Postpartum Complications

1. Postpartum Complications Identify Risk Factors Apply PP Assessment Skills Compare Types of PP Hemorrhage Discuss PP Infection Discuss Thromboembolic Disorders Compare PP Depression w/ Psychosis Plan Nursing Interventions

2. PP Complications • Assess postpartum client's prenatal history and ongoing labor/birth to identify risk factors leading to postpartum complications • Assess with knowledge that many physiologic changes of postpartum period are similar to depression • Document specific and objective observations

3. Risk Factors for Complications • Overdistention of uterus due to large baby, multiple gestation, multiparity • Rapid or prolonged labor • Oxytocin induction of labor • Precipitous induction of labor • Precipitous delivery, cesarean section • PROM • Urinary catheterization

4. Vital Signs • Elevated temperature • Temperature elevations should last for only 24 hours • After 24 hours > 100.4°F (38ºC) = infection • Elevated heart rate • Decreased blood volume - bradycardia rates of 50 to 70 beats per minute occur during first 6 to 10 days • Tachycardia = Increased blood loss, difficult labor/birth • Elevated blood pressure, low blood pressure • Blood pressure should be stable, may be decreased • Symptoms of shock • Breath sounds clear

5. BUBBLEHE ASSESSMENT • B = Breast • U = Uterus • B = Bladder • B = Bowels • L = Lochia • E = Episiotomy, Laceration, C/S Incision • H = Homan’s sign, Hemorrhoids • E = Emotional status, bonding

6. BUBBLEHE Assessment • Breasts – Cracked, blistered, or bleeding nipples • Note engorgement, red streaks, lumps, clogged milk ducts • Assess for mastitis • Erythema, heat in breast • Fever, chills, malaise, headache • Engorgement, pain • Supplemental feedings • Change in routine or infant feeding patterns • Abrupt weaning • Treatment: Proper latch-on technique, encourage frequent feeding, position changes during feedings, fluid intake 3000mL/day, antibiotics, analgesics, warm compresses, can breastfeed or pump w/ mastitis

9. BUBBLEHE Assessment • Uterus – Position height, tone (bogginess), position out of midline, heavy lochia flow • Uterine atony - Lack of uterine muscle tone - caused by conditions that overdistend uterus and affect uterine contractibility, and medication • Perform fundal massage and check for clots • Administer uterine stimulants (oxytocin) as ordered to monitor for side effects • Uterus is firm and if there is bright red bleeding - this may indicate laceration • Contact physician – need for suture of laceration

10. BUBBLEHE Assessment • Bladder - Assess frequency, burning, or urgency - palpate for bladder distention • Have patient void frequently • In & Out catheterize if necessary • Insert indwelling urinary catheter – color, odor, amount • Bowel: Assess bowel sounds, flatus, and distention • Increase fluids and fiber in diet • Administer stool softeners

11. BUBBLEHE Assessment • Lochia - examine perineal pads - Note • Amount • Color and odor • Consistency • Presence and size of clots

12. BUBBLEHE Assessment • Episiotomy/Laceration/C/S Incision - Inspect for REEDA, pain • Mediolateral episiotomies for increased bleeding • R = Redness • E = Edema • E = Ecchymosis • D = Discharge, Drainage • A = Approximation

13. BUBBLEHE Assessment • Extremities • Assess for pedal edema, redness and warmth • Check Homan's sign every shift • Hemorrhoids – Assess

14. BUBBLEHE Assessment • Emotional Status - Focuses on mother's general attitude, feelings of competence, support systems, care giving skill - evaluates fatigue and ability to accomplish developmental task • Determine mother's phase of adjustment to parenting • Bonding • Describe level of attachment to infant

15. Pain Assessment and Medication • Postpartum client may need medications to promote comfort, treat anemia, prevent rubella, and prevent development of antigens (in nonsensitized Rh-negative woman) • Postpartum clients should be informed about name of medication, expected action, possible side effects • Nurse must review safety measures with medications

