Presentation on theme: "The Postpartum Period Puerperium = fourth trimester of pregnancy - the 6-week interval between the birth of the newborn and the return of the reproductive."— Presentation transcript:
1 The Postpartum PeriodPuerperium = fourth trimester of pregnancy - the 6-week interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state
2 Uterine Involution Uterine Involution: Uterine fundal descent: return of the uterus to its pre-pregnancy size and condition, which begins immediately after expulsion of the placenta with contraction of the uterine smooth muscleUterine fundal descent:immediately after birth uterus is in the midline approximately 2 cm below the level of the umbilicus, size of grapefruit (like 16 weeks of gestation), weighs approximately 1000 g.Within 12 hours the fundus may be approximately 1 cm above the umbilicusDuring next few days the fundus descends 1 to 2 cm (fingerbreadth) every 24 hours.By the sixth postpartum day the fundus is normally located halfway between the umbilicus and the symphysis pubis.A week after birth the uterus once again lies in the true pelvis.After the ninth postpartum day the uterus should not be palpable abdominally.
3 Uterine InvolutionIncreased estrogen and progesterone levels are responsible for stimulating the massive growth of the uterus during pregnancy. Prenatal uterine growth results from both hyperplasia, an increase in the number of muscle cells, and from hypertrophy, an enlargement of the existing cells. Postpartally, the decrease in these hormones causes autolysis, the self-destruction of excess hypertrophied tissue. The additional cells laid down during pregnancy remain and account for the slight increase in uterine size after each pregnancy.Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection.
4 Lochia Assessment Lochia–vaginal discharge after childbirth. It takes 6 weeks for the vagina to regain its pre-pregnancy contour.For the first 2 hours after birth the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochia flow should steadily decrease.Lochia: rubra, serosa or albaAssessment of lochia includes noting color, presence and size of clots and foul odor.Day lochia rubra (blood with small pieces of decidua and mucus) Day – lochia serosa (pink or pinkish brown serous exudate with old blood, cervical mucus, erythrocytes and leukocytes, tissue debris)Day lochia alba (yellowish white discharge with leucocytes, decidua, epithelian cells, mucus, serum, bacteria)The amount of lochia is usually less after cesarean births. Flow of lochia usually increases with ambulation and breastfeeding and receives an oxytocin medication
5 LOCHIAL AND NONLOCHIAL BLEEDINGLOCHIAL BLEEDINGNONLOCHIAL BLEEDING Lochia usually trickles from the vaginal opening. The steady flow is greater as the uterus contractsA gush of lochia may result as the uterus is massaged. If it is dark in color, it has been pooled in the relaxed vagina, and the amount soon lessens to a trickle of bright red lochia (in the early puerperium).BleedingIf the bloody discharge spurts from the vagina, there may be cervical or vaginal tears in addition to the normal lochia.If the amount of bleeding continues to be excessive and bright red, a tear may be the source.
6 Cervix The cervix is soft immediately after birth. By 18 hours postpartum it has shortened, become firm, and regained its form.The cervix up to the lower uterine segment remains edematous, thin, and fragile for several days after birth.The ectocervix (portion of the cervix that protrudes into the vagina) appears bruised and has some small lacerations—optimal conditions for the development of infection.The cervical os, which dilated to 10 cm during labor, closes gradually.Two fingers may still be introduced into the cervical os for the first 4 to 6 days postpartum; however, only the smallest curette can be introduced by the end of 2 weeks.The external cervical os never regains its prepregnant appearance; it is no longer shaped like a circle but appears as a jagged slit that is often described as a "fishmouth."Lactation delays the production of cervical and other estrogen-influenced mucus and mucosal characteristics.
