Postpartum complications

Postpartum complications. Nursing care during Postpartum period with risk factors

Prepared by assistant professor N.Petrenko, MD, PhD

 

LEARNING OBJECTIVES

• Identify causes, signs and symptoms, possible complications, and medical and nursing management of postpartum hemorrhage.

• Differentiate the causes of postpartum infection.

• Summarize assessment and care of women with postpartum infection.

• Describe thromboembolic disorders, including incidence, etiology, signs and symptoms, and management.

• Describe sequelae of childbirth trauma.

• Discuss postpartum emotional complications, including incidence, risk factors, signs and symptoms, and management.

• Summarize the role of the nurse in the home setting in assessing potential problems and managing care of women with postpartum complications.

 

KEY TERMS AND DEFINITIONS

endometritis Postpartum uterine infection, often beginning at the site of the placental implantation

hemorrhagic (hypovolemic) shock Clinical condition in which the peripheral blood flow is inadequate to return sufficient blood to the heart for normal function, particularly oxygen transport to the organs or tissue

inversion of the uterus Condition in which the uterus is turned inside out so that the fundus intrudes into the cervix or vagina, usually caused by a too vigorous removal of the placenta before it is detached by the natural process of labor

mastitis Infection in a breast, usually confined to a milk duct, characterized by influenza-like symptoms and redness and tenderness in the affected breast

mood disorders Disorders that have a disturbance in the prevailing emotional state as the dominant feature; cause is unknown

pelvic relaxation Refers to the lengthening and weakening of the fascial supports of pelvic structures

postpartum depression (PPD) Depression occurring within 4 weeks of childbirth, lasting longer than postpartum blues and characterized by a variety of symptoms that interfere with activities of daily living and care of the baby

postpartum hemorrhage (PPH) Excessive bleeding after childbirth; traditionally defined as a loss of 500 ml or more after a vaginal birth and 1000 ml after a cesarean birth

puerperal infection Infection of the pelvic organs during the postbirth period; also called childbed fever

subinvolution Failure of a part (e.g., the uterus) to reduce to its normal size and condition after enlargement from functional activity (e.g., pregnancy)

thrombophlebitis inflammation of a vein with secondary clot formation

urinary incontinence (Ul) Uncontrollable leakage of urine

uterine atony Relaxation of uterus; leads to postpartum hemorrhage

 

Collaborative efforts of the health care team are needed to provide safe and effective care to the woman and family experiencing postpartum complications. This chapter focuses on hemorrhage, infection, sequelae of childbirth trauma, and psychologic complications.

 

POSTPARTUM HEMORRHAGE

DEFINITION AND INCIDENCE

Postpartum hemorrhage (PPH) continues to be a leading cause of maternal morbidity and death in the United States today. It is a life-threatening event that can occur with littie warning and is often unrecognized until the mother has profound symptoms (Norris, 1997). PPH has been traditionally defined as the loss of greater than 500 ml of blood after vaginal birth and 1000 ml after cesarean birth. A 10% change in hematocrit between admission for labor and postpartum or the need for erythrocyte transfusion also has been used to define PPH (American College of Obstetricians and Gynecologists [ACOG], 1998). However, defining PPH is not a clear-cut issue. The ACOG states that hemorrhage is difficult to define clinically (ACOG, 1998). Diagnosis is often based on subjective observations, with blood loss often being underestimated by as much as 50%.

Traditionally, PPH has been classified as early or late with respect to the birth. Early, acute, or primary PPH occurs within 24 hours of the birth. Late or secondary PPH occurs more than 24 hours but less than 6 weeks postpartum (ACOG, 1998). Today's health care environment encourages shortened stays after birth, thereby increasing the potential for acute episodes of PPH to occur outside the traditional hospital or birth center setting.

 

ETIOLOGY AND RISK FACTORS

The most common cause of PPH is uterine atony, which complicates approximately 1 in 20 births (Gonik, 1999). Less common causes include retained placenta, placenta accreta, cervical or vaginal lacerations, uterine rupture or inversion, lower genital tract lacerations and hematomas, infection, and coagulopathies (ACOG, 1998; Varner,

 

BOX 1 Risk Factors for Postpartum Hemorrhage Uterine atony • Overdistended uterus -Large fetus -Multiple fetuses -Hydramnios -Distention with clots • Anesthesia and analgesia -Conduction anesthesia • Previous history of uterine atony • High parity • Prolonged labor, oxytocin-induced labor • Trauma during labor and birth -Forceps birth -Vacuum-assisted birth -Cesarean birth Retained placental fragments Lacerations of the birth canal Ruptured uterus Inversion of the uterus Placenta accreta Placental abruption Placenta previa Coagulation disorders Manual removal of a retained placenta Magnesium sulfate administration during labor or postpartum Endometritis Uterine subinvolution

 

It is helpful to consider the problem of excessive bleeding with reference to the stages of labor. From birth of the infant until separation of the placenta, the character and quantity of blood passed may suggest excessive bleeding. For example, dark blood is probably of venous origin, perhaps from varices or superficial lacerations of the birth canal. Bright blood is arterial and may indicate deep lacerations of the cervix. Spurts of blood with clots may indicate partial placental separation. Failure of blood to clot or remain clotted indicates a pathologic condition or coagulopathy such as disseminated intravascular coagulation.

Excessive bleeding may occur during the period from the separation of the placenta to its expulsion or removal. Commonly, such excessive bleeding is the result of incomplete placental separation, undue manipulation of the fundus, or excessive traction on the cord. After the placenta has been expelled or removed, persistent or excessive blood loss usually is the result of atony of the uterus (failure to contract well or maintain contraction) or prolapse of the uterus into the vagina. Late PPH may be the result of subinvolution of the uterus, endometritis, or retained placental fragments (ACOG, 1998).

 

UTERINE ATONY

Uterine atony is marked hypotonia of the uterus. Normally, placental separation and expulsion are facilitated by contraction of the uterus, which also prevents hemorrhage from the placental site. The corpus is in essence a basket weave of strong, interlacing smooth muscle bundles through which many large maternal blood vessels pass. If the uterus is flaccid after detachment of all or part of the placenta, brisk venous bleeding occurs and normal coagulation of the open vasculature is impaired and continues until the uterine muscle is contracted.

Uterine atony accounts for more than 90% of all cases of PPH (Norris, 1997). It is associated with high parity, hydramnios, a macrosomic fetus, and multifetal gestation. In such conditions the uterus is "overstretched" and contracts poorly after the birth. Other causes of atony include traumatic birth, use of halogenated anesthesia (e.g., halothane) or magnesium sulfate, rapid or prolonged labor, chorioamnionitis, and use of oxytocin for labor induction or augmentation (ACOG, 1998; Varner, 1998).

 

LACERATIONS OF THE GENITAL TRACT

Lacerations of the cervix, vagina, and perineum are also causes of PPH. Hemorrhage related to lacerations should be suspected if bleeding continues despite a firm, contracted uterine fundus. This bleeding can be a slow trickle, an oozing, or frank hemorrhage. Factors that influence the causes and incidence of obstetric lacerations of the lower genital tract include operative birth, precipitous birth, congenital abnormalities of the maternal soft parts, and contracted pelvis. Size, abnormal presentation, and position of the fetus; relative size of the presenting part and the birth canal; previous scarring from infection, injury, or operation; and vulvar, perineal, and vaginal varicosities can also cause lacerations.

Extreme vascularity in the labial and periclitoral areas often results in profuse bleeding if laceration occurs. Hematomas may also be present.

Lacerations of the perineum are the most common of all injuries in the lower portion of the genital tract. These are classified as first, second, third, and fourth degree. An episiotomy may extend to become either third- or fourth-degree laceration.

Prolonged pressure of the fetal head on the vaginal mucosa ultimately interferes with the circulation and may produce ischemic or pressure necrosis. The state of the tissues in combination with the type of birth may result in deep vaginal lacerations, with consequent predisposition toward vaginal hematomas.

A pelvic hematoma may be vulvar, vaginal, or retroperitoneal in origin. Vulvar hematomas are the most common. Pain is the most common symptom, and most vulvar hematomas are visible. Vaginal hematomas occur more commonly in association with a forceps-assisted birth, an episiotomy, or primigravidity (Ridgeway, 1995). During the postpartum period, if the woman reports a persistent perineal or rectal pain or a feeling of pressure in the vagina, a careful examination is performed. However, a subperitoneal hematoma may cause minimal pain, and the initial symptoms may be signs of shock (Ridgeway, 1995).

Cervical lacerations usually occur at the lateral angles of the external os. Most are shallow, and bleeding is minimal. More extensive lacerations may extend into the vaginal vault or into the lower uterine segment.

 

RETAINED PLACENTA

Nonadherent retained placenta

Retained placenta may result from partial separation of a normal placenta, entrapment of the partially or completely separated placenta by an hourglass constriction ring of the uterus, mismanagement of the third stage of labor, or abnormal adherence of the entire placenta or a portion of the placenta to the uterine wall. Placental retention because of poor separation is common in very preterm births (20 to 24 weeks of gestation).

Management of nonadherent retained placenta is by manual separation and removal by the primary health care provider. Supplementary anesthesia is not usually needed for women who have had regional anesthesia for birth. For other women, administration of light nitrous oxide and oxygen inhalation anesthesia or intravenous (IV) thiopental facilitates uterine exploration and placental removal. After this removal, the woman is at continued risk for PPH or for infection.

 

Adherent retained placenta

Abnormal adherence of the placenta occurs for reasons unknown, but it is thought to result from zygotic implantation in an area of defective endometrium so that there is no zone of separation between the placenta and the decidua. Attempts to remove the placenta in the usual manner are unsuccessful, and laceration or perforation of the uterine wall may result, putting the woman at great risk for severe PPH and infection (Cunningham et al., 2001).

Unusual placental adherence may be partial or complete. The following degrees of attachment are recognized:

• Placenta accreta, slight penetration of myometrium by placental trophoblast

• Placenta increta, deep penetration of myometrium by placenta

• Placenta percreta, perforation of uterus by placenta

Bleeding with complete or total placenta accreta may not occur unless separation of the placenta is attempted. With more extensive involvement, bleeding will become profuse when delivery of the placenta is attempted. Treatment includes blood component replacement therapy, and hysterectomy may be indicated (Clark, 1999).

 

INVERSION OF THE UTERUS

Inversion of the uterus after birth is a potentially life-threatening complication. The incidence of uterine inversion is approximately 1 in 2000 to 2500 births (ACOG, 1998) and may recur with a subsequent birth. Uterine inversion may be partial or complete. Complete inversion of the uterus is obvious; a large, red, rounded mass (perhaps with the placenta attached) protrudes 20 to 30 cm outside the introitus. Incomplete inversion cannot be seen but must be felt; a smooth mass will be palpated through the dilated cervix. Contributing factors to uterine inversion include fundal implantation of the placenta, vigorous fundal pressure, excessive traction applied to the cord, uterine atony, leiomyomas, and abnormally adherent placental tissue (Bowes, 1999). Uterine inversion occurs most often in multiparous women and with placenta accreta or increta. The primary presenting signs of uterine inversion are hemorrhage, shock, and pain.

Prevention—always the easiest, cheapest, and most effective therapy-is especially appropriate for uterine inversion. The umbilical cord should not be pulled on strongly unless the placenta has definitely separated.

