Postpartum High Risk: NURS 323

Postpartum High Risk: NURS 323

• All women should be assessed in the postpartum period
• Not all women experience postpartum complications but postpartum care is to reduce risk
• Nursing assessments identify potential complications and respond with prompt interventions

Learning Outcomes

• Understand primary causes of postpartum hemorrhage, the underlying pathophysiology, related medical care and nursing actions
• Analyze the risk factors, assessment, prevention management and nursing management of common postpartum complications
• Examine the primary postpartum infection and the related medical and nursing actions
• Describe the primary postpartum psychological complications and the related medical care and nursing actions
• Understand of knowledge related to gestational diabetes, related medical management and nursing actions

Common Postpartum Complications

• Hemorrhage is possible
  • Venous Thromboembolic disease: DVT, Pulmonary Embolism
• Infection is possible
• Postpartum mood disorder can occur
• Gestational Diabetes may appear

Hemorrhage

• It is defined as blood loss of > 500 ml for vaginal delivery and > 1000 ml after a cesarean section
• Early postpartum hemorrhage occurs within 24 hours after birth
• Late postpartum hemorrhage occurs 24 hours to 6 weeks after birth
• Common causes include large babies, multiples, high parity, prolonged labor
• Leading cause of maternal death globally according to WHO, 2015
• Any amount of bleeding that places the mother in hemodynamic jeopardy
• Active management during the 3rd stage of labor with placenta delivery, is key
• Hemorrhage occurs in 18% of births and is the most common maternal morbidity in developed countries

Risk Factors for Postpartum Hemorrhage

• Neonatal macrosomia: birth weight greater than 4,000 g
• Placenta previa or placenta accreta can cause hemorrhaging
• Multiple gestations/high parity causes more frequent uterine stretching
• Polyhydramnios is also a risk
• Augmented or induced labor is a risk
• Ineffective uterine contractions- prolonged first and second stage of labor tires out uterine muscles
• Precipitous labor and/or birth-Fast and intense contractions in a short time weakens muscles
• Previous cesarean sections/operative vaginal delivery is a risk

Pathophysiology of Postpartum Hemorrhage: "The 4 T's"

• Tone: uterine atony Is the most common reason for increased bleeding
• Tissue: retained placental fragments
• Trauma: during labor and birth
• Thrombin disorders: coagulopathy (preexisting or acquired), disseminated intravascular coagulation (DIC)

Indications of Postpartum Hemorrhage

• A 10% decrease in hemoglobin/hematocrit postpartum
• Saturation of peri pad within 15 minutes
  • Weigh pad to measure blood loss
• Fundus remains boggy after fundal massage
• Tachycardia (late sign) compensates for hypotension
• Decrease in blood pressure (late sign) indicates hypovolemia

Postpartum Hemorrhage: Tone: Uterine Atony

• Causes:
  • Large baby, multiples, high parity
  • Prolonged labor, induction of labor, fever
• Signs/symptoms:
  • Bleeding may be slow and steady or perfuse
  • Large boggy uterus, clots
• Nursing actions:
  • Fundal massage is action
  • Monitor bleeding-wigh pads (1gm=1mL)
  • Monitor vital signs and labs
  • Administer oxygen

Postpartum Hemorrhage: Tissue

• Causes: retained or abnormal placenta
• Signs/symptoms: in addition to the other signs and symptoms
  • Uterus may not respond to interventions
  • May remain larger and have a fundus elevated with strings of tissue in the blood
  • Prolonged lochia rubra
• Nursing actions:
  • Call provider to assess: may need dilation and curettage (D&C)
  • Monitor signs of shock
  • Consider oxygen 10-12 L per mask

Placenta Accreta

• Abnormal adherence of placenta to myometrium leads to increased risk for postpartum hemorrhage and hysterectomy
  • The uterine wall is affected
• Diagnosis: typically after birth if placenta does not separate
• Can be diagnosed antepartum with ultrasound and MRI, but usually diagnosed at delivery
• Approximately 1 in 2,500 pregnancies experience placenta accreta, increta or percreta
• Risk factors include advanced maternal age, smoking, prior cesarean birth

Types of Accretas

• Accreta
  • Placenta attaches too deep in the uterine wall but does not penetrate the uterine muscle
  • Accounts for approximately 75% of all cases
• Increta
  • Placenta attaches even deeper into the uterine wall and does penetrate into the uterine muscle
  • Accounts for approximately 15% of all cases
• Percreta
  • Placenta penetrates through the entire uterine wall and attaches to another organ such as the bladder
  • Least common of the three conditions, accounting for approximately 5% of all cases

