postpartum complications identify risk factors apply pp assessment skills compare types of pp...

Postpartum ComplicationsPostpartum Complications

Identify Risk FactorsIdentify Risk FactorsApply PP Assessment SkillsApply PP Assessment Skills

Compare Types of PP HemorrhageCompare Types of PP HemorrhageDiscuss PP InfectionDiscuss PP Infection

Discuss Thromboembolic DisordersDiscuss Thromboembolic DisordersCompare PP Depression w/ PsychosisCompare PP Depression w/ Psychosis

Plan Nursing InterventionsPlan Nursing Interventions

PP ComplicationsPP Complications

• Assess postpartum client's Assess postpartum client's prenatal historyprenatal history and and ongoing labor/birthongoing labor/birth to identify risk to identify risk factors leading to postpartum complicationsfactors leading to postpartum complications

• Assess with knowledge that many Assess with knowledge that many physiologic changes of postpartum period physiologic changes of postpartum period are similar to depressionare similar to depression

• Document specific and objective Document specific and objective observationsobservations

Risk Factors for ComplicationsRisk Factors for Complications

• Overdistention of uterus due to large baby, Overdistention of uterus due to large baby, multiple gestation, multiparitymultiple gestation, multiparity

• Rapid or prolonged laborRapid or prolonged labor

• Oxytocin induction of laborOxytocin induction of labor

• Precipitous induction of laborPrecipitous induction of labor

• Precipitous delivery, cesarean sectionPrecipitous delivery, cesarean section

• PROMPROM

• Urinary catheterizationUrinary catheterization

Vital SignsVital Signs

• Elevated temperature Elevated temperature • Temperature elevations should last for only 24 hours Temperature elevations should last for only 24 hours • After 24 hours > 100.4After 24 hours > 100.4°F (38ºC) = infection°F (38ºC) = infection

• Elevated heart rate Elevated heart rate • Decreased blood volume - bradycardia rates of 50 to 70 beats Decreased blood volume - bradycardia rates of 50 to 70 beats

per minute occur during first 6 to 10 daysper minute occur during first 6 to 10 days• Tachycardia = Increased blood loss, difficult labor/birthTachycardia = Increased blood loss, difficult labor/birth

• Elevated blood pressure, low blood pressureElevated blood pressure, low blood pressure• Blood pressure should be stable, may be decreasedBlood pressure should be stable, may be decreased

• Symptoms of shockSymptoms of shock• Breath sounds clearBreath sounds clear

BUBBLEHE ASSESSMENTBUBBLEHE ASSESSMENT

• B = BreastB = Breast• U = UterusU = Uterus• B = BladderB = Bladder• B = BowelsB = Bowels• L = LochiaL = Lochia• E = Episiotomy, Laceration, C/S Incision E = Episiotomy, Laceration, C/S Incision • H = Homan’s sign, HemorrhoidsH = Homan’s sign, Hemorrhoids• E = Emotional status, bondingE = Emotional status, bonding

BUBBLEHE AssessmentBUBBLEHE Assessment

• Breasts – Cracked, blistered, or bleeding nipplesBreasts – Cracked, blistered, or bleeding nipples• Note engorgement, red streaks, lumps, clogged milk ductsNote engorgement, red streaks, lumps, clogged milk ducts

• Assess for mastitisAssess for mastitis• Erythema, heat in breastErythema, heat in breast• Fever, chills, malaise, headacheFever, chills, malaise, headache• Engorgement, pain Engorgement, pain • Supplemental feedingsSupplemental feedings• Change in routine or infant feeding patternsChange in routine or infant feeding patterns• Abrupt weaningAbrupt weaning

• Treatment: Proper latch-on technique, encourage frequent Treatment: Proper latch-on technique, encourage frequent feeding, position changes during feedings, fluid intake feeding, position changes during feedings, fluid intake 3000mL/day, antibiotics, analgesics, warm compresses, 3000mL/day, antibiotics, analgesics, warm compresses, can breastfeed or pump w/ mastitiscan breastfeed or pump w/ mastitis


• Uterus – Position height, tone (bogginess), Uterus – Position height, tone (bogginess), position out of midline, heavy lochia flowposition out of midline, heavy lochia flow• Uterine atony Uterine atony - Lack of uterine muscle tone - - Lack of uterine muscle tone -

caused by conditions that overdistend uterus and caused by conditions that overdistend uterus and affect uterine contractibility, and medicationaffect uterine contractibility, and medication

