Module 5: Nursing Care of the High-risk Client during Postpartum Period - PDF

NCM 109 – CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) S.Y. 2024-2025 | 2nd Semester | Midterm Term Module 5: Nursing Care of the High-risk Client during Postpartum Period Description Although the postpartum is usually a pe...

NCM 109 – CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) S.Y. 2024-2025 | 2nd Semester | Midterm Term Module 5: Nursing Care of the High-risk Client during Postpartum Period Description Although the postpartum is usually a period of health, complications can occur. When they do, immediate intervention is essential to prevent long-term disability and interference with parent–child relationships. This module adds information about how to care for a woman and her family when there is a complication during this time. Learning Outcomes LO1 Integrate concepts, theories and principles of sciences and humanities in the formulation and application of appropriate nursing care to mothers with complications during pregnancy to achieve quality maternal and child nursing care. LO2 Apply maternal and child nursing concepts and principles in the prevention of complications during postpartum period LO3 Assess mothers who is experiencing complications during postpartum period with the use of specific methods and tools to address existing health needs. LO4 Formulate nursing diagnoses to address needs / problems of mothers and her family experiencing complications during postpartum period. LO5 Implement safe and quality nursing interventions to meet the needs and promote optimal outcomes for mothers and her family during a postpartum complication. LO7 Evaluate with mothers and family the expected outcomes for the effectiveness and achievement of care. LO8 Institute appropriate corrective actions to prevent or minimize complications during postpartum period. Module Outline I. Postpartum Hemorrhage A. Uterine atony B. Laceration C. Retained placental fragments D. Uterine inversion E. Disseminated Intravascular Coagulation F. Subinvolution G. Perineal Hematoma II. Puerperal Infection A. Mastitis B. Endometritis III. Emotional and Psychological Complications A. Postpartum Module 5: Postpartum Complications 1  Module Postpartum complications are always potentially serious because they can impact so many people. A complication may be so serious it could cause a personal injury, leave a woman with her future fertility impaired, or even result in death. Any complication that affects the health of the mother can also affect her interactions with her newborn, such as causing her to discontinue breastfeeding. Her family can be disrupted because of an extended hospital stay or impairment that prevents her from performing her normal family responsibilities. Financial difficulties may arise because of her inability to maintain employment and need for additional child and health care. Fortunately, most postpartal complications are preventable, and if they do occur, the majority can be treated effectively without long-term complications. I. Postpartum hemorrhage Hemorrhage, one of the primary causes of maternal mortality associated with childbearing, is a major threat during pregnancy, throughout labor, and continuing into the postpartum period. Postpartum hemorrhage is bleeding of 500 mL or more after delivery which can occur early (primary postpartum hemorrhage) during the first 24 hours after delivery, or later (secondary postpartum hemorrhage) after the first 24 hours following delivery. The conditions that increase a woman’s risk for a postpartal hemorrhage are shown in table 1. The four main reasons for postpartum hemorrhage are (Fig 1): A. Uterine atony B. Trauma (lacerations, hematomas, uterine inversion, uterine rupture) C. Retained placental fragments. D. Disseminated intravascular coagulation (DIC) These causes are generally referred to as the four Ts of postpartum: tone, trauma, tissue and thrombin. Figure 1. The common causes of postpartal hemorrhage Module 5: Postpartum Complications 2 Table 1. Conditions that increase a Woman’s Risk for a Postpartal Hemorrhage Conditions that distend the uterus beyond average Multiple gestation capacity Polyhydramnios A large baby (>9 lb) Uterine myomas (fibroid tumors Conditions that could have caused cervical or uterine An operative birth lacerations Rapid birth Conditions with varied placental site or attachment Placenta previa Placenta accreta Premature separation of the placenta Retained placental fragments Conditions that leave the uterus unable to contract Deep anesthesia or analgesia readily Labor initiated or assisted with an oxytocin agent High parity or maternal age over 35 years of age Previous uterine surgery Prolonged and difficult labor Chorioamnionitis or endometritis Secondary maternal illness such as anemia Prior history of postpartum hemorrhage Prolonged use of magnesium sulfate or other tocolytic therapy Conditions that lead to inadequate blood coagulation Fetal death Disseminated intravascular coagulation Consequences of postpartum hemorrhage are: 1. Circulatory collapse leading to shock and death. 