ALTERED POST PARTUM
The common postpartum complications are:
– Infections of the genital tract.
– Infections of breasts
– Urinary tract infections
– Postpartum hemorrhage
– Vulval hematoma
– Pulmonary embolism
– Postpartum depression
Puerperal Infections (Puerperal sepsis)
– Infections of the perineum and vulva
– Pelvic cellulitis ( parametritis )
– Urinary Tract Infections
Infections of the genital tract
Postpartum infections of the genital tract are due to bacteria ascending from the genital tract. Usually the infection is localized but it can spread through blood or lymph causing systemic infection. Common manifestation is fever, 39oC ( 102.2oF) at any time or 38oC (101.4oF) on two successive occasions 4 hours apart after the first 24 hours of delivery.
Infections of the perineum and vulva
The common bacteria that cause infection are:
Streptococcus, Staphylococcus , Peptostreptococcus, Peptococcus, Clostridium, Gardnerella vaginalis, Escherichia coli, Klebsiella pneumoniae, Proteus
– Infections of the perineum and vulva: Localized infections commonly involving a perineal laceration or episiotomy wound.
– Endometritis: Localized infections from the inner uterine wall usually begin at the placental side and may spread to the entire endometrium
– Risk factors: Prolonged labor and rupture of membranes.
Assessment of altered post partum
– Persistent temperature 38oC or high grade fever
– Uterine tenderness
– Foul smelling discharge
– Lower abdominal pain
– Loss of appetite
– Sometimes foul smelling lochia
– Pelvic cellulitis (Parametritis): Infections to the tissues of broad ligament. Sometimes develop into a pelvic abscess.
– Peritonitis: Infection to the peritoneum accompanying pelvic cellulitis.
– Rapid pulse
– Rapid shallow respiration
– Difficulty to sleep
– Constant severe abdominal pain
– Abdominal distention
– Positive culture of lochia
– Increased WBC count
Infection of the fallopian tubes. The fallopian tube become edematous and tubal lumen is filled with purulent discharge. Cervical culture may show N.gonorrhoeae.
Symptoms of salpingitis
– Rapid pulse
– Abdominal pain
Cesarean wound infections
Infections following cesarean delivery: includes endometritis, pelvic abscesses and incisional wound infections. 10 – 20 % of women with cesarean births experience endometritis. Prolonged rupture of membranes and prolonged labor leads to the development of endometritis.
Assessment Symptoms of Cesarean wound infections
– Fever start with in 48 hours
– Indurations and erythema of the incision
– Foul smell
– Necrosis of the wound area
Nursing Management of Cesarean Wound Infections
– Nursing diagnosis
Alteration in comfort, acute pain related to infection of genital tract.
– Client’s body temperature returns to normal.
– Vital signs are within normal limits.
– Appetite returns to normal.
– Ambulates without difficulty.
– No pain.
– Normal involution.
Nursing Interventions Intervention in Cesarean Wound Infections
– Monitor vital signs to obtain base line data and deviations from normal.
– Monitor for signs and symptoms of infection.
– Obtain specimen for culture and sensitivity.
– Encourage comfort measures-heat therapy, bath, back rub, positioning.
– Fowler’s position to promote lochial drainage.
– Encourage fluid intake.
– If peritonitis NPO and naso-gastric suction until bowel function is returned. Medications as per order – antibiotics and analgesics.
– Assist with procedures like wound debridement or cleansing.
Prevention of infections in the postpartum client
– Advice the client to avoid possible sources of infection especially respiratory tract infections, URTI and communicable diseases.
– Minimize visitors.
– Use separate equipments for providing care for each client.
– Careful hand washing after contact with each client.
– Personnel with an infection should not work in maternity ward.
– Clean dry masks covering nose and mouth should be worn during delivery and procedures.
– Inspect the perineum and lochia at least every 8 hours for signs of infection.
– Follow aseptic techniques while giving perineal care.
– Teach proper techniques for perineal care to the client – not touching the labia or perineal part with the fingers and not separating the labia because this permits the cleansing solution to enter the vagina.
– Teach breastfeeding mothers to inspect their nipples for redness or cracks after each feeding.
– Teach the client to report the signs and symptoms of any infection promptly.
– Early ambulation of the client to promote circulation.
– Enhance intake of fluid and a balanced diet.
