Maternity Chapter 25

Therapeutic Management (femoral thrombophlebitis)

Treatment consists of the administration of anticoagulants, the application of moist heat (to decrease inflammation), and bed rest with the affected leg elevated. A bed cradle over the leg can lift the pressure of the bedclothes off the affected leg and can both decrease the sensitivity of the leg and improve circulation. Assess the woman for risk of a pressure ulcer and provide good back, buttocks, and heel care for as long as she is on bed rest. Although simple in theory, application of moist compresses is, unfortunately, one of the most technically difficult treatments to carry out because dressings invariably dry or become cold and dampen bed clothes after only a short time. Compresses and water used in this way do not have to be sterile because with thrombophlebitis, there is no break in the skin. Because of edema in the area, be certain to test water temperature by dipping your inner wrist into it before soaking a dressing to be sure it is not so warm it could cause a burn. Cover wet, warm dressings with a plastic pad to hold in heat and moisture. In addition, position a commercial pad with circulating heating coils or chemical hot packs over the plastic to ensure soaks stay warm. Be certain the weight of a hot pack or pad does not rest on the leg, causing an obstruction to flow of blood. Never massage the skin over the clotted area because this could loosen the clot, causing a pulmonary or cerebral embolism. Check the woman's bed frequently to be certain the mattress does not become wet from seeping water. For compresses to stay in place, a woman must lay with her leg fairly immobile. However, be certain she does not interpret this as meaning she cannot turn or move about. Help her select activities to exercise the other parts of her body or stimulate her mind such as reading a good book or information on newborn care. Women who have been discharged from the hospital may be cared for at home on bed rest or may need to return to the hospital so strict bed rest can be enforced. If infection was the underlying cause of the condition, an antibiotic to treat the initial infection will be prescribed. In order to prevent further blood clotting, an anticoagulant such as unfractionated heparin (given IV) or low-molecular-weight heparin (given subcutaneously) will be prescribed. Thrombolytics (medications that dissolve clots) may also be prescribed; these should be initiated within the first 24 hours for best results. With the use of anticoagulants, a blood coagulation study will be necessary to establish a baseline value followed by sequential tests to determine the effectiveness of the drug therapy. Heparin therapy is usually continued until symptoms resolve and the international normalized ratio (INR) is >2 for at least 24 hours (Box 25.7). Be certain that protamine sulfate, the antagonist for heparin, and vitamin K, the antagonist for warfarin, are both readily available until the woman's anticoagulation therapy is stabilized. Following this initial treatment with heparin, a woman will be discharged on subcutaneous heparin or oral anticoagulation therapy such as warfarin (Coumadin). If she will be doing her own subcutaneous injections at home, be certain she demonstrates good injection technique before discharge, is aware of complications associated with anticoagulant therapy, and understands the importance of required blood work so she schedules these appropriately. The woman can continue to breastfeed while receiving heparin. She has to discontinue breastfeeding during therapy with warfarin (Coumadin) because warfarin-derived anticoagulants are passed in breast milk. If the thrombophlebitis does not seem to be severe and the woman wants to restart breastfeeding after the course of warfarin (Coumadin) (about 10 days), encourage her to manually express breast milk at the time of normal feedings so she maintains a good milk supply. Lochia usually increases in amount in a woman who is receiving an anticoagulant. Be sure to keep a meaningful record of the amount of this discharge, so that it can be estimated; "lochia serosa with scattered pinpoint clots; three perineal pads saturated in 8 hours," for example, is far more meaningful than "large amount of lochia." Also assess for other possible signs of bleeding, such as bleeding gums, ecchymotic spots on the skin, or oozing from an episiotomy suture line. With proper treatment, the acute symptoms of femoral thrombophlebitis last only a few days, but the full course of the disease takes 4 to 6 weeks before it is fully resolved. Anticoagulant therapy may need to be continued for as long as 3 to 6 months. The affected leg may never return to its former size and may always cause discomfort after long periods of standing.

UTERINE INVERSION

Uterine inversion is a prolapse of the fundus of the uterus through the cervix so that the uterus turns inside out. This usually occurs immediately after birth

FOR A WOMAN EXPERIENCING A POSTPARTUM COMPLICATION (the nursing process)

assessment nursing diagnosis outcome identification and planning implementation outcome evaluation

ASSESSING THE POSTPARTAL WOMAN WITH COMPLICATIONS

-elevated temp -pallor -pain and swelling -relaxed uterus -uterine hemorrhage -abdominal pain -pain of symphysis pubis on walking -lochia with foul odor -feeling of extreme sadness or unreality -thready, rapid, weak pulse -decreased blood pressure -perineal pain -pain and tenderness in calf of leg -positive homans sign

PREVENTING THROMBOPHLEBITIS

Ask your primary care provider if you can use a side-lying or back-lying (supine recumbent) position for birth rather than a lithotomy position because a lithotomy position can increase the tendency for pooling of blood in the lower extremities. If you will be using a lithotomy position, ask for padding on the stirrups to prevent pressure on the calf of your legs. Drink adequate fluids to be certain you're not dehydrated (6 to 8 glasses of fluid per day). Do not sit with your knees crossed or bent sharply and avoid wearing constricting clothing such as knee-high stockings. Ambulate as soon after birth as possible because walking is the best preventive measure. When resting in bed, wiggle your toes or do leg lifts to improve venous return. Ask your primary care provider if he or she recommends support stockings in the immediate postpartal period. Be certain to put these on before ambulating in the morning before leg veins fill.

Urinary System Disorders

Because a woman's bladder is compressed by the infant's head during birth, several urinary tract disorders can occur.

DISSEMINATED INTRAVASCULAR COAGULATION

DIC is a deficiency in clotting ability caused by vascular injury. It may occur in any woman in the postpartal period, but it is usually associated with premature separation of the placenta, a missed early miscarriage, or fetal death in utero.

Assessment (infection of the perineum)

Infections of the perineum usually remain localized. They are revealed by symptoms similar to those of any suture-line infection, such as pain, heat, and a feeling of pressure. The woman may or may not have an elevated temperature depending on the systemic effect and spread of the infection. Inspection of the suture line will reveal inflammation. One or two stitches may have sloughed away, so an area of the suture line is open with purulent drainage present (Fig. 25.3). Notify the woman's primary care provider of the localized symptoms, and culture the discharge using a sterile cotton-tipped applicator touched to the secretions.

Cervical Lacerations

Lacerations of the cervix are usually found on the sides of the cervix, near the branches of the uterine artery. If the artery is torn, the blood loss may be so great that blood gushes from the vaginal opening. Because this is arterial bleeding, it is a brighter red than the venous blood lost with uterine atony. Fortunately, this bleeding ordinarily occurs immediately after detachment of the placenta, when the primary care provider is still in attendance.

Mastitis

Mastitis (infection of the breast) may occur as early as the seventh postpartal day or not until the baby is weeks or months old The organism causing the infection usually enters through cracked and fissured nipples. Therefore, to prevent mastitis, it's important to prevent nipples from cracking through measures such as: -Making certain the baby is positioned correctly and grasps the nipple properly, including both the nipple and areola -Helping a baby release a grasp on the nipple before removing the baby from the breast -Washing hands between handling perineal pads and touching breasts -Exposing nipples to air for at least part of every day -Possibly using a vitamin E ointment daily to soften nipples -Encouraging women to begin breastfeeding (when the infant sucks most forcefully) on an unaffected nipple (if a woman has one cracked nipple and one well nipple) Occasionally, the organism that causes mastitis comes from the nasal-oral cavity of the infant. In these instances, the infant has usually acquired Staphylococcus aureus, a methicillin-resistant S. aureus infection (MRSA), or candidiasis while in the hospital. The infant introduces the organisms into the milk ducts by sucking, where they proliferate (breast milk is an excellent medium for bacterial growth). Because this spreads from one person to another, this is termed epidemic mastitis or epidemic breast abscess. When it occurs, it is usually discovered that several women discharged from the hospital at the same time have similar infections.

Nursing Care Planning to Empower a Family

Plan a balanced program of nutrition, exercise, and sleep. Plan meals that are easy to prepare, sleep whenever your baby sleeps, and begin a program of walking daily with your baby. Share your feelings with a support person. Many communities have postpartum support groups to help with this. Take some time every day to do something for yourself (e.g., work on a scrapbook, go shopping) so you have a break from baby care. Do not try to be perfect. Analyze what are the important things to do and get them done. Let unimportant things go for another day. Do not let yourself be isolated by baby care. Use the Internet or your cell phone to keep in contact with your friends so you are not lonely.

Reproductive System Disorders

Pregnancy has the potential to leave reproductive system organs weakened or displaced, especially in women with grand multiparity or who had an instrument birth.

