POSTPARTUM Definitions
Diastasis recti- 6 pack has separated
Engorgement- if not breastfeeding, wear a tight bra and no hot water
Homan’s sign-
Involution- everything is going back to normal
Lochia
Uterine atony- the most common reason for PP hemorrhage
Retained Placenta- If the placenta is left they will get an infection or bleed
Appearance:
Uterine atony- boggy, can rub it and move it
Retained placenta- tight and can’t get it out
Subinvolution- The uterus will be okay and the patient will go home but 2 weeks later they call and say they are bleeding heavy. Involution is not happening the way it should.
PP BLEEDING: Hemorrhage
500 cc or more – rapid loss
Atony /subinvolution-**most prevalent
usually within the first 6 hours or at 1-2 weeks postpartum, up to 6 weeks
DUE TO full bladder*- Due to void within 6 hours, exhausted uterus, use of tocolytics- mag sulfate (muscle relaxant, can hemorrhage, need to keep pit going), infection , over distention due to poly-hydramnios, multiple gestation or large infant, fibroids, multiparity, prolonged second stage, retained placental fragments, Oxytocin stimulation, PIH tx with Mag sulfate, long or precipitous labor- contractions were back to back exhausting the uterus, too vigorous massage of fundus, DIC
SS - Boggy uterus, thick red blood with or without clots, heavy -excessive bleeding(>1 pads/hr)
Treatment: massage vigerously, call for methergen order (do not give if they have high bp) or hemabate (will have diarrhea), if losing LOC, put legs up in the air to get blood flow to the brain
Prevention: massaging, IV with Pit in it, keep bladder empty, put baby to breast, to prevent hematoma, ice on the area
- Ween off of pit if they had pit to get them started
- Anyone who has had multiples or large baby- will cramp more, should take motrin
TX - Monitor closely and prevent - keep bladder empty, put baby to breast, gentle massage, IF HEMORRAGING – Massage, Place a Foley, Maintain or start IV, Support blood volume by increasing flow, Start Oxytocin, Elevate knees and lower legs at 45% angle, O2 if necessary, Allay fears, Notify provider
Therapeutic management - MD Orders
Labs – H&H (ask for CBC), T&C, DIC studies
Methergine (don’t give if high b/p, give with motrin for cramping ) & Prostaglandin administration
Bimanual massage/uterine packing- doctor will press on top of uterus and cervix
Blood replacement
Hysterectomy- if we can’t stop it, will end up with a hysterectomy
Pack uterus with curlex – when the packing comes out, give the patient something for comfort prior to taking it out, feels like taking out a dry tampon
Discharge Plan
- Warnings
- Return of rubra after the 4th day- need to come in
- S/S of infection- ***smell!, if you notice people are staying away, you might want to get checked. Smells like dead chicken
- Pts that have hemorrhaged need a longer recovery period than 6 weeks- probably 8 weeks
Potential Complications of hemorrhage
- Shock (582)- get the legs up so her brain gets oxygen it needs
- Organ failure (Sheehan’s)- all organ failure
- DIC
- Need for uterine artery ligation- prevents blood from going into the area /hysterectomy
- Death
- Retained placenta can lead to infection and subinvolution
PP Bleeding: Injury
At risk: precipitous delivery, large baby, lithotomy position with instrumentation
Lacerations:
- Cervical lacerations
- Vaginal lacerations
- Difficult to repair
- May need packing
- Foley- will be putting a lot pressure on the urethra so foley helps
- Perineal lacerations
- S/S = Bright red bleeding, constant trickle
- TX: Notify provider, who will suture
- See slide 13 for classifications of lacerations
Hematomas:
- can be on the outside or inside. If on the inside- lots of pain but don’t see anything, outside- still complaining of pain after pain meds
- S/S = May not have any external bleeding , will see localized swelling of labia, vagina, rectal area, extreme pain . Fever, chills , leg edema
