Chapter 23: Conditions Occurring After Delivery

Question 1

Postpartum Early Warning Criteria:

Criteria used to help nurses serving postpartum patients include (having to do with mood):

Answer 1

Maternal agitation, confusion or unresponsiveness

Question 2

Postpartum Early Warning Criteria:

Criteria used to help nurses serving postpartum patients include (having to do how they are feeling):

Answer 2

Report of headache or SOB by patient with preeclampsia

Question 3

Postpartum Early Warning Criteria:

Criteria used to help nurses serving postpartum patients include (having to do vital signs):

Answer 3

Systolic bp <90 or >160 mmHg

Diastolic bp >100 mmHg

HR < 50 or > 120 bpm

RR < 10 or > 30 breaths/min

O2 Sat on room air < 95%

Oliguria for 2 or more hours <35mL/hr

Question 4

Postpartum Hemorrhage:

What is typical blood loss after a vaginal birth?

Answer 4

Typical blood loss after vaginal birth is 500 mL

Question 5

Postpartum Hemorrhage:

What is typical blood loss after c-section?

Answer 5

1,000 mL after a cesarean birth.

Question 6

Postpartum Hemorrhage:

What is postpartum hemorrhage?

Answer 6

A postpartum hemorrhage (PPH) is bleeding of more than 1,000 mL despite uterine massage and first-line uterotonics (such as oxytocin [Pitocin]).

Question 7

Postpartum Hemorrhage:

What is classified as major postpartum hemorrhage? What is classified as severe?

Answer 7

Blood loss over 1,000 mL may be classified as major; over 2,000 mL is severe.

Question 8

Postpartum Hemorrhage:

When does primary or early PPH occur?

Answer 8

Primary or early PPH occurs within 24 hours of birth.

Question 9

Postpartum Hemorrhage:

When does delayed or secondary PPH occur?

Answer 9

Delayed or secondary PPH may occur 24 hours to 12 weeks after birth.

Question 10

Postpartum Hemorrhage:

After birth, what does the uterus do to prevent PPH?

Answer 10

After birth the uterus normally maintains hemostasis and prevents PPH by clotting and contraction of the myometrium of the uterus.

Question 11

Postpartum Hemorrhage:

What is PPH often caused by?

Answer 11

PPH is often caused by uterine atony, blood coagulopathies, or trauma.

Question 12

Postpartum Hemorrhage Risk Factors:

Answer 12

1. Atony
2. Trauma
3. Coagulopathy

Question 13

Slide 4 and 5 read

Question 14

Postpartum Hemorrhage Treatment includes:

What should you do with the fundus?

Answer 14

Fundal massage of a boggy uterus.

Question 15

Postpartum Hemorrhage Treatment includes:

What should you assess for if fundus is firm?

Answer 15

Assess for lacerations or hematoma if the fundus is firm

Question 16

Postpartum hemorrhage treatment includes:

What should be done if there is an inability to void?

Answer 16

Bladder catheterization for inability to void.

Question 17

Postpartum Hemorrhage Treatment:

What should be established?

Answer 17

Establishing intravenous access.

Question 18

Postpartum Hemorrhage Treatment includes:

What should be administered?

Answer 18

Oxytocin (Pitocin) administered as a first-line uterotonic medication.

Question 19

Hypovolemic Shock:

When is it triggered?

Answer 19

Triggered when the volume of circulating blood decreases to a degree that the body’s organs do not have enough oxygen to function properly.

Question 20

Hypovolemic Shock:

What are symptoms of hypovolemic shock?

Answer 20

Hypotension

Tachycardia

Tachypnea

Oliguria

Mental status changes

Cool, pale, and clammy skin

Slowed capillary refill

Question 21

Hypovolemic Shock Treatment:

What needs to be done with blood volume?

Answer 21

Restoration of circulating blood volume (usually normal saline or lactated Ringer’s)

Question 22

Hypovolemic Shock Treatment:

What needs to be established?

Answer 22

Establish 2 large-bore IV lines

Question 23

Hypovolemic Shock Treatment:

What should be monitored?

Answer 23

Monitor urine output using a Foley catheter.

Monitor vital signs.

Question 23

Hypovolemic Shock Treatment:

What should labs be drawn up for?

Answer 23

Draw labwork as ordered to evaluate red blood cell count and assess for disseminated intravascular coagulation (DIC).

