Postpartum Care and Complications: A Comprehensive Guide, Exams of Obstetrics

Download Postpartum Care and Complications: A Comprehensive Guide and more Exams Obstetrics in PDF only on Docsity! 1 2023-2024 OB FINAL EXAM STUDY GUIDE RIVIEW GRADED A Postpartum  The postpartum or the puerperium period is the period of time following the delivery of the child during which the body tissues, especially the reproductive system reverts back to the pre-pregnant state, both anatomically and physiologically.  The puerperium or the postpartum period lasts for 6 weeks. o 1) Immediate Postpartum: the 24-hour period immediately following delivery. o 2) Early Postpartum or puerperium: up to 7 days. o 3) Remote postpartum or puerperium: up to 6 weeks. Reproductive system  Involution of the uterus: rapid reduction in size of the uterus to a nonpregnant state following birth.  Following delivery of the placenta the uterus contracts into a hard mass; the size of a grapefruit  Exfoliation is a very important aspect of involution; if healing of the placenta site leaves a fibrous scar, the area available for future implantation is limited, as is the number of possible pregnancies.  With the dramatic decrease in the levels of circulating estrogen and progesterone following placental separation, the uterine cells atrophy, and the hyperplasia of pregnancy begins to reverse.  Factors that enhance involution include: o an uncomplicated labor and birth o complete expulsion of the placenta or membranes o breastfeeding o manual removal of the placenta during a cesarean birth o and early ambulation.  Factors that slow uterine involution include: o Prolonged labor o Anesthesia o Difficult birth o Grand multiparity o Full bladder o Incomplete expulsion of the placenta or membranes o Infection o Over distension of the uterus (Overstretching of uterine muscles with conditions such as multiple gestation, hydramnios, or a very large baby may set the stage for slower uterine involution.) Uterus  At delivery fundus is at the umbilicus  1-2 hours: midway between umbilicus and symphysis pubis  12 hours: 1 cm above or at umbilicus  After that the height of the uterine fundus decreases (involutes) by approximately 1 cm per day.  Within 6 to 12 hours after birth, the fundus of the uterus rises to the level of the umbilicus because of blood and clots that remain within the uterus and changes in support of the uterus by the ligaments.  A fundus that is above the umbilicus and boggy (feels soft and spongy rather than firm and well contracted) is associated with excessive uterine bleeding. As blood collects and forms clots within the uterus, the fundus rises; firm contractions of the uterus are interrupted, causing a boggy uterus (uterine atony). When the fundus is higher than expected on palpation and is not in the midline (usually deviated to the right), distention of the bladder should be suspected; the bladder should be emptied immediately and the uterus remeasured.  If the woman is unable to void, in-and-out catheterization of the bladder may be required.(straight cath)  After birth the top of the fundus remains at the level of the umbilicus for about half a day. On the first postpartum day, the top of the fundus is located about 1 cm below the umbilicus. The top of the fundus descends approximately one finger breadth(width of index, second, or third finger), or 1 cm, per day until it descends into the pelvis on about the 10th day. Breast feeding hastens this process.  oversized uterus during the pregnancy(because of hydramnios, [LGA] infant, or multiple gestation), the time frame for uterine involution process is lengthened. 2  If intrauterine infection is present, in addition to foul-smelling lochia or vaginal discharge, the uterine fundus descends much more slowly. o When infection is suspected, other clinical signs such as fever and tachycardia in addition to delayin involution must be assessed. o Any slowing of descent is called subinvolution (is the failure of the uterus to return to a nonpregnant state) o Common causes- retained placental fragments and infection Lochia- more common in the mornings and multiparous mom tend to have more, also moms who had a vaginal birth VS a Csection  Rubra- 1-3 days – dark red, bloody, fleshy, musty, stale non-offensive odor; clots, sometimes meconium and vernix. A few clots (no larger than a nickel is common) LARGE clots are not normal  Serosa- 4-10 days – pinkish, watery, odorless  Alba-11-21 days; ( a week or two) yellow to white, possible stale odor  When the lochia flow stops, the cervix is considered closed, and chances of infection ascending from the vagina to the uterus decrease.  Foul smelling lochia: assess for (WBC) count and differential and assessment for uterine tenderness and fever.  Persistent discharge of lochia rubra or a return to lochia rubra indicates subinvolution or late postpartal hemorrhage  Continuous bleeding is consistent with vaginal/uterine lacerations. Lacerations should be suspected if the uterus is firm and of expected size and if no clots can be expressed. Vaginal changes  Edematous  Multiple small lacerations  Perineal pain can last for up to 2 weeks  By 6 weeks the nonbreastfeeding woman’s vagina usually appears normal.  The lactating woman is in a hypoestrogenic state because of ovarian suppression, and her vaginal mucosa may be pale and without rugae; the effects of the low estrogen level may lead to dyspareunia (painful intercourse), may be reduced by the addition of lubricant.  Tone and contractility of the vaginal orifice may be improved by perineal tightening exercises such as Kegel exercises  Painful intercourse due to lowered estrogen which leads to decreased vaginal lubrication and vasoconstricition for 6–10 weeks Perineal changes • Edematous and bruising • If episiotomy present ; sore tender, pain subsides in 5-6 days • Observe for REEDA • Healing can take up to 2-3 weeks; complete up to 4-6 months • Perineal discomfort • Perineal lacerations: place ice pack, sitz bath, or packing • DO NOT give pt enema or suppository • Recurrence of ovulation & menstruation  In nonbreastfeeding mothers, menstruation generally returns between 4 and 6 weeks after birth.  nonlactating mothers the average time to first ovulation can be as early as 27 days with a mean time of 70 to 75 days (6-8 weeks) 5  This helps her work through the process, sort out the reality from her fantasized experience, and clarify anything that she did not understand o Food & Sleep are her major needs o Passive, & somewhat dependent o Touches and explores infant  Taking-hold o Second or third PP day ready to resume control of their bodies, mothering, and life in general o If she is breastfeeding, she may worry about her technique or the quality of her milk o If her baby spits up after a feeding, she may view it as a personal failure o She may also feel demoralized by the fact that the nurse or an older family handles her baby proficiently while she feels unsure and tentative o She requires assurance that she is doing well as a mother o Todays mothers seem to be more independent and adjust more rapidly. o Obsessed with body functions o Anticipatory guidance most effective o Rapid mood swings o Mothering functioning established; sees infant as unique person  Postpartum blues o Postpartum depression is a nonpsychotic depressive episode that begins in the postpartum period first few days o Manifested by  Mood swings  Anger  Weepiness  Tearfulness  Anorexia  Difficulty sleeping  Feeling of let down o Occurs while still in hospital o Usually resolves within 10-14 days o If worsen; referral may be urgent o Postpartum depression prevalence rates are estimated to be 10-15%. o Etiologies: hormonal changes, psychologic adjustments, an unsupportive environment, and insecurity, genetic predisposition, and sleep loss, fatigue, and discomfort o The routine use of a screening tool such as the Edinburgh Postnatal Depression Scale or Postpartum Depression Predictors Inventory-Revised.  