Transcript Complications of the Post-Partal Period

Complications of the PostPartal Period
Postpartum Hemorrhage
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Definition
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Early-postpartum hemorrhage of
>500cc within the first 24hrs.
postpartum
Late-postpartum hemorrhage of
>500cc after the first 24 hrs
postpartum
Postpartum Hemorrhage
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Predisposing Factors
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Multiparity
Macrosomia
Bladder distention
Oxytocin augmentation/induction
Preeclampsia,
Asian or Hispanic heritage
Retained placenta
Placenta previa
Dysfunctional labor
Prolonged 3rd stage of labor
Postpartum Hemorrhage
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Causes
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Early
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Uterine Atony
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Most common 2nd to over distention of
uterus or tired muscle
Lacerations in vagina
 Hematoma
 Uterine Inversion
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Postpartum Hemorrhage
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Causes
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Late
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Retained placental fragments
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Infection
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Most common cause of late pp hemorrhage
Backache, foul smelling lochia, leukorrhea
Uterine Subinvolution
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Fundal height is greater than expected,
lochia fails to progress from rubra to serosa
to alba normally.
Postpartum Hemorrhage
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Prevention
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Adequate prenatal care
Good nutrition
Avoidance of traumatic procedures
Risk assessment
Early recognition and management of
complications
Signs of Hemorrhage (Olds, 2008)
Postpartum Hemorrhage
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Nursing Care
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Assessment
 Fundus-uterine massage if a soft, boggy
uterus is detected
 urinary output-if inadequate ask pt. to void or
catheterization may be required
 Vital signs
 Lochia-note color and amount
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Weigh pads/chux
Hgb/hct
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A decrease in Hgb of 1.0-1.5g/dl or a decrease in
HCT of 2-4% reflects a blood lossof 450-500ml
Postpartum Hemorrhage
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Nursing Care
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Intervention
 Fundal massage-immediate and most effective
intervention
 Empty bladder
 Position with legs elevated
 Keep pt. informed
 Administer O2
 Notify PCP
 Initiate IV if none, in severe hemorrhage place
second IV
Estimating Blood Loss
Ideal Method=Weighing
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250cc
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355 cc
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1cup
5cm clot (orange)
12oz soda can
500 cc
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2 cups
10cm clot (softball)
Administer Uterotonics
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Medications used:
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Pitocin (Oxytocin)—increase IV rate for bolus
Methergine (Methylergonovine Maleate)
adrenergic antagonist 0.2-0.4 mg p.o. or 0.2 mg q
2-4hr IM or IV
 Check BP due to risk of hypertensive crisis,
(do not give to patients with PIH)
Prostaglandins-for more critical situations
 Hemabate (Carboprost tromethaminie), (do
not give to patients with Asthma)
 Prostin/15 M (dinoprostone) to decrease
blood loss 2nd to uterine atony. 250 mcgs
(1ml) IM repeated q 1.5-3.5 hrs.
 Cytotec (misoprostol) 600-1000 mcg rectally
(only if others not available or have failed)
Nursing Care for postpartum
hemorrhage
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Intervention
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Patient teaching
 Provide clear explanations about condition and
the importance for the need to recover
 Rise slowly to minimize orthostatic
hypotension
 Encourage to sit while holding the newborn
 Encourage to eat foods high in iron
 Continue to observe for signs of hemorrhage
or infection
Vulvar, Vaginal, and Pelvic Hematoma
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Causes
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Results from an injury to a blood vessel
without noticeable trauma to superficial
tissue such as after a forceps delivery.
Soft tissue (labia majora or perineal
area) can hold 250-500 cc’s of blood.
Hematomas
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Predisposing factors
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Preeclampsia
Pudendal anesthesia
First full-term birth
Precipitous labor
Prolonged seconds stage
Macrosmia
Forceps or vacuum assisted birth
Vulvar varicosities
Vulvar Hematoma
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Symptoms
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Severe pain-rectal pressure
Area is very painful to touch
Firm to touch
Skin may be discolored-reddish
Unable to void due to pressure on the urethra
Can be hard to detect if hematoma is high in
vagina
Flank pain
Abdominal pain
Decreased lochia
*signs of shock*
Hematomas
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Nursing intervention
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Apply ice packs and analgesia
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Typically resolve on own over several
days
Medical treatment
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For hematomas > 5 cm and those that
expand
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Incision and drainage of hematoma is
needed
Puerperal Infection
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Definition-infection with
temp>100.4 or 38 degrees on 2
occasions after 1st 24 hours.