Infection of the glandular tissue of the breast usually caused by staphylococcus aureus and sometimes by streptococcus.
Pathophysiology of Mastitis
Microorganisms enter into the ductal system through erosions of the nipple or areola. The source of infection may be from the newborn’s mouth or from the client’s fingers. The microorganisms multiply in the plugged lactiferous ducts causing infection.
– Epidemics of mastitis occur when organisms are transmitted from nursery personnel to many newborns and then to the mothers
– Daily observation of breasts- consistency, color, surface temperature, nipple condition.
– Breast engorgement.
– Enlargement of axillary lymph nodes.
Nursing care plan of Mastitis
Nursing diagnosis of Mastitis
– Knowledge deficit R/T care of the breasts, breast feeding techniques and preventing infection.
– Client demonstrates proper breast and nipple care and breast-feeding techniques.
– Reports any signs of infection promptly.
– Pain is decreased.
– Infection is resolved.
Interventions In Mastitis
– Teach breast and nipple care.
– Breast-feeding techniques.
– Teach the signs and symptoms of infection.
– Inspect nipples 8th hourly for cracks, fissures, blisters and excoriated areas and tenderness.
– Heat and cold applications to relieve pain
– Firm supportive brassiere for breast support.
– Administer antibiotics as per order.
– Assist with procedures such as incision and drainage.
– If fever high or I & D is done stop breast-feeding.
– Expression of breast milk to maintain lactation.
Urinary Tract Infections
Infection to the urinary tract is a major risk in the postpartum clients due to the physiologic urinary stasis, dilatation of the ureters and vesicoureteral reflux. If the client is unable to void fully the remaining urine in the bladder act as a good culture medium for bacteria leading to cystitis (inflammation of the bladder) and pyelonephritis (inflammation of the renal pelvis).
Risk factors of Urinary Tract Infections
– Cesarean birth
– Forceps delivery
– Vacuum delivery
– Epidural anesthesia
– Urinary catheterization
Signs and symptoms of Urinary Tract Infections
– Burning pain on urination.
– Supra pubic tenderness.
– Low grade fever
– Urine culture +ve
– High grade fever (40-41oC)
– Flank pain
– Lower abdominal pain
– Blood – increased WBC count.
– Urinalysis similar to cystitis.
Nursing care plan In Urinary Tract Infections
Nursing diagnosis 1:
– Altered urinary elimination R/T postpartum urinary stasis and infection.
– Client verbalizes relief of pain on urination.
– Client reports that the bladder feels empty after voiding.
– After delivery observe the time of voiding.
– If not passing urine after 6 hours catheterize.
– If bladder fullness is present after voiding, catheterize for residual urine.
– Encourage voiding every 2-4 hours.
– Sitz bath
– Encourage ambulation.
– Teach her Kegel exercises.
– Collect urine for culture and sensitivity.
– Promote nutrition, hydration and rest.
– Keep intake and output.
– Medications as per order- antibiotics – ampicillin, amoxicillin, nitrofurantion.
– Analgesics & antispasmodics to relieve pain and discomfort.
Nursing diagnosis 2:
– Knowledge deficit R/T prevention of UTI
– Client identifies measures to prevent UTI
– Teach client proper perineal care.
– Use of cotton under clothing.
– Increase fluid intake.
– Frequent voiding.
– Voiding before and after intercourse.
– Teach the S/S of infection.
– Early treatment of vaginary and pelvic infections.
Nursing diagnosis 3:
– Risk for altered parenting R/T infection and interference with bonding.
– Client resumes bonding with neonate
– Encourage baby care by the mother.
– Continue breastfeeding.
– Involve partner also in baby care.
– Blood loss of more than 500 ml within a 24 hour period.
Classification of Postpartum hemorrhage
– Immediate – within 24 hours
– Delayed or late – after 24 hours, usually between 5-15th postpartum day; can be as late as 6th week.
Causes of postpartum hemorrhage
– Uterine atony
– Lacerations of the genital tract
– Vulvar, vaginal and pelvic hematomas
– Uterine inversion
– Uterine rupture
– Abnormal placental implantation (Placenta accreta or increta)
– Retained placental tissue
– Subinvolution of placental site
Uterine atony – Risk factors
– Uterine over distention due to multiple pregnancy, polyhydramnios, big baby
– Grand multipara
– Uterine fibroids
– Placenta previa or abruptioplacenta
– Cesarean or forceps delivery
– Oxytocin augmentation or induction of labor
– Precipitate labor or prolonged labor
– Prolonged third stage
– Retained placental fragments
– Deep anesthesia.
