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Complications of Postpartum Postpartum Hemorrhage Early Occurs when blood loss is greater than 500 ml.

l. in the first 24 hours after a vaginal delivery or greater than 1000 ml after a cesarean birth *Normal blood loss is about 300 - 500 ml.) Late Hemorrhage that occurs after the first 24 hours Main Causes of Early Hemorrhage are:

1. Uterine Atony
2. 3. 4. 5.

Lacerations Retained Placental Fragments Inversion of the Uterus Placenta Accreta

Uterine Atony Etiology and Pathophysiology: The most frequent cause of postpartal hemorrhage is UTERINE ATONY. The myometrium fails to contract and the uterus fills with blood because of the lack of pressure on the open vessels of the placental site. Predisposing Factors: 1. Prolonged labor 2. Over distention of the uterus 3. Grandmultiparity 4. Excessive use of analgesics and anesthesia 5. Intrapartum stimulation with Pitocin 6. Trauma due to obstetrical procedures In most cases the nurse can predict which woman is at risk for hemorrhage. The key to successful management is PREVENTION. Prevention begins with adequate nutrition, good prenatal care, and early diagnosis and management of any complication. Traumatic procedures should be avoided such as intrauterine manipulation., forceps rotation, and overmassage of fundus. Signs 1. 2. 3. 4. and Symptoms: Excessive or bright red bleeding A boggy uterus that does not respond to massage Abnormal clots Any unusual pelvic discomfort or backache

Nursing Care: *The fundus should be well contracted, midline, firm, and recede 1 FB/day. 1. 2. 3. Carefully document vaginal bleeding by counting or weighing of peri pads. 1 GM. = 1 ML. Fundal massage, be sure bladder is empty. Massage and leave alone. Dont overmassage. Assess V/S for hypovolemic shock.

4. 5. 6.

IVs with oxytocin Pitocin. If woman has a normal blood pressure then may give Methergine or Ergotrate to contract uterus. D&C or Hysterotomy elevate and hold uterus out of pelvis and massage. Hysterectomy if unable to control bleeding

LACERATIONS
ETIOLOGY AND PATHOPHYSIOLOGY: Lacerations of the birth canal are second only to uterine atony as a major cause of postdelivery hemorrhage. Predisposing Factors: 1. Spontaneous or Precipitous delivery 2. Size, Presentation, and Position of baby 3. Contracted Pelvis 4. Vulvar, perineal, and vaginal varices Signs and Symptoms: 1. Bright red bleeding where there is a steady trickle of blood and the uterus remains firm. 2. Hypovolemia **Continuous bleeding from so-called minor sources may be just as dangerous as a sudden loss of a large amount of blood. Treatment and Nursing Care: 1. Meticulous inspection of the entire lower birth canal 2. Suture any bleeders 3. Vaginal pack-- nurse may remove and assess bleeding after removal 4. Blood replacement Test Yourself ! You are assigned to Mrs. B. who delivered vaginally. As you do your post-partum assessment, you notice that she has a large amount of lochia rubra. What would be the first measure to determine if it is related to uterine atony or a laceration? (Answer: assess the fundus) RETAINED PLACENTAL FRAGMENTS Etiology and Pathophysiology: This occurs when there is incomplete separation of the placenta and fragments of placental tissue retained. Signs and Symptoms: Boggy , relaxed uterus Dark red bleeding Treatment and Nursing Care: D & C - clean out any fragments that may be left Administration of Oxytocins to contract the uterus Administration of Prophylactic antibiotics

INVERSION OF THE UTERUS Etiology and Pathophysiology: The uterus inverts or turns inside out after delivery. Complete inversion - a large red rounded mass protrudes from the vagina Incomplete inversion - uterus can not be seen, but felt Predisposing Factors: Traction applied on the cord before the placenta has separated. **Dont pull on the cord unless the placenta has separated. Incorrect traction and pressure applied to the fundus, especially when the uterus is flaccid **Dont use the fundus to push the placenta out Treatment and Nursing Care: 1. Replace the uterus--manually replace and pack uterus 2. Combat shock, which is usually out of proportion to the blood loss 3. Blood and Fluid replacement 4. Give Oxytocin 5. Initiate broad spectrum antibiotics 6. May need to insert a Nasogastric tube to minimize a paralytic ileus **Notify the Recovery Nurse what has occurred! Care must be taken when massaging PLACENTA ACCRETA Etiology and Pathophysiology: Placenta accreta is a condition that occurs when all or part of the decidua basalis is absent and the placenta grows directly onto the uterine muscle. This may be partial where only a portion abnormally adhered or it may be complete where all adhered . Signs and Symptoms:

During the third stage of labor, the placenta does not want to separate. Attempts to remove the placenta in the usual manner are unsuccessful, and
lacerations or perforation of the uterus may occur Treatment: 1. If it is only small portions that are attached, then these may be removed manually 2. If large portion is attached--a Hysterectomy is necessary! HEMATOMA Etiology and Pathophysiology: Bleeding into the tissues of the perineal area can cause hematoma formation. May have at least 500 cc. Pooled in the hematoma. May be around the episiotomy site. Signs and Symptoms: 1. Pain perineal. More than normal amount of pain. Mild analgesics are not sufficient to decrease the amount of pain. 2. Hard, firm, area on the perineum Treatment 1. 2. 3. and Nursing Care: I & D incision and drainage. May leave in a penrose drain. Dressing changes Replace the blood loss

4.

Comfort measures LATE POSTPARTUM HEMORRHAGE

Etiology and Pathophysiology: Occasionally, late postpartal hemorrhage occurs around the fifth to the fifteenth day after delivery when the woman is home and recovering. The most frequent causes are: 1. Retained placental fragments 2. Subinvolution the uterus fails to follow the normal pattern of involution and remains enlarged. SIGNS AND 1. 2. 3. SYMPTOMS: Lochia fails to progress from rubra to serosa to alba. The uterus is higher in the abdomen. Irregular or excessive bleeding.

TREATMENT AND NURSING CARE: 1. Oral administration of Methergine for 24-48 hours. 2. D&C

PUERPERAL INFECTIONS
A Puerperal Infection is an infection of the genital tract, usually of the endometrium associated with parturition and generally encompasses the time from delivery to 6 weeks postpartum. Can occur after abortion or delivery. CAUSATIVE FACTORS: The vagina and cervix of pregnant women generally contain pathogenic bacteria sufficient to cause infection. Generally, other factors must be present, however, for infection to occur. The most common infecting organisms are HEMOLYTIC STREPTOCOCCUS GROUPS A or B. Other aerobic bacteria responsible are: E. Coli, Klebsiella, and Pseudomonas. Anaerobic bacteria include Clostridium. PREDISPOSING FACTORS: 1. Trauma 2. Hemorrhage 3. Prolonged labor 4. Urinary tract infection 5. Anemia 6. Hematomas (perineal) 7. Excessive vaginal exams 8. P.R.O.M. Signs and Symptoms: 1. Temperature of 100.4F (38.0C) or higher, the temperature to occur on any two consecutive days of the first ten postpartum days, exclusive of the first 24 hours, and to be taken by mouth. **This definition is established by the Joint Commission on Maternal Welfare . 2. Profuse, foul smelling vaginal discharge, sometimes frothy. 3. Malaise, anorexia, chills, tachycardia

4.

Pelvic pain

Following delivery of the placenta, the placenta site provides an excellent culture media for bacterial growth. The site in the contracted uterus is 4 cm. round, dark red, elevated area composed of numerous veins. The remaining portion of decidua is also susceptible because of thinness and hypervascularity. The cervix may also present bacterial breeding ground because of multiple small lacerations. Complications of Puerperal Infections: 1. Pelvic cellulitis 2. Peritonitis SIGNS OF CONDITION WORSENING: 1. Fever spiking to 102F to 104F 2. Elevated white blood count 3. Chills 4. Extreme lethargy 5. Nausea and vomiting 6. Abdominal rigidity and rebound tenderness TREATMENT AND NURSING CARE: Diagnosis of the infection site is accomplished by physical exam, blood work, and urinalysis. Culture of urine and body discharges. 1. 2. 3. 4. 5. 6. 7. Antibiotic therapy Broad spectrum Warm sitz baths Promote drainage have pt. lie in High Fowlers position so wont go up and out tubes to the abdominal cavity Maintain Fluid and Electrolyte balance at least 3000 to 4000 cc/day. IVs Keep uterus contracted give oxytocin drugs Provide narcotic analgesics for alleviation of pain Nasogastric suction if develops peritonitis

