C hapter Postpartum Complications · hemorrhagic (hypovolemic) ... to the woman and family...

819

Postpartum

Complications

C h a p t e r

DEITRA LEONARD LOWDERMILK

25

• Identify causes, signs and symptoms, possiblecomplications, and medical and nursing man-agement of postpartum hemorrhage.

• Differentiate the causes of postpartum infection.

• Summarize assessment and care of womenwith postpartum infection.

• Describe thromboembolic disorders, includingincidence, etiology, signs and symptoms, andmanagement.

• Describe sequelae of childbirth trauma.• Discuss postpartum emotional complications,

including incidence, risk factors, signs andsymptoms, and management.

• Summarize the role of the nurse in the homesetting in assessing potential problems andmanaging care of women with postpartumcomplications.

LEARNING OBJECTIVES

endometritis Postpartum uterine infection, oftenbeginning at the site of the placental implantation

hemorrhagic (hypovolemic) shock Clinical condi-tion in which the peripheral blood flow is inade-quate to return sufficient blood to the heart fornormal function, particularly oxygen transport tothe organs or tissue

inversion of the uterus Condition in which theuterus is turned inside out so that the fundus in-trudes into the cervix or vagina

mastitis Infection in a breast, usually confined to amilk duct, characterized by influenza-like symp-toms and redness and tenderness in the affectedbreast

mood disorders Disorders that have a disturbancein the prevailing emotional state as the dominantfeature; cause is unknown

pelvic relaxation Refers to the lengthening andweakening of the fascial supports of pelvic struc-tures

postpartum depression (PPD) Depression occur-ring within 4 weeks of childbirth, lasting longer

than postpartum blues and characterized by a va-riety of symptoms that interfere with activities ofdaily living and care of the baby

postpartum hemorrhage (PPH) Excessive bleedingafter childbirth; traditionally defined as a loss of500 ml or more after a vaginal birth and 1000 mlafter a cesarean birth

puerperal infection Infection of the pelvic organsduring the postbirth period; also called postpartuminfection

subinvolution Failure of a part (e.g., the uterus) toreduce to its normal size and condition after en-largement from functional activity (e.g., pregnancy)

thrombophlebitis inflammation of a vein with sec-ondary clot formation

urinary incontinence (UI) Uncontrollable leakage ofurine

uterine atony Relaxation of uterus; leads to post-partum hemorrhage

KEY TERMS AND DEFINITIONS

ELECTRONIC RESOURCESAdditional information related to the content in Chapter 25 can be found on

the companion website at http://evolve.elsevier.com/Lowdermilk/Maternity/• NCLEX Review Questions• WebLinks

or on the interactive companion CD • NCLEX Review Questions• Plan of Care—Postpartum Hemorrhage• Plan of Care—Postpartum Depression

819-847_CH25_Lowdermilk.qxd 12/7/05 1:08 PM Page 819

Collaborative efforts of the health care teamare needed to provide safe and effective careto the woman and family experiencing post-partum complications. This chapter focuses

on hemorrhage, infection, sequelae of childbirth trauma, andpsychologic complications.

Definition and IncidencePostpartum hemorrhage (PPH) continues to be a leadingcause of maternal morbidity and mortality in the UnitedStates (Papp, 2003) and worldwide. It is a life-threateningevent that can occur with little warning and is often unrec-ognized until the mother has profound symptoms. PPH hasbeen traditionally defined as the loss of more than 500 mlof blood after vaginal birth and 1000 ml after cesarean birth.A 10% change in hematocrit between admission for laborand postpartum or the need for erythrocyte transfusion alsohas been used to define PPH (American College of Obste-tricians and Gynecologists [ACOG], 1998). However, defin-ing PPH is not a clear-cut issue. ACOG states that hemor-rhage is difficult to define clinically. Diagnosis is often basedon subjective observations, with blood loss often being un-derestimated by as much as 50% (ACOG, 1998).

Traditionally, PPH has been classified as early or late withrespect to the birth. Early, acute, or primary PPH occurswithin 24 hours of the birth. Late or secondary PPH occursmore than 24 hours but less than 6 weeks postpartum(ACOG, 1998). Today’s health care environment encouragesshortened stays after birth, thereby increasing the potentialfor acute episodes of PPH to occur outside the traditionalhospital or birth center setting.

Etiology and Risk FactorsIt is helpful to consider the problem of excessive bleedingwith reference to the stages of labor. From birth of the in-fant until separation of the placenta, the character and quan-tity of blood passed may suggest excessive bleeding. For ex-ample, dark blood is probably of venous origin, perhapsfrom varices or superficial lacerations of the birth canal.Bright blood is arterial and may indicate deep lacerations ofthe cervix. Spurts of blood with clots may indicate partial pla-cental separation. Failure of blood to clot or remain clottedindicates a pathologic condition or coagulopathy such as dis-seminated intravascular coagulation (DIC) (ACOG, 1998).

Excessive bleeding may occur during the period from theseparation of the placenta to its expulsion or removal. Com-monly such excessive bleeding is the result of incomplete pla-cental separation, undue manipulation of the fundus, or ex-cessive traction on the cord. After the placenta has beenexpelled or removed, persistent or excessive blood loss usu-ally is the result of atony of the uterus or inversion of theuterus into the vagina. Late PPH may be the result of subin-volution of the uterus, endometritis, or retained placental

POSTPARTUM HEMORRHAGE

fragments (ACOG, 1998). Risk factors for PPH are listed inBox 25-1.

Uterine AtonyUterine atony is marked hypotonia of the uterus. Normally,placental separation and expulsion are facilitated by con-traction of the uterus, which also prevents hemorrhage fromthe placental site. The corpus is in essence a basket-weave ofstrong, interlacing smooth muscle bundles through whichmany large maternal blood vessels pass (see Fig. 4-3). If theuterus is flaccid after detachment of all or part of the pla-centa, brisk venous bleeding occurs, and normal coagulationof the open vasculature is impaired and continues until theuterine muscle is contracted.

Uterine atony is the leading cause of PPH, complicat-ing approximately one in 20 births (Shevell & Malone,2003). It is associated with high parity, hydramnios, amacrosomic fetus, and multifetal gestation. In such con-ditions, the uterus is “overstretched” and contracts poorlyafter the birth. Other causes of atony include traumaticbirth, use of halogenated anesthesia (e.g., halothane) ormagnesium sulfate, rapid or prolonged labor, chorioam-nionitis, and use of oxytocin for labor induction or aug-mentation (Shevell & Malone, 2003).

820 U N I T S E V E N COMPLICATIONS OF CHILDBEARING

Risk Factors for Postpartum Hemorrhage

Uterine atony• Overdistended uterus

—Large fetus—Multiple fetuses—Hydramnios—Distention with clots

• Anesthesia and analgesia—Conduction anesthesia

• Previous history of uterine atony• High parity• Prolonged labor, oxytocin-induced labor• Trauma during labor and birth

—Forceps-assisted birth—Vacuum-assisted birth—Cesarean birth

Lacerations of the birth canalRetained placental fragmentsRuptured uterusInversion of the uterusPlacenta accretaCoagulation disordersPlacental abruptionPlacenta previaManual removal of a retained placentaMagnesium sulfate administration during labor or

postpartum periodEndometritisUterine subinvolution

BOX 25-1


Lacerations of the Genital TractLacerations of the cervix, vagina, and perineum also arecauses of PPH. Hemorrhage related to lacerations should besuspected if bleeding continues despite a firm, contracteduterine fundus. This bleeding can be a slow trickle, an ooz-ing, or frank hemorrhage. Factors that influence the causesand incidence of obstetric lacerations of the lower genitaltract include operative birth, precipitate birth, congenital ab-normalities of the maternal soft parts, and contracted pelvis.Size, abnormal presentation, and position of the fetus;relative size of the presenting part and the birth canal; pre-vious scarring from infection, injury, or operation; and vul-var, perineal, and vaginal varicosities also can cause lacera-tions.

Extreme vascularity in the labial and periclitoral areas of-ten results in profuse bleeding if laceration occurs. Hema-tomas also may be present.

Lacerations of the perineum are the most common of allinjuries in the lower portion of the genital tract. These areclassified as first, second, third, and fourth degree (see Chap-ter 14). An episiotomy may extend to become either third-or fourth-degree laceration.

Prolonged pressure of the fetal head on the vaginal mu-cosa ultimately interferes with the circulation and may pro-duce ischemic or pressure necrosis. The state of the tissuesin combination with the type of birth may result in deepvaginal lacerations, with consequent predisposition to vagi-nal hematomas.

Pelvic hematomas may be vulvar, vaginal, or retroperi-toneal in origin. Vulvar hematomas are the most com-mon. Pain is the most common symptom, and most vul-var hematomas are visible. Vaginal hematomas occur morecommonly in association with a forceps-assisted birth,an episiotomy, or primigravidity (Benedetti, 2002). Dur-ing the postpartum period, if the woman reports a per-sistent perineal or rectal pain or a feeling of pressure inthe vagina, a careful examination is made. However, aretroperitoneal hematoma may cause minimal pain, andthe initial symptoms may be signs of shock (Benedetti,2002).

Cervical lacerations usually occur at the lateral angles ofthe external os. Most are shallow, and bleeding is minimal.More extensive lacerations may extend into the vaginal vaultor into the lower uterine segment.

Retained PlacentaNonadherent retained placentaRetained placenta may result from partial separation of a

normal placenta, entrapment of the partially or completelyseparated placenta by an hourglass constriction ring of theuterus, mismanagement of the third stage of labor, or abnor-mal adherence of the entire placenta or a portion of the pla-centa to the uterine wall. Placental retention because of poorseparation is common in very preterm births (20 to 24 weeksof gestation).

Management of nonadherent retained placenta is by man-ual separation and removal by the primary health careprovider. Supplementary anesthesia is not usually needed forwomen who have had regional anesthesia for birth. For otherwomen, administration of light nitrous oxide and oxygen in-halation anesthesia or intravenous (IV) thiopental facilitatesuterine exploration and placental removal. After this re-moval, the woman is at continued risk for PPH and for in-fection.

Adherent retained placentaAbnormal adherence of the placenta occurs for reasons

unknown, but it is thought to result from zygotic implan-tation in an area of defective endometrium so that there isno zone of separation between the placenta and the decidua.Attempts to remove the placenta in the usual manner are un-successful, and laceration or perforation of the uterine wallmay result, putting the woman at great risk for severe PPHand infection (Cunningham et al., 2005).

Unusual placental adherence may be partial or complete.The following degrees of attachment are recognized:

• Placenta accreta—slight penetration of myometrium byplacental trophoblast

• Placenta increta—deep penetration of myometrium byplacenta

• Placenta percreta—perforation of uterus by placentaBleeding with complete or total placenta accreta may not

occur unless separation of the placenta is attempted. Withmore extensive involvement, bleeding will become profusewhen removal of the placenta is attempted. Treatment in-cludes blood component replacement therapy, and hys-terectomy may be indicated (Clark, 2004).

Inversion of the UterusInversion of the uterus after birth is a potentially life-threatening but rare complication. The incidence of uterineinversion is approximately 1 in 2000 to 2500 births (ACOG,1998), and the condition may recur with a subsequent birth.Uterine inversion may be partial or complete. Complete in-version of the uterus is obvious; a large, red, rounded mass(perhaps with the placenta attached) protrudes 20 to 30 cmoutside the introitus. Incomplete inversion cannot be seenbut must be felt; a smooth mass will be palpated throughthe dilated cervix. Contributing factors to uterine inversioninclude fundal implantation of the placenta, vigorous fun-dal pressure, excessive traction applied to the cord, uterineatony, leiomyomas, and abnormally adherent placental tis-sue (Bowes & Thorp, 2004). Uterine inversion occurs mostoften in multiparous women and with placenta accreta orincreta. The primary presenting signs of uterine inversion arehemorrhage, shock, and pain.

Prevention—always the easiest, cheapest, and most effec-tive therapy—is especially appropriate for uterine inversion.The umbilical cord should not be pulled on strongly unlessthe placenta has definitely separated.

C H A P T E R 25 Postpartum Complications 821


Subinvolution of the UterusLate postpartum bleeding may occur as a result of subin-volution of the uterus. Recognized causes of subinvolutioninclude retained placental fragments and pelvic infection.

Signs and symptoms include prolonged lochial discharge,irregular or excessive bleeding, and sometimes hemorrhage.A pelvic examination usually reveals a uterus that is largerthan normal and that may be boggy.

Assessment and NursingDiagnosesPPH may be sudden and even exsanguinating. The nursemust therefore be alert to the symptoms of hemorrhage andhypovolemic shock and be prepared to act quickly to min-imize blood loss (Fig. 25-1 and Box 25-2).

CARE MANAGEMENT


Anticipate pharmacologicmanagement: antibiotics,

vasoactive drugs,uterotonic agents

Anticipate surgicalintervention

Anticipate fluid/bloodreplacement therapy

Continuous assessmentof maternal

hemodynamic status

Assess for underlyingcause and start

supplemental oxygen

Suspectedcoagulopathy

Placentaretained

Anticipate needfor anesthesia

Give tocolyticas ordered

Anticipate and assistwith manual

removal of placenta

Give uterotonicsas ordered

If bleeding continuesor signs and

symptoms of shock

Uterus firm

Assess for cervicalor vaginal

lacerations/hematoma

Anticipate and assistwith repair

Bleeding continues

Start supplemental oxygen

Repeat laboratory studies

Anticipate fluid/bloodreplacement therapy

Anticipate surgical intervention

Atony persistsUterus firms

Continueassessmentsfor maternal

hemodynamicstatus

Fundus boggy

Empty urinarybladder

Give uterotonicsas ordered

Placentadelivered

Fundalmassage

Postbirth hemorrhage

Assessment to determine source ofbleeding and signs of shock

Anticipate laboratory studies: CBC, blood typingand crossmatch, coagulation studies

Establish venous access/verify patencyof venous access and start IV fluids

Fig. 25-1 Nursing assessments for postpartum bleeding. CBC, Complete blood count; IV, in-travenous; s/s, signs and symptoms; uterotonics, medications to contract the uterus.


