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Post-Partum Hemorrhage
Blood loss of more that
Lacerations
Retained placental
fragments DIC
Uterine Atony
Relaxation of the uterus Causes
Deep anesthesia or analgesia Labor assisted with oxytocin agent Greater than 30 years old High parity Previous uterine surgery Abruptio placenta Prolonged & difficult labor Posible chorioamnionitis Secondary maternal illness (anemia) Prior Hx of postpartum hemorrhage Endometritis Prolonged use of tocolytic drugs
Assessment:
Gush of blood Signs of shock may appear Relaxation of the uterus
Management:
Palpate womans fundus at frequent interval Massage the uterus Observe for the consistency and amount of lochia Assess vital signs Encourage to empty the bladder Administer oxygen 4L/m Administer oxytocin/methergine as ordered Bimanual massage Prostaglandin administration Blood replacement hysterectomy
Lacerations
Causes:
Difficult or precipitate labor In primigravidas With birth of large infants Use of lithotomy position and instruments
Types:
Cervical laceration Vaginal lacerations
Perineal lacerations
Cervical Lacerations
Usually found on the sides of the cervix, near the
Vaginal Lacerations
Hard to repair
Management
Vagina may be packed to
maintain pressure at the suture line Insert indwelling catheter Document Nursing care specially the insertion of packing. Remove the packing after 24 hours
Perineal Lacerations
Categories:
1st Degree vaginal mucous membrane and skin
of the perineu to the fourchette 2nd Degree vagina, perineal skin, fascia, levator ani muscle, perineal body 3rd Degree entire perineum, reaches the external sphincter of the rectum 4th Degree entire perineum, rectal sphincter, some of the mucous membrane of the rectum
Management:
Document the degree of laceration Increase fluid intake
6 to 10 days post partum Uterus is not fully contracted Can be assessed using a sonogram Management
D&C
Methotrexate
Instruct the mother to
Subinvolution
Incomplete return of the uterus to its prepregnant
size and shape. Uterus is still enlarged and soft at 4th-6th week post partum. Causes:
Retained placental fragments Mild endometritis myoma
Management:
Administration of methergine (4 times a day) Educate woman of the normal process of involution
and lochial discharges before going home If endometritis is observed, oral antibiotic is initiated.
Perineal Hematomas
Collection of blood in the subcutaneous layer of
Severe pain in perineal area Feeling of pressure between womans leg Purplish discoloration and swelling Tender to palpation
Causes:
Injury to blood vessels during birth Precipitous births of woman with perineal
Management
Report presence of hematoma, its size, shape and
degree of womans discomfort Administer mild analgesic as for pain relief as prescribed Apply ice pack If episiotomy or line is opened to drain hematoma,
Left it open and packed with a gauze Document the insertion of packing Remove packing after 24 to 48 hours.
Puerperal Infection
Causes:
Rupture of membranes more than 24 hours before
birth Retained placental fragments Postpartal hemorrhage Preexisting anemia Prolonged and difficult labor/ use of instruments Internal fetal heart monitoring Local vaginal infection is present at the time of birth Uterus was explored at the time of birth
Management:
Antibiotics after C/S testing of microorganism
Endometritis
Infection of the
hours postpartum Increase WBC Chills Loss of appetite Malaise Locia dark brown & has a foul odor
Management:
Asess lochial discharge (amount, color, consistency,
odor) Appropriate antibiotic c/s culture should be from the vagina Administration of methergine Increase fluid intake Analgesic for pain Encourage ambulation/ semi-fowlers position Wear gloves in helping the woman change perineal pads Teach woman the proper hand washing technique
perineum. Assessment:
Pain, heat, feeling of pressure Inflammation of the suture line Purulent drainage may be pressent
Management:
Remove perineal sutures to allow drainage Packing the open lesion Sitz baths or warm compresses to hasten drainage
and cleanse the area Frequent change of perineal pads Wipe front to back after a bowel movement Analgesic for pain as prescribed Antibiotic after the c/s testing
Peritonitis
Infection of the peritoneal
Rapid pulse
Vomiting Appearance of being
acutely ill
Management:
Insertion of NGT IVF or TPN may be needed
Thrombophlebitis
Phlebitis inflammation of lining of blood vessels
endometritis
Prevention:
Prevention of endometritis by good aseptic
technique Ambulation Limiting the time a woman remains in the stirrups Wearing support stockings 2 weeks after delivery Do not sit with knees bend sharply
Femoral Thrombophlebitis
Assessment:
Femoral, saphenous,
popliteal veins are involved Edema White leg appearance Chills, pain, redness in the affected leg Swelling below the lesion Homans sign (+)
Management:
Bed rest with affected leg elevated Application of moist heat
Administration of anticoagulants/thrombolytics
Avoid massaging the affected area Administration of analgesics
If anticoagulant is given,
Lochial discharge may increase Avoid the use of salicylic acid for pain
Pelvic Thrombophlebitis
Involves the ovarian, uterine, & hypogastric veins
abscess
Management:
Bed rest Administration of anticoagulants/antibiotics Abscess can be incised by laparotomy Removal of the affected vessel before attempting to
Prevention:
Prevent wearing of tight clothing on the lower
extremities Resting with the feet elevated Ambulating daily during pregnancy
Pulmonary Embolus
Obstruction of
Management:
Administration of thrombolytics
Woman is transferred to the ICU for continuing
care
Mastitis
Infection of the breast Caused by cracked and fissured nipples Prevention:
making certain the baby is position correctly and
grasps the nipple properly (both nipple and areola) Releasing a babys grasp on the nipple before removing the baby from the breast Washing hands between handling perineal pads and touching the breast Exposing nipples to air for at least part of every day Vitamin E ointment to soften nipples daily
Assessment:
Localized pain, Swelling Redness Fever
Breast milk
becomes scant
Management:
Broad spectrum antibiotic Continue breast feeding Cold or ice compresses Wear supportive bra
Urinary Retention
Results from inadequate bladder emptying.
forceps during birth Pressure of birth causes edema, thus leading to decreased sensation for voiding Leads to overdistention of urinary bladder
Assessment:
Bladder distention Frequent voiding but in small amount Overall output is inadequate If first voiding after birth is less than 100 ml, suspect
Management:
Urinary catheterization Explain how catheter works Remove catheter after 24 hours Encourage woman to void 6 hours after the removal of catheter If after 8 hour from removal of catheter, the woman has not voided, reinsertion may be necessary
Assessment:
Burning sensation upon urination Hematuria Feeling of frequency Sharp pain on voiding Low-grade fever Lower abdominal pain
Management:
Instruct client how to obtain a clean-catch urine Broad spectrum antibiotic (amoxicillin) Encourage fluid intake Analgesics for pain (tylenol)
the uterus:
Retroflexion Anteflexion Retroversion anteversion
birth Symptoms: sadness, tears Etiology: hormonal changes, stress of life changes Therapy: Support, empathy Nursing role: offering compassion and understanding
Post-Partum Depression
Onset: 1 to 12 months after
birth Symptoms: Anxiety, feeling of loss, Sadness Etiology: History of previous depression, hormonal response, lack of social support Therapy: Counseling, drug therapy Nursing Role: referring to counseling
Post-Partum Psychosis
Onset: within first month
after birth Symptoms: delusions, hallucinations of harming infant or self Etiology: possible activation of previous mental illness, hormonal changes, family history of bipolar disorder Therapy: Psychotherapy, drug therapy Nursing Role: referring to counseling, safeguarding