Postpartum Hematoma - Nursing Care Management

• Nursing Care Management 109 focuses on care for mother and child at risk.
• Students will learn to discuss the signs and symptoms of postpartum hematoma.
• Students will Identify nursing care management for infections in the puerperium stage.
• Students will Identify different psychological challenges of mothers postpartum.

Post-partum Hematoma

• It involves localized collections of blood in loose connective tissue beneath the skin, covering external genitalia, vaginal mucosa, or broad ligaments.
• It can occur without laceration of the overlying tissue.

Pathophysiology and Etiology

• Trauma during spontaneous labor can cause post-partum hematoma.
• Trauma during operative vaginal delivery can cause post-partum hematoma.
• Inadequate suturing of an episiotomy can cause post-partum hematoma.
• Delayed homeostasis of difficult or prolonged second stage of labor, or both can cause post-partum hematoma.

Clinical Manifestations

• Complaints of pressure and pain are clinical manifestations of post-partum hematoma.
• Pain may be verbalized as excruciating.
• Discolored skin that is tight, full feeling and painful to touch is a clinical manifestation of post-partum hematoma.
• Possible decrease in BP, tachycardia can result from post-partum hematoma.
• There can be a decrease or absence of lochia flow with post-partum hematoma.

Management and Complications

• Small hematomas (<3cm) are left to resolve on their own with ice packs.
• Large hematomas (>3cm) may require evacuation of the blood and ligation of the bleeding vessel.
• Analgesics and broad-spectrum antibiotics may be ordered due to increased chance of infection.
• Hypovolemic shock from extreme blood loss is a complication of post-partum hematoma.
• Anemia and infection are complications of post-partum hematoma.
• Potential complications include increased length of postpartum recovery period, calcification and scar tissue, and dyspareunia (painful intercourse).

Nursing Interventions

• Inspect perineal and vulvar area for signs of hematoma periodically postpartum.
• Inspect the vaginal area for signs of hematoma if woman is unable to void.
• Monitor vital signs periodically and evaluate for signs of shock.
• Pain can be relieved from hematomas with: applying ice bag to perineal area, medicating with mild analgesics, and positioning for comfort to decrease pressure on the affected area.
• Catheterize the patient if unable to void.
• Teach the woman the importance of eating a balanced diet and to include food rich in protein and vitamin C.

Post-Partum Infections

• Endometritis is a type of peurperal infection.
• Wound Dehiscence is a type of peurperal infection.
• Mastitis is a type of peurperal infection.
• UTI is a type of peurperal infection.
• Septic pelvic thrombophelibitis is a type of puerperal infection.

Endometritis

• It is the most common site of infection is the uterine endometrium during the immediate postpartum period.
• Presents with a temperature elevation over 101°F (38.4°C), often within the first 24 to 48 hours after childbirth.
• There is uterine tenderness and foul-smelling lochia.
• Urinary tract infections can occur during any part of the pregnancy and puerperium.
• Other infections are more likely to occur following discharge from the hospital.

Mastitis

• It is usually unilateral and develops after the flow of milk has been established.
• The most common causative organism is Staphylococcus aureus, introduced from the infant's mouth through a fissure in the nipple.
• The infection involves the ductal system, causing inflammatory edema, enlarged axillary lymph nodes, and breast engorgement with obstruction of milk.
• Without treatment, mastitis may progress to a breast abscess.
• Symptoms include fever, malaise and localized breast tenderness.
• Management centers on antibiotic therapy (e.g., cephalosporins and vancomycin), application of heat or cold to the breasts, hydration, and analgesics.
• Lactation can be maintained through emptying the breasts every 2 to 4 hours by breastfeeding, manual expression, or breast pump.
• Nursing care includes teaching the breastfeeding mother about signs of mastitis and strategies to prevent cracked nipples.

Wound

• The surgical incision requires ongoing nursing assessment after a cesarean birth.
• The nurse should assess for approximation of the wound edges, and make note of any redness, discoloration, warmth, edema, unusual tenderness, or drainage.
• Surrounding tissue should be carefully evaluated for any reactions to the tape securing the dressing, if a dry sterile dressing has been applied.

Urinary Tract Infections (UTIs)

• Risk factors include: Catheterization, multiple vaginal exams, poor postpartum hygiene, genital tract trauma, epidural anesthesia, PROM, and a history of UTIs during pregnancy.

Septic Pelvic Thrombophlebitis

• It is an extremely rare condition that occurs after delievery when an infected blood clot, or thrombus, causes inflammation in the pelvic vein, or phlebitis.
• About one in every 3,000 women will develop septic pelvic vein thrombophlebitis after delivery of their baby.
• Symptoms usually occur within a week after giving birth.
• The most common symptoms are: Fever, chills, abdominal pain or tenderness, flank or back pain, a "ropelike" mass in the abdomen, nausea and vomiting.
• The fever will persist even when taking antibiotics.

HIV Considerations

• Women who have HIV or AIDS require special precautionary care during the puerperium.
• All personnel who come in close contact with the patient should wear latex gloves (unless the patient has a latex allergy).
• Nonlatex gloves and safety glasses prevent the transmission of blood and body fluids, if the patient has a latex allergy.
• Patients need to avoid contact of personal body fluids with the infant's mucous membranes and open skin lesions.
• Breastfeeding is not advised due to the risk of transmission of HIV to the infant.

