Unit 7D - The Postpartum Woman at Risk (recorded lecture)
POSTPARTUM INFECTION: Nursing assessment
*Read Pic Assess for risk factors BUBBLE Assess sor s/s of infection S/S of PP infection -Nurses play a key role in identifying signs and symptoms that suggest a postpartum infection. -nurses must assess new mothers for risk factors and identify early, subtle signs and symptoms of an infectious process. -Review the client's history and physical examination and labor and birth record for factors that might increase her risk for developing an infection.
POSTPARTUM DISORDERS: Postpartum Depression
-(PPD) is a form of clinical depression that can affect women, and sometimes men, after childbirth. -Unlike the postpartum blues, women with PPD feel worse over time, and changes in mood and behavior do not go away on their own. -PPD may persist for a minimum of 6 months if untreated. -The symptoms of PPD are more severe than those of the blues and require treatment. Some signs and symptoms of PPD include feelings of: Restlessness Worthlessness Guilt Hopelessness Moodiness Sadness Overwhelm Loss of enjoyment Low-energy levels Loss of libido -The levels of estrogen, progesterone, serotonin, and thyroid hormone decrease sharply and return to normal during the immediate postpartum period, which can trigger depression and can change a woman's mood and behavior. -PPD may lend itself to prophylactic intervention because its onset is predictable, the risk period for illness is well defined, and women at high risk potentially could be identified using a screening tool. -Management mirrors that of any major depression: a combination of antidepressant medication, anti anxiety medication, adequate sleep and rest, and psychotherapy in an outpatient or inpatient setting.
POSTPARTUM INFECTION: Management
-Aseptic technique -Pharmacologic -Education
VENOUS THROMBOEMBOLIC CONDITIONS: Nursing assessment
-Assess the woman closely for risk factors and signs and symptoms of thrombophlebitis. -Look for risk factors in the woman's history such as use of oral contraceptives before the pregnancy; smoking; employment that necessitates prolonged standing; history of thrombosis; thrombophlebitis or endometritis; or evidence of current varicosities. -Also look for other factors that can increase a woman's risk, such as prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, maternal age older than 34 years, and multiparity. -Ask the woman if she has pain or tenderness in the lower extremities. -Suspect superficial venous thrombosis in a woman with varicose veins who reports tenderness and discomfort over the site of the thrombosis, most commonly in the calf area -Be alert for signs and symptoms of PE, including unexplained sudden onset of shortness of breath and severe chest pain. -The woman may be apprehensive and diaphoretic. Additional manifestations may include tachypnea, tachycardia, fever, hypotension, syncope, distention of the jugular vein, decreased oxygen saturation (shown by pulse oximetry), cardiac arrhythmias, hemoptysis, and a sudden change in mental status as a result of hypoxemia
Nursing Management of the postpartum women at risk: Introduction
-Numerous adaptations and adjustments must be made to assimilate the newborn into the established family unit. -It is a time designed for maternal recovery, family attachment, and new role development. -Typically, recovery from childbirth progresses without complications both physiologically and psychologically. -However, the woman can experience deviations from health, developing postpartum conditions that can place her at risk. -These high-risk conditions or complications can become life-threatening.
POSTPARTUM DISORDERS: Management
-Nurses need to educate themselves about this disorder to facilitate early recognition of signs and symptoms of it, which in turn would make early treatment possible, thus supporting recovery. -Encourage the client to verbalize what she is going through and emphasize the importance of keeping her expectations realistic. -The nurse can play an important role in assisting women and their partners with postpartum adjustment. -Have available referral sources for psychotherapy and support groups appropriate for women experiencing postpartum adjustment difficulties.
