NURSING CARE OF THE POSTPARTUM CLIENT

Hemorrhage

one of the most important causes of maternal mortality associated with childbearing, poses a possible threat throughout pregnancy and is also a major potential danger in the immediate postpartal period.

Postpartum Hemorrhage

• leading cause of maternal death

• loss of more than 500 ml of blood at the time of delivery or immediately after

Early postpartum hemorrhage

blood loss of 500 ml or more following separation & expulsion of the placenta w/in 24 hours after birth; occurs in 4% of all women giving birth.

uterine atony

- relaxation of the uterus, is the most frequent cause of postpartal hemorrhage

A. Overdistention

B. Effects of anesthesia

C. Prolonged difficult labor

D. Placenta previa

E. Abruption placenta

▪ loss of uterine muscle tone that may be due to:

shock and blood loss

If the vaginal bleeding is extremely copious, a woman will exhibit symptoms of ___

seepage

When the vaginal bleeding occurs gradually, it results in ___, not a gush of blood.

• relaxed uterus

• abrupt gush of blood

• s/s of shock

Signs and symptoms of uterine atony

state of contraction

In the management for uterine atony, palpate a woman’s fundus at frequent intervals postpartally to be certain that her uterus is remaining in a ____

Uterine massage

vigorous fundal massage to encourage contraction (1st step in controlling postpartal hemorrhage

dilute intravenous infusion of oxytocin (Pitocin)

If a uterus cannot remain contracted, her physician or nurse-midwife probably will order a ____ to help the uterus maintain tone.

dilute venous infusion of oxytocin 10-40 u /1000 ml of 5% Dextrose solution (Ringer’s lactate solution)

Oxytocic agents

Blood replacements

to replace blood loss and iron therapy to ensure good hemoglobin formation

Bimanual compression

insert one hand in the patient’s vagina while massaging/pushing against the fundus through the abdominal wall with the other hand

Administration of prostaglandin - IM

promotes strong, sustained uterine contraction if the oxytocin is not very effective

• Carboprost tromethamine (Hemabate), a prostaglandin F2a derivative, or

• methylergonovine maleate (Methergine)

prostaglandin- IM examples for uterine atony

Methylergonovine

causes increased blood pressure so it is contraindicated with a woman with hypertension (generally a blood pressure over 140 mm Hg systolic).

oxygen by face mask ; 4 L/min ; supine

If a woman is experiencing respiratory distress from decreasing blood volume, administer ____ at a rate of about ____. Position her ____ to allow adequate blood flow to her brain and kidneys.

Hysterectomy

done in rare instances of extreme uterine atony

laceration

tear in the perineum or vulva, bleeding persists despite firm uterus

• With difficult or precipitate births

• In primigravidas

• With the birth of a large infant (9 lbs)

• With the use of a lithotomy position and instruments

Large lacerations, however, can cause complications. They occur most often:

• Cervical

• Vaginal

• Perineal

Sites of Lacerations

Cervical Laceration

usually found on the sides of the cervix near the branches of the uterine artery.

Cervical Laceration

- occurs immediately after delivery of the placenta, when the physician or nurse midwife is still in attendance.

venous blood lost with uterine atony

If the artery is torn, the blood loss may be so great that blood gushes from the vaginal opening. Because this is arterial bleeding, it is brighter red than the ______.

Suturing

repair of Cervical Laceration is difficult because bleeding may be so intense, it obstructs visualization of the area

Vaginal Laceration

Although they are rare, lacerations can also occur in here. They are easier to assess than cervical lacerations, because they are easier to view.

• Suturing

• Vaginal packing

• Indwelling urinary catheter (Foley catheter)

Managements of Vaginal Laceration

Suturing

Because vaginal tissue is friable, vaginal lacerations are also hard to repair.

Vaginal packing

Some oozing often occurs after a repair, so the vagina may be packed to maintain pressure on the suture line.

stasis and infection ; toxic shock syndrome

Packing that is left in place too long leads to ___ similar to ___, a form of septic shock.

Indwelling urinary catheter (Foley catheter)

may be placed at the same time, because the packing causes pressure on the urethra and can interfere with voiding.

Perineal Laceration

occur when a woman is placed in a lithotomy position for birth, because this position increases tension on the perineum.

First degree Vaginal

mucous membrane and skin of the perineum to the fourchette

Second degree

Vagina, perineal skin, fascia, levator ani muscle, and perineal body

Third degree

Entire perineum, extending to reach the external sphincter of the rectum

Fourth degree

Entire perineum, rectal sphincter, and some of the mucous membrane of the rectum

• Suturing

• Encourage the client have diet high in fluid.

• Stool softener

Management of Perineal Laceration

inversion of uterus

uterus turns inside out during the delivery of the placenta or birth of the fet

• Traction applied to the umbilical cord

• Pressure applied to the uterus (fundal push)

• Placenta attached to the fundus

• Short umbilical cord

inversion of uterus causes;

• sudden gush of large amount of blood

• fundus not palpable in the abdomen

• s/s of shock (hypotension, dizziness, paleness, or diaphoresis)

s/s of inversion of uterus

IV Fluid line

-to increase blood volume and replace blood loss

Antibiotics

to prevent infections because uterine endometrium was exposed.

• Administration of general anesthesia

• nitroglycerin or a tocolytic drug intravenously

to relax the uterus.

Hysterectomy

if bleeding is profuse, this is done as management for inversion of uterus

Administration of oxytocin

after manual replacement helps the uterus to contract and remain in its natural place

hematoma

collection of blood in the subcutaneous layer of tissue of the perineum.

• Vulvar varicosities

• Precipitate labor

• Forceps delivery

• Inadequate suturing of lacerations

• Rupture of vein during episiorrhap

Causes of hematoma

Rupture of vein during episiorrhapy

They may occur at the site of an episiotomy or laceration repair if a vein was punctured during repair.

