Postpartum Complications PDF

Chapter 13: Postpartum Complications Care of the Woman with Postpartum Hemorrhage - Leading cause of maternal mortality - Amount of blood lost varies between vaginal and cesarean birth - Normal blood loss is 500mL vaginally and 1,000mL through cesarean - Primary and secondary hemo...

Chapter 13: Postpartum Complications Care of the Woman with Postpartum Hemorrhage - Leading cause of maternal mortality - Amount of blood lost varies between vaginal and cesarean birth - Normal blood loss is 500mL vaginally and 1,000mL through cesarean - Primary and secondary hemorrhage - Primary: Occurs within the first 24 hours - Secondary: Occurs after 24 hours or through 6 weeks postpartum - Subinvolution - Risk Factors: - Retained placenta - Failure to progress during second stage of labor - Placenta accreta - Lacerations - LGA newborns - Instrumental delivery - Hypertension - Induced labor - Augmentation with oxytocin - Overdistention of uterus - BMI over 40 - Mnemonic: 4 T’s of hemorrhage - Tone: (uterine atony) Most common cause. - Muscles fail to contract after delivery of placenta - Remains open, causing hypovolemic shock - Subinvolution: Failure of uterus to follow patterns of normal involution; organ remains large; common cause of late PPH - Tissue: Retained placenta - Most common cause of late PPH - Trauma: Forceps delivery causing lacerations - Thrombosis: Disorder of coagulation and platelets - Fibrin not creating clots over placental site - Signs and Symptoms: - Heavy vaginal bleeding - Constant trickling or oozing of blood - Uterine atony - Passing of blood clots larger than a quarter - Return of lochia rubra - Cool, clammy pale skin - Tachycardia and decreased BP (late due to large blood loss and shock) - Nursing Care: - Collaborative process of health care team - Identify excessive bleeding - Notify rapid response  - Management: - Fundal massage - Support lower segment, measure vitals, assess LOC, and amount of vaginal bleeding - Notify physician/midwife - Weigh peripads and linens to obtain accurate measurement: 1g=1mL - Assess bladder - IV fluids: Isotonic, albumin, packed RBCs (PRBCs) - Monitor oxygen: 2 to 3 L via nasal cannula - Elevate legs: 20-30 degrees - Oxytoxic drugs if ordered - Oxytoxin: Stimulates smooth muscle contractions - Diuretic/vasopressor - Constricts blood vessels and raises BP - May cause water intoxication - Methylergonovine: Directly stimulates uterine and vascular smooth muscle - Not effective in patients with hypocalcemia - Carboprost: Stimulates uterus and GI tract - Last resort: expensive - Bimanual exam - Operating room Care of Woman with a Hematoma - Hematoma: Collection of blood outside blood vessel - Common locations: Vaginal wall and vulvar area - Risk factors: - Episiotomy - Lacerations to genital tract - Instrumental delivery - Nulliparity - Difficult/prolonged second stage of labor - Signs and Symptoms: - Constant pain and pressure - Discoloration and bulging of the tissue.= - Tenderness of the tissue - Feeling of needing to defecate - Inability to urinate - Signs of shock in large hematomas - Medical Management: - Observe peri-area for swelling/discoloration - Report abnormal findings - Apply ice for 2 minutes in hematomas less than 3-5cms - Sitz bath and pain management - Significant blood loss managed as PPH  - Monitor vital signs - Explain treatment/rationale - Greater than 5cm: Drain in OR Care of Woman with Uterine Infection - Also known as endometritis - Risk Factors: - Prolonged labor or rupture of membranes - Internal monitoring - Cesarean delivery - Frequent vaginal infections - Organisms: Usually present in vagina/cervix - Escherichia Coli - Group B Streptococcus (GBS) - Signs and Symptoms: - Temperature at or over 100.4F for 2+ days - Foul-smelling lochia - Lower abdominal tenderness - Medical Management: - Pelvic exam - CBC - Blood cultures - Pelvic ultrasound - Administer IV fluids and antibiotics - Nursing Care: - Administer IV fluids - Administer pain meds and antipyretics - Encourage fluid and foods that boost immune system - Protein, vitamin A, C, & E, and zinc - Explain treatment and rationale - Support with bonding and breastfeeding Care of a Woman with Wound Infection - Can occur in episiotomy incisions, perineal lacerations