Postpartum Care and Complications PDF

POSTPARTUM CARE AND COMPLICATIONS PEURPERIUM – first 6 weeks after delivery. Patients need the following instruction: care of the neonate, breastfeeding her limitations if any Patient needs emotional support. VAGINAL DELIVERIES Pain control and perineal care...

POSTPARTUM CARE AND COMPLICATIONS PEURPERIUM – first 6 weeks after delivery. Patients need the following instruction: care of the neonate, breastfeeding her limitations if any Patient needs emotional support. VAGINAL DELIVERIES Pain control and perineal care o Pain can be reduced with non-steroidal anti-inflammatory drugs. Patients with vaginal deliveries involved either episiotomies or lacerations. Perineal care is particularly important. o Ice packs around the clock for both pain and edema in perineum and labia. Check perineum if it is intact and no hematomas. Check if patient had hemorrhoids, common in pregnancy and postpartum. Use stool softeners, ice pack, increase fluids and high fiber diets. CESAREAN DELIVERIES Wound care and pain management is the key issues in post cesarean care. Local wound care and observation for signs of wound infection or separation (dehiscence). Pain can be managed with narcotics (as per doctor’s order). Patients on narcotics should also be on stool softeners and occasional laxatives, fluids and high fiber diet. Patients usually received antibiotics as prophylaxis against infection. BREAST CARE All postpartum patients need breast care, regardless of whether they or they will not breastfeed their baby. Nurse should promote breastfeeding. Patient will experience onset of lactation, engorgement or “let down”, approximately 24 to 72 hours postpartum. When this occurs, breast usually warmer, firmer and tender. Patient may experience low-grade fever and may have pain or warmth in breast. for patients not breastfeeding, icepacks, a tight bra, analgesic and anti-inflammatories are useful. Patient who are breastfeeding feels relief from breastfeeding, this can lead to difficulties such as tenderness and erosion around the nipple. POSTPARTUM CONTRACEPTION Advised to have pelvic rest or to resume sexual activity until the 6-week follow-up visit. Advised patient to consult their health practitioner about contraceptive or family planning. POSTPARTUM COMPLICATIONS: 1. POSTPARTUM HEMORRHAGE – defined as blood loss exceeding 500 ml in vaginal delivery and greater than 1000ml in cesarean section. If hemorrhage occur within first 24 hours, it is early postpartum hemorrhage. After 24 hours, late or delayed postpartum hemorrhage. Common causes of postpartum bleeding includes; UTERINE ATONY, RETAINED PLACENTA, PLACENTA ACCRETA, CERVICAL LACERATION AND VAGINAL LACERATION. Inform attending physician for any assessment indicating patient is experiencing postpartum bleeding and to Start IV fluids and possible blood transfusion, as per doctors order. 2. VAGINAL LACERATIONS AND HEMATOMAS Vaginal lacerations with uncontrolled bleeding should be considered in the care of postpartum bleeding, report your assessment to the attending physician and document report. Patient may develop retroperitoneal hematoma that can lead to large blood loss. Patient usually complain of back pain and large drop of hematocrit, report assessment to attending physician and document report. 3. CERVICAL LACERATIONS Cervical lacerations can cause postpartum hemorrhage. If any lacerations are seen upon assessment, inform the physician, they usually repair the laceration. 4. UTERINE ATONY Uterine atony is the leading cause of postpartum hemorrhage. Patient is higher risk of uterine atony if they have chorioamnionitis, exposure to magnesium sulfate (preeclampsia & eclampsia), multiple gestations, macrosomic fetus and history of atony in prior pregnancies. Palpation to the uterus to know if there is uterine atony, which is soft, enlarged and boggy. Uterine fundus should be contracted. If atony continues, physician may order to shift patient to OR for dilatation and curettage. Documents all nursing assessment, interventions and orders form the doctors and all that transpired during your tour of duty. 5. RETAINED PRODUCTS OF CONCEPTION Careful inspection of placenta should always be performed. However vaginal delivery, it can be difficult to determine whether small piece of placenta has been left behind in uterus. Usually retained placental membranes or placental tissue pass in the lochia. They occasionally lead to endomyometritis and postpartum hemorrhage.  If hemorrhage continues and no further POCs via exploration by the doctor, placenta accreta should be suspected. 6. ACCRETA Placenta accreta, increta, and percreta are the result of abnormal attachment of placental tissue or the uterus that may invade into or beyond the uterine myometrium, leading to incomplete separation of placenta postpartum and postpartum hemorrhage. Risk factors for developing placenta accreta include placenta previa and prior uterine surgery, including cesarean delivery and myomectomy. 7. UTERINE RUPTURE Uterine rupture is estimated to occur in 0.5% to 1.0% of patients with prior uterine scare and about 1 in 15,0000 to 20,000 women with an unscarred uterus. It is an intrapartum complication but may occur with bleeding postpartum. Rare for rupture to occur in a nulliparous patient. Risk factors include previous uterine surgery, breech extraction, obstructed labor, and high parity. Symptoms include abdominal pain, and a “popping sensation intra-abdominally. If hemorrhage cannot be controlled, hysterectomy may be indicated. 8. UTERINE INVERSION Uterine deliveries may occur in 1 in 2,500 deliveries. Risk factors include fundal implantation of the placenta, uterine atony, placenta accreta, and excessive traction on the cord during the third stage. Uterine inversion can be an obstetric emergency if hemorrhage occurs. Inform the doctor on duty in DR and document findings after patient stabilizes her situation or if for laparotomy, endorse patient with the file with complete nurses note about the patient. 9. ENDOMYOMETRITIS Endomyometritis is a polymicrobial infection of the uterine lining that often invades the underlying wall. It is commonly seen after cesarean sections but can be seen with vaginal deliveries as well, particularly if manual removal of placenta was required. It is increased in patient with meconium, chorioamnionitis and prolonged rupture of membranes. Usually treated with broad spectrum intravenous antibiotics. Nurse should report vital signs and blood investigation to the attending physician and document the findings. 10. MASTITIS Mastitis is a regional infection of breast, commonly caused by patient skin flora or the oral flora of breast-feeding infants. Organisms enter an erosion or cracked nipple and proliferate, leasing to infection. Lactating women will often have warm, diffusely, tender, and firm breast, particularly at the time of engorgement or milk let-down. Should be differentiated for focal tenderness, erythema, and differences in temperature from one region of breast to another, which is the classic signs of mastitis.  Patient should continue to breast feed, which prevents intraductal accumulation of infected material. Patients who are not breastfeeding should breast pump in the acute phase of infection. 11. POSTPARTUM DEPRESSION Postpartum blues with mood swings and changes in appetite and sleep, it not frank postpartum depression. Pathophysiology of depression may be due to rapid changes in estrogen, progesterone, and prolactin. May be related of lack of sleep-in postpartum period, as well as psychosocial stress of caring newborn. These are common and seen higher rates in patients with history of depression or other mental illness as well as in patients with poor support networks. Patients may experience low energy level, anorexia, insomnia, hypersomnolence, extreme sadness and other depressive symptoms for greater than a few weeks may have postpartum depression. These patients often incapable of caring for their infants. Occasionally depressed patients have suicidal ideation, which is a much clearer marker for depression and merits close observation. PPD symptoms usually pass on their own with support and encouragement. If progress to more severe postpartum depression or psychosis, caregiver needs to determine whether the patient is having suicidal or homicidal ideation. Social worker and professional counselor should be involved, also immediate family and other close to patient who can provide support. end