NRSE360 EXAM#3 postpartum complications

DVT

• Blood clot forms in a deep vein during/after childbirth

• The lower extremity can be of superficial or deep veins. PP client @ great risk, can lead to PE

DVT: findings

• Leg pain, tenderness, unilateral area of swelling, warmth, redness

• Hardened vein over thrombosis, calf tenderness

• Diagnostic procedures: Doppler USN, MRI

Nursing assessment: risk factors for DVT

• Pregnancy, Operative vaginal birth, C/S (doubles the risk), PE or varicosities

• Immobility, Obesity, Smoking, Multiparity, Age > 35 yo, History of thromboembolism, Diabetes, Leg pain

Why are patients at risk for DVT?

hypercoagulability, venous stasis, endothelial injury

Hypercoagulability 

• Pregnancy and the postpartum period are prothrombotic states—the body increases clotting factors

• This adaptation is meant to reduce bleeding risk during delivery, but it also increases the risk of thrombosis.

• Coagulation factors remain elevated for several weeks postpartum.

venous stasis

• The enlarged uterus compresses the inferior vena cava and pelvic veins during pregnancy, which reduces venous return from the lower extremities.

• Immobility during labor, delivery, and the recovery period further contributes to venous stasis.

endothelial injury

• Vascular trauma can occur during delivery (especially cesarean section), from instrumentation, or from tissue damage.

• This injury to the endothelium activates the coagulation cascade and promotes thrombus formation.

Nursing care: DVT prevention

• Compression device before ambulation, ROM with bedrest, Early, frequent ambulation, Elevate legs when sitting, avoid crossing legs, Maintain fluids, No smoking

Nursing care: DVT management

• Encourage rest, bedrest, elevate feet above the level of heart, Warm moist compresses, Do not massage legs (Why?), Measure leg circumference, Antiembolism stockings, Treat pain, Anticoagulant Rx

Anticoagulants Medications: Heparin 

• IV prevents formation of new clots & prevents enlargement of existing clots 

• IV Heparin for cont. infusion 3-5days with adjusted doses according to labs- (activated partial thromboplastin time- aPTT)

• Protamine sulfate antidote

• Client should report bleeding, bruising, blood in urine

Anticoagulants Medications: Warfarin (Coumadin)

• Used to treat clots PO , 3 months

• Phytonadione (Vitamin K) should be available for prolonged clotting time

• Monitor PT & INR

• Client should watch for bleeding & bruising

• Use birth control but no oral contraceptives

• Teratogenic effects to fetus

Client education for Anticoagulation Rx

• Avoid Aspirin, Motrin/NSAIDS (increases bleeding risk)

• Use electric razor for shaving 

• Avoid alcohol, Use soft toothbrush, Do not rub/massage legs, Elevate legs

• Avoid prolonged sitting/leg crossing

• Avoid green, leafy veggies Due to Vitamin K, may interact with anticoagulants)

A nurse is caring for a postpartum client diagnosed with a deep vein thrombosis (DVT) in her left leg. Which nursing intervention is most appropriate?

A. Massage the affected leg to promote venous return.

B. Encourage early ambulation to prevent further clot formation.

C. Maintain the affected leg in bed with warm, moist compresses applied.

D. Administer Motrin as prescribed for pain relief.

C

PE

• Fragments, clot dislodge into circulation

• Complication of DVT, embolism moved into pulmonary artery, lodges into lung, obstructs blood flow to lungs

• Expected findings: Apprehension, chest pain, dyspnea, Hemoptysis, Heart murmurs, Peripheral edema, distended neck veins, High temp, hypotension, Hypoxia

PE: treatment

Place pt in semi-fowlers, Give O2, Lung scan, Chest X-Ray, same meds as for DVT & thrombolytics: Alteplase & Streptokinase

Most serious complication of DVT:

• Pulmonary Embolism (PE) – Most serious and potentially fatal complication

• Cause: A thrombus dislodges and travels to the pulmonary arteries.

Most serious complication of DVT: PE Nursing sings to monitor

• Sudden onset dyspnea (shortness of breath)

• Chest pain (often sharp or pleuritic)

• Tachypnea (rapid breathing), Tachycardia

• Hemoptysis (coughing up blood)

• Anxiety, restlessness

• Low oxygen saturation

• Cyanosis or collapse in severe cases

Most serious complication of DVT: PE

• if suspected

• This is an emergency—call the rapid response team, administer oxygen, monitor vital signs, and prepare for diagnostic imaging (e.g., CT pulmonary angiogram

A nurse is caring for a client who is 3 days postpartum following a cesarean birth. The client suddenly reports shortness of breath and sharp chest pain. The nurse notes tachycardia, anxiety, and a respiratory rate of 32/min. Which of the following is the priority nursing action?

