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Lecture 16

Nursing Care of a Family Experiencing a Postpartal Complication

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Objectives

Describe common deviations from the normal that can occur during the puerperium.
Establish a nursing care plan for a woman experiencing postpartum complications such as hemorrhage, infection, and psychosis.

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Postpartal Hemorrhage

Hemorrhage, one of the most important causes of maternal mortality associated with childbearing, poses a possible threat throughout pregnancy.
It is a major potential danger in the immediate postpartal period.
Traditionally, postpartal hemorrhage has been defined as any blood loss from the uterus greater than 500 mL within a 24-hour period.

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Postpartal Hemorrhage

Hemorrhage may occur either early (i.e., within the first 24 hours), or late (anytime after the first 24 hours during the remaining days of the 6-week puerperium).
The greatest danger of hemorrhage is in the first 24 hours because of the grossly denuded and unprotected area left after detachment of the placenta.
There are four main causes for postpartal hemorrhage: uterine atony, lacerations, retained placental fragments, and disseminated intravascular coagulation.

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Postpartal Hemorrhage

Uterine Atony:

Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartal hemorrhage.
The uterus must remain in a contracted state after birth to allow the open vessels at the placental site to seal.
Factors that predispose to poor uterine tone and an inability to maintain a contracted state are summarized in Box 23.3.

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Postpartal Hemorrhage

When caring for a client in whom any of these conditions are present, be especially cautious in your observations and be on guard for signs of uterine bleeding.
This is especially important because many postpartal clients are discharged within 48 hours after birth.

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Postpartal Hemorrhage (cont’d)

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Postpartal Hemorrhage

The first step in controlling hemorrhage is to attempt uterine massage to encourage contraction (Box 23.4). 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.

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Postpartal Hemorrhage

With uterine atony, even if the uterus responds well to massage, the problem may not be completely resolved. After you remove your hand from the fundus, the uterus may relax and the lethal seepage may begin again.
Therefore, remain with the woman after massaging her fundus, to be certain the uterus is not relaxing again. Observe carefully, including fundal height and consistency and lochia, for the next 4 hours.

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Postpartal Hemorrhage

If a uterus cannot remain contracted, the physician or nurse-midwife probably will order a dilute intravenous infusion of oxytocin (Pitocin) to help the uterus maintain tone.
Intramuscular methylergonovine (Methergine), an ergot compound, is a second possibility.

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Postpartal Hemorrhage

Additional measure that can be helpful are the following:

Offer a bedpan or assist the woman with ambulating to the bathroom at least every 4 hours to keep her bladder empty. A full bladder pushes an uncontracted uterus into an even more uncontracted state. To reduce bladder pressure, insertion of a urinary catheter may be ordered.
If the woman is experiencing respiratory distress from decreasing blood volume, administer oxygen by face mask at a rate of 4 L/minute. Position her supine to allow adequate blood flow to her brain and kidneys.

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Postpartal Hemorrhage

Obtain vital signs frequently and make sure to interpret them accurately, looking for trends. For example, a continuously rising pulse rate is an ominous pattern.
Hysterectomy: In the rare instance of extreme uterine atony, ligation of the uterine arteries or a hysterectomy may be necessary.

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Postpartal Hemorrhage

Lacerations:

Small lacerations or tears of the birth canal are common and may be considered a normal consequence of childbearing. However, large lacerations are complications. They occur most often in the following circumstances:

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Postpartal Hemorrhage

With difficult or precipitate births
In primigravidas
With the birth of a large infant (more than 9 lb)
With the use of a lithotomy position and instruments
Either cervical, vaginal, or perineal lacerations may occur. After birth, any time a uterus feels firm but bleeding persists, suspect a laceration of one of these three sites.

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Postpartal Hemorrhage

Retained Placental Fragments:

Occasionally, a placenta does not deliver in its entirety; fragments of it separate and are left behind. 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— 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.

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Postpartal Hemorrhage

Assessment

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 blood.
On examination, usually the uterus is not fully contracted. Retained placental fragments also may be detected by sonography.

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Postpartal Hemorrhage

Therapeutic Management

Removal of the placental fragment is necessary to stop the bleeding.
Usually, a dilatation and curettage (D&C) is performed to remove the placental fragment. In some instances, placenta accreta is so deeply attached that it cannot be surgically removed.

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Postpartal Hemorrhage

Methotrexate may be prescribed in these instances to destroy the retained placental tissue (Kay, 2003).
Because the hemorrhage from retained fragments may be delayed until after a woman is at home, be certain the client knows to continue to observe the color of lochia discharge and to report any tendency for the discharge to change from lochia serosa or alba back to rubra.

