NSG210 Durham Ch. 14: High-Risk Postpartum Nursing Care (Postpartum Complications)

Source: Durham & Chapman, Maternal-Newborn Nursing 4e, Chapter 14, pp. 449-477 (textbooks/DURHAM_OB_CH14.pdf, also in textbooks/exam03/). Running head: “Postpartum Complications and Nursing Care.” Week 10 reading (OB Lectures 6-7, October 28); on Exam 3. The syllabus weekly outline also lists Ch. 14 under Week 12. Lecture slides: raw/nsg210_wk10_OBLecture4.md (Postpartum Hemorrhage, slides 11-17; Post-Partum depression screenings). Normal postpartum care is in nsg210-durham-ch12-postpartum-care; baby blues are in nsg210-durham-ch13-transition-to-parenthood. Preeclampsia and the VTE bundle are covered in Ch. 7 (nsg210-exam-2-outline-durham-ch07).

Learning Outcomes

1. Describe the primary causes of postpartum hemorrhage (PPH) and related nursing and medical care.
2. Describe the primary postpartum infections and related care.
3. Describe the primary postpartum psychological complications and related care.
4. Describe the primary postpartum cardiovascular complications and related care.
5. Describe how social determinants of health affect maternal outcomes.

Nursing diagnoses: risk for hemorrhage (atony, lacerations, retained tissue, hematoma); risk for infection (tissue trauma, prolonged rupture of membranes); risk for mood disorders (stress, hormones, sleep loss, poor support); risk for maternal morbidity and mortality related to health equity and social determinants of health.

I. Overview and Severe Maternal Morbidity

• Over half of maternal deaths occur in the days, weeks and months after birth; most complications appear after discharge and may require readmission (often without the infant, which disrupts attachment)
• Most common preventable causes of severe maternal morbidity (SMM) and death: obstetric hemorrhage, infection, perinatal mood and anxiety disorders (PMADs), hypertensive disorders, venous thromboembolism (VTE)
• Pregnancy-related problems can arise up to 1 year after delivery
• Teach her to seek care for a persistent or worsening headache, vision changes, breathing difficulty, excessive swelling of the hands or face, or fever
• SMM rose 75% in the past decade; hemorrhage is the most frequent cause of SMM and of preventable maternal death; 63.2% of pregnancy-related deaths were judged preventable
• Contributors: lack of access to the right level of care, health inequities, social determinants of health, transportation, chronic conditions, cesarean birth
• Women of color have higher rates of complications and death, attributed to racism, discrimination, poor access, structural determinants, implicit bias and communication barriers. LGBTQ parents and women with physical, sensory or intellectual disabilities also face higher risk

Critical Component, risk reduction for postpartum complications:

• Review prenatal and intrapartum records for risk factors (anemia, long labor, operative vaginal birth)
• Assess for complications and intervene early
• Assist with ambulation (or appropriate activity for women with disabilities) to reduce VTE
• Prevent bladder overdistention (atony, neurogenic bladder, cystitis)
• Hand hygiene for staff, patients and visitors
• Diet, fluids, activity, rest; assess for psychological complications
• Culturally appropriate care for women of color, women with disabilities and LGBTQ patients

Box 14-1, obstetric hemorrhage safety bundle (Readiness, Recognition and Prevention, Response, Reporting and Systems Learning, Respectful Care): hemorrhage cart with first- and second-line drugs; team drills; massive transfusion protocol including for patients who decline blood; assess and communicate hemorrhage risk at admission, in labor and postpartum; measure cumulative blood loss quantitatively; actively manage the third stage; huddles and debriefs.

II. Postpartum Hemorrhage

A. Definitions and quantification

• Traditional: over 500 mL after vaginal birth or over 1,000 mL after cesarean, with a 10% drop in hemoglobin or hematocrit
• ACOG: cumulative blood loss of 1,000 mL or more, OR any blood loss with signs of hypovolemia, within 24 hours of birth (includes intrapartum loss)
• PPH describes an event, not a diagnosis; occurs in about 2% to 6% of vaginal births; a top-five cause of maternal death worldwide
• Complications: hemorrhagic (hypovolemic) shock, DIC, organ failure, death
• Primary (early): within 24 hours, from atony, lacerations or hematomas; greatest risk in the first hour
• Secondary (late): 24 hours to 6 weeks (Ch. 12 says up to 12 weeks), from hematomas, subinvolution or retained placental tissue

