen, factors VII, VIII, X), venous stasis (due to enlarged uterus compressing pelvic veins), and potential vessel injury during delivery — these are VIRCHOW'S TRIAD.
• VIRCHOW'S TRIAD: (1) Hypercoagulability, (2) Venous Stasis, (3) Vessel Wall Injury — all three are present in the postpartum state, making thrombosis risk very high.
• Risk factors: cesarean birth, obesity, prolonged immobility/bed rest, varicose veins, previous DVT, age >35, high parity, dehydration, and smoking.
• DEEP VEIN THROMBOSIS (DVT): most commonly affects the deep veins of the LEGS (especially the femoral and popliteal veins); can also affect the pelvic veins.
• DVT manifestations: UNILATERAL leg pain, warmth, redness, and swelling (edema); the affected leg feels tender and tense; may have low-grade fever.
• Homans' Sign (calf pain on dorsiflexion of the foot) — historically used but NOW CONSIDERED UNRELIABLE; it is neither sensitive nor specific for DVT; its absence does NOT rule out DVT.
• PULMONARY EMBOLISM (PE) is the FEARED, LIFE-THREATENING COMPLICATION of DVT — occurs when a clot breaks off and lodges in the pulmonary vasculature.
• PE manifestations: SUDDEN DYSPNEA (most prominent), PLEURITIC CHEST PAIN (worse with breathing), TACHYPNEA, TACHYCARDIA, APPREHENSION/ANXIETY, cyanosis, possible hemoptysis (coughing up blood); this is a MEDICAL EMERGENCY.
• CRITICAL NURSING ACTION for suspected DVT: DO NOT MASSAGE THE AFFECTED LEG — massage can dislodge the thrombus and cause embolism.
• DVT management: BED REST with the AFFECTED LEG ELEVATED (promotes venous return without dislodging clot), WARM MOIST COMPRESSES (reduce inflammation and pain), and ANTICOAGULATION.
• ANTICOAGULATION THERAPY: Heparin (unfractionated) or Low-Molecular-Weight Heparin (LMWH/enoxaparin) are SAFE in BOTH pregnancy and lactation — they do NOT cross the placenta in significant amounts and do NOT enter breast milk in significant amounts.
• WARFARIN is TERATOGENIC (causes fetal warfarin syndrome — nasal hypoplasia, bone stippling, CNS abnormalities) and is CONTRAINDICATED IN PREGNANCY. However, warfarin IS ACCEPTABLE postpartum during breastfeeding.
• Monitoring and antidotes: HEPARIN → monitor with aPTT (activated Partial Thromboplastin Time); antidote is PROTAMINE SULFATE. WARFARIN → monitor with INR (International Normalized Ratio) or PT; antidote is VITAMIN K.
• LMWH (enoxaparin): monitored with anti-Xa levels (anti-factor Xa assay); does not require routine aPTT monitoring.
• PREVENTION is a nursing priority — teach and implement: EARLY AMBULATION after delivery (key intervention), leg exercises (ankle pumps, flexion/extension) while in bed, adequate oral hydration, compression stockings/sequential compression devices (SCDs) for at-risk patients.
• For PE: call for help, give supplemental oxygen immediately, position the patient upright if possible, establish IV access, prepare for anticoagulation and possible thrombolytic therapy, and prepare for emergency response.

Definitions

Section Title

Thromboembolic Disorders (DVT and Pulmonary Embolism)

Common Mistakes

• Massaging a leg with suspected DVT — this is DANGEROUS and can cause the clot to embolize to the lungs.
• Giving warfarin to a pregnant patient — warfarin is TERATOGENIC and contraindicated in pregnancy; use heparin/LMWH instead.
• Confusing the monitoring parameters: aPTT monitors heparin, INR monitors warfarin — do not mix these up.
• Confusing the antidotes: Protamine sulfate = heparin antidote; Vitamin K = warfarin antidote.
• Using Homans' sign as a definitive diagnostic test — it is unreliable; teach students to assess for clinical signs (redness, warmth, swelling, pain) collectively.
• Forgetting that early ambulation is the PRIMARY nursing preventive intervention for thromboembolism postpartum.

Exam Tips

• NLE 'three-way comparison' question: If symptoms are mild, tearful, 3 days postpartum, and resolves in 2 weeks = Baby Blues. If persistent sadness, months postpartum, needs medication = PPD. If hallucinations + delusions + commands to harm infant = Postpartum Psychosis → hospitalize.
• NEVER LEAVE MOTHER ALONE WITH BABY = the answer whenever postpartum psychosis is described in the stem.
• PPD first-line SSRI for breastfeeding mothers = SERTRALINE — know this specific drug name.
• Baby blues affects up to 80% of mothers — it is NORMAL, not a disease.
• Postpartum psychosis is associated with BIPOLAR DISORDER — this connection is tested.
• EPDS = the screening tool for PPD; administer to ALL postpartum mothers.

Key Points

• THREE LEVELS of postpartum mood disorders exist — distinguished by severity, duration, and presence of psychotic features. The NLE frequently tests the ability to differentiate between them.
• LEVEL 1 — POSTPARTUM BLUES (Baby Blues): affects up to 80% of all postpartum mothers — it is the MOST COMMON mood disturbance.
• Baby Blues: onset within 2–3 days after delivery; symptoms include mild mood swings, tearfulness, anxiety, irritability, and emotional lability; the mother REMAINS IN CONTACT WITH REALITY (no psychosis) and is ABLE TO CARE FOR HER BABY.
• Baby Blues duration: resolves SPONTANEOUSLY within approximately 2 WEEKS without formal treatment.
• Management of Baby Blues: REASSURANCE that this is normal, REST, SOCIAL SUPPORT — no antidepressants or psychiatric referral needed.
• LEVEL 2 — POSTPARTUM DEPRESSION (PPD): a TRUE major depressive episode; more severe and persistent than baby blues.
• PPD onset: within the first year postpartum, commonly within weeks to months; does NOT resolve spontaneously.
• PPD symptoms: persistent sadness and hopelessness, profound fatigue, sleep disturbance (insomnia or hypersomnia), appetite changes, poor concentration, worthlessness and guilt, loss of interest in baby or in pleasurable activities, social withdrawal, and sometimes THOUGHTS OF HARMING SELF OR INFANT (suicidal or infanticidal ideation).
• PPD REQUIRES TREATMENT: PSYCHOTHERAPY (cognitive behavioral therapy) and ANTIDEPRESSANTS — SSRIs are preferred; SERTRALINE (Zoloft) is the first choice in breastfeeding mothers because it has the most safety data.
• EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS): a validated 10-item self-report screening tool used to identify mothers at risk for PPD; all postpartum mothers should be screened.
• Risk factors for PPD: personal or family history of depression or anxiety, lack of social support, traumatic birth experience, ill or NICU baby, financial stress, relationship problems, significant hormonal shifts, and sleep deprivation.
• LEVEL 3 — POSTPARTUM PSYCHOSIS: the MOST SEVERE and a PSYCHIATRIC EMERGENCY.
• Postpartum psychosis onset: usually within the FIRST 1–2 WEEKS postpartum (rapid onset is a hallmark).
• Postpartum psychosis symptoms: DELUSIONS, HALLUCINATIONS (especially COMMAND HALLUCINATIONS — voices telling the mother to harm the infant), disorganized/bizarre thinking, complete BREAK FROM REALITY, confusion, and agitation; strongly associated with BIPOLAR DISORDER.
• CRITICAL SAFETY INTERVENTION for postpartum psychosis: NEVER LEAVE THE MOTHER ALONE WITH THE INFANT — immediate safety separation is the PRIORITY nursing action.
• Postpartum psychosis management: URGENT PSYCHIATRIC HOSPITALIZATION, antipsychotic medications, mood stabilizers, and ensuring the safety of BOTH mother and infant.
• Breastfeeding is typically suspended during postpartum psychosis due to maternal medications and inability to safely care for the infant.
• The nurse's role under RA 9173 includes mental health assessment, patient advocacy, proper documentation, and referral to the appropriate healthcare team member (psychiatrist, social worker).
• Summary comparison: Baby Blues = mild, 2 weeks, resolves with support; PPD = moderate-severe, weeks to months, needs treatment; Postpartum Psychosis = severe, 1–2 weeks onset, emergency hospitalization.

Definitions

Section Title

Postpartum Mood Disorders

Common Mistakes

• Treating baby blues with antidepressants — baby blues is SELF-LIMITING and requires only reassurance and support.
• Thinking PPD only occurs in the first week — PPD can develop any time in the FIRST YEAR postpartum.
• Confusing PPD with postpartum psychosis — PPD has no psychotic features (hallucinations, delusions); psychosis does.
• Leaving the mother alone with the baby in postpartum psychosis — this is the MOST CRITICAL error; the infant's safety is at risk.
• Not screening all mothers for PPD — universal screening with EPDS is the standard of care.
• Recommending breastfeeding cessation for baby blues or PPD — breastfeeding can continue safely in most cases of baby blues and PPD.