2. Puerperal anemia and morbidity 3. Damage to the pituitary blood supply - Sheehan's syndrome 4. Fear of further pregnancies A. Uterine Atony - Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartal hemorrhage. - The uterus must remain in a contracted state after birth to keep the open vessels at the placental site from bleeding. - Factors that predispose to poor uterine tone or any inability to maintain a contracted state are summarized in Table 1. - When caring for a woman in whom any of these conditions are present, be especially cautious in your observations and be on guard for signs of uterine bleeding. This is especially important because many postpartal women are discharged within 48 hours after birth. - Assessment 1. A soft (boggy) uterus noted on palpation of the uterine fundus. 2. Signs of Shock and Hypovolemia Module 5: Postpartum Complications 3  a. Persistent significant bleeding: Perineal pad is soaked within 15 minutes. b. Restlessness, increased pulse rate, decrease in blood pressure, cool and clammy skin, ashen or grayish color. c. Complaints of weakness, lightheadedness, dyspnea - Interventions 1. Massage the uterus until firm (Fig. 2) 2. Empty the woman’s bladder (by voiding or catheterization) if that is contributing to the uterine atony. 3. Elevate woman’s extremities. 4. Oxygen by mask = 10-12lpm 5. Position flat 6. Monitor VS 7. Notify the health care provider (HCP) if interventions do not resolve the atony, because this could be an indication of hemorrhage. 8. Administer medications. a. Oxytocin bolus or dilute IV. b. Carbopost tromethamine (Hemabate) q 15 – 90 minutes x 8 doses c. Methylergonovine maleate (Methergine) q 2-4 hours x 5 doses d. Misoprostol (Cytotec) x 2 doses 9. Bimanual massage The doctor inserts one hand into the woman’s vagina while pushing against the fundus through the abdominal wall with the other hand. 10. Blood transfusion 11. Hysterectomy A B Figure 2. Technique for fundal massage. (A). The other hand is cupped to massage and gently Module 5: Postpartum Complications 4 compress the fundus toward the lower uterine segment. (B). One hand remains cupped against the uterus at the level of the symphysis pubis to support the uterus. B. Laceration - Small lacerations or tears of the birth canal are common and may be considered a normal consequence of childbearing. - Large lacerations, however, can cause complications. - Causes a. Difficult or precipitate births b. Primigravidas c. Birth of a large infant (>9 lb) d. Use of a lithotomy position and instruments during the stage 2 of labor - Either cervical, vaginal, or perineal lacerations may occur. - After birth, any time a uterus feels firm, but bleeding persists, suspect a laceration of one of these three sites. - Types of lacerations 1. Cervical Lacerations Lacerations of the cervix are usually found on the sides of the cervix, near the branches of the uterine artery. If the artery is torn, the blood loss may be so great that blood gushes from the vaginal opening. Because this is arterial bleeding, it is brighter red than the venous blood lost with uterine atony. Fortunately, this bleeding ordinarily occurs immediately after delivery of the placenta, when the physician or nurse midwife is still in attendance. 2. Vaginal Lacerations Vaginal lacerations are easier to locate and assess than cervical lacerations because they are much easier to view. 3. Perineal lacerations Lacerations of the perineum are apt to occur when a woman is placed in a lithotomy position for birth rather than a supine position because a lithotomy position increases tension on the perineum. Perineal lacerations are classified by four categories, depending on the extent and depth of the tissue involved (Table2). Module 5: Postpartum Complications 5  Table 2 Classification of perineal lacerations Classification Description First degree Vaginal mucous membrane and skin of the perineum to the fourchette Second degree Vagina, perineal skin, fascia, levator ani muscle, and perineal body Third degree Entire perineum, extending to reach the external sphincter of the rectum Fourth degree Entire perineum, rectal sphincter, some mucous membrane of the rectum - Interventions 1. Document the degree of laceration. 2. Repair of the laceration with regional anesthesia to relax uterine muscle for cervical laceration. 3. Diet high in fluid and stool softener to prevent constipation. 