012610-golson-postpartum_care-spring-29 by xiaoyounan


									Postpartum Care

 Physiological and Psychological
  Adaptations after Childbirth

             Debbie Golson MSN, RN
              Learning Outcomes

•Describe the basic physiological changes that occur in a
      woman’s body during the postpartal period, the related
      nursing assessment and care with patient education.
•Formulate nursing diagnosis and nursing care based on
     “normal” findings of the postpartum assessment.
•Compare abnormal findings in the nursing assessment with
     possible causes and appropriate nursing care.
•Examine the nurse’s impact in assessing predisposing factors
     of postpartum complications, implementing preventive
     care, and teaching for self help.
            Learning Outcomes

•Describe the psychological adjustments that normally occur
      during the postpartal period, the related nursing
      assessment and care including education to promote
      patient and family wellness.
•Identify the impact of cultural influences on providing holistic
      nursing care for the postpartal family.
•Examine the individualized postpartal nursing needs of the
     woman, including the childbearing adolescent, who
     delivered vaginally or by cesarean section.
•Evaluate identified teaching topics and outcomes related to
      postpartum discharge.
Postpartal (Puerperium)
• 4TH Stage of Labor: 1-4 hrs. after delivery
• Begins immediately after delivery of placenta
• Continues for 6 weeks, or until body returns to
  near pre-pregnant state
            Physical Adaptations

•       Involution of uterus- “uterus going back to pre-preg state”
        • Rapid reduction in size of uterus to nonpregnant state (5-6
        • Contractions constrict and occlude underlying blood vessels at
          placental site.
    • Placental site
        • Heals by exfoliation (6wks)
        • No scar formation occurs, if it does scarring could prevent egg
•       Subinvolution
        • Any slowing of decent
Involution/Fundal Position
• Stages of Involution
       • Post-delivery: midway between
           umbilicus and symphysis pubis

       • 6-12 hrs: rises to
         level of umbilicus
         then at 1-2 cm below first PP day

       • 24 hrs – 10 days:
         descends 1cm/day until reaches
         pelvic cavity

       • Universal measurement
Fundal position “usually mid-line”
•        May be displaced to the left or right by a distended bladder
•        Becomes “boggy/mushy” with uterine atony
           increased risk for hemorrhage “bladder is full and is pushing uterus up”
•        Debris from delivery and uterine lining
                          Rubra—dark red 1-3 days
                          Serosa—pink        4-10 days
                          Alba—white         11-24 days
         •Increased with exertion and breastfeeding
         •Unexplained increase or return to Rubra is abnormal
Vaginal changes
•   Following birth edematous and bruised
    Small superficial lacerations may be present
• Decreases in size for 3 weeks in nonlactating woman
• Decreases in size slower in lactating woman due to
hypoestrogenic state. B/c you don’t ovulate during breastfeeding.
• Low estrogen leads to painful intercourse due to
decreased vaginal lubrication (6-10 wks)

Cervical Changes
• Following birth - spongy and flabby and formless and may appear
• Permanently changed by the first childbearing.
• Dimple-like to a lateral slit (fish mouth)
Perineal changes
   • May appear edematous with some bruising
   •   Episiotomy edges should be approximated

Ovulation and menstruation
   •      Estrogen/Progesterone drop rapidly after delivery of
                In nonlactating woman, returns within 6 weeks
                In lactating woman, return varies due to increased levels of
       prolactin (supports milk production)
           •May precede menstruation, making breastfeeding not
                reliable means of contraception
               Additional Physiological

   •Preparation for lactation - estrogen and progesterone
        •After birth, the interplay of maternal hormones leads to the
        establishment of milk production
   •Infant sucking: stimulates prolactin / milk production; stimulates release
   of oxytocin milk “let down” uterine contractions/cramping. Breastfeeding
   helps lose buldge.

