High Risk Postpartum Nursing Care- 14 Flashcards
Risk Reduction for postpartum complications
- Reviewing the prenatal and intrapartum records for risk factors
- Assessing for signs of a postpartum complication and intervening appropriately.
- Assisting the woman with ambulation.
- Preventing overdistended bladder.
- Using good hand washing techniques by health care workers, patients, and visitors.
• Promoting health with appropriate diet, fluids, activity, and rest.
ambulation-why
Ambulation decreases risk of venous thromboembolism.
Preventing overdistended bladder-why
Overdistended bladder can place the woman at risk for uterine atony, neurogenic bladder, and/or cystitis.
at risk moms
maternal age, pre-pregnancy obesity, preexisting chronic medical conditions, and cesarean deliveries.
Severe maternal morbidity (SMM)
unexpected perinatal outcomes that result in significant short- or long-term consequences to a woman’s health.
Postpartum hemorrhage (PPH)
blood loss greater than 500 mL for vaginal deliveries and greater than 1,000 mL for cesarean deliveries with a 10% drop in hemoglobin and/or hematocrit
The primary causes of PPH
Tone: uterine atony
● Tissue: retained placental fragments
● Trauma: lower genital track lacerations
● Thrombin disorders: disseminated intravascular coagulation
physiological changes that decrease amount of blood loss
● Hypercoagulability
● Contractions of the uterine myometrium
Tone (uterine atony) nursing actions
• Assist the uterus to contract via massage and/or medications
• Maintain fluid balance
• Monitor bleeding
Monitor vital signs and labs
• Administer oxygen 10–12 L via face mask
• Keep patient warm
Tissue- placenta retained or abnormal nursing actions
- Call provider to assess; D&C may be needed
- Monitor for signs of shock
- Administer oxygen if indicated
Trauma- lacerations/hematoma nursing actions
- Assess for visible hematoma
- Call provider to assess
- Anticipate possible excision and ligation if >3 cm
- Consider indwelling catheter
- Continue to assess vital signs, blood loss, and fluid maintenance
- Pain management, including ice to the area
Thrombin disorders
- Preeclampsia
- Stillbirth
nursing actions
- Early recognition is key factor in survival
- Confirm accurate blood loss estimates
- Monitor lab values, vital signs, intake and output
- Manage systemic manifestations such as volume replacement, platelets IV, oxygen by mask at 10 L/min
Indications of Primary PPH
- A 10% decrease in the hemoglobin and/or hematocrit postbirth
- Saturation of the peripad within 15 minutes
- A fundus that remains boggy after fundal massage
- Tachycardia (late sign)
- Decrease in blood pressure (late sign)
Uterine atony
decreased tone in the uterine muscle
Uterine atony s/s
● Soft (boggy) fundus versus firm fundus
● Saturation of the peripad within 15 minutes
● Slow and steady or sudden and massive bleeding
● Presence of blood clots
● Pale color and clammy skin
● Anxiety and confusion
● Tachycardia
● Hypotension
Uterine atony nursing actions
- review records for risks
- assess for displaced uterus
- assist to bathroom
- cath if needed + bladder scan
- assess fundus
- massage if boggy+ reassess every 5-15min
- baby on breast can release oxytocin
- assess lochia for amounts and clots
- review labs for hemoglobin and hematocrit
- contact physician with abnormalities
- emotional support
Methylergonovine (Methergine)
Actions: Directly stimulates smooth and vascular smooth muscles causing sustaining uterine contractions.
● Indications: Prevent or treat PP hemorrhage/uterine atony/subinvolution.
Carboprost—Tromethamine (Hemabate)
● Actions: Contraction of uterine muscle
● Indications: Uterine atony
Misoprostol (Cytotec)
● Actions: Acts as a prostaglandin analogue; causes uterine contractions.
● Indications: To control PP hemorrhage.
Not FDA approved
Oxytocin (Pitocin)
● Actions: Stimulates uterine smooth muscle that produces intermittent contractions. Has vasopressor and antidiuretic properties.
● Indications: Control of PP (postpartum) bleeding after placental expulsion.
Lacerations- when
● Give birth to large babies (fetal macrosomia).
● Experience an operative vaginal delivery, such as use of forceps or vacuum extraction.
● Experience a precipitous labor and birth.