LACERATIONS

Small lacerations or tears of the birth canal are common and may be considered a normal consequence of childbearing. Large lacerations, however, can be sources of infection or hemorrhage. They occur most often: -With difficult or precipitate births -In primigravidas -With the birth of a large infant (>9 lb) -With the use of a lithotomy position and instruments (e.g., forceps, vacuum extraction) Lacerations may occur in the cervix, the vagina, or the perineum. After birth, anytime a uterus feels firm but bleeding persists, suspect a laceration at one of these three sites is causing the bleeding.

CLASSIFICATION OF PERINEAL LACERATIONS

*First degree* Vaginal mucous membrane and skin of the perineum to the fourchette *Second degree* Vagina, perineal skin, fascia, levator ani muscle, and perineal body *Third degree* Entire perineum, extending to reach the external sphincter of the rectum *Fourth degree* Entire perineum, rectal sphincter, and some of the mucous membrane of the rectum

Assessment (endometritis)

A benign temperature elevation may occur on the first postpartal day, particularly if a woman is not drinking enough fluid. In contrast, the fever of endometritis usually manifests itself on the third or fourth postpartal day, suggesting that much of the invasion occurred during labor or birth (consistent with the time it takes for infectious organisms to grow). Normally, the white blood cell count of a postpartal woman is increased to 20,000 to 30,000 cells/mm3 due to the stress of labor. Because of this increase, the conventional method of detecting infection (elevated white blood cell count) is not of great value in the puerperium. Infection is suspected, instead, in postpartal women who have a temperature over 100.4°F (38°C) for two consecutive 24-hour periods. Because women may be at home when this elevated temperature occurs, be certain they know to take their temperature if they feel it is increased and to notify their primary care provider if it is elevated. A rise in temperature that occurs on the third or fourth day postpartum occurs coincidentally at the same time as breast filling occurs. Do not be led astray by attributing an elevated temperature at this time to breast filling. Suspect fever on the third or fourth day postpartum as possible endometritis until proven otherwise. Depending on the severity of the infection, a woman may have accompanying chills, loss of appetite, and general malaise. Her uterus usually is not well contracted and is painful to touch. She may feel strong afterpains. Lochia usually is dark brown and has a foul odor. It may be increased in amount because of poor uterine involution, but if the infection is accompanied by high fever, lochia may, in contrast, be scant or absent. A sonogram may be prescribed to confirm the presence of placental fragments that could be a possible cause of the infection.

WOMEN WITH UNIQUE POSTPARTAL CARE NEEDS

A number of women have unique postpartal needs because of unexpected circumstances.

PERINEAL HEMATOMAS

A perineal hematoma is a collection of blood in the subcutaneous layer of tissue of the perineum. The overlying skin, as a rule, is intact with no noticeable trauma. Blood accumulates underneath, however, from injury to blood vessels in the perineum during birth. Hematomas are most likely to occur after rapid, spontaneous births and in women who have perineal varicosities. They may occur at the site of an episiotomy or laceration repair if a vein was punctured during suturing. Although these can cause a woman acute discomfort and concern, they usually represent only minor bleeding.

PULMONARY EMBOLUS

A pulmonary embolus is obstruction of the pulmonary artery by a blood clot; it usually occurs as a complication of thrombophlebitis when a blood clot moves from a leg vein to the pulmonary artery. The signs of pulmonary embolus are sudden, sharp chest pain; tachypnea; tachycardia; orthopnea (inability to breathe except in an upright position); and cyanosis (the blood clot is blocking both blood flow to the lungs and return to the heart). This is an emergency. A woman needs oxygen administered immediately and is at high risk for cardiopulmonary arrest. Her condition is extremely guarded until the clot can be lysed or adheres to the pulmonary artery wall and is reabsorbed. Because of the seriousness of this condition, a woman with a pulmonary embolism commonly is transferred to an intensive care unit for continuing care.

URINARY TRACT INFECTIONS

A woman who is catheterized at the time of childbirth or during the postpartal period is prone to the development of a urinary tract infection because bacteria may be introduced into the bladder at the time of catheterization. Pushing with labor may also have allowed some secretions to enter the urinary urethra.

The Woman Whose Newborn Has Died

A woman whose newborn dies at birth always has questions about what happened. She is likely to feel bewildered, perhaps bitter, and perhaps resentful that despite emergency interventions, the hospital staff was not able to save her child. She asks, "Why me? Of all the women here, why was my baby the one who died?" She and her family need concerned support from healthcare personnel to help them cope with such a devastating loss Most women are interested in seeing the baby. This is generally therapeutic because it helps them begin grieving. Clean the baby, wrap the baby in an infant blanket, and bring him or her to the parents. Remain with them but give them time to handle and inspect the child as they wish. Parents may want to take a photograph or a lock of hair for a memory book. Be familiar with the forms the mother or father have to sign when a baby dies or is born dead. Know whether your state requires stillborn infants to be given a name and a burial. Other women on the unit tend to stay away from a woman whose child has died, as if what happened to her baby is contagious. Friends and relatives may be equally unable to talk about the situation. Most women, therefore, are anxious to have a nurse approach them and say, "Do you want to talk about what's happened?" Be careful not to use trite sympathy phrases such as "one door closes, another one opens" or "God must have another purpose for you" because although these may be your beliefs, they may not be the woman's beliefs. Provide a private room for the family to allow them an opportunity to grieve and visit freely as they begin to work through this potentially devastating event in their life.

POSTPARTAL DEPRESSION

Almost every woman notices some immediate (1 to 10 days postpartum) feelings of sadness (postpartal "blues") after childbirth. This probably occurs as a response to the anticlimactic feeling after birth and also probably is related to hormonal shifts as the levels of estrogen, progesterone, and gonadotropin-releasing hormone in her body decline. In as many as 20% of women, however, especially in women who are disappointed in some aspect of their newborn or who have poor family support, these normal feelings continue beyond the immediate postpartal period (possibly as long as 1 year) or reflect a more serious problem than usual "baby blues." They become postpartum depression (Box 25.9). Depression of this type, manifested by overwhelming sadness, can occur in both new mothers and fathers (Paulson, Bazemore, Goodman, et al., 2016). The syndrome can interfere with breastfeeding, child care, and returning to a career. Both women and men may notice extreme fatigue, an inability to stop crying, increased anxiety about their own or their infant's health, insecurity (unwillingness to be left alone or inability to make decisions), psychosomatic symptoms (nausea and vomiting, diarrhea), and either depressive or extreme mood fluctuations Risk factors for postpartal depression include: -History of depression -Troubled childhood -Low self-esteem -Stress in the home or at work -Lack of effective support -Different expectations between partners (e.g., if a woman wants a child and her partner does not) -Disappointment in the child (e.g., a boy instead of a girl) It is difficult to predict which women will develop postpartal depression before birth because childbirth can result in so many varied reactions. In the postpartal period, discovery of the problem as soon as symptoms develop is a nursing priority. A number of depression scales to help detect postpartum depression are available (such as the Patient Health Questionnaire-9 (PHQ-9) or the Edinburgh Postnatal Depression Scale [EPDS]), but conscientious observation and discussion with women can reveal symptoms as well. The woman may need counseling and possibly antidepressant therapy to integrate the experience of childbirth into her life This is crucial to the development of a healthy maternal-infant bond, to the health of any other children in the family, and to overall family functioning. Ask at postpartal return visits and well-child visits about symptoms that would suggest depression and recommend an appropriate referral

Therapeutic Management (UTI)

Although sulfa drugs are usually prescribed for a urinary tract infection, they are contraindicated for breastfeeding women because they can cause neonatal jaundice. Typically, therefore, a broad-spectrum antibiotic such as amoxicillin or ampicillin will be prescribed to treat a postpartal urinary tract infection. If an antibiotic contraindicated during breastfeeding is prescribed, check with a woman's primary care provider about possibly changing the antibiotic to one that is safe for breastfeeding. Otherwise, once she is home, in order to breastfeed, the woman will not take the prescribed antibiotic. In addition to the antibiotic, encourage a woman to drink large amounts of fluid (a glass every hour) to help flush the infection from her bladder. She may need an oral analgesic, such as acetaminophen (Tylenol), to reduce the pain of urination for the next few times she voids until the antibiotic begins to have an effect and the burning sensation disappears. Otherwise, because voiding is painful, she may not drink the fluid you suggest, knowing it will increase the number of times she needs to void. Although symptoms of a urinary tract infection decrease quickly, be certain the woman understands the importance of continuing to take the prescribed antibiotic for the full 5 to 7 days to eradicate the infection completely. Plan with the woman what will be an effective reminder system for her to use, such as a chart on her refrigerator door or a reminder signal on her smartphone because when women are busy—and a woman caring for a newborn is busy—forgetting to take medicine is easy to do. If she stops taking the antibiotic, however, bacteria in the urine will begin to multiply again and, in another week, symptoms and the active infection will recur. Discuss with the woman common methods that all women should use to prevent urinary tract infections such as voiding after intercourse as more assurance that she can remain infection free

outcome evaluation

An evaluation of a woman with a postpartal complication should address both her and her family's health as well as her family's ability to integrate the new child into the family. The evaluation may suggest the need for home care follow-up to assist a woman in coping with both old and new responsibilities in the face of reduced energy from an illness. Examples of expected outcomes include: -Lochia is free of foul odor. -Fundus remains firm and midline with progressive descent. -Patient maintains a urinary output greater than 30 ml/hr. -Lochia discharge amount is 6 in. or less on a perineal pad in 1 hour. -Patient maintains vital signs and oxygen saturation within defined normal limits. -Patient identifies signs and symptoms that should be reported. -Patient demonstrates attachment behaviors with infant despite separation or activity restrictions.

