Chapter 28: Postpartum Maternal Complications Flashcards
(130 cards)
1
Q
What are the most common postpartum complications?
A
- Hemorrhage
- Thromboembolic disorders
- Infection
- Postpartum mood and anxiety disorders
2
Q
Postpartum hemorrhage is defined as
A
- Blood loss of >500 mL after vaginal birth and >1000 mL after c-section.
- Decreased hematocrit of > 10% since admission.
3
Q
Early Postpartum Hemorrhage occurs
A
- Within the first 24 hours after birth.
- Common during the first hour after delivery.
4
Q
Late Postapartum Hemorrhage occurs
A
After 24 hours or up to 6-12 weeks after birth.
5
Q
What is the main cause of early postpartum hemorrhage?
A
-Uterine atony
6
Q
What are other causes of early postpartum hemorrhage?**
A
- Trauma to birth canal during labor and delivery
- Hematoma
- Retention of placental fragments
- Abnormalities of coagulation
7
Q
Uterine Atony
A
Lack of muscle tone -> failure of the uterine muscle fibers to contract firmly around the blood vessels when the placenta separates.
8
Q
Relaxed uterine muscles can lead to
A
Rapid bleeding of endometrial arteries at the placental site.
9
Q
What are predisposing factors for uterine atony?
A
- Overdistention of uterus (i.e multiple gestation, a large infant, hydramnios)
- Multiparity (muscle fibers that have been stretched)
- Intrapartum factors
10
Q
What are intrapartum factors that predispose a women to uterine atony?
A
· Barely effective contractions = prolonged labor
· Excessively vigorous contractions = precipitate labor.
· Labor that was induced or augmented with oxytocin
· Retention of a large segment of the placenta
11
Q
What are clinical manifestations of early postpartum hemorrhage?
A
o A uterine fundus that is difficult to locate
o A soft or “boggy” feel when the fundus is located
o A uterus that becomes firm as it is massaged but loses its tone when massage is stopped
o A fundus that is located above the expected level
o Excessive lochia, especially if it is bright red
o Excessive clots expelled
12
Q
What are normal findings of the uterus for the first 24 hours after childbirth?
A
- Uterus should feel like a firmly contracted ball roughly the size of a large grapefruit.
- Should be easily located at about the level of the umbilicus.
- Lochia should be dark red and moderate in amount.
13
Q
Saturation of one peripad with lochia in 15 minutes =
A
Excessive loss of blood
14
Q
A constant, steady trickle or slow seeping of lochia
A
Is just as dangerous as the saturation of one peripad in 15 minutes.
15
Q
Non-Pharmacologic Interventions for Early Postpartum Hemorrhage
A
- If uterus is not firmly contracted, first intervention is to massage the fundus until firm in order to express cots that may have accumulated in uterus.**
- Empty bladder
16
Q
How can an accumulation of clots in the uterus cause a postpartum hemorrhage?
A
It interferes with the ability of the uterus to contract effectively.
17
Q
How are clots expressed from the uterus?
A
- By applying firm but gentle pressure on the fundus in the direction of the vagina.
- Critical that the uterus is contracted before attempting to express clots.
18
Q
Pushing on an un-contracted uterus could
A
Invert the uterus and cause massive hemorrhage and rapid shock.
19
Q
Why is emptying the bladder an important intervention in postpartum hemorrhage?
A
A full bladder lifts the uterus, moving it up and to the side, preventing effective contraction of the uterine muscles.
20
Q
What are pharmacological measures for early postpartum hemorrhage?
A
- Rapid IV of dilute oxytocin (pitocin)
- If oxytocin isn’t effective, prostaglandin F20 is used.
- Methylergonovine (Methergine)
- Misoprostol (Cytotec) or Prostin E2 (Dinoprostone)
21
Q
Methylergonovine (Methergine): Contraindications
A
Elevates blood pressure and should not be given in women who are hypertensive.
22
Q
What can be done to treat postpartum hemorrhage uterine massage and pharmacological measures are ineffective?
A
- Physician or nurse-midwife may use bimanual compression of the uterus to stop the bleeding. (One hand is inserted into the vagina and the other compresses the uterus through the abdominal wall)
- Balloon may be inserted into the uterus to apply pressure against uterine surface to stop the bleeding.
- Uterine packing may also be used.
- May be necessary to return woman to delivery area for exploration of uterine cavity and removal of placental fragments that interfere with uterine contraction.
23
Q
What is the last resort treatment for a woman with an uncontrollable postpartum hemorrhage?
