Transcript Chapter_021
Chapter 21 Postpartum Complications All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. Postpartum Hemorrhage Definition and incidence Leading cause of maternal death worldwide PPH traditionally defined as loss of more than: • 500 ml of blood after vaginal birth • 1000 ml after cesarean birth Life-threatening with little warning Often unrecognized until profound symptoms All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 2 Postpartum Hemorrhage (Cont.) Etiology and risk factors Uterine atony • Marked hypotonia of uterus Lacerations of genital tract Hematomas Retained placenta • Nonadherent retained placenta • Adherent retained placenta All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 3 Postpartum Hemorrhage (Cont.) Inversion of uterus Turning inside out of uterus Potentially life threatening 1 in 3000 births Subinvolution of uterus Late postpartum bleeding Retained placental fragment and pelvic infection All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 4 Care Management Medical management Early recognition is critical First step is evaluation of contractility of uterus Firm massage of fundus Management is directed toward increasing contractility and minimizing blood loss All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 5 Care Management (Cont.) Hypotonic uterus Bleeding with a contracted uterus Uterine inversion Subinvolution Herbal remedies Has been used with some success after initial control of bleeding Nursing interventions All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 6 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 7 Hemorrhagic (Hypovolemic) Shock Medical management Nursing interventions Fluid or blood replacement therapy Legal tip – standard of care for bleeding emergencies allows for provisions to be made for nurses to initiate actions independently All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 8 Case Study You are the mother-baby nurse assigned to Ms. Avery. She is a gravida 6 para 5015 who gave birth to a 9-lb baby boy this morning. Ms. Avery had an uncomplicated and precipitous vaginal birth. Perineum is intact. She is breastfeeding. All laboratory results are normal. She is now 5 hours postpartum. A family member calls out from the patient room for assistance. When you walk into the room, Ms. Avery is standing up on her way to the bathroom with a large pool of blood on the floor. She states, “I don’t know what happened; it all just came when I stood up. I am so dizzy and light-headed." All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 9 Case Study (Cont.) What should the nurse do? What are Ms. Avery’s risk factors for PPH? What should the medical management include? All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 10 Coagulopathies Idiopathic thrombocytopenic purpura (ITP) von Willebrand disease—type of hemophilia Disseminated intravascular coagulation Consumptive coagulopathy Consumes large amounts of clotting factors Widespread external bleeding, internal bleeding, or both All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 11 Thromboembolic Disease Results from blood clot caused by inflammation or partial obstruction of vessel Superficial venous thrombosis Deep venous thrombosis Pulmonary embolism Incidence and etiology Clinical manifestations Medical management Nursing interventions All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 12 Postpartum Infections Puerperal sepsis: any infection of genital tract within 28 days after miscarriage, induced abortion, or birth Most common infecting agents are numerous streptococcal and anaerobic organisms Endometritis Wound infections Urinary tract infections Mastitis All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 13 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 14 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 15 Sequelae of Childbirth Trauma Disorders of uterus and vagina related to pelvic relaxation and urinary incontinence; are often result of childbearing Uterine displacement and prolapse Posterior displacement, or retroversion Retroflexion and anteflexion Uterine prolapse a more serious displacement All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 16 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 17 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 18 Sequelae of Childbirth Trauma (Cont.) Cystocele and rectocele Cystocele: protrusion of bladder downward into vagina when support structures in vesicovaginal septum are injured Rectocele is herniation of anterior rectal wall through relaxed or ruptured vaginal fascia and rectovaginal septum Urinary incontinence All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 19 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 20 Sequelae of Childbirth Trauma (Cont.) Genital fistulas (perforations) May result from congenital anomaly, gynecologic surgery, obstetric trauma, cancer, radiation therapy, gynecologic trauma, or infection • Vesicovaginal: between bladder and genital tract • Urethrovaginal: between urethra and vagina • Rectovaginal: between rectum or sigmoid colon and vagina All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 21 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 22 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 23 Care Management Dependence upon the problem and severity of symptoms Kegel exercises Pessaries