Postpartum Complications Twila Brown Ph D RN Postpartum

Postpartum Complications Twila Brown, Ph. D, RN

Postpartum Hemorrhage n n n Blood loss greater than 500 m. L Early postpartum hemorrhage – First 24 hours after delivery » Uterine atony » Lacerations of the genital tract » Hematomas » Uterine rupture Late postpartal hemorrhage – Usually 1 -2 weeks – Retention of placental tissue

Early Postpartal Hemorrhage: Uterine atony n Causes – Over distention – Dysfunctional labor – Induction – Cesarean – Grand multiparity – Preeclampsia – Retained placenta fragments – Asian or Hispanic n Assessment – Fundus » Soft » Difficult to find » Above expected level – Lochia » Excessive » Bright red » Clots

Early Postpartal Hemorrhage: Uterine atony n Interventions – Assess for bleeding – Assess fundal height – Encourage voiding – Oxytocin (Pitocin) – Fundal massage – Contact physician – Methylergonovine (Methergine) – IV fluid and/or transfusion – Bimanual compression of uterus – Ligation of uterine vessels or hysterectomy

Early Postpartal Hemorrhage: Lacerations n n n Perineal, vaginal, cervical Predisposing factors – Primiparous – Precipitous delivery – Macrosomia – Forceps or vacuum-assisted birth – Mediolateral episiotomy Assessment – Firm uterus – Bright red blood – Stream of unclotted blood

Early Postpartal Hemorrhage: Hematomas n n n Blood in soft subcutaneous tissue Predisposing factors – Prolonged pressure of fetal head – Forceps or vacuum extraction – Prolonged or precipitous labor – Macrosomia – Pudendal anesthesia Subperitoneal hemotoma – Uterine artery branch or vessels in broad ligament – Severe pain and hypovolemic shock

n Early Postpartal Hemorrhage: Hematomas Vaginal – Assessment » Unilateral purplish discoloration » Pain » Feeling of fullness in vagina or rectal pressure » Difficult voiding – Intervention » Analgesia » Ice packs » Sitz bath » Surgery

Late Postpartum Hemorrhage n Assessment – Subinvolution – Lochia » Fails to progress from rubra to alba » Saturation of more than 1 pad per hour » Abnormal clots – Bladder distention – Increased rectal, back, or pelvic pain – Increased pulse or decreased blood pressure – Signs of anemia

Late Postpartal Hemorrhage n Intervention – Teach » Signs of hemorrhage » Massage fundus » Iron administration – Pitocin or Methergine – IV fluid or blood transfusion, – Oxygen – Dilation and curettage

Puerperal Infections n n Reproductive tract associated with childbirth – Metritis, perineal or cesarean wound Causes of metritis – Cesarean - Prolonged labor – PROM - Multiple vaginal exams – Scalp electrodes - Internal uterine monitor – OB trauma - Instrument assisted birth – Manual removal of placenta – Prexisting infection – Compromised health status

Puerperal Infections: Metritis n Assessment – Abd/Uterine pain – Foul smelling vaginal discharge – Fever 101 -104 F – Chills – Malaise – 30% increase in WBC n Interventions – CBC – Cultures – Hygiene – Abscess is drained – IV antibiotics – Antipyretics – ICU hospitalization

Puerperal Infections: Perineal and Cesarean wounds n n n Perineal wound – Assessment Cesarean wound – Assessment Intervention – Sutures removed – Drain purulent material – Antibiotics – Analgesics – Warm compress or sitz baths

Overdistention of the Bladder n n n Cause – Unable to empty bladder due to trauma or anesthesia Assessment – Distended bladder – Displaced uterus, increased vaginal bleeding, boggy uterus, backache, restless Intervention – Encourage voiding – Perineal ice packs – Pour water over perineum – Aseptic straight catheter X 1

Urinary Tract Infections n n Cause – Retention of urine – Bacteria from catheterization Cystitis – Assessment – Intervention » Increase fluids >> Void frequently » Empty bladder >> Urine culture and antibiotics – Prevention » Hygiene » Void q 2 -4 hrs » Increase acidity in urine

Urinary Tract Infections n Pyelonephritis – Assessment » UTI signs >> High fever » Chills >> Flank pain » N&V >> Acutely ill – Management » IV antibiotics >> Increase fluids » Antipyretics >> Analgesic » Follow-up culture in 2 weeks

Mastitis n n n Infection of breast tissue Causes – Bacteria enters through cracks in nipple – Milk stasis – Poor hand washing – Breast not dry or wet breast pad – Incorrect placement of baby causes sore nipples Assessment – Fever > 101 F and chills, acutely ill – Flu-like symptoms, malasia, headache – Painful, warm, red area of breast

