CHAPTER 24
Postpartum Complications
Janet Andrews
OBJECTIVES
On completion of this chapter the reader will be able to:
• Identify causes, signs and symptoms, possible complications, and medical and nursing
management of postpartum hemorrhage.
• Describe hemorrhagic shock (hypovolemic shock) as a complication of postpartum
hemorrhage, including collaborative management.
• Identify causes, signs and symptoms, possible complications, and medical and nursing
management of postpartum infection.
• Describe thromboembolic disorders, including incidence, etiology, signs and
symptoms, and management.
• Describe structural disorders of the uterus and vagina that can result from childbearing.
• Differentiate among perinatal mood disorders, including incidence, risk factors, signs
and symptoms, severity, and management.
• Describe the nurse's role in assisting families who are grieving from perinatal loss.
Providing safe and effective care to women and their families experiencing postpartum
physical and psychological complications, sequelae of childbirth trauma, or grief related to
perinatal loss requires a collaborative effort from all members of the health care team.
Whenever possible the mother–baby dyad must be supported to remain together.
Involvement of partners and families in caring for mom and baby is important in the face of
postpartum complications. This chapter focuses on the postpartum complications of
hemorrhage and infection, sequelae of childbirth trauma, psychological complications, and
loss and grief.
Postpartum Hemorrhage Exemplar
Postpartum Hemorrhage
Definition and Incidence
Postpartum hemorrhage (PPH) is among the leading causes of maternal death worldwide.
It is a life-threatening event that can occur with little warning and is often unrecognized
until the mother has profound symptoms. It is preventable in more than half of cases (Della
Torre, Kilpatrick, Hibbard, et al., 2011). PPH occurs in 5% of births worldwide (Society of
Obstetricians and Gynaecologists of Canada [SOGC], 2014). Traditionally, PPH has been
1109
defined as the loss of more than 500 mL of blood during a vaginal birth and more than
1000 mL of blood during a Caesarean birth, but definitions have changed in that any blood
loss that has the potential to cause hemodynamic instability should be considered PPH
(SOGC, 2014).
PPH is classified as primary or late with respect to the birth. Early, acute, or primary PPH
occurs within 24 hours of the birth. Late or secondary PPH occurs more than 24 hours but
less than 6 weeks after the birth and is due to retained products, infection, or both (Francois
& Foley, 2012). Due to shortened hospital stays after birth, the potential for acute episodes
of PPH to occur outside the traditional hospital or birth centre setting has increased.
Risk factors for and causes of PPH are listed in Box 24-1. It is common to look at the
etiology of PPH within four categories: tone, tissue, trauma, and thrombin. These are
referred to as the four T's of PPH.
Box 24-1
Risk Factors and Causes of Postpartum Hemorrhage
Tone: Uterine Atony
• Overdistended uterus—Large fetus, multiple fetuses, hydramnios, distension with clots
• Anaesthesia and analgesia—Conduction anaesthesia
• Previous history of uterine atony
• High parity
• Prolonged labour, oxytocin-induced labour
• Magnesium sulphate administration during labour or postpartum period
• Chorioamnionitis
• Uterine subinvolution
Trauma
• Lacerations of the birth canal
• Trauma during labour and birth—Forceps-assisted birth, vacuum-assisted birth,
Caesarean birth
• Ruptured uterus
• Inversion of the uterus
• Manual removal of a retained placenta
Tissue
• Retained placental fragments
• Placenta accreta, increta, percreta
• Placental abruption
• Placenta previa
Thrombin
• Coagulation disorders
Tone (Uterine Atony)
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Uterine atony is marked hypotonia (relaxation) of the uterus. Normally, placental
separation and expulsion are facilitated by contraction of the uterus, which also prevents
hemorrhage from the placental site. The uterine corpus is in essence a basket weave of
strong, interlacing smooth-muscle bundles through which many large maternal blood
vessels pass (see Fig. 6-3). The pregnant uterus processes 500 mL of blood per minute.
Therefore it is essential for the myometrium to contract particularly after the expulsion of
the placenta. If the uterus is flaccid after detachment of all or part of the placenta, brisk
venous bleeding occurs, and normal coagulation of the open vasculature is impaired and
continues until the uterine muscle is contracted.
Uterine atony is the leading cause of early PPH. It is associated with high parity,
polyhydramnios, fetal macrosomia, and multifetal gestation. In such conditions, the uterus
is “overstretched” and contracts poorly after birth. Other causes of atony include traumatic
birth, use of halogenated anaesthetic (e.g., halothane), magnesium sulphate, rapid or
prolonged labour, chorioamnionitis, use of oxytocin for labour induction or augmentation,
and uterine atony in a previous pregnancy (Francois & Foley, 2012).
Late postpartum bleeding may occur as a result of subinvolution of the uterus (delayed
return of the enlarged uterus to normal size and function). Recognized causes of
subinvolution include retained placental fragments (discussed below, in the section Tissue)
and pelvic infection. Signs and symptoms include prolonged lochial discharge, foul odour,
pain, fever, irregular or excessive bleeding, and sometimes hemorrhage. A pelvic
examination usually reveals a larger-than-normal uterus that may be boggy. The woman is
often at home when the symptoms occur. Discharge teaching should emphasize the signs of
normal involution, potential complications, and the importance of prompt assessment by a
health care provider in the event of PPH.
Trauma
Any lacerations of the genital tract, extensions or lacerations during Caesarean birth,
uterine rupture, and uterine inversion are all considered trauma and can cause PPH.
Lacerations of the perineum are the most common of all injuries in the lower portion of the
genital tract. These are classified as first, second, third, and fourth degree (see Chapter 17,
p. 451). An episiotomy may extend to become either a third- or fourth-degree laceration.
Hemorrhage related to lacerations should be suspected if bleeding continues despite a
firm, contracted uterine fundus. This bleeding can be a slow trickle, an oozing, or frank
hemorrhage.
Factors that influence the causes and incidence of obstetrical lacerations of the lower
genital tract include operative birth, precipitous birth, congenital abnormalities 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; and deep engagement in the
pelvis prior to Caesarean birth may all lead to tissue trauma.
Hematomas
Although rarely causing hemodynamic instability, bleeding may spread into connective
tissues, remaining concealed. Pelvic hematomas (i.e., a collection of blood in the connective
tissue) may be vulvar, vaginal, or retroperitoneal in origin. Vulvar hematomas are the most
common. Pain is the most common symptom, and most vulvar hematomas are visible.
Vaginal hematomas occur more commonly in association with a forceps-assisted birth, an
episiotomy, or primigravidity (Francois & Foley, 2012).
Retroperitoneal hematomas are least common but may be life threatening. They are
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caused by laceration of one of the vessels attached to the hypogastric artery, usually
associated with rupture of a Caesarean scar during labour. During the postpartum period,
if the woman reports a persistent perineal or rectal pain or a feeling of pressure in the
vagina, a careful examination is made. However, a retroperitoneal hematoma may cause
minimal pain, and the initial symptoms may be signs of shock (Francois & Foley, 2012).
Hematomas are usually surgically evacuated. Once the bleeding has been controlled,
usual postpartum care is provided with attention to pain relief, monitoring of the amount
of bleeding, replacement of fluids, and review of laboratory results (hemoglobin and
hematocrit).
Inversion of the Uterus
Uterine inversion (turning inside out) after birth is a potentially life-threatening
complication. It occurs in approximately 1 in 25,000 births (SOGC, 2014) and can recur with
a subsequent birth. Uterine inversion may be incomplete, complete, or prolapsed.
Incomplete inversion cannot be seen; a smooth mass can be palpated through the dilated
cervix. In complete inversion the lining of the fundus crosses through the cervical os and
forms a mass in the vagina. Prolapsed inversion of the uterus is obvious; a large, red,
rounded mass (perhaps with the placenta attached) protrudes 20 to 30 cm outside the
introitus.
Factors contributing to uterine inversion include fundal implantation of the placenta,
vigorous fundal pressure, excessive traction applied to the cord, fetal macrosomia, short
umbilical cord, tocolysis, prolonged labour, uterine atony, nulliparity, and abnormally
adherent placental tissue (Francois & Foley, 2012). The primary presenting signs of uterine
inversion are sudden and include hemorrhage, shock, and pain. The uterus is not palpable
abdominally. The uterus must be replaced into its proper position by the obstetrical health
care provider.
Prevention—always the easiest, cheapest, and most effective therapy—is especially
appropriate for uterine inversion. The umbilical cord should not be pulled unless the
placenta has definitely separated.
Uterine inversion is an emergency situation requiring immediate interventions that
include maternal fluid resuscitation, repositioning of the uterus within the pelvic cavity,
and correction of associated clinical conditions. Tocolytics or halogenated anaesthetics may
be given to relax the uterus before attempting replacement (Francois & Foley, 2012).
Oxytocic agents are given after the uterus is repositioned; broad-spectrum antibiotics
should be initiated. The woman's response to treatment should be observed closely to
prevent shock or fluid overload. If the uterus has been repositioned manually, care must be
taken to avoid aggressive fundal massage.
Tissue
Delivery of the placenta occurs in the third stage of labour. Uterine involution and the
prevention of PPH rely on expulsion of the entire placenta. Retained placental segments
(tissue) may result from partial separation of a normal placenta, the existence of an
additional succenturiate lobe, entrapment of the partially or completely separated placenta
by an hourglass constriction ring of the uterus, mismanagement of the third stage of labour,
or abnormal adherence of the entire placenta or a portion of the placenta to the uterine wall.
Nonadherent retained placenta is managed through manual separation and removal by
the obstetrical care provider. Supplementary anaesthesia is usually not needed for women
who have had regional anaesthesia for birth. For other women, administration of light
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nitrous oxide and occasionally general anaesthetic is required for uterine exploration and
placental removal. After the removal, the woman is at continued risk for PPH and infection.
Dilation and curettage (D&C) may be needed in order to remove retained placental
fragments or debride the placental site.
In rare instances there is abnormal adherence of the placenta to the myometrium.
Although the cause is unknown, this condition is thought to result from zygote
implantation in an area of defective endometrium, resulting in no zone of separation
between the placenta and the decidua. Attempts to remove the placenta in the usual
manner are unsuccessful, and laceration or perforation of the uterine wall can result,
putting the woman at great risk for severe PPH and infection (Francois & Foley, 2012).
Unusual placental adherence can be partial or complete. The following degrees of
attachment are recognized:
• Placenta accreta—Slight penetration of myometrium
• Placenta increta—Deep penetration of myometrium
• Placenta percreta—Perforation of uterus
Placenta accreta can be diagnosed before birth using ultrasonography and magnetic
resonance imaging (MRI), but often it is not recognized until there is excessive bleeding
after birth. Bleeding with complete or total placenta accreta may not occur unless
separation of the placenta is attempted. With more extensive involvement, bleeding
becomes profuse when delivery of the placenta is attempted. Less blood is lost if the
diagnosis is made antenatally and no attempt is made to manually remove the placenta.
Treatment includes blood component replacement therapy. Hysterectomy can be indicated
if bleeding is uncontrolled (Cunningham, Leveno, Bloom, et al., 2014; SOGC, 2014).
Thrombin (Coagulopathies)
The final T in the etiology of PPH stands for thrombin, or coagulopathies. When bleeding is
continuous and there is no identifiable source, a coagulopathy may be the cause. The
woman's coagulation status must be assessed quickly and continuously. Abnormal results
depend on the cause and may include increased prothrombin time, increased partial
thrombo​plastin time, decreased platelets, decreased fibrinogen level, increased fibrin
degradation products, and prolonged bleeding time. Causes of coagulopathies may be preexisting or pregnancy related, such as idiopathic or immune thrombocytopenic purpura
(ITP), von Willebrand disease, thrombocytopenia with pre-eclampsia, or disseminated
intravascular coagulation (DIC). Coagulopathies may also develop as a result of fetal
demise, severe infection, or amniotic fluid embolus (SOGC, 2014).
Idiopathic Thrombocytopenic Purpura (ITP)
Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder in which
antiplatelet antibodies decrease the lifespan of the platelets. Thrombocytopenia, capillary
fragility, and increased bleeding time are diagnostic findings. ITP may cause severe
hemorrhage after Caesarean birth or from cervical or vaginal lacerations. The incidence of
postpartum uterine bleeding and vaginal hematomas is also increased.
Medical management focuses on control of platelet stability. If ITP was diagnosed during
pregnancy, the woman likely was treated with corticosteroids or IV immune globulin.
Platelet transfusions are usually given when there is significant bleeding. A splenectomy
may be needed if the ITP does not respond to medical management (Cunningham et al.,
2014).
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von Willebrand Disease (vWD)
von Willebrand disease (vWD), a type of hemophilia, is probably the most common of all
hereditary bleeding disorders. Although vWD is rare, it is among the most common
congenital clotting defects in North American women of child-bearing age. It results from a
deficiency or defect in a blood-clotting protein called von Willebrand factor (vWF). There are
as many as 20 variations of vWD, most of which are inherited as autosomal dominant traits
—types I and II are the most common ones (Cunningham et al., 2014). Symptoms include
recurrent bleeding episodes, such as nosebleeds or after tooth extraction, bruising easily,
heavy menstrual bleeding, prolonged bleeding time (the most important test), factor VIII
deficiency (mild to moderate), and bleeding from mucous membranes. Although factor VIII
increases during pregnancy, a risk for PPH still exists as levels of vWF begin to decrease
(Cunningham et al., 2014).
The woman may be at risk for bleeding for up to 4 weeks after birth. The treatment of
choice is administration of desmopressin, which promotes the release of vWF and factor
VIII. It can be given nasally, intravenously, or orally. Transfusion therapy with plasma
products that have been treated for viruses and contain factor VIII and vWF also may be
used. Concentrates of antihemophiliac factor (Humate) may be used (Cunningham et al.,
2014).
Disseminated Intravascular Coagulation (DIC)
Disseminated intravascular coagulation (DIC), also known as consumptive coagulopathy, is
an imbalance between the body's clotting and fibrinolytic systems. It is a pathological form
of clotting that is diffuse and consumes large amounts of clotting factors, including
platelets, fibrinogen, prothrombin, and factors V and VII. Widespread external bleeding,
internal bleeding, or both can result. DIC also causes vascular occlusion of small vessels
that results from small clots forming in the microcirculation. In the obstetrical population,
DIC may occur as a result of acute antepartum hemorrhage or PPH, placental abruption,
amniotic fluid embolism, dead fetus syndrome (i.e., fetus dies but is retained in utero for at
least 6 weeks), severe pre-eclampsia, sepsis, saline abortion, and acute fatty liver of
pregnancy (Francois & Foley, 2012).
The diagnosis of DIC is made according to clinical findings and laboratory markers.
Physical examination reveals unusual bleeding; spontaneous bleeding from the woman's
gums or nose may be noted. Petechiae may appear around a blood pressure cuff placed on
the woman's arm. Excessive bleeding may occur from the site of a slight trauma (e.g.,
venipuncture sites, intramuscular or subcutaneous injection sites, nicks from shaving
abdomen, and injury from insertion of a urinary catheter). Hypotension is out of proportion
to the observed blood loss. Other symptoms include tachycardia and diaphoresis.
Laboratory tests reveal decreased levels of platelets, fibrinogen, proaccelerin,
antihemophiliac factor, and prothrombin (the factors consumed during coagulation).
Fibrinolysis is increased at first but is later severely depressed. Degradation of fibrin leads
to the accumulation of fibrin split products in the blood; these have anticoagulant
properties and prolong the prothrombin time. Bleeding time is normal, coagulation time
shows no clot, clot-retraction time shows no clot, and partial thromboplastin time is
increased. DIC must be distinguished from other clotting disorders before therapy is
initiated.
Primary medical management in all cases of DIC involves correction of the underlying
cause (e.g., removal of the dead fetus, treatment of existing infection or of pre-eclampsia or
eclampsia, or removal of a placental abruption). Volume replacement, blood component
1114
therapy, optimization of oxygenation and perfusion status, and continued reassessment of
laboratory parameters are the usual forms of treatment. Resolution of DIC usually begins
with the birth of the newborn (Francois & Foley, 2012; SOGC, 2014).
Nursing interventions include assessing for signs of bleeding, administering fluid or
blood replacement as ordered, observing for signs of complications from the administration
of blood and blood products, and protecting the woman from injury. Because renal failure
is one consequence of DIC, urinary output is monitored, usually by insertion of an indwelling urinary catheter. Urinary output must be maintained at more than 30 mL/hr.
The woman and her family will be anxious or concerned about her condition and
prognosis. The nurse should offer explanations about care and provide emotional support
to them throughout this critical time.
Collaborative Care
Early recognition and treatment of PPH are critical to care management. The first step is to
evaluate the contractility of the uterus. If the uterus is hypotonic, management is directed
toward increasing contractility and minimizing blood loss.
If the uterus is firmly contracted and bleeding continues, the source of bleeding still must
be identified and treated. Assessment may include visual or manual inspection of the
perineum, vagina, uterus, cervix, or rectum and laboratory studies (e.g., hemoglobin,
hematocrit, coagulation studies, platelet count). Treatment depends on the source of the
bleeding.
The Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends active
management of the third stage of labour in order to prevent PPH, where possible (Senikas,
Leduc, Lalonde, et al., 2009). This involves administering oxytocin after the delivery of the
anterior shoulder, considering delayed cord clamping, gentle cord traction, and immediate
fundal massage after the complete birth. If it takes longer than 30 minutes to deliver the
placenta, the risk of PPH increases six-fold (MoreOB, 2010).
The initial management of excessive postpartum bleeding due to uterine atony is firm
massage of the uterine fundus. Expression of any clots in the uterus, elimination of bladder
distension, and continuous intravenous (IV) infusion of 10 to 40 units of oxytocin in
1000 mL of Ringer's lactate or normal saline solution are also primary interventions. If the
uterus fails to respond to oxytocin, other uterotonic medications are administered.
Misoprostol (Cytotec), a synthetic prostaglandin E1 analog, is often used. An advantage is
that it can be given by more than one route. Common dosages of misoprostol are 600 to
1000 mcg rectally or 400 mcg sublingually. A 0.2-mg dose of ergonovine may be given
intramuscularly to produce sustained uterine contractions; this can be repeated every 2 to 4
hours. A 0.25-mg dose of a derivative of prostaglandin F2α (carboprost tromethamine
[Carboprost; Hemabate]) may be given intramuscularly. It can also be given
intramyometrially at Caesarean birth or intra-abdominally after vaginal birth. Carboprost
can be repeated in recurrent doses of 0.25 mg every 15 to 90 minutes, up to eight doses.
Women with a history of asthma should not receive this medication because it can cause
bronchoconstriction (Francois & Foley, 2012) (see the Medication Guide for a comparison of
uterotonic drugs used to manage PPH). In addition to the medications used to contract the
uterus, rapid administration of crystalloid solutions or blood, blood products, or both will
be needed to restore the woman's intravascular volume (Francois & Foley, 2012). (See
Research Focus box.)
Oxygen can be given by nonrebreather face mask to enhance oxygen delivery to the cells.
An in-dwelling urinary catheter is usually inserted to monitor urine output as a measure of
intravascular volume and to keep the bladder empty. Laboratory studies usually include a
1115
complete blood count with platelet count, fibrinogen, fibrin split products, prothrombin
time, and partial thromboplastin time. Blood type and antibody screen are done if not
previously performed (Cunningham et al., 2014; SOGC, 2014).
If bleeding persists, bimanual compression may be performed by an obstetrical health
care provider. This procedure involves inserting a fist into the vagina and pressing the
knuckles against the anterior side of the uterus and then placing the other hand on the
abdomen and massaging the posterior uterus with it. If the uterus still does not become
firm, the physician or midwife performs manual exploration of the uterine cavity for
retained placental fragments. If the preceding procedures are ineffective, surgical
management is needed. Surgical management options include uterine tamponade (uterine
packing or an intrauterine tamponade balloon), bilateral uterine artery ligation, ligation of
utero-ovarian arteries and infundibulo​pelvic vessels, and selective arterial embolization.
Uterine compression suturing (using, for example, B-Lynch or Hayman vertical sutures)
may be performed and is sometimes combined with a tamponade balloon. If other
treatment measures are ineffective, hysterectomy will likely be needed (Cunningham et al.,
2014; Francois & Foley, 2012).