Emotional and Psychological Complications of the Puerperium

Any woman who is extremely stressed or who gives birth to an infant who in any way does not meet her expectations such as being the wrong sex, being physically or cognitively challenged, or being ill may become so depressed she has difficulty bonding with her infant. Both depression and an inability to bond is a postpartal complication with far-reaching implications, possibly affecting the future health of the entire family.

POSTPARTAL PSYCHOSIS

As many as 1 woman in 500 has enough symptoms during the year after the birth of a child to be considered psychiatrically ill (this statistic seems high but represents the current rate of overall mental illness in woman) When the illness coincides with the postpartal period or occurs during the following year, it is termed postpartal psychosis. Rather than being a response to the physical aspects of childbearing, it is probably a response to the crisis of childbearing. The majority of these women have had symptoms of mental illness before pregnancy. If the pregnancy had not precipitated the illness, a death in the family, loss of a job or income, divorce, or some other major life crisis might have precipitated the same recurrence. A woman with postpartal psychosis usually appears exceptionally sad. By definition, psychosis exists when a person has lost contact with reality. Because of this break with reality, the woman may deny she has had a child and, when the child is brought to her, insist she was never pregnant. She may voice thoughts of infanticide or that her infant is possessed. If observation tells you a woman is not functioning in reality, you cannot improve her concept of reality by simple measures such as explaining what her correct perception should be because her sensory input is too disturbed to comprehend this. In addition, she may interpret your contrasting opinion as threatening and respond with anger or threats. Instead, the woman needs referral to a professional psychiatric counselor and probably antipsychotic medication While waiting for such a skilled professional to arrive, do not leave the woman alone because her distorted perception might lead her to harm herself. In addition, don't leave her alone with her infant because she could harm the infant as well. Always keep in mind when evaluating women during pregnancy or the puerperium that postpartal psychosis, although rare, does exist. Remembering childbearing can lead to this degree of mental illness helps you to put childbearing into perspective. Because it can cause such a crisis in a woman's life, it cannot be considered an everyday incident in anyone's life.

Therapeutic Management (pelvic thrombophlebitis)

As with femoral thrombophlebitis, therapy involves total bed rest and the administration of analgesics, antibiotics, and anticoagulants. The disease runs a long course of 6 to 8 weeks. If an abscess forms, it can be located by sonogram and incised by laparotomy. A woman may need surgery to remove the affected vessel before she attempts to become pregnant again. Regardless of the type of thrombophlebitis, teach women preventive measures to reduce the risk of recurrence with future pregnancies such as wearing nonconstricting clothing on their lower extremities, resting with the feet elevated, and ambulating daily. Caution a woman to tell her primary care provider before her next pregnancy of the difficulty she experienced at this time, so that extra prophylactic precautions can be taken to prevent thrombophlebitis in a future pregnancy.

POSTPARTAL PREECLAMPSIA

Because preeclampsia usually develops during pregnancy, it is discussed in Chapter 21. Mild preexisting hypertension from this may increase in severity during the first few hours or days after birth. Rarely, it develops for the first time in a woman who has had no prenatal or intranatal symptoms. When this happens, the cardinal symptoms are the same as those of prenatal preeclampsia: proteinuria, edema, and increased blood pressure The reason the condition occurs is usually retention of some placental material. The woman may be taken to surgery to have a D&C to be certain all placental fragments have been removed from her uterus. After the D&C, blood pressure often falls dramatically to normal. If not, continued treatment measures are the same as for antepartal preeclampsia: bed rest, a quiet atmosphere, frequent monitoring of vital signs and urine output, and the administration of magnesium sulfate or an antihypertensive agent. Antihypertensive therapy can be administered in higher doses than during pregnancy because there is no longer any risk of injury to a fetus. Seizures, if they occur postpartally as a symptom of eclampsia, typically develop 6 to 24 hours after birth. Seizures occurring more than 72 hours after birth are probably not the result of eclampsia but the result of some cause unrelated to childbearing. Women in whom postpartal preeclampsia develops may be bewildered by what has happened to them. If seizures occur, they are frightened to discover how little control they have over their body. They worry they will have a seizure after they are at home while holding their baby. You can assure them that preeclampsia, although it appears late, is a condition of pregnancy, so the symptoms will fade quickly. Women with chronic hypertension need frequent monitoring during a future pregnancy to help detect preeclampsia symptoms should these occur

Cardiovascular System Disorders

Because pregnancy requires major changes in the volume of blood and gestational hypertension may occur, some excess volume and pressure changes can still be present in the postpartal period.

Blood Replacement

Blood transfusion to replace blood loss with postpartal hemorrhage is often necessary. In most agencies, blood typing and cross-matching is done when a woman is admitted to the labor service so blood can be rapidly cross-matched. Under usual circumstances, the average woman takes the full postpartal period to regain her strength. Women who experience postpartal hemorrhage tend to have an even longer recovery period, because the physiologic exhaustion of body systems can interfere with recovery. Iron therapy may be prescribed to ensure good hemoglobin formation. Activity level, exertion, and postpartal exercise may be somewhat restricted. Discuss with the woman the possibility of having someone stay with her at home, at least for the first week, to help with the care of her newborn and to prevent exhaustion so childbearing doesn't turn into a less than satisfying event. Extensive blood loss is one of the precursors of postpartal infection because of the general debilitation that results. Therefore, observe any woman who has experienced more than a normal loss of blood for changes such as scant or odorous lochia discharge. Monitor her temperature closely in the postpartal period to detect the earliest signs of developing infection. Make certain the woman knows how to assess for normal lochia and temperature once she is discharged.

LOW-MOLECULAR-WEIGHT HEPARIN

Classification: Heparin is a common anticoagulant. Action: Heparin blocks the conversion of prothrombin to thrombin and of fibrinogen to fibrin, decreasing clotting ability and resulting in the inhibition of thrombus and clot formation. It is used to prevent and treat thrombosis and pulmonary embolism Pregnancy Risk Category: B Dosage: Dosage is dependent on coagulation studies. Dosage is considered therapeutic when the activated partial thromboplastin time (aPTT) is 1.5 to 3 times the control value. The drug is given by subcutaneous injection. Possible Adverse Effects: Hemorrhage, bruising, thrombocytopenia (lowered platelet count), urticaria (hives and itching) Nursing Implications -Obtain coagulation studies as prescribed; adjust dosage as necessary. -Heparin is usually injected into subcutaneous tissue of the abdomen. For best absorption, rotate injection sites. Do not aspirate for blood return or massage the injection site afterward to avoid bruising or hematoma formation. -Avoid any intramuscular injection of other medications because a hematoma may form at the injection site. -Assess a woman and alert her to self-assess for signs and symptoms of bleeding, such as oozing from the gums, nosebleeds, hematuria, or frank or occult blood in stool. -Closely monitor patient's lochia, including amount and color. Assess pad count to determine extent of vaginal bleeding. -Keep protamine sulfate, the antidote, readily available in case of overdose. Instruct the woman about antibleeding precautions such as using a soft toothbrush to minimize the risk of bleeding and in the correct injection technique and allow her to demonstrate this before health agency discharge.