Abdominal / GI
   •   Risk for constipation; Sluggish due to progesterone
   •   Decreased abdominal musculature/peristalsis
   •   Narcotic usage; Dehydration
   •   Fear of pain and tearing episiotomy delays elimination
   •   Flatulence causes abdominal discomfort
       •Stool softeners approved
   •Puerperal diuresis PP Diuresis– 2000-3000cc/24hrs.
   •Overdistention of bladder due to rapid filling of bladder
   •Increased distension/ retention leads to UTI
   •Uterine relaxation (atony)
   •Increased risk of hemorrhage
   •Uterus deviates to side and becomes boggy
   • Returns to Pre-pregnancy state by 12 weeks
   • Natural diuresis of increased blood volume
   • Increased cardiac output
   • First 48hrs – Increased risks CHF and pulmonary edema especially
   with history of PIH “HTN” or heart disease
   • CBC decrease normal due to blood loss - pre-labor values in 2-6
       •Risk of thromboembolism for 6 weeks
       •Increased fibrinogen for 1 wk – which will increase risk of DVT
       •Headaches due to fluid shift - HTN, Epidural/Spinal
Vital signs
   •   A temperature up to 100.4 may be due to dehydration
   and/or exertion in the first 24 hours - Afebrile after 24 hr BP WNL “BP w/in
   normal limits”, may decrease initially - ↑BP may indicate PIH “preg induced
   HTN”. If Temp stays high after 24hrs = infection.
   • Pulse rate may decrease to 50-70 (normal). BUT, Tachycardia 

Lab Values
   •   Prepregnant state by the end of the postpartum period
   • Increased risk of thromboembolism
   • White blood cell (WBC) counts up to 30,000 may occur early postpartum.
   Treat the symptoms, not the lab values
   • Convenient rule of thumb is a 2 point drop in hematocrit “amount of
   RBCs in the blood” equals a blood loss of 500 mL
Postpartal chill
   •   Normal First 2 hours after delivery
   •   Nervous response or vasomotor change
   •   Due to shift in fluids and work of labor
   •   Treat with warm blanket or warm beverage
   •   Assure pt that it is common occurrence (gone w/in the hr)
   •   Chills / fever late in the postpartum period may indicate sepsis

Postpartal diaphoresis
   • Fluid shift
   • Increased perspiration
   • Common at night
  • Common in multiparas
  •   Increased with uterine distention
          •Caused by intermittent contractions
  •   May cause severe discomfort for the first 2-3 days
  •   Breastfeeding, Oxytocins may increase the severity
  •     (Pitocin, Methergine “is used if pitocin isn’t working”, Ergotrate) “to stop the
  •    Mild analgesic may be indicated for pain relief. (Toradol “caution: can cause
  urinary distension”, Norco, Davocet N-100, Percocet, Motrin)
          Psychological Adaptations

Maternal Role adjustment (see Book)
• 1st - 2nd PP days - passive and somewhat dependent
•        Hesitant about making decisions
•        Food or sleep are of major importance
•        “Taking In” phase according to Rubin
• 3rd day, mother is ready to resume control. “Taking Hold” phase occurs
during this time
•Today’s mother’s adjust more rapidly as LOS “length of stay” has shortened
    •Education is more important.
Maternal role attainment
•       Process by which a woman learns mothering behaviors
              Psychological Adaptations

•Initial attachment Behavior
   •   En face “when the father is looking in the face of the child, bonding)
   •   Fingertip exploration
   •   Reciprocity “mutual dependence or action or influence”
•Father-Infant Interactions
   • Engrossment (the characteristic sense of absorption,
   preoccupation, and interest in the infant demonstrated by fathers during
   early contact with the newborn
•Cultural Influences
   •   Postpartum care my be affected by cultural beliefs:
   •   Do not make generalizations
   •   Extended family may play an important role in care
Psychological Adaptations
              Psychological Adaptations

