Chapter 16
Complicated Postpartum Period
The following are some normal things:
After painsà multip usually experiences more because of less muscle tone.
Tx: Tylenol and warm compresses.
Lactating women need 500-700 extra calories per day. High protein and high iron diet. At least 3 quarts of fluid.
Breast binder and ice packs for those who do not breast fee.
May not ovulate with first period and sometimes up to 3 months. Breast feeding woman may not have a period but will still ovulate so therefore she can get pregnant even though she is not having a period.
Psychological Adaptation:
3 Phases à
Complicated puerperum:
It is essential to give adequate verbal and written instructions as to what danger signs to look for.
Physical Complicationsà hemorrhage, infection, birth canal injuries (lacerations and hematomas), and venous thrombosis.
Can occur immediately or 4-6 weeks after delivery.
Early hemorrhage occurs in first 24 hours.
Late occurs after 24 thru 6 weeks.
Normal is 300-500ml loss of blood.
If >500ml, considered to be hemorrhaging.
Causes:
Uterus lacks normal muscle tone (does not remain contracted).
Can see a trickle or steady flow.
When bleeding heavily, there will also be clots.
Assess fundus – it will be boggy.
Risk:
Usually given pitocin or ergotrate to help uterus contract and expel clots.
Pieces of the placenta remain attached to the uterus.
This prevents uterus from contracting.
Typically what happens when mom has gone home and has already gone thru stages of lochia and then starts to have bright red blood.
A D&C is usually done.
Tissue tears caused by the trauma during birth. Described in degrees up to 4 which is the worst and is a tear that goes all the way through rectal muscles.
Can be in the cervix, vaginal wall, labia, and perineum.
The way to distinguish bleeding from a laceration or uterine atony is the following: Lac = fundus is firm and in normal position, trickle of bright red blood. UA = fundus is boggy.
Will be stitched.
Significant blood loss but no obvious bleeding.
Injury to blood vessel without injury to underlying tissue.
Will not always see it.
If you can see it, it will be blue.
May be hidden in vagina.
Characteristic: painful.
If you see a swollen area, touch it with a gloved hand, if it hurts the patient, then it is a hematoma, if not then it is just swelling.
There can be 250-500ml of blood in one.
Will have to do an I&D.
Most are not very bad and can be treated with an ice pack.
Bladder should be emptied before checking fundus.
Can cause uterus not to contract effectively.
Describes the failure of the uterus to return to its pre-pregnant size and location.
Most common cause: retained placental fragments.
Let mom know about normal phases of lochia so she knows when there is a problem.
Also teach her to feel the top of her uterus to see if it is going back into pelvic area.
Infection also can go along with this. Odor can indicate infection.
Usually a rare occurrence.
Tiny clots clog up the capillaries and can get a pulmonary embolus.
Tx: removing the cause.
Care of Woman with Postpartum Hemorrhage:
Assessment à palpate fundus for consistency, location and size.
This is done q15x4, q30x2, q4, q8.
If fundus is boggy then massage it. If expressing clots, fundus must be firm.
Check lochia for amount, color, and odor.
Be sure to check under buttocks for bleeding.
Assess perineum for hematomas and lacerations.
Monitor vitals à check BP, pulse, resps, LOC, skin color, and temperature.
The BP is NOT going to be the 1st thing affected by hemorrhage.
There is an increase in total blood volume.
Reaches peak in 48 hours.
She can lose 30-50% of blood volume before you see a decrease in BP.
Foley catheter is used to measure output. If 30-50cc/h, she is getting good tissue perfusion.
Shock = poor tissue perfusion.
As long as urine is being produced, she is getting good tissue perfusion.
Pulse will go up if hemorrhaging, typically in postpartum, it is between 60-70.
Discharge Teaching related to Hemorrhage:
RETURN TO MD.