7 VAGINA AND PERINEUM Vagina Perineum vaginal mucosa is thin, atrophic, with decrease amount of lubrication and without rugae as a result of estrogen deprivation which lead to coital discomfort (dyspareunia) until ovarian function returns and menstruation resumes.The greatly distended, smooth-walled vagina gradually returns to its prepregnancy size by 6 to 8 weeks after childbirth. Rugae reappear by approximately the fourth week, but they are never as prominent as they are in the nulliparous woman. Most rugae are permanently flattened.Perineumthe introitus is erythematous and edematous, especially in the area of the episiotomy or laceration repair. It is barely distinguishable from that of a nulliparous womanEpisiotomy. Most episiotomies are visible only if the woman is lying on her side with her upper buttock raised or if she is placed in the lithotomy position.Hemorrhoids (anal varicosities) are commonly seen. Internal hemorrhoids may evert while the woman is pushing during birth. Women often experience associated symptoms such as itching, discomfort, and bright red bleeding with defecation. Hemorrhoids usually decrease in size within 6 weeks of childbirth.
8 Endocrine SystemPlacental hormones (human chorionic somatomammotropin, estrogens, cortisol, and the placental enzyme insulinase)dramatically decrease and reverse the diabetogenic effects of pregnancy, resulting in significantly lower blood sugar levels in the immediate puerperium.Estrogen and progesterone levels drop markedly after expulsion of the placenta and reach their lowest levels 1 week postpartum. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy.In nonlactating women, estrogen levels begin to rise by 2 weeks after birth and by postpartum day 17 are higher than in women who breastfeedβ-Human chorionic gonadotropin disappears from maternal circulation in 14 days
9 Endocrine System Pituitary hormones and ovarian function The persistence of elevated serum prolactin levels in breastfeeding women appears to be responsible for suppressing ovulation. Because levels of follicle-stimulating hormone (FSH) have been shown to be identical in lactating and nonlactating women, it is thought that the ovulation is suppressed in lactating women because the ovary does not respond to FSH stimulation when increased prolactin levels are presentProlactin levels in blood rise progressively throughout pregnancy.In nonlactating women, prolactin levels decline after birth and reach the prepregnant range in 4 to 6 weeksIn breastfeeding woman prolactin levels remain elevated into the sixth week after birth, and influence by the frequency of breastfeeding, the duration of each feeding, and the degree to which supplementary feedings are used.Ovulation occurs as early as 27 days after birth in nonlactating women, with a mean time of 70 to 75 days. Approximately 70% of nonbreastfeeding women resume menstruating by 3 months after birth.In women who breastfeed, the mean length of time to initial ovulation is 17 weeks. In lactating women, both resumption of ovulation and return of menses are determined in large part by breastfeeding patterns. Many women ovulate before their first postpartum menstrual period occurs; thus there is need to discuss contraceptive options early in the puerperium.The first menstrual flow after childbirth is usually heavier than normal. Within three to four cycles the amount of menstrual flow returns to the woman's prepregnancy volume
10 BREASTSPromptly after birth, there is a decrease in the concentrations of hormones (i.e., estrogen, progesterone, hCG, prolactin, cortisol, and insulin) that stimulated breast development during pregnancy. The time it takes for these hormones to return to prepregnancy levels is determined in part by whether the mother breastfeeds her infant.BREASTFEEDING MOTHERSAs lactation is established, a mass (lump) may be felt in the breast. Unlike the lumps associated with fibrocystic breast disease or cancer (which may be consistently palpated in the same location), a filled milk sac shifts position from day to day. Before lactation begins, the breasts feel soft and a yellowish fluid, colostrum, can be expressed from the nipples. After lactation begins, the breasts feel warm and firm. Tenderness may persist for approximately 48 hours after the start of lactation. Bluish-white milk with a skim-milk appearance (true milk) can be expressed from the nipples. The nipples are examined for erectility and signs of irritation such as cracks, blisters, or reddening.NONBREASTFEEDING MOTHERSThe breasts generally feel nodular in contrast to the granular feel of breasts in nonpregnant women. The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. Colostrum is present for the first few days after childbirth. Palpation of the breast on the second or third day, as milk production begins, may reveal tissue tenderness in some women. On the third or fourth postpartum day, engorgement may occur. The breasts are distended (swollen), firm, tender, and warm to the touch (because of vasocongestion). Breast distention is caused primarily by the temporary congestion of veins and lymphatics rather than by an accumulation of milk. Milk is present but should not be expressed. Axillary breast tissue (the tail of Spence) and any accessory breast or nipple tissue along the milk line may be involved. Engorgement resolves spontaneously, and discomfort decreases usually within 24 to 36 hours. A breast binder or tight bra, ice packs, or mild analgesics may be used to relieve discomfort. Nipple stimulation is avoided. If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.