Medication Guide
Uterotonic Drugs Used to Manage Postpartum Hemorrhage
Drug
Oxytocin
(Synto
cinon)
Action
Adverse Effects
Contraction Infrequent: water
of uterus;
intoxication,
decreases
nausea and
bleeding
vomiting
Contradictio
Dosage and Route
ns
None for
PPH
Nursing Considerations
20–40 units/L diluted in lactated
Ringer's solution or normal
saline at 125 to 200
milliunits/min IV; or 10 to 20
units IM
Continue to monitor vaginal
bleeding and uterine tone
Do not use if 600 to 1000 mcg rectally once or
history of
400 mcg sublingual or PO
allergy to
once
prostagla
ndins
Continue to monitor vaginal
bleeding and uterine tone
Misoprost Contraction
ol
of uterus
(Cytot
ec)*
Headache, nausea,
vomiting,
diarrhea, fever,
chills
Methylerg Contraction
onovin
of uterus
e;
Ergon
ovine
Maleat
e
Hypertension,
Hypertensio 0.2 mg IM every 2 to 4 hr up to
hypotension,
n, prefive doses; may also be given
nausea, vomiting,
eclampsia
intrauterine or orally
headache
, cardiac
disease
Carbopro Contraction
st
of uterus
tromet
hamin
e
(Hema
bate)
Headache, nausea,
vomiting,
diarrhea, fever,
chills,
tachycardia,
hypertension
Avoid with
0.25 mg IM or intrauterine every Continue to monitor vaginal
asthma or
15 to 90 min up to eight doses
bleeding and uterine tone
hypertens
ion
Tranexam For blood
ic acid
clotting
(Cyclo
and to
kapro
stop
n)
prolonge
d
bleeding
Nausea, vomiting,
diarrhea,
dizziness
History of
10mg/kg IV
blood
clots or
taking
any
anticoagu
lant
*Off-label
Check blood pressure before
giving, and do not give if
>140/90 mm Hg; continue
monitoring vaginal bleeding
and uterine tone
Often given to prevent PPH in
someone with a bleeding
disorder
use; research reports vary in conclusions about dosage and efficacy of use in comparison to
1116
other medications used to manage postpartum hemorrhage.
IM, intramuscular; IV, intravenous; PO, by mouth; PPH, postpartum hemorrhage.
Research Focus
Active Third-Stage Labour Management for Preventing
Postpartum Hemorrhage
— Pat Mahaffee Gingrich
Ask the Question
For third-stage labour, what management techniques are most effective for prevention of
postpartum hemorrhage (PPH)?
Search for the Evidence
Search Strategies
English-language research-based publications on uterotonics, postpartum hemorrhage
(or haemorrhage), labour bleeding, cord clamping, active management, oxytocin,
prostaglandins were included.
Databases Used
Cochrane Collaborative Database, National Guideline Clearinghouse (AHRQ), CINAHL,
PubMed, UpToDate
Critically Analyze the Evidence
PPH is still a major cause of maternal death, especially in low- and middle-income
countries.
• In third-stage labour, uterine contractions expel the placenta and constrict the blood
vessels of the uterine wall. To prevent PPH, health care providers actively manage
third-stage labour by clamping the cord before pulsations have stopped, administering
uterotonics to increase uterine contractions, and providing steady traction on the cord
and counterpressure on the fundus, causing earlier expulsion of the placenta.
• Maternal effects: When compared with expectant management, the active-management
protocol results in less maternal blood loss and less maternal anemia (Begley, Gyte,
Devane, et al., 2011). Adverse effects of active management include adverse effects of
the uterotonics and uterine pressure: higher maternal diastolic pressure, pain requiring
analgesia, nausea and vomiting. Active management is also more likely to result in
readmission for bleeding, for unknown reasons.
• Effects on the newborn: Birth weight is less when the cord was clamped before
cessation of pulsing, because there is less transfer of blood volume to the newborn.
However, there are no differences in the number of neonatal intensive care unit (NICU)
admissions nor the occurrences of neonatal jaundice (Begley et al., 2011).
• Uterotonics stimulate smooth muscle contraction of the uterus. Intravenous carbetocin,
when compared with oxytocin, results in less need for uterine massage and use of other
uterotonics, but no difference in occurrence of PPH. When compared with ergometrineoxytocin, carbetocin is associated with less blood loss and fewer adverse effects of
nausea, vomiting, and postpartum hypertension (Su, Chong, & Samuel, 2012).
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• Prostaglandins are also uterotonic. Oral or sublingual misoprostol is better than
placebo for preventing blood loss and need for blood transfusion but causes doserelated shivering, increased temperature, and diarrhea.
• Conventional injectable uterotonics such as intramuscular (IM) ergot alkaloids are the
drugs of choice for preventing PPH, but prostaglandins may be useful in low-resource
areas (Tunçalp, Hofmeyr, & Gülmezoglu, 2012).
Apply the Evidence: Nursing Implications
• Active management of third-stage labour is beneficial and recommended. However, it
may be possible to individualize the protocol. Women should be educated before
labour on their options for third-stage management and the risks and benefits of
uterotonics.
• Some women request that the cord clamping be delayed until pulsations have ceased.
This may benefit the newborn without significantly increasing the woman's risk for
PPH.
• Nurses need to carefully assess the fundus and bleeding while recovering the
immediate postpartum woman and are frequently the first to notice PPH.
• A protocol for PPH should be made clear to all staff. All staff should be able to identify
when bleeding is too heavy and know the correct steps of emptying the bladder, uterine
massage, and whom to call immediately.
References
Begley CM, Gyte GM, Devane D, et al. Active versus expectant management for
women in the third stage of labour. Cochrane Database Systematic Review. 2011;(11);
10.1002/14651858.CD007412.pub3.
Su L, Chong Y, Samuel M. Carbetocin for preventing postpartum haemorrhage.
Cochrane Database Systematic Review. 2012;(4); 10.1002/14651858.CD005457.pub4.
Tunçalp Ö, Hofmeyr GJ, Gülmezoglu AM. Prostaglandins for preventing
postpartum haemorrhage. Cochrane Database Systematic Review. 2012;(8);
10.1002/14651858.CD000494.pub4.
Nursing Alert
Use of ergonovine or methylergonovine is contraindicated in the presence of
hypertension or cardiovascular disease.
Herbal Remedies
Herbal remedies have been used, with some success, to control PPH after the initial
management and control of bleeding. Some herbs have homeostatic actions, whereas others
work as oxytocic agents to contract the uterus. However, published evidence of the safety
and efficacy of herbal therapy is lacking. Evidence from well-controlled studies is needed
before recommendations for their use can be made.
Nursing Care
The nurse must be alert to the symptoms of hemorrhage and hypovolemic shock and be
prepared to act quickly to minimize blood loss (Fig. 24-1). Astute assessment of circulatory
status can be done with noninvasive monitoring (Box 24-2). Frequent monitoring of the
1118
woman and encouraging her to empty her bladder are important nursing interventions for
treatment and prevention of PPH. Interventions are based on the cause of PPH, as
previously discussed. Nurses must be able to quantify blood loss accurately. The American
Association of Women, Obstetrical and Neonatal Nurses (AWHONN) (2015) states that
visual estimation of blood loss can be inaccurate, with underestimates of 33 to 55%, which
can delay life-saving treatment. Weighing is a much more accurate method of determining
blood loss and is recommended by AWHONN. See Additional Resources at the end of the
chapter for a video on how to quantify blood loss.
FIGURE 24-1 Nursing assessments for postpartum bleeding. CBC, complete blood
count; IV, intravenous; tocolytics, medications to relax the uterus; uterotonics,
medications to contract the uterus.
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Box 24-2
Noninvasive Assessments of Circulatory Status in
Postpartum Women Who Are Bleeding
Palpation of Pulses (Rate, Quality, Equality)
• Arterial
Inspection
• Skin colour, temperature, turgor
• Level of consciousness
• Capillary refill
• Neck veins
• Mucous membranes
Auscultation
• Heart sounds/murmurs
• Breath sounds
Observation
• Presence or absence of anxiety, apprehension, restlessness, disorientation
Measurement
• Blood pressure
• Pulse oximetry
• Urinary output
The woman and her family will be anxious about her condition. The nurse can intervene
by calmly providing explanations about interventions being performed and the need to act
quickly.
Once the woman's condition is stabilized, preparations for discharge can be made.
Discharge instructions for a woman who has experienced PPH are similar to those for any
postpartum woman. In addition, the woman should be told that she will probably feel
fatigue, even exhaustion, and will need to limit her physical activities to conserve her
strength. She may need instructions in increasing her dietary iron and protein intake as
well as using iron supplementation to rebuild lost red blood cell (RBC) volume. She may
need assistance with infant care and household activities until she has regained strength.
Some women have problems with delayed lactation or insufficient milk production and
develop a perinatal mood disorder (PMD). Referrals for home care follow-up or to
community resources may be needed (see Nursing Care Plan: Postpartum Hemorrhage,
available on Evolve).
Shock Exemplar
Hemorrhagic (Hypovolemic) Shock
Hemorrhage may result in hemorrhagic (hypovolemic) shock. Shock is an emergency
1120
situation in which the perfusion of body organs may become severely compromised; death
may occur. Physiological compensatory mechanisms are activated in response to
hemorrhage. The adrenal glands release catecholamines, causing arterioles and venules in
the skin, lungs, gastrointestinal tract, liver, and kidneys to constrict. The available blood
flow is diverted to the brain and heart and away from other organs, including the uterus. If
shock is prolonged, the continued reduction in cellular oxygenation results in an
accumulation of lactic acid and acidosis (from anaerobic glucose metabolism). Acidosis
(lowered serum pH) causes arteriolar vasodilation; venule vasoconstriction persists. A
circular pattern is established (i.e., decreased perfusion, increased tissue anoxia and
acidosis, edema formation, and pooling of blood further decrease the perfusion). Cellular
death occurs. See the Emergency box for assessment of and interventions for hemorrhagic
shock.
Emergency
Hemorrhagic Shock
Assessment
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
Interventions
Summon assistance and equipment.
Start intravenous infusion per standing orders.
Ensure patent airway; administer oxygen.
Continue to monitor status.
Collaborative Care
Vigorous treatment is necessary to prevent adverse outcomes. Management of
hypovolemic shock involves restoring circulating blood volume and eliminating the cause
of the hemorrhage (e.g., lacerations, uterine atony, or inversion). Critical to successful
management of the woman with a hemorrhagic complication is establishment of venous
access, preferably with a large-bore IV catheter. The use of two IV lines facilitates fluid
resuscitation. Fluid resuscitation includes the administration of crystalloids (lactated
Ringer's, normal saline solution), colloids (albumin), blood, and blood components. To
restore circulating blood volume, a rapid IV infusion of crystalloid solution is given at a
rate of 3 mL infused for every 1 mL of estimated blood loss (e.g., 3000 mL infused for
1000 mL of blood loss). Packed RBCs are usually infused if the woman is still actively
bleeding and no improvement in her condition is noted after the initial crystalloid infusion.
Infusion of fresh frozen plasma may be needed if clotting factors and platelet counts are
below normal values (Cunningham et al., 2014; Francois & Foley, 2012; SOGC, 2014).
1121
Hemorrhagic shock can occur rapidly, but the classic signs of shock may not appear until
the postpartum woman has lost 30 to 40% of her blood volume. The nurse must continue to
reassess the woman's condition as evidenced by the degree of measurable and anticipated
blood loss and mobilize appropriate resources.
Most interventions are instituted to improve or monitor tissue perfusion. Fluid
resuscitation must be monitored carefully because fluid overload can occur. Intravascular
fluid overload occurs most often with colloid therapy.
Transfusion reactions can follow administration of blood or blood components, including
cryoprecipitates. Even in an emergency, each unit of blood or blood products should be
carefully checked per hospital protocol. Complications of fluid or blood replacement
therapy include hemolytic reactions, febrile reactions, allergic reactions, circulatory
overloading, and air embolism.
Legal Tip
Standard of Care for Bleeding Emergencies
The standard of care for obstetrical emergency situations such as PPH or hypovolemic
shock is that provision should be made for the nurse to implement nursing actions
independently. Policies, procedures, standing orders or protocols, and clinical guidelines
should be established by each health care facility in which births occur and should be
agreed on by health care providers involved in the care of obstetrical patients.
The nurse continues to monitor the woman's pulse and blood pressure. If invasive
hemodynamic monitoring is ordered, the nurse may assist with placement of a central
venous pressure (CVP) or pulmonary artery (Swan-Ganz) catheter. The nurse then
monitors CVP, pulmonary artery pressure, or pulmonary artery wedge pressure as
ordered.
Additional assessments to be made include evaluation of skin temperature, colour, and
turgor and assessment of the woman's mucous membranes. Breath sounds should be
auscultated before fluid volume replacement to provide a baseline for future assessment.
Inspection for oozing at the sites of incisions or injections and assessment of the presence of
petechiae or ecchymosis in areas not associated with surgery or trauma are critical in the
evaluation for DIC.
Oxygen is administered, preferably by a nonrebreathing face mask, at 10 to 12 L/min to
maintain oxygen saturation. Oxygen saturation should be monitored with a pulse
oximeter, although measurements may not always be accurate in a patient with
hypovolemia or decreased perfusion. Level of consciousness is assessed frequently and
provides additional indications of blood volume and oxygen saturation (Gilbert, 2011). In
early stages of decreased blood flow, the woman may report “seeing stars” or feeling dizzy
or nauseated. She may become restless and orthopneic. As cerebral hypoxia increases, she
may become confused and react slowly to stimuli or not at all. Some women state they have
headaches. An improved sensorium is an indicator of improved perfusion.
Continuous electrocardiographic monitoring may be indicated for the woman who is
hypotensive or tachycardic, continues to bleed profusely, or is in shock. A Foley catheter
with a urometer is inserted to allow hourly assessment of urine output. The most objective
and least invasive assessment of adequate organ perfusion and oxygenation is a urine
output of at least 30 mL/hr (Cunningham et al., 2014). Hemoglobin and hematocrit levels,
platelet count, and coagulation studies need to be closely monitored.
1122
Pulmonary embolism Exemplar
Venous thrombosis Exemplar
Venous Thromboembolic Disorders
Venous thromboembolism (VTE) results from the formation of a blood clot or clots inside
a blood vessel and is caused by inflammation (thrombophlebitis) or partial obstruction of
the vessel. Three thromboembolic conditions are of concern in the postpartum period:
• Superficial venous thrombosis—Involvement of the superficial saphenous venous
system
• Deep venous thrombosis (DVT)—Involvement varies but can extend from the foot to the
iliofemoral region
• Pulmonary embolism (PE)—Complication of deep venous thrombosis occurring when
part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the
vessel and obstructs blood flow to the lungs
Incidence and Etiology
Pregnant women have a four to five times increased risk of thromboembolism, and it is one
of the leading causes of death in the postpartum period. The incidence of VTE, which
includes DVT and PE, is 4.3 per 10,000 pregnancies postpartum (Chan, Rey, Kent, et al.,
2014). VTE can occur in any trimester of pregnancy or during the postpartum period. DVT
occurs most often during pregnancy, although it can occur up to 3 weeks postpartum, and
PE is more common in the postpartum period. The incidence of VTE in the postpartum
period has declined in the last 30 years because early ambulation after childbirth, a
preventive measure, has become standard practice. However, PE is a major cause of
maternal death (Chan et al., 2014; Pettker & Lockwood, 2012). The major causes of
thromboembolic disease are venous stasis and hypercoagulation, both of which are present
in pregnancy and continue into the postpartum period. Caesarean birth nearly doubles the
risk for VTE; other risk factors include operative vaginal birth; history of venous
thrombosis, PE, or varicosities; obesity; maternal age over 35; multiparity; and smoking
(Pettker & Lockwood, 2012).
The SOGC recommends that each woman be evaluated for risk, and consideration for
thromboprophylaxis should be individualized (Chan et al., 2014). Women who are at risk
for VTE should have TED stockings applied soon after birth. If compression stockings do
not fit, then a sequential compression device (SCD) should be used (Royal College of
Obstetricians and Gynaecologists, 2009).
Clinical Manifestations
Superficial venous thrombosis is the most common form of postpartum thrombophlebitis.
It is characterized by pain and tenderness in the lower extremity. Physical examination may
reveal warmth; redness; and an enlarged, hardened vein over the site of the thrombosis.
DVT is more common in pregnancy and is characterized by unilateral leg pain, calf
tenderness, and swelling. Physical examination may reveal redness and warmth, but
women may also have a large clot with few symptoms.
Acute PE usually results from dislodged deep vein thrombi. Presenting symptoms are
dyspnea and tachypnea (more than 20 breaths/min). Other signs and symptoms frequently
seen include tachycardia (more than 100 beats/min), apprehension, pleuritic chest pain,
1123
cough, hemoptysis, elevated temperature, and syncope (Cunningham et al., 2014; Pettker &
Lockwood, 2012).
Physical examination is not a sensitive diagnostic indicator for thrombosis. Venous
ultrasonography with or without colour Doppler is the most commonly used diagnostic
test. MRI and D-dimer assays may also be used (Chan et al., 2014). With PE,
echocardiographic abnormalities may be seen in right ventricular size or function.
Pregnancy limits the usefulness of arterial blood gases and oxygen saturation in diagnosis.
A ventilation-perfusion scan, spiral computed tomography scan, magnetic resonance
angiography, and pulmonary arteriogram may be used for diagnosis (Chan et al., 2014;
Pettker & Lockwood, 2012).
Collaborative Care
Anticoagulant therapy is the treatment of choice for superficial VTE, DVT, and PE.
Superficial venous thrombosis is also treated with analgesia (nonsteroidal antiinflammatory medications), rest with elevation of the affected leg, and elastic compression
stockings (Cunningham et al., 2014). DVT is initially treated with anticoagulant therapy
(usually continuous IV heparin), bedrest with the affected leg elevated, and analgesia. After
the symptoms have decreased, the woman may be fitted with elastic compression stockings
to use when she is allowed to ambulate. Anticoagulant therapy involves a combination of
IV, oral, and subcutaneous injections and may require prolonged therapy.
Acute pulmonary embolus is an emergent situation that requires prompt treatment.
Massive pulmonary emboli can lead to pulmonary hypertension and right ventricular
dysfunction; mortality is increased to 25% in these cases (Cunningham et al., 2014).
Immediate treatment of PE is anticoagulant therapy. Continuous IV heparin therapy is used
for PE until symptoms have resolved. Intermittent subcutaneous heparin or oral
anticoagulant therapy is often continued for up to 6 months (Pettker & Lockwood, 2012).
In the hospital, nursing care of the woman with a thrombosis consists of continued
assessments: inspection and palpation of the affected area; palpation of peripheral pulses;
measurement and comparison of leg circumferences; inspection for signs of bleeding;
monitoring for signs of PE, including chest pain, coughing, dyspnea, and tachypnea; and
checking respiratory status for presence of crackles. Laboratory reports are monitored for
prothrombin or partial thromboplastin times. The woman and her family are assessed for
their level of understanding about the diagnosis and their ability to cope during the
unexpected extended period of recovery.
Interventions include explanations and education about the diagnosis and treatment. The
woman will need assistance with personal care as long as she is on bedrest. The family
should be encouraged to participate in her care if she and they wish. While the woman is
on bedrest, she should be encouraged to change positions frequently but not to place the
knees in a sharply flexed position that could cause pooling of blood in the lower
extremities. She should also be cautioned not to rub the affected areas, because rubbing
could cause the clot to dislodge. Once the woman is allowed to ambulate, she should be
taught how to prevent venous congestion by putting on the elastic stockings before getting
out of bed.
Medications used vary by hospital and physician. All anticoagulant therapies require
monitoring of clotting times. The physician should be notified if clotting times are outside
the therapeutic level. If the woman is breastfeeding, she should consult with the lactation
consultant.
Pain can be managed with a variety of measures. Changing of positions, elevation of the
leg, and application of moist heat may decrease discomfort. It may be necessary to
1124
administer analgesics and anti-inflammatory medications.
Nursing Alert
Medications containing aspirin are not given to women on anticoagulant therapy because
aspirin inhibits synthesis of clotting factors and can lead to prolonged clotting time and
increased risk of bleeding.
The woman and her family must be taught how to administer subcutaneous injections
and about site rotation. They should also be given information about safe care practices to
prevent bleeding and injury while she is on anticoagulant therapy, such as using a soft
toothbrush and an electric razor. She will need information about follow-up with her health
care provider for monitoring of clotting times and ensuring that the correct dosage of
anticoagulant therapy is maintained.
Fever Exemplar
Postpartum Infections
Postpartum infection or puerperal infection is any clinical infection of the genital canal that
occurs within 28 days after miscarriage, induced abortion, or birth. The definition of
postpartum infection is the presence of a fever of 38° C (100.4° F) or more on 2 successive
days of the first 10 postpartum days (not counting the first 24 hours after birth) (Katz, 2012).
In North America it occurs after approximately 2% of vaginal births and 10 to 15% of
Caesarean births (Katz, 2012). Common postpartum infections include endometritis, wound
infections, mastitis, urinary tract infections (UTIs), and respiratory tract infections.
The most common infecting organisms are the numerous streptococcal and anaerobic
organisms. Staphylococcus aureus, gonococci, coliform bacteria, and Clostridia are less
common but serious pathogenic organisms that can cause puerperal infection. Postpartum
infections are more common in women who are obese, have concurrent medical or
immunosuppressive conditions, or who had a Caesarean or other operative birth.
Intrapartal factors such as prolonged rupture of membranes, prolonged labour, and
internal maternal or fetal monitoring also increase the risk of infection (Cunningham et al.,
2014). Factors that predispose the woman to postpartum infection are listed in Box 24-3.