A
Hysterectomy
24
Q
Fluid Replacement in Early Postpartum Hemorrhage
A
-LR
-Whole blood
-Packed RBC
-Normal Saline
-Plasma extenders
Need enough fluid to maintain a UO: 30-60 ml/hr.
25
Early Postpartum Hemorrhage: Trauma
- Second most common cause of early postpartum hemorrhage.
| - Can include vaginal, cervical or perineal lacerations as well as hematomas.
26
What are predisposing factors for trauma in early postpartum hemorrhage?
- Many of the same factors that increase the risk of uterine atony increase the risk of soft tissue trauma during childbirth.
- Induction and augmentation of labor and use of assistive devices such as a vacuum extractor.
27
What are types of trauma associated with early postpartum hemorrhage?
Lacerations
| Hematomas
28
What are the most common sites for lacerations associated with early postpartum hemorrhage?
Vagina
Perineum
Cervix
Around urethral meatus
29
When do lacerations usually occur?
During the second stage of labor.
30
Lacerations of the birth canal should always be suspected if
- Excessive uterine bleeding continues when the fundus is contracted firmly and is at the expected location.
- Color is bright red (lochia is usually dark red)
- Bleeding is heavy or may appear to be minor with a steady trickle of blood that continues.
31
Hematomas
Occurs when bleeding into loose connective tissue occurs while overlying tissue remains intact.
32
Hematomas develop as a result of
- blood vessel injury in spontaneous deliveries
| - deliveries in which vacuum extractors or forceps are used.
33
Hematomas may be found in what areas?
Vulvar, vagina and retroperitoneal
34
The rapid bleeding into soft tissue may cause a
Visible vulvar hematoma; a discolored bulging mass that is sensitive to the touch.
35
Hematomas in the vagina or retroperitoneal areas
Cannot be seen
36
Pain associated with hematomas
Produces deep, severe, unrelieved pain and feelings of pressure that are not relieved by usual pain-relief measures.
37
Formation of a hematoma should also be suspected if**
The mother demonstrates systemic signs of concealed blood loss such as tachycardia or decreasing blood pressure when the fundus is firm and lochia is within normal limits.
38
What is the therapeutic management for trauma associated with early postpartum hemorrhage?
- Surgical repair is often necessary. (D/t difficult visualizing lacerations of the vagina or cervix)
- Small hematomas usual reabsorb naturally.
- Large hematomas may require incision, evacuation of the clots and location of the bleeding so that it can be ligated.
39
Common causes of late postpartum hemorrhage are
1. Subinvolution
2. Retention of placental fragments
3. Infection of the uterus
40
Subinvolution
Delayed return of the uterus to its non pregnant size and consistency.
41
How can retention of placental fragments lead to late postpartum hemorrhage?
Clots form around the retain fragments, and excessive bleeding can occur when the clots slough away several days after delivery.
42
How is retention of placental fragments preventable?
Nurse-midwife or Physical carefully inspects the placenta to determine whether it is intact. If a portion of the placenta is missing, the HCP manually explores the uterus, locates the missing fragments and removes them.
43
What are predisposing factors for retention of placental fragments?
➢ Manual removal of placenta
➢ Placenta Accreta (abnormal adherence of the placenta to the uterine wall)
➢ Previous C-section
➢ Uterine Leiomyomas
44
Therapeutic Management of Late Postpartum Hemorrhage
- Is directed toward the control of excessive bleeding.
| - Include pharmacological measures
45
Pharmacological measures for late postpartum hemorrhage
- Oxytocin
- Methylergonovine
- Prostaglandins
- Broad spectrum antibiotics (if postpartum infection is suspected)
46
What can be used to identify placental fragments that remain in the uterus?
Sonography
47
Bleeding is considered heavy if
Saturation of 1 pad/hr
48
Bleeding is considered excessive if
Saturation of 1 pad/15 min
49
What are nursing implications for abnormal S&S of lochia?
- Assess for trauma
| - Save and weigh pads, linen savers, and bed linens so estimation of blood loss is more accurate.
50
Abnormal UO
< 30 ml/hr
51
Abnormal skin findings
Cool, damp, pale
52
If the skin is cool, damp and pale, the nurse should
- Look for signs of hypovolemia
| - Assessment and management nay entire health care team is necessary.
53
How often should uterine and CV status be monitored?
· Monitor every 15 minutes for first hour after birth
· Every 30 minutes for next hour
· Hourly for approximately 2 more hours
· Q8 hours or more frequently if there is bogginess, position out of midline
54
What are the three most common thromboembolic disorders encountered during pregnancy and postpartum?
1. Superficial venous thrombophlebitis (SVT)
2. Deep vein thrombosis (DVT)
3. Pulmonary embolism
55
Superficial venous thrombophlebitis
Involves the saphenous venous system and is confined to the lower leg.
