Chapter 28

Thromboembolic Disorders

A thrombus is a collection of blood factors, primarily platelets and fibrin, on a vessel wall. Thrombophlebitis occurs when the vessel wall develops an inflammatory response to the thrombus. This further occludes the vessel. An embolus is a mass that may be composed of a thrombus or amniotic fluid released into the bloodstream that may cause obstruction of capillary beds in another part of the body, frequently the lungs. A pulmonary embolus is a potentially fatal complication that occurs when the pulmonary artery is obstructed by a blood clot that was swept into circulation from a vein or by amniotic fluid. The three most common thromboembolic disorders encountered during pregnancy and the postpartum period are superficial venous thrombophlebitis (SVT), deep vein thrombosis (DVT), and, occasionally, pulmonary embolism (PE). SVT generally involves the saphenous venous system and is confined to the lower leg. DVT can involve veins from the foot to the iliofemoral region. It is a major concern because it predisposes to PE.

Providing support for the family

Acknowledge the anxiety and provide simple appropriate explanations of the activity. "I know all this activity must be frightening. She is bleeding a little more than we would like and we are doing several things at once."

colloboration with hcp

Administer medications, fluids, and treatments as ordered by the health care provider or as stated in the facility's protocol. Note the effects and relay the information to the health care provider. Physicians and nurse-midwives depend on the nurse for accurate information, and they base medical management on information relayed by the nurse. Because of oxytocin's antidiuretic effect, listen to breath sounds to identify signs of pulmonary edema from fluid overload if large amounts of oxytocin are given. Document blood pressure if methylergonovine (Methergine) is given. If measures fail to control bleeding, notify the health care provider so that additional procedures can be initiated. These may include preparation for operative intervention (surgical preparation, consent signed for operative procedure, or confirmation that blood replacement is available).

Therapeutic Management of endo

Administration of IV antibiotics is the initial treatment for endometritis. The goal is to confine the infectious process to the uterus and to prevent spread of the infection throughout the body. Broad-spectrum antibiotics such as the cephalosporins, clindamycin plus gentamicin, or ampicillin plus aminoglycosides are often used. Metronidazole with penicillin may also be given. Antibiotics are continued until the woman has been afebrile and asymptomatic for 24 to 48 hours (Davies & Gibbs, 2008; Duff et al., 2009). To decrease the incidence of endometritis and wound infections, many physicians give a single prophylactic IV dose of an antibiotic to any woman who is having a cesarean birth or who is at an increased risk for infection. Current practice is for the antibiotic to be given during surgery after umbilical cord clamping to avoid exposure of the infant to the drug. However, recent studies suggest that administration of antibiotics prior to the skin incision may decrease the risk of postoperative infection of the mother without a significant risk to the fetus or newborn (Tita, Rouse, Blackwell, et al., 2009). Other medications include antipyretics for fever and oxytocics, such as methylergonovine, to increase drainage of lochia and promote involution.

Initial treatment to prevent thrombus

Anticoagulant therapy is started to prevent extension of the thrombus. Therapy may begin with a continuous infusion of IV UH that is later changed to subcutaneous UH. The activated partial thromboplastin time (aPTT) should be monitored, and the heparin dose adjusted to maintain a therapeutic level of 1.5 to 2.5 times the control (Castro & Ogunyemi, 2010). Subcutaneous LMWH may be used instead of UH and requires less frequent laboratory monitoring. Antifactor Xa and platelets may be monitored if LMWH is used. The woman is placed on bed rest, with the affected leg elevated to decrease interstitial swelling and to promote venous return from the leg. She is allowed to ambulate when symptoms have disappeared. Analgesics may be prescribed to control pain and antibiotics will be used as necessary to prevent or control infection. Moist heat provides relief of pain and increases circulation.

Predisposing Factors to late post partum hemmorrhage

Attempts to deliver the placenta before it separates from the uterine wall, manual removal of the placenta, placenta accreta (see Chapter 27), previous cesarean birth, and uterine leiomyomas are primary predisposing factors for retention of placental fragments.

WOMEN WANT TO KNOW: How Do I Prevent Thrombosis (Blood Clots)?

Methods to improve peripheral circulation will help prevent the occurrence of thrombophlebitis: •Improve your circulation with a regular schedule of activity, preferably walking. •Avoid prolonged standing or sitting in one position. •When sitting, elevate your legs and avoid crossing them. This will increase the return of venous blood from the legs. •Maintain a daily fluid intake of 12 or more 8-oz glasses to prevent dehydration and consequent sluggish circulation. •Stop smoking. Smoking is a risk factor for thrombosis and can cause respiratory problems in you and your newborn.

Lochia

Bleeding (steady trickle, dribble, oozing, seeping, or profuse flow); heavy: saturation of 1 pad/hr; excessive: 1 pad/15 min Assess for trauma; save and weigh pads, linen savers, and bed linens so estimation of blood loss will be more accurate. Notify health care provider.

Planning should reflect the nurse's responsibility to:

Monitor for signs of postpartum hemorrhage. •Perform actions that minimize postpartum hemorrhage and prevent hypovolemic shock. •Notify the health care provider if signs of excessive blood loss are observed or if the woman does not respond as desired.

DRUG GUIDE: Methylergonovine (Methergine)

Classification: Ergot alkaloid, uterine stimulant Action: Stimulates sustained contraction of the uterus and causes arterial vasoconstriction. Indications: Used for the prevention and treatment of postpartum or postabortion hemorrhage caused by uterine atony or subinvolution. Dosage and Route: Usual dosage is 0.2 mg intramuscularly (IM) every 2 to 4 hours for a maximum of five doses. Change to the oral route 0.2 mg every 6 to 8 hours for a maximum of 7 days. Intravenous use not recommended; use in life-threatening emergency only and give over at least 60 seconds with close monitoring of blood pressure (BP) and pulse; may cause severe hypertension. Absorption: Well absorbed after oral or IM route. Excretion: Metabolized by the liver; excreted in the feces and urine. Contraindications and Precautions: Methylergonovine should never be used during pregnancy or to induce labor. Do not use if the mother is hypersensitive to ergot. Contraindicated for women with hypertension, severe hepatic or renal disease, thrombophlebitis, coronary artery disease, peripheral vascular disease, hypocalcemia, or sepsis or before the fourth stage of labor. Adverse Reactions: Nausea, vomiting, uterine cramping, hypertension, dizziness, headache, dyspnea, chest pain, palpitations, peripheral ischemia, seizure, and uterine and gastrointestinal cramping. Nursing Considerations: Before administering the medication, assess the blood pressure. Follow facility protocol to determine at what BP level medication must be withheld. Caution the mother to avoid smoking, because nicotine constricts blood vessels. Remind her to report any adverse reactions.

