High Risk Post Partum
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What constitutes Post Partum hemorrhage?
- Early is within the first 24 hrs
- Estimated blood loss for Vaginal Del: 500ml +
- Estimated blood loss for C-birth: 1000ml +
- Can be caused by uterine atony, lacerations, retained placental pieces, and hematomas
What are the symptoms of uterine atony?
- Boggy uterus
- Heavy lochia, often with clots
- Bladder distention
- Possible signs of hypovolemic shock
What factors contribute to uterine atony?
- Birth weight >4000g
- Abnormal or prolonged labor
- Over-distended uterus (multiples or grandparity)
- Use of oxytocin during labor
- Tocolytic use
- Prolonged third stage of labor
- Cesarean Birth, forceps, or vacuum assisted
- Retained placental fragments
- Bladder distension
What is the treatment for uterine atony?
- Bimanual compression of uterus
- Medications: oxytocin, methergonovine (methergine),Carboprost (hemabate), or rectal Misoprostal (Cytotec)
- IV Therapy for risk of hypovolemia
- Platelet Transfusion
- Uterin packing
- Uterine tamponade- foley with 30ml balloon inserted into uterus and over inflated to 60-80ml of saline to put pressure on vessels at placental site
What can cause early post partum hemorrhage other than uterine atony?
- Lacerations in the perineal, vagina, or cervix
- S/S of a laceration include bright red bleeding with a firm fundus at mid-line
- Hematomas in the vulva, vagina,or pelvis may be bleeding into an enclosed space
- Small (<3cm) hematomas may resolve without treatment
- Larger (>3cm) hematomas may require and incision and drainage if she is symptomatic
What is Late Postpartum hemorrhage and what can cause it? What is the treatment?
- occurs after the first 24 hrs within 6 weeks postpartum
- Can be caused by hemotomas
- Subinvolusion is when the uterus does not descend back into the pelvis and can be r/t fibroids, retained placental pieces, or metritis
- In subinvolusion, the lochia will return to rubra with back pain
- Retained placental pieces can also cause late postpartum hemorrhage
- Treatment: D & C to removed retained placental pieces, methylergonovine (methergine) to shrink fibroids, or antibiotic therapy for metritis
- * if hypovolemic shock occurs, this is called a code crimson
What are the three common types of Postpartal Thromboembolitic Diease?
- Superficial Vein Thrombosis
- Deep Vein Thrombosis
- Pulmonary Embolism
What are the risk factors, treatment, and nursing care for Postpartal Thromboembolitic Disease?
- Risk Factors: pregnancy, c-birth, metritis, decreased mobility, obesity
- Medical Treatment: coagulation therapy (heparin & Warfarin ok to BF), antibiotics, bed rest with leg elevated, compression stockings)
- Nursing Care: decrease the risk of formation of thrombosis by maintaining pressure stockings and early ambulation, administer meds as ordered
What is a Puerperal Infection and where is it most common?
- Infection of the reproductive tract up to 6 weeks postpartum
- Common sites:
- -Uterus (metritis)
- -Bladder (cystitis)
- -Breast (mastitis)
- -Incision (wound)
What is Metritis and what nursing care is involved?
- The most common postpartum infection
- Infection of the endometrium, myometrium, and or parametrium
- Nursing care includes reducing the risk by using proper ascetic technique, teaching the woman about proper personal hygiene, administer antibiotics, pain relief, and discharge teaching
What can cause postpartal cystitis and what nursing care is involved?
- urinary retention
- trauma to the bladder
- Nursing care: reduce risk for infection, monitor s/s, admin antibiotics as ordered
What is mastitis and how is it treated?
- Unilateral infection of the breast connective tissue
- Prevent is the best treatment: decrease nipple irritation and prevent cracked nipples, proper hand hygiene for both staff and mom
- If an infant has oral thrush, treat mom as well as it can spread to her nipple
- Other treatment includes antibiotics, analgesics, warm compresses, continue to breastfeed, pump and dump only for abscess
What are common sites for postpartal wound infections and what nursing care is involved?
- Perineal Wound
- Cesarean Wound
- Nursing care: assess wound, proper hand hygiene for mother & hospital personnel, antibiotics, pain management
What are the post partum blues?
- Also called Adjustment Reaction with Depressed mood
- 50-75% of new mothers
- Mild Depression
- Self Limiting
- Relation to changes in estrogen, progesterone, and prolactin
What are the contributing factors to post partum blues and how is it treated?
- Contributing factors include emotional letdown, pain, fatigue, anxiety, and ears about physical changes
- -provide reassurance that this is normal
- -promote rest and comfort
- -allow mom to talk about experience and feelings
- -encourage family to watch for s/s of deepening depression
- -symptoms disappear without medical intervention
What is post partum depression and what are the risk factors?
- Post partum mood disorder affects 14-15% of women
- May occur up to a year after birth
- Risk factors:
- -history of depression before pregnancy
- -depression or anxiety during pregnancy
- -inadequate social support
- -poor quality relationship with partner
- -life and child stresses
- -complications of pregnancy and/or childbirth
What are the symptoms of post partum depression?
- Significant weight loss
- Changes in psychomotor activity; agitation or retardation
- Decreased Energy
- Feelings of Worthlessness
- Inability to care for self or infant
- Decreased ability to concentrate
- Recurrent thoughts of death
- Suicide Attempts
What is the treatment for post partum depression?
- Mild: Psychotherapy
- Moderate: psychotherapy & antidepressant
- Severe: Intense psychiatric care, crisis intervention, psychotherapy, antidepressants, electroconvulsive therapy
What is post partum PTSD and what are the s/s?
- Woman's labor and birth did not occur in the manner she had envisioned
- Her perceptions of events are different from reality
- S/S: feeling numb, seemingly dazed, unaware of environment, intrusive thoughts, flashbacks to traumatic events, tachycardia, hyperventilation, nausea (s/s may develop after discharge)
What is post partum psychosis and what are the s/s?
- rare and only occurs 1-2/ 1000 patients
- Variant of Bipolar Disorder
- Develops 1-2 weeks PP
- Media attention when accompanied by infanticide
- -paranoia, grandious or bizarre delusions associated with baby
- -mood swings
- -extreme agitation
- -depressed or elated moods
- -distraught feelings about ability to enjoy infant
- -confused thinking
- -strange beliefs that she or the infant must die
- -disorganized behavior
What is the treatment for post partum psychosis?
- Anti-psychotic medications (cannot breastfeed)
- Removal of infant (may be temporary or permanent)
- Social Support
- Electroconvulsive therapy
Define perinatal loss, Intrauterine fetal demise (IUFD), and Spontaneous abortion (miscarriage)
- Perinatal loss: death of the fetus occurring from conception to 28 days after birth
- IUFD: death occurring after 20 wks and before birth
- Spontaneous Abortion (miscarriage): death occurring before 20 wks gestation
What factors affect bereavement and grief of the family after fetal loss?
- age of the parents
- family dynamics
- early or late in the pregnancy
- multifetal pregnancy
What nursing care can be done when there is fetal loss?
- Avoid Cliche's
- Facilitate family mourning
- Postmorten Care
- Memory box of infant
- Discharge care
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