Baby blues- a normal emotion
   • Transient period of depression during first 2 weeks
   • Mood swings, anger, weepiness, anorexia, insomnia,
   and a feeling of letdown
   • Cause? Hormonal changes and psychological adjustments
   • Usually resolve naturally in 2 to 3 weeks with support and
   reassurance. If symptoms persist, the client should be
   evaluated for postpartum depression
   • Postpartum depression- >3wks, ineffective ADLs, State law that PPD
   gets educated.
   • Postpartum psychosis- Extreme PPD, murder/suicide
Postpartum Assessment
     and Nursing Care
Current OB Status
 •    Admit assessment
 •    Delivery information
 •    Blood type – mom/baby (very Important Baby/mom match, rh
     factor) Else mother’s antibodies/RBC could attack the baby.
 • Rubella status- NEED to know, common cause of most
  congenital anomalies (mother & baby don’t have antibodies to
 • L/D complications
 • Medications/Narcotics – last 24 hrs

 Prenatal History
 •    Previous pregnancies – complications (Prenatal will affect later)
 •    Abnormal lab results
 •    Antepartal testing and procedures
Medical History
•   Allergies
•   Chronic illness – HTN, DM, HIV
•   STD
Psychosocial history
• Depression prior to pregnancy
•   Support system
Culture- Jehovah’s W.- Will not accept blood transxn
• Ethnicity
•   Demographics
•   Personal Beliefs/Preferences
•   Socioeconomic
•   Diet
Vital Signs – q 4 hours
•   BP- should remain at baseline during pregnancy
    •       High BP – preeclampsia, essential HTN
    •       Low BP - hemorrhage or may be WNL for pt

•   HR- 50 – 90 bpm – tachycardia – hemorrhage

•   Respirations- 16-24 – tachypnea – respiratory dx
    •   TCDB and IS post-op
    •   Spinal Duramorph may cause decr resp.
•   Temperature- 98 – 100.4 – first 24 hours only due to
    •       After 24 hours 100.4 or above suggests infection- due
             PROM “Pre-Mature Rupture of membranes” pass,
        prolonged labor
        •    May have low grade temp when lactating
        •    Teach pt. how to take temperature
Pain Assessment

•         Orient patient to pain scale

•           Assess origin of pain – uterine, abdominal, perineal,
    rectal, headache, breasts

•        Evaluate for hematomas: vulvar, vaginal, pelvic –
    severe pain with firm uterus.

•          Pain Management: Epidural, PCA, Analgesics
    (Tylenol, Norco), Nonpharmacologic measures. (heatpads,
    ice) Note patients response to pain medications. PostPar
    med, Toradol- nonsteroidal anti-inflammatory drug”

•         Monitor for side effects of medications
• Incisions
   •   Tubal Ligation: “tubes tied”
        • Small umbilicus incision

   •   Post-op Cesarean Section: “Bikini cut”
       • Low transverse abdominal
       • Midline abdominal, risk abd hernia
       • Heals in 6-8 weeks

   •   Perineal:
       • Episiotomy or laceration
       • Heals in 4-6 weeks
       • No intercourse for 6 wks to facilitate healing
       • REEDA assessment: redness, edema, ecchymosis,
         discharge, approximation (great for any type of
Everything you need to check

     •   B = Breast
     •   U = Uterus
     •   B = Bladder
     •   B = Bowel
     •   L = Lochia “vag discharge after delivery”
     •   E = Episiotomy/Laceration
     •   H = Hemorrhoids/Homans
     •   E = Emotional
     •   B = Bonding
• Determine breast or bottle-feeding
• General appearance – reddened area- Mastitis. Size (may
  affect breastfeeding)
• Encourage supportive bra
• Sports bra for 2 weeks if bottle-feeding, to try and
  compress to prevent pain
• Palpation – soft, filling, full, engorged
• Mastitis – (an infection) mass, tender, red, heat
• Engorgement – tenderness, heat, edema express milk,
  warm packs, pump
• Nipples – supple, intact, erect with stimulation
• Cracked, sore, red, bleeding, flat inverted (can use lanolin
  cream to treat, or their own breast milk)
• May need shields or shells with breastfeeding
    • Shields to prevent bra irritation
    • Shells- to make nipple “stand-up” making it easier for infant
• Assess technique, Lactation specialist referral

   Uterus and Fundus (Next slide)
• Have pt. void before assessment.
   • Full bladder will displace uterus above umbilicus and cause
     uterine atony with increased bleeding

• Assess risk factors Gently massage fundus
   • If soft and boggy/ mushy– Teach self-massage
   • Assess every 15 minutes for first hour after delivery,
     30min for second hour, hourly for 2 more hours, then
     every 4 hours - monitor for complications Oxytocics to
     promote contractions, decrease bleeding, side effects:
        • Pitocin: Hypotension
        • Methergine: Hypertension, given IM w/ SE of HTN
        • Remember, Methergine is alternative to Pitocin.
    • With cesarean section, abdomen very tender, use care
      and inspect incisional area for signs of infection, healing.
One hand to assess the top. Other hand steady.