Maternal role attainment- Becoming a Mother (BAM) o Takes about 3–10 months o Social support, the womans age & personality traits, the marital relationship, the presence of underlying anxiety or depression, the womans previous childcare skills, the temperament of her infant, and the familys socioeconomic status all influence the womans success in attaining the maternal role. o Maternal role attainment is a process by which a woman learns mothering behaviors & becomes comfortable with her identity as a mother; often occurs in four stages: o Anticipatory stage: during pregnancy looks for a role model  Occurs during pregnancy  The woman looks for a role model (especially her own mother). Example – how to mother o Formal stage: birth of child; influenced by others; tries to please everybody  When child is born  Influenced by guidance of others & tries to act as she believes others expect her to act  Tries to please everybody o Informal stage: mother begins making own decisions  When the mother begins to make her own choices about mothering  The woman begins to develop her own style of mothering and finds ways of functioning that work well for her o Personal stage: final; comfortable with her concept of maternal role  The final stage of maternal role attainment  When the woman reaches this stage, she is comfortable with the notion of herself as “mother”  Challenges o Finding time for self  To read a book, talk to her partner, or even eat a meal without interruption o Feelings of incompetence 6  They have not mastered all aspects of the mothering role o Fatigue from sleep deprivation  The demands of nighttime care are tremendously draining, especially if the woman has other children o Loss of freedom and added responsibility  They will never again be quite as carefree as they were before becoming mothers o Challenge caring for older children  Woman feels guilty because the new baby takes up so much time. Sibling rivalry or ill feelings about the baby from other children can put additional stress on the mother. o Challenge caring for active baby  Mothers sometimes cite the infant’s behavior as a challenge, especially when the child is about 8 months old.  Infant crawling and getting into things, teething may cause fussiness, and the baby’s tendency to put everything in his or her mouth requires constant vigilance by the parent Development of Family Attachment • A mother’s first interaction with her infant is influenced by many factors: o Involvement with her family of origin o Her relationships o The stability of her home environment o Communication patterns she developed o The degree of nurturing she received as a child • The following personal characteristics are also important: o Level of trust o Level of self-esteem o Capacity for enjoying herself o Adequacy of knowledge about childbearing and childrearing o Prevailing mood or usual feeling tone o Reactions to the present pregnancy  Initial attachment behavior o Mother proceeds from fingertip exploration of the newborns extremities toward palmar contact with larger body areas and finally to enfolding the infant with the whole hand and arm. The time to accomplish these steps varies from minutes to days o Mother increases the proportion of time spent in en face position, face-to-face position, eye to eye contact about 20cm, same plane o Mother uses soft, high-pitched voice o Mother relies heavily on her senses of sight, touch, and hearing in getting to know the baby o While interacting with newborn, the mother may be experiencing shock, disbelief, or denial. o Acquaintance phase:  The first few days after her child’s birth, the new mother applies herself to the task of getting to know her baby  Newborn is becoming acquainted.  Within a few days after birth, infants show signs of recognizing recurrent situations and responding to changes in routine.  Babies are actively acquainting themselves to mother o Mutual regulation phase:  Mother and infant seek to determine the degree of control each partner in their relationship will exert  In this phase of adjustment, a balance is sought between the needs of the mother and the needs of the infant  The most important consideration is that each should obtain a good measure of enjoyment from the interaction  During this phase, negative maternal feelings are likely to surface or intensify  Some negative feelings are normal in the first few days after birth, and the nurse should be supportive when the mother vocalizes these feelings  When mutual regulation arrives at the point here both mother & infant primarily enjoy each other’s company, reciprocity has been achieved.  Reciprocity is an interactional cycle that occurs simultaneously between mother and infant/interaction between mother and infant is mutually gratifying and is sought and initiated by both partners. It involves mutual cuing behaviors, expectancy, rhythmicity, and synchrony.  Engrossment o Father’s absorption, preoccupation, and interest in infant; stimulated by active participation in the birth= engrossment o Siblings and Other  Family-centered care and rooming-in permits siblings and grandparents to participate in the attachment process  Cultural influences o Remember that mother’s or family expectations may be different from what the nurse expect o Foods, hygiene practices and family support may vary Collaborative Care 7  Couplet care: nurses care for mother and baby as a unit o Allows mother and significant others time to interact with the infant o Provides increased opportunities for parentchild interaction because the newborn shares the mothers room and they are cared for together.  LDRP model o After delivery infants room-in with mothers o In some hospitals woman remains in the same room throughout all four phases Assessments during the fourth stage of labor  Vital signs: every 15 minutes  Temperature: at least once in first hour o Temperature elevations (less than 38 C [100.4F]) caused by normal process should last for only 24 hours  Generalized shaking and chattering of the teeth  Uterus: every 15 minutes for fundal height and tone  Assess fundus: tone; palpation o One gloved hand above symphysis pubis: prevents any downward displacement; prolapse or inversion o Feel for uterine fundus o Assess position of fundus in relation to umbilicus; measure in fingerbreadths o Gently massage boggy fundus until uterus returns to firm; greatest risk of hemorrhage within first hour following birth  Lochia: assess every 15 minutes for color, amount, and any clots o Expected finding: moderate lochia rubra with no clots o Excessive lochia: uterine atony; retention of placental fragments; lacerations of the perineum, vagina, or cervix  Uterine atony o Clots present; fundus found higher than expected o Massage carefully to expel any blood clots  Perineum: every 15 minutes; identify edema or signs of hematoma  Apply ice to the affected area Postpartal Nursing Assessment Physical assessment M-mental status o Orientated to Person, place, and time A- auscultation o Lungs should be clear; if diminished could be a sign of fluid overload, asthma, pulmonary embolus, pulmonary edema B- breast o Should be smooth, may be soft, filling, full or engorged. o Reddened area- can indicate mastitis U- uterus o Firm, midline after birth o Boggy- full bladder or uterine bleeding B- bladder B- bowel o Normal bowel movement by 2 or 3rd day after birth o If not patient may be constipated L- lochia o Scant to moderate amount, earthy odor; no clots o Normal progression: First 1-3 days: rubra o Following rubra: Days 3-10: serosa (alba seldom) o Large amount, clots – hemorrhage o Foul smelling lochia- infection o Failure to progress normally or return to rubra from serosa- subinvolution E- episiotomy, epidural site o No redness, edema, ecchymosis, or discharge; edges well approximated o If otherwise can indicated infection H- hemorrhoids, homan’s sign o None present; if present, should be small & nontender o Full, tender- inflamed hemorrhoids Vital signs  Temperature elevations due to normal process should last up to 24 hours o Normal temperature: 36.6C to 38 C (98 F to 100.4 F)  If elevated consider the time since birth to determine dehydration/infection  If elevation is associated with symptoms assess hx. 10 – Check: sutures intact – No episiotomy or laceration: assess for edema and bruising – Cool compresses or ice packs  The perineum is inspected with the woman lying in a Sims’ position.  