Pueperal infection

Puerperal infection is a term used to describe bacterial infections after childbirth. Until the advent of antibiotics, puerperal infection often resulted in death. Even today, it is a cause of maternal death, especially in developing nations. The most common postpartum infections are endometritis, an infection of the inner lining of the uterus, wound infections, urinary tract infections, mastitis, infection of the breast, and septic pelvic thrombophlebitis. Endomyometritis is an infection of the muscle and inner lining of the uterus. If the surrounding tissues are also involved, endoparametritis is present. Metritis is the infection of the decidua, myometrium, and parametrial tissues of the uterus.

DRUG GUIDE: Carboprost Tromethamine (Hemabate, Prostin/15M)

Classification: Prostaglandin, oxytocic. Action: Stimulates contraction of the uterus. Indications: Used for the treatment of postpartum hemorrhage caused by uterine atony. Also used for abortion. Dosage and Route: Postpartum hemorrhage: 250 mcg intramuscularly. May repeat at 15- to 90-min intervals. Maximum total dose 2 mg. Absorption: Metabolized by the liver and by enzymes in the lungs. Excretion: Primarily excreted in urine. Contraindications and Precautions: Contraindicated for women with hypersensitivity to carboprost or other prostaglandins; acute pelvic inflammatory disease; cardiac, pulmonary, renal, or hepatic disease. Use caution if the woman has a history of asthma, hypotension or hypertension, anemia, jaundice, diabetes, epilepsy, previous uterine surgery. Adverse Reactions and Side Effects: Excessive dose may cause tetanic contraction and laceration or uterine rupture. May cause uterine hypertonus if used with oxytocin. Nausea, vomiting, diarrhea (frequent), fever, chills, facial flushing, headache, hypertension or hypotension, tachycardia, pulmonary edema. Nursing Considerations: Should be refrigerated. Give via deep intramuscular injection and aspirate carefully to avoid intravenous injection. Rotate sites if repeated. Monitor vital signs. Administer antiemetics and antidiarrheals as ordered.

Manifestations of PE

Clinical signs and symptoms depend on how much the flow of blood is obstructed. Dyspnea, chest pain, tachycardia, and tachypnea are the most common signs (Cunningham, et al., 2010). Syncope (fainting) is uncommon and may indicate massive emboli (Lockwood, 2009). Pulmonary rales, cough, hemoptysis (expectoration of blood or bloody sputum), abdominal pain, and low-grade fever may also occur. Pulse oximetry shows decreased oxygen saturation. Arterial blood gas determinations show decreased partial pressure of oxygen, and chest radiography reveals areas of atelectasis and pleural effusion. An electrocardiogram may show abnormalities in size or function of the right ventricle. Spiral computed tomography is a frequently used diagnostic tool and can detect 88% to 100% of pulmonary emboli (Martin & Foley, 2008). Magnetic resonance angiography may also be performed. A negative d-dimer test is a good indication that PE is not present (Lockwood, 2009). A venous ultrasound is also performed to identify a DVT. A ventilation-perfusion scan to show areas of the lung that are ventilated but not perfused is done less often.

Skin

Cool, damp, pale Look for signs of hypovolemia; vigilant assessment and management by entire health care team is necessary.

Postpartum Hemorrhage

Current definitions include blood loss of more than 500 mL after vaginal birth or 1000 mL after cesarean birth, a decrease in hematocrit level of 10% or more since admission or the need for a blood transfusion (Cunningham, et al., 2010) and continued bleeding even with the "usual treatment" (Belfort & Dildy, 2011) Hemorrhage in the first 24 hours after childbirth is called early postpartum hemorrhage. Hemorrhage after 24 hours or up to 6 to 12 weeks after birth, is called late postpartum hemorrhage. Hemorrhage, along with hypertensive disorders, cardiovascular conditions, pulmonary embolism, and infection is a leading cause of maternal morbidity and mortality

urine output

Decreased urine output Report decrease in output. Should be at least 30 mL/hr

PPD therapeutic management

Depression responds best to a combination of psychotherapy, social support, and medication. Psychotherapy may be helpful to assist the woman to cope with changes in her life. The woman's partner and immediate family must be included in counseling sessions so they can develop an understanding of what the woman feels and needs. In one study, support from trained peers demonstrated some success (Dennis, Hodnett, Reisman, et al., 2009; Morrell, Slade, Warner, et al., 2009). However, a more recent study (Letourneau, Stewart, Dennis, et al., 2011) did not support this finding. If psychotherapy alone is not effective, it should be combined with medication. Selective serotonin reuptake inhibitors and tricyclic antidepressants are the most commonly prescribed medications. It may take up to 4 weeks for the medications to be fully effective, and they may be continued for 9 to 12 months after remission of symptoms (Beck, 2008). Whether the woman is still pregnant or is breastfeeding must be considered when any drugs are prescribed as some are safer than others for use in pregnancy and lactation. Women who discontinue medications for depression during pregnancy are more likely to have a relapse during pregnancy or postpartum (Haskett, 2011). In addition, women who have depression and do not take medication during pregnancy are more likely to have inadequate prenatal care and preterm delivery (Dossett, 2008). Electroconvulsive therapy may also be necessary for mothers who are suicidal. It is used when the woman has not improved with other treatment.

Hematoma

Hematomas occur when bleeding into loose connective tissue occurs while overlying tissue remains intact. Hematomas develop as a result of blood vessel injury in spontaneous deliveries and deliveries in which vacuum extractors or forceps are used. Hematomas may be found in vulvar, vaginal, and retroperitoneal areas. The rapid bleeding into soft tissue may cause a visible vulvar hematoma, a discolored bulging mass that is sensitive to touch. Hematomas in the vagina or retroperitoneal areas cannot be seen. Hematomas produce deep, severe, unrelieved pain and feelings of pressure that are not relieved by usual pain-relief measures. Formation of a hematoma should be suspected if the mother demonstrates systemic signs of concealed blood loss, such as tachycardia or decreasing blood pressure, when the fundus is firm and lochia is within normal limits.

Wound Care Nursing Considerations

Despite their small size, wound infections are painful and annoying to the mother. Perineal infections cause discomfort during many activities, such as walking, sitting, or defecating, and are particularly troublesome because they are not expected by the new mother. Wound infections may require readmission to the hospital or home health care visits. The woman requires reassurance and supportive care. Comfort measures include sitz baths, warm compresses, and frequent perineal care. She should be taught to wipe from front to back and to change perineal pads frequently. Good hand washing techniques are emphasized. Adequate fluid intake and a healthy diet are important. Activity may be modified depending on the site, severity, and treatment of the wound infection. The infant is not routinely isolated from the mother with a wound infection, but the woman must be advised how to protect her infant from contact with contaminated articles such as dressings. Anticipatory guidance should include teaching side effects of medications, signs of worsening condition, self-care measures, and the importance of hand washing.