11 Fourth Stage of LaborGoal of nursing care is to assist woman and their partners during their initial transition to parentingNursing's role is to monitor the recovery of the new mother and infant, to identify and manage promptly any deviations from the normal processes that may occur, and to promote and support parent-infant attachment
12 Fourth Stage of Labor First 1 to 2 hours after birth During this time, maternal organs undergo their initial readjustment to the nonpregnant state and the functions of body systems begin to stabilize.Meanwhile, the newborn continues the transition from intrauterine to extrauterine existenceExcellent time to begin BreastfeedingEncouraging of the motherColostrum prompting elimination of meconium
13 Care in the Immediate Postpartum Period AssessmentDuring first hour every 15 minutesDuring second hours every 30 minutesVS (Ps, BP, T)fundal height and firmnessbladder distensionamount of lochiapresence of edemastatus of perineum,Postanesthesia recovery (every 15 min)ActivityRespirationBPLevel of cosciousnessColorgeneral anesthesiaAwake, alert, orient to time, place, and person, respiratory rate, oxygen saturation levels at least 95%, as measured by a pulse oximeterepidural or spinal anesthesiashould be able to raise her legs, extended at the knees, off the bed, or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed. The numb or tingling, prickly sensation should be entirely gone from her legs. Often, it takes 1.5 to 2 hours for these anesthetic effects to disappear.Providing comfort measuresAnalgesicsPromoting bladder eliminationProviding fluid and food
14 Nursing Care After Cesarean Birth Same as with normal vaginal delivery exceptPostanesthesia recoveryMonitoring of abdominal dressingUrinary catheterRespiratory carePrevention of thrombophlebitisInterventions for painSlide 14
16 General Assessment Enter the room quietly, speak quietly. Wash hands and provide for privacy.Inform patient before turning on lights.Note LOC, activity level, position, color, general demeanor.Take note of the total environment:Safety/patient considerationsNote equipment and medical devices
17 Breast AssessmentBreasts: Soft, engorged, filling, swelling, redness, tenderness.Nipples: Inverted, everted, cracked, bleeding, bruised, presence of colostrum or breastmilk.Colostrum–yellowish fluid rich in antibodies and high in protein.Engorgement occurs by day 3 or 4. Due to vasoconstriction as milk production beginsLactation ceases within a week if breastfeeding is never begun or is stopped.
18 Nipple soreness is a portal of entry for bacteria - breast infection (Mastitis). Maternal after pains: may be due to breastfeeding and multiparityAlways stay with the client when getting out of bed for the first time – hypotension effect and excess bleedingWhen assessing fundal height, if you notice any discrepancies in fundal height have patient void and then reassess.
19 Assessing Uterine Fundus Location in relation to umbilicusDegree of firmnessIs it at Midline or deviated to one side?Bladder Full?A boggy uterus may indicate uterine atony or retained placental fragments.Boggy refers to being inadequately contracted and having a spongy rather than firm feeling.
20 Massaging the FundusEvery 15 mins during the 1st hr, every 30 mins during the next hr, and then, every hr until the patient is ready for transfer.Document fundal height.Evaluate from the umbilicus using fingerbreadths.This is recorded as 2 fingers below the umbilicus (U/2), one finger above the umbilicus (1/U), and so forth.The fundus should remain in the midline. If it deviates from the middle- distended bladder.
