Transcript Pp_comp - Austin Community College

Postpartum Hemorrhage
• Early
– Occurs when blood loss is greater than
500 ml. in the first 24 hours after a
vaginal delivery or greater than 1000 ml
after a cesarean birth
*Normal blood loss is about 300 - 500 ml.)
• Late
– Hemorrhage that occurs after the first 24
hours
Postpartum Hemorrhage
• Other definitions:
• A decrease in the hematocrit of 10 points
between time of admission and time
postbirth
• Need for fluid replacement following
childbirth
Main Causes of Early
Hemorrhage are:
• Uterine Atony
• Lacerations
• Retained Placental Fragments
• Inversion of the Uterus
• Placenta Accreta
Uterine Atony
The myometrium fails to
contract and the uterus fills
with blood because of the lack
of pressure on the open blood
vessels of the placental site.
Uterine Atony
Predisposing Factors
Prolonged
labor
Trauma due
to Obstetrical
Procedures
Overdistention
of the
Uterus
Grandmultiparity
Intrapartum
Stimulation
with Pitocin
Excessive use of
Analgesia / Anesthesia
Uterine Atony
• Most common cause of Hemorrhage
• Key to successful management is:
PREVENTION!
• Nurse many times can predict which
women are at risk for hemorrhaging.
Uterine Atony
A boggy uterus that does not
respond to massage
Abnormal
Clots
Signs
and
Symptoms
Excessive
or
Bright Red
Bleeding
Unusual pelvic discomfort or backache
Nursing Care
• Assess and Document Bleeding
• Fundal massage and express clots
• Bimanual Compression
• Assess Vital Signs (shock)
Nursing Care
• Give medications
– Pitocin
– Methergine
– Carboprost Tromethamine (Hemabate)
(May inject the medications directly
into the uterus)
• Replace blood / fluids
• D & C, Hysterectomy
Post Partum Hemorrhage
*Lacerations*
• PREDISPOSING FACTORS
1. Spontaneous or Precipitous delivery
2. Size, Presentation, and Position of baby
3. Contracted Pelvis
4. Vulvar, perineal, and vaginal varices
• Signs and Symptoms
1. Bright red bleeding where there is a
steady trickle of blood and the uterus
remains firm.
2. Hypovolemia
POSTPARTUM HEMORRHAGE
LACERATIONS
• Treatment and Nursing Care
1. Meticulous inspection of the entire
lower birth canal
2. Suture any bleeders
3. Vaginal pack-- nurse may remove and
assess bleeding after removal
4. Blood replacement
Test Yourself !
• You are assigned to Mrs. B. who
delivered vaginally. As you do your
post-partum assessment, you notice
that she has a large amount of lochia
rubra.
– What would be the first measure to
determine if it is related to uterine
atony or a laceration?
– Answer: feel the fundus- if firm
Hematoma
Bleeding into the soft
tissues surrounding
the episiotomy or
laceration.
May follow forceps or
vacuum extraction
*A unit or more of blood may
be in the hematoma
Hematoma
Major Symptom: PAIN- deep, severe,
unrelieved, feelings of pressure
Many times bleeding is concealed.
Major symptom is rectal pain and
tachycardia.
Treatment:
May have to be incised and drained.
Inversion of the Uterus
• The uterus inverts or turns inside out after
delivery.
• Complete inversion - a large red rounded
mass protrudes from the vagina
• Incomplete inversion - uterus can not be seen,
but felt
• Predisposing Factors:
– Traction applied on the cord before the
placenta has separated.
**Don’t pull on the cord unless the placenta
has separated.
– Incorrect traction / pressure applied to the
fundus, when the uterus is flaccid
**Don’t use the fundus to “push the placenta
out”
Inversion of the Uterus
Placenta
Uterus
Traction on
the cord
starts the
uterus to
invert
Uterus continues
to be pulled and
inverted
Inversion of the Uterus
Vagina
Vagina
Uterus
Inverted
Uterus
Manually
pushed back
into place
Treatment and Nursing Care
• Replace the uterus--manually replace and
pack uterus
• Combat shock, which is usually out of
proportion to the blood loss
• Blood and Fluid replacement
• Give Oxytocin
• Initiate broad spectrum antibiotics
• May need to insert a Nasogastric tube to
minimize a paralytic ileus
Notify the Recovery Nurse what has occurred!
Care must be taken when massaging
Placenta Accreta
All or part of the decidua basalis is
absent and the Placenta grows
directly into the uterine muscle.
Placenta Accreta
• Signs:
– During the third stage of labor, the
placenta does not want to separate.
– Attempts to remove the placenta in
the usual manner are unsuccessful,
and lacerations or perforation of the
uterus may occur
• Treatment
– Removal of the uterus Hysterectomy
Treatment
• If it is only small portions that
are attached, then these may be
removed manually
• If large portion is attached--a
Hysterectomy is necessary!
Late Postpartum Hemorrhage
• Most common cause is Retained Placental
fragments
• Sub involution
• Treatment
–D & C
–Methergine
Retained Placental Fragments
• This occurs when there is incomplete
separation of the placenta and fragments of
placental tissue retained.