Hypovolemic shock

During and after giving birth, the woman can tolerate blood loss that approaches the volume of blood added during pregnancy (approximately 1500 to 2000 mL). A woman who was anemic before birth has less reserve than a mother with normal blood values. The amount of blood lost can be estimated by comparing the hematocrit before labor and delivery with one measured after delivery. If the hematocrit is lower after delivery, the woman lost the amount of blood added during pregnancy and an additional 500 mL for each 3% drop in the hematocrit value (Cunningham et al., 2010). When blood loss is excessive, hypovolemic shock (acute peripheral circulatory failure resulting from loss of circulating blood volume) can ensue. Hypovolemia, abnormally decreased volume of circulating fluid in the body, endangers vital organs by depriving them of oxygen. The brain, heart, and kidneys are especially vulnerable to hypoxia and may suffer damage in a brief period.

Venous Stasis

During pregnancy, compression of the large vessels of the legs and pelvis by the enlarging uterus causes venous stasis. Stasis is most pronounced when the pregnant woman stands for prolonged periods of time. It results in dilated vessels that increase the potential for continued pooling of blood postpartum. Relative inactivity and activity restriction caused by complications during pregnancy lead to venous pooling and stasis of blood in the lower extremities. Prolonged time in stirrups for delivery and repair of the episiotomy also may promote venous stasis and increase the risk of thrombus formation.

early post partum hemorrhage

Early postpartum hemorrhage usually occurs during the first hour after delivery and is most often caused by uterine atony (Cunningham et al., 2010). Atony refers to lack of muscle tone that results in failure of the uterine muscle fibers to contract firmly around blood vessels when the placenta separates. Trauma to the birth canal during labor and delivery, hematomas (localized collections of blood in a space or tissue), retention of placental fragments, and abnormalities of coagulation are other causes. Hemorrhage from disseminated intravascular coagulation and placenta previa are discussed in Chapter 25. Also, placenta accreta (abnormal adherence of the placenta to the uterine wall) and inversion of the uterus

Endometritis

Etiology Endometritis is usually caused by organisms that are normal inhabitants of the vagina and cervix. Most infections are polymicrobial with both aerobic and anaerobic organisms involved. Organisms most often found include aerobic and anaerobic streptococci, Escherichia coli, Klebsiella pneumoniae, Proteus, Bacteroides, and Gardnerella. (Dickinson, 2011). Chlamydia trachomatis is not a cause of early infection but is associated with late-onset infections, 2 or more weeks after birth (Rhode, 2011). Manifestations The mother with severe endometritis looks sick. She presents a different picture from the typical happy new mother. The major signs and symptoms are temperature of 38° C (100.4° F) or higher; chills; malaise; anorexia; abdominal pain and cramping; uterine tenderness; and purulent, foul-smelling lochia. Additional signs include tachycardia and subinvolution. In most cases the signs and symptoms occur within the 36 hours after delivery (Duff et al., 2009). Laboratory data may confirm the diagnosis. The results of a complete blood count may show an elevation in the number of leukocytes (15,000/mm3 to 30,000/mm3). Leukocyte levels are normally elevated to as high as 30,000/mm3 during the early postpartum time (Blackburn, 2013), however, leukocytosis that is not decreasing should prompt further evaluation. A blood culture may be obtained. Cultures of the vagina or endometrium are not usually helpful. A catheterized urine specimen may also be obtained.

first 24 hours after birth

For the first 24 hours after childbirth, the uterus should feel like a firmly contracted ball roughly the size of a large grapefruit. It should be easily located at about the level of the umbilicus. Lochia should be dark red and scant to moderate in amount. Saturation of one peripad in 15 minutes represents an excessive blood loss (Whitmer, 2011). The nurse must realize that although bleeding may be profuse and dramatic, a constant steady trickle, dribble, or slow seeping is just as dangerous

TABLE 28-2 RISK FACTORS FOR PUERPERAL INFECTION

History of previous infections (urinary tract infection, mastitis, thrombophlebitis) May be more vulnerable to infectious process Colonization of lower genital tract by pathogenic organisms Infections usually caused by several microbes that have ascended to uterus from lower genital tract Cesarean birth Provides increased portals of entry for bacteria Trauma Provides entrance for bacteria and makes tissues more susceptible Prolonged rupture of membranes Removes barrier of amniotic membranes and allows access by organisms to interior of uterus Prolonged labor Increases number of vaginal examinations; allows time for bacteria to multiply Catheterization Could introduce organisms into bladder Excessive number of vaginal examinations Increases chance that organisms from vagina or outside source are carried into uterus Retained placental fragments Provide growth medium for bacteria and may interfere with flow of lochia Hemorrhage Results in loss of infection-fighting components of blood Poor general health (excessive fatigue, anemia, frequent minor illnesses) Increases vulnerability to infections and complications of labor Poor nutrition (decreased protein, vitamin C) Less able to repair tissue and defend against infection Poor hygiene Increases exposure to pathogens Medical conditions, such as diabetes mellitus Decreases ability to defend against infections of any kind; diabetes increases glucose level in urine Low socioeconomic status More likely to have poor nutrition and inadequate prenatal care

Therapeutic management of late post partum hemorrhage

Initial treatment for late postpartum hemorrhage is directed toward control of the excessive bleeding. Oxytocin, methylergonovine, and prostaglandins are the most commonly used pharmacologic measures. Placental fragments may be dislodged and swept out of the uterus by the bleeding, and if the bleeding subsides when oxytocin is administered, no other treatment is necessary. Sonography can identify placental fragments that remain in the uterus. If bleeding continues or recurs, dilation and curettage, stretching of the cervical os to permit suctioning or scraping of the walls of the uterus, may be necessary to remove fragments. Broad-spectrum antibiotics may be given if postpartum infection is suspected because of uterine tenderness, foul-smelling lochia, or fever.

SVT

Manifestations SVT is most often associated with varicose veins and limited to the calf area. It can also occur in the arms as a result of IV therapy. Signs and symptoms include swelling of the involved extremity as well as redness, tenderness, and warmth. It may be possible to palpate an enlarged, hardened, cordlike vein. The woman may experience pain when she walks, but some women have no signs at all. Therapeutic Management Treatment includes analgesics, rest, and elastic support. Elevation of the lower extremity improves venous return. Warm packs may be applied to the affected area. Anticoagulants are not needed but antiinflammatory medications may be used. After a period of bed rest with the leg elevated, the woman may ambulate gradually if symptoms have disappeared. She should avoid standing for long periods and should continue to wear support hose to help prevent venous stasis and a subsequent episode of superficial thrombosis. There is little chance of PE if the thrombosis remains in the superficial veins of the lower leg.

