1. Nancy Pares, RN, MSN Metro Community College
NURS Unit 3
Nancy Pares, RN, MSN
Metro Community College

2. Objective 1 and 2
Relate specific pathophysiology and nursing process specific to postpartum.
Idenitify specific post partum complications and nursing management
Placental issues, uterine issues, vaginal issues

3. Assessment of Postpartum Hemorrhage
Fundal height and tone
Vaginal bleeding
Signs of hypovolemic shock
Development of coagulation problems
Signs of anemia

4. Risk Factors for Postpartum Hemorrhage
Cesarean delivery
Unusually large episiotomy
Operative delivery
Precipitous labor
Atypically attached placenta
Fetal demise
Previous uterine surgery

5. Causes of Postpartum Hemorrhage
Uterine atony
Lacerations of the genital tract
Episiotomy
Retained placental fragments
Vulvar, vaginal, or subperitoneal hematomas

6. Causes of Postpartum Hemorrhage (continued)
Uterine inversion
Uterine rupture
Problems of placental implantation
Coagulation disorders

7. Nursing Interventions
Uterine massage if a soft, boggy uterus is detected
Encourage frequent voiding or catheterize the woman
Vascular access
Assess abnormalities in hematocrit levels
Assess urinary output
Encourage rest and take safety precautions

8. Nursing Diagnoses: Postpartum Hemorrhage
Health-seeking Behaviors related to lack of information about signs of delayed postpartal hemorrhage
Fluid Volume Deficit related to blood loss secondary to uterine atony, lacerations, hematomas, coagulation disorders, or retained placental fragments

9. Prevention of Postpartum Hemorrhage
Adequate prenatal care
Good nutrition
Avoidance of traumatic procedures
Risk assessment
Early recognition and management of complications

10. Postpartal Hemorrhage
Table 38–2 Signs of postpartal hemorrhage.

11. Self-Care Measures: Postpartum Hemorrhage
Fundal massage, assessment of fundal height and consistency
Inspection of the episiotomy and lacerations if present
Report:
Excessive or bright red bleeding, abnormal clots
Boggy fundus that does not respond to massage
Leukorrhea, high temperature, or any unusual pelvic or rectal discomfort or backache

12. Community Based Care: Postpartum Hemorrhage
Clear explanations about condition and the woman’s need for recovery
Rise slowly to minimize orthostatic hypotension
Woman should be seated while holding the newborn
Encourage to eat foods high in iron
Continue to observe for signs of hemorrhage or infection

13. Uterine Atony Risk factors Assessment findings
Overdistension of the uterus
Uterine anomaly
Poor uterine tone
Assessment findings
Excessive bleeding, boggy fundus

14. Uterine Atony (continued)
Management
Fundal massage
Blood products if loss is excessive
Medications
Oxytocin, methergine, carboprost tromethamine (Hemabate)

15. Uterine Atony
Table 38–1 Uterine stimulants used to prevent and manage uterine atony.

16. Uterine Atony
Table 38–1 (continued) Uterine stimulants used to prevent and manage uterine atony.

17. Retained Placental Fragments
Risk factors
Mismanagement of third stage
Placental malformations
Abnormal placental implantation
Assessment findings
Excessive bleeding, boggy fundus

18. Placental Adherence Accreta villi attach to the outer layer myometrium
Increta
villi attach within the muscle layer of the myometrium
Percreta
villi attach deep within the myometrium

19. Retained Placental Fragments (continued)
Management
Manual exploration of the uterus
D&C
Blood products if loss is excessive

20. Lacerations Risk factors Assessment findings Management
Operative delivery
Precipitous delivery
Extension of the episiotomy
Varices
Assessment findings
Excessive bleeding with a firm uterus
Management
Suture if needed
Blood products if loss is excessive

21. Objective 2
Identify nursing process for post partum psycho social disorders

22. Assessment of Postpartum Psychiatric Disorders
Depression scales
Anxiety and irritability
Poor concentration and forgetfulness
Sleeping difficulties
Appetite change
Fatigue and tearfulness

23. Postpartum Blues Occurs within 3 to 10 days of delivery
Generally transient
Usually resolves without treatment
Assessment findings
Tearful, fatigue, anxious, poor appetite

24. Postpartum Blues (continued)
Etiology
Hormonal changes and adjustment to motherhood
Longer than two weeks in duration requires medical evaluation

25. Postpartum Mood Disorder: Depression
Onset slow, usually around the fourth week after delivery
Assessment findings
Depressed mood, fatigue, impaired concentration, thoughts of death or suicide
Risk factors
History of depression, abuse, low self-esteem
Management
Psychotherapy, medications, hospitalization

26. Postpartum Psychosis Generally after the second PP week
Assessment findings
Sleep disturbance, agitation, delusions
Risk factors
Personal or family history of major psychiatric illness
Management
May lead to suicide or infanticide
Hospitalization, medications, psychotherapy

27. Postnatal Depression
Table 38–10 (continued) Postpartum depression predictors inventory (PDPI)—revised and guide questions for its use.

