Exam 2 Flashcards
What is trauma-informed care?
Trauma-informed care: Care that recongizes the impact of trauma on individuals and creates a safe space, supports, and heals with an emphasis on safety and trust.
What are possible settings for childbirth?
1) Traitional hospital settings with L&D and PP
2) Free-standing birth centers
3) Home births
What is labor?
Labor: Regular uterine contractions with cervical change in order to expell the fetus, amniotic fluid, placenta, and membranes from the uterus into the world.
What is preterm labor?
Preterm labor: labor that in a gravid person w/ a gestational age prior to 37 weeks
What does dystocia mean?
Dystocia: Abnormally slow or protracted labor
What does nulliparous labor “Nullip” mean?
Nulliparous labor: labor in a person who has never given birth to a child
Multiparous labor: labor in a person who has given birth before
What are the characteristics of a normal labor: between how many weeks, what risk level, what position/presentation, post-birth condition
1) Spontaneous labor at 37-42 weeks
2) Low risk throughout
3) Birth in vertex presentation = fetus is head down, headfirst and facing your spine with its chin tucked to its chest
4) Parent and child are in good condition post birth
**What is the cause of labor?
Exact cause of labor initiation is unknown
**What is the lightening and when does it happen?
Lightening: the subjective feeling by the pregnant person as the baby settles into the lower uterine segement
When: 2-3 weeks before term
**What is engagement and when does it happen and for whom?
Engagement: When the widest part of the baby’s head passes through the pelivc inlet and into the pelvis
When/who: 2-3 weeks before term in first time parents
**What are some events, aside from lightening and engagement, that occur before the onset of labor?
1) Vaginal secretions increase
2) Mucus plug is discharged
3) Cervix is soft and effaced
4) Persistant bachache may be present
5) Possible rupture of membranes (amniotic sac)
6) Spotting, bloody show
**Are stages of labor typically shorter or longer for nullip parents?
They are typically longer for nullip parents
**Describe the first stage of labor and it’s substages:
**First stage: the initiation of labor to complete dilation (10cm)
* Latent: minor contractions, pregnant person is talkative, eager, 0-3cm dilated
* Active: increased contractions that are strong, rapid dilation, fetal head engages, effacement complete, bloody show, N/V, shaking 4-7cm dilated
* Transition: strong contractions with no break, have the urge to push, most difficult, shaky, emesis common, sweaty belly and brow, 8-10cm dilated
**Describe the second through fourth stages of labor:
Second stage: complete dilation to birth of baby
Third stage: birth of baby to delivery of the placenta (5-30 minutes)
Fourth stage: placental delivery to 1 hour postpartum, stabilization
**What is the cutoff time for the third stage of labor? What is the term for failure to deliver this key product of conception during the third stage?
1) Cutoff time: 30 minutes
2) Retained placenta: is the term used when the placenta is stil within the uterus after 30 minutes and it is considered an urgent concern
What the important action a nurse must take after a placenta has been delivered?
Inspect it for intactness to ensure none is left in the uterus
What happens to the cervix and vagina during the first stage?
Cervix
* Dilation: goes from 0 to 10cm dilated, completely opened
* Effacement: is complete with cervical thinning at 100% = paper thin
Vagina:
* Stretches for distension
* Increased lubrication
Describe the second stage of labor:
1) Spontaneous urge to push w/o epidural
2) Contractions increase or stay instense
3) Fetal head may develop caput (cone shape d/t swelling = normal), mold, and rotate
4) Completion of body mechanics = baby is facing down, back to front, and tucked = vertex
5) Takes longer in nullips
What are physiologic labor changes?
1) Cardiac output increases at second stage
2) Heart rate increases in first and second stage
3) BP increases during contractions and normalizes between
4) Increased WBC count
5) Increased RR
6) Temperature slightly elevated
7) Gastric motility and absorption decreased w/ N/V during transitions
8) Low blood glucose
What are the five P’s of Labor?
1) Passenger
2) Passageway
3) Positions
4) Powers
5) Psyche
What does passengers mean in labor?
Size of fetal head and other factors allowing the fetus to navigate the birth canal
What does “presentation” mean in labor? Which type is compatible?
Presentation: the part of the fetus nito the pelvic inlet first
* Head: cephalic - vertex = compatible
* Shoulder: transverse lie = not compatible
* Sacrum/feet: breech = not great
What does “lie” mean in labor? Which type is compatible with birth?
Lie: relationship of maternal longitudinal axis (spine) to fetal spine
* Longitudinal: vertical (compatible)
* Transverse: horiztonal (not compatible)
What does “attitude” mean in labor? Which type is compatible with birth?
Attitude: relationship of fetal body parts to one another
* Flexion: chin to chest and extremities to torso = compatible
* Extension: chin and extremities extend away = not compatible
**What does fetal “position” mean in labor? What is the preferred fetal position?
Position: relationship of the presenting part of the fetus (i.e. sacrum, mentum, occiput) in relationship to its directional position of one of four pelvic quadrants
Preferred positon: Left occipitalanterior (LOA) - right occipitalanterior is also acceptable but less preferred
**What does passageway mean in labor? Describe each shape and which ones are good/bad?
Passageway: Pelivmetry-pelic shapes
* Gynecoid: the most common, best shape, 50% of pelvic shapes
* Android: male-type pelvis, may be difficult, labor will likely not progress, bad
* Platypelloid: least common, NOT conducive to vaginal birth
* Anthropoid: often results in occiput posterior birth (face up), 25%
There are three major parts to the fetal head. Which two are fused and which one is not and why?
1) Fetal face = should be well fused
2) Base of skull = should be well fused
3) Vault of cranium = not fused, normal, allows for head to adjust to peliv shape
**What does fetal station mean? Which station is at ischial spine? At what station can pushing start?
Fetal station: relationship of presenting part to an imaginary drawn line between the ischial spines of the maternal pelvis
* -5, -4, -3, -2, -1 = above ischial spines
* 0 = at ischial spine
* +1, +2, +3, +4, +5 = below ischial spine
* You can start pushing at 0 and + stations
What is fetal engagement? At what station is engagement?
Engagement: The latgest diameter of the presenting part reaches or passes through pelvic inlet
Station: 0
What is biparietal diameter? How is it related to vertex position?
Biparietal diameter: is the maximum width of a fetus’ head and is used to assess engagement
Relation to vertex: it’s related to vertex beucase biparietal diameter is the smallest when in vertex position
What does power mean in the 5 P’s? Define contractions, duration, frequency, and intensity of them:
Power: It means the contractions of the birthing person.
Contractions: rhythmic tightenings and shortening of the uterine muscle
* Duration: beginning of one contracting to completion
* Frequency: time between the beginning of one contraction to the beinning of the next
* Intensity: the strength of uterine contractions
How is the intensity of uterine contractions described in terms of palpation?