 

SUBINVOLUTION OF THE UTERUS

Late postpartum bleeding may occur as a result of subinvolution of the uterus. Recognized causes of subinvolution include retained placental fragments and pelvic infection. Signs and symptoms include prolonged lochial discharge, irregular or excessive bleeding, and sometimes he morrhage. A pelvic examination usually reveals a uterus that is larger than normal and one that may be boggy.

 

CARE MANAGEMENT

Assessment and Nursing Diagnoses

Fig. 1 Nursing assessments for postpartum bleeding. CBC, Complete blood count; IV, intravenous; s/s, signs and symptoms.

 

BOX 2 Noninvasive Assessments of Cardiac Output in Postpartum Patients Who Are Bleeding Palpation of pulses (rate, quality, equality) • Arterial • Blood pressure Auscultation • Heart sounds/murmurs • Breath sounds Inspection • Skin color, temperature, turgor • Level of consciousness • Capillary refill • Urinary output • Neck veins • Pulse oximetry • Mucous membranes Presence or absence of anxiety, apprehension, restlessness, disorientation

 

PPH may be sudden and even exsanguinating. The nurse must therefore be alert to the symptoms of hemorrhage and hypovolemic shock and be prepared to act quickly to minimize blood loss (Fig. 1 and Box 2).

The woman's history should be reviewed for factors that cause predisposition to PPH (see Box 25-1). The fundus is assessed to determine whether it is firmly contracted at or near the level of the umbilicus. Bleeding should be assessed for color and amount. The perineum is inspected for signs of lacerations or hematomas to determine the possible source of bleeding.

Vital signs may not be reliable indicators of shock immediately postpartum because of the physiologic adaptations of this period. However, frequent vital sign measure ments during the first 2 hours after birth may identify trends related to blood loss (e.g., tachycardia, tachypnea, falling blood pressure).

Assessment for bladder distention is important because a distended bladder can displace the uterus and prevent contraction. The skin is assessed for warmth and dryness; nail beds are checked for color and promptness of capillary refill. Laboratory studies include evaluation of hemoglobin and hematocrit levels.

Late PPH may develop 24 hours after birth or later in the postpartum period. The woman may be at home when the symptoms occur. Discharge teaching should emphasize the signs of normal involution, as well as potential complications. Nursing diagnoses for women experiencing

PPH include the following:

• Deficient fluid volume related to

-excessive blood loss secondary to uterine atony, lacerations, or uterine inversion

• Risk for imbalancedfluid volume related to

-blood and fluid volume replacement therapy

• Risk for infection related to

-excessive blood loss or exposed placental attachment site

• Risk for injury (maternal) related to

-attempted manual removal of retained placenta

-administration of blood products

-operative procedures

• Fear/anxiety related to

-threat to self

-knowledge deficit regarding procedures and operative management

• Ineffective peripheral tissue perfusion related to

-excessive blood loss and shunting of blood to central circulation

 

Expected Outcomes of Care

Expected outcomes of care for the woman experiencing PPH may include that the woman will do the following:

• Identify and use available support systems

• Maintain normal vital signs and laboratory values

• Develop no complications related to excessive bleeding

• Express understanding of her condition, its management, and discharge instructions

 

Plan of Care and Interventions

Medical management

Early recognition and acknowledgment of the diagnosis of PPH are critical to care management. The first step is to evaluate the contractility of the uterus. If the uterus is hypotonic, management is directed toward increasing contractility and minimizing blood loss.

The initial management of excessive postpartum bleeding is firm massage of the uterine fundus, expression of any clots in the uterus, eliminating any bladder distention, and continuous IV infusion of 10 to 40 units of oxytocin added to 1000 ml of lactated Ringer's or normal saline solution. If the uterus fails to respond to oxytocin, a 0.2 mg dose of ergonovine (Ergotrate) or methylergonovine (Methergine) may be given intramuscularly to produce sustained uterine contractions. If these first-line drugs are not effective, a derivative of prostaglandin F2a (carboprost tromethamine, 0.25 mg) is given intramuscularly. It can also be given intramyometrially at cesarean birth or intraabdominally after vaginal birth. Most hemorrhage can be controlled after one or two injections of 0.25 mg intramuscularly (ACOG, 1998). See Table 1 for a comparison of drugs used to manage PPH. In addition to the medications used to contract the uterus, rapid administration of crystalloid solutions or blood is needed to restore the woman's intravascular volume.

 

TABLE 1 Drug Used to Manage Postpartum Hemorrhage
	OXYTOCIN (PITOCIN)	METHYLERGONOVINE (METHERGINE)	PROSTAGLANDIN F2α (PROSTIN/15M; HEMABATE)
Action	Contraction of uterus; decreases bleeding	Contraction of uterus	Contraction of uterus
Side effect	Infrequent; water intoxication; nausea and vomiting	Hypertension, nausea, vomiting, headache	Headache, nausea, vomiting, fever
Contraindications	None forPPH	Hypertension, cardiac disease	Asthma, hypersensitivity
Dosage; route	10-40 U/L diluted in lactated Ringer's solution or normal saline at 125-200 mU/min IV or 10-20 U IM	0.2 mg IM every 2-4 hr up to 5 doses; 0.2 mg IV only for emergency	0.25 mg IM or intramyometrially every 15 min up to 5 doses
Nursing considerations	Continue to monitor vaginal bleeding and uterine tone	Check blood pressure before giving and do not give if >140/90 mm Hg; continue monitoring vaginal bleeding and uterine tone	Continue to monitor vaginal bleeding and uterine tone

 

NURSE ALERT Use of ergonovine or methylergonovine is contraindicated in the presence of hypertension or cardiovascular disease. Prostaglandin F2l, should be used cautiously in women with cardiovascular disease or asthma (Bowes, 1999).

 

Hypotonic uterus. Oxygen can be given to enhance oxygen delivery to the cells. A urinary catheter is usually inserted to monitor urine output as a measure of intravascular volume. Laboratory studies usually include a complete blood count with platelet count, fibrinogen, fibrin split products, prothrombin time, and partial thromboplastin time. Blood type and antibody screen are done if not previously performed (ACOG, 1998).

If bleeding persists, bimanual compression may be considered by the obstetrician or nurse-midwife. This procedure involves inserting a fist into the vagina and pressing the knuckles against the anterior side of the uterus, then placing the other hand on the abdomen and massaging the posterior uterus with it. If the uterus still does not become firm, manual exploration of the uterine cavity for retained placental fragments is implemented. If the preceding procedures are ineffective, surgical management may be the only alternative. Surgical management options include vessel ligation (uteroovarian, uterine, hypogastric), angiographic embolization, and hysterectomy (ACOG, 1998).

Bleeding with a contracted uterus. If the uterus is firmly contracted and bleeding continues, the source of bleeding still must be identified and treated. Assessment may include visual or manual inspection of the perineum, vagina, uterus, cervix, or rectum and laboratory studies (e.g., hemoglobin, hematocrit, coagulation studies, platelet count) (ACOG, 1998). Treatment depends on the source of the bleeding. Lacerations are usually sutured. Hematomas may be managed with observation, cold therapy, ligation of the bleeding vessel, or evacuation. Fluids or blood replacement may be needed (Roberts, 1995).

Uterine inversion. Uterine inversion is an emergency situation requiring immediate recognition, replacement of the uterus within the pelvic cavity, and correction of associated clinical conditions. Medical management of this condition includes treating shock, repositioning the uterus, giving oxytocic agents after the uterus is repositioned, and initiating broad-spectrum antibiotics (Benedetti, 2002; Bowes, 1999).

Subinvolution. Treatment of subinvolution depends on the cause. Ergonovine or methylergonovine (0.2 mg every 4 hours for 2 or 3 days) and antibiotic therapy are the most common medications used (Cunningham et al., 2001). Dilation and curettage may be needed to remove retained placental fragments or to debride the placental site.

 

Herbal remedies

BOX 3 Herbal Remedies for Postpartum Hemorrhage
HERBS	ACTION
Witch hazel	Hemostatic
Lady's mantle	Hemostatic
Blue cohosh	Oxytocic
Cotton root bark	Oxytocic
Motherwort	Promotes uterine contraction; vasoconstrictive
Shepherd's purse	Promotes uterine contraction
Alfalfa leaf	Increases availability of vitamin K; increases hemoglobin
Nettle	Increases availability of vitamin K; increases hemoglobin

 

Herbal remedies have been used with some success to control PPH in some settings. Some herbs have homeostatic actions; others work as oxytocic agents to contract the uterus (Beal, 1998; Schirmer, 1998). Box 25-3 lists herbs that have been used and their actions. However, published evidence of the safety and efficacy of herbal therapy is lacking. Evidence from well-controlled studies is needed before recommendation for practice should be made (Enkin et al., 1995).

 

Nursing interventions

Immediate nursing care of the woman with PPH includes assessment of vital signs and uterine consistency and administration of oxytocin or other drugs to stimulate uterine contraction according to standing orders or protocols. The primary health care provider is notified if not present.

The woman and her family will be anxious about her condition. The nurse can intervene by calmly providing explanations about interventions being performed and the need to act quickly.

After the bleeding has been controlled, the care of the woman with lacerations of the perineum is similar to that for women with episiotomies (analgesia as needed for pain and hot or cold applications as necessary). The need for increased roughage in the diet and increased intake of fluids is emphasized. Stool softeners may be used to assist the woman in reestablishing bowel habits without straining and putting stress on the suture lines.

 

NURSE ALERT TO prevent injury to the suture line, a woman with third- or fourth-degree lacerations is not given rectal suppositories or enemas.

 

The care of the woman who has experienced an inversion of the uterus focuses on immediate stabilization of hemodynamic status. This requires close observation of her response to treatment to prevent shock or fluid overload. If the uterus has been repositioned manually, care must be taken to avoid aggressive fundal massage.

Discharge instructions for the woman who has had PPH are similar to those for any postpartum woman. In addition, she should be told that she will probably feel fatigue, even exhaustion, and will need to limit her physical activities to conserve her strength. She may need instructions in increasing her dietary iron and protein intake and iron supplementation to rebuild lost red cell volume. She may need assistance with infant care and household activities until she has regained strength. Some women have problems with delayed or insufficient lactation and postpartum depression. Referrals for home care follow-up or to community resources may be needed (see Plan of Care).

 

Evaluation

The nurse can be reasonably assured that care was effective to the extent that the expected outcomes were achieved.

 

PLAN OF CARE Postpartum Hemorrhage

NURSING DIAGNOSIS Deficient fluid volume related to postpartum hemorrhage

Expected Outcome Patient will demonstrate fluid balance as evidenced by stable vital signs, prompt capillary refill time, and balanced intake and output.

 

Nursing Interventions/Rationales

Monitor vital signs, oxygen saturation, urine specific gravity, and capillary refill to provide baseline data.

Measure and record amount and type of bleeding by weighing and counting saturated pads. If woman is at home, teach her to count pads and save any clots or tissue. If woman is admitted to hospital, save any clots and tissue for further examination to estimate type and amount of blood loss for fluid replacement.

Provide quiet environment to promote rest and decrease metabolic demands.

Give explanation of all procedures to reduce anxiety.

Begin IV access with 18-gauge or larger needle for infusion of isotonic solution as ordered to provide fluid or blood replacement.

Administer medications as ordered, such as oxytocin, Methergine, or Prostin, to increase contractility of the uterus.

Insert indwelling urinary catheterr to provide most accurate assessment of renal function and hypovolemia.

Prepare for surgical intervention as needed to stop the source of bleeding.