• Signs
– Boggy , relaxed uterus
– Dark red bleeding
• Treatment
–D & C
– Administration of Oxytocins
– Administration of Prophylactic antibiotics
Are these Early, Late, or Both ?
• Uterine Atony
• _________________
• Retained placental
fragments
• _________________
• Lacerations
• _________________
• Inversion of the uterus• _________________
• Placenta accreta
• _________________
• Hematoma
• _________________
Review
Early Signs of Hemorrhage
• An uncontracted uterus – boggy
• Large gush, steady trickle, oozing, or seeping
of blood from the vagina
• Saturation of more than one pad in 15 minutes
• Severe unrelieved perineal or rectal pain
• Tachycardia
Review
Hypovolemic Shock
• Signs
– Tachycardia
– Drop in B/P
– Narrowing of pulse pressure
– Tachypnea
– Skin becomes pale and cool and can
progress to cold and clammy
– Becomes anxious  confused lethargic
– Urinary output decreases
• Treatment
– Blood/Fluid replacements, oxygen, surgery
Thromboembolic Disorder
•
Predisposing Factors
•
Signs and Symptoms
Slowing of blood in the legs
Trauma to the veins
Hypercoagulation
Sudden onset of pain
Tenderness of the calf
Reddness and an increase in skin temperature
Positive Homan’s Sign
Thromboembolic Disease
• Treatment
Heparin --it does not cross into breast
milk
Antidote: protamine sulfate
Teach patient to report any unusual
bleeding, or petchiae, bleeding gums,
hematuria, epistasis, etc.
•
Complication
Pulmonary Emboli
Puerperal Infections
• Definition
Infection of the genital tract
that occurs within 28 days
after abortion or delivery
• Causes
Streptococcus Groups A and B
Clostridium, E. Coli
Puerperal Infections
• Predisposing Factors
1. Trauma
2. Hemorrhage
3. Prolonged labor
4. Urinary Tract Infections
5. Anemia and Hematomas
6. Excessive vaginal exams
7. P R O M
Critical to Remember
• Signs and Symptoms of Puerperal Infection
1.Temperature increase of 100.4 or higher
on any 2 consecutive days of the first
10 days post-partum, not including the
first 24 hours.
2. Foul smelling lochia, discharge
3. Malaise, Anorexia, Tachycardia, chills
4. Pelvic Pain
5. Elevated WBC
PUERPERAL INFECTION
TREATMENT AND NURSING CARE
• Administer Broad Spectrum Antibiotics
• Provide with warm sitz baths
• Promote drainage--have pt. lie in HIGH
fowlers position
• Force fluids and hydrate with IV’s 3000 - 4000
cc. / day
• Keep uterus contracted, give methergine
• Provide analgesics for alleviation of pain
• Nasogastric suction if peritonitis develops
Test Yourself !
• What is the classic sign of a
Puerperal Infection?
• Answer: Temperature increase of 100.4 or
higher on any 2 consecutive days of the
first 10 days post-partum, not including
the first 24 hours.
Complications of
Puerperal Infections
Pelvic Cellulitis
Peritonitis
Signs and Symptoms:
Spiking a fever of 102 0 F to 104 0 F
Elevated WBC
Chills
Extreme Lethargy
Nausea and Vomiting
Abdominal Rigidity and Rebound Tenderness
Preventive Measures
•
•
•
•
•
Prompt treatment of anemia
Well-balanced diet
Avoidance of intercourse late in pregnancy
Strict asepsis during labor and delivery
Teaching of postpartum hygiene measures
– keep pads snug
– change pads frequently
– wipe front to back
– use peri bottle after each elimination
Wound Infection
• Infection of the Episiotomy, Perineal
laceration, Vaginal or vulva lacerations
• Wound infection of Cesarean incision site
• Signs:
– Reddened, edematous, firm, tender edges
of skin
– Edges separate and purulent material
drains from the wound.
• Treatment
– Antibiotics
– Wound care
Check Yourself
 Mrs. X. was admitted with endometritis
and Mrs. Y. was admitted with an infection
in her cesarean incision. Are both classified
as a Puerperal Infection?
Answer: yes
 What would be the major difference in
presenting symptoms you would note on
nursing assessment?
Answer: foul smelling lochia
Puerperal Cystitis
• Prevention:
• Monitor the patients urination diligently!
• Don’t allow to go longer than 3 - 4 hours
before intervening.
• Treatment
• Antibiotics -- Ampicillin
• Urinary Tract Antispasmotics
• Causes:
• Stretching or Trauma to the base of the
bladder results in edema of the trigone
that is great enough to obstruct the
urethra and to cause acute retention.
