Postpartum Depression

Risk Factors

• Depression during pregnancy or previous PPD
• First pregnancy
• Hormonal fluctuations
• Medical problems during pregnancy
• Family Hx of depression, mental illness, or alcoholism
• Immaturity or low self esteem
• Marital dysfunction
• Anger about pregnancy
• Single; young
• Unplanned; financial worries

Postpartum Depression

 Explanations

• Up to 19% of women have in first 3 mo
• S/S - Decreased interest in surroundings, sees infant as demanding, and feelings of guilt, shame, loss of self.
• Infants tend to be fussier and make less positive facial expressions.
• Therapy Mngmt - Psychotherapy, social support, and medication
• Whole family for counseling; meds for 6mo or more.
  

Postpartum Depression

 Postpartum Psychosis

• Rare; causes psychiatric admission
• Hx of Bipolar
• Warning Signs - Sleep disturbances, confusion, agitation, irritability, hallucinations, delusions, and possibility to harm infant or herself.
  

Postpartum Hemmorrhage

 Explinations

• Blood loss of more than 500mL Vag birth or 1000mL C/S
• Decreased hct of 10% or more or need for transfusion
• Mom builds up 1000 - 1200 mL for pregnancy
• Up to 750 mL/min perfuses into placenta during pregnancy
• Steady trickle just as dangerous as gushes
• 1 pad per hour is normal. Over that = hemmorrhage
• Soft boggy fundus = hemmorrhage; increase in fundus size

Postpartum Hemorrhage

 Early Postpartum Hemorrhage

Nursing Considerations

• 1st hr after birth; massage fundus q15min
• Uterine atony - 80-90% of early PPH; long labor multiple births
• Trauma

• 1st massage fundus until firm
• Document size and ammount of clots; pad counts
  
• Full bladder needs to be relieved
• IV pitocin; methergine (arteriole vasoconstriction)
• "I dont feel right"
• hematoma - severe pressure pain (concealed bleed)
  

Postpartum Hemorrhage

Late Postpartum Hemorrhage

Nursing Considerations

• Subinvolution - slower than expected return of the uterus to nonpregnancy size
• Placental fragments - C/S removal; pulled out; can cause infection
• Typically occurs without warning on PP day 6 - 6wks
• Teach how to massage own fundus on discharge.

• Overdistention
• Multiparity
• Prolonged labor
• C/S
• General Anesthesia
• Forceps/Vacuum
• Manual removal of placenta
• Clotting disorders
• Placenta previa, placenta accreta, or low implantation
  

• An uncontracted uterus
• Large gush or slow, stea trickle, ooze, or dribble of blood from the vagina
• Saturation of one peripad per 15 min
• Severe, unrelieved perineal or rectal pain
• Tachycardia
  

• Fever, chills
• Pain or redness of wounds
• Tachycardia
• Purulent wound drainage or wound edges not approx.
• Uterine subinvolution
• Elevated WBC
• Frequent or urgent urination, dysuria, or hematuria
• Suprapubic pain
• Localized area of warmth, redness, or tenderness in the breasts
  

Anxiety; feelings of guilt

Agitation

Fatigue/Sleepiness

Irritability

Confusion

Appetite changes

Lack of energy

Crying

Less responsive to infant

• Prematurity - Less than 1500g
• 10-25% mortality
• From high level O2 use, O2 free radicals, high Positive pressure ventilation that damage bronchial epithelium and cause inflammation.
• Results in inflammation, atelectasis, edema, airway hyperreactivity with loss of cilia, thickening of walls of airway, and fibrotic changes
• Increase need for vent/innability to wean
• Tachycardia, tachypnea, retractions, rales, wheezing, resp acidosis, increased secretions, and bronchospasms.

• Prevention is key; Minimize exposure to O2
• Avoid fluid overload; Diuretics and fluid restriction
  
• Supportive Tx with bronchodilators and Abx to prevent infection
• Increase calories and protein
• May go home on O2 or Vent and require frequent hospitalization

Lose cilia; 99-100% SPO2, turn down O2; Use minimum ammount of O2

• Poor feeding or feeding intolerance
• Lethargy
• Irritability
• Weak cry or suck
• Decreased muscle tone
• Cool skin temp
• Mottled, pale, or acrocyanotic skin
• signs of hypoglycemia or resp. difficulty
• Poor weight gain
  

• Urine output <1mL/kg/hr
• Urine S.G. >1.02
• Weight loss
• Dry skin
• Sunken anterior fontanel
• Poor tissue turgor
• Blood:elevated sodium, protein, and hematocrit levels
• hypotension
  

