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Postpartum Hemorrhage

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- traditionally defined as loss of more than 500 mL of blood after vaginal birth, and more than 1000 mL of blood after c-section - cause of maternal morbidity and mortality - life-threatening with little warning - often unrecognized until there are profound symptoms

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Postpartum Hemorrhage: Etiology and Risk Factors

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- uterine atony: marked hypotonia of uterus - lacerations of genital tract - hematomas - retained placenta, both nonadherent and adherent - inversion of uterus: turning inside out of uterus - subinvolution of uterus: late postpartum bleeding; prolonged lochial discharge and irregular bleeding

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Nursing Care Management: Assessment

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- early recognition is critical - first step is evaluation of contractility of uterus - firm massage of fundus - administer IV fluids and medication to manage bleeding

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Nursing Care Management: Plan of Care and Implementation

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- hypotonic uterus - bleeding with a contracted uterus - uterine inversion - subinvolution - herbal remedies

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Early (Primary) Postpartum Hemorrhage

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- occurs in the first 24 hours after childbirth

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Early (Primary) Postpartum Hemorrhage Causes

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- uterine atony - lacerations of the birth canal - retained placental fragments - vulvar, vaginal, and pelvic hematomas - uterine inversion - DIC secondary disorder caused by: HELLP placental abruption pre-eclampsia/eclampsia sepsis shock - nursing should provide supportive measures, treat the cause to reverse damage from DIC

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Late (Secondary) Postpartum Hemorrhage

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occurs in from 24 hours to 6 weeks after birth

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Late (Secondary) Postpartum Hemorrhage Causes

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- subinvolution of the placental site - retained products (placenta) or other source of infection - DIC can also develop from late causes of post partum hemorrhage

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Nursing Management for the Woman at Risk for Postpartum Hemorrhage: Nursing Diagnosis

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- fluid volume, deficit - bleeding, risk for

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Nursing Management for the Woman at Risk for Postpartum Hemorrhage: Planning and Implementation

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- hospital-based nursing care - labs, H&H

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Hemorrhagic (Hypovolemic) Shock

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- a clinical state of inadequate tissue and organ perfusion from inadequate blood or plasma volume in the vascular space

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Treatment for Hemorrhagic Shock

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- IV fluid volume replacement - catheter insertion to monitor input and output - ventilator therapy - cerebral evaluation - in pregnancy and postpartum, BP is not an early indicator of impending shock, so consider the patient's symptoms

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Common Postpartum Reproductive Tract Infection or Wound Infection

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- puerperal sepsis: any infection of genital canal within 28 days after abortion or birth - most common infecting agents are numerous streptococcal and anaerobic organisms - endometritis: an inflammation of the endometrium portion of the uterine lining - wound infections: episiotomy, c-section incision - urinary tract infections - mastitis: inflammation of the breast

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Postpartum Uterine Infection

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- uterine infection of metritis and endometritis, the lining of the uterus, the myemetrium, and parametrial tissues - occur in 1% to 3% of women who give birth vaginally

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Risk Factors for Postpartum Uterine Infection

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- c-section prior to onset of labor - pre rupture of membranes - prolonged labor preceding c-section - multiple vaginal exams - compromised health status - use of fetal scalp electrodes - obstetric trauma - chorioamnionitis - diabetes - pre-existing bacterial vaginosis - instrument-assisted childbirth - manual removal of the placenta - lapses in aseptic technique - anemia - malnutrition - retained products of conception

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Endometritis

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- an inflammation of the endometrium portion of the uterine lining - usually at the placental site - localized infection can lead to: salpingitis peritonitis pelvic abscess formation septicemia secondary abscesses possible in lungs or liver

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Further Complications

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- DIC - thrombophlebitis - pulmonary embolus - septic shock - fatality

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Signs and Symptoms

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- fever >100.4 F on 2 successive days (not counting the 1st 24 hours postpartum) - fatigue and lethargy - anorexia - chills - lower abdominal distress - nausea and vomiting

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Pelvis Cellulitis (Parametritis)

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- an infection involving the connective tissue of the broad ligament or, in more severe forms, the connective tissue of all the pelvic structure - perineal wound infection - cesarean wound infection

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Chorioamnionitis

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- inflammation of the amnion, usually secondary to bacterial infection - may be caused by or result from PROM may lead to: - placentitis - fetal congenital pneumonia - opmhlatis - septicemia - endometritis

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Clinical Therapy

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- localized wound infection is treated with broad spectrum antibiotics, Sitz baths, and analgesiscs - wounds with evidence of pus or serosanguinous effusion or infected stitch are opened and drained

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Causes of Postpartum Infections

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- any clinical infection of the genital canal occurring 28 days after childbirth or abortion - vagina (endogenous) - introduction of pathogens form outside the vagina (exogenous)

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Care of the Woman with a Urinary Tract Infection

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- overdistention of the bladder: urine retention, difficulty voiding - cystitis: lower urinary tract infection - occurs in 10% of women - those with history more likely - usually an E. Coli infection - chronic STDs put patient at more risk - pyelonephritis may develop if not treated

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Care of the Woman with Mastitis

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- breast infections - occurs in 1% of all women - may be associated with breastfeeding - almost always on one side - usually caused by Staph. aureus, E. coli, or Strep

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Signs and Symptoms of Mastitis

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- usually caused by an infected nipple - infection and inflammation obstruct the flow of milk - chills, fever, malaise, tenderness at site - abscess will develop if not treated

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Treatment of Mastitis

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- antibiotics - hot/cold therapy - lactation maintained by emptying breasts - prevent by cleanliness and proper breastfeeding techniques