Question 24

Hypovolemic Shock Treatment: What should be administered?

Answer 24

Administer blood transfusions as ordered.

Question 25

Thromboembolic Disease: What is a VTE?

Answer 25

A venous thromboembolism (VTE) is a blood clot or multiple clots that form within a vein.

Question 26

Thromboembolic Disease : What are factors that place a pregnant patient at risk for thromboembolic disease?

Answer 26

Factors that place a patient who is pregnant at risk for thromboembolic disease include: dilated veins leading to slower blood flow and pooling, endothelial injury related to surgical intervention or placental detachment, and the increase of coagulation factors in pregnancy to decrease the risk of hemorrhage.

Question 27

Thromboembolic Disease: Where are VTEs formed?

Answer 27

VTEs may be limited to superficial veins or form in deeper veins of the lower extremities (a deep vein thrombosis [DVT]).

Question 28

Thromboembolic Disease : How does a PE form?

Answer 28

A DVT can break off and travel to the pulmonary artery, which is known as a pulmonary embolism (PE).

Question 29

Thromboembolic Disease : What amount of maternal deaths does PEs account for in the US?

Answer 29

Pulmonary embolisms account for 9.2% of maternal deaths in the United States.

Question 30

Thromboembolic Disease: What are symptoms of DVT?

Answer 30

Symptoms of a DVT include swelling, pain, localized redness, warmth, and tenderness.

Question 31

Thromboembolic Disease: How are DVTs diagnosed?

Answer 31

DVTs are often diagnosed with ultrasound imaging.

Question 32

Thromboembolic Disease : What does treatment of DVTs include?

Answer 32

Treatment of a DVT may include anticoagulation therapy or surgery.

Question 33

Thromboembolic Disease : What is more common than a DVT?

Answer 33

A superficial vein thrombosis is more common than a DVT.

Question 34

Thromboembolic Disease: What are symptoms of a superficial vein thrombosis?

Answer 34

Symptoms include: pain, tenderness, induration (hardening), and erythema (redness) along the length of the vein and sometimes a low-grade fever. The vein may feel cord-like.

Question 35

Thromboembolic Disease : How does a superficial vein thrombosis progress?

Answer 35

A superficial vein thrombosis is often self-limiting.

Question 36

Thromboembolic Disease: SUPPORTIVE MEASURES for the care of patients with superficial, uncomplicated VTEs include:

Answer 36

Elevating affective leg Warm or cold compresses for comfort NSAIDs Compression stockings

Question 37

Thromboembolic Disease : Treatment for symptomatic VTEs include:

Answer 37

Anticoagulation possibly as long as 3 months

Question 37

Thromboembolic Disease: What is considered a medical emergency?

Answer 37

A PE is a medical emergency.

Question 37

Thromboembolic Disease: What treatment should begin prior to confirmation of PE/Thromboembolic disease?

Answer 37

Anticoagulant treatment should begin prior to confirmation of the diagnosis.

Question 38

Thromboembolic Disease : How long does anticoagulation therapy continue for?

Answer 38

Anticoagulant therapy continues for approximately 6 months.

Question 38

Thromboembolic Disease : How are symptoms of PE?

Answer 38

Symptoms of PEs are often nonspecific and include dyspnea, cough, sweating, and pleuritic chest pain.

Question 38

Thromboembolic Disease : How is diagnosis of PE made?

Answer 38

Diagnosis of a PE is accomplished by a ventilation/perfusion (V/Q) scan and computer tomographic pulmonary angiography.

Question 38

Postpartum Infections: What can they be related to?

Answer 38

Postpartum infections can be related to: perineal or cesarean wounds, septic thrombophlebitis, endometritis, mastitis, breast abscess, and urinary tract infections.

Question 39

Postpartum Infections: Symptoms of postpartum infection can be how?

Answer 39

Symptoms of a postpartum infection can be nonspecific.

Question 40

Postpartum Infections: General symptoms of a postpartum infection include:

Answer 40

A fever that persists beyond the initial 24 hours after birth. A fever that begins 2 to 10 days after birth. Elevated white blood cell count that continues to rise rather than fall.

Question 41

What kind of symptoms may a women feel for a short time which is normal?