Lacerations s/s
● A firm uterus that is midline with heavier than normal bleeding
● Bleeding that is usually a steady stream without clots
● Tachycardia
● Hypotension
Lacerations nursing actions
● review records and monitor moms who are at higher risk
● vital signs
● blood loss 1g=1ml
Notify the physician or midwife of increased bleeding with a firm fundus.
● Administer medications for pain management as ordered.
● Prepare the woman for a pelvic examination.
● Provide emotional support to the woman and her family.
Hematomas
blood collects within the connective tissues of the vagina or perineal areas related to a vessel that ruptures and continues to bleed
hematomas s/s
● Women express severe pain in the vaginal/perineal area, and the intensity of pain cannot be controlled by standard post-partum pain management.
● Presence of tachycardia and hypotension.
●can displace the uterus- uterine atony
hematomas nursing action
● Apply ice to the perineum for the first 24 hours to decrease the risk of hematoma.
● Assess the degree of pain by using a pain scale.
● Monitor for decrease in blood pressure and an increase in pulse rate, symptoms that indicate shock.
● Administer prescribed analgesia for pain management.
● Review laboratory reports such as H&H, as a decrease in H&H may be an indication of blood loss.
Subinvolution of the uterus
uterus does not decrease in size and does not descend into the pelvis
Subinvolution of the uterus s/s
● The uterus is soft and larger than normal for the days postpartum.
● Lochia returns to the rubra stage and can be heavy.
● Back pain is present.
Subinvolution of the uterus nursing actions
● Review prenatal and labor records for risk factors.
● Monitor women who are at risk for subinvolution of the uterus more frequently.
● Patient education is the primary action, as PPH from subinvolution usually occurs after discharge.`
Retained placental tissue
small portions of the placenta called cotyledons remain attached to the uterus during the third stage of labor.
can interfere with involution of the uterus, potentially leading to endometritis and subinvolution of the uterus.
endometritis
an inflammatory condition of the lining of the uterus and is usually due to an infection
Retained placental tissue s/s
● Profuse bleeding that suddenly occurs after the first postpartum week
● Subinvolution of the uterus
● Elevated temperature and uterine tenderness if endometritis is present
● Pale skin color
● Tachycardia
● Hypotension
Retained placental tissue nursing actions
education on warning signs
Post PPH nursing actions
● Assess the fundus and lochia every hour and PRN for the first 4 hours and then PRN.
● Instruct the woman on how to assess the fundus, how to do fundal massage, and the signs of PPH that should be reported to the health care provider.
● Increase oral and IV fluid intake to decrease risk of hypovolemia.
● Explain the importance of preventing bladder distention to reduce the risk for further PPH.
● Assist with ambulation since there is an increase of orthostatic hypotension related to blood loss.
● Anticipate the risk of fatigue related to blood loss.
● Provide uninterrupted rest periods while in the hospital.
●H&H labs
●info on diet high in iron to decrease risk of anemia
●psychosocial- talk about feelings
Disseminated intravascular coagulation (DIC)
syndrome in which the coagulation pathways are hyperstimulated. When this occurs, the woman’s body breaks down blood clots faster than it can form them, quickly depleting the body of clotting factors and leading to hemorrhage and death.
Disseminated intravascular coagulation (DIC) s/s
● Prolonged, uncontrolled uterine bleeding
● Bleeding from the IV site, incision site, gums, and bladder
● Purpuric areas at pressure sites, such as blood pressure cuff site
● Abnormal clotting study results, such as low platelets and activated partial thromboplastin time
● Increased anxiety
●shock
Disseminated intravascular coagulation (DIC)
● Reduce risk of DIC.
● Obtain IV site with large-bore intracatheter as per orders- fluids
● Administer oxygen as ordered.
● Obtain laboratory specimens as ordered.
● Review laboratory results and notify the physician of results.
● Start blood transfusion as ordered.
● Provide emotional support and information to the woman and her family to decrease level of anxiety.
● Facilitate transfer to ICU.
Anaphylactoid syndrome of pregnancy
amniotic fluid enters the maternal vascular system. Amniotic fluid within the vascular system initiates a cascading process that leads to cardiorespiratory collapse and DIC
Anaphylactoid syndrome of pregnancy s/s
● Dyspnea
● Seizures
● Hypotension
● Cyanosis
● Cardiopulmonary arrest
● Uterine atony that causes massive hemorrhage and leads to DIC
● Cardiac and respiratory arrest
Anaphylactoid syndrome of pregnancy nursing actions
- monitor for warning signs
- notify physician about changes
- administer O2
- Establish two IV sites with large-bore intracatheters: one for IV fluid replacement and one for blood replacement.
