The Postpartal Family at Risk

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

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

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

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

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

Bimanual Compression

Manual Removal of the Placenta

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

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

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

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

Endometritis

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

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

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

Mastitis

Breast Problems

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

Thromboembolic Factors

Vitamin K Foods

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

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

Postnatal Depression

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

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

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

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

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

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

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

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

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

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

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

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

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

Self-Care Measures: UTI Good perineal hygiene Maintain adequate fluid intake Empty bladder when she feels the urge to void or at least every 2-4 hours while awake

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

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

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

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

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

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

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

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