Puerperal Infection
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Predisposing factors
 C-section
 Prolonged premature ROM
 Prolonged labor preceding c-section
 Multiple VE
 Compromised health status
 Low socioeconomic status, anemia, obesity,
smoking, poor nutrition
 FECG, IUPC
 Obstetric trauma
 Episiotomy, lacerations
 Chorioamnionitis
 Vacuum, forceps
 Manual removal of placenta
 Diabetes mellitus
Puerperal Infection
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Assessment
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R: redness
E: edema
E: ecchymosis
D: discharge
A: approximation
Puerperal Infection
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Signs/Symptoms
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Foul smelling lochia
Increased temp >38.4 p first 24 hrs pp
Tenderness of fundus upon palpation
Fever
Malaise
Abdominal pain
Larger than expected uterus
Tachycardia
Puerperal Infection Nursing Care
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Treatment/Prevention
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Good perineal care
Hygiene practices to prevent
contamination of the perineum
Thorough handwashing
Sitz baths
Adequate fluid intake
Diet high in protein and vitamin C
Thromboembolic Disease
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Seen in 1% of vaginal deliveries
and 2-20% of c-sections
Definition
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Venous thrombosis is a clot in a
superficial or deep vein (femoral vein is
common site), dangerous when clot
loosens from wall of vein and becomes
an embolism, which can travel to the
heart, brain, or lungs.
Thromboembolic Disease
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Thrombophlebitis
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Occurs when a clot forms b/c of an
inflammation of the vein wall-usually
clot is more adherent to vein walls thus
a lesser chance of becoming an
embolism
Thromboembolic Disease
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Predisposing factor of clot formation
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Increased amount of blood clotting
factors, i.e. increased number of
circulation platelets
Thromboembolic Disease (from Olds, 2008
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Who is at risk
Thromboembolic Disease
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Symptoms
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Positive homan’s sign-may occasionally
be neg
Redness, swelling, pain at site
Low grade fever
Thromboembolic Disease
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Treatment
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Local heat
Elevate limb
Bedrest
Analgesics
TED hose
Anticoagulant (heparin. Coumadin)
Thromboembolic Disease Prevention
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Early ambulation
TED hose, SCD’s
No smoking
Elevate legs when sitting
Avoid prolonged standing or sitting
(contribute to venous stasis)
Avoid crossing legs
Take frequent breaks while taking car
trips
Pulmonary Embolism
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Definition
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When a clot traveling through the
venous system becomes lodged within
the pulmonary circulatory system,
causing an infarction or occlusion.
 IT IS LIFE THREATENING AND
REQUIRES IMMEDIATE INTERVENTION
Pulmonary Embolism
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Etiology
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Usually preceded by deep vein
thrombosis
Diagnosis
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Verified by
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Abg’s, chest x-ray, and pulmonary
angiogram
Pulmonary Embolism
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Symptoms
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Dyspnea
Tachypnea and tachycardia
Substernal, chest or pleuritic pain
Cough
Hemoptysis
Apprehension
Paleness or cyanosis or both
Pulmonary Embolism
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Treatment
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Two primary goals
 Anticoagulation (IV Heparin)
 Cardiorespiratory support (O2 per mask,
Aminophylline, IV fluids)
Additional treatment
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Fibrinolytic therapy (streptokinase or
urokinase) may be used to lyse clots.
Pain management may include IV narcotics
(demerol or morphine)
Arrhythmias may also require Lidocaine IV
Cystitis (UTI)
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Etiology
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Escherichia coli causative agent in most
cases of postpartal cystitis
Predisposing factors
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Retention of residual urine
Non aseptic technique during
catheterization
Bladder trauma from childbirth
Cystitis (UTI)
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Assessment
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Frequency and urgency
Dysuria
Nocturia
Hematuria
Suprapubic pain
Slightly elevated temperature
Diagnosis
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Clean catch urine midstream is obtained and
sent for microscopic study and culture and
sensitivity
Cystitis (UTI)
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Prevention/Nursing Care
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Good perineal hygiene
Good fluid intake
Frequent emptying of the bladder
 Assist the woman to a normal voiding position
 Provide medication for pain
 Perineal ice packs
Frequent monitoring of the bladder
Void before and after intercourse
Cotton underwear
Increase acidity of the urine
Teach s/s of UTI
Cystitis (UTI)
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Treatment
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Antibiotics
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Macrobid, Bactrim DS, Septra DS
Mastitis
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Etiology
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Staphylococcus Aureus (found in
infants nose and throat)
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Infection begins when bacteria invade the
breast tissue after it has been
traumatized or milk stasis occurs (milk
acts as favorable medium for the invasion
of bacteria)
Mastitis Predisposing factors
Mastitis
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Assessment
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Breast consistency
Skin color
Surface temperature
Nipple condition
Presence of pain
Signs and symptoms
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Onset is sudden, p 10 days
Site is unilateral
Localized area, red, hot, swollen
Pain is localized (often wedge shaped)
Temperature .38.4
Flulike symptoms-fever, chills, ha, muscle aches
Mastitis
Figure 38–2 Mastitis. Erythema and swelling are present in the upper outer quadrant of the breast.