- TX: Ice to area pressure gauzes, Notify provider. MD may need to incise, drain & pack
Small ones will absorb in 2-3 days others up to 6 weeks
Potential Complications for lacerations & hematomas
- Blood loss, shock
- Infections, abscesses
- Sepsis/shock
- DIC
Disseminated Intravascular Coagulation (DIC)
Clotting disorder – Acceleration of the clotting mechanism and activation of the fibrinogen system
- Due to PPH, Abruption, Infection, retain fetal demise, amniotic fluid embolus, PIH, retained placenta, septic AB
S/S Acute onset usually hours after initial insult Purpura, petechae, bruising Prolonged bleeding from venipuncture Uncontrolled hemorrhage** Oliguria and acute renal failure Convulsions/coma/death
Tx –(583)
Stop the underlying cause if we know what it is
Restore normal clotting function
IV Heparin therapy to free up the clotting factors
Blood/platelet replacement
Antithrombin III, fibrinogen, cryoprecipitate
Allay fears
Explain Heparin used
Continue to monitor labs
Potential complications –
Anoxia of various tissues ie brain, kidneys
Organ failure
See slide 18 for labs and expected results with DIC
Cardiovascular System: Postpartum pregnancy-induced hypertension
Postpartum - pregnancy-induced hypertension
- Can happen at any time and can happen fast
S/S
Sudden BP 140/90, + Clonus, elevated DTRs, Visual disturbances, Headache,generalized edema
Therapeutic management-
PIH labs, seizure precautions, freq VS, I&O, Mag SO4 or some other anti hypertensive
May have to have D&C for placental fragments
PC- Renal damage, Eclampsia
If my patient is on mag- check respirations, reflexes, if never had reflexes- strength test
Cardiovascular system- Phlebitis
Inflammation of blood vessels
Risk factors – hypercoagulability of blood, dehydration, varicosities, multiparity, heart problems, stasis
More prone to having clots
SS –
Superficial - +Homan’s, redness, heat, swelling over area, pain, < pedal pulse,
For DVT - + Homan’s, pain, fever, chills, limb swelling and pallor
Pelvic – Chills, fever, abd. discomfort, usually follows endometritis, may develop into abscess, tx – Antibx
Can have negative homans and still have a problem
DVT:
TX – *Measure legs, bedrest, warm compresses, elevation (if ordered), *doppler studies- to see if it’s superficial or deep, anticoags, PT/PTT, analgesics, Monitor pulses & RESPS, stockings & pneumatics only with order
Potential Complications
Embolisms that could lead to strokes, lung and heart problems
Pulmonary Embolus
Obstruction of the pulmonary artery with a clot usually from a DVT
One side is less active than the other
S/S
Sharp chest pain, tachycardia, tachypnea, orthopnea, pallor, cyanosis, syncope, BP, crackles, anxiety, hemoptysis
Tx –
O2,confirm with CT, ***Transfer to ICU for possible vent, anticoagulants
PC- Possible arrest- should not be on OB floor, transfer to ICU
PP INFECTION: Endometritis
Infection of endometrium- inflammation
May infect other organs and lead to pelvic abscess, septic pelvic thrombophlebitis,and septicemia
RISK - Long labor, prolonged ROM, multiple vag exams, C- section- usually wipe out the uterus, retained fragments, uterine exploration, PPH, anemia, IFM, GBS
Mixed bacteria, including GBS, chlamidia, E coli, gonorrhea, etc
SS -Delayed involution, abdominal pain (cramping), tachycardia, chills/fever, scant lochia (foul odor), tender uterus
TX - Assess all other possible sources of infection, culture urine, lochia & wound. Antibx - Monitor response, watch for septic shock, rest, hydrate, give analgesics and antipyretics, support NEED culture, methergine (squeezes out pus), analgesics and pyretics, monitor for sepsis
Potential Complications
Peritonitis
PP INFECTION: Peritonitis
- Extension of endometritis spread thru lymphatics
- Direct thru fallopian tubes or uterine wall
- Abscess may form – lowest part of peritoneum
