Transcript Postpartum Complications

Postpartum Complications
Identify Risk Factors
Apply PP Assessment Skills
Compare Types of PP Hemorrhage
Discuss PP Infection
Discuss Thromboembolic Disorders
Compare PP Depression w/ Psychosis
Plan Nursing Interventions
PP Complications
• Assess postpartum client's prenatal history
and ongoing labor/birth to identify risk
factors leading to postpartum complications
• Assess with knowledge that many
physiologic changes of postpartum period
are similar to depression
• Document specific and objective
observations
Risk Factors for Complications
• Overdistention of uterus due to large baby,
multiple gestation, multiparity
• Rapid or prolonged labor
• Oxytocin induction of labor
• Precipitous induction of labor
• Precipitous delivery, cesarean section
• PROM
• Urinary catheterization
Vital Signs
• Elevated temperature
• Temperature elevations should last for only 24 hours
• After 24 hours > 100.4°F (38ºC) = infection
• Elevated heart rate
• Decreased blood volume - bradycardia rates of 50 to 70
beats per minute occur during first 6 to 10 days
• Tachycardia = Increased blood loss, difficult labor/birth
• Elevated blood pressure, low blood pressure
• Blood pressure should be stable, may be decreased
• Symptoms of shock
• Breath sounds clear
BUBBLEHE ASSESSMENT
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B = Breast
U = Uterus
B = Bladder
B = Bowels
L = Lochia
E = Episiotomy, Laceration, C/S Incision
H = Homan’s sign, Hemorrhoids
E = Emotional status, bonding
BUBBLEHE Assessment
• Breasts – Cracked, blistered, or bleeding nipples
• Note engorgement, red streaks, lumps, clogged milk ducts
• Assess for mastitis
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Erythema, heat in breast
Fever, chills, malaise, headache
Engorgement, pain
Supplemental feedings
Change in routine or infant feeding patterns
Abrupt weaning
• Treatment: Proper latch-on technique, encourage frequent
feeding, position changes during feedings, fluid intake
3000mL/day, antibiotics, analgesics, warm compresses,
can breastfeed or pump w/ mastitis
BUBBLEHE Assessment
• Uterus – Position height, tone (bogginess),
position out of midline, heavy lochia flow
• Uterine atony - Lack of uterine muscle tone caused by conditions that overdistend uterus
and affect uterine contractibility, and
medication
• Perform fundal massage and check for clots
• Administer uterine stimulants (oxytocin) as ordered
to monitor for side effects
• Uterus is firm and if there is bright red bleeding
- this may indicate laceration
• Contact physician – need for suture of laceration
BUBBLEHE Assessment
• Bladder - Assess frequency, burning, or
urgency - palpate for bladder distention
• Have patient void frequently
• In & Out catheterize if necessary
• Insert indwelling urinary catheter – color, odor,
amount
• Bowel: Assess bowel sounds, flatus, and
distention
• Increase fluids and fiber in diet
• Administer stool softeners
BUBBLEHE Assessment
• Lochia - examine perineal pads - Note
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Amount
Color and odor
Consistency
Presence and size of clots
BUBBLEHE Assessment
• Episiotomy/Laceration/C/S Incision Inspect for REEDA, pain
• Mediolateral episiotomies for increased
bleeding
• R = Redness
• E = Edema
• E = Ecchymosis
• D = Discharge, Drainage
• A = Approximation
BUBBLEHE Assessment
• Extremities
• Assess for pedal edema, redness
and warmth
• Check Homan's sign every shift
• Hemorrhoids – Assess
BUBBLEHE Assessment
• Emotional Status - Focuses on mother's
general attitude, feelings of competence,
support systems, care giving skill evaluates fatigue and ability to accomplish
developmental task
• Determine mother's phase of adjustment to
parenting
• Bonding
• Describe level of attachment to infant
Pain Assessment and Medication
• Postpartum client may need medications to
promote comfort, treat anemia, prevent
rubella, and prevent development of
antigens (in nonsensitized Rh-negative
woman)
• Postpartum clients should be informed
about name of medication, expected action,
possible side effects
• Nurse must review safety measures with
medications
Pain Assessment and Medication
• Relief of Perineal Discomfort
• Ice packs
• Topical agents (Epifoam)
• Perineal care
• Relief of hemorrhoidal discomfort may
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Sitz baths
Topical anesthetic ointments (Nupercainal)
Rectal suppositories
Witch hazel pads (Tucks)
A sitz bath promotes healing and provides relief from
perineal discomfort during the initial weeks following birth.