The nurse lifts the buttock to expose the perineum and anus.  If an episiotomy was done or a laceration required suturing, the nurse assesses the wound.  To evaluate the state of healing, the nurse inspects the wound for redness, edema, ecchymosis, drainage, and approximation (REEDA scale).  After 24 hours some edema may still be present, but the skin edges should be well approximated so that gentle pressure does not separate them.  Gentle palpation should elicit minimal tenderness, and there should be no hardened areas suggesting infection.  Ecchymosis interferes with normal healing, as does infection.  Foul odors associated with drainage indicate infection.  Hematomas sometimes occur, although these are considered abnormal.  The nurse next assesses whether hemorrhoids are present around the anus.  If present, they are assessed for size, number, and pain or tenderness.  Nurse can casually add that the sutures are special and will dissolve slowly over the next few weeks as the tissues heal. Calves – Homans sign- assess client’s lower legs: redness, swelling, or warmth are indication of early thrombophlebitis – To assess for thrombophlebitis, the nurse should have the woman stretch her legs out with the knees slightly flexed and the legs relaxed. The nurse then grasps the woman’s foot and sharply dorsiflexes it. The second leg is assessed in the same way. No discomfort or pain should be present. If pain is elicited, the nurse notifies the physician that the woman has a positive Homans’ sign – The nurse also evaluates the legs for edema by comparing both legs, because usually only one leg is involved. – Some facilities have discontinued performing a Homans’ sign in the nursing assessment, stating it is not diagnostic and could lead to emboli if the clot is dislodged during assessment. Although assessment of the Homans’ sign is not diagnostic – Heparin therapy is used in postpartum women who do develop a deep vein thrombosis. – Early ambulation is an important aspect in the prevention of thrombophlebitis. – . The mother’s legs should be assessed for return of sensation following regional anesthesia. – The cesarean birth client requires range of motion exercises until she is ambulating more freely. – Leg exercises that may be performed in bed, dorsiflexion on an hourly basis while on bed rest, ambulation, and avoiding pressure behind the knees and crossing the legs. Psychological and emotional state – Monitor mother and infant: evidence of attachment behaviors – Assess mother’s emotional state: level of maternal fatigue – Evaluate woman’s teaching needs – Some new mothers have little or no experience with newborns and may feel totally overwhelmed. They mays how these feelings by asking questions and reading all available material – Clues indicating adjustment difficulties include excessive continued fatigue, marked depression, excessive preoccupation with physical status or discomfort, evidence ofl ow self-esteem, lack of support systems, marital problems, inability to care for or nurture the newborn, and current family crises (illness or unemployment). – These characteristics frequently indicate a potential for maladaptive parenting, which may lead to child abuse or neglect (physical, emotional, intellectual) and cannot ignored. Postpartal Nursing Education Caring for the breasts in the nursing mother Engorgement: vascular congestion and milk stasis  Fullness generally lasts only 24 hours, the breasts remain soft enough for the newborn to suckle, and there is no pain. Engorged breasts are hard, painful, and warm and appear taut and shiny. The consistency is like gravel.  The infant should suckle for an average of 15 minutes per feeding and should feed at least 8 to 12 times in 24 hours.  If the baby is unable to nurse more frequently, the mother may express some milk manually or with a pump, taking care to avoid traumatizing the breast tissue.  Warm compresses before nursing stimulate let-down and soften the breast so that the infant can grasp the areola more easily. Cool compresses after nursing can help slow refilling of the breasts and provide comfort to the mother.  Ice packs may also be used as a comfort measure.  The mother should wear a well-fitted nursing bra 24 hours a day to support the breasts and prevent discomfort from tension.  Infant not fully emptying mother’s breasts  Encourage feeding every 2 or 3 hours  Application of warm compresses  Express small amount of breast milk: to soften breasts, to latch successfully 11 Nipple tenderness: progress to redness, bruising, or cracking  Common cause: improper positioning and latch  Some discomfort often occurs initially with breastfeeding; it peaks between day 3 and 6 and then recedes.  Breastfeeding difficulty and nipple soreness are often causes for women to discontinue breastfeeding.  The nurse should counsel the mother not to switch to formula feeding or delay feedings because these measures cause engorgement and more soreness.  The baby’s position at the breast is a critical factor in nipple soreness.  The mother’s hand should be off the areola, and the baby should be facing the mother’s chest, with ear, shoulder, and hip aligned.  Because the area of greatest stress to the nipple is in line with the newborn’s chin and nose, encouraging the mother to rotate positions when feeding the infant may decrease nipple soreness.  Changing positions alters the focus of greatest stress and promotes more complete breast emptying.  Soreness may also result from continuous negative pressure if the infant falls asleep with the breast in his or her mouth.  Nipple soreness is especially pronounced during the first few minutes of a feeding.  If the mother is not expecting this discomfort, she may become discouraged and quickly stop.  The let- down reflex may take a few minutes to activate, and it may not occur if the mother stops nursing too quickly. The infant is unsatisfied, and the possibility of breast engorgement increases.  Nipple soreness can also result from the vigorous feeding of an overeager infant. Thus the mother may find it helpful to nurse more frequently.  Promoting letdown just before feeding may help.  Other self-care measures include applying ice to the nipples and areola for a few minutes before feeding to promote nipple erectness and numb the tissue initially.  During bathing, mothers should be advised to only rinse their nipples with water and to avoid soap because this can dry the nipple out and lead to soreness.  Change the pads on the boobs frequently so they are maintain dry.  If nipple soreness persists, the woman should be advised to consult a certified lactation consultant to determine the etiology of the soreness.  Nipple dermatitis, which causes swollen, reddened, burning nipples, is most commonly caused by thrush or by allergic response to breast cream preparations.  If the nipple soreness has a sudden onset and is accompanied by burning or itching, shooting pains through the breast, and a deep pink coloration of the nipple, it may be caused by a thrush infection transmitted from the infant to the mother.  