Maternity - Postpartum, part 4: Changes, Deep Vein Thrombosis, Pulmonary Embolism
by Meris Shuwarger November 30, 2021 Updated: March 31, 2022 8 min read
Hi, I'm Meris with Level Up RN, and in this video, I'm going to be talking to you about some important concepts for postpartum care, including the cardiovascular changes associated with pregnancy and postpartum changes, along with deep vein thrombosis and pulmonary embolism. I'm going to be following along using our maternity flashcards. We are in the postpartum care section. If you want a set for yourself, you can grab them at leveluprn.com. And if you already have your own deck, I would invite you to follow along with me. Okay, let's get started.
Okay, so first up, we were talking about cardiovascular changes in the postpartum period. One of the most important things to know, and it's here in bold, red text, has to do with what is a normal amount of blood loss. I need to know what's normal so that I can know when it's abnormal, right? So here in bold, red text, 500 milliliters blood loss for a vaginal delivery is considered normal, and up to 1,000 milliliters or a full liter of blood loss is considered normal with a C-section. So specifically with a C-section, we get pretty good estimated blood loss because of things like suction and weighing sponges and things like that. So, typically, a patient would come to you and they would say they had five 580 MLs of EBL, estimated blood loss, or 900 MLs, and that's really important to get in report. Now, when we talk about a vaginal delivery, we can also estimate blood loss, and typically, that's done by weighing pads, or if there were special type of drape sheets that catch blood, then we could actually measure that. So it's an important thing to ask for in report and to know when you're assessing your patient because, again, if I had-- let's say I lost that full one liter, and I had a C-section, and then you start to see that I'm bleeding more and more and more, you need to think, "Well, she's already lost a full liter. We're already at our normal cut-off. Maybe I need to tell the doctor," right?
So, cardiac output. Remember, we have increased cardiac output 'cause we have increased blood volume in pregnancy, so it's going to remain elevated for about the first 48 hours, and then it will gradually decrease, but it takes a full 12 weeks for it to return to your patient's pre-pregnancy baseline. And similarly, the blood volume that your patient has is going to drop rapidly after birth because of that blood loss, but it's also going to take about four weeks for the blood volume to return to pre-pregnancy baseline as well. Now, some really important labs here on this card. Remember that your patient is in a hypercoagulable state following the delivery of an infant. And this is a good thing because it helps to prevent postpartum hemorrhage, but we also need to think about the fact that, if I am at more at risk for four coagulation, for clotting, I'm more at risk for things like forming a thrombus, right? So I need to be thinking about that and assessing my patient for those, and we'll talk about that in a moment. Now, it is also normal for your patients' white blood cell count to be elevated for one to two weeks up to 25,000 millimeters cubed. So if you're used to thinking of this as 4.5 to 10 or 11 is a normal white count, we're talking about 25. Up to 25 is considered normal. So that is a significant elevation from what we would think of as being normal in any other patient. So think about that. For one to two weeks, that is normal.
Now, nursing care, we need to assess for signs of thrombus formation, and we will get to that in a moment. And then I also need to encourage my patient to be ambulatory as early as possible to help to decrease that risk. So, now, let's talk about where they are most likely to form a thrombus, which is going to be a deep vein thrombosis formed in one of the deep veins, primarily of the leg. Now, risk factors. We know about the risk factors of DVT as it relates to med surge, but the biggest risk factor for these patients is just the fact that they just had a baby. If we add immobility, obesity, diabetes, smoking, anything like that to the list, their risk increases. Now, when we talk about signs and symptoms, you probably know these. You've probably taken med surge already, but let's review them again. Unilateral pain and swelling in the leg is going to be a big sign here. If we had erythema, or redness, warmth in the area, or swelling-- I'm sorry, or hardness, which is sometimes called induration, all of those would be abnormal, and so we would want to check for those things every time we check on our patient. Are you having any pain in your legs? I'm looking to see if they're symmetrical, if they look swollen, anything like that.
