Postpartum Care and Complications PDF

Postpartum Care and Complications  What is the Postpartum Period? Time from delivery to return of reproductive organs to pre-pregnancy state Typically, 6 weeks post-delivery Sometimes called “the fourth trimester” POSTPARTUM PHYSIOLOGIC ADAPTATION  Postpartum Ph...

Postpartum Care and Complications  What is the Postpartum Period? Time from delivery to return of reproductive organs to pre-pregnancy state Typically, 6 weeks post-delivery Sometimes called “the fourth trimester” POSTPARTUM PHYSIOLOGIC ADAPTATION  Postpartum Physiologic Adaptation: Endocrine System Placental Hormones (hormones produced by the placenta that are abruptly cut off after delivery of placenta) Estrogen diuresis of extracellular fluid (that was accumulated during pregnancy) breast engorgement remains low for BF mothers Progesterone (will return with menses) hCG & hPL  Postpartum Physiologic Adaptation: Endocrine System Pituitary Hormones Prolactin Milk production Supply & demand: dependent upon frequency, duration, & supplement use Oxytocin Milk ejection reflex (let-down) Uterine contractions→ involution  Postpartum Physiologic Adaptation: Reproductive System Uterine Involution Smooth muscle fibers of myometrium compress blood vessels Fundus descends 1 cm, or one “fingerbreadth” every 24hrs Contractions or “after pains” Oxytocin (IV, breastfeeding) Stronger with multiparous and breastfeeding Lochia Vaginal discharge- sloughing of superficial layers, blood, & cells First 1-2 hours: halfway between the symphysis pubis and Continuous 4-8 weeks post-delivery umbilicus Postpartum Physiologic Adaptation: Reproductive System Ovulation May occur as soon as 4 weeks postpartum! Longer for BF mothers r/t high prolactin levels Birth control plan prior to discharge  Postpartum Physiologic Adaptation: Reproductive System Breasts Colostrum “Premilk” or “Liquid gold” production by hormonal response estrogen ↑ immunoglobulins Lactogenesis milk “coming in” or breast “filling” engorgement ~ day 4 PP production by supply & demand Breastmilk changes to meet demands of growing infant- supply and demand  Postpartum Physiologic Adaptation: Cardiovascular System Pregnancy-induced hypervolemia helps to tolerate blood loss from delivery 1st hour after delivery: ↑ pulse and cardiac output, then gradual decrease Bradycardia expected from decreased cardiac output Decrease in blood volume during PP period: Blood loss during birth (300-1000mL) Diaphoresis and diuresis first 2-5 days PP Weight loss (lochia, birth, diuresis) during first 5 days BP should be unchanged (↑ preeclampsia, ↓ hemorrhage)  Postpartum Physiologic Adaptation: Urinary/Renal System Diuresis and diaphoresis: increased UOP begins ~12hr PP Trauma/pain/anesthesia increase risk of Urinary retention Stress incontinence UTI risks Distended bladder: uterine atony Accurate output measurements of urine UOP may be 3000 ml/day Goal: void 6-8 hrs post delivery, >150ml/void  Postpartum Physiologic Adaptation: Musculoskeletal System Joints restabilized within 6-8 weeks Feet can remain permanently increased in size Muscle tone begins to be restored after delivery of placenta (progesterone decrease) Rectus abdominus muscles are separated (diastasis recti)- exercise necessary to regain muscle tone Pelvic floor laxity- kegel exercises  Postpartum Physiologic Adaptation: Gastrointestinal System Constipation Slowed peristalsis Hemorrhoids Integumentary System Profuse diaphoresis Improvement in hyperpigmentation Striae gravidarum gradually fades Hair loss common first 3-4 months PP POSTPARTUM