• Perform fundal massage and check for clotsPerform fundal massage and check for clots• Administer uterine stimulants (oxytocin) as ordered to Administer uterine stimulants (oxytocin) as ordered to

monitor for side effectsmonitor for side effects

• Uterus is firm and if there is bright red bleeding - Uterus is firm and if there is bright red bleeding - this may indicate lacerationthis may indicate laceration

• Contact physician – need for suture of lacerationContact physician – need for suture of laceration


• Bladder - Assess frequency, burning, or Bladder - Assess frequency, burning, or urgency - palpate for bladder distentionurgency - palpate for bladder distention• Have patient void frequentlyHave patient void frequently• In & Out catheterize if necessaryIn & Out catheterize if necessary• Insert indwelling urinary catheter – color, odor, Insert indwelling urinary catheter – color, odor,

amount amount

• Bowel: Assess bowel sounds, flatus, and Bowel: Assess bowel sounds, flatus, and distentiondistention• Increase fluids and fiber in dietIncrease fluids and fiber in diet• Administer stool softenersAdminister stool softeners


• Lochia - examine perineal pads - NoteLochia - examine perineal pads - Note• AmountAmount• Color and odorColor and odor• ConsistencyConsistency• Presence and size of clotsPresence and size of clots


• Episiotomy/Laceration/C/S Incision - Inspect Episiotomy/Laceration/C/S Incision - Inspect for REEDA, painfor REEDA, pain• Mediolateral episiotomies for increased bleedingMediolateral episiotomies for increased bleeding

• R = RednessR = Redness

• E = EdemaE = Edema

• E = EcchymosisE = Ecchymosis

• D = Discharge, DrainageD = Discharge, Drainage

• A = ApproximationA = Approximation


• ExtremitiesExtremities• Assess for pedal edema, rednessAssess for pedal edema, redness

and warmth and warmth • Check Homan's sign every shift Check Homan's sign every shift

• Hemorrhoids – AssessHemorrhoids – Assess


• Emotional Status - Focuses on mother's Emotional Status - Focuses on mother's general attitude, feelings of competence, general attitude, feelings of competence, support systems, care giving skill - evaluates support systems, care giving skill - evaluates fatigue and ability to accomplish fatigue and ability to accomplish developmental taskdevelopmental task• Determine mother's phase of adjustment to Determine mother's phase of adjustment to

parentingparenting

• BondingBonding• DescribeDescribe level of attachment to infant level of attachment to infant

Pain Assessment and MedicationPain Assessment and Medication

• Postpartum client may need medications to Postpartum client may need medications to promote comfort, treat anemia, prevent rubella, promote comfort, treat anemia, prevent rubella, and prevent development of antigens (in and prevent development of antigens (in nonsensitized Rh-negative woman)nonsensitized Rh-negative woman)

• Postpartum clients should be informed about Postpartum clients should be informed about name of medication, expected action, possible name of medication, expected action, possible side effectsside effects

• Nurse must review safety measures with Nurse must review safety measures with medicationsmedications


• Relief of Perineal DiscomfortRelief of Perineal Discomfort• Ice packsIce packs• Topical agents (Epifoam)Topical agents (Epifoam)• Perineal carePerineal care

• Relief of hemorrhoidal discomfort may includeRelief of hemorrhoidal discomfort may include• Sitz bathsSitz baths• Topical anesthetic ointments (Nupercainal)Topical anesthetic ointments (Nupercainal)• Rectal suppositoriesRectal suppositories• Witch hazel pads (Tucks)Witch hazel pads (Tucks)

A sitz bath promotes healing and provides relief from perineal discomfort during the initial weeks following birth.


• AfterpainsAfterpains• Positioning (prone position)Positioning (prone position)• Analgesia administered an hour before Analgesia administered an hour before

breastfeedingbreastfeeding• Encourage early ambulation - monitor for Encourage early ambulation - monitor for

dizziness and weaknessdizziness and weakness


• Cesarean section: Cesarean section: • Administer analgesics within the first 24 to 72 hours - allows Administer analgesics within the first 24 to 72 hours - allows

woman to become more mobile and activewoman to become more mobile and active• Morphine PCA, oxycodone, ibuprofen, acetaminophen ESMorphine PCA, oxycodone, ibuprofen, acetaminophen ES

• Encourage non-pharmacologic methods of pain relief Encourage non-pharmacologic methods of pain relief (breathing, relaxation, and distraction) - encourage rest, (breathing, relaxation, and distraction) - encourage rest, proper positioning, back rubs, and oral careproper positioning, back rubs, and oral care

• Encourage visits by family and newborn, which provides distraction Encourage visits by family and newborn, which provides distraction

