Postpartum Hemorrhage: Loss of 500cc of blood or more during 1 st 24 postpartal hr in vaginal birth; 1000cc in cesarean birth. Excessive loss of blood secondary to trauma, decreased uterine contractility; results in hypovolemia. Etiology (in order of frequency): a) Uterine Atony:
2. Multiparity. 3. Prolonged or precipitous labor. 4. Anesthesia – deep inhalation or regional (particularly saddle block). 5. Myomata (fibroids). 6. Oxytocin induction of labor. 7. Overmassage of uterus in postpartum. 8. Distended bladder. b) Lacerations – cervix, vagina, perineum.
c)Retained placental fragments – usually delayed postpartum hemorrhage. d)Hematoma – deep pelvic, vaginal, or episiotomy site. Assessment: –Uterus (boggy, flaccid). –Signs of shock (air hunger; tachycardia; tachypnea; hypotension). –Blood values (Hgb, Hct, clotting time). –Estimated blood loss (during labor/birth; pp). –Pain (vulvar, vaginal, perineal). –Perineum (distended; edema; hematoma). –Lacerations (bright red vaginal bleeding with firm fundus).
Medical Management: –IV oxytocin infusion; methergine, ergotrate; prostaglandin). –Blood work (clotting time, platelet count, fibrinogen level, Hgb, Hct, CBC). –Type & cross match for blood replacement. –Surgical (repair lacerations; evacuation, ligation of hematome; curettage – retained placenta). Nursing Interventions: –Minimize blood loss (fundal massage, give meds). –Stabolize status (IV line, meds,surgery prep).
–Prevent infection (aseptic technique). –Continual monitoring (VS, bleeding – pad counts or weigh, fundal status). –Health Teaching – after episode.
Subinvolution: Delayed return of uterus to normal size, shape, position. Inability of inflamed uterus (endometritis) to contract effectively; failure of ctx to effect closure of vessels in site of placental attachment. Etiology: –PROM with secondary amnionitis, endometritis. –Retained placental fragments. –Oxytocin stim of labor in overdistended uterine muscle.
Hypofibrinogenemia: Decreased clotting factors, fibrinogen; may be accompanied by DIC. Etiology: –Missed AB (retained fetus syndrome). –Fetal death, delayed emptying of uterine contents. –Abruptio placenta. –Amniotic fluid embolism. –Hypertension.
Assessment: –Observe for bleeding from injection sites, epistaxis, purpura. –DIC assessment. –Maternal VS, pt color. –I&O. –Lab results: Thrombin clot test – size & persistence of clot. Prothrombin time – prolonged. Bleeding time – prolonged. Platelet count – decreased. Activated partial thromboplastin time – prolonged. Fibrinogen (factor 1 concentration) – decreased. Fibrin degradation products – present.
Medical Mgt: –Replace platelets. –Replace blood loss. –IV heparin – to inhibit conversion of bibrinogen to fibrin. Nursing Mgt: –Continuous monitoring (VS; I&O hourly; skin – color, petechiae; blood loss). –Control blood loss (IV line; give fluids or blood products; position – side-lying to maintain blood supply to vital organs). –Emotional support (for woman & family).
PP Depression / Psychosis: General aspects: –Usually occurs within 2 wks of birth. –Increased incidence among single parents. –Increased incidence among women with history of clinical depression. –Most common symptomatology: affective disorders. –Psychiatric intervention required if prolonged or severe; if underlying cause unresolved; increased risk in subsequent pregnancies. Etiology: Theory – birth of a child may emphasize unresolved role conflicts, unachieved normal development tasks.
Assessment: –Withdrawal. –Paranoia. –Anorexia, sleep disturbance, mood swings. –Depression – may alternate with manic behavior. –Potential for self-injury or child abuse / neglect. Nursing Mgt: –Emotional support. –Safeguard status of mother and infant. –Maintain nutrition / hydration. –Minimize stress, facilitate effective coping.
Classification of Perineal Lacerations First degree Second degree Third degree Fourth degree Chapter 28
Perineal Pain Cause: episiotomy / repaired laceration. Unrelieved pain may indicate a hematoma, examine area closely. (perineal hematoma = severe pain). Normally reduced and asymptomatic by 3 weeks postpartum.
