Postpartum Complications: Mastitis

• Postpartum complications include mastitis and thromboembolic disorders.
• Student nurses should be able to define postpartum complications at risk for common deviations from the normal during the puerperium, including pre-existing factors.
• Student nurses should be able to integrate knowledge of postpartum complications. at risk for common deviations from the normal during the puerperium and formulate nursing care plans to give quality maternal and child health nursing care.

Mastitis

• Breast connective tissue infection primarily in lactating women, usually caused by S. aureus, E. coli, Streptococcus species, and Candida albicans.
• Can occur as early as the seventh postpartum day or weeks/months later.
• Organisms causing mastitis originate from the infant's nasal-oral cavity.
• Breast milk is a good bacterial growth medium.
• Epidemic mastitis/breast abscess occurs when the infant transmits organisms into milk ducts through sucking.
• S. aureus, Methicillin-resistant S. Aureus (MRSA) or Candidiasis is usually acquired in the hospital.
• Predisposing factors include traumatized/fissured/cracked nipples, engorgement, milk stasis, poor milk drainage, missed feedings, lowered maternal defenses (stress/fatigue), poor hygiene, tight clothing, or poor support of pendulous breasts.
• Enlarged or tender axillary lymph nodes, flu-like symptoms, and generalized fever can occur.
• C & S of breast milk is performed; infection is usually not transmitted to breastmilk.
• Administer antibiotics, analgesics, antipyretics, and promote comfort with a well-fitting support bra worn 24 hours a day.
• Adequate nutrition, hydration, rest and sleep, good handwashing, and continued breastfeeding are recommended.
• Assess vital signs and educate about proper breast care, latch-on, let-down reflex, breastfeeding necessity, & signs of complications.
• Change infant's position during feeding to relieve nipple pressure and prevent milk stasis through frequent breastfeeding.
• Preventative measures include proper baby positioning/grasping, releasing the nipple grasp correctly, hand washing, exposing nipples to air, using vitamin E ointment, breastfeeding on the unaffected nipple first if one nipple is cracked.

Thrombophlebitis

• Inflammation of a blood vessel lining with blood clot formation, often extending from an endometrial infection.
• Contributing factors are elevated fibrinogen levels, dilated lower extremity veins due to fetal head pressure, and sluggish blood circulation.
• Occurs most often in women who are inactive in labor/early puerperium, spend prolonged time in a birthing room with legs in stirrups, have pre-existing obesity/excessive weight gain, varicose veins, postpartal infection, history of thrombophlebitis, are older than 35/ multiparous, have a family history, or smoke (nicotine-induced vasoconstriction).

Superficial Thrombophlebitis

• Symptoms appear on the 3rd or 4th postpartum day.
• Tenderness occurs in a portion of the vein.
• Local heat, redness, and low-grade fever are present, but pulmonary embolism is rare, and management includes early ambulation.
• Following CS, patients are encouraged to perform leg exercises to promote venous return, monitor for pulmonary embolism and bleeding signs from heparin/Coumadin therapy.
• Keep protamine sulfate (heparin antagonist) and Vitamin K (Coumadin antagonist) available.
• Further management involves warm, moist soaks, leg elevation, bedrest, avoiding prolonged sitting/standing/leg crossing, support stockings, increased fluids, serial leg measurements, rest/sleep, leg elevation, and non-aspirin analgesics.

Femoral Thrombophlebitis

• Occurs in femoral, saphenous, or popliteal veins.
• Accompanied by arterial spasm, diminishing leg arterial circulation, called milk leg/Phlegmasia Alba Dolens.
• Unilateral symptoms: redness, swelling, warmth, hard inflamed vessels and Homan's sign.
• A negative Homan’s sign does NOT rule out obstruction, so Doppler ultrasound or contrast venography is needed to confirm a diagnosis.
• Manage with anticoagulants (heparin initially, then SQ heparin/oral warfarin), discontinuing breastfeeding, moist heat application, bed rest with leg elevation, never massaging the clotted area (risk of embolism).
• Assess for bleeding, which presents with Lochia serosa, bleeding gums, ecchymotic spots, and oozing at the suture line.
• High-risk women might also be prescribed aspirin as needed.

Pelvic Thrombophlebitis

• Ovarian, uterine, or hypogastric veins are involved, usually following a mild endometritis.
• It occurs later than femoral thrombophlebitis, around the 14th or 15th day postpartum.
• Prevent with good aseptic technique during and after birth.
• Symptoms include high fever, chills, abdominal pain, weakness, general malaise, ultrasound of the affected leg, and potential pelvic abscesses if vein necrosis occurs.
• Severe cases may lead to lung, kidney, or heart valve abscesses.
• Manage with rest, analgesics, antibiotics, anticoagulants, laparotomy if an abscess forms, teaching preventive measures, non-constricting clothing, rest with feet elevated, ambulation, and cautioning about future pregnancies given pelvic thrombophlebitis history.

Septic Pelvic Thrombophlebitis

• Develops with infections of the reproductive tract that predisposes women to pulmonary embolism.
• Infection ascends along the venous system, and thrombophlebitis develops in the uterine, ovarian, or hypogastric veins, and is usually unresponsive to antibiotics.
• Characterized by abdominal or flank pain with guarding.
• It occurs on the 2nd to 3rd postpartum day, with fever and tachycardia, intermittent fever and chills, and potential for pulmonary embolism.

Pulmonary Embolus

• Obstruction of the pulmonary artery by a blood clot.
• A complication of thrombophlebitis.
• Signs include sudden, sharp chest pain, tachypnea, tachycardia, orthopnea, and cyanosis.
• Manage with O2 therapy immediately, close care for cardiopulmonary arrest, with the clot either lysing or adhering to artery walls and is reabsorbed.

Postpartum Blues

• Affects some women during the first 10 days postpartum.
• Feelings of sadness are related to anticlimactic feelings after birth and hormonal shifts (E/P and GnRH levels).

Postpartum Depression

• Occurs in 20% of women and is more serious than baby blues, with symptoms lasting longer than 1 year.
• Symptoms include overwhelming sadness, extreme fatigue, inability to stop crying, increased anxiety about her own or her infant's health, insecurity, psychosomatic symptoms (N/V, diarrhea), and depressive/manic mood fluctuations.
• Risk factors include a history of depression, troubled childhood, low self-esteem, stress at home/work, lack of support, different expectations between partners, and disappointment in the child.
• Manage through problem discovery, observation, discussion, counseling, and possible antidepressant therapy.

Postpartal Psychosis

• Affects 1 in 500 women.
• Symptoms include exceptional sadness, lost contact with reality, denying the child, and thoughts of infanticide.
• It requires psychiatric counseling and antipsychotic medication.