High Risk Postpartum STUDENT PDF

The Patient at Risk in Post Partum Sarah Wooldridge, MSN, RN Modified from C. Whitaker, MSN, RN, IBCLC, CCE; K. Baisch MSN, APRN; & Krista Roach MSN, FNP-C,...

The Patient at Risk in Post Partum Sarah Wooldridge, MSN, RN Modified from C. Whitaker, MSN, RN, IBCLC, CCE; K. Baisch MSN, APRN; & Krista Roach MSN, FNP-C, WHNP-BC Objectives:  Describe care of the patient with pre-eclampsia, diabetes, and cardiac disease during the post partum period  Identify conditions which put a patient at increased risk for bleeding during the post partum period  Describe causes of early post partum bleeding  Identify appropriate nursing assessment techniques to be used in the event of early postpartum bleeding and related nursing interventions  List commonly used pharmacological interventions for bleeding and needed nursing assessments and interventions when these drugs are administered  Identify situations which put a patient at increased risk for infection during the post partum period  Describe the assessment and nursing care of a patient with post partum thromboembolic disorders Postpartum High-Risk Factors Table 28-2 pg. 622 Postpartum Complications Cardiovascu Bleeding Infection lar Hemorrhag Endometrit DVT e (Uterine is Embolism Atony) Mastitis Hypertensi Laceration ve s disorders Retained placental fragments Hematoma Post-Partum Hemorrhage  Early (immediate or primary): 1st 24 hours after birth  Late (Secondary): From 24 hours to 12 weeks after birth  Drop in maternal HCT of 3% or > from pre-birth baseline or excessive bleeding that causes hemodynamic instability or requires blood transfusion  Significant cause of maternal mortality and morbidity  Accounts for one-sixth of all maternal deaths in U.S.  PP hemorrhage definitions  > 500ml (vaginal)  > 1000ml (C/S)  May also occur intra-abdominally and as hematomas  S/S may not occur until 10-30% of blood lost d/t ↑ blood volume of pregnancy Signs of Postpartum Hemorrhage Post partum Hemorrhage Mnemonic: The 4 T’s Tone (uterine atony) Tissue (retained placenta) Trauma (traumatic birth, lacerations, episiotomy) Thrombin (coagulation disorders, DIC) TONE: Uterine Atony Lack of uterine muscle tone Naturalmamanz.blogspot.com Caused by conditions that over-distend uterus and affect uterine contractibility Most common cause of early PP hemorrhage Perform fundal massage and check for clots – 1st action Administer uterine stimulants as ordered to monitor for side effects Contributing factors to Uterine Atony Overdistention of uterus  Prolonged 3rd stage multiple gestation,  > 30 minutes to deliver placenta hydramnios, etc.  Preeclampsia Dysfunctional or  Operative birth prolonged labor  Vacuum or forceps Induction or  Asian or Hispanic augmentation of labor heritage (think about Pitocin that is used  Retained placental to make the uterus contract) Grand multiparity fragments Gravida 6, 8, 9  Placenta previa or Medications (MgSO4, accreta anesthesia, Ca+ channel  Distended bladder blockers)  Obesity Assessment findings for Uterine Atony Uterus larger than normal and boggy with Institute massage Prolonged lochia discharge Irregular or excessive bleeding Tachycardia & hypotension – late sign? Pallor of skin & mucous membranes; cool clammy skin with loss of turgor Nursing Intervention for Uterine Empty Atony bladder Institute fundal massage Record amt of bleeding VS frequently (remember warning!) Use of oxytocics—Oxytocin, Methergine, Ergotrate, Hemabate , Cytotec Initiate/Maintain IVF Uterine tamponade Surgery –in rare cases Transfusions if required Figure 30-1 Manual compression of the uterus and massage with the abdominal hand usually will effectively control hemorrhage from uterine atony. Performed by HCP. Not a nursing role First line 2nd line Uterine Stimulants Used to Prevent and Manage Uterine Atony TISSUE: Retained Placental Fragments  Placenta or fragments not delivered within 30min of delivery  Commonly occurs when fundus is massaged prior to spontaneous placental separation  Suspect if patient is bleeding with firm fundus and no laceration  Inspect placenta thoroughly after birth for intactness  Fundal exploration may be performed after birth if missing fragments (cotyledons) noted  May be seen in early or late PP hemorrhages (most common cause of late PP hemorrhage) TISSUE: Retained Risk factors: Placental Fragments  Partial separation of normal placenta  Excessive traction of umbilical cord prior to complete separation of placenta  Placental tissue