UTI

Manifestations Symptoms typically begin on the 1st or 2nd postpartum day. They include dysuria (a burning pain on urination), urgency, frequency, and suprapubic pain. Hematuria may also occur. A low-grade fever is sometimes the only sign. In some women, an upper urinary tract infection, such as pyelonephritis, may develop the 3rd or 4th postpartum day, with chills, spiking fever, costovertebral angle tenderness, flank pain, and nausea and vomiting. This infection of the kidney pelvis may result in permanent damage to the kidney if not promptly treated. Therapeutic Management Most urinary tract infections can be treated with antibiotics on an outpatient basis. Asymptomatic bacteriuria during pregnancy increases the risk of pyelonephritis 20 to 30 times. Treatment reduces the incidence of pyelonephritis significantly (Duff et al., 2009). Pyelonephritis during pregnancy may require hydration and IV administration of broad-spectrum antibiotics. In addition, the woman should be observed for signs of preterm labor. If the postpartum woman is only mildly ill, she can be treated with oral antibiotics at home. Urinary analgesics, such as phenazopyridine (Pyridium), may also be ordered. Antibiotics that are safe for use during lactation are given if the mother is breastfeeding.

Mastitis

Mastitis, an infection of the breast, occurs most often 2 to 4 weeks after childbirth, although it may develop at any time during breastfeeding. Approximately 5% to 10% of lactating women are affected (Duff et al., 2009). It usually affects only one breast. Etiology Mastitis is often caused by Staphylococcus aureus, E. coli, and Streptococci (Ambrose & Repke, 2011). The bacteria are most often carried on the skin of the mother or in the mouth or nose of the newborn. The organism may enter through an injured area of the nipple, such as a crack or blister, although no obvious signs of injury may be apparent. Soreness and pain of a nipple may result in insufficient emptying of the breast during breastfeeding. Engorgement and stasis of milk may precede mastitis. This may occur when a feeding is skipped, when the infant begins to sleep through the night, or when breastfeeding is suddenly stopped. Constriction of the breasts by a bra that is too tight may interfere with emptying of all the ducts and may lead to infection. The mother who is fatigued or stressed or who has other health problems that might lower her immune system is also at increased risk for mastitis.

Nursing Considerations for PE

Monitoring for Signs When caring for a woman with DVT, nurses must be aware of the danger of PE and focus the assessment for early signs and symptoms. This includes frequent assessment of respiratory rate as well as thorough and frequent auscultation of breath sounds. Abnormalities, such as diminished or unequal breath sounds, or coughing should be reported immediately to the health care provider. Additional signs that require immediate attention include air hunger, dyspnea, tachycardia, pallor, and cyanosis. Facilitating Oxygenation Oxygen should be administered at 8 to 10 L/min by tight face mask. The nurse should remain with the mother to allay fear and apprehension. The head of the bed should be raised to facilitate breathing. Narcotic analgesics, such as morphine, may be used to relieve pain. Sedatives may be given to help control anxiety. Seeking Assistance The woman's condition is precarious until the clot is lysed or until it adheres to the pulmonary artery wall and is reabsorbed. The primary nurse should call for assistance to initiate interventions. These include continuous assessment of vital signs and administration of IV heparin and emergency drugs that may be needed. The woman who has PE requires critical care nursing skills and is usually transferred to an intensive care unit.

Postpartum mood disorders

Mood disorders are disturbances in function, affect, or thought processes that can affect the family after childbirth as severely as physiologic problems. Postpartum blues ("baby blues") is a transient, self-limiting mood disorder (discussed in Chapter 20). Postpartum depression (PPD), postpartum psychosis and bipolar disorder are more serious disorders that disrupt the family and require intervention.

Therapeutic Management

Nurses are with the mother during the hours after childbirth and are responsible for assessments and initial management of uterine atony. If the uterus is not firmly contracted, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. One hand is placed just above the symphysis pubis to support the lower uterine segment while the other hand gently but firmly massages the fundus in a circular motion. Figure 28-2 illustrates fundal massage. Clots that may have accumulated in the uterine cavity interfere with the ability of the uterus to contract effectively. They are expressed by applying firm but gentle pressure on the fundus in the direction of the vagina. It is critical that the uterus is contracted firmly before attempting to express clots. Pushing on a uterus that is not contracted could invert the uterus and cause massive hemorrhage and rapid shock (see Chapter 27). If the uterus does not remain contracted as a result of uterine massage, or if the fundus is displaced, the problem may be a distended bladder. A full bladder lifts the uterus, moving it up and to the side, preventing effective contraction of the uterine muscles. Assist the mother to urinate, or catheterize her to correct uterine atony caused by bladder distention. Note urine output then reassess the uterus. Pharmacologic measures also may be necessary to maintain firm contraction of the uterus. A rapid intravenous (IV) infusion of dilute oxytocin (Pitocin) often increases uterine tone and controls bleeding (see Drug Guide: Oxytocin, p. 417). Methylergonovine (Methergine) may be given intramuscularly (IM), but it elevates blood pressure and should not be given to a woman who is hypertensive. The usual route of administration is IM; IV use is reserved for life-threatening emergencies only (see Drug Guide: Methylergonovine). Analogs of prostaglandin F2-alpha (PGF2α; carboprost tromethamine [Hemabate; Prostin/15M]) are very effective when given IM or into the uterine muscle if oxytocin is ineffective in controlling uterine atony (Kim, Hayashi, & Gambone, 2010). (See Drug Guide: Carboprost Tromethamine.) Prostaglandin E2 (dinoprostone [Prostin E2]) or misoprostol (Cytotec) given rectally may also be used to control bleeding. If uterine massage and pharmacologic measures are ineffective in stopping uterine bleeding, the physician or nurse-midwife may use bimanual compression of the uterus. In this procedure, one hand is inserted into the vagina, and the other compresses the uterus through the abdominal wall (Figure 28-3). A balloon may be inserted into the uterus to apply pressure against the uterine surface to stop bleeding (Belfort & Dildy, 2011; Thorp, 2009). Uterine packing may also be used. It may be necessary to return the woman to the delivery area for exploration of the uterine cavity and removal of placental fragments that interfere with uterine contraction. A laparotomy may be necessary to identify the source of the bleeding. Uterine compression sutures may be placed to stop severe bleeding. Ligation of the uterine or hypogastric artery or embolization (occlusion) of pelvic arteries may be required if other measures are not effective. Hysterectomy is a last resort to save the life of a woman with uncontrollable postpartum hemorrhage. Hemorrhage requires prompt replacement of intravascular fluid volume. Lactated Ringer's solution, whole blood, packed red blood cells, normal saline, or other plasma extenders are used. Enough fluid should be given to maintain a urine flow of at least 30 mL/hour and preferably 60 mL/hour (Cunningham et al., 2010). Typically, the nurse is responsible for obtaining properly typed and cross-matched blood and inserting large-bore IV lines that are capable of carrying whole blood.

pathophys of PE

PE is a serious complication of DVT and a leading cause of maternal mortality. As many as 15% to 25% of DVTs will lead to PE if not recognized and treated (Martin & Foley, 2008). PE occurs when fragments of a blood clot dislodge and are carried to the lungs. An embolus can also consist of amniotic fluid and its debris, a condition called anaphylactoid syndrome (see Chapter 27). The embolus lodges in a vessel and partially or completely obstructs the flow of blood into the lungs. If pulmonary circulation is severely compromised, death may occur within a few minutes. If the embolus is small, adequate pulmonary circulation may be maintained until treatment can be initiated.

