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Postpartum Complications 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 Mosby items and derived items © 2006, 2002 by Mosby, Inc. 2 of 34 Postpartum Infections Puerperal sepsis: any infection of genital canal within 28 days after abortion or birth Most common infecting agents are numerous streptococcal and anaerobic organisms Endometritis Wound infections Urinary tract infections Mastitis 3 of 34 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 Infections Endometritis 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 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 Mosby items and derived items © 2006, 2002 by Mosby, Inc. 10 of 34 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 Postpartum Infections Mastitis Puerperal Mastitis usually caused by common skin bacteria particularly staphylococcus being introduced into the ductal system through Postpartum Infections Mastitis 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 Infections Mastitis 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 Infections Mastitis Postpartum Infections Mastitis Postpartum Infections Care Management Prevention is the best intervention Hand washing Good maternal perineal hygiene Antibiotic administration Wound management Breast care 18 of 34 Sequelae of Childbirth Trauma Disorders of uterus and vagina related to pelvic relaxation and urinary incontinence, are often result of childbearing Uterine displacement and prolapse Posterior displacement, or retroversion Retroflexion and anteflexion Prolapse a more serious displacement • Cervix and body of uterus protrude through vagina and vagina is inverted 19 of 34 Sequelae of Childbirth Trauma Uterine prolapse 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 Uterine prolapse Sequelae of Childbirth Trauma Uterine prolapse Sequelae of Childbirth Trauma Uterine prolapse Sequelae of Childbirth Trauma Uterine prolapse Sequelae of Childbirth Trauma Cystocele and rectocele Cystocele: protrusion of bladder downward into vagina when support structures in vesicovaginal septum are injured Rectocele is herniation of anterior rectal wall through relaxed or ruptured vaginal fascia and rectovaginal septum Urinary incontinence 25 of 34 Sequelae of Childbirth Trauma Cystocele and rectocele Sequelae of Childbirth Trauma Cystocele and rectocele Sequelae of Childbirth Trauma Cystocele and rectocele Sequelae of Childbirth Trauma Cystocele and rectocele Sequelae of Childbirth Trauma Cystocele and rectocele Sequelae of Childbirth Trauma Cystocele and rectocele Sequelae of Childbirth Trauma Genital fistulas May result from congenital anomaly, gynecologic surgery, obstetric trauma, cancer, radiation therapy, gynecologic trauma, or infection • Vesicovaginal: between bladder and genital tract • Urethrovaginal: between urethra and vagina • Rectovaginal: between rectum or sigmoid colon and vagina 32 of 34 Types of Fistulas That May Develop in Vagina, Uterus, and Rectum 33 of 34 Postpartum Psychologic Complications Mental health disorders in postpartum period have implications for mother, newborn, and entire family Interfere with attachment to newborn and family integration May threaten safety and well-being of mother, newborn, and other children 34 of 34 Postpartum Psychologic Complications Postpartum depression without psychotic features PPD: an intense and pervasive sadness with severe and labile mood swings Treatment options • Antidepressants, anxiolytic agents, and electroconvulsive therapy • Psychotherapy focuses fears and concerns of new responsibilities and roles, and monitoring for suicidal or homicidal thoughts 35 of 34 Postpartum Psychologic Complications Postpartum depression with psychotic features Postpartum psychosis: syndrome characterized by depression, delusions, and thoughts of harming either infant or herself Psychiatric emergency, and may require psychiatric hospitalization Antipsychotics and mood stabilizers such as lithium are treatments of choice 36 of 34 Loss and Grief Losses of what was hoped for, dreamed about, and/or planned Any perception of loss of control during the birthing experience Birth of a child with handicap Maternal death Fetal or neonatal death 37 of 34 Loss and Grief Conceptual model of parental grief Acute distress Intense grief Reorganization Anticipatory grief 38 of 34 Loss and Grief Plan of care and implementation Communicating and care techniques • Actualize the loss • Provide time to grieve • Interpret normal feelings • Allow for individual differences • Cultural and spiritual needs of parents • Physical comfort 39 of 34 Loss and Grief Plan of care and implementation Options for parents • Seeing and holding • Bathing and dressing • Privacy • Visitations: other family members or friends • Religious rituals/funeral arrangements • Special memories • Pictures 40 of 34 Maternal Death Rare for woman to die in childbirth Families are at risk for developing complicated bereavement and altered parenting of surviving baby and other children in family Referral to social services can help combat potential problems before they develop 41 of 34 Key Points Postpartum hemorrhage is most common and serious type of excessive obstetric blood loss Hemorrhagic (hypovolemic) shock is an emergency situation; the perfusion of body organs may become severely compromised and death may ensue Potential hazards of therapeutic interventions may further compromise the woman with hemorrhagic disorders 42 of 34 Key Points Postpartum infection is a major cause of maternal morbidity and mortality Postpartum urinary tract infections are common because of trauma experienced during labor Breast infection affects about 1% of women soon after childbirth 43 of 34 Key Points Structural disorders of uterus and vagina related to pelvic relaxation are often the delayed but direct result of childbearing Understanding of grief responses and bereavement process is fundamental to the nursing process Therapeutic communication and counseling techniques can help families in identifying their feelings and in feeling comfortable in expressing their grief 44 of 34 Key Points Follow-up after discharge is an essential component in providing care to families who have experienced a loss Nurses need to be aware of their own feelings of grief and loss to provide a nonjudgmental environment of care and support for bereaved families 45 of 34