Postpartum Complications Tracey Whitley BSN RNCOB CEFM Graduate

Postpartum Complications Tracey Whitley, BSN, RNC-OB, C-EFM Graduate Student University of North Carolina at Charlotte

Postpartum Complications �Objectives �Please refer back to your Course 3250 Schedule Postpartum complications- when everything does not go as planned

Emotional Complications �Women are at greatest risk of developing psychiatric disorders during childbearing years �History of disorder �Mood �Anxiety �Substance abuse �Schizophrenia �Personality �Assessment during pregnancy and postpartum is critical �Referral to mental health specialist is recommended �Mental health disorders have implications for the woman and also the entire family

Emotional Complications-Mood �Defined as- primary feature is a disturbance in the prevailing emotional state � 5 signs/ symptoms must be present almost everyday �Depressed mood, often with spontaneous crying �Markedly diminished interest in all activities �Insomnia or hypersomnia �Weight changes (gain or loss) �Psychomotor retardation or agitation �Fatigue or loss of energy �Feeling of worthlessness or inappropriate guilt �Diminished ability to concentrate �Suicidal ideation with or without a plan

Emotional Complications-Mood �Screening �Edinburgh Postnatal Depression Scale �Collaborative care �Medication � Risk vs. benefit of using the drug � Table 32 -1 �Counseling �Nursing care �Education �Respect choice �Coping skills

Emotional Complications-Anxiety �Most common �Nursing care �Empowerment �Includes �Education �Phobias �Sensory interventions �Panic disorders �Behavioral interventions �Generalized anxiety �Muscle relaxation and �Obsessive compulsive guided imagery disorders �Positive self talk and �Post-traumatic stress motivation, question disorders negative thinking �Medication-benzodiazepines and antidepressants (Table 32 -2 and Table 32 -3)

Emotional Complications- Postpartum Depression �Postpartum depression (PPD) is the most common mental health disorder in postpartum period �Up to 60% of women have a mild depression or “baby blues” �Serious depression affects 10 -15% of postpartum women �Postpartum onset is defined as within 4 weeks of birth �Cause can be biological, psychological, situational, or multifactorial

Emotional Complications- Postpartum Depression �Etiology and risk factors �Hormonal changes �History of major depressive disorder �Severe premenstrual dysphoria �Family history of mood disorder �Maritial discord �Lack of a confiding relationship �Stressful life event in the last year �Mood or anxiety symptoms during the pregnancy

Emotional Complications- Postpartum Depression �PPD- without or with psychotic features �Without psychosis �Intense and pervasive sadness with severe and labile mood swings �Intense fears, anger, anxiety, and despondency �Irritability is a distinguishing feature �Guilt, rejection of the infant, and jealousy �With psychosis �Rare (0. 1%-0. 2%) but high reoccurrence (30%-50%) �Auditory or visual hallucinations �Paranoid or grandiose delusions �Delirium or disorientation �Extreme deficits in judgment accompanied by impulsivity

Emotional Complications- Postpartum Depression �Screening �Active listener and observer �Screening tools- Edinburg Postnatal Depression scale �Ask questions in a way that the patient will respond honestly �Care �Patient and family education �Observe mood, appetite, sleep, ability to concentrate

Emotional Complications- Postpartum Depression

Substance Abuse �Often a dual diagnosis �Anxiety and/or depression �Well documented adverse effects on pregnancy and fetus �Risk factors �Socioeconomic factors � Unemployed � Unmarried � Intimate Partner Violence �Mood disorders �Treatment �Less than 10% receive treatment � Social stigma � Fear �Late or no prenatal care �Criminal Charges

Substance Abuse �Drugs most commonly abused: �Nicotine �Caffeine �Alcohol �Opiates � Morphine � Codeine/ hydrocodone etc � Methadone �Illicit drugs � Marijuana (Cannabis) � Cocaine and Methamphetamine � Heroin

Substance Abuse �Screenings �CAGE (box 32 -1) �Historical data �Lab results �Collaborative care �Treatment is individualized �What can the nurse do? (pp. 776 -767) �Be knowledgeable about how to screen and identify those that abuse substances �Determine readiness for change �Uses supportive interventions �Motivational interviewing techniques

Postpartum Hemorrhage �Leading cause of maternal morbidity and mortality in the United States and the world �Often with little to no warning �Unrecognized until profound life threatening symptoms are present �Blood loss is often underestimated by as much as 50% �Typically defined as blood loss �>500 m. L for vaginal deliveries �>1000 m. L for cesarean deliveries

Postpartum Hemorrhage �Onset �Early (acute or primary)- within 24 hours after birth �Late (secondary) more than 24 hours up to 6 -12 weeks postpartum �Risk factors (Box 34 -1) �Uterine atony- marked hypotonia of the uterus (leading cause) �Laceration- cervix, vagina, perineum- bleeding despite firm uterus �Retained placenta �Inversion of the uterus (do not pull on the cord and assess the fundus correctly!)

