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Obstetrics > Complications in Post Partum > Flashcards

Complications in Post Partum Flashcards

1
Q

Hemorrhage occurs in ____ of all births

A

5%

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2
Q

What is the leading cause of maternal death worldwide?

A

PPH

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3
Q

National and Global Maternal Mortality Target in Sustainable Development Goals

A

National Target: by 2030, no country should have MMR > 140 maternal deaths per 100 000 live births (2x global target)

Global Target: by 2030, reduce MMR <70 maternal deaths per 100 000 live births

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4
Q

2 Types of PPH

A
  1. primary (early)
  2. secondary (late)
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5
Q

Primary PPH definition and usual cause

A

Birth to 24 hours
Uterine Atony

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6
Q

Secondary PPH definition and usual cause

A

24 hours to 6 weeks
Not uterine atony issues - usually retained products

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7
Q

What makes PPH difficult to define?

A
  • numerous causes
  • bleeding is normal PP
  • difficulty in quantifying/measuring
  • interventions based on symptoms occur as priority before measurement
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8
Q

Definition we follow of PPH

A

EBL of more than 500 in vaginal delivery and 1000 CS

Any blood loss resulting in hemodynamic instability

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9
Q

Why is using a 10% decline in hematocrit not a good way to define PPH?

A
  • Not realistic/reasonable clinically to wait for return of bloodwork
  • May have been anemic in pregnancy
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10
Q

Why is using “need for transfusion” not a good way to define PPH?

A
  • Not realistic/reasonable to wait to assess for need
  • Subjective assessment for need
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11
Q

Cardiovascular adaptations of pregnancy

A

Increased BV, SV, CO and sometimes pulse

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12
Q

Hemodynamic instability can be tip of the iceberg because of _________________ but a lot can be going on under the surface

A

compensatory mechanisms

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13
Q

Patients can lose ______ of blood volume before displaying symptoms of hypovolemia

A

20-25%

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14
Q

systolic, s+s and degree of shock for EBL 500-1000 (10-15%)

A

normal

palpitations, dizziness, tachycardia

compensated

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15
Q

systolic, s+s and degree of shock for EBL 1000-1500 (15-25%)

A

slight decrease

weakness, sweating, tachycardia

mild

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16
Q

systolic, s+s and degree of shock for EBL 1500-2000 (25-35%)

A

70-80mmHg

restlessness, pallor, oliguria

moderate

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17
Q

systolic, s+s and degree of shock for EBL 2000-3000ml (35-45%)

A

50-70mmHg

collapse, air hunger, anuria

severe

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18
Q

4 Primary Causes of PPH

A

Tone
Trauma
Tissue
Thrombin

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19
Q

Risk factors for abnormalities of uterine contractions (tone causing PPH)

A
  1. over distention (polyhydraminos, multiples, macro)
  2. uterine exhaustion (rapid, prolonged, high parity, oxy induction)
  3. intra-amniotic infection (fever, prolonged ROM)
  4. functional/anatomic distorion of uterus (fibroid, placenta previa, abnormalities)
  5. uterine relaxing medications
  6. distended bladder
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20
Q

What stage management is key in prevention of PPH

A

3rd stage

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21
Q

Studies have shown what intervention in 3rd stage reduces PPH by 40%

A

administration of uterotonic

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22
Q

PPH management/prevention during 3rd stage

A
  1. uterotonic administration (oxytocin or carbetocin)
  2. palpate fundus
  3. maintain cord tension to guide placenta
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23
Q

Signs of PPH in 1st hour after delivery (9)

A
  1. rise in fundus
  2. boggy uterus not responding to massage
  3. abnormal clots
  4. increase rubra
  5. excessive bright red bleeding
  6. increased HR, decreased BP
  7. bleeding in presence of firmly contracted uterus
  8. pelvic/back discomfort r/t internal bleeding in peritoneal cavity creating pressure
  9. decreased LOC
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24
Q

When is trauma suspected as PPH cause vs atony?

