Postpartum Complications and Nursing Care

Postpartum Complications and Nursing Care

Learning Outcomes

  • Postpartum Hemorrhage: Understand primary causes and associated nursing actions and medical care.

  • Postpartum Infections: Recognize signs and symptoms, nursing actions, and medical care for postpartum infections.

  • Psychological Complications: Describe key postpartum psychological issues and nursing management.

  • Cardiovascular Complications: Understand cardiovascular complications postpartum and related nursing care.

  • Social Determinants: Develop a plan to help postpartum patients mitigate negative outcomes influenced by social factors.

Introduction

  • The postpartum period is critical for the health of both mothers and newborns, emphasizing the need for careful monitoring during recovery, particularly for mothers who experienced complications during pregnancy or childbirth.

Common Causes of Maternal Morbidity and Mortality

  • Highlighted are prevalent yet preventable causes of severe maternal morbidity and mortality, including:

    • Hemorrhage

    • Infection

    • Perinatal mood and anxiety disorders (PMADs)

    • Hypertensive disorders

    • Venous thromboembolism (VTE)

Postpartum Hemorrhage

Definition

  • Postpartum Hemorrhage (PPH) is defined as:

    • Blood loss greater than 500 mL for vaginal deliveries, greater than 1,000 mL for cesarean deliveries, accompanied by a ≥10% drop in hemoglobin and/or hematocrit

    • Cumulative blood loss of 1,000 mL or more or blood loss accompanied by hypovolemia symptoms within 24 hours postpartum (includes intrapartum loss).

Treatment Approach

  • Two-pronged approach:

    1. Resuscitation: Management of obstetric hemorrhage and potential hypovolemic shock.

    2. Identification and management of underlying causes of hemorrhage.

Nursing Management

  • Key actions include:

    • Recognizing signs and symptoms, and informing healthcare providers early for intervention.

Threshold Parameters for Postpartum Hemorrhage

  • Signs and symptoms indicating maternal hypovolemia include:

    • Tachycardia

    • Hypotension

    • Tachypnea

    • Low oxygen saturation (≤ 95%)

    • Oliguria

    • Pallor

    • Dizziness or altered mental status.

Causes of Postpartum Hemorrhage

Precipitating Factors

  • The four Ts that contribute to hemorrhage:

    1. Tone: Uterine atony.

    2. Tissue: Retained or abnormal placenta.

    3. Trauma: Lacerations.

    4. Thrombin disorders: Coagulation issues.

Detailed Overview of the Four Ts
Tone (Uterine Atony)

  • Uterus has decreased tone (large, soft, boggy). This occurs due to:

    • Uterine muscles not contracting enough after childbirth.

    • Common in women with:

    • Overdistended uterus (multiple pregnancies or large fetus).

    • High parity (more than five births).

    • Prolonged or dysfunctional labor.

Tissue

  • Retained placental tissue can cause secondary postpartum hemorrhage (PPH) and prevent uterine involution leading to complications like endometritis.

Trauma

  • Lacerations in the cervix, vagina, labia, and perineum often occur during operative vaginal deliveries or precipitous labor.

Thrombin Disorders

  • Hematomas (vulvar, vaginal, cervical, retroperitoneal) can create complications, observed in conditions like preeclampsia.

Nursing Actions for the Four Ts

  • Tone:

    • Assist the uterus to contract via massage or medication.

    • Monitor bleeding by weighing pads (1 gm = 1 mL).

    • Maintain fluid balance potentially utilizing another IV line.

    • Administer oxygen (10-12 L via mask) and keep patient warm.

    • Call healthcare providers for assessment if severe.

  • Tissue:

    • Monitor for signs of retained tissue.

    • Signs include the persistence of a firm uterus with continuous bleeding or strings of tissue seen in the blood.

  • Trauma:

    • Monitor for visible hematomas and prepare for surgical intervention if necessary.

    • Assess for lacerations contributing to bleeding.

  • Thrombin:

    • Recognize symptoms such as oozing from IV sites, bleeding gums, and consultation for increased clotting factors.

