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M6 13-005

Exam 10: Postpartal Complications

Postpartum Hemorrhage blood loss greater than 500 ml after vaginal birth, or 1000 ml after cesarean birth.
Postpartum Hemorrhage (Hemat) A more measurable definition is a decrease in hematocrit of 10 percent or more since admission.
Postpartum Hemorrhage (Two Types) Early postpartum hemorrhage.  Late postpartum hemorrhage.
Early Postpartum Hemorrhage Hemorrhage that occurs within 24 hours of delivery.
Early Postpartum Hemorrhage (Causes) Uterine Atony. Trauma.
Uterine Atony lack of muscle tone that results in failure of the uterine muscle fibers to contract firmly around blood vessels when the placenta separates.
Uterine Atone Predisposing Factors Over-distension of the uterus Intrapartum factors Augmented labor with oxytocin DIC Multiparity
Uterine Atony Clinical Signs Uterus is difficult to palpate, Boggy (soft) The fundal height is high Excessive lochia
Uterine Atony Therapeutic Management Massage the fundus until it is firm Assist mother to urinate if full bladder Rapid IV infusion of oxytocin (Pitocin)
Uterine Atony Pharmacological Measures oxytocin (Pitocin) methylergonovine (Methergine) prostaglandin (Hemabate, Prostin) misoprostol (Cytotec)
Uterine Atony Surgical Management Exploration Ligation Hysterectomy
Uterine Atony Nursing Management Assess fundus When assessing, NO FULL BLADDER.
Early Postpartum Hemorrhage Trauma Predisposing Factors: -uterine atony -Induction and augmentation of labor -assistive devices
Lacerations: Causes Cervical Lacerations. Lacerations of the vagina, perineum & periurethral. Bleeding from lacerations often is bright red & maybe heavy or may have a steady trickle of blood.
Hematomas Resulting from birth trauma are usually on the vulva or inside the vagina.
Hematomas: S/S & Predisposing Factors Prolonged or rapid labor. Large baby. Use of forceps or vacuum extract.
Hematomas: Medical Treatment 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.
Late Postpartum Hemorrhage: Most Common Causes Subinvolution Fragments of placenta that remain attached to the myometrium when the placenta is delivered.
Subinvolution Failure of the uterus to return to normal size following childbirth.
Late Postpartum Hemorrhage: Predisposing Risk Factors Attempts to deliver the placenta before it separates from the uterine wall. Manual removal of the placenta. Placenta accreta. 
Late Postpartum Hemorrhage: Therapeutic Management Initial treatment - control of excessive bleeding. -Oxytocin, Methergine, and prostaglandins are the most commonly used pharmacologic measures. Dilation and curettage may be necessary to remove fragments if bleeding continues or recurs. Antibiot
Late Postpartum Hemorrhage: Nursing Intervention Assess frequently for a resumption of bleeding Allow rest periods Assist in getting out of bed Encourage intake of foods high in iron. If problems arise, act to minimize hemorrhaging
Hypovolemic Shock: Causes Excessive Blood Loss
Hypovolemic Shock: Clinical Signs and Symptoms Tachycardia.   Increased respiratory rate. Decreased blood pressure. Skin and mucous membranes become pale, cold and clammy. Anxiety, confusion, restlessness and lethargy. Urinary output decreased.
Hypovolemic Shock: Nursing Interventions Vital signs The location and consistency of the fundus, amount of lochia, skin temperature and color and capillary refill are assessed. A pulse oximeter Labs Urinary catheter Vasopressors may be needed
Subinvolution of the Uterus : Common Causes Retained placenta. Pelvic infection.
Subinvolution of the Uterus: Signs and Symptoms Prolonged discharge of lochia. Irregular or excessive uterine bleeding. Pelvic pain or feelings of pelvic heaviness. Backache, fatigue and persistent malaise.
Subinvolution of the Uterus: Therapeutic Management correcting the cause of the subinvolution.
Subinvolution of the Uterus: Nursing Considerations Teach mom & family how to assess for condition. How to locate and palpate the fundus and estimate fundal height. Explain changes of lochia from lochia rubra to lochia serosa and then to lochia alba. Report any deviation or duration of lochia.
Lochia Rubra occurring immediately after childbirth, consisting of blood (dark Red), fragments of decidua, and mucus. It usually lasts from 1 to 3 days.
Lochia Serosa vaginal discharge occurring 3 to 10 days after delivery. It is pink or brown-tinged and contains blood, mucus, and leukocytes.
