E
ven though I was an assertive practicing attorney in my thirties, my first pregnancy was filled with nagging feelings of doubt about this upcoming event in my life.Throughout my pregnancy I was so busy with trial work that I never had time to really evaluate my feelings. I was always reading about the bodily changes that were tak- ing place, and on one level I was feeling excited, but on another level I was emotionally drained. Shortly after the birth of my daughter, those suppressed nagging feelings of doubt surfaced big time and practically immobilized me. I felt exhausted all the time and was only too glad to have someone else care for my daughter. I didn’t breast- feed because I thought it would tie me down too much.
Although at the time I thought this “low mood” was normal for all new mothers, I have since found out it was postpartum depression. How could any woman be depressed about this wondrous event?
Thoughts: Now that postpartum depression has been “taken out of the closet” and recognized as a real emotional disorder, it can be treated. This woman showed tendencies during her pregnancy but was able to suppress the feelings and go forward. Her descrip- tion of her depression is very typical of many women who suffer in silence, hoping to get over these feelings in time. What can nurses do to promote awareness of this disorder? Can it be prevented?
Begin the assessment by reviewing the history to identify general risk factors that could predispose a woman to depression:
• Poor coping skills
• Low self-esteem
• Numerous life stressors
• Mood swings and emotional stress
• Previous psychological problems or a family history of psychiatric disorders
• Substance abuse
• Limited or lack of social support network
Also review the history for specific pregnancy and birth factors that may increase the woman’s risk
C h a p t e r 2 2 Nursing Management of the Postpartum Woman at Risk 793
KEY CONCEPTS
Postpartum hemorrhage is a potentially life- threatening complication of both vaginal and cesarean births. It is the leading cause of maternal mortality in the United States.
A good way to remember the causes of postpar- tum hemorrhage is the “5 T’s”: tone, tissue, trauma, thrombin, and traction.
Uterine atony is the most common cause of early postpartum hemorrhage, which can lead to hypovolemic shock.
Oxytocin (Pitocin), misoprostol (Cytotec), dino- prostone (Prostin E2), methylergonovine maleate (Methergine), and prostaglandin PGF2α (carbo- prost [Hemabate]) are commonly used drugs used to manage postpartum hemorrhage.
Failure of the placenta to separate completely and be expelled interferes with the ability of the uterus to contract fully, thereby leading to hemorrhage.
Causes of subinvolution include retained placental frag- ments, distended bladder, uterine myoma, and infection.
Lacerations should always be suspected when the uterus is contracted and bright-red blood continues to trickle out of the vagina.
Conditions that cause coagulopathies may include idiopathic thrombocytopenic purpura (ITP), von Willebrand disease (vWD), and disseminated intra- vascular coagulation (DIC).
Pulmonary embolism is a potentially fatal condition that occurs when the pulmonary artery is obstructed by a blood clot that has traveled from another vein into the lungs, causing obstruction and infarction.
The major causes of a thrombus formation (blood clot) are venous stasis and hypercoagulation, both of which are common in the postpartum period.
Postpartum infection is defined as a fever of 100.4° F (38° C) or higher after the first 24 hours after childbirth, occurring on at least 2 of the first 10 days exclusive of the first 24 hours.
Common postpartum infections include metritis, wound infections, urinary tract infections, and mastitis.
Postpartum emotional disorders are commonly clas- sified on the basis of their severity: “baby blues,”
postpartum depression, and postpartum psychosis.
Management of postpartum depression mirrors the treatment of any major depression: a combination of antidepressant medication, antianxiety medica- tion, and psychotherapy in an outpatient or inpa- tient setting.
Discuss factors that may increase a woman’s vulnerability to stress during the postpartum pe- riod, such as sleep deprivation and unrealistic ex- pectations, so couples can understand and respond to those problems if they occur. Stress that many women need help after childbirth and that help is available from many sources, including people they already know. Assisting women to learn how to ask for help is important so they can gain the support they need. Also provide educational materials about postpartum emotional disorders. Have available re- ferral sources for psychotherapy and support groups appropriate for women experiencing postpartum ad- justment difficulties.
BOX 22.2
COMMON ASSESSMENT FINDINGS ASSOCIATED WITH POSTPARTUM DEPRESSION
• Loss of pleasure or interest in life
• Low mood, especially in the morning, sadness, tearfulness
• Exhaustion that is not relieved by sleep
• Feelings of guilt
• Weight loss
• Low energy
• Irritability
• Poor personal hygiene
• Constipated
• Preoccupied and unfocused
• Indecisiveness
• Diminished concentration
• Anxiety
• Despair
• Compulsive thoughts
• Loss of libido
• Loss of confidence
• Sleep difficulties (insomnia)
• Loss of appetite
• Bleak and pessimistic view of the future
• Not responding to infant’s cries or cues for attention
• Social isolation, won’t answer the door or the phone
• Feelings of failure as a mother
Adapted from American College of Obstetricians and Gynecologists [ACOG]. (2011). FAQ 091: Postpartum depression. Retrieved from http://www.acog.org/~/media/for%20patients/faq091.ashx; Caple, C., & Uribe, L. (2012). Postpartum depression. Retrieved from CI- NAHL Plus with Full Text, Ipswich, MA; and Centers for Disease Control and Prevention. (2012). Postpartum depression. Retrieved from http://www.cdc.gov/reproductivehealth/Depression/index.
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