68C_PP03L009_ELO B_Postpartum Complications_V 2.0.pdf

NURSING CARE DURING THE POSTPARTUM PERIOD NP03L007 ELO B · VERSION 2.0 POSTPARTUM COMPLICATIONS Introduction to Maternity and Pediatric Nursing, 8th. Ed, pp. 247-258 TERMINAL LEARNING OBJECTIVE In a clinical setting, given a postpartum scenario, perform safe and effective nursing care for a postpart...

NURSING CARE DURING THE POSTPARTUM PERIOD NP03L007 ELO B · VERSION 2.0 POSTPARTUM COMPLICATIONS Introduction to Maternity and Pediatric Nursing, 8th. Ed, pp. 247-258 TERMINAL LEARNING OBJECTIVE In a clinical setting, given a postpartum scenario, perform safe and effective nursing care for a postpartum family without harm. ENABLING LEARNING OBJECTIVE: B Perform postpartum nursing care for a mother experiencing circulatory complications. POSTPARTUM COMPLICATIONS Shock Hemorrhage Thromboembolic disorders Puerperal infections Subinvolution of the uterus Mood Disorders SHOCK AND CHILDBEARING Type of Shock Cause Cardiogenic Pulmonary embolism Anemia Hypertension Cardiac disorder Hypovolemic Postpartum hemorrhage Blood clotting disorder Anaphylactic Allergic response to drugs administered Septic Puerperal infection CLINICAL MANIFESTATIONS Tachycardia Decreased blood pressure Narrowing pulse pressure Skin and mucous membranes become pale, cold and clammy Anxiety, confusion, restlessness and lethargy Urinary output decreased MEDICAL MANAGEMENT Stop the bleeding Give IV fluids Give blood transfusions Give oxygen Indwelling catheter Uterine massage and oxytocic medications NURSING INTERVENTIONS Vital signs The location and consistency of the fundus, amount of lochia, skin temperature and color and capillary refill are assessed Administer and monitor oxygen Urinary catheter Administer IV fluids Emotional support POSTPARTUM HEMORRHAGE Blood loss greater than 500 ml after vaginal birth, or 1000 ml after cesarean birth A more measurable definition is a decrease in hematocrit of 10 percent or more since admission Two Types: Early postpartum hemorrhage Late postpartum hemorrhage EARLY POSTPARTUM HEMORRHAGE Hemorrhage that occurs within 24 hours of delivery The three causes are: Uterine Atony Lacerations Hematoma TYPES OF EARLY POSTPARTUM HEMORRHAGE Uterine Atony Lacerations Soft, high uterine fundus that is difficult to feel through woman’s abdominal wall Continuous trickle of blood that is brighter than normal If visible, appears as blue or purplish mass on vulva lochia Severe and poorly relieved pain and/or pressure in Fundus that is usually firm vulva, pelvis, or rectum Characteristics Heavy lochia, often with large clots or sometimes a persistent moderate flow Bladder distention that causes uterus to be high and usually displaces it to one side Onset of hypovolemic shock that may be gradual and easily overlooked Hematoma Large amount of blood lost into tissues, which causes signs and symptoms of hypovolemic shock Lochia that is normal in amount and color Possible signs of hypovolemic shock Contributing Factors Bladder distention Rapid labor Prolonged or rapid labor Abnormal or prolonged labor Use of instruments such as forceps or vacuum extractor during birth Large infant Overdistended uterus Multiparity (five or more births) Use of oxytocin during labor Medications that relax uterus Operative birth Low placental implantation Use of forceps or vacuum extractor UTERINE ATONY Refers to lack of muscle tone that results in failure of the uterine muscle fibers to contract firmly around blood vessels when the placenta separates Bleeding continues until the fibers contract to stop the flow of blood PREDISPOSING FACTORS Over-distension of the uterus Intrapartum factors Augmented labor with oxytocin DIC Multiparity CLINICAL SIGNS Uterus is difficult to palpate Boggy (soft) The fundal height is high Excessive lochia Massage the fundus until it is firm Assist mother to urinate if full bladder THERAPEUTIC MANAGEMENT Rapid IV infusion of oxytocin (Pitocin) methylergonovine (Methergine) prostaglandin (Hemabate, Prostin) misoprostol (Cytotec) SURGICAL MANAGEMENT If all other measures are ineffective: Exploration Ligation Hysterectomy NURSING MANAGEMENT Assess the consistency and location of the fundus Ensure the patient does not have a full bladder when doing assessments When inspecting for blood loss, always ask the woman to turn on her side because blood that pools under her is not visible when checking pads from the front Measure vital signs every 15 minutes to detect trends LACERATIONS OF THE REPRODUCTIVE TRACT Cervical lacerations Lacerations of the vagina, perineum and periurethral Bleeding from lacerations often is bright red and may be heavy or may have a steady trickle of blood HEMATOMAS OF THE REPRODUCTIVE TRACT Hematomas resulting from birth trauma are usually on the vulva or inside the vagina Vulva hematoma PREDISPOSING RISK FACTOR Prolonged or rapid labor Large baby Use of forceps or vacuum extract MEDICAL MANAGEMENT Small