Postpartum DVT, PE, and DIC

DVT Contradiction

• Hormonal birth control is a contradiction for clients with a DVT history.

Pulmonary Embolism

• Tachypnea is a sign of pulmonary embolism.
• Low O2 is a symptoms of pulmonary embolism.
• Chest pain can indicate pulmonary embolism
• Clients with a history of DVT may need close attention due to high suspicion of PE.

DVT/PE Prevention in Postpartum

• Early and frequent ambulation helps prevent DVT/PE in postpartum.

Post C-Section

• Sequential Compression Devices (SCDs) are used for mothers after a C-section before they can walk normally.

Disseminated Intravascular Coagulation (DIC)

• Stands for Disseminated Intravascular Coagulation.
• DIC is a serious condition causing abnormal blood clotting throughout the body's blood vessels.

DIC Findings

• Lab changes
• Oozing from IV sites, lacerations, or the uterus indicate DIC
• Epistaxis (nose bleed) can indicate DIC.

DIC Interventions

• ICU care may be required for mothers experiencing DIC.
• Blood products may be needed for mothers experiencing DIC.

Postpartum Hemorrhage (PPH)

• Early PPH sign: Soaking a pad in 15 minutes.
• Late PPH signs: Hypotension and tachycardia.

Causes of PPH

• Tone issues can cause PPH
• Trauma (unseen lacerations) can cause PPH
• Retained Tissue can cause PPH
• Thrombin (coagulation disorder) related issues can cause PPH

Boggy Uterus

• Massage the uterus until firm is the first step if the uterus feels boggy.
• Do NOT massage if the uterus is already firm.

PPH Examination

• Examine for placental fragments.

Trickle with Firm Uterus

• Cervical or deep vaginal lacerations are likely the cause.

PPH Medications

• Oxytocin is a medication used for PPH.
• Methylergonovine is a medication used for PPH.
• Caroprost is a medication used for PPH.
• Tranexamic acid (TXA) is a medication used for PPH.
• Misoprostol is a medication used for PPH.

Contradictions

• Caroprost is contraindicated for clients with asthma.
• Misoprostol is contraindicated for clients with hypertension (HTN).

Uterine Atony

• Uterine Atony: A soft, boggy, poorly contracted uterus that most commonly causes early PPH

Uterine Atony Distension

• Distension could indicate Macrosomia.
• Distension could indicate Multifetal gestation.

Uterine Atony: Long Labor

• A long labor could indicate a tired uterus.

Subinvolution of the Uterus

• The uterus remains enlarged with continued lochia discharge.
• Subinvolution may result in postpartum hemorrhage.

Postpartum Uterus Progress

• Initially, the uterus is at the umbilicus and decreases 1 fingerbreadth (fb) per day.
• By day 1, it should be 1 fb below the uterus; by day 2 postpartum, 2 fb below; until no longer palpable by 14 days postpartum.

IVF Maintenance

• Maintain, especially if bleeding occurs.
• Stop oxytocin if running.
• Notify the provider if complications arise.
• Do NOT massage or administer uterotonics, as this can worsen the condition.

IVF Important Focus

• Fluid replacement is important.

Retained Placenta

• Bleeding with clots may indicate retained placenta.
• Subinvolution may indicate retained placenta.
• Poor milk supply may indicate retained placenta.
• Ask "Was the placenta intact?" as part of the examination

Retained Placenta Examination

• Examine any expelled clots for fragments of placenta.

Cervical/Deep Vaginal Laceration

• Expect a trickle of bleeding with a firm uterus/normal lochia (trauma).

Laceration/Hematoma Interventions

• Stool softeners
• Splinting sutures on the toilet

Laceration/Hematoma Pain Relief

• Use ice packs to the perineum.
• Apply witch hazel pads.

Laceration/Hematoma Education

• Use a peri bottle.
• Blot instead of wipe.
• Change pads frequently.

Laceration/Hematoma

• Topical anesthetics are typically used.

Hematoma Factors

• Bulge on the perineum
• Usually near a laceration or episiotomy
• Very tender
• May appear eccymotic

4 Ts of PPH

• Tissue: Accreta
• Tone: Macrosomia
• Trauma: Laceration
• Thrombin: Amniotic fluid embolism

Signs/Symptoms of Endometritis

• Fever
• Increasing pelvic/uterine tenderness
• Foul-smelling lochia (like rotten meat)

Endometriosis Medication

• Antibiotics are used.

Endometriosis Nurse Actions

• Ensure breasts are emptied by pumping or nursing to keep up supply and prevent mastitis.

Signs/Symptoms of Mastitis

• Cracked nipples
• Unilateral breast pain
• Pain when nursing
• Red streaks or spots on breast
• Fever
• Malaise

Mastitis Intervention

• Must continue to frequently empty breast by pumping or nursing.

Mastitis Medications

• Antibiotics
• Ibuprofen/Tylenol

Pulmonary Edema Risk

• Prolonged bedrest

Postpartum Infection Intervention

• Assess vital signs every 15 minutes x 1 hour, then every 30 minutes x 1 hour regarding prolonged rupture risk.

Nursing Interventions for UTI

• Peri care
• Changing pad
• Remove foley ASAP

Breastfeeding Intervention

• Provide education: Such as alcohol/substance/medication safety.

Engorgement

• Bilateral, hard, tender, and painful breast.

