Postpartum High Risk - NURS 323

Postpartum High Risk - NURS 323

Learning Outcomes

• Primary causes of postpartum hemorrhage and its pathophysiology are important to describe, including medical care and nursing actions.
• Common postpartum complications require analysis of risk factors, assessment, prevention, and nursing management.
• Primary postpartum infections need an examination of related medical and nursing actions.
• Postpartum psychological complications need describing together with related medical care and nursing actions.
• A comprehensive understanding of gestational diabetes with related medical management and nursing actions is important.

Common Postpartum Complications

• Hemorrhage is a key postpartum complication.
• Venous thromboembolic disease, including DVT and pulmonary embolism, is a risk.
• Postpartum mood disorder is a significant concern.
• Gestational Diabetes postpartum is another potential complication.
• Postpartum care aims to reduce the risk of complications.
• Nursing assessments are essential for identifying potential complications and implementing timely interventions.

Hemorrhage

• Postpartum hemorrhage involves blood loss > 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.
• Hemorrhage is a main cause of maternal death across the world (WHO,2015)
• Bleeding that compromises the patient's hemodynamic stability is defined as hemorrhage.
• Active management during the 3rd stage of labor is important for prevention.
• Hemorrhage occurs in 18% of births and is the most common cause of maternal morbidity in developed countries.

Risk Factors: Postpartum Hemorrhage

• Neonatal macrosomia, with birth weight greater than 4,000 g, is a risk factor.
• Placenta previa or placenta accreta increases risk.
• Polyhydramnios, which involves large amounts of amniotic fluid, is a risk factor.
• Augmented or induced labor can contribute to hemorrhage.
• Ineffective uterine contractions with prolonged first and second stages of labor can cause hemorrhage.
• Previous cesarean sections or operative vaginal delivery increase the risk.
• Multiple gestations or high parity increases the risk due to more frequent uterine stretching.

Pathophysiology of Postpartum Hemorrhage (4 T's)

• Tone (uterine atony) is the main reason for postpartum hemorrhage.
• Tissue (retained placental fragments) can cause hemorrhage.
• Trauma during labor and birth can cause hemorrhage.
• Thrombin disorders: coagulopathy (preexisting or acquired), disseminated intravascular coagulation (DIC) can cause hemorrhage.

Indications of Postpartum Hemorrhage

• A 10% decrease in hemoglobin/hematocrit postpartum can indicate hemorrhage.
• Saturation of peripad within 15 minutes necessitates weighing the pad.
• 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 include large baby, multiples, high parity.
• Prolonged labor, induction of labor, and fever.
• Bleeding may be slow and steady or profuse.
• Large boggy uterus, clots.
• Perform fundal massage for interventions.
• Monitor bleeding by weighing pads (1gm=1mL).
• Monitor vital signs and labs.
• Administer oxygen.

Postpartum Hemorrhage: Tissue

• The causes include retained or abnormal placenta.
• Uterus may not respond to interventions.
• May remain larger-fundus elevated, strings of tissue in the blood.
• Prolonged lochia rubra.
• Provider might do dilation and curettage (D&C).
• Monitor signs of shock.
• Consider oxygen at 10-12 L per mask.

Placenta Accreta

• Abnormal adherence of placenta to myometrium of uterine wall leads to increased postpartum hemorrhage risk.
• Diagnosed typically after birth when the placenta does not separate.
• Antepartum diagnosis is possible via ultrasound and MRI, but delivery diagnosis is more common.
• Risk factors include advanced maternal age, smoking, and previous cesarean birth.
• The placenta penetrates too deep in the uterine wall but does not penetrate the uterine muscle accounting for 75% of cases.
• Approximately 1 in 2,500 pregnancies experience placenta accreta, increta, or percreta.
• Placenta increta occurs when it attaches even deeper with penetration into the uterine muscle and represents 15% of cases.
• Placenta percreta occurs when it penetrates through the entire uterine wall attaching to another organ, like the bladder- only 5% of cases.

Placenta Accreta: Assessment and Management

• Stage 3 labor finds placenta does not deliver.
• Increased risk of postpartum hemorrhage.
• Increased risk of hysterectomy.

Postpartum Hemorrhage: Trauma

• Lacerations may result from birth trauma.
• Firm uterus with continued bleeding is a sign.
• Steady trickle of unclotted, bright red blood is apparent.
• 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 requires emergency management.

Postpartum Hemorrhage: Trauma - Hematoma

• Hematoma occurs in the vular, vaginal, cervical, or retroperitoneal areas.
• Sudden onset of painful perineal pressure, firm uterus, and a bulging area under the skin with difficulty voiding or sitting are signs.
• Assess hematoma.
• Call provider to assess.
• Anticipate possible excision.
• Pain management; include ice pack to perineum.

Postpartum Hemorrhage: Coagulopathies

• Risk factors: Preeclampsia and Stillbirth
• Disseminated intravascular coagulapathy (DIC).
• Oozing from IV sites, bleeding gums.
• Nose bleeds, petechiae.
• Hypotension and signs of shock.
• Abnormal clotting lab values.

Postpartum Hemorrhage: Thrombin disorders.