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Postpartal Hemorrhage

Disseminated Intravascular Coagulation:

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.

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Postpartal Hemorrhage

Subinvolution:

Subinvolution is: incomplete return of the uterus to its prepregnant size and shape.
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, or an accompanying problem (e.g., a myoma) that is interfering with complete contraction.

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Postpartal Hemorrhage

Therapeutic Management

Oral administration of Methergine, 0.2 mg four times daily, usually is prescribed to improve uterine tone and complete involution.
If the uterus is tender to palpation, suggesting endometritis, an oral antibiotic also may be prescribed.
A chronic loss of blood from subinvolution will result in infection or anemia and lack of energy, conditions that possibly could interfere with bonding

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Postpartal Hemorrhage (cont’d)

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Puerperal Infection

Infection of the reproductive tract is another leading cause of maternal mortality.
Factors that predispose women to infection in the postpartal period are shown in Box 23.6.
The risk of infection is even greater if tissue edema and trauma are present.

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Puerperal Infection

If infection occurs, the prognosis for complete recovery depends on many factors, including the following:

- Virulence of the invading organism

- The woman's general health

- Portal of entry

- Degree of uterine involution

- Presence of lacerations in the reproductive tract.

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Puerperal Infection

Infection of the Perineum
endometritis
Peritonitis
Thrombophlebitis
Mastitis

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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 it is associated with chorioamnionitis and cesarean birth

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Endometritis:�

Assessment

The fever of endometritis (more than 100.4°F (38°C) usually manifests on the third or fourth postpartal day,

- elevated WBC not of great value in the puerperium. WHY?

- chills, loss of appetite, and general malaise.

- Uterus not well contracted and is painful to the touch.

- strong afterpains.

- culture from the vagina, using a sterile swab

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Endometritis:�Assessment

Lochia usually is

- dark brown and has a foul odor.

- may be increased in amount because of poor uterine involution, but if the infection is accompanied by high fever, lochia may be scant or absent.

Sonography may be ordered to confirm the presence of placental fragments that are adding to the infection.

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Endometritis:�Therapeutic Management

- appropriate antibiotic, such as clindamycin (Cleocin), as determined by a culture of the lochia.

- An oxytocic agent such as Methergine may be prescribed to encourage uterine contraction.

- additional fluid

- analgesic for pain relief.

- Sitting in a Fowler's position or walking encourages lochia drainage by gravity

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Endometritis:�Therapeutic Management

-- good hand washing techniques before and after handling pads.

-- clients’ teaching about the signs and symptoms of endometritis is essential.

-- course of infection is about 7 to 10 days.

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Endometritis:�Therapeutic Management

-- may be discharged home on intravenous antibiotic therapy with follow-up by a home care nurse.

-- interference with future fertility.

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Peritonitis

Peritonitis: infection of the peritoneal cavity, is usually an extension of endometritis.

- major cause of death from puerperal infection.

The infection spreads 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.

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Peritonitis: Assessment

Symptoms :

- rigid abdomen,

- abdominal pain,

- high fever,

- rapid pulse,

- vomiting, and

- the appearance of being acutely ill.

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Peritonitis: �Therapeutic Management

- Peritonitis is often accompanied by paralytic ileus (blockage of inflamed intestines). This requires insertion of a nasogastric tube to prevent vomiting and rest the bowel.

- Intravenous fluid or total parenteral nutrition may be necessary.

- need analgesics for pain relief.

- large doses of antibiotics to treat the infection.

- Her hospital stay will be extended, but with effective antibiotic therapy, the outcome usually is good.

- Peritonitis can interfere with future fertility, because it leaves scarring and adhesions in the peritoneum.

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Thrombophlebitis

Phlebitis is inflammation of the lining of a blood vessel.

Thrombophlebitis is inflammation with the formation of blood clots.

usually an extension of an endometrial infection.

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Thrombophlebitis

It tends to occur for the following reasons:

- The fibrinogen level is still elevated from pregnancy, leading to increased blood clotting

- Dilatation of lower extremity veins is still present

- The relative inactivity of the period or a prolonged time spent in delivery or birthing room stirrups leads to pooling, stasis, and clotting of blood in the lower extremities

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Thrombophlebitis

is classified as:

1- superficial vein disease (SVD) or

2- deep vein thrombosis (DVT).

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Thrombophlebitis:� Women most prone to thrombophlebitis

- obese,

- have varicose veins,

- have had a previous thrombophlebitis,

- are older than 30 years of age with

- increased parity, or

- have a high incidence of thrombophlebitis in their family

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Thrombophlebitis:� how to prevent ?