Box 24-3
Predisposing Factors for Postpartum Infection
Preconception or Antepartal Factors
• History of previous venous thrombosis, urinary tract infection, mastitis, pneumonia
• Diabetes mellitus
• Alcoholism
• Substance use
• Immunosuppression
• Anemia
• Malnutrition
• Obesity
1125
Intrapartal Factors
• Caesarean birth
• Prolonged rupture of membranes
• Chorioamnionitis
• Prolonged labour
• Bladder catheterization
• Internal fetal or uterine pressure monitoring
• Multiple vaginal examinations after rupture of membranes
• Epidural anaesthesia
• Retained placental fragments
• Postpartum hemorrhage
• Episiotomy or lacerations
• Hematomas
Endometritis
Endometritis (infection of the lining of the uterus) is the most common postpartum
infection. It usually begins as a localized infection at the placental site but can spread to the
entire endometrium. Incidence is higher after Caesarean birth. Signs of endometritis
include fever (usually greater than 38°C); increased pulse; chills; anorexia; nausea; fatigue
and lethargy; pelvic pain; uterine tenderness; and foul-smelling, profuse lochia.
Leukocytosis and a markedly increased RBC sedimentation rate are typical laboratory
findings of postpartum infections. Anemia may also be present. Blood cultures or
intracervical or intrauterine bacterial cultures (aerobic and anaerobic) should reveal the
offending pathogens within 36 to 48 hours (Cunningham et al., 2014).
Wound Infections
Wound infections are common postpartum infections that often develop after the woman is
at home. Sites of infection include the Caesarean incision and repaired laceration or
episiotomy site. Predisposing factors are similar to those for endometritis (see Box 24-3).
Signs of wound infection include erythema, edema, warmth, tenderness, seropurulent
drainage, and wound separation. Fever and pain may also be present. In order to decrease
the risk of wound infections in women who have a Caesarean birth, the SOGC recommends
that all women undergoing elective or emergency Caesarean section receive antibiotic
prophylaxis. The timing of the antibiotic should be 15 to 30 minutes before the skin incision
(van Schalkwyk, Van Eyk, Yudin, et al., 2010). Prophylactic antibiotics may also be
considered for women who have third- and fourth-degree perineal injury, and the dose
may be doubled for women who are morbidly obese (body mass index [BMI] >35) (van
Schalkwyk et al., 2010).
Treatment of wound infections may involve combined antibiotic therapy with wound
debridement. Wounds can be opened and drained. Nursing care includes frequent
assessments of the wound and vital signs and wound care. Comfort measures are sitz
baths, warm compresses, and perineal care. The woman should be taught good hygiene
techniques (e.g., changing perineal pads front to back, hand hygiene before and after
perineal care), self-care measures, and the signs of worsening conditions to watch for and
report to the primary health care provider. The woman is usually discharged home for self-
1126
care or home nursing care after treatment is initiated in the inpatient setting.
Urinary Tract Infections
UTIs occur in 2 to 4% of postpartum women. Risk factors include urinary catheterization,
frequent pelvic examinations, epidural anaesthesia, genital tract injury, history of UTI, and
Caesarean birth. Signs and symptoms include dysuria, frequency and urgency, low-grade
fever, urinary retention, hematuria, and pyuria. Costovertebral angle tenderness or flank
pain may indicate an upper UTI. The most common infecting organism is Escherichia coli,
although other Gram-negative aerobic bacilli also may cause UTIs.
Medical management for UTIs consists of antibiotic therapy, analgesia, and hydration.
Postpartum women are usually treated on an outpatient basis; therefore teaching should
include instructions on how to monitor temperature, bladder function, and appearance of
urine. The woman should also be taught about signs of potential complications and the
importance of taking all antibiotics as prescribed. Other suggestions for prevention of UTIs
include proper perineal care, wiping from front to back after urinating or having a bowel
movement, and increasing fluid intake.
Mastitis
Mastitis, or breast infection, affects 2 to 10% of women soon after childbirth. Mastitis is
almost always unilateral and develops well after the flow of milk has been established (Fig.
24-2). The infecting organism generally is the hemolytic S. aureus. An infected nipple fissure
usually is the initial lesion, followed by ductal system involvement. Inflammatory edema
and engorgement of the breast obstruct the flow of milk in a lobe; regional, then
generalized, mastitis follows. If treatment is not prompt, mastitis may progress to a breast
abscess.
FIGURE 24-2 Mastitis.
Symptoms rarely appear before the end of the first postpartum week and are more
common in the second to fourth weeks. Chills, fever, malaise, and local breast tenderness
are noted first. Localized breast tenderness, pain, swelling, redness, and axillary
adenopathy may also occur. Antibiotics are prescribed for treatment. Lactation can be
maintained by emptying the breasts every 2 to 4 hours by breastfeeding, manual
expression, or a breast pump.
1127
Because mastitis rarely occurs before the postpartum woman is discharged, she should
be taught in hospital about its warning signs and receive counselling about prevention of
cracked nipples. Management includes intensive antibiotic therapy (e.g., cephalosporins
and vancomycin, which are particularly useful in staphylococcal infections), support of
breasts, local heat or cold, adequate hydration, and analgesics.
Almost all instances of acute mastitis can be avoided by using proper breastfeeding
technique to prevent cracked nipples. Missed feedings, waiting too long between feedings,
and abrupt weaning may lead to clogged nipples and mastitis. Cleanliness practised by all
who have contact with the newborn and new mother also reduces the incidence of mastitis.
See also Chapter 27.
Nursing Care
Women with factors predisposing to postpartum infection (see Box 24-3) should be
assessed carefully. Nurses need to assess for relevant signs and symptoms, discussed here
earlier, that can accompany each infection. Elevation of temperature, redness, and swelling
are common signs. The woman may also state she has chills, fever, localized tenderness, or
pain. Depending on the type of infection, laboratory tests usually performed include a
complete blood count, venous blood cultures, urine cultures, and uterine tissue cultures.
Review of the woman's history and the laboratory results should be included in the
assessment.
The most effective and least expensive treatment of postpartum infection is prevention.
Preventive measures include good prenatal nutrition to control anemia and intrapartal
hemorrhage. Good maternal perineal hygiene with thorough hand hygiene should be
emphasized. Use of aseptic techniques by all health care personnel during childbirth and
the postpartum period is very important.
Postpartum women are usually discharged home before 48 hours after birth, which is
often before signs of infection are evident. Nurses in birth centres and hospital settings
need to be able to identify women at risk for postpartum infection and provide anticipatory
teaching and counselling before the woman's discharge (see Community Focus box). After
discharge, telephone follow-up, hot lines, support groups, lactation consultants, home visits
by a community health nurse, and teaching materials (movies, written materials, apps) are
all interventions that can be implemented to decrease the risk of postpartum infections.
Nurses working in the community must be able to recognize signs and symptoms of
postpartum infection and convey these to the woman so that she knows when to contact
her primary health care provider. Community nurses must also be able to provide the
appropriate nursing care for women who need follow-up home care.
Community Focus
Prevention of Postpartum Infection
After giving birth, many women are discharged home before an infection can develop.
Prepare a “Fact Sheet About Postpartum Infection” that could be distributed to
postpartum women on discharge from the hospitals or birth centres in your community.
Include signs and symptoms, and phone numbers and addresses of health care providers
who could be contacted. Many Canadian communities have large populations who do
not speak English, and this must be considered when teaching and producing handout
information.
1128
Structural Disorders of the Vagina and Uterus
Related to Child-Bearing
Women are at risk for problems related to the reproductive system from the age of
menarche through menopause and the older years. These problems, which include
structural disorders of the uterus and vagina related to pelvic relaxation and urinary
incontinence (UI), are often the delayed but direct result of child-bearing.
With fetopelvic disproportion, prolonged labour, or a precipitous birth, structures of the
vesical and vaginal walls are stretched and may be injured. The bladder neck and urethra
may be compressed between the presenting part and the pubic bones or forced downward
ahead of the presenting part. Since soft tissue damage usually occurs behind an intact
vaginal epithelium, there is nothing visible to repair. However, defects may also occur in
women who have never been pregnant.
Structural disorders can have far-reaching effects for the woman and her family. Beyond
the obvious physiological alterations, the woman can also experience threats to her selfimage and her ability to cope. A woman's concept of herself as a sexual being may also be
affected. Her partner and family may need support as well.
Pelvic Organ Prolapse Exemplar
Uterine Displacement and Prolapse
Normally, the round ligaments hold the uterus in anteversion, and the uterosacral
ligaments pull the cervix backward and upward. Uterine displacement is a variation of this
normal placement (Fig. 24-3). The most common type of displacement is posterior
displacement, or retroversion, in which the uterus is tilted posteriorly and the cervix rotates
anteriorly. Other variations include retroflexion and anteflexion.
1129
Collaborative Care
Mild to moderate UI can be significantly decreased or relieved in many women through
bladder training and pelvic muscle (Kegel) exercises (Dumoulin & Hay-Smith, 2010). Other
management strategies include pelvic-flow support devices (i.e., pessaries), vaginal
estrogen therapy, serotonin–norepinephrine reuptake inhibitors, electrical stimulation,
insertion of an artificial urethral sphincter, and surgery (e.g., anterior repair) (Tarnay &
Bhatia, 2010).
Nursing Care
Assessment for problems related to structural disorders of the uterus and vagina focuses
primarily on the genitourinary tract, the reproductive organs, bowel elimination, and
psychosocial and sexual factors. A complete health history, a physical examination, and
laboratory tests are done to support the appropriate medical diagnosis. The nurse must
assess the woman's knowledge of the disorder, its management, and possible prognosis.
Assessment for depression that can result from decreased quality of life and functional
status is also important.
In general, nurses working with women with structural disorders can provide
information and self-care education to prevent problems before they occur, manage or
reduce symptoms and promote comfort and hygiene if symptoms are already present, and
recognize when further intervention is needed. For example, women may need guidance
about changes in lifestyle (e.g., losing weight) and education about pelvic muscle exercises
(Sung, West, Hernandez, et al., 2009). This information can be part of all postpartum
discharge teaching or provided at postpartum follow-up visits in clinics or physician or
midwife offices, during postpartum home visits, or during gynecological health
examinations. Information on how to prevent or recognize problems can be provided at
workshops for women or at health fairs in community settings.
When surgery is required, the nurse will focus care on preparing the woman for surgery
and her postoperative care. Preoperative teaching involves the primary nurse, operating
room nurse, surgeon, and anaesthesiologist. Postoperative nursing care focuses on
prevention of infection and helping the woman avoid putting stress on the surgical site.
The nurse in the health-promotion setting is usually most aware of the woman's living
circumstances, physical limitations, and social problems and therefore may be best suited to
coordinate continuity of care after discharge.
Postpartum Psychological Complications
For many women the weeks after birth are a time of vulnerability to psychological
complications, causing significant distress for the mother, disrupting family life, and, if
prolonged, negatively affecting the child's emotional and social development. Perinatal
mood disorders, which includes anxiety or major and minor depressive episodes that occur
during pregnancy or in the first 12 months after delivery, is one of the most common
medical complications during pregnancy and the postpartum period, affecting one in seven
women. It is important to identify pregnant and postpartum women with a mood disorder
because untreated perinatal depression and other mood disorders can have devastating
effects on women, infants, and families (ACOG, 2015). Pre-existing mood and anxiety
disorders are particularly likely to recur or worsen during these weeks. Because birth is
usually thought to be a happy event, a new mother's emotional distress can puzzle and
1136
immobilize family and friends. Nurses can offer anticipatory guidance, assess the mental
health of new mothers, offer therapeutic interventions, and make referrals, when necessary.
Failure to do so can result in tragic consequences. Mood disorders are the predominant
mental health disorder in the postpartum period.
Perinatal Mood Disorders (PMD)
Perinatal mood disorders (PMD) have traditionally been called postpartum mood
disorders, but the terminology has been revised to perinatal mood disorders because these
mental health issues may affect women any time during pregnancy and in the first year
after the birth of the baby, although they most commonly begin within the first 12 weeks
postpartum. These affective disorders range in severity from “the blues” to depression,
anxiety, obsessive-compulsive disorder, bipolar disorder, and psychosis.
Up to 80% of women experience a mild depression or “baby blues” after the birth of a
child; however, functioning of the woman is usually not impaired. Baby blues are
characterized by mood swings; feelings of sadness, anxiety, or both; crying; difficulty
sleeping; and loss of appetite. The symptoms are normal, resolve within a few days, and
treatment is not needed. See Chapter 22, p. 579, for further discussion of postpartum blues.
Serious mood disorders, experienced by 10 to 15% of postpartum women, can eventually
incapacitate them to the point of being unable to care for themselves or their babies
(Sadock, Sadock, & Ruiz, 2009). PMD affects women from all cultures, although the
manifestations vary. The incidence of mental health issues in some cultures is
underreported because of its stigma and the hesitancy to seek professional help (Callister,
Beckstrand, & Corbett, 2011; Goyal, Wang, Shen, et al., 2012). PMD affects parental infant
attachment and the quality of parenting, and children are at increased risk of developing
mental, social, and behavioural difficulties (Dennis, 2014). The complications of having a
PMD are listed in Box 24-4.
Box 24-4
Potential Complications of Having a Perinatal Mood
Disorder
• Mother–infant attachment issues
• Depression in the partner
• Long-term emotional behavioural and cognitive problems in the child
• Relationship problems and family breakdown
• Social, financial, and occupational complications
• Self-harm and suicide
• Infant and sibling neglect and occasionally infanticide
From Lazarus, R., & Gutteridge, K. (2013). Post-natal psychiatric disorders. In S. E. Robson & J. Wough (Eds.), Medical
disorders in pregnancy: A manual for midwives. Boston: Wiley Blackwell.
Major Depressive Disorder Exemplar
Some women have more serious mood disorders that can eventually incapacitate them to
the point of being unable to care for themselves or their babies. The cause of a PMD can be
biological, psychological, situational, or multifactorial. Estrogen fluctuations and
1137
postpartum hypogonadism (the change from the high levels of estrogen and progesterone
at the end of pregnancy to the much lower levels of both hormones that are present after
birth) are important etiological factors. Women at greatest risk for PMD are those with a
history of anxiety or depression and especially those who have had a previous episode of
major depressive disorder (MDD), including during or after pregnancy (Cunningham et al.,
2014; Davey, Tough, Adair, et al., 2011). Other risk factors include younger age, unintended
pregnancy, personal history of severe premenstrual dysphoria, family history of mood
disorder, unmarried status, marital discord, lack of social support, lower socioeconomic
status, lower education level, substance use, and stressful life events in the year before the
pregnancy (Cunningham et al., 2014; Le Strat, Dubertret, & Le Foll, 2011). Women facing
multiple or severe psychosocial problems or chronic interpersonal difficulties are at
increased risk for a major depressive episode. Dennis (2014) concluded that women who
have feelings of incompetence, a loss of self, and loneliness are also at risk.
Complications of pregnancy and birth increase the risk for PMD (Blom, Jansen, Verhulst,
et al., 2010). Having a preterm, low-birth-weight, and ill neonate is associated with higher
rates of depression (Vigod, Villegas, Dennis, et al., 2010). Women who are victims of
intimate partner violence are also at increased risk for depression (Beydoun, Beydoun,
Kaufman, et al., 2012; Cerulli, Talbor, Tang, et al., 2011; Woolhouse, Gartland, Hegarty,
et al., 2012). Cultural practices can positively or negatively affect the development of PMD.
Women facing multiple or severe psychosocial problems or chronic interpersonal
difficulties are at increased risk for experiencing a major depressive episode. Box 24-5 lists
common risk factors for PMD.
Box 24-5
Risk Factors for Perinatal Mood Disorders
• Depression during pregnancy
• Anxiety during pregnancy
• Experiencing stressful life events during pregnancy or the early postpartum period
• Traumatic birth experience
• Preterm birth/infant admission to neonatal intensive care
• Low levels of social support
• Previous history of depression
• Breastfeeding problems
Data from Lancaster, C. A., Gold, K. J., Flynn, H. A., et al. (2010). Risk factors for depressive symptoms during
pregnancy: A systematic review. American Journal of Obstetrics and Gynecology, 202, 5–14; Robertson, E., Grace, S.,
Wallington, T., & Stewart, D. E. (2004). Antenatal risk factors for postpartum depression: A synthesis of recent
literature. General Hospital Psychiatry, 26, 289–295.
Paternal Mood Disorder
Often, women are not alone in their experience of a mood disorder; partners may have
depression or anxiety as well. The incidence is unclear, with reports varying from 10% to
more than 50% (Letourneau, Tryphonopoulos, Duffett-Leger, et al., 2012; Paulson &
Bazemore, 2010). The best predictor of paternal depression is having a partner with
postpartum depression. According to Dennis (2010), maternal postpartum depression
increases the incidence of paternal depression to 25 to 50%. Men may not exhibit classic
1138
symptoms of PMD but are likely to display fatigue, frustration, anger, irritability,
indecisiveness, and withdrawal from social situations, usually between 3 and 6 months
postpartum (Paulson & Bazemore, 2010). Lone-parent mood disorders as well as dualpartner mood disorders significantly affect development of the children; further studies are
required to develop intervention strategies.
Anxiety Disorders Exemplar
Obsessive compulsive disorder Exemplar
Postpartum Anxiety Disorders
Anxiety disorders include generalized anxiety disorder, obsessive-compulsive disorder,
panic disorder and panic attacks, specific phobias, social anxiety disorder, and posttraumatic stress disorder. Common characteristics of these disorders are irrational fear,
worry, and tension; physical symptoms such as trembling, nausea and vomiting, dizziness,
dyspnea, and insomnia are often seen (Cunningham et al., 2014).
Women who have obsessive-compulsive disorder (OCD) often report worsening of their
symptoms during pregnancy and in the postpartum period (Forray, Focseneanu, Pittman,
et al., 2010). Onset of OCD can occur after birth. Compulsive checking on the sleeping baby
and repetitive ritualistic washing are common. Obsessions are usually focused and specific
and associated with fear of consequences (Speisman, Storch, & Abramowitz, 2011).
It is very important to distinguish between the symptoms of OCD in the postpartum
woman and those of postpartum psychosis, because either can involve ideation regarding
harming the newborn (Speisman et al., 2011). Delusions and hallucinations are typical in
psychosis and have implications for infant safety, but these are not found in OCD.
Aggressive thoughts of women with psychoses are not distressing to them, whereas
women with OCD find their obsessive thoughts are very disturbing (Speisman et al., 2011).
Panic attacks are discrete periods of sudden onset of intense apprehension, fearfulness, or
terror (American Psychiatric Association [APA], 2013). During these attacks, symptoms
such as shortness of breath, palpitations, chest pain, choking, smothering sensations, and
fear of losing control are present. Women with panic attacks have reported having intrusive
thoughts about terrible injury done to the infant, such as stabbing or burns, sometimes by
themselves. Rarely do these women harm their baby. Nurses need only to listen to a mother
with such attacks to hear symptoms of panic disorder. Usually these women are so
distraught that they will share their thoughts with whoever will listen. Often the family has
tried to tell them that what they are experiencing is normal; however, they know that their
symptoms are not normal. These women need to have their feelings validated, and they
need monitoring or treatment.
Collaborative care.
There are effective treatments for anxiety disorders; this fact should be communicated to
affected women. Cognitive-behavioural therapy (CBT) is an option that is limited in
duration, does not expose the infant to medications, and has proven durability of effect. For
pharmacological therapy, the effectiveness of treatment, widespread availability, and ease
of administration make selective serotonin reuptake inhibitors (SSRIs) an appealing and
popular option (Cunningham et al., 2014; Speisman et al., 2011). Medications should be
prescribed with careful consideration of safety for the breastfeeding infant. Each woman
should be approached on an individualized basis: the severity of her symptoms needs to
assessed, her history and response to any previous treatments should be obtained, her
preferences need to be acknowledged, and the potential benefits and risks of each treatment
1139
must be conveyed. Treatment is usually a combination of medications, education,
psychotherapy, and CBT, along with an attempt to identify any medical or physiological
contributors.
Education is a crucial nursing intervention. New mothers should be provided with
anticipatory guidance concerning the possibility of anxiety disorders during the
postpartum period. Preparing for the attacks can help offset their unexpected, terrifying
nature. Women can be reassured that it is common to feel a sense of impending doom and
fear of insanity during panic attacks. Nurses can help women identify panic triggers that
are particular to their own lives. Keeping a diary can help in identifying such triggers.
Family and social supports are helpful. The new mother needs to be encouraged to put
usual chores on hold and to ask for and accept help. Support groups can help these mothers
experience some comfort in seeing others in similar circumstances.
A variety of other treatment options can be recommended for women with anxiety
disorders. These include sensory interventions such as music therapy and aromatherapy,
behavioural interventions such as breathing exercises and progressive muscle relaxation,
cognitive interventions such as positive self-talk training, and exercise.
Depressive disorders Exemplar
Generalized Anxiety Disorder Exemplar
Postpartum Depression
Postpartum depression can be mild to severe. It is characterized by low mood and lack of
interest in activities that would normally be of interest to the person. In addition, the
depressed person often has low energy, a general lack of enjoyment, and labile mood
swing. Whereas postpartum blues affects 50 to 80% of women, with similar symptoms of
irritability, tearfulness, and low mood, it is transient. Depression, by contrast, is more
serious and persistent than postpartum blues and often includes reduced concentration and
self-esteem as well as feelings of hopelessness and guilt. Women often describe alterations
in sleep patterns and appetite and, in severe cases, suicidal ideation (Lazarus & Gutteridge,
2013). These symptoms rarely disappear without outside help (Dennis, 2010). Most of these
mothers seek help only after reaching a “crisis point” (McCarthy & McMahon, 2008). The
occurrence of this type of depression is higher among younger women and those with less
education. Mothers who have no one to talk to about their problems after giving birth tend
to have a high rate of depression and a low rate of seeking help. This situation can be a
concern for newly immigrated women who have difficulty with language and limited
social support. Having established and supportive relationships facilitates seeking of care,
as does outreach and follow-up (Sword, Busser, Ganann, et al., 2008).