 

NURSING DIAGNOSIS Ineffective tissue perfusion related to hypovolemia

Expected Outcome Woman will have stable vital signs, oxygen saturation, arterial blood gases, and adequate hematocrit and hemoglobin.

Nursing Interventions/Rationales

Monitor vital signs, oxygen saturation, arterial blood gases, and hematocrit and hemoglobin to assess for hypovolemic shock and decreased tissue perfusion.

Assess for any changes in level of consciousness to assess for evidence of hypoxia.

Assess capillary refill, mucous membranes, skin temperature to note indicators of vasoconstriction.

Give supplementary oxygen as ordered to provide additional oxygenation to tissues.

Suction as needed, insert oral airway, to maintain clear, open airway for oxygenation.

Monitor arterial blood gases to provide information about acidosis or hypoxia.

Administer sodium bicarbonate if ordered to reverse metabolic acidosis.

 

NURSING DIAGNOSIS Anxiety related to sudden change in heaith status

Expected Outcome Woman will verbalize the anxious feelings are diminished.

Nursing Interventions/Rationales

Using therapeutic communication, evaluate woman's understanding of events to provide clarification of any misconceptions.

Provide calm, competent attitude and environment to aid in decreasing anxiety.

Explain all procedures to decrease anxiety about the unknown.

Allow woman to verbalize feelings to permit clarification of information and promote trust.

Continue to assess vital signs or other clinical indicators of hypovolemic shock to evaluate if psychologic response of anxiety intensifies physiologic indicators.

HEMORRHAGIC (HYPOVOLEMIC) SHOCK

Hemorrhage may result in hemorrhagic (hypovolemic) shock. Shock is an emergency situation in which the per fusion of body organs may become severely compromised and death may occur. Physiologic compensatory mechanisms are activated in response to hemorrhage. The adrenal glands release catecholamines, causing arterioles and venules in the skin, lungs, gastrointestinal tract, liver, and kidneys to constrict. The available blood flow is diverted to the brain and heart and away from other organs, including the uterus. If shock is prolonged, the continued reduction in cellular oxygenation results in an accumulation of lactic acid and acidosis (from anaerobic glucose metabolism). Acidosis (lowered serum pH) causes arteriolar vasodilation; venule vasoconstriction persists. A circular pattern is established; that is, decreased perfusion, increased tissue anoxia and acidosis, edema formation, and pooling of blood further decrease the perfusion. Cellular death occurs. See the Emergency box for assessments and interventions for hemorrhagic shock.

 

EMERGENCY Hemorragic Shock
ASSESSMENTS	CHARACTERISTICS
Respirations	Rapid and shallow
Pulse	Rapid, weak, irregular
Blood pressure	Decreasing (late sign)
Skin	Cool, pale, clammy
Urinary output	Decreasing
Level of consciousness	Lethargy -> coma
Mental status	Anxiety —> coma
Central venous pressure	Decreased
INTERVENTION
Summon assistance and equipment
Start IV infusion per standing orders
Ensure patent airway; administer oxygen
Continue to monitor status

 

MEDICAL MANAGEMENT

Vigorous treatment is necessary to prevent adverse sequelae. Medical management of hypovolemic shock involves restoring circulating blood volume and treating the cause of the hemorrhage (e.g., lacerations, uterine atony or inversion). To restore circulating blood volume, a rapid IV infusion of crystalloid solution is given at a rate of 3 ml infused for every 1 ml of estimated blood loss (e.g., 3000 ml infused for 1000 ml of blood loss). Packed red blood cells are usually infused if the woman is still actively bleeding and no improvement in her condition is noted after the initial crystalloid infusion. Infusion of fresh frozen plasma may be needed if clotting factors and platelet counts are below normal values (Cunningham et al., 2001).

 

NURSING INTERVENTIONS

Hemorrhagic shock can occur rapidly, but the classic signs of shock may not appear until the postpartum woman has lost 30% to 40% of blood volume. The nurse needs to continue to reassess the woman's condition, as evidenced by the degree of measurable and anticipated blood loss, and mobilize appropriate resources.

Most interventions are instituted to improve or monitor tissue perfusion. The nurse continues to monitor the woman's pulse and blood pressure. If invasive hemodynamic monitoring is ordered, the nurse may assist with the placement of the central venous pressure (CVP) or pulmonary artery (Swan-Ganz) catheter and monitor CVP, pulmonary artery pressure, or pulmonary artery wedge pressure as ordered (White & Poole, 1996).

Additional assessments to be made include evaluation of skin temperature, color, and turgor, as well as assessment of the woman's mucous membranes. Breath sounds should be auscultated before fluid volume replacement, if possible, to provide a baseline for future assessment. Inspection for oozing at the sites of incisions or injections and assessment of the presence of petechiae or ecchymosis in areas not associated with surgery or trauma are critical in the evaluation for disseminated intravascular coagulopathy.

Oxygen is administered, preferably by nonrebreathing face mask, at 10 to 12 L/min to maintain oxygen saturation. Oxygen saturation should be monitored with a pulse oximeter, although measurements may not always be accurate in a patient with hypovolemia or decreased perfusion. Level of consciousness is assessed frequently and provides additional indications of blood volume and oxygen saturation. In early stages of decreased blood flow, the woman may report "seeing stars" or feeling dizzy or nauseated. She may become restless and orthopneic. As cerebral hypoxia increases, she may become confused and react slowly or not at all to stimuli. Some women complain of headaches. An improved sensorium is an indicator of improved perfusion.

Continuous electrocardiographic monitoring may be indicated for the woman who is hypotensive or tachycardic, continues to bleed profusely, or is in shock. A Foley catheter with a urometer is inserted to allow hourly assessment of urinary output. The most objective and least invasive assessment of adequate organ perfusion and oxygenation is urinary output of at least 30 ml/hr (White & Poole, 1996). Blood may need to be drawn and sent to the laboratory for studies that include hemoglobin and hematocrit levels, platelet count, and coagulation profile.

 

FLUID OR BLOOD REPLACEMENT THERAPY

Critical to successful management of the woman with a hemorrhagic complication is establishment of venous access, preferably with a large-bore IV catheter. The establishment of two IV lines facilitates fluid resuscitation. Vigorous fluid resuscitation includes the administration of crystalloids (lactated Ringer's, normal saline solutions), colloids (albumin), blood, and blood components. Fluid resuscitation must be carefully monitored because fluid overload may occur. Intravascular fluid overload occurs more frequently with colloid therapy. Transfusion reactions may follow administration of blood or blood components, including cryoprecipitates. Even in an emergency, each unit should be checked per hospital protocol. Complications of fluid or blood replacement therapy include hemolytic reactions, febrile reactions, allergic reactions, circulatory overload, and air embolism.

 

LEGAL TIP Standard of Care for Bleeding Emergencies

The standard of care for obstetric emergency situations such as postpartum hemorrhage or hypovolemic shock is that provision should be made for the nurse to implement actions independently. Policies, procedures, standing orders or protocols, and clinical guides should be established by each health care facility in which births occur and should be agreed on by health care providers involved in the care of obstetric patients.

 

COAGULOPATHIES

When bleeding is continuous and there is no identifiable source, a coagulopathy may be the cause. The woman's coagulation status must be assessed quickly and continuously. The nurse may draw and send blood to the laboratory for studies. Abnormal results depend on the cause and may include increased prothrombin time, increased partial prothrombin time, decreased platelets, decreased fibrinogen level, increased fibrin degradation products, and prolonged bleeding time. Causes of coagulopathies may be pregnancy complications such as idiopathic thrombocytopenic purpura or von Willebrand disease.

 

IDIOPATHIC THROMBOCYTOPENIC PURPURA

Idiopathic or immune thrombocytopenic purpura (ITP) is an autoimmune disorder in which antiplatelet antibodies decrease the life span of the platelets. Thrombocytopenia, capillary fragility, and increased bleeding time are diagnostic findings. ITP may cause severe hemorrhage after cesarean birth or from cervical or vaginal lacerations. Incidences of postpartum uterine bleeding and vaginal hematomas are also increased.

Medical management focuses on control of platelet stability. If ITP was diagnosed during pregnancy, the woman probably was treated with corticosteroids or IV immunoglobulin. Platelet transfusions are usually given when there is significant bleeding. A splenectomy may be needed if the ITP does not respond to medical management. Neonatal thrombocytopenia, a result of the maternal disease process, occurs in approximately 50% of cases and is associated with a high mortality rate (Kilpatrick & Laros, 1999).

 

VON WILLEBRAND DISEASE

Von Willebrand disease, a type of hemophilia, is probably the most common of all hereditary bleeding disorders (Kleinert et al., 1997). Although von Willebrand disease is rare, it is among the most common congenital clotting defects in American women of childbearing age. It results from a factor VIII deficiency and platelet dysfunction that is transmitted as an incomplete autosomal dominant trait to both sexes. Symptoms include a familial bleeding tendency, previous bleeding episodes, prolonged bleeding time (the most important test), factor VIII deficiency (mild to moderate), and bleeding from mucous membranes. Factor VIII increases during pregnancy, and this increase may be sufficient to offset danger from hemorrhage during childbirth. However, the woman's condition should be observed for at least 1 week after childbirth. Treatment of von Willebrand disease may include replacement of factor VIII if it is at less than 30% of normal levels and administration of cryoprecipitate or fresh frozen plasma.

 

DISSEMINATED INTRAVASCULAR COAGULATION

Disseminated intravascular coagulation (DIC) is a pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, including platelets, fibrinogen, prothrombin, and factors V and VII. Widespread external bleeding, internal bleeding, or both can result. DIC also causes vascular occlusion of small vessels resulting from small clots forming in the microcirculation. In the obstetric population, DIC may occur as a result of abruption placentae, amniotic fluid embolism, dead fetus syndrome (fetus has died but is retained in utero for at least 6 weeks), severe preeclampsia, septicemia, cardiopulmonary arrest, and hemorrhage.

The diagnosis of DIC is made according to clinical findings and laboratory markers. Physical examination reveals unusual bleeding; spontaneous bleeding from the woman's gums or nose may be noted. Petechiae may appear around a blood pressure cuff placed on the woman's arm. Excessive bleeding may occur from the site of a slight trauma (e.g., venipuncture sites, intramuscular or subcutaneous injection sites, nicks from shaving of perineum or abdomen, and injury from insertion of a urinary catheter). Symptoms may also include tachycardia and diaphoresis. Laboratory tests reveal decreased levels of platelets, fibrinogen, proaccelerin, antihemophiliac factor, and prothrombin (the factors consumed during coagulation). Fibrinolysis is increased at first but is later severely depressed. Degradation of fibrin leads to the accumulation of fibrin split products in the blood; these have anticoagulant properties and prolong the prothrombin time. Bleeding time is normal, coagulation time shows no clot, clot retraction time shows no clot, and partial thromboplastin time is increased. DIC must be distinguished from other clotting disorders before therapy is initiated.

Primary medical management in all cases of DIC involves correction of the underlying cause (e.g., removal of the dead fetus, treatment of existing infection or of preeclampsia or eclampsia, or removal of a placental abruption). Volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters are the usual forms of treatment. Plasma levels usually return to normal within 24 hours after birth. Platelet counts usually return to normal within 7 days (Kilpatrick & Laros, 1999).

Nursing interventions include assessment for signs of bleeding and signs of complications from the administration of blood and blood products, administering fluid or blood replacement as ordered, and protecting from injury. Because renal failure is one consequence of DIC, urinary output is monitored, usually by insertion of an indwelling urinary catheter. Urinary output must be maintained at more than 30 ml/hr.