•    Increased risk for distension, retention due to postpartal
    diuresis (2000-3000cc)

•    Must void q 4-6 hours post vaginal delivery, or within 4 hours
    of removal of foley catheter. Use alternatives (warm water,
    running water in sink, peppermint oil, increased fluids) to assist
    voiding before straight cath or reinserting foley

•    Full bladder leads to uterine atony and increase bleeding

•    Assess for UTI
•    Increased risk of constipation due to fear of pain from
    episiotomy, hemorrhoids, perineal trauma

•    Normal BM by 2nd or 3rd day.

•    Encourage fluids, ambulation, stool softeners, roughage
    in diet

•     Post-op cesarean section / BTL « bilateral tubal
    ligation » need to pass flatus before eating to avoid
           abdominal distension and discomfort. No straws,
    carbonated drinks, or heavy sweets
• Amount, color, odor, presence of clots
• Scant to moderate amount, no clots. Large amount with
  clots must be evaluated for hemorrhage due to uterine
  atony, retained placenta, unknown cervical laceration (heavy
  bleeding with firm uterus). Pools in vaginal vault after lying
  down, may ‘gush’ when pt. stands up. Always reassess with
  clean pad
• Usually with cesarean section lochia is scant due to uterine
• Odor is nonoffensive, earthy. If foul, suspect infection
• Last 3-4 weeks until placental site is healed
• Return to rubra – subinvolution “a medical condition in which
   after childbirth, the uterus does not return to its normal size”
Episiotomy and Perineum
•      Inspected perineum and anus with woman lying in Sims’ position
    (sideways w/ knees bent and pillow between legs)

•      With episiotomy or laceration with repair, assess wound
    (REEDA). Edema, bruising, tenderness, normal. Hardened areas
    with increased pain – hematoma, infection. Apply ice pack, teach
    to pat dry after voiding, use Dermoplast spray, sitz bath, pain meds
    (Norco, Toradol, Darvocet, Tylenol). NOTHING RECTALLY with 3rd or
    4th degree episiotomy or tear.

•     Hemorrhoids may be present. Assess size, pain or tenderness.
    Tucks ‘hemorrhoid pads’ , sitz bath, stool softeners

•     Provide teaching concerning episiotomy, hygiene,
    comfort measures, hand washing
Homan’s/Lower Extremities (Homan’s to check for DVTs)
• Increased risk for thrombophlebitis, thrombus formation due
  to hypercoagulability, anemia, obesity, traumatic childbirth,

• Homan’s not diagnostic, only evaluation tool. Only true
  diagnostic is LEVD
    • Homan’s Sign- Pain in the calf w/ dorsiflexion of the foot

• Heparin therapy with DVT

• Early ambulation, SCD’s, ROM while bedridden

• Teach signs and symptoms of DVT, especially for discharge.
    • Symptoms: tenderness, pain, swelling, warmth, and discoloration
      of the skin.

