Postpartum Module The Woman with a Postpartum Complication

Postpartum Module The Woman with a Postpartum Complication Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc.

Postpartum Hemorrhage Early postpartum hemorrhage (PPH) Ø Late PPH Ø First 24 hours From 24 hours up to 6 weeks postpartum Can sometimes be prevented by careful examination of factors that predispose the woman to excessive bleeding Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 2

Predisposing Factors for PPH Overdistention of uterus Multiparity (>5) Use of tocolytic drugs Precipitate labor or delivery Prolonged labor Use of forceps or vacuum extractor Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 3

Predisposing Factors for PPH (cont. ) Cesarean birth or previous uterine surgery Manual removal of placenta Uterine inversion Previous PPH General anesthesia Placenta previa, accreta, or low implantation Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 4

Predisposing Factors for PPH (cont. ) Drugs: oxytocin, prostaglandins, magnesium sulfate Chorioamnionitis Clotting disorders Disseminated intravascular clotting Uterine leiomyomas (fibroids) Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 5

Uterine Atony Manifestations Fundus is difficult to locate Ø "Boggy" or soft feel to the fundus Ø Becomes firm when massaged Ø Excessive lochia and clots Ø Management Measures to contract the uterus Ø Provide fluid replacement Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 6

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Bimanual Compression Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 9

Perineal Trauma Soft tissue trauma Lacerations Ø Hematomas Ø Management Ø Involves repairing the trauma before excessive blood loss occurs Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 10

Subinvolution Delayed return of the uterus to its nonpregnant size and consistency Retention of placental fragments Ø Infection Ø Nurses should teach the family signs and symptoms that may need to be reported to the health care provider. Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 11

Hypovolemic Shock During and after birth, women can tolerate a blood loss approaching that of blood added during pregnancy. Ø 1500 to 2000 m. L Compensatory mechanisms maintain the blood pressure so that vital organs are perfused. Hypovolomia occurs with excessive blood loss. Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 12

Early Signs of PPH Uncontracted uterus Large gush or slow, steady trickle of blood from vagina Saturation of more than one peripad per 15 minutes Severe, unrelieved perineal or rectal pain Tachycardia Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 13

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. Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 14

Case Study (cont. ) 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 light-headed. " Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 15

Case Study (cont. ) Questions What should the nurse do? 2. What are Ms. Avery's risk factors for PPH? 3. What should the medical management include? 1. Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 16

Thrombus Formation Venous stasis Increased levels of coagulation factors Decreased levels of thrombolytic factors Blood vessel injury Deep vein thrombosis Pulmonary embolism Anticoagulant therapy Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 17

Factors that Increase the Risk of Thrombosis Inactivity or bed rest Obesity Cesarean birth Smoking History of previous thrombosis Varicose veins Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 18

Factors that Increase the Risk of Thrombosis (cont. ) Diabetes mellitus Trauma Prolonged labor Prolonged time in stirrups in second stage of labor Maternal age 30 years or older Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 19

Factors that Increase the Risk of Thrombosis (cont. ) Increased parity Use of forceps Antiphospholipid antibody syndrome Inherited thrombophilias Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 20

Question To provide optimum care for the postpartum woman, the nurse understands that the most common causes of subinvolution are _____. PPH and infection B. multiple gestation and PPH C. uterine tetany and overproduction of oxytocin D. retained placental fragments and infection A. Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 21

Puerperal Infection (Bacterial infections after birth) Most common postpartum infections: Endometritis: infection of the inner lining of the uterus) Wound infection Urinary tract infection Mastitis Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 22

Signs and Symptoms of Postpartum Infection Fever, chills Pain or redness of wounds Purulent wound drainage or wound edges not approximated Tachycardia Uterine subinvolution Abnormal duration of lochia, foul odor Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 23

Signs and Symptoms of Postpartum Infection (cont. ) Elevated white blood cell count Frequency or urgency of urination, dysuria, or hematuria Suprapubic pain Localized area of warmth, redness, or tenderness in breasts Body aches, general malaise Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 24

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Nursing Considerations for Mastitis Antibiotics Maintain lactation: breastfeeding or pumping every 1. 5 – 2 hours helps with comfort and milk stasis – have mom start on unaffected side Massage and warm compresses/shower Encourage fluid intake – should be 2500 -3000 ml per day Analgesics Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc. 26

Nursing Assessment of Postpartum Infection Fever/chills Pain or redness of wounds Change in vital signs; Tachycardia Uterine subinvolution Abnormal duration of lochia, foul ordor Elevevated WBC Frequency of urination, dysuria or hematuria Suprapubic pain Localized areas of warmth, redness or tenderness in the breasts Body aches or general malaise ‘flu like symptoms’ Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc. 27

Postpartum Mood Disorders Postpartum blues Postpartum depression A disabling affective disorder that affects the entire family Ø Begins after birth and lasts at least 2 weeks Ø Postpartum psychosis Ø A much more rare condition Bipolar disorder Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 28

Anxiety Disorders Panic disorder Tachycardia, shortness of breath Ø Fear of dying or "going crazy" Ø Postpartum obsessive-compulsive disorder Ø Consuming thoughts of harming the baby Postraumatic stress disorder Ø Women perceive childbirth as a traumatic event. Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 29

Nursing Education around Postpartum Mood Disorders Provide anticipatory guidance Acknowledgment and demonstrated caring Help mother verbalize her feelings Enhance sensitivity to infant cues and model behaviors to show mother how to respond Help family members Discuss options and resources Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc. 30

Case Study You are the mother-baby nurse providing couplet care to Ms. Hart and her new baby girl, Chloe. Data 36 -year-old G 3 P 1021. Married with husband very involved in care of baby since birth. Ø OB history includes history of 2 SABs. Current pregnancy result of IVF. Ø Uncomplicated C/S 48 hours ago after failed induction and long labor. Apgars 9/9 for baby. Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 31

Case Study (cont. ) Data (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. Ø RN now enters 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. " Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 32

Case Study (cont. ) Questions 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? 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? 1. Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 33