ASSESSMENT AND MANAGEMENT  POSTPARTUM ASSESSMENT: Vital Signs VITAL SIGN ASSESSMENT 1ST HOUR: Q 15 min 2ND HOUR: Q 30 min THEN Q4H for 1st 24 hrs NORMAL PP VS VARIATIONS: TEMP up to 100.4 during first 24 hrs BRADYCARDIA  POSTPARTUM ASSESSMENT AND MANAGEMENT: Assessment B U B B L E E E Breasts Bladder Lochia Extremities Uterus Bowel Episiotomy Emotional (Perineum) Status POSTPARTUM ASSESSMENT AND MANAGEMENT: Focused Assessment General Headaches/vision changes? Chest pain/SOB? Heart/lungs How is BF going? Nipple pain? Breasts Uterus Cramping/abdominal pain? Last void? Bladder BM/flatus? Bowel Lochia Last pad change? How is your bottom feeling? Episiotomy/perineum Extremities Swelling? Worse or better? Emotional Status Big changes! How feeling?  POSTPARTUM ASSESSMENT AND MANAGEMENT: Breasts & Breastfeeding Nipple assessment: everted, flat, or inverted Everted Nipple Persistent pain, redness, cracking, blistered, or bleeding are not normal! Interventions for sore nipples: Begin with breast that is less sore Change NB position for deeper latch Inverted Nipple Ice packs, lanolin, colostrum, breast shields Initiate 1st feeding within one hour of delivery→ colostrum and baby alert Painful uterine contractions are common with BF Increase caloric intake and include calcium- Cracked Nipple enriched foods POSTPARTUM ASSESSMENT AND MANAGEMENT: Engorgement Swelling of the breast tissue- “filling” Bilateral fullness, firm, warm, tender Milk “comes in” on postpartum day 3-5 Interventions for relief: Frequent feedings for adequate emptying Heat/warmth before feeding; ice following feeding NSAIDs  POSTPARTUM ASSESSMENT AND MANAGEMENT: Breast Care for the Formula-feeding Parent Engorgement will resolve on its own Wear well-fitting, supportive bra 24 hours/day Avoid breast stimulation! NO pumping or hand-expressing milk Avoid hot water to breasts in shower Discomfort interventions: Ice or cold compress Cabbage leaves or peppermint oil NSAIDs POSTPARTUM ASSESSMENT AND MANAGEMENT: Fundal Assessment First 1-2 hours: halfway between the symphysis pubis and umbilicus NORMAL: Firm and midline, at appropriate height for days PP ABNORMAL: Boggy, deviated from midline, higher than expected POSTPARTUM ASSESSMENT AND MANAGEMENT: Bladder A full bladder can interfere with uterine involution and increase the risk of excessive bleeding. If the bladder is full, the fundus may be deviated to the right and above the umbilicus. If fundus deviated, FIRST EMPTY BLADDER, then reassess and massage. POSTPARTUM ASSESSMENT AND MANAGEMENT: Bowel Expect bowel movement 1-3 days postpartum “Expected” Complications Constipation (caused by immobility, trauma, medications, change in body fluids) Interventions: ambulation, fiber & fluids, stool softener Hemorrhoids (from pregnancy or pushing) Interventions: fiber & fluids, sitz bath, witch hazel pads, stool softener, cream Cesarean section Splinting, avoid straining Gas pains- rocking chair, diet modifications  POSTPARTUM ASSESSMENT AND MANAGEMENT: Lochia Lochia Rubra Lochia Serosa Lochia Alba Typically lasts 3-4 days after birth Typically days 4-10 Typically 2-4 weeks Bright red in color Thin Color turns from pinkish-brown Blood clots are normal Color turns from red-pink to to yellowish-white pinkish-brown Contains little red blood Contains mucus No odor Lesser flow with few/no clots No real flow POSTPARTUM ASSESSMENT AND MANAGEMENT: Lochia Quantity Assess with every VS check and prn ALWAYS assess under buttocks when assessing bleeding! Saturating a pad in < 15 minutes is EXCESSIVE bleeding Quantify bleeding as