High Risk Postpartum

Thromboembolic Conditions (2)

Nursing Assessment: Risk Factors and Signs and Symptoms. Nursing Management: Prevention, Adequate circulation: NSAIDs, bed rest, anti embolism stockings, anticoagulant therapy such as heparin; emergency measures for pulmonary embolism, Education.

Carboprost; Hemabate

Stimulates uterine contractions to reduce bleeding when not controlled by the first-line therapy of oxytocin.

A nurse is making a follow up visit to a new parent and 3-month-old infant. The nurse is talking with the client about her role as a mother and caring for her infant. Which statement by the client would lead the nurse to immediately call the health care provider?

"I am so angry with myself, I just want to give up my life right now". The client's statement about being angry at herself and wanting to give up suggests postpartum psychosis. This information would need to be reported, because there is a threat to the mother's safety and possibly the infant's safety. The nurse should not leave the client alone.

A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching?

"I should brush my teeth vigorously to stimulate the gums". The client is at risk for bleeding and as such should gently brush her teeth with a soft toothbrush to prevent injury.

Dinoprostone; Prostin E2

20 mg vaginal or rectal suppository. May be repeated every 2 hours. Nursing Implications: Monitor blood pressure frequently since hypotension is a frequent side effects along with vomiting and diarrhea, nausea, temperature elevation.

Which situation should concern the nurse treating a postpartum client within a few days of birth?

A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now.

Signs of Postpartum Hemorrhage

A uterus that DOES NOT contract or DOES NOT remain contracted. Large gush or slow, steady trickle, ooze, or dribble blood from the vagina. Saturation of one peri pad per 15 minutes. Severe, unrelieved perineal or rectal pain. TACHYCARDIA.

Methylergonovine Maleate: Nursing Implications

Assess bleeding, uterine tone, vital signs every 15 min according to protocol. Offer explanation to client and family about what is happening and purpose of medication. Monitor for possible adverse effects such as hypertension, seizures, uterine cramping, nausea, vomiting, and palpitations.

Comfort Level: Severe pelvic or rectal pain.

Assess for signs of hematoma, usually perineal or vaginal; examine vulva for masses.

Lochia: Bleeding; steady trickle, dribble, oozing, seeping, or profuse flow. Heavy, saturation.

Assess for trauma; save and weigh pads, linen savers, and bed linens for estimation. Notify healthcare provider.

Oxytocin Nursing Implications

Assess fundus for evidence of contraction, compare amount of bleeding every 15 min or according to orders. Monitor vital signs every 15 minutes. Monitor uterine tone to prevent hyperstimulation.

Prostaglandin Nursing Implications

Assess vital signs, uterine contractions, client's comfort level, and bleeding status per protocol. Offer explanation to client and family about what is happening. Monitor for possible adverse effects such as fever, chills, headache, nausea, vomiting, diarrhea, flushing, and bronchospasm.

Carboprost; Hemabate Nursing Implications

Assess vitals, uterine contractions, client's comfort level, bleeding status as per protocol. Offer explanation to client and family about what is happening, purpose of medication. Monitor for possible adverse effects: fever, chills, headache, nausea, vomiting, diarrhea, flushing, bronchospasm.

prostaglandin contraindications

Asthma or Active Cardiac Vascular Disease

Postpartum Hemorrhage

Blood loss >500mL during vaginal birth or > 1,000 mL during cesarean birth. Most common cause: Uterine atony. Therapeutic Management: focus on underlying cause. Uterine Massage. Removal of retained placental fragments, antibiotics for infection, repair of lacerations.

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates?

Blood pressure, pulse, reports of dizziness. Continue to monitor the woman's vital signs for changes. If she reports dizziness or lightheadedness when getting up, obtain her blood pressure while lying, sitting, and standing, noting any change of 10 or more.

Postpartum Danger Signs (2)

Calf pain with dorsiflexion of foot. Swelling, redness, discharge at episiotomy, epidural, or abdominal sites. Dysuria, burning, incomplete emptying of bladder. Shortness of breath, difficulty breathing without exertion. Depression, extreme mood swings.

Common Postpartum Disorders

Hemorrhage. Infection. Thromboembolic disease. Postpartum affective disorder.

Postpartum Danger Signs

Fever more than 100.4° F, 38° C. Foul-smelling lochia, unexpected change in color/amount. Large blood clots, or bleeding that saturates a peri pad in 1 hour. Severe headaches, visual changes, spots, headaches.

Postpartum Hemorrhage: Assessment and Management

Fundal massage; pad count. Administration of uterotonic. Fluid administration, monitoring for signs and symptoms of shock. Emergency measures if DIC occurs.