Preventive Measures: Prompt treatment of anemia Well-balanced diet Avoidance of intercourse late in pregnancy Strict asepsis during labor and delivery Teaching of postpartum hygiene measures o keep pads snug o change pads frequently o wipe front to back o use peri bottle after each elimination LOCALIZED INFECTION A less severe complication of the puerperium is localized infection of the episiotomy, perineal lacerations, vaginal or vulva lacerations. Wound infection of abdominal incision site following cesarean birth. With a localized infection, there is no foul smelling lochia. Signs and Symptoms: 1. Reddened, edematous, firm, tender edges of the skin.

2.

Edges separate and purulent material mixed with serosangious liquid drains from the wound.

Treatment and Nursing Care: Antibiotics Wound care

MASTITIS
A distinction needs to be made between true mastitis and localized inflammation of the breasts resulting from a blocked milk duct. A blocked milk duct responds readily to breast massage. In Mastitis there is a bacteria caused infection that needs vigorous intervention. Almost always unilateral and develops well after the flow of milk is established. Types:

Mammary Cellulitis - inflammation of the connective tissue between the lobes in the
breast

Mammary Adenitis - infection in the ducts and lobes of the breasts


Development of Mastitis:

Signs and Symptoms: 1. Marked engorgement and pain. 2. Chills, fever, tachycardia, hardness and reddening of breasts. 3. Enlarged and tender lymph nodes. Treatment of Mastitis: 1. Rest 2. Appropriate Antibiotics--Usually Cephalosporins 3. Hot and / or Cold Packs 4. Dont stop Breast Feeding because: If the milk contains the bacteria, it also contains the antibiotic Sudden cessation of lactation will cause severe engorgement which will only complicate the situation Breastfeeding stimulates circulation and moves the bacteria containing milk out of the breast PREVENTATIVE MEASURES: 1. Meticulous hand washing by all personnel. 2. Frequent feedings of infant. If the mother finds that one area of breasts feel distended, several methods may help: a. rotate position of baby for nursing so that babys gums compress different sinuses each time. b. If breast not emptied at feeding manual expression or breast pump can assure that breast is emptied. c. As infant nurses, mother should massage distended area to help emptying. COMPLICATION: A complication of mastitis is development of a BREAST ABSCESS. Breast feeding is discontinued on the affected side, but may feed on the unaffected side. TREATMENT: The abscess is incised and drained and may need to teach mom how to change dressings. Test Yourself: The major causative organism of mastitis is _____________. Mastitis develops mainly in ____________ who are nursing . It is almost always ________________ and develops well after the flow of milk has been established. There are two types of mastitis. One that develops between the lobes of the breast is called____________________. The one that develops within the lobes and ducts of the breast is called __________________. Mammary cellulitis mainly develops due to _______________. Mammary adenitis develops when ____________________of the breasts occurs. With improper treatment or no treatment, mastitis can lead to ________________. PUERPEAL CYSTITIS Etiology and Pathophysiology:

Diuresis is a normal physiological function during the immediate postpartal period. The body uses this mechanism to begin to eliminate the extra fluid volume that has accumulated during pregnancy. Stretching or trauma to the base of the bladder occurs to some degree in any vaginal delivery, the resulting edema of the trigone is great enough to obstruct the urethra and to cause acute retention. Anesthesia can inhibit normal neural control of the bladder and lead to overdistention and decrease bladder sensitivity. So, Residual urine and Bladder trauma can lead to CYSTITIS. PREVENTION: Diligent monitoring of the bladder during the recovery period and preventive health measures greatly reduce the number of women who get overdistention. a. Encourage mother to void regular and complete emptying, proper wiping techniques and good perineal care. b. Catheterize with extreme gentleness and sterility. Signs and Symptoms: 1. Frequency, urgency 2. Dysuria 3. Nocturia Treatment 1. 2. 3. 4. and Nursing Care: Cath urine for C&S Antibiotics - Ampicillin Urinary tract antispasmotic Force fluids