Mild: like pressing the tip of one’s nose trying to indent it
Moderate: like pressing one’s chin trying to indent it
Strong: like pressing on one’s head trying to indent it
What does positions mean in the 5 P’s and what can it optimize?
Positions: means frequent position changes to promote comfort, reduce fatigue, and promote circulation
Optimize: promotes optimization of fetal position
What does psyche mean in the 5 P’s?
Psyche: the mental and emotional state of the birthing person
What is pain versus suffering?
Pain: unpleasant sensations we want to avoid
Suffering: distressing state that includes feeling of helplessnesss and loss of control
What are ways to promote physical comfort as part of the atmosphere, partner suggestions, and encouraging use of space during labor?
Atmosphere: relaxation techniques, calming vocalizations, rhythmic breathing
Partner suggestions: massage/pressure, wiping face with damp cloth, praise
Encouraging use of space: using the bath/shower, birth ball, lounge
**What physical assessment tasks should the nurse complete during labor?
1) Vitals: BP, HR, RR, temp
2) Leopold’s maneuvers: abdominal palpation to determine fetal position
3) Heart assessment
4) Lung assessment
5) Ask about any headache, diziness, or vision changes
6) Check upper and lower pulses
7) Check cervical dilation and effacement
8) Check status of membranes
9) Monitor contraction pattern
10) Assess pain
**What assessments should be done during the first stage of labor?
1) Review prenatal hx and labs
2) Review cultural preferences, language, and religious preferences
3) Labor status: contractions, cervix, membranes
4) Fetal status: FHR, amniotic fluid (clear = good, red=bad, brown/green indicate meconeum = bad)
5) Maternal status: coping level, comfort level, desires for L&D, support for L&D
What are active phase labor assessments?
1) Support pain relief options
2) Fetal survelliance: FHR + contractions
What are second stage of labor preparations?
1) Position change support
2) Delivery meds ready
3) Continue to monitor fetus + parent
4) Meet baby
What are third stage of labor assessments?
1) Uterine contractions to deliver placenta
2) Check fundal tone
3) Weigh pads for bleeding
4) Set up for laceration repair as needed
5) Parent-baby bonding
6) Breastfeeding if desired
What are fourth stage of labor assessments?
1) Fundal checks and vitals
2) Bonding (skin-to-skin, breastfeeding)
3) Bathroom needs
4) Bring to PP
What is family centered care and what are its three beliefs?
Family centered care: recognizes physical and psychosocial needs of the family including the newborn and older children
Beliefs:
* Childbirth is noraml and healthy
* Childbirth affects the whole family
* Families can decision-make with all the information and support
What are three barriers to family centered care? What can help alleviate these problems?
1) Lack of communication, role negotiation, and relationships between providers and parents
2) Lack of time by providers
3) Lack of support from system and provider team
Validation of these difficulties can help alleviate them
What age range is the birth rate declining for? Are individuals becoming pregnant earlier or later in life?
1) Declining for 15-24 y/o
2) People are waiting to become pregnant until later in their lives
What does maternal death mean?
Any death while pregnant, aside from accidental/incidental causes, or within 42 days after pregnancy irrespective of duration, site, or termination or any cause d/t pregnancy
Which population is disproportionately affected by maternal and infant death rates?
Black individuals
What are the three main causes of maternal death?
1) Cardiovascular conditions or other related CV issues
2) Infections/sepsis
3) Cardiomyopathy
About how many pregnancy-related deaths have been considered to be preventable?
80%+
**What are methods for fetal surveillance (FHR and uterine activity)?
FHR:
1) Intermittent ascultation of FHR (handheld doppler)
2) Continuous electronic FHR recording (external transducer, internal fetal scalp electrode)
Uterine activity recording:
1) External tocodynanometer or pressure transducer = “Toco”
2) Internal intrauterine pressure catheter = balloon captures reading and strength
What is a normal fetal heart rate?
110-160 BPM
**What is baseline fetal heart rate? What might being below or above the normal range indicate?
Baseline: the average FHR during a 10 minute window rounded to 5BPM
* Below 110 BPM = bradycardia, which may indicate hypoxia
* 110-160 BPM = normal
* Above 160 BPM = tachycardia, possible fetal fever or distress
What does variability mean in FHR tracing?
Variability: fluctuations in the baseline FHR quantified as the amplitude from peak-to-trough in BPM
What are the four types of FHR variability and what can they mean?
1) Absent: amplitude undetectable
2) Minimal: amplitude 0-5 BPM
- Absent or minimal may mean hypoxia, acidemia, fetal sleep, or medication effects
3) Moderate: amplitude 6-25 BPM = what we want, good
4) Marked: amplitude is >25 BPM = may mean acute hypoxia or umbilical compression
What are accelerations? Are accelerations good or bad? What should an acceleration be at 32 weeks or greater of gestation?
Accelerations: temporary increases in FHR of at least 15 BPM lasting at least 15 seconds.
They are generally a reassuring sign of good oxygenation and movement
32 weeks+: peak is equal to or greater than 15 BPM and lasts at least or longer than 15 seconds
Early deceleration: What is it, onset to nadir time, and cause
Early: a gradual decrease and return to baseline in FHR associated with a contraction where the nadir of the decel and peak of the contraction happen at the same time.
Onset to nadir: is >30 seconds
Cause: head compression, not very concering
Late decerlation: what is it, onset to nadir, cause
Late deceleration: a gradual decrease and return to baseline in FHR associated with a contraction where the nadir of the decel occurs after the peak of the contraction.
Onset to nadir: >30 seconds
Cause: placental insufficiency = need fetal monitoring
Variable deceleration: what is it, onset to nadir, cause
Variable deceleration: abrupt decrease below baseline by greater than or equal to 15 BPM lasting at least 15 seconds but less than 2 minutes from onset to baseline.
Onset to nadir: less than 30 seconds
Cause: cord compression or prolapse
Prolonged deceleration: what is it, cause
Prolonged deceleration: decrease in FHR below baseline greater than or equal to 15 BPM lasting longer than 2 minutes but less than 10.
Cause: epidural, sudden position change by mother or fetus, quick labor
What is a baseline change in FHR tracing?
Baseline change: when a prolonged deceleration or acceleration lasts longer than 10 minutes
**Describe the acronym VEAL CHOP in FHR tracing:
V: Variable deceleration
E: Early deceleration
A: Acceleration
L: Late deceleration
C: Cord compression/prolapse (bad)
H: Head compression (fine)
O: Okay
P: Placental insufficiency (not great)
Letters go with their respective letter in each word, i.e. V+C, E+H, etc
**Define uterine contractions in FHR tracing, what is the normal amount, what is duration and frequency of contractions?
Uterine contractions: number of contractions in a 10 minute window averaged over 30 minutes
Normal: 5 or less contractions in 10 minutes, averaged over 30 minutes
Duration: start of one contraction to the end of the contraction
Frequency: start of one contraction to the beginning of another contraction
What is tachysystole in uterine contractions and how is it treated?