Estrogen therapy Surgical repair Hygiene practices All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 24 Postpartum Psychologic Complications Mental health disorders in postpartum period have implications for mother, newborn, and entire family Interfere with attachment to newborn and family integration May threaten safety and well-being of mother, newborn, and other children All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 25 Postpartum Psychologic Complications (Cont.) Mood disorders 80% of women experience a mild depression or “baby blues” Symptoms resolved within a few days 10% to 15% of women experience more serious depression Paternal postpartum depression All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 26 Postpartum Psychologic Complications (Cont.) Postpartum depression without psychotic features Postpartum depression: an intense and pervasive sadness with severe and labile mood swings Medical management • Antidepressants, anxiolytic agents, mood stabilizers and electroconvulsive therapy • Psychotherapy focuses fears and concerns of new responsibilities and roles; monitoring for suicidal or homicidal thoughts All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 27 Postpartum Psychologic Complications (Cont.) Postpartum depression with psychotic features Postpartum psychosis: syndrome characterized by depression, delusions, and thoughts of harming either infant or herself Psychiatric emergency; may require psychiatric hospitalization Associated with bipolar (or manic-depressive) disorder All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 28 Care Management Screening for postpartum depression Nursing care on the postpartum unit Nursing care in the home and community Referrals Providing safety Psychiatric hospitalization Psychotropic medications Other treatments for postpartum depression All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 29 Postpartum Anxiety Disorders Generalized anxiety disorder Obsessive-compulsive disorder Panic disorder and panic attacks Specific phobias Social anxiety disorder Posttraumatic stress disorder All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 30 Case Study You are the mother-baby nurse providing couplet care to Ms. Hart and her new baby girl, Chloe. 36-year-old G3P1021. Married with husband very involved in care of baby since birth. OB history includes history of two spontaneous abortions (SABs). Current pregnancy result of in vitro fertilization (IVF). Uncomplicated C/S 48 hours ago after failed induction and long labor. Apgar score 9/9 for baby. Breastfeeding but baby sleepy at the breast and now with elevated bilirubin level—going home with bili blanket. All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 31 Case Study (Cont.) Family involved with many visitors since the birth. RN now enters room to provide discharge teaching. During your visit, Ms. Hart breaks down in tears and states, “I am so exhausted. This just hasn’t worked out how I imagined. I feel so overwhelmed.” All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 32 Case Study (Cont.) What can you say to Ms. Hart and what suggestions will you make? What would be your plan of care? What might increase her risk of postpartum depression (PPD)? What do you think of the language the team uses to describe the outcome of her induction of labor? How might this affect the mother’s selfesteem? All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 33 Loss and Grief Situational life crises superimposed on childbearing Infertility Premature labor or birth Cesarean birth Gender of infant not desired Birth of child with handicap Maternal death Fetal or neonatal death All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 34 Loss and Grief (Cont.) Grief responses Overlapping phases in grief process Acute distress Intense grief Reorganization All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 35 Loss and Grief (Cont.) Family aspects of grief Grandparents and siblings Communicating and caring techniques Help mother, father, and other family members actualize the loss Help parents with decision making All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 36 Loss and Grief (Cont.) Communicating and caring techniques Help bereaved to acknowledge and express their feelings Normalize grief process and facilitate positive coping Meet the physical needs of postpartum bereaved mother Create memories for parents to take home All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 37 Loss and Grief (Cont.) Cultural and spiritual needs of parents Provide culturally sensitive care at and after discharge Provide postmortem care respecting parents wishes Documentation Provide sensitive care both at and after discharge All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 38 Maternal Death Emotional toll on nursing and medical staff Mortality\morbidity review Critical incident debriefing Attending funeral services Follow-up with grief counselor All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 39 Question The most effective and least expensive treatment of puerperal infection is prevention. What is important in this strategy? Large doses of vitamin C during pregnancy Prophylactic antibiotics Strict aseptic technique, including handwashing, by all health care personnel Limited protein and fat intake All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 40