High Risk Postpartum Nursing Care- 14 Flashcards by Jordan Parshall

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.

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ambulation-why

Ambulation decreases risk of venous thromboembolism.

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Preventing overdistended bladder-why

Overdistended bladder can place the woman at risk for uterine atony, neurogenic bladder, and/or cystitis.

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at risk moms

maternal age, pre-pregnancy obesity, preexisting chronic medical conditions, and cesarean deliveries.

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Severe maternal morbidity (SMM)

unexpected perinatal outcomes that result in significant short- or long-term consequences to a woman’s health.

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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

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The primary causes of PPH

Tone: uterine atony

● Tissue: retained placental fragments

● Trauma: lower genital track lacerations

● Thrombin disorders: disseminated intravascular coagulation

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physiological changes that decrease amount of blood loss

● Hypercoagulability

● Contractions of the uterine myometrium

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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

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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

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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

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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

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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)

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Uterine atony

decreased tone in the uterine muscle

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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

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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

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Methylergonovine (Methergine)

Actions: Directly stimulates smooth and vascular smooth muscles causing sustaining uterine contractions.

● Indications: Prevent or treat PP hemorrhage/uterine atony/subinvolution.

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Carboprost—Tromethamine (Hemabate)

● Actions: Contraction of uterine muscle

● Indications: Uterine atony

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Misoprostol (Cytotec)

● Actions: Acts as a prostaglandin analogue; causes uterine contractions.

● Indications: To control PP hemorrhage.

Not FDA approved

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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.

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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.

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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

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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.

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Hematomas

blood collects within the connective tissues of the vagina or perineal areas related to a vessel that ruptures and continues to bleed

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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

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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.

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Subinvolution of the uterus

uterus does not decrease in size and does not descend into the pelvis

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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.

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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.`

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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.

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endometritis

an inflammatory condition of the lining of the uterus and is usually due to an infection

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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

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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

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High Risk Postpartum Nursing Care- 14 Flashcards

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