The woman’s history should be reviewed for factors thatcause predisposition to PPH (see Box 25-1). The fundus isassessed to determine whether it is firmly contracted at ornear the level of the umbilicus. Bleeding should be assessedfor color and amount. The perineum is inspected for signsof lacerations or hematomas to determine the possible sourceof bleeding.

Vital signs may not be reliable indicators of shock im-mediately postpartum because of the physiologic adaptationsof this period. However, frequent vital sign measurementsduring the first 2 hours after birth may identify trends relatedto blood loss (e.g., tachycardia, tachypnea, decreasing bloodpressure).

Assessment for bladder distention is important becausea distended bladder can displace the uterus and prevent con-traction. The skin is assessed for warmth and dryness; nailbeds are checked for color and promptness of capillary re-fill. Laboratory studies include evaluation of hemoglobinand hematocrit levels.

Late PPH develops at least 24 hours after the birth or laterin the postpartum period. The woman may be at home whenthe symptoms occur. Discharge teaching should emphasizethe signs of normal involution, as well as potential compli-cations. Nursing diagnoses for women experiencing PPH in-clude the following:

• Deficient fluid volume related to—excessive blood loss secondary to uterine atony,lacerations, or uterine inversion

• Risk for imbalanced fluid volume related to—blood and fluid volume replacement therapy

• Risk for infection related to—excessive blood loss or exposed placental attach-ment site

• Risk for injury related to—attempted manual removal of retained placenta—administration of blood products—operative procedures

• Fear or anxiety related to—threat to self—deficient knowledge regarding procedures and op-erative management

• Risk for impaired parenting related to—separation from infant secondary to treatment regimen

• Ineffective (peripheral) tissue perfusion related to—excessive blood loss and shunting of blood to cen-tral circulation

Expected Outcomes of CareExpected outcomes of care for the woman experiencing PPHmay include that the woman will do the following:

• Maintain normal vital signs and laboratory values

• Develop no complications related to excessive bleeding

• Express understanding of her condition, its manage-ment, and discharge instructions

• Identify and use available support systems

Plan of Care and InterventionsMedical managementEarly recognition and acknowledgment of the diagnosis

of PPH are critical to care management. The first step is toevaluate the contractility of the uterus. If the uterus is hy-potonic, management is directed toward increasing con-tractility and minimizing blood loss.

The initial management of excessive postpartum bleed-ing is firm massage of the uterine fundus, expression of anyclots in the uterus, elimination of any bladder distention,and continuous IV infusion of 10 to 40 units of oxytocinadded to 1000 ml of lactated Ringer’s or normal saline so-lution. If the uterus fails to respond to oxytocin, a 0.2-mgdose of ergonovine (Ergotrate) or methylergonovine(Methergine) may be given intramuscularly to produce sus-tained uterine contractions. However, it is more common toadminister a 0.25-mg dose of a derivative of prostaglandinF2� (carboprost tromethamine) intramuscularly. It also canbe given intramyometrially at cesarean birth or intraab-dominally after vaginal birth. Oral (400 mcg) and rectal(1000 mcg) administration of misoprostol also is used, butthere is no consensus about efficacy (Berg & Smith, 2002).See Table 25-1 for a comparison of drugs used to managePPH. In addition to the medications used to contract theuterus, rapid administration of crystalloid solutions and/orblood or blood products will be needed to restore thewoman’s intravascular volume (Mousa & Walkinshaw, 2001).

Use of ergonovine or methylergonovineis contraindicated in the presence of hypertension orcardiovascular disease. Prostaglandin F2a should be

NURSE ALERT


Noninvasive Assessments of CardiacOutput in Postpartum Patients Who AreBleeding

• Palpation of pulses (rate, quality, equality)—Arterial—Blood pressure

• Auscultation—Heart sounds and murmurs—Breath sounds

• Inspection—Skin color, temperature, turgor—Level of consciousness—Capillary refill—Urinary output—Neck veins—Pulse oximetry—Mucous membranes

• Observation—Presence or absence of anxiety, apprehension, rest-

lessness, disorientation

BOX 25-2


used cautiously in women with cardiovascular diseaseor asthma (Bowes & Thorp, 2004).

Hypotonic uterus. Oxygen can be given to enhanceoxygen delivery to the cells. A urinary catheter is usually in-serted to monitor urine output as a measure of intravascu-lar volume. Laboratory studies usually include a completeblood count with platelet count, fibrinogen, fibrin split prod-ucts, prothrombin time, and partial thromboplastin time.Blood type and antibody screen are done if not previouslyperformed (ACOG, 1998).

If bleeding persists, bimanual compression may be con-sidered by the obstetrician or nurse-midwife. This procedureinvolves inserting a fist into the vagina and pressing theknuckles against the anterior side of the uterus, and thenplacing the other hand on the abdomen and massaging theposterior uterus with it. If the uterus still does not becomefirm, manual exploration of the uterine cavity for retainedplacental fragments is implemented. If the preceding pro-cedures are ineffective, surgical management may be the onlyalternative. Surgical management options include vessel liga-tion (uteroovarian, uterine, hypogastric), selective arterial em-bolization, and hysterectomy (Shevell & Malone, 2003).

Bleeding with a contracted uterus. If theuterus is firmly contracted and bleeding continues, thesource of bleeding still must be identified and treated. As-sessment may include visual or manual inspection of theperineum, vagina, uterus, cervix, or rectum and laboratorystudies (e.g., hemoglobin, hematocrit, coagulation studies,platelet count). Treatment depends on the source of thebleeding. Lacerations are usually sutured. Hematomas maybe managed with observation, cold therapy, ligation of the

bleeding vessel, or evacuation. Fluids and or blood re-placement may be needed (Benedetti, 2002).

Uterine inversion. Uterine inversion is an emer-gency situation requiring immediate recognition, replace-ment of the uterus within the pelvic cavity, and correctionof associated clinical conditions. Tocolytics (e.g., magnesiumsulfate, terbutaline) or halogenated anesthetics may be givento relax the uterus before attempting replacement (Hostetler& Bosworth, 2000). Medical management of this conditionincludes repositioning the uterus, giving oxytocin after theuterus is repositioned, treating shock, and initiating broad-spectrum antibiotics (Benedetti, 2002; Bowes & Thorp,2004).

Subinvolution. Treatment of subinvolution dependson the cause. Ergonovine, 0.2 mg every 4 hours for 2 or 3 days, and antibiotic therapy are the most common med-ications used (Cunningham et al., 2005). Dilation and curet-tage (D&C) may be needed to remove retained placentalfragments or to debride the placental site.

Herbal remediesHerbal remedies have been used with some success to

control PPH after the initial management and control ofbleeding, particularly outside the United States. Some herbshave homeostatic actions, whereas others work as oxytocicagents to contract the uterus (Tiran & Mack, 2000). Box 25-3 lists herbs that have been used and their actions. How-ever, published evidence of the safety and efficacy of herbaltherapy is lacking. Evidence from well-controlled studies isneeded before recommendation for practice should be made(Brucker, 2001).


TABLE 25-1

Drugs Used to Manage Postpartum Hemorrhage

OXYTOCIN METHYLERGONOVINE PROSTAGLANDIN F2�

(PITOCIN) (METHERGINE)* (PROSTIN/15M; HEMABATE)

IM, Intramuscularly; IV, intravenously.*Information about methylergonovine may also be used to describe ergonovine (Ergotrate).

Continue to monitor vaginalbleeding and uterine tone

Check blood pressure beforegiving and do not give if�140/90 mm Hg; continuemonitoring vaginal bleedingand uterine tone

Continue to monitorvaginal bleedingand uterine tone

Nursing considerations

0.25 mg IM or intramyometri-ally every 15 to 90 min upto eight doses

0.2 mg IM q2-4h up to five doses;0.2 mg IV only for emergency

10-40 units/L dilutedin lactated Ringer’ssolution or normalsaline at 125 to 200milliunits/min IV or10 to 20 units IM

Dosage and routeAsthma, hypersensitivityHypertension, cardiac diseaseNone for PPHContraindications

Headache, nausea, vomiting,fever

Hypertension, nausea, vomiting,headache

Infrequent; water in-toxication; nauseaand vomiting

Side effects

Contraction of uterusContraction of uterusContraction of uterus;decreases bleeding

Action


Nursing interventionsImmediate nursing care of the woman with PPH includes

assessment of vital signs, uterine consistency, bleeding, andadministration of oxytocin or other drugs to stimulate uter-ine contraction according to standing orders or protocols.Venous access is established if not already in place. The pri-mary health care provider is notified if not present.

The woman and her family will be anxious about her con-dition. The nurse can intervene by calmly providing expla-nations about interventions being performed and the needto act quickly.

After the bleeding has been controlled, the care of thewoman with lacerations of the perineum is similar to thatof women with episiotomies (analgesia as needed for painand hot or cold applications as necessary). The need for in-creased roughage in the diet and increased intake of fluidsis emphasized. Stool softeners may be used to assist thewoman in reestablishing bowel habits without straining andputting stress on the suture lines.

To avoid injury to the suture line, awoman with third- or fourth-degree lacerations is notgiven rectal suppositories or enemas or digital rectal examinations.

The care of the woman who has experienced an inversionof the uterus focuses on immediate stabilization of hemo-dynamic status. This requires close observation of her re-sponse to treatment to prevent shock or fluid overload. Ifthe uterus has been repositioned manually, care must betaken to avoid aggressive fundal massage.

Discharge instructions for the woman who has had PPHare similar to those for any postpartum woman. In addition,she should be told that she will probably feel fatigue, even

NURSE ALERT

exhaustion, and will need to limit her physical activities toconserve her strength. She may need instructions in in-creasing her dietary iron and protein intake and iron sup-plementation to rebuild lost red blood cell (RBC) volume.She may need assistance with infant care and household ac-tivities until she has regained strength. Some women haveproblems with delayed or insufficient lactation and post-partum depression (PPD). Referrals for home care follow-upor to community resources may be needed (see Resourcesat the end of this chapter).

EvaluationThe nurse can be reasonably assured that care was effectiveto the extent that the expected outcomes were achieved (Planof Care).

Hemorrhage may result in hemorrhagic (hypovolemic)shock. Shock is an emergency situation in which the perfu-sion of body organs may become severely compromised anddeath may occur. Physiologic compensatory mechanisms areactivated in response to hemorrhage. The adrenal glands re-lease catecholamines, causing arterioles and venules in theskin, lungs, gastrointestinal tract, liver, and kidneys to con-strict. The available blood flow is diverted to the brain andheart and away from other organs, including the uterus. Ifshock is prolonged, the continued reduction in cellular oxy-genation results in an accumulation of lactic acid and acidosis(from anaerobic glucose metabolism). Acidosis (reducedserum pH) causes arteriolar vasodilation; venule vasocon-striction persists. A circular pattern is established; that is, de-creased perfusion, increased tissue anoxia and acidosis,edema formation, and pooling of blood further decrease theperfusion. Cellular death occurs. See the Emergency box forassessments and interventions for hemorrhagic shock.

Medical ManagementVigorous treatment is necessary to prevent adverse sequelae.Medical management of hypovolemic shock involves re-storing circulating blood volume and treating the cause ofthe hemorrhage (e.g., lacerations, uterine atony, or inversion).To restore circulating blood volume, a rapid IV infusion of crystalloid solution is given at a rate of 3 ml infused forevery 1 ml of estimated blood loss (e.g., 3000 ml infused for1000 ml of blood loss). Packed RBCs are usually infused ifthe woman is still actively bleeding and no improvement inher condition is noted after the initial crystalloid infusion.Infusion of fresh-frozen plasma may be needed if clottingfactors and platelet counts are below normal values (Cunningham et al., 2005).

Nursing InterventionsHemorrhagic shock can occur rapidly, but the classic signsof shock may not appear until the postpartum woman has

HEMORRHAGIC (HYPOVOLEMIC) SHOCK


Herbal Remedies for PostpartumHemorrhage

HERB ACTION

Witch hazel HomeostaticLady’s mantle HomeostaticBlue cohosh OxytocicCotton root bark OxytocicMotherwort Promotes uterine contraction;

vasoconstrictiveShepherd’s purse Promotes uterine contractionAlfalfa leaf Increases availability of vitamin

K; increases hemoglobinNettle Increases availability of vitamin

K; increases hemoglobinRaspberry leaf Homeostatic; promotes uterine

contraction

Source: Beal, M. (1998). Use of complementary and alternative therapiesin reproductive medicine. Journal of Nurse-Midwifery, 43(3), 224-233;Schirmer, G. (1998). Herbal medicine. Bedford TX: MED2000; Skidmore-Roth, L. (2004). Mosby’s handbook of herbs and natural supplements (2nded.). St. Louis: Mosby; & Tiran, D., & Mack, S. (Eds.). (2000). Complementarytherapies for pregnancy and childbirth (2nd ed.). Edinburgh: BaillièreTindall.

BOX 25-3


lost 30% to 40% of blood volume. The nurse must continueto reassess the woman’s condition, as evidenced by the de-gree of measurable and anticipated blood loss, and mobilizeappropriate resources.

Most interventions are instituted to improve or monitortissue perfusion. The nurse continues to monitor the wo-man’s pulse and blood pressure. If invasive hemodynamicmonitoring is ordered, the nurse may assist with the place-ment of the central venous pressure (CVP) or pulmonary ar-tery (Swan-Ganz) catheter and monitor CVP, pulmonary

artery pressure, or pulmonary artery wedge pressure as or-dered (Poole & White, 2003).

Additional assessments to be made include evaluation ofskin temperature, color, and turgor, as well as assessment ofthe woman’s mucous membranes. Breath sounds should beauscultated before fluid volume replacement, if possible, toprovide a baseline for future assessment. Inspection for ooz-ing at the sites of incisions or injections and assessment of thepresence of petechiae or ecchymosis in areas not associatedwith surgery or trauma are critical in the evaluation for DIC.


Postpartum HemorrhagePLAN OF CARE

NURSING DIAGNOSIS Deficient fluid volume re-lated to postpartum hemorrhage

Expected Outcome Woman will demonstrate fluidbalance as evidenced by stable vital signs, promptcapillary refill time, and balanced intake and output.

