Chapter 23 is over conditions occurring after delivery. Patients often think of the postpartum period as low risk. It's a time of healing after an altered state of health.
As nurses, we should remember that the postpartum period is still a time of altered health and that vigilance and attentive care is critical. Please take a couple minutes to review your objectives for this chapter. This is box 23.1 in your textbook. It is Maternal Early Warning Criteria. This is criteria designed for nurses taking care of the postpartum patient.
So this is criteria designed to educate the nurse on patients who are started to have some type of complication after delivery. So hemorrhage or having problems with preeclampsia. The maternal early warning criteria include maternal agitation, confusion, unresponsiveness, report of headache or shortness of breath in a patient with preeclampsia, systolic blood pressures, and they're less than 90 or greater than 160, diastolic blood pressures that are greater than 100, heart rate that is less than 50 or greater than 120, respiratory rate of less than 10 or greater than 30, oxygen saturation on room air at sea level less than 95 percent, or oliguria for two or more hours of less than 35 mils per hour.
One of the first things I want to talk about as far as a complication or condition that occurs in the postpartum period is postpartum hemorrhage. Typical blood loss after a vaginal birth is 500 mils. After a c-section it is 1,000 mils.
A postpartum hemorrhage is bleeding of more than 1,000 mils despite uterine massage and first-line uterotonics such as oxytocin. Early postpartum hemorrhage occurs within the first 24 hours after delivery. Delayed or secondary postpartum hemorrhage occurs 24 hours up to 12 weeks after delivery.
After birth, the uterus normally maintains hemostasis, and it prevents postpartum hemorrhage by clotting and contraction of the myometrium of the uterus. Postpartum hemorrhage is often caused by uterine acne, blood coagulopathies, or trauma. Box 23.2 in your textbook is postpartum hemorrhage risk factors. So this talks about what puts the patient at risk for acne.
So retained placenta, failure to... progress in the second stage of labor, large for gestational age infants, induction of labor, an adherent placenta, so a placenta that's not wanting to release from that uterine wall, it's wanting to stay adhered to that uterus, prolonged first or second stage of labor, uterine over distension, uterine infection. or high parity, so having had five or more pregnancies with a gestational period of greater than or equal to 20 weeks.
Other causes can be from trauma or coagulopathies. Postpartum hemorrhage symptoms is in box 23.3 in your text. So loss of 500 to 1000 mils, your blood pressure should be normal. There may be some palpitations or lightheadedness.
There may be a little bit of a minimal increase in the heart rate. You're going to start seeing some more differences with this loss of 1500 mils. You're going to see a lower blood pressure. You're going to see weakness, diaphoresis. increased respiratory rate of 20 to 24 breaths per minute and a heart rate of 100 to 120 beats per minute so as the increase in loss of blood you start seeing more and more severe symptoms So with 15 to 2,000 ml blood loss, you're going to start seeing a systolic blood pressure of less than 90, restlessness, confusion, pallor, oliguria, delayed capillary refill, and an even more increased heart rate of 120 to 140. So with a blood loss of 2,000 to 3,000 ml, you're going to see a blood pressure of less than 90, a pulse pressure of less than 25. Delayed capillary refill, lethargy, air hunger, no urine production, so anuria, and a heart rate of greater than 140 beats per minute.
The treatment for postpartum hemorrhage, call for help. So as soon as you realize you've got a patient who's hemorrhaging, call for help. Do fundal massage on a boggy uterus.
Assess for lacerations. hematoma if the fundus is firm bladder catheterization for an inability to void because you know if we've got a full bladder that's going to increase uterine acne establishing an IV access so we have already discontinued our IV access establish IV access if you bleed you believe you're going to have severe hemorrhaging or you may need to give blood components you might want to establish a second IV access. Oxytocin administration is your first line uterotonic medications but other medications may need to be given for hemorrhage such as methogen or hemobate. Bi-manual compression of the uterus is also done for management of uterine acne.
The physician will massage the anterior wall of the uterus with one hand on the abdomen and massage through the vagina of the anterior wall with the other hand made into a fist. Hypovolemic shock occurs when hemorrhage is uncontrolled. It is a dangerous, life-threatening condition in which the organs become dangerously underperfused and under-oxygenated. This leads to compromised function and even can lead to death. It is triggered when the volume of circulating blood decreases to a degree that the body's organs do not have enough oxygen to function properly.
Symptoms of hypovolemic shock include Hypovolemic shock include Hypotension, tachycardia, tachypnea, oliguria, mental status changes, cool, pale, and clammy skin, and slowed capillary refill. So refer back to your postpartum hemorrhage symptoms that were in that box 23.3. Treatment for hypovolemic shock is restoration of that circuit. blood volume usually normal saline and lactated ringers are established as your mainline IV fluids like I said you're going to establish a second large-bore IV so typically you're going to use an 18 gauge IV access over a 20 or 22 so we want to establish that 18 gauge IV Monitor urine output using that Foley catheter. Monitor vital signs.
You're going to draw lab work to evaluate your red blood cell count and assess for DIC. You're going to want to administer blood transfusions as ordered. And so the other conditions that I want to mention that in the postpartum period are postpartum mood disorders. There are two primary categories of depressive mood disorders associated with pregnancy.
The first is postpartum blues and the other is postpartum depression. Postpartum blues is transient, it's self-limiting, The mood disorder starts two or three days after delivery and it typically resolves within two weeks. Postpartum depression, it is a major depression with an onset typically during pregnancy or in the first four weeks after birth. Postpartum psychosis is a rare postpartum disorder that affects a woman's sense of reality.
Women may also experience post-traumatic distress disorder in the postpartum period. Postpartum blues, like I said, it is transient. The symptoms of postpartum blues include insomnia, fatigue, dysphoria, and impaired concentrations. Such symptoms can also occur with postpartum depression.
What distinguishes the two is that postpartum depression is not self-limiting and has more stringent diagnostic criteria. 10 to 16% of women experience postpartum depression. Box 23.4 in your textbook goes over the risk factors for postpartum depression. Please look at these risk factors and be familiar with them.
Postpartum depression is Diagnosed in women that meet at least five of the nine diagnostic criteria for major depressive disorder during a two-week period with at least one of the symptoms being a depressed mood or a diminished pleasure in all or most activities. Warning signs for postpartum depression include low mood for at least two weeks. Negative attitude towards the infant. Anxiety about the health of the infant.
Concern about the ability to care for the infant. Use of alcohol, street drugs, drugs prescribed to others, or tobacco. Treatments include medication and therapy. This you can find in your book. It is a good table.
It is figure 23.5. It's a conceptual model of postpartum depression. You can find that on page 512. Postpartum psychosis, as I said before, is more rare.
It is a disturbance of a woman's perception of reality as evidenced by hallucinations. thought disorganization, disorganized behavior, and delusions. It's most common in women who suffer from depression with schizophrenia, schizoaffective disorder, or psychosis. The condition may occur within 48 hours of delivery. The priority of care is the safety of the patient and the safety of the infant.
Treatment off requires inpatient psychiatric care.