Chapter 28 Postpartum Maternal Complications Copyright 2014 2010

Postpartum Hemorrhage Early postpartum hemorrhage Uterine atony Ø Trauma Ø Late postpartum hemorrhage Subinvolution

Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier

Hypovolemic Shock Pathophysiology Clinical signs and symptoms Therapeutic management Nursing considerations Copyright © 2014,

Application of the Nursing Process: Woman with Excessive Bleeding Assessment Ø Uterine atony or

Case Study You are the mother–baby nurse assigned to Ms. Avery. She is a

Case Study (Cont. ) What should the nurse do? What are Ms. Avery’s risk

Subinvolution of the Uterus Definition Ø Slower-than-expected return of the uterus to its nonpregnant

Thromboembolic Disorders Incidence and etiology Venous stasis Hypercoagulation Blood vessel injury Additional predisposing factors

Superficial Venous Thrombosis Clinical signs and symptoms Therapeutic management Analgesics Ø Rest Ø Elastic

Deep Venous Thrombosis Signs and symptoms Diagnosis Doppler Ø Magnetic resonance imaging (MRI) Ø

Application of the Nursing Process: Deep Venous Thrombosis Assessment Nursing diagnoses Expected outcomes Intervention

Pulmonary Embolism Pathophysiology Clinical signs and symptoms Dyspnea, chest pain, tachycardia, and tachypnea Ø

Puerperal Infection Definition Ø Temperature of 38° C (100. 4° F) or higher after

Endometritis Etiology Clinical signs and symptoms Therapeutic management Complications Nursing considerations Copyright © 2014,

Wound Infection Clinical signs and symptoms Therapeutic management Nursing considerations Copyright © 2014, 2010,

Urinary Tract Infections Etiology Clinical signs and symptoms Therapeutic management Nursing considerations Copyright ©

Mastitis Etiology Clinical signs and symptoms Therapeutic management Nursing considerations Copyright © 2014, 2010,

Septic Pelvic Thrombophlebitis Clinical signs and symptoms Therapeutic management Copyright © 2014, 2010, 2006,

Application of the Nursing Process: Infection Assessment Nursing diagnoses Expected outcomes Interventions Evaluations Copyright

Postpartum Mood Disorders Postpartum depression Incidence Ø Predictors Ø Clinical signs and symptoms Ø

Application of the Nursing Process: Postpartum Depression Assessment Nursing diagnoses Expected outcomes Interventions Evaluations

Case Study You are the mother-baby nurse providing couplet care to Ms. Hart and

Case Study (Cont. ) Breastfeeding but baby sleepy at the breast and now with

Case Study (Cont. ) 1. What can you say to Ms. Hart, and what

Postpartum Mood Disorders (Cont. ) Bipolar II disorder Postpartum psychosis Copyright © 2014, 2010,

Postpartum Anxiety Disorders Panic disorder Postpartum obsessive compulsive disorder Post-traumatic stress disorder Copyright ©

Question Fran delivered a 9 lb, 10 oz baby 1 hour ago. When you

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Postpartum Hemorrhage Early postpartum hemorrhage Uterine atony Ø Trauma Ø Late postpartum hemorrhage Subinvolution Ø Retained placental fragments Ø Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 2

Application of the Nursing Process: Woman with Excessive Bleeding Assessment Ø Uterine atony or trauma Nursing diagnoses Expected outcomes Intervention Evaluation Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 8

Case Study You are the mother–baby nurse assigned to Ms. Avery. She is a gravida 6 para 5015 who gave birth to a 9 -lb baby boy this morning. Ms. Avery had an uncomplicated and precipitous vaginal birth. Perineum is intact. She is breastfeeding. All labs are normal. She is now 5 hours postpartum. A family member calls out from the patient room for assistance. When you walk into the room, Ms. Avery is standing up on her way to the bathroom with a large pool of blood on the floor. She states, “I don’t know what happened; it all just came when I stood up. I am so dizzy and lightheaded. " Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 9