Postpartum Hemorrhage: Trauma

• Lacerations may result from birth trauma
  • Firm uterus with continued bleeding
  • Steady trickle of unclotted, bright red blood - fresh blood, not from uterus
• Nursing actions:
  • Call provider to evaluate, locate, and repair laceration
  • Monitor vital signs and lochia
  • Weigh pads and underpads to monitor blood loss
• Inversion of the uterus is an emergency that requires key management

Postpartum Hemorrhage: Trauma - Hematoma

• Signs/symptoms
  • Firm uterus, Sudden onset of painful perineal pressure, blood pooling
  • Bulging area just under skin, difficulty voiding or sitting
• Nursing actions
  • Assess visible hematoma
  • Call provider to assess
  • Monitor vital signs
  • Anticipate possible excision
  • Provide pain management; include ice pack to perineum

Postpartum Hemorrhage: Coagulopathies

• Risk factors; preeclampsia, stillbirth
• Signs/symptoms: Disseminated intravascular coagulopathy (DIC)
  • Oozing from IV sites, bleeding gums
  • Nose bleeds, petechiae
  • Hypotension and signs of shock
  • Abnormal clotting lab values

Postpartum Hemorrhage: Thrombin Disorders

• Nursing actions include early recognition and prompt interventions
  • Confirm blood loss estimates
  • Monitor labs, vital signs and lab values
• Manage systemic issues with fluid, platelets, oxygen
• Venous Thromboembolic refers to blood clot that starts in vein
  • Risk factors: oral contraceptives before pregnancy, smoking, history of thrombosis
  • Signs and symptoms: calf swelling, erythema, positive Homan's sign
• Nursing actions: Prevention is key
  • Adequate circulation, antiembolism stockings, early ambulation, assess lung sounds
  • Education for anticoagulation therapy if indicated
  • Oral contraceptives are contraindicated, also avoid aspirin and ibuprofen if taking anticoagulants

Postpartum Hemorrhage: Therapeutic Management

• Focus on underlying cause
• Uterine massage is a useful intervention
• Removal of retained placental fragments
• Antibiotics for a suspected infection
• Repair of lacerations if present
• Uterine tamponade
• Interventional radiology for ablation
• Last resort: hysterectomy

Medications for Postpartum Hemorrhage: Uterotonics

• Given to all patients during postpartum
• Oxytocin (Pitocin) Classification: hormone/oxytocic
  • Action: promotes uterine smooth muscle contractions
  • Route/dose: 10-20 units IV or 10 units IM
  • Never administer as bolus IV undiluted
  • Side effects: nausea, vomiting, water intoxication
  • Monitor: vaginal bleeding and uterine tone
• Methylgonovine (Methergine): oxytocic/ergot alkaloids
  • Action: Direct stimulation smooth muscles uterus-sustained uterine contractions
  • Given only during postpartum
  • Potent contractions
  • Route/dose: 0.2mg IM or Oral 0.2 m every g IM every 2-1 hours for up to 5 doses -Monitor vaginal bleeding and uterine tone
  • Contraindications: hypertension, could increase HTN
• Misoprostol (Cytotec): Classification antiulcer/prostaglandins
  • Action: causes uterine contractions and helps it contract down
  • Route/dose: PO rectal 500-1,000 mcg X1 rectal or oral and works faster
  • Side effects: headache, N/V/D
  • Monitor vaginal bleeding and uterine tone
• Carboprost (Hemabate): Classification: synthetic prostaglandins
  • Action: Controls postpartum hemorrhage due to uterine atony, avoid if asthma, potential bronchospasm
  • Route/dose: 250 mcg IM or intrauterine injection
  • Contraindications: Asthma, active cardiac, pulmonary or hepatic disease
  • Monitor: vaginal bleeding and uterine tone
• Tranexamic Acid (TXA): Classification antifibrinolytic agent
  • Action: antifibrinolytic- improve blood clotting
  • Route/Dose: 1 gm slow IV injection or diluted in 50-100 ml IV fluid and administer over 10 minutes
  • Used if other medical interventions not effective
  • Side effects: hypotension and anaphylaxis
  • Monitor: hemodynamics and thromboembolic events

Postpartum Infections

• Fever >38°C or 100.4°F after first 24 hours may be due to dehydration
• Organisms usually those of normal vaginal flora (aerobic and anaerobic)
• Infections to be aware of: endometritis infection of endometrium, decidua, and adjacent myometrium
• Wound infections: episiotomy, lacerations, C-Section wounds
• Urinary tract infections due to post catherization
• Mastitis: inflammation of the breast

Postpartum Infection Continued

• Therapeutic management includes broad-spectrum antibiotics for metritis
• Wound care for wound infections is very important
• Give fluids and antibiotics for UTIs
• Empty breasts and give antibiotics for mastitis
• Nursing assessment includes knowing the risk factors: surgical birth, PROM, long labor, multiple vaginal exam
• Signs and symptoms: Increased temp, Uterine tenderness, Foul smelling lochia, Breasts: reddened and/or palpable mass, acute pain

