4500 Class 8 — Postpartum Hemorrhage Flashcards
3 main topics covered in Complications in Postpartum
- PP Hemorrhagr
- PP Depression
- PP Infection (Madtoitis & Endometritis)
What are VTE Disorders (according to readings?) p. 539-541
What is thrombophlebitis? p. 539
What is superficial venous thrombosis? p. 539
What is DVT? p. 539
What is pulmonary embolism? p. 539
Who is most at risk developing VTE disorders?
What are clinical manifestations of DVT?
What are clinical manifestations of PE?
What are you looking for during assessment to identify DVT or PE?
Nursing interventions to help prevent DVT or PE from occuring postpartum period?
What is the main medical treatment fro DVT and PE?
Ebl in vaginal delivery
> 500 mL
Ebl in caesarean birth
> 1000 mL
What is considered early/primary/acute PPH
within 24 hours of delivery
What are the top causes of POSTPARTUM HEMORRHAGE? (4 Ts)
- TONE — Uterine Atony
- TISSUE — Retained Placenta, Placenta accrete / Increta / Percreta (MAL ATTACHMENT OF PLACENTA)
- TRAUMA — Uterine Inversion, Uterine Rupture, Laceration, Hematoma, Episiotomy
- THROMBIN — Coagulopathies
What are trauma that could cause PPH
- UTERINE INVERSION
- UTERINE RUPTURE
- LACERATION
- HEMATOMA
- EPISIOTOMY
What are active management in 3rd stage of labor that can prevent PPH?
- OXYTOCIN - uterotonics as ordered
- FUNDAL MASSAGE
2, GENTLE CORD TRACTION - done by physician. Can consider delayed cord clamping
Inspect placenta
Prevent full bladdrr
It is hypotonia, or relaxation of the uterus
- uterus not contracting well
UTERINE ATONY
Manifestion of uterine atony
Blood loss of 500 ml per minute
- boggy uterine, 2-3/u
WHAT ARE RISK FACTORS AND CAUSES FOR POSTPARTUM HEMORRHAGE
- Often results when the uterus is “overstretched” or overdistended from..
a. Fetal macrosomia / large fetus
b. Polyhydramios
c. distention with clots - HIG PARITU
- Hx of uterine atony
- OVERTIRED UTERUS - prolonged labour and induction/augmentation with oxytocin
- Birth Trauma — vacuum- or forceps-assisted delivery
- Magnesium sulphate administration during labor or postpartum period
- Anaesthesia and analgesia —
- Chorioamnitis
- Uterine suninvolutiom
- Obesity
Uterine Atony NURSING MANAGEMENT
- Uterine/fundal massage
- EMPTY BLADDER — indwelling cath may se inserted, rationale: a full bladder pushes an uncontracted uterus into an even more i]uncontracted state
- ENSURE LARGE BORE IV ACCESS
- Administer UTEROTONIC MEDICATIONS
- Administer BLOOD COMPONENTS as ordered
— may require more extesive procedures (bimanual compression/surgical procedures)
— ** DO ACCURATE ins and outs when person is bleeding
Name top 4 UTEROTONIC DRUGS
- OXYTOCIN
- MISOPROSTOL
- CARBOPOST
- ERGOMETRINE (ERGONOVINE)
OXYYYYY TOCIN
- It is the 1st line drug for uterine atony
- Different dosing compared to labour
How do we give Oxytocin as uterotonic drug during a PPH?
10-40 units in ringers lactate
It is a uterotonic drug that
- is also used as a cervical ripening agent
- given orally / rectally
- can cause increase in temp
MISOPROSTOL
It stimulates muscle layers of uterus.
Given IM or directly to uterus during c-section.
CARBOPROST
A uterotonic drug that can cause diarrhea
CARBOPROST
Ot is a uterotonic drug that can cause bronchospasm
Carboprost
A uterotonic drug that we must avoid giving to people with asthma
Carboprost
A uterotonic drug that is NOT for people with high BP or Hx of HTN
ERGOMETRINE (ERGONOVINE)
What are issues in TISSUE that may cause PPH???! Name four!
- Retained placental fragments — Succenturiate lobe-jagged edge of placenta
- Placental abruption
- Placenta previa
- PLACENTA ACCRETE, INCRETA, PERCETA (mal-attachment of placenta)
problem during pregnancy when the placenta completely or partially covers the opening of the uterus (cervix)
PLACENTA PREVIA
Adnormal sdherance of placenta that may cause PPH
Placenta accreta/ increta/ perceta
How is placenta accreta/increta/perceta confirmed?
MRI
When to intervene in placenta increta/accreta/perceta???
If pass e0 minutes, manual removal of placenta
— there will be lots of bleeding, hard to pull off the wall
Nursing management of RETAINED PLACENTA
VS
Astute assessments
1. Could require manual removal of placenta — by obstetrical care provider
Pain control.
IV access with large bire IV (18G)
Ensure correct sponge and needle count.
