Classification: Ergot alkaloid, uterine stimulant
Action: Stimulates sustained contraction of the uterus and causes arterial vasoconstriction.
Indications: Used for the prevention and treatment of postpartum or postabortion hemorrhage caused by uterine atony or subinvolution.
Dosage and Route: Usual dosage is 0.2 mg intramuscularly (IM) every 2 to 4 hours for a maximum of five doses. Change to the oral route 0.2 mg every 6 to 8 hours for a maximum of 7 days. Intravenous use not recommended; use in life-threatening emergency only and give over at least 60 seconds with close monitoring of blood pressure (BP) and pulse; may cause severe hypertension.
Absorption: Well absorbed after oral or IM route.
Excretion: Metabolized by the liver; excreted in the feces and urine.
Contraindications and Precautions: Methylergonovine should never be used during pregnancy or to induce labor. Do not use if the mother is hypersensitive to ergot. Contraindicated for women with hypertension, severe hepatic or renal disease, thrombophlebitis, coronary artery disease, peripheral vascular disease, hypocalcemia, or sepsis or before the fourth stage of labor.
Adverse Reactions: Nausea, vomiting, uterine cramping, hypertension, dizziness, headache, dyspnea, chest pain, palpitations, peripheral ischemia, seizure, and uterine and gastrointestinal cramping.
Nursing Considerations: Before administering the medication, assess the blood pressure. Follow facility protocol to determine at what BP level medication must be withheld. Caution the mother to avoid smoking, because nicotine constricts blood vessels. Remind her to report any adverse reactions.
Classification: Prostaglandin, oxytocic.
Action: Stimulates contraction of the uterus.
Indications: Used for the treatment of postpartum hemorrhage caused by uterine atony. Also used for abortion.
Dosage and Route: Postpartum hemorrhage: 250 mcg intramuscularly. May repeat at 15- to 90-min intervals. Maximum total dose 2 mg.
Absorption: Metabolized by the liver and by enzymes in the lungs.
Excretion: Primarily excreted in urine.
Contraindications and Precautions: Contraindicated for women with hypersensitivity to carboprost or other prostaglandins; acute pelvic inflammatory disease; cardiac, pulmonary, renal, or hepatic disease. Use caution if the woman has a history of asthma, hypotension or hypertension, anemia, jaundice, diabetes, epilepsy, previous uterine surgery.
Adverse Reactions and Side Effects: Excessive dose may cause tetanic contraction and laceration or uterine rupture. May cause uterine hypertonus if used with oxytocin. Nausea, vomiting, diarrhea (frequent), fever, chills, facial flushing, headache, hypertension or hypotension, tachycardia, pulmonary edema.
Nursing Considerations: Should be refrigerated. Give via deep intramuscular injection and aspirate carefully to avoid intravenous injection. Rotate sites if repeated. Monitor vital signs. Administer antiemetics and antidiarrheals as ordered.
Nurses are with the mother during the hours after childbirth and are responsible for assessments and initial management of uterine atony. If the uterus is not firmly contracted, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. One hand is placed just above the symphysis pubis to support the lower uterine segment while the other hand gently but firmly massages the fundus in a circular motion. Figure 28-2 illustrates fundal massage.
Clots that may have accumulated in the uterine cavity interfere with the ability of the uterus to contract effectively. They are expressed by applying firm but gentle pressure on the fundus in the direction of the vagina. It is critical that the uterus is contracted firmly before attempting to express clots. Pushing on a uterus that is not contracted could invert the uterus and cause massive hemorrhage and rapid shock (see Chapter 27).
If the uterus does not remain contracted as a result of uterine massage, or if the fundus is displaced, the problem may be a distended bladder. A full bladder lifts the uterus, moving it up and to the side, preventing effective contraction of the uterine muscles. Assist the mother to urinate, or catheterize her to correct uterine atony caused by bladder distention. Note urine output then reassess the uterus.