White patches or streaks in the infant’s mouth indicate a need for treatment of the mouth and nipple infection.  The infection can be treated with a variety of antifungal preparations and does not preclude breastfeeding.  It is important for both the mother and the infant to receive treatment to prevent cross transferring of the fungus.  Pain or bruising: upper portion of nipple— infant pinching nipple with gums o Lift infant’s head up: baby faces nipple directly  Candida albicans causes nipple pain: bright red and shiny, sore nipples Remedies  Application of small amount of expressed colostrum or breast milk, tea bags, warm water compresses, lanolin cream, and air- drying nipples following feedings  Warm water compresses Breast  Regardless of feeding method, it is important for the nurse to assess the newborn’s fluid and nutritional intake.  As part of the physical assessment the newborn’s nude weight is determined.  If the weight loss since birth is 10% or more, the nurse assesses the baby for signs of dehydration such as loose skin with decreased skin turgor, dry mucous membranes, sunken anterior fontanelle, and decreased frequency and amount of voiding and stooling.  Risk factors for suboptimal breastfeeding include maternal obesity, primiparity, young maternal age, use of formula supplementation, use of pacifiers, cesarean birth, second stage greater than 1 hour, low birth weight, breastfeeding difficulty, and flat or inverted nipples. Monitoring the fundus  Intravenous administration: 10 to 20 units of oxytocin added to 1,000 mL of fluid  Allow woman up to use the bathroom  Woman cannot void: bladder distended; catheterize  Stress incontinence postpartum: Kegel exercises that should began while the woman is still at the hospital.  Exercise can help maintain insulin and high-density lipoprotein (HDL) cholesterol levels, as well as improve aerobic fitness.  The postpartal woman is more likely to have positive views of her well-being, more self-esteem, and less fatigue if she continues to do stretching and her own pattern of exercise after she is home.  The addition of pelvic floor exercises can also decrease such problems as urinary leakage or urinary incontinence. 12  Exercise also helps facilitate postpartum weight loss, reduces stress, and provides the mother with needed time alone. Fundus  Before examination of the abdomen, the woman should void.  The nurse determines the relationship of the fundus to the umbilicus and also assesses the firmness of the fundus.  The top of the fundus is measured in finger breadths above, below, or at the umbilicus.  The nurse notes whether the fundus is in the midline or displaced to either side of the abdomen. If not midline, the uterus position should be located.  The most common cause of displacement is a full bladder; this finding requires further assessment. If the fundus is in midline but higher than expected, it is usually associated with clots within the uterus.  The nurse should then record the results of the assessment.  In the woman who has had a cesarean birth, the abdominal incision is extremely tender.  The nurse should palpate the fundus with extreme care and inspect the abdominal incision for signs of healing, such as approximation (edges of incision appear “glued” together), bleeding, and any signs of infection, including drainage, foul odor, or redness.  The nurse should document whether internal sutures, steri-strips, or staples are intact.  The nurse can also review characteristics of normal healing, incision care, and discuss signs of infection.  Involving the mom in her own care encourages her participation. Having her massage her own uterus may lessen bleeding and reduce the need for more thorough massage. Monitoring lochia  Excessive lochia: evaluate uterus and bladder  Assess bladder for distention: primary cause of uterine atony  Assess odor: foul-smelling indicates endometritis  During the first 1 to 3 days the lochia should be rubra.  A few small clots are normal and occur as a result of blood pooling in the vagina.  However, the passage of numerous or large clots is abnormal, and the cause should be investigated immediately.  After 2 to 3 days, the lochia flow becomes serosa.  Lochia should never exceed a moderate amount, such as that needed to partially saturate perineal pads daily, with an average of six.  The nurse has to ask the woman about the appearance of clots, if is normal compared to her other periods.  If heavy bleeding is reported but not seen, the nurse asks the woman to put on a clean perineal pad and then reassess the woman’s pad in 1 hour.  When a more accurate assessment of blood loss is needed, the perineal pads can be weighed, with 1 g considered the approximate equivalent of 1 mL of blood.  Clots and heavy bleeding may be caused by uterine relaxation(atony), retained placental fragments, or rarely, an unknown cervical laceration, seen as heavy bleeding but with firm fundus, that may required further assessment.  Woman that had c-section will bleed less in the first 24 hrs than with vaginal birth.  If the woman is at increased risk for bleeding, or is actually experiencing heavy flow of lochia rubra, her blood pressure, pulse, and uterus need to be assessed frequently, and the physician/CNM may prescribe oxytocin(Pitocin) or methylergonovine maleate (Methergine).  The odor of the lochia is non-offensive and never foul. If a foul odor is present, so is an infection. When using narrative nursing notes, chart the amount of lochia first, followed by character. For example: ■ Lochia: moderate rubra ■ Lochia: small rubra/serosa Caring for the episiotomy  Perineal care with warm water  Apply ice to decrease swelling  The perineum is inspected with the woman lying in a Sims’ position. The nurse lifts the buttock to expose the perineum and anus.  If an episiotomy was done or a laceration required suturing, the nurse assesses the wound.  To evaluate the state of healing, the nurse inspects the wound for redness, edema, ecchymosis, drainage, and approximation.  The nurse next assesses whether hemorrhoids are present around the anus. If present, they are assessed for size, number and pain or tenderness.  The sutures are special and will dissolve slowly over the next few weeks as the tissues heal. By the time the sutures are dissolved the tissues are strong and the incision edges will not separate.  An example of documenting a perineal assessment might read:  “Midline episiotomy; no edema, tenderness, or ecchymosis present. Skin edges well approximated”; or, if a perineal laceration repair, “Skin edges intact, no edema, tenderness, or ecchymosis, pain meds helpful.  Woman reports sitz bath and Tucks pads or pain relief measures are controlling discomfort.”  Use of peri-bottle following each voiding or defecation. 15  Postpartal hemorrhage is prevented, beginning with adequate prenatal care, good nutrition, avoidance of traumatic procedures, risk assessment, early recognition, and management of complications as they arise.  Any woman at risk should be typed and cross-matched for blood and have intravenous (IV) lines in place with needles suitable for blood transfusion (18-gauge minimum).  After expulsion of the placenta, the fundus is palpated to ensure that it is firmly contracted. If it is not firm (if it is boggy), fundal massage is performed until the uterus contracts. Fundal massage is painful for the woman who has not received regional anesthesia; If bleeding is excessive, the clinician will likely order (IV) oxytocin at a rapid infusion rate and may elect to do a bimanual massage  IV fluids n blood transfusions are determined based on the H&H and coagulation studies  Conservative management with utrine stimulants: Misoprostol; its use in labor induction, is being used to prevent and treat uterine atony after failed attempts to control bleeding with oxytocics. Misoprostol used rectally is absorbed quickly and causes uterine contraction within minutes. When conservative measures do not successfully control bleeding, surgical intervention is required.  