• Position client on left side, include exercises, early Position client on left side, include exercises, early ambulation, avoid carbonated beverages and straws - may ambulation, avoid carbonated beverages and straws - may need enemas, stool softeners, “hot toddy”need enemas, stool softeners, “hot toddy”

LabsLabs

• White blood cell count often elevated after deliveryWhite blood cell count often elevated after delivery• 25,000 to 30,000mm25,000 to 30,000mm³³• Return to normal in one weekReturn to normal in one week

• Platelet levels fall w/ placental separationPlatelet levels fall w/ placental separation• Return to normal by 6Return to normal by 6thth PP week PP week

• Activation of clotting factors predispose to thrombus Activation of clotting factors predispose to thrombus formationformation• Hemostatic system reaches non-pregnant state in 3 to 4 Hemostatic system reaches non-pregnant state in 3 to 4

weeksweeks

• Monitor hemoglobin and hematocrit - assess for signs Monitor hemoglobin and hematocrit - assess for signs of anemiaof anemia

PP HemorrhagePP Hemorrhage

• > 500 mL of blood after vaginal birth> 500 mL of blood after vaginal birth• >1000mL of blood after cesarean section >1000mL of blood after cesarean section • Causes:Causes:

• Uterine atonyUterine atony• Hematoma, lacerationHematoma, laceration• Uterine inversionUterine inversion• Bladder distentionBladder distention• Delivery after circlageDelivery after circlage


• Interventions:Interventions:• Massage fundus, inspect perineum, pad count Massage fundus, inspect perineum, pad count • Voiding frequently or catheterizeVoiding frequently or catheterize• IV fluidsIV fluids• a. oxytocin (20 units per 1000ml IV) 50 mu/min or 10 – a. oxytocin (20 units per 1000ml IV) 50 mu/min or 10 –

20 units IM (monitor fluid levels)20 units IM (monitor fluid levels) b. methylergonovine (Methergine) 0.2 mg IM b. methylergonovine (Methergine) 0.2 mg IM

(hypertension, seizures)(hypertension, seizures) c. prostaglandin F (Hemabate, Carboprost) 0.25 mg IM c. prostaglandin F (Hemabate, Carboprost) 0.25 mg IM

or intramyometrially by MD (N/V, diarrhea, h/a, or intramyometrially by MD (N/V, diarrhea, h/a, bradycardia, wheezing, cough, chills, fever)bradycardia, wheezing, cough, chills, fever)

• Notify health care providerNotify health care provider• Check CBC results Check CBC results

• Hemoglobin (12-16 g/dL), hematocrit (37-47%)Hemoglobin (12-16 g/dL), hematocrit (37-47%)


• Late hemorrhageLate hemorrhage• Retained placental fragmentsRetained placental fragments

• Commonly occurs when fundus is massaged prior to spontaneous Commonly occurs when fundus is massaged prior to spontaneous placental separation placental separation

• Suspect if patient is bleeding with firm fundus and no lacerationSuspect if patient is bleeding with firm fundus and no laceration• Inspect placenta thoroughly after its deliveryInspect placenta thoroughly after its delivery

• SubinvolutionSubinvolution• Usually occurs 1 to 2 weeks after birthUsually occurs 1 to 2 weeks after birth• Failure of uterus to return to normal size after pregnancy - lochia Failure of uterus to return to normal size after pregnancy - lochia

rubra of greater than 2 weeks duration rubra of greater than 2 weeks duration • InfectionInfection

• Provide patient with discharge instructions and Provide patient with discharge instructions and information about possible complicationsinformation about possible complications

Thromboembolic DisorderThromboembolic Disorder

• Risk of thromboembolism lasts 6 weeksRisk of thromboembolism lasts 6 weeks• Superficial – risk greater 3 – 4- days PPSuperficial – risk greater 3 – 4- days PP

• Redness, warmth, tenderness, swelling over clot areaRedness, warmth, tenderness, swelling over clot area

• Deep vein thrombosisDeep vein thrombosis• Homan's positive sign, pain, fever and chills, paleness and Homan's positive sign, pain, fever and chills, paleness and

swelling in lower extremitiesswelling in lower extremities• Assess for pulmonary embolusAssess for pulmonary embolus

• Ultrasound, CT scan, venographyUltrasound, CT scan, venography• Clotting times, PT, PTT, INRClotting times, PT, PTT, INR

