LEC 8: Postpartum Health Challenges Flashcards
1
Q
Features of PPH
A
- Occurs in 5 to 15% of deliveries
- Early PPH
- Birth to 24 hours
- Late PPH
- 24 hours to 6 weeks
- Cause of significant maternal mortality and morbidity
- Prevention, early recognition and appropriate interventiona re key to minimize impact
2
Q
Postpartum Haemorrhage (PPH)
A
- Incidence
- Worldwide: 140,000 PPH deaths/year
- Canada: 2.5 deaths/ 1,000,000 births
- Identification of those at risk and early interventions
- Prophylaxis
- Routine oxytocin adminsitration in the 3rd stage of labour
- Can decrease the risk pf PPH more than 40%
3
Q
Risk Factors for Postpartum Hemorrhage
A
- Percipitous labour (less than 3 hours)
- Uterine atony
- Placenta previa or abruption placentae
- Labour indictuion or augmentation
- Operative procedures (vaccumed extractions, forcebs, ceaserean birth)
- Retained placental fragments
- Prolong third stage of labour (more thant 30 minutes)
- Multiparity, more than three briths closely spaced
- Uterin overdistention (large infant, twins, hydramios)
4
Q
Why is PPH dificult to define?
A
- >500 mL vaginal delivery
- > 1,000 mL c-section delivery
- 10% declin in hematocrit
- Need for tansfusion
5
Q
4 T’s of the Most Common Reasons for PPH to Occur
A
- Tone (70%)
- Trauma (20%)
- Tissue (10%)
- Thrombin (<1%)
6
Q
4 T’s: Tine: Uterin Atony (70%)
A
- Lack of uterine muscle tone
7
Q
Why may the uterine have difficulty getting abck to resting tone?
A
- Overdistended uterus
- Exhausted
- Infection
- Abnormalities
8
Q
Treatment for Lack of Uterine Muscle Tone
A
- Perform fundal massage
- If the uterus does not firm up with fundal message, check for clots and tissue
- Empty bladder
- Adminsiter uterine stimulants
- Oxttocin IV/IM
- Cytotec (Misoprostil)
- Cerbetocin (if C/S)
- Hemabate IM
- May see antifibrinolytic given
- Tranexamic acid
9
Q
4 T’s: Trauma (20%)
A
- Cervical, vaginal, perineal laceratons suspected when bright-red bleeding in presence of contracted uterus
- Fundus is nice and firm- DO NOT need ocytocin or to due fundus massage
- Risk: assisted delivery such as forceps or vaccumed
- May need to srugically intervent ot fix the laceration
- Hematome
- Uterin inversion
- Not very common
- Uterine rupture
- Not very common
10
Q
4 T’s: Tissue Retained Products of Conception (10%)
A
- Somone who goes home and then starts bleeding. Will look clotty and darker red- want to message the fundus and start oxytocin- if there is retained tissue cannot fix with simple massage- might need to go back to the OR and have a DnC- if during the funal masssage tissue comes out need ot send of testing
- Occurs in 2 to 3% of all vaginal births
- If not expelled
- Manually removed
- If woman does not have an epidural anesthesia in place need sgenreal anestetic
11
Q
4 T’s: Thrombin (<1%)
A
- Pre-exhisting or acqurired bleeding disorders
- Something to wonder about if none of the interventions where working
- Interventions” packed cells, pee
12
Q
Signs of PPH
A
- Blood and blood clots
- Might be lots of blood but clotty or bright red
- Excessive or bright red bleeding
- A boggy fundus that does not respond to massage
- Abnormal clots
- Any unsual pelvic discomfort or backache
- Persistent bleeding in the presence of a firmly contracted uterus
- Rise in the level of the fundus of the uterus
- Increased pulse or decreased BP
- Hematoma formation or bulging/ shini in the perineal area
- Decreased level of consciousness
- Rising or dispalced uterus
- Full baldder can cause a dispalce uterus and increase risk for PPH
13
Q
Treatment of PPH
A
- Intial treatment includes:
- Early recognition
- Soaking a pad in an hour
- Clots larger than a loonie
- Prompt attention to resuscitation (ABC’s)
- Identification of the cause of the bleeding
- Appropriate treatment based on etiology
- Multidisciplinary appraoch
- Early recognition
- Fundal massage to stimualte contraction and evacuate
- Identify and suture lacerations
- Vital signs (watching for signs of shock)
14
Q
If Bleeding Won’t Stop: What do you do?