Uterine packing has also been common but not really used.  Retained placental fragments: common in early and late hemorrhage. Retention of fragments is usually attributable to partial separation of the placenta during massage of the fundus before spontaneous placental separation. Following birth, the placenta should always be inspected for intactness and for evidence of missing fragments.  This cause should be immediately suspected if bleeding persists and no lacerations are noted  Sonography maybe used to diagnose retained placental fragments.  Curettage, formerly standard treatment, is now thought by some to traumatize the implantation site, thereby increasing bleeding and the potential for uterine adhesions.  Uterine inversion: a prolapse of the fundus to or through the cervix so that the uterus is turned inside out afterbirth—  Uterine inversion is often associated with factors such as: fundal implantation or abnormal adherence of the placenta, protracted labor, weakness of the uterine musculature, uterine relaxation secondary to anesthesia or drugs such as magnesium sulfate, and excess traction on the umbilical cord or vigorous manual removal of the placenta. Most cases of uterine inversion are managed by immediate repositioning of the uterus within the pelvis by the physician. Bleeding Complications  Ongoing assessment and observation for signs of shock: hypovolimic o Hypotension o Tachycardia/thready pulse o Decrease pulse pressure o Cold, pale clammy skin o Cyanosis o Oliquria o Extreme thirst o Apathy, lethargy and confusion o If the fundus is firm she shouldn’t be bleeding so if she is it could be laceration o Bright red blood means active bleeding  Planning/intervention o Decrease blood loss o Prompt identification of cause o Massage fundus o Insertion of foley catheter as needed o Bimanual compression (MD or CNM) o Pharmacologic agents: Pitocin, Methergine o Large -bore needle o If they have an iv they will give Pitocin its better; however, if she is coming from home they will give her methergine but be careful giving this drug to pt with cardiovascular disease (Methergine) Always Check BP and HR prior before adminstration  IM use: 0.2 mg q2–4h. Onset: 2 to 5 min. Duration: 3 h (for 5 dose maximum). PO use: 0.2 mg q4h (for 6 doses). Onset: 7 to 15 min. Duration: 3 h (for 1 week). IV administration not recommended. Contraindications  Women with labile or high blood pressure, known sensitivity to drug, or cardiac disease. Use with caution during lactation. Expected effects  Sustained uterine contractions that help to prevent or reverse postpartal hemorrhage caused by uterine atony; management of postpartal subinvolution. Side effects 16  Hypertension, dizziness, headache, flushing/hot flashes, tinnitus, nausea and vomiting, palpitations, chestpain. Overdose or hypersensitivity is recognized by seizures; tingling and numbness of fingers and toes. Implications for Nursing Management of the Postpartal Woman Receiving Uterine Stimulants  Assess fundus for evidence of contraction and amount of uterine bleeding at least q10–15 min 1–2 h after administration, then q30–60 min until stable. More frequent assessments are determined by the woman’s condition or by orders of the physician/CNM.  Assess blood loss by hematocrit and hemoglobin levels.  Monitor pulse and blood pressure q15 min for at least 1 h after administration, then q30–60 min until stable.  Apply pulse oximeter and administer oxygen according to agency protocol.  Weigh peripads or Chux dressing.  Note expected duration of action of drug being administered, and take care to recheck fundus at that time.  When the drug is ineffective, the fundus remains atonic (boggy or uncontracted), and bleeding continues, massage the fundus. If massage fails to cause sustained contraction, notify the physician/CNM immediately.  Monitor woman for signs of known side effects of the drug; report to physician/CNM if side effects occur.  Continuous EKG monitoring may be indicated for hypotension, continuous bleeding, tachycardia, or shock.  Elevate the legs to a 20- to 30-degree angle to increase venous return.  Remind the woman and her support person that uterine cramping is an expected result of these drugs and that medication is available for discomfort.  Administer analgesic medications as needed for pain relief. Provide nonpharmacologic comfort measures.  If analgesic medication ordered is insufficient for pain relief, notify the physician/CNM.  Provide information to client and family regarding importance of not smoking during Methergine administration (nicotine from cigarettes leads to constricted vessels and may lead to hypertension) and signs of toxicity. When Prostaglandin Is Used  Check temperature q1–2h and/or after chill. Administer antipyretic medication as ordered for prostaglandin-induced fever.  Auscultate breath sounds frequently for signs of adverse respiratory effects.  Assess for nausea, vomiting, and diarrhea. Administer antiemetic and antidiarrheal medications as ordered. (In some settings, women are Pre medicated with these drugs.) Bleeding Complications cont.  Surgical intervention ( only happen when everything else fail) o Utero-ovarian, uterine, and hypogastric vessel ligation o Angiographic embolization o Hysterectomy last thing they will do because the mom cant have any more kids o Check the h&h and continue checking Lacerations of the Genital Tract o Early postpartum hemorrhage is associated with lacerations of the perineum, vagina, or cervix. Several factors predispose women to higher risk ofreproductive tract lacerations: Nulliparity Epidural anesthesia Precipitous childbirth (less than 3 hours) o Thorough inspection of the genital tract by the birth attendant facilitates recognition and timely repair of most lacerations. o Genital tract lacerations should be suspected when vaginal bleeding persists in the presence of a firmly contracted uterus. o The nurse who suspects a laceration should notify the clinician so that the laceration can be immediately sutured to control the hemorrhage and restore the integrity of the reproductive tract. The woman may be moved to a delivery or surgical area for access to special lighting to facilitate treatment. Bleeding Complications cont.  Late postpartum hemorrhage  Although early postpartum hemorrhage usually occurs within hours after birth, delayed hemorrhage generally occurs within 1 to 2 weeks after childbirth, most frequently as a result of subinvolution( failure to return to normal size) of the placental site or retention of placental fragements. o Often develops 7-14 days following birth and can occur as late as 1 month after birth o Associated with infection/retained placental fragments o Most frequently it occurs as a result of subinvolution (failure to return to normal size) of the placental site or retention of placental fragments. o Deficiency of immunologic factors has been implicated as a cause. o Faulty implantation in the less vascular lower uterine segment, retention of placental tissue, or infection may contribute to subinvolution. With subinvolution, the postpartum fundal height is greater than expected. o In addition, lochia flow often fails to progress from rubra to serosa to alba normally. o Lochia rubra that persists longer than 2 weeks postpartum is highly suggestive of subinvolution o Some women report scant brown lochia or irregular heavy bleeding. Leukorrhea, o backache, and foul lochia may occur if infection is a cause. 