Critical Component, quantification of blood loss (QBL):

• Normal vaginal blood loss about 500 mL within 24 hours
• Visual estimation (EBL) underestimates by up to 50%; overestimation leads to unneeded transfusion
• AWHONN: formally quantify cumulative blood loss after EVERY birth
• Methods: calibrated under-buttock drapes; weigh blood-soaked items and clots and subtract dry weight (1 g = 1 mL)

Physiology limiting blood loss: hypercoagulability (factor VIII and platelet activity rise in pregnancy, factor V rises after placental separation, more fibrin) and myometrial contraction compressing the placental-site vessels.

B. The 4 Ts (Table 14-1), in order of frequency

Risk factors for PPH:

• Preexisting: high parity, previous PPH, previous uterine surgery, clotting disorders
• Current pregnancy: antepartum hemorrhage; uterine overdistention (macrosomia, multiples, polyhydramnios); chorioamnionitis; placental abnormality (succenturiate lobe, previa, accreta, abruption, molar pregnancy); fetal death
• Labor and birth: rapid or prolonged labor; tocolytics or halogenated anesthetics; large episiotomy; operative vaginal birth; cesarean; abnormally located or attached placenta; uterine inversion

C. Recognizing hypovolemia

• Signs of hypovolemia: tachycardia, hypotension, tachypnea, SpO2 under 95%, oliguria, pallor, dizziness, altered mental status. Also lightheadedness, weakness, palpitations, diaphoresis, restlessness, confusion, air hunger, syncope
• Hypotension, dizziness, pallor and oliguria do NOT appear until blood loss is substantial
• Pregnancy hypervolemia (30% to 70% more blood volume, an extra 1 to 2 L) masks a typical 500 mL loss; classic shock signs may not show until 10% to 30% of total volume is lost. Normal vital signs do not rule out shock
• First BP sign of hypovolemia may be a narrowed pulse pressure of 30 mm Hg or less; track MAP
• Tachypnea and tachycardia may appear while BP is still normal or slightly low

Critical Component, indications of primary PPH:

• 10% drop in Hgb or Hct after birth
• Pad saturated within 15 minutes
• Fundus that stays boggy after massage
• Tachycardia (late sign)
• Falling BP (late sign)

Clinical Judgment, trigger parameters: a red trigger mandates immediate bedside evaluation; a yellow trigger calls for further evaluation. Values as extracted (table partly garbled; check Clinical Judgment box on p. 455):

D. Nursing actions during PPH

• Ask for help; type and cross-match packed RBCs if heavy loss is expected; notify the blood bank
• Quantify loss: weigh pads and Chux (gram scale on the unit). Excessive bleeding = one pad saturated in 15 minutes; watch for slow steady seepage too
• VS at least every 15 minutes, including MAP
• Two large-bore IVs (14, 16 or 18 gauge)
• Volume: crystalloid (NS or LR) 3:1 or colloid (Hespan, albumin) 1:1 while awaiting blood. Goal urine output at least 30 mL/hr and Hct 30%
• Labs: H&H (compare with admission), type and cross-match, fibrinogen, PT, PTT, fibrin split and degradation products, chemistry; ABG if needed
• Each unit of packed RBCs (about 240 mL) raises Hct about 3 points and Hgb about 1 g/dL
• Clotting factor deficits: cryoprecipitate (fibrinogen), recombinant activated factor VII, FFP
• Correct massage technique (support the lower segment) with only enough force to firm the uterus or expel clots; overaggressive massage tires the muscle and worsens atony
• Anticipate pain from massage and uterotonics
• Foley catheter (full bladder impedes contraction; accurate output)
• Uterotonics per protocol
• Pulse oximetry; oxygen by nonrebreather at 10 to 12 L/min
• Continuous ECG for hypotension, continued bleeding, tachycardia or shock
• Elevate the legs 20 to 30 degrees
• Accurate I&O
• If unresolved: uterine packing or balloon tamponade, D&C, laparotomy, uterine artery ligation, embolization, hysterectomy; notify the OR team

Box 14-2, staging obstetric hemorrhage:

Box 14-3, massive transfusion protocol: emergency release of at least 4 units O-negative or uncross-matched RBCs; give 2 to 4 units O-negative before crossmatch; massive transfusion pack ratio 6 units PRBCs : 4 units FFP : 1 apheresis platelets. If labs abnormal, repeat the pack, repeat labs, consider cryoprecipitate and other agents (prothrombin complex concentrate, recombinant factor VIIa, tranexamic acid). Severe hemorrhage may need at least 4 units of blood products.

