mat pt 3 ppt and notes-PPH and infection (mother) Flashcards
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.
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
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
why do UTIs occur postpartum
UTIs are very common after delivery. Delivering the baby causes trauma to urethra, exams, catheterizations also contribute
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)
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
most common cause of PPH
uterine atony
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
how quickly should womans lochia normally
within a wk postpartum
what could cause uterine atony
conditions that distend the uterus
Cervical or uterine laceration
uterus unable to contract readily
inadequate blood coagulation
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
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
how much blood saturates a pad
best way to assess a pad
25-50ml
weigh it
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)?
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
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 cantubal 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 localizedher 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 gravitycollects
- Rigid abdm (don’t just check her fundus when assessing in gen), high fever, rapid pulse, V
• Might lead to scarring & impact fertility