– PIH, preeclampsia
Other causes for PPH
– Bleeding disorders
– Disseminated Intravascular coagulation
– Sub involution
– Fetal death
Management of Postpartum Hemorrhage
– Emergency management: Uterine massage
– Place one hand on the symphysis pubis supporting the base of the uterus and grasp the uterine – fundus with the other hand and massage gently.
– Other management
– Empty the bladder
– Oxytocin infusions at a rapid rate
– Ligation of uterine vessel
– Hysterectomy if all the other measures fail.
Nursing management Postpartum Hemorrhage
Assessment and symptoms of postpartum hemorrhage
– Profuse outpouring of blood from vagina.
– Heavier than usual vaginal bleeding continuing for hours.
– Boggy uterus or atonic uterus.
– Signs of shock if severe bleeding occurs
– Low BP
– Cold extremities
– Decreased urinary output
– Anxiety, restlessness
– Changes in the level of consciousness.
Nursing diagnosis: Fluid volume deficit R/T excessive blood loss.
Goals: Client’s vital signs and lab values remain normal.
– Monitor V/S every 5-10 minutes.
– Observe skin color, O2 saturation, skin temperature and LOC.
– Evaluate the amount of vaginal bleeding – pad count presence of clots, pooling of blood.
– Suturing of cervical and vaginal lacerations.
– Fluid replacement with IVF or blood.
– Medications as per order-oxytocin.
– Cervical lacerations
– Repair by suturing
– If difficult suturing under GA.
– Vaginal lacerations
– Repair by suturing.
– Use packs if necessary.
Retained placental parts
– Elevated HCG levels in the blood.
– Positive pregnancy test.
– Confirmation by US.
Management of Retained placental parts
– D & C
– If placenta accreta which can not be removed treatment with methotrexate.
– Incomplete return of uterus to the prepregnant state.
– Oral methyl ergonovin (Methergin)
– If due to infection
Subinvolution of uterus
– Blood escaping into the tissue beneath the skin covering external genitalia or vaginal mucosa.
Assessment of Subinvolution of uterus
– Severe perineal pain
– Swelling in the external genitalia or vagina. Record the size as 5 cm or 100 fils size rather than – writing small.
– Bluish-black skin
– Management: If enlarging, incision, ligation of the bleeding vessel and evacuation of clot.
– Nursing diagnosis and interventions of Subinvolution of uterus
– Alteration in comfort, pain related to collection of blood in the subcutaneous tissue.
– If mild, analgesics for pain.
– Cold applications.
– A thrombus formed in the uterine or pelvic vein enter into circulation (embolus) and occludes pulmonary artery.
Blood flow to the lungs is obstructed and sudden death can occur.
If the embolus is amniotic fluid the condition is called amniotic fluid embolism.
Assessment Pulmonary embolism
– Sudden chest pain.
– Expectoration of blood and mucus (hemoptysis).
– Air hunger.
– Signs of shock
– Respiratory arrest.
Nursing diagnosis: High risk for respiratory failure R/T occlusion of pulmonary artery by a clot.
Goal: Client remains free from complications.
– Keep ready for CPR.
– Continuous monitoring of vital signs.
– Assess breathing pattern and skin color.
– Start an IV line.
– Arrange for X-ray, ECG, ABG and pulmonary angiography.
– Sedation as per order- Morphine or Demerol.
– Thrombolytic therapy-streptokinase or urokinase.
– Anticoagulant therapy with heparin or warfarin to prevent further emboli.
Infection of the veins of the leg with clot formation. Ovarian and pelvic veins also may be included.
Assessment of Thrombophlebitis
– Pain in the groin or hips and extending downward.
– Pale skin.
– Swelling of the calf or thigh
Nursing diagnosis: Alteration in comfort, pain related to infection and inflammation to the veins.
Goal: Client verbalizes relief of pain.
Interventions of Homan’s sign
– Elevation of affected leg
– Heat and cold applications
– Do not massage or rub the affected part.
– Careful handling of the leg to prevent trauma and dislodgement of clots.
– Encourage fluid intake.
– Analgesic for pain.
– Heparin to prevent clot formation.
– Antibiotics or antimicrobials for infection.