Chpter 22: Nursing Management Of The Postpartum Woman At Risk

Question 1

The four most common conditions that place the postpartum at risk

Answer 1

Hemorrhage, thromboembolic disease, infections, and postpartum affective disorders

Question 2

Postpartum hemorrhage

Answer 2

The leading cause of maternal death. Usually occurs within four hours of birth the blood loss of the greater than 500 mL after vaginal birth or more than 1000mL after cesarean birth. Objectively it is any bleeding that places the mother in hemodynamic jeopardy.

The most common cause of postpartum hemorrhage is uterine atony.
Because of the increase in blood during pregnancy, signs of hemorrhage such as decreased blood pressure, increased pulse, decreased urinary output, do not appear until as much as 1800 - 2100 mL of blood has been lost.

Causes include lacerations, episiotomy, retain placental fragments, uterine inversion, coagulation disorders, LGA, failure to progress during the second stage, placenta accreta, induction, surgical birth, hematomas.

Question 3

Uterine Atony

Answer 3

Failure of the uterus to contract and retract afterbirth.

Having a full bladder that displaces the uterus can call this. The absence of uterine contractions can result in excessive blood loss.

Over distention is a major risk factor for uterine atony

Uterine massage is used to treat this.

Question 4

5 T’s for causes of postpartum hemorrhage

Answer 4

Tone(abnormalities of uterine contraction: uterine atony, distended bladder
Tissue (retained in uterus): retained placenta and clots
Trauma (of the genital tract): vaginal, cervical, or uterine injury
Thrombin (coagulation abnormalities): coagulopathy/pre-existing or acquired
Traction (of the cord): causing uterine inversion

Question 5

placenta accreta

Answer 5

An uncommon condition in which the chorionic villi adhere to the myometrium, causing the placenta to adhere abnormally to the uterus and not separate and deliver spontaneously. This causes hemorrhage

Question 6

Uterine inversion

Answer 6

Prolapse of the uterine fundus to or through the cervix so that the uterus is turned inside out afterbirth. This is more common with multiparity, adherence of the placenta, excessive traction on the umbilical cord, vigorous fundal pressure, manual removal of placenta. Management involves gentle pushing of the uterus back into position under general anesthesia, oxytocin to stimulate contractions and antibiotics

Question 7

Subinvolution

Answer 7

Incomplete involution of the uterus or failure to return to its normal size and condition after birth. This can cause hemorrhage, pelvic peritonitis, abscess formation. Causes include retain placental fragments, distended bladder, uterine myoma, and infection.

This presents as a fundal height higher than expected, a boggy uterus, lochia does not change colors from red to serious in a few weeks. Treatment is to promote uterine stimulation and antibiotics.

Question 8

Idiopathic thrombocytopenia purpura-ITP

Answer 8

Disorder of increase platelet destruction caused by autoantibodies which increase a woman’s risk of hemorrhaging. It is a decrease in the number of circulating platelets. Treated with glucocorticoids and immunoglobulins

Question 9

Von Willebrand disease

Answer 9

Congenital bleeding disorder that is inherited as an autosomal dominant trait. It has a prolonged bleeding time, deficiency of von Willebrand factor, impairment of platelet adhesion. Common symptoms include nosebleeds and hematomas. Monitor closely in the first week postpartum.

Question 10

Disseminated intravascular coagulation/D I C

Answer 10

Life-threatening acquired coagulopathy in which the clotting system is abnormally activated, resulting in widespread clot formation in small vessels throughout the body which leads to the depletion of platelets and coagulation factors. It is a secondary diagnosis that is a complication of abruptio placenta, amniotic fluid embolism, intrauterine fetal death with prolonged retention of the fetus, severe preeclampsia, HELLP syndrome, septicemia, and hemorrhage. Clinical features include petechiae ecchymosis, bleeding gums, fever, hypotension, acidosis, hematomas, tachycardia, proteinuria, uncontrolled bleeding during birth, and acute renal failure. Correct the underlying disorder.

Question 11

Hematoma

Answer 11

The uterus would be firm with bright red bleeding. Observe for a bluish bulging area just under the skin of the perineal area. Woman will report severe pelvic pain and have difficulty voiding. She may also have hypotension tachycardia and anemia

Question 12

Nursing management of a hemorrhage

Answer 12

Fundal massage, intravenous fluid resuscitation, administration of uterotonic medications. If they fail to control bleeding aggressive intervention such as bimanual compression, intrauterine packing, balloon tamponade, blood transfusions

Question 13

Massaging the fundus

Answer 13

Place one gloved hand on the fundus. Place the other gloved hand above the symphysis pubis to support the lower uterine segment. With the hand on the fundus massage in a circular manner but do not over massage. Assess for uterine firmness. If firm apply gentle yet firm pressure in a downward motion toward the vagina to express any clots. Do not do this if the uterus is not firm because it could lead to a uterine inversion. Assist woman with perineal care and a new perineal pad. Remove gloves and wash

Question 14

Uterotonic drug contraindications

Answer 14

Pitocin: never give undiluted as a bolus IV
Cytotec: allergy, active CVD, pulmonary or hepatic disease
Prostin E2-active cardiac, pulmonary, renal, or hepatic disease
Methergine: if the woman is hypertensive
Hemabate: asthma

Question 15

Hypovolemic shock

Answer 15

Assess for anxiety which may indicate shock. Monitor blood pressure, pulse, capillary refill, mental status, urinary output. Must control the source of the bleed, oxygen to maintain tissue perfusion.