The symptoms of postpartum major depression do not differ from those of
nonpostpartum depression except that the mother's ruminations of guilt and inadequacy
feed her worries about being an incompetent and inadequate parent. New mothers report
an increased yearning for sleep, sleeping heavily but awakening instantly with any infant
noise, and an inability to go back to sleep after infant feedings. Determining difficulty
falling asleep is a relevant screening question to ascertain risk for depression.
A distinguishing feature of major depression is irritability. These episodes of irritability
may flare up with little provocation and may sometimes escalate to violent outbursts or
dissolve into uncontrollable sobbing. Many of these outbursts are directed against
significant others (“He never helps me”) or the baby (“She cries all the time, and I feel like
hitting her”). Postpartum women with major depressive episodes often have spontaneous
crying long after the usual duration of baby blues.
1140
Many women feel especially guilty about having depressive feelings at a time when they
believe they should be happy. They may be reluctant to discuss their symptoms or their
negative feelings toward the infant. A prominent feature of depression is rejection of the
infant, often caused by abnormal jealousy. The mother may be obsessed by the notion that
the baby may take her place in her partner's affections. Attitudes toward the infant may
include disinterest, annoyance with care demands, and blaming because of her lack of
maternal feeling. The mother may appear awkward in her responses to the baby. Obsessive
thoughts about harming the infant are very frightening to her. Often she does not share
these thoughts because of embarrassment; when she does, other family members can
become very frightened.
Collaborative care.
The natural course is one of gradual improvement over the 6 months after birth, although
50% of women will remain clinically depressed at 6 months with approximately 25%
continuing beyond the first year if they remain untreated (Dennis, 2010). Often supportive
treatment alone is not efficacious for major depression. Pharmacological intervention is
often required. Treatment options include antidepressants, antianxiety drugs, and
electroconvulsive therapy. Alternative therapies such as herbs, dietary supplements,
massage, aromatherapy, and acupuncture may be helpful. Psychotherapy for the depressed
postpartum mother focuses on her fears and concerns regarding her new responsibilities
and roles, and monitoring for suicidal or homicidal thoughts. For some women,
hospitalization is necessary.
Major depressive disorder with psychotic features Exemplar
Postpartum Psychosis
The most severe of the perinatal mood disorders, postpartum psychosis, is rare, affecting
approximately 0.1 to 0.2% of postpartum women (Sadock et al., 2009). Once a woman has
had one episode of postpartum psychosis, there is a 30 to 50% likelihood of recurrence with
each subsequent birth (APA, 2013). This disorder tends to show onset within 2 weeks
postpartum; however, it can present later in the course of the illness as a depression
(Sadock et al., 2009).
Episodes of postpartum psychosis are typified by auditory or visual hallucinations,
paranoid or grandiose delusions, elements of delirium or disorientation, and extreme
deficits in judgement accompanied by high levels of impulsivity that can contribute to
increased risks of suicide or infanticide (in 5% of psychotic women) (Sadock et al., 2009).
Characteristically, the woman has fatigue, insomnia, and restlessness and may have
episodes of tearfulness and emotional lability. The woman may state she has the inability to
move, stand, or work. Later, suspiciousness, confusion, incoherence, irrational statements,
and obsessive concerns about the baby's health and welfare may be present. Delusions may
occur in 50% of all women with postpartum psychosis, and hallucinations in about 25%.
Auditory hallucinations that command the mother to kill the infant can also occur in severe
cases. When delusions are present, they are often related to the infant. The mother may
think the infant is possessed by the devil, has special powers, or is destined for a terrible
fate (APA, 2013). Grossly disorganized behaviour may be manifested as a disinterest in the
infant or an inability to provide care. Some affected mothers insist that something is wrong
with the baby or accuse nurses or family members of hurting or poisoning their child.
Nurses are advised to be alert for mothers who are agitated, overactive, confused, or
suspicious.
1141
Bipolar disorder Exemplar
Postpartum psychosis is most commonly associated with the diagnosis of bipolar (or
manic-depressive) disorder (Sadock et al., 2009; Sharma, Burt, & Ritchie, 2009). This mood
disorder is defined by the presence of one or more episodes of abnormally elevated energy
levels, cognition, and mood and one or more depressive episodes. The elevated moods are
clinically referred to as mania. Clinical manifestations of a manic episode include at least
three of the following: grandiosity, decreased need for sleep, pressured speech, flight of
ideas, distractibility, psychomotor agitation, and excessive involvement in pleasurable
activities without regard for negative consequences (APA, 2013). While in a manic state,
mothers need constant supervision when caring for their infant. Usually, however, they are
too preoccupied to provide child care. Individuals who experience manic episodes also
commonly experience depressive episodes or symptoms or mixed episodes, in which
features of both mania and depression are present at the same time. These episodes are
usually separated by periods of “normal” mood, but in some individuals, depression and
mania may rapidly alternate. These rapid changes in mood are known as rapid cycling.
Collaborative care.
Postpartum psychosis carries a relatively good prognosis with early detection and
aggressive treatment; however, if left untreated, it can progress to the second postpartum
year and become more refractory to treatment (Sadock et al., 2009). Postpartum psychosis is
a psychiatric emergency, and the mother will probably need inpatient psychiatric care.
Antipsychotics and mood stabilizers such as lithium are the treatments of choice (Tables 241 and 24-2). Antidepressants should be used very cautiously in treating postpartum
psychosis, even when depressive symptoms are present, because of the risk for
precipitating rapid cycling. Because of potential risks to the breastfeeding infant, informed
consent regarding the risks and benefits of exposing the newborn to a psychotropic agent
and maternal mental illness must be discussed and documented (see additional discussion
of lactation and psychotropic medications later in this chapter). Electroconvulsive therapy
(ECT), especially when bilaterally administered, has also been shown to be highly effective
in the treatment of postpartum psychosis. It is usually advantageous for the mother to have
contact with her baby if she so desires, but visits must be closely supervised. Psychotherapy
is indicated after the period of acute psychosis has passed.
TABLE 24-1
MOOD STABILIZERS
MOOD STABILIZERS
PREGNANCY RISK CATEGORY LACTATION RISK CATEGORY
Carbamazepine (Tegretol)
C
L2
Clonazepam (Klonopin, Rivotril)
C
L3
Gabapentin
C
L3
Lamotrigine (Lamictal)
C
L3
Lithium carbonate (Carbolith, Lithane) C
L4
Topiramate (Topamax)
C
L3
Valproic acid (Depakene, Epival ECT)
D
L2
C, animal studies show adverse effects on fetus but no controlled studies in pregnant women, or no studies
available; D, positive evidence of human fetal risk; L2, medication studied in limited number of
breastfeeding women with no adverse effects in infant, or evidence is remote; L3, no controlled studies, or
studies show minimal nonthreatening effects; L4, possibly hazardous.
1142
Sources: Hale, T. (2012). Medications and mother's milk (15th ed.), Amarillo, TX: Pharmasoft; Schatzberg,
A., Cole, J. O., & DeBattista, C. (Eds.). (2010). Manual of clinical psychopharmacology (7th ed.), Arlington,
VA: American Psychiatric Publishing.
TABLE 24-2
ANTIPSYCHOTIC MEDICATIONS
ANTIPSYCHOTIC MEDICATIONS
PREGNANCY RISK
CATEGORY
LACTATION RISK
CATEGORY
Traditional Antipsychotics
Chlorpromazine hydrochloride
C
L3
Fluphenazine hydrochloride; fluphenazine deconate (Modecate
Concentrate)
C
L3
Haloperidol
C
L2
Perphenazine
C
L3
Thioridazine
C
L4
Trifluoperazine
Unknown
Unknown
Aripiprazole (Abilify)
C
L3
Clozapine (Clozaril)
C
L3
Loxapine (Loxitane)
C
L4
Olanzapine (Zyprexa)
C
L2
Quetiapine (Seroquel)
C
L4
Risperidone (Risperdal)
C
L3
Ziprasidone (Zeldox)
C
L4
Atypical Antipsychotics
C, Animal studies show adverse effects on fetus but no controlled studies in pregnant women, or no studies
available; L2, medication studied in limited number of breastfeeding women with no adverse effects in
infant, or evidence is remote; L3, no controlled studies, or studies show minimal nonthreatening effects; L4,
possibly hazardous.
Sources: Hale, T. (2012). Medications and mother's milk (15th ed.), Amarillo, TX: Pharmasoft; Schatzberg,
A., Cole, J. O., & DeBattista, C. (Eds.). (2010). Manual of clinical psychopharmacology (7th ed.), Arlington,
VA: American Psychiatric Publishing.
Nursing Care
Nurses can also assist women by teaching them self-care, especially the symptoms and risk
factors for PMD; helping them to feel safe and empowered in discussing their mental and
social health; and facilitating adequate social and partner support. Women and their
families should be given written resources in their native language and emergency
numbers to call. Last but not least, follow-up is a powerful tool for detection and deterrence
of PMD. In practice it is the responsibility of all who are in contact with the woman to
provide screening, assessment, and education to facilitate early detection and treatment.
Even though the prevalence of PMD is fairly well established, women may be unlikely to
seek help from a mental health care provider. This can be related to social stigma of mental
illness, cultural beliefs, lack of knowledge, or fear of child custody implications (Yonkers,
Vigod, & Ross, 2011). Primary health care providers can usually recognize severe
depression or postpartum psychosis but may miss milder forms; even if it is recognized, the
woman may be treated inappropriately or subtherapeutically. Nurses should be
strategically positioned to offer anticipatory guidance, assess the mental health of new
mothers, offer therapeutic interventions, and make referrals when necessary. Failure to do
1143
so may result in tragic consequences. Identification and treatment of PMD must be
continued beyond the immediate postbirth period to prevent negative effects of maternal
mood disorders on the children of these mothers. To recognize symptoms of PMD as early
as possible, the nurse should be an active listener and demonstrate a caring attitude. Nurses
cannot depend on women to volunteer unsolicited information about their mental health or
ask for help. Examples of ways to initiate conversation include the following: “Now that
you've had your baby, how are things going for you? Have you had to change many things
in your life since having the baby?” and “How much time do you spend crying?” If the
nurse assesses that the new mother is depressed, the nurse must ask if the mother has
thought about hurting herself or the baby. The woman may be more willing to answer
honestly if the nurse says, “Many women feel depressed after having a baby, and some feel
so bad that they think about hurting themselves or the baby. Have you had these
thoughts?”
Nursing Alert
Because mothers with postpartum psychosis may harm their infants, extra precaution is
needed in assessment and intervention. The nurse needs to ask specifically if the mother
has had thoughts about harming her baby.
Screening for Perinatal Mood Disorders
When PMD is identified early, it is highly treatable. Screening for anxiety or depression
during pregnancy and the postpartum period aids in prevention and early intervention for
PMD. Women at risk should be identified (see Box 24-4), although all women should be
screened during pregnancy and postpartum (ACOG, 2015).
The Registered Nurses' Association of Ontario (RNAO) Best Practice Guideline:
Interventions for Postpartum Depression recommends use of the Edinburgh Postnatal
Depression Scale (EPDS) as the screening tool of choice (RNAO, 2005). The EPDS is a selfreport assessment designed specifically to identify women experiencing PMD (Fig. 24-9). It
has been used and validated in studies in numerous cultures and is viewed as a valid
screening tool throughout pregnancy and postpartum for PMD. The assessment tool asks
the woman to respond to 10 statements about the common symptoms of depression. The
woman is asked to choose the response that is closest to describing how she has felt for the
past week. A maximum score on the EPDS is 30; women with scores of 13 or greater on the
EPDS and those who have a history of depression or anxiety require more intensive
postpartum follow-up. Women who answer “yes” to the question about the thought of
hurting themselves need immediate care.
1144
FIGURE 24-9 Edinburgh Postnatal Depression Scale (EPDS). (© 1987 The Royal College of
Psychiatrists. Cox, J. L., Holden, J. M., & Sagovsky, R. [1987]. Detection of postnatal depression: Development of
the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782–786. Written
permission must be obtained from the Royal College of Psychiatrists for copying and distribution to others or for
republication [in print, online or by any other medium]. Translations of the scale, and guidance as to its use, may
be found in Cox, J. L., Holden, J., & Henshaw, C. [2014]. Perinatal mental health: The Edinburgh Postnatal
Depression Scale (EPDS) manual [2nd Ed.]. London: RCPsych Publications.
http://www.rcpsych.ac.uk/usefulresources/publications/books/rcpp/9781909726130.aspx.)
1145
Screening for PMD can be done before women are discharged from the hospital although
this may be too early and while the screening may identify some who are at risk, it is
important that follow-up screening is also done. PMD is most likely to occur around 4
weeks after birth. Follow-up assessments for risks and signs of PMD can be done by
primary care providers during pediatric care visits for the infant and during postpartum
follow-up visits for the mother. Women with a positive screen should be referred
appropriately for evaluation and treatment.
On the Postpartum Unit
The postpartum nurse must observe the new mother carefully for any signs of tearfulness
and conduct further assessments as necessary. Nurses must discuss PMD to prepare all
new parents for potential problems in the postpartum period and discuss ways to help
prevent a PMD (see Patient Teaching box). The family must be able to recognize the
symptoms and know where to go for help. Printed materials that explain what the woman
can do to prevent a mood disorder can be used as part of discharge education (Logsdon,
Tomasulo, Eckert, et al., 2012).
Mothers are often discharged before the blues or depression occurs. If the postpartum
nurse is concerned about the mother, a mental health consult should be requested before
the mother leaves the hospital. The family must be able to recognize the symptoms and
know where to go for help. Written materials that explain what the woman can do to
prevent depression are useful.
Nursing Alert
Because the newborn may be scheduled for a checkup before the mother's 6-week
checkup, nurses in well-baby clinics or physician offices should be alert for signs of PMD
in new mothers and be knowledgeable about community referral resources.
Patient Teaching
Preventing a Perinatal Mood Disorder
• Share knowledge about postpartum emotional problems with close family and friends.
• At least once each day or every other day, purposely relax for 15 minutes, using deep
breathing or meditating or by taking a hot bath.
• Take care of yourself: eat a balanced diet.
• Exercise on a regular basis, at least 30 minutes a day.
• Sleep as much as possible; make a promise to yourself to try to sleep when the baby
sleeps.
• Get out of the house: try to leave home for 30 minutes a day; take a walk outdoors or
walk at the mall.
• Share your feelings with someone close to you; don't isolate yourself at home with the
TV.
• Don't overcommit yourself or feel like you need to be a superwoman. Ask for help
from family and friends.
• Don't place unrealistic expectations on yourself; you don't need to be a perfect mother.
• Be flexible with your daily activities.
1146
• Go to a new mothers' support group: for example, take a postpartum exercise class or
attend a breastfeeding support group.
• Don't be ashamed of having emotional problems after your baby is born. It happens to
approximately 15 to 20% of women.
In the Home and Community
Postpartum home visits can reduce the incidence of or complications from PMD. A brief
home visit or phone call at least once a week until the new mother returns for her
postpartum visit may save the life of a mother and her infant; however, home visits may
not be feasible or available. Some provinces have mandatory telephone follow-up of all
new mothers after the birth, and women who are identified as high risk should receive
more comprehensive follow-up. Supervision of the mother with emotional complications
may become a prime concern. Because PMD can greatly interfere with her mothering
functions, family and friends may need to participate in the infant's care. This is a time for
extended family and friends to determine what they can do to help; the nurse can work
with them to ensure adequate supervision and their understanding of the woman's mental
illness.
When the woman has a PMD, a partner often reacts with confusion, shock, denial, and
anger and feels neglected and blamed. The nurse can provide nonjudgemental
opportunities for the partner to express feelings and concerns, help the partner identify
positive coping strategies, and be a source of encouragement for the partner to continue
supporting the woman. Suggestions for partners of women with PMD include helping
around the house, setting limits with family and friends, going with her to doctor's
appointments, educating himself or herself about PMD, writing down concerns and
questions to take to the primary care provider or therapist, and just being with her—sitting
quietly, hugging her, and demonstrating concern and compassion. Both the woman and her
partner need an opportunity to express their needs, fears, thoughts, and feelings in a
nonjudgemental environment.
Even if the woman is severely depressed, hospitalization can be avoided if adequate
resources can be mobilized to ensure safety for both mother and infant. The community
health nurse will need to make frequent phone calls or home visits for assessment and
counselling. Community resources that may be helpful are temporary child care or foster
care, homemaker service, meals on wheels, parenting guidance centres, mother's-day-out
programs, and telephone support groups such The Pacific Post Partum Support Society and
The Peel Postpartum Mood Disorder Program (see Additional Resources at the end of the
chapter).
Referral
Women with moderate to severe cases of PMD should be referred to a mental health
professional such as an advanced-practice psychiatric nurse or psychiatrist for evaluation
and therapy. Inpatient psychiatric hospitalization may be necessary. This decision is made
when the safety of the mother or child is threatened.
Providing Safety
If delusional thinking about the baby is suspected, the nurse should ask, “Have you
thought about hurting your baby?” When PMD is suspected, the nurse asks, “Have you
thought about hurting yourself?” Four criteria measure the seriousness of a suicidal plan:
1147
method, availability, specificity, and lethality. Has the woman specified a method? Is the
method of choice available? How specific is the plan? If the method is concrete and
detailed, with access to it right at hand, the suicide risk is increased. How lethal is the
method? The most lethal method is shooting, with hanging being a close second. The least
lethal method is slashing one's wrists. Medication overdose with tricyclic antidepressants
(TCAs) causes death. Use of TCAs in suicidal women should be avoided because of the
danger of overdose.
Nursing Alert
Suicidal thoughts or attempts are among the most serious symptoms of PMD and require
immediate assessment and intervention.
Psychiatric Hospitalization
Women with postpartum psychosis have a psychiatric emergency and must be referred
immediately to a psychiatrist who is experienced in working with women with psychosis,
can prescribe medication and other forms of therapy, and can assess the need for
hospitalization.
Legal Tip
Commitment for Psychiatric Care
If a woman with PMD is experiencing active suicidal ideation or harmful delusions about
the baby and is unwilling to seek treatment, legal intervention may be necessary to
commit the woman to an inpatient setting for treatment.
Within the hospital setting, the reintroduction of the baby to the mother can occur at the
mother's own pace. A schedule is set for increasing the number of hours during which the
mother cares for the baby over several days, culminating in the infant staying overnight in
the mother's room. This enables the mother to experience meeting the infant's needs and
giving up sleep for the baby, a situation that is difficult for new mothers even under ideal
conditions. The mother's readiness for discharge and caring for the baby should be
assessed. Her interactions with her baby should also be carefully supervised and guided. A
postpartum nurse may be asked to assist the psychiatric nursing staff in assessment of the
mother–infant interactions.
Nurses need to observe the mother for signs of bonding with the baby. Attachment
behaviours are defined as eye-to-eye contact; physical contact that involves holding,
touching, cuddling, and talking to the baby and calling the baby by name; and the initiation
of appropriate care. A staff member should be assigned to keep the baby in sight at all
times. Indirect teaching, praise, and encouragement are designed to bolster the mother's
self-esteem and self-confidence.
Psychotropic Medications
If a woman is diagnosed with depression, antidepressant medications will often be used. If
the woman is not breastfeeding, antidepressants can be prescribed without special
precautions.
A variety of medications can be prescribed for these women, including tricyclic
1148
Approximately 60% of all full-term newborns are visibly jaundiced (yellow) by the second
through fifth day of life (Barrington, Sankaran, & CPS, 2007/2016). In most cases it is
physiological jaundice, caused by increased levels of unconjugated bilirubin; physiological
jaundice is usually self-limiting, requires no treatment, and resolves in a few days.
Physiological jaundice or neonatal hyperbilirubinemia occurs in 80% of preterm newborns.
The incidence of physiological jaundice is increased in Asian and Indigenous infants. It
must be differentiated from pathological jaundice, or hyperbilirubinemia, which is
associated with higher levels of unconjugated bilirubin. This type of jaundice can appear in
the first 24 hours and often requires phototherapy to resolve. (See Chapter 25, pp. 653–655
for further discussion on pathophysiology of jaundice.)
Every newborn should be assessed for jaundice; this can be easily done when vital signs
are assessed. Jaundice is generally first noticed in the head, especially the sclera and
mucous membranes, and then progresses gradually to the thorax, abdomen, and
extremities. Visual assessment of jaundice alone does not provide an accurate assessment of
the level of serum bilirubin, especially in dark-skinned newborns; only 50% of babies with a
total serum bilirubin (TSB) concentration greater than 128 mcmol/L appear jaundiced
(Barrington et al., 2007/2016). To differentiate cutaneous jaundice from normal skin colour,
the nurse applies pressure with a finger over a bony area (e.g., the nose, forehead, sternum)
for several seconds to empty all the capillaries in that spot. If jaundice is present, the
blanched area will look yellow before the capillaries refill. The conjunctival sacs and buccal
mucosa are also assessed, especially in darker-skinned infants. Assessing for jaundice in
natural light is recommended because artificial lighting and the reflection from walls can
distort the actual skin colour.
