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NURS 330: Obstetrics > LEC 8: Postpartum Health Challenges > Flashcards

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
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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%
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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)
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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
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5
Q

4 T’s of the Most Common Reasons for PPH to Occur

A
  1. Tone (70%)
  2. Trauma (20%)
  3. Tissue (10%)
  4. Thrombin (<1%)
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6
Q

4 T’s: Tine: Uterin Atony (70%)

A
  • Lack of uterine muscle tone
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7
Q

​Why may the uterine have difficulty getting abck to resting tone?

A
  • Overdistended uterus
  • Exhausted
  • Infection
  • Abnormalities
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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
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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
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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
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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
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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
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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
  • Fundal massage to stimualte contraction and evacuate
  • Identify and suture lacerations
  • Vital signs (watching for signs of shock)
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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
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15
Q

Thrombosis

A
  • PP woman at risk
    • Venous stasis
    • Hypercoagualtion
  • PP risk of pulmonary embolism
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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
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

NURS 330: Obstetrics (19 decks)

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