Postpartum Hemorrhage �Medical management �Hypotonic uterus � Massage � Empty Bladder � Drugs (Oxytocin, Methergine, Prostaglandin)- Chart p. 827 �Uterus is firm- look for source (laceration? ? ? ) �Uterine inversion- emergency � Tocolytics relax uterus � Provider will attempt to replace to normal position � Antibiotics

Postpartum Hemorrhage �Nursing management �Be alert �Prepare to act quickly �Quick non-invasive assessment (Box 34 -3) �Education �Hemorrhagic Shock �May not appear in postpartum woman until she has lost 30 -40% of her blood volume! �Fluid volume replacement and blood replacement �Stop the bleeding!

Postpartum Hemorrhage

Postpartum Infection �Infection of the genital tract occurring within 28 days of a pregnancy end (miscarriage, abortion, birth) �Major cause of morbidity and mortality �Types of infection �Endometritis- most common �Wound infection �Mastitis �Urinary tract infection �Respiratory �C-section more at risk than vaginal �Women with comorbidities or pregnancy complications more at risk

Postpartum Infection �Endometritis �Usually begins at the placenta site �Higher incidence after c-section �Wound infection �Cesarean incision or episiotomy/laceration site �Urinary Tract Infection �Mastitis � 1 st time mothers �Unilateral can progress to breast abscess

Postpartum Infection �Nursing care �Prevention � Education of patient during pregnancy, during hospitalization, and at discharge � Good hygiene � Aseptic technique during childbirth and postpartum period �Supportive care � Give medications as ordered � Encourage hydration � Rest � Pain relief

Perinatal Loss �Causes of perinatal loss �Infertility �Ectopic pregnancy �Miscarriage �Fetal death �Neonatal death �Grief �Painful emotions and related behavioral and physical responses to a major loss

Perinatal Loss �What is grief? �Total response to an emotional experience r/t loss �Affects person emotionally, somatically, cognitively �No time period �No right or wrong �Is different for every person (even within the same family)

Perinatal Loss �Immediate reaction/ acute phase? �Somatic? � Nausea/vomiting/diarrhea � Hyperventilation/ sighing � Palpitations/ chest heaviness � Vertigo/ headache �Behavioral/ cognitive � Feelings- anger, , disbelief, apathy, guilt, hostile, � ADLs- sometimes unable to do the simplest task � Feels like they cannot think/ reason � Shock and numbness- just going through the motions. �Long term- depression, difficulty adjusting back into life, anxiety about next pregnancy, and feeling toward other children.

Perinatal Loss �Family responses �Mom and Father� Differences in genders with grief � Incongruent grief �Grandparents � Unsure of their role � Grieving for the lost child/ baby but also for their child who is suffering � Survivor guilt (death is out of order) �Siblings � Does the sibling’s response depend on age developmental stages? � Less than 6 - viewed as temporary and reversible, may have caused it because of negative thoughts � 6 -12 view death as inevitable and irreversible � Over 12 can think of death abstractly.

Perinatal Loss �Nursing Diagnoses (p. 936) �Anxiety r/t… �Ineffective coping r/t… �Powerlessness r/t… �Interrupted family processes r/t… �Ineffective sexuality pattern r/t… �Fatigue and disturbed sleep pattern r/t… �Complicated grief r/t… �Situational low self-esteem r/t… �Spiritual distress r/t… �Outcomes- parent-centered, mutual goals �Interventions- help, assist, reassure, meet needs, communicate, demonstrate �Evaluation

Perinatal Loss �What is the role of the nurse? �What to say/ do � What are some appropriate things to say to a family that is experiencing a loss? �What NOT to say/ do � Avoid the room/ interaction with the family � Make comments like… � Rush the family with decisions/ time

References �Fishel, A. H. (2012). Mental health disorders and substance abuse in pregnancy. In D. L. Lowdermilk, S. E. Perry, K. Cashion, and K. R. Alden (Eds). Maternity & Women’s Health Care (10 th ed. )(pp. 757 -778). St. Louis, MO: Elsevier Mosby �Lowdermilk, D. L. (2012). Postpartum complications. In D. L. Lowdermilk, S. E. Perry, K. Cashion, and K. R. Alden (Eds). Maternity & Women’s Health Care (10 th ed. )(pp. 824 -836). St. Louis, MO: Elsevier Mosby �Miles, M. S. (2012). Perinatal loss and grief. In D. L. Lowdermilk, S. E. Perry, K. Cashion, and K. R. Alden (Eds). Maternity & Women’s Health Care (10 th ed. )(pp. 931 -949). St. Louis, MO: Elsevier Mosby �Blood loss pictures from Simulation day at Novant Health Forsyth Medical Center, Winston-Salem North Carolina (November 6, 2013). �Pictures of postpartum depression from Google images