The woman and her family will be anxious or concerned about her condition and prognosis. The nurse offers explanations about care and provides emotional support to the woman and her family through this critical time.

THROMBOEMBOLIC DISEASE

A thrombosis is the formation of a blood clot or clots inside a blood vessel and is caused by inflammation (thrombophlebitis) or partial obstruction of the vessel. Three thromboembolic conditions are of concern in the postpartum period:

• Superficial venous thrombosis: involvement of the superficial saphenous venous system

• Deep venous thrombosis: involvement varies but can extend from the foot to the iliofemoral region

• Pulmonary embolism: complication of deep venous thrombosis occurring when part of a blood clot dislodges and is carried to the pulmonary artery where it occludes the vessel and obstructs blood flow to the lungs

 

INCIDENCE AND ETIOLOGY

The incidence of thromboembolic disease in the postpartum period varies from approximately 0.5 to 3 per 1000 women (Laros, 1999). The incidence has declined in the last 20 years because early ambulation after childbirth has become standard practice. The major causes of thromboembolic disease are venous stasis and hypercoagulation, both of which are present in pregnancy and continue into the postpartum period. Other risk factors include cesarean birth, history of venous thrombosis or varicosities, obesity, maternal age greater than 35, multiparity, and smoking (Falter, 1997).

 

CLINICAL MANIFESTATIONS

 

Fig. 2 Deep vein thrombophlebitis. (Courtesy Julie L. Perry.)

 

Superficial venous thrombosis is the most frequent form of postpartum thrombophlebitis. It is characterized by pain and tenderness in the lower extremity. Physical examination may reveal warmth; redness; and an enlarged, hardened vein over the site of the thrombosis. Deep vein thrombosis is more common in pregnancy and is characterized by unilateral leg pain, calf tenderness, and swelling (Fig. 2). Physical examination may reveal redness and warmth, but the woman may also have a large amount of clot and have few symptoms (Stenchever et al., 2001). A positive Homans' sign may be present, but further evaluation is needed because the calf pain may be attributed to other causes such as a strained muscle resulting from the birthing position. Pulmonary embolism is characterized by dyspnea and tachypnea. Other signs and symptoms frequently seen include apprehension, cough, tachycardia, hemoptysis, elevated temperature, and pleuritic chest pain (Laros, 1999).

Physical examination is not a sensitive diagnostic indicator for thrombosis. Venography is the most accurate method for diagnosing deep venous thrombosis; however, it is an invasive procedure that exposes the woman and fetus to ionizing radiation and is associated with serious complications. Noninvasive diagnostic methods are more commonly used; these include real-time and color Doppler ultrasound. Cardiac auscultation may reveal murmurs with pulmonary embolism. Electrocardiograms are usually normal. Arterial Po2 may be lower than normal. A ventilation/perfusion scan, Doppler ultrasound, and pulmonary arteriogram may be used for diagnosis (Laros, 1999).

 

MEDICAL MANAGEMENT

Superficial venous thrombosis is treated with analgesia (nonsteroidal antiinflammatory agents), rest with elevation of the affected leg, and elastic stockings (Falter, 1997). Local application of heat may also be used. Deep venous thrombosis is initially treated with anticoagulant (usually continuous IV heparin) therapy, bed rest with the affected leg elevated, and analgesia. After the symptoms have decreased, the woman may be fitted with elastic stockings to use when she is allowed to ambulate. IV heparin therapy continues for 5 to 7 days. Oral anticoagulant therapy (warfarin) is started during this time and will be continued for approximately 3 months. Continuous IV heparin therapy is used for pulmonary embolism until symptoms have resolved. Intermittent subcutaneous heparin or oral anticoagulant therapy is usually continued for 6 months.

 

NURSING INTERVENTIONS

In the hospital setting nursing care of the woman with a thrombosis consists of continued assessments: inspection and palpation of the affected area; palpation of peripheral pulses; checking Homans' sign; measurement and comparison of leg circumferences; inspection for signs of bleeding; monitoring for signs of pulmonary embolism, including chest pain, coughing, dyspnea, and tachypnea; and respiratory status for presence of crackles. Laboratory reports are monitored for prothrombin or partial prothrombin times. The woman and her family are assessed for their level of understanding about the diagnosis and their ability to cope during the unexpected extended period of recovery.

Interventions include explanations and education about the diagnosis and the treatment. The woman will need assistance with personal care as long as she is on bed rest; the family should be encouraged to participate in the care if that is what they wish. While the woman is on bed rest, she should be encouraged to change positions frequently, but not to place the knees in a sharply flexed position that could cause pooling of blood in the lower extremities. She should also be cautioned not to rub the affected area because this action could cause the clot to dislodge. Once the woman is allowed to ambulate, she is taught how to prevent venous congestion by putting on the elastic stockings before getting out of bed.

Heparin and warfarin are administered as ordered, and the physician is notified if clotting times are outside the therapeutic level. If the woman is breastfeeding, she is assured that neither heparin nor warfarin is excreted in significant quantities in breast milk. If the infant has been discharged, the family is encouraged to bring the infant for feedings as permitted by hospital policy; the mother can also express milk to be sent home.

Pain can be managed with a variety of measures. Position changes, elevating the leg, and application of moist warm heat may decrease discomfort. Administration of analgesics and antiinflammatory medications may be needed.

 

NURSE ALERT Medications containing aspirin are not given to women on anticoagulant therapy because aspirin inhibits synthesis of clotting factors and can lead to prolonged clotting time and increased risk of bleeding.

 

The woman is usually discharged home on oral anticoagulants and will need explanations about the treatment schedule and possible side effects. If subcutaneous injections are to be given, the woman and family are taught how to administer the medication and about site rotation. The woman and her family should also be given information about safe care practices to prevent bleeding and injury while she is on anticoagulant therapy, such as using a soft toothbrush and using an electric razor. She will also need information about the need for follow-up with her health care provider to monitor clotting times and to make sure the correct dose of anticoagulant therapy is maintained (Lowdermilk & Grohar, 1998). The woman should also use a reliable method of contraception if taking warfarin because this medication is considered teratogenic (Toglia & Nolan, 1997).

 

POSTPARTUM INFECTIONS

Postpartum infection, or puerperal infection, is any clinical infection of the genital canal that occurs within 28 days after miscarriage, induced abortion, or childbirth. The first symptom of postpartum infection is usually a fever of 38° C or more on 2 successive days of the first 10 postpartum days (not counting the first 24 hours after birth) (Cunningham et al., 2001). Puerperal infection is probably the major cause of maternal morbidity and death throughout the world; however, it occurs after only 6% of births in the United States (3% after vaginal births; 5 to 10 times higher after cesarean births) (Gibbs & Sweet, 1999). Common postpartum infections include endometritis, wound infections, mastitis, urinary tract infections, and respiratory tract infections.

The most common infecting organisms are the numerous streptococcal and anaerobic organisms. Staphylococcus aureus, gonococci, coliform bacteria, and clostridia are less common but serious pathogenic organisms that also cause puerperal infection. Postpartum infections are more common in women who have concurrent medical or immunosuppressive conditions or who had a cesarean or other operative birth. Intrapartal factors such as prolonged rupture of membranes, prolonged labor, and internal maternal or fetal monitoring also increase the risk of infection (Varner, 1998). Factors that predispose the woman to postpartum infection are listed in Box 4.

 

BOX 4 Predisposing Factors for Postpartum Infection PRECONCEPTION OR ANTEPARTUM FACTORS History of previous venous thrombosis, urinary tract infection, mastitis, pneumonia Diabetes mellitus Alcoholism Drug abuse Immunosuppression Anemia Malnutrition INTRAPARTUM FACTORS Cesarean birth Prolonged rupture of membranes Chorioamnionitis Prolonged labor Bladder catheterization Internal fetal/uterine pressure monitoring Multiple vaginal examinations after the rupture of membranes Epidural anesthesia Retained placental fragments Postpartum hemorrhage Episiotomy or lacerations Hematomas

 

ENDOMETRITIS

Endometritis is the most common cause of postpartum infection. It usually begins as a localized infection at the placental site (Fig. 3) but can spread to involve the entire endometrium. Incidence is higher after cesarean birth. Assessment for signs of endometritis may reveal a fever (usually greater than 38° C); increased pulse; chills; anorexia; nausea; fatigue and lethargy; pelvic pain; uterine tenderness; or foul-smelling, profuse lochia (Calhoun & Brost, 1995). Leukocytosis and a markedly increased red blood cell sedimentation rate are typical laboratory findings of postpartum infections. Anemia may also be present. Blood cultures or intracervical or intrauterine bacterial cultures (aerobic and anaerobic) should reveal the offending pathogens within 36 to 48 hours.

 

 

Fig. 3 Postpartum infection—endometritis.

 

WOUND INFECTIONS

Wound infections are also common postpartum infections but often develop after the woman is at home. Sites of infection include the cesarean incision and the episiotomy or repaired laceration site. Predisposing factors are similar to those for endometritis (see Box 4). Signs of wound infection include erythema, edema, warmth, tenderness, seropurulent drainage, and wound separation. Fever and pain may also be present.

 

URINARY TRACT INFECTIONS

Urinary tract infections (UTIs) occur in 2% to 4% of postpartum women. Risk factors include urinary catheterization, frequent pelvic examinations, epidural anesthesia, genital tract injury, history of UTI, and cesarean birth. Signs and symptoms include dysuria, frequency and urgency, low-grade fever, urinary retention, hematuria, and pyuria. Costovertebral angle tenderness or flank pain may indicate upper UTI. Urinalysis results may reveal Escherichia coli, although other gram-negative aerobic bacilli may also cause UTIs.

 

MASTITIS

 

Fig. 4 Mastitis.

 

Mastitis affects approximately 1% of women soon after childbirth, most of whom are first-time mothers who are breastfeeding. Mastitis almost always is unilateral and develops well after the flow of milk has been established (Fig. 4). The infecting organism generally is the hemolytic S. aureus. An infected nipple fissure usually is the initial lesion, but the ductal system is involved next. Inflammatory edema and engorgement of the breast soon obstruct the flow of milk in a lobe; regional, then generalized, mastitis follows. If treatment is not prompt, mastitis may progress to a breast abscess. Symptoms rarely appear before the end of the first postpartum week and are more common in the second to fourth weeks. Chills, fever, malaise, and local breast tenderness are noted first. Localized breast tenderness, pain, swelling, redness, and axillary adenopathy may also occur. Antibiotics are prescribed. Lactation can be maintained by emptying the breasts every 2 to 4 hours by breastfeeding, manual expression, or breast pump.

 

CARE MANAGEMENT

Prenatal and intrapartal factors that can predispose a woman to postpartum infection are listed in Box 4. Signs and symptoms associated with postpartum infection have been discussed with each infection. Laboratory tests usually performed include a complete blood count, venous blood cultures, and uterine tissue cultures. Nursing diagnoses for women experiencing postpartum infection include the following:

• Deficient knowledge related to

-etiology, management, course of infection

-transmission and prevention of infection

• Impaired tissue integrity related to

-effects of infection process

• Acute pain related to

-mastitis

-puerperal infection

-urinary tract infection

• Interrupted family processes related to

-unexpected complication to expected postpartum recovery

-possible separation from newborn

-interruption in process of realigning relationships after the addition of the new family member

• Risk for impaired parenting related to

-fear of spread of infection to newborn

 

The most effective and least expensive treatment of postpartum infection is prevention. Preventive measures include good prenatal nutrition to control anemia and intrapartal hemorrhage. Good maternal perineal hygiene is emphasized. Strict adherence by all health care personnel to aseptic techniques during childbirth and the postpartum period is important.