Interventions for Treatment of Hemorrhage

  • Stage 1 to 4: Assess and treat stages of blood loss.

  • Uterotonics:

  • Medications:

    1. Oxytocin (Pitocin):

    • Classification: Oxytocic hormone.

    • Route: IV or IM, no IV push.

    • Actions: Stimulates uterine contractions, vasopressor effects.

    • Dosage forms commonly include 20 units in 1 L of normal saline.

    • Monitoring begins after a bolus, typically for a minimum of 4 hours.

    1. Methylergonovine (Methergine):

    • Oxytocic medication.

    • Dosage: PO 200-400 Mcg, IM 200 Mcg.

    1. Carboprost-Tromethamine (Hemabate):

    • Prostaglandin action to control uterine atony.

    1. Misoprostol (Cytotec):

    • Prostaglandin analogue; used off-label for uterine contractions.

    1. Tranexamic Acid (TXA):

    • Antifibrinolytic, not a uterotonic, administered ideally within 3 hours postpartum.

Coagulation Disorders

DIC (Disseminated Intravascular Coagulation)

  • DIC represents a syndrome where hyperstimulation of coagulation pathways leads to rapid depletion of clotting factors resulting in hemorrhage.

Anaphylactoid Syndrome of Pregnancy

  • Known as AFE (Amniotic Fluid Embolism), involves serious maternal complications including hypoxia, acute lung injury, hypotension, and potential cardiac arrest shortly after childbirth.

Venous Thromboembolic Disease (VTE)

  • VTE represents a significant risk postpartum, with two primary types: deep vein thrombosis (DVT) and pulmonary embolism (PE).

Postpartum Infection Nursing Care

Endometritis

  • Risk factors, assessment methods, and management plans discussed specifically for this infection.

Urinary Tract Infection (UTI)

  • Address risk factors and management strategies for monitoring and addressing UTIs postpartum.

Mastitis

  • Understanding signs, symptoms, and management of mastitis in the postpartum period.

Wound Infections

  • Identifying at-risk populations, assessment, and management strategies for wound infections.

Clinical Indicators of Postpartum Infection

  • Key observations include:

    • Fever on the third postpartum day

    • Tachycardia correlating with fever

    • Presence of lochia with foul odor or increased WBC (≥20,000/mm³) levels.

Management of Pregnancy Complications in the Postpartum Period

Severe Hypertension

  • Recognizing and managing acute postpartum hypertensive episodes requiring immediate intervention.

Diabetes Management

  • Monitoring insulin needs for diabetic mothers postpartum and ensuring follow-up for gestational diabetes.

Maternal Obesity

  • Discussing risk factors associated with obesity postpartum and associated nursing actions.

Postpartum Follow-Up

  • Importance of establishing contact with postpartum care teams and clear instructions for follow-up care post-discharge.

Notable Emergency Symptoms for Postpartum Patients

Warning Signs

  • Educating postpartum patients to watch for:

    • Chest pain

    • Breath obstruction or shortness of breath

    • Seizures

    • Severe headache with vision changes

    • Heavy bleeding or significant blood clots

    • Signs of infection in the incision

Postpartum Psychological Complications

Overview

  • Childbirth can trigger significant psychiatric issues, affecting about 15% of women, leading to major mood disorders.

Types of Disorders

  • Postpartum Depression (PPD): Occurs within the first 6 to 12 months, affecting approximately 11.5% of mothers.

  • Postpartum Psychosis: Prevalence of 0.1% to 2.6%, appears rapidly after birth, marked by severe symptoms requiring immediate intervention.

Paternal Psychological Impact

  • Paternal postnatal depression (PPND) seen in 1% to 8% of new fathers.

Summary

  • Notable that the most preventable cause of maternal morbidity and mortality postpartum remains insufficiently addressed. - Recognizing the significance of follow-up care, as only 60% of women receive such care postpartum, underlining the crucial role of nurses in monitoring, prevention, and patient education.