Conditions That Increase a Woman's Risk for a Postpartal Hemorrhage

Conditions that distend the uterus beyond average capacity Multiple gestation Polyhydramnios (excessive amount of amniotic fluid) A large baby (>9 lb) The presence of uterine myomas (fibroid tumors) Conditions that could have caused cervical or uterine lacerations An operative birth A rapid birth Conditions with varied placental site or attachment Placenta previa Placenta accreta Premature separation of the placenta Retained placental fragments Conditions that leave the uterus unable to contract readily Deep anesthesia or analgesia Labor initiated or assisted with an oxytocin agent High parity or maternal age over 35 years of age Previous uterine surgery Prolonged and difficult labor Chorioamnionitis or endometritis Secondary maternal illness such as anemia Prior history of postpartum hemorrhage Prolonged use of magnesium sulfate or other tocolytic therapy Conditions that lead to inadequate blood coagulation Fetal death Disseminated intravascular coagulation (DIC)

SEPARATION OF THE SYMPHYSIS PUBIS

During pregnancy, many women feel some discomfort at the symphysis pubis because of relaxation of the joint preparatory for birth. If a fetus is unusually large or the fetal position is not optimal, the ligaments of the symphysis pubis may be so stretched by birth they actually tear. After birth, the woman experiences acute pain on turning or walking; her legs tend to rotate externally, giving her a waddling gait. A defect over the symphysis pubis can be palpated: The area is swollen and feels tender to touch Bed rest and the application of a snug pelvic binder to immobilize the joint may be necessary to relieve pain and allow healing. As with all ligament injuries, a 4- to 6-week period is necessary for healing to be complete. During this time, a woman should avoid heavy lifting; she may need to arrange for a person to help her with child care at home. She may be advised to consider a cesarean birth for any future pregnancy.

Additional measures that can be helpful to combat uterine atony include:

Elevate the woman's lower extremities to improve circulation to essential organs. Offer a bedpan or assist the woman to the bathroom at least every 4 hours to be certain her bladder is emptying because a full bladder predisposes a woman to uterine atony. To reduce the possibility of bladder pressure, insertion of a urinary catheter may be prescribed. Administer oxygen by face mask at a rate of about 10 to 12 L/min if the woman is experiencing respiratory distress from decreasing blood volume. Position her supine (flat) to allow adequate blood flow to her brain and kidneys. Obtain vital signs frequently and assess them for trends such as a continually decreasing blood pressure with a continuously rising pulse rate. When planning continuing care after sudden blood loss, remember that a woman may be so exhausted from labor and the effect of the blood loss that she resents frequent uterine and blood pressure assessments. Explain that you realize these measures are disturbing, but that they are important for her welfare. Obtain measurements as quickly and gently as possible to cause a minimum of discomfort and disruption, allowing the woman time to rest.

ENDOMETRITIS

Endometritis is an infection of the endometrium, the lining of the uterus Bacteria gain access to the uterus through the vagina and enter the uterus either at the time of birth or during the postpartal period. This may occur with any birth, but the infection is usually associated with chorioamnionitis and a cesarean birth

Key points to review

Hemorrhage (defined as a loss of blood greater than 500 ml within a 24-hour period) is a major potential danger in the immediate postpartal period. The most frequent causes of postpartal hemorrhage are uterine atony or a retained placental fragment. Continuous limited blood loss can be as important as sudden, intense bleeding. Administration of oxytocin or uterotonics may be necessary to initiate uterine tone and halt the bleeding. Other causes of hemorrhage include lacerations (vaginal, cervical, or perineal) and DIC. Lacerations are most apt to occur with an instrument birth or with the birth of a large infant. Puerperal infection (a temperature greater than 100.4°F [38.0°C]) after the first 24 hours is a potential complication after any birth until the denuded placental surface has healed. Retained placental fragments and the use of internal fetal monitoring leads are potential sources of infection. Thrombophlebitis, an inflammation of the lining of a blood vessel, occurs most often as an extension of an endometrial infection. Therapy includes bed rest with moist heat applications and anticoagulant therapy. Never massage the leg of a woman with thrombophlebitis. Doing so can cause the clot to move and become a pulmonary embolus, which is a possibly fatal complication. Mastitis is an infection of the breast. The symptoms include pain, swelling, and redness. Antibiotic therapy is necessary to promote healing. Postpartal "blues" are a normal accompaniment to birth. Postpartal depression (a feeling of extreme sadness) and postpartal psychosis (an actual separation from reality) are not normal and need accurate assessment so a woman can receive adequate therapy for these conditions. A woman whose child dies at birth or is born with a physical or cognitive challenge needs special consideration after birth. This obviously creates a time of stress, and a woman needs supportive nursing care. Establishing a firm family-newborn relationship may be difficult when a woman has a postpartal complication. Planning nursing care that allows a woman to care for her baby and begin her new family role not only meets QSEN competencies but also best meets a family's total needs.

Postpartum Hemorrhages

Hemorrhage, one of the primary causes of maternal mortality associated with childbearing, is a major threat during pregnancy, throughout labor, and continuing into the postpartum period. Traditionally, postpartum hemorrhage is defined as blood loss of 500 ml or more following a vaginal birth; this occurs in as many as 5% to 15% of postpartal women. With a cesarean birth, hemorrhage is present when there is a 1,000-ml blood loss or a 10% decrease in the hematocrit level Although hemorrhage may occur either early (within the first 24 hours following birth) or late (from 24 hours to 6 weeks after birth), the greatest danger is in the first 24 hours because of the grossly denuded and unprotected uterine area left after detachment of the placenta. The four main reasons for postpartum hemorrhage are uterine atony, trauma (lacerations, hematomas, uterine inversion, or uterine rupture), retained placental fragments, and the development of disseminated intravascular coagulation (DIC). These causes are generally referred to as the four T's of postpartum hemorrhage: tone, trauma, tissue, and thrombin—a common mnemonic for the etiology of hemorrhage experienced in the puerperium

Assessment (femoral thrombophlebitis)

If a pelvic thrombophlebitis develops, a woman will generally have an elevated temperature, a systemic fever, chills, and pain. Comparatively, a woman experiencing a femoral thrombophlebitis will usually have unilateral localized symptoms such as redness, swelling, warmth, and a hard inflamed vessel in the affected leg. Symptoms for thrombophlebitis usually present about 10 days after birth. The woman's leg begins to swell below the lesion at the point at which venous circulation is blocked. Her skin may become so stretched from swelling that it appears shiny and white. A Homans sign (pain in the calf of the leg on dorsiflexion of the foot) may be positive; however, a negative Homans sign does not rule out obstruction. The diameter of the leg at thigh or calf level may be increased compared with the other leg. Doppler ultrasound or contrast venography will be prescribed to confirm the diagnosis

Assessment (UTI)

If a urinary tract infection develops, the woman notices symptoms of burning on urination, possibly blood in the urine (hematuria), and a feeling of frequency or that she always has to void. The pain feels so sharp on voiding that she may resist voiding, further compounding the problem of urinary stasis. She may also have a low-grade fever and discomfort from lower abdominal pain. Obtain a clean-catch urine specimen from any woman with symptoms of a urinary tract infection as an independent nursing action To make sure lochial discharge does not contaminate the specimen, provide a sterile cotton ball for the woman to tuck into her vagina after perineal cleansing. Be certain to ask if she removed the cotton ball after the procedure; otherwise, it could cause stasis of vaginal secretions and increase the possibility of endometritis. Mark the specimen "possibly contaminated by lochia" so that any blood in the specimen will not be overly interpreted by the laboratory technician.

INFECTION OF THE PERINEUM

If a woman has a suture line on her perineum from an episiotomy or a laceration repair, a ready portal of entry exists for bacterial invasion.

Assessment (retained placental fragments)

If an undetected retained fragment is large, bleeding will be apparent in the immediate postpartal period because the uterus cannot contract with the fragment in place. If the fragment is small, bleeding may not be detected until postpartum day 6 to 10, when the woman notices an abrupt discharge and a large amount of vaginal bleeding. On examination, usually the uterus is found to not be fully contracted.

