Nancy Pares, RN, MSNMetro Community College

Relate specific pathophysiology and nursing process specific to postpartum.

Idenitify specific post partum complications and nursing management◦ Placental issues, uterine issues, vaginal issues

Fundal height and tone Vaginal bleeding Signs of hypovolemic shock Development of coagulation problems Signs of anemia

Cesarean delivery Unusually large episiotomy Operative delivery Precipitous labor Atypically attached placenta Fetal demise Previous uterine surgery

Uterine atony Lacerations of the genital tract Episiotomy Retained placental fragments Vulvar, vaginal, or subperitoneal

hematomas

Uterine inversion Uterine rupture Problems of placental implantation Coagulation disorders

Uterine massage if a soft, boggy uterus is detected

Encourage frequent voiding or catheterize the woman

Vascular access Assess abnormalities in hematocrit levels Assess urinary output Encourage rest and take safety precautions

Health-seeking Behaviors related to lack of information about signs of delayed postpartal hemorrhage

Fluid Volume Deficit related to blood loss secondary to uterine atony, lacerations, hematomas, coagulation disorders, or retained placental fragments

Adequate prenatal care Good nutrition Avoidance of traumatic procedures Risk assessment Early recognition and management of

complications

Fundal massage, assessment of fundal height and consistency

Inspection of the episiotomy and lacerations if present

Report:◦ Excessive or bright red bleeding, abnormal clots◦ Boggy fundus that does not respond to

massage◦ Leukorrhea, high temperature, or any unusual

pelvic or rectal discomfort or backache

• Clear explanations about condition and the woman’s need for recovery

• Rise slowly to minimize orthostatic hypotension

• Woman should be seated while holding the newborn

• Encourage to eat foods high in iron• Continue to observe for signs of

hemorrhage or infection

Risk factors◦ Overdistension of the

uterus◦ Uterine anomaly◦ Poor uterine tone

Assessment findings◦ Excessive bleeding, boggy

fundus

Management◦ Fundal massage◦ Blood products if loss is excessive◦ Medications

Oxytocin, methergine, carboprost tromethamine (Hemabate)

Risk factors◦ Mismanagement of third stage◦ Placental malformations◦ Abnormal placental implantation

Assessment findings◦ Excessive bleeding, boggy fundus

Accretavilli attach to the outer layer myometrium

Incretavilli attach within the muscle layer of the

myometriumPercreta

villi attach deep within the myometrium

Management◦ Manual exploration of the uterus◦ D&C◦ Blood products if loss is excessive

Risk factors◦ Operative delivery◦ Precipitous delivery◦ Extension of the episiotomy◦ Varices

Assessment findings◦ Excessive bleeding with a firm uterus

Management◦ Suture if needed◦ Blood products if loss is excessive

Identify nursing process for post partum psycho social disorders

Depression scales Anxiety and irritability Poor concentration and forgetfulness Sleeping difficulties Appetite change Fatigue and tearfulness

Occurs within 3 to 10 days of delivery Generally transient Usually resolves without treatment Assessment findings

◦ Tearful, fatigue, anxious, poor appetite

Etiology◦ Hormonal changes and adjustment to motherhood

Longer than two weeks in duration requires medical evaluation

Onset slow, usually around the fourth week after delivery

Assessment findings◦ Depressed mood, fatigue, impaired concentration,

thoughts of death or suicide Risk factors

◦ History of depression, abuse, low self-esteem Management

◦ Psychotherapy, medications, hospitalization

Generally after the second PP week Assessment findings

◦ Sleep disturbance, agitation, delusions Risk factors

◦ Personal or family history of major psychiatric illness

Management◦ May lead to suicide or infanticide◦ Hospitalization, medications, psychotherapy

• Help parents understand the lifestyle changes and role demands

• Provide realistic information• Anticipatory guidance• Dispel myths about the perfect mother or

the perfect newborn • Educate about the possibility of postpartum

blues • Educate about the symptoms of postpartum

depression

Signs and symptoms of postpartum depression

Contact information for any questions or concerns

Foster positive adjustments in the new family

Assessment of maternal depression Teach families symptoms of depression Give contact information for community

resources Make referrals as needed

Ineffective Individual Coping related to postpartum depression

Risk for Altered Parenting related to postpartal mental illness

Risk for Violence against self (suicide), newborn, and other children related to depression

Components of grief work◦ Accepting the painful emotions involved◦ Reviewing the experiences and events◦ Testing new patterns of interaction and role

relationships

Four stages of grief◦ Shock and numbness◦ Searching and yearning◦ Disorientation◦ Reorganization

Symptoms of normal grief

Inability to conceive Spontaneous abortion Preterm delivery Congenital anomalies Fetal demise Neonatal death Relinquishment SIDS

Review nursing interventions associated with◦ DVT, Hematoma, hemorrhoids, endometritis,

wound infections, urinary infections and STD

R: redness E: edema E: ecchymosis D: discharge A: approximation

Fever Malaise Abdominal pain Foul-smelling lochia Larger than expected uterus Tachycardia

