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Complications of the Post-Partal Period

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Title: Complications of the Post-Partal Period


1
Complications of the Post-Partal Period
2
Postpartum Hemorrhage
  • Definition
  • Early-postpartum hemorrhage of gt500cc within the
    first 24hrs. postpartum
  • Late-postpartum hemorrhage of gt500cc 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 Loss Ideal MethodWeighing
  • 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 ccs 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 gt 5 cm and those that expand
  • Incision and drainage of hematoma is needed

17
Puerperal Infection
  • Definition-infection with tempgt100.4 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 gt38.4 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 homans 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, SCDs
  • 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
  • Abgs, 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 382 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
  • 10-15of 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-gtgets better-gtthen 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

51
Postpartum Depression Prevention
52
Postpartum Depression
  • Treatment (must be multifaceted)
  • Psychotherapy
  • Cognitive and supportive therapy
  • Marital therapy
  • Support groups as DADs (depression after
    delivery
  • Social support

53
Postpartum Depression Treatment contd
  • Medications-antidepressants (these work with
    mothers experiencing insomnia, agitation, and
    anxiety attacks)
  • Sinequan (doxepin)
  • Tofranil (imipramine)
  • Desyrel (trazadone HCL)
  • Meds-antidepressants ( these work with mothers
    experiencing severe fatigue who are hard to wake
    up or act more despondent)
  • Norpramin (desipramine HCL)
  • Prozac (fluoxetine HCL)
  • Vivactil (protriptyline HCL)
  • Medications-antimanic drugs (may be used to
    control hyperactivity or manicky behavior)
  • Lithium or Tegretol

54
Postpartum Psychosis
  • Occurs in 1-2/1000 mothers
  • Course symptoms
  • Manic state
  • Delirium-confusion or dissociative episodes
  • Delusion-see visions/hallucinations, hear voices
    often r/t baby

55
Postpartum Psychosis
  • Risk factors
  • Previous puerperal psychosis
  • Hx of bipolar disorder
  • Prenatal stressors (lack of support, low
    socioeconomic status)
  • Obsessive personality
  • Family hx of mood disorder

56
Postpartum psychosis
  • Treatment
  • Hospitalization-ideally on a psychiatric
    mother/baby unit seen in England
  • Psychotherapy
  • Medications-antipsychotic drugs
  • Stelazine (trifluoperazine HCL)
  • Haldol (haloperidol)
  • Mellaril (thioridazine HCL)
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