Bimanual Compression

If fundal massage and administration of uterotonics (drugs to contract the uterus) are not effective at stopping uterine bleeding, a sonogram may be done to detect possible retained placental fragments. The woman's primary care provider may attempt bimanual compression. With this procedure, the primary care provider inserts one hand into a woman's vagina while pushing against the fundus through the abdominal wall with the other hand. If this is ineffective, the woman may be returned to the birthing room, so that her uterine cavity can be explored manually. Under sonogram visualization, a balloon catheter may be introduced vaginally and inflated with sterile water until it puts pressure against the bleeding site. Vaginal packing is inserted during this procedure to stabilize the placement of the balloon. Be certain to document the presence of the packing so it can be removed before agency discharge because retained packing serves as a growth medium for microorganisms that could lead to postpartal infection

REPRODUCTIVE TRACT DISPLACEMENT

If the ligaments of the uterus are weakened because of pregnancy, they may no longer be able to maintain the uterus in its usual position or level after pregnancy, thus creating concerns such as retroflexion, anteflexion, retroversion, and anteversion or prolapse of the uterus. These uterine displacement disorders can interfere with future childbearing and fertility and may cause continued pain or a feeling of lower abdominal heaviness or discomfort. If the walls of the vagina are weakened, a cystocele (outpouching of the bladder into the vaginal wall) or a rectocele (outpouching of the rectum into the vaginal wall) may occur. These are identified on pelvic exam or by sonogram. If extensive, surgery to repair such conditions may be necessary. If stress incontinence (involuntary voiding on exertion) occurs, Kegel exercises to strengthen perineal muscles, injection of bulking agents, pelvic floor physical therapy, or Botox may be helpful

The Woman Whose Child Is Born With an Illness or a Physical Challenge

Immediately after birth, the average woman often has momentary difficulty believing that her pregnancy is finally over, and her child has been born. This difficulty can be compounded for a woman whose child is challenged in some way because she must not only grasp the fact that her baby has been born but also that her baby is different from the one she envisioned During pregnancy, most women say they do not care about the sex of their child as long as the child is born healthy. This can make them feel cheated or disappointed when this one requirement is not met. They may experience a loss of self-esteem: They have given birth to an imperfect child and so they see themselves as imperfect. A woman sometimes responds with a grief reaction, as if her child had died because the image of the "perfect" child she thought she was carrying has died. Parents should be shown their child moments after birth so if a condition or problem exists, the newborn's condition, prognosis, and usual plans for care can be immediately explained to them. Although hearing such an explanation is a shock to couples, it allows them to face the problem as early as possible and while they are surrounded by professional support people. The primary care provider usually makes it her or his responsibility to tell the parents about the infant's concern. Be prepared to reinforce this information or review the explanation during the postpartum period because people who are under stress are not good listeners and may need repeated explanations before they completely understand the problem. Encourage the parents to care for the child during the postpartal period, so they can touch, relate to, and "claim" the infant in as nearly normal a manner as possible. Many women wait until their support person is present to visit an intensive care nursery so that visiting with their ill newborn is a family activity. Open lines of communication between the parents and the hospital staff, which allow for free discussion of feelings and fears, will do much to strengthen parent-child relationships and prepare for future hospitalizations or care of the child.

Assessment (urinary retension)

In a postpartal woman, urinary retention with overflow may be more difficult to detect than primary or simple overdistention. With primary overdistention, a woman does not void at all. A longer than usual time (>8 hours) passes after birth or between voids. Assessment by percussion or palpation of the bladder reveals bladder distention. With urinary retention and overflow, a woman is able to void. Voiding is very frequent, however, and in very small amounts, so her overall output is inadequate. Always measure the amount of a woman's first voiding after birth because with diuresis occurring, this should be large. As a rule, if this first voiding is less than 100 ml, suspect urinary retention. Urinary retention is confirmed by catheterizing a woman immediately after she voids. If the amount of urine left in the bladder after voiding (termed residual) is greater than 100 ml, the woman is retaining more than the usual amount of urine. Typically, the prescription for catheterization is written as: "Catheterize for residual urine. If this is greater than 100 ml, leave indwelling catheter in place." Always use an indwelling (Foley) catheter, rather than a temporary one (straight catheter), therefore, to catheterize for residual urine so this can be inflated and left in place. Use strict antiseptic technique to prevent introducing pathogenic bacteria into the sterile urinary tract and causing a urinary tract infection. Catheterizing a woman during the early postpartal period can be more difficult than usual because vulvar edema often distorts the position and appearance of the urinary meatus. Use a gentle technique, remembering that a woman's perineum is apt to feel tender to touch.

Therapeutic Management (uterine atony)

In the event of uterine atony, the first step in controlling hemorrhage is to attempt fundal massage to encourage contraction (Box 25.4). Unless the uterus is extremely lacking in tone, this procedure is usually effective in causing contraction, and, after a few seconds, the uterus assumes its healthy, grapefruit-like feel With uterine atony, even if the uterus responds well to massage, the problem may not be completely resolved because, as soon as you remove your hand from the fundus, the uterus may relax and the lethal seepage will begin again. To prevent this, remain with a woman after massaging her fundus and assess to be certain her uterus is not relaxing again. Continue to assess carefully for the next 4 hours. If a woman's uterus does not remain contracted, contact her primary care provider so interventions to increase contraction such as administering a bolus or a dilute intravenous infusion of oxytocin (Pitocin) can be prescribed to help the uterus maintain tone When oxytocin is given intravenously (IV), its action on the uterus is immediate. Be aware, however, that oxytocin has a short duration of action, approximately 1 hour, so symptoms of uterine atony can recur quickly if it is administered only as a single dose (see Chapter 23, Box 23.3 for cautions to be aware of with an oxytocin infusion). If oxytocin is not effective at maintaining tone, carboprost tromethamine (Hemabate), a prostaglandin F2a derivative, or methylergonovine maleate (Methergine), an ergot compound, both given intramuscularly, are second possibilities. Misoprostol (Cytotec), a prostaglandin E1 analogue, may also be administered rectally to decrease postpartum hemorrhage. Carboprost tromethamine may be repeated every 15 to 90 minutes up to 8 doses; methylergonovine maleate may be repeated every 2 to 4 hours up to 5 doses. A second dose of misoprostol should not be administered unless a minimum of 2 hours has elapsed. It's important to check that all of these drugs are readily available for use on a hospital unit in the event of postpartum hemorrhage. Because prostaglandins tend to cause diarrhea and nausea as side effect, assess for this after administration; some women will need to be administered an antiemetic to limit these side effects Be aware that all of these medications can increase blood pressure and so must be used cautiously in women with hypertension. Assess blood pressure prior to administration and about 15 minutes afterward to detect this potentially dangerous side effect.

Puerperal Infections

Infection of the reproductive tract in the postpartal period is another major cause of maternal mortality. Factors that predispose women to infection during this time are shown in Box 25.5. When caring for a woman who has any of these circumstances, be aware that the risk for postpartal infection is greatly increased. Theoretically, the uterus is sterile during pregnancy and up until the membranes rupture. After rupture, pathogens can begin to invade; the risk of infection grows even greater if tissue edema and trauma are present. If infection should occur, the prognosis for complete recovery depends on such factors as the woman's general health, virulence of the invading organism and portal of entry, the degree of uterine involution at the time of the invasion, and the presence of lacerations in the reproductive tract. A puerperal infection is always potentially serious, because, although it usually begins as only a local infection, it has the potential to spread to the peritoneum (peritonitis) or the circulatory system (septicemia), conditions that can be fatal in a woman whose body is already stressed from childbirth. Organisms commonly cultured postpartally include group B streptococci, staphylococci, and aerobic gram-negative bacilli such as Escherichia coli. The management for puerperal infection focuses on the use of an appropriate antibiotic after culture and sensitivity testing of the isolated organism.

implementation

Interventions for a woman with a postpartum complication should include instruction for both self-care and child care (if appropriate) because continuing to review these measures helps a woman accept her situation as temporary, thus reinforcing the idea she will be able to care for herself and her infant when she is healthy again.

Although the puerperium is usually a period of health, complications can occur.

It's important to be knowledgeable about predisposing factors and clinical manifestations of postpartum complications to ensure the prompt initiation of corrective measures in order to prevent long-term consequences to a woman and her family Postpartum complications are always potentially serious because they can impact so many people. A complication may be so serious it could cause a personal injury, leave a woman with her future fertility impaired, or even result in death. Any complication that affects the health of the mother can also affect her interactions with her newborn, such as causing her to discontinue breastfeeding Her family can be disrupted because of an extended hospital stay or from an impairment that prevents her from performing her normal family responsibilities. Financial difficulties may arise because of her inability to maintain employment and the need for additional child and health care. Fortunately, most postpartum complications are preventable, and if they do occur, the majority can be treated effectively without long-term complications.

Perineal Lacerations

Lacerations of the perineum are more apt to occur when a woman is placed in a lithotomy position for birth rather than a supine position because a lithotomy position increases tension on the perineum. Perineal lacerations are classified by four categories, depending on the extent and depth of the tissue involved.