abnormally adherent to wall of uterus  Preterm birth esp. between 20-24wks gest. Physical Assessment Findings:  Uterine atony, subinvolution, or inversion  Excessive bleeding or blood clots >quarter size  Return of lochia rubra after progressing to lochia alba  Foul odor lochia or vaginal discharge  Elevated temperature Treatment: Figure 30-1 Manual removal of placenta. The fingers are alternately  Manual removal or D&C of fragments abducted, adducted, and advanced  Nursing prep for procedure until the placenta is completely detached. Performed by HCP. Not nursing role TRAUMA: Lacerations, Episiotomy Bright red Predisposing bleeding with firm factors: uterus Nulliparity – 1st Suspect if mother pregnancy is bleeding Epidural anesthesia heavily in Precipitous birth presence of firmly Forceps or vacuum contracted assisted birth fundus Macrosomia – big Contact baby physician/CNM to Oxytocin use suture laceration Lacerations: Definition 1st degree: superficial tear confined to epithelial layer 2nd degree: extend into perineal body, but not into external anal sphincter 3rd degree: involve superficial or deep injury to external anal sphincter 4th degree: extends completely through the rectal mucosa TRAUMA: Hematoma Bleeding into the tissues—usually vulva or vagina due to traumatic birth Symptoms: swelling, severe pain at the site or rectal pain, inability to void Bulging, discoloration (blueish, purple, or red-purple mass) on vulva Treatment: Ice packs, pain meds  Pts may report unrelieved pain even with pain meds  Last resort: evacuation and cauterization Late PP Hemorrhage  Generally occurs within from 24 hours-12 weeks after birth  Frequently due to subinvolution (failure of uterus to return to normal size)  fundal height > than expected  Much less common than Early PP Hemorrhage  Contributing factors  Deficiency of immunologic factors  Faulty implantation in less vascular lower uterine segment  Retained placental fragments (most common cause)  Infections  Nursing Management of PP Hemorrhage  GOAL: STOP HEMORRHAGE-CORRECT HYPOVOLEMIA & TREAT UNDERLYING CAUSE  Identify any risk factors prenatal and upon admission  Early recognition and management of complications  Frequent assessments after birth (fundal, VS, lochia)  Boggy uterus → Aggressive massage – 1st line of treatment  Monitor for S/S shock  Pain assessments: after regional anesthesia has subsided monitor for perineal pain (associated with hematomas)- usually “intense”  May also have rectal pressure (posterior vagina)  May have difficulty urinating (upper vagina)  Perineal assessments: ecchymosis, edema, tenseness of tissue overlying the hematoma, bulging mass at introitus & extreme tenderness to palpation VIDEO: Quantifying blood loss: https://www.youtube.com/watch?v=F_ac-aCbEn0&list=UUPrOhL3Od7ZeFDq27ycS00g  Nursing Management of PP Hemorrhage (cont)  Perform pad counts- weigh pads (1ml=1gm)  This includes everything during delivery as well  All linens, blood, gauze etc.  VS q 15 minutes  Maintain IV access if risk factors present  Monitor bladder status (keep empty)  Monitor and evaluate Labs (H&H)  Monitor mental status  Administer meds per HCP order  If risk of PP hemorrhage, type and cross match for blood  Assess for s/s hemorrhage: fatigue, pallor, H/A, thirst, B/P and pulse changes  Monitor urinary output  Box 30-1 Nursing actions during PPH COGNITION; READINESS; RESPONSE; RECORD  Puerperal Infections  Infection of reproductive tract associated with childbirth-occurs up to 6 weeks PP  Endometritis (uterine lining): most common  Peritonitis can occur (uncommon)  Puerperal morbidity:  “Temperature of 38°C (100.4°F) or higher with the temperature occurring on any 2 of the first 10 postpartum days, exclusive of the first 24 hours, and when taken by mouth by standard technique at least four times a day” (London, Ladewig, Davidson, Ball, Bindler, Cowen, Wisely & Dawson 2021, p. 677).  