Engorgement Interventions

• Warm compress
• Well-fitted bra
• Frequent nursing

Breastfeeding Dietary Needs

• Increase fluid intake and calories (about 500/day).
• Avoid dieting, especially early on.

Postpartum Blues vs. Depression

• Postpartum Blues Anxiety: Poor social support, history of PTSD or depression, intense mood swings, rejection of the infant, and severe anxiety and panic attack are signs of postpartum depression; also watch for difficulty sleeping.
• Postpartum Depression Psychosis: Change in hormones lasts a couple of weeks; recognize restlessness and fatigue.

Postpartum Depression Risk Factors

• History of mental illness (especially bipolar).
• Lack of a support system

Assessment for Postpartum Depression

• Ask about thoughts of harming themselves or others.

Postpartum Psychosis Interventions

• Do not leave the mother alone.
• Supervise infant care.

Methylergonovine Contradiction

• Clients with hypertension (HTN)

Carboprost Contradiction

• Clients with asthma and hypertension

Terbutaline action

• To relax the uterus prior to the provider's attempt at replacement of the uterus into the uterine cavity and uterus repositioning.

Clot Buster Medication

• Streptokinase

Oxytocin action

• Promotes uterine contractions and expels the retained fragments of placenta.

Misoprostol action

• Controls postpartum hemorrhage.

Clotting Promoting Medication

• Tranexamic acid (TXA)
• Can treat heavy menstrual periods in women.

Medication Administration Expected Findings

• Decreased bleeding
• Uterus firm

RhoGAM Uses

• To prevent an immune response to Rh positive blood in people with an Rh negative blood type.

BUBBLE HE

• B-Breast
• U-Uterus
• B-Bowel
• B-Bladder
• L-Lochia
• E-Episiotomy
• H-Homan's Sign & hemorrhoids
• E-Education

Uterus Exam Preparation

• Have the client void.

Diastasis Recti

• This is the separation of the rectus abdominis muscle in the midline caused by the abdominal distention.
• A benign condition that can occur in the third trimester.

Uterus Assessment Actions

• Have the client void and reassess.

Postpartum Lightheadedness Actions

• Monitor vital signs and bleeding.
• Assist the client to the bathroom for the first few times.

Respiratory Issues

• Those who Received oxytocin
• Those who received Large amounts of IV fluids
• Those who received Tocolytics such as magnesium sulfate or terbutaline

Postpartum Risk Factors

• Multiple births, infection, or preeclampsia.
• Those who were on bedrest (high risk for pulmonary edema).

Taking-In Phase

• A period of dependent behaviors, occurs during the first 24 to 48 hours after birth.

Taking-Hold Phase

• The movement between dependent and independent behaviors, follows the taking-in phase, and can last weeks.

Letting-Go Phase

• The movement from independence to the new role of mother is fluid and interchangeable with the taking-hold phase

Lesbian Parents

• Research indicates less parental stress than heterosexual couples.

Fathers in Prenatal Care

• Involving fathers in prenatal care increases their involvement in postpartum care.

Sibling Adjustment

• Spending time during the prenatal period talking about the upcoming arrival of a new baby
• Providing opportunities for siblings to feel the baby move and hear the heartbeat during pregnancy
• Providing opportunities for siblings to spend time with their new brother or sister during the hospital stay
• Encouraging siblings to lie in bed with their mother during hospital visits
• Giving siblings a present from their new brother or sister
• Understanding the importance of quality time with other children, such as sitting and reading books with them, playing games, and listening to them
• Taking siblings on a special outing while the infant stays at home with a babysitter
• Explaining why babies cry and how they communicate

Dysfunctional Adjustment Factors

• Disinterest in learning.
• Anxiety/disinterest/feeling inadequate about care for the infant.

Expressions of Inadequacy

• "Tell me more about..." type of questions.

NICU Care

• Pumping
• Bonding
• Care

Bleeding Indications

• Soaking a pad in 1 hour or less and clots are bigger than egg size.

Expected Lochia Changes

• Rubra to serosa, to alba
• Progressively lighter

When to Alert Provider

• Fever over 100.4 F
• Pain in pelvis or perineum (continually getting worse)
• Painful/warm red area on breast
• Foul smelling lochia

Engorgement Management

• Well-fitted bra
• Warm compress
• Frequent feeding

Preeclampsia Symptoms

• Vision changes
• Unrelieved headache
• RUQ pain

Mother Sleep

• Sleep when the baby sleeps.

Resumption of Intercourse

• Bleeding stops
• Perineum healed
• Physically and emotionally ready

Exercise Recommendation

• Can start walking by 2 weeks and build from there.
• Healthy people need 150 minutes per week.

Infection Treatment

• Take medication as prescribed.
• Finish all medications

NFP and BBT

• Natural family planning.
• Basal body temperature
• Daily temperature taken before getting out of bed in the morning.
• Regular cervical mucus checks

Condoms

• Male and female condoms help prevent STIs and pregnancy.
• Use no oil based lubes.
• Single use

Diaphragm

• Per use device, must be fitted and needs Rx, refitted after a birth

IUD

• Can be placed prior to discharge
• Copper and progestin
• Stay in place for 3-10 years depending on type
• No STI protection
• Compatible with breastfeeding

Sterilization Methods

• Vasectomy
• Tubal ligation
• Sterilization implant