Tachysystole: >5 contractions in 10 minutes, averaged over 30 minutes
Treatment: maternal repositioning, fluid bolus, discontinue oxytocin
What factors affect intensity and fatigue during labor?
1) Interval of contractions and duration
2) Fetal size
3) Rapidity of fetal descent
4) Maternal position
5) Maternal mobility during labor
Why is childbirth pain unique?
1) Self-limiting and normal
2) Can be prepared for
3) Ends with birth
Describe the pain and characteristics of each labor stage:
1st stage: dilation of the cervix is the main source of pain, hypoxia of uterine muscles during contractions, stretch of uterus, pressure on lower back, butt, thighs
2nd stage: distension of vaginal perineum, hypoxia of uterus continues, pressure again
3rd stage: perineal pain, uterine contractions, cervical dilation w/ placental expulsion
4th stage: contractions, after pains (breastfeeding), perineal/incisional pain
How should you ask a laboring individual about their pain? When should you assess them for pain?
How: “Are you coping with your labor?”
When: on admission, every shift, as needed, any sign of change
What are signs the laboring patient is not coping with their pain?
1) States they are not coping or doing well
2) Panicked
3) Tense
4) Crying
5) Fear
What are pain management goals during labor?
1) Safe for birthing person
2) Safe for fetus
3) Ideally does not interfere with course of labor
When can each pain management method be used during labor: non-pharmacological, nitrous oxide, sedatives, opioids, epidural, nerve block
non-pharmacological: anytime
nitrous oxide: anytime
sedatives: early labor only
opioids: early to active labor and during the 3rd stage
epidural: early to active labor
nerve block (local infiltration): 2nd stage to 3rd stage
What are some possible comfort measures to alleviate pain during labor:
1) Heat/cold
2) Toch/massage
3) Psychosocial support
4) Hydrotherapy
5) Continuous labor support (doula, partner, friends, family)
6) Breathing techniques
7) Movement
8) Birth ball
9) TENS machine (electrical stimulation)
10) Sterile water injections for back pain
Nitrous oxide: what is it, how does it help pain, long or short lasting
What is it: also known as laughing gas, it is an inhaled anesthetic of 50:50 mix of O2 and nitrous oxide via handheld mask
Helps: only modulates pain, it does not remove it
Length: short duration
Sedatives: what sedative is most commonly given during labor, what does it help with
Sedative: Vistaril (hydroxyzine pamoate) 25-100mg
Helps with: N/V, anxiety and apprehension, sleep induction at higher doses
Opioids: which opioids are given during labor, what is pain relief dependent on, do they cross the placenta, side effects (maternal, fetal, newborn)
Opioids: Morphine (5-10mg IM) or Fentanyl (50-100mcg IV)
Dependent on: pain relief is dependent on maternal metabolism
Placenta: All cross the placenta
Side effects:
* Maternal: dizziness, N/V, sedation, tachycardia, hypotension
* Fetal: decreased variability in FHR tracing
* Newborn: respiratory depression at birth
Narcan: what is it, when is it available to use, what does it reverse, contraindications
What is it: opiate antagonist
When: available anytime, labor and birth
Reverses: it reverses respiratory depression, sedation, and hypotension
Contraindications: mother/fetus/neonate with maternal drug abuse or methadone treatment becuase it** may precipitate withdrawal**
What does regional analgesia vs. regional anesthesia block?
Regional analgesia: provides moderate pain relief with motor block
Regional anesthesia: provides complete pain relief with motor block
Local perineal infiltration anesthesia: when is it given, what kind of medication
When: prior to episiotomy or after birth for repair of lesions
Medication: 1% lidocaine (10-20mL to site)
What is a pudendal nerve block and which stages of labor is it used in?
Pudendal nerve block: needle guide and luer-lock syringe to inject medication for pain relief
Stages: 2nd and 3rd stages
What are the advantages and disadvantages of spinal anesthesia?
Advantages:
* Awake and can participate in birth experience
* Retains relaxed airway
Disadvantages:
* maternal hypotension
* FHR changes d/t impaired placental perfusion
* Delayed respiratory depression
* N/V
* Puritis
* Urinary retention = needs catheterization
* Spinal headache
Spinal block: what is it, when used, effect
What is it: a pain relief measure placed into the subarachnoid space (L3-L4)
Use: c-section
Effect: paralysis from xiphyoid process down
**Epidural block: what is it, when used, effect
What is it: a pain relief measure placed lower into the epidural space (between L4+L5) given via continuous infusion of anesthetic (marcaine) and opiate (fentanyl)
Use: vaginal delivery often during active labor
Effect: abdominal paralysis and analgesia only - can move
**What is the nursing role before spinal anesthesia admistration?
1) vitals (mother and fetus)
2) Hydration
3) Check labor progress
4) Assess pain
5) Help void
6) Guide parent during process
7) Have O2 and suction ready
8) Monitor for toxicity
9) IV for saline/Lactated ringers
**What is the nursing role during/after spinal anesthesia administration?
1) Vitals
2) Assess pain
3) Check if bladder distended (Cath needed)
4) Change positions side-to-side every hour
5) Bed rails up
6) Call light in reach
7) Educate patient to not get up without help
8) Educate patient to not place pressure on anestheized parts
9) Check insertion site for reactions
10) Keep insertion site clean and dry
11) Assess for sensory and motor return
12) Encourage pushing
General anesthesia: when used, risks
When: only in emergencies, not offered to patients
Risks: difficulty with intubation/extubation, aspiration of GI contents
How is pain managed postpartum after vaginal delivery:
- Analgesia PO (acetaminophen)
- NSAIDs PO (ibuprofen)
- Topical comfort
Alternate acteaminophen and ibuprofen every 3 hours
How is pain managed postpartum after c-section delivery:
- Opoid analgesia, patient controlled first 24 hours, and then PO (i.e. oxycodone)
- NSAID IV (i.e. toradol) first 24 hours only, then PO (IV and PO NSAIDs cannot be used at the same time)
What is induction of labor and what do you need to document when doing this?
Induction of labor: artificial initiation of labor before spontaneous onset, useful when deliery outweighs benefits of continued pregnancy
Documentation: Ensure documented risk/benefit/alternatives with rationale for induction method, method used, risks of method
What are maternal indications for labor induction:
- PROM
- Hypertensive disorder of pregnany
- Intrauterine fetal demise
- Maternal diabetes
- Post-term pregnancy
- Elective
What are fetal indications for labor induction:
- Fetal growth restriction
- Oligohydraminos
- Chorioamnionitis
- Non-reassuring FHR tracing
What are contraindications for induction of labor?