56
Clinical manifestations of superficial venous thrombophlebitis include
➢ Varicose veins & limited to calf area
| ➢ Can occur in the arms from IV therapy
57
Signs and symptoms of superficial venous thrombophlebitis
➢ Swelling of involved extremity, SHRT (swelling, heat, redness tenderness)
➢ Possible palpation of enlarged, hardened, cordlike vein
➢ May or may not experience pain when walking
58
Therapeutic management for superficial venous thrombophlebitis
➢ Analgesics
➢ Warm packs applied to affected area
➢ Anti-inflammatory NOT anticoagulants can be used
➢ Bed rest + elevated legs; gradual ambulation if no symptoms
➢ Wear support hose
59
What are factors that increase the risk of thrombosis?
```
· Inactivity
· Prolonged bed rest
· Obesity
· Csection
· Sepsis
· Smoking
· Hx of thrombosis
· Varicose veins
· DM
· Trauma
· Prolonged labor & time in stirrups in second stage of labor
```
60
Deep Vein Thrombosis
Involves veins from the foot to the ileofemoral region.
61
What is the major concern for DVT?
It predisposed to PE
62
What causes DVT?
Caused by inflammatory process and obstruction of venous return.
63
What are signs and symptoms of DVT?
➢ Pain in leg, groin, lower back or RLQ
➢ SHRT: Swelling of the leg (>2cm larger than other leg)
➢ (+) Homans sign; not a reliable test
➢ reflex arterial spasms: cool to the touch & decreased peripheral pulses
64
How is DVT diagnosed?
➢ Venous ultrasonography with vein compression and Doppler flow: analysis veins of the upper legs
➢ Magnetic resonance imaging (MRI): diagnosing pelvic and leg thrombosis
65
What are the initial pharmacological measurements for DVT?
1. IV unfractionated heparin that is later changed to SQ unfractionated heparin.
2. Analgesics
3. ABT
66
Unfractionated Heparin
Doesn’t dissolve clots but prevents enlargement in DVT.
67
What should be monitored when giving unfractionated heparin?
aPTT and platelet count
68
The dose of unfractionated heparin should be adjusted to maintain a therapeutic level shown by aPTT of **
1.5-2.5 times control
69
If SQ low-molecular-weight heparin is used instead of unfractionated heparin,
Less frequent laboratory monitoring is necessary.
70
What are the initial non-pharmacological measures to treat DVT?
▪ Bed rest, with the affected leg elevated to decrease interstitial swelling and to promote venous return from the leg.
▪ Continuous, moist heat for relief of pain and to increase circulation.
▪ Gradual ambulation, which is allowed when symptoms have disappeared. Sitting with the legs dependent should be avoided.
71
Warfarin during pregnancy
Is contraindicated because it is teratogenic
72
Warfarin during the postpartum period
- Used before heparin is stopped to provide continuous anticoagulation.
- Heparin is then topped when INR has been at therapeutic level for 2 days.
- Warfarin is continued for 6 weeks to 6 months.
73
Is warfarin safe during lactation?
Yes
74
What are lifestyle changes that can improve peripheral circulation?
- Avoid clothing that is constricting around the legs and prolonged sitting.
- If prolonged sitting is necessary, walk for a short time hourly or move feet and legs frequently to help prevent circulatory stasis.
75
Pulmonary embolism
When the pulmonary artery is obstructed by a blood clot that was swept into circulation from a vein or by amniotic fluid.
76
What are three major causes of thrombosis in pregnancy?
1. Venous stasis
2. Hypercoagulable blood
3. Injury to endothelial surface
77
How can venous stasis occur in pregnancy?
1. Enlarging uterus -> compresses large vessels of the legs and pelvis -> venous stasis.
2. Standing for prolonged periods of time.
3. Inactivity during pregnancy and activity restriction.
4. Prolonged time in stirrups for delivery and repair of the episiotomy.
78
What can cause hypercoagulable blood during pregnancy?
- Increased levels of coagulation factors (prevents maternal hemorrhage)
- Decrease in fibrinolytic system
79
What can cause injury to the endothelial surface in pregnancy?
- Lower extremity trauma, operative delivery, prolonged labor.
- C-section
80
Which of the three major causes of thrombosis are present in all pregnancies?
Venous stasis and hypercoagulable blood.
81
When is low molecular weigh heparin changed to UH? **
At approximately 36 weeks of gestation.
82
Why is a change necessary from low molecular weight heparin to UH?
Necessary because UH has a shorter half-life and epidural anesthesia, which may be needed in labor, is contraindicated within 24 hours of the last dose of LMWH.