S/S – rigid abdomen, abdominal pain, high fever, rapid pulse, vomiting often accompanied by paralytic ileus- treat like bowel obstruction, NPO & NG tube, possibly TPN
TX – NG tube, IV and TPN prn, Analgesics, Antibx, extended hospital stay, adhesions and possible sterility
Sepsis, Shock
Infection of perineum – usually localized
RISK – poor hygiene, contaminated delivery
S/S- pain, heat, feeling of pressure, 1-2 sutures gone- pus eats through sutures, incision open, purulent drainage
TX- Open, Possible packing/drain, antibx, Sitz baths, warm compresses, freq. pad change
PP INFECTION: Mastitis
Inflammation/infection of the breast due to poor drainage of the ducts & alveoli, or missed feedings
Risks- Engorgement, improper latch on, im-proper release, **cracked nipples- bacteria can back up into system , plugged ducts- put baby to breast
SS - Flu like sx, chils, fever, hot, red, swollen, sore portion of the breast
TX Supportive bra, moist heat, cold (comfort), rest, fluids, antibx
Prevention: ***Proper latch
See slide 24 for more on PP infections
Emotional/Psychological Complications
Child born with illness or is physically challenged
- Grieving
- Education
Child who has died
- Fetal demise- wash the baby and wrap the baby
- Grieving
Postpartal depression:
- Baby blues - 50- 80%
starts 3-7 days PP, lasting only a few days
SS - crying, irritable, chg in appetite & sleep
attributed to hormonal changes, interrupted sleep, fatigue, role change and confusion
PP Depression - 10-15%**
starts any time up to year and can last a year
SS - Restless, irritable,crying spells, loss of control over emotions, thought ,and actions, obsessive thinking, anxiety attacks, impaired concentration, anger, unable to cope with baby care, isolation, insomnia, hopelessness, over-whelmed, contemplating or attempting suicide
TX - Rest, Support, well balanced diet, limit sugars and caffeine, prenatal vits, B vits, support groups, education (some providers treat with hormones, *soy products, *zoloft)
Need to know they are not ‘CRAZY”
- At risk: *Single parent, Demanding baby, *Hx of depression (postpartum with first baby, probably have it again), anxiety, panic, obsessive compulsive thoughts, behaviors, mania, family Hx of pp depression, marital conflicts, major life changes thyroid imbalance, hx of PMS, infertility
Postpartal psychosis:
- 2/1000
- SS - VARY greatly –MEDICAL EMERGENCY
- Manic like state - racing thoughts, mood extremes, hyperactivity
- Delirious state - waxing/waning confusion and dissociative episodes
- Psychotic depression - psychomotor retardation and delusions
- TX - Hospitalization and antipsychotic drugs
- ***911 call!
Urinary System Disorders: Urinary retention
Due to: Edema from trauma, pain, sensation, anesthesia
S/S- Inadequate voiding, distention, inadequate emptying
TX –Confirm with cath for residual (Use Foley), If more than 100 cc leave in, DC in 24 hours allow 6 hours to void (If can’t recath), Cath for residual again after void, can use bladder scan to see if you need to cath again
Urinary System Disorders: UTI
probably due to caths
S/S - Frequency, burning, hematuria etc.
Tx Clean catch urine for C&S (Mark as possible contamination with Lochia), fluids, analgesics, antibx (Sulfa is the usual urinary tract med but due to Breast feeding usually will see broad spectrum antibx used)
Reproductive System Disorders: Separation of symphysis pubis
Relaxin causes softening of joint leads to separation and sometimes ligament tearing
S/S ***Pain, swelling, waddling gait,
Tx – Bed rest, pelvic binder- stops the grinding, analgesics, no heavy lifting
Reproductive System Disorders: Reproductive tract displacement
Retro, ante, retroflexion or uterine prolapse (relaxin and stretched ligaments
- S/S – pain, heaviness
- Pessary, surgery
Cysto or rectocele
- S/S –incontinence and constipation
- Tx – Kegal exercises, Surgery
Vulnerable Populations to complications
Victims of abuse
Limited access to care
Homelessness