ASSESSMENT (mastitis)

Mastitis is usually unilateral, although epidemic mastitis, because it originates with the infant, may be bilateral. The affected breast feels painful and appears swollen and reddened. Fever accompanies these first symptoms within hours, and breast milk becomes scant. If the diagnosis is not clear from the typical symptoms, the woman may have a sonogram prescribed to be certain a deep lying breast abscess isn't also present

nursing diagnosis

Nursing diagnoses during this time vary depending on the postpartal complication. Some examples include: -Deficient fluid volume related to blood loss -Ineffective breastfeeding related to the development of mastitis -Risk for impaired parenting related to postpartum depression -Risk for injury to self and newborn related to postpartal psychosis -Acute pain related to a collection of blood in traumatized tissue (hematoma) secondary to birth trauma -Situational low self-esteem related to inability to perform regular tasks -Social isolation related to precautions necessary to protect infant and others from infection transmission -Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis (blood clot) -Risk for infection related to microorganism invasion of episiotomy, surgical incision site, or migration of microorganisms from the vagina to the uterus

RETAINED PLACENTAL FRAGMENTS

Occasionally, a placenta does not detach in its entirety; fragments of it separate and are left still attached to the uterus. Because the portion retained keeps the uterus from contracting fully, uterine bleeding occurs. Although this is most likely to happen with a succenturiate placenta—a placenta with an accessory lobe (see Chapter 23)—it can happen in any instance. Placenta accreta—a placenta that fuses with the myometrium because of an abnormal decidua basalis layer—may also be retained. This is associated with previous cesarean birth and in vitro fertilization and occurs at an incidence of about 1 out of 3,000 births; it can be identified by an ultrasound exam during pregnancy. Removing such a deeply embedded placenta can lead to severe postpartal hemorrhage. To identify the complication of a retained placenta, every placenta should be inspected carefully after birth to be certain it is complete. Retained placental fragments may also be detected by ultrasound. A blood serum sample that contains human chorionic gonadotropin (hCG) hormone also reveals that part of a placenta is still present.

COMPARING POSTPARTAL BLUES, DEPRESSION, AND PSYCHOSIS

Onset Postpartal Blues: 1-10 days after birth Postpartal Depression: 1-12 months after birth Postpartal Psychosis: Within first year after birth Symptoms Postpartal Blues: Sadness, tears Postpartal Depression: Anxiety, feeling of loss, sadness Postpartal Psychosis: Delusions or hallucinations of harming infant or self Incidence Postpartal Blues: 70% of all births Postpartal Depression: 10% of all births Postpartal Psychosis: 1%-2% of all births Etiology (possible) Postpartal Blues: Probable hormonal changes, stress of life changes Postpartal Depression: History of previous depression, hormonal response, lack of social support Postpartal Psychosis: Possible activation of previous mental illness, hormonal changes, family history of bipolar disorder Therapy Postpartal Blues: Support, empathy Postpartal Depression: Counseling, possibly drug therapy Postpartal Psychosis: Psychotherapy, drug therapy Nursing role Postpartal Blues: Offer compassion and understanding Postpartal Depression: Screen for depression and refer to counseling Postpartal Psychosis: Refer to psychiatric care, safeguarding mother from injury to self and newborn

Therapeutic Management (sub involution)

Oral administration of methylergonovine, 0.2 mg four times daily, is the usual prescription to improve uterine tone and complete involution. If the uterus feels tender to palpation, suggesting endometritis is present, an oral antibiotic also will be prescribed. Being certain women are able to recognize the normal process of involution and lochia discharge before hospital discharge helps women to be able to identify subinvolution and seek early care if it occurs. A chronic loss of blood from subinvolution will result in anemia and a lack of energy, conditions that possibly could interfere with infant bonding or lead to infection.

outcome identification and planning

Outcome identification for a woman with a postpartum complication may be particularly difficult, because although a woman wants to do everything necessary to return to health, she also does not want anything to interfere with her ability to bond with and take care of her new child. As a rule, however, never underestimate how much a woman will endure to enable herself to "mother" her new child. This ability of a mother to overcome challenges to meet her child's needs is the essence of motherhood. When planning care for a postpartum family, provide for measures that will restore the woman most quickly to health and promote contact among her, her child, and her primary support person. If physical contact between a mother and her newborn is not possible, give the mother frequent reports of her infant's condition and include her in planning care for her newborn. During her taking-in phase, ask the nursery staff to contact the mother at least once every nursing shift to update her on her infant's status; during her taking-hold phase, encourage her to contact the nursery. If the infant is being cared for in another facility, ask them to provide photographs of the infant. This provides something tangible to which a new mother can connect with her newborn. Many women respond well to notes written as if they were from her child, for example, "Hi, Mom. I'm drinking well but I miss you and can't wait for you to get better and take care of me. Love, Kelsey." Such a note serves to lessen a woman's concern for her child (because she is doing well) and also helps to promote mother-infant attachment. Because childbirth is generally seen as a happy time, being faced with a postpartal complication can cause a great deal of emotional stress. The risk of both postpartal depression and postpartal psychosis increases when a complication develops. Refer patients to helpful websites and other resources when appropriate

PELVIC THROMBOPHLEBITIS

Pelvic thrombophlebitis involves the ovarian, uterine, or hypogastric veins. It usually follows a mild endometritis and occurs later than femoral thrombophlebitis, often around the 14th or 15th day of the puerperium. Inflammation of the blood vessels in the pelvic area causes a partial obstruction, which leads to slowed blood flow and clots in the stagnant blood in the vessel. Risk factors are the same as for femoral thrombophlebitis. The prevention of endometritis by the use of good aseptic technique during and after birth is important to help prevent the disorder

Therapeutic Management (perineal lacerations)

Perineal lacerations are sutured and treated the same as an episiotomy repair. Make certain the degree of the laceration is documented because women with fourth-degree lacerations need extra precautions to avoid having sutures loosened or infected. Both sutured lacerations and episiotomy incisions tend to heal in the same length of time. A diet high in fluid and a stool softener may be prescribed for the first week after birth to prevent constipation and hard stools, which could break the new sutures. Any woman who has a third- or fourth-degree laceration should not have an enema or a rectal suppository prescribed or have her temperature taken rectally because the hard tips of equipment could open sutures near to or including those of the rectal sphincter. Although fourth-degree lacerations can lead to long-term dyspareunia, rectal incontinence, or sexual dissatisfaction, they usually heal without further complications.

Assessment (perineal hematomas)

Perineal sutures almost always give a postpartal woman some discomfort. If a woman reports severe pain in the perineal area or a feeling of pressure between her legs, inspect the perineal area to see if a hematoma could be causing this. If a hematoma is present, it appears as an area of purplish discoloration with obvious swelling. It could be as small as 2 cm or as large as 8 cm in diameter (Fig. 25.2). At first it may feel fluctuant, but as seepage into the area continues and tissue is drawn taut, it palpates as a firm globe and feels tender.

Therapeutic Management (peritonitis)

Peritonitis is often accompanied by a paralytic ileus (a blockage of inflamed intestines). This requires insertion of a nasogastric tube to prevent vomiting and to rest the bowel. Intravenous fluid or total parenteral nutrition will then be necessary. A woman will need analgesics for pain relief and intravenous antibiotics to treat the infection. Her hospital stay will be extended, but with effective antibiotic therapy, the outcome should be good. Peritonitis can interfere with future fertility because it can leave scarring and adhesions in the peritoneum, which separate the fallopian tubes from the ovaries to the extent that ova can no longer easily enter the tubes.

PERITONITIS

Peritonitis, or infection of the peritoneal cavity, usually occurs as an extension of endometritis. It is one of the gravest complications of childbearing and is a major cause of death from puerperal infection. The infection spreads from the uterus through the lymphatic system or directly through the fallopian tubes or uterine wall to the peritoneal cavity. An abscess may form in the cul-de-sac of Douglas because this is the lowest point of the peritoneal cavity and gravity causes infected material to localize there.

Thrombophlebitis

Phlebitis is inflammation of the lining of a blood vessel. Thrombophlebitis is inflammation with the formation of blood clots. Thrombophlebitis is classified as either superficial vein disease (SVD) or deep vein thrombosis (DVT). When either type occurs in the postpartum period, it tends to occur because: A woman's fibrinogen level is still elevated from pregnancy, leading to increased blood clotting. Dilatation of lower extremity veins is still present as a result of pressure of the fetal head during pregnancy and birth so blood circulation is sluggish. It tends to occur most often in women who: Are relatively inactive in labor and during the early puerperium because this increases the risk of blood clot formation Have spent prolonged time in a birthing room with their legs positioned in stirrups Have preexistent obesity and a pregnancy weight gain greater than the recommended weight gain, which can lead to inactivity and lack of exercise Have preexisting varicose veins Develop a postpartal infection Have a history of a previous thrombophlebitis Are older than age 35 years or have increased parity Have a high incidence of thrombophlebitis in their family Smoke cigarettes because nicotine causes vasoconstriction and reduces blood flow

Therapeutic Management (retained placental fragments)

Removal of the retained placental fragment is necessary to stop the bleeding and can usually be accomplished by a dilatation and curettage (D&C). If it cannot be removed, methotrexate may be prescribed to destroy the retained fragment. Because the hemorrhage from retained fragments may be delayed until after a woman is at home, be certain women know to continue to observe the color of lochia and to report any tendency for the discharge to change from lochia serosa or alba back to rubra. In some instances, placenta accreta is so deeply attached that balloon occlusion and embolization of the internal iliac arteries may be necessary to minimize blood loss. In others, a hysterectomy must be performed