Question 16

Thromboembolic conditions

Answer 16

A thrombosis can cause inflammation of the blood vessel lining call thrombophlebitis which in turn can lead to a thromboembolism. Superficial thrombophlebitis can because by the use of lithotomy position during birth. DVTs can lead to pulmonary emboli.

Question 17

Preventing thrombotic conditions

Answer 17

Teach about risk factors, symptoms, and preventive measures. Encourage activity such as leg exercises and walking. Use SCD. Elevate legs. Stop smoking. Wear compression stockings. Passive range of motion exercises in bed. Deep breathing exercises. Use warfarin aspirin or heparin. Do not put pillows underneath knees and do not cross legs. Avoid leaving legs in Stirruos and use padded stirrups. Avoid sitting or standing in one position for prolonged period. Use the bed cradle to keep linens and blankets off. Avoid trauma to the legs. Increase fluids. Avoid oral contraceptives. Early ambulation is that using it and most cost-effective method along with compression stockings.

Question 18

Postpartum infection

Answer 18

Defined as a fever of 100.4 or higher after the first 24 hours after birth, occurring on at least two of the first 10 days. Risk factors include surgical birth, prolonged rupture of membranes, long labor with multiple vaginal exams, age, low socioeconomic status, and anemia.

Question 19

Metritis

Answer 19

And infectious condition that involves the endometrium, decidua, and myometrium. If it extends it can turn into parametritis which involves the broad ligament, ovarian and fallopian tubes. Once membranes rupture the uterine cavity is no longer sterile.

Signs and symptoms include lower abdominal pain, elevated temperature, foul-smelling lochia, anorexia, nausea, fatigue and lethargy, leukocytosis and elevated sedimentation rate

Treatment includes broad-spectrum antibiotics pain management and fluid replacement

Question 20

Mastitis

Answer 20

Usually within the first two weeks, it is an inflammation of the breast. The frequent reason most women stop breast-feeding. It is caused from anything that creates milk stasis such as insufficient drainage of the breast, rapid weaning, oversupply, pressure on the breast, a blocked duct, missed feedings, breakdown. The most common organism is Staphylococcus at. This comes from the breast-feeding infants mouth and throat. If not treated it may turn into an abscess. Flulike symptoms are often the first experience. Breasts are red, Tender, hot. Treatment includes milk removal, pain medication, and antibiotics. Increase the frequency of nursing. Use ice or warmed packs.

Question 21

Treatment of wounds infections

Answer 21

Open drainage of the wound, frequent dressing changes, handwashing, perennial pad changes, hydration, ambulation to prevent venous stasis, parenteral antibiotics.

Signs and symptoms include drainage, separation of edges, edema, erythema, tenderness, discomfort, fever, increased white blood cell count

Question 22

Treatment of urinary tract infections

Answer 22

Increase fluids, nutrition to acidify the urine such as vitamin C or cranberry juice. Antibiotics if needed.

Signs and symptoms include urgency, frequency, dysuria, flank pain, low-grade fever, urinary retention, hematauria, nitrate positive urine, cloudy urine with strong odor

Question 23

REEDA

Answer 23

Is to assess perineum. Each category has a number from 0 to 3 with a high score being 15.

Redness 
edema 
ecchymosis 
discharge 
approximation of skin edges

Question 24

Postpartum affective disorders

Answer 24

They may be caused by plummeting levels of estrogen and progesterone immediately after birth. Greater changes in these levels, the greater the chance for developing a mood disorder.

Question 25

The baby blues

Answer 25

Anxiety, irritability, mood swings, tearfulness, increased sensitivity, being overwhelmed, fatigue. Usually peak days 4-5 and resolved by postpartum Day 10. Does not affect the mother’s ability to function. They are self-limiting and require no treatment other than reassurance and validation. Follow-up is important to make sure it does not turn into depression

Question 26

Postpartum depression

Answer 26

More common in teen moms. The depression feels worse over time, with changes in mood and behavior that do not go away. They last longer and are more severe and required treatment. Signs include restless, worthless, guilty, hopeless, moody, sad, overwhelmed, loss of enjoyment, low energy level, loss of libido, crying, lack of energy, indecisive, memory loss, lack of pleasure, changes in appetite sleep and weight, lack of concern, withdrawn, pains that do not subside, negative feelings too baby, Lack of interest in baby, worried about hurting the baby, suicidal thoughts. Usually evident in the first six weeks.
Hormones involved include estrogen, progesterone, Serotonin, and thyroid. Factors that may lead to depression include feelings about the pregnancy, fatigue, being less attractive, no help from partner, lack of social support, doubts about being a good mom, stress, loss of freedom.
EPDS Edinburgh postnatal Depression Scale
PDSS Postpartum depression predictor scale

Question 27

Postpartum Psychosis

Answer 27

Emergency psychiatric condition which can result in an increased risk for suicide and infanticide. Symptoms include mood lability, delusional beliefs, hallucinations, disorganized thinking, sleep disturbances, fatigue, depression, hypomania, tearfulness, confusion, feelings of guilt and worthlessness. Women should not be left alone with their infants. They may require hospitalization for several months. Usually is seen within the first three months postpartum