THE HIGH-RISK POSTPARTUM EXPERIENCE

Complications in the PP Period -Postpartum hemorrhage -Postpartum infections -Thromboembolic disorders -Psychiatric disorders -Perinatal loss

Maternal Mortality

Hemorrhage Vaginal birth >500 mLs. C-Section birth >1,000 mLs Causes: Uterine atony Common in multipara women as uterus has lost its tone and ability to contract. Also seen in women carrying twins, large baby, polyhydramnios Retained placenta Small section of placenta is retained or entire placenta has implanted deeply into the uterine wall (accreta). Continues to receive blood supply Cervical lacerations Fundus will be firm but a steady flow of blood will continue until laceration is repaired. Common with large babies; precipitous deliveries Hematoma Due to broken blood vessel in perineum. Patient will report extreme pain, rectal pressure and an urge to have a bowel movement

Uterine Atony

Signs of Postpartal Hemorrhage -Excessive or bright red bleeding -A boggy fundus that does not respond to massage -Abnormal clots -Persistent bleeding despite a firmly contracted uterus -Increased pulse or decreased B/P -Decreased level of consciousness

Hypovolemic Shock in the Maternity Patient

Placental Bleeding Causes

Hemorrhage Nursing Interventions: -Massage fundus for firmness, height, position -Assess bladder for fullness/distention; empty bladder -Assess for signs of shock -Weigh peri pads to estimate blood loss (1gm=1cc) -Monitor vital signs, urinary output, LOC -Elevate legs 15-30 degrees -O2 by mask at 8-10 L/min if loss is excessive -Replace fluids and administer uterine stimulants -Administer blood replacement as per MD orders

HEMORRHAGE: Pharmacologic Management # 1: Pitocin (oxytocin): 10-40 units/L IV or 10-20 U IM # 2: Methergine (methylergonovine maleate): 0.2 mg IM q 2-4 hr. Once stable, 0.2 mg PO Q 6 hr X 24 hours # 3: Hemabate (prostin 15M/carboprost): 250 mcg IM or intra-myometrically #4: Cytotec (misoprostol): 800-1,000 mcg rectally

Pitocin

Methergine

Hemabate

Postpartum Infections Reproductive tract infections Endometritis Chorioamnionitis Wound infections Breast infections Mastitis Urinary tract infections

Thromboembolic Disorders -Superficial thrombophlebitis -Deep vein thrombosis (DVT) -Pulmonary embolism (amniotic fluid embolism) -Disseminated Intravascular Coagulation (DIC)

Deep Vein Thrombosis

Disseminated Intravascular Coagulation (DIC) -A form of clotting that is diffuse and consumes large amounts of clotting factors -Widespread external, internal bleeding or both -DIC is always a secondary diagnosis therefore must treat the condition that triggered DIC

DIC: Nursing Management REMAIN CALM! -Vital signs q 1-15 min until stable -Assess for shock with vital signs -Accurate I & O -Quantify blood loss; hang blood products -Explain situation to patient & family

Postpartum Psychiatric Disorders 1) Postpartum Blues Affects 50-70% of new mothers Mild, temporary depression; weepy, may feel overwhelmed, insecure in own abilities Occurs within a few days of birth 2) Postpartum Depression 3) Postpartum Psychosis

Psychiatric Disorders Postpartum Depression Usually occurs around 4th week Persistent Unable to cope; social withdrawal Despondency Insomnia; fatigue May have thoughts of death/suicide Postpartum Psychosis Hallucinations Delusions, phobias Disorganization Emotional lability Bizarre or violent behavior; mania Changes in appetite; sleep patterns May harm/kill infant

Perinatal Loss -Approximately 15 - 20% of all pregnancies end in miscarriage -Miscarriages combined with stillbirths, newborn deaths and SIDS equals approximately 1/3 of all pregnancies

Nursing Interventions: -Encourage verbalization of feelings -Discuss grieving process -Prepare patient for side effects of induction -Liberal use of analgesia and anesthesia -Offer opportunity to see, touch, hold infant -Prepare family for appearance of infant -Provide a Memory Box: tangible remembrances (lock of hair, gown, pictures, foot prints)

Perinatal Loss -Discuss autopsy and explain benefits -Discuss plans for funeral or memorial services -Offer spiritual support from clergy -Offer baptism or blessing -Provide information re: support groups -Provide written grief materials -Follow-up with a bereavement counselor, social worker, clergy

“Resolve Through Sharing” National perinatal loss support group Picture of leaf or white rose placed on patient’s door to alert health care team of perinatal loss Best RN response? “I’m so sorry for your loss” Avoid saying: “You can have another baby” “Your baby is in heaven” “It just wasn’t meant to be”