Pharmacologic measures also may be necessary to maintain firm contraction of the uterus. A rapid intravenous (IV) infusion of dilute oxytocin (Pitocin) often increases uterine tone and controls bleeding (see Drug Guide: Oxytocin, p. 417). Methylergonovine (Methergine) may be given intramuscularly (IM), but it elevates blood pressure and should not be given to a woman who is hypertensive. The usual route of administration is IM; IV use is reserved for life-threatening emergencies only (see Drug Guide: Methylergonovine). Analogs of prostaglandin F2-alpha (PGF2α; carboprost tromethamine [Hemabate; Prostin/15M]) are very effective when given IM or into the uterine muscle if oxytocin is ineffective in controlling uterine atony (Kim, Hayashi, & Gambone, 2010). (See Drug Guide: Carboprost Tromethamine.) Prostaglandin E2 (dinoprostone [Prostin E2]) or misoprostol (Cytotec) given rectally may also be used to control bleeding.
If uterine massage and pharmacologic measures are ineffective in stopping uterine bleeding, the physician or nurse-midwife may use bimanual compression of the uterus. In this procedure, one hand is inserted into the vagina, and the other compresses the uterus through the abdominal wall (Figure 28-3). A balloon may be inserted into the uterus to apply pressure against the uterine surface to stop bleeding (Belfort & Dildy, 2011; Thorp, 2009). Uterine packing may also be used. It may be necessary to return the woman to the delivery area for exploration of the uterine cavity and removal of placental fragments that interfere with uterine contraction.
A laparotomy may be necessary to identify the source of the bleeding. Uterine compression sutures may be placed to stop severe bleeding. Ligation of the uterine or hypogastric artery or embolization (occlusion) of pelvic arteries may be required if other measures are not effective. Hysterectomy is a last resort to save the life of a woman with uncontrollable postpartum hemorrhage.
Hemorrhage requires prompt replacement of intravascular fluid volume. Lactated Ringer's solution, whole blood, packed red blood cells, normal saline, or other plasma extenders are used. Enough fluid should be given to maintain a urine flow of at least 30 mL/hour and preferably 60 mL/hour (Cunningham et al., 2010). Typically, the nurse is responsible for obtaining properly typed and cross-matched blood and inserting large-bore IV lines that are capable of carrying whole blood.
Recognition of hypovolemic shock may be delayed because the body activates compensatory mechanisms that mask the severity of the problem. Carotid and aortic baroreceptors are stimulated to constrict peripheral blood vessels. This shunts blood to the central circulation and away from less essential organs, such as the skin and extremities. The skin becomes pale and cold, but cardiac output and perfusion of vital organs are maintained.
In addition, the adrenal glands release catecholamines, which compensate for decreased blood volume by promoting vasoconstriction in nonessential organs, increasing the heart rate, and raising the blood pressure. As a result, blood pressure remains normal initially, although a decrease in pulse pressure (difference between systolic and diastolic blood pressures) may be noted. The tachycardia that develops is an early sign of compensation for excessive blood loss.
As shock worsens, the compensatory mechanisms fail, and physiologic insults spiral. Inadequate organ perfusion and decreased cellular oxygen for metabolism result in a buildup of lactic acid and the development of metabolic acidosis. Decreased serum pH (acidosis) results in vasodilation, which further increases bleeding. Eventually, circulating volume becomes insufficient to perfuse cardiac and brain tissue. Cellular death occurs as a result of anoxia, and the mother dies.
Priority assessments for uterine atony include the fundus, bladder, lochia, vital signs, skin temperature, and color. Assess the consistency and the location of the uterine fundus. The fundus should be firmly contracted, at or near the level of the umbilicus and midline. If the fundus is above the level of the umbilicus and displaced, a full bladder may be the cause of excessive bleeding. A full bladder lifts the uterus and impedes contraction, which allows excessive bleeding. An accumulation of clots also expands the uterus, making contraction difficult and resulting in continued bleeding. (See Procedure: Assessing the Uterine Fundus in Chapter 20 on p. 442 for assessing the fundus.)
Obese women have an increased risk for uterine atony with subsequent postpartum hemorrhage (Blomberg, 2011), however, assessment of the fundus is difficult in this population. Monitor these women frequently for other signs of uterine atony and attempt to assess the uterine fundus while watching for increased lochia flow or clots to be expelled.