Case Study (Cont. ) What should the nurse do? What are Ms. Avery’s risk factors for postpartum hemorrhage (PPH)? What should the medical management include? Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 10

Subinvolution of the Uterus Definition Ø Slower-than-expected return of the uterus to its nonpregnant size Causes Retained placental fragments Ø Pelvic infection Ø Therapeutic management Nursing considerations Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 11

Thromboembolic Disorders Incidence and etiology Venous stasis Hypercoagulation Blood vessel injury Additional predisposing factors Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 12

Superficial Venous Thrombosis Clinical signs and symptoms Therapeutic management Analgesics Ø Rest Ø Elastic stockings Ø Elevation of lower extremities Ø Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 14

Deep Venous Thrombosis Signs and symptoms Diagnosis Doppler Ø Magnetic resonance imaging (MRI) Ø Therapeutic management Ø Prevention of thrombus formation Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 15

Application of the Nursing Process: Deep Venous Thrombosis Assessment Nursing diagnoses Expected outcomes Intervention Evaluation Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 16

Pulmonary Embolism Pathophysiology Clinical signs and symptoms Dyspnea, chest pain, tachycardia, and tachypnea Ø Pulmonary rales, cough Ø Hemoptysis (expectoration of blood or bloody sputum) Ø Abdominal pain Ø Low-grade fever Ø Therapeutic management Nursing considerations Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 17

Puerperal Infection Definition Ø Temperature of 38° C (100. 4° F) or higher after the first 24 hours and occurring on at least 2 of the first 10 days following childbirth Effects Risk factors Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 18

Endometritis Etiology Clinical signs and symptoms Therapeutic management Complications Nursing considerations Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 19

Application of the Nursing Process: Infection Assessment Nursing diagnoses Expected outcomes Interventions Evaluations Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 27

Postpartum Mood Disorders Postpartum depression Incidence Ø Predictors Ø Clinical signs and symptoms Ø Impact on the family Ø Therapeutic management Ø Cultural aspects Ø Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 28

Application of the Nursing Process: Postpartum Depression Assessment Nursing diagnoses Expected outcomes Interventions Evaluations Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 29

Case Study You are the mother-baby nurse providing couplet care to Ms. Hart and her new baby girl Chloe. 36 -year-old G 3 P 1021. Married with husband very involved in care of baby since birth OB history includes history of 2 SABs Current pregnancy result of IVF Uncomplicated C/S 48 hours ago after failed induction and long labor; Apgars 9/9 for baby Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 30

Case Study (Cont. ) Breastfeeding but baby sleepy at the breast and now with elevated bilirubin level—going home with bili blanket Family involved with many visitors since the birth RN now enters the room to provide discharge teaching. During your visit Ms. Hart breaks down in tears and states, “I am so exhausted. This just hasn’t worked out how I imagined. I feel so overwhelmed. ” Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 31

Case Study (Cont. ) 1. What can you say to Ms. Hart, and what suggestions will you make? 2. What would be your plan of care? 3. What might increase her risk of postpartum depression (PPD)? 4. What do you think of the language the team uses to describe the outcome of her induction of labor? How might this affect the mother’s self -esteem? Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 32

Postpartum Anxiety Disorders Panic disorder Postpartum obsessive compulsive disorder Post-traumatic stress disorder Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 34

Question Fran delivered a 9 lb, 10 oz baby 1 hour ago. When you arrive to perform her 15 -minute assessment, she tells you that she "feels all wet underneath. " You discover that both pads are completely saturated and that she is lying in a 6 -inch diameter puddle of blood. What is your first action? a. b. c. d. Call for help Assess the fundus for firmness Take her blood pressure Check the perineum for lacerations Copyright © 2014, 2010, 2006, 2002, 1998, 1994, by Saunders, an imprint of Elsevier Inc. 35