83
Heparin is discontinued during labor and birth and is resume when? **
Approximately 3-6 hours after vaginal delivery and 6-8 hours after cesarean birth.
84
A woman’s time in stirrups should be limited to
No more than 1 hour.
85
How can thrombus formation be prevented?
- LMWH or UH
- Ambulation, ROM and gentle leg exercises
- No pillows under the knees (can cause pooling of blood in the lower extremities)
- Compression stockings
86
Endomyometritis
Infection of the muscle and inner lining of uterus
87
Enoparametritis
If surrounding tissues are involved
88
Metritis
Infection of the decidua, myometrium, and parametric tissues of uterus.
89
Puerperal infection
Term used to describe bacterial infections after childbirth.
90
The most common postpartum infections include:
```
o Endometritis (infection of inner lining of uterus)
o Wound infections
o UTI
o Mastitis (infection of breast)
o Septic pelvic thrombophlebitis
```
91
Infection can be indicated by
- Temperature of 38 C (100.4 F) or higher after the first 24 hours and occurring on at least 2 of the first 10 days following childbirth.
- Although a slight elevation of temperature may occur during the first 24 hours because of dehydration or the exertion of labor, any mother with fever should be assessed for other signs of infection.
92
What can cause an increased risk of infection in women?
1. Increased in blood flow to reproductive tract during pregnancy and after childbirth allows bacteria to be picked up by blood vessels and carry infection to the rest of the body.
2. Decreased acidity of the vagina by amniotic fluid, blood and lochia which are all alkaline.
3. Necrosis of the endometrial lining + presence of lochia = favorable environment for the growth of anaerobic bacteria.
93
What are other risk factors for infection during pregnancy?
1. C-sarean birth
2. Trauma to maternal tissues
3. PROM (organisms from vagina enter uterine cavity)
4. Long labor or many vaginal examinations during labor
5. Postpartum hemorrhage
6. Prenatal conditions (poor nutrition, anemia)
7. Lack of knowledge of hygiene or lack of access to facilities that permits adequate hygiene
94
Endometritis is usually caused by
Organisms that are normal inhabitants of the vagina and cervix.
95
Endometritis: Most infections are
Polymicrobial (w/ both aerobic and anaerobic organisms involved)
96
Chlamydia trachomatis in endometritis
Is not a cause of early infection but is associated with late-onset infections..
97
Clinical Manifestations of Endometritis
1. Temperature of 38 C (100.4 F) or higher w/in 36 hours of birth
2. Chills, malaise
3. Anorexia, abdominal pain, cramping
4. UTERINE TENDERNESS AND FOULD-SMELLING LOCHIA
5. Tachycardia
6. Subinvolution
98
Laboratory data may confirm the diagnosis of endometritis
- Increase in the number of leukocytes.
- Cultures of the vagina or endometrium are usually not helpful.
- A catheterized urine specimen may also be obtained.
99
Leukocytosis that is not decreasing
Should prompt further evaluation. A blood culture may be obtained.
100
Therapeutic Management of Endometritis
- IV antibiotics is initial treatment (broad spectrum)
- Antipyretics for fever
- Methylergonovine for increased drainage of lochia and promotion of involution.
101
Typical broad spectrum antibiotics used to treat Endometritis
Cephalosporins
Clindamycin + gentamicin
Ampicillin + aminoglycosides
Metronidazole + PCN
102
How long are ABT used for treatment of Endometritis?
Continued until the woman has been afebrile and asymptomatic for 24-48 hours.
103
What are complications of Endometritis?
- Salpingitis: infection of the Fallopian tubes
- Oophoritis: infection of ovaries
- Peritonitis: inflammation of the membrane lining the walls of the abdominal and pelvic cavities.
104
What are signs and symptoms that infection is spreading?
▪ Fever and abdominal pain will be particularly pronounced.
| ▪ Peritonitis: paralytic ileus and abdominal distention with absent bowel sounds
105
Nursing Considerations for Endometritis
- Fowler’s position to promote drainage of lochia.
- Medication for pain
- Observe for signs of improvement or new S&S such as N/V, abdominal distention, absent bowel sounds and severe abdominal pain.
- Assess VS q2hours while fever is present and 4 hours afterward.
106
Comfort measures for patient’s with endometritis include
```
Warm blankets
Cool compresses
Cold or warm drinks
Use of a heating pad
Foods high in vitamin C and protein to aid healing are encouraged.
```
107
Patient Teaching: Endometritis
- S&S of worsening condition, side effects of therapy and the importance of adhering to the treatment plan and follow up care.