Infection: Nursing Actions

• Hand hygiene
• Educate correct peri care and frequent change of peri pads can decrease risk for endometritis
• Proper breast latch for neonate to prevent cracked/sore nipples
• Frequent breast feeding can improve mastitis and may minimize stress
• Educate the patients own signs/symptoms of infection
• Wound care, educate how to assess for infection
• Increase fluids and protein in the diet
• Administer antibiotics as ordered

Postpartum Mood Disorders

• Postpartum or baby blues
  • Occurs 50-80% first few days after birth up to 10 days postpartum
  • Tearfulness, irritability, sadness, fatigue, feeling overwhelmed
  • Self limiting, resolves with sleep, increased risk for postpartum depression
• Postpartum depression
  • Occurs within 6 months following birth, 10-15% new mothers
  • Not self limiting, usually requires interventions
  • Persistent feelings of sadness, intense mood swings, withdraw from family and friends
• Postpartum psychosis
  • Develops within first 3 weeks postpartum
  • Emergency psychiatric interventions needed
  • Hallucinations, hypomania, sleep disturbance, severe depression

Postpartum Depression: Nursing Interventions

• Nursing assessment
• Screening for depression during pregnancy and postpartum is recommended
• Recognize signs/symptoms using the screening tool
  • Edinburgh postnatal depression scale (self report)
• Nursing management includes, assistance with coping and adjustment
• Educate about childbirth classes and what to expect
• Referrals for support are available

Management of Pregnancy Complications

• Postpartum Diabetes
• Glycemic control and follow-up after delivery
• Nursing actions includes to encourage a return for the 6 week glucose screening
• Client education and counseling can help with adjustment
• Women with GDM have up to 50% increase risk of developing Type 2 Diabetes within 10 to 20 years (CDC, 2019)

Women with Disabilities

• More recently, an increased number of women with disabilities want to become pregnant
• Adequate health care is essential for these women throughout their pregnancy
• Studies have shown that healthcare professionals are not properly trained to treat women with physical disabilities (WWPD)
• Healthcare workers lack confidence in treating women with disabilities, resulting in negative clinical encounters.
• Women with disabilities are be less likely to seek out necessary care from an Ob-Gyn or midwife during the prenatal and postnatal period
• Woman with IDD may need significant support with feeding skills, and other care related to the health and safety of the baby in the first days of life

Considerations for Women with Disabilities

• Suboptimal health-seeking behavior is a serious concern as WWPD are at a higher risk for caesarean section and adverse pregnancy outcomes
  • Increased risks for early labor
  • Increased risks for preterm birth
  • Increased risks for pre-eclampsia
  • Increased risks for autonomic dysreflexia
  • Increased risks for offspring with low brithweight
• Lack of knowledge about pregnancy in women with ID and barriers such as health care provider's attitude towards disability puts the pregnant woman at higher risk for complications of pregnancy
• Needs of women with IDD in pregnancy are quite varied and differ depending on the reason for the physical disability e.g. women with spinal cord injuries are at risk for autonomic dysreflexia and wheelchair accessibility, and may be be at increased risk of bladder infection.

Case Study: Postpartum Hemorrhage

• AW is 34 year old G4P4; delivered a female vaginally two hours ago
  • Baby weighed 8 pounds
  • Baby had Apgars of 8 and 9
  • Patient has a history of hypertension by is otherwise healthy
• The patient has yet to void, and the nurse begins 2 hour check with assistance
• Vitals: Pulse 100, BP 100/68, RR 20, T 98.9
• Nurse should assess fundus

Assessments related to Postpartum Hemorrhage

• Nurse should determine if fundis is palpable 2 cm above the umbilicus and deviated to the right side
• Fundus should not be firm
• A large amount of vaginal bleeding and clots are noted saturating the obstetric pad
• To alleviate the issue in this scenario
  • Massage fundus
  • Assess lochia
  • Weigh pads

Medications for Postpartum

• Massage of fundus can lead to boggy issue so a provider may order medication for that situation
• In this case the use of Methylgonovine(Methergine) is not appropriate because the mother has hypertension
• Nurse should question the order based on the diagnosis

Nursing Interventions to Manage Postpartum Hemorrhage

• Uterine Massage is appropriate
• Administration of IV fluids is appropriate
• Weighing peri-pads is appropriate
• oxygenation is appropriate intervention
• Applying surprapubic pressure is not
• Administering tocolytic medications is not appropriate
• Emptying of patient's bladder is appropriate
• Ambulating patient in hallway is not appropriate

Summary

• The most common cause of severe maternal morbidity and mortality postpartum are preventable
• Most complications occur after discharge, yet only 60% of women receive follow-up care
• Nurses have a key role in prevention, early identification, and follow-up postpartum