Skin: Cool, Damp, Pale

Look for signs of hypovolemia; vigilant assessment by entire healthcare team.

Fundus: Soft, boggy, displaced

Massage, express clots, and assist to void or catheterize; notify primary healthcare provider.

Post Partum Complications

Mastitis, URI, UTI, Thrombophlebitis, Hematoma, Abscess Formation, Endometritis, Perineal Cellulitis. Maintain Semi- Fowlers Position to localize infection. Risk Factors: Cesarean Delivery, Prolonged Range of Motion, Prolonged Labor, Bladder Cathiterization, Hemorrhage.

Signs of Postpartum Psychosis

Medical Emergency. Surfaces within 3 weeks of giving birth. Sleep disturbances, fatigue, depression, hypomania.

signs and symptoms of baby blues

Mood swings, Irritability, Weepiness, Appetite change, overwhelmed, difficulty sleeping, feeling let down, anxiety, forgetfulness.

Postpartum Affective Disorders: Assessment and Management

Risk factors, signs, symptoms. Edinburgh Scale: Mothers who score above 13 are likely to be suffering from a depressive illness of varying severity. Max Score: 30. Possible Depression: 10+. Always look at item 10 which is suicidal thoughts. Assistance with coping and adjustment, education, and referrals for support.

Urine output: Decreased urine output.

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

Postpartum Depression Risk Factors

Social support, low self-esteem, life stress, fatigue, prenatal, depression. Additional significant predictors are: prenatal anxiety, poor marital relationships, history of depression, difficult infant temperament, maternity blues, single marital status, unplanned or unwanted pregnancy.

Methylergonovine Maleate; Methergine

Stimulates the uterus or to prevent and treat postpartum hemorrhage due to atony or sub involution. 0.2 mg IM injection. May be repeated in 5 minutes and every 2 to 4 hours there after.

What causes Perinatal Mood Disorders?

The exact cause are unknown.

Carboprost; Hemabate Contraindications

active cardiac, pulmonary, renal, or hepatic disease.

Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts?

applying ice. Ice promotes comfort by decreasing blood flow or vasoconstriction, numbing the area, and discouraging further letdown of milk.

Which measurement best describes postpartum hemorrhage?

blood loss of 1,000 ml, occurring at least 24 hours after birth.

Which measurement best describes postpartum hemorrhage?

blood loss off 500 mL within 24 hours of vaginal birth and a loss of blood over 1,000 ml caesarean birth.

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes the client's history of asthma. Which medication if prescribed would the nurse question?

carboprost. Carboprost is contraindicated with asthma due to the risk of bronchial spasms.

signs postpartum depression

lack of enjoyment in life. lack of interest in others. intense feeling of inadequacy. inability to cope. loss of mental concentration. disturbed sleep. constant fatigue and feeling of ill health.

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis?

mastitis

Misoprostol (Cytotec)

safe for patients with hypertension.

Every postpartum client has the potential of hemorrhage. While assessing a client's status, which finding would be of little benefit in identifying the possibility of hemorrhage?

signs of shock. Signs of shock do not appear until the hemorrhage is far advanced due to the increased fluid and blood volume of pregnancy.

Mastitis

usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Mastitis needs to be assessed and treated with antibiotic therapy.

Methylergonovine Maleate: Nursing Implications (2)

Report any complaints of chest pain promptly. Contraindications: Hypertension. Do not give to a hypertensive client. Client may have pre existing condition of hypertension or could be at a risk for pre ecampsia.

Vital Signs: Tachycardia, decreasing pulse pressure, falling blood pressure, decreasing oxygen saturation level.

Report signs of excessive blood loss.

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder.

Who usually experiences breast engorgement?

Women who do not breastfeed often experience moderate to severe engorgement and breast pain when no treatment is applied. Ice promotes comfort by decreasing blood flow, numbing the area, and discouraging further letdown of milk.

What postpartum client should the nurse monitor most closely for signs of a postpartum infection?

a client who had a nonelective cesarean birth.

Subinvolution

Incomplete involution of the uterus after birth. Can be caused by retained placental fragments, distended bladder, uterine myoma, or infection. Complications of subinvolution are hemorrhage, pelvic peritonitis, salpingitis, abscess formation.

The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation?

Infection. Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection.

The nurse is caring for four postpartum clients, monitoring them for postpartum infection. Which client is the priority due to current vital signs suggesting a postpartum infection? Client 35 hours postpartum with a temperature of 99.6. Client 30 hours postpartum with a temperature of 100.4. Client 20 hours postpartum with a temperature of 102.4°. Client 25 hours postpartum with a temperature of 99.2°.