A
- IV 20-40 IU oxytocin/ 100 mls at 120 mls/hr (large bored IV- 18 G+)
- Uterotonic medicaiton
- Cytotec, Ergometrine, Hemabate, Carbetocin
- CBC, Crossmathc, blood transfusion
- Foley, oxygen, NPO
- Pack uterus/ Bakri balloon
- Cauterization
- Hysterectomy
15
Q
Thrombosis
A
- PP woman at risk
- Venous stasis
- Hypercoagualtion
- PP risk of pulmonary embolism
16
Q
Interventions/ Thrombosis Prevention
A
- Avoid
- Smoking
- Sitting/ standing in one positon for long periods
- Oral contraceptives
- Encourage
- Early activity
- Leg exercises
- Consider
- Compression devices
- Ordered on the majority of the c-section patient
- Antocoagulatns
- Compression devices
17
Q
Infections: Metritis
A
- Abdominal pain
- Fever
- Foul lochia
- Nausea/ anorexia
- Fatigue
- Lathargy
- Increased WBC
- WBC can be slightly elevated BUt if it was an infection it would be very high
18
Q
Infections: Wound Infection
A
- Surgical, laceration, episotomy
- REEDA
- Pain/tenderness at site
- Fever
- Increased WBC
- Foul odour
19
Q
Infections: UTI
A
Commonly occurs during pregnancy
20
Q
Infection: Mastitis
A
- Infection of a milk duct- occurs due to a plugged duct
- Massage any areas, ocntinue to feed baby
- Accompaned by fever
21
Q
Risk Factors for Postpartum Infection
A
- Operative procedure
- Forceps
- C-section
- Caccume extraction
- History of diabetes, including gestaionl-onset diabetes
- Proling labour
- More than 24 hours
- Use of indwelling urinary catheter
- Anemia (hemoglobin <120 g/L)
- Multiple vaginal examination during labour
- Prolonged rupture of membranes (more thant 24 hours)
- Manual extraction of placenta
- Compromised immune system (HIV positive)
22
Q
Factors Placing a Woman at Risk for Postpartum Infection
A
- Prolonged (>6 hours) premature rupture of membranes (removes the protective barrier to fetus and amniotic fluid so bacteria can ascend)
- Insertion of fetal scalp electrode or intrauterine pressure catheter for internal fetal monitoring during labour (provides entry into uterine cavity)
- Cesarean birth (allows bacterial entry due to break in protective skin barrier)
- Instrument-assisted childbirth, such as forceps or vacuum extraction (increases risk for trauma to genital tract, which provides bacteria access to grow)
- Urinary catheterization (could allow entry of bacteria into bladder due to break in aseptic technique)
- Regional anesthesia that decreases perception to void (causes urinary stasis and increases risk for urinary tract infection)
- Unwell staff attending to woman (promotes droplet infection from personnel)
- Compromised health status, such as anemia, obesity, smoking, drug abuse (reduces the body’s immune system and decreases ability to fight infection)
- Preexisting colonization of lower genital tract with bac- terial vaginosis, C. trachomatis, group B streptococci, S. aureus, and E. coli (allows microbes to ascend)
- Retained placental fragments (provides medium for bacterial growth)
- Manual removal of a retained placenta (causes trauma to the lining of the uterus and thus opens up sites for bacterial invasion)
- Trauma to the genital tract, such as episiotomy or lacera- tions (provides a portal of entry for bacteria)
- Prolonged labour with frequent vaginal examinations to check progress (allows time for bacteria to multiply and increases potential exposure to microorganisms or trauma)
- Poor nutritional status (reduces body’s ability to repair tissue)
- Gestational diabetes (decreases body’s healing ability and provides higher glucose levels on skin and in urine, which encourages bacterial growth)
- ·Break in aseptic technique during surgery or birthing process by the birth attendant or nurses (allows entry of bacteria)
23
Q
Postpartum Danger Sings
A
- Fever >38 degrees
- Foul odour to lochia or unexpected change to colour or amount
- Visual changes or headaches
- Claf pain
- Swelling, redness, discharge at incision site
- Dysuria, brining on voiding
- SOB or difficulty breathing
- Depression or extreme mood swings