PPD

PPD is a period of depression that begins after childbirth and lasts at least 2 weeks. It includes depressed mood or loss of interest in almost all activities. It also includes at least four of the following: changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; or recurrent thoughts of death or plans or attempts of suicide PPD is the most common complication of childbirth, affecting 10% to 15% of postpartum women (Stuart, 2009). Women of all ethnic groups and educational levels are affected. PPD is underdiagnosed and underreported (Goodman & Tyer-Viola, 2010). It usually develops during the first 3 months but may occur at any time during the first year postpartum.

Assessment of woman with infectioon

Pay particular attention to signs that may be expected in infection, such as fever, tachycardia, pain, or unusual amount, color, or odor of lochia. Generalized symptoms of malaise and muscle aching may also be significant. Examine all wounds each shift for signs of localized infection, such as redness, edema, tenderness, discharge, or pulling apart of incisions or sutured lacerations. Ask the mother if she has difficulty emptying her bladder or discomfort related to urination. Assess the mother's knowledge of hygiene practices that prevent infections, such as proper handwashing, perineal care, and handling of perineal pads. Evaluate her knowledge of breastfeeding and any problems that might result in breast engorgement and stasis of milk in the ducts. Examine the nipples for signs of injury that might provide a portal of entry for organisms.

initial postpartum assessment

The initial postpartum assessment includes a chart review to determine whether prolonged labor, birth of a large infant, use of vacuum extractor or forceps, or other risk factors for hemorrhage are present. This alerts the nurse to women at increased risk for hemorrhage.

postpartum anxiety disorders

Postpartum anxiety disorders include panic disorder, postpartum obsessive-compulsive disorder (OCD), and posttraumatic stress disorder. Panic disorder manifests as episodes of tachycardia, palpations, shortness of breath, chest pain, and fear of dying or of "going crazy." Episodes are repetitive and interfere with the woman's daily life. Antianxiety and antidepressant medications and counseling are the treatment for this condition. Postpartum OCD is a condition where the woman has consuming thoughts that she might harm the baby and fears being alone with the baby. Anxiety and depression occur, and the woman may perform compulsive behaviors to avoid acting on her thoughts. Some mothers avoid their infants while others obsessively check on the infants frequently day and night (O'Hara & Segre, 2008). Treatment includes antianxiety and antidepressant medications and counseling. In posttraumatic stress disorder, women perceive childbirth as a traumatic event. They have nightmares and flashbacks about the event, anxiety, and avoidance of reminders of the traumatic event; some have depression after giving birth. Feeling a lack of caring or communication or having a birth very different from what they expected may contribute to this disorder. Women need to talk about their experiences and how they perceived them and often search for answers about their experiences. They may feel isolated from their infants and have prolonged difficulty feeling close to them. Celebrating the child's birthdays may be distressing as they are anniversaries of the trauma experienced when the child was born

Hypercoagulation

Pregnancy is characterized by changes in the coagulation and fibrinolytic systems that persist into the postpartum period. During pregnancy, the levels of many coagulation factors are elevated. In addition, the fibrinolytic system, which causes clots to disintegrate (lyse), is suppressed. The result is that factors that promote clot formation are increased, and factors that prevent clot formation are decreased to prevent maternal hemorrhage, resulting in a higher risk for thrombus formation during pregnancy and the postpartum period.

Chart Review

Presence of predisposing factors Perform more frequent evaluations.

Uterine atony assesments

Priority assessments for uterine atony include the fundus, bladder, lochia, vital signs, skin temperature, and color. Assess the consistency and the location of the uterine fundus. The fundus should be firmly contracted, at or near the level of the umbilicus and midline. If the fundus is above the level of the umbilicus and displaced, a full bladder may be the cause of excessive bleeding. A full bladder lifts the uterus and impedes contraction, which allows excessive bleeding. An accumulation of clots also expands the uterus, making contraction difficult and resulting in continued bleeding. (See Procedure: Assessing the Uterine Fundus in Chapter 20 on p. 442 for assessing the fundus.) Obese women have an increased risk for uterine atony with subsequent postpartum hemorrhage (Blomberg, 2011), however, assessment of the fundus is difficult in this population. Monitor these women frequently for other signs of uterine atony and attempt to assess the uterine fundus while watching for increased lochia flow or clots to be expelled. Also remember to check under the woman's legs, buttocks, and back for lochia drainage by asking the woman to turn on her side. This allows visibility of any blood that may not be obvious from the front. Although bleeding may be profuse and dramatic, a continuing small but steady trickle or oozing may also lead to significant blood loss that becomes increasingly life threatening. It is difficult to estimate the volume of lochia by visual examination of peripads. More accurate information is obtained by weighing peripads, linen savers, and, if necessary, bed linens, before and after use and subtracting the difference. One gram (weight) equals approximately 1 mL (volume). Measure vital signs at least every 15 minutes or more often, if necessary. Apply a pulse oximeter to determine oxygen saturation levels. This helps to detect trends, such as tachycardia or a decrease in pulse pressure that may reveal a deteriorating status in a woman with significant blood loss. Initially, the body compensates for excessive bleeding by constricting the peripheral blood vessels and shunting blood to vital organs. This can be misleading because the vital signs may remain normal even when the woman is becoming hypovolemic. The skin should be warm and dry, mucous membranes of the lips and mouth should be pink, and capillary return should occur within 3 seconds when the nails are blanched. These signs confirm adequate circulating volume to perfuse the peripheral tissue.

antidote for anticoagulants

Protamine sulfate, which is the antidote for UH and is partially effective against LMWH, should be available. The antidote for warfarin is vitamin K.

Postpartum pychosis

Psychosis is a mental state in which a person's ability to recognize reality, communicate, and relate to others is impaired. Postpartum psychosis can be classified as depressed or manic types (Stuart, 2009). It is a rare condition that affects 1 or 2 women per 1000 births. It can occur as early as 2 days after delivery and is a psychiatric emergency that usually requires hospitalization. Manifestations include agitation, irritability, rapidly shifting moods, disorientation, and disorganized behavior. Some mothers also have delusions about the baby and may experience hallucinations (Miller, 2011). The majority of women with postpartum psychosis have no significant history of psychiatric illness (O'Hara & Segre, 2008). Women who have had one episode of postpartum psychosis are at risk for having another episode. Management requires hospitalization, pharmacologic treatment, and psychiatric care (Cunningham et al., 2010). Assessment and management of postpartum psychosis are beyond the scope of maternity nurses, and mothers who experience this condition must be referred to specialists for comprehensive therapy. Women with signs of postpartum psychosis need immediate medical attention, and hospitalization is usually necessary to prevent suicide or infanticide.