Clinical Judgment, alternatives to whole blood (for example, Jehovah’s Witnesses): plan before delivery and ask about advance directives; options include cryoprecipitate, albumin, erythropoietin, and cell saver (the patient’s own blood washed, filtered and returned).

E. Uterine atony

• Major cause of primary PPH
• Risk: overdistention (multiples, large fetus), more than five births, prolonged or dysfunctional labor with or without oxytocin
• Findings: boggy fundus; pad saturated in 15 minutes; slow steady or sudden massive bleeding; clots; pale clammy skin; anxiety and confusion; tachycardia; hypotension
• Nursing: review risk factors; check for a displaced uterus (text says usually to the patient’s LEFT here; Ch. 12 says to the right), then void or catheterize and reassess; bladder scan; if boggy, massage and reassess every 5 to 15 minutes; put the baby to breast (releases oxytocin); express clots; weigh pads; review H&H; notify the provider; large-bore IV; uterotonics; transfusion per protocol; emotional support
• Medical: uterotonics (oxytocin IM or IV after placental delivery, methylergonovine, misoprostol, carboprost); bimanual compression by the provider; isotonic non-dextrose crystalloid 3 L per 1 L of estimated loss; blood, platelets, FFP, cryoprecipitate; uterine packing or a balloon tamponade (about 300 mL saline); D&C or hysterectomy if all else fails

F. Lacerations

• Second most common cause of primary PPH
• Risk: macrosomia, operative vaginal birth (forceps, vacuum), precipitous labor and birth
• Findings: FIRM midline uterus with heavier bleeding; steady stream without clots; tachycardia; hypotension
• Medical: inspect cervix, vagina, perineum and labia; surgical repair
• Nursing: monitor VS and weighed blood loss; notify the provider of increased bleeding with a firm fundus; pain medication; prepare for pelvic exam; support

G. Hematomas

• Blood collects in the connective tissue of the vagina or perineum from a ruptured vessel; blood loss is hidden, so PPH may not be recognized until shock
• Most common causes: episiotomy, forceps, prolonged second stage
• Can displace the uterus and cause atony
• Findings: SEVERE vaginal or perineal pain not controlled by usual measures; tachycardia, hypotension. Vaginal hematomas cannot be seen; she reports heaviness or fullness in the vagina or rectal pressure. Perineal hematomas show swelling, discoloration and tenderness
• Medical: small ones are monitored; large ones are incised, evacuated and the vessel ligated, with immediate pain relief
• Nursing: ice to the perineum for the first 24 hours to prevent; pain scale; ask about pressure or fullness when pain increases; watch BP and pulse; analgesia; review H&H; notify the provider

H. Subinvolution

• Uterus fails to shrink and descend; usually later in the postpartum period
• Causes: fibroids, endometritis, retained placental tissue
• Findings: soft uterus larger than expected for the day; lochia returns to rubra and may be heavy; back pain
• Medical: ultrasound; D&C for retained tissue; oral Methergine for fibroids; antibiotics for endometritis
• Nursing: patient education is the primary action because bleeding usually happens after discharge (report increased bleeding, clots, return to bright red); infection prevention; women with fibroids go home on oral Methergine

I. Retained placental tissue

• Primary cause of SECONDARY PPH; cotyledons remain attached after the third stage; manual removal of the placenta raises the risk
• Interferes with involution; may lead to endometritis
• Findings: profuse bleeding that starts suddenly after the first week; subinvolution; fever and uterine tenderness if endometritis; pallor (light skin) or blue discoloration of skin or mucous membranes (dark skin); tachycardia; hypotension
• Medical: D&C; IV antibiotics
• Nursing: education is primary; report a sudden increase in lochia, bright red bleeding, fever or uterine tenderness

J. Nursing care after a PPH

• Follow the staging protocol
• Fundus and lochia every hour for 4 hours, then PRN
• Teach fundal checks, massage and signs of PPH
• Increase oral and IV fluids; prevent bladder distention
• Assist with ambulation (orthostatic hypotension); expect fatigue; protect rest
• Let the woman and family talk about the experience
• Iron-rich diet; review H&H and report abnormal results