per protocol or when bleeding is concerning (QBL) POSTPARTUM ASSESSMENT AND MANAGEMENT: Perineum Assess side-lying REEDA Redness Edema Ecchymosis Discharge Approximation Laceration Episiotomy  POSTPARTUM ASSESSMENT AND MANAGEMENT: Perineal Care Hygiene: peri-bottle Comfort Ice 1st 24 hrs → Warm sitz baths 2nd 24hrs Tucks pads/anesthetic spray Excessive pain → further evaluation Avoid: suppositories/enema if 3rd or 4th degree lacerations POSTPARTUM ASSESSMENT AND MANAGEMENT: Extremities and Emotional State DVT and Postpartum Depression Coming Up…  POSTPARTUM ASSESSMENT AND MANAGEMENT: Safety Falls risk Non-skid socks/slippers Environment Analgesics/anesthesia/orthostatic hypotension Call light Infant safety Maternal fatigue/meds/blood loss/lack of food Matching wristbands Code Pink POSTPARTUM DISCHARGE EDUCATION Vaginal ~48hrs PP C-section ~96 hrs PP  POSTPARTUM DISCHARGE TEACHING: Immunizations Rh Immune Globulin/RhoGAM Rh- mom with Rh + baby give within 72 hrs Rubella* Administer if NON-immune Varicella* If NON-immune TDAP If not received during pregnancy *LIVE VACCINES: 1) warning: protection to prevent pregnancy for next 4 weeks 2) monitor: if received RhoGAM at same time recheck titers @ 3 mo  POSTPARTUM DISCHARGE TEACHING: Sex & Contraception Pregnancy risk Contraceptive plan BEFORE discharge Consider medical hx and breastfeeding status Ovulation can occur as soon as 4 weeks PP When resume sexual activity When bleeding has stopped, and perineum healed (2-6 weeks) When birth parent feels ready What to expect MILD discomfort is normal More extensive vaginal lacerations may have more discomfort Vaginal dryness, especially if breastfeeding→ use lubricant  POSTPARTUM DISCHARGE TEACHING: Postpartum Warning Signs Fever = T > 100.4 Localized redness/pain/warmth in calf Unimproved or worsening or Localized pain/redness in breast abdominal or pelvic pain Severe or unresolved headache or Change in vaginal discharge or odor headache with vision changes Heavy bleeding (soaking pad < 1 hour) Chest pain ↑ incisional pain, redness, odor, SOB drainage Seizures Urinary frequency/urgency/pain Thoughts of self-harm or harm to infant  POSTPARTUM COMPLICATIONS  POSTPARTUM COMPLICATIONS: Uterine Atony- Causes of Postpartum Hemorrhage TONE (#1 cause) TRAUMA Medications (oxytocin induction) Prolonged or precipitous delivery General anesthesia Assisted delivery Distended bladder Lacerations Overdistension of uterus Hematoma Magnesium sulfate Uterine rupture TISSUE TRACTION Retained placenta (>30 min) Cord detachment Retained clots Uterine inversion THROMBIN Coagulopathy (ITP/DIC)  POSTPARTUM COMPLICATIONS: Postpartum Hemorrhage Cumulative blood loss > 1000 mL with signs and symptoms of hypovolemia within 24 hours of delivery, regardless of the route of delivery. #1 cause of maternal PREVENTION mortality & Risk Assessment (next slide) morbidity Oxytocin 3rd stage of labor in the world Quantification of blood loss (QBL)  POSTPARTUM COMPLICATIONS: Postpartum Hemorrhage- Risk Factors Low Risk Medium Risk High Risk No history PPH History PPH Placenta previa Singleton pregnancy Overdistended uterus Placenta accreta (placenta (Multiple gestation, grown in to uterine wall- polyhydramnios) unable to detach) No previous uterine incision Prior c-section Placental abruption 4 vaginal births History >1 PPH No known bleeding disorders Low platelets Known coagulopathy Prolonged labor Extremely low platelets Preeclampsia (MgSO4) Fetal demise 2+ Medium Risk Factors  POSTPARTUM COMPLICATIONS: Postpartum Hemorrhage ASSESSMENT FINDINGS Uterine Atony* (boggy