Also remember to check under the woman's legs, buttocks, and back for lochia drainage by asking the woman to turn on her side. This allows visibility of any blood that may not be obvious from the front. Although bleeding may be profuse and dramatic, a continuing small but steady trickle or oozing may also lead to significant blood loss that becomes increasingly life threatening.
It is difficult to estimate the volume of lochia by visual examination of peripads. More accurate information is obtained by weighing peripads, linen savers, and, if necessary, bed linens, before and after use and subtracting the difference. One gram (weight) equals approximately 1 mL (volume).
Measure vital signs at least every 15 minutes or more often, if necessary. Apply a pulse oximeter to determine oxygen saturation levels. This helps to detect trends, such as tachycardia or a decrease in pulse pressure that may reveal a deteriorating status in a woman with significant blood loss. Initially, the body compensates for excessive bleeding by constricting the peripheral blood vessels and shunting blood to vital organs. This can be misleading because the vital signs may remain normal even when the woman is becoming hypovolemic. The skin should be warm and dry, mucous membranes of the lips and mouth should be pink, and capillary return should occur within 3 seconds when the nails are blanched. These signs confirm adequate circulating volume to perfuse the peripheral tissue.
Signs and symptoms of DVT or PE are absent in 75% of those affected (Lockwood, 2009). When present, they may be attributed to normal benign changes of pregnancy (Farquharson & Greaves, 2011). Those that occur are caused by an inflammatory process and obstruction of venous return. The woman may report pain in the leg, groin, or lower back or right lower quadrant pain (Rhode, 2011). Swelling of the leg (more than 2 cm larger than the opposite leg), erythema, heat, and tenderness over the affected area are the most common signs. A positive Homans sign (presence of leg pain when the foot is dorsiflexed) has been thought to be an indicator of DVT. However, Homans sign may be absent in women who have a venous thrombosis or may be caused by a strained muscle or bruise. It is not a reliable or valid test. Reflex arterial spasms may cause the leg to become pale and cool to the touch with decreased peripheral pulses. Additional symptoms may include pain on ambulation, chills, general malaise, and stiffness of the affected leg. Women who have had a previous DVT or PE are at risk for another. These women and others at high risk may receive prophylactic heparin, which does not cross the placenta. Either standard unfractionated heparin (UH) or a low-molecular-weight heparin (LMWH), such as enoxaparin (Lovenox) or tinzaparin (Innohep), may be used. LMWH is longer acting and can be given less frequently and with less laboratory testing. It has fewer side effects and is less likely to cause bleeding. However, it is more expensive than UH and must be given subcutaneously. UH is given IV or subcutaneously.
Women receiving LMWH during pregnancy are changed to UH at approximately 36 weeks of gestation. The change is necessary because UH has a shorter half-life, and epidural anesthesia, which may be needed in labor, is contraindicated within 24 hours of the last dose of LMWH. Heparin is discontinued during labor and birth and resumed approximately 6 to 12 hours after uncomplicated birth and 12 hours after the epidural catheter is removed (American College of Obstetricians and Gynecologists [ACOG], 2011).
If stirrups must be used during the birth, risks of thrombus development can be reduced by placing the woman's legs in stirrups that are padded to prevent prolonged pressure against the popliteal angle during the second stage of labor. If possible, the time in stirrups should be no more than 1 hour.
To prevent thrombus formation after childbirth, all new mothers are encouraged to ambulate frequently and as early as possible. Ambulation prevents stasis of blood in the legs and decreases the likelihood of thrombus formation. If the woman is unable to ambulate, range-of-motion and gentle leg exercises, such as flexing and straightening the knee and raising one leg at a time, should begin within 8 hours after childbirth. In addition, the mother should not use pillows under her knees or the knee gatch on the bed. These devices may cause sharp flexion at the knees and pressure against the popliteal space, leading to pooling of blood in the lower extremities.
