mat pt 3 ppt and notes-PPH and infection (mother) Flashcards by Willow Belanger

why does High risk, prolonged, or difficult delivery warrant increased postpartum monitoring/what is pt at risk of

there is an increased risk of PPH, infection, PPD.

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acronym that can be used to assess new mom postpartum

what kind of GI problem are you worried about

B-breasts
U-uterus
B-bladder
B-bowel--worried about constipation d/t the narcotics. Also the trauma to perineal area can transmit to rectal area. They are hesitant to have BM
L-legs
E-emotions

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what are common complications postpartum

Mastitis, breastfeeding problems
PPH-uterine atony,  cervical or vaginal lacerations,  hematomas (ouch!) or retained POC, endometritis/perineal cellulitis
UTIs
Constipation/Pain
Thrombophlebitis
Postpartum Depression

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why do UTIs occur postpartum

UTIs are very common after delivery. Delivering the baby causes trauma to urethra, exams, catheterizations also contribute

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what amount of blood loss is typical w PPH and when is the greatest danger of hemorrhage

traditionally blood loss of 500m+ from vaginal. If cesarean >1000ml or 10% dec in Hct
greatest danger for hem is in first 24h (and the first 2-4hrs in particular) although it can occur late (>24h after)

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what are the primary causes of PPH and how to easily remember them in summary

the 4 Ts
Tissue-things left in uters
Tone-uterine atony
Trauma-tears to uterus, rectum
Thrombi-Clotting issue

Prolonged labour
Polyhydramnios
Macrosomia
Shoulder dystocia
Multiple gestation
Use of forceps
Retained products of conception (POC)
Endometritis

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most common cause of PPH

uterine atony

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what constitutes a late PPH and why does this occur usually

Late: >24hrs to 6wks is gen due to POC. Eg amniotic sac, clots. Or could be from infection

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how quickly should womans lochia normally

within a wk postpartum

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what could cause uterine atony

conditions that distend the uterus

Cervical or uterine laceration

uterus unable to contract readily

inadequate blood coagulation

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inadequate blood coag and conditions that distend the uterus as risks of PPH

what conditions could lead to these

conditions that distend the uterus:
o	Multiple gestation
o	Hydramnios
o	Lg baby >9lb
o	Fibroid tumours or uterine myomas

inadequate blood coagulation
• Fetal death
• DIC

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risk of PPH
uterus unable to contract readily
what might lead to this

deep anesthesia or analgesia
labor w oxytocin assist or ugment
high parity or mat age >35
previout uterine sx
prolonged or difficult labour
chorioamnionitis or endometritis
2* mat illness like anemia
Hx of PPH
Prolonged use of magnesium sulfate or other tocolytic

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how much blood saturates a pad

best way to assess a pad

25-50ml

weigh it

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what to assess to catch PPH before it happens

Fundus –placement, timing
Lochia-amount, timing, colour, clotting
Perineum-are there tears, sutures, bruising, swelling?
VS (pulse, respirations, blood pressure)
Pallor and fatigue or SOBOE, capillary refill?
Has the patient voided?
Does the patient have any risk factors?
Does or should the patient have an IV? And is there any medication in the IV (oxytocin)?

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the pts fundus is off to the right side what does this indicate?
the fundus has gone down 1 fingerbreadth in a day is this bad

to R often indicates bladder is full

normal amount for fundus to dec

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how often should women be changing their pads

check when she changed it last as soon as you come on. We do not want it soaked. Advocate for her changing her pad q3hrs as theres risk of infection

what is most important assessment or first thing to do w PPH
where could the bleed be coming from

why is PPH such a concern in terms of severity

not vitals! check the lochia and the fundus. they are the more important irculatory assessment

If the bleeding isnt coming from uterus then check the perineum. If you see a bright red trickle from vagina-its likely a tear or it could be a clot

the uterus gets 1L a min and therefore she can bleed out in mins

how to deal with PPH

call for help
• fundal massage to encourage contraction-usually effective unless severely lacking tone. Ask her to void first unless blood loss makes it urgnt. Then one hand at top of fundus and one at symphis pubis to support and prevent prolapsed, rotate upper hand. Do until firm then continue to support w slight downward P from upper hand.
Lower the head of the bed (it lowers the height of the uterus and gets blood to vital organs)
Oxytocin bolus then, mesoprostole, ergometrin (IM), hemobate/carboprost
If this doesnt work then wheel to hysterectomy
Catheter for bladder ut of the way

it says oxygen in our notes
you can elevate her legs

what is a consideration w oxytocin bolus

it will only work for an hr so atony might resume if given single dose

what does hemabate/carboprost tromethamine have a side effect
what is it

it is a prostaglandin
(causes sm muscle contraction. Causes quite extreme cramping. Causes bowels to cramp as well. This tends to cause uncontrolled diarrhea in the bed

how is misoprostole given what side effect does it have and what might pt need

Misoprostol (cytotec) a prostaglandin E1 analogue might be given rectally if other methods ineffective or unavail
Prostaglandins tend to cause diarrhea and nausea. Might need antiemetic

