NURS 333 Chapter 23 Conditions Occurring After Delivery

Maternal Early Warning Criteria

-maternal aggitation, confusion, or unresponsiveness

-report of headache, or SOB by patient with preeclampsia

-systolic BP <90 or >160

-diastolic BP >100

-HR <50 or >120

-RR <10 or >30

-O2 sat on room air at sea level <95%

-oliguria for 2 or more hours (<35 ml/hr)

Postpartum Hemorrhage

is bleeding of more than 1,000 mL despite uterine massage and first-line uterotonics (such as oxytocin).

After birth the uterus normally maintains hemostasis and prevents PPH by clotting and contraction of the myometrium of the uterus.

PPH is often caused by uterine atony, blood coagulopathies, or trauma.

Postpartum Hemorrhage Risk Factors

- prolonged labor

- augmented labor

- rapid labor

- operative delivery

- overdistended uterur

- hx of PPH

- chorioamnionitis

early PPH

occurs within 24 hours of birth

delayed or secondary PPH

24 hours to 12 weeks after delivery

uterine atony

Clinical manifestations:

Boggy uterus

Heavy bleeding

Confirmed by bimanual exam

Prevention:

Recognizing risk factors

Initiating early intervention and treatment

Nursing Actions and Interventions for Uterine Atony

Review prenatal and/or intrapartum records

Monitor vital signs

Establish intravenous access and draw labs

Perform fundal checks, assess bleeding, fundal massage

Assess and monitor patient more frequently

Administer and/or have uterotonics per orders and protocol

Reassure patient and provide explanation for nursing action/ interventions

Provide comfort measures

Lacerations

Clinical manifestations

Steady stream of bleeding despite firm fundus

Absence of clots

Origin is often masked

Pain and hemodynamic instability are often presenting symptoms

Tachycardia and hypotension

Diagnosis

Inspection of the lower genital tract

Prevention

Minimal use of instrumentation

Limited use of an episiotomy

Offer operative delivery

Nursing Actions and Interventions for Lacerations

Review prenatal and intrapartum records

Monitor vital signs

Perform fundal checks and assess for bleeding

Monitor blood loss

Prepare patient for pending pelvic exam

Administer pain medication as prescribed

Provide comfort measures and emotional support

hematoma

Risk Factors

Episiotomy

Instrumented vaginal delivery

Prolonged Second Stage

Clinical Manifestations

Severe pain in the vaginal or perineal areas

Pain often uncontrolled by standard analgesia

Swelling, discoloration, and tenderness

Vaginal bleeding may or may not be present

Diagnosis

Examine affected areas

Prevention

Avoid episiotomy and operative deliveries

Minimize second stage of labor

Nursing Actions and Interventions for Hematoma

Review prenatal and intrapartum records

Monitor vital signs

Apply ice to perineal area for first 24 hours postpartum

Assess pain

Administer pain meds as prescribed

Review lab results

Inform physician or APN as indicated

Postpartum hemorrhage treatment

Call for help.

Fundal massage of a boggy uterus.

Assess for lacerations or hematoma if the fundus is firm.

Bladder catheterization for inability to void.

Establishing intravenous access.

Oxytocin administered as a first-line uterotonic medication.

Oxytocin

Pitocin

20 to 40 units IV in Lactated Ringers; 10 units IM

IVF bolus

Immediate

Duration: 1 hour

Contracts the upper segment of the myometrium which constricts arteries and decreasing blood flow to the uterus

Don't administer an undiluted rapid IV infusion because it will cause hypotension

Methylergonovine (Methergine)

0.2 mg IM; PO*

Every 2 to 4 hours

Ergot alkaloid that causes generalized smooth muscle contraction in the upper and lower uterine segments

used with caution with those with preeclampsia, hypertension

Carboprost

Hemabate

250 mcg IM

Every 15 min up to 2 mg

Prostaglandin causes uterine contraction and vasoconstriction

Absolute contraindication is hypersensitivity; used with caution with those with asthma

Misoprostol

Cytotec

100 to 200 mcg rectally

Prostaglandin that promotes uterine contractility and tone

B. Evaluate the patient's uterus and lochia.

A family member of a postpartum patient comes out of the patient's room to tell the nurse that the patient is pale, sweaty, and "isn't acting right." What should the nurse do first?

