Lecture 8 - At Risk Postpartum Flashcards
What is the leading cause of maternal death worldwide? Why?
PPH
–> Occurs with little warning and is often unrecognized until the person has profound symptoms
What was the traditional definition of a PPH? What is recommended now?
Estimate blood loss following vaginal and caesarean birth:
V –> 500 ml
CS –> 1000 ml
Recently, the recommendation is to measure (weigh) the blood
What is an early/acute/primary PPH? What causes it?
In the first 24 hours
–> Uterine atony
–> Lacerations
–> Retained placental tissue
–> Coagulopathies
What is the most common kind of PPH?
Early
What is a late PPH? What causes it?
Occurs 24 hours-12 weeks
–> Subinvolution d/t retained placental tissue, uterine infection
How do we manage the third stage of labour to prevent PPH?
- Administer IV/IM oxytocin after delivery of the anterior shoulder
- Immediate skin-to-skin
- Delayed cord clamping (1-3 mins)
What infusion rate should oxytocin be administered to avoid overdosing?
Hang a secondary line and 4 IU/100 ml
–> Infuse at 7.5-15 IU/hour
How can we prevent PPH before labour?
Be alert to the symptoms and be prepared to act quickly.
Assess and treat ID/IDA at or before 28 weeks
What assessments/interventions should be done to prevent PPH?
- Empty bladder
- Assess tone + massage fundus PRN
- Accurate measurement of blood loss
- If bleeding, assess circulatory status
What are the four Ts of risk factors for PPH?
Tone - uterus
Trauma - laceration, hematoma, uterine inversion
Tissue - Retained placenta
Thrombin - coagulopathies
Which pre-existing and pregnancy related coagulopathies can affect coagulation status?
Pre-Existing: ITP, vWD
Pregnancy Related: DIC, HELLP
What does the ORDER acronym stand for with managing PPH?
O - Oxygen
R - Restore circulating volume
D - Drugs as ordered for uterine tone
E - Evaluate response
R - Remedy underlying cause through bimanual compression or prep for surgery
what is considered mild, moderate, and severe shock?
Mild - < 20% Blood Loss
–> Diaphoresis, increased cap refill, cool extremities, anxiety
Mod - 20-40% Blood Loss
–> TachyTachy
–> Postural HypoTN
–> Oliguria
Severe - > 40% Blood Loss
–> HypoTN, hemodynamic instability
–> Agitation, confusion
What is considered mild shock from blood loss?
Mild - < 20% Blood Loss
–> Diaphoresis, increased cap refill, cool extremities, anxiety
What is considered moderate shock from blood loss?
Mod - 20-40% Blood Loss
–> TachyTachy
–> Postural HypoTN
–> Oliguria
What is considered severe shock from blood loss?
Severe - > 40% Blood Loss
–> HypoTN, hemodynamic instability
–> Anxiety/agitation
What does a superficial venous thrombosis look and feel like?
Similar to DVT
–> Pain, tenderness, warm, red, enlarged or hardened area
Why are superficial venous thrombosis less concerning than DVT?
Superficial is less likely to dislodge into heart/lungs/cerebral circulation
–> More adherent to venous walls
How is superficial venous thrombosis managed?
NSAIDS
Rest + elevation
Ambulation
Compression stockings
Heat
Anticoagulant therapy might be indicated
Superficial venous thrombosis is most common at what point during pregnancy?
Postpartum period
When is DVT most common during the pregnancy process?
During the pregnancy itself d/t weight of baby
How is DVT diagnosed?
Imaging
Why is DVT harder to detect?
Redness, warmth will be harder to notice
How is DVT treated?
IV Heparin
Bedrest, leg elevation, analgesia
With improvement some ambulation, compression stockings and PO warfarin for 3 months
How is PE managed?
Assess for ABCS + IV Access maintained
–> Treat for shock
–> O2
Immediate continuous IV heparin
What are some risks of postpartum infection?
Obesity
Concurrent immunosuppression
C/S birth or other operative
Prolonged ROM
Prolonged labour
Internal fetal monitoring
What are the four most common kinds of infection in the postpartum period?
Endometritis
Wound
UTI
Mastitis (Infection)
What is the most common infection during the postpartum period? What are the symptoms and how is it treated?
Endometritis
–> Chills, nausea, lethargy, pelvic pain + tenderness, foul smelling lochia
–> IV antibiotics, rest, hydration, pain relief, comfort measures
What are signs of wound infections postpartum?
Poor REEDA assessment
Treatment: culture site, IV abx, wound care + sitz bath + warm compresses to perineal area
What predisposes people to UTI in the postpartum period?
Catheterization, pelvic exams, epidural, c/s, personal hx
When does infective mastitis usually occur? What are the symptoms? What are the treatments?
Usually week 3 or later
–> Flu-like symptoms, local breast tenderness, pain, redness
–> Treat with abx, continue breastfeeding
What is the best prevention for postpartum infection?
Hand washing, hygiene.
Anticipatory teaching
–> Nutrition, hydration, hygiene, S&S of infection
What are the relevant labs when assessing coagulation status?
pt, ptt, fibrinogen degradation products (elevated)
Plts, fibrinogen (low)
What is a late sign of hypovolemic shock of a postpartum patient?
HypoTN - well compensated until severe hypovolemia
What veins are affected by superficial venous thrombosis?
The superficial saphenous system
What veins are affects by DVT?
Extend from foot to the iliofemoral region
