Chapter 14 Flashcards
what are the 4 R’s of the maternal safety bundle for obstetric hemorrhage?
Readiness
Recognition & Prevention
Response
Reporting systems learning
what is included in “readiness”
- hemorrhage cart
- immediate access to hemorrhage meds
- response team (Code team)
- massive transfusion protocol
- unit education on protocols
what is included in “recognition & prevention”
- assessment of risk prenatally
- assessment on admission
- assessment postpartum
- measurement of cumulative blood loss
- active management of the third stage
what is included in “response”
- unite emergency management plan
- support for families
what is included in “reporting systems learning”
- huddle prior to delivery
- debrief after event
- multidisciplinary review of serious hemorrhages
PPH risk assessment: low risk
- no previous uterine incision (no c/s hx)
- singleton pregnancy
- </= 4 previous vaginal births
- no known bleeding disorders
- no history of PPH
PPH risk assessment: medium risk
- induction of labor with oxytocin or cervical ripening
- multiple gestation
- > 4 vaginal births
- prior c/s or uterine incision
- large uterine fibroids
- hx of one previous PPH
- family hx in first degree relatives who experience PPH
- chorioamnionitis
- fetal demise
- polyhydramnios
PPH risk assessment: high risk
- has 2+ medium risk factors
- active bleeding more than “bloody show”
- suspected placenta accreta or percreta
- placenta previa or low-lying placenta
- known coagulopathy
- hx of more than one PPH
- hematocrit < 30 AND other risk factors
- platelets < 100,000/mm3
anticipatory interventions: low risk PPH
none
anticipatory interventions: medium risk PPH
- notify appropriate personnel- provider, anesthesia, blood bank, charge nurse, clinical nurse specialist
anticipatory interventions: high risk PPH
- notify appropriate personnel- provider, anesthesia, blood bank, charge nurse, clinical nurse specialist
- consider delivery at a facility with the appropriate level of care capable of managing a high risk mother
how much blood loss constitutes postpartum hemorrhage?
> 500 mL: vaginal delivery
750-1000 mL: c/s
what are the two approaches to hemorrhage?
- resuscitation and management
- identify the cause (figure out: why?)
risk factors that cause PPH
- macrosomia
- placenta abnormalities
- multiple gestation
- previous uterine surgery (c/s- think weakening of the uterine lining)
- prior PPH
- high parity (how many times they have been pregnant)
- precipitous labor/birth (< 3 hours)
what are the 4 T’s to identify the cause of PPH?
tone
tissue
trauma
thrombosis (clotting)
PPH causes: what is tone?
uterine atony
PPH causes: what is tissue?
retained placenta
PPH causes: what is trauma?
lacerations, hematomas
PPH causes: what is thrombin?
coagulation
stage 1 PPH
- blood loss: > 500 mL vaginal or >1000 mL c/s
- normal VS and labs
stage 2 PPH
- continues to bleed, >1000 mL vaginal or >1500 mL c/s blood loss
- > 2 uterotonics
- monitoring VS and labs
- 2 units Type specific blood
stage 3 PPH
- continues to bleed, >1500 mL blood loss
- > 1 unit of packed RBC: 1-unit FFP
- abnormal VS and labs
stage 4 PPH
- cardiovascular collapse
- profound hypovolemic shock
- amniotic embolism (will also see DIC)
lacerations and hematomas: risk factors
- large baby
- operative vaginal delivery
- precipitous labor
hematoma in the vaginal canal
- cannot be visualized by the nurse
- women express severe pain, heaviness in the vagina and rectal pressure
- might see discoloration and tenderness
retained placental tissue is at an increased risk when the placenta is _____
removed manually
what is the primary cause of PPH?
retained placental tissue
signs of retained placental tissue
- profuse bleeding after the first week postpartum
- subinvolution of the uterus
- elevated temperature (100.4)
- tachycardia
- hypotension
interventions for retained placental tissue
- D&C
- IV antibiotics
coagulation disorders
- DIC
- anaphylactoid syndrome
- venous thromboembolic disease (VTE)
-two types: DVT and PE
DVT and PE testing
doppler studies
DVT and PE treatment
- anticoagulation therapy
- elastic stockings
wound infections can come from
- laceration
- episiotomy
- c/s incision
risk factors for wound infections
- obesity
- DM
- malnutrition
- long labor
- pre-existing infection
symptoms of wound infections
- erythema
- heat
- swelling
- tenderness
- drainage (want to send to lab)
- low grade fever
- increased pain
what types of bacteria cause wound infection?
