Further Postpartum Complications (AFE, DVT, and more) (Nursing)

00:01 Our next complication is an amniotic fluid embolus.

00:05 An amniotic fluid embolus occurs when some of that amniotic fluid that's been floating around in the sac actually enters the bloodstream and causes an anaphylactic reaction.

00:16 Clinic features include anxiousness, chest pain, shortness of air, an elevated temperature, hypotension, low oxygenation or hypoxia, or distended neck veins.

00:30 The risk factors for an amniotic fluid embolus include abnormal placentation.

00:35 If we have a situation where a placenta is not normally formed, it's possible for the amniotic fluid to make its way through that placenta into that blood stream, having a lot of fluid or polyhydramnios.

00:48 An operative delivery.

00:50 Advance maternal age which might increase our risk of polyhydramnios.

00:54 An induction of labor because the labor may be prolonged, or preeclampsia which result from abnormal placentation.

01:03 Diagnosing an amniotic fluid embolism is made by excluding everything else.

01:08 So, postmortem, if the client does not live through this experience, we can identify vernix and amniotic fluid in the bloodstream.

01:17 This is an OB emergency and it's going to require full OB support and likely CPR in order to save the patient's life.

01:26 Our next complication is deep vein thrombosis or DVT.

01:30 And a DVT is a blood clot that occurs within a deep vein and usually we're talking about the legs, because that's where our deep veins are located.

01:39 Clinical features include pain, swelling, warmth around the area, calf tenderness, and a hardened vein.

01:48 So these are all going to be things you might be able to feel or the client might report to you.

01:52 Risk factors, pregnancy, all by itself. We're hypercoagulable and sometimes not as mobile.

01:58 A surgical birth may slow down mobility.

02:01 Varicosities. So if you've already had issues with your veins during pregnancy, it's very possible we could get a clot formation.

02:09 Obesity, smoking, a history of a DVT or diabetes, those are all going to be risk factors for DVT.

02:18 When we diagnose a DVT, it's going to be by assessment, and that assessment could take the place of a physical assessment for all of those indicators that we talked about before, or maybe an ultrasound to identify the thrombus; or a CT scan, or an MRI.

02:34 depending on how deep the thrombus is, the CT scan and the MRI may be the ways we find out the DVT is present.

02:42 Let's talk about the nursing care of a client experiencing a DVT.

02:46 First, we want to do an assessment, so checking for the warmth and the heat and the tenderness is going to be really important for making this diagnosis.

02:55 Then we want to apply SCD or a sequential compression device to the legs, especially for clients that are immobile, to help move the fluid and move the circulation of the legs to keep everything going.

03:08 We want to encourage mobility so if it's possible for the client to get up and walk, that's the best thing to do.

03:15 We want to encourage fluids because that's going to move and move the circulation through the body.

03:21 Warm compresses over the site is going to be really helpful.

03:25 Elevating the legs. Do not massage the thrombus, because we don't want to break that clot off and have it move into the blood stream, not what we want.

03:35 And we want to administer anti-coagulants as ordered and that might be heparin or coumadin.

03:40 We want to make sure the client is taking that because we want to break down that thrombus.

03:45 Moving on to the next complication, hematoma.

03:49 So hematoma is a collection of clotted blood around 250 milliliters to 500 mL inside the tissue.

03:57 The clinical features for hematoma include pain or pressure, that we can't explain for any other reason.

04:04 So if you think about a client who's delivered in their postpartum, they're going to have some pain.

04:09 But if you are continuously given pain medication then it doesn't seem to match up with what happened during labor and delivery, then we need to think about hematoma, because sometimes, you can't see the hematoma, but it's absolutely increasing pressure and is very uncomfortable.

04:26 They may have bulging tissue and you might be able to see the hematoma, or they may be experiencing a hemoglobin and hematocrit, and yet, you don't see a lot of lochia coming out, and you need to think about a hematoma formation somewhere.

04:40 They may also have difficulty urinating because the hematoma in some way, is blocking the outflow of urine.

04:47 Risk factors for hematoma include an operative birth.

04:51 And when we say operative birth, in this particular instance, we don't just mean a cesarean.

04:56 Sometimes we mean forceps or vacuum, because that can also damage the tissues in the vagina.

05:03 Having a precipitous birth, where the baby's delivered really quickly and it moves through the vagina can increase the chances of a hematoma, and a prolonged second state due to the trauma of the vaginal tissue.

05:16 We can diagnose a hematoma by seeing it, so if it's external or close to the outlet of the vagina, we can actually see the hematoma.

05:26 Sometimes, if we do a vaginal exam, we can feel the hematoma in the vaginal vault.

05:31 Now, if we have a hematoma that forms further up in the pelvis, then we may need an MRI or CT to fully visualize the hematoma.

05:40 Let's talk about the nursing care of a hematoma.

05:43 The pain assessment is going to be important because that's how we might know the hematoma is even there in the first place, so asking about discomfort in the location of the pain will help us to identify hematoma.

05:55 Blood loss evaluation.

05:57 So if we know what the estimated blood loss was for delivery or the QBL, and we can compare it to a hemoglobin or a hematocrit, we might make a notation that the numbers are slightly off and there's bleeding going on somewhere.

06:10 An application of an ice pack to a hematoma we can see, that small, less than 5 cm, may absolutely be appropriate.

06:19 Now, remember the rules of ice packs, not longer than 20 minutes or it will necrose the tissue.

06:25 Again, watching the hemoglobin and hematocrit for signs of a dropping hemoglobin-hematocrit, might be how we diagnose and how we care for the hematoma.

06:34 We want to notify the provider that we think a hematoma might be present.

06:38 And then we want to assist with the draining, if that's what the provider decides needs to be done.

06:45 Our very last complication is an episiotomy dehiscence, and what this is, is an opening.

06:52 Dehiscence means an open spot, so an opening of the stitches from an episiotomy.

06:57 Now this also applies for repairs that might be done to lacerations, even when no episiotomy has been performed. Same rules, just different cause.

07:07 The clinical features include redness, swelling, pain, odor, and maybe an infected sort of drainage, so pus or something like that.

07:18 If the nurse notes that the wound is opening, the very first thing we want to do is to call the provider.

07:25 Antibiotics and pain medication are typically ordered because a wound that opens back up, especially in the vaginal track, is going to be pretty uncomfortable.

07:34 It may be necessary to debride the wound and then to re-stitch it after the infection is gone.