16. Pain Assessment and Medication • Relief of Perineal Discomfort • Ice packs • Topical agents (Epifoam) • Perineal care • Relief of hemorrhoidal discomfort may include • Sitz baths • Topical anesthetic ointments (Nupercainal) • Rectal suppositories • Witch hazel pads (Tucks)

17. A sitz bath promotes healing and provides relief from perineal discomfort during the initial weeks following birth.

18. Pain Assessment and Medication • Afterpains • Positioning (prone position) • Analgesia administered an hour before breastfeeding • Encourage early ambulation - monitor for dizziness and weakness

19. Pain Assessment and Medication • Cesarean section: • Administer analgesics within the first 24 to 72 hours - allows woman to become more mobile and active • Morphine PCA, oxycodone, ibuprofen, acetaminophen ES • Encourage non-pharmacologic methods of pain relief (breathing, relaxation, and distraction) - encourage rest, proper positioning, back rubs, and oral care • Encourage visits by family and newborn, which provides distraction • Position client on left side, include exercises, early ambulation, avoid carbonated beverages and straws - may need enemas, stool softeners, “hot toddy”

20. Labs • White blood cell count often elevated after delivery • 25,000 to 30,000mm³ • Return to normal in one week • Platelet levels fall w/ placental separation • Return to normal by 6th PP week • Activation of clotting factors predispose to thrombus formation • Hemostatic system reaches non-pregnant state in 3 to 4 weeks • Monitor hemoglobin and hematocrit - assess for signs of anemia

21. PP Hemorrhage • > 500 mL of blood after vaginal birth • >1000mL of blood after cesarean section • Causes: • Uterine atony • Hematoma, laceration • Uterine inversion • Bladder distention • Delivery after circlage

23. PP Hemorrhage • Interventions: • Massage fundus, inspect perineum, pad count • Voiding frequently or catheterize • IV fluids • a. oxytocin (20 units per 1000ml IV) 50 mu/min or 10 – 20 units IM (monitor fluid levels) b. methylergonovine (Methergine) 0.2 mg IM (hypertension, seizures) c. prostaglandin F (Hemabate, Carboprost) 0.25 mg IM or intramyometrially by MD (N/V, diarrhea, h/a, bradycardia, wheezing, cough, chills, fever) • Notify health care provider • Check CBC results • Hemoglobin (12-16 g/dL), hematocrit (37-47%)

24. PP Hemorrhage • Late hemorrhage • Retained placental fragments • Commonly occurs when fundus is massaged prior to spontaneous placental separation • Suspect if patient is bleeding with firm fundus and no laceration • Inspect placenta thoroughly after its delivery • Subinvolution • Usually occurs 1 to 2 weeks after birth • Failure of uterus to return to normal size after pregnancy - lochia rubra of greater than 2 weeks duration • Infection • Provide patient with discharge instructions and information about possible complications

26. Thromboembolic Disorder • Risk of thromboembolism lasts 6 weeks • Superficial – risk greater 3 – 4- days PP • Redness, warmth, tenderness, swelling over clot area • Deep vein thrombosis • Homan's positive sign, pain, fever and chills, paleness and swelling in lower extremities • Assess for pulmonary embolus • Ultrasound, CT scan, venography • Clotting times, PT, PTT, INR

27. Thromboembolic Disorder • Treatment • Anticoagulant therapy - labs • Bedrest w/ elevation of leg • Daily measurement of calf & thigh • Elastic support stockings • Warm, moist packs to leg • Encourage early ambulation • For clients on bed rest, turn and do range of motion exercises, encourage fluids to avoid dehydration, encourage no smoking, advise against prolonged sitting or crossing legs, avoid rubbing area

28. PP Infection • Fever (>100.4°F, 38C), purulent discharge from vagina or incision, erythema at incision site, burning during urination, redness/pain in breast about fourth postpartum week • Report signs of severe infection: Foul-smelling lochia, uterine tenderness/ subinvolution, severe lower abdominal pain, change in vital signs, chills, lethargy, nausea/vomiting, abdominal guarding