A. Administer oxygen via face mask at 10 L/min

B. Obtain a stat electrocardiogram (ECG)

C. Prepare to administer an anticoagulant

D. Elevate the head of the bed and reassure the client

A

Coagulation Disorder

Disseminated Intravascular Coagulation (DIC)

• Complication of underlying pathology (Amniotic fluid embolism)

• Coagulation pathways hyperstimulated, breakdown of blood clots (faster than form), quick depletion of clotting factors ➔hemorrhage & death

Coagulation Disorder risk factors

•  Abruptio placenta, HELLP syndrome, Amniotic fluid embolism

Coagulation Disorder assessment findings

• Prolonged uncontrollable uterine bleeding, 

• Bleeding from IV site, gums, bladder

• Purpuric areas at pressure sites (such as BP cuff)

• Abnormal clotting study results

• Anxiety, S/S of shock (Pale & clammy skin, HR, RR, BP)

DIC: Client-Centered Care .

Unusual bleeding from nose, gums, IV site, incisions, petechiae, bleeding gums, hematuria, tachycardia, hypotension, diaphoresis, oliguria 

• Volume expanders, fluids, blood, platelets, antibiotics, uterogenic agents etc

• Indwelling urinary Catheter

• Surgical intervention as needed- Hysterectomy

• Critical Care (ICU)

DIC: labs, care, focus

• Give Oxygen, Monitor VS

• Labs: CBC, Blood type/crossmatch, clotting factor

• With DIC: Focus on assessing/correcting underlying cause (Ex preeclampsia, abruption etc)

Amniotic Fluid Embolism:

Anaphylactoid Syndrome of Pregnancy 

• Amniotic fluid [containing fetal cells, lanugo, vernix] enters maternal vasculature, initiates cascading process➔ cardio-resp. collapse & DIC

• Potential areas of entry: cervix, site of placental separation, site of uterine trauma (Lacerations

AFE: Stage 1

• Amniotic fluid & fetal cells enter maternal circulation

• release of endogenous mediators

• pulmonary vasospasm & pulmonary hypotension

• Elevated right ventricular pressure & hypoxia

• Myocardial & pulmonary capillary damage

• Left heart failure and acute respiratory distress

AFE: stage 2

• Stage 2: Hemorrhage & death

Amniotic Fluid Embolism (risk factors, assessment findings)

• Risk factors: Induction of labor, abruptio placenta, placenta previa

• Assessment findings: Dyspnea, Seizures, BP, Cyanosis, CP arrest, Uterine atony (leading to DIC)

Amniotic Fluid Embolism (medical management)

Medical management: No evidence to support any care that improves outcome, Maintain cardiac/respiratory function, stop hemorrhage, correct blood loss, Labs, transfuse blood (Blood, PRBCs, Plts), Chest Xray, ICU, may need heart/lung bypass

Amniotic Fluid Embolism nursing care

• Nursing care: Monitor, Report abnormalities, O2, Establish 2 IV sites (for fluid & blood), labs, Blood, Emotional/family support, Transfer to ICU

A 28-year-old woman is 2 hours postpartum after a normal vaginal delivery. She suddenly develops dyspnea, hypotension, and cyanosis, followed by signs of disseminated intravascular coagulation (DIC). Which of the following is the priority nursing action?

A) Administer intravenous oxytocin

B) Prepare for cardiopulmonary resuscitation and oxygen therapy

C) Encourage the patient to cough and deep breathe

D) Monitor vital signs every 15 minutes

B

Pathophysiology of Postpartum Hemorrhage: “5 T’s”

• Tone: uterine atony, distended bladder

• Tissue: retained placenta and clots

• Trauma: vaginal, cervical, or uterine injury

• Thrombin: coagulopathy (preexisting or acquired)

• Traction: causing uterine inversion

causes if PP hemorrhage

Most common uterine atony (current or past), subinvolution, Overdistended uterus, High parity, Prolonged labor, oxytocin induced or precipitous delivery

• Lacerations of the genital tract, Episiotomy, lacerations, hematoma, Retained placental fragments

• Uterine inversion, Ruptured uterus, Coagulation disorders, Hematomas of the vulva, vagina, or subperitoneal areas, Pregnancy complications (previa, abruption)

• Magnesium Sulfate in labor, Blood loss

• Any amount of bleeding that places the mother in hemodynamic jeopardy, May result in hypovolemia and shock