-- Prevention of endometritis

-- Ambulation and limiting the time a woman remains in obstetric stirrups

--Use a well padded stirrups to prevent any sharp pressure

--If the woman had varicose veins during pregnancy, wearing support stockings for the first 2 weeks after delivery

- If these are prescribed, be certain the woman puts them on before she rises in the morning.

- remove the support stockings twice daily and assess the skin

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Femoral Thrombophlebitis (milk leg)

- the femoral, saphenous, or popliteal veins are involved.

- can accompanying arterial spasm often diminishes arterial circulation to the leg as well.

- This decreased circulation, along with edema, gives the leg a white or drained appearance.

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femoral thrombophlebitis: �Assessment

- elevated temperature,

- chills,

- pain, and

- redness in the affected leg about 10 days after birth.

- swelling of the leg below the lesion

- The skin becomes so stretched from swelling that it appears shiny and white.

- The diameter of the leg at thigh or calf level may be increased compared with the other side.

- Doppler ultrasonography or contrast venography usually is ordered to confirm the diagnosis.

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Femoral Thrombophlebitis Therapeutic Management

- bed rest

- with the affected leg elevated,

- administration of anticoagulants,

- and application of moist heat.

- may be cared for at home or may have to return to the hospital

- Provide good back, buttocks, and heel care.

- Check for bed wrinkles so that the woman does not develop the secondary problem of a pressure ulcer while on bed rest.

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Femoral Thrombophlebitis Therapeutic Management

- Never massage the skin over the clot; this could loosen the clot, causing a pulmonary or cerebral embolism.

- Heat supplied by a moist, warm compress can help decrease inflammation.

- offer reading material about newborns. This activity helps her maintain bed rest and also educates her about infant care.

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Femoral Thrombophlebitis Therapeutic Management

- administration of an analgesic.

- An appropriate antibiotic to reduce the initial infection

- an anticoagulant (coumarin derivative or heparin) or a thrombolytic agent such as streptokinase or urokinase is prescribed to dissolve the clot

- Blood coagulation levels are measured daily before administration of the anticoagulant.

- a baseline activated partial thromboplastin time (APTT) or prothrombin time (PT) is obtained.

- Protamine sulfate, the antagonist for heparin, should be readily available any time heparin is administered.

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Femoral Thrombophlebitis Therapeutic Management

- breast-feed while receiving heparin.

- If she does not wish to breast-feed, she can be switched to warfarin (antidote is vitamin K)

- Lochia usually increases

- assess for other possible sites of bleeding

- takes 4 to 6 weeks before it is resolved.

- The affected leg may never return to its former size and may always cause discomfort after long periods of standing.

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Pelvic Thrombophlebitis

-- Pelvic thrombophlebitis involves:

- the ovarian,

- uterine, or

- hypogastric veins.

--It usually follows a mild endometritis.

-- Risk factors are the same as for femoral thrombophlebitis. �

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Pelvic thrombophlebitis

Pelvic thrombophlebitis occurs later than femoral thrombophlebitis, often around the 14th or 15th day of the puerperium.

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Pelvic thrombophlebitis:�Assessment

-- The woman suddenly becomes extremely ill,

-- a high fever, chills, and

-- general malaise.

-- results in: a pelvic abscess.

-- It can become systemic and result in

- a lung,

- kidney, or

- heart valve abscess.

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Pelvic thrombophlebitis:�Therapeutic Management

-- total bed rest and

-- administration of antibiotics and

-- anticoagulants.

-- The disease runs a long course of 6 to 8 weeks.

-- If an abscess forms, it can be located and incised by laparotomy, if necessary.

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Pelvic thrombophlebitis:�

-- high mortality rate (with abcess).

-- interfere with future fertility.

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preventive measures to reduce the risk of recurrence of thrombophlebitis

- These measures include:

- not wearing constricting clothing on the lower extremities,

- resting with the feet elevated, and

- ambulating daily during pregnancy.

- tell her physician or nurse-midwife about her history

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Pulmonary Embolus�

A pulmonary embolus is obstruction of the pulmonary artery by a blood clot; it usually occurs as a complication thrombophlebitis.

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signs of pulmonary embolus

-- sudden, sharp chest pain;

-- tachypnea;

-- tachycardia;

-- orthopnea (inability to breathe except in an upright position); and

-- Cyanosis

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pulmonary embolus:�management

- This is an emergency.

- needs oxygen administered immediately and

- is at high risk for cardiopulmonary arrest.

- clot is lysed or adheres to the pulmonary artery wall and is reabsorbed.

- transferred to an intensive care unit for continuing care.