uterus) Blood clots larger than quarter Persistent bleeding Excessive bleeding= Soaking peripad 140/90, HTN) Carboprost (Hemabate) IM (do not give if hx of asthma) Misoprostol (Cytotec) SL or PR **common AE of all these meds include n/v, diarrhea, fever, chills, HA, ↑ BP  POSTPARTUM COMPLICATIONS: Postpartum Hemorrhage CONTINUED INTERVENTIONS (STAGE 2) 2nd IV line (16-18G)→ STAT labs & possible blood transfusion T&C, CBC (H&H), Coagulation studies Obtain 2 units of RBCs (do not wait on labs if clinically unstable) Prepare OR for procedural/surgical intervention (JADA, hysterectomy) (move to Stage 3) POSTPARTUM COMPLICATIONS: Postpartum Hemorrhage  POSTPARTUM COMPLICATIONS: Postpartum Hemorrhage- Procedural Interventions Jada System Bimanual massage May be performed at the bedside Low-level vacuum system Contracts uterus Bakri balloon  POSTPARTUM COMPLICATIONS: Postpartum Hemorrhage Discharge Education risk for PPD May have delayed engorgement or lactogenesis Longer rest and recovery time – Slow increase in activity Increase fluid intake Increase Fe rich foods Leafy greens and darker meats Iron supplements taken with Vitamin C  POSTPARTUM COMPLICATIONS: Risk Factors Deep Vein Thrombosis (Extremities) Hypercoagulable state and venous stasis Pregnancy C-section Obesity Smoking >35y/o Expected Findings Calf tenderness Unilateral area of swelling, warmth, redness, pain Hardened vein over thrombosis  POSTPARTUM COMPLICATIONS: DVT Management Elevate extremity Warm, moist compress Do NOT massage Prevention Measure leg circumference SCDs Analgesics Early ambulation Anticoagulants Compression hose Leg elevation Avoid prolonged immobility Increase fluid intake Prophylactic anticoagulants (hx of DVT)  POSTPARTUM COMPLICATIONS: Pulmonary Embolus PE S/S Tachypnea (RR > 20) Tachycardia (HR > 100) Dyspnea, hypoxia Chest pain, apprehension Cough, hemoptysis Syncope Emergent situation Increased postpartum risk due to hypercoagulable state of pregnancy and venous stasis.  POSTPARTUM COMPLICATIONS: DVT & PE Management ANTICOAGULANTS BLEEDING ASSESSMENT Heparin (SQ or IV) or Warfarin (oral) Monitor lochia for signs of (avoid NSAIDs/aspirin) hemorrhage D/C home on oral anticoagulant Monitor for other signs of bleeding Monitor PT/PTT/INR (and educate patient): petechiae hematuria nose bleeds bleeding gums bruising  POSTPARTUM COMPLICATIONS: Vulvar/Vaginal Hematoma Bluish or purple vulvar or vaginal mass Ecchymosis Edema Difficulty voiding Severe or worsening perineal or pelvic pain Typically appears in first 48 hours  POSTPARTUM COMPLICATIONS: Postpartum Infections MASTITIS: INFLAMMATION OF THE BREAST Causes: Milk stasis, clogged milk duct, engorgement, cracked nipples, poor breastfeeding technique May have a hard, painful lump Localized redness/warmth/pain to breast Fever and flu-like symptoms  POSTPARTUM COMPLICATIONS: Postpartum Infections MASTITIS: TREATMENT Continue to breastfeed frequently & ensure adequate emptying Apply warm packs or ice packs for discomfort Proper newborn positioning and latching-on technique Rest, fluids, NSAIDs If worsening, consult HCP for antibiotics  POSTPARTUM COMPLICATIONS: Postpartum Infections ENDOMETRITIS Most common postpartum infection ↑ risk with c-section Fever, tachycardia Pelvic pain Abnormal vaginal discharge/bleeding  POSTPARTUM COMPLICATIONS: Postpartum Infections WOUND INFECTION C-section, episiotomy, laceration Wound warmth, erythema, tenderness, pain, drainage Wound dehiscence: separation of incision edges Wound evisceration: protrusion of internal contents through separated wound edges