1) Complete placenta previa
2) Non-cephalic presentation
3) Active genital herpes
Contraindicated becuase they are high risk and need C-section instead
What is done as part of a vaginal exam prior to induction of labor?
1) Palpate cervix
2) Check presentation (Head first?)
3) Position (LOA?)
4) Membrane status
5) Pelvic asssessment -> fetopelvic relationship (station)
What is a bishop score? What goes into a bishop score? What score determines ready for induction versus cervical ripening?
Bishop score: a score of 0-15 that determines if inducement is possible or if ccervical ripening is needed
Components: dilation, effacement, cervix position, station, cervical consistency
Induce: 6 or higher
Ripen: less than 6
Mechanical cervical ripening: options, benefits risks
Options: Foley or Cook balloon (double) - open the cevix
Benefits: safe for those with prior cesarean
Risk: rupture of membranes on insertion, fetal head displacement
Pharmagcologic cervical ripening: options, contraindications, risk, and treatment of the risk
Options: Prostaglandins such as misoprostol (Cytotec; PO/Vaginal; very small dose) + Dinoprastone (Cervidil ; Vaginal)
Contraindication: cannot be used in those with previous c-section/uterine surgery as there is risk of overstimulating the uterus/scar tissue rupturing it
Risk: Tachysystole is possible (>5 contractions in 10 minutes)
* Tx: position changes, fluid bolus, discontinue pitocin, remove meds
What is induction compared to augmentation of labor?
Induction: initiating labor before it begins on its own
Augmentation: stimulating uterine contractions after labor has begun
What are the two common methods of induction/augmentation? What Bishop score do you need to induce?
1) IV Pitocin (most common)
2) Artificial Rupture of Membranes (AROM)
3) **bishop score of 6 or more to induce)
**Pitocin: what is it, route, effects, dangers
What is it: a synthetic version of oxytocin used via IV for induction
Route: IV
Effects: causes uterine contractions
Dangers: Tachysystole, uterine rupture, uterine atony to postpartum hemorrhage
**What are six important points when starting a Pitocin infusion?
1) Hang bag as a secondary line (piggyback)
2) Insert secondary line into primary line as close to proximal port (near the IV site) as possible to limit the amount of drug infused after stopping
3) Low dose to start and increase every 20-30 minuntes until uterine contractions are regular
4) Requires verification by two nurses in MAR d/t high risk status
5) Monitor patient’s BP/HR Q30 minutes
6) Must continually monitor FHR and contractions
**What five actions should you take if you’re using Pitocin and notice non-reassuring fetal heart tones?
1) Reduce/stop the Pitocin
2) Increase rate of primary IV line
3) Move patient to side-lying position
4) Assess FHR and contractions
5) Administer Terbutaline: a tocolytic that is a beta 2 agonist to relax smooth muscle and delay contractions
Artificial rupture of membranes (AROM): what is it, when is it used, risks
What is it: a procedure to artificially rupture the amniotic sac by using an amnihook to induce/augment labor
Used: Labor augmentation, labor induction, internal fetal monitoring needed
Risk: cord prolapse, chorioamnionitis
What is the nursing role in artificial rupture of membranes?
1) FHR: obtain baseline FHR 20-30 minutes prior to the precedure and continue to monitor after
2) Supplies: towels, omnihook, sterile gloves, sterile lubricant
3) Chart: color, quantity/amount, and odor of fluid
4) Assess: for any infection following rupture
Operative vaginal delivery: types, indications
Types: vacuum and forceps
Indications: to shorten 2nd stage with reason =
* maternal exhaustion
* ineffective pushing
* cardiac/pulmonary disease
* intrapartum infection
* cord compression
* non-reassuring FHR
* premature placental separation
What are the maternal and fetal risks for an operative vaginal delivery?
Maternal:
1) laceration or hemtoma to vagina/perineum
2) Need for a large epiosiotomy
Fetal:
1) ecchymosis (bruising)
2) facial/scalp lacerations/abrasions
3) facial nerve injury
4) cephalohematoma
5) intracranial hemorrhage
What are nursing maternal and fetal considerations for an operative vaginal delivery
Maternal:
1) Patient’s bladder should be empty
2) Observe for trauma
3) Cold application to perineum/vagina to reduce pain, bruising, and edema
4) Check if fundus is firm
Fetal:
1) Assess FHR
2) Check for any skin breaks
3) Check facial asymmetry
4) Check for any neurologic abnormalities
5) Assess for scalp edema and facial bruising (both will resolve w/o tx)
What is tiral of labor after cesarean (TOLAC) and VBAC mean?
1) TOLAC: means the parent is trying to labor and deliver vaginally after already having a c-section
2) VBAC: a successful vaginal birth after c-section
What considerations should be made before a trial of labor after cesarean (TOLAC)?
1) Small, but significant risk of uterine rupture
2) Avoid in setting w/o emergency services access or anesthesia
3) Prostaglandins like misoprostol (Cytotec) and dinaprostone (Cervidil) cannot be used
4) Pitocin can be used
5) Continuous FHR will be needed
What are the benefits vs. risks of trial of labor after cesarean (TOLAC)?
Benefits:
1) Achieved VBAC
2) Avoid surgery
3) Lower rates of hemorrhage, infection, and thromboembolism
4) Shorter recovery
5) Decreased risk of multiple c-sections
6) VBAC = fewer complicaions than c-section
Risks:
1) Unsuccessful TOLAC ending in a c-section has more complication than elective, repeat c-section or VBAC.
What are the indications for a cesarean birth? Which two indications make up half of all c-sections?
1) Labor dystocia 1+2 make up half of all c-sections
2) Abnormal FHR tracing
3) Fetal mal-presentation
4) Macrosomia
5) Genital herpes
6) Placenta previa
What are the risks of a c-section?
1) Major hemorrhage
2) Uterine rupture
3) Anesthetic complications
4) Shock
5) Cardiac arrest
6) Infection
7) Wound disruption
8) Injury to newborn
**What are c-section pre-op interventions?
1) Assess the time of last oral intake (must be NPO 8 hours before surgery)
2) Allergies
3) Current meds and last dose
4) Informed consent signed
5) Lab work: CBC, blood type and screen
6) Pre-op teaching
7) Start IV + bolus
8) Clip abdominal hair
9) Administer pre-op antibiotic = Ancef (Cefazolin)
10) Meds to control gastric secretions = Pepcid
11) Insert catheter
12) Help patient onto table and place a hip wedge
13) Get grounding pad for cautery
14) Sterile prep of abdomen
What is dystocia and dysfunctional labor?
Dystocia: lack of progres in labor for any reason
Dysfunctional labor: long, difficult, or abnormal labor
Name 1 reason from each of the 5 P’s that may contribute to dysfunctional labor:
1) Passenger: fetal causes, size, HR
2) Passageway: bony pelvic structure
3) Power: inneffective contractions or pushing efforts
4) Position: abnormal presentation
5) Psyche: maternal coping fails
What are risk factors for labor dystocia/dysfunction?