• Urine output >3 mL/kg/hr
• Urine S.G. <1.001
• Edema
• Weight gain
• Bulging Fontanels
• Blood: decreased sodium, protein, and hematocrit levels
• Moist breath sounds
• Difficulty breathing
  

• High pitched, intense, harsh cry
• Whimpering moaning
• Cry face
• Eyes squeezed shut
• Grimacing
• Tense, rigid muscles or flaccid muscle tone
• Flailing
• Red, dusky, pale
• Increased HR, Resp rate, BP; apnea; decreased HR, resp rate, O2
  

• Rapid respirations develop soon after birth
• Cause thought to be excess or delay of absorption of fluid in lungs.
• Resp as high as 120
• Grunting, retracting, nasal flaring (same as RDS)
• CXR shows hhyperinflation and streaking of lungs (fluid in lungs)
• Self limiting, lasting 1-5 days
• Higher in C/S babies
• Caused from maternal analgesics/bleeding/diabetes
• May have to gavage feed to prevent aspiration
• Watch Blood sugar (hypoglycemia) and temp.
  

• Postterm infants w/decreased amniotic fluid, prone to cord compression
• Rare before 36wks
• Results in obstruction of airway, pneumonitis, and air trapping, atelectasis
  
• Causes - Fetal stress/low O2
• Dont want baby to spontaniously breath at birth; Intibate; ET tube w/suction; remove amniotic fluid; stimulate to breath.
• If infant breaths, proceed as a normal baby would.
  

Hyperbilirubinemia

Pathologic Jaundice

• Patho when appears in first 24hrs, rises by >5mg/dl/day, or >95% for infants age.
• May lead to Kernicterus (bilirubin in brain)
• Causes - Hemolytic disease because incompatibility w/maternal blood; Rh incompatibility; ABO incompatibility; infection; polycytememia
• Phototherapy: Bilirubin absorbs in light and changes into water soluable photoisomers excreted by bile and urine. Lights/blanket/bed.
• Exchange transfusion - Blood transfusion when lights dont work.
  

Hyperbilirubinemia

Pathologic Jaundice

• Educate on equipment
• Check transcutaneous or serum bili levels
• Ensure proper feeding (breast milk is a natural laxative and will excrete the bilirubin faster)
• Maintain temp
• Keep eyes covered under lights
• Phototherapy as much as possible.
• Test bilirubin levels as ordered
  

• Give to Rh neg. moms to prevent production of antibodies that attack fetus; Given at 28wks pregnancy or within 72 hrs of delivery; Can also be given 72 hrs after termination of 13wks gestation or more.

• 0.1 mg/kg; Dont give to baby whose mom is addicted to opiates because it will cause withdrawels/seizures.
• IV preferred; 1-2 minutes to start working; Within 4 hrs of delivery w/resp. depression; Observe for recurrent resp. depression. Metabolized in liver and excreted through kidneys.
  

• Heart rate; 0=absent; 1 = below 100bpm; 2 = 100 bpm or higher
• Resp rate; 0=No spontanious resp; 1=Slow resp or weak cry; 2=Spontanious resp with strong, lusty cry
• Muscle tone; 0=Limp; 1=Minimal flexion of extremities w/sluggish movement; 3=Flexed body posture w/spontanious and vigorous movement
• Reflex Response; 0=No response to suction or gentle slap on soles; 1=Minimal response (grimace) to suction or slap; 2=Responds promptly to suction or gentle slap with cry or active movement
• Color; 0=Pallor or cyanosis; 1=Bluish hands and feet only; 2=Pink or absense of cyanosis w/pink mucous membranes.
• Score of 0-10 at 1 and 5 min.
  

• Mag. Sulf. - Controls preeclampsia; up to 24hrs after birth, may still need to prevent siezures; hypoactive reflexes = toxicity.
• Methergine - For soft boggy fundus; Dont give to HTN pts

NAS

Neonaal abstinence syndrome

• Fever;tight muscle tone
• Strong suck (appears hungry); poor suck/swallow/breath
• Dont wake up baby
• Give baby urine drug test and meconium test to see what drug they were exposed to.
• Gavage feeding and IV hydration
  
• Hyperactive Moro is a sign
• Irritable, poor tone, high-pitched cry, BS levels abnormal
  

• First - Involves the superficial vag. mucosa or perineal skin
• Second - Involves the vag mucosa, perineal skin, and deeper tissues (fascia and muscles)
• Third - Involves anal sphincter
• Fourth - Extends through anal sphincter into the rectal mucosa.