VENOUS THROMBOEMBOLIC CONDITIONS: Nursing Management
-Nursing management focuses on preventing thrombotic conditions, promoting adequate circulation if thrombosis occurs, and educating the client about preventive measures, anticoagulant therapy, and danger signs. Preventing Thrombotic Conditions -Preventing venous stasis by encouraging activity that causes leg muscles to contract and promotes venous return (leg exercises and walking) -Dorsi/plantar flexion of feet with prolonged sitting to promote venous return Promoting Adequate Circulation -The mainstay of venous thromboembolic conditions is anticoagulation -while interventions such as thrombolysis and inferior vena cava filters are reserved for limited circumstances. -For the woman with superficial venous thrombosis, administer NSAIDs for analgesia, facilitate rest and elevation of the affected leg, apply warm compresses to the affected area to promote healing, and use anti embolism stockings to promote circulation to the extremities. -Implement bed rest or limited ambulation if ordered and elevation of the affected extremity for the woman with DVT. Educating the Client -look at pic!/printed too
POSTPARTUM HEMORRHAGE (read pic)
-Postpartum hemorrhage (PPH) is a potentially life-threatening complication that can occur after both vaginal and cesarean births. -They are consequence of the third stage of labor management -Morbidity from PPH can be severe, with sequelae including organ failure, shock, edema, thrombosis, acute respiratory distress, sepsis, anemia, intensive care admissions, and prolonged hospitalization. -A major Obstetric hemorrhage is defined as a blood loss of more than 1500 to 2500 mls or bleeding that required more than 5 units of transferred blood. -Timely, accurate, identification and initiation of appropriate interventions would improve outcomes.
POSTPARTUM DISORDERS: Intro
-Postpartum period involves extraordinary physiologic, psychological, and sociocultural changes in the life of a woman and her family. -Often, the birth of a newborn is associated with positive feelings such as happiness, joy, and gratitude for the birth of a healthy infant. -However, women may also feel weepy, overwhelmed, or unsure of what is happening to them. -They may experience fear about loss of control. They may also feel scared, alone, or guilty, or as if they have somehow failed. -Many types of affective disorders occur in the postpartum period. Although their descriptions and classifications may be controversial, the disorders form a spectrum on the basis of their severity as postpartum or baby blues, postpartum depression, and postpartum psychosis.
POSTPARTUM DISORDERS: Postpartum Psychosis
-Postpartum psychosis, an emergency psychiatric condition, can result in a significant increased risk for suicide and infanticide. -Symptoms of postpartum psychosis, such as mood lability, delusional beliefs, hallucinations, and disorganized thinking, can be frightening for the women who are affected and for their families -It generally surfaces within 3 months of giving birth and is manifested by sleep disturbances, fatigue, depression, and hypomania. -The mother will be tearful, confused, and preoccupied with feelings of guilt and worthlessness. -Early symptoms resemble those of depression, but they may escalate to delirium, hallucinations, extreme disorganization of thought, anger toward herself and her infant, bizarre behavior, delusions, disorientation, depersonalization, delirium-like appearance, manifestations of mania, and thoughts of hurting herself and the infant. -Women with postpartum psychosis should not be left alone with their infants. Most women with postpartum psychosis are hospitalized for up to several months -Psychotropic drugs are almost always part of treatment, along with individual psychotherapy and support group therapy.
POSTPARTUM DISORDERS: Postpartum Blues
-The woman typically experiences rapid cycling mood symptoms during the first postpartum week. -She will exhibit mild depressive symptoms of anxiety, irritability, mood swings, tearfulness, increased sensitivity, despondency, feelings of being overwhelmed, difficulty thinking clearly, insomnia, loss of appetite, and fatigue. -The "blues" typically peak on postpartum days 4 and 5 and usually resolve by postpartum day 10. Baby blues are usually self-limiting and require no formal treatment other than reassurance and validation of the woman's experience, as well as assistance in caring for herself and the newborn.
POSTPARTUM INFECTION: Risk factors
-There is a higher occurrence in cesarean births than in vaginal births -Postpartum infection is defined as a fever of 100.4°F (38°C) or higher after the first 24 hours after childbirth, occurring on at least 2 of the first 10 days after birth, exclusive of the first 24 hours Risk factors surgical birth, prolonged rupture of membranes, long labor with multiple vaginal examinations, inadequate hand hygiene, internal fetal monitoring, uterine manipulation, chorioamnionitis, instrumental birth, obesity, untreated infection prior to birth, retained placental fragments, obesity, gestational diabetes, extremes of client age, low socioeconomic status, and anemia during pregnancy.