• Early recognition and prompt interventions are key.
• Confirm blood loss estimates.
• Monitor labs, vital signs and lab values.
• Manage systemically with IV fluids, platelets, Oxygen by mask.
• Venous Thromboembolic is when a blood clot starts in vein.
• Risk factors include oral contraceptives before pregnancy, smoking, and hx of thrombosis.
• Signs and symptoms are calf swelling, erythema, positive Homan's sign.
• Adequate circulation, antiembolism stockings, early ambulation needed, assess lung sounds.
• Education for anticoagulation therapy if indicated/contraindicated
• Oral contraceptives are contraindicated or using anticoagulants, avoid aspirin and ibuprofen as they increase risk for blleding

Postpartum Hemorrhage: Therapeutic Management

• Focus on the underlying cause.
• Uterine massage
• Removal of retained placental fragments is important.
• Antibiotics for infection.
• Repair of lacerations
• Uterine tamponade
• Interventional radiology for ablation
• Hysterectomy is the last resort.

Medications for Postpartum Hemorrhage: Uterotonics

• Oxytocin(Pitocin): All patients postpartum get this hormone. It promotes uterine smooth muscle contractions at 10-20 units IV or 10 units IM; Side effects: nausea, vomiting, monitor vaginal bleeding
• Methylgonovine (Methergine): It is given only postpartum and stimulates uterus for sustained contractions in 02.mg IM or Oral every 2-1 hours for up to 5 doses and can increase HTN; Contraindicated: hypertension, monitor vaginal bleeding with uterine tone
• Misoprostol (Cytotec): causes uterine contractions given when works faster PO rectal 500-1,000 mcg X1 rectal or oral, check vaginal bleeding with uterine tone; Side effects: headache, N/V/D

Medications for Postpartum Hemorrhage: Uterotonics

• Carboprost(Hemabate): synthetic prostaglandins for uterus to avoid potential bronchospasm if you had or have athsma give 250 mcg IM monitor vaginal bleeding and active cardiac and pulmonary issues.
• Tranexamic Acid (TXA): for antifibrinolytic to improve blood clotting inject 1gm in 50-100 ml of fluid over 10 mins, use if other medical intervention is not effective as it may cause hypertension monitor hemodynamics as it causes thromboembolic attacks

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).
• Endometritis is an infection of endometrium, decidua, and adjacent myometrium.
• Wound infections occur in the episiotomy, lacerations, and C-section wounds.
• Urinary tract infections are due to fully catheter.
• Mastitis: inflammation of the breast

Postpartum Infection: Continued

• Broad-spectrum antibiotics are the therapeutic management for metritis.
• Wound care also needs to be done.
• Fluids and antibiotics used for UTIs.
• Breast emptying and antibiotics for mastitis.
• Surgical birth, PROM, long labor, multiple vaginal exams increase 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, and acute pain

Infection: Nursing actions

• Hand hygiene
• Educate correct peri care and frequent change of peri pads can decrease risk for endometritis
• Ensure breasts have proper latch for neonate to prevent cracked/sore nipples.
• Frequent breast feeding to improve mastitis.
• Educate signs/symptoms of infection and prevention.
• Wound care, educate how to assess for infection.
• Increase fluids, and protein in diet.
• Administer antibiotics as ordered.

Postpartum Mood Disorders

• Postpartum or baby blues occurs in 50-80 % first few days after birth up to 10 days postpartum. It's indicated by symptoms of Tearfulness, irritability, sadness, fatigue, feeling overwhelmed; is self limiting, resolves with sleep, increased risk for postpartum depression
• Postpartum depression occurs within 6 months following birth, 10-15% new mothers; It's not self-limiting, usually requires interventions with sypmtoms of persistent sad feelings, intense mood swings and withdrawal
• Postpartum psychosis develops within first 3 weeks for emergency psychiatric patients is important needed, Symptoms of hallucinations, hypomania, sleep disturbance, severe depression

Postpartum Depression

• Nursing assessment for screening of depression during pregnancy and postpartum.
• It is important to recognize signs/symptoms with Edinburgh postnatal depression scale (self report).
• Assistance with coping and adjustment is needed for Nursing management.
• Education should include discharge.
• Referrals for support.

Management of Pregnancy Complications (Postpartum Diabetes)

• Glycemic control and follow-up after delivery.
• Encourage to return for 6 week glucose screening.
• Nursing actions and client education with counseling.
• Women with GDM have up to 50% increase risk for developing Type 2 Diabetes within 10 to 20 years (CDC, 2019).

Women Who Become Pregnant and Have IDD

• More women with disabilities wanting to become pregnant is increasing.
• Ensuring adequate health care
• Health care workers lack confidence in treating women with disabilities and multiple studies have shown health practitioners were improperly trained to take physical disabilities, WWPD, to care .
• Barriers cause women with disabilities, WWPD to need support to make sure they receive necessary OB care.
• Suboptimal health is a risk concern among women with women w/physical disabilities, WWPD, who are at a higher risk
• Early and preterm labor may be risks.
• Pre-eclampsia and autonomic dysreflexia are also risks.
• Baby may have low birthweight.
• Lack of data may put pregnant women at risk

Case Study and Key Points:

• Post birth hemorrhage, bleeding should be assessed first and massaged .
• Always first assess patients with the lowest B/P.
• Avoid giving Methergine to a patient with Hypertension to prevent blood vessel complications.
• Uterine massage, IV fluids, medication and oxygen can manage hemorrhage.
• Contradicting patient in hallway without full vitals and or medical assessment.
• Key interventions are to ensure they receive necessary care.

Summary

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