Tocolytic may be required/
2. Labs
3. Blood components as ordered
4. Uterotonics as ordered
** HYSTERECTOMY may be indicated in the case of ACRETA/ INCRETA/ PERCRETA
What are considered trauma that could cause PPH
- Lacerations
- Trauma during labour and birth — forceps-assissten and vacuum-assissted
- Trauma during caesarean
- Rupture uterus
- Inversion of uterus
- Manual removal of a retained placenta
What happens in the inversion of the uterus
Uterus turns inside out. It is potentially life threatening
Uterus cannot be seen, but felt.
Incomplete inversion of uterus
Lining of uterus protrudes
Complete inversion
When uterus protrude 20-30 sm, round large mass in place***?
Prolapse
- Fundal implantation of the placenta
- Vigorous fundal pressure
- Excessive traction applied to cord
- Fetal macrosomia
- Tocolysis
- Prolonged labor
- Uterine atony
- Abnormally adherent placental tissue
causes of inversion of uterus
Inversion of the uterus NURSING INTERVENTION
- Call for help! It is an emergency situation
- Ensure large bore IV 918G) is in place
- Fluid resus as ordered
- Uterus must be placed into the pelvic cavity by the obstetrical health care provider
- Tocolytics or halogenated anesthetics may be given to relax the uterus before attempting to replace
- Uterotonics generally administered after uterus is replaceed
Avoid aggressive fundal massage
It is often described as a “slow-trickle” or oozing — a constant flow
It usually a result of
a. Difficult or precipitous (fast) births
b. Fetal size, abnormal presentation, position
c. Operative assisted vaginal birth (vacuum or forceps)
LACERATION
Nursing management of LACERATION
- IV as needed
- Assis pain management and repair
- Ensure correct sponge and needle count during repair
- If packing is inserted, clearly document including the time insetted, how much, amd where
- Pt education
- Labs as needed
What is the simplest definition of a hematoma
It is the collection of blood in the connective tissue — concealed!
What is the most common form of hematoma
Vulvar
It is rare, life threatening, can happen in caesarean. Patient will feel rectal pain! Pt in significant pain. May require surgical evacuation.
Retroperitoneal HEMATOMA
Differentiate Uterine Atony VS. Trauma
In uterine atony
1. UTERINE IS BOGGY
2. Bleeding is INTERMITTENT
3. CLOTS & DARK blood
In trauma
1. Uterus is FIRM
2. CONTINOUS BLEEDING
3. Blood is BRIGHT RED (arterial)
What are Thrombin - COAGULOPATHIES that can cause PPH
- ITP (Idiopathic Thrombocytopenia Purpura)
- Von Willebrand Disease
- DIC (Disseminated Intravascular Coagulation)
ITP. What is it?
Idiopathic Thrombocytopenia Purpura
It is an autoimmune disorder where antiplatelet antibodies decrease the lifespan of plate;ets — result in longer bleeding time
What to do with ITP?
Platelet transfusion!
It can cause HTN.
Factor 8 deficiency and platelet dysfunction which leads to prolonged bleeding time.
It will increase risk for PPH.
Von Willebrand Disease
What to give w pt’s with von willebrand disease
DDAVP - Desmopression
Acetate
(IV 30 mins before birth of newborn)
What happens with DIC?
When there is an imbalance between the body’s clotting and fibrinolytic system.
It is an acquired clotting disorder where low fibrin level
Initiall lots at the sire of bleed then tehre will be deficit in the remainder of body
What are signs that there might be DIC
Bloodwork reveals — decreased PLT, fibrinogen, prothrombin
Diaphoresis
TACHY
HYPOtension
Peteciae around where BP was placed
Spontaneous bleeding from gums, nose, IV site, IM site. subcut injection. Etc
What are the risk factors that may cause DIC
Acute APH
Acute PPH
Placental abruption
Aminotic fluid embolism
Fetal demise that remains in utero for extended periods
Severe preeclampsia
Sepsis
+ still birth
When suspecting DIC, that to do???
Rule out other clotting disorders first!
Therapy for DIC — disseminated intravascular coagulation
FLUID REPLACEMENT as ordered
BLOOD COMPONENT REPLACEMENT as ordered
Optimization of oxygenation and perfusion
Labs as ordered
Consider placement of FOLEY with urometer
Emplain and support
What can happen w DIC.
Renal failure.
Urinaty output should be more than 30 ml / hour
What is given to support blood clotting
TRANEXAMIC ACID - an antifibrinolytics drug
What are these a sign of…
Rapid & shallow resps
Rapid, irregular, weak pulse
Decreased BP (late sign)
Pale, cool, clammy skin
Decreased urinary output
Increasing anxiety and disorientation
Lethargic
HEMORRHAGIC SHOCK
What to do — HENORRHAGIC SHOCK
- IV AV+CCES LARGE BORE IV (18G) — ,ah require two lines
- FLUID REESUS
- Blood component administratiom
- Lab studies as ordered
- O2 administration
- Uirnary output — indwelling i]urinary catheter
What to assess for PP bleeding?
CBC
IV
Tocolytics
Uterotonics
