Complications of the Post-Partal Period

1. Complications of the Post-Partal Period

2. Postpartum Hemorrhage • Definition • Early-postpartum hemorrhage of >500cc within the first 24hrs. postpartum • Late-postpartum hemorrhage of >500cc after the first 24 hrs postpartum

3. Postpartum Hemorrhage • Predisposing Factors • Multiparity • Macrosomia • Bladder distention • Oxytocin augmentation/induction • Preeclampsia, • Asian or Hispanic heritage • Retained placenta • Placenta previa • Dysfunctional labor • Prolonged 3rd stage of labor

4. Postpartum Hemorrhage • Causes • Early • Uterine Atony • Most common 2nd to over distention of uterus or tired muscle • Lacerations in vagina • Hematoma • Uterine Inversion

5. Postpartum Hemorrhage • Causes • Late • Retained placental fragments • Most common cause of late pp hemorrhage • Infection • Backache, foul smelling lochia, leukorrhea • Uterine Subinvolution • Fundal height is greater than expected, lochia fails to progress from rubra to serosa to alba normally.

6. Postpartum Hemorrhage • Prevention • Adequate prenatal care • Good nutrition • Avoidance of traumatic procedures • Risk assessment • Early recognition and management of complications

7. Signs of Hemorrhage (Olds, 2008)

8. Postpartum Hemorrhage • Nursing Care • Assessment • Fundus-uterine massage if a soft, boggy uterus is detected • urinary output-if inadequate ask pt. to void or catheterization may be required • Vital signs • Lochia-note color and amount • Weigh pads/chux • Hgb/hct • A decrease in Hgb of 1.0-1.5g/dl or a decrease in HCT of 2-4% reflects a blood lossof 450-500ml

9. Postpartum Hemorrhage • Nursing Care • Intervention • Fundal massage-immediate and most effective intervention • Empty bladder • Position with legs elevated • Keep pt. informed • Administer O2 • Notify PCP • Initiate IV if none, in severe hemorrhage place second IV

10. Estimating Blood LossIdeal Method=Weighing • 250cc • 1cup • 5cm clot (orange) • 355 cc • 12oz soda can • 500 cc • 2 cups • 10cm clot (softball)

11. Administer Uterotonics • Medications used: • Pitocin (Oxytocin)—increase IV rate for bolus • Methergine (Methylergonovine Maleate) adrenergic antagonist 0.2-0.4 mg p.o. or 0.2 mg q 2-4hr IM or IV • Check BP due to risk of hypertensive crisis, (do not give to patients with PIH) • Prostaglandins-for more critical situations • Hemabate (Carboprost tromethaminie), (do not give to patients with Asthma) • Prostin/15 M (dinoprostone) to decrease blood loss 2nd to uterine atony. 250 mcgs (1ml) IM repeated q 1.5-3.5 hrs. • Cytotec (misoprostol)600-1000 mcg rectally (only if others not available or have failed)

12. Nursing Care for postpartum hemorrhage • Intervention • Patient teaching • Provide clear explanations about condition and the importance for the need to recover • Rise slowly to minimize orthostatic hypotension • Encourage to sit while holding the newborn • Encourage to eat foods high in iron • Continue to observe for signs of hemorrhage or infection

13. Vulvar, Vaginal, and Pelvic Hematoma • Causes • Results from an injury to a blood vessel without noticeable trauma to superficial tissue such as after a forceps delivery. Soft tissue (labia majora or perineal area) can hold 250-500 cc’s of blood.