A

When bright red bleeding (arterial) and presence of contracted uterus

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25
Q

Causes of trauma as PPH cause

A
  1. lacerations
  2. hematoma
  3. uterine inversion
  4. uterine rupture
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26
Q

What is the most common cause of late PPH

A

Retained products, lobes, membranes, clots

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27
Q

Define retained placenta

A

Retention of placenta beyond 30 minutes after birth

28
Q

What occurs with retention of placenta

A
  • manually removed
  • if client does not have epidural anesthesia in place, may need general anesthetic
29
Q

Treatment for PPH

A

Based on etiology

  • fundal assessment + massage
  • empty bladder
  • uterine stimulants (oxy, misoprostol, carbetocin, hemabate)
  • antifibrinolytic (tranexamix acid TXA)
  • identify and ensure lacerations sutures
  • VS for signs of shock
  • ANTICIPATION
30
Q

Position of patient when expelling clots

A

Supine, max 30 degrees

31
Q

What orders can you anticipate if PPH persists

A
  • 18G + access
  • crystalloid +/- oxytocin bolus
  • uterotonics, antifibrinolytics, transfusion
  • foley, oxy, NPO
  • bimanual massage
  • packing uterus
  • cauterization/hysterectomy
32
Q

Medications for PPH (4) + doses

A

Oxytocin: titrated doses

Misoprostol/Cytotec: 400-800 SL/PO/PR

Carboprost/Hemabate: 250 IM

Ergotrate: 0.25

33
Q

What should women to avoid thrombosis

A
  • smoking
  • sitting/standing in one position for long periods
  • oral contraceptives
34
Q

What should you encourage for women to avoid thrombosis

A
  • early activity
    § up 6-10 hours after c-section
  • leg exercises
35
Q

What should you consider to avoid thrombosis

A
  • compression devices
  • anticoagulants
36
Q

Metritis definition and symptoms

A

Infection of uterus

  • Abdominal pain, fever, foul lochia, nausea/anorexia, fatigue, lethargy, WBC
37
Q

9 PP danger signs

A

§ Fever >38°
§ Foul odor to lochia or unexpected change to colour or amount
§ Large blood clots or saturating 1 pad/hour
§ Visual changes or severe headaches
§ Calf pain
§ Swelling, redness, discharge at incision/episiotomy site
§ Dysuria, burning on voiding
§ SOB or difficulty breathing
§ Depression or extreme mood swings

38
Q

What is the #1 cause of death PP

A

Suicide

39
Q

What percent of women are vulnerable to perinatal mood and anxiety disorders

A

1 in 5 (20%)

40
Q

Risk Factors for PMAD

A
  • Female (minimal research on trans community
  • Hx of Depression - Discontinuation of Anti-depressants (thinks they need to come off during pregnancy – no reason for anyone to come off in early pregnancy)
  • Low income, education
  • Single
  • Age
  • Relationship issues – IPV
  • Lack of social support (feeling alone is biggest contributor)
  • Stress – Often precedes 1st episode
  • Substance Abuse
  • Ethnic minority – (new immigrant), Aboriginal
  • Unplanned pregnancy
  • Difficult pregnancy and delivery
41
Q

To be defined as depression you need 1 or both of these symptoms:

A
  1. Depressed mood most of the day
  2. Anhedonia
    * severely diminished interest or pleasure in activities
    * “What do you like about being pregnant/being a mother?”
42
Q

Besides a depressed mood most of the day and anhedonia, what are additional symptoms of PPD

A
  • Weight changes
  • Insomnia or hypersomnia
  • Psychomotor; restless, agitated, slowed
  • Diminished energy level
  • Feelings of worthlessness or excessive guilt
  •  concentration,  indecisiveness
  • Recurrent thoughts of death or suicide
43
Q

Post Partum Pinks

A
  • 11%, 44% mental health high risk
  • Elation hours/days after birth
  • Normal to be happy and excited
    o but extremes in mood in either direction need to be monitored
  • Not captured in early discharge
  • Sleep – prolonged time without sleep increases risk
  • Bipolar at risk
  • Expectations of pregnancy
44
Q