Graduated compression stockings or sequential compression devices are used for mothers with varicose veins, a history of thrombosis, or a cesarean birth. Sequential compression devices should be applied preoperatively for a woman undergoing a cesarean birth who is not on anticoagulant therapy and should be continued until she begins to ambulate postpartum (ACOG, 2011). Compression stockings should be applied before the mother gets out of bed to prevent venous congestion, which begins as soon as she stands. It is important that she understands the correct way to put on the stockings. Improperly applied stockings can roll or bunch and slow venous return from the legs.
Clinical signs and symptoms depend on how much the flow of blood is obstructed. Dyspnea, chest pain, tachycardia, and tachypnea are the most common signs (Cunningham, et al., 2010). Syncope (fainting) is uncommon and may indicate massive emboli (Lockwood, 2009). Pulmonary rales, cough, hemoptysis (expectoration of blood or bloody sputum), abdominal pain, and low-grade fever may also occur. Pulse oximetry shows decreased oxygen saturation. Arterial blood gas determinations show decreased partial pressure of oxygen, and chest radiography reveals areas of atelectasis and pleural effusion.
An electrocardiogram may show abnormalities in size or function of the right ventricle. Spiral computed tomography is a frequently used diagnostic tool and can detect 88% to 100% of pulmonary emboli (Martin & Foley, 2008). Magnetic resonance angiography may also be performed. A negative d-dimer test is a good indication that PE is not present (Lockwood, 2009). A venous ultrasound is also performed to identify a DVT. A ventilation-perfusion scan to show areas of the lung that are ventilated but not perfused is done less often.
Treatment of PE is aimed at dissolving the clot and maintaining pulmonary circulation. Oxygen is used to decrease hypoxia, and narcotic analgesics are given to reduce pain and apprehension. Bed rest with the head of the bed elevated is used to help reduce dyspnea. The level of care, including support of ventilation, depends on the woman's pulmonary status. Pulse oximetry and arterial blood gases are evaluated. Heparin therapy is initiated and is continued throughout pregnancy if the embolism occurs prior to birth. Therapy may be continued with warfarin for months after delivery to prevent further emboli.
Emergency medications, such as dopamine, may be used to support falling blood pressure. Thrombolytic drugs, such as streptokinase, urokinase, or tissue-type plasminogen activator, may be used for life-threatening pulmonary emboli but are associated with bleeding (Martin & Foley, 2008). Embolectomy (surgical removal of the embolus) may be attempted if no time exists to allow the clot to dissolve.
Puerperal infection is a term used to describe bacterial infections after childbirth. Until the advent of antibiotics, puerperal infection often resulted in death. Even today, it is a cause of maternal death, especially in developing nations. The most common postpartum infections are endometritis, an infection of the inner lining of the uterus, wound infections, urinary tract infections, mastitis, infection of the breast, and septic pelvic thrombophlebitis. Endomyometritis is an infection of the muscle and inner lining of the uterus. If the surrounding tissues are also involved, endoparametritis is present. Metritis is the infection of the decidua, myometrium, and parametrial tissues of the uterus. Etiology
Endometritis is usually caused by organisms that are normal inhabitants of the vagina and cervix. Most infections are polymicrobial with both aerobic and anaerobic organisms involved. Organisms most often found include aerobic and anaerobic streptococci, Escherichia coli, Klebsiella pneumoniae, Proteus, Bacteroides, and Gardnerella. (Dickinson, 2011). Chlamydia trachomatis is not a cause of early infection but is associated with late-onset infections, 2 or more weeks after birth (Rhode, 2011).
The mother with severe endometritis looks sick. She presents a different picture from the typical happy new mother. The major signs and symptoms are temperature of 38° C (100.4° F) or higher; chills; malaise; anorexia; abdominal pain and cramping; uterine tenderness; and purulent, foul-smelling lochia. Additional signs include tachycardia and subinvolution. In most cases the signs and symptoms occur within the 36 hours after delivery (Duff et al., 2009).
Laboratory data may confirm the diagnosis. The results of a complete blood count may show an elevation in the number of leukocytes (15,000/mm3 to 30,000/mm3). Leukocyte levels are normally elevated to as high as 30,000/mm3 during the early postpartum time (Blackburn, 2013), however, leukocytosis that is not decreasing should prompt further evaluation. A blood culture may be obtained. Cultures of the vagina or endometrium are not usually helpful. A catheterized urine specimen may also be obtained.
