Week 9 - Postpartum Complications Flashcards
Postpartum mood changes/”Baby blues”
within 3-5 days postpartum
tearfulness
agitation
mood swings
anxiety
sleep and appetite disturbances
overwhelmed
vigilance
How long do the postpartum mood changes/baby blues last for?
2 weeks
T or F: Postpartum mood changes/baby blues interfere with the client’s ability to care for themselves and baby.
FALSE
do not interfere
Perinatal Mood Disorders (PMD)
anxiety, depression, psychosis
requires TREATMENT
When do Perinatal Mood Disorders (PMD) occur?
during pregnancy to 1 year after birth
may not occur right away
When do Perinatal Mood Disorders (PMD) most commonly occur?
4 - 6 weeks following birth
Protective factor
positive birth experience
Risk factors
marginalized communities
discrimination, racism
family history
previous history of anxiety or depression
Signs of PMD (many)
lack of sleep
not keeping up with activities
crying
negative feelings, not loving being a mom
can lead to a crisis
hearing voices
losing touch with reality
wanting to hurt self or the baby
Treatment for Perinatal Mood Disorders (PMD)
medication
nutrition
exercise
therapy
support systems
awareness, knowing you’re not alone
Etiology of Perinatal Mood Disorders (PMD)
COMPLEX
biological, psychological, situational, or multifactorial
CFIM cognitive domain example
education on baby’s care and well being
what the health conditions are, how they’re treating it, hospital policies etc.
CFIM affective domain example
sharing in a birth circle
sharing experiences in the community - therapeutic to share experience, validate ur emotions
CFIM behavioural domain example
setting different roles on NICU visits
behaviours that would help with milk production
exercise, sleep - protective factors
Ontario Perinatal Record Screening for Anxiety and Depression
validated across different cultures
validated when individual does it themselves
best for individual to do it**
lower score=better
score over 12 - refer
screening, not diagnosis
Ontario Perinatal Record Screening for Anxiety and Depression - screening
GAD-2 - anxiety screening
PHQ-2 - depression screening
T-ACE Screening Tool (Alcohol)
What to use if patient scores high on the PHQ-2 for depression
Edinburgh Perinatal / Postnatal Depression Scale (EPDS)
Perinatal Depression
low mood
lack of interest in activities
mild to severe
intense, pervasive sadness and labile mood swings
How long do perinatal depression symptoms last for?
last longer than 2 weeks
Treatment for perinatal depression
psychotherapy
CBT
psychodynamic therapy
antidepressants
antianxiety medications
electroconvulsive therapy
Medication consideration
breastfeeding and what meds can be used
Examples of open-ended questions to ask clients regarding mental health
“Now that you’ve had your baby, how are things going for you?”
“How have things changed for you since you’ve had your baby.”
“Some people have thoughts of hurting themselves or their baby. Have you had any of these thoughts?”
Things to promote with clients
exercise
sharing their feelings
sleep
seeking support
ask for hel
don’t overcommit
realistic expectations
flexibility in the day
Risk factors for perinatal mood disorders in partners
previous history
partner with postpartum depression
financial and work stress
poor social and relational support
difference with parenting expectations vs. reality
Symptoms of perinatal mood disorders in partners
fatigue
frustration
anger
irritability
Nursing interventions for perinatal mood disorders in partners
include partners inhealth teaching regarding PMD
universal screening with validated tools
advocating for stronghealthcare team relationships
Postpartum psychosis overview
SEVERE
rare
typical onset: within 2 weeks
Postpartum psychosis symptoms
RAPID onset
unusual behaviour
hallucinations
paranoid
disorientation
high levels of impulsivity increase risk for suicide or infanticide
Collaborative care for postpartum psychosis
inpatient psychiatric care
antipsychotics
mood stabilizers
benzodiazepines
electroshock therapy
Leading cause of maternal death
postpartum hemorrhage
Postpartum hemorrhage definition
any blood loss that has the potential to cause hemodynamic instability
also blood loss that doesn’t meet traditional cut-offs, BUT creates hemodynamic instability
life-threatening, will little warning
Postpartum hemorrhage blood loss amount after vaginal birth
500 mL
Postpartum hemorrhage blood loss amount after C-section
1,000 mL
T or F: Postpartum hemorrhage is largely preventable
TRUE
problem: not recognizing or recognizing late
need early intervention
Primary postpartum hemorrhage
within first 24 hours after birth
When do primary postpartum hemorrhages most commonly occur?
within 4 hours***
Secondary postpartum hemorrhage
after 24 hours but less than 6 weeks
Best way to measure postpartum bleeding amount
direct measurement
weigh blood soaked items (wet weight - dry weight)
sponge counts
pad counts
use containers
T or F: Practitioners underestimate blood loss.
TRUE
Preventing postpartum hemorrhage
active management in the 3rd stage of labour
oxytocin after delivery of anterior shoulder
gentle cord traction (no pulling)
immediate fundal assessment after birth
Oxytocin administration
usually 10 unit
push IV or IM
IM - vastus lateralis
Risk of PPH increases six-fold if the 3rd stage of labour takes longer than….
30 minutes
placenta may be retained
4 Ts of Postpartum Hemorrhage
Tone - uterine attony*
Trauma - perineum, cervix
Tissue - retained placenta
Thrombin - ability to clot
Risk factors for uterine attony (many)
overdistended uterus (macrosomia, multiples, polyhydramnios)
high parity
prolonged labour
oxytocin-induced labour (cells oversaturated, less response)
MgSo4 administration
chorioamnionitis (affects ability to contract)
Examples of trauma
lacerations of birth canal
uterine rupture (previous C-section and trialing vaginal birth)
uterine inversion
hematomas (on perineum - medical emergency)
Risk factors for trauma
operative birth
precipitous birth
When to suspect bleeding from lacerations
bleeding despite a firm uterus
faster
signs of shock
Examples of tissue
detained placental fragments
placenta previa
placenta accreta (mild invasion)
placenta increta (deeper invasion)
placenta percreta (completely through the uterus)
What is done for retained tissue
manual removal by OB provider
Dilation and curettage (D&C) may be required
Considerations for manual removal of tissue
painful!
ensure adequate management
consult anesthesia
Thrombin risk factors and causes
Idiopathic thrombocytopenic purpura (ITP)
von Willebrand’s disease
Disseminated intravascular coagulation (DIC)
Disseminated intravascular coagulation (DIC)
pathological clotting
very bad!
shock, SOB
prolonged PTT
low platelets
low fibrinogen
correction of underlying cause
Signs of hemorrhagic shock (many)
tachypnea and shallow respirations
tachycardia, weak and irregular HR
hypotension (late sign)
cool, pale, clammy skin
urinary output decreasing
LOC - lethargic
anxious
What is one of the first signs of shock?
anxiety!
T or F: Classic signs of shock may not appear until a significant amount of blood is lost.
TRUE
until 30-40% of blood is lost
blood volume increases during pregnancy - protective
Management of a PPH (many)
early recognitive
MASSAGE THE FUNDUS
watch blood clots as you’re massaging
eliminate bladder distention
meds
IV fluids - bolus
blood transfusion
oxygen administration
bimanual compression by OB
manual exploration of the uterus for retained placenta
uterine tamponade (packing or balloon)
ligation of arteries
uterine compression suturing
hysterectomy
Max amount of time that a balloon can be left in for
24 hours
What to do if fundus is firm and patient is still bleeding
assess for source of bleeding (trauma, thrombin)
Drugs for postpartum bleeding (5)
1) oxytocin*
2) misoprostol
3) carboprost thromethamine (Hemabate)
4) methylergonovine; ergonovine
5) tranexamic Acid
Oxytocin
contracts uterus
decreases bleeding
no contraindication for PPH
monitor bleeding and tone
Misoprostol
contracts uterus
don’t give if allergic to prostaglandins
monitor bleeding and tone
Carboprost thromethamine (Hemabate)
contracts uterus
contraindications: avoid with severe asthma or hypertension
monitor bleeding and tone
Methylergonovine; Ergonovine
contracts uterus
contraindication: HTN, PET, cardiac disease
check BP before giving
do not give if greater than 140/90**
Postpartum infections
puerperal infection
endometriosis
wound infections
UTIs
mastitis
Puerperal infection
any infection of genital canal within 28 days after abortion or birth
Signs of a puerperal infection
fever
foul smelling lochia
lethargy
severe abdominal pain
subinvolution of the uterus
tachycardia in mom (> mom) and baby (>160)
Most common infectious agents (2)
1) streptococci
2) anaerobes
Intrapartum risk factors for infection (many)
episiotomy or lacerations
C-section
prolonged rupture of membranes
chorioamnionitis
prolonged labour
frequent bladder catheterization
internal FHR monitor or IUPC
multiple vaginal exams after ROM
epidural
retained placental fragments
PPH
Infection prevention measures
limits vag exams to every 4 hours/as necessary
using squirt bottle after going to the bathroom
good hand hygeien
nothing in the vagina
prophylactic antibiotics in some cases
Venous Thromboembolic (VTE) Disorders
blood clot(s) inside a blood vessel due to venous stasis and hypercoagulation
occurs during pregnancy or postpartum (up to 3 weeks)
What increases risk for embolus?
a) vaginal birth
b) C-section
b) C-section
less ambulation
Priority for prevention VTE
early ambulation!
VTE risk factors
C-section
operative vaginal delivery
history of VTE, PE or varicosities
obesity
maternal age greater than 35 years
multiparity
smoking
Clinical manifestations of venous thromboembolism
pain and tenderness in lower extremities
warmth
redness
enlargement and hardened vein
Clinical manifestations of PE
dyspnea & tachypnea
tachycardia
chest pain
cough & hemoptysis
elevated temperature
