Chapter 22 Flashcards
Define postpartum hemorrhage
blood loss greater than 500 for vaginal birth and/or blood loss greater than 1000 for cesarean birth
blood loss of more than 1,500 mL to 2,500 mL or bleeding that requires more than 5 units of transfused blood
major Obstetric hemorrhage
primary vs delayed postpartum hemorrhage
<24 hours blood loss, 24 hours to 12 weeks blood loss
failure of uterus to contract and retract after birth
uterine atony
mild shock signs and symptoms
- diaphoresis
- increased capillary refill
- cool extremities
- anxiety
moderate shock signs and symptoms
- tachycardia
- postural hypotension
- oliguria
Severe shock signs and symptoms
- hypotension
- agitation/confusion
- hemodynamic instability
4 Ts that show cause of PPH
Tone (uterinatoney)
Tissue (retained placenta)
Trauma (Lacerations, inversions, rupture)
Thrombin (DIC, coagulopathy)
refers to incomplete involution of the uterus or failure to return to its normal size and condition after birth.
Subinvolution
Causes subinvolution
myometrial fibers do not contract effectively and cause relaxation, placental fragments
- ) an autoimmune disorder of increased platelet destruction caused by autoantibodies
- )congenital bleeding disorder that is inherited as an autosomal dominant trait
- ) clotting system is abnormally activated, resulting in widespread clot formation in the small vessels throughout the body, which leads to the depletion of platelets and coagulation factors.
- ) Idiopathic thrombocytopenia
- ) von Willebrand disease
- )DIC (treat through fluids and plasma, heparin)
how to treat uterine atony
-massage uterus (fundus)
Therapeutic management for obstetric Hemorrhaging
- focus on underlying condition
- uterine massage
- removal of retained fragments
- antibiotics
- repair laceration
Risk for Tone obstetric hemorrhage
- overdistention of uterus (polyhydramnios, Multifetal gestation, macrosomia)
- uterine exhaustion (Rapid Labor or prolonged labor, oxytocin over use)
- uterine Infection
Risk for tissue obstetric bleeding
Incomplete placental birth
uterine subinvolution
Risk for trauma obstetric bleeding
lacerations
uterine inversion
rupture
Nursing assessment in obstetric hemorrhage
- assess the amount of bleeding (counting peripad, SAPHE pads collect 50 ml each square)
- assess placenta for intactness
- assess for hematoma (needs surgical intervention)
- assess for coagulopathy (petechia and echymosis)
- tachycardia, decease LOC
How to assess for hematoma
- asses perineal area for bluish bulging discoloration
- severe perineal or pelvic pain with difficulty voiding
- shock may be present
Nursing management for obstetric hemorrhage
- ) initial measures include massage, IV fluid, and utertonic medications
- ) if that don’t work, we do bimanual compression, internal uterine packing , and /or balloon tamponade
- ) if 2nd line still don’t work, then do : undergo radiologic embolization, pelvic devascularization, or hysterectomy.