Swelling of the lower extremities is very normal following delivery of an infant, but I want to make sure that it's symmetrical swelling and that we aren't seeing one leg is getting really large versus the other one is not. So, diagnosis, there are some labs that can be done. Things like a D-dimer or can be done. But really, the way to truly diagnose a DVT is going to be with a venous Doppler ultrasound. MRI or CT scan may also be possible, but that duplex scan is really going to tell us what's going on with the veins in the legs. So the treatment would be-- the big one is going to be anticoagulants, right? We have to keep that clot from getting any larger, and then analgesics as well for the pain. So when it comes to nursing care for a DVT, though, we want to elevate the extremity because we want to help to promote blood return from that extremity. But we do not ever want to put a pillow or what is called a knee gatch directly behind the knee because that's actually going to keep blood from getting past that knee itself, and that is not going to be helpful for this patient.
We also want to use warm, moist compresses. This can help to improve the circulation in that area. And then, of course, if our patient is started on anticoagulants, then we need to implement bleeding precautions, assess them for signs of bleeding, monitor their coagulation labs, and that sort of thing as well. Now, when it comes to preventing a DVT, the best prevention is going to be early ambulation. It is hard to convince a patient to get out of bed when they have just had an infant push through their vagina or had a big hole cut in them to have the baby removed, right? It's hard to ambulate. But even if we can just get up to the chair, walk to the bathroom, that sort of a thing is going to still count as early ambulation. And then we're going to encourage them to keep improving and going farther and maybe going for laps around the unit as they can tolerate it. We also can put on anti-embolic stockings, so compression stockings, compression hose. That's going to help with blood return from the legs. Elevate the legs when sitting, but avoid crossing the legs. Again, remember, it's that same idea of that knee gatch. It's going to keep that blood from getting back where it needs to go.
Increase your fluid intake. We want our patients to be drinking two to three liters of water. That's really going to help as well. And then, of course, smoking cessation is going to be important. Avoiding smoking is going to decrease the risk for forming DVTs as well. Additionally, we want to teach our patients not to massage their legs because, although it might feel good, we could potentially dislodge that clot and send it up into the circulation. And now, we could have a PE, which is life-threatening. And let's talk about pulmonary embolism now. So pulmonary embolism is when we have a thrombus, from wherever it came from, that has now gotten into the circulation and is in the lungs, right? So it is actually moving into the pulmonary vasculature. So we are occluding the blood flow to the lungs. Very, very bad news. This can be potentially catastrophic for your patient. This could lead to death. So biggest signs and symptoms are going to be chest pain and shortness of breath, right? If your patient suddenly reports that they're having difficulty breathing or they feel like they can't catch their breath or, "I'm having this chest pain," you need to be thinking pulmonary embolism.
We could also have hypotension. Hypoxia, right? We could see that they are actually having decreased oxygen saturation because of the pulmonary embolism, peripheral edema, probably related to the DVT where it came from, tachypnea - I'm breathing more frequently now because I'm trying to compensate for the fact that I have this clot in my lungs - and bloody sputum. They could actually start coughing up bloody sputum. So the diagnosis here is going to be with a VQ scan, which is a ventilation-perfusion scan, but most places are going to do a CTA. We're going to do CT angiography of the lungs, which is going to actually allow us to look at the vasculature in the lungs and assess for clots, and that is going to be typically the way that it is diagnosed.
Treatment would be thrombolytics, so not just giving an anticoagulant at this point. We need to actually break up that clot with a thrombolytic like alteplase or streptokinase. Those would be some options. And then, nursing care, put the patient in semi-Fowler's or high Fowler's, whatever is going to help them to breathe better. Remember, we always want to start least to most invasive, and sitting your patient up is going to help them to breathe. We can administer oxygen per order. Again, if your patient's hypoxic, struggling to breathe, tachypneic, we want to give them oxygen. And then, of course, bleeding precautions once we give a patient a thrombolytic. I hope that review was helpful. I'm going to give you some quiz questions to test your knowledge of some key facts I provided you in this video.
Okay, so, first up, I want you to tell me what is the cutoff for normal blood loss for a patient who has had a C-section? What is the volume of blood that is considered normal for blood loss? Okay, next question. You're caring for a patient who is postpartum, and they report sudden-onset chest pain and dyspnea, and you see that their SpO2 is now 90%. What complication do you anticipate this patient is experiencing? And lastly, name some patient education that the nurse should provide to postpartum patients about the prevention of deep vein thrombosis. I gave you a whole lot of ways to help to prevent DVTs. Think of some of them and let me know. Let me know how you did in the comments. I want to hear about it. Thanks so much, and happy studying.
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