staphylococcus or streptococcus
mastitis
inflammation or infection of the breast tissue in lactating women
- staphylococcus
symptoms of mastitis
- tender, engorged and erythematous breast
nurse actions: mastitis
- keep breastfeeding
- antibiotic therapy
- proper handwashing
- massage breast during nursing
acute onset of severe hypertension reflects of BP a ____
- systolic > 160
- diastolic > 110
med management of acute onset of severe hypertension
- mag sulfate until 24 hours after delivery
- IV labetalol (20mg-40mg-80mg)
- hydralazine if still elevated (5mg-10mg-20mg)
- nifedipine 10 mg immediate onset,
-30mg XL / 60mg XL as maintenance
nursing actions for acute onset of severe hypertension
- BP q5-10 min when acute
- admin meds with BP over 160 or 110
- watch for signs of preeclampsia
what are signs of preeclampsia?
- HA
- swelling
- DTRs 3-4+
diabetes
- glycemic control
- follow up care after delivery
- draw A1c
- GDM need more follow-up care
- previously diabetic moms usually go back to normal
PP depression
severe depression that occurs in the first 6-12 months postpartum
- unable to care for self or infant
PP depression risk factors
- hx of depression prior to and during pregnancy
- anxiety
- lack of social support
- poor relationship with partner
- complicated pregnancy/delivery
PP depression assessment
- sleep and appetite changes
- uncontrolled crying
- anxiety
- fear
PP depression management
mild: psychotherapy
moderate: psychotherapy and meds
severe: intensive inpatient treatment
when are patients at the highest risk for seizures from preeclampsia with severe features?
- 24 hours prior to delivery
- 24 hours post delivery
mag sulfate remains on for _____
24 hours post delivery for seizure prophylaxis
nurse actions for seizure precaution r/t preeclampsia
- monitor strict I&Os using an indwelling catheter with a urimeter
- continuous O2 sat monitoring
- hourly assessment of BP and RR
- assess lungs and DTRs q2 hrs
- mag levels drawn and sent q6 hrs while on therapy
mag sulfate toxicity warning signs
- RR < 12 bpm
- urine output < 30 mL in 1 hr or < 50 mL in 2 hr
- diminished or loss of DTRs
mag sulfate toxicity interventions
- turn off mag sulfate
- assess need for calcium gluconate
mag sulfate antidote is
calcium gluconate
baby blues
- appr. 80-80% of moms experience this
- begins on day 3 postpartum and lasts through first 2 weeks
- largely results from hormonal changes and lack of sleep
- should be gone by 2 weeks postpartum- if not, follow up with MD
signs of baby blues
mom is:
- weepy
- happy
- exhausted
- feeling overwhelmed
baby blues interventions
- best thing to do is monitor for worsening symptoms
- rest as much as possible
- take time for self - even if 15 minutes daily
postpartum psychosis
variant of bipolar disorder
- causes cognitive impairment and disorganized behavior that is a complete change from their previous behavior
- happens in the first 3 weeks
how prevalent is PP psychosis
- rare but dangerous: 6/12 women in every 1000 live births
- high risk for infanticide and suicide
PP psychosis risk factors
- bipolar disorder (BPD)
- family history of BPD
PP psychosis assessment (s/x)
- paranoia
- mood swings
- extreme agitation
- confused thinking
- strange beliefs
PP psychosis management
- hospitalization
- psychiatric evaluation
- therapy
- remove infant from situation
PPH meds
- oxytocin (pitocin)
- methylergonovine (methergine): avoid with HTN
- hemabate/carboprost: avoid with asthma, use with caution with HTN
- misoprostol (cytotec)
- Tranexamic Acid (TXA)
PPH stage 1: blood bank
- confirm active type and screen and consider crossmatch of 2 units PRBCs
PPH stage 1: actions
- determine etiology
- prepare OR, if clinically indicated
PPH stage 2: blood bank
- obtain 2 unites PRBCs- don’t wait for labs, transfuse right away
- thaw 2 units FFP
PPH stage 2: actions
- for uterine atony: consider uterine balloon or packing, possible surgical interventions
- consider moving patient to OR
- escalate therapy with goal of homeostasis
PPH: possible interventions
- bakri balloon
- compression suture/B-Lynch suture
- uterine artery ligation
- hysterectomy
PPH stage 3: blood bank
- initiate massive blood transfusion protocol
- if clinical coagulopathy : add cryoprecipitate, consult for additional agents)
PPH stage 3: action
- achieve homeostasis, intervention based on etiology
- escalate interventions
PPH stage 4: blood bank
- simultaneous aggressive massive transfusion
PPH stage 4: action
- immediate surgical intervention to ensure hemostasis (hysterectomy)
managing maternal hemorrhage: normal VS _____ assure patient stability
do not always
managing maternal hemorrhage: actions
- notify team
- bring cart and meds to patient room
- activate massive transfusion protocol
managing maternal hemorrhage: infusions
- start 2nd large bore IV (16G preferred)
- ringers lactated (RL) replaces blood loss at 2:1
- prepare for transfusion
- blood coagulation factors
- warm blood products and infusions to prevent hypothermia, coagulopathy, and arrhythmias
managing maternal hemorrhage: meds for uterine atony
- oxytocin (pitocin): 10-40 units per 500-1000mL solution
- methylergonovine (methergine): 0.2 mg IM; avoid w/ HTN
- prostaglandin F2 alpha (hemabate): 250 mcg IM (may repeat q15 min, max 8 doses); avoid w/ asthma; caution w/ HTN
- misopostol (cyctotec): 800-1000 mcg PR, 600 mcg PO, or 800 mcg SL
what is the most common reason for delay in surgical intervention for life-saving measure to treat PPH?
