ch. 33 postpartum complications

Question 1

postpartum hemorrhage (PPH)

Answer 1

1) cumulative blood loss >/= 1000mL
2) bleeding associated with s/sx of hypovolemia within 24 hours of the birth process regardless of type of birth

• leading cause of maternal morbidity and mortality
• often unrecognized until mother profound symptoms

3) types:
(a) early, acute, or primary PPH occurs within 24H of birth
(b) late or secondary PPH occurs more than 24H but up to 12 weeks after the birth

Question 2

PPH causes

Answer 2

1) uterine atony
(a) marked hypotonia of uterus: if inadequate uterine contraction occurs, the uterus remains flaccid and rapid blood loss can follow
(b) leading cause of early PPH
(c) associated with: high parity (+2 children), hydraminos (>2L), macrosomic fetus (8/13,9/4), obesity (>32 bmi), multifetal gestation (twins)

2) placental complications:
(a) retained placenta
(b) fragments of placenta remain
(c) unusual placental adherence
- placenta accreta: slight penetration of myometrium
- placenta increta: deep penetration of myometrium
- placenta percreta: perforation of myometrium and uterine serosa, possibly involving adjacent organs (hysterectomy)

3) lacerations of genital tract

4) hematomas: perineal lacerations high risk

5) inversion of the uterus (uterus inside out)
(a) potentially life threatening but rare

6) subinvolution of the uterus
(a) cause of late postpartum bleeding
(b) s/sx include prolonged lochial discharge, irregular/excessive bleeding, sometimes hemorrhage

Question 3

pph: interprofessional care mgmt

Answer 3

1) institutions must develop standardized mgmt protocols and regularly conduct emergency drills
- california maternal quality care collaborative: BEST practice approach
- safety bundle for obstetric hemorrhage recommended:
(a) readiness
(b) recognition and prevention
(c) response
(d) reporting and systems learning

2) assessment: early recognition and treatment of PPH are critical -> anticipate what may happen, hemorrhage cart on standby

3) medical mgmt:
- firm massage of the uterine fundus
- elimination of bladder distention (voiding)
- continuous IV infusion of 10-40 units of oxytocin added
- uterotonic medications
- meds: pitocin (oxy), cytotec (misoprestol), hemabate (SE: diarrhea, careful w/ asthmatics), methergen (SE: increased BP)

4) surgical mgmt: DIC, hemorrhage

5) nursing interventions

Question 4

hemorrhagic (hypovolemic) shock

Answer 4

1) results from hemorrhage:
- emergency situation in which perfusion of organs may become severely compromised, death may occur
- hypovolemic shock

2) interprofessional care mgmt:
- standardized mgmt protocols and interprofressional teamwork are key
- restoring circulating blood volume and eliminating the cause of the hemorrhage
- fluid or blood replacement therapy
- restore oxygen delivery to the tissues and to maintain cardiac output
- decrease cell death
- trendelenburg, increase IV fluids, OR (d&c), Jada (can help to decrease bleeding), 2nd IV, increased oxytocin

Question 5

coagulopathies

Answer 5

1) when postpartum bleeding is continuous and there is no identifiable source, an inherited or acquired coagulopathy should be suspected

2) idiopathic thrombocytopenia purpura (ITP): autoimmune disorder in which antiplatelet antibodies decrease the life span of platelets (low plt)

3) von willebrand disease (vWD):
- a type of hemophilia
- deficiency or defect in blood clotting proteins

Question 6

venous thromboembolic disorders

Answer 6

1) venous thromboembolism:
- results from formation of blood clot or clots inside a blood vessel, caused by inflammation or partial obstruction of vessel

2) types:
(a) superficial venous thrombosis: involvement of the superficial saphenous venous system
(b) deep venous thrombosis (DVT): occurs most often in the lower extremities
- involvement varies but can extrend from the foot to the iliofemoral region
(c) pulmonary embolism (PE): complication of DVT occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs

TIP:
- homen’s sign: dorsiflexion of foot, NOT done anymore bc it can mobilize clot

Question 7

venous thromboembolic disorder (incidence/etiology, clinical manifestations, interprofessional care mgmt)

Answer 7

1) incidence/etiology:
- VTE is a leading cause of maternal death in the developed world and accounts for 9.5% of pregnancy related deaths in the US
- major causes: venous stasis, hypercoagulation
- cesarean birth nearly doubles the risk for VTE

2) clinical manifestations:
- superficial venous thrombosis (most common form) is characterized by pain and tenderness in the lower extremity
- deep vein thrombosis (DVT) -> swelling, pain in calves, peripheral pulses, heart legs
- acute pulmonary embolism (PE)

3) interprofessional care mgmt:
- ongoing assessments
- education
- anticoagulant use (heparin), DONT ambulate if suspected DVT -> anticoags, then pt. can ambulate

Question 8

postpartum infections

Answer 8

1) aka puerperal infection (sepsis)

2) any clinical infection of the genital tract that occurs within 28 days after miscarriage, induced abortion, or birth

3) defined as presence of:
- fever 38C+ (100.4F) or more on 2 successive days of the first 10 postpartum days (not including the first 24 hours after birth)

4) endometritis:
- infection of the lining of the uterus
- MOST COMMON puerperal infection
- mgmt: IV broad spectrum antibiotic therapy (2g ancef to decrease PP infection), (ampicillin, gentomycin, zosyn)

5) wound infections:
- often develop after mothers are discharged home
- rates of wound infection after cesarean birth are 3-5%
- mgmt: vancomycin

6) urinary tract infections (UTIs):
- cystitis and pyelonephritis are common among postpartum women due to several risk factors related to pregnancy (risk before/after urination - bidet)
- stasis of bladder -> neurogenic bladder -> cystitis

7) interprofessional care mgmt:
- assessments and interventions