Nursing Care of Women with Complications After Birth Chapter 10 Nursing Care of Women with Complications After Birth

Objectives Describe signs and symptoms for each postpartum complication. Identify factors that increase a woman’s risk for developing each complication. Explain nursing measures that reduce a woman’s risk for developing specific postpartum complications. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Objectives (cont.) Describe the medical and nursing management of postpartum complications. Explain general and specific nursing care for each complication. Compare and contrast mood disorders in the postpartum period. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Categories of Postpartum Complications Discuss shock and hemorrhage. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Shock Defined as a condition in which the cardiovascular system fails to provide essential oxygen and nutrients to the cells Cardiogenic Hypovolemic Anaphylactic Septic Describe cardiogenic, hypovolemic, anaphylactic, and septic shock. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Hemorrhage Early—within 24 hours postpartum Late—between 24 hours and 6 weeks postpartum Major risk is hypovolemic shock Interrupts blood flow to body cells Prevents normal oxygenation, nutrient delivery, and waste removal Signs and symptoms Tachycardia Falling systolic blood pressure Pale, cold, and clammy skin Mental status changes Decreased urinary output Discuss the differences and clinical manifestations of early and late hemorrhage. Provide scenarios describing clinical manifestations of early and late hemorrhage. Audience Response Question #1 The first sign of hypovolemic shock is most often: 1. decreased urinary output. 2. pale skin. 3. decreased systolic blood pressure. 4. tachycardia. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Safety Alert Because postpartum women often have a slow pulse rate, suspect hypovolemic shock or infection if the pulse rate is greater than 100 beats/min Discuss the pathophysiology regarding a pulse rate greater than 100 beats/min and its indication for hypovolemic shock or infection. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Care Frequent vital signs Monitor oxygen saturation levels Assessment of lochia Observation for perineal hematoma Assessment of fundus Firm with bleeding may indicate vaginal laceration Accurate measurement of intake and output Monitoring intravenous fluid therapies Monitor for signs of anemia Provide emotional support to the woman Discuss the rationale for and give an example of frequently assessing vital signs. In what ways could you provide emotional support to a postpartum woman? Discuss methods to monitor anemia. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Early Postpartum Hemorrhage Causes Uterine atony Lacerations or tears of the reproductive tract Hematomas in the reproductive tract Describe the pathophysiology for each cause listed. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Late Postpartum Hemorrhage Causes Retention of placental fragments Subinvolution Nursing care Teach the woman to report persistent bright red bleeding Return of red bleeding after it has changed to pink or white Prepare for intravenous medication Prepare for possible surgical intervention What is the medical treatment for postpartum hemorrhage? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Thromboembolic Disorders A venous thrombosis is a blood clot within a vein Causes or risks Venous stasis during pregnancy Pressure behind knees if legs are in stirrups Fibrinogen levels increase during pregnancy, whereas clot-dissolving factors in the blood are normally decreased during pregnancy Varicose veins Types of thromboembolic disorders Superficial vein thrombosis (SVT) Deep vein thrombosis (DVT) Pulmonary embolism (PE) Discuss the pathophysiology regarding the causes or risks of thromboembolic disorders. Describe each type of thromboembolic disorder. Audience Response Question #2 Classic symptoms of DVT include muscle pain, positive Homans' sign, and swelling of the affected limb. 1. True 2. False Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Care to Prevent a Thromboembolism Watch for signs or symptoms of PE Dyspnea Coughing Chest pain Teach woman not to cross legs, as it impedes blood flow Avoid pressure in the popliteal space behind the knee Early ambulation and range of motion exercises If antiembolic stockings are prescribed, the nurse should teach the woman the correct method of putting on the stockings Describe the correct method to put on antiembolic stockings. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Anticoagulant Therapy Teach the woman taking this type of medication Danger signs Prolonged bleeding from minor injuries Nosebleeds Unexplained bruising Use a soft-bristled toothbrush Stress the importance of completing follow-up blood tests Help the woman cope with this form of medical therapy What is the nurse’s role regarding anticoagulant therapy and patient education? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Puerperal Infection An infection or septicemia after childbirth, with a fever of 38° C (100.4° F) after the first postpartum day Risks Cracks in the nipples of the breasts Surgical incision Tissue trauma during labor Open wound at the placental insertion site Retained placenta or blood clots Increased pH of the vagina after birth Endometritis (inflammation of the lining of the uterus) Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