1) Advanced maternal age
2) Obesity
3) Nulliparity
4) Short stature
5) Possible induction of labor
What is hypertonic labor dysfunction and what is the nursing care?
Hypertonic labor dysfunction: painful and frequent contractions, but ineffective in causing cervical change
Nursing care: supportive coping, rest, manage expectantly
What is hypotonic labor dysfunction and what is the nursing care?
Hypotonic labor dysfunction: inadequate uterine activity
Nursing care: position changes, labor augmentation (pitocin, AROM)
What care possible causes for ineffective pushing during labor and what is the nursing care?
Causes: exhaustion, absent urge (anesthesia), or a very dense epidural
Nursing care: change positions, contact anesthesia about epidural rate, assisted delivery may be needed (vacuum, forceps), c-section prep
What are possible problems with the passenger in continued dysfunctional labor?
1) Fetal size - macrosomia
2) Fetal presentation/position - rotational abnormalities, deflexsion abnormalities, breech
3) Multifetal pregnancy
4) Fetal anomalies like hydrocephalus
Problems with passage: what is pelvic dystocia?
Pelvic dystocia: when a contracted pelvis reduces birth canal capacity caused by abnormalities, malnutrition, trauma, or immature pelvis
Problems with passage: what is soft-tissue dystocia?
Soft-tissue dystocia: non-bony obstructions such as placenta previa, fibroids, tumors, full bladder/rectum
Aside from soft-tissue and pelvic dystocia, what other passge problems can cause dystocia?
1) Edema
2) STIs can weaken the cervical tissue affecting dilation and effacement
What are possible problems with psyche in continued dysfunctional labor?
1) Environment
2) Fear
3) Lack of trust
What is prolonged labor and what are the risks?
Prolonged labor: labor that falls outside the normal labor curve (duration)
Risks:
1) Maternal/neonatal infection
2) Maternal exhuastion
3) High levels of anxiety in future labors
4) Manternal hemorrhage
What is precipitate labor and what are the risks?
Precipitate labor: is rapid birth within 3 hours of labor onset
Risks:
1) Tears
2) Infection
3) Fetal/maternal harm
What is preterm and what are the possible consequences?
Preterm labor: Any birth before 37 weeks
Consequences:
1) Developmental delays
2) Respiratory issues
3) Vision/hearing impairment
4) Financial/personal cost
**What is the second leading cause of infant death and what percentage of live births is it?
- Preterm birth is the second leading cause of infant death
- It accounts for 10.4% of live births
Which group of individuals has the highest rate of preterm births?
Black individuals
What are factors associated with preterm birth?
1) Demographics
2) Social/economic
3) Medical complication
4) Obstetric history
5) Current conditions in pregnancy
What are risk factors of preterm birth?
1) Low pre-pregnancy weight
2) Smoking
3) Substance use
4) Short interval pregnancy spacing (less than 18 months)
5) H/o preterm birth
6) Cervical length concerns
What are signs/symptoms of preterm labor?
1) Palpable contractions
2) ROM
3) Pelvic/vaginal pressure
4) Low backache
5) Cramps
6) Vulvar/thigh pain
7) Bleeding/spotting
8) Diarrhea
**How is preterm labor defined? How many contractions in what time frame?
Preterm labor: regular contractions AND cervical changes
Contractions: 4 contractions in 20 minutes or 8 in 60 minutes
**Are bedrest and hydration effective mangement strategies in preterm labor?
No, they are not effective and outdated
**What four medications can be used to manage preterm labor?
1) Corticosteroids: Betamethasone
2) Tocolytic: Terbutaline
3) Tocolytic: Nifedipine
4) Tocolytic/neuroprotectant: Magnesium sulfate
**Betamethasone: what is it, rationale for use, route, dose
What is it: a corticosteroid used in the management of preterm labor
Rationale: used to enhance fetal lung development/maturity
Route: IM in the butt
Dose: two doses, each 24 hours apart between 24-33 weeks if at risk of delivery within 7 days
Terbutaline: what is it, rationale for use, MoA, route, side effects, max number of doses
What is it: a tocolytic acting helping to delay preterm labor
Rationale: short term use to delay delivery allowing time to administer corticosteroid (betamethasone)
MoA: Rleaxes uterine smooth muscle by stimulating B2 receptors reducing contractions
Route: SubQ
Side effects: Tachycardia (fetal and maternal), palpitations
Max dose: 3 dose max d/t side effects
Nifedipine: what is it, rationale for use, MoA, route, side effects
What is it: a tocolytic helping to delay preterm labor
Rationale: used to delay preterm labor in order to deliver corticosteroid
MoA: Calcium channel blocker in smooth muscle decreasing contractions
Route: PO
Side effects: hypotension, headache, dizziness, flushing, nausea
Magnesium sulfate: rationale for use in labor
Rationale: used for fetal neuroprotection before 32 weeks during preterm labor (can also be used as a tocolytic)
What is the most important way to prevent preterm birth?
Good prenatal care
When preventing preterm birth what needs to be communicated to the patient?
1) Importance of prenatal care
2) Education on normal pregnancy and warning signs
3) Consequences of preterm labor/birth
Define SROM, PROM, and PPROM
SROM: spontaneous rupture of membranes when water breaks at term and labor follows
PROM: prelaobor rupture of membranes is when spontaneous rupture occurs but without labor following
PPROM: preterm prelabor rupture of membranes is preterm and prelabor rupture
What should the nurse ask if a patient complains of vaginal discharge or a gush of fluid while pregnant?
1) When, amount of fluid, color, and odor
2) Any bleeding present
3) Any contractions, pain, or pressure
4) Is there fetal movement
5) What is your gestational age
6) Instruct them to go to the clinic/hospital to be evaluated
What might mimic rupture of membranes?
1) Urination, leakage
2) Vaginal discharge
**PPROM has a higher risk of neonatal and maternal complications. What are they?
1) Infection
2) Preterm labor
3) Nonatal morbidty
What are risk factors of PROM/PPROM?
1) Amniotic infections
2) Low BMI
3) Short cervical length
4) Smoking
5) 2/3rd trimester bleeding
6) Ilicit drug use
7) Low SES
8) H/o PROM/PPROM
What are complication of PROM/PPROM?
1) Intrauterine infection
2) Premature fetus
3) Newborn sepsis
4) Respiratory distress in newborn
How is PROM managed?