4. Avoid enema or rectal suppositories. C. Retained Placental Fragments Occasionally, a placenta does not deliver in its entirety; fragments of it separate and are left behind. Because the portion retained keeps the uterus from contracting fully, uterine bleeding occurs. - Risk factors: 1. Succenturiate placenta—a placenta with an accessory lobe. 2. Placenta accreta—a placenta that fuses with the myometrium because of an abnormal decidua basalis layer. 3. Previous cesarean birth 4. In vitro fertilization - Assessment 1. Detection of retained placental fragments thru: a. Ultrasound b. Inspection of placenta carefully after birth c. Blood serum sample contains gonadotropin hormone. 2. Bleeding occurs because the uterus cannot contract with the large fragment in place. 3. Bleeding may not be detected until postpartum day 6 to 10, if the fragment is small. 4. Uterus not fully contracted. - Intervention 1. Removal of the retained placental fragment by dilatation and curettage (D&C). 2. Observe lochia and report reversal of pattern. 3. Balloon occlusion and embolization for placenta accrete. Module 5: Postpartum Complications 6  4. Hysterectomy as a last resort. D. Uterine Inversion Uterine inversion is a prolapse of the fundus of the uterus through the cervix so that the uterus turns inside out with either birth of the fetus or delivery of the placenta. - Risk factors 1. Traction is applied to the umbilical cord to remove the placenta. 2. Pressure is applied to the uterine fundus when the uterus is not contracted. 3. Placenta is attached at the fundus so that, during birth, the passage of the fetus pulls the fundus down. - Assessment 1. Blood suddenly gushes from the vagina. 2. Fundus and uterus protrude from the vagina. 3. Fundus not palpable in the abdomen 4. Signs of shock: hypotension, dizziness, paleness, or diaphoresis - Intervention 1. Never attempt to replace an inversion because handling of the uterus may increase the bleeding. 2. Never attempt to remove the placenta if it is still attached, because this only creates a larger surface area for bleeding. 3. IV fluid line needs to be started, if one is not already present (use a large-gauge needle, because blood will need to be replaced). 4. Administer oxygen by mask and assess vital signs. 5. Be prepared to perform cardiopulmonary resuscitation (CPR) if the woman’s heart should fail from sudden blood loss. 6. The woman will immediately be given general anesthesia or possibly nitroglycerin or a tocolytic drug intravenously, to relax the uterus. 7. The physician or nurse midwife then replaces the fundus manually. 8. Administration of oxytocin after manual replacement helps the uterus to contract and remain in its natural place. 9. Because the uterine endometrium was exposed, a woman will need antibiotic therapy to prevent infection. 10. She needs to be informed that cesarean birth will probably be necessary in any future pregnancy, to prevent the possibility of repeat inversion. E. Disseminated Intravascular Coagulation Module 5: Postpartum Complications 7  Disseminated intravascular coagulation (DIC) is a deficiency in clotting ability caused by vascular injury. It may occur in any woman in the postpartal period, but it is usually associated with premature separation of the placenta, a missed early miscarriage, or fetal death in utero. DIC is discussed in Module 2 (Bleeding in Pregnancy) F. Subinvolution Subinvolution is incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a 4- or 6- week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present. Subinvolution may result from: a. a small retained placental fragment, b. mild endometritis (infection of the endometrium), c. uterine myoma/fibroids - Assessment 1. Prolonged lochial discharge 2. Irregular or excessive bleeding 3. Larger than normal uterus 4. Boggy uterus - Interventions 1. Prevent excessive blood loss, infection, other complications. a. Massage uterus b. Monitor BP and pulse rate. c. Administer medications. d. Prepare for possible D & C 2. Assist the client and family deal with physical and emotional stress of postpartum complications. G. Perineal Hematomas - Perineal hematoma is a collection of blood in the subcutaneous layer of tissue of the perineum. - The overlying skin, as a rule, is intact with no noticeable trauma. - Such blood collections can be caused by injury to blood vessels in the perineum during birth. - They are most likely to occur after rapid, spontaneous births and in women who have perineal varicosities. - They may occur at the site of an episiotomy or laceration repair if a vein was punctured during repair. - They can cause a woman acute discomfort and concern and they usually represent only minor bleeding. - Assessment 1. Severe pain in the perineal area or a feeling of pressure between the mother’s legs Module 5: Postpartum Complications 8  2. Appears as an area of purplish discoloration with obvious swelling. 3. The area is tender to palpation. 