Contamination with bacteria can occur once membranes rupture  Alkaline pH vaginally postpartum favors growth of aerobes Risk Factors for Postpartum Uterine Infections Babble.com  Cesarean birth (single, most significant risk)- especially with extended  Obstetric trauma labor with ROM (episiotomy/laceration)  PROM  Chorioamnionitis  Prolonged labor preceding  Diabetes (4 X’s more C/S common)  Multiple vaginal exams  Preexisting BV or CT  Compromised health status  Instrument assisted birth (smoking, poor nutritional intake, anemia, alcohol, use of  Manual removal of placenta illicit drugs, high parity with  Retained placenta recent birth & obesity) fragments  Internal monitoring used  Non-aseptic technique intrapartum  Immunocompromised Endometritis & Metritis  Endometritis: Inflammation of endometrium portion of uterine lining (*most common)  Metritis: Inflammation of endometrium portion of uterine wall  May occur 1-3% during vaginal births, 30-35% C/S  Aerobic & anaerobic organisms can cause metritis  S/S:  Vaginal discharge is bloody; may be scant or profuse (“tomato soup consistency”) may have an odor  Uterine tenderness/pelvic pain  “Sawtooth” temperature spikes (101°F to 104°F)  Classic s/s Tachycardia Chills  Common Causative Organisms in Endometritis Treatment for Endometritis  Endometritis rates have fallen d/t prophylactic administration of antibiotics with cesarean sections (by 60-70%)  Obtain Hx and perform physical exam  Blood cultures, lochia cultures & UA (r/o UTI)  DO THIS BEFORE EVER GIVING ANTIBIOTICS!!  Antibiotic administration (usually see improvement in 48 hours)  Start broad spectrum antibiotics till culture is back  Usually Penicillins or cephalosporins  Will continue antibiotics until afebrile for 24- 48 hours Nursing Management for Endometritis  Assessment of perineum, lochia, incision (abdominal or perineal): Q 8 hours  VS  Administer meds as ordered by HCP  Adequate fluid intake (IV fluids given per order)  S/S: tachycardia, foul smelling lochia, chills, fever, malaise, etc  Evaluate Labs (WBC: ↑ of more than 30% in a 6 hour period indicative of infection)  Instruct on good perineal care  Proper hand washing  Promote comfort (hygiene, pain, positioning, oral care)  If acutely ill, promote attachment behaviors Nursing care plan: p. 679-6  Thromboembolic disease  May occur antepartum, but usually a PP complication  Venous thrombosis (thrombus formation): can be superficial or deep vein, usually in legs  Thrombophlebitis: thrombus formed in response to inflammation in vein wall  Pulmonary Embolus: rare, life threatening condition occurs when thrombi formed in deep vein dislodges and is carried to pulmonary artery Webdicine.com  Homans’sign: With the woman’s knee flexed, the nurse dorsiflexes the foot. Pain in the foot or leg is a positive Homans’sign. Virchow’s Triad Alteration in blood flow Endothelial damage Hypercoagubility (alteration in blood components) Source: © Image Source/Getty Images. Thromboembolic Disease Trauma to extremity Risk factors DM—Diabetes mellitus Cesarean birth AMA—advanced Immobility (prolonged) maternal age >35yrs Venous stasis Inherited coagulation Obesity disorders Cigarette smoking Factor V Leiden Previous Multiparity thromboembolic Anemia disease Malignancy or strong family Exogenous hormone history use Varicose veins  Measures to Decrease Risk of Thromboembolic Table 30-4 Disease in Childbearing Women Page 685 Thromboembolic Disease: Superficial thrombophlebitis More common PP than during pregnancy Usually saphenous vein More common with women with preexisting varices S/S: PP day 3 or 4 Tenderness in portion of vein, local heat & redness, normal temp or low grade temp, slight pulse ↑ Tender palpable cord may be noted along portion of vein PE rare Tx: bed rest, elevation of limb, local heat application, analgesics & support hose Thromboembolic Disease: Deep vein thrombosis (DVT)  More frequently seen with a hx of thrombosis  OB complications that ↑ incidence (preeclampsia, operative birth, polyhydramnios)  S/S:  May include edema of ankle & leg  Initial low grade temp→ high temp with chills  Pain/tenderness  Palpable cord, change in limb color, diff in limb circumference ( > 2 cm)  Diagnosis: Hx & PE, compression venous ultrasonography (VUS) & D-dimer assays  Tx: Unfractured heparin or LMWH, strict bedrest, leg elevation and analgesics (if fever present, IV antibiotics given)  Do not want to dislodge the clot  Avoid compression stockings and sequential devices Nursing Care of Women with Thromboembolic Disease  Assess leg for s/s thromboembolic disorder  Evaluate need for antiembolism stockings (L&D, PP)  Promote hydration  Avoid prolonged stirrup use  Progressive ambulation after acute phase  Encourage leg exercises, leg elevation  If on anticoagulant therapy: maintain safe administration of meds, comfort measures, monitor for Side Effects, Physical Assessments & assess for increase in PP bleeding  Teaching highlights p. 686  Have antidote for heparin available ????? Table 29-4 When to Contact the Primary Care Provider PP DANGER SIGNS Questions???