Postpartum Complications. Mosby items and derived items © 2006, 2002 by Mosby, Inc. 2 of 34...

Postpartum ComplicationsPostpartum Complications

Mosby items and derived items © 2006, 2002 by Mosby, Inc. 2 of 34

Postpartum Infections

Endometritis – malodorous lochia, fever (100.6), chills, abdominal pain, uterine tenderness,

tachycardia and subinvolution

The infection may spread to cause peritonitis and septic pelvic thrombophlebitis

Treat with IV antibiotics

Emotional support

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Postpartum InfectionsPostpartum Infections

Puerperal sepsis: any infection of genital Puerperal sepsis: any infection of genital canal within 28 days after abortion or birthcanal within 28 days after abortion or birth

Most common infecting agents are Most common infecting agents are numerous streptococcal and anaerobic numerous streptococcal and anaerobic organismsorganisms

EndometritisEndometritis

Wound infectionsWound infections

Urinary tract infectionsUrinary tract infections

MastitisMastitis

Complications of Puerperium

Fever

UTI/Pyelonephritis

DVT/Thrombophlebitis

“Milk fever” (Lasts < 24 hours)

Drug reaction

Perineal infection(Day five)

Pulmonary Atelectasis (48 hours)

Mastitis (2-3 weeks post partum)

Postpartum InfectionsPostpartum Infections EndometritisEndometritis

Postpartum Endometritis

Infection of the decidua (pregnancy endometrium)

Incidence

<3% after vaginal delivery

10-50% after cesarean delivery

• 5-15% after scheduled elective cesareans

Risk Factors

Prolonged labor, prolonged ROM, multiple vaginal exams, internal monitors, maternal DM, meconium, manual removal of placenta, low socioeconomic status

PP Endometritis

Polymicrobial, ascending infection

Mixture of aerobes and anaerobes from genital tract

BV and colonization with GBS increase likelihood of infection

Clinical manifestations (occur within 5 days pp)

Fever – most common sign

Uterine tenderness

Foul lochia

Leukocytosis

Bacteremia – in 10-20%, usually a single organism

PP Endometritis

Workup

CBC

Blood cultures

Urine culture

DNA probe for GC/chlamydia

Imaging studies if no response to adequate abx in 48-72h

• CT scan abd/pelvis

• US abd/pelvis

PP Endometritis

Treatment

Broad spectrum IV abx

• Clindamycin 900mg IV q8h and

• Gentamicin 1.5mg/kg IV q8h

Treat until afebrile for 24-48h and clinically improved; oral therapy not necessary

Add ampicillin 2g IV q4h to regimen when not improving to cover resistant enterococci

Prevention

Abx prophylaxis for women undergoing C-section

• Cefazolin 1-2g IV as single dose

Mosby items and derived items © 2006, 2002 by Mosby, Inc. 10 of 34

Postpartum Infections

Mastitis - A breast infection occurring 1-2 weeks after childbirth

Engorgement and blocked mild duct increases risk

Fever, localized breast pain, redness,warmth and inflammation

Breastfeeding should continue

Antibiotics

Nurse's role is to support, educate and refer

Mastitis Infection of the lactating breast- 2nd or 3rd

week after birth

Caused by S. aureus, often on hands of mother or caregivers

Can enter through a crack in the nipple

Engorgement & stasis of milk frequently precede mastitis

Mastitis Continued

SIGNS & SYMPTOMS:

Feels like the flu with fatigue & aching muscles

Fever of 101.1F

Localized area of redness & inflammation

THERAPEUTIC MANAGEMENT

ATB & decompression of breast by breastfeeding or pumping

Bedrest during acute phase

Fluids & analgesics for discomfort

    Puerperal Mastitis usually caused by common skin bacteria particularly staphylococcus being introduced into the ductal system through

Postpartum InfectionsPostpartum InfectionsMastitisMastitis

Breast infections may cause pain, redness, warmth of the breast along with the following

symptoms: Tenderness and swelling Body aches Fatigue Breast engorgement Fever and chills Rigor or shaking

Postpartum InfectionsPostpartum InfectionsMastitisMastitis

Most breast infections occur in breastfeeding women when bacteria enters the breast through cracks in the nipple. In severe infections, abscesses may occur. Antibiotics may be indicated for treatment.