pathophysiology of hypovolemic shock

Recognition of hypovolemic shock may be delayed because the body activates compensatory mechanisms that mask the severity of the problem. Carotid and aortic baroreceptors are stimulated to constrict peripheral blood vessels. This shunts blood to the central circulation and away from less essential organs, such as the skin and extremities. The skin becomes pale and cold, but cardiac output and perfusion of vital organs are maintained. In addition, the adrenal glands release catecholamines, which compensate for decreased blood volume by promoting vasoconstriction in nonessential organs, increasing the heart rate, and raising the blood pressure. As a result, blood pressure remains normal initially, although a decrease in pulse pressure (difference between systolic and diastolic blood pressures) may be noted. The tachycardia that develops is an early sign of compensation for excessive blood loss. As shock worsens, the compensatory mechanisms fail, and physiologic insults spiral. Inadequate organ perfusion and decreased cellular oxygen for metabolism result in a buildup of lactic acid and the development of metabolic acidosis. Decreased serum pH (acidosis) results in vasodilation, which further increases bleeding. Eventually, circulating volume becomes insufficient to perfuse cardiac and brain tissue. Cellular death occurs as a result of anoxia, and the mother dies.

Nursing Diagnosis rt thrombus

Risk for Bleeding related to lack of understanding of anticoagulant therapy precautions.

Septic pelvic thrombophlebitis

Septic pelvic thrombophlebitis is the least common of the puerperal infections, occurring in 1 of 3000 pregnancies (Ambrose & Repke, 2011). It usually is not seen until 2 to 4 days after childbirth. It occurs when infection spreads along the venous system and thrombophlebitis develops. Manifestations The primary symptom is pain in the groin, abdomen, or flank. Spiking fever, tachycardia, gastrointestinal distress and decreased bowel sounds may be present. The only sign may be fever that does not respond to antibiotic therapy. Laboratory data may be used to exclude other diagnoses and usually include complete blood count with differential, blood chemistries, coagulation studies, and cultures. Pelvic ultrasound, computed tomography, or MRI may be performed. Therapeutic Management Readmission to the hospital is usually necessary. Primary treatment includes anticoagulation therapy with IV heparin and IV antibiotics. Warfarin may be given when heparin is discontinued. Supportive care is similar to that for DVT and includes monitoring for safe levels of anticoagulation therapy and for signs and symptoms of PE.

Comfort level

Severe pelvic or rectal pain Assess for signs of hematoma, usually perineal or vaginal; examine vulva for masses or discoloration; report findings.

DVT

Signs and symptoms of DVT or PE are absent in 75% of those affected (Lockwood, 2009). When present, they may be attributed to normal benign changes of pregnancy (Farquharson & Greaves, 2011). Those that occur are caused by an inflammatory process and obstruction of venous return. The woman may report pain in the leg, groin, or lower back or right lower quadrant pain (Rhode, 2011). Swelling of the leg (more than 2 cm larger than the opposite leg), erythema, heat, and tenderness over the affected area are the most common signs. A positive Homans sign (presence of leg pain when the foot is dorsiflexed) has been thought to be an indicator of DVT. However, Homans sign may be absent in women who have a venous thrombosis or may be caused by a strained muscle or bruise. It is not a reliable or valid test. Reflex arterial spasms may cause the leg to become pale and cool to the touch with decreased peripheral pulses. Additional symptoms may include pain on ambulation, chills, general malaise, and stiffness of the affected leg.

Fundus

Soft, boggy, displaced Massage, express clots, and assist to void or catheterize; notify primary health care provider if measures are ineffective.

subinvolution of the uterus

Subinvolution refers to a slower-than-expected return of the uterus to its nonpregnant size after childbirth. Normally the uterus descends at the rate of approximately 1 cm or one fingerbreadth per day. By 14 days, it is no longer palpable above the symphysis pubis. The endometrial lining has sloughed off as part of the lochia, and the site of placental attachment is well healed by 6 weeks after childbirth if involution progresses as expected. The most common causes of subinvolution are retained placental fragments and pelvic infection. Signs of subinvolution include prolonged discharge of lochia, irregular or excessive uterine bleeding, and sometimes profuse hemorrhage. Pelvic pain or feelings of pelvic heaviness, backache, fatigue, and persistent malaise are reported by many women. On bimanual examination, the uterus feels larger and softer than normal for that time of the puerperium.

vital signs

Tachycardia, decreasing pulse pressure, falling blood pressure, decreasing oxygen saturation level Report signs of excessive blood loss.

definition of puerperal infection

The definition of puerperal infection is a temperature of 38° C (100.4° F) or higher after the first 24 hours and occurring on at least 2 of the first 10 days following childbirth. Although a slight elevation of temperature may occur during the first 24 hours because of dehydration or the exertion of labor, any mother with fever should be assessed for other signs of infection.

preventing hemorrhage

The key to successful management of early postpartum hemorrhage is early recognition and response. All postpartum women are at risk for hemorrhage. However, always be aware of factors that increase this risk further and be particularly vigilant in monitoring these women so that excessive bleeding can be anticipated and minimized. When predisposing factors are present, initiate frequent assessments. Many hospitals and birth centers have a standard of care that calls for assessments every 15 minutes during the first hour after delivery, every 30 minutes for the next 2 hours, and hourly for the next 4 hours. This plan may not be adequate for the woman at known risk for postpartum hemorrhage because bleeding occurs rapidly. A delay in assessment could result in a great deal of blood loss.

subsquent treatment for thrombus prevention

The long-term management of DVT depends on whether the woman is pregnant or in the postpartum period. The pregnant woman with a DVT receives anticoagulation therapy until labor begins. It is resumed 6 to 12 hours after birth and continued for 6 weeks to 6 months after birth (ACOG, 2011). Warfarin (Coumadin) is contraindicated during pregnancy because of teratogenic effects and the risk of fetal hemorrhage. Therefore, pregnant women are given UH or LMWH, which do not cross the placenta. During the postpartum period, warfarin is started before heparin is stopped to provide continuous anticoagulation. Heparin is discontinued when the international normalized ratio (INR) has been at therapeutic levels for 2 days. Warfarin therapy is continued for at least 6 weeks postpartum (Ambrose & Repke, 2011). Warfarin is safe for use during lactation. Longer use of warfarin is necessary in some women with continuing risk factors. The INR is used to monitor coagulation time when warfarin is used. Before discharge from the birth facility, the mother should be taught about lifestyle changes that can improve peripheral circulation. This includes avoiding clothing that is constricting around the legs and prolonged sitting. If sitting for long periods is necessary, walking for a short time hourly or moving her feet and legs frequently will help prevent circulatory stasis.

late post partum hemorrhage

The most common causes of late postpartum hemorrhage are subinvolution (delayed return of the uterus to its nonpregnant size and consistency) and fragments of placenta that remain attached to the myometrium when the placenta is delivered. Clots form around the retained fragments, and excessive bleeding can occur when the clots slough away several days after delivery. Infection of the uterus may also be a cause. Subinvolution is discussed on p. 673. Late postpartum hemorrhage caused by retained placental fragments is generally preventable. When the placenta is delivered, the nurse-midwife or physician carefully inspects it to determine whether it is intact. If a portion of the placenta is missing, the health care provider manually explores the uterus, locates the missing fragments, and removes them. Late postpartum hemorrhage, also called secondary postpartum hemorrhage, is defined as hemorrhage occurring between 24 hours and 6 weeks after birth (Ambrose & Repke, 2011). It frequently happens after discharge from the facility and can be dangerous for the unsuspecting mother. (Women must be taught how to assess the fundus and normal characteristics and duration of lochia flow. They should be instructed to notify their health care provider if bleeding persists or becomes unusually heavy.)