THROMBOEMBOLC DISEASE Superficial thrombophlebitis is limited to the superficial saphenous veins, whereas deep thrombophlebitis generally involves most of deep venous system. PREDISPOSING FACTORS: 1. Slowing of blood flow in legs usually in Moms who have a Cesarean delivery. 2. Trauma to the vessels during delivery. Signs and Symptoms: 1. Sudden onset of pain, tenderness of calf, redness and an increase in skin temp. 2. Positive Homans Sign. Treatment and Nursing Care: Heparin it does not cross into breast milk. COMPLICATION: PULMONARY EMBOLI substernal chest pain, sudden and intense; dyspnea; pallor and cyanosis; increased jugular pressure; confusion; hypotension; sudden apprehension; hemoptysis.

PUERPERAL PSYCHIATRIC DISORDER


Introduction:

Mental health problems can complicate the puerperium. Pregnancy is NOT the cause of psychiatric illness. However, the psychological and physical stresses relating to new obligations of motherhood may precipitate an emotional crisis. The principle emotional disturbances complicating the postpartum period are AFFECTIVE/MOOD DISORDERS and SCHIZOPHRENIA/POSTPARTUM PSYCHOSIS. AFFECTIVE/MOOD DISORDERS: The most common mood disorders are postpartum depression and bipolar disorder. POSTPARTUM DEPRESSION: Predisposing Factors: 1. History of depression 2. Environmental and Family stress issues those with fewer support systems, more stressful life events, and few personal resources with which to combat these events. 3. Hormonal changes 4. Infant- related Assessment: 1. Lack of interest or energy, loss of usual emotional response toward her spouse or family 2. Anorexia 3. Sleeplessness 4. Poor personal hygiene 5. Inability to follow directions, poor concentration 6. Feelings of unworthiness, guilt, shame 7. Obsessive thoughts of failure as mother; disinterest in the new infant, unable to feel love for infant BIPOLAR DISORDER Predisposing Factors: Similar to those of postpartum depression. Assessment: Manic Phase: 1. Grandiosity 2. Decreased need for sleep 3. Flight of ideas / distractability 4. Psychomotor agitation / hyperactive 5. Rejection of the infant TREATMENT AND NURSING CARE FOR MOOD DISORDERS: 1. Antidepressive drugs. a. SSRI Prozac, Paxil, Zoloft b. Cyclic Compounds Tofranil, Asendin, Norpramin, Sinequan c. MAO Inhibitors Nardil, Parnate d. Other Medications Wellbutrin, Effexor, Desyrel e. Lithium, Depakene, or Tegretol for Bipolar disorder

**None of these drugs have been proven safe with lactation 2. 3. 4. 5. 6. 7. Psychotherapy and allow mother to express her distress. Encourage communication with husband or significant other who is available to provide support when loneliness and anxiety becomes a problem. Explain importance of good nutrition and rest. Discuss changes that normally occur in the beginning weeks after taking the baby home; acknowledge her new role Although some thoughts seem unreasonable, she should acknowledge these feelings to herself and insist that other acknowledge them too. Re-introduce the baby to the mother at the mothers own pace.

SCHIZOPHERENIA: Schizophrenia is far less common. It may surface when the mother does not have the ability to adjust to and cope with her new obligations as a mother. Affects adolescents and younger adults. Signs and Symptoms: 1. Irritability 2. Euphoria 3. Exhibits little need for sleep 4. Hostility toward husband; husband neglected 5. Overly suspicious, seldom aware they have a problem 6. Sudden onset of delusion or hallucinations 7. Often believes hers to be an immaculate conception 8. Abandons reality, totally neglects the infant; retreats into her own world. 9. May have delusions and erroneously believe that her baby is dead, malformed, or severely ill TREATMENT AND NURSING CARE: 1. Remove the baby from the situation: If the mother appears to have rejected her baby it is never wise to compel her to care for him or her. This forces the woman to deal with feelings of guilt, shame, and hostility that may overwhelm her and endanger the infant. 2. Hospitalization is necessary. 3. Antipsychotic Medications Stelazine, Clozaril, Risperdal, Haldol, Navane, etc. 4. When she is better then bring in baby and help her to develop a plan of care. Give praise for small tasks so can gain confidence.

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