Management of endometritis consists of IV broadspectrum antibiotic therapy (cephalosporins, penicillins, or clindamycin and gentamicin) and supportive care, including hydration, rest, and pain relief. Antibiotic therapy is usually discontinued 24 hours after the woman is asymptomatic (Gibbs & Sweet, 1999). Assessments of lochia, vital signs, and changes in the woman's condition continue during treatment. Comfort measures depend on the symptoms and may include cool compresses, warm blankets, perineal care, and sitz baths. Teaching should include side effects of therapy, prevention of spread of infection, signs and symptoms of worsening condition, and adherence to the treatment plan and the need for followup care. Women may need to be encouraged or assisted to maintain mother-infant interactions and breastfeeding (if allowed during treatment).

Postpartum women are usually discharged to home by 48 hours after birth. This is often before signs of infection are evident. Nurses in birth centers and hospital settings need to be able to identify women at risk for postpartum infection and to provide anticipatory teaching and counseling before discharge. After discharge, telephone followup, hot lines, support groups, lactation counselors, home visits by nurses, and teaching materials (videos, written materials) are all interventions that can be implemented to decrease the risk of postpartum infections. Home care nurses need to be able to recognize signs and symptoms of postpartum infection so that the woman can contact her primary health care provider. These nurses must also be able to provide the appropriate nursing care for women who need follow-up home care.

Treatment of wound infections may combine antibiotic therapy with wound debridement. Wounds may be opened and drained. Nursing care includes frequent wound and vital sign assessments and wound care. Comfort measures include sitz baths, warm compresses, and perineal care. Teaching includes good hygiene techniques (i.e., changing perineal pads front to back, handwashing before and after perineal care), self-care measures, and signs of worsening conditions to report to the health care provider. The woman is usually discharged to home for self-care or home nursing care after treatment is initiated in the inpatient setting.

Medical management for UTIs consists of antibiotic therapy, analgesia, and hydration. Postpartum women are usually treated on an outpatient basis; therefore teaching should include instructions on how to monitor temperature, bladder function, and appearance of urine. The woman should also be taught about signs of potential complications and the importance of taking all antibiotics as prescribed. Other suggestions for prevention of UTIs include proper perineal care, wiping from front to back after urinating or having a bowel movement, and increasing fluid intake.

Because mastitis rarely occurs before the postpartum woman is discharged, teaching should include warning signs of mastitis and counseling about prevention of cracked nipples. Management includes intensive antibiotic therapy (e.g., cephalosporins and vancomycin, which are particularly useful in staphylococcal infections), support of breasts, local heat (or cold), adequate hydration, and analgesics.

Almost all instances of acute mastitis can be avoided by proper breastfeeding technique to prevent cracked nipples. Missed feedings, waiting too long between feedings, and abrupt weaning may lead to clogged nipples and mastitis. Cleanliness practiced by all who have contact with the newborn and new mother also reduces the incidence of mastitis. See Chapter 20 for further information.

SEQUELAE OF CHILDBIRTH TRAUMA

Women are at risk for problems related to the reproductive system from the age of menarche through menopause and the older years. These problems include structural disorders of the uterus and vagina related to pelvic relaxation and urinary incontinence. They can be a delayed result of childbearing. For example, the structures and soft tissues of the vagina and bladder may be injured during a prolonged labor, during a precipitous birth, or when cephalopelvic disproportion occurs. Defects can also occur in women who have never been pregnant.

 

UTERINE DISPLACEMENT AND PROLAPSE

Normally, the round ligaments hold the uterus in anteversion, and the uterosacral ligaments pull the cervix backward and upward. Uterine displacement is a variation of this normal placement. The most common type of displacement is posterior displacement, or retroversion, in which the uterus is tilted posteriorly and the cervix rotates anteriorly. Other variations include retroflexion and anteflexion (Fig. 5).

 

 

Fig. 5 Types of uterine displacement. A, Anterior displacement. B, Retroversion (backward displacement of uterus).

 

By 2 months postpartum, the ligaments should return to normal length, but in approximately one third of women the uterus remains retroverted. This condition is rarely symptomatic, but conception may be difficult because the cervix points toward the anterior vaginal wall and away from the posterior fornix, where seminal fluid pools after coitus. If symptoms occur, they may include pelvic and low back pain, dyspareunia, and exaggeration of premenstrual symptoms. Uterine prolapse is a more serious type of displacement. The degree of prolapse can vary from mild to complete. In complete prolapse, the cervix and body of the uterus protrude through the vagina and the vagina is inverted (Fig. 6).

 

 

Fig. 6 Prolapse of uterus.

 

Uterine displacement and prolapse can be caused by congenital or acquired weakness of the pelvic support structures (often referred to as pelvic relaxation). In many cases problems can be related to a delayed but direct result of childbearing. Although extensive damage may be noted and repaired shortly after birth, symptoms related to pelvic relaxation most often appear during the perimenopausal period, when the effects of ovarian hormones on pelvic tissues are lost and atrophic changes begin. Pelvic trauma, stress and strain, and the aging process are also contributing causes. Other causes of pelvic relaxation include reproductive surgery and pelvic radiation.

 

Clinical manifestations

Generally, symptoms of pelvic relaxation relate to the structure involved: urethra, bladder, uterus, vagina, cul-de-sac, or rectum. The most common complaints are pulling and dragging sensations, pressure, protrusions, fatigue, and low backache. Symptoms may be worse after prolonged standing or deep penile penetration during intercourse. Urinary incontinence may be present.

 

CYSTOCELE AND RECTOCELE

 

 

Cystocele and rectocele almost always accompany uterine prolapse, causing the uterus to sag even further backward and downward into the vagina. Cystocele (Fig. 7, A) is the protrusion of the bladder downward into the vagina that develops when supporting structures in the vesicovaginal septum are injured. Anterior wall relaxation gradually develops over time as a result of congenital defects of supports, childbearing, obesity, or advanced age. When the woman stands, the weakened anterior vaginal wall cannot support the weight of the urine in the bladder; the vesicovaginal septum is forced downward, the bladder is stretched, and its capacity is increased. With time the cystocele enlarges until it protrudes into the vagina. Complete emptying of the bladder is difficult because the cystocele sags below the bladder neck. Rectocele is the herniation of the anterior rectal wall through the relaxed or ruptured vaginal fascia and rectovaginal septum; it appears as a large bulge that may be seen through the relaxed introitus (Fig. 7, B).

 

Clinical manifestations

Cystoceles and rectoceles often are asymptomatic. If symptoms of cystocele are present, they may include complaints of a bearing-down sensation or that "something is in my vagina." Other symptoms include urinary frequency, retention, incontinence, and possible recurrent cystitis and UTIs. Pelvic examination will reveal a bulging of the anterior wall of the vagina when the woman is asked to bear down. Unless the bladder neck and urethra are damaged, urinary continence is unaffected. Women with large cystoceles complain of having to push upward on the sagging anterior vaginal wall to be able to void.

Rectoceles may be small and produce few symptoms, but some are so large that they protrude outside of the vagina when the woman stands. Symptoms are absent when the woman is lying down. A rectocele causes a disturbance in bowel function, the sensation of "bearing down," or the sensation that the pelvic organs are falling out. With a very large rectocele, it may be difficult to have a bowel movement. Each time the woman strains during bowel evacuation, the feces are forced against the thinned rectovaginal wall, stretching it more. Some women facilitate evacuation by applying digital pressure vaginally to hold up the rectal pouch.

 

URINARY INCONTINENCE

Approximately 25% to 34% of women between ages 25 and 54 years have urinary incontinence (UI) (Thorn, 1998). Although nulliparous women can have UI, the incidence is higher in women who have given birth and also increases with parity (Sampselle et al., 2000). Conditions that disturb urinary control include stress incontinence, due to sudden increases in intraabdominal pressure (such as that due to sneezing or coughing); urge incontinence, caused by disorders of the bladder and urethra, such as urethritis and urethral stricture, trigonitis, and cystitis; neuropathies, such as multiple sclerosis, diabetic neuritis, and pathologic conditions of the spinal cord; and congenital and acquired urinary tract abnormalities.

Stress incontinence may follow injury to bladder neck structures. A sphincter mechanism at the bladder neck compresses the upper urethra, pulls it upward behind the symphysis, and forms an acute angle at the junction of the posterior urethral wall and the base of the bladder (Fig. 8). To empty the bladder, the sphincter complex relaxes and the trigone contracts to open the internal urethral orifice and pull the contracting bladder wall upward, forcing urine out. The angle between the urethra and the base of the bladder is lost or increased if the supporting pubococcygeus muscle is injured; this change, coupled with urethrocele, causes incontinence. Urine spurts out when the woman is asked to bear down or cough in the lithotomy position.

 

Fig. 8 Urethrovasical angle. A, Normal angle. B, Widening (absence) of angle)

 

Clinical manifestations

Involuntary leaking of urine is the main sign. Episodes of leaking are common during coughing, laughing, and exercise.

 

GENITAL FISTULAS

Genital fistulas are perforations between genital tract organs. Most occur between the bladder and the genital tract (e.g., vesicovaginal); between the urethra and the vagina (urethrovaginal); and between the rectum or sigmoid colon and the vagina (rectovaginal) (Fig. 9). Genital fistulas may also be a result of a congenital anomaly, gynecologic surgery, obstetric trauma, cancer, radiation therapy, gynecologic trauma, or infection (e.g., in the episiotomy).

 

 

Fig. 9 Types of fistulas that may develop in vagina, uterus, and rectum. (From Phipps, W., Sands, J., & Marek. J. [1999]. Medical-surgical nursing: Concepts and clinical practice [6th ed.]. St. Louis: Mosby.)

 

Clinical manifestations

Signs and symptoms of vaginal fistulas depend on the site but may include presence of urine, flatus, or feces in the vagina; odors of urine or feces in the vagina; and irritation of vaginal tissues.

 

CARE MANAGEMENT

Assessment for problems related to structural disorders of the uterus and vagina focuses primarily on the genitourinary tract, the reproductive organs, bowel elimination, and psychosocial and sexual factors. A complete health history, physical examination, and laboratory tests are done to support the appropriate medical diagnosis. The nurse needs to assess the woman's knowledge of the disorder, its management, and possible prognosis.

The health care team works together to treat the disorders related to alterations in pelvic support and to assist the woman in management of her symptoms. In general, nurses working with these women can provide information and self-care education to prevent problems before they occur, to manage or reduce symptoms and promote comfort and hygiene if symptoms are already present, and to recognize when further intervention is needed. This information can be part of all postpartum discharge teaching or can be provided at postpartum follow-up visits in clinics or physician/midwife offices, or during postpartum home visits.

 

 

Fig. 1O Examples of pessaries. A, Smith. B, Hodge without support. C, Incontinence dish without support. D, Ring without support. E, Cube. R Gellhorn. (Courtesy Milex Products Inc., Chicago, IL.)