Postpartum InfectionsPostpartum InfectionsMastitisMastitis

Postpartum InfectionsPostpartum InfectionsMastitisMastitis

Postpartum InfectionsPostpartum InfectionsMastitisMastitis

Postpartum Infections Postpartum Infections Care ManagementCare Management

Prevention is the best interventionPrevention is the best intervention

Hand washingHand washing

Good maternal perineal hygieneGood maternal perineal hygiene

Antibiotic administrationAntibiotic administration

Wound managementWound management

Breast careBreast care

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Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma

Disorders of uterus and vagina related to Disorders of uterus and vagina related to pelvic relaxation and urinary incontinence, pelvic relaxation and urinary incontinence, are often result of childbearing are often result of childbearing

Uterine displacement and prolapseUterine displacement and prolapse

Posterior displacement, or retroversionPosterior displacement, or retroversion

Retroflexion and anteflexionRetroflexion and anteflexion

Prolapse a more serious displacementProlapse a more serious displacement

• Cervix and body of uterus protrude through vagina Cervix and body of uterus protrude through vagina and vagina is inverted and vagina is inverted

Uterine prolapse occurs when the uterus falls through the cervix (the connection between the uterus and the vagina) into the vagina. Symptoms and treatment depends on how much of the uterus has fallen into the vagina.

Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma Uterine prolapseUterine prolapse

Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma Uterine prolapseUterine prolapse

Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma Uterine prolapseUterine prolapse

Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma Uterine prolapseUterine prolapse

Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma Uterine prolapseUterine prolapse

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Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma

Cystocele and rectoceleCystocele and rectocele

Cystocele: protrusion of bladder downward Cystocele: protrusion of bladder downward into vagina when support structures in into vagina when support structures in vesicovaginal septum are injuredvesicovaginal septum are injured

Rectocele is herniation of anterior rectal wall Rectocele is herniation of anterior rectal wall through relaxed or ruptured vaginal fascia and through relaxed or ruptured vaginal fascia and rectovaginal septum rectovaginal septum

Urinary incontinenceUrinary incontinence

Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma Cystocele and rectoceleCystocele and rectocele

Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma Cystocele and rectoceleCystocele and rectocele

Sequelae of Sequelae of Childbirth Trauma Childbirth Trauma

Cystocele and Cystocele and rectocelerectocele

Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma Cystocele and rectoceleCystocele and rectocele

Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma Cystocele and rectoceleCystocele and rectocele

Sequelae of Childbirth Trauma Sequelae of Childbirth Trauma Cystocele and rectoceleCystocele and rectocele

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Sequelae of Childbirth TraumaSequelae of Childbirth Trauma

Genital fistulasGenital fistulas

May result from congenital anomaly, May result from congenital anomaly, gynecologic surgery, obstetric trauma, cancer, gynecologic surgery, obstetric trauma, cancer, radiation therapy, gynecologic trauma, or radiation therapy, gynecologic trauma, or infectioninfection

• Vesicovaginal: between bladder and genital tractVesicovaginal: between bladder and genital tract

• Urethrovaginal: between urethra and vaginaUrethrovaginal: between urethra and vagina

• Rectovaginal: between rectum or sigmoid colon and Rectovaginal: between rectum or sigmoid colon and vaginavagina

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Types of Fistulas That May Develop Types of Fistulas That May Develop in Vagina, Uterus, and Rectumin Vagina, Uterus, and Rectum

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Postpartum Psychologic ComplicationsPostpartum Psychologic Complications

Mental health disorders in postpartum Mental health disorders in postpartum period have implications for mother, period have implications for mother, newborn, and entire familynewborn, and entire family

Interfere with attachment to newborn and Interfere with attachment to newborn and family integrationfamily integration

May threaten safety and well-being of mother, May threaten safety and well-being of mother, newborn, and other childrennewborn, and other children

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Postpartum Psychologic ComplicationsPostpartum Psychologic Complications

Postpartum depression without psychotic Postpartum depression without psychotic featuresfeatures

PPD: an intense and pervasive sadness with PPD: an intense and pervasive sadness with severe and labile mood swings severe and labile mood swings

Treatment options Treatment options

• Antidepressants, anxiolytic agents, and Antidepressants, anxiolytic agents, and electroconvulsive therapyelectroconvulsive therapy

• Psychotherapy focuses fears and concerns of new Psychotherapy focuses fears and concerns of new responsibilities and roles, and monitoring for responsibilities and roles, and monitoring for suicidal or homicidal thoughts suicidal or homicidal thoughts