1. Vulvar

2. Vaginal

3. Vulvovaginal

4. Retroperitoneal

hematoma types

• perineal pain

• swelling

• skin discoloration- purplish discoloration with obvious swelling; be as small as 2 cm or as large as 8 cm in diamete

• tenderness feeling of pressure over the vagina

Signs and symptoms of hematoma

Ligation of bleeders

If the hematoma is large when discovered or continues to increase in size, the woman may have to be returned to the delivery or birthing room to have the site incised and the bleeding vessel ligated under local anesthesia.

Analgesics

for pain relief

Ice packs

may prevent further bleeding.

• Ligation of bleeders

• Analgesics

• Ice packs

• Antibiotics

Management of Hematoma

Disseminated intravascular coagulation (DIC)

is a deficiency in clotting ability caused by vascular injury.

Disseminated intravascular coagulation (DIC)

It may occur in any woman in the postpartal period, but it is usually associated with premature separation of the placenta, a missed early miscarriage, or fetal death in utero

retained placental fragments

part of placental tissue is left in the uterus interfering with

• uterine atony

• laceration

• inversion of uterus

• hematoma

• coagulation disorders

Early postpartum hemorrhage list

• retained placental fragments

• sub-involution

Late postpartum hemorrhage list

retained placental fragments

Occasionally, a placenta does not deliver in its entirety; fragments of it separate and are left behind. Because the portion retained keeps the uterus from contracting fully, uterine bleeding occurs.

• vaginal bleeding

• soft or non-palpable uterus

• s/s of shock

Signs and symptoms of retained placental fragments

D and c

to remove the placental fragment

sub-involution

failure of the uterus to return to its prepregnant state

sub-involution

at a 4- or 6- week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present

1. Retained placental fragments

2. Infection

3. Uterine tumors

Causes of sub-involutio

• enlarged boggy uterus

• prolonged lochial discharge

• backache

Signs and symptoms of sub-involution

• Administration of methergine

• Antibiotics

• D and c

• Client instruction for s/s to report

Management of sub-involution

Administration of methergine - Oral administration of methylergonovine, 0.2 mg four times daily

usually is prescribed to improve uterine tone and complete involution.

Postpartal infection

Theoretically, the uterus is sterile during pregnancy and until the membranes rupture. After rupture, pathogens can invade. The risk of infection is even greater if tissue edema and trauma are present.

Puerperal infection

general term for infection of the genital tract after delivery

Puerperal infection

is always potentially serious, because, although it usually begins as only a local infection, it can spread to involve the peritoneum (peritonitis) or the circulatory system (septicemia).

▪ Virulence of the invading organism

▪ The woman’s general health

▪ Portal of entry

▪ Degree of uterine involution at the time of the microorganism invasion

▪ Presence of lacerations in the reproductive tract

If infection occurs, the prognosis for complete recovery depends on:

Infections of the perineum

usually remain localized. They are revealed by symptoms similar to those of any suture-line infection, such as pain, heat, and a feeling of pressure.

pain/pressure on the affected area

(+) pus

fever

redness and swelling

dysuria

Signs and Symptoms of Infection of the perineum,vulva, and cervix

Perineal heat lamp, sitz bath, warm compress

to hasten drainage and cleanse the area

Analgesics

-to alleviate discomfort

Endometritis

– infection of the endometrium

Endometritis

Bacteria gain access to the uterus through the vagina and enter the uterus either at the time of birth or during the postpartal period. This may occur with any birth, but the infection is usually associated with chorioamnionitis and cesarean birth.

▪ Cs

▪ PROM

▪ Prolonged labor

Risk factors of Endometritis

Thrombophlebitis

inflammation of the lining of the blood vessels with associated blood clot formation

• Femoral

• Pelvic

Thrombophlebitis types

Femoral

occurs 10 days after delivery

milk leg or phlegmasia alba dolens

It was formerly believed that breast milk drained into the leg, giving it its white appearance. The condition was, therefore, formerly called _____ (“white inflammation”)

homan’s sign

pain in the calf of the leg on dorsiflexion of the foot

Doppler ultrasound or contrast venography

ordered to confirm the diagnosis of Femoral Thrombophlebitis

• Anticoagulant- (coumarin derivative or heparin) or a

• thrombolytic agent such as streptokinase or urokinase

is prescribed to dissolve the clot through the activation of fibrinolytic precursors and prevent further clot formation.

Pelvic

14-15th day postpartum

Pelvic thrombophlebitis

It involves the ovarian, uterine, or hypogastric veins. It usually follows a mild endometritis and occurs later than femoral thrombophlebitis, often around the 14th or 15th day of the puerperium

Pelvic thrombophlebitis

Signs and symptoms:

high fever

chills

general malaise

pelvic abcess

1. Bed rest

2. Anticoagulant

3. Antibiotic

Management of

Pelvic thrombophlebitis

Pulmonary Embolism

an obstruction of the pulmonary artery by a blood clot; complication of thrombophlebitis

orthopnea

inability to breathe except in an upright position

Pulmonary Embolism

is at high risk for cardiopulmonary arrest.

Postpartal blues

feeling of sadness after childbirth; related to hormonal shifts as the levels of estrogen, progesterone and gonadotropin-releasing hormone in the body decline

Postpartal Depression

a more serious problem than postpartal blues; occurs in women who are disappointed in some aspects of their newborn or who have poor family support.

History of depression

Troubled childhood

Low self-esteem

Stress in the home or work

Lack of effective support

Disappointment in the child

Risk Factors of Postpartum Psychiatric Disorders

Postpartal Psychosis

a mental illness which coincides with the postpartal period; a response to the crisis of childbearing