Nursing Interventions/Rationales

• Monitor vital signs, oxygen saturation, urine specific grav-ity, and capillary refill to provide baseline data.

• Measure and record amount and type of bleeding by weigh-ing and counting saturated pads. If woman is at home, teachher to count pads and save any clots or tissue. If woman isadmitted to hospital, save any clots and tissue for further ex-amination to estimate type and amount of blood loss for fluidreplacement.

• Provide quiet environment to promote rest and decreasemetabolic demands.

• Give explanation of all procedures to reduce anxiety.• Begin IV access with 18-gauge or larger needle for infusion

of isotonic solution as ordered to provide fluid or blood re-placement.

• Administer medications as ordered, such as oxytocin, meth-ylergonovine, or prostaglandin F2�, to increase contractilityof the uterus.

• Insert indwelling urinary catheter to provide most accurateassessment of renal function and hypovolemia.

• Prepare for surgical intervention as needed to stop the sourceof bleeding.

NURSING DIAGNOSIS Ineffective tissue perfu-sion related to hypovolemia

Expected Outcome Woman will have stable vitalsigns, oxygen saturation, arterial blood gases, andadequate hematocrit and hemoglobin.


• Monitor vital signs, oxygen saturation, arterial blood gases,and hematocrit and hemoglobin to assess for hypovolemicshock and decreased tissue perfusion.

• Assess for any changes in level of consciousness to assessfor evidence of hypoxia.

• Assess capillary refill, mucous membranes, and skin tem-perature to note indicators of vasoconstriction.

• Give supplementary oxygen as ordered to provide additionaloxygenation to tissues.

• Suction as needed, insert oral airway, to maintain clear, openairway for oxygenation.

• Monitor arterial blood gases to provide information about aci-dosis or hypoxia.

• Administer sodium bicarbonate if ordered to reverse meta-bolic acidosis.

NURSING DIAGNOSIS Anxiety related to suddenchange in health status

Expected Outcome Woman will verbalize that anx-ious feelings are diminished.


• Using therapeutic communication, evaluate woman’s un-derstanding of events to provide clarification of any mis-conceptions.

• Provide calm, competent attitude and environment to aid indecreasing anxiety.

• Explain all procedures to decrease anxiety about the un-known.

• Allow woman to verbalize feelings to permit clarification ofinformation and promote trust.

• Continue to assess vital signs or other clinical indicators ofhypovolemic shock to evaluate if psychologic response ofanxiety intensifies physiologic indicators.

NURSING DIAGNOSIS Risk for infection relatedto blood loss and invasive procedures as a resultof postpartum hemorrhage

Expected Outcomes Woman will verbalize under-standing of risk factors. Woman will demonstrateno signs of infection.


• Maintain Standard Precautions and use good handwashingtechnique when providing care to prevent introduction of orspread of infection.

• Teach woman to maintain good handwashing technique (par-ticularly before handling her newborn) and to maintainscrupulous perineal care with frequent change and carefuldisposal of perineal pads to avoid spread of microorganisms.

• Monitor vital signs to detect signs of systemic infection.• Monitor level of fatigue and lethargy, evidence of chills, loss

of appetite, nausea and vomiting, and abdominal pain, whichare indicative of extent of infection and serve as indicatorsof status of infection.

• Monitor lochia for foul smell and profusion as indicators ofinfection state.

• Assist with collection of intrauterine cultures or other spec-imens for laboratory analysis to identify specific causative or-ganism.

• Monitor laboratory values (i.e., white blood cell [WBC] count,cultures) for indicators of type and status of infection.

• Ensure adequate fluid and nutritional intake to fight infection.• Administer and monitor broad-spectrum antibiotics if or-

dered to prevent infection.• Administer antipyretics as ordered and necessary to reduce

elevated temperature.

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Oxygen is administered, preferably by nonrebreathingface mask, at 10 to 12 L/min to maintain oxygen saturation.Oxygen saturation should be monitored with a pulse oxime-ter, although measurements may not always be accurate ina woman with hypovolemia or decreased perfusion. Levelof consciousness is assessed frequently and provides addi-tional indications of blood volume and oxygen saturation.In early stages of decreased blood flow the woman may re-port “seeing stars” or feeling dizzy or nauseated. She may be-come restless and orthopneic. As cerebral hypoxia increases,she may become confused and react slowly or not at all tostimuli. Some women complain of headaches (Curran,2003). An improved sensorium is an indicator of improvedperfusion.

Continuous electrocardiographic monitoring may be in-dicated for the woman who is hypotensive or tachycardic,continues to bleed profusely, or is in shock. A Foley catheterwith a urometer is inserted to allow hourly assessment of uri-nary output. The most objective and least invasive assess-ment of adequate organ perfusion and oxygenation is uri-nary output of at least 30 ml/hr (Benedetti, 2002). Bloodmay be drawn and sent to the laboratory for studies that in-clude hemoglobin and hematocrit levels, platelet count, andcoagulation profile.

Fluid or Blood ReplacementTherapyCritical to successful management of the woman with a hem-orrhagic complication is establishment of venous access,preferably with a large-bore IV catheter. The establishmentof two IV lines facilitates fluid resuscitation. Vigorous fluidresuscitation includes the administration of crystalloids (lac-tated Ringer’s, normal saline solutions), colloids (albumin),blood, and blood components (Benedetti, 2002). Fluid re-suscitation must be carefully monitored because fluid over-load may occur. Intravascular fluid overload occurs more fre-quently with colloid therapy. Transfusion reactions mayfollow administration of blood or blood components,

including cryoprecipitates. Even in an emergency, each unitmust be checked per hospital protocol. Complications offluid or blood replacement therapy include hemolytic re-actions, febrile reactions, allergic reactions, circulatory over-load, and air embolism.

Standard of Care for Bleeding EmergenciesThe standard of care for obstetric emergency situationssuch as PPH or hypovolemic shock is that provisionshould be made for the nurse to implement actions in-dependently. Policies, procedures, standing orders orprotocols, and clinical guidelines should be establishedby each health care facility in which births occur andshould be agreed on by health care providers involvedin the care of obstetric patients.

When bleeding is continuous and there is no identifiablesource, a coagulopathy may be the cause. The woman’s co-agulation status must be assessed quickly and continuously.The nurse may draw and send blood to the laboratory forstudies. Abnormal results depend on the cause and may in-clude increased prothrombin time, increased partial throm-boplastin time, decreased platelets, decreased fibrinogenlevel, increased fibrin degradation products, and prolongedbleeding time. Causes of coagulopathies may be pregnancycomplications such as idiopathic thrombocytopenic purpura(ITP), or von Willebrand disease and DIC.

Idiopathic ThrombocytopenicPurpuraITP is an autoimmune disorder in which antiplatelet anti-bodies decrease the life span of the platelets. Thrombocy-topenia, capillary fragility, and increased bleeding time arediagnostic findings. ITP may cause severe hemorrhage aftercesarean birth or from cervical or vaginal lacerations. The in-cidence of postpartum uterine bleeding and vaginalhematomas also is increased. Neonatal thrombocytopenia,a result of the maternal disease process, occurs in about 50%of cases and is associated with high mortality (Kilpatrick &Laros, 2004).

Medical management focuses on control of platelet sta-bility. If ITP was diagnosed during pregnancy, the womanlikely was treated with corticosteroids or IV immunoglob-ulin. Platelet transfusions are usually given when there is sig-nificant bleeding. A splenectomy may be needed if the ITPdoes not respond to medical management.

von Willebrand Diseasevon Willebrand disease, a type of hemophilia, is probablythe most common of all hereditary bleeding disorders(Strozewski, 2000). Although von Willebrand disease is rare,it is among the most common congenital clotting defects inU.S. women of childbearing age. It results from a factor VIIIdeficiency and platelet dysfunction that is transmitted as an

COAGULOPATHIES

LEGAL TIP


EMERGENCYHemorrhagic Shock

ASSESSMENTS CHARACTERISTICS

• Respirations • Rapid and shallow• Pulse • Rapid, weak, irregular• Blood pressure • Decreasing (late sign)• Skin • Cool, pale, clammy• Urinary output • Decreasing• Level of consciousness • Lethargy → coma• Mental status • Anxiety → coma• Central venous pressure • Decreased

INTERVENTION

• Summon assistance and equipment.• Start intravenous infusion per standing orders.• Ensure patent airway; administer oxygen.• Continue to monitor status.


incomplete autosomal dominant trait to both sexes. Symp-toms include a familial bleeding tendency, previous bleed-ing episodes, prolonged bleeding time (the most importanttest), factor VIII deficiency (mild to moderate), and bleed-ing from mucous membranes. Although factor VIII increasesduring pregnancy, there is still a risk for PPH as levels of von Willebrand factor begin to decrease (Roque, Funai, &Lockwood, 2000).

The woman may be at risk for bleeding for up to 4 weekspostpartum. Treatment of von Willebrand disease may in-clude replacement of factor VIII and administration ofdesmopressin or antifibrinolytics (Strozewski, 2000).

Cryoprecipitate is no longer recom-mended by the Medical and Scientific Advisory Coun-cil of the National Hemophilia Association as a treat-ment for von Willebrand disease because it may containdonor viruses (Strozewski, 2000).

Disseminated IntravascularCoagulationDIC is a pathologic form of clotting that is diffuse and con-sumes large amounts of clotting factors, including platelets,fibrinogen, prothrombin, and factors V and VII. Widespreadexternal bleeding, internal bleeding, or both can result. DICalso causes vascular occlusion of small vessels resulting fromsmall clots forming in the microcirculation. In the obstet-ric population, DIC may occur as a result of abruptio pla-centae, amniotic fluid embolism, dead fetus syndrome (fe-tus has died but is retained in utero for at least 6 weeks),severe preeclampsia, septicemia, cardiopulmonary arrest, andhemorrhage.

The diagnosis of DIC is made according to clinical find-ings and laboratory markers. Physical examination reveals un-usual bleeding; spontaneous bleeding from the woman’sgums or nose may be noted. Petechiae may appear arounda blood pressure cuff placed on the woman’s arm. Excessivebleeding may occur from the site of a slight trauma (e.g.,venipuncture sites, intramuscular or subcutaneous injectionsites, nicks from shaving of perineum or abdomen, and in-jury from insertion of a urinary catheter). Symptoms alsomay include tachycardia and diaphoresis. Laboratory testsreveal decreased levels of platelets, fibrinogen, proaccelerin,antihemophiliac factor, and prothrombin (the factors con-sumed during coagulation). Fibrinolysis is increased at firstbut is later severely depressed. Degradation of fibrin leadsto the accumulation of fibrin split products in the blood;these have anticoagulant properties and prolong the pro-thrombin time. Bleeding time is normal, coagulation timeshows no clot, clot-retraction time shows no clot, and par-tial thromboplastin time is increased. DIC must be distin-guished from other clotting disorders before therapy is ini-tiated.

Primary medical management in all cases of DIC involvescorrection of the underlying cause (e.g., removal of the deadfetus, treatment of existing infection or of preeclampsia or

NURSE ALERT

eclampsia, or removal of a placental abruption). Volume re-placement, blood component therapy, optimization of oxy-genation and perfusion status, and continued reassessmentof laboratory parameters are the usual forms of treatment.Plasma levels usually return to normal within 24 hours after birth. Platelet counts usually return to normal within7 days (Kilpatrick & Laros, 2004).

Nursing interventions include assessment for signs ofbleeding and signs of complications from the administrationof blood and blood products, administering fluid or bloodreplacement as ordered, and protecting the woman from in-jury. Because renal failure is one consequence of DIC, uri-nary output is monitored, usually by insertion of an in-dwelling urinary catheter. Urinary output must bemaintained at more than 30 ml/hr.

The woman and her family will be anxious or concernedabout her condition and prognosis. The nurse offers expla-nations about care and provides emotional support to thewoman and her family through this critical time.

A thrombosis results from the formation of a blood clot orclots inside a blood vessel and is caused by inflammation(thrombophlebitis) or partial obstruction of the vessel. Threethromboembolic conditions are of concern in the postpar-tum period:

• Superficial venous thrombosis: Involvement of the su-perficial saphenous venous system

• Deep venous thrombosis: Involvement varies but can ex-tend from the foot to the iliofemoral region

• Pulmonary embolism: Complication of deep venousthrombosis occurring when part of a blood clot dis-lodges and is carried to the pulmonary artery, whereit occludes the vessel and obstructs blood flow to thelungs

Incidence and EtiologyThe incidence of thromboembolic disease in the postpar-tum period varies from about 0.5 to 3 per 1000 women(Laros, 2004). The incidence has declined in the last 20 yearsbecause early ambulation after childbirth has become thestandard practice. The major causes of thromboembolic dis-ease are venous stasis and hypercoagulation, both of whichare present in pregnancy and continue into the postpartumperiod. Other risk factors include cesarean birth, history ofvenous thrombosis or varicosities, obesity, maternal ageolder than 35 years, multiparity, and smoking (Weiss &Bernstein, 2000).

Clinical ManifestationsSuperficial venous thrombosis is the most frequent form ofpostpartum thrombophlebitis. It is characterized by pain andtenderness in the lower extremity. Physical examination mayreveal warmth, redness, and an enlarged, hardened vein overthe site of the thrombosis. Deep vein thrombosis is more

THROMBOEMBOLIC DISEASE



common in pregnancy and is characterized by unilateral legpain, calf tenderness, and swelling (Fig. 25-2). Physical ex-amination may reveal redness and warmth, but women alsomay have a large amount of clot and have few symptoms(Stenchever, Droegemueller, Herbst, & Mishell, 2001). A po-sitive Homans sign may be present, but further evaluationis needed because the calf pain may be attributed to othercauses such as a strained muscle resulting from the birthingposition. Pulmonary embolism is characterized by dyspneaand tachypnea. Other signs and symptoms frequently seeninclude apprehension, cough, tachycardia, hemoptysis, el-evated temperature, and pleuritic chest pain (Laros, 2004).

Physical examination is not a sensitive diagnostic indi-cator for thrombosis. Venography is the most accuratemethod for diagnosing deep venous thrombosis; however,it is an invasive procedure that exposes the woman and fe-tus to ionizing radiation and is associated with serious com-plications. Noninvasive diagnostic methods are more com-

monly used; these include real-time and color Doppler ul-trasound. Cardiac auscultation may reveal murmurs withpulmonary embolism. Electrocardiograms are usually nor-mal. Arterial PO2 may be lower than normal. A ventilation/perfusion scan, Doppler ultrasound, and pulmonary arteri-ogram may be used for diagnosis (Laros, 2004).

Medical ManagementSuperficial venous thrombosis is treated with analgesia (non-steroidal antiinflammatory agents), rest with elevation of theaffected leg, and elastic stockings (Laros, 2004). Local ap-plication of heat also may be used. Deep venous thrombo-sis is initially treated with anticoagulant (usually continuousIV heparin) therapy, bed rest with the affected leg elevated,and analgesia. After the symptoms have decreased, thewoman may be fitted with elastic stockings to use when sheis allowed to ambulate. IV heparin therapy continues for 3 to 5 days or until symptoms resolve. Oral anticoagulanttherapy (warfarin) is started during this time and will be con-tinued for about 3 months. Continuous IV heparin therapyis used for pulmonary embolism until symptoms have re-solved. Intermittent subcutaneous heparin or oral antico-agulant therapy is usually continued for 6 months.

Nursing InterventionsIn the hospital setting, nursing care of the woman with athrombosis consists of continued assessments: inspectionand palpation of the affected area; palpation of peripheralpulses; checking Homans sign; measurement and compar-ison of leg circumferences; inspection for signs of bleeding;monitoring for signs of pulmonary embolism including chestpain, coughing, dyspnea, and tachypnea; and respiratory sta-tus for presence of crackles. Laboratory reports are monitoredfor prothrombin or partial thromboplastin times. Thewoman and her family are assessed for their level of under-standing about the diagnosis and their ability to cope dur-ing the unexpected extended period of recovery.

Interventions include explanations and education aboutthe diagnosis and the treatment. The woman will need as-sistance with personal care as long as she is on bed rest; thefamily should be encouraged to participate in the care if thatis what she and they wish. While the woman is on bed rest,she should be encouraged to change positions frequently butnot to place the knees in a sharply flexed position that couldcause pooling of blood in the lower extremities. She alsoshould be cautioned not to rub the affected area, as this ac-tion could cause the clot to dislodge. Once the woman is al-lowed to ambulate, she is taught how to prevent venous con-gestion by putting on the elastic stockings before getting outof bed.

Heparin and warfarin are administered as ordered, and thephysician is notified if clotting times are outside the thera-peutic level. If the woman is breastfeeding, she is assured thatneither heparin nor warfarin is excreted in significant quan-tities in breast milk. If the infant has been discharged, thefamily is encouraged to bring the infant for feedings as


Fig. 25-2 Deep vein thrombophlebitis.


permitted by hospital policy; the mother also can expressmilk to be sent home.

Pain can be managed with a variety of measures. Positionchanges, elevating the leg, and application of moist warmheat may decrease discomfort. Administration of analgesicsand antiinflammatory medications may be needed.

Medications containing aspirin are notgiven to women receiving anticoagulant therapy be-cause aspirin inhibits synthesis of clotting factors andcan lead to prolonged clotting time and increased riskof bleeding.

The woman is usually discharged home with oral anti-coagulants and will need explanations about the treatmentschedule and possible side effects. If subcutaneous injectionsare to be given, the woman and family are taught how to ad-minister the medication and about site rotation. The womanand her family also should be given information about safecare practices to prevent bleeding and injury while she is re-ceiving anticoagulant therapy, such as using a soft toothbrushand using an electric razor. She also will need informationabout follow-up with her health care provider to monitorclotting times and to make sure the correct dose of anti-coagulant therapy is maintained. The woman also should use a reliable method of contraception if taking warfarin, be-cause this medication is considered teratogenic (Gilbert &Harmon, 2003).

Postpartum or puerperal infection is any clinical infectionof the genital canal that occurs within 28 days after miscar-riage, induced abortion, or childbirth. The definition usedin the United States continues to be the presence of a feverof 38° C or more on 2 successive days of the first 10 post-partum days (not counting the first 24 hours after birth)(Cunningham et al., 2005). Puerperal infection is probablythe major cause of maternal morbidity and mortalitythroughout the world; however, it occurs after about 6% ofbirths in the United States (5 to 10 times higher after ce-sarean births than after vaginal births) (Gibbs, Sweet, & Duff,2004). Common postpartum infections include en-dometritis, wound infections, mastitis, urinary tract infec-tions (UTIs), and respiratory tract infections.

The most common infecting organisms are the numer-ous streptococcal and anaerobic organisms. Staphylococcus aureus, gonococci, coliform bacteria, and clostridia are lesscommon but serious pathogenic organisms that also causepuerperal infection. Postpartum infections are more com-mon in women who have concurrent medical or immuno-suppressive conditions or who had a cesarean or other op-erative birth. Intrapartal factors such as prolonged ruptureof membranes, prolonged labor, and internal maternal or fe-tal monitoring also increase the risk of infection (Gibbs,Sweet, & Duff, 2004). Factors that predispose the woman topostpartum infection are listed in Box 25-4.

POSTPARTUM INFECTIONS

NURSE ALERT

EndometritisEndometritis is the most common cause of postpartum infection. It usually begins as a localized infection at the pla-cental site (Fig. 25-3) but can spread to involve the entire endometrium. Incidence is higher after cesarean birth. As-sessment for signs of endometritis may reveal a fever (usu-ally greater than 38° C); increased pulse; chills; anorexia; nau-sea; fatigue and lethargy; pelvic pain; uterine tenderness;and/or foul-smelling, profuse lochia (Duff, 2002). Leuko-cytosis and a markedly increased RBC sedimentation rate aretypical laboratory findings of postpartum infections. Ane-mia also may be present. Blood cultures or intracervical orintrauterine bacterial cultures (aerobic and anaerobic) shouldreveal the offending pathogens within 36 to 48 hours.

Wound InfectionsWound infections also are common postpartum infectionsbut often develop after the woman is at home. Sites of in-fection include the cesarean incision and the episiotomy orrepaired laceration site. Predisposing factors are similar tothose for endometritis (see Box 25-4). Signs of wound in-fection include erythema, edema, warmth, tenderness, sero-purulent drainage, and wound separation. Fever and painalso may be present.

Urinary Tract InfectionsUrinary tract infections (UTIs) occur in 2% to 4% of post-partum women. Risk factors include urinary catheterization,


Predisposing Factors for PostpartumInfection

PRECONCEPTION OR ANTEPARTAL FACTORS

• History of previous venous thrombosis, urinary tractinfection, mastitis, pneumonia

• Diabetes mellitus• Alcoholism• Drug abuse• Immunosuppression• Anemia• Malnutrition

INTRAPARTAL FACTORS

• Cesarean birth• Prolonged rupture of membranes• Chorioamnionitis• Prolonged labor• Bladder catheterization• Internal fetal or uterine pressure monitoring• Multiple vaginal examinations after rupture of mem-

branes• Epidural anesthesia• Retained placental fragments• Postpartum hemorrhage• Episiotomy or lacerations• Hematomas

BOX 25-4


frequent pelvic examinations, epidural anesthesia, genitaltract injury, history of UTI, and cesarean birth. Signs andsymptoms include dysuria, frequency and urgency, low-gradefever, urinary retention, hematuria, and pyuria. Costoverte-bral angle (CVA) tenderness or flank pain may indicate up-per UTI. Urinalysis results may reveal Escherichia coli, althoughother gram-negative aerobic bacilli also may cause UTIs.

MastitisMastitis affects about 1% of women soon after childbirth,most of whom are first-time mothers who are breastfeeding.Mastitis almost always is unilateral and develops well afterthe flow of milk has been established (Fig. 25-4). The in-fecting organism generally is the hemolytic S. aureus. Aninfected nipple fissure usually is the initial lesion, but theductal system is involved next. Inflammatory edema and en-gorgement of the breast soon obstruct the flow of milk ina lobe; regional, then generalized, mastitis follows. If treat-ment is not prompt, mastitis may progress to a breast ab-scess.

Symptoms rarely appear before the end of the first post-partum week and are more common in the second to fourthweeks. Chills, fever, malaise, and local breast tenderness arenoted first. Localized breast tenderness, pain, swelling, red-ness, and axillary adenopathy also may occur. Antibiotics areprescribed. Lactation can be maintained by emptying thebreasts every 2 to 4 hours by breastfeeding, manual expres-sion, or breast pump.

Signs and symptoms associated with postpartum infectionwere discussed with each infection. Laboratory tests usuallyperformed include a complete blood count, venous bloodcultures, and uterine tissue cultures. Nursing diagnoses forwomen experiencing postpartum infection include the fol-lowing:

• Deficient knowledge related to—cause, management, course of infection—transmission and prevention of infection

• Impaired tissue integrity related to—effects of infection process

• Acute pain related to—mastitis—puerperal infection—UTI

• Interrupted family processes related to—unexpected complication to expected postpartumrecovery—possible separation from newborn—interruption in process of realigning relationshipsafter the addition of the new family member

• Risk for impaired parenting related to—fear of spread of infection to newborn

The most effective and least expensive treatment of post-partum infection is prevention. Preventive measures includegood prenatal nutrition to control anemia and intrapartalhemorrhage. Good maternal perineal hygiene with thoroughhandwashing is emphasized. Strict adherence by all healthcare personnel to aseptic techniques during childbirth andthe postpartum period is very important.

Management of endometritis consists of IV broad-spectrum antibiotic therapy (cephalosporins, penicillins, or clindamycin and gentamicin) and supportive care,

CARE MANAGEMENT


Fig. 25-3 Postpartum infection—endometritis.

Fig. 25-4 Mastitis.


including hydration, rest, and pain relief (French & Smaill,2002). Antibiotic therapy is usually discontinued 24 hoursafter the woman is asymptomatic (Gibbs, Sweet, & Duff,2004). Assessments of lochia, vital signs, and changes in thewoman’s condition continue during treatment. Comfortmeasures depend on the symptoms and may include coolcompresses, warm blankets, perineal care, and sitz baths.Teaching should include side effects of therapy, preventionof spread of infection, signs and symptoms of worseningcondition, and adherence to the treatment plan and the needfor follow-up care. Women may need to be encouraged orassisted to maintain mother-infant interactions and breast-feeding (if allowed during treatment).

Postpartum women are usually discharged to home by48 hours after birth. This is often before signs of infectionare evident. Nurses in birth centers and hospital settings mustbe able to identify women at risk for postpartum infectionand to provide anticipatory teaching and counseling beforedischarge. After discharge, telephone follow-up, hot lines,support groups, lactation counselors, home visits bynurses, and teaching materials (videos, written materials) areall interventions that can be implemented to prevent or in-crease recognition of postpartum infections. Home carenurses must be able to recognize signs and symptoms ofpostpartum infection so that the woman can contact herprimary health care provider. These nurses also must be ableto provide the appropriate nursing care for women who needfollow-up home care.

Treatment of wound infections may combine antibiotictherapy with wound debridement. Wounds may be openedand drained. Nursing care includes frequent wound and vi-tal sign assessments and wound care. Comfort measures in-clude sitz baths, warm compresses, and perineal care. Teach-ing includes good hygiene techniques (e.g., changing perinealpads front to back, handwashing before and after perinealcare), self-care measures, and signs of worsening conditionsto report to the health care provider. The woman is usuallydischarged to home for self-care or home nursing care aftertreatment is initiated in the inpatient setting.

Medical management for UTIs consists of antibiotic ther-apy, analgesia, and hydration. Postpartum women are usu-ally treated on an outpatient basis; therefore teaching shouldinclude instructions on how to monitor temperature, blad-der function, and appearance of urine. The woman alsoshould be taught about signs of potential complications andthe importance of taking all antibiotics as prescribed. Othersuggestions for prevention of UTIs include using proper peri-neal care, wiping from front to back after urinating or hav-ing a bowel movement, and increasing fluid intake.

Because mastitis rarely occurs before the postpartumwoman who is breastfeeding is discharged, teaching should in-clude warning signs of mastitis and counseling about preven-tion of cracked nipples. Management includes intensive an-tibiotic therapy (e.g., cephalosporins and vancomycin, whichare particularly useful in staphylococcal infections), support ofbreasts, local heat (or cold), adequate hydration, and analgesics.

Almost all instances of acute mastitis can be avoided byusing proper breastfeeding technique to prevent cracked nip-ples. Missed feedings, waiting too long between feedings, andabrupt weaning may lead to clogged nipples and mastitis.Cleanliness practiced by all who have contact with the new-born and new mother also reduces the incidence of masti-tis. See Chapter 20 for further information.

Women are at risk for problems related to the reproductivesystem from the age of menarche through menopause andthe older years. These problems include structural disordersof the uterus and vagina related to pelvic relaxation andurinary incontinence (UI). They can be a delayed result ofchildbearing. For example, the structures and soft tissues ofthe vagina and bladder may be injured during a prolongedlabor, during a precipitous birth, or when cephalopelvic dis-proportion occurs. Defects can also occur in women whohave never been pregnant.

Uterine Displacement and ProlapseNormally, the round ligaments hold the uterus in antever-sion, and the uterosacral ligaments pull the cervix backwardand upward (see Fig. 4-2). Uterine displacement is a varia-tion of this normal placement. The most common type ofdisplacement is posterior displacement, or retroversion, inwhich the uterus is tilted posteriorly and the cervix rotatesanteriorly. Other variations include retroflexion and ante-flexion (Fig. 25-5).

By 2 months postpartum the ligaments should return tonormal length, but in approximately one third of women theuterus remains retroverted. This condition is rarely symp-tomatic, but conception may be difficult because the cervixpoints toward the anterior vaginal wall and away from theposterior fornix, where seminal fluid pools after coitus. Ifsymptoms occur, they may include pelvic and low back pain,dyspareunia, and exaggeration of premenstrual symptoms.