A. Notify the patient's primary health care provider.

B. Evaluate the patient's uterus and lochia.

C. Obtain a set of vital signs.

D. Reassure the family member that the patient is doing well.

Hypovolemic Shock

Triggered when the volume of circulating blood decreases to a degree that the body's organs do not have enough oxygen to function properly

Symptoms of hypovolemic shock

Hypotension

Tachycardia

Tachypnea

Oliguria

Mental status changes

Cool, pale, and clammy skin

Slowed capillary refill

Thromboembolic Disease

is a blood clot or multiple clots that form within a vein.

account for 9.2% of maternal deaths in the United States.

symptoms include swelling, pain, localized redness, warmth, and tenderness.

are often diagnosed with ultrasound imaging.

Treatment may include anticoagulation therapy or surgery.

risk factors for thromboembolic disease

include dilated veins leading to slower blood flow and pooling, endothelial injury related to surgical intervention or placental detachment, and the increase of coagulation factors in pregnancy to decrease the risk of hemorrhage.

superficial vein thrombosis

is more common than a DVT. Symptoms include pain, tenderness, and redness along the length of the vein. The vein may feel cord-like. A superficial vein thrombosis is often self-limiting

Postpartum Infections

can be related to perineal wounds, cesarean wounds, endometritis, mastitis, and urinary tract infections.

Symptoms can be nonspecific.

General symptoms include:

A fever that persists beyond the initial 24 hours after birth.

A fever that begins 2 to 10 days after birth.

Elevated white blood cell count that continues to rise rather than fall.

Perineal Wounds

Associated with third- and fourth-degree lacerations.

Risk factors include:

Operative vaginal delivery

Prolonged second stage of labor

Third- or fourth-degree laceration

Meconium-stained fluid

Assessment findings include tenderness, redness, and swelling, as well as purulent discharge.

Treatment requires removal of sutures and opening of the wound.

Antibiotics are not necessary unless there is evidence of cellulitis.

Endometritis

infection of the lining of the uterus.

Occurs in up to 27% of cesarean births and 1% to 3% of vaginal deliveries.

Risk factors include chorioamnionitis, prolonged labor, and prolonged rupture of membranes.

Infection may cause the uterus to become soft and subinvoluted, which predisposes the woman to hemorrhage.

Signs and symptoms include:

Fever

Uterine tenderness

Flu-like symptoms

Tachycardia

Typically treated with intravenous infusion of a broad-spectrum antibiotic.

Lactational Mastitis

Inflammation of the breast tissue often associated with infection.

Factors contributing to mastitis include delayed breast emptying, poor drainage of one or more ducts, inconsistent pressure on breasts (like poorly fitting bra), oversupply of milk, or nipple trauma.

Most common in the first 3 months of breastfeeding.

Symptoms include tender, red area of breast, malaise, or a high fever.

Treatment may include:

Cold compresses

NSAIDs

Regular and complete emptying of the breast

Antibiotics

Urinary Tract Infection (UTI)

Postpartum women are prone to UTIs because of the frequency of bladder catheterization and genital procedures.

Symptoms include urinary urgency and pain with urination.

Pyelonephritis is a UTI of the upper urinary tract.

Symptoms include flank pain, nausea and vomiting, and fever.

Treatment is generally antibiotics.

False

Is the following statement true or false?

A patient who had a spontaneous vaginal delivery 12 hours ago and is found to have a low-grade fever and slightly elevated white blood cell count probably has an infection that should be treated.

postpartum blues

is a transient, self-limiting mood disorder that starts 2 or 3 days after delivery and resolves within 2 weeks

postpartum depression

is major depression with an onset during pregnancy or in the first 4 weeks after birth.

Estimated 10% to 16% of women experience

postpartum psychosis

is a rare disorder that affects a woman's sense of reality.

Disturbance of a woman's perception of reality as evidenced by hallucinations, thought disorganization, disorganized behavior, and delusions.

Most common in women who suffer from depression with schizophrenia, schizoaffective disorder, or psychosis.

Condition may occur within 48 hours of delivery.

The priority of care is the safety of the patient and the safety of the infant.

Treatment often requires inpatient psychiatric care.

Warning signs for postpartum depression

Low mood for at least 2 weeks

Negative attitude toward the infant

Anxiety about the health of the infant

Concern about the ability to care for the infant

Use of alcohol, street drugs, drugs prescribed to others, or tobacco

B. Interview the patient using open-ended questions.

A home health nurse notices the patient, who delivered 6 weeks ago, appears disheveled, the house is dirty, and the infant appears to be well-fed but is wearing a dirty onesie. What should the nurse do first?

A. Notify the patients primary health care provider.

B. Interview the patient using open-ended questions.

C. Call child protective services due to the risk of postpartum psychosis.

D. Realize the patient has a new baby and is likely sleep deprived.