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Postpartum Psychologic ComplicationsPostpartum Psychologic Complications

Postpartum depression with psychotic Postpartum depression with psychotic featuresfeatures

Postpartum psychosis: syndrome Postpartum psychosis: syndrome characterized by depression, delusions, and characterized by depression, delusions, and thoughts of harming either infant or herself thoughts of harming either infant or herself

Psychiatric emergency, and may require Psychiatric emergency, and may require psychiatric hospitalizationpsychiatric hospitalization

Antipsychotics and mood stabilizers such as Antipsychotics and mood stabilizers such as lithium are treatments of choicelithium are treatments of choice

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Loss and Grief Loss and Grief

Losses of what was hoped for, dreamed Losses of what was hoped for, dreamed about, and/or plannedabout, and/or planned

Any perception of loss of control during Any perception of loss of control during the birthing experiencethe birthing experience

Birth of a child with handicap Birth of a child with handicap

Maternal deathMaternal death

Fetal or neonatal deathFetal or neonatal death

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Loss and Grief Loss and Grief

Conceptual model of parental griefConceptual model of parental grief

Acute distressAcute distress

Intense griefIntense grief

ReorganizationReorganization

Anticipatory griefAnticipatory grief

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Loss and Grief Loss and Grief

Plan of care and implementationPlan of care and implementation

Communicating and care techniquesCommunicating and care techniques

• Actualize the lossActualize the loss

• Provide time to grieveProvide time to grieve

• Interpret normal feelingsInterpret normal feelings

• Allow for individual differencesAllow for individual differences

• Cultural and spiritual needs of parentsCultural and spiritual needs of parents

• Physical comfortPhysical comfort

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Loss and Grief Loss and Grief

Plan of care and implementationPlan of care and implementation

Options for parentsOptions for parents

• Seeing and holdingSeeing and holding

• Bathing and dressingBathing and dressing

• PrivacyPrivacy

• Visitations: other family members or friendsVisitations: other family members or friends

• Religious rituals/funeral arrangementsReligious rituals/funeral arrangements

• Special memoriesSpecial memories

• PicturesPictures

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Maternal DeathMaternal Death

Rare for woman to die in childbirth Rare for woman to die in childbirth

Families are at risk for developing Families are at risk for developing complicated bereavement and altered complicated bereavement and altered parenting of surviving baby and other parenting of surviving baby and other children in family children in family

Referral to social services can help Referral to social services can help combat potential problems before they combat potential problems before they developdevelop

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Key Points Key Points

Postpartum hemorrhage is most common Postpartum hemorrhage is most common and serious type of excessive obstetric and serious type of excessive obstetric blood lossblood loss

Hemorrhagic (hypovolemic) shock is an Hemorrhagic (hypovolemic) shock is an emergency situation; the perfusion of emergency situation; the perfusion of body organs may become severely body organs may become severely compromised and death may ensuecompromised and death may ensue

Potential hazards of therapeutic Potential hazards of therapeutic interventions may further compromise the interventions may further compromise the woman with hemorrhagic disorderswoman with hemorrhagic disorders

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Key Points Key Points

Postpartum infection is a major cause of Postpartum infection is a major cause of maternal morbidity and mortalitymaternal morbidity and mortality

Postpartum urinary tract infections are Postpartum urinary tract infections are common because of trauma experienced common because of trauma experienced during laborduring labor

Breast infection affects about 1% of Breast infection affects about 1% of women soon after childbirthwomen soon after childbirth

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Key Points Key Points

Structural disorders of uterus and vagina Structural disorders of uterus and vagina related to pelvic relaxation are often the related to pelvic relaxation are often the delayed but direct result of childbearingdelayed but direct result of childbearing

Understanding of grief responses and Understanding of grief responses and bereavement process is fundamental to bereavement process is fundamental to the nursing processthe nursing process

Therapeutic communication and Therapeutic communication and counseling techniques can help families in counseling techniques can help families in identifying their feelings and in feeling identifying their feelings and in feeling comfortable in expressing their griefcomfortable in expressing their grief

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Key Points Key Points

Follow-up after discharge is an essential Follow-up after discharge is an essential component in providing care to families component in providing care to families who have experienced a losswho have experienced a loss

Nurses need to be aware of their own Nurses need to be aware of their own feelings of grief and loss to provide a feelings of grief and loss to provide a nonjudgmental environment of care and nonjudgmental environment of care and support for bereaved familiessupport for bereaved families