- labs
- blood replacement
- emotional support
Venous thromboembolism (VTE)
blood clot that starts in a vein
deep vein thrombosis (DVT)
which is a clot in a deep vein, usually in the leg but sometimes in the arm or other veins
pulmonary embolism (PE)
DVT clot breaks free from a vein wall, travels to the lungs, and blocks blood supply.
Venous thromboembolism (VTE) risks
Hypercoagulability, increased venous stasis, decreased venous outflow, uterine compression of the inferior vena cava and pelvic veins, reduced mobility, and changes in levels of coagulation factors
Classic signs of DVT
dependent edema, abrupt unilateral leg pain, erythema, low-grade fever, and positive Homan’s sign (i.e., pain with dorsiflexion of foot)
PE signs
shortness of breath, tachypnea, tachycardia, dyspnea, pleural chest pain, and anxiety.
Venous thromboembolism (VTE) nursing actions
- ambulations after symptoms dissipate
- elastic stockings
- manage pain
- Teach woman how to administer heparin subcutaneously to her abdomen.
- Instruct woman to report side effects such as bleeding gums, nosebleeds, easy bruising, or excessive trauma at injection site.
Endometritis
infection of the endometrium, myometrium, and/or parametrial tissue that usually starts at the placental site and spreads to encompass the entire endometrium.
Endometritis s/s
● Elevated temperature greater than 100.4°F (38°C) with or without chills
● Midline lower abdominal pain or discomfort
● Uterine tenderness
● Tachycardia
● Subinvolution
● Malaise
● Headache
● Chills
● Lochia heavy and foul-smelling when anaerobic organisms are present
Endometritis nursing actions
- reduce risk
- teach proper hand wash
- proper pericare
- change pad frequently
- early ambulation- uterine drainage
- intake of fluids
- high protein and vitamins C diet
- monitor WBC count
- monitor for S/S
- antibiotics
- pain management
- emotional support
- discharge teaching
Urinary tract infections (UTIs)
A woman’s urethra and bladder are often traumatized during labor and birth due to intermittent or continuous catheterizations and the pressure of the infant as it passes through the birth canal.
bladder and urethra lose tone after delivery
Cystitis
lower urinary tract infection.
UTI s/s
● Low-grade fever (101.3°F [38.5°C])
● Burning on urination
● Suprapubic pain
● Urgency to void
● Small, frequent voidings—less than 150 mL per voiding
UTI nursing actions
- assist to bathroom a few hours after birth
- cath if needed
- remind woman to void 2-3 hours
- measure voids
- change pads
- postpartum women should drink 3000ml/day
- monitor for s/s
- labs when needed
- antibiotics
- push hydration
- education
Mastitis
inflammation/infection of the breast tissue that is common among lactating women.
usually from newborns mouth
mastitis s/s
● Breast tenderness or warmth to the touch
● Generally feeling ill (malaise)
● Breast swelling and hardness
● Pain or a burning sensation continuously or while breastfeeding
● Skin redness, often in a wedge-shaped pattern
● Fever of 101°F (38.3°C) or greater
mastitis nursing actions
education
- complete emptying
- clean hands
- methods to decrease irritation and tissue breakdown
- diet
- educate on massage of breasts
- palpate and inspect breasts
- antibiotics
- pain management
- warm compression
Wound infection
can occur at the laceration site, episiotomy site, and cesarean incision site.
Wound infection s/s
● Erythema
● Heat
● Swelling
● Tenderness
● Purulent drainage
● Low-grade fever
● Increased pain at incision or laceration site
Wound infection risk factors
● Obesity
● Diabetes
● Malnutrition
● Long labor
● Prolonged operative time during cesarean section
● Premature rupture of membranes
● Preexisting infection, including chorioamnionitis
● Immunodeficiency disorders
● Corticosteroid therapy
● Poor suturing technique
Acute Onset of Severe Hypertension Postpartum
IV labetalol and hydralazine
The goal is not to normalize BP but to achieve a range of 140–150/90–100 mm Hg to prevent repeated, prolonged exposure to severe systolic hypertension.
Management of Diabetes Postpartum
education and empowerment is critical from the outset, and appropriate postpartum follow-up is essential
Pregestational Diabetes
Insulin requirements for the pregestational diabetic woman decrease in the immediate postpartum period.