- delayed pending correction of coagulopathy
leading causes of pregnancy-related deaths
- embolism 29%
- hemorrhage 17.7%
- infection 14.5%
- cardiomyopathy 11.3%
leading causes of pregnancy-associated deaths
- injury 51.9%
- cancer 8.7%
- generalized septicemia 5.8%
- cardiac arrhythmia 4.8%
chronic hypertension
- SBP >/= 140 or DBP >/= 90
- pre-pregnancy or < 20 weeks
gestational hypertension
- SBP >/= 140 or DBP >/= 90 on at least two occasions at least 4 hours apart after 20 weeks gestation in women with previously normal BP
- absence of proteinuria or systemic s/sx
preeclampsia/eclampsia
- SBP >/= 140 or DBP >/= 90
- proteinuria with or without s/sx
- presentation of s/sx/lab abnormalities but no proteinuria
chronic hypertension with superimposed preeclampsia
- preeclampsia in a woman with a history of hypertension before pregnancy or before 20 weeks gestation
preeclampsia with severe features
- SBP ≥ 160 or DBP ≥ 110 (can be confirmed within a short interval to facilitate timely
antihypertensive therapy) - Thrombocytopenia (platelet count less than 100,000/microliter)
- Impaired liver function that is not accounted for by alternative diagnoses and as indicated by
abnormally elevated blood concentrations of liver enzymes (to more than twice the upper limit
normal concentrations), or by severe persistent right upper quadrant or epigastric pain
unresponsive to medications. - Renal insufficiency (serum creatinine concentration more than 1.1 mg/dL or a doubling of the
serum creatinine concentration in the absence of other renal disease) - Pulmonary edema
- New-onset headache unresponsive to medication and not accounted for by alternative diagnoses
- Visual disturbances
severe hypertension
SBP >/= 160 and/or DBP >/= 110
- measured on two occasions at least 4 hours apart
hypertensive emergency
- persistent, severe hypertension that can occur antepartum, intrapartum, or postpartum
- defined as:
-two severe BP values (>/=160/110) taken 15-60 min apart
-severe values do not need to be consecutive
first line therapies for HTN disorders
- IV labetalol
- IV hydralazine
- oral nifedipine
*if no IV access
- oral nifedipine
- oral labetelol
anticonvulsant meds (for recurrent seizures or when magnesium is C/I)
- lorazepam
- diazepam
- phenytoin
- keppra
second line therapies for HTN disorders
recommend emergency consult with:
- maternal fetal medicine
- internal medicine
- anesthesiology
- critical care
- emergency medicine
*may also consider:
- labetalol or nicardipine via infusion pump
- sodium nitroprusside for extreme emergencies
when to treat: severe HTN
SBP >/= 160 or DBP >/= 110
- repeat BP q5 min for 15 min
- notify physician after one severe BP value is obtained
when to treat: hypertensive emergency
- if severe BP elevations persist for 15 min or more, begin treatment ASAP. preferably w/in 60 min of the second elevated value
- if two elevated BPs are obtained within 15 min, treatment may be initiated if clinically indicated
monitoring BP: maternal
once BP is controlled, measure
- every 10 minutes for 1 hour
- every 15 minutes for 2nd hour
- every 30 minutes for 3rd hour
- every hour for 4 hours
monitoring BP: fetal
- fetal monitoring surveillance as appropriate for gestational age
HTN disorders: want to obtain baseline labs of:
- CBC
- platelets
- LDH
- liver function tests
- electrolytes
- BUN creatinine
- urine protein
complications of HTN disorders: maternal
- CNS (seizure, unremitting HA, visual disturbances)
- pulmonary edema or cyanosis
- epigastric or right upper quadrant pain
- impaired liver function
- thrombocytopenia
- hemolysis
- coagulopathy
- oliguria (<30 mL/hr for 2 consecutive hours)
complications of HTN disorders: fetal
- abnormal FHR tracing
- IUGR
HTN d/o: seizure prophylaxis
- mag sulfate (if not already initiated)
HTN d/o: maternal BP monitoring- control with ___ and target range is ____
- control with oral agents
- target range of 140-150/90-100
HTN d/o: if preterm (< 34 weeks) & expected management planned
- antenatal corticosteroids
- subsequent pharmacotherapy
HTN d/o: contraindications to delay in delivery for fetal benefit of corticosteriods
