Nursing Care of the High-Risk Post-Partal Clients

Post-Partum Hemorrhage
Blood loss of more that

500 ml within a 24 hour period following delivery Four types:

Uterine Atony

Lacerations
Retained placental

fragments DIC

Uterine Atony
Relaxation of the uterus Causes

Deep anesthesia or analgesia Labor assisted with oxytocin agent Greater than 30 years old High parity Previous uterine surgery Abruptio placenta Prolonged & difficult labor Posible chorioamnionitis Secondary maternal illness (anemia) Prior Hx of postpartum hemorrhage Endometritis Prolonged use of tocolytic drugs

 Assessment:
Gush of blood Signs of shock may appear Relaxation of the uterus

Management:

Palpate womans fundus at frequent interval Massage the uterus Observe for the consistency and amount of lochia Assess vital signs Encourage to empty the bladder Administer oxygen 4L/m Administer oxytocin/methergine as ordered Bimanual massage Prostaglandin administration Blood replacement hysterectomy

Lacerations
Causes:
Difficult or precipitate labor In primigravidas With birth of large infants Use of lithotomy position and instruments

Types:
Cervical laceration Vaginal lacerations

Perineal lacerations

Cervical Lacerations
Usually found on the sides of the cervix, near the

branches of uterine artery Management:

Provide adequate space, lighting, suture supplies Reassure the woman

Vaginal Lacerations
Hard to repair

Management
Vagina may be packed to

maintain pressure at the suture line Insert indwelling catheter Document Nursing care specially the insertion of packing. Remove the packing after 24 hours

Perineal Lacerations
Categories:
1st Degree vaginal mucous membrane and skin

of the perineu to the fourchette 2nd Degree vagina, perineal skin, fascia, levator ani muscle, perineal body 3rd Degree entire perineum, reaches the external sphincter of the rectum 4th Degree entire perineum, rectal sphincter, some of the mucous membrane of the rectum

 Management:
Document the degree of laceration Increase fluid intake

Stool softener as prescribed

No taking of temp. Reactally & Rectal suppository (3rd

& 4th degree) Episiorrhaphy

Retained Placental Fragments

May not be detected until

6 to 10 days post partum Uterus is not fully contracted Can be assessed using a sonogram Management
D&C

Methotrexate
Instruct the mother to

observe lochial discharge

Subinvolution
Incomplete return of the uterus to its prepregnant

size and shape. Uterus is still enlarged and soft at 4th-6th week post partum. Causes:
Retained placental fragments Mild endometritis myoma

 Management:
Administration of methergine (4 times a day) Educate woman of the normal process of involution

and lochial discharges before going home If endometritis is observed, oral antibiotic is initiated.

Perineal Hematomas
Collection of blood in the subcutaneous layer of

tissue of the perineum Assessment

Severe pain in perineal area Feeling of pressure between womans leg Purplish discoloration and swelling Tender to palpation

Causes:
Injury to blood vessels during birth Precipitous births of woman with perineal

varicosities Often found at the site of episiotomy or laceration

 Management
Report presence of hematoma, its size, shape and

degree of womans discomfort Administer mild analgesic as for pain relief as prescribed Apply ice pack If episiotomy or line is opened to drain hematoma,
Left it open and packed with a gauze Document the insertion of packing Remove packing after 24 to 48 hours.

Puerperal Infection
Causes:
Rupture of membranes more than 24 hours before

birth Retained placental fragments Postpartal hemorrhage Preexisting anemia Prolonged and difficult labor/ use of instruments Internal fetal heart monitoring Local vaginal infection is present at the time of birth Uterus was explored at the time of birth

 Management:
Antibiotics after C/S testing of microorganism

Endometritis
Infection of the

endometrium Associated with chorioamnionitis and CS Assessment:

Elevation of temp after 24

hours postpartum Increase WBC Chills Loss of appetite Malaise Locia dark brown & has a foul odor

 Management:
Asess lochial discharge (amount, color, consistency,

odor) Appropriate antibiotic c/s culture should be from the vagina Administration of methergine Increase fluid intake Analgesic for pain Encourage ambulation/ semi-fowlers position Wear gloves in helping the woman change perineal pads Teach woman the proper hand washing technique

Infection of the Perineum

Occurs if woman have a suture line at the

perineum. Assessment:
Pain, heat, feeling of pressure Inflammation of the suture line Purulent drainage may be pressent

 Management:
Remove perineal sutures to allow drainage Packing the open lesion Sitz baths or warm compresses to hasten drainage

and cleanse the area Frequent change of perineal pads Wipe front to back after a bowel movement Analgesic for pain as prescribed Antibiotic after the c/s testing

Peritonitis
Infection of the peritoneal

cavity May interfere with fertility in the future Assessment:

Rigid abdomen Abdominal pain High fever

Rapid pulse
Vomiting Appearance of being

acutely ill

 Management:
Insertion of NGT IVF or TPN may be needed

Analgesic for pain relief as

ordered Large doses of anitibiotics

Thrombophlebitis
Phlebitis inflammation of lining of blood vessels

Thrombophlebitis - Inflammation with the

formation of blood clots. Risk factors:

Obesity Varicose veins Previous thrombophlebitis Older than 30 years of age with increase parity

endometritis

 Prevention:
Prevention of endometritis by good aseptic

technique Ambulation Limiting the time a woman remains in the stirrups Wearing support stockings 2 weeks after delivery Do not sit with knees bend sharply

Femoral Thrombophlebitis
Assessment:
Femoral, saphenous,

popliteal veins are involved Edema White leg appearance Chills, pain, redness in the affected leg Swelling below the lesion Homans sign (+)

 Management:
Bed rest with affected leg elevated Application of moist heat

Administration of anticoagulants/thrombolytics
Avoid massaging the affected area Administration of analgesics

 If anticoagulant is given,
Lochial discharge may increase Avoid the use of salicylic acid for pain

Pelvic Thrombophlebitis
Involves the ovarian, uterine, & hypogastric veins

May interfere with future fertility

Assessment:
Woman suddenly becomes extremely ill High fever, chills, malaise Can cause pelvic, lung, kidney & heart valve

abscess

 Management:
Bed rest Administration of anticoagulants/antibiotics Abscess can be incised by laparotomy Removal of the affected vessel before attempting to

get pregnant again

 Prevention:
Prevent wearing of tight clothing on the lower

extremities Resting with the feet elevated Ambulating daily during pregnancy

Pulmonary Embolus
Obstruction of

pulmonary artery by a blood clot. Complication of thrombophlebitis Signs/Symptoms:

Sudden sharp chest

pain Tachypnea Tachycardia Orthopnea cyanosis

 Management:

Administration of thrombolytics
Woman is transferred to the ICU for continuing

care

Mastitis
Infection of the breast Caused by cracked and fissured nipples Prevention:
making certain the baby is position correctly and

grasps the nipple properly (both nipple and areola) Releasing a babys grasp on the nipple before removing the baby from the breast Washing hands between handling perineal pads and touching the breast Exposing nipples to air for at least part of every day Vitamin E ointment to soften nipples daily

 Assessment:
Localized pain, Swelling Redness Fever

Breast milk

becomes scant

 Management:
Broad spectrum antibiotic Continue breast feeding Cold or ice compresses Wear supportive bra

Warm and wet compresses to reduce inflammation

and edema If abscess is present,

Drainage may be necessary Breast feeding on the affected side is discontinued

URINARY SYSTEM DISORDERS

Two types:
Urinary Retention Urinary Tract Infection

Urinary Retention
Results from inadequate bladder emptying.

Associated with the use of anesthesia and

forceps during birth Pressure of birth causes edema, thus leading to decreased sensation for voiding Leads to overdistention of urinary bladder

 Assessment:
Bladder distention Frequent voiding but in small amount Overall output is inadequate If first voiding after birth is less than 100 ml, suspect

urinary retention Residual urine of more than 100 ml

 Management:
Urinary catheterization Explain how catheter works Remove catheter after 24 hours Encourage woman to void 6 hours after the removal of catheter If after 8 hour from removal of catheter, the woman has not voided, reinsertion may be necessary

Urinary Tract Infection

May result from urinary catheterization

Assessment:
Burning sensation upon urination Hematuria Feeling of frequency Sharp pain on voiding Low-grade fever Lower abdominal pain

 Management:
Instruct client how to obtain a clean-catch urine Broad spectrum antibiotic (amoxicillin) Encourage fluid intake Analgesics for pain (tylenol)

REPRODUCTIVE SYSTEM CHANGES

Reproductive Tract Displacement
if liganmenst are weakened, the ff can happen to

the uterus:
Retroflexion Anteflexion Retroversion anteversion

If vaginal walls are weakened: Cystocele rectocele

 Separation of Symphysis Pubis

Causes: Unusually large fetus Fetal position is not optimal Assessment: Acute pain on turning or walking Legs tend to rotate externally, resulting to a waddling gate Management Bed rest application of snug pelvic binder to immobilize joint Avoid lifting heavy objects

EMOTIONAL AND PSYCHOLOGICAL COMPLICATIONS

Post-Partum Blues
Onset: 1 to 10 days after

birth Symptoms: sadness, tears Etiology: hormonal changes, stress of life changes Therapy: Support, empathy Nursing role: offering compassion and understanding

 Post-Partum Depression
Onset: 1 to 12 months after

birth Symptoms: Anxiety, feeling of loss, Sadness Etiology: History of previous depression, hormonal response, lack of social support Therapy: Counseling, drug therapy Nursing Role: referring to counseling

 Post-Partum Psychosis
Onset: within first month

after birth Symptoms: delusions, hallucinations of harming infant or self Etiology: possible activation of previous mental illness, hormonal changes, family history of bipolar disorder Therapy: Psychotherapy, drug therapy Nursing Role: referring to counseling, safeguarding