29. PP Infection • Cesarean section • Pulmonary infections may occur because of immobility and use of narcotics because of altered immune response • Wound infection • REEDA assessment of incision

30. PP Infection • Increase in WBC > 30% in 6 hours • Teach hygiene • Adequate fluids, diet high in protein, vitamin C • Administer antibiotics, pain medication • Wound care • Rest • Fowler’s position with metritis to promote drainage of lochia

31. PP Depression/Psychosis • Depression: Overwhelming sadness, low self-esteem, lack of desire to care for child • Depression more severe in primiparas than in multiparas • Observe for episodic tearfulness, feels overwhelmed, unable to cope, fatigued, anxious, irritable, oversensitive, suicidal • Observe new mother for objective signs of depression - listen for feelings of failure and self accusation

32. PPDepression/Psychosis • Psychosis • Evident within 3 months PP • Agitation, hyperactivity, insomnia, mood lability, confusion, irrationality, difficult remembering or concentrating, poor judgment, delusions, hallucinations • Increased recurrence in subsequent pregnancies

33. PP Depression/Psychosis • Identify risk factors prenatally • Ambivalence, lack of support, dissatisfaction w/ self, primiparity, history PP depression or bipolar • Referral for counseling, support groups • Medication • Lithium, antipsychotics, antidepressants • ECT w/ psychotherapy • Removal of infant • Support

34. Nursing Diagnoses • Constipation related to fear of tearing stitches or pain • Acute pain related to perineal edema episiotomy, laceration, incision from birth • Health-seeking behaviors: Information about infant care related to expressed desire to improve parenting skills • Readiness for enhanced family coping related to successful adjustment to new baby

35. Nursing Diagnoses • Ineffective breastfeeding related to improper latch-on by infant • Altered tissue perfusion related to obstructed venous return • Risk for injury related to spread of infection • Risk for altered parenting related to decreased maternal-infant interaction

37. Teach for Postpartum Self-Care • Teach patient normal adaptation: • Progressive descent of fundus, no reversal of lochia - be aware of postpartum fatigue and obtain extra rest • Teach about nutritional needs: • Adequate hydration, dietary measure if anemic, nutritional needs for breastfeeding • Teach about comfort measures, activity, methods to prevent fatigue, coping skills

38. Teach for Postpartum Self-Care • Teach to watch for infection of incisions • Patient needs to be aware of action of prescribed medications and potential side effects • Teach to watch for overwhelming feelings of sadness or inability to care for infant • Provide list of support organizations in the community

40. NCLEX Question On examining a client who gave birth 3 hours ago, a nurse finds the client has completely saturated a perineal pad within 15 minutes. Which actions should the nurse take? Select all that apply. A. Begin an IV infusion of Lactated Ringer’s solution B. Assess the patient’s vital signs C. Palpate the patient’s fundus D. Place the patient in high Fowler’s position E. Administer a pain medication

41. NCLEX Question The nurse observes several interactions between a mother and her new son. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply. A. Talks and coos to her son B. Cuddles her son close to her C. Doesn’t make eye contact with her son D. Requests the nurse to take the baby to the nursery for feedings E. Encourages the father to hold the baby F. Takes a nap when the baby is sleeping

42. NCLEX Question The nurse is instructing the client on breastfeeding. Which instructions should the nurse include to help the mother prevent mastitis? Select all that apply. A. Wash nipples with soap and water B. Change the breast pads frequently C. Expose nipples to air part of each day D. Wash hands before handling breast and breastfeeding E. Make sure the baby grasps only the nipple F. Release baby’s grasp on nipple before removing from breast

43. NCLEX Question Which lab values indicate normal coagulation status? • PT – 10 seconds, PTT – 50 seconds, INR – 1 • PT – 15 seconds, PTT – 90 seconds, INR – 5 • PT – 12 seconds, PTT – 65 seconds, INR – 3 • PT – 14 seconds, PTT – 75 seconds, INR - 4