The causes of postpartum hemorrhage is by using the five Ts:
1. Tone: uterine atony, distended bladder 2. Tissue: retained placenta and clots; uterine subinvolution 3. Trauma: lacerations, hematoma, inversion, rupture 4. Thrombin: coagulopathy (preexisting or acquired) 5. Traction: too much pulling on umbilical cord Tone -Tone is the T that refers to uterine atony. -Distended bladder can also displace the uterus from the midline to either side, which impedes its ability to contract to reduce bleeding. Tissue -Failure of complete placental separation and expulsion which lead to refrain fragments, which occupies space and prevents the uterus from contracting fully, to clamp down on the blood vessels; this can lead to hemorrhage. Subinvolution of the uterus -Refers to incomplete involution of the uterus or failure to return to its normal size and condition after birth. Trauma -Lacerations and hematomas resulting from birth trauma can cause significant blood loss. Thrombin -Refers to inherited and acquired bleeding disorders and lack of coagulating factors. -Thrombosis (formation of a blood clot) helps prevent PPH immediately after birth by providing hemostasis. -Fibrin deposits and clots in supplying vessels play a significant role in the hours and days after birth. -Disorders that interfere with the clot formation can lead to postpartum hemorrhage. DIC -Is a life-threatening, acquired coagulopathy in which the clotting system is abnormally activated, resulting in widespread clot formation in the small vessels throughout the body, which leads to the depletion of platelets and coagulation factors. -DIC is not itself a specific illness; rather it is always a secondary diagnosis that occurs as a complication of placental abruption, anaphylactoid syndrome of pregnancy, intrauterine fetal death with prolonged retention of the fetus, acute fatty liver of pregnancy, severe preeclampsia, HELLP syndrome (hemolysis, i.e., the breakdown of red blood cells, elevated liver enzymes, and low platelet count), septicemia, and postpartum hemorrhage. -Clinical features include petechiae, ecchymoses, bleeding gums, fever, hypotension, acidosis, hematomas, tachycardia, proteinuria, uncontrolled bleeding during birth, and acute renal failure. Traction -Refers to the pulling of the umbilical cord after the birth of the fetus to extract the placenta before it is completely separated from the uterine wall. -Strong traction placed on the umbilical cord to expel the placenta can result in cord detachment from the placenta or uterine inversion resulting in a massive hemorrhage.
VENOUS THROMBOEMBOLIC CONDITIONS: DVT & PE
DVT. -Deep venous thrombi have a high probability of propagating and leading to pulmonary emboli, which may cause chest pain, breathlessness, and sudden death -The three most common venous thromboembolic conditions occurring during the postpartum period are superficial venous thrombosis, DVT, and PE. PE -Pulmonary embolism is a potentially fatal condition that occurs when the pulmonary artery is obstructed by a blood clot that has traveled from another vein into the lungs, causing obstruction and infarction. -PE is one of the leading causes of pregnancy-related death in the United States. -Risk for postpartum venous thromboembolism is highest during the first 3 weeks after childbirth and follows a surgical birth.
VENOUS THROMBOEMBOLIC CONDITIONS: Definition and Patho
Definition -A thrombosis (blood clot within a blood vessel) can cause an inflammation of the blood vessel lining (thrombophlebitis), which in turn can lead to a thromboembolism (obstruction of a blood vessel by a blood clot carried by the circulation from the site of origin). Patho -Thrombus formation typically results from venous stasis, injury to the innermost layer of the blood vessel, and hypercoagulation related to pregnancy. -Venous stasis and hypercoagulation are both common in the postpartum period. -If a clot dislodges and travels to the pulmonary circulation, PE can occur.
POSTPARTUM INFECTION: Therapeutic management
ENDOMETRITIS -Broad-spectrum antibiotics are used to treat the infection. -Measures to restore and promote fluid and electrolyte balance, provide analgesia, and provide emotional support. SURGICAL SITE INFECTIONS -Involves recognition of the infection, followed by opening of the wound to allow drainage. -Aseptic wound management hydration, and ambulation to prevent venous stasis and also analgesics. URINARY TRACT INFECTIONS -UTIs are common during the postpartum period and could be prevented by timely removal of urinary catheters used during labor or surgical births -Risk factors include catheterization, epidural anesthesia, and vaginal procedures. -Fluids are used to treat dehydration. -Acidifying the urine by taking large doses of vitamin C or a regular intake of cranberry juice. MASTITIS -Treatment of mastitis focuses on two areas: emptying the breasts and controlling the infection. -Want them to cont. breastfeeding. -Provide antibiotic therapy, symptomatic treatment, warm compresses topical lotions and reassurance, emotional support, education, and support for ongoing breast-feeding.