21 Uterine Atony Lack of muscle tone in the cervix. Uterus feels soft and boggyThe bladder has increased capacity and decreased muscle tone. This leads to over-distension of the bladder, incomplete emptying of bladder, retention of residual urine and increased risk of UTI and postpartum hemorrhage.
22 Bowels & Bladder When was the patients last bowel movement? Is she passing flatus? (gas)Assess for bowel soundsVoiding pattern - without difficulty/pain, urine may be blood tinged from lochiaNursing interventions: Assist to the bathroom. Use measures to encourage voiding (privacy). Encourage use of peri-bottle with warm water, fluids, fiber, frequent ambulation, stool softeners; teach effects of pain medication.
23 Urinary SystemA full bladder can displace the uterus and lead to postpartum hemorrhageIn the woman who voids frequently, small amounts of urine may have increased residual urine because her bladder does not empty completelyResidual urine in the bladder may promote the growth of microorganismsSlide 23
24 Lochia: Pad Count Scant: 1-inch stain on pad in 1 hour Light/small: 4 inches in 1 hourModerate: 6 inches in 1 hourHeavy/large: Pad saturated in 1 hourExcessive: Pad saturated in 15 minCan estimate blood loss by weighing pads:500 mL = 1 lb. or 454 g
25 Episiotomy/Perineal Assessment Patient in lateral Sims (side lying) position.Use the acronym REEDARedness, Edema, Ecchymosis, Discharge, Approximation of suture lines “edges of episiotomy”) to guide assessment.Even if there is no episiotomy, the perineum should still be assessed.Nursing care and patient teachingCold packsTopical and systemic medicationsNonpharmacologic pain relief methodsUnusual perineal discomfort may be a symptom of impending infection or hematoma. Hemorrhoids ?
26 Episiotomy Pain Relief Instruct Mother:Tighten her buttocks and perineum before sitting to prevent pulling on the episiotomy and perineal area and to release tightening after being seated.Rest several times a day with feet elevated.Practice Kegel exercise many times a day to increase circulation to the perineal area and to strengthen the perineal muscles.
28 Routine care for the postpartum woman: Educate about danger signs (1) Vaginal bleeding:More than 2 or 3 pads soaked in minutes after delivery, ORBleeding increases rather than decreases after deliveryNotes to the facilitator:Present slides and briefly resume the danger signs that indicate a postpartum woman may be having a complication.Emphasize the importance of educating women and their partners about danger signs so that they can recognize them in a timely fashion.
29 Routine care for the postpartum woman: Educate about danger signs (2) Severe abdominal painFever and too weak to get out of bed
30 Routine care for the postpartum woman: Educate about danger signs (3) Fast or difficult breathingSevere headache, blurred visionConvulsions
31 Routine care for the postpartum woman: Educate about danger signs (4) Pain in the perineum or draining pusFoul-smelling lochiaDribbling of urine or pain on micturition
32 Routine care for the postpartum woman: Educate about danger signs (5) The woman doesn’t feel well.Breasts swollen, red or tender breasts, or sore nipples
33 Postpartum Hemorrhage (PPH) Definition and incidencePPH traditionally defined as loss of more than:500 ml of blood after vaginal birth1000 ml after cesarean birthCause of maternal morbidity and mortalityLife-threatening with little warningOften unrecognized until profound symptoms
34 Etiology of PPH tone, tissue, trauma, thrombin The causes of postpartum hemorrhage can be thought of as the four Ts:tone,tissue,trauma,thrombin
35 Postpartum Hemorrhage Etiology and risk factors (1) Uterine atonyMarked hypotonia of uterusLeading cause of PPH, complicating approximately 1 in 20 birthsBrisk venous bleeding with impaired coagulation until the uterine muscle contracts35 of 34
37 Management of uterine atony Explore the uterine cavity.Inspect vagina and cervix for lacerations.If the cavity is empty, Massage and give methylergonovine 0.2 mg, the dose can be repeated every 2 to 4 hours.Rectal 800mcg. Misoprostol is beneficial.