4. At first it may feel fluctuant, but as seepage into the area continues and tissue is drawn taut, it palpates as a firm globe. - Interventions 1. Report the presence of a hematoma, its size, and the degree of the woman’s discomfort to her primary care provider. 2. Assess the size by measuring it in centimeters with each inspection. 3. Administer a mild analgesic as ordered for pain relief. 4. Applying an ice pack (covered with a towel to prevent thermal injury to the skin) may prevent further bleeding. 5. Usually, the hematoma is absorbed over the next 3 or 4 days. 6. If the hematoma is large when discovered or continues to increase in size, the woman may have to be returned to the delivery or birthing room to have the site incised and the bleeding vessel ligated under local anesthesia. II. Puerperal Infection Any infection of the reproductive organs that occurs within 28 days of delivery or abortion. Requires a complete physical examination and examination of urine specimen, throat swab or sputum, high vaginal swab and in some cases blood culture. Factors that predispose women to infection in the postpartal period are shown in Table 3. When caring for a woman who has any of these circumstances, be aware that the risk for postpartal infection is greatly increased. Table 3. Conditions that increase a Woman’s Risk for Postpartal Infection Risk Factor Basis for Risk Rupture of membranes more than 24 hours before Bacteria may have started to invade the uterus while birth the fetus was still in utero. Retained placental fragments within the uterus The tissue necroses and serves as an excellent for bacterial growth Postpartal hemorrhage The woman’s general condition is weakened Preexisting Anemia The woman’s general condition is weakened Prolonged and difficult labor, particularly with Trauma to the tissue may leave lacerations or fissures instrument births for easy portals of entry for infection Internal fetal heart monitoring electrode Contamination may have been introduced with placement of the scalp electrodes. Module 5: Postpartum Complications 9  Local vaginal infection presents at the time of birth A direct spread of infection has occurred. Theoretically, the uterus is sterile during pregnancy and until the membranes rupture. After rupture, pathogens can invade. The risk of infection is even greater if tissue edema and trauma are present. If infection occurs, the prognosis for complete recovery depends on: - Virulence of the invading organism - The woman’s general health - Portal of entry - Degree of uterine involution at the time of the microorganism invasion - Presence of lacerations in the reproductive tract A puerperal infection is always potentially serious, because, although it usually begins as only a local infection, it can spread to involve the peritoneum (peritonitis) or the circulatory system (septicemia). These conditions can be fatal in a woman whose body is already stressed from childbirth. Organisms commonly cultured postpartally include group B streptococci and aerobic gram-negative bacilli such as Escherichia coli. Staphylococcal infections also are becoming more common. - Assessment 1. Fever 2. Localized vaginal, vulvar, perineal infections. 3. Manifestations of endometritis 4. Parametritis 5. Signs and symptoms of peritonitis - Intervention 1. Use of an appropriate antibiotic after culture and sensitivity testing of the isolated organism. 2. Provide client of the family teaching especially prevention for future pregnancies a. During pregnancy - Correct all anemia states. - Avoid sexual intercourse. - Douching during the last 2 months of pregnancy b. During labor - Strict aseptic technique – wearing of cap, mask, gown. - Keep perineal and vaginal laceration to a minimum. - Avoid contact with people with URTI. - Replace blood loss. c. During puerperium Module 5: Postpartum Complications 10  - Use of clean/sterile perineal pads always - Perineal flushing every after urination and bowel elimination A. Mastitis It is an infection of the breast, usually unilateral, frequently caused by cracked nipples in the nursing mother. The causative organism is usually hemolytic S. Aureus. If untreated, may result in breast abscess. Mastitis occurs primarily in breast-feeding mothers 2 to 3 weeks after delivery but may occur at any time during lactation. - Assessment 1. Redness, tenderness or hardened are in the breast. 2. Maternal chills, malaise 3. Elevated vital signs, especially temperature and pulse. - Interventions 1. Teach/ stress importance of hand washing to nursing mother and wash own hands before touching client’s breast. 2. Apply ice if ordered between feedings. 3. Empty breast regularly: baby may continue to nurse or have mother use hospital-grade pump. 4. Wear supportive bra; avoid wearing an underwire bra. 5. Maintain lactation in breast feeding mothers. 