14. Hematomas • Predisposing factors • Preeclampsia • Pudendal anesthesia • First full-term birth • Precipitous labor • Prolonged seconds stage • Macrosmia • Forceps or vacuum assisted birth • Vulvar varicosities

15. Vulvar Hematoma • Symptoms • Severe pain-rectal pressure • Area is very painful to touch • Firm to touch • Skin may be discolored-reddish • Unable to void due to pressure on the urethra • Can be hard to detect if hematoma is high in vagina • Flank pain • Abdominal pain • Decreased lochia • *signs of shock*

16. Hematomas • Nursing intervention • Apply ice packs and analgesia • Typically resolve on own over several days • Medical treatment • For hematomas > 5 cm and those that expand • Incision and drainage of hematoma is needed

17. Puerperal Infection • Definition-infection with temp>100.4 or 38 degrees on 2 occasions after 1st 24 hours.

18. Puerperal Infection • Predisposing factors • C-section • Prolonged premature ROM • Prolonged labor preceding c-section • Multiple VE • Compromised health status • Low socioeconomic status, anemia, obesity, smoking, poor nutrition • FECG, IUPC • Obstetric trauma • Episiotomy, lacerations • Chorioamnionitis • Vacuum, forceps • Manual removal of placenta • Diabetes mellitus

19. Puerperal Infection • Assessment • R: redness • E: edema • E: ecchymosis • D: discharge • A: approximation

20. Puerperal Infection • Signs/Symptoms • Foul smelling lochia • Increased temp >38.4 p first 24 hrs pp • Tenderness of fundus upon palpation • Fever • Malaise • Abdominal pain • Larger than expected uterus • Tachycardia

21. Puerperal Infection Nursing Care • Treatment/Prevention • Good perineal care • Hygiene practices to prevent contamination of the perineum • Thorough handwashing • Sitz baths • Adequate fluid intake • Diet high in protein and vitamin C

22. Thromboembolic Disease • Seen in 1% of vaginal deliveries and 2-20% of c-sections • Definition • Venous thrombosis is a clot in a superficial or deep vein (femoral vein is common site), dangerous when clot loosens from wall of vein and becomes an embolism, which can travel to the heart, brain, or lungs.

23. Thromboembolic Disease • Thrombophlebitis • Occurs when a clot forms b/c of an inflammation of the vein wall-usually clot is more adherent to vein walls thus a lesser chance of becoming an embolism

24. Thromboembolic Disease • Predisposing factor of clot formation • Increased amount of blood clotting factors, i.e. increased number of circulation platelets

25. Thromboembolic Disease (from Olds, 2008 • Who is at risk

26. Thromboembolic Disease • Symptoms • Positive homan’s sign-may occasionally be neg • Redness, swelling, pain at site • Low grade fever

27. Thromboembolic Disease • Treatment • Local heat • Elevate limb • Bedrest • Analgesics • TED hose • Anticoagulant (heparin. Coumadin)

28. Thromboembolic Disease Prevention • Early ambulation • TED hose, SCD’s • No smoking • Elevate legs when sitting • Avoid prolonged standing or sitting (contribute to venous stasis) • Avoid crossing legs • Take frequent breaks while taking car trips

29. Pulmonary Embolism • Definition • When a clot traveling through the venous system becomes lodged within the pulmonary circulatory system, causing an infarction or occlusion. • IT IS LIFE THREATENING AND REQUIRES IMMEDIATE INTERVENTION

30. Pulmonary Embolism • Etiology • Usually preceded by deep vein thrombosis • Diagnosis • Verified by • Abg’s, chest x-ray, and pulmonary angiogram

31. Pulmonary Embolism • Symptoms • Dyspnea • Tachypnea and tachycardia • Substernal, chest or pleuritic pain • Cough • Hemoptysis • Apprehension • Paleness or cyanosis or both

32. Pulmonary Embolism • Treatment • Two primary goals • Anticoagulation (IV Heparin) • Cardiorespiratory support (O2 per mask, Aminophylline, IV fluids) • Additional treatment • Fibrinolytic therapy (streptokinase or urokinase) may be used to lyse clots. • Pain management may include IV narcotics (demerol or morphine) • Arrhythmias may also require Lidocaine IV

33. Cystitis (UTI) • Etiology • Escherichia coli causative agent in most cases of postpartal cystitis • Predisposing factors • Retention of residual urine • Non aseptic technique during catheterization • Bladder trauma from childbirth