III. Coagulation Complications

A. Disseminated intravascular coagulation (DIC)

• Coagulation pathways are overstimulated; clotting factors are consumed faster than they can be made, leading to hemorrhage and death
• Four obstetric types: asymptomatic; bleeding (fibrinolysis dominant); massive bleeding (both); organ failure (hypercoagulation dominant)
• Predisposing conditions: placental abruption (most frequent cause of death from DIC); preeclampsia with severe features or eclampsia; HELLP; amniotic fluid embolism; massive hemorrhage; sepsis; retained fetal demise or demise of a twin
• Findings: prolonged uncontrolled uterine bleeding; bleeding from IV sites, incisions, gums and bladder; purpura at pressure sites such as the BP cuff; low platelets and abnormal clotting studies; anxiety; shock
• Medical: labs (fibrinogen, PT, PTT, platelets); treat the cause; IV fluids, blood, platelets, FFP, cryoprecipitate, oxygen; transfer to ICU with a perinatologist
• Nursing: review risk factors; VS and urine output hourly for renal perfusion; treat PPH early; report rising HR, falling BP or respiratory changes; large-bore IV; fluids, oxygen, labs, transfusion; support; facilitate ICU transfer

B. Anaphylactoid syndrome of pregnancy (amniotic fluid embolism, AFE)

• Rare, often fatal; in pregnancy, labor and birth, or the first 24 hours after birth
• Now thought to be an abnormal systemic inflammatory response rather than simple amniotic debris in the circulation
• Classic picture: hypoxia from acute lung injury, transient pulmonary hypertension, hypotension, cardiac arrest, coagulopathy
• Suspect with sudden dyspnea, hypotension, cyanosis, coagulopathy, severe hypoxemic respiratory failure, or cardiopulmonary arrest during or right after birth
• Medical: supportive; oxygen or mechanical ventilation; CBC, platelets, ABG, fibrinogen, PT; type and screen; chest x-ray; blood and platelets; ICU; possibly heart-lung bypass
• Nursing: notify the physician immediately; two large-bore IVs (one for fluids, one for blood); targets: SBP at least 90, urine output at least 30 mL/hr, SaO2 at least 90%, PaO2 at least 60 mm Hg; correct coagulopathy; call a code and start CPR when indicated; ICU transfer

C. Venous thromboembolism (VTE)

• DVT: clot in a deep vein, usually the leg. PE: a DVT clot breaks free and blocks pulmonary blood flow. Thigh clots embolize more than lower-leg clots
• Pregnancy raises VTE risk about five times (hypercoagulability, venous stasis, vena cava and pelvic vein compression); about 80% of pregnancy thromboembolic events are venous; PE and VTE cause 1.1 deaths per 100,000 deliveries (9.2% of pregnancy-related deaths)
• Risk is highest antepartum but extends through 12 weeks postpartum, dropping significantly by 6 weeks
• Other risk factors: prior VTE, thrombophilia, obesity, cancer, smoking, immobility, trauma, infection, diabetes, heart disease, hypertension, renal disease, sickle cell disease
• DVT signs: dependent edema, abrupt unilateral leg pain, erythema, low-grade fever, positive Homans sign (pain on dorsiflexion)
• PE signs: shortness of breath, tachypnea, tachycardia, dyspnea, pleuritic chest pain, fever, anxiety
• Diagnosis: DVT by Doppler ultrasound, MR venography, pulsed Doppler; PE by chest x-ray, CT and ECG
• Treatment: IV heparin titrated to PTT 1.5 to 2.5 times control for at least 5 to 7 days, then subcutaneous heparin; LMWH is safe in pregnancy (less bleeding, thrombocytopenia and osteoporosis; minimal in breast milk; does not cross the placenta). PE: stabilize, ICU, thrombolytics or embolectomy

Nursing actions for thrombophlebitis:

• Supportive bandage or antiembolism stockings; warm packs; slight elevation of the leg
• Serial calf circumferences: a difference over 2 cm = swelling
• VS every 4 hours (slight temperature rise possible); compare pulses
• Bedrest with leg elevation until swelling falls and anticoagulation works; then ambulate as soon as symptoms allow (bedrest increases stasis)
• IV heparin then oral warfarin; watch for bleeding (heavy lochia, petechiae, mucous membrane bleeding, hematuria, oozing IV sites); keep protamine sulfate (heparin antidote) available
• Teach subcutaneous heparin injection into the abdomen; report bleeding gums, nosebleeds, easy bruising
• Pain management; prepare for diagnostic tests

IV. Postpartum Infections

• About 6% of postpartum women; about 12.7% of maternal deaths
• Common sites: uterus, bladder, breast, incision
• Risk factors: history of cesarean (most important), premature rupture of membranes, frequent cervical exams (use sterile gloves), internal fetal monitoring, preexisting pelvic infection including bacterial vaginosis, diabetes, poor nutrition, obesity
• Complications: abscess, cellulitis, thrombophlebitis, scarring, infertility, sepsis, septic shock, death

A. Endometritis (metritis)

• Infection of the endometrium, myometrium or parametrial tissue; usually starts at the placental site
• MOST COMMON cause of postpartum fever; about 2% after vaginal birth and 15% after cesarean
• Risk: cesarean (primary), prolonged labor or rupture of membranes, internal monitoring or amnioinfusion, poor nutrition, smoking, anemia, multiple cervical exams, pyelonephritis, diabetes
• Findings: temperature over 100.4 F (38 C) with or without chills, usually around postpartum day 3 (the most important finding); midline lower abdominal pain; uterine tenderness extending laterally; tachycardia (about 10 bpm per degree C); subinvolution; malaise, headache
• Lochia: heavy and foul-smelling with anaerobes (a later sign); scant and odorless with beta-hemolytic strep
• Labs: WBC over 20,000/mm3 with increased neutrophils; endometrial and blood cultures (blood cultures positive in only about 10%); urinalysis to rule out UTI
• Treatment: mild cases oral antibiotics; moderate to severe cases IV broad-spectrum antibiotics, commonly clindamycin plus gentamicin, adding ampicillin if refractory. Improvement expected within 48 to 72 hours. Continue IV until afebrile for 24 to 48 hours (text gives both)
• Complications: pelvic abscess, septic pelvic thrombophlebitis, persistent fever, retained infected placenta

Nursing actions:

• Prevention: hand hygiene; wipe front to back; change pads every 3 to 4 hours; early ambulation (promotes uterine drainage); fluids (at least 3,000 mL/day for prevention); diet high in protein and vitamin C
• Care: fluids (2,000 mL); calories 1,800 to 2,000 if lactating, 1,500 if not; output at least 30 mL/hr (antibiotic renal toxicity); VS every 4 hours, every 2 hours if febrile; semi-Fowler position and ambulation for drainage; oxytocics as ordered; comfort and hygiene; pain control
• Watch for septic shock: HR over 120, hypotension, tachypnea, altered sensorium, oliguria

B. Urinary tract infection

• Causes: catheterization, birth trauma to the urethra and bladder, loss of bladder tone, retention and stasis, epidural, vaginal procedures. Organisms: bowel flora (E. coli, Klebsiella, Proteus, Enterobacter)
• Risk: epidural (no urge to void), overdistended or incompletely emptied bladder, operative vaginal birth (urethral edema), vaginal exams, catheter, genital tract injury, cesarean
• Findings: low-grade fever (101.3 F, 38.5 C), burning, suprapubic pain, urgency, small frequent voids under 150 mL
• Medical: UA, CBC, culture and sensitivity; oral antibiotics started before culture results
• Nursing: void within a few hours of birth; catheterize if unable to void within 2 to 3 hours; remind to void every 3 to 4 hours (may not feel the urge for 24 to 48 hours); measure voids for 24 hours (each at least 150 mL); change pads every 3 to 4 hours; at least 2,000 mL/day, mostly water; acidifying foods (cranberry juice, apricots, plums); teach to finish antibiotics, wipe front to back, wear cotton underwear, and report signs of pyelonephritis