Noninvasive monitoring of bilirubin via cutaneous reflectance measurements
(transcutaneous bilirubinometry [TcB]) allows for repetitive estimations of bilirubin;
however, there are limitations to the use of TcB monitors (Fig. 26-7). They are more accurate
at lower TSB levels, are not accurate once phototherapy is initiated, and may be unreliable
with changes in skin colour and thickness. TcB monitors may be used to screen clinically
significant jaundice and decrease the need for serum bilirubin measurements (Barrington
et al., 2007/2016). The CPS recommends monitoring healthy newborns at 35 weeks of
gestation or greater before discharge from the hospital using hour-specific serum bilirubin
levels to determine the infant's risk for development of hyperbilirubinemia requiring
medical treatment or closer screening (Barrington et al., 2007/2016). Use of a nomogram (see
Fig. 26-8) with three levels (high, intermediate, or low risk) of rising TSB values assists in
the determination of newborns that might need further evaluation after discharge.
Universal bilirubin screening based on hour-specific TSB may be done at the same time as
the routine newborn profile (phenylketonuria [PKU], galactosemia, and others) (Barrington
et al., 2007/2016).
1252
FIGURE 26-7 Transcutaneous monitoring of bilirubin with a transcutaneous
bilirubinometry (TcB) monitor. (Courtesy Cheryl Briggs, BSN, RNC-NIC.)
FIGURE 26-8 Nomogram for evaluation of screening total serum bilirubin (TSB)
concentration in term and late preterm infants, according to the TSB concentration
obtained at a known postnatal age in hours. (From Barrington, K. J., Sankaran, K., & Canadian
Paediatric Society. [2007/2016]. Guidelines for detection, management and prevention of hyperbilirubinemia in
term and late term newborn infants [35 or more weeks gestation]. Paediatric Child Health, 12[Suppl B], 1B–12B.
Figure reproduced and adapted with permission from Pediatrics, 114, 297–316. Copyright © 2004 by the AAP.)
Risk factors that place infants in the high-risk category include gestational age 35 to 38
weeks, exclusive breastfeeding not well established and excessive weight loss, a sibling
who had neonatal jaundice, visible bruising, cephalohematoma, DAT+ or other known
hemolytic disease, G6PD deficiency (diagnosed at birth), ethnic background (East Asian),
asphyxia (Apgar 0–3 beyond 5 minutes and cord PH less than 7), acidosis (ph less than 7
beyond initial cord sample), albumin less than 30 g/L, sepsis currently treated, temperature
instability, and significant lethargy/poor feeding (Barrington et al., 2007/2016; Provincial
Council for Maternal & Child Health [PCMCH] & Ministry of Health and Long-term Care,
2013). It is recommended that healthy infants (35 weeks or greater) receive assessment of
bilirubin between 24 and 72 hours of life. If intervention is not required, further follow-up
will depend on individual risk factors. If an infant is discharged before 24 hours of age, the
infant needs further review within 24 hours by someone experienced in newborn care and
1253
with access to testing (Barrington et al., 2007/2016). Close follow-up of infants at risk for
severe hyperbilirubinemia is essential; parents should be educated about the symptoms
and encouraged to follow postdischarge recommendations.
If an infant is jaundiced in the first 24 hours of life, a TcB or TSB level should be
measured and results interpreted on the basis of the newborn's age in hours according to
the hour-specific nomogram for infants born at 35 weeks of gestation or later. Repeat
testing is based on the risk level (low, intermediate, or high), the age of the newborn, and
the progression of jaundice.
Pathological jaundice is that level of serum bilirubin which, if left untreated, can result in
sensorineural hearing loss, mild cognitive delays, and kernicterus, which is the deposition
of bilirubin in the brain. Kernicterus describes the yellow staining of the brain cells that
may result in bilirubin encephalopathy. The damage occurs when the serum concentration
reaches toxic levels, regardless of cause.
Nursing Alert
Breastfeeding is essential in preventing hyperbilirubinemia. Newborns should breastfeed
early (within the first hour after birth) and often (at least 8–12 times/24 hr). Colostrum
acts as a laxative to promote stooling, which helps rid the body of bilirubin.
Therapy for hyperbilirubinemia.
The best therapy for hyperbilirubinemia is prevention. Because bilirubin is excreted in
meconium, prevention can be facilitated by early and frequent feeding, which stimulates
passage of meconium. However, despite early passage of meconium, some term infants
may have trouble conjugating the increased amount of bilirubin derived from
disintegrating fetal red blood cells (RBCs). As a result, the serum levels of unconjugated
bilirubin may rise beyond normal limits, causing hyperbilirubinemia. The goal of treatment
of hyperbilirubinemia is to help reduce the newborn's serum levels of unconjugated
bilirubin. There are two ways to reduce unconjugated bilirubin levels: phototherapy and
exchange blood transfusion.
Phototherapy.
The purpose of phototherapy is to reduce the level of circulating unconjugated bilirubin or
to keep it from increasing. Phototherapy uses light energy to change the shape and
structure of unconjugated bilirubin and convert it to molecules that can be excreted. The
dose and effectiveness of phototherapy are affected by the source of light. Phototherapy
units vary in the spectrum of light they deliver and in the filters that are used. The most
effective therapy is achieved with special blue fluorescent tubes or a specially designed
light-emitting diode (LED). Phototherapy lights do not emit significant ultraviolet
radiation; the small amount that is emitted does not cause erythema. Most of the ultraviolet
light is absorbed by the glass wall of the fluorescent tube and by the plastic cover of the
light (Kamath, Thilo, & Hernandez, 2011). Phototherapy is usually effective for treatment of
hyperbilirubinemia that has not reached levels associated with acute bilirubin
encephalopathy or kernicterus.
The effectiveness of phototherapy is related to the distance between the light and the
newborn and on the area of skin that is exposed. During phototherapy, the unclothed infant
is placed under a bank of lights approximately 45 to 50 cm from the light source. Research
suggests that the newborn be placed supine for maximum exposure to the light source
(Bhethanabhotia, Thurak, Sankar, et al., 2013). Phototherapy can be used for the infant in an
1254
isolette (Fig. 26-9) or in an open crib. The distance varies according to unit protocol and
type of light used. The lamp's energy output should be monitored routinely with a
photometer during treatment to ensure efficacy of therapy. Phototherapy is used until the
infant's serum bilirubin level decreases to within an acceptable range. The decision to
discontinue therapy is based on the observation of a definite downward trend in bilirubin
values.
FIGURE 26-9 Infant under phototherapy lights while in isolette. (Olesia
Bilkei/Shutterstock.com.)
The infant's eyes must be protected by an opaque mask to prevent overexposure to the
light. The eye shield should cover the eyes completely but not occlude the nares. Before the
mask is applied, the infant's eyes should be closed gently to prevent excoriation of the
corneas. The mask should be removed periodically and during infant feedings so that the
eyes can be checked and cleansed with water and the parents can have visual contact with
the infant (see Family-Centred Care box and Fig. 26-10).
Family-Centred Care
Phototherapy and Parent–Infant Interaction
The traditional use of phototherapy has evoked concerns regarding a number of
psychobehavioural issues, including parent–infant separation, potential social isolation,
decreased sensorineural stimulation, altered biological rhythms, altered feeding patterns,
and activity changes. Parental anxiety is greatly increased, particularly at the sight of the
newborn blindfolded and under special lights. The interruption of breastfeeding for
phototherapy is a potential deterrent to successful maternal–infant attachment and
interaction. Because research has demonstrated that bilirubin catabolism occurs primarily
within the first few hours of the initiation of phototherapy, there is increased support for
the removal of the infant from treatment for feeding and holding. Intermittent
phototherapy may be just as effective as continuous therapy when used correctly.
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FIGURE 26-10 Infant with eyes covered while receiving phototherapy. (Courtesy Cheryl
Briggs, BSN, RNC-NIC.)
Phototherapy may cause changes in the infant's temperature, depending partially on the
bed used: bassinet, isolette, or radiant warmer. When under a phototherapy light, infants
are usually clothed only with a diaper. The infant's temperature should be closely
monitored at least every 2 hours. Phototherapy lights can increase the rate of insensible
water loss, which contributes to fluid loss and dehydration. Therefore, it is important that
the infant be adequately hydrated. The healthy newborn is kept hydrated with human milk
or infant formula; there is no advantage or benefit to administering oral glucose or plain
water because these do not promote excretion of bilirubin in stools and may in fact
perpetuate enterohepatic circulation, thus delaying bilirubin excretion.
It is important to closely monitor urinary output as an indicator of hydration status while
the infant is receiving photo​therapy. Urine output can be decreased or unaltered; the urine
can have a dark gold or brown appearance.
The number and consistency of stools should also be monitored. Bilirubin breakdown
increases gastric motility, which results in loose stools that can cause skin excoriation and
breakdown. The infant's buttocks must be cleaned after each stool to maintain skin
integrity. A fine maculopapular rash may appear during phototherapy, but this is transient.
Additional systems used for phototherapy include a bassinet system that provides
special blue light above and beneath the infant. Another phototherapy device is a fibreoptic blanket that is connected to a light source (see Fig. 26-11). The blanket is flexible and
can be placed around the infant's torso or underneath the infant in the bassinet. There are
also bilirubin beds with LED lights in a pad that covers the surface of the bassinet. The LED
lights do not produce heat and can be used with radiant warmers. These devices are
usually less effective when used alone than with conventional phototherapy lights. They
can be very useful in combination with overhead phototherapy lights. In certain instances,
the infant's bilirubin levels increase rapidly and intensive phototherapy is required; this
situation involves the use of a combination of conventional lights and fibre-optic blankets
to maximize bilirubin reduction. Although fibre-optic lights do not produce heat as
conventional lights do, staff should ensure that a covering pad is placed between the
infant's skin and the fibre-optic device to prevent skin burns, especially in preterm infants.
The newborn can remain in the mother's room in an open crib or in her arms during
treatment. The use of eye patches depends on whether the devices are used alone or in
combination with phototherapy lights.
1256
FIGURE 26-11 A mother can put her newborn skin-to-skin without interrupting
phototherapy when a fibre-optic blanket is used. (Courtesy Mother and Childcare, Phillips
Healthcare.)
Home phototherapy.
The use of home phototherapy should be reserved for healthy term infants with bilirubin
levels in the “optional phototherapy” range according to the nomogram. The concern is
that home phototherapy units do not provide the same level of irradiance or body surface
coverage as phototherapy devices used in the hospital.
Follow-up.
Serum levels of bilirubin in the newborn continue to rise until the fifth day of life. Many
parents leave the hospital within 24 hours of birth, and some as early as 6 hours after birth.
Therefore, parents must receive education regarding jaundice and its treatment. They
should have written instructions for assessing the infant's condition and the name of a
contact person to whom they should report their findings and concerns.
Close follow-up is needed for infants who have been treated for hyperbilirubinemia.
Repeat testing of serum bilirubin levels and follow-up visits with the pediatric health care
provider are expected. When follow-up serum bilirubin levels are needed after discharge
from the hospital, a health care technician or nurse may draw the blood for the specimen or
the parents may take the baby to a laboratory to have blood drawn for a serum bilirubin. In
some cases, parents take the newborn to an outpatient clinic or to the physician's office to
be evaluated.
Exchange transfusion.
When phototherapy is not effective in reducing serum bilirubin levels or in treating severe
hyperbilirubinemia such as in hemolytic disease, exchange transfusion may be needed. This
procedure is done in an intensive care setting. The infant's blood is replaced with a
combination of blood products such as RBCs mixed with 5% albumin or fresh frozen
plasma (Kaplan, Wong, Sibley, et al., 2011). This invasive procedure is rarely done and can
be minimized by early management and treatment (see discussion in Chapter 29).
Hypoglycemia Exemplar
Hypoglycemia.
Hypoglycemia during the early newborn period of a term infant is defined as a blood
1257
glucose concentration less than that needed to support adequate neurological, organ, and
tissue function; however, there is a lack of consensus regarding the precise level at which
this concentration occurs.
At birth, the maternal source of glucose is cut off with the clamping of the umbilical cord.
Most healthy term newborns experience a transient decrease in glucose levels to as low as
1.7 mmol/L during the first 1 to 2 hours after birth, with a subsequent mobilization of free
fatty acids and ketones to help maintain adequate glucose levels (Blackburn, 2013). Infants
who are asphyxiated or have other physiological stress may experience hypoglycemia as a
result of a decreased glycogen supply, inadequate gluconeogenesis, or overutilization of
glycogen stored during fetal life. There is concern about neurological injury as a result of
severe or prolonged hypoglycemia, especially in combination with ischemia (Kalhan &
Devaskar, 2011).
There is no need to routinely assess glucose levels of healthy term infants (Aziz, Dancey,
& CPS, 2004/2014). Breastfeeding early and often helps these newborns maintain adequate
glucose levels.
Glucose levels should be measured in newborns at 34 weeks of gestation or more if risk
factors or clinical manifestations of hypoglycemia are present. In infants who are at risk for
altered metabolism as a result of maternal illness factors (diabetes, gestational
hypertension) or newborn factors (perinatal hypoxia, infection, hypothermia,
polycythemia, congenital malformations, hyperinsulinism, SGA, LGA, fetal hydrops), close
observation and monitoring of blood glucose levels within 2 hours of birth, after an initial
feeding, are recommended. The frequency of glucose testing is determined by the risk
factors for each individual newborn. Infants of diabetic mothers should undergo glucose
screening before feedings for at least the first 12 hours after birth; further testing is done if
glucose levels are less than 2.6 mmol/L. However, preterm and SGA infants may be
vulnerable up to 36 hours of age so should be screened until 36 hour of age if feeding is
established and blood glucose is maintained at 2.6 mmol/L or higher (Aziz et al., 2004/2014).
The CPS recommendations state that asymptomatic, at-risk babies should receive at least
one effective feeding before a blood glucose check at 2 hours of age and should be
encouraged to feed regularly thereafter. At-risk babies who have a blood glucose of less
than 1.8 mmol/L at 2 hours of age despite one feeding (breastfeeding or approximately
5 mL/kg to 10 mL/kg of formula or glucose water) or less than 2.0 mmol/L after subsequent
feeding should receive an intravenous (IV) dextrose infusion. At-risk babies who
repeatedly have blood glucose levels of less than 2.6 mmol/L despite subsequent feeding
should also be considered for IV therapy (Aziz et al., 2004/2014).
Glucose testing should be done in any infant with clinical signs of hypoglycemia. The
clinical signs can be transient or recurrent and include jitteriness, lethargy, poor feeding,
abnormal cry, hypotonia, temperature instability (hypothermia), respiratory distress,
apnea, and seizures (Kalhan & Devaskar, 2011). It is important to remember that
hypoglycemia can be present in the absence of clinical manifestations.
Hypoglycemia in the low-risk term infant is usually eliminated by feeding the infant a
source of carbohydrate (i.e., preferably human milk) and putting the newborn skin-to-skin
with a parent. Occasionally, the IV administration of glucose is required for infants with
persistently high insulin levels or in those with depleted stores of glycogen.
Nursing Alert
Late preterm infants are at increased risk for hypoglycemia. They have decreased
glycogen stores and lack hepatic enzymes for gluconeogenesis and glycogenolysis. Their
hormonal regulation and insulin secretion are immature. The increased risk of cold stress
1258
and feeding difficulties adds to the risk for hypoglycemia (Cooper, Holditch-Davis,
Verklan, et al., 2012).
Hypocalcemia.
Hypocalcemia in infants is defined as serum calcium levels less than 2 mmol/L in the term
infant and slightly lower (1.75 mmol/L) in the preterm infant. Hypocalcemia is common in
critically ill newborns but also can occur in infants of mothers with diabetes or in those who
experienced perinatal asphyxia or trauma and in low-birth-weight and preterm infants.
Infants born to mothers treated with anticonvulsants during pregnancy are also at risk
(Rigo, Mohamed, & De Curtis, 2011). Early-onset hypocalcemia usually occurs within the
first 24 to 48 hours after birth. Signs of hypocalcemia include jitteriness, tremors, twitching,
high-pitched cry, irritability, apnea, and laryngospasm, although some infants may be
asymptomatic. Jitteriness is a symptom of both hypoglycemia and hypocalcemia; therefore,
hypocalcemia must be considered if the therapy for hypoglycemia proves ineffective.
In most instances, early-onset hypocalcemia is self-limiting and resolves within 1 to 3
days. Treatment usually includes early feeding of an appropriate source of calcium, such as
fortified human milk or a preterm infant formula (Jones, Hayes, Starbuck, et al., 2011). In
some cases (e.g., the medically unstable, extremely low-birth-weight infant) the
administration of IV elemental calcium and phosphorus may be necessary.
Laboratory and Screening Tests
Because newborns experience many transitional events in the first 28 days of life, laboratory
samples are often gathered to determine adequate physiological adaptation and to identify
disorders that may adversely affect the child's life beyond the neonatal period. Most
laboratory tests for newborn screening may be obtained from the newborn with a heel
puncture, also known as a heel stick. Tests that may be performed include bilirubin levels,
blood glucose, newborn screening tests (e.g., PKU, hypothyroidism [T4], sickle cell disease,
and galactosemia), and drug serum levels. Box 26-5 lists standard laboratory values in a
term newborn.
Box 26-5
Standard Laboratory Values in a Term Newborn
Hemoglobin
140–240 g/L
Hematocrit
0.47–0.48
Glucose
1.7–3.3 mmol/L
Leukocytes (white blood cells) 9–30 × 109/L
Bilirubin, total serum
<30 mcmol/L
Blood Gases
Arterial
pH 7.32–7.49
PCO2 26–41 mm Hg
PO2 60–70 mm Hg
Venous
pH 7.31–7.41
PCO2 40–50 mm Hg
PO2 40–50 mm Hg
PCO2, partial pressure of carbon dioxide; PO2, partial pressure of oxygen.
1259
harmful to the preterm infant as hypoglycemia. Increased circulating levels of glucose may
lead to osmotic changes, increased urine output, and fluid shifts in the already
compromised CNS of the preterm infant. The net result of hyperglycemia may be cellular
dehydration and IVH. Preterm infants undergoing stress (i.e., surgery) may also become
hyperglycemic with increased catecholamine release, which inhibits insulin release and
glucose utilization (Blackburn, 2012). In summary, ELBW and VLBW infants should be
monitored closely for both hypoglycemia and hyperglycemia.
Heat Loss
SGA infants are particularly susceptible to temperature instability as a result of decreased
brown fat deposit, decreased adipose tissue, large body surface exposure, inability to
accomplish flexed position due to poor muscle tone, and decreased glycogen storage in
major organs such as the liver and heart. Close attention must be given to maintenance of a
neutral thermal environment.
Large-for-Gestational-Age Infants
An infant is considered large for gestational age (LGA) when the weight is above the
ninetieth percentile on growth charts or 2 standard deviations above the mean weight for
gestational age. The LGA infant is at greater risk for morbidity than the SGA and preterm
infant; such infants have a higher incidence of birth injuries, asphyxia, and congenital
anomalies such as heart defects. In Canada the rate of infants born who were LGA was
10.4% in 2010 (PHAC, 2013).
LGA newborns may be preterm, term, or postterm; they may be infants of diabetic
mothers. Each of these problems carries special concerns. Regardless of coexisting potential
problems, the LGA infant is at risk by virtue of size alone.
The nurse needs to assess the LGA infant for hypoglycemia and trauma resulting from
vaginal or Caesarean birth. Any specific birth injuries should be identified and treated
appropriately.
Infants of Diabetic Mothers
Before insulin therapy, few women with diabetes were able to conceive; for those who did,
the mortality rate for both the mother and infant was high. The morbidity and mortality of
infants of diabetic mothers (IDMs) have been reduced significantly as a result of effective
control of maternal diabetes and an increased understanding of fetal disorders. Because
infants born to women with gestational diabetes mellitus (DM) are at risk for the same
complications as IDMs, the following discussion of IDMs includes infants born to women
with gestational DM.
The severity of maternal diabetes affects infant survival. It is determined by the duration
of the disease before pregnancy; age of onset; extent of vascular complications; and
abnormalities of the current pregnancy, such as pyelonephritis, diabetic ketoacidosis,
pregnancy-induced hypertension, and inability to follow treatment regimen. The single
most important factor influencing fetal well-being is the euglycemic status of the mother. It
has been found that reasonable metabolic control that begins before conception and
continues during the first weeks of pregnancy can prevent malformation in an IDM.
Elevated levels of hemoglobin A1c during the periconception period appear to be
associated with a higher incidence of congenital malformations (see Chapter 15). In the case
of gestational diabetes, macrosomia is the most common finding; serious complications are
rare (Mitanchez, 2010).