Administration of IV antibiotics is the initial treatment for endometritis. The goal is to confine the infectious process to the uterus and to prevent spread of the infection throughout the body. Broad-spectrum antibiotics such as the cephalosporins, clindamycin plus gentamicin, or ampicillin plus aminoglycosides are often used. Metronidazole with penicillin may also be given. Antibiotics are continued until the woman has been afebrile and asymptomatic for 24 to 48 hours (Davies & Gibbs, 2008; Duff et al., 2009).
To decrease the incidence of endometritis and wound infections, many physicians give a single prophylactic IV dose of an antibiotic to any woman who is having a cesarean birth or who is at an increased risk for infection. Current practice is for the antibiotic to be given during surgery after umbilical cord clamping to avoid exposure of the infant to the drug. However, recent studies suggest that administration of antibiotics prior to the skin incision may decrease the risk of postoperative infection of the mother without a significant risk to the fetus or newborn (Tita, Rouse, Blackwell, et al., 2009). Other medications include antipyretics for fever and oxytocics, such as methylergonovine, to increase drainage of lochia and promote involution.
The woman with endometritis should be placed in a Fowler's position to promote drainage of lochia. She should be medicated as needed for abdominal pain or cramping, which may be severe. Monitor the woman's response to treatment and note signs of improvement or of continued infection (nausea and vomiting, abdominal distention, absent bowel sounds, and severe abdominal pain). Assess vital signs every 2 hours while fever is present and every 4 hours afterward. Comfort measures include warm blankets, cool compresses, cold or warm drinks, or use of a heating pad. Foods high in vitamin C and protein to aid healing are encouraged along with oral fluids to maintain hydration.
Teaching should include signs and symptoms of worsening condition, side effects of therapy, and the importance of adhering to the treatment plan and follow-up care. If the woman is so sick that she must be separated from her infant or her infant is discharged before the mother, a nursing diagnosis of "Risk for Impaired Attachment related to separation from infant" should be considered. If the mother is breastfeeding, she will need help to pump her breasts to establish and maintain lactation.
Wound infections are common types of puerperal infection because any break in the skin or mucous membrane provides a portal of entry for organisms. The most common sites are cesarean surgical incisions, episiotomies, and lacerations. Infection of the incision occurs along with endometritis in 3% to 5% of women after cesarean (Duff et al., 2009). Risk factors include obesity, diabetes, hemorrhage, anemia, chorioamnionitis, corticosteroid therapy, and multiple vaginal examinations.
Signs of wound infection are edema, warmth, redness, tenderness, and pain. The edges of the wound may pull apart, and seropurulent drainage may be present. If the wound remains untreated, generalized signs of infection, such as fever and malaise, may develop as well. As with other puerperal infections, cultures may reveal mixed aerobic and anaerobic bacteria. Necrotizing fasciitis is a rare infection that may occur at any incision site. The necrosis may spread, and the condition may be fatal.
An incision and drainage of the affected area may be necessary. The wound exudate is cultured and broad-spectrum antibiotics are ordered until a report of the organism is returned. Analgesics are often necessary, and warm compresses or sitz baths may be used to provide comfort and to promote healing by increasing circulation to the area. Surgical debridement is performed for necrotizing fasciitis.
Despite their small size, wound infections are painful and annoying to the mother. Perineal infections cause discomfort during many activities, such as walking, sitting, or defecating, and are particularly troublesome because they are not expected by the new mother.
Wound infections may require readmission to the hospital or home health care visits. The woman requires reassurance and supportive care. Comfort measures include sitz baths, warm compresses, and frequent perineal care. She should be taught to wipe from front to back and to change perineal pads frequently. Good hand washing techniques are emphasized. Adequate fluid intake and a healthy diet are important. Activity may be modified depending on the site, severity, and treatment of the wound infection.
The infant is not routinely isolated from the mother with a wound infection, but the woman must be advised how to protect her infant from contact with contaminated articles such as dressings. Anticipatory guidance should include teaching side effects of medications, signs of worsening condition, self-care measures, and the importance of hand washing.