                             Homan’s Sign
Emotional Status
•    First 24 hrs – passive ‘taking in’ – passive, talks about labor
    and birth experience. Sleeps frequently (fatigue from labor)

•    12 -36 hrs – ‘taking hold’ – begins to assume responsibility.
    May have mood swings, crying, irritability (baby blues)

•    Assess mother’s attitude, support systems, caregiving skills,
    feelings of competence in comparison to disinterest,
    withdrawn behavior, depression

•    Educate patient and family concerning postpartal
    depression, sign, symptoms, support groups, referrals
• Observe interaction with newborn; en face, cuddles,
  soothes, identifies family characteristics

• Disappointment over sex usually transient "temporary",
  yet continued expressions, refusal to care for infant,
  lack of bonding behaviors must be evaluated further

• Cultural practices may modify mother’s response to

• Provide supportive, nonjudgemental teaching and
  evaluate mother’s knowledge level

• Family centered care and rooming in facilitates bonding
  with father and siblings
•    Promote successful infant feeding

•    Bottlefeeding: supportive bra, ice packs 4 times
    a day if engorgement develops, avoid heat and
    stimulation of breasts. Feed every 3-4 hours

•    Breastfeeding: supportive bra, nursing on
    demand, assist with positioning (football, cradle,
    side lying hold). Teach breast care: no soap, air
    dry after breastfeeding, use lanolin. Lactation
    specialist referral

•    After cesarean birth, assess for grief due to loss
    of fantasized birth. Support effective coping
  Assess adolescent mother’s needs and maternal-
infant interaction based on level of maturity.
Include self-care, infant care, contraception, goal
setting, peer relationships, resources.

For the woman giving up her newborn,
nonjudgemental support is essential. Respect
special requests regarding her care and infant: See
and hold infant, early discharge, admit to med/surg
      Many factors for putting infant up for
adoption: single, adolescent, economic status,
result of incest or rape, partner disapproval of
  Discharge criteria and teaching
•VS, assessment stable

•RhoGAM received if mom is Rh-negative and infant Rh-positive (means mother has
not been sensitized to 1st baby’s blood). RhoGAM is blood product; consent with
verification by 2 nurses required. 300 mu given IM within 72 hours of delivery. (Also
received at 28 weeks) ( w/ 2nd baby she will rec RhoGAM at 28wks. Then have dose again
post-delivery to protect next child.)

•Rubella received if titer 1:10 or less, 0.5 cc sq – AVOID PREGNANCY FOR 3 MONTHS
(Rubella Titer- a serologic test to determine a patient's state of immunity against rubella)

•If less than 1:10, then she’l need a Rubella dose b/c Rubella Measles will cause
defects. Live vacine stays in system for 3months so preg prevention methods need to
be in place.
• Instruct in proper administration of medications
    • Antibiotics, analgesics, prenatal vitamins, Iron
    • Resuming home medications
        •Get Pediatrician approval if breastfeeding

• Teaching content: Maternal/Infant care, home safety, special needs (Car seat,
multiple births, infant with anomaly). Signs/symptoms of postpartum
complications: Hemorrhage, infection, DVT, depression and when to report
complications to physician

• Newborn care: feeding, bathing, cord and circumcision care, safety – MUST
have car seat
•  Resume sexual activity when episiotomy is healed and lochia flow has
  stopped. Use water soluble lubricant. Plan for contraceptive by 6 wk
  PP visit.
• Resumption of activity, especially post-op
Postpartal Complications
• Postpartum Hemorrhage
   • Early
   • Late
• Infections
• Mastitis
• PP Blues
• PP Depression
• PP Psychosis
No Qs
off this
              PP Hemorrhage

• Early
   • >500 cc in first 24 hrs after vaginal birth
   • >750-1000 cc after cesarean section
   • decrease in HCT of 10 points
        • Blood loss often underestimated
        • May occur intra-abdominally
        • Remember: Convenient rule of thumb is a 2 point drop
          in hematocrit “amount of RBCs in the blood” equals a
          blood loss of 500 mL (so -10pts is a loss of 2,500cc!?!)
• Late or Delayed
   • 24 hrs – 6 wks after delivery
Predisposing Factors

•   Uterine over distention – large infant
•   Grand multiparity
•   Anesthesia or MgSO4 “muscle relaxant”
•   Trauma (ex: car accident)
•   Abnormal labor pattern
•   Oxytocin Induction
•   Prolonged labor
•   Hx anemia, hemorrhage
•   Red headed (natural redhead will bleed more)
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Impending signs
• Excessive bleeding
   • >2 pads/30min-1hr
• Light headedness – Nausea, after laying down for hrs
  getting up soon after may cause faintness
• Visual disturbances
• Anxiety
• Pale/ashen color, clammy skin
• Increasing P/R and lower BP