Lochia Alba final vaginal discharge after childbirth, largely mucus, when the amount of blood is decreased and the leukocytes are increased; it is usually of 10 to 14 days' duration but may last for 6 weeks.
Thromboembolic Disorders: Major Causes Venous Stasis. Hypercoagulation. Blood Vessel Injury.
Venous Stasis Compression of large vessels of the legs and pelvis.
Hypercoagulation Due to the changes in the coagulation and fibrinolytic systems that persist into the postpartum period.
Blood Vessel Injury May occur during vaginal or cesarean birth and could trigger a pelvic vein thrombosis.
Thromboembolic Disorders: Predisposing Factors Varicose veins. Obesity. History of thrombophlebitis. Use of oral contraceptives before pregnancy. Smoking. Women older than 35 years or who have had more than three pregnancies are also at increased risk.
Superficial Venous Thrombosis (SVT): Signs and Symptoms Swelling of the involved extremity. Redness, tenderness and warmth. An enlarged, hardened, cordlike vein may be palpated. The woman may experience pain when walking. Often there are no signs at all.
Superficial Venous Thrombosis (SVT): Therapeutic Management Analgesics, rest, and elastic support. Elevation of the lower extremity improves venous return. Warm packs may be applied to promote healing. Avoid standing for long periods and should continue to wear support hose to prevent subsequent episodes.
Deep Vein Thrombosis (DVT): S/S Swelling of the leg. Erythema, heat or tenderness. Pedal edema. Positive Homan’s Sign. Affected leg may become pale and cool to the touch with decreased peripheral pulses. Pain on ambulation. Chills, general malaise. Absent signs in 75%
Deep Vein Thrombosis (DVT): Diagnosis Ultrasonography with vein compression. Doppler flow analysis. MRI may be used for pelvic veins.
DVT : Therapeutic Prevention Identifying high risk Ambulate or Range of Motion Antiembolism stockings or sequential compression devises Lifestyle changes
DVT : Therapeutic Treatment when a DVT occurs includes BR, elevating the affected leg. Gradual ambulation. Anticoagulant therapy Analgesics to control pain. Antibiotic therapy to prevent or control infection. Continuous moist heat for pain relief and increase circulation.
DVT Therapeutic Management: Subsequent Treatment Heparin During the postpartum period, heparin can be changed to warfarin (Coumadin) therapy and may be continued for 6 weeks to 6 months.
Thromboembolic Disorders Nursing Management: Assess mother before and after childbirth Palpate pedal pulses Assess the affected and unaffected Determine the degree of discomfort present and treat as ordered.
Deep Vein Thrombosis (DVT): Monitor Signs of bleeding Be alert for signs of Hemorrhage. Monitor for pulmonary embolism.
Deep Vein Thrombosis (DVT): Patient Teaching Instruct the woman in measures to prevent excessive anticoagulation. Explain the need for repeated labs to regulate the dose of the anticoagulants.
Name two risk factors for thrombosis common in pregnancy? Increased clotting factors & venous stasis.
What are signs and symptoms of a pulmonary embolism? Sudden chest pain, cough, dyspnea, depressed consciousness & signs of heart failure.
Puerperal Infections bacterial infection after childbirth.
Puerperal Sites for Infections Endometritis Wound Infections -Episiostomy -Lacerations -Surgical Incision Mastitis. UTIs. Septic Pelvic Thrombophlebitis.
Puerperal Infection: S/S Temperature of 38C (100.4 F) or higher after the first 24 hours.  Localized redness, edema, and pain. Fever, malaise, achiness and loss of appetite.
Puerperal Infection: Predisposing Risk Factors Childbirth. Breastfeeding.   Cesarean birth. Use of forceps or vacuum extractor. Prolonged rupture of membranes.  Urinary catheterization. Repeated vaginal examinations during labor. Retained fragments of placenta. Anemia. Poor nutritional state.
Specific Infections: Endometritis An infection of the uterine lining. Inflammation and infection of the endometrium lining (lining of the uterus).
Endometritis: S/S temperature occurs within 36 hours & include: -Chills, malaise, lethargy and anorexia. -Uterine tenderness. -Abdominal pain and cramping. -Foul-smelling lochia. -Leukocytosis after the first day that is not decreasing.
Endometritis: Therapeutic Management Culture and sensitivity of the uterine cavity. IV Antibiotics usually clindamycin plus gentamicin are often used until the woman has been afebrile for 48 hours. Analgesics such as antipyretics for fever.
Endometritis: Complication major risk of endometritis is that the infection may spread to the nearby organs.
