Postpartum Conditions and Care

Importance of the Postpartum Period

• Postpartum period is a time of healing but still a time of altered health.
• Vigilance and attentive care are critical for nurses during this period.

Maternal Early Warning Criteria (Box 23.1)

• Designed to educate nurses on complications after delivery.
• Criteria include:
  • Maternal agitation, confusion, unresponsiveness.
  • Headache or shortness of breath in preeclampsia.
  • Systolic BP < 90 or > 160.
  • Diastolic BP > 100.
  • Heart rate < 50 or > 120.
  • Respiratory rate < 10 or > 30.
  • Oxygen saturation < 95%.
  • Oliguria (urine output < 35 ml/hr for 2+ hours).

Postpartum Hemorrhage

• Typical Blood Loss:
  • Vaginal birth: 500 ml
  • C-section: 1000 ml
• Definition: Bleeding > 1000 ml despite uterine massage and use of oxytocin.
• Timing:
  • Early hemorrhage: within 24 hours post-delivery.
  • Delayed hemorrhage: 24 hours to 12 weeks post-delivery.
• Causes:
  • Uterine atony, blood coagulopathies, trauma.
• Risk Factors (Box 23.2):
  • Retained placenta, large infants, induced labor, adherent placenta, prolonged labor stages, uterine overdistension/infection, high parity.
• Symptoms (Box 23.3):
  • Blood loss 500-1000 ml: Normal BP, palpitations, lightheadedness, mild heart rate increase.
  • Blood loss 1500 ml: Lower BP, weakness, diaphoresis, increased respiratory and heart rate.
  • Blood loss 1500-2000 ml: Systolic BP < 90, restlessness, confusion, pallor, oliguria, increased heart rate.
  • Blood loss 2000-3000 ml: BP < 90, pulse pressure < 25, lethargy, air hunger, anuria, heart rate > 140.

Treatment for Postpartum Hemorrhage

• Call for help immediately.
• Fundal massage on a boggy uterus.
• Assess for lacerations or hematoma.
• Bladder catheterization for inability to void.
• Establish IV access, possibly a second IV for severe cases.
• Administer oxytocin and possibly other uterotonics (methylergometrine, carboprost).
• Bimanual compression of the uterus (performed by physician).

Hypovolemic Shock

• Cause: Uncontrolled hemorrhage leading to underperfusion and underoxygenation of organs.
• Symptoms:
  • Hypotension, tachycardia, tachypnea, oliguria, mental status changes, cool/clammy skin, delayed capillary refill.
• Treatment:
  • Restore blood volume with IV fluids (normal saline, lactated Ringer’s).
  • Establish 18-gauge IV access.
  • Monitor urine output and vital signs.
  • Lab work for red blood cell count and DIC assessment.
  • Administer blood transfusions as ordered.

Postpartum Mood Disorders

• Categories:
  • Postpartum blues: Transient, self-limiting mood disorder, starts 2-3 days after delivery, resolves within 2 weeks.
  • Postpartum depression: Major depression, onset during pregnancy or first 4 weeks post-birth.
  • Postpartum psychosis: Rare disorder affecting reality perception, possible onset within 48 hours post-delivery.

Symptoms and Risk Factors

• Postpartum Blues: Insomnia, fatigue, dysphoria, impaired concentration.
• Postpartum Depression: Low mood for 2+ weeks, negative attitude towards infant, substance use, anxiety about infant care.
• Risk Factors (Box 23.4): Refer to textbook.
• Diagnostic Criteria: 5 of 9 criteria for major depressive disorder.
• Treatment: Medication and therapy (see Figure 23.5 on page 512).
• Postpartum Psychosis: Hallucinations, thought disorganization, delusions, requires inpatient psychiatric care for safety of patient and infant.