C. Mastitis

• Inflammation or infection of breast tissue in lactating women; usually ONE breast, most often the upper outer quadrant
• Usually in the first 3 to 6 months of breastfeeding (Ch. 12: typically 3 to 4 weeks); 2% to 10% of women in the first 3 months
• Most common organism: Staphylococcus aureus, usually from the infant’s mouth or throat
• Self-limiting; continued breastfeeding helps clear it and does NOT harm the baby; resolves 24 to 48 hours after antibiotics start; abscess in about 10%
• Contributing factors: prior mastitis or plugged duct, cracked or sore nipples, oversupply, infrequent or missed feedings, using only one feeding position, tight bra, rapid weaning
• Findings: tender warm breast; malaise or muscle aches; swelling and hardness; pain or burning; wedge-shaped redness; fever of 101 F (38.3 C) or higher
• Medical: oral antibiotics for 10 to 14 days; culture expressed milk if not resolving
• Nursing: teach correct latch and removal, several feeding positions, air-drying nipples, emptying both breasts fully, not missing feeds, hand washing, a larger bra, massage over tender areas and the axilla; warm (or cold) compresses; analgesics; keep breastfeeding or pumping the affected breast; reassure that it is common and easily treated

D. Wound infections

• Sites: laceration, episiotomy, cesarean incision. Organisms: staph, strep, gram-negatives
• Risk: obesity, diabetes, malnutrition, long labor, long cesarean, premature rupture of membranes, chorioamnionitis, immunodeficiency, corticosteroids, poor suturing
• Findings: erythema, swelling, tenderness, purulent drainage, low-grade fever, increased pain
• Medical: culture if indicated; no purulent drainage: oral antibiotics and warm compresses; purulent drainage: open and drain, IV antibiotics
• Nursing: REEDA assessment; report abnormal findings; cultures; antibiotics; analgesia; hot packs for abdominal wounds or sitz baths for perineal wounds; hand hygiene; diet with protein, fluids, rest

V. Cardiovascular and Metabolic Conditions

A. Acute-onset severe hypertension postpartum

• Severe: systolic 160 or higher and/or diastolic 110 or higher; needs urgent treatment within 30 to 60 minutes of confirmation to prevent stroke, seizure and death
• First-line: IV labetalol, IV hydralazine; immediate-release oral nifedipine, especially if no IV access
• BP every 5 to 15 minutes per protocol; none of these drugs requires cardiac monitoring
• Adverse effects: hydralazine can cause maternal hypotension (SBP 90 or less); labetalol can cause neonatal bradycardia and is avoided with asthma, heart disease or heart failure; nifedipine can raise maternal HR and cause overshoot hypotension
• Teach that symptoms can occur up to 6 weeks postpartum: stomach pain, severe headache, nausea, swelling of hands and face, seeing spots, shortness of breath
• BP check 3 to 10 days after discharge (ACOG; also stated as no later than 7 to 10 days)

B. Diabetes postpartum

• Hyperglycemia affects 7% to 18% of pregnancies
• Pregestational diabetes: insulin needs drop right after birth; resume subcutaneous insulin at prepregnancy doses with oral intake. Watch closely for mastitis, endometritis and wound infection. Breastfeeding strongly encouraged
• Gestational diabetes: most return to normal, but up to one-third have diabetes or impaired glucose metabolism at postpartum screening; 15% to 50% develop type 2 later. Screen at 6 to 12 weeks postpartum. Sevenfold higher risk of type 2 diabetes; high risk of GDM in future pregnancies
• Nursing: counsel on weight loss and exercise; identify barriers and supports; link to dietitians and primary care; follow-up 2 to 6 weeks after discharge with the diabetes provider (Medicaid often ends at 6 weeks)

C. Maternal obesity (BMI 30 or higher)

• Higher risk of infection, wound complications, GDM, hypertension, sleep apnea, preeclampsia, thrombosis, early end of breastfeeding, anemia, depression; 46% gain more than recommended
• Consider pharmacological VTE prophylaxis plus pneumatic compression in very high-risk patients
• Nursing: turn her to the side to assess fundus and lochia accurately; teach about future risks (type 2 diabetes, DVT, chronic hypertension); refer for diet and exercise counseling before another pregnancy (diet plus exercise beats exercise alone); football hold and rolled towels under the breast for breastfeeding; sleep sitting up; equipment rated for at least 400 lb