Action to take
• Check uterine tone, massage, effect
• Elevate legs, lower head
• Oxygen - IV Fluids
• Pitocin, Methergine “Pitocin Alt., prevent of PP hemorrhage”,
• Call for help
Early PP Hemorrhage

• Within first 24 hrs.
   • Causes
       • Uterine atony
       • Lacerations – vaginal/cervical
       • Retained placental fragments
       • Hematomas – vulvar, vaginal, pelvic
       • Subinvolution “the uterus does not return to its
          normal size” of uterus
       • Prolonged labor
       • Multipara “refers to the number of times a woman
          has given birth”
Uterine Atony

• Failure of the uterus to stay firmly contracted
   • Slow, steady or massive hemorrhage
   • Underestimated blood loss
   • May be hidden behind blood clot

• Treatment
   • Uterine massage
   • IVF, Oxytocin
   • Surgery – curettage, ligation, hysterectomy
Retained Placental Fragments

• Partial separation caused by:
   • Pulling on cord
   • Uterine massage prior to separation
   • Placenta accreta “Placenta that attaches to muscle of

• Treatment:
   • Uterine massage
   • Manual removal
   • Oxytocin “causes uterine contractions”, Methergine
       “prevention and treatment of postpartum hemorrhage”
    • D & E “Dilation and evacuation”
    • Most common cause of Late PP Hemorrhage
Late PP Hemorrhage
• Occurs 24 hrs. – 6 wks after delivery

    • Causes:
       • Irritation at placental healing site due to retained
         placental fragments or fibrin deposits
       • Subinvolution of placental site

    • Symptoms:
       • Excessive, bright red bleeding
       • Boggy fundus with large clots
       • Backache
       • Increase T,P,R – decreased B/P

    • Treatment:
        • Massage, IV Oxytocin, D&E

• Results from injury to blood vessel
   • Usually in vagina or vulva
   • May extend to other pelvic structures
   • Develop rapidly
   • contain 300 – 500cc blood

• Symptoms:
   • Severe pain
   • Difficulty voiding (from pressure of hematoma)
   • Mass felt on vaginal exam
   • Flank pain
   • Abdominal distention
   • Shock

• Treatment: Ice to area, I&D, Incisional packing
        Subinvolution of Uterus

• Uterus remains large, does not involute
   • Causes:
       • Retained placental fragments
       • Infection

    • Symptoms:
       • Lochia “Vaginal discharge after delivery” fails to progress –
         returns to Rubra
       • Leukorrhea- “white discharge from the vagina” backache and

    • Treatment:
        • Methergine “Pitocin Alt., prevent/treat of PP hemorrhage”
        • Curettage “Scraping of material from cavity wall”
        • Antibiotics - IVF
Postpartum Infections

• Temp of 101 or higher in first 24hrs following delivery
• Temp of 100.4 or higher for 2 days during the next 10
  days postpartum
• Types:
   • Endometritis (#1 infection)
   • Parametritis, Peritonitis
   • Pyelonephritis / Cystitis
   • Thrombophlebitis
   • Mastitis (shows at 2wk after discharge, s/s hot redness of
  Predisposing factors to Postpartum Infections
Antepartal            Intrapartal
Hx of infections           Prolonged labor / PROM
Anemia                     Vacuum/Forceps delivery
Immunodeficiency           Diabetes / HTN
Poor nutrition             Multiple Vag Exams
Postpartal                 Internal Monitoring
Manual removal of          Episiotomy
   placenta                Cesarean section
Hemorrhage                 Poor aseptic techniqe
Retained placenta    Localized
IV site phlebitis          Episiotomy
Diabetes                   Lacerations
                           C/S incision

                                      Per Golson, No Qs
                "Inflammation of uterus lining"

• Infection of the uterine lining-placental site
• Most common pp infection.
• Sometimes secondary to chorioamnionitis “bacteria/virus in
  amniotic fluid”
    • Reason why we normally administer antibiotic
    • prophylaxis on C/S patients after the cord is
    • clamped

    • Endometritis
        • laboratory analysis- reveals elevated WBC, US, & bacteriologic
          identification of the pathogen.
        • Treatment includes- antibiotics, rest, analgesia, adequate fluid
          intake, and, if necessary, surgical drainage of a suppurating abscess,
          hysterectomy, or salpingo-oophorectomy.