PP hemorrhage blood loss

• >500 mL following a vaginal birth

• >1,000 mL following a cesarean birth

Postpartum Hemorrhage: Therapeutic Management

• Focus on underlying cause, Uterine massage

• Removal of retained placental fragments

• Antibiotics for infection, Repair of lacerations

• Assess for bladder distention, I&O as needed, Maintain IV as needed

• Elevate legs 20-30o to increase venous return

Medications for Postpartum Hemorrhage

Oxytocin (pitocin), Methylergonovine (Methergine), Misoprostol (Cytotec), Carboprost (Hemabate), Tranexamic Acid (TXA), antibiotics for infection

Oxytocin (Pitocin):

• Uterine stimulant, promotes contractions 

Methylergonovine (Methergine):

• Uterine stimulant, Controls PPH, Do not give to clients with hypertension

Misoprostol (Cytotec):

• Uterine stimulant, Controls PPH

Carboprost (Hemabate):

• Uterine Stimulant, Controls PPH, Do not give to clients with Asthma 

Tranexamic Acid (TXA):

• Antifibrinolytic, Improves blood clotting

A nurse is caring for a client who is 2 hours postpartum after a vaginal delivery. The client’s fundus is boggy, and there is bright red bleeding saturating one pad every 5 minutes. Which intervention should the nurse implement first?

A. Administer IV oxytocin as prescribed

B. Massage the fundus until firm

C. Start oxygen via nasal cannula at 2 L/min

D. Insert a urinary catheter to monitor output

B

Hemorrhage: retained placenta (definition and risk factors)

• Small portions of the placenta (cotyledons) remain attached to the uterus during the 3rd stage of labor (Inspect placenta!)

• Risk factor: Manual removal of placenta

Hemorrhage: retained placenta (assessment findings, medical management, nursing action)

• Assessment findings: Bleeding after 1st week, return of lochia rubra after progress to serosa or alba, subinvolution, temp, uterine tenderness (with metritis), pale color, HR, BP

• Medical management: D&C, IV antibiotics, Oxytocin (to expel fragments, Terbutaline to relax uterus prior to D&C if Oxytocin was unsuccessful for placental expulsion)

• Nursing actions: Patient education on S/S infection, Bleed, Temp, uterine tenderness

Hemorrhage: lacerations

• Cervix, vagina, labia, perineum, rectum

• Risk for infection

• Episiotomy with extension to 3rd, 4th degree laceration

Hemorrhage: lacerations (risk factors, assessment findings, medical management)

• Risk factors: Macrosomia, Operative del., Precipitous del.

• Assessment findings: Firm uterus with heavy bleed, Tachycardia, hypotension, Oozing of blood with/without clots, excessive lochia rubra, Episiotomy may extend

• Medical management: Visual inspection & surgical repair

hemorrhage lacerations: nursing action

• Nursing actions: Review documentation, monitor & assess for blood loss, VS,

• Notify provider of findings, Pain medication, Prepare woman for pelvic exam, Emotional/family support

vaginal laceration: 1st degree

vaginal mucosa torn

vaginal laceration: 2nd degree

perineal muscles torn

vaginal laceration: 3rd degree

anal sphincter torn

vaginal laceration: 4th degree

rectum torn

Hemorrhage: Hematomas (definition, risk factors)

• Collection of blood within the connective tissue of vagina or peri area r/t a vessel that ruptures & continues to bleed

• Risk factors: Episiotomy, forceps, prolonged 2nd stage

Hemorrhage: Hematomas (assessment finding)

Assessment findings: Severe pain, HR, BP,

• Vaginal: Not visible by RN (Severe pain, heaviness/fullness in vagina, rectal pressure)

• Perineal: Swelling, discoloration (blue bulging under skin), tenderness

Hemorrhage: Subinvolution of the uterus (definition, risk factors, labs)

• Uterus remains enlarged with continues lochia drainage, can lead to Postpartum hemorrhage

• Risk factors: Pelvic infection & endometritis, retained placenta

• Prolonged, irregular or excessive bleeding

• Enlarged, boggy uterus with fundal height above Umbilicus 

• Labs: H&H, cultures

• May need Dilation & Curettage (D&C)

Hemorrhage: Subinvolution of the uterus

• Care: PP Assessment, VS, Breastfeeding, Early ambulation, Frequent voiding,  Possible D&C

• Medications: uterine stimulants  Oxytocin, methylergonovine, antibiotics for infection 

Hemorrhage: Hematomas (assessment, interventions, nursing)

• Assessment (cont): With 200-500 cc blood, can displace uterus➔atony ➔PPH

• Small: Evaluate & monitor

• Large: Surgically excised, blood evacuated, open vessel identified & ligated, provides immediate relief of pain

• Nursing actions: Review documentation & identify risks, Ice x 24 hrs, Assess/treat pain, Review labs [H&H], notify provider of findings, Emotional support & teaching

The nurse is assessing. a client who had a vaginal delivery 30 minutes ago. The nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. The nurse's initial action is which of the following?