D. Follow-up after complications

• Comprehensive visit within 6 weeks (usually 4 to 6 weeks); earlier (3 to 10 days) for high-risk conditions; BP check within 7 to 10 days (some say 3 to 5) for hypertensive disorders
• Up to 1 in 4 women had no phone number to call with concerns; give contact information and written follow-up timing
• Counsel that GDM, hypertensive disorders and preterm birth raise lifetime cardiometabolic risk
• Call the provider for: fever; foul lochia; clots golf-ball size or larger or a pad soaked in 1 hour; incision discharge, redness or severe pain; hot, red, painful breasts or legs; nipple bleeding or severe pain; severe headache or blurred vision; chest pain or dyspnea at rest; frequent painful urination; signs of depression
• POST-BIRTH warning signs (AWHONN): Pain in chest; Obstructed breathing; Seizures; Thoughts of hurting yourself or someone else; Bleeding (a pad an hour or egg-size clots); Incision not healing; Red or swollen leg that is painful or warm; Temperature 100.4 F or higher; Headache that does not improve or with vision changes

VI. Postpartum Psychological Complications

• Childbirth is one of the most powerful triggers of psychiatric illness in a woman’s life
• About 15% of women have a major mood disorder that affects their ability to care for themselves or the infant; PMADs can occur any time in the first year
• Maternal suicide is the LEADING cause of death in pregnancy and the year after delivery, exceeding hemorrhage and hypertension
• Fewer than 20% of women later diagnosed with PPD reported symptoms to a provider; ask every woman about her mood
• The nurse’s primary role: assess for early signs and report to the provider
• Box 14-4, maternal mental health safety bundle: screening tools in every setting; mental health history at intake; validated screening in pregnancy and postpartum; stage-based response to positive screens; emergency referral for suicidal or homicidal ideation or psychosis; follow-up on referrals

Table 14-2:

A. Postpartum depression (PPD)

• DSM-5: major depressive disorder with peripartum onset
• 10% to 20% have depression or anxiety in pregnancy or postpartum (the most common complication of childbirth); PPD affects about 11.5%; higher in lesbian and bisexual women
• Onset within 6 to 12 months
• Diagnosis: depressed mood or loss of interest for at least 2 weeks plus four of: weight change over 5% in a month; insomnia or hypersomnia; psychomotor agitation or slowing; fatigue; worthlessness or guilt; poor concentration or indecision; decreased interest in activities
• Risk factors: depression before pregnancy, depression or anxiety during pregnancy, poor social support, poor partner relationship, life and childcare stress, pregnancy or birth complications, little support from her mother, low socioeconomic status, childhood sexual abuse, intimate partner violence
• Findings: sleep and appetite changes; more fatigue than expected; despondency; uncontrolled crying; anxiety, fear or panic; poor concentration; guilt or worthlessness; unable to care for self or baby; less affection and responsiveness toward the infant; thoughts of harming the baby or suicide
• Management: mild, interpersonal psychotherapy; moderate, psychotherapy plus antidepressants; severe or suicidal, intensive psychiatric care, crisis intervention, psychotherapy, antidepressants, ECT. Best evidence: antidepressants and telecommunication therapy
• Nursing: review history; watch mother-infant interaction in at-risk women; teach the woman and partner the signs to report; support groups and resources (postpartum.net); professional support can reduce onset; complementary options (massage, exercise, acupuncture) for those avoiding drugs; teach that a non-birth mother or partner can also become depressed

B. Postpartum psychosis

• DSM-5: brief psychotic disorder with peripartum onset; rare (0.1 to 2.6 per 1,000 births)
• Rapid onset, as early as 2 to 3 days after birth, so nurses may spot it before discharge
• Highest risk: preexisting bipolar disorder; personal or family history of bipolar or affective disorder
• Diagnosis: one or more of delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior
• Findings: paranoia; grandiose or bizarre delusions usually about the baby; mood swings; extreme agitation; depressed or elated mood; confusion; strange beliefs such as that she or the baby must die; disorganized behavior
• PSYCHIATRIC EMERGENCY: risk of suicide and infanticide; needs immediate care and inpatient psychiatric admission; antipsychotics, antidepressants, psychotherapy, ECT
• Nursing: review history for bipolar or affective disorder; teach the family early signs (mood swings, hallucinations, strange beliefs) and to call immediately