Uterine prolapse is a more serious type of displacement.The degree of prolapse can vary from mild to complete. Incomplete prolapse, the cervix and body of the uterus protrudethrough the vagina and the vagina is inverted (Fig. 25-6).

Uterine displacement and prolapse can be caused by con-genital or acquired weakness of the pelvic support structures(often referred to as pelvic relaxation). In many cases prob-lems can be related to a delayed but direct result of child-bearing. Although extensive damage may be noted and re-paired shortly after birth, symptoms related to pelvicrelaxation most often appear during the perimenopausal pe-riod, when the effects of ovarian hormones on pelvic tissuesare lost and atrophic changes begin. Pelvic trauma, stress andstrain, and the aging process are also contributing causes.Other causes of pelvic relaxation include reproductive sur-gery and pelvic radiation.

SEQUELAE OF CHILDBIRTH TRAUMA



Clinical manifestationsGenerally, symptoms of pelvic relaxation relate to the

structure involved: urethra, bladder, uterus, vagina, cul-de-sac, or rectum. The most common complaints are pullingand dragging sensations, pressure, protrusions, fatigue, andlow backache. Symptoms may be worse after prolongedstanding or deep penile penetration during intercourse. Uri-nary incontinence may be present.

Cystocele and RectoceleCystocele and rectocele almost always accompany uterineprolapse, causing the uterus to sag even further backward anddownward into the vagina. Cystocele (Fig. 25-7, A) is the

protrusion of the bladder downward into the vagina that de-velops when supporting structures in the vesicovaginal sep-tum are injured. Anterior wall relaxation gradually developsover time as a result of congenital defects of supports, child-bearing, obesity, or advanced age. When the woman stands,the weakened anterior vaginal wall cannot support the weightof the urine in the bladder; the vesicovaginal septum isforced downward, the bladder is stretched, and its capacityis increased. With time the cystocele enlarges until it pro-trudes into the vagina. Complete emptying of the bladderis difficult because the cystocele sags below the bladder neck.Rectocele is the herniation of the anterior rectal wall throughthe relaxed or ruptured vaginal fascia and rectovaginal sep-tum; it appears as a large bulge that may be seen through therelaxed introitus (Fig. 25-7, B).

Clinical manifestationsCystoceles and rectoceles often are asymptomatic. If

symptoms of cystocele are present, they may include com-plaints of a bearing-down sensation or that “something is inmy vagina.” Other symptoms include urinary frequency, re-tention, incontinence, and possible recurrent cystitis andUTIs. Pelvic examination will reveal a bulging of the ante-rior wall of the vagina when the woman is asked to beardown. Unless the bladder neck and urethra are damaged, uri-nary continence is unaffected. Women with large cystoce-les complain of having to push upward on the sagging an-terior vaginal wall to be able to void.

Rectoceles may be small and produce few symptoms, butsome are so large that they protrude outside of the vaginawhen the woman stands. Symptoms are absent when thewoman is lying down. A rectocele causes a disturbancein bowel function, the sensation of “bearing down,” orthe sensation that the pelvic organs are falling out. With avery large rectocele, it may be difficult to have a bowelmovement. Each time the woman strains during bowel


Fig. 25-5 Types of uterine displacement. A, Anterior displacement. B, Retroversion (backwarddisplacement of uterus).

A B

Slight prolapseNormal

Marked prolapse(procidentia)

Fig. 25-6 Prolapse of uterus.


evacuation, the feces are forced against the thinned recto-vaginal wall, stretching it more. Some women facilitate evac-uation by applying digital pressure vaginally to hold up therectal pouch.

Urinary IncontinenceUrinary incontinence (UI) affects young and middle-agedwomen, with the prevalence increasing as the woman ages(Sampselle, 2003). Although nulliparous women can haveUI, the incidence is higher in women who have given birthand also increases with parity (Sampselle, 2003). Conditionsthat disturb urinary control include stress incontinence, be-cause of sudden increases in intraabdominal pressure (suchas from sneezing or coughing); urge incontinence, caused bydisorders of the bladder and urethra, such as urethritis andurethral stricture, trigonitis, and cystitis; neuropathies, suchas multiple sclerosis, diabetic neuritis, and pathologic con-ditions of the spinal cord; and congenital and acquired uri-nary tract abnormalities.

Stress incontinence may follow injury to bladder neckstructures. A sphincter mechanism at the bladder neck com-presses the upper urethra, pulls it upward behind the sym-physis, and forms an acute angle at the junction of the pos-terior urethral wall and the base of the bladder (Fig. 25-8).To empty the bladder, the sphincter complex relaxes and thetrigone contracts to open the internal urethral orifice andpull the contracting bladder wall upward, forcing urine out.The angle between the urethra and the base of the bladderis lost or increased if the supporting pubococcygeus muscleis injured; this change, coupled with urethrocele, causes in-continence. Urine spurts out when the woman is asked tobear down or cough in the lithotomy position.

Clinical manifestationsInvoluntary leaking of urine is the main sign. Episodes of

leaking are common during coughing, laughing, and exercise.

Genital FistulasGenital fistulas are perforations between genital tract organs.Most occur between the bladder and the genital tract (e.g.,vesicovaginal); between the urethra and the vagina (ure-throvaginal); and between the rectum or sigmoid colon andthe vagina (rectovaginal) (Fig. 25-9). Genital fistulas may alsobe a result of a congenital anomaly, gynecologic surgery, ob-stetric trauma, cancer, radiation therapy, gynecologictrauma, or infection (e.g., in the episiotomy).

Clinical manifestationsSigns and symptoms of vaginal fistulas depend on the site

but may include presence of urine, flatus, or feces in thevagina; odors of urine or feces in the vagina; and irritationof vaginal tissues.

Assessment for problems related to structural disorders of theuterus and vagina focuses primarily on the genitourinarytract, the reproductive organs, bowel elimination, and psy-chosocial and sexual factors. A complete health history, phys-ical examination, and laboratory tests are done to supportthe appropriate medical diagnosis. The nurse needs to assessthe woman’s knowledge of the disorder, its management, and the possible prognosis.

The health care team works together to treat the disordersrelated to alterations in pelvic support and to assist the

CARE MANAGEMENT


A B

Fig. 25-7 A, Cystocele. B, Rectocele. (From Seidel, H., Ball, J., Dains, J., & Benedict, G. [2003].Mosby’s guide to physical examination [5th ed.]. St. Louis: Mosby.)


woman in management of her symptoms. In general, nursesworking with these women can provide information and self-care education to prevent problems before they occur, tomanage or reduce symptoms and promote comfort and hy-giene if symptoms are already present, and to recognize whenfurther intervention is needed. This information can be partof all postpartum discharge teaching or can be provided at

postpartum follow-up visits in clinics or physician or nurse-midwife offices or during postpartum home visits.

Interventions for specific problems depend on the prob-lem and the severity of the symptoms. If discomfort relatedto uterine displacement is a problem, several interventionscan be implemented to treat uterine displacement. Kegel ex-ercises (see p. 93) can be performed several times daily toincrease muscle strength. A knee-chest position performedfor a few minutes several times a day can correct a mildlyretroverted uterus. A fitted pessary device may be insertedin the vagina to support the uterus and hold it in the cor-rect position (Fig. 25-10). Usually a pessary is used only fora short time because it can lead to pressure necrosis andvaginitis. Good hygiene is important; some women may betaught to remove the pessary at night, cleanse it, and replaceit in the morning. If the pessary is always left in place, reg-ular douching with commercially prepared solutions or weakvinegar solutions (1 tablespoon to 1 quart of water) to re-move increased secretions and keep the vaginal pH at 4 to4.5 are suggested. After a period of treatment, most womenare free of symptoms and do not require the pessary. Sur-gical correction is rarely indicated.

Treatment for uterine prolapse depends on the degree ofprolapse. Pessaries may be useful in mild prolapse to supportthe uterus in the correct position. Estrogen therapy also maybe used in the older woman to improve tissue tone. If theseconservative treatments do not correct the problem, or ifthere is a significant degree of prolapse, abdominal or vagi-nal hysterectomy is usually recommended.

Treatment for a cystocele includes use of a vaginal pessary or surgical repair. Pessaries may not be effective.


Uterus

Bladder

Urethrovesicalangle

Urethra

Vagina

Intact perineal body

Uterus

Bladder

Urethra

Vagina

Urethrovesicalangle (absent)

Fig. 25-8 Urethrovesical angle. A, Normal angle. B, Widening (absence) of angle.

Vesico-cervical

Recto-vaginal

Vesico-vaginal

Vesico-uterine

Perineo-vaginal

Urethro-vaginal

Fig. 25-9 Types of fistulas that may develop in vagina,uterus, and rectum. (From Phipps, W., Sands, J., & Marek, J.[2003]. Medical-surgical nursing: Health and illness perspec-tives [7th ed.]. St. Louis: Mosby.)

A B


Anterior repair (colporrhaphy) is the usual surgical procedureand is usually done for large, symptomatic cystoceles. Thisinvolves a surgical shortening of pelvic muscles to providebetter support for the bladder. An anterior repair is oftencombined with a vaginal hysterectomy.

Small rectoceles may not need treatment. The womanwith mild symptoms may get relief from a high-fiber diet andadequate fluid intake, stool softeners, or mild laxatives. Vagi-nal pessaries usually are not effective. Large rectoceles thatare causing significant symptoms are usually repaired sur-gically. A posterior repair (colporrhaphy) is the usual pro-cedure. This surgery is performed vaginally and involvesshortening the pelvic muscles to provide better support forthe rectum. Anterior and posterior repairs may be performedat the same time and with a vaginal hysterectomy.

Mild to moderate UI can be significantly decreased or re-lieved in many women by bladder training and pelvic mus-cle (Kegel) exercises (Sampselle, 2003). Other managementstrategies include pelvic flow support devices (i.e., pessaries),

estrogen therapy, insertion of an artificial urethral sphinc-ter, and surgery (e.g., anterior repair) (Stenchever et al., 2001).

Nursing care of the woman with a cystocele, rectocele, orfistula requires great sensitivity, because the woman’s reac-tions are often intense. She may become withdrawn or hos-tile because of embarrassment caused by odors and soilingof her clothing that are beyond her control. She may haveconcerns about engaging in sexual activities because her part-ner is repelled by these problems. The nurse may tactfullysuggest hygiene practices that reduce odor. Commercial de-odorizing douches are available, or noncommercial solu-tions, such as chlorine solution (1 teaspoon of chlorinehousehold bleach to 1 quart of water) may be used. The chlo-rine solution is also useful for external perineal irrigation. Sitzbaths and thorough washing of the genitals with unscented,mild soap and warm water help. Sparse dusting with de-odorizing powders can be useful. If a rectovaginal fistula ispresent, enemas given before leaving the house may providetemporary relief from oozing of fecal material until correc-tive surgery is performed. Irritated skin and tissues may ben-efit from use of a heat lamp or application of an emollientointment. Hygienic care is time consuming and may needto be repeated frequently throughout the day; protectivepads or pants may need to be worn. All of these activitiescan be demoralizing to the woman and frustrating to her andher family.

Mental health disorders have implications for the mother,the newborn, and the entire family. Such conditions can in-terfere with attachment to the newborn and family integra-tion, and some may threaten the safety and well-being of themother, newborn, and other children.

Mood DisordersMood disorders are the predominant mental health disor-der in the postpartum period, typically occurring within 4 weeks of childbirth (American Psychiatric Association[APA], 2000). Many women experience a mild depression,or “baby blues,” after the birth of a child. Others can havemore serious depressions that can eventually incapacitatethem to the point of being unable to care for themselves ortheir babies. Nurses are strategically positioned to offer an-ticipatory guidance, to assess the mental health of new moth-ers, to offer therapeutic interventions, and to refer when nec-essary. Failure to do so may result in tragic consequences.

The Diagnostic and Statistical Manual of Mental Disor-ders contains the official guidelines for the assessment anddiagnosis of psychiatric illness (APA, 2000). However, spe-cific criteria for postpartum depression (PPD) are not listed.Instead, postpartum onset can be specified for any mood dis-order either without psychotic features (i.e., PPD) or withpsychotic features (i.e., postpartum psychosis) if the onset oc-curs within 4 weeks of childbirth (APA, 2000).

POSTPARTUM PSYCHOLOGIC COMPLICATIONS


Fig. 25-10 Examples of pessaries. A, Smith. B, Hodgewithout support. C, Incontinence dish without support. D, Ringwithout support. E, Cube. F, Gellhorn. (Courtesy Milex Prod-ucts, Inc., a division of CooperSurgical, Trumbull, CT.)

A B

C D

E F


Etiology and risk factorsThe cause of PPD may be biologic, psychologic, situa-

tional, or multifactorial. A personal history or a family his-tory of mood disorder, mood and anxiety symptoms in theantepartal period, as well as postpartum blues increases therisk for PPD (APA, 2000). In a metaanalysis of 84 studiespublished in the 1990s, Beck (2001) found 13 risk factors forPPD, four of which had not been identified previously aspredictors. The effect sizes of the risk factors identified in anupdated metaanalysis revealed that 10 predictors have amedium relation with PPD, and three predictors have a smallrelation (Beck, 2002). A revised version of the PostpartumDepression Predictors Inventory (PDPI) has been published(Beck, 2002). Box 25-5 lists all 13 risk factors for PPD, withthose having the greater effect size listed first.

In addition, research has found that fatigue is an impor-tant predictor of PPD (Bozoky & Corwin, 2002). As early as7 postpartum days, fatigue is predictive of depression at post-partum day 28.

Postpartum depression withoutpsychotic featuresPPD is an intense and pervasive sadness with severe and

labile mood swings and is more serious and persistent thanpostpartum blues. Intense fears, anger, anxiety, and de-spondency that persist past the baby’s first few weeks are nota normal part of postpartum blues. Occurring in approxi-mately 10% to 15% of new mothers, these symptoms rarelydisappear without outside help. The majority of these moth-ers do not seek help from any source, and only about 20%consult a health professional. The occurrence of PPD amongteenage mothers was more than 2.5 times that for oldermothers (Herrick, 2002). African-American mothers weretwice as likely as Caucasian mothers to experience PPD.Younger mothers (younger than 20 years) and those with lessthan a high school education were significantly less likely to

seek help and had higher rates of PPD (Herrick, 2002). Moth-ers who had no one to talk to about their problems after giving birth had a high rate of PPD and a low rate of helpseeking.