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Three Major Causes of Thromboembolic Disease (Virchow's Triad)

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1. Hypercoagulability of blood 2. Venous stasis 3. Injury of the epithelium of the blood vessel

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Contributing Factors to Thromboembolic Disease Postpartum

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1. Increased amounts of certain blood-clotting factors 2. Postpartum thrombocytosis 3. Release of thromboplastin substances 4. Increase amounts of fibrinolysis inhibitors

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Care of the Woman with Postpartum Thromboembolic Disease

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- superficial leg vein disease - deep vein thrombosis - clinical therapy: heparin, Lovenox, warfarin

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Nursing Interventions

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- *encourage early ambulation* - if on bed rest, encourage leg exercises - encourage fluids - no smoking - use antiembolism stockings - avoid prolonged sitting and crossing of legs - encourage elevated legs while sitting

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Postpartum Psychologic Complications

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- mental health disorders in postpartum period have implications for mother, newborn, and entire family - interferes with attachment to newborn and family integration - may threaten safety and well-being of mother, newborn, and other children

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Types of Postpartum Psychiatric Disorder

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- adjustment reaction with depressed mood - postpartum mood episodes with psychotic features - peripartum major mood episode - post-traumatic disorder

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Postpartum Depression Without Psychotic Features

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- postpartum depression: an intense and pervasive sadness with severe and labile mood swings - treatment options: - antidepressants, anxiolytic agents, and electroconvulsive therapy - psychotherapy focuses fears and concerns of new responsibilities and roles; monitoring for suicidal or homicidal thoughts

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Adjustment Reaction with Depressed Mood

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- maternal "baby blues" - occurs in 50-75% of moms - mild depression interspersed with happier feelings - occurs within a few days after birth - self limiting

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Postpartum Mood Episodes with Psychotic Features

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- incidence: 1-2/1000 - usually evident within the first 1-3 months - increased risk in subsequent pregnancies

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Postpartum Mood Episodes with Psychotic Features: Risk Factors

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- previous psychosis - bipolar disorder - family history of mood disorders

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Postpartum Mood Episodes with Psychotic Features: Symptoms

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- agitation - insomnia - difficulty remembering - hyperactivity - irrational thoughts and behaviors - confusion - delusions and hallucinations related to infant leading to infanticide

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Postpartum Mood Episodes with Psychotic Features: Treatment

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- removal of infant (potential for mom to harm baby) - hospitalization - sedatives and medical therapy - psychotherapy - ECT

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Peripartum Major Mood Episode or Postpartum Depression: Risk Factors

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- primiparity - ambivalence about pregnancy - history of postpartum depression and bipolar illness - lack of social support - lack of a stable and supportive relationship - low self-esteem

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Post-Traumatic Stress Disorder

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- directly experiencing the traumatic event - witnessing, in person, the event as it occurred to others - learning that the traumatic event occurred to a close family member or close friend - experiencing repeated or extreme exposure to adverse details

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Interventions

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- intervene to prevent traumatic birth experiences - provide technically competent care - assess for anxiety and fears on admission to labor - debrief the woman and family after a stressful traumatic childbirth experience - visit the woman during her hospitalization

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Bacteremia Shock (AKA Septic Shock): Women at Risk

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- diabetic mothers - women on immunosuppressant drugs - women with endometritis

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Sings and Symptoms of Shock

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- high spiking temp and chills - apathy - body temp to subnormal - cool, pale, moist skin - rapid pulse - hypotension - peripheral cyanosis - oliguria - altered mental status - renal failure - DIC - bleeding - decreased cardiac output

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Laboratory Data

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- blood cultures - probable cardiac, neuro, and pulmonary complications - priority in septic shock is to administer antibiotics

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Sequelae of Childbirth Trauma

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- disorders of uterus and vagina related to pelvic relaxation and urinary incontinence - often result of childbearing

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Sequelae of Childbirth Trauma: Uterine Displacement and Prolapse

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- posterior displacement, or retroversion - retroflexion and anteflexion - prolapse a more serious displacement

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Sequelae of Childbirth Trauma: Cystocele and Rectocele

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- cystocele: protrusion of bladder downward into vagina when support structures in vesicovaginal septum are injured - rectocele: herniation of anterior rectal wall through relaxed or ruptured vaginal fascia and rectovaginal septum - urinary incontinence

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Sequelae of Childbirth Trauma: Genital Fistulas

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- may result from congenital anomaly, gynecologic surgery, obstetric trauma, cancer, radiation therapy, gynecologic trauma, or infection - vesicovaginal: between bladder and genital tract - urethrovaginal: between urethra and vagina - rectovaginal: between rectum or sigmoid colon and vagina

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Loss and Grief

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- losses of what was hoped for, dreamed about, and/or planned - any perception of loss of control during the birthing experience - birth of child with handicap - maternal death - fetal or neonatal death - cluster of painful responses - overlapping phases in grief process: acute distress intense grief reorganization - family aspects of grief: grandparents and siblings

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Loss and Grief: Communicating and Care Techniques

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- help mother, father, and siblings actualize their loss - help parents with decision making - help bereaved to acknowledge and express their feelings - normalize grief process and facilitate positive coping - meet the physical needs of postpartum bereaved mother - create memories for parents to take home

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Loss and Grief: Cultural and Spiritual Needs of Parents

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- provide culturally sensitive care at and after discharge - provide postmortem care respecting parents' wishes - documentation

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Maternal Death

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- rare for woman to die in childbirth - families are at risk for developing complicated bereavement and altered parenting of surviving baby and other children in family - emotional toll on nursing and medical staff must be addressed

Nursing 121: Unit 3, The Postpartum Family at Risk – Flashcards

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