CarboprostTromethamine (hemabate) a prostaglandin F2a derivative or
methylergonovine maleate (Methergine) is an ergot compound. Both given IM.
• Misoprostol (cytotec) prostaglandin

what common side effect do these all have

• These meds all inc BP, beware ifpt has HTN

what does PPH put pt at risk of

and why
what kind of care might she need after PPH (not immed after)

PP depression
Situational low self-esteem r/t postpartum fatigue and inability to feed infant
Risk for impaired role transition r/t fatigue d/t PPH
Ineffective breastfeeding r/t fatigue d/t PPH
infection

A PPH…might take 6wks to rebuild blood volume
The fatigue can feed into PPD
They might need help with hygiene
Theyre going to be exhausted
They might need help with getting to shower
They might need follow up nursing care

what to teach the mom after PPH/what to evaluate

Evaluation
How much blood was lost (EBL)?
Is the patient well oxygenated, perfused, are they short of breath on exertion? Are VS within normal limits?
Did your nursing care allow for rest, successful feeding?
Do the family understand the increased needs for iron rich foods, rest, and support in general?
Does the family know the signs and symptoms of PPD and who to contact if they are concerned? Has the mother had her need for rest and sleep protected while receiving nursing care?

best position to assess flow

lying on side to check for blood pooling underneath her

what is bimanual compression and when is it used

* If fundal massage & meds don’t help the bleed then sonogram might be done for retained POC * Dr might order bimanual compression: insert a hand into vag while pushing against fundus through abdm wall w other hand. If doesn’t work might open her up surgically to see

what can puerperal infection lead to and why

peritonitis or septicemia | Septicemia is easy from this as the uterus is so highly vascularized and it enters so easily

what inc the risk of PP infect

``` >24 ROM Retained POC PPH Pre-existing anemia Prolonged labour Use of instruments Internal fetal monitoring Repeated vaginal exams ++ manual exploration of uterus after delivery Unsterilized equipment and gloves Improper or no pericare after delivery Poor handwashing Shared supplies between patients Cleaning between patients limited or poorly done Bedding soiled (think PV losses, moisture, feet in the bed, guests on the bed) ```

with Rupture of Membranes when might htey intervene and why is this such a risk for infection why is PPH a risk

>24hr ROM. The amniotic fluid is like sugar to the bact...they love it. With all the exams etc you introduce infect. More than 18hrs ROM and no baby and they might give Abx PPH-when they lose their blood they also lose their immunologic factors. Also anemia

what to teach mums to do to prevent infect

Must teach all women how to provide pericare. Every time that you go to bathroom empty bowels then use squirt bottle. Discourage women from walk around in bare feet and then sit cross-legged

what are the assessments for postpartum infection

Assessments-uterine pain, malaise, foul smelling lochia, fever, increased PV losses, discoloured lochia, usually starting 3-4 days after delivery, WBC count may not be helpful as is commonly elevated after delivery

how does fever affect breast milk production how might Abx be bad for babe

• W high fever breast milk might become deficient manual expression or formula the Abx could be incompatible w breastfeeding. could lead to thrush--watch for opportunistic fungal growth . also might affect vit K so watch for bruising

how does infection present in terms of lochia, WBC, and timing postpartum

Lochia may be frothy. May have greenish tinge An infected uterus cant involute and the bleeding picks up The infect is usually 3-4days after inoculation with the bact-eg after delivery WBCs if >16 its likely infect. The WBCs are higher than usual pre-emptively

how is temperature affected by events postpartum

* Benign temp elevation may occur during first postpartal day esp if not drinking enough * Fever of endometritis gen manifests on day 3-4 postpartum (likely theyre infected during birth) * Temp of 38* for 2 consecutive 24hr periods suggests infect * Rise in temp on 3rd or 4th day occurs at same time of breast milk cong in but suspect endometritis until its ruled out

what is endometritis what is complication of endometritis

* Infect of lining of uterus. Can occur w any birth but gen assoc w chorioamnionitis&csection * Endometritis cantubal scarring & impact fertility

interventions for infection postpartum

Interventions-Teach signs and symptoms of infection prior to discharge, abx, analgesia, oxytocic agent may be needed to support involution, strict asepsis and infection control measures to prevent spread of microorganisms to others

what causes infect of perinuem | how to address infection of perineum

* Can be from sutures. Gen remains localizedher temp might not inc. other s/s present * Systemic or topical Abx, sitz bath, moist, warm compress, Hubbard tank, change pads freq, back to front, might open the sutures & let wound heal by tertiary intention * Don’t put babe on sheets w any infect

how to differentiate lactogenesis from infection

A woman is diaphoretic and sas she feels hot and like shes getting the flu. Lactogenesis can cause a slight raise in temp. Milk comes in on day 3 around when an infect would. Look at lochia, ask about it, palpate uterus-make sure its 3-4cm below the umbilicus

peritonitis often occurs from what how might she present possibl complications

* Gen as result of endometritis where the infect spreads through lymphatic sys or directly from fallopian tubes or uteine wall to peritoneal cavity * Abscess may form in cul de sca of Douglas as its lowest point of peritoneal cavity and gravitycollects * Rigid abdm (don’t just check her fundus when assessing in gen), high fever, rapid pulse, V • Might lead to scarring & impact fertility