The symptoms of postpartum major depression do notdiffer from the symptoms of nonpostpartum mood disor-ders except that the mother’s ruminations of guilt and in-adequacy feed her worries about being an incompetent andinadequate parent. In PPD, there may be odd food cravings(often sweet desserts) and binges with abnormal appetite andweight gain. New mothers report an increased yearning forsleep, sleeping heavily but awakening instantly with any in-fant noise, and an inability to go back to sleep after infantfeedings.

A distinguishing feature of PPD is irritability. Theseepisodes of irritability may flare up with little provocation,and they may sometimes escalate to violent outbursts or dis-solve into uncontrollable sobbing. Many of these outburstsare directed against significant others (“He never helps me”)or the baby (“She cries all the time and I feel like hittingher”). Women with postpartum major depressive episodesoften have severe anxiety, panic attacks, and spontaneous cry-ing long after the usual duration of baby blues.

Many women feel especially guilty about having de-pressive feelings at a time when they believe they should behappy. They may be reluctant to discuss their symptoms ortheir negative feelings toward the child. A prominent featureof PPD is rejection of the infant, often caused by abnormaljealousy (APA, 2000). The mother may be obsessed by the


Risk Factors for Postpartum Depression

• Prenatal depression• Low self-esteem• Stress of child care• Prenatal anxiety• Life stress• Lack of social support• Marital relationship problems• History of depression• “Difficult” infant temperament• Postpartum blues• Single status• Low socioeconomic status• Unplanned or unwanted pregnancy

Source: Beck, C. (2001). Predictors of postpartum depression: An update.Nursing Research, 50(5), 275-282; & Beck, C. (2002). Revision of the Post-partum Depression Predictors Inventory. Journal of Obstetric, Gynecologic,and Neonatal Nursing, 31(4), 394-402.

BOX 25-5

Critical Thinking ExercisePostpartum Depression

The nurses on the postpartum unit are revising their dis-charge teaching plan. Sara would like to include a sectionon postpartum depression (PPD). Joan thinks this infor-mation is not needed as she believes most of the moth-ers are happy and there is so much else to teach. They askyou, the nurse educator on the unit, for advice on mak-ing a decision about including information about post-partum depression. What advice will you give?1 Evidence—Is there sufficient evidence to draw con-

clusions about advice to give about the inclusion ofpostpartum depression information in dischargeteaching?

2 Assumptions—Describe underlying assumptionsabout each of following issues:a. Anticipatory guidance as a nursing intervention for

PPDb. Women and risks of depression, including PPDc. Effects of PPD on parenting

3 What implications and priorities are needed in devel-oping a discharge teaching plan?

4 Does the evidence objectively support your conclu-sion?

5 Are there alternative perspectives to your con-clusion?

��



EVIDENCE-BASED PRACTICE

Support for Postpartum Depression

and was provided by health visitors trained in nondirec-tive counseling who made eight half-hour home visits.The 1997 trial also began at 12 weeks and involved six sessions with a psychologist trained in cognitive-behavior therapy.

Statistical Analyses

• Both trials used the Edinburgh Postnatal DepressionScale, which not only has good evidence of reliability andvalidity but also allowed pooling of the data. The odds ra-tio and 95% confidence intervals were calculated for thecategoric data.

FINDINGS

• At 25 weeks postpartum, the mothers who had receivedthe intervention were significantly less depressed thanthe controls.

LIMITATIONS

• Postpartum depression was confirmed by a clinical in-terview, but the reliability and validity of that was not ad-dressed. The participants were not blinded to the treat-ment allocation, but the health assessors and outcomeassessors were blinded to group. One study had a 30%dropout rate, which may have introduced bias. Both thenumber of studies (i.e., both are from one country) andsamples are small, limiting generalizability.

CONCLUSIONS

• Supportive intervention in the postpartum period may beeffective in relieving postpartum depression.

IMPLICATIONS FOR PRACTICE

• Isolation may contribute to postpartum depression. So-cial or professional support may, in theory, help alleviatedepression in the vulnerable postpartum woman, but theevidence is too scanty to make policy recommendations.

IMPLICATIONS FOR FURTHER RESEARCH

• Larger studies of the benefits suggested by this small re-view for improving postpartum depression with increasedsupport are needed. Of urgent interest is the optimumtiming and duration of such intervention, especially as apreventive measure. The type and training of effectivesupport caregivers, the type of intervention, and the set-ting are important to determine. Perhaps the family canbecome involved in the support intervention. Cost is a pri-mary driving factor in mental health services, which needevidence of cost-effectiveness. Long-term follow-upmay provide insight into the benefits derived for themother and the infant and family by alleviating postpar-tum depression.

BACKGROUND

• Clinicians use various definitions of postpartum depres-sion, with ranges of incidence varying from 7% to 30%.Although many define any depression lasting longer than6 months as chronic, there is no consensus regarding du-ration. Symptoms can be disabling to the woman, in-cluding excessive fatigue, insomnia, inability to cope, sui-cidal ideation, and lack of maternal feelings for the baby.It is distinguished from postpartum psychosis, a psychi-atric emergency that may include hallucinations, delu-sions, and disorganized thoughts and behaviors. Post-partum depression can disrupt relationships, especiallywith her partner, and her infant can experience attach-ment disorders and cognitive delays. Causes of post-partum depression are unknown. Hormones may chal-lenge some threshold after birth in the psychologicallyvulnerable woman. Some factors associated with post-partum depression include age, parity, anxiety, socialclass, obstetric complications, past psychiatric history,psychosocial and marital stressors, and unplannedpregnancy. Isolation seems to exacerbate the symptoms,and support seems to relieve them. Support has beenfound to be beneficial to pregnant and laboring women(see “Continuous Labor Support,” Evidence-Based Prac-tice box for Chapter 14). A meaningful relationship witha supportive caregiver reinforces the concept that thewoman matters to someone, increasing feelings of well-being, control, and positive affect. Although medicationsare sometimes useful in postpartum depression, re-searchers have found compliance to be low.

OBJECTIVE

• The authors sought evidence of the effectiveness of pro-fessional and/or social support for women who have beendiagnosed with postpartum depression. The interventionswere emotional support, counseling, or tangible assis-tance (child care, household assistance) via phone, homeor clinic visits, individually or in groups, to women withpostpartum depression. The controls were women withpostpartum depression receiving “usual care” in that set-ting.

• Outcome measures could include unbiased indicators ofmaternal or family morbidity, duration and resolution ofdepression, and social functioning.

METHODS

Search Strategy

• The reviewers searched Cochrane, MEDLINE, and 38 rel-evant journals via Zetoc, an electronic current awarenessservice. Search keywords were not noted.

• Two randomized, controlled trials met the criteria, rep-resenting 137 women from the United Kingdom. In the1989 trial, the intervention began at 12 weeks postpartum

Reference: Ray, K., & Hodnett, E. (2001). Caregiver support for postpartum depression (Cochrane Review), In The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons.


notion that the offspring may take her place in her partner’saffections. Attitudes toward the infant may include disin-terest, annoyance with care demands, and blaming becauseof her lack of maternal feeling. When observed, she may ap-pear awkward in her responses to the baby. Obsessivethoughts about harming the child are very frightening to her.Often she does not share these thoughts because of em-barrassment, but when she does, other family members be-come very frightened.

Medical management. The natural course is oneof gradual improvement over the 6 months after birth. Sup-port treatment alone is not efficacious for major postpartumdepression. Pharmacologic intervention is needed in most in-stances. Treatment options include antidepressants, anxiolyticagents, and electroconvulsive therapy (ECT). Psychotherapyfocuses on the mother’s fears and concerns regarding her newresponsibilities and roles, as well as monitoring for suicidalor homicidal thoughts. For some women, hospitalization isnecessary.

Postpartum depression with psychotic featuresPostpartum psychosis is a syndrome most often charac-

terized by depression (as described previously), delusions,and thoughts by the mother of harming either the infant orherself (Sadock & Sadock, 2000). A postpartum mood dis-order with psychotic features occurs in 1 to 2 per 1000 birthsand may occur more often in primiparas (Sadock & Sadock,2000). Once a woman has had one postpartum episode withpsychotic features, there is a 30% to 50% likelihood of re-currence with each subsequent birth (APA, 2000).

Symptoms often begin within days after the birth, al-though the mean time to onset is 2 to 3 weeks and almostalways within 8 weeks of birth (Sadock & Sadock, 2000).Characteristically, the woman begins to complain of fatigue,insomnia, and restlessness and may have episodes of tear-fulness and emotional lability. Complaints regarding the in-ability to move, stand, or work are also common. Later, sus-piciousness, confusion, incoherence, irrational statements,and obsessive concerns about the baby’s health and welfaremay be present (Sadock & Sadock, 2000). Delusions may bepresent in 50% of all women, and hallucinations in ap-proximately 25%. Auditory hallucinations that commandthe mother to kill the infant can also occur in severe cases.When delusions are present, they are often related to the in-fant. The mother may think the infant is possessed by thedevil, has special powers, or is destined for a terrible fate(APA, 2000). Grossly disorganized behavior may be mani-fested as a disinterest in the infant or an inability to providecare. Some will insist that something is wrong with the babyor accuse nurses or family members of hurting or poison-ing him or her. Nurses are advised to be alert for motherswho are agitated, overactive, confused, complaining, or sus-picious.

A specific illness included in depression with psychoticfeatures is bipolar disorder. This mood disorder is preceded

or accompanied by manic episodes, characterized by ele-vated, expansive, or irritable moods. Clinical manifestationsof a manic episode include at least three of the followingsymptoms that have been significantly present for at least 1 week: grandiosity, decreased need for sleep, pressuredspeech, flight of ideas, distractibility, psychomotor agitation,and excessive involvement in pleasurable activities withoutregard for negative consequences (APA, 2000). Because thesewomen are hyperactive, they may not take the time to eator sleep, which leads to inadequate nutrition, dehydration,and sleep deprivation. While in a manic state, mothers willneed constant supervision when caring for their infants.Mostly they will be too preoccupied to provide child care.

Medical management. A favorable outcome is as-sociated with a good premorbid adjustment (before the on-set of the disorder) and a supportive family network (Sadock& Sadock, 2000). Because mood disorders are usuallyepisodic, women may experience another episode of symp-toms within a year or two of the birth. Postpartum psychosisis a psychiatric emergency, and the mother will probablyneed psychiatric hospitalization. Antipsychotics and moodstabilizers such as lithium are the treatments of choice. If themother is breastfeeding, some sources recommend that nopharmacologic agents should be prescribed (Sadock &Sadock, 2000), but other sources advise caution while pre-scribing some agents (Stowe, Strader, & Nemeroff, 2001). An-tipsychotics and lithium should be avoided in breastfeedingmothers, but other mood stabilizers may be compatible withbreastfeeding (see later discussion). It is usually advantageousfor the mother to have contact with her baby if she so de-sires, but visits must be closely supervised. Psychotherapy isindicated after the period of acute psychosis is past.

Even though the prevalence of PPD is fairly well established,women are unlikely to seek help from a mental health careprovider. Primary health care providers can usually recognizesevere PPD or postpartum psychosis but may miss milderforms; even if the disorder is recognized, the woman maybe treated inappropriately or subtherapeutically (Gold, 2002).In as many as 50% of women with PPD, the disorder willgo undetected (Beck & Gable, 2001).

Assessment and NursingDiagnosesTo recognize symptoms of PPD as early as possible, the nurseshould be an active listener and demonstrate a caring atti-tude. Nurses cannot depend on women volunteering un-solicited information about their depression or asking forhelp. The nurse should observe for signs of depression andask appropriate questions to determine moods, appetite,sleep, energy and fatigue levels, and ability to concentrate.Examples of ways to initiate conversation include the fol-lowing: “Now that you have had your baby, how are thingsgoing for you? Have you had to change many things in your

CARE MANAGEMENT



life since having the baby?” and “How much time do youspend crying?” If the nurse assesses that the new mother isdepressed, she or he must ask if the mother has thoughtabout hurting herself or the baby. The woman may be morewilling to answer honestly if the nurse says, “Lots of womenfeel depressed after having a baby, and some feel so badlythat they think about hurting themselves or the baby. Haveyou had these thoughts?”

Nurses can use screening tools in assessing whether thedepressive symptoms have progressed from postpartum bluesto PPD. Examples are the Edinburgh Postnatal DepressionScale (EPDS) (Cox, Holden, & Sagovsky, 1987) and thePDPI (Beck, 2002).

The EPDS is a self-report assessment designed specificallyto identify women experiencing PPD. It has been used andvalidated in studies in numerous cultures (Eberhard-Gran,Eskild, Tambs, Opjordsmoen, & Samuelsen, 2001) and haseven been used to measure depression and anxiety in fathers(partners) (Matthey, Barnett, Kavanagh, & Howie, 2001). Theassessment tool asks the woman to respond to 10 statementsabout the common symptoms of depression. The woman isasked to choose the response that is closest to describing howshe has felt for the past week.

Through focused research over at least a decade, Beck hasdeveloped and continues to refine the Postpartum Depres-sion Checklist (PDC) and the Postpartum DepressionScreening Scale (PDSS) (Beck & Gable, 2000; Beck & Gable,2001). The latest revision (PDPI) is a checklist of 13 symp-toms of PPD. The published tool is designed to be used bynurses and other health care providers to elicit informationfrom the woman during an interview during pregnancy andcontinuing in the postpartum period to assess risk (Beck,2002). Areas assessed include the predictors of depression aslisted in Box 25-5.

If the initial interaction reveals some question that thewoman might be depressed, a formal screening is helpful indetermining the urgency of the referral and the type ofprovider. Also important is the need to assess the woman’sfamily members because they may be able to offer valuableinformation, as well as have a need to express how they havebeen affected by the woman’s emotional disorder (Maley,2002).

