1. THE HIGH-RISK POSTPARTUM EXPERIENCE

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

3. Maternal Mortality

4. 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

5. Uterine Atony

6. 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

7. Hypovolemic Shock in the Maternity Patient

8. Placental Bleeding Causes

9. 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 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

10. HEMORRHAGE: Pharmacologic Management
# 1: Pitocin (oxytocin): units/L IV or 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

11. Pitocin

12. Methergine

13. Hemabate

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

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

16. Deep Vein Thrombosis

17. 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

18. 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

19. 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

20. 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

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

22. 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)

23. 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

24. “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”