34. Cystitis (UTI) • Assessment • Frequency and urgency • Dysuria • Nocturia • Hematuria • Suprapubic pain • Slightly elevated temperature • Diagnosis • Clean catch urine midstream is obtained and sent for microscopic study and culture and sensitivity

35. Cystitis (UTI) • Prevention/Nursing Care • Good perineal hygiene • Good fluid intake • Frequent emptying of the bladder • Assist the woman to a normal voiding position • Provide medication for pain • Perineal ice packs • Frequent monitoring of the bladder • Void before and after intercourse • Cotton underwear • Increase acidity of the urine • Teach s/s of UTI

36. Cystitis (UTI) • Treatment • Antibiotics • Macrobid, Bactrim DS, Septra DS

37. Mastitis • Etiology • Staphylococcus Aureus (found in infants nose and throat) • Infection begins when bacteria invade the breast tissue after it has been traumatized or milk stasis occurs (milk acts as favorable medium for the invasion of bacteria)

38. Mastitis Predisposing factors

39. Mastitis • Assessment • Breast consistency • Skin color • Surface temperature • Nipple condition • Presence of pain • Signs and symptoms • Onset is sudden, p 10 days • Site is unilateral • Localized area, red, hot, swollen • Pain is localized (often wedge shaped) • Temperature .38.4 • Flulike symptoms-fever, chills, ha, muscle aches

40. Mastitis Figure 38–2 Mastitis. Erythema and swelling are present in the upper outer quadrant of the breast. Axillary lymph nodes are often enlarged and tender. The segmental anatomy of the breast accounts for the demarcated, often V-shaped wedge of inflammation.

41. Mastitis • Prevention • Proper feeding techniques • Supportive bra worn at all times to avoid milk stasis • Good handwashing • Prompt attention to blocked milk ducts

42. Mastitis Nursing Care • Teach mother how to pump if necessary • Assist with feelings about being unable to breastfeed • Referral to lactation consultant or La Leche League • Bedrest for 24 hours • Increase fluids • Supportive bra • Frequent feedings • Warm compress • analgesics

43. Mastitis treatment • 7-10 days of antibiotics • Penicillinase-resistant penicillin or cephalosporin • Non-steroidal anti-inflammatory agents to treat fever and inflammation

44. Mastitis-Self care instructions • Importance of regular, complete emptying of the breasts • Good infant positioning and latch-on • Principles of supply and demand • Importance of taking a full course of antibiotics • Report flu-like symptoms

45. Postpartum Disorders • Postpartum Blues • Postpartum Depression • Postpartum Psychosis

46. Postpartum Psychiatric Disorders • Assessment Depression scales Anxiety and irritability Poor concentration and forgetfulness Sleeping difficulties Appetite change Fatigue and tearfulness

47. Postpartum Blues • “Baby” blues occurs 50-75% of mothers • Characterized by mild depression interspersed with happier feelings. • Signs and symptoms-sadness, crying but still able to feel happy • Onset/duration • Transient • Occur 4-5 days pp and last for a few hours or at most 1-2 days • Not culture specific

48. Postpartum Depression • 10-15%of women are clinically depressed at 3 mo. pp. Only 2-3% of these women are referred to a pychiatrist. 25% of mothers depressed in the first 3 mo. Are likely to develop chronic depression

49. Postpartum Depression • Course of symptoms • Get the blues->gets better->then in a few weeks, feels depressed (can last up to a year) • Mother focuses on guilt and inadequacies of being a mother • Chronic tiredness/exhaustion • Tiredness/exhaustion • Low spirits and low tolerance for stress • Can lead to problems r/t baby (irritability and hostility) • ***Some research show a relationship b/t maternal postnatal depression and cognitive development of the child and later behavior patterns***

50. Postpartum Depression • Predisposing Factors/Risk Factors • Lack of social support (single mom, Yuppie mom) • Previous dysmenorrhea • Hx of previous pp depression • Hx of miscarriage • Sever attack of blues p birth • Stress p birth ( marital or housing prob) • Depression in 2nd trimester of pregnancy • Hx of illness • Poor physical maternal health