Planning is focused on meeting the individualized needsof the family to ensure safety, especially for the mother andinfant and any other children, and to facilitate functionalfamily coping. Nursing diagnoses may include the following:

• Risk for self-directed (mother) or other-directed (children)violence related to—postpartum depression

• Situational low self-esteem in the mother related to—stresses associated with role changes

• Disabled family coping related to—increased care needs of mother and infant

• Risk for impaired parenting related to—inability of depressed mother to attach to infant

• Risk for injury to newborn related to—mother’s depression (inattention to infant’sneeds for hygiene, nutrition, safety) and psycho-tropic medications via breast milk

Expected Outcomes of CareSpecific measurable criteria can be developed based on thefollowing general outcomes:

• The mother will no longer be depressed.

• The mother’s and infant’s physical well-being will bemaintained.

• The family will cope effectively.

• Family members will demonstrate continued healthygrowth and development.

• The infant will be fully integrated into the family.

Plan of Care and InterventionsOn the postpartum unitThe postpartum nurse must observe the new mother care-

fully for any signs of tearfulness and conduct further as-sessments as necessary. PPD must be discussed by nurses toprepare new parents for potential problems in the postpar-tum period (Patient Instructions for Self-Care box and Chap-ter 17). The family must be able to recognize the symptomsand know where to go for help. Written materials that ex-plain what the woman can do to prevent depression couldbe used as part of discharge planning.

Mothers are often discharged from the hospital before theblues or depression occurs. If the postpartum nurse is con-cerned about the mother, a mental health consultationshould be requested before the mother leaves the hospital.Routine instructions regarding PPD should be given to theperson who comes to take the woman home; for example,“If you notice that your wife (or daughter) is upset or cry-ing a lot, please call the postpartum care provider immedi-ately—don’t wait for the routine postpartum appointment.”

Because the newborn may be scheduledfor a checkup before the mother’s 6-week checkup,nurses in well-baby clinics or pediatrician offices shouldbe alert for signs of PPD in new mothers and be knowl-edgeable about community referral resources.

In the home and communityPostpartum home visits can reduce the incidence of or

complications from depression. A brief home visit or phonecall at least once a week until the new mother returns for herpostpartum visit may save the life of a mother and her in-fant; however, these contacts may not be feasible or avail-able. Supervision of the mother with emotional complica-tions may become a prime concern. Because depression cangreatly interfere with her mothering functions, family andfriends may need to participate in the infant’s care. This isa time for the extended family and friends to determine whatthey can do to help, and the nurse can work with them to

NURSE ALERT



ensure adequate supervision of the woman and their un-derstanding of the woman’s mental illness.

When the woman has PPD, a partner often reacts withconfusion, shock, denial, and anger and feels neglected andblamed. The nurse can talk with the woman about how hercondition is hard for him, too, and that he is probably veryworried about her. Men often withdraw or criticize whenthey are deeply worried about their significant others. Thenurse can provide nonjudgmental opportunities for the part-ner to verbalize feelings and concerns, help the partner iden-tify positive coping strategies, and be a source of encour-agement for the partner to continue supporting thewoman. Both the woman and her partner need an oppor-tunity to express their needs, fears, thoughts, and feelings ina nonjudgmental environment.

Even if the mother is severely depressed, hospitalizationcan be avoided if adequate resources can be mobilized to en-sure safety for both mother and infant. The nurse in homehealth care will need to make frequent phone calls or homevisits to do assessment and counseling. Community re-sources that may be helpful are temporary child care or fos-ter care, homemaker service, Meals on Wheels, parentingguidance centers, mother’s-day-out programs, and telephonesupport groups or other support programs (Wroblewski &Tallon, 2004) (see Resources at end of chapter).

Referral. Women with moderate to severe PPDshould be referred to a mental health therapist, such as anadvanced practice psychiatric nurse, for evaluation and ther-apy to avoid the effects that PPD can have on the womanand on her relationships with her partner, baby, and otherchildren (Brown, 2001). Inpatient psychiatric hospitalizationmay be necessary. This decision is made when the safetyneeds of the mother or children are threatened.

Providing safety. When depression is suspected,the nurse asks, “Have you thought about hurting yourself?”If delusional thinking about the baby is suspected, the nurseasks, “Have you thought about hurting your baby?” There

are four criteria to measure in assessing the seriousness of asuicidal plan: method, availability, specificity, and lethality.Has the woman specified a method? Is the method of choiceavailable? How specific is the plan? If the method is concreteand detailed, with access to it right at hand, the suicide riskincreases. How lethal is the method? The most lethal methodis shooting, with hanging a close second. The least lethal isslashing one’s wrists. Medication overdose can also be usedto cause death.

Suicidal thoughts or attempts are one ofthe most serious symptoms of PPD and require imme-diate assessment and intervention (Levy, Sanders, &Sabraw, 2002).

Psychiatric hospitalization. Women with post-partum psychosis are a psychiatric emergency and must bereferred immediately to a psychiatrist who is experienced inworking with women with PPD, who can prescribe med-ication and other forms of therapy and assess the need forhospitalization.

Legal CommitmentIf a woman with PPD is experiencing active suicidalideation or harmful delusions about the baby and is un-willing to seek treatment, legal intervention may benecessary to commit the woman to an inpatient settingfor treatment.

Within the hospital setting, the reintroduction of thebaby to the mother can occur at the mother’s own pace. Aschedule is set for increasing the number of hours the mothercares for the baby over several days, culminating in the in-fant staying overnight in the mother’s room. This allows themother to experience meeting the infant’s needs and givingup sleep for the baby, a situation difficult for new motherseven under ideal conditions. The mother’s readiness for dis-charge and caring for the baby is assessed. Her interactionswith her baby are also carefully supervised and guided.

Nurses should also observe the mother for signs of bond-ing with the baby. Attachment behaviors are defined as eye-to-eye contact; physical contact that involves holding, touch-ing, cuddling, and talking to the baby and calling the babyby name; and the initiation of appropriate care. A staff mem-ber is assigned to keep the baby in sight at all times. Indi-rect teaching, praise, and encouragement are designed to bol-ster the mother’s self-esteem and self-confidence.

Psychotropic medications. PPD is usuallytreated with antidepressant medications. If the woman withPPD is not breastfeeding, antidepressants can be prescribedwithout special precautions. The commonly used antide-pressant drugs are often divided into four groups: selectiveserotonin reuptake inhibitors (SSRIs), heterocyclics (in-cluding the tricyclic antidepressants [TCAs]), monoamineoxidase inhibitors (MAOIs), and other antidepressant agentsnot in the above classifications (Keltner & Folks, 2001) (Box25-6).

LEGAL TIP

NURSE ALERT


PATIENT INSTRUCTIONSFOR SELF-CARE

Activities to Prevent PostpartumDepression

• Share knowledge about postpartum emotional prob-lems with close family and friends.

• Take care of yourself: eat a balanced diet, exercise ona regular basis, and get enough sleep. Ask someone totake care of the baby so that you can get a full night’ssleep.

• Share your feelings with someone close to you; don’tisolate yourself at home.

• Don’t overcommit yourself or feel like you need to bea superwoman.

• Don’t place unrealistic expectations on yourself.• Don’t be ashamed of having emotional problems after

your baby is born—it happens to approximately 15%of women.


The SSRIs are prescribed more frequently today thanother groups of antidepressant medications. They are rela-tively safe and carry fewer side effects than the TCAs. Themost frequent side effects with the SSRIs are gastrointesti-nal disturbances (nausea, diarrhea), headache, and insomnia.In approximately one third of patients the SSRIs reduce li-bido, arousal, or orgasmic function.

The TCAs cause many central nervous system (CNS) andperipheral nervous system (PNS) side effects. A commonCNS effect is sedation, and this could easily interfere withmothers caring for their babies. A mother could fall asleepwhile holding the baby and drop him or her, or she couldhave trouble getting fully awake during the night to care for the baby. Other side effects include weight gain, tremors,grand mal seizures, nightmares, agitation or mania, and extrapyramidal side effects. Anticholinergic side effects in-clude dry mouth, blurred vision (usually temporary), diffi-culty voiding, constipation, sweating, and orgasm difficulty(Keltner & Folks, 2001).

Hypertensive crisis is the main reason that MAOIs are notprescribed more frequently. The woman should be taughtto watch for signs of hypertensive crisis—throbbing, occip-ital headache, stiff neck, chills, nausea, flushing, retroorbitalpain, apprehension, pallor, sweating, chest pain, and palpi-

tations (Keltner & Folks, 2001). This crisis is brought on bythe woman eating foods that contain tyramine, a sympat-homimetic pressor amine, which normally is broken downby the enzyme monoamine oxidase. The nurse must do ex-tensive teaching about avoidance of foods that contain tyra-mine such as aged cheeses, nuts, soy sauce, preserved meats,and tap beers (National Headache Foundation, 2005).

The woman taking mood stabilizers (Box 25-7) must betaught about the many side effects, and especially, for thoseon lithium, the need to have serum lithium levels assessedevery 6 months. Women with severe psychiatric syndromessuch as schizophrenia, bipolar disorder, or psychotic de-pression will probably require antipsychotic medications(Box 25-8). Most of these antipsychotic medications cancause sedation and orthostatic hypotension—both of whichcould interfere with the mother being able to safely care forher baby. They can also cause PNS effects such as consti-pation, dry mouth, blurred vision, tachycardia, urinary re-tention, weight gain, and agranulocytosis. CNS effects mayinclude akathisia, dystonias, parkinsonism-like symptoms,tardive dyskinesia (irreversible), and neuroleptic malignantsyndrome (potentially fatal).

Psychotropic medications and lactation. Amajor clinical dilemma is the psychopharmacologic treat-ment of women with PPD who want to breastfeed their in-fants. In the past, women were told to discontinue lactation.


Antidepressant Medications

SELECTIVE SEROTONIN REUPTAKE INHIBITORS

Citalopram (Celexa)Fluoxetine (Prozac)Fluvoxamine (Luvox)Paroxetine (Paxil)Sertraline (Zoloft)

TRICYCLICS

Amitriptyline (Elavil)Amoxapine (Asendin)Clomipramine (Anafranil)Desipramine (Norpramin)Doxepin (Sinequan)Imipramine (Tofranil)Nortriptyline (Pamelor)Protriptyline (Vivactil)

QUADRICYCLICS

Maprotiline (Ludiomil)Mirtazapine (Remeron)

MONOAMINE OXIDASE INHIBITORS

Phenelzine (Nardil)Tranylcypromine (Parnate)

OTHER AGENTS

Bupropion (Wellbutrin) IR and SRNefazodone (Serzone)Trazodone (Desyrel)Venlafaxine (Effexor)

BOX 25-6

Mood Stabilizers

• Carbamazepine (Tegretol XR)• Clonazepam (Klonopin)• Divalproex (Depakote)• Lithium carbonate (Eskalith)

BOX 25-7

Commonly Used Antipsychotic Medications

PHENOTHIAZINES

• Chlorpromazine (Thorazine)• Fluphenazine (Prolixin)• Perphenazine (Trilafon)• Thioridazine (Mellaril)• Trifluoperazine (Stelazine)

OTHER

• Clozapine (Clozaril)• Haloperidol (Haldol)• Loxapine (Loxitane)• Olanzapine (Zyprexa)• Pimozide (Orap)• Quetiapine (Seroquel)• Risperidone (Risperdal)• Thiothixene (Navane)• Ziprasidone (Geodon)

BOX 25-8


Today, we know that 5% to 17% of all nursing mothers takea prescription medication (Stowe, Strader, & Nemeroff,2001). The FDA has not approved any psychotropic med-ication for use during lactation. However, the AmericanAcademy of Pediatrics (AAP) has published reports on ex-cretion of medications into human breast milk since 1983.Almost all of the psychotropic medications listed in the 2001report are drugs for which the effects on the breastfeedingnewborn are “unknown but still may be of concern” (AAP,2001). The reason for the concern is that although the med-ications appear to be in low concentrations in breast milk(commonly a milk-to-serum ratio of 0.5 to 1), many drugshave a long half-life, and levels may build up in plasma andtissue of nursing infants. Long-term effects on the newbornare unknown (AAP, 2001). Because all psychotropic med-ications pass through breast milk to the infant, the risks as-sociated with the use of such medication must be weighedagainst the risks associated with maternal agitation and po-tentially self-destructive behavior.

Breast milk-excretion studies have demonstrated that an-tidepressants are present in breast milk, with a milk-to-serumratio that is typically greater than 1:1 (Stowe, Strader, & Ne-meroff, 2001) and often in higher concentrations in the fattyhind milk (Newport, Wilcox, & Stowe, 2001). Most TCAsappear to be safe during breastfeeding. Minimal data areavailable concerning the SSRIs, so earlier reviews recom-mended using the secondary amine TCAs. In light of the in-creasing data on SSRIs, and the lack of adverse reports, theserecommendations are likely to be revised (Stowe, Strader, &Nemeroff, 2001). MAOIs are usually avoided; no humandata have been published on the newer antidepressants.

The elapsed time between maternal dosing and infantfeeding has been shown to affect the amount of antide-pressant medication to which the infant is exposed. Ad-justing both the schedule of dosing of the antidepressant andthe infant’s feeding schedule may considerably reduce theconcentration of the drug to which the infant is exposed. Inaddition, eliminating the one daily feeding with the high-est concentration may be necessary (Stowe, Strader, & Nemeroff, 2001). Most of the drugs listed in Boxes 25-6 and25-7 are classified as drugs whose effects on infants are un-known but may be of concern.

Antipsychotic medications are excreted into breast milk.None of these medications has been proven safe during lac-tation; the AAP does not rate any of the antipsychotic med-ications as compatible with breastfeeding.

Mood-stabilizing and antimanic medications are presentin breast milk. Lithium is contraindicated in breastfeeding.The benefits of breastfeeding and the potential risks must becarefully considered before use of other mood stabilizers(AAP, 2001).