- Uncontrolled hypertension
- Eclampsia
- Pulmonary edema
- Suspected abruption placenta
- Disseminated intravascular coagulation (DIC)
- Nonreassuring fetal status
- Intrauterine fetal demise (IUFD)
HTN d/o postpartum surveillance: inpatient
- measure BP q4 hours after delivery until stable
- do not use NSAIDs for women with elevated BP
- do not discharge patient until BP is well controlled for at least 24 hours
HTN d/o postpartum surveillance: outpatient
- for patients with preeclampsia ,visiting nurse evaluation recommended:
-within 3-5 days
-again 7-10 days after delivery (earlier if persistent sx)
HTN d/o postpartum surveillance: antihypertensive therapy
- recommended for persistent PP HTN: SBP: >/= 150 or DBP >/= 100 on at least two occasions at least 4 hours apart
- persistent SBP >/= 160 or DBP >/= 110 should be treated within 1 hour
discharge planning: general preeclampsia info
all patients receive information of
- s/sx
- importance of reporting information to HCP asap
- culturally, competent, patient-friendly language
discharge planning: for patients WITH preeclampsia
- BP monitoring recommended 72 hours after delivery
- outpatient surveillance (visiting nurse evaluation) recommended:
-within 3-5 days
-again in 7-10 days after delivery (earlier if persistent sx)
signs of hypovolemic shock
- hypotension
- pallor
- diaphoresis
- dizziness
- tachycardia
- tachypnea (rapid breathing)
- AMS (altered mental status: goofy, off)
- oliguria
what are “later signs” of PPH?
- light headedness
- pallor
- dizziness
What percentage of blood loss may occur before the primary signs/symptoms of PPH present?
10-30% blood loss
what are the normal uterotonics that we may administer in stage 2 of PPH?
methergine
hemabate
oxytocin
medical factors of uterine atony (tone)
- large baby
- high parity
- rapid labor
- fever
- fibroids
signs and symptoms of uterine atony (tone)
- bleeding may be slow and steady, or profuse
- large, boggy uterus
- clots
nursing actions of uterine atony (tone)
- assist the uterus to contract via massage or medications
- monitor bleeding - weigh pads and Chux (1g = 1 mL)
- maintain fluid balance (may need second IV, foley catheter)
- monitor VS and lab results; blood type and screen if ordered
- admin O2 10-12L via face mask
- keep patient warm
signs and symptoms of lacerations (trauma)
- firm uterus with continued bleeding
- steady trickle of unclotted, bright red blood
nursing actions of lacerations (trauma)
- call provider to evaluate, locate, and repair laceration
- monitor VS and lochia
- weigh pads and Chux to monitor blood loss
signs and symptoms of hematomas (trauma)
- firm uterus
- sudden onset of painful perineal pressure
- bulging area just under the skin
- difficulty voiding or sitting
nursing actions of hematoma (trauma)
- assess for visible hematoma
- call provider to assess
- anticipate possible excision and ligation if greater than 3 cm
- consider indwelling catheter
- continue to assess VS, blood loss, and fluid maintenance
- provide pain management, including ice to the area
signs and symptoms of retained placental tissue (tissue)
- in addition to the previously noted items, uterus may not respond to interventions
- uterus may remain larger than normal
- strings of tissue may be seen in the blood
nursing actions for retained placental tissue
- call provider to assess; D&C may be needed
- monitor for signs of shock
- admin O2 if indicated
what two other obstetric conditions can cause DIC?
- preeclampsia
- HELLP
what does a high PTT mean?
taking too long to clot
what does a low PTT mean?
clotting too fast
medical factors of thrombin disorders
- preeclampsia
- stillbirth
signs and symptoms of thrombin disorders
- DIC (systemic)
- oozing from the IV site
- nosebleeds
- petechiae
- bleeding gums
- hypotension and other signs of shock
- abnormal clotting lab values
antihypertensive medications are
- labetalol
- hydralazine
- nifedipine
with what form of antihypertensive meds is cardiac monitoring not required
- IV labetalol
- IV hydralazine
- immediate release oral nifedipine
what should nurses look out for in their patients taking hydralazine?
- mitral valve disease