6. Administer antibiotic and analgesic as prescribed. B. Endometritis Endometritis is an infection of the lining of the uterus occurring in the postpartum period and caused by bacteria that invade the uterus at the placental site. The infection may spread and involve the entire endometrium and cause peritonitis or pelvic thrombophlebitis. - Assessment 1. Chills and fever 2. Increased pulse 3. Decreased appetite. 4. Headache 5. Backache 6. Prolonged, severe afterpains 7. Tender, large uterus 8. Foul odor to lochia or reddish-brown lochia 9. Ileus 10. Elevated white blood cell count. Module 5: Postpartum Complications 11  - Interventions 1. Monitor vital signs. 2. Position the client in Fowler’s position to facilitate drainage of lochia. 3. Provide a private room for the mother; inform the mother that isolation of the newborn from the mother is unnecessary. 4. Instruct the mother in proper hand-washing techniques. 5. Initiate contact precautions as necessary. 6. Monitor intake and output and encourage fluid intake. 7. Administer antibiotics as prescribed. 8. Administer comfort measures such as back rubs and position changes and pain medications as prescribed. 9. Administer oxytocic medications as prescribed to improve uterine tone. 10. Provide psychological support. III. Thrombophlebitis - Phlebitis is inflammation of the lining of a blood vessel. - Thrombophlebitis is inflammation with the formation of blood clots. When thrombophlebitis occurs in the postpartal period, it is usually an extension of an endometrial infection. It tends to occur because: 1. A woman’s fibrinogen level is still elevated from pregnancy, leading to increased blood clotting. 2. Dilatation of lower extremity veins is still present as a result of pressure of the fetal head during pregnancy and birth. - It tends to occur most often in women who: a. Are relatively inactive in labor and during the early puerperium because of this increases the risk of blood clot formation. b. Have spent prolonged time in delivery or birthing room with their legs positioned in stirrups. c. Have preexisting obesity and pregnancy weight gain greater than the recommended weight gain, which can lead to inactivity and lack of exercise. d. Have preexisting varicose veins. e. Develop postpartal infection. f. Have history of a previous thrombophlebitis. g. Are older than the age of 35 years or have increased parity. h. Have a high incidence of thrombophlebitis in their family. i. Smoke cigarettes because nicotine causes vasoconstriction and reduces blood flow. Module 5: Postpartum Complications 12 - A clot forms in a vessel wall as a result of inflammation of the vessel wall. A partial obstruction of the vessel can occur. Increased blood-clotting factors in the postpartum period place the client at risk. - Types 1. Superficial thrombophlebitis 2. Femoral thrombophlebitis 3. Pelvic thrombophlebitis - Assessment 1. Superficial a. Palpable thrombus that feels bumpy and hard b. Tenderness and pain in affected lower extremity c. Warm and pinkish red color over the thrombus area 2. Femoral a. Malaise b. Chills and fever c. Diminished peripheral pulses d. Shiny white skin over affected area e. Pain, stiffness, and swelling of affected leg 3. Pelvic a. Severe chills b. Dramatic body temperature changes c. Pulmonary embolism may be the first sign - Interventions 1. Specific therapies may depend on the location of thrombophlebitis. 2. Assess the lower extremities for edema, tenderness, varices, and increased skin temperature. 3. Maintain bed rest. 4. Elevate the affected leg. 5. Apply a bed cradle and keep bedclothes off the affected leg. 6. Never massage the leg. 7. Monitor for manifestations of pulmonary embolism. 8. Apply hot packs or moist heat to the affected site as prescribed to alleviate discomfort. 9. Apply elastic stockings (support hose) if prescribed. 10. Administer analgesics and antibiotics as prescribed. 11. Heparin sodium intravenously may be prescribed for femoral or pelvic thrombophlebitis to prevent further thrombus formation. Module 5: Postpartum Complications 13 IV. Emotional and Psychological Complications of the Puerperium Any woman who is extremely stressed or who gives birth to an infant who in any way does not meet her expectations such as being the wrong sex, being physically or cognitively challenged, or being ill may have difficulty bonding with her infant. Inability to bond is a postpartal complication with far-reaching implications, possibly affecting the future health of the entire family. A. Postpartal Depression Almost every woman notices some immediate (1 to 10 days postpartum) feelings of sadness (postpartal “blues”) after childbirth. This probably occurs as a response to the anticlimactic feeling after birth and also probably is related to hormonal shifts as the levels of estrogen, progesterone, and gonadotropin-releasing hormone in her body decline or rise. In as many as 20% of women, however, especially