NRS 3026 Chapter 18 Psychosocial Adaptations & Post-partum Maternal Complications

when is the golden hour?

1st hr PP

bonding

a bond develops through satisfying interaction, begins in pregnancy

ex: eye contact, grasping finger, synchronous movements to parent’s voice, root/latch/suckle

taking-in phase

focused on own need for fluid/food/sleep

allows others to make decisions

mom is integrating her birth experience into reality

taking-hold phase

more independent mom, assumes responsibility for self-care and shift attention to infant

may verbalize anxiety about competence and welcomes information about newborn care

letting-go phase

relinquishes role as childless couple

gives up idealized birthing expectations

accepts real infant

allow to verbalize feelings of grief

mild depression

early onset, lasts no longer than 2 weeks, and is frequently expressed

sx: fatigue, weeping, mood instability, anxiety

maternal temperament

personality traits are a major influence on attachment

which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus?

notify the physician of an impending hemorrhage

assess the BP and pulse

evaluate the lochia

assist the pt in emptying the bladder

assist the pt in emptying the bladder

what is the definition of PPH (volume weise)?

greater than or equal to 1000mL of blood loss

(>1000 for c-section, >500 for vaginal)

causes of PPH

uterine atony

lacerations of the cervix, birth canal, or perineum

retained placental fragments

full bladder

what can cause DIC in post-partum?

abruptio placenta, missed abortion, intrauterine fetal death

PPH symptoms

sudden bleeding (>15mins to saturate a pad)

hypovolemic shock: low BP, increase HR, low O2

soft, relaxed, non-contracting uterus

oozing from laceration site

the 4 T’s of PPH

1. tone → uterine atony → tx: uterine massage, oxytocin

2. trauma → lacerations/hematoma → tx: repair laceration, surgery if uterine rupture

3. tissue → retained products of conception → tx: uterine evacuation, abx (endometritis)

   1. thrombin → DIC → replace coagulation factors

primary (early) PPH causes

uterine atony: labor-related, overdistention of utertus, anesthesia

pelvic trauma: iatrogenic, spontaneous

retained conception products

coagulopathy: DIC, thrombocytopenia, inherited disorders

uterine inversion

abnormal placentation: placenta previa or accreta

secondary (late) PPH causes

abnormal placentation: subinvolution of placental site, placenta accreta

retained conception products

infection: endometritis, infxn of c-section scar

coagulopathies

uterine pathology: fibroids, cervical cancer

PPH treatment (non-pharm)

perform uterine fundal massage

prompt blood & fluid replacement

notify PCP

vaginal packing/bakri ballon (blows up to 50cc and slowly reduce to help uterus contract

increase IV fluids

D&C (clear out inside of uterus of clots n stuff) or hysterectomy (last resort)

PPH tx medications

1. Pitocin → first line, aka oxytocin

   1. during labor: give a small dose

   2. PP: give a LARGE dose

2. Carboprost (Hemabate) → for hemorrhaging moms

   1. NOT FOR ASTHMA PTS bc of contractile effects on SM

   2. AE: explosive diarrhea

3. Methergine → hemorrhaging moms

   1. NOT FOR HTN PTS d/t vasocontricting effects

   2. 4º tear moms should get this unless CI

4. Misoprostil (Cytotec) → muscle contraction if pitocin is not available

   1. AE: spontaneous abortion

5. TXA → if mom have both asthma and HTN

dilation and curettage (D&C)

cervix is slowly opened with speculum and dilators to access uterus

curette is inserted into uterus to remove tissue lining inside the uterus

JADA insertion

used to help the uterus contract with a vacuum and a 60mL balloon to seal the cervical os

*cannot give both Bakri or Jada

risk factors for PPH

grand multiparity

precipitous birth → rapid labor <3hrs of contractions starting

large baby → overdistention of the uterus

perineal hematoma & cause

injury to vessel leads to collection of blood in SQ tissue

causes: spontaneous, assisted delivery (forceps or vacuum)

perineal hematoma assess and tx

assess: severe vulvar pain (purple grape/prune), unilateral discoloration, fullness feeling in vagina

tx: ice packs, analgesic, surgical ligation and evacuation

thromboembolic disorders causes

1. venous stasis: compression of large vessels of leg/pelvic d/t enlarged uterus

2. hypercoagulation state of pregnancy: increased clot formation risk and decrease available factors that prevent clot formation

