Chapter 22: Postpartum Complications

Question 1

early postpartum hem vs. late postpartum hem

Answer 1

early: w/n 24 hrs of birth
late: 24 hrs - 6 weeks

Question 2

Causes of postpartum hem (7)

Answer 2

uterine atony (most common)
lacerations of genital tract
Episiotomy
Retained placental fragments
Uterine inversion
Coagulation disorders
hematomas of vulva vagina or sub-peritoneal areas

Question 3

5 T’s of postpartum hemorrhage

Answer 3

Tone: uterine atony, distended bladder
Tissue: retained placenta
Trauma:
Thrombin: coagulopathy
Traction: causing uterine inversion

Question 4

Why is retained tissue bad

Answer 4

Uterus can’t contract fully, cant clamp down on blood vessels

Question 5

Uterine inversion

Answer 5

prolapse of uterine fundus to or through cervix so that uterus is turned inside out after birth

Question 6

disorder of increased platelet destruction caused by autoantibodies

whats the risk?

Answer 6

Idiopathic thrombocytopenia purpura (ITP)

-increased hem risk!

Question 7

Congenital bleeding disorder inherited as autosomal dom trait

Answer 7

Von willebrand

Question 8

Life-threatening acquired coagulopathy in which clotting system is abnormally activated - widespread clot formation in small vessels

Answer 8

Disseminated Intravascular Coagulation

Question 9

What primary diagnoses lead to DIC? (6)

Answer 9

Abruptio placentae
amniotic fluid emobolism
Intrauterine fetal death with prolonged retention of fetus
Severe preeclampsia
HELLP syndrome
Septicemia and hemorrhage

Question 10

Mgmt of uterine inversion

Answer 10

gentle pushing of usterus back into position

Question 11

Uterine atony mgmt

Answer 11

Massage
Meds
Removal of retained placental fragments
Repair of lacerations

Question 12

ITP tx

Answer 12

glucocorticoids and IV immunoglobulin

Question 13

Postpartum hem assessment (3)

Answer 13

Risk factors
uterine tone
vaginal bleeding

Question 14

Nursing mgmt postpartum hem

Answer 14

fundal massage
pad count
adminstration of uterotonic
fluid administration
Check bladder
bimanual compression (MD or CNM)
monitoring for s/s shock
Emergency measures for DIC

Question 15

Uterotonic drugs (4)

Answer 15

• oxytocin (pitocin)
• misoprostol (cyotec) or dinoprostone (prostin E2)
• methylegronovine maleate (Methergine)
• carboprost (Hemabate)

Question 16

pitocin contraindications

Answer 16

never give undiluted as bolus injection

Question 17

misoprostol/cyotec contraindications

Answer 17

allergy, active CVD, pulmonary or hepatic disease

Question 18

Dinoprostin (prostin E2) contraindications

Answer 18

Active cardiac, pulmonary, renal or hepatic disease

Question 19

Methylergonovine maleate/methergine contraindcations

Answer 19

Hypertension!

Question 20

Carboprost/Hemobate contraindcations

Answer 20

Asthma!

Question 21

Carboprost/hemobate SE

Answer 21

diarrhea

Question 22

Hematoma risk factors (8)

Answer 22

1. preeclampsia
2. pudendal anesthesia
3. nulliparity
4. precipitous labor
5. prolonged second stage
6. macrosomia
7. forceps/vacuum assisted birth
8. history of vulvar varicosities

Question 23

hematoma s/s (3)

Answer 23

pain out of proportion
rectal pelvic pressure
signs of shock

Question 24

Tx of hematoma:

<5 cm vs. >5 cm

Answer 24

<5: ice, observation, pain meds, sitz bath

>5: incision and drainage

Question 25

3 most common thromboembolic conditions occuring during postpartum period

Answer 25

superficial venous thrombosis Deep venous thrombosis Pulmonary embolism

Question 26

Risk factors for thromboembolic conditions

Answer 26

``` obesity >35 yo smoking imobility grand multip severe anemia varicose veins hx thrombosis, thrombophlebitis, endometritis ```

Question 27

S/s thromboembolic conditions

Answer 27

``` edema pain warmth redness heat changes in skin color decreased peripheral pulse ```

Question 28

s/s pulmonary embolism

Answer 28

``` sudden onset of SOB severe chest pain apprehensive and diaphoretic tachypnea tachycardia hypotension syncope JVD decreased oxygen saturation cardiac arrhythmia hemoptysis suden change of mental status ```

Question 29

PE prevention

Answer 29

- NSAIDs for analgesia - Bed rest - Anti-embolism stockings - Heparin, warfarin, aspirn - Edu about risk factors, symptoms, and prevention - Activity - elevating legs above heart - stopping smoking - apply compression stockings - passive ROM in bed - deep-breath exercises - NO pillows under knees, no crossing legs for long time - Bed cradle to keep blankets off extremities - increase fluid intake - NO oral contraceptives - warm compresses to affected area

Question 30

s/s postpartum infection

Answer 30

fever >38.5 or 100.4 after 1st 24 hours

Question 31

c/s and risk of metritis

Answer 31

increases it dramatically! 10-20% of c/s

Question 32

Endometritis risk factors (11)

Answer 32

1. prolonged labor 2. PROM 3. multiple cervical exams 4. internal monitoring 5. meconium 6. operative delivery (c/s) 7. GBS 8. HIV 9. preterm/postterm 10. GDM 11. Severe anemia

Question 33

S/s endometritis (5)

Answer 33

``` temp foul smelling lochia chills malaise tachycardia ```

Question 34

Dx of endometritis

Answer 34

-temp >38.0 on 2 successive days between 1-10 days postpartum (orally, at least 4 hours apart)

Question 35

mastitis timing

Answer 35

w/n first 2 weeks

Question 36

Engorgment timing

Answer 36

day 3-5

Question 37

Most common cause of mastitis

Answer 37

S. aureus

Question 38

Mastitis s/s

Answer 38

fever > 38.3 myalgia, chills, malaise, flu-like localized breast tenderness red, warm, hard area

Question 39

Cystitis/pylonephritis

Answer 39

``` Frequency and urgency dysuria Nocturia Hematuria Suprapubic pain Elevated temp CVA tenderness ```