Thromboembolic DisorderThromboembolic Disorder

• Treatment Treatment • Anticoagulant therapy - labsAnticoagulant therapy - labs

• Bedrest w/ elevation of legBedrest w/ elevation of leg

• Daily measurement of calf & thighDaily measurement of calf & thigh

• Elastic support stockingsElastic support stockings

• Warm, moist packs to legWarm, moist packs to leg

• Encourage early ambulationEncourage early ambulation

• For clients on bed rest, turn and do range of motion For clients on bed rest, turn and do range of motion exercises, encourage fluids to avoid dehydration, exercises, encourage fluids to avoid dehydration, encourage no smoking, advise against prolonged sitting encourage no smoking, advise against prolonged sitting or crossing legs, avoid rubbing area or crossing legs, avoid rubbing area

PP InfectionPP Infection

• Fever (>100.4Fever (>100.4°F, 38°F, 38C)C), purulent discharge , purulent discharge from vagina or incision, erythema at incision from vagina or incision, erythema at incision site, burning during urination, redness/pain site, burning during urination, redness/pain in breast about fourth postpartum weekin breast about fourth postpartum week

• Report signs of Report signs of severe infectionsevere infection: Foul-: Foul-smelling lochia, uterine tenderness/ smelling lochia, uterine tenderness/ subinvolution, severe lower abdominal pain, subinvolution, severe lower abdominal pain, change in vital signs, chills, lethargy, change in vital signs, chills, lethargy, nausea/vomiting, abdominal guardingnausea/vomiting, abdominal guarding


• Cesarean section Cesarean section • Pulmonary infections may occur because of Pulmonary infections may occur because of

immobility and use of narcotics because of immobility and use of narcotics because of altered immune response altered immune response

• Wound infectionWound infection• REEDA assessment of incisionREEDA assessment of incision


• Increase in WBC > 30% in 6 hoursIncrease in WBC > 30% in 6 hours• Teach hygieneTeach hygiene• Adequate fluids, diet high in protein, Adequate fluids, diet high in protein,

vitamin Cvitamin C• Administer antibiotics, pain medicationAdminister antibiotics, pain medication• Wound careWound care• RestRest• Fowler’s position with metritis to promote Fowler’s position with metritis to promote

drainage of lochiadrainage of lochia

PP Depression/PsychosisPP Depression/Psychosis

• Depression: Overwhelming sadness, low self-esteem, Depression: Overwhelming sadness, low self-esteem, lack of desire to care for child lack of desire to care for child

• Depression more severe in Depression more severe in primiparasprimiparas than in than in multiparasmultiparas

• Observe for episodic tearfulness, Observe for episodic tearfulness,

feels overwhelmed, unable to cope, fatigued, feels overwhelmed, unable to cope, fatigued,

anxious, irritable, oversensitive, suicidalanxious, irritable, oversensitive, suicidal• Observe new mother for objective signs of depression Observe new mother for objective signs of depression

- listen for feelings of failure and self accusation- listen for feelings of failure and self accusation

PPDepression/PsychosisPPDepression/Psychosis

• PsychosisPsychosis• Evident within 3 months PPEvident within 3 months PP• Agitation, hyperactivity, insomnia, mood Agitation, hyperactivity, insomnia, mood

lability, confusion, irrationality, difficult lability, confusion, irrationality, difficult remembering or concentrating, poor judgment, remembering or concentrating, poor judgment, delusions, hallucinationsdelusions, hallucinations

• Increased recurrence in Increased recurrence in

subsequent pregnancies subsequent pregnancies

PP Depression/PsychosisPP Depression/Psychosis

• Identify risk factors prenatallyIdentify risk factors prenatally• Ambivalence, lack of support, dissatisfaction w/ Ambivalence, lack of support, dissatisfaction w/

self, primiparity, history PP depression or bipolarself, primiparity, history PP depression or bipolar

• Referral for counseling, support groupsReferral for counseling, support groups• MedicationMedication

• Lithium, antipsychotics, antidepressantsLithium, antipsychotics, antidepressants

• ECT w/ psychotherapyECT w/ psychotherapy• Removal of infantRemoval of infant• SupportSupport

Nursing DiagnosesNursing Diagnoses

• ConstipationConstipation related to fear of tearing stitches related to fear of tearing stitches or painor pain

• Acute painAcute pain related to perineal edema related to perineal edema episiotomy, laceration, incision from birthepisiotomy, laceration, incision from birth

• Health-seeking behaviorsHealth-seeking behaviors: Information about : Information about infant care related to expressed desire to infant care related to expressed desire to improve parenting skillsimprove parenting skills

• Readiness for enhanced family copingReadiness for enhanced family coping related related to successful adjustment to new babyto successful adjustment to new baby

Nursing DiagnosesNursing Diagnoses

• Ineffective breastfeedingIneffective breastfeeding related to related to improper latch-on by infantimproper latch-on by infant

• Altered tissue perfusionAltered tissue perfusion related to related to obstructed venous return obstructed venous return

