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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