hematomas usually resolve without treatment Large hematomas may require incision and drainage of the clots Bleeding vessel is ligated, or area packed with a hemostatic material to stop bleeding LATE POSTPARTUM HEMORRHAGE Typically, it occurs without warning 6 days to 6 weeks days after delivery Most Common Causes: Fragments of placenta that remain attached to the myometrium Subinvolution PLACENTAL FRAGMENTS Causes Placenta did not separate cleanly Placenta was manually removed Placenta grows deeply into the uterine muscle MEDICAL MANAGEMENT Initial treatment - control of excessive bleeding. Oxytocin, Methergine, and prostaglandins are the most used pharmacologic measures Ultrasound to identify remaining fragments Dilation and curettage may be necessary to remove fragments Antibiotics NURSING MANAGEMENT Teach about expected changes in lochia Teach to report persistent bright red bleeding Implement pharmacologic treatment Assist with surgical treatment SUBINVOLUTION OF THE UTERUS SUBINVOLUTION Slower than normal return of the uterus to nonpregnant condition Causes Infection Retained fragments of placenta CLINICAL MANIFESTATIONS: SUBINVOLUTION Fundal height is higher than expected Persistent lochia rubra or slowed lochia progression Pelvic pain, heaviness & fatigue Methylergonovine to firm the uterus MEDICAL MANAGEMENT Antibiotics Dilation and curettage NURSING MANAGEMENT Teach about normal changes in lochia Report fever, persistent pain, persistent lochia rubra, foul smelling vaginal discharge Teach to palpate fundus May be admitted to hospital CHECK ON LEARNING What color is lochia rubra? CHECK ON LEARNING What are the signs & symptoms of hemorrhage and what should be taught at discharge? THROMBOEMBOLIC DISORDERS THREE MAJOR CAUSES Venous Stasis Compression of large vessels of the legs and pelvis Hypercoagulation Changes in the coagulation and fibrinolytic systems Blood Vessel Injury May occur during vaginal or cesarean birth and could trigger a pelvic vein thrombosis CLINICAL MANIFESTATIONS Superficial venous thrombus (SVT) Painful, hard, reddened warm vein Easily seen Deep venous thrombosis (DVT) Pain, calf tenderness, pain with walking Leg edema, color changes Positive Homan’s sign CLINICAL MANIFESTATIONS Pulmonary embolism (PE) Signs and symptoms Chest pain Cough Dyspnea Decreased LOC Heart failure MEDICAL MANAGEMENT Confirmed by ultrasound Analgesics Local application of heat Elevate legs Pneumatic compression devices Anticoagulant therapy DVT treated with Heparin or LMWH NURSING IMPLICATIONS Assess for venous thrombus and complications Thrombi prevention Early ambulation & ROM Teach administration of anticoagulants Signs of excessive anticoagulation Prevention of bleeding Monitor blood coagulation studies CHECK ON LEARNING Name two risk factors for thrombosis common in pregnancy? CHECK ON LEARNING Choose the most appropriate intervention to prevent deep venous thrombosis in a woman who is 1-day post-cesarean birth. a. Encourage her to walk several times each day b. Provide her with increased fluids that she enjoys c. Take her temperature to identify an elevation d. Instruct her to stay in bed most of the day PUERPERAL SEPSIS PUEPERAL SEPSIS Bacterial infection after childbirth Risk factors Tissue trauma Open wound at placental insertion site Incisions Cracked nipples Increased pH of the vagina SIGNS AND SYMPTOMS Temperature of 38º C (100.4º F) or higher after the first 24 hours Localized redness, edema, discharge and approximation Fever, pain, and foul odor MEDICAL MANAGEMENT Limit the spread Culture and sensitivity from suspected site Bed rest to conserve energy NURSING MANAGEMENT Good hygiene to reduce number of bacteria Promote adequate rest and nutrition High protein and vitamin C for healing High iron to correct anemia Teach signs of infection Teach antibiotic administration Apply peripads ENDOMETRIOSIS An infection of the uterine lining CLINICAL MANIFESTATIONS Tender, enlarged uterus Prolonged severe cramping Foul-smelling lochia Fever and other systemic signs of infection Signs of subinvolution MEDICAL MANAGMENT Culture and sensitivity of the uterine cavity IV Antibiotics NURSING IMPLICATIONS Teach usual progression of lochia Fowler’s position to facilitate drainage Administer analgesics Assess for absent bowel sounds, abdominal distention, and nausea/vomiting WOUND INFECTION Most commonly occurs in cesarean surgical incisions, episiotomies or lacerations Signs and Symptoms include: Inflammation (redness, edema, warmth, pain) Separation of suture line Purulent drainage MEDICAL MANAGMENT Culture and sensitivity Antibiotics NURSING IMPLICATIONS Aseptic or sterile technique Teach proper perineal hygiene Use of sitz baths URINARY TRACT INFECTIONS Signs and Symptoms include: Low-grade fever Burning, urgency, and frequency Chills, spiking fever, flank pain and nausea and vomiting all occur if the infection has progressed to the upper urinary tract