1) Weighing risks vs. benefits of expectant and induction of labor
2) GBS status
3) Monitoring for s/s of infection
4) Fetal monitoring
**How is PPROM managed?
1) Hospitalization (possibly for weeks)
2) Labor induction if possible at 34-36 weeks (if less than 34 weeks, infection versus preterm birth risks are weighed)
3) Monitor for infection (Tachycardia, temperature, tenderness)
4) Fetal considerations (Goal = prevent complications of prematurity = betamethasone for lung development, latency antibiotics, and mag sulfate for neuroprotection)
**What is chorioamnionitis? What is Triple I?
Chorioamnionitis: bacterial infection of the amniotic cavity
Triple I: Intrauterine inflammation, infection, or both (indicates the origin of the chorio)
**What are risk factors of chorioamnionitis?
1) Prolonged ROM
2) Multiple vaginal exams
3) Prolonged labor duration
4) Low SES
5) Nulliparity
6) Young age
**What are the symptoms of chorioamnionitis?
1) Maternal temp of 100.4+ AND one of the following:
2) WBC >15,000
3) Maternal HR >100
4) FHR >160
5) Tender uterus
6) Foul smelling amniotic fluid
**What are neonatal complications of chorioamnionitis?
1) Pnueomonia
2) Bacteremia
3) Meningitis
4) Respiratory distress syndrome
5) Inflammatory response -> pulmonary + CNS damage
**What is the nursing role in chorioamnionitis?
1) Antibiotics: ampicillin/gentamycin, penecillin
2) Expedite delivery
3) Intrauterine resuscitation
4) Intrapartum: maternal and fetal vitals, antibiotics, education
5) Postpartum: endometritis, UTI, and spesis monitoring, S/S education on infection
What is cord prolapse? What is the main problem?
Cord prolapse: It is when the umbilical cord prolapses out of the uterus in front of the presenting fetus cuasing compression of the cord between the fetus and pelvis
Problem: Cord compression decreases O2 delievery to fetus possibly resulting in death
What are risk factors for cord prolapse?
1) PROM
2) Polyhydramnios
3) Long umbilical cord
4) Fetal malpresentation
5) Multiparity
6) Multiple gestation
7) High fetal station
8) Growth restricted fetus (small)
**What is the nurse role in cord prolapse?
1) support the fetal head - put on a sterile glove and lift the head to relieve compression. You must stay in this position until c-section.
2) Get help and position maternal hips higher than head
What is shoulder dystocia and turtle sign?
Shoulder dystocia: The descent of the anterior or posterior shoulder is obstructed by the pubis symphysis
Turtle sign: infant’s head come out of the vagina and then gets sucked back in slightly and wont move
What are risk factors for shoulder dystocia?
1) Large birth weight/size (large for gestational age/macrosomia)
2) Diabetes melitus
3) Prolonged labor
4) Excessive weight gain in pregnancy
5) H/o of prior shoulder dystocia
How is shoulder dystocia diagnosed?
Diagnosed when there is failure to deliver the shoulder and slight downward traction does not move the infant
What are maternal and neonatal complications of shoulder dystocia?
Maternal:
1) Higher risk of PP hemorrhage and lacerations
2) Obstetric anal sphincter injuries
3) Symphaseal separation and lateral femoral cutaenous neuropathy
Neonatal:
1) Brachial plexus injuries
2) Clavical/humerus fractures
3) Encephalopathy d/t asphyxiation
4) Death
**What is the nursing role in shoulder dystocia?
1) COMMUNICATE
2) Do your assigned role
3) Document: time of head delivery, time of shoulder dystocia diagnosis, and time of delivery
4) Request help -NICU/RNs
5) Communicate to the pregnant person to not push
6) Assist with first maneuvers (McRobert’s, suprapubic pressure
7) NEVER GIVE FUNDAL PRESSURE
What two maneuver’s can help in shoulder dystocia and how are they done?
1) McRobert’s: place the pregnant person supine with legs pulled up toward the chest (helps shift the pelvis)
2) Suprapubic pressure: place downward pressure just above the pubic bone (helps push the shoulder down)
What is the incidence of baby blues and postpartum depresision
1) Baby blues: 80-85% of pregnant people will experience this
2) PP Depression: 8-20% of PP individuals will experience this, about 1in 7
What are the baby blues, when do they peak, and when does it resolve?
Baby blues: a transient period of “depression” that is common PP and may be d/t hormonal fluctuations, sleep deprevation, and role change
Peak: 3-5 days after delivery
Resolves: 10-12 days PP, self-resolving
What are the symptoms of the baby blues?
1) Mood lability
2) Anxiety
3) Sleeplessness
4) Crying
5) Loss of appetite
**What is the nursing role in baby blues?
1) Education
* S/S of depression
* Provide resources
* Discuss sleep hygiene
* Discuss infant behavior regulation
What is perinatal or pospartum depression and what is the diagnosis?
PP Depression: major of minor depressive episodes that occur during pregnancy or the first 12 months after birth
Dx:
1) depressed mood and/or anhedonia must be present for most of the day for two weeks with at least 5 of the following
2) changes in weight or appetite (loss/gain)
3) Insomnia or hypersomnia
4) Psychomotor agitation or slowness (apparent to others)
5) Fatigue
6) Feelings of worthlessness/guilt (often with helplessness/hopelessness)
7) Thoughts of death or suicide
8) Functional impairment must be present
How is postpartum depression different than the baby blues?
1) PP depression often accompanied by a previous history of mood disorders/episodes
2) PP depression is longer than baby blues, it lasts at least two weeks and is more severe with functioning impaired
3) PP depression is not self resolving while baby blues is
What mental health disorder is most common is those who experience postpartum psychosis?
1) bipolar disorder 1 (up to 30%)
What non mental health factor contributes significantly to postpartum psychosis development?
Sleep deprivation for >48 hours
What is bereavement and mourning?
Bereavement: entire process precipitated by the loss of a loved one through death
Mourning: the cultural/public display of grief through one’s behavior; a process through which grief may be resolved
What are the 5 stages of grief by Kubler-Ross? Do these stages follow a linear path?
1) Denial - shock, numbness, disbelief
2) Anger - guilt, frustration, anxiety
3) Bargaining - difficulty finding meaning, reaching out to others
4) Depression - searching, disorientation, overwhelmed, hostility
5) Acceptance - resolution, moving forward, integration
- These stages do not follow a linear path and individuals may go through all of them, some of them, in any order, and may reexperience them
Define early and late pregnancy loss, and concurrent death on survival multi-fetal pregnancy:
1) Early pregnancy loss: loss in the first or second trimester, less than 20 weeks
2) Late pregnancy loss: intrauterine fetal death (IUFD) and still birth >20 weeks
3) Concurrent death: Loss of one twin
What is nursing care for grief and loss in childbirth?
1) Being sensitive and emotionally present, responsive to grief
2) Comprehensive plan of grief care
3) Clinic and hospital guidelines use and social service use
4) Offer written material
5) F/u with the parents by phone, card, or at a clinic visit
What is the postpartum period considered? What are some challenges during this time?
