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Patients are susceptible to postpartum hemorrhage and infection for several days after giving birth.
Accurately assess normal involution and estimated blood loss because symptoms of shock may not appear until the patient has lost a significant amount of her total blood volume. Preparation and resources to manage maternal hemorrhage in a timely manner can be lifesaving.
Prevent postpartum infections with adequate patient care techniques, hand hygiene, and the appropriate use of antibiotic therapy.
The postpartum period begins with the expulsion of the placenta and continues until the maternal reproductive organs have returned to their normal, nonpregnant state. This period varies for each patient as the maternal systems continue to change during the first 6 weeks after birth.undefined#ref1">1 During the postpartum period, the uterus undergoes involution and other maternal reproductive organs return to their nonpregnant state. In addition, the breasts and the cardiovascular, respiratory, endocrine, urinary, gastrointestinal, integumentary, musculoskeletal, neurologic, and immune systems also must go through multiple changes.1
Monitoring during the postpartum period should be dictated by the type of events during delivery, the type of anesthesia or analgesia used, and any complications identified.3 Nursing assessment helps detect problems early in order to initiate interventions in a timely manner and thus prevent serious complications. The nurse incorporates education into assessments, instructing the patient and her support person about what to expect during the postpartum period and what to report to her practitioner once she goes home.2
Along with all the physiologic changes in the postpartum period, the patient and her support person are also undergoing psychosocial changes as they adapt to the newborn. This bonding and integration process is essential to a positive outcome for the postpartum period. The nurse is also responsible for performing psychosocial assessments based on skillful observation and interviewing at regular intervals throughout the inpatient stay.11
Maternal assessments related to the prevention of hemorrhage include vital signs, uterine fundal location and tone, bladder, lochia, and perineal and labial areas.13 The maternal temperature should be assessed at the beginning of the immediate postpartum period and blood pressure, pulse, and respirations should be assessed every 15 minutes for approximately 2 hours after the birth.3,13 Assessment of the uterine fundus and lochia should be performed with each vital sign assessment.13 Ongoing postpartum assessments (Table 1) should be performed at least once per shift, and more frequently if complications are encountered, according to the organization’s practice. Periodic assessments should be completed to detect deviations from normal, determine the level of patient discomfort, ensure patient safety, assess the transition to parenting, and provide appropriate patient and support person education.
All postpartum units should have standardized postpartum hemorrhage medication procedures. Additionally, practitioners should stay up-to-date regarding the use of uterotonic agents. Uterotonic medications such as oxytocin, methylergonovine, misoprostol, and carboprost should be readily available for a postpartum hemorrhage emergency. All postpartum units should be equipped with a cart or kit to be used in a postpartum hemorrhage emergency. A cart would include all instruments needed to treat a postpartum hemorrhage before a hysterectomy is considered.6
Rationale: Actual weight should be verified or measured. Stated, estimated, or historical weight should not be used.
Rationale: Crackles in the lungs may indicate fluid overload.
Monitor vital signs closely if the patient has excessive bleeding.
Rationale: Maintaining firm uterine tone is essential to prevent excessive postpartum bleeding.
Uterine inversion is an obstetric emergency and can be accompanied by hemorrhage and shock.
Rationale: Although the amount of lochia may appear to be small, lochia may flow on the linens under the patient and excessive bleeding may be undetected. The side-lying position will provide an unobstructed view of the perineum.
Immediately assess and intervene with a patient and notify the practitioner if a perineal pad becomes saturated in 1 hour or less with pooling of blood under the patient. This indicates excessive bleeding.
Rationale: Excessive postpartum blood loss may result from undetected hematomas and lacerations.
Rationale: A distended bladder may cause uterine atony and excessive uterine bleeding.
Rationale: The normal increase of clotting factors and fibrinogen beginning in pregnancy and continuing in the immediate postpartum period in combination with vessel damage and decreased activity places patients in the postpartum period at increased risk for developing venous thromboembolism.
Rationale: The practitioner is notified because further assessment and testing may be indicated.
Ensure adequate supervision and monitoring for the mother and her newborn after administration of opioids because they may cause respiratory depression.
Do not discharge the obstetric patient from the recovery care until she has completely recovered from the effects of anesthesia.
Rationale: Rho(D) immune globulin is administered to an Rh negative, Coombs-negative mother whose newborn is Rh positive.
2 Injection of Rh immune globulin within 72 hours after birth (even when it has been administered during the antepartum period) appears to prevent alloimmunization, also known as Rh-isoimmunization, in the Rh-negative woman who has had a fetomaternal transfusion of Rh-positive fetal red blood cells (RBCs).
Rationale: Women who are rubella nonimmune should receive a rubella vaccine before discharge to prevent contracting rubella during future pregnancies because rubella is known to be teratogenic.
Rationale: The Tdap vaccine is recommended for pregnant patients during each pregnancy in the early part of gestational weeks 27 through 36 and for postpartum patients who have not previously received it.
7 Postpartum administration only provides protection to the mother and takes 2 weeks to provide protection against transmission of pertussis to the newborn.
7 The only time patients should receive the vaccine in the postpartum period is if they have never before received the vaccine. A repeat postpartum vaccination is not recommended.
Rationale: The stressful postpartum period may lead to the onset of various mood disorders such as postpartum baby blues, depression, or psychosis. Women should be screened at least once during the perinatal period for signs of depression and anxiety.
3 Women with signs of depression and anxiety, a history of perinatal mood disorders, or risk factors for perinatal mood disorders must be closely assessed, monitored, and evaluated and appropriate treatment should be facilitated by the practitioner.
Behling, D.J., Renaud, M. (2015). Development of an obstetric vital sign alert to improve outcomes in acute care obstetrics. Nursing for Women’s Health, 19(2), 128-141. doi:10.1111/1751-486X.12185
Shields, L.E. and others. (2015). Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. American Journal of Obstetrics & Gynecology, 212(3), 272-280. doi:10.1016/j.ajog.2014.07.012
Skupski, D.W. and others. (2017). Improvement in outcomes of major obstetric hemorrhage through systematic change. Obstetrics & Gynecology, 130(4), 770-777. doi:10.1097/AOG.0000000000002207
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