-infection of the reproductive tract up to six weeks postpartum

(temp 38C after first 24hrs)

endometritis

urinary tract 

mastitis

Endometritis 

Risk Factors

Prolonged rupture of membranes

prolonged labor

multiple vaginal exams

 RESULT: Chorioamnionitis

Trauma(perineum, vagina, cervix)

Catheterization

Retained placental fragments

Cesarean Birth

Concurent Problems (diabetes)

Endometritis

Assessment Data

Uterine tenderness

Chills and malaise

abd cramping

Fever after 1st 24hrs

foul smelling lochia

uterine subinvolution

elevated WBC's

Puerperal Infections

(from endometritis, UTI, mastitis)

Endometritis             UTI                                    Mastitis

Prolonged ROM                                                poor hand washing

Prolonged labor                                         newborn oral contact

trauma                      trauma                            (staph aureus)

cath                         catheterization             Milk Stasis

retained placental       stasis/reflux                from infrequent bleeding

   fragments                 from gen anesthesia   from engorgement    

C/S                             from pressuire on       from clogged duct

Concurrent problems       bladder from presenting

                                  part

 Endometritis

Medical and Nursing Management

(highest to lowest priority)

Fowler's postion(to help with drainage)

Analgesics for pain

IV antibiotics

non-pharm comfort (warm blankets, cool compress, cold/warm drinks, heating pad)

assist with infant care

Urinatry Tract Infection

Postpartum Complication

RISK FACTORS

Trauma

-pressure on urethra from presenting part

Catheterization

Stasis/Reflux

-regional anesthesia

-pressure on bladder from presenting part

UTI

ASSESSMENT DATA

Dysuria

Frequency

Suprapubic pain (where bladder is)

Low grade temp

Flank pain

elevated temp

UTI

MEDICAL AND NURSING MANAGEMENT

PRIORITIES

Antibiotics

Analgesics

Encourage frequent voiding

Reinforce perineal hygiene

Encourage increased fluid intake

Discharge teaching

(S&S of worsening UTI)

Discharge Teaching for

UTI

S&S of worsening

(chills, spiking fever, N/V)

proper perineal care

increase fluid intake

urinate frequently

Mastitis

RISK FACTORS

Poor hand washing

Newborn oral contact

-staph aureus

Milk stasis from..

-infrequent breastfeeding

-engorgement

-clogged duct

-incorrect bras

-pinching breasts (accidents)

Mastitis

ASSESSMENT DATA

Flu like symptoms

temp 38C or greater

localized pain over effected breast area

warmth and erythema of affected breast

Mastitis

MEDICAL AND NURSING MANAGEMENT

Frequent breast feeding

monitor breast feeding technique 

(correct position and latch)

antibiotics

analgesics

non pharm (warm compresses)

Assistance with newborn care

Mastitis

Discharge Teaching

Since this happens 2-4 weeks after birth provide info about prevention. 

Teach about positioning the infant correctly, avoiding nipple trauma,

milk stasis, empty breast completely

Avoid tight bras and carriers.

Risk Factors of 

THROMBOEMBOLIC DISORDERS

SVT vs DVT

Sperficial Thrombophlebitis

compression of large veins confined to lower leg (saphenous system)

Deep Vein Thrombosis

compression of large veins from foon to iliofemoral

Compression:injurs innermost layer of blood vessels

BOTH Risk Factors

venous stasis

postpartum hypercoagulation

Superficial Thrombophlebitis

SVT

ASSESSMENT DATA

Localized tenderness

swelling

warmth

erythema

Superficial Thrombophlebitis

SVT

MEDICAL AND NURSING MANAGEMENT

Ambulation as tolerated 

analgesics

moist heat

elevation of leg

ANTICOAGULATION NOT INDICATED

Deep Vein Thrombosis

DVT

ASSESSMENT DATA

Positive Homan's sign

extremity cool to palpation

(due to relfex arterial spasms, which also cause decrease peripheral pulses)

edema of effected extremity

DVT

MEDICAL AND NURSING MANAGEMENT

Detected by doppler flow studies

bedrest

analgesics

IV anticoagulation

Monitor for Pulmonary embolism

-dyspnea

-shortness of breath

-decreased oxygen saturation

DIFFERENCES BETWEEN 

SVT/DVT

SVT                      DVT

Assessment                      Assessment

warmth                               cool 

localized tenderness              positive homan's

Management                     Management

ambulate                          bed rest

NO anticoagulation             IV anticoagulation -HEPARIN

elevate

those at high risk get Heparin during pregnancy

pad the stirrups during birth

limit time in sitirrups <1hr

EARLY POST PARTUM 

HEMORRHAGE

Late Postpartum 

Hemorrhage

What is the abnormal blood loss during the first 24 hours following 

vaginal delivery

What is the abnormal blood loss during the first 24 hours following

a Cesarean Delivery

Identify the primary cause of 

EARLY Postpartum hemorrhage

UTERINE ATONY

(boggy)

Identify predisposing

RISK FACTORS

with 

UTERINE ATONY

Uterine Overdistention

Multiparity

Rapid Labor

Prolonged Labor

Early Postpartum

Hemorrhage

Other Causes

Trauma

Lacerations of...