Axillary lymph nodes are often enlarged and tender. The segmental anatomy of the breast accounts for
the demarcated, often V-shaped wedge of inflammation.
Mastitis
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Prevention
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Proper feeding techniques
Supportive bra worn at all times to
avoid milk stasis
Good handwashing
Prompt attention to blocked milk ducts
Mastitis Nursing Care
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Teach mother how to pump if necessary
Assist with feelings about being unable to
breastfeed
Referral to lactation consultant or La
Leche League
Bedrest for 24 hours
Increase fluids
Supportive bra
Frequent feedings
Warm compress
analgesics
Mastitis treatment
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7-10 days of antibiotics
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Penicillinase-resistant penicillin or
cephalosporin
Non-steroidal anti-inflammatory
agents to treat fever and
inflammation
Mastitis-Self care instructions
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Importance of regular, complete
emptying of the breasts
Good infant positioning and latch-on
Principles of supply and demand
Importance of taking a full course of
antibiotics
Report flu-like symptoms
Postpartum Disorders
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Postpartum Blues
Postpartum Depression
Postpartum Psychosis
Postpartum Psychiatric Disorders
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Assessment
Depression scales
Anxiety and irritability
Poor concentration and forgetfulness
Sleeping difficulties
Appetite change
Fatigue and tearfulness
Postpartum Blues
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“Baby” blues occurs 50-75% of mothers
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Characterized by mild depression interspersed
with happier feelings.
Signs and symptoms-sadness, crying but
still able to feel happy
Onset/duration
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Transient
Occur 4-5 days pp and last for a few hours or
at most 1-2 days
Not culture specific
Postpartum Depression
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10-15%of women are clinically
depressed at 3 mo. pp. Only 2-3%
of these women are referred to a
pychiatrist. 25% of mothers
depressed in the first 3 mo. Are
likely to develop chronic depression
Postpartum Depression
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Course of symptoms
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Get the blues->gets better->then in a few weeks,
feels depressed (can last up to a year)
Mother focuses on guilt and inadequacies of being a
mother
Chronic tiredness/exhaustion
Tiredness/exhaustion
Low spirits and low tolerance for stress
Can lead to problems r/t baby (irritability and
hostility)
***Some research show a relationship b/t maternal
postnatal depression and cognitive development of
the child and later behavior patterns***
Postpartum Depression
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Predisposing Factors/Risk Factors
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Lack of social support (single mom, Yuppie
mom)
Previous dysmenorrhea
Hx of previous pp depression
Hx of miscarriage
Sever attack of blues p birth
Stress p birth ( marital or housing prob)
Depression in 2nd trimester of pregnancy
Hx of illness
Poor physical maternal health
Postpartum Depression Prevention
Postpartum Depression
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Treatment (must be multifaceted)
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Psychotherapy
Cognitive and supportive therapy
 Marital therapy
 Support groups as DAD’s (depression
after delivery
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Social support
Postpartum Depression Treatment
cont’d
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Medications-antidepressants (these work with
mothers experiencing insomnia, agitation, and
anxiety attacks)
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Meds-antidepressants ( these work with mothers
experiencing severe fatigue who are hard to “wake
up” or act more despondent)
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Sinequan (doxepin)
Tofranil (imipramine)
Desyrel (trazadone HCL)
Norpramin (desipramine HCL)
Prozac (fluoxetine HCL)
Vivactil (protriptyline HCL)
Medications-antimanic drugs (may be used to
control hyperactivity or manicky behavior)
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Lithium or Tegretol
Postpartum Psychosis
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Occurs in 1-2/1000 mothers
Course symptoms
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Manic state
Delirium-confusion or dissociative
episodes
Delusion-see visions/hallucinations,
hear voices often r/t baby
Postpartum Psychosis
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Risk factors
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Previous puerperal psychosis
Hx of bipolar disorder
Prenatal stressors (lack of support, low
socioeconomic status)
Obsessive personality
Family hx of mood disorder
Postpartum psychosis
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Treatment
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Hospitalization-ideally on a psychiatric
mother/baby unit seen in England
Psychotherapy
Medications-antipsychotic drugs
Stelazine (trifluoperazine HCL)
 Haldol (haloperidol)
 Mellaril (thioridazine HCL)
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