Nursing Care of High Risk Postpartal Clients: Postpartum Hemorrhage

Postpartal Hemorrhage

• Postpartal hemorrhage is excessive bleeding (> 500 ml in vaginal delivery) following delivery.
• Types of postpartal hemorrhage:
  • Early (primary): Blood loss during the first 24 hours after delivery.
  • Late (secondary): Blood loss between 24 hours and 6 weeks after delivery.
• Conditions that increase the risk of postpartal hemorrhage:
  • Prolonged third stage of labor
  • Deep anesthesia or analgesia
  • Retained placental fragments
  • Maternal age > 35 years
  • Previous uterine surgery
  • Prolonged and difficult labor
  • Secondary maternal illness (e.g., anemia)
  • Prior history of postpartum hemorrhage

Causes of Postpartal Hemorrhage

• Uterine atony (lack of uterine muscle tone)
• Lacerations (cervical, vaginal, or perineal)
• Retained placental fragments
• Uterine inversion
• Disseminated intravascular coagulation

Uterine Atony

• The lack of uterine muscle tone, leading to excessive bleeding.
• Causes:
  • Conditions that overdistend the uterus (e.g., multiple gestation, hydramnios)
  • Conditions that affect uterine contractility (e.g., prolonged labor, precipitous labor)
• Therapeutic management:
  • Attempt uterine massage to encourage contraction
  • Remain with the woman after massaging her fundus to ensure it is not relaxing again
  • Observe fundic height and consistency and lochia carefully

Retained Placental Fragments

• A condition where the placenta does not deliver entirely, leaving fragments behind.
• Causes:
  • Prolonged labor
  • Opera@ve delivery (forceps or vacuum extraction)
  • Prolonged second stage of labor
• Therapeutic management:
  • Removal of the retained placental fragment
  • Dilation and curettage (D & C) may be performed to remove the placental fragment

Lacerations

• Either cervical, vaginal, or perineal lacerations may occur.
• Predisposing factors:
  • Primiparous state
  • Epidural anesthesia
  • Precipitous childbirth
  • Macrosomia
  • Forceps or vacuum-assisted birth
  • Mediolateral episiotomy

Disseminated Intravascular Coagulation

• A complex disorder caused by overs@imulation of clotting and anti-clotting mechanisms.
• Predisposing factors:
  • Pre-eclampsia or eclampsia
  • Amniotic fluid embolism
  • Sepsis
  • Abruptio placenta
  • Prolonged intrauterine fetal demise

Late Postpartal Hemorrhage

• Bleeding after 24 hours until the sixth week postpartum.
• Subinvolution (failure of the uterus to return to normal size after pregnancy)
• Lochia may not progress from rubra to serosa to alba normally.### Postpartal Infections
• Postpartal infections can occur within the first 6 weeks after childbirth or 4 weeks after abortion.
• The uterus may feel larger and softer, and the client may experience pain or tenderness over the uterus.
• Predisposing factors include:
  • Caesarian delivery
  • Anemia
  • Prolonged rupture of membranes
  • Invasive procedures such as internal fetal monitoring
  • Multiple vaginal examinations
  • Retention of placental fragments
  • Chorioamnionitis
  • Preexisting bacterial vaginosis
  • Manual removal of placenta
• Nursing assessment:
  • Temperature greater than 100.4°F on any 2 of the first 10 days postpartum, excluding the first 24 hours
  • Abnormal lochia
  • Foul odor
  • Scant or profuse lochia in amount
  • Tachycardia
  • Delayed involution
  • Fundal height does not descend as expected
  • Pain, tenderness, or inflammation of the perineum
  • Backache
  • Malaise
  • Fatigue
  • Chills
  • Abnormal laboratory results
• Priority nursing diagnosis:
  • Hyperthermia
  • Risk for altered parenting
  • Risk for impaired parent/infant attachment

Wound Infection

• Wound infection can occur in the abdominal incision for Caesarian delivery or the episiotomy site.
• Infection rate following Caesarian births is 3-5%, with the highest rate occurring after emergency Caesarian.
• Culture of wound drainage frequently reveals mixed pathogens.
• Nursing assessment:
  • REEDA assessment:
    • Redness
    • Edema
    • Ecchymosis
    • Discharge
  • Body temperature
  • Localized tissue warmth
  • Tenderness
  • Generalized fever
• Priority nursing diagnosis:
  • Hyperthermia
  • Acute pain
  • Deficient knowledge

MASTITIS or Breast Infection

• Mastitis is an infection of the breast connective tissue, primarily in women who are lactating.
• Causative organisms include Staphylococcus aureus, Escherichia coli, Haemophilus parainfluenzae, and Streptococcus species.
• Predisposing factors:
  • Traumatized tissue, fissured or cracked nipples
  • Engorgement, milk stasis, or poor drainage of milk
  • Missed feedings
  • Lowered maternal defenses caused by fatigue or stress
  • Poor hygiene practices
  • Tight clothing or poor support of pendulous breasts
• Nursing assessment:
  • Breast consistency
  • Nipple condition
  • Flu-like symptoms
  • Generalized fever
  • Body temperature
• Priority nursing diagnosis:
  • Hyperthermia
  • Acute pain
  • Deficient knowledge