Therapeutic Management (perineal hematomas)

Report the presence of a hematoma, its estimated size, and the degree of the woman's discomfort to her primary care provider. Describe a definite size such as "5 centimeters" or the size of a quarter or a half dollar rather than documenting it as "large" or "small" as this best establishes a baseline and will enable you to assess if it is growing larger. Administer a mild analgesic as prescribed for pain relief. Applying an ice pack (covered with a towel to prevent thermal injury to the skin) may prevent further bleeding. Usually, a hematoma is absorbed over the next 3 or 4 days. If one is large when discovered or continues to increase in size, the woman may have to be returned to the birthing room to have the site incised and the bleeding vessel ligated under local anesthesia. You can assure the woman that even though the hematoma is causing her considerable discomfort, it is not a serious complication and will slowly reabsorb over the next 6 weeks, causing no further difficulty. If an episiotomy incision line was opened to drain a hematoma, it may be left open and packed with gauze rather than resutured. Be certain to record this packing was placed so it can be removed in 24 to 48 hours. A suture line opened this way heals by tertiary intention or from the bottom to the top, rather than side to side, so healing will occur more slowly than a usual primary intention suture line. Be certain the woman has clear instructions before discharge regarding necessary suture line care she will need to do at home, such as keeping it clean and dry and perhaps using a sitz bath once or twice a day.

Conditions That Increase a Woman's Risk for Postpartal Infection

Rupture of the membranes more than 24 hours before birth Bacteria may have started to invade the uterus while the fetus was still in utero. Retained placental fragments within the uterus The tissue necroses and serves as an excellent bed for bacterial growth. Postpartal hemorrhage The woman's general condition is weakened. Preexisting anemia The woman's general condition is weakened. Prolonged and difficult labor, particularly with instrument births Trauma to the tissue may leave lacerations or fissures for easy portals of entry for infection. Internal fetal heart monitoring electrode Contamination may have been introduced with placement of the scalp electrodes. Local vaginal infection present at the time of birth A direct spread of infection has occurred. Uterus explored after birth for a retained placenta or abnormal bleeding site The infection was introduced with exploration.

SUBINVOLUTION

Subinvolution is the incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present. Subinvolution may result from a small retained placental fragment, a mild endometritis (infection of the endometrium), or an accompanying problem such as a uterine myoma that is interfering with complete contraction.

Assessment (peritonitis)

Symptoms are the same as those of a surgical patient in whom a peritoneal infection develops: rigid abdomen, abdominal pain, high fever, rapid pulse, vomiting, and the appearance of being acutely ill. When assessing the abdomen of a postpartal woman, be sure to note not only that her uterus is well contracted but also that the remainder of her abdomen is soft because the occurrence of a rigid abdomen (i.e., guarding) is one of the first symptoms of peritonitis.

Therapeutic Management (urinary retension)

The amount of urine to remove from an overdistended bladder is controversial. There is a suggestion that removing more than 750 to 1,000 ml of urine at any one time may create such an extreme pressure change in the lower abdomen that it causes blood to flow into the area, causing supine hypotension. There is little evidence of this actually happening, however, and particularly not in the postpartal period, when a bladder is easily distended and the uterus is larger than normal. Although this shift in pressure may not be as important as usual, follow your healthcare agency's policy concerning how much urine to remove from a full bladder at catheterization. If an indwelling catheter will be left in place, be certain to explain the rationale for its insertion, and how the inflated balloon will hold it in place so the woman does not limit activity and leave herself open to other complications, such as thrombophlebitis. After 24 hours, the indwelling catheter is usually clamped for a short time and then removed. Encourage a woman to void by the end of 6 hours after removal of the catheter by offering fluid, administering an analgesic so she can relax, assisting her to the bathroom as necessary, and trying time-tested solutions such as running water at the sink or letting her hold her hand under warm running water. In most women, bladder and vulvar edema have decreased so much by this time that they are able to void without further difficulty. If a woman has not voided by 8 hours after catheter removal, she may need reinsertion of the indwelling catheter for an additional 24 hours. Difficulty with bladder function after childbirth is becoming less of a problem because less anesthesia and fewer forceps are used at birth, thus decreasing bladder and vulvar pressure. If problems do arise, they may be difficult for a woman to accept because bladder elimination is a basic step of self-care and discouraging for a woman who wants to be able to care not only for herself but also a new infant. You can assure the woman that bladder complications are not uncommon after childbirth. Fortunately, they are usually present for no longer than 48 hours and most likely do not recur.

2020 National Health Goals for Nursing Care of a Family Experiencing a Postpartum Complication

The postpartal period is a time when women are very susceptible to hemorrhage and thrombophlebitis and, when these complications develop, women may choose not to breastfeed because of them. The 2020 National Health Goals that speak to this include: Reduce the maternal mortality rate to no more than 11.4 per 100,000 live births from a baseline of 12.7 per 100,000. Increase the proportion of infants who are breastfed to at least 81.9% from a baseline of 74%. Increase the proportion of infants who are breastfed at 6 months from a baseline of 43.5% to 60.6%

Therapeutic Management (cervical lacerations)

The repair of a cervical laceration usually requires sutures and can be difficult because, if the bleeding is intense, this obstructs visualization of the area. A woman is not always aware of what is happening at this point, but she quickly senses something is seriously wrong. Try to maintain an air of calm and, if possible, stand beside the woman at the head of the table. She may be worried that the extra activity in the room has something to do with her baby. Assure her of her baby's condition and inform her about the need to stay in the birthing room a little longer than expected while the primary care provider places sutures or packing. Remember, the protective attitude a woman has felt toward her body all during pregnancy now turns toward her baby, so she usually is relieved to learn any problem that may be occurring is hers, not her infant's. If the cervical laceration appears to be extensive or difficult to repair, it may be necessary for the woman to be given a regional anesthetic to relax the uterine muscle and to prevent pain. Explain the need for an anesthetic and the procedures being carried out. Be certain the primary care provider has adequate space to work, adequate sponges and suture supplies, and a good light source.

THERAPEUTIC MANAGEMENT (mastitis)

Treatment consists of antibiotics effective against penicillin-resistant staphylococci such as dicloxacillin or a cephalosporin, and, because symptoms often appear after a hospital discharge, it is treated on an outpatient basis Breastfeeding should be continued if possible because keeping the breast emptied of milk helps to prevent the growth of bacteria. Some women find an infected breast too painful to allow their infant to suck, however, and prefer to express milk manually from the affected breast until their antibiotic has taken effect and the mastitis has diminished (about 3 days). Cold or ice compresses and a good supportive bra help with pain relief until the process improves, although warm, wet compresses can also be helpful because this reduces inflammation and edema. If therapy is started as soon as symptoms appear, the condition runs a short course of about 2 or 3 days. If left untreated, a breast infection can become a localized abscess. If unrecognized, this can spread to involve a large portion of the breast and even rupture through the skin, with thick, purulent drainage. If an abscess forms, breastfeeding on that breast is discontinued as the abscess may need incision and drainage. Encourage women to continue to pump breast milk, if possible, until the abscess has resolved in order to preserve breastfeeding. Many women find a breast this infected too tender to do this, however, so instead choose to bottle-feed their infant. Although this is not the outcome she hoped for, you can assure a woman that formula feeding will be an acceptable alternative for this child. Neither mastitis nor a breast abscess leaves any permanent breast disease. A woman can be assured that such an incident is not associated with the development of breast cancer and does not interfere with future breastfeeding potential. Box 25.8 shows an interprofessional care map illustrating both nursing and team planning for a woman with mastitis.

Therapeutic Management (infection of the perineum)

Typically, either a systemic or topical antibiotic is ordered even before the culture report is returned. An analgesic may be prescribed to alleviate discomfort. It may be necessary to remove perineal sutures to open the area and allow for drainage. Sitz baths, moist warm compresses, or Hubbard tank treatments may be prescribed to hasten drainage and cleanse the area. Remind the woman to change perineal pads frequently. Because they are contaminated by drainage, if left in place too long, they might cause vaginal contamination or reinfection. Repeat again that the woman should wipe front to back after urinating or a bowel movement to prevent bringing contamination forward from the rectum onto the healing area. With a local infection of this nature, a woman is usually discharged with a referral for home care follow-up because the incision site, once opened, must heal by tertiary rather than by primary intention. Infections of this nature are annoying and painful, but fortunately, with improved techniques during birth and the puerperium, perineal infections occur only rarely. Because they are localized, there is no need to restrict the woman from caring for her infant as long as she washes her hands well before holding her newborn. Be certain not to place the infant on the bottom bed sheet of the woman's bed where the baby could contact pathogenic bacteria. Encourage the woman to ambulate and ask for analgesia as needed. Often, the pain from an infected suture line is severe, and the woman may decrease ambulation unless she is urged to continue.