17 o There may be a history of heavy early postpartal bleeding or difficulty with expulsion of the placenta. o When portions of the placenta have been retained in the uterus, bleeding continues because normal uterine contractions that constrict the bleeding site are prohibited. o They will do an US to confirm if there is placenta tissue in the uterus Bleeding Complications cont.  Signs and symptoms o Gush of foul-smelling uterine bleeding Other s/s: o Uterine tenderness o Low grade fever o Lochia rubra(if this return then it is a problem) o Diagnostic test: ultrasound Signs of Postpartal Hemorrhage o Excessive or bright-red bleeding (saturation of more than one pad per hour) o A boggy fundus that does not respond to massage o Abnormal clots o High temperature o Any unusual pelvic discomfort or backache o Persistent bleeding in the presence of a firmly contracted uterus o Rise in the level of the fundus of the uterus o Increased pulse or decreased BP o Hematoma formation or bulging/shiny skin in the perineal area o Decreased level of consciousness Bleeding Complications cont.  Planning/intervention o Physiologic needs o Psychological needs o Focus: safety and well-being o Laboratory studies h&h and wbc o Pharmacologic agents o Surgical : curettage; hysterectomy o Broad-spectrum antibiotics  put an 18 gauge needle  The doctor will give prophylactic antibiotics o Subinvolution is most commonly diagnosed during the routine postpartal examination at 4 to 6 weeks. The woman may relate a history of irregular or excessive bleeding or describe the symptoms listed previously. o An enlarged, softer-than-normal uterus palpated bimanually is an objective indication of subinvolution. o Treatment includes oral administration of methylergonovine maleate [Methergine] 0.2 mg orally every 3 to 4 hours for24 to 48 hours. o When uterine infection is present, antibiotics are also administered. o The woman is re evaluated in 2 weeks. If retained placenta is suspected or other treatment is ineffective, curettage may be indicated. o Decrease the risk of vulvar or vaginal hematoma by applying an ice pack to the woman’s perineum during the first hour after birth and intermittently thereafter for the next 8 to 12 hours. If a small hematoma develops despite preventive measures, a sitz bath after the first 12 hours will aid fluid absorption once bleeding has stopped and will promote comfort , as will the judicious use of analgesic agents. Nursing diagnoses that may apply to a woman experiencing postpartal hemorrhage include the following:  Deficient Fluid Volume related to blood loss secondary to uterine atony, lacerations, or retained placental fragments  Health-Seeking Behaviors related to lack of information about signs of delayed postpartal hemorrhage. o If the nurse detects a soft, boggy uterus, it is massaged until firm. o If the uterus is not contracting well and appears larger than anticipated, the nurse may express clots during fundal massage. Once clots are expressed, the uterus tends to contract more effectively. o If the woman seems to have a slow, steady, free flow of blood, the nurse should do pad counts and if possible begin to weigh the perineal pads. o The nurse monitors the woman’s vital signs every 15 minutes, or more frequently if indicated. o If the fundus is displaced upward or to one side because of a full bladder, the nurse encourages the woman to empty her bladder—or catheterizes her if she is unable to void—to allow for efficient uterine contractions. o When there are risk factors for postpartal hemorrhage or frequent fundal massage has been necessary to sustain uterine contractions, the nurse maintains any vascular access (IV) started during labor and anticipates the need for a second IV in 20 o Clinical findings in the initial 24-48 hours tend to be related to group B streptococcus (GBS) o Late onset postpartal metritis is most commonly associated with genital mycoplasmas & Chlamydia trachomatis o In mild cases of metritis, the woman generally has:  Vaginal discharge that is bloody  Foul smelling  Scant or profuse o In severe cases:  Uterine tenderness  Sawtooth temperature spikes usually btwn 38.3 C (101F) & 40 C (104F)  Tachycardia  Chills  Foul-smelling lochia o Treatment:  Treated aggressive administration of antibiotics  Improvement should occur withn 48-72 hrs  Antibiotics are continued till the woman is afebrile for 24-48 hrs Most common 24-48 hours after birth ( POWERPOINT)  Assessment and signs and symptoms: o Fever o Chills o Anorexia o Malaise o Tachycardia o “Just not feeling well” o Lower abdominal pain o Malodorous lochia o Prolonged or painful afterpains  Planning/interventions o CBC with diff o Blood cultures and cultures of the lochia, endomerium and cervix o IV antibiotics( usually Gentamycin & Clindamycin ) o Semiflowler’s position o Perinatal hygiene o Hydration, nutrition o Comfort measures o Monitor elimination  Wound infections (Powerpoint) o Lacerations or episiotomy and Cesarean wounds o Perineal infections o Relatively rare o Related to infected lochia, fecal contamination, poor hygiene o Instrument assisted births (forceps/vacuums)  Abdominal wound (Powerpoint) o Prolonged hospital stay o Staphylococcus o Wound dehiscence  Assessment and signs and symptoms: (Powerpoint) o Do not present until the 4 -5 day postoperatively o Erythema o Edema o Induration o Warmth o Tenderness o Purulent drainage  Planning /interventions (Powerpoint) o Vital signs o CBC with diff o Wound cultures o Wound care 21 o Pharmacologic treatment: antibiotics o Sitz bath q 4-6 hours  Perineal wound infections o When perineal wound infection occurs it is recognized by the classic signs:  Redness  Warmth  Edema  Purulent drainage  And later on gaping of the wound that was well approximated previously  Local pain may be severe o Treat by draining the purulent material o Sutures are removed and wound is left open o Broad spectrum antibiotics are used o Once free of infection, mother returns for secondary closure of the wound under regional anesthesia  Cesarean wound infections o Predisposing factors to infection include:  Obesity  DM  Prolonged postpartal hospitalization  PROM  Metritis  Prolong labor  Anemia  Steroid therapy  Immunosupression o Signs of infection are: (may not be evident until after discharge)  Erythema  Warmth  Skin discoloration  Edema  Tenderness  Purulent drainage, sometimes mixed with sanguineous fluid  Gaping of wound edges  Fever, pain, malodorous lochia, & other systemic signs are also common  Abdominal distention & decreased bowel sounds may be noted.  Culture of the wound drainage commonly reveals mixed pathogens. o Clinical therapy  Diagnose by careful history and complete physical exam, blood tests, aerobic and anaerobic endometrial cultures, and urine cultures to rule out UTI  When localized infection develops it is treated with borad-spectrum antibiotics, sitz baths, and analgesics as necessary for pain relief  If abscess has developed or a stitch site is infected, the suture is removed & the area is allowed to drain  Packing the wound with saline gauze twice to three times daily using aseptic technique allows removal of necrotic debris when packing is removed  Cephalosporins, penicillinase- resistant penicillin, are commonly used with anaerobic coverage by clindamycin and gentamicin or ampicillin in refractory cases o Nursing assessment and diagnosis  Inspect perineum every 8-12hrs for signs of early infection  REEDA scale  Redness  Edema  Ecchymosis  Discharge  Approximation  Immediately report any degree of induration (hardening)  Note and report any fever, malaise, abdominal pain, foul smelling lochia, larger than expected uterus, tachycardia  WBC count can’t be used reliably because of the normal increase in WBC’s during postpartum period  A WBC count of 14,000 to 16,000 is not an unusual finding (NORMAL)  An increase of more than 30% in a 6hr period is indicative of infection o Nursing diagnosis:  Risk for injury related to the spread of infection 22 UTI’s  Pain related to the presence of infection  Risk for impaired parenting related to delayed parent-infant attachment secondary to malaise and other symptoms of infection o Planning and implementation  Make sure woman understand the importance of perineal care, good hygiene practices to prevent contamination of the perineum and hand washing  Wiping from front to back, changing pads after voiding  Encourage sitz baths which are cleansing and promote healing  Adequate fluid intake and diet high in protein and vitamin C which are necessary for wound healing  Breastfeeding mothers receiving antibiotics should be instructed to inspect the infants mouth for signs of thrush & to report the finding to the HCP  Inform patient about the importance of pelvic rest; that is she should not use tampons or douches nor have intercourse until she has been examined by the HCP.  