PP period: The first 6 weeks after birth
Challenges: sleep, fatigue, pain, breastfeeding, stress, exacerbation or onset of mental health issues, lack of sexual desire, substance abuse, intimate partner violence
What is involution and what can it be ehanced by?
Involution: the rapid reduction in size of the uterus and return to prepregnancy state
Enhanced by: uncomplicated labor and birth, complete placental expulsion, breastfeeding, and early ambulation
What is subinvolution and what does it increase the risk of?
Subinvolution: when the process of involution does not happen properly
Risk for: PP hemorrhage
What is exfoliation?
It allows for the healing of the placental site and is an important part of involution
Where should you expect the uterus to be after birth? How far should it drop each day after birth?
After birth: At umbilicus
Drop: It should drop one fingerbreadth each day after birth (i.e. 2 days = 2 fingerbreadths below umbilicus)
Who is after pain/involution more acutely uncomfortable for?
1) Multiparas
2) Distended uterus (multifetal gestation, polyhydramnios, LGA, retained blood clots)
3) Breastfeeding person - more cramping d/t oxytoxin
What are nursing consideration for involution/after pains?
1) Administer analgesics short term (Tylenol/motrin)
2) Change positions
3) Apply heat
What should lochia look like postpartum?
1) After birth - bright red
2) First 3 days: dark red - “rubra”
3) 4-10 days: pink-brown-tinged - “serosa”
4) Days 11-14 (up to 6 weeks): cream, yellow - “Alba”
5) Onward: clear
**How much blood loss is expected postpartum?
Up to 500 mL of blood loss is expected
What happens to the cervix and uterus postpartum?
Cervix:
1) Internal os closes and cervix returns to almost normal
2) External os may remain slightly open (1cm) and is slit-like by 1 week
Vagina:
1) Rugae regained by 3-4 weeks
2) Edematous tissue resolves by 6-10 weeks
3) Mucpsa becomes atrophic and does not regain its thickness until estrogen production by ovaries is reestablished
4) Breastfeeding people are likely to experience vaginal dryness and dyspareunia (painful intercourse)
How does the body tolerate substantial bloodloss during childbirth?
By undergoing hypervolemia
How is cardiac output affected postpartum?
1) Immediately after delivery it increase
2) Returns to normal pre-labor values within an hour
3) 6-12 weeks it returns to pre-pregnancy levels
How does plasma volume return to pre-pregnancy levels postpartum?
1) Diuresis
2) Diaphoresis
What two factors clotting risk increased postpartum and when do they resolve?
1) Leukocytosis occurs increasing WBC to >30,000 during labor and immediately following - Resolves in 6 days
2) Increased plasma fibrinogen; resolves within 4-6 weeks PP
How is elimination affected postpartum?
1) Intestines are sluggish b/c of progesterone and decreased muscle tone
2) BM may not occur for 2-3 days
3) Temporary constipation is common
4) Normal elimination is achieved by days 8-14
**How is the urinary tract affected postpartum?
1) Diminished sensitivity to fluid pressure = lack of urge to void
2) Bladder fills rapidly d/t diuresis increasing the risk of distension adn retention of risidual urine increasing the risk of UTIs
3) Stretched uterine ligaments can allow a full bladder may push fundus from midline
4) Stress incontinence may occur, but improves within 3 months and with pelvic floor exercises
**If the fundus is not midline, what should you first suspect?
You should suspect bladder distension
**What is the problem with bladder distension pushing the fundus from midline?
Decreases uterine contraction leading to atony and increased risk of postpartum hemorrhage
How is the musculosketeal system affected postpartum?
1) Relaxin gradually decreases and the ligaments and cartilage of the pelvis return to pre-pregnancy conditions; may cause hip/join pain
2) May have overall muscle ache/fatigue for 1-2 days d/t labor effort (arms, neck, shoulder back)
Diastesis recti: what is it, when does it resolve, how can you help reduce it
What is it: when the longitudinal abdominal wall muscles are separated
Resolves: within 6 weeks
Reduce: can help reduce it with gentle abdominal exercises to strengthen muscles
Postpartum neurologic difficulties: bilateral/frontal and spinal headache - what causes them and how do you treat spinal headaches
1) Bilateral and frontal headaches: within the first week d/t changes in fluid and electrolyte balances
2) Spinal headache: headache caused by CSF leak after epidural, may be more severe when upright and relieved when supine
* Tx: blood patch
What are endocrine changes to ovulation during the postpartum period?
1) The first few cycels, lactating and non-lactating are often anovulatory
2) Ovulation may occur before menses return
3) Ovulation resumes as early as 3 weesk PP
4) Non-breastfeeding: 6-8 weeks start ovulating, almost all by 6 months
5) Breastfeding: resume as early as 8 weeks or 18 months
Describe postpartum weight loss immediately after, in the following weeks, and adipose tissue:
1) Immediately post partum: 10-12 pounds are lost from the fetus, amniotic fluid, blood loss, and placenta.
2) 2 weeks postpartum: 9 pounds are lost as fluid
3) Adipose tissue: gained during pregnancy is hard to remove and takes about 6-12 months to reach prepregnancy weight
How long are hospital stays for vaginal deliveries and for c-sections?
Vaginal: 1-2 day stay
C-section: 2-4 day stay
What is the postpartum assessment schedule?
1) Immediately following birth: every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then every hour for 2 hours
2) Then Q4H for 24 hours
3) Then Q8H until dischage
What are the 7B’s + E
1) Brain
2) Breasts
3) Belly
4) Bladder
5) Bottom
6) Bloods
7) Bowels
8) Extremities
What is the brain assessment as part of the 7 B’s
Brain: emotional status, feelings toward birth experience, having a new child, bonding
What is the breasts assessment as part of the 7 B’s
Breasts:
* Breast vs. formula feeding
* Tenderness
* Soft vs firm
* Color
* Nipples everted, flat, inverted
* Signs of nipple trauma = air dry them, apply cream to soothe
* May feel lump as lobes begin to produce milk
What is the belly assessment as part of the 7 B’s
Belly:
* Incision and dressing if c-section
* Uterus consistency and location (up and right = bladder distension?; soft/boggy = fundal massage pressing down to lower segment)
What is the bladder assessment as part of the 7 B’s and what are signs of a distended bladder?
Bladder:
* Monitor first 2-3 voids post birth or removal of catheter
* 300-400 mL voids indicates empty bladder
Signs of distended bladder:
1) fundus displaced from midline
2) excessive lochia
3) bladder discomfort
4) base of bladder above pubic symphysis
What is the bottom assessment as part of the 7 B’s
1) Inspect the perineum for healing of any lacerations and episiotomy
2) Inspect for edema and hematoma
3) Use a peri bottle after using the bathroom, pat dry instead of wiping
4) Change pads
5) Use ice and topical agents for comfort
What is REEDA when in specting the perineum/bottom area?