85% of women spontaneously recover from blues by _________

A

2 weeks

45
Q

______ of women experience their first major depression in PP

A

60%

46
Q

Who is PPD most likely in:

A

women who have idealized birth and motherhood

47
Q

Causes of PPF

A

udden decrease in hormones PP, thyroid, cholesterol, folate, anemia, lack of support, stress

48
Q

Post partum psychosis

A
  • 0.1-0.2% women
  • risk of recurrence with subsequent births 30 -50% if not followed
  • Insomnia, agitation, hallucinations, bizarre perceptions
  • Self-harm, infanticide, homicide
  • Bipolarity, mood swings
  • Usually in 1st few weeks and later PP
  • Associated with sleep disturbances
  • Postpartum care
49
Q

Anxiety more prominent in ________, depression more prominent _______

A

pregnancy

PP

50
Q

Describe anxiety’s temporal relationship with depression

A

o Comorbid
o Those with teenage anxiety more likely to develop PPD
o Those with PPD more likely to be anxious later on

51
Q

OCD in PP

A
  • Intrusive, repetitive thoughts
  • harm coming to baby
  • Guilt, worry, shame
  • Hypervigilent
  • Behaviours to avoid harm or minimize triggers
  • Assure
  • Thought ≠ action
52
Q

Contributing factors during labor process that contribute to PPD

A
  • Long, painful labor
  • Bad pain management
  • Anesthesia not working, emergency GA
  • Hemorrhage/manual removal retained placenta
  • Assisted birth (forceps/vacuum)
  • Emergency C/S
  • Fetal/neonatal anomaly
  • Baby in NICU
  • Feared for her of her baby’s life or health, during or after birth
  • Previous traumatic event-sexual abuse/IPV
  • Powerless for during the birth-lack of trust
  • Unsupportive or unsympathetic staff-felt uncared for
53
Q

Effects on Pregnancy of PMAD

A

– Preterm, hypertension, abruptio, less prenatal care or vitamins
– More likely to go to doctor with somatic complaints
Birth

54
Q

Effects on birth of PMAD

A

– More likely with epidural, operative birth

55
Q

Effects on newborn of PMAD

A

– Lower Apgar scores
– fussier, sleep issues, ˂breastfeed (prolactin and oxytocin are feel good hormones)

56
Q

Effects on PP period of PMAD

A

– Psychosis as major cause of suicide

57
Q

Effects on family of PMAD

A

– Partners 10%, more severe the mother, worse for partners
– Partners experience later on
– Siblings of baby
– Mother less likely to interac

58
Q

4 Recommendations of Mother First Building Capacity

A
  1. increase awareness
  2. universal screening
  3. prioritize maternal mental health in health services
  4. sustainability and accountability
59
Q

What score on Edinburgh Postnatal Depression Scale indicates probable depression

A

greater than or equal to 12

60
Q

3 Sections of Universal Screening for PPD

A
  1. edinburgh postnatal depression scale
  2. women abuse screening tool (WAST)
  3. TACE alcohol assessment (tolerance, annoyed, cut down, eye opener
61
Q

How often is the edinburgh postnatal depression scale utilized

A
  • 2 times in Pregnancy
  • 3 times in Postpartum
62
Q

What 2 questions are asked in WAST

A
  1. “In general, how would you describe your relationship: a lot of tension, some tension, no tension?”
  2. “Do you and your partner work out arguments: with great difficulty, some difficulty, no difficulty?”
63
Q

4 Questions asked in TACE assessment

A

T - how many drinks can you hold (2 points for more than 3)

A - have you ever been annoyed by people’s criticism of your drinking (1)

C - Are you trying to cut down (1)

E - have you ever used alcohol as an eye opener in the morning (1)

64
Q

What if your patient answers 0 to all questions but seems depressed?

A

A screen is a screen

Follow your gut

borderline…?worried about answering honestly

65
Q

What if patient answers high to first 9 questions on edinburgh but doesn’t answer question 10

A

– Fear of answering…apprehension

66
Q

ru awesome

A

yes

Obstetrics (12 decks)

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