• Anesthesia
Mastitis
• Types:
– Mammary Cellulitis - inflammation
of the connective tissue between the lobes
in the breast
– Mammary Adenitis - infection in the
ducts and lobes of the breasts
Development of Mastitis
Improper
breaking of
suction
First
Nursing
Experience
Supplemental
Feedings
"Lazy Feeder"
Poor
Positioning
of Infant
Strong
Sucking
Infant
Abrupt
Weaning
Interval
between
nursing too long
Nipple Trauma
Pain
Impaired
Let down
Cracked
nipples
Engorgement
Stasis
of milk
Entry for Bacteria
Plugged ducts
Mastitis
Treatment,
Problem will resolve
No Treatment
Breast Abscess
Mastitis
Marked Engorgement
Pain
Chills, Fever, Tachycardia
Hardness and Redness
Enlarged and tender
lymph nodes
Treatment of Mastitis
• Rest
• Appropriate Antibiotics--Usually Cephalosporins
• Hot and / or Cold Packs
•
Don’t Stop Breast Feeding because:
– If the milk contains the bacteria, it also
contains the antibiotic
– Sudden cessation of lactation will cause
severe engorgement which will only
complicate the situation
– Breastfeeding stimulates circulation and
moves the bacteria containing milk out of the
breast
Mastitis
Meticulous
handwashing
Preventive Measures
Rotate position of
baby on the breast
Frequent feedings
and massage
distended area to
help emptying
Complication of Mastitis
Breast Abscess
Breast Feeding is stopped on the affected side,
but may feed on the unaffected side.
Treatment: Incision and Drainage
Test Yourself
The major causative organism of mastitis is
_________________________.
Mastitis develops mainly in ______________ who are nursing .
It is almost always ________________ and develops well
after the flow of milk has been established.
There are two types of mastitis. One that develops between
the lobes of the breast is called____________________.
The one that developswithin the lobes and ducts of the
breast is called __________________.
Mammary cellulitis mainly develops due to _______________.
Mammary adenitis develops when ____________________
of the breasts occurs. With improper treatment or no
treatment, mastitis can lead to ________________.
Mood Disorders
• The Most common Mood Disorders are:
– Postpartum Depression
– Postpartum Psychosis
Postpartum Depression
• Predisposing Factors:
–
–
–
–
–
Primiparity
Ambivalence about the pregnancy
History of Depression
Environmental and Family Stress issues
Dissatisfaction with herself
Postpartum Depression
Assessment
 Persistent lack of interest or energy, loss of
usual emotional response toward her
spouse or family
 Obsessive thoughts of failure as mother,
incompetent, inadequate parent
 Anxiety, Irritability
 Forgetfulness; Inability to follow directions
 Anorexia
 Persistent Sleeplessness
 Poor personal Hygiene
 Feelings of unworthiness
Postpartum Depression
• Creates strain on the family
• Family members may decrease their
interactions with the depressed woman when
she needs support the most.
• Infants of depressed mothers tend to be fussier
and more discontented. They show fewer
positive facial expressions.
Nursing Care
Antidepressant Drugs
a. SSRI
• Prozac, Paxil, Zoloft
b. Cyclic compounds
• Tofranil, Asendin, Norpramin, Sinequan
c. MAO Inhibitors
• Nardil, Parnate
d. Other:
• Wellbutrin, Effexor, Desyril
e. Lithium, Depakene, Tegretol for bipolar
disorder
Treatment for Depression
2. Psychotherapy
3. Encourage communication with her husband or
support person who is available to provide
support when loneliness or anxiety becomes a
problem
4. Explain importance of good nutrition and rest
Treatment and Nursing Care
5. Discuss changes that normally occur in the
beginning weeks after taking a baby home
6. Although some of her feelings may seem
“unreasonable”, she should acknowledge
these feelings to herself and insist that others
acknowledge them too.
7. Re-introduce the baby to the mother at the
mother own pace
Convey a caring attitude
This helps mothers decrease their emotional
distress and guide them in regaining their
well-being
Postpartum Psychosis
SCHIZOPHRENIA
• Far less common
• May surface when the mother does not
have the ability to adjust to and cope with
her new obligations as a mother
• Affects mostly adolescents and younger
adults
Schizophrenia
Signs and Symptoms
 Irritability, Hyperactivity
 Insomnia; Exhibit little need for sleep
 Mood lability
 Hostility toward spouse is obvious
 Overly Suspicious, seldom aware
they have a problem
 Often believe hers to have been an
immaculate conception
 Abandons reality, totally neglects her
infant
 May have delusions and erroneously
belief that baby is dead, malformed or
severely ill; hallucinations
Treatment and Nursing Care
 Remove the baby from the situation
 Hospitalization
 Antipsychotic Medications
Stelazine, Clozaril, Risperdal, Haldol,
Navane
 When she is better, then bring the baby back
for short visits at first. Give praise for small
tasks that the mother can accomplish with
the baby.
Review
• What is the time difference between early and
late postpartum hemorrhage?
• What is the most common cause of postpartum
hemorrhage?
• How will the nurse recognize uterine atony?
• What is the FIRST nursing action if uterine
atony is discovered?
• What would the nurse suspect if the placenta
fails to release from the uterine wall after
delivery?
• How do the signs and symptoms of hematoma
differ from those of uterine atony or a
laceration?
• What laboratory study should the nurse suspect
if the woman is on heparin anticoagulation?
• What is the significance of a board-like
abdomen in a woman who has endometritis?
• Why is it important that the breast-feeding
mother with mastitis empty her breasts
completely?
• What is the KEY difference between postpartum
blues and postpartum depression?
The End