Postpartum infection is defined as a fever of 100.4°F (38°C) or higher after first 24 hours after childbirth, occurring on at least 2 of first 10 days after birth, exclusive of first 24 hours. Of clients listed, client at 30 hours postpartum with a temperature of 100.4°F should be monitored for postpartum infection.

Misoprostol; Cytotec

Stimulates the uterus to contract/ to reduce bleeding; a prostaglandin analog. 800 mcg per rectum, one dose. Dose ranges from 400 to 1,000 mcg.

Oxytocin; Pitocin

Stimulates the uterus to or to contract the uterus to control bleeding from the placental site. Given intravenous or Intramuscular. More commonly given IV. 20 to 40 units in a liter IV or 10 units IM.

Prostaglandin; PGF2a

Stimulates uterine contractions and is used to treat postpartum hemorrhage due to uterine atony when not controlled by other methods. 0.25 mg IM injection. May be repeated every 15 to 90 minutes, for up to 8 doses.

Hematoma

The formation of a hematoma following the escape of blood into the tissues of the reproductive sac after delivery. Predisposing conditions include operative delivery with forceps or injury to a blood vessel.

New Jersey

The state ranks 47th nationally with a mortality rate of 37 deaths per every 100,000 live births, according to the New Jersey Department of Health.

The nurse is providing care for a postpartum client who has been diagnosed with a perineal infection and who is being treated with antibiotics. What is the nurse's most appropriate intervention?

Encourage fluid intake. Adequate fluid intake is necessary during antibiotic therapy.

Increase the proportion of adults with major depressive episodes who receive treatment.

Helps foster need for early identification of risk factors and prompt intervention to reduce potential negative outcomes of pregnancy and birth. Will help minimize devastating effects of complications during postpartum period and woman's ability to care of her newborn.

Thromboembolic Conditions

Inflammation of blood vessel lining. Three most common types: Superficial thrombosis, deep vein thrombosis, pulmonary embolism. Pathophysiology: Venous Stasis, Injury to innermost layer of blood vessel. Hyper Coagulation.

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis?

Perform handwashing before breastfeeding. As a primary preventive measure to prevent mastitis, the nurse should instruct the client to perform good handwashing before breastfeeding.

Chart Review: Presence of predisposing factors.

Perform more frequent evaluation.

The nurse notes uterine atony in the postpartum client. Which assessment is completed next?

Perineal Pad. Uterine atony is a cause of PPH due to inability of uterus to contract effectively. Assessment of perineal pad for the characteristics and amount of bleeding is essential. It is important to monitor all postpartum women for excessive bleeding because two-thirds of women who experience PPH have no risk factors.

Signs of Postpartum Depression

Postpartum depression and psychosis symptoms last longer and are more severe and require treatment. May lead to poor binding, alienation from loved ones, daily dysfunction and violent thoughts or actions. Major depressive episode associated with childbirth. Symptoms lasting beyond 6 weeks and worsening.

Risk Factors for Postpartum Hemorrhage

Precipitous labor, less than 3 hours. Uterine atony. Placenta previa, abruptio placenta. induction, augmentation. Operative procedures, vacuum extraction, forceps, cesarean birth. Retained placental fragments. Prolonged third stage of labor, 30 minutes +. Multiparity, more than three births closely spaced. Uterine overdistension, large infant, twins, hydramnios.

Oxytocin Nursing Implications (2)

Reassure client about need for uterine contraction and administer analgesics for comfort. Offer explanation to client and family about what is happening and purpose of medication.

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching?

Symptoms include fever, chills, malaise, and localized breast tenderness. Mastitis is an infection of the breast characterized by flu-like symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus.

A nurse is caring for a client in the clinic. The client reports burning during urination for the past few days. Assessment reveals cloudy urine, with the presence of white blood cells (WBCs). Vital signs: temperature, 101.4°F (38.5°C); heart rate, 101 beats/min; blood pressure, 100/64 mm Hg.

The nurse should first obtain a culture for sensitivity before administering antibiotics. Once the culture has been obtained, the nurse should administer a broad-spectrum antibiotic per provider prescription. An NSAID could be administered for a fever but the priority is a culture and administering an antibiotic.

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression?

The nurse should monitor the client for symptoms such as inability to concentrate, loss of confidence, and decreased interest in life to verify the presence of postpartum depression.

Causes of Postpartum Hemorrhage

Tone: Uterine Atony. Commonly caused by distended bladder. Tissue: retained placenta and clots. Trauma: vaginal cervical, or uterine injury. Thrombin: coagulation, preexisting or acquired. Traction: causing uterine inversion.

Reduce maternal deaths

Will help to contribute to lower rates of maternal mortality by focusing on thorough risk assessments in the postpartum period of potential infections and postpartum hemorrhage.