Complications in Post Partum Flashcards
Hemorrhage occurs in ____ of all births
5%
What is the leading cause of maternal death worldwide?
PPH
National and Global Maternal Mortality Target in Sustainable Development Goals
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
2 Types of PPH
- primary (early)
- secondary (late)
Primary PPH definition and usual cause
Birth to 24 hours
Uterine Atony
Secondary PPH definition and usual cause
24 hours to 6 weeks
Not uterine atony issues - usually retained products
What makes PPH difficult to define?
- numerous causes
- bleeding is normal PP
- difficulty in quantifying/measuring
- interventions based on symptoms occur as priority before measurement
Definition we follow of PPH
EBL of more than 500 in vaginal delivery and 1000 CS
Any blood loss resulting in hemodynamic instability
Why is using a 10% decline in hematocrit not a good way to define PPH?
- Not realistic/reasonable clinically to wait for return of bloodwork
- May have been anemic in pregnancy
Why is using “need for transfusion” not a good way to define PPH?
- Not realistic/reasonable to wait to assess for need
- Subjective assessment for need
Cardiovascular adaptations of pregnancy
Increased BV, SV, CO and sometimes pulse
Hemodynamic instability can be tip of the iceberg because of _________________ but a lot can be going on under the surface
compensatory mechanisms
Patients can lose ______ of blood volume before displaying symptoms of hypovolemia
20-25%
systolic, s+s and degree of shock for EBL 500-1000 (10-15%)
normal
palpitations, dizziness, tachycardia
compensated
systolic, s+s and degree of shock for EBL 1000-1500 (15-25%)
slight decrease
weakness, sweating, tachycardia
mild
systolic, s+s and degree of shock for EBL 1500-2000 (25-35%)
70-80mmHg
restlessness, pallor, oliguria
moderate
systolic, s+s and degree of shock for EBL 2000-3000ml (35-45%)
50-70mmHg
collapse, air hunger, anuria
severe
4 Primary Causes of PPH
Tone
Trauma
Tissue
Thrombin
Risk factors for abnormalities of uterine contractions (tone causing PPH)
- over distention (polyhydraminos, multiples, macro)
- uterine exhaustion (rapid, prolonged, high parity, oxy induction)
- intra-amniotic infection (fever, prolonged ROM)
- functional/anatomic distorion of uterus (fibroid, placenta previa, abnormalities)
- uterine relaxing medications
- distended bladder
What stage management is key in prevention of PPH
3rd stage
Studies have shown what intervention in 3rd stage reduces PPH by 40%
administration of uterotonic
PPH management/prevention during 3rd stage
- uterotonic administration (oxytocin or carbetocin)
- palpate fundus
- maintain cord tension to guide placenta
Signs of PPH in 1st hour after delivery (9)
- rise in fundus
- boggy uterus not responding to massage
- abnormal clots
- increase rubra
- excessive bright red bleeding
- increased HR, decreased BP
- bleeding in presence of firmly contracted uterus
- pelvic/back discomfort r/t internal bleeding in peritoneal cavity creating pressure
- decreased LOC
When is trauma suspected as PPH cause vs atony?
When bright red bleeding (arterial) and presence of contracted uterus
Causes of trauma as PPH cause
- lacerations
- hematoma
- uterine inversion
- uterine rupture
What is the most common cause of late PPH
Retained products, lobes, membranes, clots
Define retained placenta
Retention of placenta beyond 30 minutes after birth
What occurs with retention of placenta
- manually removed
- if client does not have epidural anesthesia in place, may need general anesthetic
Treatment for PPH
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
Position of patient when expelling clots
Supine, max 30 degrees
What orders can you anticipate if PPH persists
- 18G + access
- crystalloid +/- oxytocin bolus
- uterotonics, antifibrinolytics, transfusion
- foley, oxy, NPO
- bimanual massage
- packing uterus
- cauterization/hysterectomy
Medications for PPH (4) + doses
Oxytocin: titrated doses
Misoprostol/Cytotec: 400-800 SL/PO/PR
Carboprost/Hemabate: 250 IM
Ergotrate: 0.25
What should women to avoid thrombosis
- smoking
- sitting/standing in one position for long periods
- oral contraceptives
What should you encourage for women to avoid thrombosis
- early activity
§ up 6-10 hours after c-section - leg exercises
What should you consider to avoid thrombosis
- compression devices
- anticoagulants
Metritis definition and symptoms
Infection of uterus
- Abdominal pain, fever, foul lochia, nausea/anorexia, fatigue, lethargy, WBC
9 PP danger signs
§ 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
What is the #1 cause of death PP
Suicide
What percent of women are vulnerable to perinatal mood and anxiety disorders
1 in 5 (20%)
Risk Factors for PMAD
- 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
To be defined as depression you need 1 or both of these symptoms:
- Depressed mood most of the day
- Anhedonia
* severely diminished interest or pleasure in activities
* “What do you like about being pregnant/being a mother?”
Besides a depressed mood most of the day and anhedonia, what are additional symptoms of PPD
- 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
Post Partum Pinks
- 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
85% of women spontaneously recover from blues by _________
2 weeks
______ of women experience their first major depression in PP
60%
Who is PPD most likely in:
women who have idealized birth and motherhood
Causes of PPF
udden decrease in hormones PP, thyroid, cholesterol, folate, anemia, lack of support, stress
Post partum psychosis
- 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
Anxiety more prominent in ________, depression more prominent _______
pregnancy
PP
Describe anxiety’s temporal relationship with depression
o Comorbid
o Those with teenage anxiety more likely to develop PPD
o Those with PPD more likely to be anxious later on
OCD in PP
- Intrusive, repetitive thoughts
- harm coming to baby
- Guilt, worry, shame
- Hypervigilent
- Behaviours to avoid harm or minimize triggers
- Assure
- Thought ≠ action
Contributing factors during labor process that contribute to PPD
- 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
Effects on Pregnancy of PMAD
– Preterm, hypertension, abruptio, less prenatal care or vitamins
– More likely to go to doctor with somatic complaints
Birth
Effects on birth of PMAD
– More likely with epidural, operative birth
Effects on newborn of PMAD
– Lower Apgar scores
– fussier, sleep issues, ˂breastfeed (prolactin and oxytocin are feel good hormones)
Effects on PP period of PMAD
– Psychosis as major cause of suicide
Effects on family of PMAD
– Partners 10%, more severe the mother, worse for partners
– Partners experience later on
– Siblings of baby
– Mother less likely to interac
4 Recommendations of Mother First Building Capacity
- increase awareness
- universal screening
- prioritize maternal mental health in health services
- sustainability and accountability
What score on Edinburgh Postnatal Depression Scale indicates probable depression
greater than or equal to 12
3 Sections of Universal Screening for PPD
- edinburgh postnatal depression scale
- women abuse screening tool (WAST)
- TACE alcohol assessment (tolerance, annoyed, cut down, eye opener
How often is the edinburgh postnatal depression scale utilized
- 2 times in Pregnancy
- 3 times in Postpartum
What 2 questions are asked in WAST
- “In general, how would you describe your relationship: a lot of tension, some tension, no tension?”
- “Do you and your partner work out arguments: with great difficulty, some difficulty, no difficulty?”
4 Questions asked in TACE assessment
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)
What if your patient answers 0 to all questions but seems depressed?
A screen is a screen
Follow your gut
borderline…?worried about answering honestly
What if patient answers high to first 9 questions on edinburgh but doesn’t answer question 10
– Fear of answering…apprehension
ru awesome
yes