MEDICAL MANAGEMENT Clean-catch or catheterized urine for culture and sensitivity Broad-spectrum IV antibiotics NURSING IMPLICATIONS Teach perineal hygiene Increased fluid intake 3000 mL fluid each day Teach acidic foods Apricots, cranberry juice, plums, prunes CHECK ON LEARNING A woman who is 3 days postpartum comes to the emergency clinic because she is having pain and burning with urination. She denies that she has had any fever and states that her lochia is “light pink”. The nurse should expect an initial order for ___________. a. Bladder analgesics b. Intravenous antibiotics c. Culture of vaginal drainage d. Clean-catch urine specimen CHECK ON LEARNING Name three nursing interventions to teach UTI prevention. MASTITIS AND BREASTFEEDING MASTITIS Occurs 2-3 weeks after giving birth Small cracks in the nipples allow bacteria to enter Risk factors Engorgement Inadequate emptying of milk CLINICAL MANIFESTATIONS Redness and heat in breast Tenderness Edema and heaviness of breast Purulent drainage Fever, chills If not treated becomes abscessed MEDICAL MANAGEMENT Antibiotics Analgesics for comfort Do NOT stop breastfeeding NURSING MANAGEMENT Teach effective breastfeeding techniques Moist heat to promote blood flow to area Warm showers to start the flow of milk and hygiene Expose nipples to air Frequent breast pad changes Massage breast during feeding Wear a supportive bra Encourage fluid intake Emotional support Ice pack or moist heat applied for discomfort CHECK ON LEARNING A postpartum mother who is breastfeeding has developed mastitis. She states that she does not think it is good for her infant to drink milk from her infected breast. The best response from the nurse would be: a. Instruct her to nurse the infant from only the unaffected breast until the infections clears up b. Suggest that she discontinue breastfeeding and start the infant on formula c. Encourage breastfeeding the infant to prevent engorgement d. Apply a tight breast binder to the infected breast until the infection subsides POSTPARTUM MOOD DISORDERS MOOD DISORDERS Pervasive and sustained emotion that can color one’s view of life 3 types of postpartum depression Adjustment disorder (Baby Blues) Postpartum mood disorders Postpartum depression Postpartum psychosis is most severe POSTPARTUM BLUES Common after birth Feels let down but finds pleasure in life and new role Roller coaster of emotions Self-limiting as adapts to new role Occurs in 75% Appears day 5 and disappears day 10 POSTPARTUM DEPRESSION Manifested within 2-4 weeks after delivery Rapid changes in hormone levels leads to increased MAO-A levels are related to onset of postpartum depression Risk factors Inadequate social support Poor relationship with partner Life and childcare stress Low self-esteem Unplanned pregnancy CLINICAL MANIFESTATIONS Lack of enjoyment in life Disinterested in others Loss of give and take in a relationship Intense feeling of inadequacy, unworthiness, guilt, inability to cope Loss of mental concentration Inability to make decisions Disturbed sleep or appetite Constant fatigue and feeling ill These behaviors interfere with maternal-child bonding IMPACT ON FAMILY Strains the coping mechanisms of the entire family Results in strained relationships Communication is impaired Further withdrawal distances her from support system Remains in touch with reality NURSING IMPLICATIONS Although early treatment is important, women often do not seek treatment All women should be assessed for depression during follow-up visits Do not assume depression is the Baby Blues; explore for persistent and pervasive feelings Promote behaviors that improve mental health Be alert for signs of self-harm MEDICAL MANAGEMENT Psychotherapy Anti-depressants Complementary and Alternative Medicine Phototherapy Exercise Community mental health support services referral Counseling should include family CHECK ON LEARNING What are the three types of mood disorders related to the postpartum period? POSTPARTUM PSYCHOSIS Much less common than postpartum depression Impaired sense of reality May accompany a psychiatric disorder, most often: Bipolar disorder Major depression BIPOLAR DISORDER Characterized by: Mania- Periods of excitability, hyperactivity, euphoria Major depression- Deep feelings of worthlessness and guilt MAJOR DEPRESSION Characterized by deep feelings of worthlessness Serious sleep and appetite disturbances Delusions about infant death MEDICAL MANAGEMENT Medical emergency Can be fatal for both mother and infant Danger during manic episodes Suicide and infanticide during major depressive episodes Beyond scope of nursing Social workers Refer woman for counseling Inpatient psychiatric treatment Appropriate environment CHECK ON LEARNING What might the infant and mother be at risk for if the mother is suffering from major depression? REVIEW OF MAIN POINTS Hemorrhagic complications Thromboembolic disorders Puerperal sepsis Mood disorders QUESTIONS?