or cesarean incisions - Signs and Symptoms: - Redness - Warmth - Poor approximation - Tenderness - Pain - Fever and malaise - Medical Management: - Lab & antibiotic - Nursing Care: - Obtaining wound culture - Administration of antibiotics  - Encourage adequate food/fluid intake - Assess pain - Teach hand washing Care of Woman with a UTI - Common due to trauma of childbirth - Foley catheter and prolonged labor are a risk factor - Organisms: Bowel flora - Esherichia Coli, Klebsiella, Proteus, Enterobacter - Signs and Symptoms: - Urgency - Dysuria - Increased frequency - Urination of small amounts - Fever - Flank pain - Hematuria - Medical Management: - Largely based on symptoms - Urine specimen - Oral antibiotics - Nursing Care: - Administer antibiotics - Encourage fluid intake - Teach peri-care: peri-bottle Care of Woman with Mastitis: - Infection of breast tissue - Organism: Staphylococcus aureus - Transmitted from infants mouth or woman’s hands through cracked nipples - Blocked milk ducts/milk stasis - Signs and Symptoms: - Sudden onset - Red swollen area or mass on breast - Fever 100.4F+ - Pain/burning sensation - Malaise - Medical Management: Breast exam, rule out breast abscess, antibiotics and pain relievers - Nursing Care: - Teaching mother to wash hands before feeding - Observing latch-on and teach correct method - Lactation specialist - Encourage regular feedings - Administer antibiotics - Assess pain and administer medications  - Reassurance - Apply warmth to breast - Teaching signs of mastitis - Care of Postpartum Thromboembolic Disease - Thromboembolism: Blood vessel becomes inflamed and thrombus develops - Pregnancy increases risk 4-6x - Highest risk in first 12 weeks - Major Causes: - Venous stasis - Hypercoagulable blood - Injury to endothelial surface of blood vessel - 1:1000 pregnancies and deliveries have complications like DVT or PE - Risk Factors: - Obesity - Prolonged bed rest - Advanced maternal age - Stillbirth - Premature birth - Gestational diabetes - Cesarean delivery - Multiparity - Varicose veins - Smoking - Prevention - Encourage patients to ambulate frequently - Carefully assess legs - Identify woman at high risk - Obtain orders for ted hose/SCDs - Signs and Symptoms - Swelling - Pain or tenderness - Erythema - Pain on ambulation - Stiffness of leg - Large, hard cordlike vein - Diagnosis: Doppler ultrasound, MRI - Medical Management: - IV heparin therapy - Low molecular weight heparin (lovenox) - Ted hose - Bed rest - Analgesics - Moist heat - Nursing Care  - Administer heparin - Monitor INR and PT - Apply ted hose - Maintain bed rest - Measure calf - Administer analgesics - Apply moist heat - Monitor for complications: PE - SOB, chest pain, cough Postpartum Depression - More serious and incapacitating than postpartum blues - Interfere with self-care and care of newborn - Usually develops during the first 4 months of life - High risk: Personal history of depression, lack of social support, stressful events, unintended pregnancy, and financial factors - Signs and Symptoms - Intense sadness with crying; feeling overwhelmed - Feeling moody/irritable - Anxiety/worrying - Feelings of guilt/inadequacy - Ambivalence - Lack of motivation for self-care or infant care - Anhedonia: Lack of pleasure in everyday things - Appetite disturbances - Insomnia - Fatigue - Thought of hurting baby - Suicidal thoughts - Medical Management: Counseling and antidepressant medications - Nursing Care: - Monitor for symptoms of suicidal thought or harming baby - Encourage antidepressant compliance - Encourage follow up appointments - Encourage counseling and community groups - Encourage rest and naps when baby sleeps - Encourage partner to help and locate help or support mother - Encourage verbalization of feelings Postpartum Psychiatric Disorder: - Postpartum psychosis: Severe form of PPD - High Risk: Those with history of bipolar disorder or previous postpartum psychosis episode - Occurs within 48-72 hours - Signs and Symptoms: - Incoherent  - Rapidly shifting mood: Depression - elations - Delusion beliefs related to infant - Hallucination - Nursing Care: - Immediate reporting - Reorienting patient with surroundings - Provide safety - Arrange for admission to psychiatric facility - Provide emotional support