POSTPARTUM INFECTION: Common infections
Endometritis -Is a uterine infection that typically develops within 2 to 4 days postpartum to as late as 6 weeks. -It is an infectious condition that involves the endometrium, decidua, and adjacent myometrium of the uterus -The uterine cavity is sterile until rupture of the amniotic sac. As a consequence of labor, birth, and associated manipulations, anaerobic and aerobic bacteria can contaminate the uterus. -The risk of endometritis increases dramatically after a cesarean birth; -This is typically an extension of chorioamnionitis that was present before birth (indeed, that may have been why the cesarean birth was performed). -Trauma to the tissues and a break in the skin (incision) provide entrances for bacteria to enter the body and multiply. Surgical Site Infections -Any break in the skin or mucous membranes provides a portal for bacteria. In the postpartum woman, sites of wound infection include cesarean surgical incisions, the episiotomy site in the perineum, and genital tract lacerations Urinary Tract Infections -UTIs are most commonly caused by bacteria often found in bowel flora, including E. coli, Klebsiella, Proteus, and Enterobacter species. -It is treated with antibiotics. Mastitis -Is defined as inflammation of the mammary gland, a common problem that may occur within the first 2 days to 2 weeks postpartum. -Usually an inflammation of a milk duct/gland caused by clogged milk. -Mom that are either breastfeeding or non breastfeeding.
POSTPARTUM DISORDERS: Assessing
Identify general risk factors that could predispose a woman to depression: Poor coping skills First pregnancy Low self-esteem Numerous life stressors History of abuse Mood swings and emotional stress Previous psychological problems or a family history of psychiatric disorders Substance abuse Limited or lack of social support network Be alert for physical findings: -activity level -level of fatigue. Ask about her sleeping habits, noting any problems with insomnia. -observe for verbal and nonverbal indicators of anxiety as well as her ability to concentrate during the interaction.Difficulty concentrating and anxious behaviors suggest a problem. -nutritional intake; weight loss due to poor food intake may be present.
POSTPARTUM HEMORRHAGE: Pathophysiology, Causes
Pathophysiology: Excessive bleeding can occur at any time between the separation of the placenta and its expulsion or removal. Causes: uterine atony: Failure of the uterus to contract and retract after birth. -It's the most common cause of early postpartum hemorrhage. -The uterus must remain contracted after birth to control bleeding from the placental site. -Uterine atony is responsible for the majority (80%) of primary or immediate PPH -While obstetric lacerations, uterine inversion, subinvolution, and rupture are generally causes of late or delayed hemorrhage (20%) Distended bladder (full bladder) -A distended bladder can also displace the uterus from the midline to either side, which impedes its ability to contract to reduce bleeding.
POSTPARTUM HEMORRHAGE: Therapeutic management & Nursing assessment
Therapeutic Management -Prompt diagnosis and understanding of the underlying triggers of this complication is essential for a favorable outcome. -Therapeutic management focuses on the underlying cause of the hemorrhage. -Delayed postpartum hemorrhage may occur, despite adequate prophylaxis. -Frequent monitoring and continued prophylaxis and/or treatment are recommended for at least 2 weeks after childbirth -When excessive bleeding is encountered, initial management steps are aimed at improving uterine tone with immediate fundal massage, intravenous fluid resuscitation, and administration of uterotonic medications. -If these methods fail to control bleeding, additional resources are mobilized and more aggressive interventions such as bimanual compression, internal uterine packing, and/or balloon tamponade techniques are employed by the health care provider. *Drugs on the picture are used to control postpartum hemorrhage. Nursing Assessment -Primary prevention of a PPH begins with an assessment of identifiable risk factors. -The period after the birth and the first hours postpartum are crucial times for the prevention, assessment, and management of bleeding. -identify early and intervene. -Begin by reviewing the mother's history, including labor and birth history, for risk factors associated with PPH -Assess the amount of bleeding. Visual estimation is the most frequently practiced method of determining blood loss, and the results are usually included in the documentation of events pertaining to the birth. -If trauma is suspected, attempt to identify the source and document it.