• Risk for injuryRisk for injury related to spread of infection related to spread of infection

• Risk for altered parentingRisk for altered parenting related to related to decreased maternal-infant interactiondecreased maternal-infant interaction

Teach for Postpartum Self-CareTeach for Postpartum Self-Care

• Teach patient Teach patient normal adaptationnormal adaptation: : • Progressive descent of fundus, no reversal of lochia Progressive descent of fundus, no reversal of lochia

- be aware of postpartum fatigue and obtain extra - be aware of postpartum fatigue and obtain extra restrest

• Teach about Teach about nutritional needsnutritional needs: : • Adequate hydration, dietary measure if anemic, Adequate hydration, dietary measure if anemic,

nutritional needs for breastfeedingnutritional needs for breastfeeding

• Teach about Teach about comfort measurescomfort measures, , activityactivity, , methods to methods to prevent fatigueprevent fatigue, , coping skillscoping skills

Teach for Postpartum Self-CareTeach for Postpartum Self-Care

• Teach to watch for Teach to watch for infectioninfection of incisions of incisions

• Patient needs to be aware of action of Patient needs to be aware of action of prescribed prescribed medicationsmedications and potential and potential side side effectseffects

• Teach to watch for Teach to watch for overwhelming feelingsoverwhelming feelings of sadness or of sadness or inability to care for infantinability to care for infant • Provide list of support organizations in the Provide list of support organizations in the

communitycommunity

NCLEX QuestionNCLEX Question

On examining a client who gave birth 3 hours ago, a On examining a client who gave birth 3 hours ago, a nurse finds the client has completely saturated a nurse finds the client has completely saturated a perineal pad within 15 minutes. Which actions perineal pad within 15 minutes. Which actions should the nurse take? Select all that apply.should the nurse take? Select all that apply.

A. Begin an IV infusion of Lactated Ringer’s solutionA. Begin an IV infusion of Lactated Ringer’s solution

B. Assess the patient’s vital signsB. Assess the patient’s vital signs

C. Palpate the patient’s fundusC. Palpate the patient’s fundus

D. Place the patient in high Fowler’s positionD. Place the patient in high Fowler’s position

E. Administer a pain medicationE. Administer a pain medication


The nurse observes several interactions between a mother The nurse observes several interactions between a mother and her new son. Which behaviors by the mother would and her new son. Which behaviors by the mother would the nurse identify as evidence of mother-infant the nurse identify as evidence of mother-infant attachment? Select all that apply.attachment? Select all that apply.

A. Talks and coos to her sonA. Talks and coos to her son

B. Cuddles her son close to herB. Cuddles her son close to her

C. Doesn’t make eye contact with her sonC. Doesn’t make eye contact with her son

D. Requests the nurse to take the baby to the nursery for D. Requests the nurse to take the baby to the nursery for feedingsfeedings

E. Encourages the father to hold the babyE. Encourages the father to hold the baby

F. Takes a nap when the baby is sleeping F. Takes a nap when the baby is sleeping


The nurse is instructing the client on breastfeeding. The nurse is instructing the client on breastfeeding. Which instructions should the nurse include to help the Which instructions should the nurse include to help the mother prevent mastitis?mother prevent mastitis?Select all that apply.Select all that apply.

A. A. Wash nipples with soap and waterWash nipples with soap and water

B. Change the breast pads frequentlyB. Change the breast pads frequentlyC. Expose nipples to air part of each dayC. Expose nipples to air part of each dayD. Wash hands before handling breast and breastfeedingD. Wash hands before handling breast and breastfeedingE. Make sure the baby grasps only the nippleE. Make sure the baby grasps only the nippleF. Release baby’s grasp on nipple before removing from F. Release baby’s grasp on nipple before removing from

breast breast


Which lab values indicate normal coagulation Which lab values indicate normal coagulation status?status?

A.A.PT – 10 seconds, PTT – 50 seconds, INR – 1PT – 10 seconds, PTT – 50 seconds, INR – 1

B.B.PT – 15 seconds, PTT – 90 seconds, INR – 5PT – 15 seconds, PTT – 90 seconds, INR – 5

C.C.PT – 12 seconds, PTT – 65 seconds, INR – 3PT – 12 seconds, PTT – 65 seconds, INR – 3

D.D.PT – 14 seconds, PTT – 75 seconds, INR - 4PT – 14 seconds, PTT – 75 seconds, INR - 4

postpartum complications identify risk factors apply pp assessment skills compare types of pp...

Documents

postpartum complicationsassess

position changes

increased blood loss

uterine muscle tone

uterine contractibility

homans sign

bowel sounds

warmth check homans