28. Prevention of Depression
Table 38–11 Primary prevention strategies for postpartum depression.

29. Prevention of Postpartum Psychiatric Disorders
Help parents understand the lifestyle changes and role demands
Provide realistic information
Anticipatory guidance
Dispel myths about the perfect mother or the perfect newborn
Educate about the possibility of postpartum blues
Educate about the symptoms of postpartum depression

30. Self-Care: Postpartum Psychiatric Disorders
Signs and symptoms of postpartum depression
Contact information for any questions or concerns

31. Community Based Care: Postpartum Psychiatric Disorders
Foster positive adjustments in the new family
Assessment of maternal depression
Teach families symptoms of depression
Give contact information for community resources
Make referrals as needed

32. Nursing Diagnoses: Postpartum Psychiatric Disorder
Ineffective Individual Coping related to postpartum depression
Risk for Altered Parenting related to postpartal mental illness
Risk for Violence against self (suicide), newborn, and other children related to depression

33. Reproductive Loss Components of grief work
Accepting the painful emotions involved
Reviewing the experiences and events
Testing new patterns of interaction and role relationships

34. Reproductive Loss (continued)
Four stages of grief
Shock and numbness
Searching and yearning
Disorientation
Reorganization
Symptoms of normal grief

35. Examples of Reproductive Loss
Inability to conceive
Spontaneous abortion
Preterm delivery
Congenital anomalies
Fetal demise
Neonatal death
Relinquishment
SIDS

36. Objective 4 Review nursing interventions associated with
DVT, Hematoma, hemorrhoids, endometritis, wound infections, urinary infections and STD

37. Assessment of Infection: REEDA Scale
R: redness
E: edema
E: ecchymosis
D: discharge
A: approximation

38. Assessment of Infection (continued)
Fever
Malaise
Abdominal pain
Foul-smelling lochia
Larger than expected uterus
Tachycardia

39. Nursing Diagnoses: Puerperal Infection
Risk for Injury related to the spread of infection
Pain related to the presence of infection
Deficient Knowledge related to lack of information about condition and its treatment
Risk for Altered Parenting related to delayed parent-infant attachment secondary to woman’s pain and other symptoms of infection

40. Endometritis Infection of the uterine lining Risk factors
Cesarean section
Assessment findings
Fever, chills
Abdominal tenderness
Foul-smelling lochia
Management
Antibiotics

41. Metritis
Table 38–3 Common causative organisms in metritis.

42. Mastitis
Table 38–4 Factors associated with development of mastitis.

43. Assessment of Mastitis
Breast consistency
Skin color
Surface temperature
Nipple condition
Presence of pain

44. Mastitis Infection of the breast Risk factors Assessment findings
Damaged nipples
Failure to empty breasts adequately
Assessment findings
Fever, chills
Breast pain, swelling, warmth, redness
Management
Antibiotics
Complete breast emptying

45. Figure 38–2 Mastitis. Erythema and swelling are present in the upper outer quadrant of the breast. Axillary lymph nodes are often enlarged and tender. The segmental anatomy of the breast accounts for the demarcated, often V-shaped wedge of inflammation.

46. Prevention of Mastitis
Proper feeding techniques
Supportive bra worn at all times to avoid milk stasis
Good handwashing
Prompt attention to blocked milk ducts

47. Self-Care Measures: Mastitis
Importance of regular, complete emptying of the breasts
Good infant positioning and latch-on
Principles of supply and demand
Importance of taking a full course of antibiotics
Report flu-like symptoms

48. Breast Problems
Table 38–5 Comparison of findings of engorgement, plugged duct, and mastitis.

49. Nursing Diagnoses: Mastitis
Health-seeking Behaviors related to lack of information about appropriate breastfeeding practices
Ineffective Breastfeeding related to pain secondary to development of mastitis

50. Community Based Care: Mastitis
Home care nurse may be the first to suspect mastitis
Obtain a sample of milk for culture and sensitivity analysis
Teach mother how to pump if necessary
Assist with feelings about being unable to breastfeed
Referral to lactation consultant or La Leche League

51. Assessment of Thrombophlebitis
Homan’s sign
Pain in the leg, inguinal area, or lower abdomen
Edema
Temperature change
Pain with palpation

52. Figure 38–3 Homans’ sign. With the client’s knee flexed to decrease the risk of embolization, the nurse dorsiflexes the client’s foot. Pain in the foot or leg is a positive Homans’ sign. SOURCE: Photographer, Elena Dorfman

53. Thrombophlebitis
Inflammation of the lining of the blood vessel due to clot formation
Can occur in the legs (DVT) or pelvis (SPT)
Risk factors
Cesarean section
Prolonged bed rest
Infection

54. Thrombophlebitis (continued)
Assessment findings
Pain, fever, redness, warmth, tender abdomen/calf
Management
Anticoagulants
Antibiotics for septic pelvic thrombophlebitis

55. Thromboembolic Factors
Table 38–6 Factors associated with increased risk of thromboembolic disease.

56. Decreasing Thromboembolic Risk
Table 38–7 Measures to decrease risk of thromboembolic disease in childbearing women.

57. Prevention of Thrombophlebitis
Avoid prolonged standing or sitting
Avoid crossing her legs
Take frequent breaks while taking car trips

58. Self-Care: Thromboembolic Disease
Condition and treatment
Importance of compliance and safety factors
Ways of avoiding circulatory stasis
Precautions while taking anticoagulants

59. Nursing Diagnoses: Thromboembolic Disease
Pain related to tissue hypoxia and edema secondary to vascular obstruction
Risk for Altered Parenting related to decreased maternal-infant interaction secondary to bed rest and intravenous lines
Altered Family Processes related to illness of family member
Deficient Knowledge related to self-care after discharge on anticoagulant therapy

60. Vitamin K Foods
Table 38–8 Foods high in vitamin K.

61. Assessment of Overdistention of the Bladder
Large mass in abdomen
Increased vaginal bleeding
Boggy fundus
Cramping
Backache
Restlessness

62. Assessment of Cystitis
Frequency and urgency
Dysuria
Nocturia
Hematuria
Suprapubic pain
Slightly elevated temperature

63. Urinary Tract Infection
Risk factors
Urinary catheterization
Long labor, operative delivery
Assessment findings
Dysuria, frequency, urgency
Fever
Suprapubic pain
Management
Antibiotics

64. Prevention of Infection
Good perineal care
Hygiene practices to prevent contamination of the perineum
Thorough handwashing
Sitz baths
Adequate fluid intake
Diet high in protein and vitamin C

65. Prevention of a UTI Good perineal hygiene Good fluid intake
Frequent emptying of the bladder
Void before and after intercourse
Cotton underwear
Increase acidity of the urine

66. Prevention of Bladder Overdistension
Frequent monitoring of the bladder
Encourage spontaneously voiding
Assist the woman to a normal voiding position
Provide medication for pain
Perineal ice packs

67. Nursing Diagnoses: Bladder Distention
Risk for Infection related to urinary stasis secondary to overdistention
Urinary Retention related to decreased bladder sensitivity and normal postpartal diuresis

68. Nursing Diagnoses: UTI
Pain with voiding related to dysuria secondary to infection
Health-seeking Behaviors related to need for information about self-care measures to prevent UTI

69. Self-Care Measures: Puerperal Infection
Activity and rest
Medications
Diet
Signs and symptoms of complications
Importance of completion of antibiotic therapy

70. Community Based Care: Puerperal Infection
May need assistance when discharged from the hospital
May need a referral for home care services
Instruct family on care of the newborn
Instruct mother about breast pumping to maintain lactation if she is unable to breastfeed

71. Community Based Care: Thromboembolic Disease
Instruct family members on care of mother and newborn
Referral for home care if necessary
Provide resources for follow-up or questions
Teach all families to observe for signs and symptoms

72. Pelvic Hematoma Assessment findings Severe perineal pain Ecchymosis
Visible outline of the hematoma
Blood loss may not be visible

73. Pelvic Hematoma (continued)
Treatment
Surgical drainage
Antibiotics
Analgesics
Blood products if loss is excessive

74. Signs and Symptoms of Shock
Hypotension
Tachycardia, weak, thready pulse
Decreased pulse pressure
Cool, pale, clammy skin
Cyanosis
Oliguria, anuria
Thirst
Hypothermia
Behavioral changes (lethargy, confusion, anxiety)
Pg 664- table

75. Nursing Implications: Shock
Monitor vital signs frequently
Large-bore IV for fluids, blood products
Administer oxygen, assess oxygen saturation
Assess hourly urine output
Assess level of consciousness

76. Nursing Implications: Shock (continued)
Administer and monitor fluids, blood products
Draw/monitor laboratory results
Assess quantity and quality of bleeding
Provide emotional support to patient/family

77. Warning signs of illness PP
Fever > 100.5
Severe pain, redness,swelling at incision site
Passing of large clots
Increased bleeding
Burning on urination
Insomnia
Impaired concentration
Feeling inadequate