Endometritis: Nursing Intervention Keep Pt in fowlers (helps drainage). Pain meds. Observation of: -Spread of infection. -Absent bowel sounds. -Abdominal distention. -Nausea or vomiting. -Increasing abdominal pain.
Endometritis: Patient Teaching Teach woman usual progression of lochia to include color and smell.
Wound Infection Most commonly occurs in cesarean surgical incisions, episiotomies or lacerations.
Wound Infection: S/S Inflammation (redness, edema, warmth, pain). Separation of suture line. Purulent drainage. Fever and malaise.
Wound Infection: Therapeutic Management Draining the affected area as needed. Culture and sensitivity of wound exudates. Broad-spectrum antibiotics may be ordered. Analgesics.
Wound Infection: Nursing Interventions -Aseptic/sterile technique for all wound care. -Teach proper perineal hygiene. -Sitz baths for perineal infection. -Teach the patient to report fever or increased pain.
Urinary Tract Infections: S/S Typically begin on the first or 2nd postpartum day. Include:. Dysuria, urgent and frequent pee. Suprapubic pain. Low-grade fever. Chills, spiking fever, flank pain and nausea and vomiting occur it it goes up. 
Urinary Tract Therapeutic Management Clean-catch or catheterized urine for culture and sensitivity. Broad-spectrum IV antibiotics. Increased fluid intake 3000ml fluid each day.
Urinary Tract Nursing Interventions Take all meds as prescribed. Increase fluid intake. (dilutes bacteria). Foods that increase acidity of urine. Proper perineal care & frequent urinary care.
What are the most likely sites for postpartum infections? Episiotomy, laceration, surgical incision, uterus, urinary tract and breast.
Name three nursing interventions to teach UTI prevention. Hygiene, fluids.
Mood Disorders disturbances in function, affect, or thought process that can affect the family as severely as physiologic problems
Postpartum Depression: Most common. It occurs in 19% of woman usually developing between the first 3 months postpartum
Postpartum Depression Predictors Combination of biologic, psychosocial and situational stressors.
Postpartum Depression: Other Pactors Hormonal fluctuations Medical problems during pregnancy or after childbirth Personal or family history of depression or mental illness.
Postpartum Depression: Risk Factors Marital dysfunction or lack of support. Anger or ambivalence about the pregnancy. Feelings of isolation, lack of support. Fatigue. Financial worries. Birth of an infant with illness or anomalies. Multifetal pregnancy. Chronic stressors.
Postpartum Depression: S/S Lack of enjoyment in life and food. Disinterest in others. Feelings of inadequacy, unworthiness, guilt, shame and inability to cope. Loss of mental concentration. Constant fatigue. Suicidal feelings and panic attacks occur. Withdrawn.
Postpartum Depression’s Impact on the Family Postpartum depression impacts and creates strain for the entire family. Communication is impaired. Infants of depressed mothers are at risk for later cognitive and behavioral problems.
Postpartum Depression Nursing Care Although early treatment is important, women often do not seek treatment. -Depression Assessment During Pregnancy. -With infant, assess Mom's emotional state. -Observe subjective -Assess objective -Determine family support -Convey a caring attit
Postpartum Depression Patient Teaching Teach mothers the signs of postpartum depression and when they should seek help Teach and model behavior to show the mother how to respond to their infants cues Include the father in discussion
Bipolar Disorder Disorder characterized by periods of depression and hypomanic episodes. Periods of irritability, hyperactivity, euphoria. Need to be assessed for risk of suicide or harming infant. Treatment is with medications and psychotherapy.
Postpartum Psychosis Occurs in 1 to 2 out of 1000 postpartum women. It generally surfaces within 3 months of delivery. -Suicide and infanticide are possible, especially during depressive episodes.
Postpartum Psychosis: S/S Sleep disturbances, confusion, agitation, irritability. Hallucinations and delusions ↑ the risk that the mother will kill herself or her baby. Tearfulness. Feelings of worthlessness. Lack of appetite. Excessive concern w/ baby’s health. Withdrawn.
Postpartum Psychosis: Assessment & Management Beyond the scope of nursing. Mom's who experience postpartum psychosis referred to psychiatric specialists. Once S/S are recognized, the woman requires immediate medical attention and hospitalization. Postpartum psychosis is a medical emergency!
What might the infant and mother be at risk for if the mother is suffering from major depression? Death
What are the three types of mood disorders related to the postpartum period? Postpartum blues, depression & psychosis.
Created by: jtzuetrong