Answer 41

Women may feel chills or shivers after birth for a short time which is normal

Question 42

Postpartum Infections: Perineal Wounds: What is it associated with?

Answer 42

Associated with third- and fourth-degree lacerations.

Question 43

Postpartum Infections: Perineal Wounds: Risks factors include:

Answer 43

Operative vaginal birth Prolonged second stage of labor Third- or fourth-degree lacerations Mediolateral episiotomy Maternal smoking Meconium-stained fluid

Question 44

Postpartum Infections: Perineal Wounds: What are assessment findings?

Answer 44

Assessment findings include tenderness, redness, and swelling, as well as purulent, yellow, and stringy exudate.

Question 45

Postpartum Infections: Perineal Wounds: What does treatment include?

Answer 45

Treatment requires removal of sutures and opening of the wound.

Question 46

Postpartum Infections: Perineal Wounds: What circumstances are antibiotics used and not used?

Answer 46

Antibiotics are not necessary unless there is evidence of cellulitis.

Question 47

Postpartum Infections: Cesarean Wounds: What percent of c-section wounds are there infections?

Answer 47

Occurs in 1% to 28% of cesarean births.

Question 48

Postpartum Infections: Cesarean Wounds When are infections usually diagnosed after a c-section?

Answer 48

Often diagnosed after discharge, from day 4 to 7 postpartum.

Question 49

Postpartum Infections: Cesarean Wounds What do signs and symptoms of infection of C-section wounds include?

Answer 49

Induration, redness, warmth Pain at the incision site Wound edges may separate Purulent discharge and fever may be noted

Question 50

Postpartum Infections: Cesarean Wounds How do Obs treat postpartum infections of C-sections? How are wounds left?

Answer 50

Obstetric providers treat by opening and draining the wound. Wounds are left open but kept moist and covered.

Question 51

Postpartum Infections: Endometritis What is endometritis?

Answer 51

Endometritis is an infection of the lining of the uterus.

Question 52

Postpartum Infections: Endometritis In what percent of c-section births and vaginal births does this occur in?

Answer 52

Occurs in up to 19% of cesarean births and 1% to 3% of vaginal births.

Question 53

Postpartum Infections: Endometritis What are risk factors to developing Endometritis?

Answer 53

Risk factors include: chorioamnionitis, prolonged labor, and prolonged rupture of membranes, multiple cervical examinations during labor, internal monitoring during labor, meconium-stained fluid, retained placenta with manual removal, low socioeconomic status, maternal diabetes or anemia, preterm birth, operative vaginal birth, postterm pregnancy, maternal human immunodeficiency virus infection, bacterial vaginosis in pregnancy, and group B Streptococcus colonization.

Question 54

Postpartum Infections: Endometritis What may endometritis do to the uterus?

Answer 54

Infection may cause the uterus to become soft and subinvoluted, which predisposes the patient to hemorrhage.

Question 55

Postpartum Infections: Endometritis Signs and symptoms include:

Answer 55

Fever (generally postpartum days 2 to 10) in absence of other cause Uterine tenderness Tachycardia Purulent discharge Flu-like symptoms

Question 56

Postpartum Infections: Endometritis How is it treated?

Answer 56

Typically treated with intravenous infusion of a broad-spectrum antibiotic.

Question 57

Postpartum Infections: Lactational Mastitis What is it?

Answer 57

Inflammation of the breast tissue often associated with infection.

Question 58

Postpartum Infections: Lactational Mastitis What are contributing factors?

Answer 58

Factors contributing to mastitis include delayed breast emptying, poor drainage of one or more ducts, inconsistent pressure on breasts (like poorly fitting bra), infrequent feedings, rapid weaning, oversupply of milk, or nipple trauma.

Question 59

Postpartum Infections: Lactational Mastitis When is it most common?

Answer 59

Most common in the first 3 months of breastfeeding.

Question 60

Postpartum Infections: Lactational Mastitis What are symptoms?

Answer 60

Symptoms include tender, red area of breast, malaise, or a high fever.

Question 61

Postpartum Infections: Lactational Mastitis Treatment may include:

Answer 61

Cold compresses NSAIDs Regular and complete emptying of the breast Antibiotics

Question 62

Postpartum Infections: Urinary Tract Infection (UTI) When are patients prone to UTIs? Why?

Answer 62

Patients in the postpartum period are prone to UTIs because of the frequency of bladder catheterization and genital procedures.