38 Management of uterine atony During the administration of uterotonic agents, bimanual compression may control hemorrhage. The physician places his or her fist in the vagina and presses on the anterior surface of the uterus while an abdominal hand placed above the fundus presses on the posterior wall. This while the Blood for transfusion made available.
39 Complications of Puerperium Uterine Atony (Cont’d)TreatmentUterine compressionOxytocicsEarly suckling causes endogenous release of oxytocinOxytocin IV/IM 10 unitsMethylergonovineMethyl prostoglandin F
40 Postpartum Hemorrhage Etiology and risk factors (2) Lacerations of genital tractShould be suspected if bleeding continues with a firm, contracted fundusIncludes perineal and cervical lacerations as well as pelvic hematomas40 of 34
41 Lacerations and trauma Postpartum Hemorrhage Etiology and risk factors (2)Lacerations and trauma UnplannedVaginal/cervical tear,surgical trauma PlannedCesarean section,episiotomy
42 Postpartum Hemorrhage Genital tract lacerations Management Genital trauma always must be eliminated first if the uterus is firm.
43 Postpartum Hemorrhage Etiology and risk factors (2) UTERINE RUPTURE Rupture of the uterus is described as complete or incomplete and should be differentiated from dehiscence of a cesarean section scar.
44 Postpartum Hemorrhage Etiology and risk factors (2) UTERINE RUPTURE The reported incidencefor all pregnancies is 0.05%,After one previous lower segment cesarean section 0.8%After two previous lower segment cesarean section is 5%all pregnancies following myomectomy may be complicated by uterine rupture.
45 Postpartum Hemorrhage Etiology and risk factors (2) UTERINE RUPTURE Complete rupture describes a full-thickness defect of the uterine wall and serosa resulting in direct communication between the uterine cavity and the peritoneal cavity.
46 Postpartum Hemorrhage Etiology and risk factors (2) UTERINE RUPTURE Incomplete rupture describes a defect of the uterine wall that is contained by the visceral peritoneum or broad ligament. In patients with prior cesarean section,
47 Postpartum Hemorrhage Etiology and risk factors (2) UTERINE RUPTURE dehiscence describes partial separation of the scar with minimal bleeding, with the peritoneum and fetal membranes remaining intact.
48 Management of Rupture Uterus The identification or suspicion of uterine rupture must be followed by an immediate and simultaneous response from the obstetric team.Surgery should not be delayed owing to hypovolemic shock because it may not be easily reversible until the hemorrhage is controlled.
49 Management of Rupture Uterus Upon entering the abdomen, aortic compression can be applied to decrease bleeding.Oxytocin should be administered to effect uterine contraction to assist in vessel constriction and to decrease bleeding.Hemostasis can then be achieved by ligation of the hypogastric artery, uterine artery, or ovarian arteries.
50 Management of Rupture Uterus At this point, a decision must be made to perform hysterectomy or to repair the rupture site. In most cases, hysterectomy should be performed.In selected cases, repair of the rupture can be attempted. When rupture occurs in the body of the uterus,bladder rupture must be ruled out by clearly mobilizing and inspecting the bladder to ensure that it is intact. This avoids injury on repair of the defect as well.
51 Management of Rupture Uterus A lower segment lateral rupture can cause transection of the uterine vessels. The vessels can retract toward the pelvic side wall, and the site of bleeding must be isolated before placing clamps to avoid injury to the ureter and iliac vessels.Typically, longitudinal tears, especially those in a lateral position, should be treated by hysterectomy, whereas low transverse tears may be repaired.