•       Kidney infection – usually R kidney

•       UTI – Common after delivery
    •   Spiking temps - Chills
    •   Flank pain
    •   Nausea and vomiting
    •   Urgency, frequency, dysuria

•       Prevention/Treatment: Antibiotics
    •   Force fluids
    •   Insure complete emptying of bladder
        • It can be very difficult and uncomfortable to cath a pt
          after a vaginal delivery.
    •   Sterile technique for cath
        • Educate patients to change pads frequently, proper
          wiping and perineal care
• Blood clot associated with bacterial infection.
   • Superficial
   • Deep Vein Thrombosis
   • PE
  Symptoms                        Treatment
   Bedrest?                        Elevate extremity
    Tenderness                     Heat
    tachycardia                    TED’s / SCD’s
    Hot to touch                   Analgesics
    Low grade fever                Bedrest?
    +/- Homan’s
    Hot to touch
• Symptoms
   • Low grade fever
   • Edema
   • Chills
   • Extremity pain below clot
   • Decreased peripheral pulse

• Dx: LEVD

• Treatment
   • Heparin (DOC if breastfeeding) /Coumadin
         • If on Coumadin = CANNOT breastfeed
    •   TED’s (rocking chair also helps prevent DVTs)
    •   Bedrest
    •   Elevate extremity
    •   Analgesics
    Pulmonary Embolism - Emergency
Sudden onset                     Treatment
   Chest Pain                    Call MD
   Dyspnea, SOB                  Oxygen
   Sweating                      Morphine Sulfate
   Pallor – Cyanosis             Aminophylline
   Confusion                     Heparin
   Hypertension                  Streptokinase
   Sense of “impending death”.
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DIC - Disseminated Intravascular Coagulation
Hemorrhage and body tries to clot off…

 • Increased prothrombin / platelets
 • Widespread formation of clots with
     • Severe generalized hemorrhaging
 • Life threatening!

 • Predisposing factors:
     •     PIH- Pregnancy-Induced Hypertension, also known as pre-
     •     Septic shock
     •     Placental/Uterine hemorrhage
     •     IUFD- intrauterine fetal demise
     •     Amniotic fluid embolism
     •     Thrombi secondary to preeclampsia
     •     Thrombi secondary to Thrombophlebitis “blood clot”
  DIC - Disseminated Intravascular
  Coagulation cont.

• Early s/s
   • Increased PT
   • Thrombocytopenia
   • Bleeding – gums, puncture sites
   • Ecchymosis “bruise”

• Treatment
   • Very complex
   • Transfusions – PRBC, Plasma, Whole blood,
           Do not stop breast feeding

• Infection of breast connective tissue, occurs mainly in
  lactating women
• Infectious mastitis, more serious, fever, flu like
  symptoms, reddened area of breast
• Symptoms seldom occur prior to 2 weeks post delivery
• Infection usually due to breast trauma, cracks in nipples
• Treatment
   • Do not stop breastfeeding
   • Heat
   • Pump breast to avoid engorgement
   • Analgesics
   • Antibiotics
  Postpartum Depression/Psychosis

• Postpartum psychosis
   • most serious disorder
   • psychiatric emergency
• Postpartum anxiety disorders
   • occurs in patients with past history of panic disorder or
     obsessive compulsive disorder
• Observe for signs of depression
   • Overwhelmed feeling, unable to cope, fatigued,
     anxious, tearful
• Observe for signs of psychosis
   • Mood lability, agitation, insomnia, irrational, poor
   • Administer a depression scale or inventory

Reference to all material from Contemporary
Maternal-Newborn Nursing Care, 7th Edition.
Ladewig, London, Davidson

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