once estimated bleeding exceeds 1500
transfuse blood
Uterine Massage procedure
- gloved hand over symphysis pubis
- other gloved hand on fundus
- massage fundus in circular manner9 do not over massage)
- if firm, apply gentle firm pressure downward toward vagina to express any clots( do not try to express if not firm)
- perineal care and add perineal pad
Uterotonic drugs
- ) oxytocin(Pitocin) - first line therapy, stimulates uterus contraction
- ) Misoprostol (Cytotec) - causes uterine contraction, not approved by FDA
- ) Dinoprostone (Prostin E2
- ) Methegrine
- ) Prostaglandin (Hemabate)
Contraindications of Utertonic drugs
- ) Pitocine - never give undiluted
- )Cytotec - allergy, CVD, pulmonary or hepatic disease
- ) Prostin E2 - Cardiac, hepatic, pulmonary, or rena diseases
- )Methergine - hypertension
- )Hemabate - not for asthma
Assessing for hypovolemic shock
- anxiety
- hypotension, tachyardia, slow capillary refil, decrease LOC, and low Urine output
Nursing interventions in the event of DIC
- transfer patient to ICU
- replace fluid and give plasma
- asses for signs of bleed (gums, petechia, echymosis, blood in stool)
three most common venous thromboembolic conditions occurring during the postpartum period
DVT, PE, superficial venous thrombosis
Thrombus paathophisiology
- Venous stasis
- injury to inner most layer of blood vessel
- hypercoagulation
Risk factors for thrombophlebitis
- oral contraceptive use
- smoking
- prolonged sitting or standing or bed rest
- history of thrombosis
- obesity, diabetes
- varicose veins
- advanced age
Signs and symptoms to assess for thrombophlebitis
- lower extremity pain
- reddened and warm lower extremities
- pain with movement of extremity
- positive homan’s sign
signs and symptoms of pulmonary embolism
- SOB
- severe chest pain
- diaphoresis
- tachypnea and tachycardia
Prevention of thrombotic conditions
- encourage activity
- dorsi and plantar flexion
- intermitent sequential compressive device or compression stockings
- elevate legs, no pillows under knees
- no smoking and avoid use of oral contraceptives
- anticoagulant therapy, aspirin
- ) Collection of blood factors on a vessel wall
- )Vessel wall develops an inflammatory response to thrombus
- )A mass composed of thrombus
- ) Thrombus
- )Thrombophlebitis
- )Embolus
environment encourages the growth of bacteria.
Alkaline environment
an infectious condition that involves the endometrium, decidua, and adjacent myometrium of the uterus
Metritis
Metritis that extends to broad ligament, ovaries, and fallopian tubes
Parametritis
common bacteria that cause pelvic infections
E.coli, Klebsiella pneumonia, G. vaginalis
Therapeutic technique for Metritis
Prophylactic antibiotic
cause for surgical site infection
- any break in the skin
Causes for UTI
- frequent vaginal examination
- genital trauma
- catheterization
- epidural
Inflammation of mammary gland
Mastitis (occur withing 2 days to 2 weeks
Risk factors for mastitis
- stasis of milk
- S. aureus, Staph albus, E. coli
Therapeutic techniques:
- ) Metritis
- )Surgical site infection
- )UTi
- )Mastitis
- ) broad spectrum antibiotics, restore fluid electrolyte balance ( resolved at 48 to 72 hours after starting therapy)
- )open wound to allow drainage, clean wounds with aseptic technique, hydration and ambulation and antibiotics and analgesics
- ) prevent by timely removal of catheter, fluids, antibiotics, vitamin C and cranberry juice
- )emptying the breasts by feeding or manual expulsion and controlling the infection via antibiotics
Factors that increase the risk of PPI
- Prolonged membrane rupture >18-24 hrs and prolonged labor
- incisional procedures and instrument assisted child birth and frequent vaginal exams
- catheterization
- regional anesthesia or epidurals
- anemia, obesity, diabetes, smoking, drug use, poor nutrition
- placental fragments
- trauma
S&S of Metritis
- Lower Abdominal pain
- fever, foul smelling lochia
- nausea, fatigue, lethargy
S&S of wound infection
- serosanguineous or purulent drainage
- unapproximated wound edges
- edema or erythema
- fever
UTI S&S
- Urgency
- frequency
- Dysuria
- Cloudy urine and positive for nitrates
Mastitis S&S
- Flue like symptoms
- tender warm, red area on one breast (inflammation)
- nipple crack skin
used for assessing a woman’s perineum status
Redness Edema Ecchymosis Discharge Approximation of skin edges (score of 0 to 3 each, the higher the score, the higher the trauma)
how long does baby blues usually last
10 days, no more than 2 weeks
difference between baby blues and PPD
PPD does not go away on its own and gets worse over time. Lasts longer than 6 weeks
an emergency psychiatric condition, can result in a significant increased risk for suicide and infanticide.
Postpartum Psychosis
S&S of Postpartum Psychosis
- mood lability, delusional beliefs, hallucinations, and disorganized thinkin, anger towards self and infant
- surfaces within 3 months
- sleep disturbance
- fatigue
- depressions