- higher risk for infection
- breastfeeding can reduce risk for type 2 diabetes
Gestational Diabetes
Most women with gestational diabetes return to normal glucose tolerance postpartum
women with a history of GDM have a sevenfold increased risk of developing type 2 diabetes
Gestational Diabetes nursing actions
●education-diet,lifestyle, resources
●follow up appointment 2-6weeks
●encourage breastfeeding
● Assessing knowledge, risk perception, self-efficacy, current prevention behaviors, and intention to change behavior.
● Identifying barriers to health promoting behaviors and solutions to promote behavior change
Maternal Obesity Postpartum
increased incidence of infection and wound complications
risk factor for venous thromboembolism
Obesity-related complications during pregnancy are associated with future metabolic dysfunction in these women.
Pregravid obesity
associated with early termination of breastfeeding, postpartum anemia, and depression
Warning signs to call for postpartum patients
● Fever
● Foul-smelling lochia
● Large blood clots (golf ball–sized or bigger) or bleeding that saturates a pad in 1 hour
● Discharge, erythema, or severe pain from incisions or stitched areas
● Hot, red, painful areas on the breasts or legs
● Bleeding and/or severe pain in the nipples or breasts
● Severe headaches and/or blurred vision
● Chest pain and/or dyspnea without exertion
● Frequent, painful urination
● Signs of depression
4 to 6 weeks postpartum follow up
physical, social, and psychological well-being and a discussion of the desired form of contraception.
Early follow-up
beneficial for women at high risk of complications, such as postpartum depression, cesarean or perineal wound infection, lactation difficulties, or chronic conditions
postpartum blues
short-term and require no medical intervention
Perinatal depression
major and minor depressive episodes that occur during pregnancy or in the first 12 months after delivery
Postpartum depression (PPD)
mood disorder characterized by severe depression that occurs within the first 6 to 12 months postpartum and affects an estimated 11.5% of postpartum women
Postpartum depression (PPD) s/s
● Sleep and appetite disturbance
● Fatigue greater than expected when caring for a newborn
● Despondency
● Uncontrolled crying
● Anxiety, fear, and/or panic
● Inability to concentrate
● Feelings of guilt, inadequacy, and/or worthlessness
● Inability to care for self and/or baby
● Decreased affectionate contact with the infant
● Decreased responsiveness to the infant
● Thoughts of harming baby
● Thoughts of suicide
Postpartum psychosis (PPP)
variant of bipolar disorder, is the most serious type of postpartum mood disorder
develops frank psychosis, cognitive impairment, and grossly disorganized behavior that represents a complete change from previous functioning.
require immediate hospitalization and evaluation, as they are at risk for injuring themselves or their infants.
Postpartum psychosis (PPP) s/s
● Paranoia, grandiose or bizarre delusions, usually associated with the baby
● Mood swings
● Extreme agitation
● Depressed or elated moods
● Distraught feelings about ability to enjoy infant
● Confused thinking
● Strange beliefs, such as that she or her infant must die
● Disorganized behavior
Postpartum psychosis (PPP) management
● Hospitalization to the psychiatric unit
● Psychiatric evaluation
● Antidepressant and antipsychotic drug treatment
● Psychotherapy
● Electroconvulsive therapy
Paternal postnatal depression (PPND)
During the first few months postpartum, the man’s testosterone levels decrease and estrogen levels increase. Lower levels of testosterone are linked with depression in men.
PPND often goes undiagnosed and untreated for the following reasons:
- The man or health care provider fails to recognize signs and symptoms of PPND
- Lack of guidelines for assessing and treating PPND
- The man downplaying the degree to which the symptoms affect his life and relationships
- The man’s reluctance to discuss his depression symptoms with friends, family, or health care professionals
- The man resisting mental health treatment; worried about stigma of depression
- Few existing programs that address PPND
Paternal postnatal depression (PPND) s/s
● The man may withdraw from social interactions.
● The man may be cynical in his interactions and experience irritable moods.
● The man may demonstrate avoidance behaviors such as spending more time away from the family.
● The man’s affect may appear to be anxious or mad versus sad.
Paternal postnatal depression (PPND) assessment findings
● Irritable
● Overwhelmed
● Frustrated
● Indecisive
● Avoidance of social situations
● Cynical
● Increased alcohol consumption
● Drug use
● Domestic violence