both are important to decrease incidence of maternal hemorrhage

superficial venous thrombosis

inflammation of BV lining in conjunction with clot formation

superficial thrombosis

localized inflammation (phlebitis) → rapidly provokes thrombus formation → limited to calf area

superficial venous thrombosis s/sx & assessment

assess: inspect both lower extremities, prevention is best

s/sx: none-inflammation, tenderness/pain, calf swelling, pedal edema

superficial venous thrombosis tx

analgesics, rest, TEDs, elevation, warm compress

DVT & assess

affects veins deep in the leg musculature that carries 90% of leg venous outflow

assess: redness, heat, edema (not equal B/L), pain in calves

DVT s/sx, dx, management

s/sx: absent in most women

dx: venous dopple or MRI

manage: prevent formation, analgesic, bed rest, elevation, warm/moist compress, SCD, anticoagulant therapy (heparin, lovenox)

PE & sx

fragments of blood clot dislodges and is carried to the pulmonary artery or its branch

sx: dyspnea, CP, tachycardia, tachypnea, hemoptysis, rales/cough, abd pain, fever

PE tx and RN considerations

tx: IV heparin and thrombectomy

RN considerations: maintain pulmonary circulation, medical emergency

PE risk factors

THROMBOSIS

• Trauma, travel, thrombophilia

• hypercoagulable state, HRT

• recreational drugs

• old age

• malignancy

• BC or patches

• obesity, obstetrical (pregnancy 1-6wk pp)

• surgery

• immobilization, iatrogenic (CVC)

• serious illness

PP infxn

bacterial infection after childbirth

temp >38º after first 24hrs and occurring on at least 2 of the first 10 days pp

ex: endometritis, wound infections (increase sepsis risk), UTI

salpingitis

infection in fallopian tubes causing them to become enlarged, hyeremic, tender

peritonitis

infxn spreads through lymphatics to peritoneum, pelvic abscess may form

endometritis

inflammation and infection of the endometrium (uterus lining)

mastitis & causes

inflammation of the breast (infected lobule d/t delayed milk release)

most often 2-4wks pp in 1% of first time (primiparas) breastfeeding moms

cause: staphylococcus from baby’s throat/nose or mom’s skin going into cracked nipples and spreads to the milk ducts

mastitis s/sx & tx

s/sx: <39º temperature, chills, malaise, HA, breast is red, warm/tender, unilateral

tx: abx, regular emptying of breast, analgesic, local heat/ice

• resolves in 24-48hrs after abx tx

  • breast abscess: can develop in 10% of moms with mastitis, fix with surgical drainage and abx

PP mood disorders theoretical cause

hormone triggers: rapid change in estrogen and progesterone in first 24hrs

thyroid hormones drop

PP mood disorder s/sx & name of scale

life stress, restless, irritable, sad, hopeless, overwhelmed

crying, no energy or motivation, withdrawal, loss of interests, trouble focusing

afraid of hurting self or baby

Edinburgh Postnatal Depression Scale (EPDS)

postpartum blues onset, sx, tx

onset: days of delivery to 3 weeks, self-limiting, in 70-80% of mothers

sx: sadness, crying, sudden mood swings, appetite loss, sleeping issues

tx: empathy and support

PPD onset, sx, tx

onset: within the first year after birth in 15-20% of moms

sx: excessive worry/anxiety, irritability/short temper, overwhelmed, trouble concentrating, guilt or worthlessness feelings

tx: Zoloft is safe for breastfeeding or psychotherapy

postpartum psychosis onset, sx, tx

onset: within 6 weeks of birth in 1-2/1000 births

sx: delusions, hallucinations, sleep disturbances, obsessive thoughts about the baby, depression>irritability>euphoria

tx: hospitalization, anti-depressants, anti-psychotics, pscyhotherapy

POST in POST-BIRTH

Pain in chest

Obstructed breathing or SOB

Seizures

Thoughts of hurting yourself or someone else

BIRTH in POST-BIRTH

Bleeding, soaking thru one pad/hour, blood clots >egg

Incision not healing

Red or swollen leg, painful and warm to touch

Temperature >100.4ºF

Headache that does not get better with medicine or changes vision

Fran delivered a 9lb 10oz baby 1 hour ago. When you arrive to perform her 15min assessment, she says that she ‘feels wet all underneath.’ you discover that both pads are completely saturate and she is lying in a 6in diameter puddle of blood. What is the first action?

empty her bladder

assess the fundus for firmness

take her BP

check perineum for lacerations

first: assess the fundus for firmness

then: check perineum for lacerations, empty bladder, take BP