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Puerperal Infection/ 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, measures that prevent cracked and fissured nipples also help prevent mastitis.
These measures include the following:

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Puerperal Infection/ Mastitis �

Making certain the baby is positioned correctly and grasps the nipple properly, including both nipple and areola.
Releasing a baby's grasp on the nipple before removing the baby from the breast.
Washing hands between handling perineal pads and touching the breasts.
Exposing nipples to air for at least part of every day.
Using a vitamin E ointment to soften nipples daily.

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Puerperal Infection/ Mastitis �

Mastitis is usually unilateral, although epidemic mastitis, because it originates with the infant, may be bilateral.
The affected breast shows localized pain, swelling, and redness.
accompanies these first symptoms within hours, and breast milk becomes scant.

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Puerperal Infection/ Mastitis �

Therapeutic Management

The woman is prescribed a broad-spectrum antibiotic.
Breast-feeding is continued, because keeping the breast emptied of milk helps to prevent growth of bacteria.
Some women find an infected breast too painful to allow their infant to suck and prefer to express milk manually from the affected breast until the antibiotic has taken effect and the mastitis has diminished (about 3 days).

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Puerperal Infection/ Mastitis

Cold or ice compresses and a good supportive bra provide much pain relief until the process improves.
Warm, wet compresses may be ordered to reduce inflammation and edema.
If therapy is started as soon as symptoms are apparent, the condition runs a short course of about 2 or 3 days.
If left untreated, a breast infection can become a localized abscess.

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Puerperal Infection/ Mastitis

This may involve a large portion of the breast and rupture through the skin, with thick, purulent drainage, necessitating incision and drainage of the abscess.
If an abscess forms, breast-feeding on that breast is discontinued.
However, the woman is encouraged to continue to pump breast milk until the abscess has resolved, to preserve breast-feeding. Some women find that the infected breast is too tender to do this.

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Postpartal Psychosis�

- psychosis exists when a person has lost contact with reality

- 1 woman in 500

- during the year after the birth

- it is probably a response to the crisis of childbearing.

-The majority of these women have had symptoms of mental illness before pregnancy.

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Postpartal Psychosis:�What precipitated the illness

- a death in the family,

- loss of a job or income,

- divorce, or

- some other major life crisis

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Postpartal Psychosis:�signs

1. sad.

2. may deny that she has had a child and, when the child is brought to her, insist that she was never pregnant.

3. She may voice thoughts of infanticide or that her infant is possessed (mad).

4. when deny her thoughts she may respond with anger or become equally threatening.

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Postpartal Psychosis:�management

- requires referral to a professional psychiatric counselor and

- antipsychotic medication.

- do not leave the woman alone (may harm herself or infant).

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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 probably is related to hormonal shifts as the levels of estrogen, progesterone, and gonadotropin-releasing hormone in her body decline or rise.

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Postpartal Depression

In a few women, these normal feelings continue beyond the immediate postpartal period and may even be present for longer than 1 year (Box 23.12).
In addition to an overall feeling of sadness, a woman may notice:

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Postpartal Depression

- extreme fatigue

an inability to stop crying,
increased anxiety about her own or her infant's health,
insecurity,
psychosomatic symptoms (nausea and vomiting, diarrhea),
either depressive or manic mood fluctuations.
Depression of this kind is termed postpartal depression and reflects a more serious problem than normal “baby blues”.
Postpartal depression is less serious than postpartal psychosis which is a psychiatric condition.

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Postpartal Depression

Risk factors for postpartal depression include:
A history of depression
A troubled childhood
Low self-esteem
Stress in the home or at work
Lack of effective support people

- Differences between partners if a woman wants a pregnancy and her partner does not could play a major role.

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Question

Which of the following is the most frequent reason for postpartum hemorrhage?
Endometritis
Uterine atony
Perineal lacerations
Disseminated intravascular coagulation

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Answer

B. Uterine atony
Rationale: When a uterus does not contract well, the denuded placental surface can bleed excessively.

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Question

A postpartal woman calls you into her room because she is having a very heavy lochia flow containing large clots. Your first action would be to
assess her blood pressure.
palpate her fundus.
have her turn to her left side.
assess her perineum.

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Answer

B. Palpate her fundus
Rationale: Palpating the fundus will cause it to contract and reduce bleeding.

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Question

A postpartum woman is diagnosed as having endometritis. Which position would you expect to place her in based on this diagnosis?
Flat in bed
On her left side
Trendelenburg
Semi-Fowler’s

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Answer

D. Semi-Fowler’s
Rationale: A semi-Fowler’s position encourages lochia to drain so it will not become stagnant and cause further infection.

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