Symptoms typically begin on the 1st or 2nd postpartum day. They include dysuria (a burning pain on urination), urgency, frequency, and suprapubic pain. Hematuria may also occur. A low-grade fever is sometimes the only sign. In some women, an upper urinary tract infection, such as pyelonephritis, may develop the 3rd or 4th postpartum day, with chills, spiking fever, costovertebral angle tenderness, flank pain, and nausea and vomiting. This infection of the kidney pelvis may result in permanent damage to the kidney if not promptly treated.
Most urinary tract infections can be treated with antibiotics on an outpatient basis. Asymptomatic bacteriuria during pregnancy increases the risk of pyelonephritis 20 to 30 times. Treatment reduces the incidence of pyelonephritis significantly (Duff et al., 2009). Pyelonephritis during pregnancy may require hydration and IV administration of broad-spectrum antibiotics. In addition, the woman should be observed for signs of preterm labor. If the postpartum woman is only mildly ill, she can be treated with oral antibiotics at home. Urinary analgesics, such as phenazopyridine (Pyridium), may also be ordered. Antibiotics that are safe for use during lactation are given if the mother is breastfeeding.
The woman with a urinary tract infection must be instructed to take the medication for the entire time it is prescribed and not to stop when symptoms abate. In addition, she must drink at least 2500 to 3000 mL of fluid each day to help dilute the bacterial count and flush the infection from the bladder. Acidification of the urine inhibits multiplication of bacteria, and drinks that acidify urine, such as apricot, plum, prune, and cranberry juices, are frequently recommended. Grapefruit and carbonated drinks should be avoided because they increase urine alkalinity. Teaching should also include measures to prevent urinary tract infections, such as using proper perineal care, increasing fluid intake, and urinating frequently. Mastitis, an infection of the breast, occurs most often 2 to 4 weeks after childbirth, although it may develop at any time during breastfeeding. Approximately 5% to 10% of lactating women are affected (Duff et al., 2009). It usually affects only one breast.
Mastitis is often caused by Staphylococcus aureus, E. coli, and Streptococci (Ambrose & Repke, 2011). The bacteria are most often carried on the skin of the mother or in the mouth or nose of the newborn. The organism may enter through an injured area of the nipple, such as a crack or blister, although no obvious signs of injury may be apparent. Soreness and pain of a nipple may result in insufficient emptying of the breast during breastfeeding.
Engorgement and stasis of milk may precede mastitis. This may occur when a feeding is skipped, when the infant begins to sleep through the night, or when breastfeeding is suddenly stopped. Constriction of the breasts by a bra that is too tight may interfere with emptying of all the ducts and may lead to infection. The mother who is fatigued or stressed or who has other health problems that might lower her immune system is also at increased risk for mastitis.
Septic pelvic thrombophlebitis is the least common of the puerperal infections, occurring in 1 of 3000 pregnancies (Ambrose & Repke, 2011). It usually is not seen until 2 to 4 days after childbirth. It occurs when infection spreads along the venous system and thrombophlebitis develops.
The primary symptom is pain in the groin, abdomen, or flank. Spiking fever, tachycardia, gastrointestinal distress and decreased bowel sounds may be present. The only sign may be fever that does not respond to antibiotic therapy. Laboratory data may be used to exclude other diagnoses and usually include complete blood count with differential, blood chemistries, coagulation studies, and cultures. Pelvic ultrasound, computed tomography, or MRI may be performed.
Readmission to the hospital is usually necessary. Primary treatment includes anticoagulation therapy with IV heparin and IV antibiotics. Warfarin may be given when heparin is discontinued. Supportive care is similar to that for DVT and includes monitoring for safe levels of anticoagulation therapy and for signs and symptoms of PE.
Pay particular attention to signs that may be expected in infection, such as fever, tachycardia, pain, or unusual amount, color, or odor of lochia. Generalized symptoms of malaise and muscle aching may also be significant. Examine all wounds each shift for signs of localized infection, such as redness, edema, tenderness, discharge, or pulling apart of incisions or sutured lacerations. Ask the mother if she has difficulty emptying her bladder or discomfort related to urination.