- Help pump her breasts to establish and maintain a lactation.
108
Mastitis
- Infection of the breast.
- Occurs most often 2-4 weeks after childbirth, although it may develop at any time during breastfeeding.
- Usually affects only one breast.
109
Mastitis can be caused by
▪Staphylococcus aureus or Viridans streptococci, which are part of normal skin flora.
▪The bacteria are most often carried on the skin of the mother or in the mouth or nose of the newborn.
▪The organism may enter through an injured area of the nipple, such as a crack or blister, although no obvious signs of injury may be apparent.
▪ Engorgement and stasis of milk
110
Soreness of a nipple may result in
Insufficient emptying of the breast during breastfeeding because of pain.
111
Engorgement and stasis of milk may precede mastitis. This may occur when:
▪ Feeding is skipped
▪ When the infant begins to sleep through the night
▪ When breastfeeding is suddenly stopped.
▪ Constriction of the breasts by a bra that is too tight may interfere with emptying of all the ducts and infection.
▪ The mother who is fatigued or stressed or who has other health problems -> weak immune system
112
What are clinical manifestations of mastitis?
- Fatigue and aching muscles
- Temperature of 39 C (102.2 F) or higher
- Chills, malaise and headache.
- Localized lump or wedge-shaped area of pain
- Redness, heat, inflammation and enlarged axillary lymph nodes.
- Hard, tender area may be palpated.
113
Untreated mastitis can lead to
Breast abscess
114
First line of treatment for mastitis
- ABT therapy
| - Emptying of the breast by breastfeeding or breast pump.
115
ABT Therapy: Mastitis
·With early antibiotic treatment, mastitis usually resolves within 24 to 48 hours.
·Antibiotics should be continued for 10 to 14 days
·Women who develop a breast abscess are treated with surgical drainage and antibiotics
116
Supportive measures for treating mastitis include
Application of moist heat or ice packs, breast support, bed rest and analgesics.
117
A woman with mastitis should
- Continue to breastfeed from both breasts.
| - If affected breast is too sore, she can use breast pump.
118
If an abscess is formed and surgically drained, breastfeeding
Can be continued as long as the incision is not near the areola and the mother is comfortable.
119
If an abscess ruptures into the milk ducts,
Breastfeeding on that side should be discontinued temporarily and a breast pump used to empty breast.
120
What are nursing considerations for the care of a woman with mastitis?
- Provide adequate information for prevention.
- Increase comfort and help mother maintain lactation.
- Mother should stay in bed during acute phase of her illness
- Her fluid intake should be 2500-3000 mL/day.
- Analgesics may be required to relieve discomfort.
121
What information should be provided to the mother to prevent mastitis?
▪ positioning the infant correctly and avoiding nipple trauma and milk stasis.
▪ The mother should breastfeed every 2 to 3 hours and should avoid formula supplements.
▪ Nursing pads should be changed as soon as they are wet.
▪ She should also avoid continuous pressure on the breasts from tight bras or infant carriers.
122
Mastitis: Moist heat
Promotes comfort and increases circulation.
123
Mastitis: Measures to make mother comfortable and prevent stasis
Breastfeeding or pumping every 1.5-2 hours makes the mother more comfortable and prevents stasis.
124
Mastitis: Starting feeding on the unaffected side causes the
Milk-ejection reflex to occur in both breasts, making milk available in the painful breast as soon as the infant begins to nurse on that side.
125
What can be done to ensure complete emptying of the breast in a woman with mastitis?
Massage over the affected area before and during the feeding helps to ensure complete emptying.
126
Teach for self-care
* Teach the mom about normal changes during the postpartum period:
* Progressive descent of fundus, changes in lochia
* Be aware of postpartum fatigue and try to obtain extra rest
* Teach about nutritional needs: Adequate hydration, dietary measure if anemic, nutritional needs for breastfeeding
* Increase calories (300/day);Calcium- 1200 mg/ day, increase H2O
* Mother needs to be aware of action of prescribed medications and potential side effects
* Teach about comfort measures, activity, methods to prevent fatigue, coping skills
127
The nurse should expect medical intervention for subinvolution to include:
Oral Methylergonovine maleate (Methergine) because it provides long-sustained contraction of the uterus.
-Not oxytocin because it provides intermittent contractions.
128
dilation and curretage
Allows examination of the uterine contents and removal of any retained placenta or membranes.
129
A temperature elevation to greater than 100.4 F on two postpartum days, including the first 24 hours indicates
Infection.
130
A client with mastitis is concerned about breastfeeding while she has an active infection. Which is an appropriate response by the nurse?
Organisms that cause mastitis are not passed to the milk.