• A . Call the primary care provider

• B. Administer Pitocin as ordered

• C. Call the primary care provider

• D. Palpate the uterine fundus

D

Metritis: Infection of uterus (risk factors, assessment)

• Risk factors: C/S, Prolonged ROM, Prolonged labor, Internal monitoring, mec stained fluid, Cervical exams, Obesity

• Assessment findings: temp >100.4 (with or w/o chills), Lower abdominal pain, Uterine tenderness, Tachycardia, Malaise, Heavy/foul-smelling lochia (anaerobic organisms, late sign that entire endometrium involved) or Scant, odorless lochia (Beta-hemolytic, streptococcus present)

Metritis: Infection of uterus (medical management, nursing actions)

• Medical management: CBC, Endometrial culture, Blood culture, urinalysis, Antibiotics

• Nursing actions: Risk reduction, Hand wash, peri care, change pads, ambulation, fluids, protein, Monitor s/s of infection, Broad Spectrum Antibiotics, pain meds, discharge teaching

Mastitis

• Breast infection: Milk stasis from plugged duct, nipple trauma, poor feeding, poor hygiene

Mastitis: risk factors, assessment

• Risk factors: History of mastitis (usually S. aureus), cracked/sore nipples, use of antifungal nipple cream (baby with thrush), Diabetes, malnutrition, other infection

• Assessment findings: Flu like symptoms (Chills, fever, aches), Pelvic pain, loss of appetite, Hard, tender, palpable mass with surrounding red area, acute pain in unaffected breast, temp, tachycardia, malaise, purulent drainage

Mastitis: medical management, nursing actions

• Medical management: Culture of breast milk from affected breast, PO antibiotics 10-14 days

• Nursing actions: Risk reduction, Antibiotics, treat pain, Warm compress to affected area, Continue to encourage nursing (empty breasts)

A postpartum client who is breastfeeding reports breast tenderness, warmth, and redness in one breast, along with a fever of 101°F (38.3°C). The healthcare provider diagnoses mastitis. Which nursing instruction is most appropriate for this client?

A. Stop breastfeeding from the affected breast until the infection resolves.

B. Apply ice packs to the affected breast every 2 hours.

C. Continue breastfeeding or pumping frequently from both breasts.

D. Wear a tight-fitting bra to support the breast and decrease pain.

C

UTI (risk factors, expected findings)

Risk factors:

• Bladder trauma & catheterizations 

• Pelvic exams, C/S, epidurals, Genital tract injuries, Hx of UTIs

• May progress to kidney damage & failure

• Expected findings: Urgency, frequency, dysuria, retention, pelvic pain, elevated temp

UTI: diagnosis and treatment

• Urinalysis for WBCs, RBCs, protein, bacteria

• Antibiotics (finish course), Tylenol for pain, PO fluids, peri care

Wound Infection: sites, risk factors, assessment findings

• Sites: Episiotomy, laceration, c/s

• Risk factors: Obesity, Diabetes, Malnutrition, Long labor, Prolonged ROM, Previous infection, Immunodeficiency, Corticosteroid Rx, Poor suturing technique

• Assessment findings: Erythema, redness, heat, swelling, tenderness, purulent drainage, low grade fever, pain at site

Wound infections: medical management, nursing actions

• Medical management: Culture, For mild to moderate wound infections without purulent drainage (PO antibiotics, heat to area), For infections with purulent drainage (Open & drain wound, IV antibiotics)

• Nursing actions: Risk reduction, REEDA assessment, Labs, Antibiotics, Hand washing, Nutrition, Medications, Discharge teaching.

Wound infections: REEDA scale

• Clinical tool used by healthcare providers to assess postpartum wound healing

• redness, edema, hemosis, drainage, approximation (wound edges) 

• Know signs of infection 

Nursing management: Perineal care

• Aseptic technique; hand washing; perineal hygiene

• Screening of visitors

The nurse is reinforcing discharge teaching for a postpartum client. Which findings should the client report to the healthcare provider? Select all that apply.

• A. Oral temperature of 100.4

• B. Breast engorgement that only improves with feeding or pumping

• C. Persistent headache, blurred vision, and epigastric pain

• D. Crying, difficulty sleeping and anxiety in the third week PP

• E. Occasional blood clots the size of a golf ball

• F. No bowel movement for 3 days after a vaginal delivery

• G. Pain, redness, warmth and swelling of the breasts

CDEG

PP signs to report to provider

• temp >100.5

• saturating >1 pad per hour

• constipation >5 days