Pain Assessment and Medication
• Afterpains
• Positioning (prone position)
• Analgesia administered an hour before
breastfeeding
• Encourage early ambulation - monitor for
dizziness and weakness
Pain Assessment and Medication
• Cesarean section:
• Administer analgesics within the first 24 to 72 hours allows woman to become more mobile and active
• Morphine PCA, oxycodone, ibuprofen, acetaminophen ES
• Encourage non-pharmacologic methods of pain relief
(breathing, relaxation, and distraction) - encourage rest,
proper positioning, back rubs, and oral care
• Encourage visits by family and newborn, which provides
distraction
• Position client on left side, include exercises, early
ambulation, avoid carbonated beverages and straws may need enemas, stool softeners, “hot toddy”
Labs
• White blood cell count often elevated after
delivery
• 25,000 to 30,000mm³
• Return to normal in one week
• Platelet levels fall w/ placental separation
• Return to normal by 6th PP week
• Activation of clotting factors predispose to
thrombus formation
• Hemostatic system reaches non-pregnant state in 3 to 4
weeks
• Monitor hemoglobin and hematocrit - assess for
signs of anemia
PP Hemorrhage
• > 500 mL of blood after vaginal birth
• >1000mL of blood after cesarean section
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Uterine atony
Hematoma, laceration
Uterine inversion
Bladder distention
Delivery after circlage
PP Hemorrhage
• Interventions:
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Massage fundus, inspect perineum, pad count
Voiding frequently or catheterize
IV fluids
a. oxytocin (20 units per 1000ml IV) 50 mu/min or 10 –
20 units IM (monitor fluid levels)
b. methylergonovine (Methergine) 0.2 mg IM
(hypertension, seizures)
c. prostaglandin F (Hemabate, Carboprost) 0.25 mg IM
or intramyometrially by MD (N/V, diarrhea, h/a,
bradycardia, wheezing, cough, chills, fever)
• Notify health care provider
• Check CBC results
• Hemoglobin (12-16 g/dL), hematocrit (37-47%)
PP Hemorrhage
• Late hemorrhage
• Retained placental fragments
• Commonly occurs when fundus is massaged prior to
spontaneous placental separation
• Suspect if patient is bleeding with firm fundus and no
laceration
• Inspect placenta thoroughly after its delivery
• Subinvolution
• Usually occurs 1 to 2 weeks after birth
• Failure of uterus to return to normal size after pregnancy lochia rubra of greater than 2 weeks duration
• Infection
• Provide patient with discharge instructions and
information about possible complications
Thromboembolic Disorder
• Risk of thromboembolism lasts 6 weeks
• Superficial – risk greater 3 – 4- days PP
• Redness, warmth, tenderness, swelling over clot area
• Deep vein thrombosis
• Homan's positive sign, pain, fever and chills, paleness and
swelling in lower extremities
• Assess for pulmonary embolus
• Ultrasound, CT scan, venography
• Clotting times, PT, PTT, INR
Thromboembolic Disorder
• Treatment
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Anticoagulant therapy - labs
Bedrest w/ elevation of leg
Daily measurement of calf & thigh
Elastic support stockings
Warm, moist packs to leg
Encourage early ambulation
For clients on bed rest, turn and do range of motion
exercises, encourage fluids to avoid dehydration,
encourage no smoking, advise against prolonged sitting
or crossing legs, avoid rubbing area
PP Infection
• Fever (>100.4°F, 38C), purulent discharge
from vagina or incision, erythema at
incision site, burning during urination,
redness/pain in breast about fourth
postpartum week
• Report signs of severe infection: Foulsmelling lochia, uterine tenderness/
subinvolution, severe lower abdominal pain,
change in vital signs, chills, lethargy,
nausea/vomiting, abdominal guarding
PP Infection
• Cesarean section
• Pulmonary infections may occur because of
immobility and use of narcotics because of
altered immune response
• Wound infection
• REEDA assessment of incision
PP Infection
• Increase in WBC > 30% in 6 hours
• Teach hygiene
• Adequate fluids, diet high in protein,
vitamin C
• Administer antibiotics, pain medication