Nursing consideration rt subinvolution

The mother is taught how to locate and palpate the fundus and how to estimate fundal height in relation to the umbilicus. The uterus should become smaller each day (by approximately one fingerbreadth). Also, explain the progressive changes from lochia rubra, to lochia serosa, and then to lochia alba (see Chapter 20). The mother is instructed to report any deviation from the expected pattern or duration of lochia. A foul odor often indicates uterine infection, for which treatment is necessary. Additional signs include pelvic or fundal pain, backache, and feelings of pelvic pressure or fullness. The mother should be able to verbalize the warning signs prior to leaving the facility.

Trauma

Trauma to the birth canal is the second most common cause of early postpartum hemorrhage. Trauma includes vaginal, cervical, or perineal lacerations as well as hematomas. Predisposing Factors Many of the same factors that increase the risk of uterine atony increase the risk of soft tissue trauma during childbirth. For example, trauma to the birth canal is more likely to occur if the infant is large or if labor and delivery occur rapidly. Induction and augmentation of labor and use of assistive devices, such as a vacuum extractor, increase the risk of tissue trauma.

lacerations

The perineum, vagina, cervix, and the area around the urethral meatus are the most common sites for lacerations. Small cervical lacerations occur frequently and generally do not require repairs. Lacerations of the vagina, perineum, and periurethral area usually occur during the second stage of labor, when the fetal head descends rapidly or when assistive devices such as a vacuum extractor or forceps are used to assist in delivery of the fetal head. Lacerations of the birth canal should always be suspected if excessive uterine bleeding continues when the fundus is contracted firmly and is at the expected location. Bleeding from lacerations of the genital tract often is bright red, in contrast to the darker red color of lochia. Bleeding may be heavy or may appear to be minor with a steady trickle (dribble or oozing) of blood that continues.

Therapeutic management of subinvolution

Treatment is tailored to correct the cause of subinvolution. Methylergonovine maleate (Methergine) given orally provides long, sustained contraction of the uterus. Infection responds to antimicrobial therapy.

Affective disorders

The postpartum period is a time of change and adjustment for the mother and the family. Postpartum women have an increased risk for mood disorders (blues, depression and psychoses, and rarely, bipolar disorders) and for anxiety disorders (obsessive-compulsive disorder, generalized anxiety disorder, panic disorder). The American Psychiatric Association considers an onset of a mental disorder during the peripartum or postpartum period a subset of the disorder, not a separate condition

Nursing considerations for UTI

The woman with a urinary tract infection must be instructed to take the medication for the entire time it is prescribed and not to stop when symptoms abate. In addition, she must drink at least 2500 to 3000 mL of fluid each day to help dilute the bacterial count and flush the infection from the bladder. Acidification of the urine inhibits multiplication of bacteria, and drinks that acidify urine, such as apricot, plum, prune, and cranberry juices, are frequently recommended. Grapefruit and carbonated drinks should be avoided because they increase urine alkalinity. Teaching should also include measures to prevent urinary tract infections, such as using proper perineal care, increasing fluid intake, and urinating frequently.

Nursing Considerations for endo

The woman with endometritis should be placed in a Fowler's position to promote drainage of lochia. She should be medicated as needed for abdominal pain or cramping, which may be severe. Monitor the woman's response to treatment and note signs of improvement or of continued infection (nausea and vomiting, abdominal distention, absent bowel sounds, and severe abdominal pain). Assess vital signs every 2 hours while fever is present and every 4 hours afterward. Comfort measures include warm blankets, cool compresses, cold or warm drinks, or use of a heating pad. Foods high in vitamin C and protein to aid healing are encouraged along with oral fluids to maintain hydration. Teaching should include signs and symptoms of worsening condition, side effects of therapy, and the importance of adhering to the treatment plan and follow-up care. If the woman is so sick that she must be separated from her infant or her infant is discharged before the mother, a nursing diagnosis of "Risk for Impaired Attachment related to separation from infant" should be considered. If the mother is breastfeeding, she will need help to pump her breasts to establish and maintain lactation.

Therapeutic Management of trauma

Therapeutic Management When postpartum hemorrhage is caused by trauma of the birth canal, surgical repair is often necessary. Visualizing lacerations of the vagina or cervix is difficult, and it is necessary to return the mother to the delivery area, where surgical lights are available. She is placed in a lithotomy position and carefully draped. Surgical asepsis is required while the laceration is being visualized and repaired. Small hematomas usually reabsorb naturally. Large hematomas may require incision, evacuation of the clots, and location of the bleeding vessel so that it can be ligated.

Incidence and Etiology of thromboembolic disorders

Thromboembolic disorders are the leading cause of maternal mortality in the United States (Rhode, 2011). Thrombi can form whenever the flow of blood is impeded. Once started, the thrombus can enlarge with successive layering of platelets, fibrin, and blood cells as the blood flows past the clot. Thrombus formation is often associated with thrombophlebitis. The three major causes of thrombosis are venous stasis, hypercoagulable blood, and injury to the endothelial surface (the innermost layer) of the blood vessel. Two of these conditions—venous stasis and hypercoagulable blood—are present in all pregnancies, and the third, blood vessel injury, is likely to occur during birth.

Therapeutic Management of PE

Treatment of PE is aimed at dissolving the clot and maintaining pulmonary circulation. Oxygen is used to decrease hypoxia, and narcotic analgesics are given to reduce pain and apprehension. Bed rest with the head of the bed elevated is used to help reduce dyspnea. The level of care, including support of ventilation, depends on the woman's pulmonary status. Pulse oximetry and arterial blood gases are evaluated. Heparin therapy is initiated and is continued throughout pregnancy if the embolism occurs prior to birth. Therapy may be continued with warfarin for months after delivery to prevent further emboli. Emergency medications, such as dopamine, may be used to support falling blood pressure. Thrombolytic drugs, such as streptokinase, urokinase, or tissue-type plasminogen activator, may be used for life-threatening pulmonary emboli but are associated with bleeding (Martin & Foley, 2008). Embolectomy (surgical removal of the embolus) may be attempted if no time exists to allow the clot to dissolve.