C. Paternal (partner) postnatal depression (PPND)

• 1% to 8% of fathers in the first 6 months; also seen in non-birth mothers and partners
• Falling testosterone and rising estrogen in new fathers are linked with depression
• Primary risk factor: maternal PPD. Others: depression during the pregnancy, unplanned pregnancy, infant health or feeding problems, poor support, stress about fatherhood, preexisting mental illness, stressful life events
• Less obvious than maternal PPD: avoidance (time away from family), withdrawal, cynicism, irritability; affect may look anxious or angry rather than sad; overwhelmed, frustrated, indecisive; increased alcohol or drug use; domestic violence
• Treatment: interpersonal psychotherapy, antidepressants; stress that untreated PPND harms the child long term

High-Yield Numbers

• PPH: over 500 mL vaginal or over 1,000 mL cesarean (traditional); ACOG 1,000 mL or more or any loss with hypovolemia within 24 hours
• 10% drop in Hgb or Hct; pad saturated in 15 minutes
• Primary PPH under 24 hours; secondary 24 hours to 6 weeks
• 1 g = 1 mL; EBL underestimates by up to 50%
• Shock signs hidden until 10% to 30% of volume lost; pulse pressure 30 mm Hg or less is an early clue
• 2,500 mL loss = 40% of volume
• IVs 14 to 18 gauge, two sites; crystalloid 3:1, colloid 1:1; goal urine at least 30 mL/hr and Hct 30%
• 1 unit PRBCs (240 mL) raises Hct 3 points and Hgb 1 g/dL
• Massive transfusion 6:4:1 (PRBC:FFP:platelets); 2 to 4 units O-negative emergency release
• Oxygen 10 to 12 L/min nonrebreather; legs up 20 to 30 degrees
• Hematoma over 3 cm: likely excision and ligation
• AFE targets: SBP 90 or more, urine 30 mL/hr or more, SaO2 90% or more, PaO2 60 or more
• Heparin PTT 1.5 to 2.5 times control for at least 5 to 7 days
• Calf circumference difference over 2 cm = swelling
• VTE risk 5 times nonpregnant; lasts to 12 weeks postpartum
• Endometritis: 2% vaginal, 15% cesarean; fever around day 3; WBC over 20,000
• UTI: low-grade fever 101.3 F (38.5 C); voids under 150 mL
• Mastitis: fever 101 F (38.3 C) or higher; antibiotics 10 to 14 days; abscess 10%
• Severe hypertension: 160 systolic or 110 diastolic; treat within 30 to 60 minutes
• GDM: screen 6 to 12 weeks; sevenfold type 2 risk
• PPD: 10% to 20% depression or anxiety; PPD about 11.5%; symptoms at least 2 weeks plus 4 criteria
• Psychosis: onset as early as 2 to 3 days
• PPND: 1% to 8% of fathers

Priority Nursing Actions and Red Flags

• Boggy uterus: massage first, then bladder, then uterotonics and notify
• Heavy bright red bleeding with a FIRM fundus: laceration
• Severe perineal or rectal pain or pressure out of proportion, with tachycardia: hematoma; do not just give more analgesia, assess and notify
• Tachycardia is the early warning; hypotension is late. Normal BP does not rule out hemorrhage
• Stage 2 hemorrhage: get blood without waiting for labs
• Bleeding from IV sites, gums or the BP cuff site: DIC; notify immediately
• Sudden dyspnea, hypotension, cyanosis or arrest during or right after birth: AFE; call a code
• Unilateral calf pain, swelling, warmth: DVT; sudden dyspnea, chest pain, tachycardia: PE
• On heparin: watch for bleeding; protamine sulfate is the antidote
• Fever around day 3 with uterine tenderness, especially after cesarean: endometritis
• Mastitis: keep breastfeeding
• Methylergonovine is contraindicated with hypertension; check BP first
• SBP 160 or DBP 110 or higher: treat within 30 to 60 minutes
• Delusions or hallucinations about the baby: psychiatric emergency (infanticide and suicide risk); do not leave the infant alone with her
• Thoughts of harming self or baby: emergency referral

Medications

Related

• nsg210-durham-ch12-postpartum-care
• nsg210-durham-ch13-transition-to-parenthood
• nsg210-exam-2-outline-durham-ch07 (preeclampsia, VTE bundle)
• nsg210-exam-2-labor-birth-study-sheet (high-risk labor, cesarean)
• nsg210-hinkle-ch26-vascular-disorders (DVT and PE in med-surg)
• INDEX