 

Interventions for specific problems depend on the problem and the severity of the symptoms. If discomfort related to uterine displacement is a problem, several interventions can be implemented to treat uterine displacement. Kegel exercises (see p. 74) can be performed several times daily to increase muscle strength. A knee-chest position performed for a few minutes several times a day can correct a mildly retroverted uterus. A fitted pessary device may be inserted in the vagina to support the uterus and hold it in the correct position (Fig. 10). Usually a pessary is used only for a short time because it can lead to pressure necrosis and vaginitis. Good hygiene is important; some women can be taught to remove the pessary at night, cleanse it, and replace it in the morning. If the pessary is always left in place, regular douching with commercially prepared solutions or weak vinegar solutions (1 tablespoon to 1 quart of water) to remove increased secretions and keep the vaginal pH at 4 to 4.5 are suggested. After a period of treatment, most women are free of symptoms and do not require the pessary. Surgical correction is rarely indicated.

Treatment for uterine prolapse depends on the degree of prolapse. Pessaries may be useful in mild prolapse to support the uterus in the correct position. Estrogen therapy also may be used in the older woman to improve tissue tone. If these conservative treatments do not correct the problem, or if there is a significant degree of prolapse, abdominal or vaginal hysterectomy is usually recommended.

Treatment for a cystocele includes use of a vaginal pessary or surgical repair. Pessaries may not be effective. Anterior repair (colporrhaphy) is the usual surgical procedure and is usually done for large, symptomatic cystoceles. This involves a surgical shortening of pelvic muscles to provide better support for the bladder. An anterior repair is often combined with a vaginal hysterectomy.

Small rectoceles may not need treatment. The woman with mild symptoms may get relief from a high-fiber diet and adequate fluid intake, stool softeners, or mild laxatives. Vaginal pessaries usually are not effective. Large rectoceles that are causing significant symptoms are usually repaired surgically. A posterior repair (colporrhaphy) is the usual procedure. This surgery is performed vaginally and involves shortening the pelvic muscles to provide better support for the rectum. Anterior and posterior repairs may be performed at the same time and with a vaginal hysterectomy.

Mild to moderate urinary incontinence can be significantly decreased or relieved in many women by bladder training and pelvic muscle (Kegel) exercises (Sampselle et al., 2000). Other management strategies include pelvic flow support devices (i.e., pessaries), estrogen therapy, insertion of an artificial urethral sphincter, and surgery (e.g., anterior repair) (Johnson, 2000; Stenchever et al., 2001).

Nursing care of the woman with a cystocele, rectocele, or fistula requires great sensitivity, because the woman's reactions are often intense. She may become withdrawn or hostile because of embarrassment caused by odors and soiling of her clothing that are beyond her control. She may have concerns about engaging in sexual activities because her partner is repelled by these problems. The nurse may tactfully suggest hygiene practices that reduce odor. Commercial  deodorizing douches are available, or noncommercial solutions, such as chlorine solution (1 teaspoon of chlorine household bleach to 1 quart of water) may be used. The chlorine solution is also useful for external perineal irrigation. Sitz baths and thorough washing of the genitals with unscented, mild soap and warm water help. Sparse dusting with deodorizing powders can be useful. If a rectovaginal fistula is present, enemas given before leaving the house may provide temporary relief from oozing of fecal material until corrective surgery is performed. Irritated skin and tissues may benefit from use of the heat lamp or application of vitamin A and D emollient ointment. Hygienic care is time consuming and may need to be repeated frequently throughout the day; protective pads or pants may need to be worn. All of these activities can be demoralizing to the woman and frustrating to her and her family.

POSTPARTUM PSYCHOLOGIC COMPLICATIONS

Mental health disorders have implications for the mother, the newborn, and the entire family. Such conditions can interfere with attachment to the newborn and family integration, and some may threaten the safety and well-being of the mother, newborn, and other children.

 

MOOD DISORDERS

Mood disorders are the predominant mental health disorder in the postpartum period, typically occurring within 4 weeks of childbirth (American Psychiatric Association [APA], 2000). Many women experience a mild depression, or "baby blues," following the birth of a child. Others can  have more serious depressions that can eventually incapacitatethem to the point of being unable to care for themselves or their babies. Nurses are strategically positioned to offer anticipatory guidance, to assess the mental health of new mothers, to offer therapeutic interventions, and to refer when necessary. Failure to do so may result in tragic consequences.

The Diagnostic and Statistical Manual of Mental Disorders contains the official guidelines for the assessment and diagnosis of psychiatric illness (APA, 1994). From less severe to most severe, the disorders are categorized as postpartum blues (discussed in Chapter 17), postpartum depression without psychotic features, and postpartum depression with psychotic features (postpartum psychosis).

 

Postpartum depression without psychotic features

Postpartum depression (PPD) is an intense and pervasive sadness with severe and labile mood swings and is more serious and persistent than postpartum blues. Intense fears, anger, anxiety, and despondency that persist past the baby's first few weeks are not a normal part of postpartum blues. Occurring in approximately 10% to 15% of new mothers, these symptoms rarely disappear without outside help.

The symptoms of postpartum major depression do not differ from the symptoms of nonpostpartum mood disorders except that the mother's ruminations of guilt and inadequacy feed her worries about being an incompetent and inadequate parent. In PPD, there may be odd food cravings (often sweet desserts) and binges with abnormal appetite and weight gain. New mothers report an increased yearning for sleep, sleeping heavily but awakening instantly with any infant noise, and an inability to go back to sleep after infant feedings.

A distinguishing feature of PPD is irritability. These episodes of irritability may flare up with little provocation, and they may sometimes escalate to violent outbursts or dissolve into uncontrollable sobbing. Many of these outbursts are directed against significant others ("He never helps me") or the baby ("She cries all the time and I feel like hitting her"). Women with postpartum major depressive episodes often have severe anxiety, panic attacks, and spontaneous crying long after the usual duration of baby blues.

Many women feel especially guilty about having depressive feelings at a time when they believe they should be happy. They may be reluctant to discuss their symptoms or their negative feelings toward the child. A prominent feature of PPD is rejection of the infant, often caused by abnormal jealousy. The mother may be obsessed by the notion that the offspring may take her place in her partner's affections. Attitudes toward the infant may include disinterest, annoyance with care demands, and blaming because of her lack of maternal feeling. When observed, she may appear awkward in her responses to the baby. Obsessive thoughts about harming the child are very frightening to her. Often she does not share these thoughts because of embarrassment, but when she does, other family members become very frightened.

Medical management. The natural course is one of gradual improvement over the 6 months after birth. Support treatment alone is not efficacious for major postpartum depression. Pharmacologic intervention is needed in most instances. Treatment options include antidepressants, anxiolytic agents, and electroconvulsive therapy. Psychotherapy focuses on the mother's fears and concerns regarding her new responsibilities and roles, as well as monitoring for suicidal or homicidal thoughts. For some women, hospitalization is necessary.

 

Postpartum depression with psychotic features

Postpartum psychosis is a syndrome most often characterized by depression (as described previously), delusions, and thoughts by the mother of harming either the infant or herself (Kaplan & Sadock, 1998).

A postpartum mood disorder with psychotic features occurs in 1 to 2 per 1000 births (Kaplan & Sadock, 1998). Once a woman has had one postpartum episode with psychotic features, there is a 30% to 50% likelihood of recurrence with each subsequent birth (APA, 2000).

Symptoms often begin within days after the birth, although the mean time to onset is 2 to 3 weeks and almost always within 8 weeks of birth (Kaplan & Sadock, 1998). Characteristically, the woman begins to complain of fatigue, insomnia, and restlessness and may have episodes of tearfulness and emotional lability. Complaints regarding the inability to move, stand, or work are also common. Later, suspiciousness, confusion, incoherence, irrational statements, and obsessive concerns about the baby's health and welfare may be present (Kaplan & Sadock, 1998). Delusions may be present in 50% of all women and hallucinations in approximately 25%. Auditory hallucinations that command the mother to kill the infant can also occur in severe cases. When delusions are present, they are often related to the infant. The mother may think the infant is possessed by the devil, has special powers, or is destined for a terrible fate (APA, 2000). Grossly disorganized behavior may be manifested as a disinterest in the infant or an inability to provide care. Some will insist that something is wrong with the baby or accuse nurses or family members of hurting or poisoning their child. Nurses are advised to be alert for mothers who are agitated, overactive, confused, complaining, or suspicious.

A specific illness included in depression with psychotic features is bipolar disorder (formerly called manic depressive illness). This mood disorder is preceded or accompanied by manic episodes, characterized by elevated, expansive, or  irritable moods. Because patients are hyperactive, they may not take the time to eat or sleep, which leads to inadequate nutrition, dehydration, and sleep deprivation. While in a manic state, mothers will need constant supervision when caring for their infant. They probably will be too preoccupied to provide child care.

Medical management. A favorable outcome is associated with a good premorbid adjustment (before the onset of the disorder) and a supportive family network (Kaplan & Sadock, 1998). Because mood disorders are usually episodic, women may experience another episode of symptoms within a year or two of the birth. Postpartum psychosis is a psychiatric emergency. Antidepressants and lithium are the treatments of choice. If the mother is breastfeeding, some sources say no pharmacologic agents should be prescribed  (Kaplan & Sadock, 1998), but other sources advise cautionwhile prescribing some agents (Schatzberg & Nemeroff, 1998) (see later discussion). The mother will probably need psychiatric hospitalization. It is usually advantageous for the mother to have contact with her baby if she so desires, but visits must be closely supervised. Psychotherapy is indicated after the period of acute psychosis is past.

 

CARE MANAGEMENT

Even though the prevalence of PPD is fairly well established, few women are referred to a mental health care provider. Those identified are often treated inappropriately with benzodiazepines or subtherapeutic doses of antidepressants.

Assessment and Nursing Diagnoses

To help ensure early recognition of symptoms of PPD, the nurse should be an active listener and demonstrate a caring attitude. Nurses cannot depend on women volunteering unsolicited information about their depression or asking for help. The nurse should observe for signs of depression and ask appropriate questions to determine moods, appetite, sleep, energy and fatigue levels, and ability to concentrate. If the nurse assesses that the new mother is depressed, she or he must ask if the mother has thought about hurting herself or the baby.

 

NURSE ALERT Recalling risk factors for postpartum depression can alert the nurse to identify those postpartum women at greatest risk. Risk factors include prenatal depression, a history of previous depression, child care stress, meager or absent social support, stressful life events, prenatal anxiety, maternity blues, and poor marital relationship (Beck, 1998a).

 

RESEARCH Postpartum Depression Screening The average annual rate of postpartum depression is 13% in women who have recently given birth, or approximately 400,000 mothers per year in the United States. It most often occurs at 6 to 8 weeks postpartum and typically lasts more than 6 months. Delayed treatment can negatively affect the whole family. Women with postpartum depression may have a more negative interaction style with their infants, with measurable infant effects of lowered activity, fewer vocalizations, and increased irritability when compared with infants of nondepressed mothers. Older children of mothers who had postpartum depression may show increased psychiatric problems and impaired cognitive development. Up to 50% of all postpartum depressions go undetected. Currently, the most widely used instrument to screen for general depression is the Beck Depression Inventory. It may overrepresent depression scores in postpartum women because of some of the normal physiologic postpartum symptoms of fatigue and sleep disturbance. To adequately measure symptoms specific for postpartum depression with questions worded in context of new motherhood, Beck developed the Postpartum Depression Screening Scale (PDSS). The PDSS is a Likert-type scale of 35 questions measuring seven dimensions: sleeping/eating disturbances, anxiety/insecurity, emotional lability, cognitive impairment, loss of self, guilt/shame, and contemplating harming oneself. The researchers tested the PDSS on 525 women from the East Coast and Midwest sections of the United States and found it to be reliable and valid. IMPLICATION FOR PRACTICE If future studies confirm its sensitivity and specificity and establish a positive predictive value, the PDSS may become a useful screening tool for an insidious disease that compromises the joy of new parenthood for many families. In the meantime, nurses can use available screening tools to assess for risk and educate new mothers about the subtle signs of postpartum depression and community resources for support of new parents.