Question 63

Postpartum Infections: Urinary Tract Infection (UTI): What are symptoms of UTIs?

Answer 63

Symptoms include urinary urgency and pain with urination, hematuria, and lower abdominal discomfort.

Question 64

Postpartum Infections: Urinary Tract Infection (UTI) What is pyelonephritis?

Answer 64

Pyelonephritis is a UTI of the upper urinary tract.

Question 65

Postpartum Infections: Urinary Tract Infection (UTI) What are symptoms of pyelonephritis?

Answer 65

Symptoms include flank pain, nausea and vomiting, and fever above 100.4°F (38°C).

Question 66

Postpartum Infections: Urinary Tract Infection (UTI): What is treatment?

Answer 66

Treatment is generally antibiotics.

Question 67

Postpartum Mood Disorders What is Postpartum blues? When does it start and resolve?

Answer 67

Postpartum blues is a transient, self-limiting mood disorder that starts 2 or 3 days after birth and resolves within 2 weeks.

Question 68

Postpartum Mood Disorders What is postpartum depression? When is onset?

Answer 68

Postpartum depression as defined by the American Psychiatric Association (APA) is major depression with an onset during pregnancy or in the first 4 weeks after birth. Onset may be as late as 6 weeks to a year after birth.

Question 69

Postpartum Mood Disorders: What is Postpartum psychosis?

Answer 69

Postpartum psychosis, a rare disorder, is the disturbance of a patient’s perception of reality postpartum as evidenced by hallucinations, thought disorganization, disorganized behavior, and delusions.

Question 70

Postpartum Mood Disorders: What is Postpartum psychosis considered?

Answer 70

It is a medical emergency.

Question 71

Postpartum Depression #1: What percent of patients experience postpartum depression?

Answer 71

Estimated 10% to 16% of patients experience postpartum depression. There is more stuff like risk factors on slide 21

Question 72

Postpartum Depression: How to be diagnosed with postpartum depression?

Answer 72

To be diagnosed with postpartum depression, a patient must meet at least five of the nine diagnostic criteria for major depressive disorder identified by the APA during a 2-week period with at least one of the symptoms being a depressed mood or diminished pleasure in all or most activities.

Question 73

Postpartum Depression : What is treatment?

Answer 73

Treatment includes medication and therapy.

Question 74

Postpartum Depression : What are warning signs of postpartum depression?

Answer 74

Low mood for at least 2 weeks Negative attitude toward the infant Little interest in the infant or infant activities Anxiety about the health of the infant Concern about the ability to care for the infant Use of alcohol, street drugs, drugs prescribed to others, or tobacco Nonadherence to recommended care Frequent off-schedule calls and/or visits to the healthcare provider

Question 75

Postpartum Depression : Factors affecting PPD?

Answer 75

History of prenatal depression Hormonal dyregulation Inadequate social support; unmarried or socially isolated Pregnancy not planned Obstetric complications Difficult infant temperament or behavior Low socioeconomic status

Question 76

Postpartum Depression : PPD Sequelae

Answer 76

Unsuccessful or no breastfeeding Poor maternal responsiveness/low bonding with infant Harsh parenting; Low use of child safety practices Poor infant attachment Child behavior problems

Question 77

Postpartum Psychosis: What is it?

Answer 77

Disturbance of a patient’s perception of reality postpartum as evidenced by hallucinations, thought disorganization, disorganized behavior, and delusions

Question 78

Postpartum Psychosis: What patients is it most common in?

Answer 78

Most common in patients with bipolar disorder or who suffer from depression with schizophrenia, schizoaffective disorder, or psychosis

Question 79

Postpartum Psychosis: When does postpartum psychosis occur?

Answer 79

Condition may occur within 48 hours of birth and almost always develops within the first few weeks after the birth

Question 80

Postpartum Psychosis: How does it manifest itself?

Answer 80

Psychosis manifests as bizarre behavior, confusion, hallucinations, delusions, and/or the appearance of delirium.

Question 81

Postpartum Psychosis: What is the priority of care for a patient with postpartum psychosis?

Answer 81

The priority of care is the safety of the patient and the safety of the infant.

Question 82

Postpartum Psychosis: What does treatment require?

Answer 82

Treatment often requires inpatient psychiatric care.