in women who are disappointed in some aspect of the newborn or who have poor family support, these normal feelings continue beyond the immediate postpartal period (possibly as long as 1 year) or reflect a more serious problem than usual “baby blues”. They become postpartum depression (Table 4). Depression of this type, manifested by overwhelming sadness, can occur in both new mothers and fathers. The syndrome can interfere with breastfeeding, childcare, and returning to a career. Both women and men may notice extreme fatigue, an inability to stop crying, increased anxiety about their own or their infant’s health, insecurity (unwillingness to be left alone or inability to make decisions), psychosomatic symptoms (nausea and vomiting, diarrhea), and either depressive or extreme mood fluctuations. Risk factors 1. History of depression 2. Troubled childhood 3. Low self-esteem 4. Stress in the home or at work 5. Lack of effective support 6. Different expectations between partners (e.g. if a woman wants a child and her partner does not) 7. Disappointment in the child (e.g. a boy instead of a girl) Table 4. Comparing Postpartal Blues, Depression, and Psychosis POSTPARTAL BLUES POSTPARTAL DEPRSSION POSTPARTAL PSYCHOSIS ONSET 1-10 days after birth 1-12 months after birth Within first year after birth SYMPTOMS Sadness, tears Anxiety, feelings of loss, Delusion or hallucinations of sadness harming infant or self Incidence 70% of all births 10% of all births 1% - 2% of all births Module 5: Postpartum Complications 14 Etiology Probable hormonal History of previous Possible activation of previous changes, stress of life depression, hormonal mental illness, hormonal changes response, lack of social changes, family history of support bipolar disorder Therapy Support, empathy Counseling, possibly drug Psychotherapy, drug therapy therapy Nursing role Offer compassion and Screen for depression and Refer to psychiatric care, understanding refer to counseling safeguarding mother form injury to self and newborn B. Postpartal Psychosis When the illness coincides with the postpartal period, it is called postpartal psychosis. Rather than being a response to the physical aspects of childbearing, however, it is probably a response to the crisis of childbearing. The majority of these women have had symptoms of mental illness before pregnancy. If the pregnancy had not precipitated the illness, a death in the family, loss of a job or income, divorce, or some other major life crisis would probably have precipitated the same recurrence. A woman with postpartal psychosis usually appears exceptionally sad. By definition, psychosis exists when a person has lost contact with reality. Because of this break with reality, the woman may deny that she has had a child and, when the child is brought to her, insist that she was never pregnant. She may voice thoughts of infanticide or that her infant is possessed. If observation tells you that a woman is not functioning in reality, you cannot improve her concept of reality by a simple measure such as explaining what a correct perception is. Her sensory input is too disturbed to comprehend this. In addition, she may interpret your attempt as threatening. She may respond with anger or become equally threatening. A psychosis is a severe mental illness that requires referral to a professional psychiatric counselor and antipsychotic medication. - Interventions 1. Do not leave woman alone. 2. Do not leave her alone with her infant. 3. Refer to psychiatric counselor and antipsychotic medication. V. Nursing Process for a Woman experiencing Postpartum Complication A. Assessment Women who assume that they will immediately return to an active lifestyle after birth of their child may view hospitalization for a postpartum complication as more upsetting than do women who view the postpartum period as one in which they are expected to rest. Assess each woman holistically, therefore, to determine how the health problem a woman is experiencing is impacting her and her family. Module 5: Postpartum Complications 15 Assessment findings associated with a postpartum complication may be extremely subtle, such as tenderness in the calf of a leg, a slight increase in uterine or perineal pain, a slight elevation in temperature, or a slight increase in the amount of lochia flow. Because the average woman usually has no postpartum complications and the length of stay in a hospital is short, it is easy to overlook these subtle signs. It is important to be alert to any findings that are “different from usual,” because they may be the beginning of a serious. To be certain, do not rely solely on a woman’s report of perineal healing or amount of lochia. Always inspect her perineum yourself, because the report of “I feel fine” or “my bleeding was just a small amount” may be deceptive if she no familiarity