R: redness
E: Edema
E: Ecchymosis (bruising)
D: Discharge (from leison/incision)
A: Approximation (are any sutures well-approximated = together, or are they coming apart?)
What is the blood assessment as part of the 7 B’s
1) Check: amount, type, odor (foul may indicate endometrial infection)
* Scant: < 2.5cm
* Light: 2.5-10cm
* Moderate: 10-15cm
* Heavy: pad fully saturated within < 1 hour (concerning)
What is the bowels assessment as part of the 7 B’s
1) Gas is common especially in c-section with anesthesia causing sluggishness = increase fiber and fluids, use stool softener
2) BM usually occurs in 2-3 days following birth
3) Constipation may cause hemorrhoids
What is the extremities assessment as part of the 7 B’s + E
Extremities: inspect legs for variosities and signs of thrombophlebitis
Edema and DTR: pedal or peritibial edema may be present, often goes away days 2-5
Abmulation: assess level of feeling and ability to move if anasthesia is used
**What comfort measures can be taken postpartum?
1) Ice packs: to cause vasoconstriction, prevent edema, best in first 12-24 hours
2) Sitz bath: first 12 hours cool water to reduce pain; 24+ hours use warm water to promote circulation and healing
3) Pericare: squit warm water over perineum after each void + and bowel movement to cleanse area, provide comfort, and prevent infection
4) Aromatherapy: for anxiety, nausea, and pain
5) Acetaminophen: pain relief
6) Ibuprofen: antiinflammatory and pain relief
7) Alternate ibuprofen and acetaminophen
8) Narcotics: surgical or severe pain as needed
9) Topical: witch hazel for comfort
How does breast care differ for bottle vs breast feeding:
Bottle: wear sports bra, use ice, ibuprofen for pain relief, body will absorb milk
Breast: educate on s/s of mastitis, proper latching to avoid trauma, air dry after feeding
**What postpartum warning signs indicate you should call your provider?
1) Severe mood changes, thoughts of harming onself
2) Concerns for infection (tender uterus, painful breasts, fever, chills)
3) Heavy bleeding
4) High BP
5) Increase in swelling
6) Shortness of breath
What are important sexual education points postpartum?
1) Nothing in the vagina for 6 weeks postpartum
2) Vaginal dryness is common (use lubricants and vaginal moisturizers)
3) Milk letdown with orgasms is common
4) Decreased sexual interest in initial postpartum period is common
Which contraceptive method can you not use while breastfeeding?
You cannot use combined birthcontrol methods (combined pill, patch, ring)
Describe each stage of perineal laceration:
Stage 1: tear is limited to fourchette, superficial skin, or vaginal mucosa
Stage 2: laceration includes the above and extends to perineal muscles
Stage 3: Tear includes the above and anal sphincter
Stage 4: Tear includes the above and rectal mucosa
What is the most preventable cause of maternal mortality?
PP hemorrhage
How is PP hemorrhage diagnosed?
Cumulative blood loss of >1,000 mL OR blood loss accompanied by s/s of hypovolemia within first 24 hours pp
What is early PP hemorrhage and what is late PP hemorrhage?
Early: hemorrhage within first 24 hours PP
Late: hemorrhage after first 24 hours up to 12 weeks PP
What are causes of PP hemorrhage:
1) Uterine atony
2) Lacerations
3) Retained placenta
4) Abnormally adhered placenta (accreta)
5) Defects in coagulation (DIC)
6) Uterine inversion
**What are risk factors for PP hemorrhage?
1) Prolonged use of oxytocin
2) High parity
3) Chorioamnionitis
4) General anesthesia
5) Twins or multiple gestation
6) Fundal implantation of cord
7) Operative vaginal delivery
8) Precipitous delivery
9) Placental abruption or previa
10) Fetal death
11) Fever, sepsis
12) Anticoagulation
What might a high risk PP hemorrhage look like?
- Low hematocrit (< 30)
- Placenta previa, accreta, increta, or percreta
- Bleeding
- Coagulation defect
- H/x of PP hemorrhage
- Abnormal vitals (high HR, low BP)
What is the main cause of early PP hemorrhage? What can cause uterine atony?
Uterine atony causes 70-80% of cases where the uterus fails to contract effectively
1) Overdistension of uterus (multiple gestation, movement, polyhydraminos)
2) prolonged labor
3) long use of labor augments
4) obesity
5) infection
What are the symptoms of PP hemorrhage?
1) uterine atony
2) blood clots
3) perineal pad saturation in < 15minutes
4) constant oozing, trickling, or frank flow with bright red blood from vagina
5) Increased HR, low BP
6) Pallor or skin, cold, clammy, poor turgor
7) Oliguria
**How is PP hemorrhage managed?
1) FUNDAL MASSAGE TO CREATE CONTRACTIONS (primary action)
2) Quantify blood loss (QBL): weight saturated pads, measure fluids, subtract irrigation
3) Assess and manage uterus: fundal massage, check height, firmness, position, check lochia
4) Check for bleeding source: check lacerations, episiotomy, hemtomas
5) Vital signs and circulation: BP, HR, O2 sat, elevate legs 20-30 degrees
6) Bladder management: assess for distension, catheter if needed
7) Fluids + 02: maintain IV fluids and O2 support at 10-12L/min via nonrebreather
What medications can be used to manage PP hemorrhage?
1) Pitocin
2) Methylergonovine (Methergine)
3) Misoprostol (Cytotec)
4) Hemabate (Carboprost tromethamine)
5) Transexamic acid (TXA):
Pitocin: what does it do, use, route
What: contracts uterus
Use: pp as postpartum hemorrhage prevention
Route: IM, IV dilution, IV during c-section
Methylergonovine (Methergine): what does it do, use, route, contraindication
What: contracts vascular smooth muscle
Route: IM (acute), PO
Contraindication: Hypertension or cardiac disease
Misoprostol (Cytotec): what does it do, route, onset
What: contracts uterus
Route: buccal, PR (rectally)
Onset: 15-20 minutes (slow)
Hemabate (Carboprost tromethamine): what does it do, route, contraindications, side effect
What does it do: contracts uterus
Route: IM
Contraindications: asthma, renal/liver/cardiovascular damage
Transexamic acid (TXA): what does it do, route, when
What: antifibrinolytic, aids in blood clotting
Route: IV
When: 20-30 minutes prior to or PRN for postpartum hemorrhage
Hematoma: what is it, symptoms, causes, location, treatment
What is it: when blood enters loose connective tissue while overlying skin is intact
Sx: deep, severe, unilateral pain, pressure, hypovolemia (tachycardia, hypotension)
Causes: bleeding lacerations r/t episiotomies or operative deliveries, injury to vessel in asbesence of laceration/incision
Location: vulva, vaginal/paravaginal, retroperitoneum
Tx: conservative tx firt (elevation), surgical intervention, arterial embolization