Common Postpartum Infections Endometritis Wound site infection Urinary tract infection Thrombophlebitis Mastitis Chapter 28
Postpartal Infection: Reproductive system infection occurring during the postpartal period. Bacterial invasion of birth canal; most common = localized infection of the lining of the uterus (endometritis). Etiology: –Anaerobic nonhemolytic streptococci. –E.coli. –C.trachomatis (bacteroides). –Staphylococci. –Predisposing conditions.
Assessment: –Fever degrees (F) or more on 2 or more occasions, after 1 st 24 hrs pp. –Other signs of infection: pain, malaise, dysuria, subinvolution, foul lochial odor. Nursing Mgt: –Prevent anemia (minimize bld loss; high protein, high vitamin diet; vitamin suppliments). –Prevent entrance / transport of microorganisms (strict aseptic technique during labor, birth, and pp; minimize vag exams in labor).
Health teaching (hand washing, perineal care, using clean pads – apply from front to back; avoid use of tampons until normal nenstrual cycle resumes).
Endometritis: Infection of the lining of the uterus. Etiology: most common = invasion by normal body flora. Characteristics: –Mild, localized: asymptomatic, or low- grade fever. –Severe: may lead to ascending infection, parametritis, pelvic abscess, pelvic thrombophlebitis. –If remains localized, self-limiting; usually resolves within 10 days.
–Increase uterine tone / facilitate involution (meds: oxytocics, antibiotics). –Minimize energy expenditure (bed rest). –Emotional support.
Urinary Tract Infections Normal physiological changes associated with pregnancy & postpartal period, increase susceptibility to bacterial invasion and growth, and can lead to ascending infections (cystitis, pylonephritis). Etiology: usually bacterial. Predisposing factors: –Birth trauma to bladder, urethra, or meatus. –Bladder hypotonia with retention (d/t intrapartal anesthesia or trauma).
–Repeated or prolonged catheterization, or poor technique. –Weakening of immune response secondary to anemia, hemorrhage. Assessment: –Maternal VS (fever, tachycardia). –Dysuria, frequency (flank pain – with pyelonephritis). –Feeling of “not emptying” bladder. –Cloudy urine; frank pus. Nursing Mgt: –Minimize perineal edema (ice pads).
Prevent overdistention of bladder. –Monitor level of fundus, lochia, bladder distention). –Encourage fluids and voiding; I&O. –Aseptic technique for catheterization. –Slow emptying of bladder on catheterization – to maintain tone. Identification of causative organism. –Obtain clean-catch (or catheterized) specimen. Health teaching (fluids, general hygiene, diet, and meds).
Thrombophlebitis: Inflammation of a vein secondary to lodging of a clot. Etiology: –Extension of endometritis with involvement of pelvic and femoral veins. –Clot formation in pelvic veins following c/s. –Clot formation in femoral (or other) veins secondary to poor circulation, compression, and venous stasis. Assessment: –Pelvic – pain; abd or pelvic tenderness.
–Calf – pain; positive Homans’ sign. –Femoral – pain; malaise, fever, chills, swelling “milk leg”. Nursing Mgt: –Prevent clot formation. Encourage early ambulation Position – avoid prolonged compression of popliteal space, use of knee gatch. Apply thromboembolic disease (TEDS) hose. –Reduce threat of emboli. Bed rest, with cradle to support bedding. Discourage massaging “leg cramps”.
Prevent infection. –Administer antibiotics as ordered. –Push fluids. Facilitate clot resolution. –Heat therapy as ordered.
Mastitis Inflammation of breast tissue. Local inflammatory response to bacterial invasion; suppuration may occur; organism can be recovered from breast milk. Etiology: most common = staf aureus; most common source = infant’s nose, throat. Assessment: –Signs of infection (fever, chills, tachycardia, malaise, abdominal pain).
–Breast: reddened area(s) localized / generalized swelling Heat, tenderness, palpable mass. Nursing Mgt: –Prevent infection (health teaching: hand washing, breast care, air dry, clean bra, no plastic liners, good BF technique, alternate position of infant to change pressure areas). –Comfort measures (bra or binder, local heat or ice packs to reduce engorgement & pain, analgesics as needed). –Emotional support. –Promote healing (maintain lactation, antibiotics)