 

BOX 5 Suggested Questions to Elicit Responses from the Postpartum Depression Checklist LACK OF CONCENTRATION Are you experiencing difficulty concentrating? Does your mind seem to be filled with cobwebs? Does it seem at times like fogginess sets in? LOSS OF INTERESTS Do you feel your life is empty of your previous interests and goals? Have you lost interest in your hobbies that used to bring you pleasure and enjoyment? LONELINESS Are you experiencing feelings of loneliness? Do you feel as though no one really understands what you are experiencing? Do you feel uncomfortable around other people? Have you been isolating yourself from other people? INSECURITY Have you been feeling insecure, fragile, or vulnerable? Does the responsibility of motherhood seem overwhelming? OBSESSIVE THINKING Is your mind constantly filled with obsessive thinking, such as "What's wrong with me?" "Am I going crazy?" "Why can't I enjoy being with my baby?" When trying to fall asleep at night, is your mind still racing with repetitive thoughts? LACK OF POSITIVE EMOTIONS Are you experiencing feelings of emptiness? Do you feel like a robot just going through the motions? When caring for your infant/child, do you feel any joy or love? LOSS OF SELF Do you feel as though you are not the same person you used to be? Are you afraid that your life will never be normal again? ANXIETY ATTACKS Are you experiencing uncontrollable anxiety attacks? Are you experiencing periods of palpitations, chest pains, sweating, or tingling hands? When going through an anxiety attack, do you feel as though you're losing your mind? LOSS OF CONTROL Do you feel you are in control of your emotions and thoughts? Are you experiencing loss of control in any aspects of your life? GUILT Are you feeling guilty because you believe you are not giving your infant/child the love and attention he or she needs? Are you experiencing guilt over thoughts of harming your infant/child? Do you feel you are a good mother? CONTEMPLATING DEATH Have you experienced thoughts of harming yourself? Have you been feeling so low that the thought of leaving this world was appealing to you?

 

BOX 6 Edinburgh Postnatal Depression Scale (EPDS) Name: Address: Baby's age: As you have recently had a baby, we would like to know how you are feeling. Please UNDERLINE the answer which comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today. Here is an example, already completed. I have felt happy Yes, all the time Yes, most of the time No, not very often No, not at all This would mean: "I have felt happy most of the time" during the past week. Please complete the other questions in the same way. IN THE PAST 7 DAYS: 1. I have been able to laugh and see the funny side of things As much as I always could Not quite so much now Definitely not so much now Not at all 2. I have looked forward with enjoyment to things As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all * 3. I have blamed myself unnecessarily when things went wrong Yes, most of the time Yes, some of the time Not very often No, never 4. I have been anxious or worried for no good reason No, not at all Hardly ever Yes, sometimes Yes, very often * 5. I have felt scared or panicky for no very good reason Yes, quite a lot Yes, sometimes No, not much No, not at all * 6. Things have been getting on top of me Yes, most of the time I haven't been able to cope at all Yes, sometimes I haven't been coping as well as usual No, most of the time I have coped quite well No, I have been coping as well as ever * 7. I have been so unhappy that I have had difficulty sleeping Yes, most of the time Yes, sometimes Not very often No, not at all * 8. I have felt sad or miserable Yes, most of the time Yes, quite often Not very often No, not at all * 9. I have been so unhappy that I have been crying Yes, most of the time Yes, quite often Only occasionally No, never *10. The thought of harming myself has occurred to me Yes, quite often Sometimes Hardly ever Never Scoring: Response categories are scored 0, 1, 2, and 3 according to increased severity of the symptom. Items marked with an asterisk are reverse scored (i.e., 3, 2, 1 and 0). The total score is calculated by adding together the scores for each of the 10 items.

 

Nurses can use screening tools in assessing whether the depressive symptoms have progressed from postpartum blues to PPD (see Research box). Examples are the Postpartum Depression Checklist developed by Beck (1995) (Box 5) and the Edinburgh Postnatal Depression Scale  (EPDS) (Cox, Holden, & Savogsky, 1989) (Box 6). If the initial interaction reveals some question that the patient might be depressed, a formal screening is helpful in determining the urgency of the referral and the type of provider. Also important is the need to assess the woman's family members because they may be able to offer valuable information, as well as have a need to express how they have been affected by the woman's emotional disorder. Planning is focused on meeting the individualized needs of the family to ensure safety, especially for the mother and infant and any other children, and to facilitate functional family coping. Nursing diagnoses may include the following:

• Risk for self-directed (mother) or other-directed (children) violence related to

-postpartum depression

• Situational low self-esteem in the mother related to

-stresses associated with role changes

• Disabled family coping related to

-increased care needs of mother and infant

• Risk for impaired parenting related to

-inability of depressed mother to attach to infant

• Risk for injury to newborn related to

-mother's depression (inattention to infant's needs for hygiene, nutrition, safety) and psychotropic medications via breast milk

 

Expected Outcomes of Care

Specific measurable criteria can be developed based on the following general outcomes:

• The mother will no longer be depressed.

• The mother's and infant's physical well-being will be maintained.

• The family will cope effectively.

• Family members will demonstrate continued healthy growth and development.

• The infant will be fully integrated into the family.

 

Plan of Care and Interventions

On the postpartum unit

 

Patient Instructions for Self-Care Activities to Prevent Postpartum Depression • Share knowledge about postpartum emotional problems with close family and friends. • Take care of yourself, including eating a balanced diet, getting exercise on a regular basis, and getting adequate sleep. Ask someone to take care of the baby so that you can get a full night's sleep. • Share your feelings with someone close to you; don't isolate yourself at home. • Don't overcommit yourself or feel like you need to be superwoman. • Don't place unrealistic expectations on yourself. • Don't be ashamed of having emotional problems after your baby is born —it happens to approximately 15% of women.

 

The postpartum nurse must observe the new mother carefully for any signs of tearfulness and conduct further assessments as necessary. PPD must be discussed by nurses to prepare new parents for potential problems in the postpartum period. The family must be able to recognize the symptoms and know where to go for help. Written materials that explain what the woman can do to prevent depression could be used as part of discharge planning.

Mothers are often discharged from the hospital before the blues or depression occurs. If the postpartum nurse is concerned about the mother, a mental health consult should be requested before the mother leaves the hospital. Routine instructions regarding PPD should be given to whomever comes to take the patient home; for example, "If you notice that your wife (or daughter) is upset or crying a lot, please call the postpartum care provider immediately—don't wait for the routine postpartum appointment."

 

In the home and community

Postpartum home visits can reduce the incidence of or complications from depression; however, home visits may not be feasible or available. Supervision of the mother with emotional complications may become a prime concern. Because depression can greatly interfere with her mothering functions, family and friends may need to participate in the infant's care. This supervision can be planned by the collaborative efforts of the nurse and family members. This is a time for the extended family and friends to determine what they can do to help, and the nurse can work with them to ensure adequate supervision of and their understanding of the woman's mental illness.

Even if the mother is severely depressed, hospitalization can be avoided if adequate resources can be mobilized to ensure safety for both mother and infant. The nurse in home health care will need to make frequent phone calls or home visits to do assessment and counseling. Community resources that may be helpful are temporary child care or foster care, homemaker service, Meals on Wheels, parenting guidance centers, mother's-day-out programs, and telephone support groups (see Resources at end of chapter).

Referral. Women with moderate to severe cases of PPD should be referred to a mental health therapist, such as an advanced practice psychiatric nurse, for evaluation and therapy so as to avoid the effects that postpartum depression can have on the woman and on her relationships with her partner, baby, and other children (Shrock, 1994). Inpatient psychiatric hospitalization may be necessary. This decision is made when the safety needs of the mother or children are threatened.

Providing safety. When depression is suspected, the nurse asks, "Have you thought about hurting yourself?" If delusional thinking about the baby is suspected, the nurse asks, "Have you thought about hurting your baby?" There are four criteria to measure in assessing the seriousness of a suicidal plan: method, availability, specificity, and lethality. Has the woman specified a method? Is the method of choice available? How specific is the plan? If the method is concrete and detailed, with access to it right at hand, the suicide risk increases. How lethal is the method? The most lethal method is shooting, with hanging a close second. The least lethal is slashing one's wrists.

 

NURSE ALERT Suicidal thoughts or attempts are one of the most serious symptoms of PPD and require immediate assessment and intervention (Fishel, 1995).

 

Psychiatric hospitalization

Women with postpartum psychosis are a psychiatric emergency and must be referred immediately to a psychiatrist who is experienced in working with women with PPD, who can prescribe medication and other forms of therapy and assess the need for hospitalization.

 

LEGAL TIP If a woman with PPD is experiencing active suicidal ideation or harmful delusions about the baby and is unwilling to seek treatment, legal intervention may be necessary to commit the woman to an inpatient setting for treatment.

 

Within the hospital setting, the reintroduction of the baby to the mother can occur at the mother's own pace. A schedule is set for increasing the number of hours the mother cares for the baby over several days, culminating in the infant staying overnight in the mother's room. This allows the mother to experience meeting the infant's needs and giving up sleep for the baby, a situation difficult for new mothers even under ideal conditions. The mother's readiness for discharge and caring for the baby is assessed. Her interactions with her baby are also carefully supervised and guided.

Nurses should also observe the mother for signs of bonding with the baby. Attachment behaviors are defined as eye-to-eye contact; physical contact that involves holding, touching, cuddling, and talking to the baby and calling the baby by name; and the initiation of appropriate care. A staff member is assigned to keep the baby in sight at all times. Indirect teaching, praise, and encouragement are designed to bolster the mother's self-esteem and self-confidence.

Psychotropic medications. PPD is usually treated with antidepressant medications. If the woman with PPD is not breastfeeding, antidepressants can be prescribed without special precautions. The commonly used antidepressant drugs are often divided into four groups: selective serotonin reuptake inhibitors (SSRIs), heterocyclics (including the tricyclic antidepressants [TCAs]), monoamine oxidase inhibitors (MAOIs), and other antidepressant agents not in the above classifications (Keltner & Folks, 1997) (Box 7).

 

BOX 7 Antidepressant Medications SELECTIVE SEROTONIN REUPTAKE INHIBITORS Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) HETEROCYCLICS/TRICYCLICS Amitriptyline (Elavil) Amoxapine (Asendin) Clomipramine (Anafranil) Desipramine (Norpramin) Doxepin (Sinequan) Imipramine (Tofranil) Nortriptyline (Pamelor) Maprotiline (Ludiomil) Protriptyline (Vivactil) MONOAMINE OXIDASE INHIBITORS Phenelzine (Nardil) Tranylcypromine (Parnate) OTHER AGENTS Bupropion (Wellbutrin) Nefazodone (Serzone) Trazadone (Desyrel) Venlafaxine (Effexor)

 

The SSRIs are prescribed more frequently today than other groups of antidepressant medications. They are relatively safe and carry fewer side effects than the TCAs. The most frequent side effects with the SSRIs are gastrointestinal disturbances (nausea, diarrhea), headache, and insomnia. In approximately one third of patients the SSRIs reduce libido, arousal, or orgasmic function.

The TCAs cause many central nervous system (CNS) and peripheral nervous system (PNS) side effects. A common CNS effect is sedation, and this could easily interfere with mothers caring for their babies. A mother could fall asleep while holding the baby and drop him or her, or she could have trouble getting fully awake during the night to care for the baby. Other side effects include weight gain, tremors, grand mal seizures, nightmares, agitation or mania, and extrapyramidal side effects. Anticholinergic side effects include dry mouth, blurred vision (usually temporary), difficulty voiding, constipation, sweating, and orgasm difficulty (Keltner & Folks, 1997).

Hypertensive crisis is the main reason that MAOIs are not prescribed more frequently. The woman should be taught to watch for signs of hypertensive crisis—throbbing, occipital headache, stiff neck, chills, nausea, flushing, retroorbital pain, apprehension, pallor, sweating, chest pain, and palpitations (Keltner & Folks, 1997). This crisis is brought on by the patient taking any of a large variety of over-the-counter medications or eating foods that contain tyramine, a sympathomimetic pressor amine, which normally is broken down by the enzyme monoamine oxidase. The nurse must do extensive teaching about avoidance of foods and medications that contain tyramine.

The woman taking mood stabilizers (Box 8) must be taught about the many side effects, and especially, for those on lithium, the need to have serum lithium levels drawn every 6 months. Women with severe psychiatric syndromes such as schizophrenia, bipolar disorder, or psychotic depression will probably require antipsychotic medications (Box 9). Most of these antipsychotic medications can cause sedation and orthostatic hypotension—both of which could interfere with the mother being able to safely care for her baby. They can also cause PNS effects such as constipation, dry mouth, blurred vision, tachycardia, urinary retention, weight gain, and agranulocytosis. CNS effects may include akathisia, dystonias, parkinsonism-like symptoms, tardive dyskinesia (irreversible), and neuroleptic malignant syndrome (potentially fatal).

 

BOX 8 Mood Stabilizers Carbamazepine (Tegretol) Clonazepam (Klonopin) Divalproex (Depakote) Lithium carbonate (Eskalith)

 

BOX 25-9 Commonly Used Antipsychotic Medications PHENOTHIAZINES Chlorpromazine (Thorazine) Fluphenazine (Prolixin) Perphenazine (Trilafon) Thioridazine (Mellaril) Trifluoperazine (Stelazine) OTHER Clozapine (Clozaril) Haloperidol (Haldol) Loxapine (Loxitane) Olanzapine (Zyprexa) Pimozide (Orap) Risperidone (Resperdal) Thiothixene (Navane)

 

Psychotropic medications and lactation. A major clinical dilemma is the antidepressant treatment of women suffering from PPD who want to breastfeed their infants. In the past, women were told to discontinue lactation. To date, the Food and Drug Administration has not approved any psychotropic medication for use during lactation. However, the American Academy of Pediatrics Committee on Drugs (1994) published a report on excretion of medications into human breast milk. Their classification includes medications that are contraindicated during breastfeeding, medications whose effects on nursing infants are unknown but may be of concern because they could alter CNS development, and medications usually compatible with breastfeeding. Because all psychotropic medications pass through breast milk to the infant, the risks associated with the use of such medication must be weighed against the risks associated with maternal agitation and potentially self-destructive behavior.

Breast milk excretion studies have demonstrated that antidepressants are present in breast milk, with a milk-toserum ratio that is typically greater than 1:1 (Schatzberg & Nemeroff, 1998). For amitriptyline and desipramine, there is a peak increase in breast milk concentrations 4 to 6 hours after an oral dose. Adjusting both the schedule of dosing of the antidepressant and the infant's feeding schedule may considerably reduce the concentration of the drug to which the infant is exposed. MAOIs are usually avoided; minimal data are available concerning the SSRIs. No human data have been published on the newer antidepressants. Most of the drugs listed in Boxes 7 and 8 are classified as drugs whose effects on infants are unknown but may be of concern.

Antipsychotic medications are excreted into breast milk. None of these medications has been proven safe during lactation; the American Academy of Pediatrics does not rate any of the antipsychotic medications as compatible with breastfeeding.

Mood-stabilizing and antimanic medications are present in breast milk. Lithium is contraindicated in breastfeeding. The benefits of breastfeeding and the potential risks must be carefully considered before use of other mood stabilizers (American Academy of Pediatrics Committee on Drugs, 1994).

Nursing implications. When breastfeeding women have emotional complications and need psychotropic medications, referral to a psychiatrist who specializes in postpartum disorders is preferred. The nurse should reinforce the need to take antidepressants as ordered. Because they do not exert any effect for approximately 2 weeks and usually do not reach full effect for 4 to 6 weeks, many women discontinue taking the medication on their own. Patient and family teaching should reinforce the schedule for taking medications in conjunction with the infant's feeding schedule.

 

Evaluation

The nurse can be assured that care has been effective if the physical well-being of the mother and infant is maintained, the mother and family are able to cope effectively, and each family member continues to show a healthy adaptation to the presence of the new member of the family (see Plan of Care).

 

PLAN OF CARE

Postpartum Depression

NURSING DIAGNOSIS Risk for injury to the newborn and woman related to patient's emotional state as evidenced by maternal behaviors and increased score on a postpartum depression scale

Expected Outcome The woman and newborn will remain free of injury.

Nursing Interventions/Rationales

Assess the postpartum woman for risk factors for depression; use assessment scale to determine which patients may be most at risk to identify patients needing prompt interventions.

Maintain frequent contact with woman by telephone calls and home visits to determine if further interventions are necessary because most patients are discharged early from the inpatient setting.

Advise woman and family to telephone health care provider if behaviors indicating depression, such as crying, increase to provide prompt care and referral if necessary and avoid injury to newborn and patient.

Provide opportunities for woman and family to verbalize feelings and concerns in a nonjudgmental setting to promote a trusting relationship.

Assess woman for any suicidal thoughts or plans to provide for safety of patient and neonate.

Refer mild cases of depression to support groups to provide group interaction with women having similar problems.

Refer moderate to severe cases of depression to mental health therapist to provide for individualized psychiatric care.

Refer breastfeeding mother to lactation consultant for information regarding effects of antidepressant and antipsychotic medications

 

NURSING DIAGNOSIS Disabled family coping related to postpartum maternal depression as evidenced by family members' denial of patient's illness

Expected Outcomes Family will identify positive coping mechanisms and initiate a plan to cope with the patient's depression.

Nursing Interventions/Rationales

Provide opportunity for family and significant others to verbalize feelings and concerns to establish a trusting relationship.

Give information to the family regarding postpartum depression to clarify any misconceptions or misinformation.

Assist family to identify positive coping mechanisms that have been effective during past crises to promote active participation in care.

Assist family to identify community sources of support to provide additional resources as needed.

Refer family to mental health counselor as needed to provide further expertise from a mental health professional.

 

POSTPARTUM ONSET OF PANIC DISORDER

Approximately 3% to 5% of women develop panic disorder or obsessive-compulsive disorder in the postpartum period. Panic attacks are discrete periods in which there is the sudden onset of intense apprehension, fearfulness, or terror (APA, 2000). During these attacks, symptoms such as shortness of breath, palpitations, chest pain, choking, smothering sensations, and fear of losing control are present. They have intrusive thoughts about terrible injury done to the infant, such as stabbing or burns, sometimes by themselves (Pederson, 1998). Rarely do they harm the baby. Nurses need only to listen to hear symptoms of panic disorder. Usually these women are so distraught that they will share with whomever will listen. Oftentimes the family has tried to tell them that what they are experiencing is normal, but they know differently.

 

Medical management

Treatment is usually a combination of medications, education, psychotherapy, and cognitive-behavioral interventions. Antidepressants such as SSRIs may be prescribed. Sertraline (Zoloft) is currently the drug of choice with panic disorder; fluvoxamine (Luvox) may be especially helpful with obsessions.

 

Nursing considerations

The following nursing interventions are suggested:

• Education is a crucial nursing intervention. New mothers should be provided with anticipatory guidance concerning the possibility of panic attacks during the postpartum period. Preparing for the attacks may help decrease their unexpected, terrifying nature (Beck, 1998b).

• Women can be reassured that it is common to feel a sense of impending doom and fear of insanity during panic attacks. These fears are temporary and disappear once the panic attack is over (Beck, 1998b).

• Nurses can help women identify panic triggers that are particular to their own lives. Keeping a diary can help identify the triggers (Beck, 1998b).

• Family and social supports are helpful. The new mother is encouraged to put usual chores on hold and to ask for and accept help.

• Support groups allow these mothers to experience comfort in seeing others like themselves.

• Sensory interventions such as music therapy and aromatherapy are nonintrusive and inexpensive.

• Behavioral interventions such as breathing exercises and progressive muscle relaxation can be helpful (Fishel, 1998).

• Cognitive interventions such as positive self-talk training, reframing and redefining, and reassurance can alter the negative thinking (Fishel, 1998).

PLAN OF CARE Postpartum Infections

NURSING DIAGNOSIS Deficient fluid volume related to postpartum hemorrhage

Expected Outcome Patient will demonstrate fluid balance as evidenced by stable vital signs, prompt capillary refill time, and balanced intake and output.

 

Nursing Interventions/Rationales

Monitor vital signs, oxygen saturation, urine specific gravity, and capillary refill to provide baseline data.

Measure and record amount and type of bleeding by weighing and counting saturated pads. If woman is at home, teach her to count pads and save any clots or tissue. If woman is admitted to hospital, save any clots and tissue for further examination to estimate type and amount of blood loss for fluid replacement.

Provide quiet environment to promote rest and decrease metabolic demands.

Give explanation of all procedures to reduce anxiety.

Begin IV access with 18-gauge or larger needle for infusion of isotonic solution as ordered to provide fluid or blood replacement.

Administer medications as ordered, such as oxytocin, Methergine, or Prostin, to increase contractility of the uterus.

Insert indwelling urinary catheterr to provide most accurate assessment of renal function and hypovolemia.

Prepare for surgical intervention as needed to stop the source of bleeding.

 

NURSING DIAGNOSIS Ineffective tissue perfusion related to hypovolemia

Expected Outcome Woman will have stable vital signs, oxygen saturation, arterial blood gases, and adequate hematocrit and hemoglobin.

Nursing Interventions/Rationales

Monitor vital signs, oxygen saturation, arterial blood gases, and hematocrit and hemoglobin to assess for hypovolemic shock and decreased tissue perfusion.

Assess for any changes in level of consciousness to assess for evidence of hypoxia.

Assess capillary refill, mucous membranes, skin temperature to note indicators of vasoconstriction.

Give supplementary oxygen as ordered to provide additional oxygenation to tissues.

Suction as needed, insert oral airway, to maintain clear, open airway for oxygenation.

Monitor arterial blood gases to provide information about acidosis or hypoxia.

Administer sodium bicarbonate if ordered to reverse metabolic acidosis.

 

NURSING DIAGNOSIS Anxiety related to sudden change in heaith status

Expected Outcome Woman will verbalize the anxious feelings are diminished.

Nursing Interventions/Rationales

Using therapeutic communication, evaluate woman's understanding of events to provide clarification of any misconceptions.

Provide calm, competent attitude and environment to aid in decreasing anxiety.

Explain all procedures to decrease anxiety about the unknown.

Allow woman to verbalize feelings to permit clarification of information and promote trust.

Continue to assess vital signs or other clinical indicators of hypovolemic shock to evaluate if psychologic response of anxiety intensifies physiologic indicators.