Emotional Adjustment

• Many mothers experience a roller coaster of emotions after childbirth, influenced by expectations about the childbirth experience.
• Factors like a complicated birth, premature birth, sick infant, parity, age, marital status, and financial stability shape postpartum emotions.
• The first 3 months after birth are the most vulnerable emotional period for mothers.
• Insecurity about infant care, constant demands, sleep deprivation, and minimal social support can cause mood changes.
• Rapid hormonal changes in the first few postpartal days and weeks may give rise to mood disorders.
• The most common of these is "the blues.".
• Puerperal mood disorders include postpartum depression and postpartum psychosis.
• "Maternity blues" are a normal reaction to the dramatic changes after childbirth, including hormone withdrawal.

Emotional Symptoms

• Symptoms include: tearfulness, mood swings, insomnia, fatigue, anxiety, difficulty concentrating, irritability, and poor appetite.
• Symptoms usually begin during the first few postpartal days, peak on the fifth day, and then subside over the next several days. Blues do not affect the woman's ability to care for herself or her newborn and family.

"Blues" Interventions

• The “blues” are treated with support and reassurance.
• Proactive education to prepare the woman and her family for the possibility of postpartum blues is important.
• The nurse needs to explore what resources the new mother will have available when she goes home.
• The discussion should focus on whether the patient has adequate food, clothing, shelter, and transportation, and whether there are relational concerns that need to be addressed before discharge.
• Community resources such as the woman's church, a Mother's Day Out group, a hobby club, or La Leche League can help the new mother realize she is not alone in the experience of nurturing a newborn, while also caring for herself and her family.
• Referral to a health care provider is appropriate for women whose symptoms persist for more than ten days, as this pattern is suggestive of postpartum depression.
• Eight to 15% of postpartal women progress to postpartum depression (PPD).
• A diagnosis of depression requires that one of two symptoms exist most or all of the day: a depressed mood or decreased interest/pleasure in previously enjoyable activities.

Risk Factors of PPD, Nurses Role, & Nursing Diagnoses

• Risk factors include: undesired/unplanned pregnancy, a history of depression, recent major life changes such as the death of a family member or moving to a new community, lack of family or social support, financial stress, marital discord, adolescent age, and homelessness.
• Extreme change in appetite, fatigue, sleeplessness, irritability, brain fog, and excessive worry are symptoms of male postpartum depression.
• The postpartum nurse needs to be aware of risk factors in order to recognize PPD.
• Risk factors that increase the risk for PPD include: a personal history of a mood disorder or a family history of a mood disorder, mood or anxiety symptoms during the prenatal period, and postpartum blues.
• The nurse should carefully assess the new mother's interaction with the baby, and note other risk factors.
• Such risk factors include: unmet pregnancy or labor and birth expectations resulting in feelings of failure, a delay in a prolonged sleep and rest period, and a demanding newborn without the presence of family members to help.
• Nurses responsibility includes recognizing a continued dependency on caregivers, or if the new mother does not respond to her infant's needs or demonstrate bonding or attachment behaviors.
• The hospital nurse's primary responsibility is to detect comments or behaviors that need to be referred to the social worker, home health nurse, physician, chaplain, lactation consultant, and community agencies.
• If a home health nurse does not visit the newborn and mother within the first week, the well baby checkup that follows 1 to 2 weeks after the hospital discharge may offer the first opportunity to assess the mother-baby dyad.
• The nurse needs to be alert for subtle cues from the new mother: comments about the baby or herself, ignoring the baby's or other children's needs, as well as the mother's physical appearance.
• Nurses should ask questions like: Does she look unkempt or exhausted? Is the baby clean and dry? Does the new mother say something about needing more help at home? Did she come to the office or clinic with the baby (and other children) or by herself?
• In a private area nurses should open up with statements, like: "Tell me how the first few days at home have gone.".
• Nonverbal cues and body language, such as affect, eye contact, and open or closed posture are important to pay attention to.
• Several depression screening tools are available if the nurse believes the new mother is demonstrating signs and symptoms of PPD.
• Possible Nursing Diagnoses for Postpartum Depression: Ineffective coping, compromised family coping, anxiety, impaired parent/infant attachment, impaired parenting, hopelessness, impaired sleep pattern, situational low self-esteem, compromised family coping, and injury to the newborn. Common medications used to treat PPD include: Fluoxetine (Prozac), Venlafaxine (Effexor), and Pamelor (Nortriptyline) among others.

Psychosis

• Postpartum psychosis is a rare but severe form of mental illness that seriously affects not only the new mother but also the entire family and involves 1 to 4 women per 1000 births.
• Postpartum women have a 10 to 15 times greater risk of psychosis. than they do at any other time in their lives.
• It occurs in the first 24 to 48 hours following birth, within first 8 postpartum weeks.
• Women with preexisting psychosis, especially bipolar disorder, are at the greatest risk for postpartum psychosis.
• Postpartum psychosis may present with symptoms of PPD.
• However, the distinguishing signs of psychosis are hallucinations, delusions, agitation, confusion, disorientation, sleep disturbances, suicidal and homicidal thoughts, and a loss of touch with reality.
• This condition may also resemble a sudden manic attack.
• Mothers require constant supervision when taking care of their child, since they may be preoccupied.