 -perineum

-vagina

-cervix

Hematoma

-vagina, perineum

Predisposing risk factors of 

vaginal, labial and/or perineal hematoma

Predisposing Factors

macrosomia

rapid labor

assisted birth (forceps, vacuum)

 Risk Factors associated with 

Lacerations

Lacerations occur during the 2nd stage of labor

when the fetal head decends rapidly

or the use of forceps/vacuum

Identify the primary cause of 

LATE POSTPARTUM 

HEMORRHAGE

Primary Cause

uterine subinvolution

(slower than normal return of uterine size)

Other

retained placental fragments

Late Postpartum Hemorrhage

MANAGEMENT

1g=1ml of blood lost

(to measure amount of blood lost)

saturation of one peripad in 15 minutes represents excessive blood loss.

Atony:lack of muscle tone that results in failure of the uterine muscle fibers to contract arount blood vessels when placenta seperates

hemorrhage occurs 

Assessment Data/Management

of Postpartum Hemorrhage

Assessments                                                 TNI's

Chart review-predisposing factors present   preform more frequent eval                           

Fundus-soft, boggy,displaced            void, massage, express clots

                                                   notify PCP if ineffective

Lochia-bleeding                               assess from trauma, weigh pads

Vital signs-tachy, decrease pulse,      report signs of excessive loss

         decrease BP, and O2

Urine output-decreased                    report less than 30ml/hr

skin-cool,damp,pale                         look for signs of hypovolemia

ASSESSMENT OF UTERINE ATONY

assess fundus, bladder, lochia, vs, skin temp and color

assess location and consistency

have her void, massage

Oxytocin (pitocin)

High Alert Med

Indications: Augment labor or firms uterine w/contractions to control bleeding

Dosage: begin with 20-40 milliunits/min-IV

             or IM 10units

TNI: observe uterus for firmness, height, monitor I&Os or bladder distention

Side Effects: prolonged may cause fluid retention, water intoxication, HYPOTENSION

Mehtylergonovine Maleate (Methergine)

Class: prostaglandin, oxytocic

Acton:stimulates contraction of uterus

Dosage: IM 2mg MAX

Side effects: excessive dose causes lateration or uterine rupture, NVDia, pulmonary edema

TNIs: refridge, deep IM aspirate, monitor vs, antiemetic, antidiarrheals

Screening for sensitization

all Rh-women

about 28weeks preg

ANTEPARTUM MANAGEMENT

Initial prenatal visit 

and repeated at 28 weeks 

Indirect Coombs is negative

mom needs prophylactic RhoGam

(no harm to current baby)

Indirect Coombs is positive

sensitation has occurred

(fetus/infant at risk for hemolytic anemia and jaundice)

no need for Rhogam

Postpartum Management of 

Rh-woman

If mother is Rh-, umbilical cord taken to determine blood type, Rh factor and antibody titer of newborn.

If baby Rh+ mother gets RhoGam (D-immunoglobulin) within 72 hrs of delivery

If baby Rh- (antibody formation does not occur) and RhoGAM not necessary

What is the difference between Indirect and Direct Coombs' testing

Identifies antibodies to Rh+ blood in

Indirect=mother serum

Direct=infant serum

ABO INCOMPATIBILITY

NEWBORN/Fetal EFFECTS

NEWBORN:Potential hemolytic anemia

potential jaundice

FETAL EFFECTS: none

Post Partum 

ABO Incompatibility Management 

Maternal Blood Type O

assess newborn blood type 

assess direct coombs (baby)

-detect antibodies to both blood type and Rh

ABO Incompatibility Management

Infant blood type A or B

and direct coombs POSITVE

monitor infant for jaundice 

(indicating hyperbilirubinemia)

anticipate treatment for possible pathologic jaundice

anticipate possible hemolytic anemia

ABO Incompatibility Management

Direct Coombs Negative

Infant is not at risk for jaundice due to blood incompatibility

infant is not at risk for hemolytic anemia