Urinary Tract Infections

• Urinary tract infections occur in 5% of postpartal women who have one catheterization and 50% of those with intermittent catheterizations.
• Infection can occur as cystitis (lower urinary tract infection) or pyelonephritis (upper urinary tract infection).
• Predisposing factors:
  • Normal postpartal diuresis
  • Increased bladder capacity
  • Decreased bladder sensitivity from stretching or trauma
  • Possible inhibited neural control of the bladder following the use of general or regional anesthesia
  • Contamination from catheterization
• Nursing assessment:
  • Frequency of urination
  • Burning or urgency
  • Hematuria
  • Elevated temperature
  • Flank pain
  • Costovertebral angle tenderness
• Priority nursing diagnosis:
  • Hyperthermia
  • Acute pain
  • Deficient knowledge

Thromboembolic Disorders

• Thromboembolic disorders may occur antepartally but are usually considered a postpartum complication.
• Types of thromboembolic disorders:
  • Superficial thrombophlebitis (more common in the postpartum)
  • Deep vein thrombosis (DVT)
  • Septic pelvic thrombophlebitis
• Septic pelvic thrombophlebitis:
  • Infection ascends upward along the venous system and develops in the uterine, ovarian, or hypogastric veins
  • Usually unresponsive to antibiotics
  • Characterized by abdominal or flank pain, present with guarding
  • Occurs on the 2nd to 3rd postpartal day with fever and tachycardia
  • Intermittent fever and chills may persist### Complications of Thrombophlebitis
• Thrombophlebitis can lead to inflammation, formation of blood clots, and pulmonary embolism
• Pulmonary embolism is a catastrophic event with a high mortality rate, often occurring within 30 minutes
• Contributing factors to pulmonary embolism include:
  • Proximal VT and recurrent thromboembolic disease
  • Increased risk with proximal VT and recurrent thromboembolic disease
• Nursing assessment for pulmonary embolism:
  • Dyspnea and chest pain
  • Diagnosis may be verified by V/Q scan, blood gas studies, or x-ray

Predisposing Factors for Thrombophlebitis

• Obesity
• Increased maternal age
• High parity
• Anesthesia or surgery resulting in vessel trauma or venous stasis
• Prolonged bedrest
• Caesarian birth
• Maternal anemia or diabetes
• Heart disease
• Endometriosis
• Varicosities, injury, or trauma to the leg
• History of deep vein thrombosis
• Cigarette smoking

Nursing Interventions for Thrombophlebitis

• Implementing support hose during labor and postpartum period
• Early ambulation following birth
• Performing regular leg exercises to promote venous return
• Monitoring for signs of pulmonary embolism
• Administering anticoagulant therapy and monitoring for signs of bleeding
• Maintaining bedrest and elevation of legs to decrease venous aching
• Promoting comfort and pain management

Postpartum Psychiatric Disorders

• Postpartum blues:
  • Occurs in 50-70% of mothers
  • Characterized by mild depression, tearfulness, and feelings of overwhelm
  • Resolves spontaneously within 10 days
• Postpartum depression:
  • Develops in 7-30% of postpartum women
  • May occur anytime in the first postpartum year
  • Characterized by feelings of guilt, crying, and overwhelm
  • Treatment includes selective serotonin reuptake inhibitors (SSRIs), individual or group psychotherapy, and practical assistance with child care and daily life
• Postpartum psychosis:
  • Occurs in 1-2 per 1000 births
  • Characterized by severe mental illness, delusions, and hallucinations
  • Requires hospitalization and treatment with antipsychotic medications, sedatives, and electroconvulsive therapy

Types of Psychotherapy

• Cognitive-behavioral therapy (CBT):
  • Helps people identify and change negative thought patterns and behaviors
  • Focuses on current problems and how to solve them
• Interpersonal therapy (IPT):
  • Helps people understand and change underlying interpersonal issues
  • Focuses on improving communication and relationships
• Psychodynamic therapy:
  • Focuses on unconscious thoughts and feelings
  • Helps people understand and change underlying psychological dynamics
• Supportive therapy:
  • Provides guidance and encouragement to help people develop their own resources
  • Focuses on building self-esteem, reducing anxiety, and improving social and community functioning

Risk Factors for Postpartum Psychiatric Disorders

• Previous postpartum psychosis
• History of bipolar disorder
• Prenatal stressors
• Obsessive personality
• Family history of mood disorder
• 10-25% reoccurrence rate in subsequent pregnancies