1413
Hypoglycemia may appear a short time after birth and in IDMs is associated with
increased insulin activity in the blood. The serum glucose level that corresponds to clinical
hypo​glycemia has not been well defined, but the Canadian Paediatric Society recommends
that serum glucose levels be maintained at 2.6 mmol/L. At-risk infants with glucose levels
less than 1.8 mmol/L on one occasion (assuming one effective feed), or repeatedly less than
2.6 mmol/L, require intervention. Symptomatic infants should be treated immediately for
blood glucose levels less than 2.6 mmol/L; there should be concurrent investigation and
management of the underlying cause (Aziz, Dancy, & Canadian Paediatric Society,
2004/2014).
Hypoglycemia in IDMs is related to hypertrophy and hyperplasia of the pancreatic islet
cells and thus is a transient state of hyperinsulinism. High maternal blood glucose levels
during fetal life provide a continual stimulus to the fetal islet cells for insulin production
(glucose easily passes the placental barrier from maternal to fetal side; however, insulin
does not cross the placental barrier). Historically, maternal hyperglycemia was believed to
contribute to fetal macrosomia. However, Hay (2012) has suggested that maternal
hyperlipidemia and increased lipid transfer to the fetus are responsible for the excessive
weight gain and fat deposition seen in such infants (Hay, 2012). IDMs are more likely to
have disproportionately large abdominal circumferences and shoulders, leading to an
increased risk of shoulder dystocia and birth injury (Dailey & Coustan, 2010). When the
newborn's glucose supply is removed abruptly at the time of birth, the continued
production of insulin soon depletes the blood of circulating glucose, creating a state of
hyperinsulinism and hypoglycemia within 0.5 to 4 hours, especially in infants of mothers
with poorly controlled diabetes. Precipitous drops in blood glucose levels can cause serious
neurological damage or death.
Hypomagnesemia Exemplar
IDMs have a characteristic appearance (Box 28-6 and Fig. 28-11). Infants of mothers with
advanced diabetes may be SGA, have IUGR, or be the appropriate size for gestational age
because of the maternal vascular (placental) involvement. There is an increase in congenital
anomalies in IDMs in addition to a high susceptibility to hypoglycemia, hypocalcemia,
hypomagnesemia, polycythemia, hyperbilirubinemia, cardiomyopathy, and RDS (Dailey
and Coustan, 2010). CNS anomalies such as anencephaly, spina bifida, and
holoprosencephaly occur at rates 10 times higher than in any other population of mothers.
Cardiac anomalies such as ventriculoseptal defects and coarctation of the aorta are
increased five-fold in IDMs, and sacral agenesis and caudal regression occur almost
exclusively in IDMs (Landon, Capalano, & Gabbe, 2012). Hyperinsulinemia and hyper​glycemia in the diabetic mother may be factors in reducing fetal surfactant synthesis, thus
contributing to the development of RDS. Although large, these infants may be delivered
before term as a result of maternal complications or increased fetal size.
Box 28-6
Clinical Manifestations of Infants of Diabetic Mothers
• Large for gestational age
• Very plump and full faced
• Abundant vernix caseosa
• Plethora
• Listless and lethargic
• Possibly meconium stained at birth
• Hypotonia
1414
FIGURE 28-11 Large-for-gestational-age infant. This infant of a diabetic mother
weighed 5 kg (11 lbs) at birth and exhibits the typical round facies. (From Zitelli, B. J., &
Davis, H. W. (2007). Atlas of pediatric physical diagnosis (5th ed.). Philadelphia: Mosby.)
Congenital hyperinsulinism is a condition that causes neonatal macrosomia, and
profound hypoglycemia is often present in the neonatal period. However, this condition is
usually not associated with maternal DM, but appears to have a genetic etiology; the
condition is also associated with syndromes such as Beckwith-Wiedemann syndrome
(Sperling, 2016).
Some IDMs are also at increased risk for deep vein thrombosis, with renal vein
thrombosis and hematuria being the most common presentation (Hay, 2012). Additional
problems in IDMs include perinatal iron deficiency and neurological impairments
(seizures, lethargy, jitteriness, and changes in tone) (Hay, 2012).
The most important management of IDMs is careful monitoring of serum glucose levels
and observation for accompanying complications such as RDS and cardiac anomalies. The
infants are examined for the presence of any anomalies or birth injuries, and blood studies
for determination of glucose, calcium, hematocrit, and bilirubin are obtained on a regular
basis.
Because the hypertrophied pancreas is so sensitive to blood glucose concentrations, the
administration of oral glucose may trigger a massive insulin release, resulting in rebound
hypo​glycemia. Therefore, feedings of breast milk or formula begin within the first hour
after birth, provided that the infant's cardiorespiratory condition is stable. Approximately
half of these infants do well and adjust without complications. Infants born to mothers with
poorly controlled diabetes may require IV dextrose infusions. Studies confirm the
importance of maintaining serum glucose levels above 2.8 mmol/L in hyper​insulinemic
infants with hypoglycemia to prevent serious neurological sequelae (Aziz et al., 2004/2014).
Enteral supplementation may be used in asymptomatic infants with blood glucose levels of
1.8 mmol/L to 2.5 mmol/L to augment caloric intake. It is recommended that symptomatic,
hypoglycemic infants (and asymptomatic infants who have failed to respond to enteral
supplementation) be treated with intravenous dextrose solution. Consider investigation,
consultation, and pharmacological intervention if target blood glucose levels are not
achieved by intravenous dextrose (Aziz et al., 2004/2014).
Oral and IV intake may be titrated to maintain adequate blood glucose levels. Frequent
blood glucose determinations are needed for the first 2 to 4 days of life to assess the degree
of hypoglycemia present at any given time. Testing blood taken from the heel with
calibrated portable reflectance meters (e.g., glucometers) is a simple and effective screening
evaluation that can then be confirmed by laboratory examination (see Heel stick, Chapter
26, p. 699).
1415
Nursing Care
The nursing care of IDMs involves early examination for congenital anomalies, signs of
possible respiratory or cardiac problems, maintenance of adequate thermoregulation, early
introduction of carbohydrate feedings as appropriate, and monitoring of serum blood
glucose levels. The latter is of particular importance because many infants with
hypoglycemia may remain asymptomatic. Symptomatic IDMs who are unable to feed
should be started on a continuous IV infusion of 10% dextrose at 4 to 6 mg/min/kg unless
blood glucose is below 1.1 mmol/L. In such cases a one-time bolus infusion of 10% dextrose
(200 mg/kg) should be given over 2 to 4 minutes, followed by a constant IV infusion of 10%
dextrose and water as noted previously (Hay, 2012). IV glucose infusion requires careful
monitoring of the site and the newborn's reaction to therapy; high glucose concentrations
(≥12.5%) should be infused via a central line instead of a peripheral site.
IDMs also need to be monitored for hypocalcemia and hypomagnesemia. Signs of
hypocalcemia are similar to those of hypoglycemia, but they occur within the first 24 hours
of age. Infants also need to be monitored closely for hyperbilirubinemia.
Because macrosomic infants are at risk for problems associated with a difficult birth, they
are monitored for birth injuries such as brachial plexus injury and palsy, fractured clavicle,
and phrenic nerve palsy. Additional monitoring of the infant for problems associated with
this condition (polycythemia, hypocalcemia, poor feeding, and hyperbilirubinemia) is also
a vital nursing function.
Some evidence indicates that IDMs have an increased risk of acquiring type 2 diabetes
and metabolic syndrome in childhood or early adulthood (Hay, 2012); therefore, nursing
care should also focus on healthy lifestyle and prevention later in life with IDMs. See the
Nursing Care Plan, The Infant of Mother With Diabetes Mellitus on the Evolve site.
Discharge teaching Exemplar
Discharge Planning and Transport
Discharge Planning
Discharge planning for the high-risk newborn begins early in the hospitalization.
Throughout the infant's hospitalization, the nurse must gather information from the health
care team members and the family. This information is used to determine the infant's and
family's readiness for discharge.
As the nurse assesses the discharge needs of the infant's parents, he or she needs to take
steps to eliminate any knowledge deficits. Discharge teaching for the high-risk newborn's
family is extensive, requires time and planning, and cannot be accomplished on the day of
discharge alone. Information should be provided about infant care, especially as it pertains
to the infant's particular needs (e.g., supplemental oxygen, gastrostomy feedings, follow-up
medical visits). Parent education includes having them give return demonstrations of their
infant care skills to show whether they are becoming increasingly independent in providing
care for their infant. Parents of a preterm infant or one with special needs should be given
the opportunity to room in and spend a night or two providing care for their infant away
from the NICU. This affords them the opportunity to become more aware of the necessary
care and to have transition time during which to ask questions regarding home care.
Additional parent teaching should include bathing and skin care; requirements for meeting
nutritional needs after discharge; safety in the home, including supine sleep position and
prevention of infection (e.g., respiratory syncytial virus); and medication administration.
Medical equipment and supplies required for care of the infant in the home should be
1416
delivered to the home before discharge; parents and care providers should have education
and ample practice in its use. Parents of an infant being discharged with special needs (i.e.,
gavage or gastrostomy feedings, oxygen, tracheostomy, or colostomy) should receive
several days of carefully planned education in the various procedures before discharge.
Car seat safety is an essential aspect of discharge planning. Parents should obtain an ageappropriate car seat before discharge and demonstrate its use with the infant. Previously it
was recommended that all infants less than 37 weeks should have an infant car seat
challenge testing done prior to discharge. The CPS latest recommendation states that while
it is clear that infants placed in a car seat are more likely to experience oxygen desaturation
or bradycardia than when they are supine, this does not predict an adverse
neurodevelopmental outcome or mortality post-discharge, therefore routine use of the
infant car seat challenge as part of discharge planning for preterm infants is no longer
recommended (Narvey & CPS Fetus and Newborn Committee, 2016).
Preterm infants have a high rate of readmission to hospital and emergency department
visits. It is imperative that the family have a health care provider they can contact for
questions regarding infant care and behaviour once they are home.
Before discharge, all high-risk or preterm infants should receive the appropriate
immunizations, metabolic screening, hematology assessment (bilirubin risk as appropriate),
and evaluation of hearing and for ROP (Jefferies & CPS Fetus and Newborn Committee,
2010). Successful discharge of a high-risk infant requires an interprofessional and familycentred approach. Medical, nursing, social services, and other professionals (physiotherapy,
occupational therapy, developmental follow-up specialist) are crucial to the smooth
transition of these infants and their families to the community and home. If the infant is
retrotransferred to a facility providing less acute care, interfacility communication is
essential to continuity of care.
Discharge to home for high-risk infants does not mean they can be treated like healthy
term newborns. Follow-up by a practitioner familiar with the issues common to the highrisk newborn is essential. Further follow-up of specific complications by qualified
specialists and referral to centres for developmental interventions can help ensure the best
outcome possible for these infants.
Referrals for appropriate community resources also need to be made for infants with
developmental disabilities or those at risk for further problems (e.g., preterm infants).
Social-service involvement is especially important for young or psychosocially high-risk
parents (e.g., parents with a history of substance use or child maltreatment).
For the family of the child who is technology dependent, special education needs should
be discussed before discharge. For further discussion of home care, see Chapter 42.
Transport to a Regional Centre
If a hospital is not equipped to care for a high-risk mother and fetus or a high-risk infant,
transfer to a specialized perinatal or regional tertiary care centre is arranged. Maternal
transport that occurs with the fetus in utero and this has two distinct advantages: (1)
neonatal morbidity and mortality are decreased, and (2) the mother and infant are not
separated at birth.
For a variety of reasons, it is not always possible to transport the mother before the birth.
Therefore, physicians and nurses in all facilities must have the skills and equipment
necessary for making an accurate diagnosis and implementing emergency interventions to
stabilize the infant's condition until transport can occur (Rojas, Shirley, & Rush, 2011). The
goal of these interventions is to maintain the infant's condition within the normal
physiological range. Specific attention should be given to vital signs, oxygenation and
1417
The most common major congenital anomalies that cause serious problems in the
neonate are congenital heart disease, abdominal wall defects, imperforate anus, neural tube
defects (NTDs), cleft lip or palate, clubfoot, and developmental dysplasia of the hip. These
are thought to result from the interaction of multiple genetic and environmental factors.
Ways of detecting and preventing some of these anomalies are being improved
continuously, as are some surgical techniques for the care of the fetus with certain
anomalies. Promoting the availability of these services to populations at risk can challenge
community health care systems. An interdisciplinary team approach is vital for providing
holistic care: the surgical treatment, rehabilitation, and education of the child, as well as
psychosocial and financial assistance for the parents. Parental disappointment and
disillusion add to the complexity of the nursing care needed for these infants.
A number of congenital anomalies are discussed in the following pediatric systems and
conditions chapters (Part 3):
• Cleft lip and palate, Chapter 46
• Esophageal atresia and tracheoesophageal fistula, Chapter 46
• Omphalocele and gastroschisis, Chapter 46
• Congenital cardiac defects, Chapter 47
• Congenital diaphragmatic hernia and choanal atresia, Chapter 45
• Neural tube defects and myelomeningocele, Chapter 54
• Developmental dysplasia of the hip and clubfoot, Chapter 53
• Hypospadias, disorders of sex development, and bladder exstrophy, Chapter 49
Newborn Screening for Disease
A number of genetic disorders can be detected in the newborn period. There is no national
policy for such detection in Canada; therefore, the extent of neonatal screening is
determined by provincial and territorial guidelines (see Table 26-3). Most provinces require
screening for phenylketonuria (PKU), congenital hypothyroidism (CH), galactosemia, and
hemoglobin defects such as sickle cell disease; screening for congenital hearing loss is
recommended to be done at the same time as disease screening.
The use of pulse oximetry to screen for critical congenital heart disease in healthy term
infants has been endorsed by the Canadian Paediatric Society and is being implemented in
numerous hospitals; it has been suggested that screening for critical congenital heart
disease be incorporated into the routine newborn screening panel (Bradshaw & Martin,
2012; Mahle, Martin, Beekman, et al., 2012). When performing cardiac screening on term
newborns, one should:
• Screen term newborns after 24 hours of life or as close to discharge from the birth hospital
as possible.
• Use a motion-tolerant pulse oximeter.
• Avoid false-positive results by screening while the infant is alert.
• Obtain pulse oximeter readings from the right hand and one foot.
The response to cardiac screening varies with the saturation values that are obtained and
are outlined below:
• Saturations ≥95% in the right hand or foot and ≤3% difference between the two
extremities is a negative screen (no further testing is required).
• Saturations of ≤90% in right hand or foot is considered a positive screening, and
additional evaluation is warranted (e.g., echocardiogram).
1465
• Saturations between 90 and 95% in the right hand or foot or >3% difference between the
two extremities warrants a repeat test in 1 hour. If screening values remain the same as
those from the first screen, consider repeating the screen in 1 hour. If parameters remain
unchanged after the second screen, repeat a third time. If unchanged, consider it a positive
screen (Kemper, Mahle, Martin, et al., 2011).
Inborn Errors of Metabolism
Inborn errors of metabolism (IEM) is the term applied to a large group of disorders caused by
a metabolic defect that results from the absence of or change in a protein, usually an
enzyme, and mediated by the action of a certain gene. These defects can involve any
substrate produced from protein, carbohydrate, or fat metabolism. IEMs are recessive
disorders and an individual must receive a defective gene from each parent for them to
occur. The parents usually are unaffected because their dominant gene directs the synthesis
of sufficient protein to meet their metabolic needs under normal circumstances.
With the advent of new biochemical techniques, it is now possible to detect the gene
responsible for causing an increasing number of these disorders early in the newborn
period so that appropriate therapies to prevent further morbidity may be implemented.
Tandem mass spectrometry has the potential for identifying up to as many as 40 IEMs.
With tandem mass spectrometry, earlier identification of IEMs may prevent further
developmental delays and morbidities in affected children.
Phenylketonuria.
Phenylketonuria (PKU), an IEM inherited as an autosomal recessive trait (the PAH gene is
located on chromosome 12q24), is caused by a deficiency or absence of the enzyme needed
to metabolize the essential amino acid phenylalanine. Classic PKU is at one end of a
spectrum of conditions known as hyperphenylalaninemia. Within the spectrum of
hyperphenylalaninemia are conditions with varying degrees of severity, depending on the
degree of enzyme deficiency. Because rarer forms are a result of a deficiency in other
enzymes and are diagnosed and treated differently, the following discussion of PKU is
limited to the severe, classic form.
In PKU the hepatic enzyme phenylalanine hydroxylase, which normally controls the
conversion of phenylalanine to tyrosine, is deficient. This results in the accumulation of
phenylalanine in the bloodstream and urinary excretion of abnormal amounts of its
metabolites, the phenyl acids. One of these phenylketones, phenylacetic acid, gives urine
the characteristic musty odour associated with the disease. Another is phenylpyruvic acid,
which is responsible for the term phenylketonuria.
Tyrosine, the amino acid produced by the metabolism of phenylalanine, is absent in
PKU. Tyrosine is needed to form the pigment melanin and the hormones epinephrine and
T4. Decreased melanin production results in similar phenotypes of most individuals with
PKU, which is blond hair, blue eyes, and fair skin that is particularly susceptible to eczema
and other dermatological problems. Children with a genetically darker skin colour may be
red haired or brunette.
Clinical manifestations in untreated PKU include failure to thrive (growth failure);
frequent vomiting; irritability; hyperactivity; and unpredictable, erratic behaviour.
Cognitive impairment is thought to be caused by the accumulation of phenylalanine and
presumably by decreased levels of the neurotransmitters dopamine and tryptophan, which
affect the normal development of the brain and CNS, resulting in defective myelinization,
cystic degeneration of the grey and white matter, and disturbances in cortical lamination.
Older children commonly display bizarre or schizoid behaviour patterns such as fright
1466
the importance of taking antidepressants as ordered. Because antidepressants usually do
not exert any significant effect for approximately 2 weeks and usually do not reach full
effect for 4 to 6 weeks, many women discontinue taking the medication on their own.
Patient and family teaching should reinforce the schedule for taking medications until
therapeutic effects are present and for as long as prescribed by the health care provider.
Other Treatments for Perinatal Mood Disorders
Other treatments for PMD include hormone therapy (often combined with antidepressant
medication), complementary or alternative therapies (e.g., yoga, massage, relaxation
techniques), ECT, and psychotherapy. ECT may be used for women with depression who
have not improved with antidepressant therapy. Psychotherapy in the form of group
therapy or individual (interpersonal) therapy has been used with positive results alone and
in conjunction with antidepressant therapy; however, more studies are needed to
determine what types of professional support are most effective. Repetitive transcranial
magnetic stimulation is a new therapy for depression, but more studies need to be done to
demonstrate the efficacy (Garcia, Flynn, Pierce, et al., 2010). Alternative therapies may be
used alone but often are used with other treatments for PMD. Safety and efficacy studies of
these alternative therapies are needed to ensure that care and advice are based on evidence.
Nursing Alert
St. John's wort is often used to treat depression. It has not been proven safe for women
who are breastfeeding.
Loss and Grief
Situational life crises can be superimposed on the experiences of child-bearing. Examples
may include infertility, premature labour or premature birth, a Caesarean birth, any
perception of loss of control during the birthing experience, the birth of a boy when the
parents wanted a girl or vice versa, the birth of a child with a handicap, a maternal death,
or fetal or neonatal death (see Community Focus box). All of these situations have a
common denominator: they are losses of what was hoped for, dreamed about, and planned.
Community Focus
Community Resources for Loss and Grief
Investigate what resources and support groups exist in your community to assist parents
who have experienced a maternal death; birth of a child with physical or intellectual
challenges; a Caesarean birth if they hoped for vaginal; or the death of a baby through
miscarriage, stillbirth, or newborn death. Are resources available? Are there groups
available for people who speak a language other than English? Are there enough of these
resources to assist parents? How difficult was it for you to identify these resources? What
could you do to make resources more known to bereaved parents and families?
These crises vary in degree, and every situation requires empathy, knowledge, and
compassion from the health care provider. At the birth, the patient, partner, and family
may be mourning instead of celebrating life.
1151
Infant mortality rates continue to decrease in Canada, with a rate of 5 deaths per 1000 live
births in 2009, and 75% of these being within the first 1 month after birth (Public Health
Agency of Canada [PHAC], 2013). The leading cause of death is prematurity (PHAC, 2013).
Infants may die in the early postpartum period from prematurity, birth defects, birth
trauma, or other acute illnesses. Thus, parents can experience grief before or during the
child-bearing experience.
The focus of this section is to prepare the nurse to provide sensitive, supportive, and
therapeutic interventions to parents and families experiencing perinatal loss in a variety of
settings. An overview of the grief process is presented as a guide for assessing and
understanding the responses of bereaved women, men, and their families. Guidelines for
intervention are given, and specific intervention approaches are discussed.
Grief Responses
Grief is the process of recovering from a loss, and in that process individuals experience
many emotional, cognitive, behavioural, and physical responses. Grief is a normal process
that can be facilitated or complicated by other life events, as well as by interactions with
health care practitioners. Parental grief responses occur in four overlapping phases.