52 Trauma-Second most common cause of early postpartum hemorrhage Lacerations – suspect this in the birth canal if uterine bleeding continues with a contracted fundusHematomas- bleeding into loose connective tissue as the vulva or vaginaVulva- discolored bulging massSurgical excision if they are large & ligation
53 Postpartum Hemorrhage Etiology and risk factors (3) Retained placentaNonadherent retained placenta – managed by manual separation and removal by the primary care providerAdherent retained placenta – may be caused by implantation into defective endometrium53 of 34
54 Postpartum Hemorrhage Etiology and risk factors (3) Three classifications of adherentretained placentaPlacenta acreta – slight penetrationof myometrium by placental trophoblastPlacenta increta – deep penetrationof myometrium by placentaPlacenta percreta – perforation of uterus by placentaPatient will experience profuse bleeding when delivery of the placenta is attempted.Management includes blood replacement and surgical intervention (hysterectomy)54 of 34
55 Postpartum Hemorrhage Etiology and risk factors (4) Inversion of uterus (turning inside out)May be life-threateningA complete inversion protrudes out of the vaginaPrimary signs – hemorrhage, shock, painPrevention is the best measure – don’t pull on the umbilical cord unless there is definite separation of the placenta55 of 34
56 Postpartum Hemorrhage Etiology and risk factors4 Inversion of uterus (turning inside out)
57 Postpartum Hemorrhage Etiology and risk factors (5) Subinvolution of uterus – delayed involution of the uterusUsually see late post partum bleedingCauses include retained placental fragments and infection57 of 34
58 Postpartum Hemorrhage Care Management AssessmentBleeding assessed for color and amountPerineum inspected for signs of lacerations or hematomas to determine source of bleedingVital signs may not be reliable indicators because of postpartum adaptationsMeasurements during first 2 hours may identify trends related to blood lossBladder distensionLaboratory studies ofhemoglobin and hematocritlevels58 of 34
59 Postpartum Hemorrhage Care Management Plan of care and implementationInitial treatment – fundal massage, expression of clots, relief of bladder distension, IV fluidsMedical managementHypotonic uterus – examine for retained placental fragments, medications, surgical interventionsBleeding with a contracted uterus – identify and treat underlying causeUterine inversion – emergency replacement of the uterus into the pelvic cavitySubinvolution – medications, surgical intervention59 of 34
60 Postpartum Hemorrhage Care Management Plan of care and implementationNursing interventionsVital signs, uterine assessment, medication administration, notification of primary care providerProviding explanations about interventions and need to act quicklyOnce stable, ongoing post partum assessments and careInstructions in increasing dietary iron, protein intake, and iron supplementationMay need assistance with infant care and household activities until strength regained60 of 34
61 Guidelines by the Scottish Executive Committee of the RCOG COMMUNICATE.RESUSCITATE.MONITOR / INVESTIGATE.STOP THE BLEEDING.