If the woman is seriously ill, ongoing assessment of urine specific gravity, as well as intake and output is necessary. It is also necessary to carefully administer antibiotics as ordered and regulate the intravenous fluid rate. The postpartal woman is at increased risk of developing urinary tract problems caused  The normal postpartal diuresis  Increased bladder capacity  Decreased bladder sensitivity from stretching or trauma  Possible inhibited neural control of the bladder following the use of general or regional anesthesia  Contamination from catheterization, the number of catheterizations performed during labor has increased. It is essential that the mother empty the bladder completely with each voiding. Risk factors: PowerPoint • Trauma to the bladder from passage of the fetus from the uterus to the perineum • Hypotonictity of the lower urinary tract leading to urinary statis • Catheterizations and vaginal exams • Instrument-assisted births Assessment and signs and symptoms PowerPoint • Primary early sign is a lingering low –grade fever • Urinary freguency • Urgency • Dysuria • Hematuria • Suprapubic or lower abdominal pain • Dark urine with foul odor OVERDISTENTION OF THE BLADDER Overdistention occurs postpartally when the woman is unable to empty her bladder, usually because of trauma or the effects of anesthesia. Risk factors for urinary retention after childbirth include  Women who have not sufficiently recovered from the effects of anesthesia cannot void spontaneously, and catheterization is necessary.  After the effects of regional anesthesia have worn off, if the woman cannot void, postpartal urinary retention is highly indicative of UTI.  nulliparity,  Instrumental childbirth,  Prolonged labor Clinical Therapy  Managed by draining the bladder with a straight catheter as a one-time measure.  If the overdistention recurs or is diagnosed later in the postpartal period, an indwelling catheter is generally ordered for 24 hours.  An alternative urinary retention protocol involves bladder ultrasound scans with intervention based on the amount of urine volume  Example -If the volume is greater than 400 mL, the bladder is drained and the catheter removed, whereas if the volume is 400 mL or less, a spontaneous void is awaited for 1 hour after which another scan is performed NURSING ASSESSMENT  The overdistended bladder appears as a large mass, reaching sometimes to the umbilicus and displacing the uterine fundus upward.  Increased vaginal bleeding occurs, the fundus is boggy  the woman may complain of cramping as the uterus attempts to contract. 25  Supportive bra  Frequent breastfeeding  Local application of warm, moist-heat compresses  Analgesics that are compatible with breastfeeding  Nonsteroidal anti-inflammatory agents are recommended to treat both fever and inflammation.  Course of 7 to 10 days of antibiotics is appropriate, usually with a penicillinase-resistant penicillin or cephalosporin  Candidal infections can be especially stubborn. Initial treatment generally involves antifungal (Nystatin [Mycostatin]), miconazole (Monistat-Derm), or clotrimazole (Lotrimin) creams or ointments once or twice daily.  Treatment regimen must include the simultaneous treatment of the mother and baby dyad.  Oral nystatin (Mycostatin suspension) is the most common treatment for the baby, followed by oral fluconazole (Diflucan)  Oral Diflucan for the mother is excreted in breast milk but is not considered toxic to the infant and can be used if other agents fail  Women should be instructed to cleanse their nipples with warm water and allow to air dry before application of the antifungal medication.  For women who prefer to avoid medication, an alternative treatment is cleansing of the nipples with a solution of 1 tablespoon of vinegar in 1 cup of water or 1 teaspoon of baking soda in 1 cup of water, followed by air-drying.  Improved outcome, decreased duration of symptoms, and decreased incidence of breast abscess result if the breasts continue to be emptied by either nursing or pumping.  Thus continued breastfeeding is recommended in the presence of mastitis.  The woman should be contacted within 24 hours of initiation of treatment to ensure that symptoms are subsiding.  Abscess is more common when there is a lag of 24 hours or more between onset of symptoms and when the woman seeks care  Breast abscess may require incision and drainage, and intravenous antistaphylococcal antibiotics NURSING ASSESSMENT  Each day the nurse assesses the mother’s breast consistency, skin color, surface temperature, nipple condition, and presence of pain to detect early signs of problems that may predispose her to mastitis.  The mother should be observed breastfeeding her baby to ensure proper technique  If an infection develops, the nurse assesses for contributing factors such as cracked nipples, poor hygiene, engorgement, supplemental feedings, change in routine or infant feeding pattern, abrupt weaning, and lack of proper breast support so that these factors can be corrected as part of the treatment plan. Nursing diagnoses  Health-Seeking Behaviors related to lack of information about appropriate breastfeeding practices  Ineffective Breastfeeding related to pain secondary to development of mastitis PLANNING AND IMPLEMENTATION  Ideally mothers are instructed in proper breastfeeding technique prenatally.  The nurse assists the mother to breastfeed soon after childbirth and reviews correct technique.  Nurses need to encourage new mothers, even those not breastfeeding, to wear a good supportive bra at all times to prevent milk stasis, especially in the lower lobes.  Meticulous hand washing by the breastfeeding mother and all personnel is the primary measure in preventing epidemic nursery infections and subsequent maternal mastitis.  Prompt attention to mothers who have blocked milk ducts eliminates stagnant milk as a growth medium for bacteria.  If the mother find that one area of her breast feels distended, she can rotate the position of her infant for nursing, manually express milk remaining in the breast after feeding (usually necessary only if the infant is not sucking well), or massage the caked area toward the nipple as the infant nurses.  Mothers who develop mastitis can apply warm, moist compresses to the affected area before and during breastfeeding.  The nurse encourages the mother to breastfeed frequently, starting with the unaffected breast until letdown occurs in the affected breast, then switching to the affected breast until it is emptied completely  After nursing, the mother can leave a small amount of milk on each nipple to prevent cracking and allow nipples to air dry.  