According to Wilke and Limbo (2012) there is an early period of acute distress, shock, and
numbness which is most intense for the first 2 weeks. From the second week to the fourth
month the phase is characterized by searching and yearning. From the fifth through the
ninth month, the third phase is defined as disorientation. The final phase, reorganization or
resolution, may be reached in the tenth through the twenty-fourth month when parents
return to their usual level of functioning in society, although the pain associated with the
death remains. The duration of grief varies with the individual, but there is general
agreement that grief is a long-term process that can extend for months and years. With a
very close relationship such as with one's baby, some aspects of grief never truly end.
Phase One: Shock and Numbness
The loss of a pregnancy or death of an infant is an acute and distressing experience for
mothers and partners who planned for and expected a normal healthy infant as the
outcome. The loss encompasses a loss of their identity as a mother or partner and of their
many dreams related to parenthood. The immediate reaction to news of a perinatal loss or
infant death is a period of acute distress. Parents generally are in a state of shock and
numbness. They may feel a sense of unreality, loss of innocence, and powerlessness, as
though they were in a bad dream or in a fog or trancelike state. Disbelief and denial can
occur. Sadness, devastation, depression, and intense outbursts of emotion and crying are
common. Individuals describe feeling stunned, having a short attention span, and an
inability to concentrate or make decisions. In contrast, lack of affect, euphoria, and calmness
may occur and may reflect numbness, denial, or a personal way of coping with stress.
Much of the attention during the time of a loss is on the mother. The response of partners
may vary more than that of mothers and depends on the level of identification with the
pregnancy. Partners may be profoundly affected and grieve deeply for a perinatal loss, and
it is important that they are supported in their grief as well as the mother.
Partners are often distressed by the grief of the mother and may feel helpless in
comforting her with the intense pain. Some partners may appear stoic and unemotional to
maintain the societal expectation that they be “strong” for the mother and other family
members. Because many men do not easily share their feelings or ask for help, special
efforts may be needed to help them acknowledge these feelings and realize that they, too,
1152
have a right to support from others in their pain.
During this time of acute distress, parents face the first task of grief: accepting the reality
of the loss. The pregnancy has ended, or the baby has died, and their lives have changed.
Although parents are often required to make many decisions such as having an autopsy,
naming the infant, and making funeral arrangements, normal functioning is impeded, and
decisions are difficult to make. Grandparents, friends, clergy, or other relatives may be
available to help the couple cope. However, it is important that the mother and her partner
ultimately make the decisions that are right for them.
Phase Two: Searching and Yearning
The phase of intense grief encompasses many difficult emotions as the parents work
through their pain and adjust to life without the wished-for child. In the early months after
the loss, parents often experience feelings of loneliness, emptiness, and yearning. The
mother may report that her arms ache to hold or nurse her baby and that she wakes to the
sound of a baby crying. Both the mother and her partner may be preoccupied with
thoughts about the wished-for child. Some parents cope with these feelings by avoiding
memories and not talking about the baby, whereas others want to reminisce and discuss
their loss over and over.
Deciding what to do about the nursery and baby clothes is particularly difficult during
this period. Some women want the room taken down before they go home, whereas others
want the room left intact until they have had time to grieve their loss. It is not unusual for a
grandparent or other family member to want to rush home to take down the nursery,
thinking that they would be sparing additional grief. In fact, their actions might only
complicate the grief if the parents were not involved in the decision. The bereaved parents
must go through these types of experiences in their own time frame so that healing can take
place.
During this phase of intense grief, guilt may emerge from the deep feelings of
helplessness in not somehow preventing the pregnancy loss or the death of the infant.
Mothers are particularly vulnerable to feeling guilt because of their sense of responsibility
for the well-being of the fetus and baby. With many perinatal losses, there is no clear cause
of the event, leaving the woman to speculate about what she might have done or not done
to bring about the loss. Guilt may be intense if the mother thinks she is being punished for
some unrelated event, such as having had a prior induced abortion. Many women describe
feeling tortured by “self-blame” and they need repeated emotional reassurance that they
are not at fault.
Other common responses during this phase are anger, resentment, bitterness, and
irritability. Anger may be focused on the health care team who failed to save the pregnancy
or infant; toward a God who allowed the loss to occur; or toward family, friends, or peers
when they do not provide the support the bereaved parents need and want. Some parents
focus their resentment on parents who do not appreciate their children or neglect and abuse
them. A sense of bitterness or generalized irritability rather than frank anger may be
another response. Physical symptoms of grief may include fatigue, headaches, palpitations,
and lack of strength.
During the grief process, fear and anxiety can occur as a profound worry that something
else bad might happen to another pregnancy. Some parents, especially mothers, are almost
obsessed with the desire to become pregnant again; others struggle with whether they can
cope with the possibility of another loss.
1153
Phase Three: Disorientation
Deep sadness and depression can arise when the parent has full awareness of the loss. This
often occurs several months after a perinatal loss and can continue for some time. Sadness
and depression can be accompanied by disorganization and problems with cognitive
processing, memory, and organization. This coupled with insomnia, social withdrawal, and
lack of energy leads to behavioural changes, such as difficulty in getting things done, an
inability to concentrate, restlessness, confused thought processes, difficulty solving
problems, and poor decision making. Disorganization, feelings of failure, and depression
often cause difficulties in keeping up with work and family expectations. In addition,
parents returning to work face issues such as handling well-meaning but painful comments
or the silence of coworkers.
Physical symptoms of grief include fatigue, headaches, dizziness, and altered appetite
and exhaustion. Parents are at risk for developing health problems and chronic undefined
feelings of illness. It may be difficult to sleep; appetite may be depressed or voracious. Lack
of sleep and inadequate nutrition and fluids can complicate other grief responses.
Grief responses are very personal, ongoing, and difficult to handle. Some parents may
suppress or deny their feelings because of perceived societal indifference toward pregnancy
loss and infant death. On the surface, suppression of feelings may be more socially
acceptable. However, denying the pain of grief may lead to eventual physical and
emotional distress or illness. Although bereaved parents have many ups and downs for
many months and even years after a child's death, few parents actually become mentally ill
or commit suicide. Knowing that these feelings are normal and that others have had similar
feelings can be helpful to them. The grief process during this phase is often difficult for
partners. Some may continue to have difficulty sharing their feelings. A rift can occur if one
parent, usually the mother, wants to talk about the loss and pain, and the other parent—
often, but not always, the partner—withdraws. Other signs of problems include reliance on
alcohol and drugs, extramarital affairs, prolonged hours at work, and over-involvement in
activities outside the home as an escape.
Phase Four: Reorganization and Resolution
According to Wilke and Limbo (2012), reorganization and resolution continue beyond 24
months for many parents. From the time of the pregnancy loss or infant death, parents
attempt to understand why this happened. This leads to a long and intense search for
meaning. At first the “why” is focused on the cause of death, which is often never
determined. Finding few good answers, parents next focus on “why me, why mine?” These
questions can lead some parents into an existential search about the meaning of life and
death. This search continues into the phase of reorganization and may lead to profound
changes in the parents' view of the fragility of life.
Time helps to slowly ease the painful feelings of grief. Reorganization occurs when
parents are better able to function at home and work, experience a return of self-esteem and
confidence, can cope with new challenges, and have placed the loss in perspective.
Reorganization begins to peak sometime after the first year, as parents begin to achieve the
task of moving on with their lives as they feel renewed energy and a sense of release.
Enjoying the simple pleasures of life without feeling guilty, nurturing self and others,
developing new interests, and re-establishing relationships are all signs of moving on. For
some women and families, another pregnancy and the birth of a subsequent child are
important steps in moving on with their lives; however, the term recovery is used because
the grief related to perinatal loss can continue to varying degrees throughout life.
1154
Parents who have suffered a pregnancy loss or infant death have shared that they will
never forget the baby who died and they are not the same people as before the loss (Box 246). The term bittersweet grief refers to the grief response that occurs with reminders of the
loss. This typically happens on birthdays, death days, and anniversaries; at school events;
during changes in the seasons; and during the time of the year when the loss occurred.
Grief feelings also can be triggered during subsequent pregnancies and after birth.
Box 24-6
I Am Strong
I am strong.
I am strong because at my 38 week OB appointment, I listened to a strong heartbeat and
the doctor said everything was great.
I am strong because she told me I was 3 cm dilated and labour could begin at any time.
I am strong because I left the office, completely excited and happy and couldn't wait to be
able to meet my new love shortly!
I am strong because the next day at 1130 pm labour and contractions began. They weren't
very strong or close together yet at that point.
I am strong because the following morning at 9 am the contractions began to get closer
together so I slipped into the tub to relax just a bit.
I am strong because by 930 am contractions became so strong and frequent, I got out of
the tub and called the hospital triage.
I am strong because they told me to make my way over to the hospital.
I am strong because, although I was in an amazing amount of pain, and contractions
were now just under 2 minutes apart, I was so excited. I had arrived at labour and
delivery around 10 am.
I am strong because they took me into the triage room and began the routine.
I am strong because I immediately knew there was a problem when the nurse seemed to
be having a hard time locating the heartbeat.
I am strong because she called in the doctor on call who tried to locate a heartbeat also.
I am strong because he gave us the news, news no parent should ever have to hear, “I'm
so sorry, but the baby doesn't have a heartbeat.”
I am strong because I cried.
I am strong because I then had to make a decision, to deliver my sleeping baby or
proceed with a Caesarean section.
I am strong because I choose to continue with the labour and contractions, I wanted to
deliver this baby. I am strong because I was planning a VBAC and I wanted it to be that
way.
I am strong because I laboured for hours and at 6 pm I delivered my baby.
I am strong because I had a son, a beautiful baby boy, 3500 gm.
I am strong because we named him Matteo.
I am strong because the nurse cleaned up my baby and brought him over to me. I am
strong because I had the opportunity to hold, cuddle and kiss my sleeping, stillborn
son.
I am strong because I cried.
I am strong because my husband and my daughter were able to hold their baby son and
baby brother.
I am strong because my family was able to come and meet my new baby.
I am strong because I knew he wouldn't be coming home.
1155
I am strong because at midnight I had to let him go.
I am strong because I cried.
I am strong because the next day I was discharged and was able to go home. I sobbed as
my husband wheeled me out of the room and down the hall.
I am strong because I had to leave the hospital, after a day of labour, contractions, pains
and sadness without my baby.
I am strong because I cried.
I am strong because we then had to go about and make arrangements for the baby boy I
wasn't able to take home.
I am strong because we chose a spot for him amongst other sleeping babies, he could
sleep with them, under a large green tree.
I am strong because I chose a cozy little pajama with elephants for my baby to sleep in
and a soft warm blanket for him to snuggle in.
I am strong because I cried.
I am strong because one week later, my husband, daughter, sleeping baby and myself,
were allowed to be in a room together for one last time.
I am strong because this is where I held his tiny hand in my fingers, I am strong because I
was able to kiss his tiny nose, his perfect lips. I am strong because I spoke to him softly.
I am strong because this is where we had to say goodbye to baby Matteo.
I am strong because I cried.
I am strong because we proceeded to the cemetery where we had a simple, sweet
ceremony for our baby.
I am strong because we all cried.
I am strong because I watched as he was buried. I am strong because my sweet baby, my
son was buried.
I am strong because I cried.. I cried.. we all cried..
I am strong because I have the hope that we will see our baby Matteo again, soon.
I am strong because I believe he now won't have to live in a world of sin, pain and
suffering, and I am strong because I know I will hold and cuddle him again, and he will
be safe in my arms.
I am strong because every day I think about him.
I am strong because every day I want him back.
I am strong because I am a mommy of two beautiful children. I am strong because I am
only currently a parent to one of them.
I am strong because of my daughter, although only 3 years old, she's strong too.
I am strong because, although every day I may be sad, I am also happy.
I am strong because I am able to cry and I am strong because I am able to smile.
I am strong because of all the blessings I have been given, including my beautiful
sleeping baby.
(Used with permission of Author.) VBAC, vaginal birth after caesarean.
Resumption of the couple's sexual relationship is an important aspect of recovery but can
be very complicated. Many parents are comforted by the belief that their babies were
conceived in love, lived in love, and died in love. Their love and intimacy created this child,
and parents may believe that they may never experience joy and closeness again. Some
couples may have an increased need for sexual activity in an attempt for closeness and
healing, whereas others have a decreased desire for sexual intimacy.
Sexuality also brings with it decisions about a future pregnancy. Some couples are eager
to have another child, although this child cannot replace the one who died and the grief
1156
will continue despite another pregnancy. Other parents have a deep fear of experiencing
the pain of loss again, which can make the resumption of sexual activity difficult. These
ambivalent feelings are normal, and couples can find themselves moving back and forth
between the emotions of exhilaration and fear. The excitement that many other parents
experience with a pregnancy is very different for previously bereaved parents. For some,
this emotional distress can affect maternal attachment to the new baby. In one study,
mothers who became pregnant again within 6 months after a stillbirth had fewer
depressive symptoms at a 3-year follow-up than those who did not have a subsequent
pregnancy (Surkan, Rådestad, Cnattinguis, et al., 2008).
Couples often mark the progress of the pregnancy in terms of fetal development, waiting
anxiously until the number of weeks of the previous loss is passed. In some cases, the fear
of repeated loss, especially after a stillbirth, is so great that induction of labour may be
considered if the fetus is mature. Support groups are important in helping women through
pregnancies after loss of a fetus or infant.
Family Aspects of Grief
Grandparents and Siblings
It is extremely important for the nurse taking care of women who have experienced a loss
to keep in mind that they have an entire family to care for, including grandparents and
siblings. Grandparents have hopes and dreams for a grandchild; these have been shattered.
The grief of grandparents is often complicated by the fact that they are experiencing intense
emotional pain by witnessing and feeling the immense grief of their own child. It is
extremely difficult to watch their son or daughter experience unimaginable emotional
trauma, with very few ways to comfort them and end their pain. As a result, the grief
response may be complicated or delayed for grandparents. On occasion, some
grandparents experience immense survivor guilt because they are alive and their
grandchild has died.
The siblings of the expected infant also experience a profound loss. Most children have
been prepared for having another child in the family, once the pregnancy is confirmed.
These children's ages and stages of development must be considered in understanding how
they view the event and experience the loss. A young child responds more to the response
of his or her parents, picking up on the fact that they are behaving differently and are
extremely sad. This can cause clinging, altered eating and sleeping patterns, or acting-out
behaviours; and it is a time when parents have limited patience for responding to and
meeting the needs of the child. Older children have a more complete understanding of the
loss. School-age children may be frightened by the entire event, whereas teens may
understand fully but feel awkward in responding.
Older siblings need to be included in grieving rituals, to the extent that the parents and
the child feel comfortable. They may need to see the baby to realize the loss. Nurses need to
have a basic understanding of how children view death and grief in order to reach out to
siblings in an appropriate and sensitive manner. Nurses also need to help parents recognize
and be sensitive to the grief of siblings, include them in family rituals, and keep the baby
alive in the family memory.
Nursing Care
Nursing care of mothers and partners experiencing a perinatal loss begins the first time
they are faced with the potential loss of their pregnancy or death of their infant. Assessment
is as important for families experiencing a miscarriage or ectopic pregnancy as it is for those
1157
experiencing stillbirth or neonatal loss. Supportive interventions are important at the time
of the loss and after the parents have returned home.
Parents often cannot recall details of their experiences at the time of the child's death, but
they may recall vividly a minor event that was perceived as particularly painful or
particularly helpful. The interventions provided below are general ideas about what may
be helpful to parents. However, care must be individualized for each parent and family.
Cultural and spiritual beliefs and practices of individual parents and families must also be
considered.
Therapeutic communication Exemplar
Communicating and Caring Techniques
Mothers, partners, and extended families look to the medical and nursing staff for support
and understanding during the time of loss. Therapeutic communication and counselling
techniques help the mother, partners, and other family members express their feelings and
emotions, understand their responses to the loss, and make decisions.
The nurse should listen patiently while people tell their story of loss and grief. It may be
necessary to ask questions that help people talk about their grief and the experiences
surrounding the loss. However, grief responses in the initial days of crisis make it difficult
for individuals to concentrate on what is being asked, think about what a question means,
and respond to a question. The use of silence often gives the bereaved person the
opportunity to collect thoughts and respond to questions. The nurse should resist the
temptation to give advice or use clichés in offering support (Box 24-7).
Box 24-7
What to Say and What not to Say to Bereaved Parents
What to Say
“I'm sad for you.”
“How are you doing with all of this?”
“This must be hard for you.”
“What can I do for you?”
“I'm sorry.”
“I'm here, and I want to listen.”
What Not to Say
“God had a purpose for her.”
“Be thankful you have another child.”
“The living must go on.”
“I know how you feel.”
“It's God's will.”
“You have to keep on going for her sake.”
“You're young; you can have others.”
“We'll see you back here next year, and you'll be happier.”
“Now you have an angel in heaven.”
“This happened for the best.”
“Better for this to happen now, before you knew the baby.”
“There was something wrong with the baby anyway.”
1158
Used with permission of Gundersen Lutheran Medical Foundation, Inc., La Crosse,
WI.
Nurses need to become comfortable with their own feelings of grief and loss to effectively
support and care for the bereaved. It is appropriate to express feelings with the bereaved
families and share the moment with them. The nurse might use some of the lines in Box 247 in helping the family share and express their grief.
Help Mother, Partners, and Other Family Members Actualize the
Loss
When a loss or death occurs, the nurse should be sure that parents have been honestly told
about the situation by their primary health care provider or others on the health care team.
It is important for their nurse to be with the parents during this time. With early pregnancy
loss, it is recommended that the term miscarriage be used consistently. With infant death,
caregivers should use the words “dead” and “died,” rather than “lost” or “gone” to assist
the bereaved in accepting this reality. One way of actualizing the loss is to tell the parents
the sex of the baby and give them the option of naming the fetus or help them name an
infant who has died. Choosing a name helps make the baby a member of their family, so
that the baby can be remembered in a special way.
Nursing Alert
A caution about naming is important to note. Naming is an individual decision that
should never be imposed on parents. Beliefs and needs vary widely across individuals,
cultures, and religions. Cultural taboos and rules in some religious faiths prohibit the
naming of an infant who has died.
On the basis of vast clinical experience with parents, many professionals believe that
seeing the dead fetus or baby helps parents face the reality of the loss, reduces painful
fantasies, and offers an opportunity for continued parenting. Many parents relish the
memory of parenting their deceased baby by holding, bathing, and dressing him or her.
However, parents should never be made to feel that they should see or hold their baby
when this is something they do not want to do. It is good policy for the nurse to first tell
them about this option and then give them time to think about it. The nurse can ask a
question such as “Some parents have found it helpful to see their baby. Would you like
time to consider this?” Later the nurse can return and ask each parent individually what he
or she has decided. Because the need or willingness to see the child also may vary between
the mother and her partner, it is important to determine what each parent really wants.
This should not be a joint decision made by one person or a decision made for the parents
by grandparents or others.
In preparation for the visit with the baby, parents appreciate explanations about what to
expect. A description of how their baby looks is important. For example, babies may have
red, peeling skin like a bad sunburn, dark discolouration similar to bruises, moulding of the
head that makes the head look soft and swollen, or birth defects. The nurse should make
the baby look as normal as possible and remember that parents see their baby with
different eyes from those of health care professionals. Bathing the baby, applying lotion to
the baby's skin, combing hair, placing identification bracelets on the arm and leg, dressing
the baby in a diaper and special outfit, sprinkling powder in the baby's blanket, and
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wrapping the baby in a pretty blanket conveys to the parents that their baby has been cared
for in a special way. Many parents participate in these activities. If the baby has been in the
morgue, he or she can be placed underneath a warmer for 20 to 30 minutes and wrapped in
a warm blanket before being brought to the parents. Cold cream rubbed over stiffened
joints can help in positioning the baby. The use of powder and lotion stimulates the parents'
senses and can help provide pleasant memories of their baby.
When bringing the baby to the parents, it is important to treat the baby as one would a
live baby. Holding the baby close, touching a hand or cheek, using the baby's name, and
talking with the parents about the special features of their baby convey that it is all right for
them to do likewise. If a baby has a congenital anomaly, the nurse can focus on aspects of
the baby that are normal. Nurses can help parents explore the baby's body as they desire.
Parents often seek to identify family resemblance. A good question might be: “Who in your
family does your baby resemble?”
Some families may like to have the opportunity to bathe and dress their baby. Although
the skin may be fragile, parents can still apply lotion with cotton balls; sprinkle powder; tie
ribbons; fasten the diaper; and place amulets, medallions, rosaries, or special toys or
mementos in their baby's hands or next to their baby. Volunteer women in communities
across the country often make special burial clothes to give parents at this difficult time.
Parents may want to perform other parenting activities, such as combing the baby's hair,
dressing the baby in a special outfit, wrapping the baby in a blanket, or placing the baby in
a crib.
Parents need to be offered time alone with their baby if they wish. They also need to
know when the nurse will return and how to call if they should need anything. If at all
possible, the family should be placed in a private room, and the room should have a
rocking chair for the parents to sit in when holding their baby. This offers the mother and
partner special time together with their baby and with other family members (Fig. 24-10).
Marking the door to the room with a special card can be helpful in reminding staff that this
family has experienced a loss (Fig. 24-11).
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FIGURE 24-10 Laura's family members say a special good-bye. (Courtesy Amy and Ken
Turner, Cary, NC.)