Fever > 100.4 POSTPARTUM COMPLICATIONS: Postpartum Infections URINARY TRACT INFECTION Secondary to bladder trauma from delivery or break in aseptic technique during bladder catheterization Teach proper perineal hygiene Encourage increased fluid intake to dilute bacteria and flush bladder Antibiotics and analgesia  POSTPARTUM COMPLICATIONS: Postpartum Preeclampsia Continue to monitor for at least 48 hours after delivery Expect magnesium sulfate administration for 24 hours to prevent seizures Assess VS q4h Educate patient with warning signs POSTPARTUM PSYCHOSOCIAL ADAPTATION  PSYCHOSOCIAL ADAPTATION PHASES OF MATERNAL POSTPARTUM ADJUSTMENT DEPENDENT DEPENDENT-INDEPENDENT INTERDEPENDENT “TAKING IN” “TAKING HOLD” “LETTING-GO” Day 2 to several weeks Adapted to new role as 1st 24-48 hours Focused on baby care parent Personal needs Learning, becoming confident, Focused on family as a Rely on others but requires + reinforcement in unit Excited new role Resumes/returns Share birth experience “Baby blues” attention to other roles  PSYCHOSOCIAL ADAPTATIONS: Parent-Infant Bonding Facilitating Parent-Infant Bonding Skin-to-skin at birth Rooming-in Encourage/assist in participating in care Early initiation of breastfeeding Encourage bonding: cuddling, feeding, diapering  PSYCHOSOCIAL ADAPTATIONS: Parent-Infant Bonding Signs of + parent-infant bonding Holds face-to-face (“en face”) with eye contact, smiling, talking to infant Touches, explores, and maintains close contact with newborn “Claiming” Points out family characteristics Names the baby Responds to crying Interprets infant cues and assigns meaning  PSYCHOSOCIAL ADAPTATION: Factors that may hinder adaptation  PSYCHOSOCIAL ADAPTATION: Postpartum Blues “Baby Blues” Caused by hormonal changes (decline in estrogen and progesterone) Occurs in first days or week and resolves within 2 weeks (without formal treatment) Sad, anxious, overwhelmed, irritable Crying for no apparent reason Loss of appetite Difficulty sleeping Headache 80% of women experience  ADVERSE PSYCHOSOCIAL ADAPTATION: Postpartum Depression Can occur any time in first year postpartum highest incidence is ~4 weeks PP Symptoms more prolonged & more intense than baby blues: Intense mood swings Fatigue Persistent feelings of sadness Impairs daily functioning May also demonstrate: Thoughts of harm Little interest in baby ADVERSE PSYCHOSOCIAL ADAPTATION: Postpartum Psychosis Typically occurs in first 2 weeks Visual, auditory, or tactile hallucinations Confusion & forgetfulness Racing thoughts/no sleep Paranoia Rapid mood swings Acts of harm to self or infant History of bipolar is higher risk  ADVERSE POSTPARTUM ADAPTATIONS: Postpartum Depression NURSING CARE Observe birth parent’s interactions with newborn (signs of bonding) Assess mood and affect Screening is key! Edinburgh Postnatal Depression Scale At discharge, postpartum visits, & well-baby visits Help in diagnosing & referrals De-stigmatize (8-20+% women experience)  ADVERSE POSTPARTUMS ADAPTATION: Postpartum Depression MEDICATION MANAGEMENT SSRIs most commonly used – Sertraline (Zoloft) Safe for use during breastfeeding Education: time to full efficacy up to 4-6 weeks Monitor infant for inability of parent to provide care: irritability poor feeding disrupted sleep ADVERSE POSTPARTUM ADAPTATIONS: Postpartum Depression EDUCATION Ask about safety & support at home Educate to recognize s/s Provide resources (La Leche League, mental health centers, counseling) Encourage Self-care (healthy diet, activity, sleep) Talk about it Avoid isolation Avoid unrealistic expectations