• Risk for Injury related to the spread of infection

• Pain related to the presence of infection• Deficient Knowledge related to lack of

information about condition and its treatment

• Risk for Altered Parenting related to delayed parent-infant attachment secondary to woman’s pain and other symptoms of infection

Infection of the uterine lining

Risk factors◦ Cesarean section

Assessment findings◦ Fever, chills◦ Abdominal

tenderness◦ Foul-smelling lochia

Management◦ Antibiotics

Breast consistency Skin color Surface temperature Nipple condition Presence of pain

Infection of the breast Risk factors

◦ Damaged nipples◦ Failure to empty breasts

adequately Assessment findings

◦ Fever, chills◦ Breast pain, swelling,

warmth, redness Management

◦ Antibiotics◦ Complete breast emptying

Proper feeding techniques Supportive bra worn at all times to avoid

milk stasis Good handwashing Prompt attention to blocked milk ducts

Importance of regular, complete emptying of the breasts

Good infant positioning and latch-on Principles of supply and demand Importance of taking a full course of

antibiotics Report flu-like symptoms

Health-seeking Behaviors related to lack of information about appropriate breastfeeding practices

Ineffective Breastfeeding related to pain secondary to development of mastitis

• Home care nurse may be the first to suspect mastitis

• Obtain a sample of milk for culture and sensitivity analysis

• Teach mother how to pump if necessary• Assist with feelings about being unable to

breastfeed• Referral to lactation consultant or La Leche

League

Homan’s sign Pain in the leg, inguinal area, or lower

abdomen Edema Temperature change Pain with palpation

Inflammation of the lining of the blood vessel due to clot formation◦ Can occur in the legs (DVT) or pelvis (SPT)

Risk factors◦ Cesarean section◦ Prolonged bed rest◦ Infection

Assessment findings◦ Pain, fever, redness, warmth, tender

abdomen/calf Management

◦ Anticoagulants◦ Antibiotics for septic pelvic thrombophlebitis

Avoid prolonged standing or sitting Avoid crossing her legs Take frequent breaks while taking car trips

Condition and treatment Importance of compliance and safety

factors Ways of avoiding circulatory stasis Precautions while taking anticoagulants

Pain related to tissue hypoxia and edema secondary to vascular obstruction

Risk for Altered Parenting related to decreased maternal-infant interaction secondary to bed rest and intravenous lines

Altered Family Processes related to illness of family member

Deficient Knowledge related to self-care after discharge on anticoagulant therapy

Large mass in abdomen Increased vaginal bleeding Boggy fundus Cramping Backache Restlessness

Frequency and urgency Dysuria Nocturia Hematuria Suprapubic pain Slightly elevated temperature

Risk factors◦ Urinary catheterization◦ Long labor, operative delivery

Assessment findings◦ Dysuria, frequency, urgency◦ Fever◦ Suprapubic pain

Management◦ Antibiotics

Good perineal care Hygiene practices to prevent contamination

of the perineum Thorough handwashing Sitz baths Adequate fluid intake Diet high in protein and vitamin C

Good perineal hygiene Good fluid intake Frequent emptying of the bladder Void before and after intercourse Cotton underwear Increase acidity of the urine

Frequent monitoring of the bladder Encourage spontaneously voiding Assist the woman to a normal voiding

position Provide medication for pain Perineal ice packs

Risk for Infection related to urinary stasis secondary to overdistention

Urinary Retention related to decreased bladder sensitivity and normal postpartal diuresis

Pain with voiding related to dysuria secondary to infection

Health-seeking Behaviors related to need for information about self-care measures to prevent UTI

Activity and rest Medications Diet Signs and symptoms of complications Importance of completion of antibiotic

therapy

May need assistance when discharged from the hospital

May need a referral for home care services Instruct family on care of the newborn Instruct mother about breast pumping to

maintain lactation if she is unable to breastfeed

Instruct family members on care of mother and newborn

Referral for home care if necessary Provide resources for follow-up or questions Teach all families to observe for signs and

symptoms

Assessment findings◦ Severe perineal pain◦ Ecchymosis◦ Visible outline of the

hematoma◦ Blood loss may not be visible

Treatment◦ Surgical drainage◦ Antibiotics◦ Analgesics◦ Blood products if loss is excessive

Hypotension Tachycardia, weak,

thready pulse Decreased pulse

pressure Cool, pale, clammy

skin

Cyanosis Oliguria, anuria Thirst Hypothermia Behavioral

changes (lethargy, confusion, anxiety)

Pg 664- table

Monitor vital signs frequently Large-bore IV for fluids, blood products Administer oxygen, assess oxygen

saturation Assess hourly urine output Assess level of consciousness

Administer and monitor fluids, blood products

Draw/monitor laboratory results Assess quantity and quality of bleeding Provide emotional support to patient/family

Fever > 100.5 Severe pain, redness,swelling at incision

site Passing of large clots Increased bleeding Burning on urination Insomnia Impaired concentration Feeling inadequate