The Dangers of Puerperal Infection A localized infection of the perineum, vagina, or cervix can ascend the reproductive tract and spread to the uterus, fallopian tubes, and peritoneum, causing peritonitis, a life-threatening condition Discuss the pathophysiology of peritonitis and the necessity for rapid assessment and treatment of the disorder. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Safety Alert Proper hand hygiene is the primary method to avoid the spread of infectious organisms Gloves should be worn when in contact with any blood, body fluids, or any other potentially infectious materials Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Care The objective is to prevent the infection from occurring Use and teach hygienic measures Promote adequate rest and nutrition for healing Teach and observe for signs of infection Teach the woman how to correctly apply perineal pads (front to back) Teach the woman to take all antimicrobial medications as prescribed What hygienic measures would you teach the patient? What should the nurse teach the patient about signs and symptoms of infection? Discuss the rationale for correct application of perineal pads. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Mastitis An infection of the breast Signs and symptoms Redness and heat in the breast Tenderness Edema and heaviness of the breast Purulent drainage may or may not be present Fever, chills, and other systemic signs of infection An abscess may form Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Treatment of Mastitis Prescribed antibiotics, mild analgesics Continue to breastfeed with unaffected breast Pump and discard the milk from affected breast (weaning can lead to engorgement and stasis of milk, which can worsen the infection) Heat promotes blood flow to the area Massage the area of inflammation to improve milk flow and reduce stasis Encourage fluid intake Wear a supportive bra Provide emotional support to the woman What is the nurse’s role in providing emotional support to the patient with mastitis? Audience Response Question #2 A woman develops mastitis in the postpartum period. She states “I am so sad I have to stop breastfeeding my baby.” The nurse responds: 1. “I will provide with the information regarding formula feeding.” 2. “You can always breastfeed if you have another child.” 3. “I will inform your physician that you are feeling sad.” 4. “It is not necessary that you discontinue breastfeeding.” Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Subinvolution of the Uterus The slower-than-expected or failure of the uterus to return to its normal prepregnant condition Normally the uterus descends at the rate of 1 cm per day Signs and symptoms Fundal height greater than expected Persistence of lochia rubra Pelvic pain and heaviness Fatigue Discuss the location of a prepregnant uterus. How does the nurse assess the fundus? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Care of the Woman with Subinvolution Teach the normal changes to expect Report abnormal pattern Fever, pain, persistent red lochia Foul-smelling vaginal discharge Comfort measures Prepare for possible surgical intervention Explain medications prescribed What are some comfort measures for subinvolution? Discuss nursing interventions to prepare the patient for surgery. Discuss typical medications ordered for a patient with subinvolution. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Disorders of Mood Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

What Is a Mood Disorder? Pervasive and sustained emotion that can color one’s view of life Give examples of mood disorders. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Postpartum Blues (“Baby Blues”) Common after birth Has periods where she feels let down Finds pleasure in her new role Usually self-limiting as woman adjusts to her new role In what ways would a new mother feel depressed? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Postpartum Depression or Psychosis Serious impairment of one’s perception of reality More serious than postpartum blues Usually manifests within 4 weeks after delivery May interfere with mother’s ability to respond to her infant’s cues Maternal-infant bonding may also be affected Give an example of a patient’s impaired sense of reality when severely depressed. How are postpartum blues different from postpartum depression? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Postpartum Depression Risk factors Inadequate social support Poor relationship with partner Life and childcare stress Low self-esteem Unplanned pregnancy How does inadequate social support affect the mother? Discuss how a poor relationship with a partner can contribute to postpartum depression. What other stressors can contribute to postpartum depression? Audience Response Question #3 Postpartum depression is an expected reaction following childbirth. 1. True 2. False Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Signs and Symptoms of Postpartum Depression Lack of enjoyment in life Lack of interest in others Intense feeling of inadequacy Inability to cope Loss of mental concentration Disturbed sleep Constant fatigue and feeling of ill health What are manifestations of a mother who lacks enjoyment in life? Describe situations in which a mother might lose mental concentration. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Care Refer to a multidisciplinary team Be a sympathetic listener for the woman Elicit feelings Observe for complaints of sleeplessness or chronic fatigue Provide support Help woman identify her support system Determine if the mother is getting enough exercise, sleep, and nutrition Help the woman identify ways to meet her own needs Refer to support groups Who would be appropriate on a multidisciplinary team? What methods are used to elicit feelings? Give examples of support systems for a postpartum patient. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Postpartum Psychosis Bipolar disorders Major depression Characterized by episodes of mania Major depression Deep feelings of worthlessness, guilt, and sleep and appetite disturbances Delusions Can be fatal for both mother and infant due to use of poor judgment Possibility of suicide or infanticide Referral for counseling is essential Virtually all antipsychotic medications pass through the breast milk; therefore, breastfeeding is contraindicated What is the difference between postpartum depression and psychosis? Give an example of a possible fatal situation for a mother with postpartum psychosis. What medications treat postpartum psychosis? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Homeless Mother and Newborn Lack of permanent home Often have difficulty accessing care Follow-up is difficult Prior to discharge, ensure mother has a place to go and a way of accessing help Facilitate referrals to outreach programs, support services within the community Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Question for Review What are the key signs of a bleeding laceration in the postpartum period? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Review Objectives Key Terms Key Points Online Resources Critical Thinking Question Review Questions Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.