Therapeutic Management (vaginal lacerations)

Unfortunately, vaginal tissue is friable, making vaginal lacerations difficult to suture. A balloon tapenade similar to the type used with a uterine hemorrhage may be effective if suturing does not achieve hemostasis. Some oozing often occurs after a vaginal repair, so the vagina may be packed to maintain pressure on the suture line. An indwelling urinary catheter (Foley catheter) may be placed following the repair because the packing causes such pressure on the urethra that it can interfere with voiding. Be certain to document in the woman's electronic record when and where packing was placed so you can be certain it is removed after 24 to 48 hours or before hospital discharge to prevent infection.

URINARY RETENTION

Urinary retention occurs when the bladder is unable to empty completely After childbirth, bladder sensation for voiding is decreased because of bladder edema caused by the pressure of birth. This concern is compounded during prolonged labor, perineal lacerations, and the use of epidural anesthesia. Unable to empty, the bladder fills to overdistention. When the woman does void, instead of emptying completely, the bladder empties only a small portion of its contents (retention with overflow). As a result, it quickly becomes overdistended again. If it is allowed to continue, bladder overdistention can cause permanent damage to bladder tone, leading to permanent incontinence

Hysterectomy or Suturing

Usually, uterine massage and administration of a drug to contract the uterus (uterotonic) are effective to halt bleeding. With extreme bleeding, embolization of pelvic and uterine vessels by angiographic techniques may be necessary. As a last resort, ligation of the uterine arteries or a hysterectomy (removal of the uterus) may be necessary (Ghosh & Mala, 2015). In this totally unexpected outcome of childbearing, provide comfort and support to both the woman and her support person. After a hysterectomy, a woman usually wants to talk about what happened, why surgery was necessary, or how she feels now that she can no longer bear children so she can sort through her feelings of "Why me?" She may reveal ambivalent feelings: She wanted to have more children (or at least have the ability to have more), but she is also grateful to be alive. She is both thankful her life has been saved, but she may also feel resentful you couldn't have done more to protect her future childbearing. She may grieve for children who will not be born. If her child was born outside the hospital (although postpartum hemorrhage is lower during home births than hospital births), she may have a need to talk about her choice of location for childbirth and that she did not choose a higher resource setting for childbirth Open lines of communication between the couple and healthcare providers that allow a family to vent their feelings are most helpful to a couple in this crisis. Referral to a grief counselor may be necessary because grieving for future children who will not be born can interfere with bonding with the present child.

UTERINE ATONY

Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum hemorrhage; it tends to occur most often in Asian, Hispanic, and Black woman. Factors that predispose a woman to poor uterine tone or the inability of her uterus to maintain a contracted state are summarized in Box 25.3. When caring for a woman in whom any of these conditions are present, be especially conscientious in your observations and be on guard for signs of uterine bleeding.

Vaginal Lacerations

Vaginal lacerations are easier to locate and assess than cervical lacerations because they are so much easier to view.

Therapeutic Management (endometritis)

When taking a culture to identify the offending organism, be certain to obtain fluid from the vagina using a sterile swab rather than from a perineal pad to ensure you are culturing the endometrial infectious organism and not an unrelated one from the pad. Treatment will consist of the administration of an appropriate antibiotic, such as clindamycin (Cleocin), as determined by the culture. An oxytocic agent such as methylergonovine may also be prescribed to encourage uterine contraction. Urge the woman to drink additional fluid to combat the fever. If strong afterpains and abdominal discomfort are present, ask if she needs an analgesic for pain relief. Sitting in a semi-Fowler's position or walking encourages lochia drainage by gravity and helps prevent pooling of infected secretions. Because any drainage on perineal pads or bed linens is contaminated, be certain to wear gloves when helping a woman change her perineal pads and changing bed linen. In addition, be certain both you and the woman use good hand washing techniques before and after handling pads. As with any infection, endometritis can be controlled best if it is discovered early. If you can interpret the normal color, quantity, and odor of lochia discharge and the size, consistency, and tenderness of a normal postpartal uterus, you can be the first person to recognize that an infection is present. Because a woman may be at home when signs of infection occur, be certain you've taught about the signs and symptoms of endometritis before healthcare agency discharge. If the infection is limited to the endometrium, the course of infection will be about 7 to 10 days. If this occurs while a woman is hospitalized, she may have to make arrangements for her baby's discharge before her own or arrange for help with newborn care when she is discharged. Be certain she knows to take the full course of antibiotics prescribed so the infection is completely eradicated and does not return. An added danger of endometritis is that it can lead to tubal scarring and interference with future fertility. At a future time, if the woman desires more children, she may need a fertility assessment (including a sonohysterosalpingogram) to determine tubal patency. With mild endometritis, this is usually not a problem, but a woman should be forewarned that it could occur.

FEMORAL THROMBOPHLEBITIS

With femoral thrombophlebitis, the femoral, saphenous, or popliteal veins are involved. Although the inflammation site in thrombophlebitis is a vein, an accompanying arterial spasm often occurs, diminishing arterial circulation to the leg as well. This decreased circulation, along with edema, gives the leg a white or drained appearance. It was formerly believed that breast milk drained into the leg, giving it its white appearance. The condition was, therefore, formerly called milk leg or phlegmasia alba dolens ("white inflammation"). Ambulation and limiting the time a woman remains in obstetric stirrups encourages circulation in the lower extremities, promotes venous return, and decreases the possibility of clot formation, thus helping to prevent thrombophlebitis. If stirrups on examining tables or birthing rooms are used, be certain that they are well padded to prevent any sharp pressure against the calves of the legs and that the woman remains in a lithotomy position for as short a period of time as possible. If a woman had varicose veins before or during pregnancy, wearing support stockings for the first 2 weeks after birth can help increase venous circulation and prevent stasis. If these are prescribed, be certain the woman knows to buy medical support stockings, not panty hose advertised as offering support, and to put them on before she rises in the morning. If she waits until she is already up and walking, venous congestion will have already occurred and the stockings will be less effective. Encourage her to remove the support stockings twice daily and assess her skin underneath for mottling or inflammation that would suggest inflammation of her veins. Women are not normally prescribed acetylsalicylic acid (aspirin) for pain because aspirin is a mild anticoagulant, which interferes with blood clotting by preventing platelet aggregation and clot formation. However, women who are high risk for thrombophlebitis may be prescribed aspirin every 4 hours as a preventive measure. If this is so, be certain to not interpret aspirin used this way as an as needed (PRN) analgesic order and withhold it depending on the woman's level of pain.

Assessment (pelvic thrombophlebitis)

With pelvic thrombophlebitis, a woman suddenly becomes extremely ill, with a high fever, chills, abdominal pain, weakness, and general malaise. Her infection can be so severe it necroses the vein and results in a pelvic abscess. In severe instances, it can become systemic and results in a lung, kidney, or heart valve abscess.

assessment

Women who assume they will immediately return to an active lifestyle after birth of their child may view an extended hospitalization for a postpartum complication as more unsettling than women who view the postpartum period as one in which they are expected to rest. Assess each woman holistically, therefore, to determine how the health problem a woman is experiencing is impacting her and her family. Assessment findings associated with a postpartum complication may be subtle, such as tenderness in the calf of a leg, an increase in uterine or perineal pain, a slight elevation in temperature, or a small increase in the amount of lochia flow (Box 25.2). Because the average woman usually has no postpartum complications and the length of stay in the hospital is short, it is easy to overlook these subtle signs, but it is important to be alert to any findings that are unusual because they may be the beginning of a serious concern. To be certain, do not rely solely on a woman's report of perineal healing or amount of lochia; always inspect her perineum and lochia yourself because the report of "I feel fine" or "my bleeding was just a small amount" may be deceptive if she has no familiarity with "normal" lochia, perineal healing, or fundal height against which to accurately compare her own condition. An increased temperature except during the first 24 hours after birth is a potentially extremely serious finding. Women may try to "explain away" an increased temperature because they know if they have an elevated temperature, they may need to stay longer in the hospital for treatment of an infection. Do not be tempted to rationalize such a finding with explanations such as, "The room was warm," or "She just drank some hot coffee." Although these factors may make a slight difference in body temperature, they do not affect it enough to account for an oral temperature greater than 100.4°F (38.0°C).

Nurses can help the nation achieve these goals by

carefully monitoring uterine involution in the postpartal period and by encouraging women to breastfeed even in the face of a postpartal complication.