63 RESUSCITATE IV access with 14 G cannula X 2 Head down tilt Oxygen by mask, 8 litres / minTransfuseCrystalloid (eg Hartmann’s)Colloid (eg Gelofusine)once 3.5 litres infused, GIVE ‘O NEG’ If no cross-matched blood available OR give uncross-matched own-group blood, as availableGive up to 1 liter Fresh Frozen Plasma and 10 units cryoprecipitate if clinically indicated
64 MONITOR / INVESTIGATE Cross-match 6 units Full blood count Clotting screenContinuous pulse / BP /ECG / OximeterFoley catheter: urine outputCVP monitoringDiscuss transfer to ITU
65 STOP THE BLEEDING Exclude causes of bleeding other than uterine atony Ensure bladder emptyUterine compressionIV syntocinon 10 unitsIV ergometrine 500 mgSyntocinon infusion (30 units in 500 ml)IM Carboprost (500 mg)Surgery earlier rather than lateHysterctomy early rather than late(GRADE B)
66 If conservative measures fail to control haemorrhage, initiate surgical haemostasis SOONER RATHER THAN LATERAt laparotomy, direct intramyometrial injection of Carboprost (Haemabate) 0.5mgBilateral ligation of uterine arteriesBilateral ligation of internal iliac (hypogastric arteries)Hysterectomy(GRADE C)
67 Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of placenta accreta or uterine rupture) (GRADE C)
68 Whole blood frequently is used for rapid correction of volume loss because of its ready availability, but component therapy is ideal. A general practice has been to transfuse 1 unit of fresh-frozen plasma for every 3 to 4 units of red cells given to patients who are bleeding profusely
69 Hemorrhagic (Hypovolemic) Shock Emergency situation in which blood is diverted to the brain and heartMay not see signs until post partum patient loses 30% to 40% of blood volumeMedical management – restore circulating blood volume and treat underlying causeNursing interventions – monitor tissue perfusion, see emergency boxFluid or blood replacement therapy69 of 34
70 Prophylactic oxytocics should be offered routinely in the management of the third stage of labour as they reduce the risk of PPH by about 60%.(GRADE A)
71 CoagulopathiesIdiopathic thrombocytopenic purpura (ITP) – decreased platelet life span, need to control platelet stabilityvon Willebrand disease—type of hemophiliaDisseminated intravascular coagulation (DIC)Pathologic clottingCorrection of underlying causeRemoval of fetusTreatment for infectionPreeclampsia or eclampsiaRemoval of placental abruption71 of 34
73 Thromboembolic Disease Results from blood clot caused by inflammation or partial obstruction of vesselMay be superficial or deep venous thrombosis or a pulmonary embolusIncidence and etiologyVenous stasisHypercoagulationClinical manifestations – redness and swelling in the affected extremity, pain, positive Homan’s sign73 of 34
74 Thromboembolic Disease Homan’s Sign Press down gently on the patient’s knee (legs extended flat on bed) ask her to flex her foot (dorsiflex)
75 Thromboembolic Disease Medical managementSuperficial – analgesia, rest/elevationDeep – anticoagulant therapy, bedrest/elevation,Pulmonary embolus – IV heparin therapyNursing interventionsassessment of the affected area, signs of bleeding, personal care, medication administrationTeach not to massage affected area!!75 of 34
76 Postpartum Infections Endometritis – malodorous lochia, fever (100.6), chills, abdominal pain, uterine tenderness, tachycardia and subinvolutionThe infection may spread to cause peritonitis and septic pelvic thrombophlebitisTreat with IV antibioticsEmotional support
77 Postpartum Infections Puerperal sepsis: any infection of genital canal within 28 days after abortion or birthMost common infecting agents are numerous streptococcal and anaerobic organismsEndometritisWound infectionsUrinary tract infectionsMastitis77 of 34
78 Complications of Puerperium FeverUTI/PyelonephritisDVT/Thrombophlebitis“Milk fever” (Lasts < 24 hours)Drug reactionPerineal infection(Day five)Pulmonary Atelectasis (48 hours)Mastitis (2-3 weeks post partum)
80 Postpartum Endometritis Infection of the decidua (pregnancy endometrium)Incidence<3% after vaginal delivery10-50% after cesarean delivery5-15% after scheduled elective cesareansRisk FactorsProlonged labor, prolonged ROM, multiple vaginal exams, internal monitors, maternal DM, meconium, manual removal of placenta, low socioeconomic status
81 PP Endometritis Polymicrobial, ascending infection Mixture of aerobes and anaerobes from genital tractBV and colonization with GBS increase likelihood of infectionClinical manifestations (occur within 5 days pp)Fever – most common signUterine tendernessFoul lochiaLeukocytosisBacteremia – in 10-20%, usually a single organism
82 PP Endometritis Workup CBC Blood cultures Urine culture DNA probe for GC/chlamydiaImaging studies if no response to adequate abx in 48-72hCT scan abd/pelvisUS abd/pelvisCT scan to exclude septic pelvic thrombophlebitis, ovarian vein thrombosis, phlegmon; US can be nl or show retained POC or intrauterine hematoma.