with “normal” lochia, perineal healing, or fundal height against which to accurately compare her own condition. An increased temperature during the first 24 hours after birth is an extremely serious finding. Women may try to “explain away” an increased temperature, because they know that if they have an elevated temperature, they are not tempted to rationalize such a finding with explanations such as, “The room was warm,” or “She just drank some hot coffee.” Although these factors may make a slight difference (part of 1°) in temperature level, they do not affect it enough to account for an oral temperature greater than 100.4° F (38.0° C). B. Nursing Diagnosis Nursing diagnoses during this time vary depending on the postpartal complication. Some examples are: 1. Deficient fluid volume related to increased lochia flow 2. Ineffective breastfeeding related to development of mastitis 3. Acute pain related to a collection of blood in traumatized tissue (hematoma) secondary to birth trauma 4. Situational low self-esteem related to inability to perform regular tasks 5. Social isolation related to precautions necessary to protect infant and others from infection transmission Risk for impaired parenting related to postpartum depression 6. Ineffective peripheral tissue perfusion related to interference with circulation from thrombophlebitis 7. Risk for infection related to microorganism invasion of episiotomy, surgical incision site, or migration of microorganism from the vagina to the uterus C. Outcome Identification and Planning Outcome identification for a woman with a postpartum complication may be particularly difficult because, although a woman wants to do everything necessary to return to health, she also does not want to allow anything to interfere with her ability to bond with her new child. As a rule, however, never underestimate how much a woman will endure to enable herself to “mother” her new child. Module 5: Postpartum Complications 16  This ability of a mother to overcome challenges to meet her child’s needs is the essence of motherhood. When planning for a postpartum family, provide for measures that will restore the woman most quickly to health and promote contact among her, her child, and her primary support person. If physical contact between a mother and her newborn is not possible, give the mother frequent reports of her infant’s health and preferences. During her taking-in phase, ask the nursery staff to contact the mother at least once every nursing shift to update her on the infant’s status; during her taking-hold phase, encourage her to contact the nursery. If the infant is being cared for in another facility, ask them to fax or e-mail photographs of the infant. This provides something concrete to which a new mother can relate. D. Implementation Interventions for a woman with a postpartum complication should include instruction for both self- care and childcare (if appropriate) because continuing to review these measures helps a woman accept her situation as temporary, thus reinforcing the idea she will be able to care for herself and her infant when she is healthy again. E. Outcome Evaluation An evaluation of a woman with a postpartum complication should address both her and her family’s health as well as her family’s ability to integrate the new child into the family. The evaluation may suggest the need for home care follow-up to assist a woman in coping with both old and new responsibilities in the face of reduce energy form illness. Examples of expected outcomes might include: 1. Lochia is free of foul odor. 2. Fundus remains firm and midline with progressive descent. 3. Patient maintains a urinary output greater than 30 ml/hr 4. Lochia discharge amount is 6 in or less on a perineal pad in 1 hour 5. Patient maintains vital signs and oxygen saturation within defined normal limits Integrative Activity Watch the following videos: 1. Postpartum hemorrhage: https://www.youtube.com/watch?v=ZSLMm5KNGEc 2. Uterine Atony: https://www.youtube.com/watch?v=GIDL3AONCys 3. Postpartum depression: https://www.youtube.com/watch?v=2ocA-zS3SoI References Silbert-Flagg, J. (2022). Maternal and child health nursing: Care of the childbearing and childbearing family (9thed.). Philadelphia, PA: WoltersKluwer. Murray S, (2014) Foundations of maternal-newborn and women’s health nursing (6thed). St. Louis, Missouri: Elsevier Saunders. Module 5: Postpartum Complications 17  Credits and Quality Assurance Prepared by: MELANIE C. TAPNIO, MAN, RN, LPT Assistant Professor Recommending Approval: DENMARK D. GABRIEL, MSN, RN, LPT Assistant Professor and Chairperson, Nursing Program Reviewed by: LEONARDO S. ANGELES, JR, PhD, MAN, RN, LPT Assistant Professor & OBE Facilitator Approved by: ELMER BONDOC, PhD, MAN, RN Dean School of Nursing and Allied Medical Science Module 5: Postpartum Complications 18