Assess the mother's knowledge of hygiene practices that prevent infections, such as proper handwashing, perineal care, and handling of perineal pads. Evaluate her knowledge of breastfeeding and any problems that might result in breast engorgement and stasis of milk in the ducts. Examine the nipples for signs of injury that might provide a portal of entry for organisms.
Depression responds best to a combination of psychotherapy, social support, and medication. Psychotherapy may be helpful to assist the woman to cope with changes in her life. The woman's partner and immediate family must be included in counseling sessions so they can develop an understanding of what the woman feels and needs. In one study, support from trained peers demonstrated some success (Dennis, Hodnett, Reisman, et al., 2009; Morrell, Slade, Warner, et al., 2009). However, a more recent study (Letourneau, Stewart, Dennis, et al., 2011) did not support this finding.
If psychotherapy alone is not effective, it should be combined with medication. Selective serotonin reuptake inhibitors and tricyclic antidepressants are the most commonly prescribed medications. It may take up to 4 weeks for the medications to be fully effective, and they may be continued for 9 to 12 months after remission of symptoms (Beck, 2008).
Whether the woman is still pregnant or is breastfeeding must be considered when any drugs are prescribed as some are safer than others for use in pregnancy and lactation. Women who discontinue medications for depression during pregnancy are more likely to have a relapse during pregnancy or postpartum (Haskett, 2011). In addition, women who have depression and do not take medication during pregnancy are more likely to have inadequate prenatal care and preterm delivery (Dossett, 2008). Electroconvulsive therapy may also be necessary for mothers who are suicidal. It is used when the woman has not improved with other treatment.
Psychosis is a mental state in which a person's ability to recognize reality, communicate, and relate to others is impaired. Postpartum psychosis can be classified as depressed or manic types (Stuart, 2009). It is a rare condition that affects 1 or 2 women per 1000 births. It can occur as early as 2 days after delivery and is a psychiatric emergency that usually requires hospitalization. Manifestations include agitation, irritability, rapidly shifting moods, disorientation, and disorganized behavior. Some mothers also have delusions about the baby and may experience hallucinations (Miller, 2011). The majority of women with postpartum psychosis have no significant history of psychiatric illness (O'Hara & Segre, 2008). Women who have had one episode of postpartum psychosis are at risk for having another episode. Management requires hospitalization, pharmacologic treatment, and psychiatric care (Cunningham et al., 2010).
Assessment and management of postpartum psychosis are beyond the scope of maternity nurses, and mothers who experience this condition must be referred to specialists for comprehensive therapy. Women with signs of postpartum psychosis need immediate medical attention, and hospitalization is usually necessary to prevent suicide or infanticide.
Postpartum anxiety disorders include panic disorder, postpartum obsessive-compulsive disorder (OCD), and posttraumatic stress disorder. Panic disorder manifests as episodes of tachycardia, palpations, shortness of breath, chest pain, and fear of dying or of "going crazy." Episodes are repetitive and interfere with the woman's daily life. Antianxiety and antidepressant medications and counseling are the treatment for this condition.
Postpartum OCD is a condition where the woman has consuming thoughts that she might harm the baby and fears being alone with the baby. Anxiety and depression occur, and the woman may perform compulsive behaviors to avoid acting on her thoughts. Some mothers avoid their infants while others obsessively check on the infants frequently day and night (O'Hara & Segre, 2008). Treatment includes antianxiety and antidepressant medications and counseling.
In posttraumatic stress disorder, women perceive childbirth as a traumatic event. They have nightmares and flashbacks about the event, anxiety, and avoidance of reminders of the traumatic event; some have depression after giving birth. Feeling a lack of caring or communication or having a birth very different from what they expected may contribute to this disorder. Women need to talk about their experiences and how they perceived them and often search for answers about their experiences. They may feel isolated from their infants and have prolonged difficulty feeling close to them. Celebrating the child's birthdays may be distressing as they are anniversaries of the trauma experienced when the child was born