Postpartum Complications Chapter 21 Postpartum Complications All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Postpartum Hemorrhage Definition and incidence Leading cause of maternal death worldwide PPH traditionally defined as loss of more than: 500 ml of blood after vaginal birth 1000 ml after cesarean birth Life-threatening with little warning Often unrecognized until profound symptoms All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Postpartum Hemorrhage (Cont.) Etiology and risk factors Uterine atony Marked hypotonia of uterus Lacerations of genital tract Hematomas Retained placenta Nonadherent retained placenta Adherent retained placenta All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Postpartum Hemorrhage (Cont.) Inversion of uterus Turning inside out of uterus Potentially life threatening 1 in 3000 births Subinvolution of uterus Late postpartum bleeding Retained placental fragment and pelvic infection All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Care Management Medical management Early recognition is critical First step is evaluation of contractility of uterus Firm massage of fundus Management is directed toward increasing contractility and minimizing blood loss All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Care Management (Cont.) Hypotonic uterus Bleeding with a contracted uterus Uterine inversion Subinvolution Herbal remedies Has been used with some success after initial control of bleeding Nursing interventions All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Hemorrhagic (Hypovolemic) Shock Medical management Nursing interventions Fluid or blood replacement therapy Legal tip – standard of care for bleeding emergencies allows for provisions to be made for nurses to initiate actions independently All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Case Study You are the mother-baby nurse assigned to Ms. Avery. She is a gravida 6 para 5015 who gave birth to a 9-lb baby boy this morning. Ms. Avery had an uncomplicated and precipitous vaginal birth. Perineum is intact. She is breastfeeding. All laboratory results are normal. She is now 5 hours postpartum. A family member calls out from the patient room for assistance. When you walk into the room, Ms. Avery is standing up on her way to the bathroom with a large pool of blood on the floor. She states, “I don’t know what happened; it all just came when I stood up. I am so dizzy and light-headed." All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Case Study (Cont.) What should the nurse do? What are Ms. Avery’s risk factors for PPH? What should the medical management include? What should the nurse do? Call for help Assist patient back to bed Ask staff to call provider Ask family members to leave the room except for partner who is seated Assess fundus for size and firmness—massage if boggy Assess for continued bleeding/clots Assess bladder—may need I&O catheter Ask staff to take vital signs   What are Ms. Avery’s risk factors for PPH? Grand multiparity Precipitous birth Large baby—overdistention of uterus What should the medical management include? If bleeding continues and uterus is not firm despite massage, the provider will likely order a medication to contract the uterus. This might include synthetic oxytocin (Pitocin), methergine, or hemabate. The provider may also manually remove any clots or placental tissue from the uterus. This is painful and the nurse may be asked to administer pain relief medications. The nurse may be asked to perform I&O catheterization in order to empty bladder and allow uterus to contract more efficiently. Another measure done by the provider to stop uterine bleeding is bimanual compression. In this procedure, one hand is inserted into the vagina and the other hand is used to compress the uterus through the abdominal wall. The nurse should continue to provide support to the patient and continue to assess her status. Once stable, the nurse should ensure that the mother understands what occurred and will answer questions from her and her partner. Self-care should be taught including warning signs of any additional heavy bleeding. Breastfeeding will be encouraged to facilitate further uterine involution. All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Coagulopathies Idiopathic thrombocytopenic purpura (ITP) von Willebrand disease—type of hemophilia Disseminated intravascular coagulation Consumptive coagulopathy Consumes large amounts of clotting factors Widespread external bleeding, internal bleeding, or both All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Thromboembolic Disease Results from blood clot caused by inflammation or partial obstruction of vessel Superficial venous thrombosis Deep venous thrombosis Pulmonary embolism Incidence and etiology Clinical manifestations Medical management Nursing interventions All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Postpartum Infections Puerperal sepsis: any infection of genital tract within 28 days after miscarriage, induced abortion, or birth Most common infecting agents are numerous streptococcal and anaerobic organisms Endometritis Wound infections Urinary tract infections Mastitis All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Sequelae of Childbirth Trauma Disorders of uterus and vagina related to pelvic relaxation and urinary incontinence; are often result of childbearing Uterine displacement and prolapse Posterior displacement, or retroversion Retroflexion and anteflexion Uterine prolapse a more serious displacement All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Sequelae of Childbirth Trauma (Cont.) Cystocele and rectocele Cystocele: protrusion of bladder downward into vagina when support structures in vesicovaginal septum are injured Rectocele is herniation of anterior rectal wall through relaxed or ruptured vaginal fascia and rectovaginal septum Urinary incontinence All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Sequelae of Childbirth Trauma (Cont.) Genital fistulas (perforations) 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 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Care Management Dependence upon the problem and severity of symptoms Kegel exercises Pessaries Estrogen therapy Surgical repair Hygiene practices All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Postpartum Psychologic Complications Mental health disorders in postpartum period have implications for mother, newborn, and entire family Interfere with attachment to newborn and family integration May threaten safety and well-being of mother, newborn, and other children All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Postpartum Psychologic Complications (Cont.) Mood disorders 80% of women experience a mild depression or “baby blues” Symptoms resolved within a few days 10% to 15% of women experience more serious depression Paternal postpartum depression All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Postpartum Psychologic Complications (Cont.) Postpartum depression without psychotic features Postpartum depression: an intense and pervasive sadness with severe and labile mood swings Medical management Antidepressants, anxiolytic agents, mood stabilizers and electroconvulsive therapy Psychotherapy focuses fears and concerns of new responsibilities and roles; monitoring for suicidal or homicidal thoughts All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Postpartum Psychologic Complications (Cont.) Postpartum depression with psychotic features Postpartum psychosis: syndrome characterized by depression, delusions, and thoughts of harming either infant or herself Psychiatric emergency; may require psychiatric hospitalization Associated with bipolar (or manic-depressive) disorder All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Care Management Screening for postpartum depression Nursing care on the postpartum unit Nursing care in the home and community Referrals Providing safety Psychiatric hospitalization Psychotropic medications Other treatments for postpartum depression All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Postpartum Anxiety Disorders Generalized anxiety disorder Obsessive-compulsive disorder Panic disorder and panic attacks Specific phobias Social anxiety disorder Posttraumatic stress disorder All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Case Study You are the mother-baby nurse providing couplet care to Ms. Hart and her new baby girl, Chloe. 36-year-old G3P1021. Married with husband very involved in care of baby since birth. OB history includes history of two spontaneous abortions (SABs). Current pregnancy result of in vitro fertilization (IVF). Uncomplicated C/S 48 hours ago after failed induction and long labor. Apgar score 9/9 for baby. Breastfeeding but baby sleepy at the breast and now with elevated bilirubin level—going home with bili blanket. All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Case Study (Cont.) Family involved with many visitors since the birth. RN now enters room to provide discharge teaching. During your visit, Ms. Hart breaks down in tears and states, “I am so exhausted. This just hasn’t worked out how I imagined. I feel so overwhelmed.” All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Case Study (Cont.) What can you say to Ms. Hart and what suggestions will you make? What would be your plan of care? What might increase her risk of postpartum depression (PPD)? What do you think of the language the team uses to describe the outcome of her induction of labor? How might this affect the mother’s self-esteem? First, validate her concerns and confirm that she has the right to feel overwhelmed. Sit down and invite her to share more with you about her feelings. Open-ended questions are most helpful. You might say that many women experience mixed feelings after giving birth and it is very normal to feel overwhelmed. It is important to provide an opportunity for Ms. Hart to identify what she is feeling and begin to make plans for support and recovery. You might ask permission to get her husband to facilitate a conversation about her feelings. Suggestions include: offering to facilitate her staying another day or two in the hospital. Insurance will pay for up to 96 hours of hospital care following a c/s birth. Offer to help facilitate a conversation with her provider for possible cancellation of discharge orders. She would benefit from continued nursing care and lactation support. In addition, this would allow the baby to be under the UV light therapy at the hospital rather than the bili blanket. Suggest that you can put a sign on her door that she cannot accept visitors at this time. You will explain this to any visitors who come to see her. Encourage husband to take the baby between feedings and allow her to rest more soundly. Call the IBCLC to provide lactation help as soon as possible. More intake of colostrum will facilitate recovery to normal bilirubin for baby Chloe. Satisfaction with breastfeeding will provide positive feelings for Ms. Hart. Before discharge, discuss with Ms. Hart and her husband about the range of mood changes that women may experience following birth. Help them identify what symptoms require follow-up with her provider. Be sure that her husband understands these clearly as well. Teach mother and father to look for Chloe’s cues and begin to learn what she is asking of them. For example, be sure that both parents understand how to identify feeding cues. Ms. Hart’s full medical history is not available, but a history of depression, life stress, lack of social support, anxiety, self-esteem, and infant temperament are among the factors that may lead to postpartum depression. Ms. Hart had a long labor and an unplanned and undesired cesarean birth. She also experienced pregnancy loss and infertility in her OB history. All of these factors may affect her emotional experience at this time. Health care providers must be aware of the language used to describe patients and their outcomes. Failure is a harsh word that may bring a sense of inadequacy or weakness. All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Loss and Grief Situational life crises superimposed on childbearing Infertility Premature labor or birth Cesarean birth Gender of infant not desired Birth of child with handicap Maternal death Fetal or neonatal death All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Loss and Grief (Cont.) Grief responses Overlapping phases in grief process Acute distress Intense grief Reorganization All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Loss and Grief (Cont.) Family aspects of grief Grandparents and siblings Communicating and caring techniques Help mother, father, and other family members actualize the loss Help parents with decision making All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Loss and Grief (Cont.) Communicating and caring techniques 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 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Loss and Grief (Cont.) Cultural and spiritual needs of parents Provide culturally sensitive care at and after discharge Provide postmortem care respecting parents wishes Documentation Provide sensitive care both at and after discharge All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Maternal Death Emotional toll on nursing and medical staff Mortality\morbidity review Critical incident debriefing Attending funeral services Follow-up with grief counselor All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Question The most effective and least expensive treatment of puerperal infection is prevention. What is important in this strategy? Large doses of vitamin C during pregnancy Prophylactic antibiotics Strict aseptic technique, including handwashing, by all health care personnel Limited protein and fat intake ANS: C Feedback A Incorrect: Good nutrition to control anemia is a preventive measure. Increased iron intake would assist in preventing anemia. B Incorrect: Antibiotics may be given to manage infections; they are not a cost-effective measure to prevent postpartum infection. C Correct: Strict adherence by all health care personnel to aseptic techniques during childbirth and the postpartum period is very important and the least expensive measure to prevent infection. D Incorrect: Good nutrition to control anemia is a preventive measure. Limiting protein and fat intake will not help prevent anemia or prevent infection. DIF: Cognitive Level: Application OBJ: Client Needs: Safe and Effective Care Environment TOP: Nursing Process: Planning All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.