Early identification of and intervention for sore nipples are also essential, as is prompt assessment of the breastfeeding mother’s breast when thrush is discovered in her newborn’s mouth. DISCHARGE PLANNING AND HOME CARE TEACHING  The nurse must stress to the breastfeeding woman the importance of adequate breast and nipple care to prevent the development of cracks and fissures, a common portal for bacterial entry.  The woman should be aware of the importance of regular, complete emptying of the breasts to prevent engorgement and stasis.  She should also understand the role of letdown in successful breastfeeding, correct positioning of the infant on the nipple, proper latch-on, and the principle of supply and demand.  If the mother is taking antibiotics, she needs to understand the importance of completing the full course of antibiotics, even if the infection seems to clear quickly.  Infants tolerate the small amount of antibiotics in breast milk without difficulty.  The infant should also be checked for possible colonization with the same bacteria present in the mother’s breast. 26  . Because mastitis tends to develop after discharge, it is important to include in- formation about signs and symptoms in the discharge teaching  All flulike symptoms should be considered a sign of mastitis until proven otherwise. If symptoms develop, the woman should contact her caregiver immediately because prompt treatment helps to prevent abscess formation. Thromboemolic Complications Thromboembolic disease may occur during the antepartum, but it is generally considered a postpartum complication. • A thrombus is the formation of a blood clot or clots inside a blood vessel and is caused by inflammation (thrombophleblitis) or partial obstruction of the vessel. • Thromboembolic disease may occur antepartally, but it is generally considered a postpartal complication. Venous thrombosis refers to blood clot (thrombus formation) at an area of impeded blood flow in a superficial or deep vein, usually in the legs. • Assess leg for edema, peripheral pulse, temperature, color, and tenderness every 8 hours. • Assess Homans’ sign every 8 hours. It can lead to : • Superficial venous thrombosis • Deep venous thrombosis • Pulmonary embolism  Three major causes of thromboembolic disease are hypercoagulability of blood, venous stasis, and injury to the epithelium of the blood vessel.  Changes in the woman’s coagulation system in pregnancy contribute to hypercoagulability and compression of the common iliac vein by the gravid uterus, which leads to venous stasis.  Superficial vein thrombophlebitis complicates the general childbearing period for 1 in 500 to 750 women. In contrast, deep vein thrombosis (DVT), which is more serious, occurs most commonly in postpartum women between postpartum days 10 to 20. Factors contributing directly to the development of thromboembolic disease postpartally include (1) increased amounts of certain blood-clotting factors; (2) postpartal thrombocytosis (increased quantity of circulating platelets and their increased adhesiveness); (3) release of thromboplastin substances from the tissue of the decidua, placenta, and fetal membranes; and (4) increased amounts of fibrinolysis inhibitors. Risk factors • Delayed ambulation • Hx. of venous trombosis • Obseity • Maternal age > 35 years • Preexisting cardiopulmonary disease or diabetes • Route of birth (increased risk with cesarean births) • Smoking • Varicose veins • Immobility • Cesarian birth • DM • Multiparity • Anemia Superficial venous thrombosis  Assessment and signs and symptoms  Involves the saphenous vein  Lower extremity unilateral pain and tenderness  Localized redness and warmth  Absent or low-grade fever  Slight elevation of pulse  Symptoms may appear 3 to 4 days pospartal  More common in women with preexisting varices (enlarged veins), although it is not limited to these women.  They may also occur as a sequelae to IV catheterization.  A tender palpable cord may be noted along a portion of the veins. Treatment  Application of heat  Elevation of affected limb  Bedrest  Analgesia  Elastic stockings 27  Treatment involves application of local heat, elevation of the affected limb, bed rest, analgesics, and the use of elastic support hose.  Anticoagulants are usually not necessary unless complications develop. Pulmonary embolism is extremely rare. DVT -clinical manifestations  Unilateral leg pain swelling and warmth  Calf tenderness on ambulation  Positive /negative Homan’s sign  Deep vein thrombosis (DVT) is more frequently seen in women with a history of thrombosis.  Obstetric complications, such as hydramnios, preeclampsia, and operative birth, are also associated with an increased incidence.  After a clinical diagnosis of DVT, a woman’s risk in a subsequent pregnancy increases. Symptoms  Edema of the ankle and leg and an initial low-grade fever often followed by high temperature and chills.  Other findings include tenderness or pain, a palpable cord, changes in limb color, and difference in limb circumference of more than 2 cm (0.8 in.)  Most DVTs occur in the left leg. Because ofreflex arterial spasm, sometimes the limb is pale and cool to the touch—the so- called milk leg or phlegmasia alba dolens and peripheral pulses may be decreased. Planning /interventions  Anticoagulant therapy- IV heparin  Lab studies  Strict bedrest  Elevation of leg  Analgesic  Antibiotics  Supportive elastic stockings  PO wafarin (Coumadin)  In questionable cases, venography provides the most accurate diagnosis of pelvic and calf DVT  If fever is present, deep thrombophlebitis is suspected, and the woman is also given antibiotics. In most cases thrombectomy (surgical removal of the clot) is not necessary.  Once the symptoms have subsided (usually in several days), the woman may begin ambulation while wearing elastic support stockings. Intravenous heparin is continued until prothrombin time reaches 1.5 to 2, and treatment with sodium warfarin (Coumadin) is begun.  The woman continues taking warfarin for 3 to 6 months at home. While taking warfarin, prothrombin times are assessed periodically to maintain correct dosage levels.  If stirrups are used, they should be comfortably padded and adjusted to provide correct support and prevent pressure on popliteal vessels.  Early ambulation is encouraged following birth, and the knee gatch on the bed should be avoided.  Women confined to bed following a cesarean birth are encouraged to perform regular leg exercises to promote venous return.  Once DVT is diagnosed, the nurse maintains the heparin therapy, provides appropriate comfort measures, and monitors the woman closely for signs of pulmonary embolism.  The nurse also assesses for evidence of bleeding related to heparin and keeps the antagonist for heparin, protamine sulfate, readily available.  Clients on warfarin need to be educated about foods high in vitamin K and the need to strive for consistent daily intake.  When the dietary intake of these foods such as cauliflower, soybean and canola oil, mayonnaise. broccoli, green and black tea, peppers, spinach, collard greens and others decreases significantly, there is a risk of bleeding.  Many multivitamins contain vitamin K; clients on warfarin may take them but should do so consistently.  They will check the PT INR and make sure is not greater than 3.  Bleeding should be reported if it fails to stop within 10 minutes.  If they are breastfeeding coumadin is contraindicated of if she is pregnant so she could use heparin subcut  Observe for signs of anticoagulant overdose with resultant bleeding,  including: o Hematuria o Epistaxis o Ecchymosis o Bleeding gums  Provide protamine sulfate, per physician order, to combat bleeding problems  related to heparin overdose.  Discuss ways of avoiding circulatory stasis such as avoiding prolonged standing, sitting, and crossing legs Nursing diagnoses that may apply to a postpartal woman with a thrombotic disease include the following: