Early Postpartum Hemorrhage Nursing Care Plan & Management

EXPLANATION

✔Correct answer:

Greater than 1000 mL. Postpartum hemorrhage (PPH) is defined as an estimated blood loss of greater than 500 mL after a vaginal birth or greater than 1000 mL after a cesarean section. In the context of a C-section, if the estimated blood loss exceeds 1000 mL, it is considered postpartum hemorrhage. Recognizing and diagnosing PPH promptly is crucial, as it can lead to significant maternal morbidity and mortality if not managed appropriately.

During a cesarean section, the blood loss is naturally higher than in a vaginal delivery due to the surgical incision in the uterine wall and other tissues. However, when the blood loss exceeds 1000 mL, it indicates that the body’s normal compensatory mechanisms may be overwhelmed, leading to hemodynamic instability. This level of blood loss can result in hypovolemic shock if not promptly addressed, requiring interventions such as uterotonic medications, blood transfusions, and sometimes surgical interventions to control the bleeding.

Imagine your body’s blood volume as the water in a large aquarium that supports all the fish (organs) inside. If you suddenly remove a large bucket of water (like losing 1000 mL of blood after a C-section), the water level drops significantly, making it harder for the fish to survive. Just like the fish need enough water to thrive, your organs need enough blood to function properly. Losing too much blood too quickly puts your entire system at risk, which is why recognizing and treating postpartum hemorrhage promptly is crucial.

Nurse Adams should closely monitor the patient’s vital signs, fundal firmness, and overall blood loss in the postoperative period. Accurate assessment and timely intervention are key to managing postpartum hemorrhage effectively.

• Monitor vital signs for any signs of hypovolemic shock, such as tachycardia, hypotension, or altered mental status.
• Assess the uterine fundus for firmness and position, ensuring it remains contracted to minimize bleeding.
• Measure and record the amount of blood loss during and after the C-section accurately.
• Administer uterotonic medications as prescribed to help contract the uterus and reduce bleeding.
• Be prepared to initiate fluid resuscitation or blood transfusions if necessary, based on the degree of blood loss.

✘Incorrect answer options:

Less than 550 mL. A blood loss of less than 550 mL is below the threshold for diagnosing postpartum hemorrhage in either a vaginal or cesarean delivery. This amount is considered within the normal range for both types of delivery.

Greater than 600 mL. While greater than 600 mL of blood loss is significant, it does not meet the threshold for diagnosing postpartum hemorrhage after a cesarean section. The correct threshold is greater than 1000 mL.

Less than 900 mL. Blood loss of less than 900 mL is still below the threshold for diagnosing postpartum hemorrhage after a C-section. The critical value to recognize postpartum hemorrhage in this context is blood loss greater than 1000 mL.

EXPLANATION

✔Correct answer:

The patient's blood pressure. Before administering Methergine (methylergonovine), it is crucial for Nurse Thompson to assess the patient’s blood pressure. Methergine is a potent vasoconstrictor and can significantly raise blood pressure, so it is contraindicated in patients with hypertension or preeclampsia. If the patient’s blood pressure is elevated, administering Methergine could lead to severe hypertensive complications, including stroke. On the other hand, Pitocin (Oxytocin) is generally safer to administer in cases of hemorrhage, as it does not have the same hypertensive effects as Methergine.

Methergine works by increasing uterine contractions, which helps to reduce postpartum hemorrhage by promoting uterine involution and decreasing uterine atony. However, because of its strong vasoconstrictive properties, it can exacerbate hypertension, making it critical to check the patient’s blood pressure before administration.

Administering Methergine without checking blood pressure is like accelerating a car without checking if the brakes are working; it could lead to a dangerous situation if there’s already a problem.

If Nurse Thompson finds that the patient's blood pressure is elevated, she should withhold Methergine and notify the healthcare provider for an alternative medication, such as Pitocin or another uterotonic that does not increase blood pressure.

• Assess the patient’s blood pressure before administering Methergine. Do not administer if blood pressure is elevated (typically defined as ≥140/90 mm Hg).
• If blood pressure is normal, proceed with the administration of Methergine as ordered, while monitoring for any adverse effects.
• Consider Pitocin if the patient has a history of or currently exhibits signs of hypertension or preeclampsia.
• Monitor the patient’s response to the medication, including uterine tone and the amount of lochia, to assess the effectiveness of the treatment.
• Continuously assess vital signs after administration to monitor for any changes or complications.

✘Incorrect answer options:

The amount of lochia present. While assessing the amount of lochia is important for evaluating the degree of hemorrhage, it is not the priority before administering Methergine or Pitocin. The immediate concern is the patient’s blood pressure, especially when considering Methergine administration.

The status of deep tendon reflexes. Deep tendon reflexes are typically assessed in the context of preeclampsia or magnesium sulfate therapy, but they are not the primary concern before administering uterotonic medications like Methergine or Pitocin.

The tone of the uterus. Assessing uterine tone is essential for determining the cause of hemorrhage (e.g., uterine atony), but it is not the immediate priority before administering these medications. Blood pressure assessment is more critical when deciding whether Methergine is appropriate.

EXPLANATION

✔Correct answer:

An increase in heart rate from 88 to 102 BPM. An increase in heart rate (tachycardia) is one of the earliest signs of postpartum hemorrhage (PPH). As the body loses blood, the heart compensates by pumping faster to maintain adequate circulation and oxygen delivery to vital organs. A rise in heart rate, especially in the context of other clinical signs, should prompt Nurse Williams to further assess the patient for potential hemorrhage. It's important to note that by the time blood pressure drops significantly, a considerable amount of blood loss has already occurred, so monitoring for subtle changes in heart rate is crucial for early detection.

Postpartum hemorrhage is defined as a blood loss of more than 500 mL after a vaginal birth or more than 1,000 mL after a cesarean section. In the early stages, the body attempts to maintain cardiac output through an increase in heart rate, as blood volume decreases. This compensatory mechanism helps to preserve perfusion to vital organs but is an early indicator of significant blood loss.

Imagine a leak in a garden hose (representing blood loss). As the water (blood) pressure decreases, you turn up the faucet (heart rate) to keep the water flow steady. An increased heart rate is like turning up the faucet, a sign that the system is trying to compensate for a problem.

Nurse Williams should immediately investigate the cause of the increased heart rate, assess for other signs of hemorrhage (such as uterine atony, increased vaginal bleeding, or decreased blood pressure), and intervene as necessary. This may include fundal massage, medication administration, or notifying the healthcare provider for further evaluation and treatment.

• Monitor vital signs closely, particularly heart rate, in the postpartum period to detect early signs of hemorrhage.
• Assess the uterine fundus for firmness and position; a boggy uterus is a common cause of postpartum hemorrhage.
• Check lochia (postpartum vaginal discharge) for amount, color, and consistency to assess bleeding.
• If hemorrhage is suspected, initiate emergency protocols, including IV access, fluid resuscitation, and administration of uterotonic agents.
• Continuously monitor the patient’s hemodynamic status and prepare for potential blood transfusion if necessary.

✘Incorrect answer options:

A temperature of 100.4°F. A slightly elevated temperature in the postpartum period can be normal, especially if the patient is dehydrated or has been in prolonged labor. While a temperature of 100.4°F may indicate an infection, it is not an early sign of hemorrhage.

An increase in respiratory rate from 18 to 22 breaths per minute. While an increased respiratory rate can occur due to many factors (e.g., anxiety, pain, or even early compensatory response to blood loss), it is not as specific or sensitive as tachycardia in detecting early postpartum hemorrhage. It is usually a later sign after other compensatory mechanisms have been overwhelmed.

A blood pressure change from 130/88 to 124/80 mm Hg. A small decrease in blood pressure may not be significant and can be within normal variations. Blood pressure tends to be a late indicator of hemorrhage, as the body initially compensates by increasing heart rate and vasoconstriction. A significant drop in blood pressure is a late sign and indicates more severe blood loss.

EXPLANATION

✔Correct answer:

Restricting the mother’s fluid intake to prevent fluid overload. Restricting the mother’s fluid intake to prevent fluid overload is the least effective action in preventing postpartum hemorrhage. Postpartum hemorrhage primarily results from uterine atony (when the uterus fails to contract adequately after delivery), trauma, retained placental tissue, or coagulopathy. Adequate hydration is crucial for maintaining overall health and ensuring effective circulation, which supports uterine contractions. There is no evidence that fluid overload is a risk factor for postpartum hemorrhage, and restricting fluids could actually be harmful, leading to dehydration and poor uterine perfusion.

Effective uterine contractions after delivery help compress the blood vessels at the placental site, reducing the risk of hemorrhage. Hydration supports the body's ability to maintain these contractions and proper blood flow. Restricting fluids does not contribute to uterine tone or prevention of hemorrhage and could, in fact, compromise the mother’s overall condition.

Imagine trying to keep a sponge (the uterus) firm and effective at soaking up water (stopping blood flow) while it’s dry and stiff (dehydrated). Without enough water (fluids), the sponge can’t perform well. Similarly, restricting fluids doesn’t help the uterus stay firm to prevent bleeding; in fact, it could make it less effective.

Nurse Kelly should focus on measures that directly contribute to preventing postpartum hemorrhage, such as encouraging breastfeeding, fundal massage, and administering prescribed uterotonics like oxytocin. These actions help maintain uterine tone and reduce the risk of excessive bleeding.

• Encourage early breastfeeding, as it stimulates the release of oxytocin, which promotes uterine contractions and reduces the risk of hemorrhage.
• Instruct the mother on how to massage her fundus to help maintain uterine tone and prevent atony.
• Administer prescribed oxytocin as ordered to facilitate uterine contractions and prevent excessive bleeding.
• Ensure the mother remains well-hydrated to support overall health and effective uterine function.

✘Incorrect answer options:

Encouraging early breastfeeding to stimulate uterine contractions. Early breastfeeding is highly effective in preventing postpartum hemorrhage because it naturally stimulates the release of oxytocin, a hormone that causes the uterus to contract and helps reduce bleeding.

Massaging the fundus regularly to maintain uterine tone. Fundal massage is a key intervention to prevent uterine atony. By massaging the uterus, the nurse can help ensure that it remains firm and contracted, minimizing the risk of hemorrhage.

Administering prescribed oxytocin to promote uterine contractions. Oxytocin is a common and effective medication used to enhance uterine contractions, thereby helping to prevent and control postpartum hemorrhage. Administering oxytocin is a critical measure in postpartum care to ensure the uterus remains firm and reduces blood loss.

EXPLANATION

✔Correct answer:

All of the choices. All the listed options—instrumental-assisted birth (vacuum or forceps), C-section, and lacerations of the cervix or vaginal wall—are types of trauma during labor and birth that can increase the risk of postpartum hemorrhage (PPH). Trauma is a significant cause of PPH, as it can lead to damage to the reproductive tract, resulting in excessive bleeding.

• Instrumental-assisted birth (vacuum or forceps): The use of instruments like forceps or a vacuum to assist in the delivery can cause trauma to the vaginal and cervical tissues. These instruments can lead to lacerations or tears that can result in significant bleeding if not promptly identified and managed.
• C-section: A cesarean section is a major surgical procedure that involves incisions in the abdominal wall and uterus. This can lead to an increased risk of PPH due to the larger surface area of the uterus exposed, the potential for uterine atony, and the possibility of surgical complications such as bleeding from the incision site.
• Lacerations of the cervix or vaginal wall: During childbirth, especially if it is rapid or involves a large baby, lacerations or tears in the cervix, vaginal wall, or perineum can occur. These tears can be a source of significant bleeding, especially if they extend into blood vessels.

Imagine the uterus as a garden hose full of water. If the hose gets a few small punctures (lacerations) or a large cut (C-section), water will start to leak out quickly. The more damage there is to the hose, the more water escapes. In the same way, any trauma to the uterus or birth canal during delivery, whether from surgical cuts or tears, creates openings for blood to escape, increasing the risk of postpartum hemorrhage.

Nurse Parker should be vigilant in monitoring for signs of PPH in patients who have experienced any of these types of trauma. This includes frequent assessments of vital signs, uterine tone, and vaginal bleeding, as well as prompt intervention if excessive bleeding is noted.

• Monitor the patient closely for signs of excessive bleeding, including changes in vital signs, fundal height, and lochia.
• Assess for and document any lacerations or tears, and ensure they are properly repaired if needed.
• In the case of a C-section, monitor the surgical site for signs of excessive bleeding or hematoma formation.
• Educate the patient on the signs of postpartum hemorrhage and when to seek immediate medical attention.
• Ensure that appropriate medications, such as uterotonics, are available and administered as needed to promote uterine contraction and reduce the risk of PPH.

EXPLANATION

✔Correct answer:

Uterine subinvolution. Uterine subinvolution is the most likely cause of delayed postpartum hemorrhage. Subinvolution refers to the uterus not returning to its pre-pregnancy size and condition as expected after childbirth. When the uterus does not properly contract and shrink, the placental site may not heal correctly, leading to delayed bleeding. This condition usually presents several days to weeks after delivery and is characterized by continued vaginal bleeding, an enlarged, soft uterus, and sometimes an open cervical os.

After childbirth, the uterus undergoes a process of involution, where it contracts and decreases in size to return to its pre-pregnancy state. This process is crucial for stopping postpartum bleeding as the uterus clamps down on the blood vessels where the placenta was attached. If the uterus fails to contract effectively, this process is incomplete, leaving the placental site vulnerable to ongoing bleeding.

Imagine trying to tie a balloon (uterus) tightly after inflating it. If you don't tie it tightly enough (incomplete involution), air (blood) will slowly leak out. Similarly, if the uterus doesn't contract properly, it can't effectively stop the bleeding.

Nurse Davis should monitor the patient for signs of uterine subinvolution, including a higher-than-expected fundal height and prolonged lochia (postpartum discharge). Management may include administering uterotonic agents such as Oxytocin, Methergine, or Misoprostol to encourage uterine contraction. The nurse should also assess for any retained placental fragments, which can contribute to subinvolution.

• Assess the fundal height and consistency regularly to monitor for signs of subinvolution.
• Monitor the amount, color, and odor of lochia to evaluate the bleeding.
• Encourage the patient to empty her bladder frequently, as a full bladder can inhibit uterine contractions.
• Administer medications as ordered to enhance uterine contractions and facilitate involution.
• Educate the patient on signs of delayed postpartum hemorrhage and when to seek medical attention.

✘Incorrect answer options:

Cervical laceration. Cervical lacerations typically cause immediate postpartum hemorrhage rather than delayed bleeding. They usually result from trauma during delivery and would present as continuous bleeding despite a firm, contracted uterus. This type of laceration is less likely to cause delayed hemorrhage.

Clotting deficiency. Clotting deficiencies, such as disseminated intravascular coagulation (DIC) or other coagulopathies, can cause significant postpartum hemorrhage but typically present earlier in the postpartum period. These conditions are usually detected during labor or immediately after delivery, not delayed hemorrhage.

Perineal laceration. Perineal lacerations, like cervical lacerations, usually cause immediate postpartum bleeding. They are associated with visible tears or cuts in the perineum that occur during childbirth. While they can be a source of blood loss, they are generally identified and managed immediately after delivery, making them less likely to be the cause of delayed hemorrhage.

EXPLANATION

✔Correct answer:

Peripheral vascular disease. Nurse Reynolds should consult the healthcare provider before administering Methergine if the patient has a history of peripheral vascular disease (PVD). Methergine (methylergonovine) is a potent vasoconstrictor, meaning it can constrict blood vessels, potentially exacerbating conditions like PVD. In patients with PVD, vasoconstriction could lead to decreased blood flow to the extremities, increasing the risk of complications such as ischemia, pain, and tissue damage. Therefore, if PVD is noted in the patient’s medical history, it is crucial to discuss alternative treatments with the healthcare provider.

Peripheral vascular disease involves the narrowing or blockage of blood vessels, typically in the limbs, due to atherosclerosis or other factors. When vasoconstrictive medications like Methergine are used in patients with PVD, they can worsen the already compromised blood flow, leading to further complications. Therefore, the administration of Methergine in such patients requires caution and usually necessitates a healthcare provider's guidance.

Imagine trying to push water through a garden hose with a kink in it (representing narrowed vessels in PVD). If you suddenly tighten the hose further (vasoconstriction from Methergine), even less water will get through, potentially causing damage to the hose or what's connected to it.

Nurse Reynolds should notify the healthcare provider if PVD is noted and discuss the risks associated with Methergine use. An alternative uterotonic, such as Pitocin, which does not have significant vasoconstrictive properties, may be considered to manage postpartum hemorrhage safely in patients with PVD.

• Review the patient’s medical history for any conditions that might contraindicate the use of Methergine, such as PVD.
• If PVD is present, communicate with the healthcare provider to determine the safest course of action.
• Consider alternative medications, like Pitocin, which do not carry the same risk of exacerbating PVD.
• Monitor the patient closely for any signs of compromised circulation if a vasoconstrictive medication is used.
• Document the consultation with the provider and any changes in the medication plan based on the patient’s condition.

✘Incorrect answer options:

Hypothyroidism. Hypothyroidism, a condition where the thyroid gland does not produce enough hormones, does not contraindicate the use of Methergine or Pitocin. While it can affect metabolism and other bodily functions, it does not directly impact the vasoconstrictive effects of Methergine or the administration of Pitocin.

Hypotension. Hypotension (low blood pressure) is generally more of a concern with Pitocin, which can cause vasodilation and further lower blood pressure. However, hypotension is not as significant a concern for Methergine, which actually raises blood pressure through vasoconstriction. While hypotension should be monitored, it does not necessarily require consultation before administering Methergine.

Type 1 diabetes. Type 1 diabetes involves the body’s inability to produce insulin and requires careful blood sugar management. While diabetes is an important consideration in overall patient care, it does not specifically contraindicate the use of Methergine or Pitocin. These medications do not directly interfere with glucose metabolism, but blood glucose levels should still be monitored during treatment.

EXPLANATION

✔Correct answer:

True. The statement is accurate. Atonic bleeding refers to excessive postpartum bleeding caused by uterine atony, which is when the uterus fails to contract effectively after childbirth. Normally, the uterus contracts after delivery to compress the blood vessels at the site where the placenta was attached, helping to prevent hemorrhage. However, when the uterus is "atonic" or lacking tone, it remains soft and flaccid, unable to compress the blood vessels adequately, leading to significant blood loss. Uterine atony is the most common cause of postpartum hemorrhage (PPH).

After delivery, the uterus should contract and become firm, which is crucial for minimizing blood loss. If the uterus fails to contract (uterine atony), blood vessels at the placental site remain open, leading to continuous bleeding. This can result in severe hemorrhage if not promptly treated with interventions such as uterotonic medications (e.g., oxytocin), fundal massage, or in severe cases, surgical intervention.

Imagine the uterus as a big rubber band that needs to tighten around a bundle of straws to stop liquid from flowing out. If the rubber band is too loose (like a uterus that isn’t contracting), the liquid (blood) will keep flowing through the straws. To stop the flow, the rubber band needs to tighten up firmly. Similarly, when the uterus doesn’t contract properly after childbirth, it can’t squeeze down on the blood vessels, leading to ongoing bleeding, known as atonic bleeding.

Nurse Kelly should closely monitor Mrs. Thompson's uterine tone by regularly palpating the fundus. If the uterus feels soft or "boggy," immediate interventions such as fundal massage or administration of uterotonic drugs should be initiated to encourage uterine contraction and reduce bleeding.

• Regularly assess the uterine fundus for tone and position; it should be firm and midline.
• Perform fundal massage if the uterus feels soft or boggy to stimulate contraction.
• Administer prescribed uterotonic medications like oxytocin to promote uterine contractions.
• Monitor the amount and characteristics of vaginal bleeding (lochia) closely.
• Prepare for further interventions if bleeding persists, such as additional medications or potential surgical options.

EXPLANATION

✔Correct answer:

Trauma, Tissue, Thrombin, Tone. The "4 T's" of postpartum hemorrhage (PPH) are Trauma, Tissue, Thrombin, and Tone. These four categories represent the primary causes of PPH and are essential for healthcare providers to understand in order to effectively diagnose and manage this potentially life-threatening condition.

• Trauma: This refers to physical injury to the reproductive tract during delivery, including lacerations, uterine rupture, or damage from surgical procedures like a C-section. Trauma can lead to significant blood loss if not promptly identified and treated.
• Tissue: Retained placental tissue or membranes can prevent the uterus from contracting properly, leading to ongoing bleeding. Ensuring complete removal of the placenta and any remaining tissues is crucial to prevent PPH.
• Thrombin: This factor involves blood clotting disorders, where the body’s ability to form clots is impaired. Conditions like disseminated intravascular coagulation (DIC) or other coagulopathies can cause or exacerbate PPH by preventing effective clotting.
• Tone: Uterine atony, or the failure of the uterus to contract effectively after delivery, is the most common cause of PPH. Without sufficient tone, the uterus cannot compress the blood vessels at the placental site, leading to excessive bleeding.

Imagine the uterus after delivery as a large bucket with four potential leaks. The first leak is a crack in the bucket (Trauma), like a tear from the delivery process. The second is a clog inside the bucket (Tissue), representing pieces of the placenta that didn’t fully come out. The third is a faulty valve at the bottom (Thrombin), symbolizing a clotting disorder that prevents the blood from sealing the leaks. Finally, if the bucket itself is too flimsy and soft (Tone), it can't hold its shape, allowing water (blood) to pour out. To prevent postpartum hemorrhage, all four of these issues need to be addressed to keep the bucket (uterus) intact and stop any leaks.

Nurse Patel should monitor Mrs. Reynolds closely for signs of any of the "4 T's" that could lead to PPH. This involves regular assessment of uterine tone, checking for signs of trauma, ensuring complete expulsion of the placenta, and monitoring for any signs of coagulation disorders.

• Regularly assess the uterus for firmness and position to ensure proper tone.
• Monitor for excessive bleeding or any signs of lacerations or other trauma.
• Ensure the placenta has been fully delivered, and check for any retained tissue.
• Assess for any history of or signs indicative of coagulation disorders that could affect thrombin function.

✘Incorrect answer options:

Trauma, Threads, Tears, Tone includes some accurate terms, but "Threads" and "Tears" are redundant or inaccurate in this context. The correct causes include Tissue (for retained placental fragments) and Thrombin (for clotting issues).

Trauma, Toxins, Travel, Thrombin introduces "Toxins" and "Travel," which are not related to the primary causes of PPH. The focus should be on uterine tone and retained tissue rather than these unrelated factors.

Travel, Tissue, Threads, Thrombin incorrectly includes "Travel" and "Threads," which are not relevant to PPH. The key factors are Trauma and Tone, in addition to Tissue and Thrombin.

EXPLANATION

✔Correct answer:

Urine retention. Urine retention is the condition most likely to contribute to uterine atony, a leading cause of postpartum hemorrhage. Uterine atony occurs when the uterus fails to contract effectively after childbirth, leading to significant blood loss. A full bladder can impede the ability of the uterus to contract properly because it displaces the uterus and prevents it from contracting efficiently. This displacement can result in a soft or "boggy" uterus, increasing the risk of excessive bleeding.

After delivery, the uterus should contract firmly to compress the blood vessels at the placental site, thereby preventing excessive bleeding. However, when the bladder is distended due to urine retention, it can push the uterus out of position, making it less effective at contracting. This condition can lead to uterine atony, where the uterus remains relaxed and unable to compress the blood vessels properly, resulting in hemorrhage.

Imagine the uterus as a tightly wrapped rubber band that needs to constrict firmly to stop the flow of blood after delivery. If there’s a balloon (the full bladder) pressing against the rubber band, it can’t tighten fully, allowing blood to continue flowing. Emptying the bladder removes that obstruction, enabling the rubber band (the uterus) to tighten as it should, effectively stopping the blood flow.

Nurse Lee should ensure that the patient’s bladder is emptied regularly, either through spontaneous voiding or catheterization, especially if the patient has difficulty urinating due to epidural anesthesia or swelling. Monitoring the bladder’s status is essential for preventing uterine atony and subsequent postpartum hemorrhage.

• Encourage the patient to void regularly, ideally every 2-3 hours, to prevent bladder distention.
• Assess the fundus regularly for firmness and position; if the uterus is displaced or boggy, check for bladder distention.
• If the patient is unable to void, consider catheterization to relieve bladder distention and allow the uterus to contract effectively.
• Educate the patient on the importance of bladder emptying in preventing postpartum hemorrhage.
• Monitor for signs of uterine atony, such as excessive vaginal bleeding, and intervene promptly if detected.

✘Incorrect answer options:

Hypertension. Hypertension is not directly related to uterine atony. While it can lead to other complications during the postpartum period, it does not typically interfere with the uterus's ability to contract.

Cervical and vaginal tears. Cervical and vaginal tears are potential sources of postpartum hemorrhage, but they do not cause uterine atony. Instead, they result in localized bleeding that requires repair, often with sutures, to control the hemorrhage.

Endometritis. Endometritis, an infection of the uterine lining, is more likely to occur days after delivery and typically presents with fever, uterine tenderness, and foul-smelling lochia. It does not directly cause uterine atony, although severe cases of infection can lead to other complications that may impact uterine contractility.