Nancy Pares, RN, MSN Metro Community College NURS 2410 Unit 3 Nancy Pares, RN, MSN Metro Community College

Objective 1 and 2 Relate specific pathophysiology and nursing process specific to postpartum. Idenitify specific post partum complications and nursing management Placental issues, uterine issues, vaginal issues

Assessment of Postpartum Hemorrhage Fundal height and tone Vaginal bleeding Signs of hypovolemic shock Development of coagulation problems Signs of anemia

Risk Factors for Postpartum Hemorrhage Cesarean delivery Unusually large episiotomy Operative delivery Precipitous labor Atypically attached placenta Fetal demise Previous uterine surgery

Causes of Postpartum Hemorrhage Uterine atony Lacerations of the genital tract Episiotomy Retained placental fragments Vulvar, vaginal, or subperitoneal hematomas

Causes of Postpartum Hemorrhage (continued) Uterine inversion Uterine rupture Problems of placental implantation Coagulation disorders

Nursing Interventions Uterine massage if a soft, boggy uterus is detected Encourage frequent voiding or catheterize the woman Vascular access Assess abnormalities in hematocrit levels Assess urinary output Encourage rest and take safety precautions

Nursing Diagnoses: Postpartum Hemorrhage Health-seeking Behaviors related to lack of information about signs of delayed postpartal hemorrhage Fluid Volume Deficit related to blood loss secondary to uterine atony, lacerations, hematomas, coagulation disorders, or retained placental fragments

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

Postpartal Hemorrhage Table 38–2 Signs of postpartal hemorrhage.

Self-Care Measures: Postpartum Hemorrhage Fundal massage, assessment of fundal height and consistency Inspection of the episiotomy and lacerations if present Report: Excessive or bright red bleeding, abnormal clots Boggy fundus that does not respond to massage Leukorrhea, high temperature, or any unusual pelvic or rectal discomfort or backache

Community Based Care: Postpartum Hemorrhage Clear explanations about condition and the woman’s need for recovery Rise slowly to minimize orthostatic hypotension Woman should be seated while holding the newborn Encourage to eat foods high in iron Continue to observe for signs of hemorrhage or infection

Uterine Atony Risk factors Assessment findings Overdistension of the uterus Uterine anomaly Poor uterine tone Assessment findings Excessive bleeding, boggy fundus

Uterine Atony (continued) Management Fundal massage Blood products if loss is excessive Medications Oxytocin, methergine, carboprost tromethamine (Hemabate)

Uterine Atony Table 38–1 Uterine stimulants used to prevent and manage uterine atony.

Uterine Atony Table 38–1 (continued) Uterine stimulants used to prevent and manage uterine atony.

Retained Placental Fragments Risk factors Mismanagement of third stage Placental malformations Abnormal placental implantation Assessment findings Excessive bleeding, boggy fundus

Placental Adherence Accreta villi attach to the outer layer myometrium Increta villi attach within the muscle layer of the myometrium Percreta villi attach deep within the myometrium

Retained Placental Fragments (continued) Management Manual exploration of the uterus D&C Blood products if loss is excessive

Lacerations Risk factors Assessment findings Management Operative delivery Precipitous delivery Extension of the episiotomy Varices Assessment findings Excessive bleeding with a firm uterus Management Suture if needed Blood products if loss is excessive

Objective 2 Identify nursing process for post partum psycho social disorders

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

Postpartum Blues Occurs within 3 to 10 days of delivery Generally transient Usually resolves without treatment Assessment findings Tearful, fatigue, anxious, poor appetite

Postpartum Blues (continued) Etiology Hormonal changes and adjustment to motherhood Longer than two weeks in duration requires medical evaluation

Postpartum Mood Disorder: Depression Onset slow, usually around the fourth week after delivery Assessment findings Depressed mood, fatigue, impaired concentration, thoughts of death or suicide Risk factors History of depression, abuse, low self-esteem Management Psychotherapy, medications, hospitalization

Postpartum Psychosis Generally after the second PP week Assessment findings Sleep disturbance, agitation, delusions Risk factors Personal or family history of major psychiatric illness Management May lead to suicide or infanticide Hospitalization, medications, psychotherapy

Postnatal Depression Table 38–10 (continued) Postpartum depression predictors inventory (PDPI)—revised and guide questions for its use.

Prevention of Depression Table 38–11 Primary prevention strategies for postpartum depression.

Prevention of Postpartum Psychiatric Disorders Help parents understand the lifestyle changes and role demands Provide realistic information Anticipatory guidance Dispel myths about the perfect mother or the perfect newborn Educate about the possibility of postpartum blues Educate about the symptoms of postpartum depression

Self-Care: Postpartum Psychiatric Disorders Signs and symptoms of postpartum depression Contact information for any questions or concerns

Community Based Care: Postpartum Psychiatric Disorders Foster positive adjustments in the new family Assessment of maternal depression Teach families symptoms of depression Give contact information for community resources Make referrals as needed

Nursing Diagnoses: Postpartum Psychiatric Disorder Ineffective Individual Coping related to postpartum depression Risk for Altered Parenting related to postpartal mental illness Risk for Violence against self (suicide), newborn, and other children related to depression

Reproductive Loss Components of grief work Accepting the painful emotions involved Reviewing the experiences and events Testing new patterns of interaction and role relationships

Reproductive Loss (continued) Four stages of grief Shock and numbness Searching and yearning Disorientation Reorganization Symptoms of normal grief

Examples of Reproductive Loss Inability to conceive Spontaneous abortion Preterm delivery Congenital anomalies Fetal demise Neonatal death Relinquishment SIDS

Objective 4 Review nursing interventions associated with DVT, Hematoma, hemorrhoids, endometritis, wound infections, urinary infections and STD

Assessment of Infection: REEDA Scale R: redness E: edema E: ecchymosis D: discharge A: approximation

Assessment of Infection (continued) Fever Malaise Abdominal pain Foul-smelling lochia Larger than expected uterus Tachycardia

Nursing Diagnoses: Puerperal Infection Risk for Injury related to the spread of infection Pain related to the presence of infection Deficient Knowledge related to lack of information about condition and its treatment Risk for Altered Parenting related to delayed parent-infant attachment secondary to woman’s pain and other symptoms of infection

Endometritis Infection of the uterine lining Risk factors Cesarean section Assessment findings Fever, chills Abdominal tenderness Foul-smelling lochia Management Antibiotics

Metritis Table 38–3 Common causative organisms in metritis.

Mastitis Table 38–4 Factors associated with development of mastitis.

Assessment of Mastitis Breast consistency Skin color Surface temperature Nipple condition Presence of pain

Mastitis Infection of the breast Risk factors Assessment findings Damaged nipples Failure to empty breasts adequately Assessment findings Fever, chills Breast pain, swelling, warmth, redness Management Antibiotics Complete breast emptying

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.

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

Self-Care Measures: Mastitis 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

Breast Problems Table 38–5 Comparison of findings of engorgement, plugged duct, and mastitis.

Nursing Diagnoses: Mastitis Health-seeking Behaviors related to lack of information about appropriate breastfeeding practices Ineffective Breastfeeding related to pain secondary to development of mastitis

Community Based Care: Mastitis Home care nurse may be the first to suspect mastitis Obtain a sample of milk for culture and sensitivity analysis Teach mother how to pump if necessary Assist with feelings about being unable to breastfeed Referral to lactation consultant or La Leche League

Assessment of Thrombophlebitis Homan’s sign Pain in the leg, inguinal area, or lower abdomen Edema Temperature change Pain with palpation

Figure 38–3 Homans’ sign. With the client’s knee flexed to decrease the risk of embolization, the nurse dorsiflexes the client’s foot. Pain in the foot or leg is a positive Homans’ sign. SOURCE: Photographer, Elena Dorfman

Thrombophlebitis Inflammation of the lining of the blood vessel due to clot formation Can occur in the legs (DVT) or pelvis (SPT) Risk factors Cesarean section Prolonged bed rest Infection

Thrombophlebitis (continued) Assessment findings Pain, fever, redness, warmth, tender abdomen/calf Management Anticoagulants Antibiotics for septic pelvic thrombophlebitis

Thromboembolic Factors Table 38–6 Factors associated with increased risk of thromboembolic disease.

Decreasing Thromboembolic Risk Table 38–7 Measures to decrease risk of thromboembolic disease in childbearing women.

Prevention of Thrombophlebitis Avoid prolonged standing or sitting Avoid crossing her legs Take frequent breaks while taking car trips

Self-Care: Thromboembolic Disease Condition and treatment Importance of compliance and safety factors Ways of avoiding circulatory stasis Precautions while taking anticoagulants

Nursing Diagnoses: Thromboembolic Disease Pain related to tissue hypoxia and edema secondary to vascular obstruction Risk for Altered Parenting related to decreased maternal-infant interaction secondary to bed rest and intravenous lines Altered Family Processes related to illness of family member Deficient Knowledge related to self-care after discharge on anticoagulant therapy

Vitamin K Foods Table 38–8 Foods high in vitamin K.

Assessment of Overdistention of the Bladder Large mass in abdomen Increased vaginal bleeding Boggy fundus Cramping Backache Restlessness

Assessment of Cystitis Frequency and urgency Dysuria Nocturia Hematuria Suprapubic pain Slightly elevated temperature

Urinary Tract Infection Risk factors Urinary catheterization Long labor, operative delivery Assessment findings Dysuria, frequency, urgency Fever Suprapubic pain Management Antibiotics

Prevention of Infection 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

Prevention of a UTI Good perineal hygiene Good fluid intake Frequent emptying of the bladder Void before and after intercourse Cotton underwear Increase acidity of the urine

Prevention of Bladder Overdistension Frequent monitoring of the bladder Encourage spontaneously voiding Assist the woman to a normal voiding position Provide medication for pain Perineal ice packs

Nursing Diagnoses: Bladder Distention Risk for Infection related to urinary stasis secondary to overdistention Urinary Retention related to decreased bladder sensitivity and normal postpartal diuresis

Nursing Diagnoses: UTI Pain with voiding related to dysuria secondary to infection Health-seeking Behaviors related to need for information about self-care measures to prevent UTI

Self-Care Measures: Puerperal Infection Activity and rest Medications Diet Signs and symptoms of complications Importance of completion of antibiotic therapy

Community Based Care: Puerperal Infection May need assistance when discharged from the hospital May need a referral for home care services Instruct family on care of the newborn Instruct mother about breast pumping to maintain lactation if she is unable to breastfeed

Community Based Care: Thromboembolic Disease Instruct family members on care of mother and newborn Referral for home care if necessary Provide resources for follow-up or questions Teach all families to observe for signs and symptoms

Pelvic Hematoma Assessment findings Severe perineal pain Ecchymosis Visible outline of the hematoma Blood loss may not be visible

Pelvic Hematoma (continued) Treatment Surgical drainage Antibiotics Analgesics Blood products if loss is excessive

Signs and Symptoms of Shock Hypotension Tachycardia, weak, thready pulse Decreased pulse pressure Cool, pale, clammy skin Cyanosis Oliguria, anuria Thirst Hypothermia Behavioral changes (lethargy, confusion, anxiety) Pg 664- table

Nursing Implications: Shock Monitor vital signs frequently Large-bore IV for fluids, blood products Administer oxygen, assess oxygen saturation Assess hourly urine output Assess level of consciousness

Nursing Implications: Shock (continued) Administer and monitor fluids, blood products Draw/monitor laboratory results Assess quantity and quality of bleeding Provide emotional support to patient/family

Warning signs of illness PP Fever > 100.5 Severe pain, redness,swelling at incision site Passing of large clots Increased bleeding Burning on urination Insomnia Impaired concentration Feeling inadequate