• Wound care
• Rest
• Fowler’s position with metritis to promote
drainage of lochia
PP Depression/Psychosis
• Depression: Overwhelming sadness, low selfesteem, lack of desire to care for child
• Depression more severe in primiparas than in
multiparas
• Observe for episodic tearfulness,
feels overwhelmed, unable to cope, fatigued,
anxious, irritable, oversensitive, suicidal
• Observe new mother for objective signs of
depression - listen for feelings of failure and self
accusation
PPDepression/Psychosis
• Psychosis
• Evident within 3 months PP
• Agitation, hyperactivity, insomnia, mood
lability, confusion, irrationality, difficult
remembering or concentrating, poor judgment,
delusions, hallucinations
• Increased recurrence in
subsequent pregnancies
PP Depression/Psychosis
• Identify risk factors prenatally
• Ambivalence, lack of support, dissatisfaction
w/ self, primiparity, history PP depression or
bipolar
• Referral for counseling, support groups
• Medication
• Lithium, antipsychotics, antidepressants
• ECT w/ psychotherapy
• Removal of infant
• Support
Nursing Diagnoses
• Constipation related to fear of tearing
stitches or pain
• Acute pain related to perineal edema
episiotomy, laceration, incision from birth
• Health-seeking behaviors: Information
about infant care related to expressed desire
to improve parenting skills
• Readiness for enhanced family coping
related to successful adjustment to new
baby
Nursing Diagnoses
• Ineffective breastfeeding related to
improper latch-on by infant
• Altered tissue perfusion related to
obstructed venous return
• Risk for injury related to spread of infection
• Risk for altered parenting related to
decreased maternal-infant interaction
Teach for Postpartum Self-Care
• Teach patient normal adaptation:
• Progressive descent of fundus, no reversal of
lochia - be aware of postpartum fatigue and
obtain extra rest
• Teach about nutritional needs:
• Adequate hydration, dietary measure if anemic,
nutritional needs for breastfeeding
• Teach about comfort measures, activity,
methods to prevent fatigue, coping skills
Teach for Postpartum Self-Care
• Teach to watch for infection of incisions
• Patient needs to be aware of action of
prescribed medications and potential side
effects
• Teach to watch for overwhelming feelings
of sadness or inability to care for infant
• Provide list of support organizations in the
community
NCLEX Question
On examining a client who gave birth 3 hours ago, a
nurse finds the client has completely saturated a
perineal pad within 15 minutes. Which actions
should the nurse take? Select all that apply.
A. Begin an IV infusion of Lactated Ringer’s solution
B. Assess the patient’s vital signs
C. Palpate the patient’s fundus
D. Place the patient in high Fowler’s position
E. Administer a pain medication
NCLEX Question
The nurse observes several interactions between a
mother and her new son. Which behaviors by the
mother would the nurse identify as evidence of
mother-infant attachment? Select all that apply.
A. Talks and coos to her son
B. Cuddles her son close to her
C. Doesn’t make eye contact with her son
D. Requests the nurse to take the baby to the nursery
for feedings
E. Encourages the father to hold the baby
F. Takes a nap when the baby is sleeping
NCLEX Question
The nurse is instructing the client on breastfeeding.
Which instructions should the nurse include to
help the mother prevent mastitis?
Select all that apply.
A. Wash nipples with soap and water
B. Change the breast pads frequently
C. Expose nipples to air part of each day
D. Wash hands before handling breast and
breastfeeding
E. Make sure the baby grasps only the nipple
F. Release baby’s grasp on nipple before removing
from breast
NCLEX Question
Which lab values indicate normal coagulation
status?
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B.
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PT – 10 seconds, PTT – 50 seconds, INR – 1
PT – 15 seconds, PTT – 90 seconds, INR – 5
PT – 12 seconds, PTT – 65 seconds, INR – 3
PT – 14 seconds, PTT – 75 seconds, INR - 4