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NSG 109: Care of Mother, Child, and Adolescent – At Risk or With Problems (Acute/Chronic)

High Risk Postpartal

Postpartal Hemorrhage

  • Defined as any blood loss from the uterus greater than 500 mL within a 24-hour period.

  • Can occur within the first 24 hours or at any time after during the puerperium period.

  • Five main causes of postpartal hemorrhage:

    • Uterine atony

    • Lacerations

    • Retained placental fragments

    • Uterine inversion

    • Disseminated Intravascular Coagulation (DIC)

Uterine Atony

Description

  • Relaxation of the uterus and is the most frequent cause of postpartal hemorrhage.

  • The first step in controlling hemorrhage is to attempt uterine massage.

  • If the uterus cannot remain contracted, an IV infusion of oxytocin (Pitocin) may be ordered.

Fundal Massage Procedure

  1. Put on gloves.

  2. Place one hand on the abdomen just above the symphysis pubis.

  3. Place the other hand around the top of the fundus.

  4. Rotate the upper hand to massage the uterus until contraction is improved.

Medical Management

  • If the uterus cannot remain contracted:

    • Oxytocin: Usually 10 to 40 U per 1000 mL of Ringer's Lactate solution, immediate action but short duration (~1 hour).

    • Carboprost tromethamine (Hemabate): May repeat every 15 to 90 minutes, up to 8 doses.

    • Methylergonovine maleate (Methergine): May be repeated every 2 to 4 hours, up to 5 doses (contraindicated in women with hypertension).

    • Rectal misoprostol: Administered as needed.

Nursing Interventions

  • Offer bedpan or assist with ambulation to the bathroom at least every 4 hours to avoid full bladder pushing an uncontracted uterus.

  • Administer oxygen (4 L/min) in case of respiratory distress due to decreased blood volume.

  • Monitor vital signs frequently and interpret accurately.

Monitoring Recovery

  • Assess uterine contraction to manage bleeding effectively.

  • Observe lochial discharge for abnormalities.

Retained Placental Fragments

Description

  • Occurs when the placenta does not fully detach and fragments remain in the uterus.

  • Can be detected via ultrasound and hCG serum samples can provide confirmation.

Assessment

  • Large retained fragments lead to apparent bleeding; smaller fragments may cause delayed bleeding (6-10 days postpartum).

  • The uterus may remain uncontracted, contributing to continued bleeding.

Therapeutic Management

  • Dilatation and Curettage (D&C) to remove retained fragments.

  • Methotrexate may be administered to destroy retained placental tissue.

Subinvolution

  • Defined as incomplete return of the uterus to its prepregnant size and shape.

  • Typically detected at 4- or 6-week postpartum visit.

  • Associated with retained placental fragments, mild endometritis, or uterine myomas.

Management

  • Methylergonovine (0.2 mg qid) for uterine contraction.

  • Antibiotics if signs of endometritis are present.

Puerperal Infection

  • Infection of the reproductive tract is a leading cause of maternal mortality.

Risk Factors for Postpartal Infection

  • Rupture of membranes (>24 hours).

  • Retained placental fragments causing necrosis.

  • History of postpartal hemorrhage.

  • Dysfunctional labor leading to tissue trauma.

Endometritis

Description

  • Infection of the endometrium, often linked with chorioamnionitis and cesarean births.

Assessment

  • Fever typically appears on the 3rd or 4th postpartum day.

  • WBC counts rise to 20,000-30,000 cells/mm3, with oral temperatures ≥38°C for consecutive days.

  • Symptoms include chills, malaise, and dark, foul-smelling lochia.

Management

  • Administer antibiotics (e.g., clindamycin).

  • Encourage uterine contractions with oxytocic agents.

  • Recommend Fowler's position or walking as mobility support.

Thrombophlebitis

  • Phlebitis involves inflammation of blood vessel linings; thrombophlebitis includes clot formation.

  • Prone to occur due to elevated fibrinogen levels from pregnancy, dilation of lower extremity veins, and prolonged immobility.

Risk Factors

  • Obesity, varicose veins, history of thrombophlebitis, and older age with higher parity.

Prevention

  • Good aseptic techniques during delivery.

  • Encourage ambulation and limit time spent on stirrups.

  • Wear support stockings postpartum.

  • Ensure adequate fluid intake and cessation of smoking.

Management of Thrombophlebitis

  • Bed rest with the affected leg elevated is crucial.

  • Administer anticoagulants (e.g., Heparin) with caution; always have Protamine sulfate available as an antagonist.

  • Use moist heat and fibrinolytics as appropriate.

  • Women can continue breastfeeding while on heparin but should discontinue during coumarin therapy.

  • Avoid salicylic acid (aspirin) unless specified for prevention.