Mastitis n n Intervention – Bed rest - Increase fluids – Supportive bra - Antibiotics – Analgesic – Breast feed frequently – Warm compress before feeding – Cold packs between feedings – Drain abscess Prevention – Early feedings and frequent feedings – Change baby’s feeding positions – Massage clogged duct – Empty breast at each feeding – Nipple care

Thromboembolic Disorders n n Blood clot formed from impeded blood flow Causes – Hypercoagulability of blood – Venous stasis – Injury to epithelium of vessels Increased risk Prevention – Avoid dehydration – Avoid trauma to legs in stirrups – Early postpartum ambulation – Leg exercises to support venous return – No smoking – Antiembolism stockings

Thromboembolic Disorders n Superficial thrombophelbitis – 3 to 4 th day after delivery – Assessment » Tenderness >> Localized heat » Swelling >> Redness » No or low fever – Intervention » Elevate leg >> Bed rest » Local moist heat >> Analgesia » Support hose – Little risk of pulmonary embolism

Thromboembolic Disorders n Deep vein thrombosis » 10 to 20 days after delivery – Assessment » Swelling » Pain » Erythema » Heat » Pedal edema » Low to high fever » Positive Homan’s » Sometimes decreased perfusion » Chills

Thromboembolic Disorders n Deep vein thrombosis – Intervention » Bed rest >> Elevate leg » Analgesia >> Antibiotics » Anticoagulant therapy n IV heparin n Coumadin for 2 to 6 months » Monitor for pulmonary embolism » Antiembolism stockings after symptoms:

Thromboembolic Disorders n Pulmonary embolism – Clot moves to pulmonary artery – Assessment » Dyspnea >> Chest pain » Cough >> Hemoptysis » Cyanosis >> Hypotension » Tachypnea >> Tachycardia – Treatment » Alert physician >> Elevate head of bed » Oxygen >> Narcotics » Anticoagulation with heparin

Psychiatric Disorders: Adjustment reaction with depressed mood n n n Postpartum blues or baby blues Assessment – Within a few days after delivery and last a few hours to 10 or more days – Mild depression with interspersed happier feelings – Tearful without reason – Feel overwhelmed, unable to cope, fatigued, anxious, irritable, oversensitive Intervention – Provide reassurance – Assist with self and infant care

Psychiatric Disorders: Post partum major mood disorder Postpartum depression n Assessment n – During first year - 4 th week to 3 months – Sad/frequent crying – Poor decision making – Insomnia or excessive sleeping – Appetite change – Feelings of worthlessness – No interest in activities – Feel inadequate as a mother

Psychiatric Disorders: Post partum major mood disorder n n Risk factors – Primiparity – Ambivalence to pregnancy – History of depression – Lack of support Treatment – Medication – Risk for suicide – Group and individual therapy – Assistance with child care and ADL’s

Psychiatric Disorders: Postpartum psychosis n Risk factors – Previous psychosis n Assessment – – – n - Poor social support Seen within 3 months Insomnia Labile mood Irrational thoughts Poor judgment - Agitation - Hyperactivity - Confusion - Poor concentration - Delusions/Hallucinations Intervention – – – Hospitalization - Antipsychotic medication Social support - Psychotherapy Considered an emergency due to suicide/infantcide risk

References n n n n Hogan, M. A. , & Glazebrook, R. S. (2007). Maternal-newborn nursing: Reviews and rationales. Upper Saddle River, NJ: Prentice Hall. Ladewig, P. A. , London, M. L. , & Davidson, M. R. (2006). Contemporary maternal-newborn nursing care (6 th ed. ). Upper Saddle River, NJ: Prentice Hall. Littleton, L. Y. , & Engebretson, J. C. (2005). Maternity nursing care. Clifton Park, NY: Thomson Delmar Learning. Murray, S. S. , & Mc. Kinney, E. S. (2006). Foundations of maternal-newborn nursing (4 th ed. ). St. Louis, MO: Saunders. Olds, S. B. , London, M. L. , Ladewig, P. W. , & Davidson, M. R. (2004). Maternal-newborn nursing & women’s health care (7 th ed. ). Upper Saddle River, NJ: Prentice Hall. Silvestri, L. A. (2002). Saunders comprehensive review for NCLEX-RN (2 nd ed. ). Philadelphia: W. B. Sanders. Straight A’s in maternal-neonatal nursing. (2004). Philadelphia: Lippincott Williams & Wilkins.

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