In summary, all psychotropic medications studied to dateare excreted in breast milk. The information about adverseeffects of psychotropic agents on infants are limited to casereports. The nursing infant’s daily dose of psychotropicagents is less than the maternal daily dose. Psychotropic

medications are excreted into breast milk with a specific in-dividual time course, allowing the minimization of infantexposure with continuation of breastfeeding. The long-termneurobehavioral effects of infant exposure to psychotropicmedications through breastfeeding are unknown. Psy-chotropic medications for breastfeeding women should beselected if they have greater documentation of prior use,lower FDA risk category, few or no metabolites, and fewerside effects (Stowe, Strader, & Nemeroff, 2001).

Nursing implications. When breastfeeding womenhave emotional complications and need psychotropic med-ications, referral to a psychiatrist who specializes in post-partum disorders is preferred. The nurse should reinforce theneed to take antidepressants as ordered. Because they do notexert any effect for approximately 2 weeks and usually do notreach full effect for 4 to 6 weeks, many women discontinuetaking the medication on their own. Patient and family teach-ing should reinforce the schedule for taking medications inconjunction with the infant’s feeding schedule.

Other treatments for PPD. Other treatments forPPD include complementary or alternative therapies suchas those listed in Box 25-9, ECT, and psychotherapy. Alter-native therapies may be used alone but often are used withother treatments for PPD. Safety and efficacy studies of thesealternative therapies are needed to ensure that care and ad-vice is based on evidence (Tiran & Mack, 2000).

St. John’s wort is often used to treat de-pression. It has not been proven safe for women whoare breastfeeding.

ECT may be used for women with PPD who have notimproved with antidepressant therapy. Psychotherapy in the form of group therapy or individual (interpersonal) ther-apy also has been used with positive results alone and in

NURSE ALERT


Possible Alternative or ComplementaryTherapies for Postpartum Depression

• Acupuncture• Acupressure• Aromatherapy• Jasmine• Ylang-ylang• Rose• Herbal remedies• Lavender tea• Healing touch or therapeutic touch• Massage• Relaxation techniques• Reflexology• Yoga

Source: Skidmore-Roth, L. (2004). Mosby’s handbook of herbs and natu-ral supplements (2nd ed.). St. Louis: Mosby; & Tiran, D., & Mack, S. (Eds.).(2000). Complementary therapies for pregnancy and childbirth (2nd ed.).Edinburgh: Baillière Tindall.

BOX 25-9


conjunction with antidepressant therapy; however, morestudies are needed to determine what types of professionalsupport are most effective (Ray & Hodnett, 2001).

EvaluationThe nurse can be assured that care has been effective if thephysical well-being of the mother and infant is maintained,the mother and family are able to cope effectively, and eachfamily member continues to show a healthy adaptation tothe presence of the new member of the family (Plan of Care).

Postpartum Onset of Panic DisorderApproximately 3% to 5% of women develop panic disorderor obsessive-compulsive disorder in the postpartum period.Panic attacks are discrete periods in which there is the sud-den onset of intense apprehension, fearfulness, or terror

(APA, 2000). During these attacks, symptoms such as short-ness of breath, palpitations, chest pain, choking, smother-ing sensations, and fear of losing control are present. Theyhave intrusive thoughts about terrible injury done to the in-fant, such as stabbing or burns, sometimes by themselves.Rarely do they harm the baby. Nurses need only to listen tohear symptoms of panic disorder. Usually these women areso distraught that they will share with whomever will listen.Oftentimes the family has tried to tell them that what theyare experiencing is normal, but they know differently.

Medical managementTreatment is usually a combination of medications, ed-

ucation, psychotherapy, and cognitive behavioral interven-tions, along with an attempt to identify any medical or phys-iologic contributors. Antidepressants such as SSRIs may be prescribed (Brown, 2001), and sertraline (Zoloft) and


Postpartum DepressionPLAN OF CARE

NURSING DIAGNOSIS Risk for injury to thewoman and/or newborn related to woman’semotional state and/or treatment

Expected Outcomes The mother and newborn willremain free of injury. The woman’s family will ver-balize understanding of the need for maternal andinfant supervision and have a plan to provide thatsupervision.


• Assess the postpartum woman for risk factors for depression(before discharge) to determine if she is at risk and in needof prompt interventions or referral.

• Provide information about signs of PPD to woman and fam-ily to promote prompt recognition of problems.

• Observe maternal-infant interactions before discharge to de-termine appropriateness.

• Maintain frequent contact with woman by telephone callsand home visits to determine if further interventions are nec-essary, because most postpartum mothers are dischargedearly from the inpatient setting.

• Counsel woman and family to telephone health careprovider if behaviors indicating depression, such as crying,increase to provide prompt care and referral if necessary andavoid injury to newborn and mother.

• Provide opportunities for woman and family to verbalize feel-ings and concerns in a nonjudgmental setting to promote atrusting relationship.

• Assess woman for any suicidal thoughts or plans to providefor safety of woman and infant.

• Assist family to develop a plan for maternal and infant su-pervision to provide for safety of woman and infant.

• Provide information about community resources for assis-tance to ensure care if woman is unable to care for herselfor infant.

• Reinforce teaching or refer breastfeeding mother to lactationconsultant to obtain information regarding effects of anti-depressant and antipsychotic medications.

NURSING DIAGNOSIS Disabled family coping re-lated to postpartum maternal depression as evi-

denced by family members’ denial of woman’sillness

Expected Outcomes Family will identify positivecoping mechanisms and initiate a plan to copewith the woman’s depression.


• Provide opportunity for family and significant others to ver-balize feelings and concerns to establish a trusting relation-ship.

• Give information to the family regarding postpartum de-pression to clarify any misconceptions or misinformation.

• Assist family to identify positive coping mechanisms thathave been effective during past crises to promote active par-ticipation in care.

• Assist family to identify community sources of support toprovide additional resources as needed.

• Refer family to mental health counselor as needed to providefurther expertise from a mental health professional.

NURSING DIAGNOSIS Risk for impaired parentingrelated to inability of mother to attach to infant

Expected Outcomes Woman demonstrates appro-priate attachment behaviors in infant interactions.Woman expresses satisfaction with infant.


• Observe maternal-infant interactions to assess quality of in-teractions and to determine need for interventions.

• Encourage woman to express her anxiety, fears, or other feel-ings to allow woman to ventilate her concerns and have themaccepted.

• Encourage the woman to have as much contact with infantas possible to minimize separation and to promote attach-ment.

• Demonstrate infant care and explain infant behaviors to en-hance mother’s care abilities and understanding of infant’sabilities.

• Make referrals as needed to community resources to assistthe woman in developing parenting skills or promoting con-fidence in infant care.

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paroxetine (Paxil) are approved in the United States for thetreatment of panic disorder; fluvoxamine (Luvox) may be es-pecially helpful with obsessions (Keltner & Folks, 2001).

Nursing considerationsThe following nursing interventions are suggested:

• Education is a crucial nursing intervention. New moth-ers should be provided with anticipatory guidance con-cerning the possibility of panic attacks during the post-partum period. Preparing for the attacks may helpdecrease their unexpected, terrifying nature (Beck, 1998).

• Women can be reassured that it is common to feel a senseof impending doom and fear of insanity during panic at-tacks. These fears are temporary and disappear once thepanic attack is over (Beck, 1998).

• Nurses can help women identify panic triggers that areparticular to their own lives. Keeping a diary can helpidentify the triggers (Beck, 1998).

• Family and social supports are helpful. The new motheris encouraged to put usual chores on hold and to ask forand accept help.

• Support groups allow these mothers to experience com-fort in seeing others like themselves.

• Sensory interventions such as music therapy and aro-matherapy are nonintrusive and inexpensive.

• Behavioral interventions such as breathing exercises andprogressive muscle relaxation can be helpful (Fishel,1998).

• Cognitive interventions such as positive self-talk training,reframing and redefining, and reassurance can alter thenegative thinking (Fishel, 1998).


COMMUNITY ACTIVITY

Identify resources in your community for womenwith postpartum depression. Develop criteria toevaluate these resources (e.g., accessibility,costs), and compare the resources according tothe results of your analysis including thestrengths and weaknesses (or pros and cons) ofeach resource.

• PPH is the most common and most serious typeof excessive obstetric blood loss.

• Hemorrhagic (hypovolemic) shock is an emergencysituation in which the perfusion of body organsmay become severely compromised, leading to sig-nificant risk of morbidity or death for the mother.

• The potential hazards of the therapeutic interven-tions may further compromise the woman with ahemorrhagic disorder.

• Clotting disorders are associated with many ob-stetric complications.

• The first symptom of postpartum infection is usu-ally fever greater than 38° C on 2 consecutive daysin the first 10 postpartum days (after the first 24 hours).

• Prevention is the most effective and inexpensivetreatment of postpartum infection.

• Structural disorders of the uterus and vagina re-lated to pelvic relaxation and UI may be a delayedresult of childbearing.

• Bladder training and pelvic muscle exercises cansignificantly decrease or relieve mild to moderateUI.

• Mood disorders account for most mental healthdisorders in the postpartum period.

• Identification of women at greatest risk for post-partum depression can be facilitated by use of var-ious screening tools.

• Suicidal thoughts or attempts are one of the mostserious symptoms of postpartum depression.

• Antidepressant medications are the usual treat-ment for postpartum depression; however, specificprecautions are needed for breastfeeding women.

Key Points

Postpartum Depression1 Yes, there is evidence to draw conclusions about including in-

formation on postpartum depression in discharge teaching.2 a. Nurses have a major opportunity and responsibility to help

women understand risk factors and to motivate them toadopt healthy lifestyles that prevent disease. Women need tobe prepared for potential problems in the postpartum periodsuch as PPD and to be counseled to engage in self care prac-tices for their own health promotion and illness prevention.Teaching activities include taking care of oneself by eatinga balanced diet, getting exercise, and getting adequate sleep;sharing feelings; not overcommitting or setting unrealistic ex-pectations for oneself; and making sure family and friendsalso have knowledge about PPD.

b. Women experience depression twice as often as men. It occursin approximately 10% to 15% of postpartum women. As-sessment tools can be used to identify women at risk for PPDto see whether the woman has progressed from postpartumblues to PPD. These screening tools elicit information fromthe woman about the common symptoms of depression. Thetool developed by Beck (2002) includes predictors of depres-sion that include prenatal depression, low self-esteem, stressof child care, prenatal anxiety, life stress, lack of social support,marital relationship problems, history of depression, “diffi-cult” infant temperament, postpartum blues, single status, lowsocioeconomic status, andunplannedorunwantedpregnancy.

c. Impaired parenting is a major risk of PPD. A prominent feature of PPD is rejection of the infant. The woman may be

Answers Guidelines to Critical Thinking Exercise


obsessed that the infant is taking her place in her partner’saffections. She may show disinterest, annoyance with caredemands, blaming self because of her lack of maternal feel-ing. She may appear awkward in her responses to the babyand may not be able to provide care for the baby. She mayhave thoughts of harming the baby or accuse others of try-ing to harm the baby. Friends and family may need to pro-vide infant care, or temporary foster care may be needed ifthere is no support system.

3 The plan should be developed to include what screening meth-ods will be used on the postpartum unit, what written materialswill be provided, whether classes or individual sessions will be

included, who will be included in the teaching session, what fol-low-up will be provided (e.g., phone calls, home visits), and whatresources are available in the community for referral or support.

4 Yes. Depression is treatable if identified early and adequate treat-ment is given. It will not go away by itself. Women who are notinformed may not seek help.

5 An alternative argument is to develop prenatal assessments andinformation about the risks of PPD and to assess throughoutpregnancy for signs of problems. Classes and written materialscan be provided during pregnancy as well by childbirth edu-cators or health care providers (see Wroblewski & Tallon, 2004).


AHCPR websitewww.hcfa.gov/medicaid/siq/siqipg/htm

Depression after Delivery (DAD)P.O. Box 1282Morrisville, PA 19067908-575-9121www.depressionafterdelivery.com

National Association for Continence1-800-252-3337www.nafc.org

National Depressive and Manic-Depressive Association730 N. Franklin St., Suite 501Chicago, IL 60610800-826-3632www.ndmda.org

National Headache Foundation1-888-NHF-5552www.headaches.org/consumer/topicsheets/tyramine.html

Postpartum Support International927 North Kellog Ave.Santa Barbara, CA 93111805-967-7636www.chss.iup.edu/postpartum

Resources

American Academy of Pediatrics (AAP) Committee on Drugs. (2001).The transfer of drugs and other chemicals into human milk. Pedi-atrics, 108(3), 776-789.

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American Psychiatric Association (APA). (2000). Diagnostic and statis-tical manual of mental disorders (4th ed., text revision). Washington,DC: American Psychiatric Association Press.

Beal, M. (1998). Use of complementary and alternative therapies in re-productive medicine. Journal of Nurse-Midwifery, 43(3), 224-233.

Beck, C. (1998). Postpartum onset of panic disorder. Journal of Nurs-ing Scholarship, 30(2), 131-135.

Beck, C. (2001). Predictors of postpartum depression: An update. Nurs-ing Research, 50(5), 275-282.

Beck, C. (2002). Revision of the Postpartum Depression Predictors In-ventory. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 31(4),394-402.

Beck, C., & Gable, R. (2000). Postpartum Depression Screening Scale:Development and psychometric testing. Nursing Research, 49(5), 272-282.

Beck, C., & Gable, R. (2001). Further validation of the Postpartum De-pression Screening Scale. Nursing Research, 50(3), 155-164.

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Berg, T., & Smith, C. (2002). Pharmacologic therapy for peripartumemergencies. Clinical Obstetrics and Gynecology, 45(1), 125-135.

Bowes, W., & Thorp, J. (2004). Clinical aspects of normal and abnor-mal labor. In R. Creasy, R. Resnik, & J. Iams (Eds.), Maternal-fetal med-icine: Principles and practice (5th ed.). Philadelphia: Saunders.

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Brown, C. (2001). Depression and anxiety disorders. Obstetrics and Gynecology Clinics of North America, 28(2), 241-268.

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Clark, S. (2004). Placenta previa and abruptio placentae. In R. Creasy,R. Resnik, & J. Iams (Eds.), Maternal-fetal medicine: Principles and prac-tice (5th ed.). Philadelphia: Saunders.

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