Preventing thrombus formation

Women who have had a previous DVT or PE are at risk for another. These women and others at high risk may receive prophylactic heparin, which does not cross the placenta. Either standard unfractionated heparin (UH) or a low-molecular-weight heparin (LMWH), such as enoxaparin (Lovenox) or tinzaparin (Innohep), may be used. LMWH is longer acting and can be given less frequently and with less laboratory testing. It has fewer side effects and is less likely to cause bleeding. However, it is more expensive than UH and must be given subcutaneously. UH is given IV or subcutaneously. Women receiving LMWH during pregnancy are changed to UH at approximately 36 weeks of gestation. The change is necessary because UH has a shorter half-life, and epidural anesthesia, which may be needed in labor, is contraindicated within 24 hours of the last dose of LMWH. Heparin is discontinued during labor and birth and resumed approximately 6 to 12 hours after uncomplicated birth and 12 hours after the epidural catheter is removed (American College of Obstetricians and Gynecologists [ACOG], 2011). If stirrups must be used during the birth, risks of thrombus development can be reduced by placing the woman's legs in stirrups that are padded to prevent prolonged pressure against the popliteal angle during the second stage of labor. If possible, the time in stirrups should be no more than 1 hour. To prevent thrombus formation after childbirth, all new mothers are encouraged to ambulate frequently and as early as possible. Ambulation prevents stasis of blood in the legs and decreases the likelihood of thrombus formation. If the woman is unable to ambulate, range-of-motion and gentle leg exercises, such as flexing and straightening the knee and raising one leg at a time, should begin within 8 hours after childbirth. In addition, the mother should not use pillows under her knees or the knee gatch on the bed. These devices may cause sharp flexion at the knees and pressure against the popliteal space, leading to pooling of blood in the lower extremities. Graduated compression stockings or sequential compression devices are used for mothers with varicose veins, a history of thrombosis, or a cesarean birth. Sequential compression devices should be applied preoperatively for a woman undergoing a cesarean birth who is not on anticoagulant therapy and should be continued until she begins to ambulate postpartum (ACOG, 2011). Compression stockings should be applied before the mother gets out of bed to prevent venous congestion, which begins as soon as she stands. It is important that she understands the correct way to put on the stockings. Improperly applied stockings can roll or bunch and slow venous return from the legs.

Bipolar II Disorder

Women with bipolar disorder suffer from periods of irritability, hyperactivity, euphoria, and grandiosity. They exhibit little need for sleep and are seldom aware they have a problem. The poor judgment and confusion they experience make self-care and infant care impossible and can be life-threatening for the mother and infant. The depressions of the bipolar disorder and major depression are similar and are characterized by tearfulness, preoccupations of guilt, feelings of worthlessness, sleep and appetite disturbances, and an inordinate concern with the baby's health. Delusions about the infant being dead or defective are common. Hallucinations may also be present. Women who have depressive symptoms must be assessed for risk of suicide or harming the infant and treated according to the severity of the threat.

Additional risk factors for thrombus

Women with varicose veins, obesity, a history of thrombophlebitis, and smoking are at additional risk for thromboembolic disease (Box 28-2). Age older than 35 years doubles the risk

Wound Care

Wound infections are common types of puerperal infection because any break in the skin or mucous membrane provides a portal of entry for organisms. The most common sites are cesarean surgical incisions, episiotomies, and lacerations. Infection of the incision occurs along with endometritis in 3% to 5% of women after cesarean (Duff et al., 2009). Risk factors include obesity, diabetes, hemorrhage, anemia, chorioamnionitis, corticosteroid therapy, and multiple vaginal examinations. Manifestations Signs of wound infection are edema, warmth, redness, tenderness, and pain. The edges of the wound may pull apart, and seropurulent drainage may be present. If the wound remains untreated, generalized signs of infection, such as fever and malaise, may develop as well. As with other puerperal infections, cultures may reveal mixed aerobic and anaerobic bacteria. Necrotizing fasciitis is a rare infection that may occur at any incision site. The necrosis may spread, and the condition may be fatal. Therapeutic Management An incision and drainage of the affected area may be necessary. The wound exudate is cultured and broad-spectrum antibiotics are ordered until a report of the organism is returned. Analgesics are often necessary, and warm compresses or sitz baths may be used to provide comfort and to promote healing by increasing circulation to the area. Surgical debridement is performed for necrotizing fasciitis.

SAFETY ALERT: Signs of Postpartum Hemorrhage

• A uterus that does not contract, or does not remain contracted • Large gush or slow, steady trickle, ooze, or dribble of blood from the vagina • Saturation of one peripad per 15 minutes • Severe, unrelieved perineal or rectal pain • Tachycardia

SAFETY ALERT: Signs and Symptoms of Postpartum Depression

• Feelings of sadness, crying • Loss of pleasure in usual activities • Anxiety, agitation or irritability • Feelings of guilt • Fatigue, sleep disturbances • Difficulty concentrating or making decisions • Depression (may not be present at first) • Suicidal thoughts

SAFETY ALERT: Signs and Symptoms of Postpartum Infection

• Fever, chills • Pain or redness of wounds • Purulent wound drainage or wound edges not approximated • Tachycardia • Uterine subinvolution • Abnormal duration of lochia, foul odor • Elevated white blood cell count • Frequency or urgency of urination, dysuria, or hematuria • Suprapubic pain • Localized area of warmth, redness, or tenderness in the breasts • Body aches, general malaise

BOX 28-2 FACTORS THAT INCREASE THE RISK OF THROMBOSIS

• Inactivity • Prolonged bed rest • Obesity • Cesarean birth • Sepsis • Smoking • History of previous thrombosis • Varicose veins • Diabetes mellitus • Trauma • Prolonged labor • Prolonged time in stirrups in second stage of labor • Maternal age older than 35 years • Increased parity • Dehydration • First-degree relative with thrombosis • Use of forceps • Antiphospholipid antibody syndrome • Inherited thrombophilias • Air travel

Major signs of uterine atony

•A uterine fundus that is difficult to locate •A soft or "boggy" feel when the fundus is located •A uterus that becomes firm as it is massaged but loses its tone when massage is stopped •A fundus that is located above the expected level •Excessive lochia, especially if it is bright red •Excessive clots expelled

BOX 28-1 COMMON PREDISPOSING FACTORS FOR POSTPARTUM HEMORRHAGE

•Overdistention of the uterus (multiple gestation, large infant, hydramnios) •Multiparity (five or more) •Precipitate labor or delivery •Prolonged labor •Use of forceps or vacuum extractor •Cesarean birth •Manual removal of the placenta •Uterine inversion •Placenta previa, placenta accreta, or low implantation •Drugs: oxytocin, prostaglandins, tocolytics, or magnesium sulfate •General anesthesia •Chorioamnionitis •Clotting disorders •Previous postpartum hemorrhage or uterine surgery •Disseminated intravascular coagulation •Uterine leiomyomas (fibroids)