83 PP Endometritis Treatment Prevention Broad spectrum IV abx Clindamycin 900mg IV q8h andGentamicin 1.5mg/kg IV q8hTreat until afebrile for 24-48h and clinically improved; oral therapy not necessaryAdd ampicillin 2g IV q4h to regimen when not improving to cover resistant enterococciPreventionAbx prophylaxis for women undergoing C-sectionCefazolin 1-2g IV as single dose
84 Postpartum Infections Mastitis - A breast infection occurring 1-2 weeks after childbirthEngorgement and blocked mild duct increases riskFever, localized breast pain, redness,warmth and inflammationBreastfeeding should continueAntibioticsNurse's role is to support, educate and refer
85 MastitisInfection of the lactating breast- 2nd or 3rd week after birthCaused by S. aureus, often on hands of mother or caregiversCan enter through a crack in the nippleEngorgement & stasis of milk frequently precede mastitis
86 Mastitis Continued SIGNS & SYMPTOMS: THERAPEUTIC MANAGEMENT Feels like the flu with fatigue & aching musclesFever of 101.1FLocalized area of redness & inflammationTHERAPEUTIC MANAGEMENTATB & decompression of breast by breastfeeding or pumpingBedrest during acute phaseFluids & analgesics for discomfort
87 Postpartum Infections Mastitis Puerperal Mastitis usually caused by common skin bacteria particularly staphylococcus being introduced into the ductal system through
88 Postpartum Infections Mastitis Breast infections may causepain,redness,warmth of the breast along with the following symptoms:Tenderness and swellingBody achesFatigueBreast engorgementFever and chillsRigor or shaking
89 Postpartum Infections Mastitis Most breast infections occur in breastfeeding women when bacteria enters the breast through cracks in the nipple. In severe infections, abscesses may occur. Antibiotics may be indicated for treatment.
92 Postpartum Infections Care Management Prevention is the best interventionHand washingGood maternal perineal hygieneAntibiotic administrationWound managementBreast care92 of 34
93 Sequelae of Childbirth Trauma Disorders of uterus and vagina related to pelvic relaxation and urinary incontinence, are often result of childbearingUterine displacement and prolapsePosterior displacement, or retroversionRetroflexion and anteflexionProlapse a more serious displacementCervix and body of uterus protrude through vagina and vagina is inverted93 of 34
94 Sequelae of Childbirth Trauma Uterine prolapse Uterine prolapse occurs when the uterus falls through the cervix (the connection between the uterus and the vagina) into the vagina. Symptoms and treatment depends on how much of the uterus has fallen into the vagina.
99 Sequelae of Childbirth Trauma Cystocele and rectoceleCystocele: protrusion of bladder downward into vagina when support structures in vesicovaginal septum are injuredRectocele is herniation of anterior rectal wall through relaxed or ruptured vaginal fascia and rectovaginal septumUrinary incontinence99 of 34
100 Sequelae of Childbirth Trauma Cystocele and rectocele
101 Sequelae of Childbirth Trauma Cystocele and rectocele
102 Sequelae of Childbirth Trauma Cystocele and rectocele
103 Sequelae of Childbirth Trauma Cystocele and rectocele
104 Sequelae of Childbirth Trauma Cystocele and rectocele
105 Sequelae of Childbirth Trauma Cystocele and rectocele
106 Sequelae of Childbirth Trauma Genital fistulasMay result from congenital anomaly, gynecologic surgery, obstetric trauma, cancer, radiation therapy, gynecologic trauma, or infectionVesicovaginal: between bladder and genital tractUrethrovaginal: between urethra and vaginaRectovaginal: between rectum or sigmoid colon and vagina106 of 34
107 Types of Fistulas That May Develop in Vagina, Uterus, and Rectum