FIGURE 24-11 Door card for room of mother who has experienced perinatal
loss. (suns07butterfly/Shutterstock.com.)
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Sensitivity to parental needs in actualizing the loss and coping with the reality of the
death is essential for their healing. Grandparents should be offered the same opportunities
to hold, rock, swaddle, and love their grandchildren so that their grief is started in a healthy
way.
Help Parents With Decision Making
At a time when parents are experiencing the great distress of a perinatal loss, and especially
if the loss was of an infant, these parents have many decisions to make. Mothers, partners,
and extended families look to the medical and nursing staff for guidance in knowing what
decisions they must and can make and in understanding the options related to those
decisions. It is a primary responsibility of the nurse to help them and to advocate for them,
because decisions made during the time of their loss will provide memories for a lifetime.
One decision might be related to conducting an autopsy. An autopsy can be very
important in answering the question “why” if there is a chance that the cause of death can
be determined. This information can be helpful in processing grief and perhaps in
preventing another loss. Some parents may believe that their baby has been through
enough and prefer not to have further information about the cause of death. Some religions
prohibit autopsy or limit the choice to instances in which autopsy may help prevent
another loss. Options for the type of autopsy, such as excluding the head, should be made
available to parents. Parents may need time to make this decision. There is no need to rush
them unless there was evidence of contagious disease or maternal infection at the time of
death.
Organ donation can be an aid to grieving and an opportunity for the family to see
something positive associated with their experience. The most common donation is of
corneas; donation of corneas from a baby can occur if the baby was born alive at 36 weeks
of gestation or later.
Prayer Exemplar
Another important decision relates to spiritual rituals that may be helpful and important
to parents. Support from clergy is an option that should be offered to all parents. Parents
may wish to have their own pastor, priest, rabbi, or spiritual leader contacted; or they may
wish to see the hospital's chaplain. They may choose to do neither. Clergy persons may
offer the parents the opportunity for baptism, when appropriate. Other rituals that may be
important include a blessing, a naming ceremony, anointing, ritual of the sick, memorial
service, or prayer.
One of the major decisions that parents must make has to do with disposition of the
body. Parents should be given information about the choices for the final disposition of
their baby, regardless of gestational age. However, nurses must be aware of cultural and
spiritual beliefs that may dictate the choices of parents, as well as the cost of burial,
alternatives to burial, and provincial laws related to burial. A fetus younger than 20 weeks
of gestation that weighs less than 500 g is considered a miscarriage; embryos, uterine tubes
removed with an ectopic pregnancy, and tissue from a pregnancy obtained during a D&C
are all considered tissue. Many hospitals will make arrangements for the cremation of these
fetuses or tissue. The nurse should know the hospital's policies and procedures about burial
and cremation and answer the parents' questions honestly. In Canada, if a fetus is greater
than or equal to 20 weeks of gestational age or is born alive, it is the parents' responsibility
to make the final arrangements for their baby.
Legal Tip
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Laws Regarding Live Birth
Laws in all provinces govern what constitutes a live birth. In most provinces, a live birth
is considered to be any products of conception expelled from a woman that show any
signs of life. Signs of life are considered to be any muscle irritability, respiratory effort, or
heart rate, regardless of gestational age. All nurses should be knowledgeable about the
provincial laws regarding what constitutes a live birth and the forms that must be
completed and filed in the case of fetal death, stillbirth, or newborn death.
In making final arrangements for their baby, parents may want a special service. They
may choose to have a service in the hospital chapel, visitation at a funeral home or their
own home, a funeral service, or a graveside service. Parents can make any of these services
as special, personal, and memorable as they like. They can choose special music, poetry, or
prose written by themselves or others.
The timing for actions such as naming the baby, seeing and holding the baby, creating
mementos (e.g., pictures and footprint moulds), disposition of the body, and funeral
arrangements should never be rushed. In some cases, the mother may be discharged home
before these decisions are made. Then the family can think about them in the comfort of
their home and contact the hospital in the following days to give their answers.
Help Bereaved to Acknowledge and Express Feelings
One of the most important goals of the nurse is to validate the experience and feelings of
the parents, by encouraging them to tell their stories and by listening with care. Because
nurses tend to be very focused on the physical and emotional needs of the mother, it is
especially important to ask the partner directly about his or her views of what happened
and the feelings of loss.
Bereaved parents have many questions surrounding the event of their loss, and some
questions can leave them feeling guilty. This is particularly true for mothers. Such
questions include “What did I do?” “What caused this to happen?” “What do you think I
should have, could have done?” Part of the grief process for bereaved parents is figuring
out what happened, their role in the loss, why it happened to them, and why it happened
to their baby. The nurse should recognize that these questions must be answered by the
bereaved themselves; it is part of their healing. For example, a bereaved mother might ask,
“Do you think that this was caused by painting the baby's room?” An appropriate response
might be, “I understand you need to find an answer for why your baby died, but we really
don't know why she died. What are some of the other things you have been thinking
about?” Trying to give bereaved parents answers when there are no clear answers or trying
to squelch their guilt feelings by telling them they should not feel guilty does not help them
process their grief. In reality, many times there are no definite answers to the question of
why this terrible thing has happened to them. However, factual information such as data
about the frequency of miscarriages in pregnant women or the fact that there usually is no
clear cause of a stillbirth can be helpful.
Feelings of anger, guilt, and sadness can occur immediately but often become more
problematic in the early days and months after a loss. When a bereaved person expresses
feelings of anger, it can be helpful to identify the feeling by simply saying, “You sound
angry,” or “You look angry.” The nurse's willingness to sit down and listen to these surface
feelings of anger can help the bereaved person move past them into the underlying feelings
of powerlessness and helplessness in not being able to control the many aspects of the
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situation.
Normalize the Grief Process and Facilitate Positive Coping
While helping parents share their feelings of pain, it is critical to help them understand
their grief responses and know that they are not alone in these painful responses. Most
parents are not prepared for the raw feelings they experience or the fact that these painful,
complex feelings and related behavioural reactions continue for many weeks or months.
Thus, reassuring them of the normality of their responses and preparing them for the
length of their grief is important.
The nurse can help the parent be prepared for the emptiness, loneliness, and yearning;
for the feelings of helplessness that can lead to anger, guilt, and fear; and for the
disorganization, difficulty making decisions, and sadness and depression that are part of
the grief process.
In the initial days after a loss, other useful nursing strategies include follow-up phone
calls, referrals to a perinatal grief support group, or providing books, pamphlets, videos, or
websites intended for helping parents who have experienced a perinatal loss (see
Additional Resources at the end of the chapter). However, as with any referral, the nurse
should first read the materials or check out the websites for applicability.
To reduce relationship problems that can occur in grieving couples, it is particularly
important to help them understand that they may respond and grieve in very different
ways. This is called incongruent grief (Wilke & Limbo, 2012). For example, one partner may
be depressed and have no energy and be unable to work, while the other partner may cope
by going back to work and working long hours. The differences in grieving can lead to
serious relationship problems and be a risk factor for complicated bereavement. Remind
the couple of the importance of being understanding and patient with each other and
seeking professional help as needed.
Nurses can reinforce positive coping efforts and encourage attempts to resume normal
activities; reinforce and encourage positive ways to hold onto memories of the pregnancy
or baby while letting go; and help the parents organize a plan for daily activities, if needed.
In particular, nurses should discourage overdependence on drugs and alcohol.
Meet the Physical Needs of the Postpartum Bereaved Mother
Coping with loss and grief after childbirth can be an overwhelming experience for the
woman and her family. One particularly difficult aspect of the loss is the sound of crying
babies and the happiness of other families on the unit who have given birth to healthy
infants. The mother should be given the opportunity to decide if she wants to remain on the
maternity unit or be moved to another hospital unit. She also should be helped to
understand the pluses and minuses of each choice. Postpartum care and grief support may
not be as good on another hospital unit where the staff are not experienced in postpartum
and bereavement care.
The physical needs of a bereaved mother are the same as those of any woman who has
given birth. The cruel reality for many bereaved mothers is that their milk can come in with
no baby to nurse, their afterpains remind them of their emptiness, and gas pains feel as
though a baby is still moving inside. The nurse should ensure that the mother receives
appropriate medications to reduce these physical symptoms. Adequate rest, diet, and fluids
must be offered to replenish her physical strength.
Mothers need postpartum care instructions on discharge. They also need ideas about
how to cope with sleep problems, such as decreasing food or fluids that contain caffeine,
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limiting alcohol and nicotine consumption, exercising regularly, using strategies for rest,
taking a warm bath or drinking warm milk before bedtime, doing relaxation exercises,
listening to restful music, or a getting a massage. Furthermore, the couple needs to be
encouraged and supported in maintaining their relationship and keeping open channels of
communication. They also need to be prepared for some of the issues related to resuming
sexual relations after perinatal loss.
Create Memories for Parents to Take Home
Parents may want tangible mementos of their baby to help them actualize the loss. Some
may want to bring in a previously purchased baby book. Special memory books, cards, and
information on grief and mourning are often available to give to parents (Fig. 24-12).
FIGURE 24-12 Memory kit assembled at John C. Lincoln Hospital, Phoenix, AZ.
Memory kits may include pictures of the infant, clothing, death certificate, footprints, ID
bands, and ultrasound picture. (Courtesy Julie Perry Nelson.)
The nurse can provide information about the baby's weight, length, and head
circumference to the family. Footprints and handprints can be taken and placed with the
other information on a special card or in a memory or baby book. Sometimes it is difficult
to obtain good handprints or footprints. Application of alcohol or acetone on the palms or
soles can help the ink adhere to make the prints clearer, especially for small babies. When
making prints, it is helpful to have a hard surface underneath the paper to be printed. The
baby's heel or palm should be placed down first and the foot or hand rolled forward,
keeping the toes or fingers extended. It may be helpful to have assistance in this procedure.
If the print does not turn out, the nurse can trace around the baby's hands and feet,
although this distorts the actual size. Moulds can also be used to make an imprint of the
baby's hand or foot.
Parents often appreciate articles that were in contact with or used in caring for the baby.
This might include the tape measure used to measure the baby, baby lotions, combs,
clothing, hats, blankets, crib cards, and identification bands. The identification band helps
the parents remember the size of the baby and personalizes the mementos. The nurse
should ask parents if they wish to have these articles. A lock of hair may be another
important keepsake. Parents must be asked for permission before cutting a lock of hair,
which can be removed from the nape of the neck where it is not noticeable.
For some parents, pictures are the most important memento. Photographs are generally
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taken whenever there is an identifiable baby and when it is culturally acceptable to the
family to take photos. It does not matter how tiny the baby is, what the baby looks like, or
how long the baby has been dead. Pictures should include close-ups of the baby's face,
hands, and feet and photos of the baby clothed and wrapped in a blanket and unclothed. If
there are any congenital anomalies, close-ups of these also should be taken. Flowers, blocks,
stuffed animals, or toys can be placed in the background to make the picture more special.
Parents may want their pictures taken holding the baby. Keeping a camera nearby and
taking pictures when parents are spending special time with their baby can provide special
memories. Some parents may have their own camera, video camera, or smartphone and ask
the nurse to record them as they bathe, dress, hold, or diaper their baby. An organization
called Now I Lay Me Down to Sleep provides a professional photographer to take pictures
for families at no cost. Their website can be consulted to determine if there is a
photographer within the geographical location.
Cultural and Spiritual Needs of Parents
Many of the responses to perinatal loss and suggested interventions described in this
section are based on middle-class European-American views. Although there may be no
particular differences in individual, intrapersonal experiences of grief based on culture,
ethnicity, or religions, there are complex differences in the meaning of children and
parenthood, the role of women and men, the beliefs and knowledge about modern
medicine, views about death, mourning rituals and traditions, and behavioural expressions
of grief. Thus, nurses must be sensitive to the responses and needs of parents from various
cultural backgrounds and religious groups. Nurses need to be aware of their own values
and beliefs and acknowledge the importance of understanding and accepting the values
and beliefs of others that are different or even in conflict with theirs. Further, it is critical to
understand that the individual and unique responses of parents to a perinatal loss cannot
be entirely predicted by their cultural or spiritual backgrounds. Each mother and partner
must be approached first as an individual needing support during a profoundly difficult
and distressing life experience.
Provide Postmortem Care
Preparation of the baby's body and transport to the morgue depend on the procedures and
protocols developed by individual hospitals. Nurses should use a sensitive and respectful
approach when taking the fetus or infant to the morgue. Postmortem care can be an
emotional and sometimes difficult task for the nurse. Nurses and organizations are
encouraged to facilitate perinatal bereavement training for all involved in perinatal loss (see
Additional Resources at the end of the chapter). Nurses may experience compassion fatigue
and are encouraged to seek assistance in the form of debriefs, support from colleagues, and
seeking professional guidance when needed.
Documentation
Many hospitals have a checklist that is used in providing care, mobilizing members of the
multidisciplinary health care team, communicating options that the family has chosen, and
keeping track of all the details in meeting the needs of bereaved parents. The checklist may
or may not be a permanent part of the chart. Documentation in the nursing notes of
primary concerns, grief responses, health teaching, health care advice, and referrals of the
mother or any other family members is essential to ensure continuity and consistency of
care.
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Provide Sensitive Care at and After Discharge
Leaving the hospital can be a devastating experience for the mother who has had a
pregnancy loss, as not carrying a baby in her arms is a very empty and painful experience.
It is especially difficult if others are seen leaving with babies; thus, the discharge of mothers
and partners who have suffered a perinatal loss should be done with great sensitivity to
their feelings (i.e., they should not be discharged at a time when other mothers with live
babies are leaving). Giving the mother a special flower to carry in her arms can be a
thoughtful gesture.
The grief of the mother and her family does not end with discharge; it really begins once
they return home, attend the funeral, and start to live their lives without their baby. There
are numerous models for providing follow-up care to parents after discharge. Although
there is no solid evidence from sound clinical trials regarding the benefit of these programs,
nonexperimental studies and clinical evaluations suggest that these programs are helpful.
Such programs include hospital-based bereavement teams who provide support during
hospitalization and follow-up contacts and memorial services.
Phone calls from hospital staff after a loss may be helpful to some parents; however, it
must be determined which parents do not want them. Follow-up calls let the parents know
that someone still thinks and cares about them. The calls are made at predictably difficult
times, such as the first week at home, 1 month to 6 weeks later, 4 to 6 months after the loss,
and at the anniversary of the death. Families who have experienced a miscarriage, ectopic
pregnancy, or death of a preterm baby may appreciate a phone call on the estimated due
date. Such calls provide an opportunity for parents to ask questions, share their feelings,
seek advice, and receive information to help them process their grief.
A grief conference can be planned when parents return for an appointment with their
doctor, nurses, and other health care providers. At the conference, the loss or death of the
infant is discussed in detail, parents are given information about the baby's autopsy report
and genetic studies, and they have the opportunity to ask questions that have arisen since
their baby's death. Parents appreciate the opportunity to review the events of
hospitalization, go over the baby's and mother's chart with their primary health care
provider, and talk with those who cared for them and their baby during hospitalization.
This is an important time to help parents understand the cause of the loss or accept the fact
that the cause will forever be unknown. This meeting also gives health care providers the
opportunity to assess how the family is coping with their loss and to offer additional
information and education on grief.
Some parents are very interested in finding a perinatal or parent grief support group.
Talking with others who have been through similar experiences, sharing memories of the
pregnancy and the baby, and gaining an understanding of the normality of the grief
process generally have been found to be supportive. Over time, it may be the only place
where bereaved parents can talk about the wished-for child and their grief. However, not
all parents find such groups helpful.
When referring parents to a group, it is important to know something about the group
and how it operates. For example, if a group has a religious base for their interventions, a
nonreligious parent would not likely find the group to be helpful. If parents experiencing a
perinatal loss are referred to a general parental grief group, they might feel overwhelmed
with the grief of parents whose older children have died of cancer, suicide, or homicide. In
addition, the grief of parents following a perinatal loss might be minimized by other
parents. Thus, the needs of the parents must be matched with the focus of the group.
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Maternal Death
Maternal death can be caused by a variety of complications, including embolism,
hypertension, hemorrhage, infection, and cardiomyopathy. In many cases, the death of a
mother is sudden and unexpected. Any instance of maternal death is tragic for the family as
well as for the nurses and other health professionals who were involved in her care. In
Canada it is rare for a woman to die in childbirth; the incidence of maternal deaths is one of
the lowest in the world: in 2010–2011 it was 6.1 per 100,000 (PHAC, 2013).
When a woman dies of a complication related to child-bearing, the husband or partner
and extended family are faced with mourning the death of a wife or partner and mother.
The loss and grief are greatly compounded when there is also the death of a fetus or
neonate. When the infant survives, the husband or partner is faced with parenting a baby
without a surviving mother. The responsibilities of infant care can be overwhelming during
this time of intense loss and grief.
Because most maternal deaths are unexpected, the grief that follows a maternal death is
sudden. This differs from anticipatory grief in which the loss is expected, such as with
cancer. The shock and disbelief associated with unplanned grief can be engulfing and
debilitating, overwhelming the normal coping abilities and creating difficulties with
everyday functioning and decision making.
Nurses and other health care professionals working with families who experience
maternal loss need to consider the context and the implications of the maternal death for
the remaining family members. Young parents may never have experienced a significant
personal loss or tragedy; in many cases, their parents and grandparents are still living.
Cultural beliefs and customs surrounding death can influence a family's response to
maternal death (Hill, 2012). The grief response of each family member will vary; grief is an
individual response, and the grieving process does not always proceed in a predictable
manner.
Families who experience maternal loss are at risk for developing complicated
bereavement and altered parenting of the surviving infant and other children in the family.
A referral to social services to help the family mobilize support systems and for counselling
can help combat potential problems before they develop and can be beneficial not only at
the time of the loss but also in the future. Follow-up care for grieving families is essential as
they progress through the stages of grief and adjust to life without the mother.
The emotional toll that a maternal death can take on the nursing and medical staff must
also be addressed. Guilt, anger, fear, sadness, and depression are all common responses to a
maternal death. The staff may want to participate in a debriefing session in which they can
review the situation surrounding the events, their participation in caring for the mother,
and their response to the death. Attending memorial or funeral services may benefit staff
and family. Follow-up conferences with a social worker or grief counsellor can help staff
members work through their grief.
Key Points
• PPH is the most common and most serious type of excessive obstetrical blood loss.
• Hemorrhagic (hypovolemic) shock is an emergency situation in which the perfusion of
body organs may become severely compromised and death may ensue.
• The potential hazards of therapeutic interventions can further compromise the woman
with hemorrhagic disorders.
• Postpartum infection is a major cause of maternal morbidity and mortality throughout the
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world.
• Postpartum UTIs are common during the postpartum period.
• Breast infection affects about 1% of women soon after childbirth.
• Structural disorders of the uterus and vagina related to pelvic relaxation are often the
delayed but direct result of child-bearing.
• Perinatal mood disorders (PMD) account for most mental health disorders in the
postpartum period.
• Suicidal thoughts or attempts are among the most serious symptoms of postpartum
psychosis.
• Treatment of PMD requires a combination of medication, education, supportive
measures, and psychotherapy.
• Antidepressant medications are the usual treatment for PMD; however, specific
precautions are needed for breastfeeding women.
• An understanding of grief responses and the bereavement process is fundamental in
implementation of the nursing process.
• Therapeutic communication and counselling techniques can help families identify their
feelings and feel comfortable in expressing their grief.
• Follow-up after discharge is an essential component to providing care to families who
have experienced a loss.
• Nurses need to be aware of their own feelings of grief and loss to provide a
nonjudgemental environment of care and support for bereaved families.
References
American Association of Women, Obstetrical and Neonatal Nurses (AWHONN).
Quantification of blood loss: AWHONN practice brief number 1. Journal of Obstetric,
Gynecologic, & Neonatal Nursing. 2015;44:158–160.
American College of Obstetricians and Gynecologists, Committee on Obstetric
Practice. Committee opinion: Screening for perinatal depression. [Retrieved from:]
http://www.beststart.org/resources/hlthy_chld_dev/BSRC_Daddy_and_Me_EN.pdf
2015.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders.
5th ed. American Psychiatric Association Press: Washington, DC; 2013.
Beydoun HA, Beydoun MA, Kaufman JS, et al. Intimate partner violence against adult
women and its association with major depressive disorder, depressive symptoms
and postpartum depression: A systematic review and meta-analysis. Social Science
and Medicine. 2012;75(6):959–975.
Blom EA, Jansen PW, Verhulst FC, et al. Perinatal complications increase the risk of
postpartum depression: The Generation R study. BJOG: An International Journal of
Obstetrics and Gynaecology. 2010;117(11):1390–1398.
Callister LC, Beckstrand RL, Corbett C. Postpartum depression and help-seeking
behaviors in immigrant Hispanic women. Journal of Obstetrics, Gynecology, and
Neonatal Nursing. 2011;40(4):440–449.
Cerulli C, Talbor NL, Tang W, et al. Co-occurring intimate partner violence and
mental health diagnoses in perinatal women. Journal of Women's Health.
2011;20(12):1797–1803.
Chan W, Rey E, Kent NE, SOGC VTE in Pregnancy Guideline Working Group. SOGC
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