Module 3 @Risk PP Family Flashcards
What percentage of maternal deaths are preventable?
1/2
What race is the most susceptible to maternal death
African American women
What are the top 4 causes of maternal mortality? What’s the top?
1) sepsis
2) cardiac disease
3) hemorrhage
4) venous thromboembolism
Many women in this US almost die due to pregnancy related complications. What’s the top pregnancy complication?
Postpartum hemmorage
In the past 10 years there’s been an 183% increase in the # of women who had a blood transfusion around the time they gave birth.
The US is one of the only countries where maternal deaths and injuries have increased
Define postpartum hemmorage
1) blood loss of > 500ml after a vaginal birth
2) 1000ml after a C/s
3) any amount of bleeding that places the mother in hemodynamic jeopardy
Early postpartum hemmorage
First 24 hours after delivery
- blood loss often underestimated
- usual cause is uterine atony (uterus fails to contract)
Late or delayed postpartum hemorrhage
24 hours to 6 weeks postpartum
Usual case is retained placental tissue
Doctors usually underestimate the amount of blood loss. Why don’t we use hemoglobin and hematocrit levels
Change is dependent on the timing of the test and amount of fluid resuscitation given.
Do different women have different blood loss capacities?
Yes. A healthy women has a 30-50% blood volume increase during pregnancy and is more tolerant than a woman who has preexisting anemia, an underlying cardiac condition, or a volume contracted condition secondary to dehydration or preeclampsia
Hence the reason postpartum hemorrhage should be diagnosed with any amount of threatening blood loss.
Potential causes of postpartum hemorrhage:
4 Ts:
1) Tone
2) Tissue
3) Trauma
4) cloTTing
Describe Tone
Uterine atony
Lack of tone is the most common etiology of postpartum hemorrhage
Impaired uterine contractions after birth
Atony: abscence of tone, occurs as a result of that failure of contraction of the myometrial muscle fibers, which can lead to rapid or severe hemorrhage & hypovolemic shock
What causes uterine atony?
Overdistension of the uterus
Prolonged rapid labor
Placental abnormalities
bladder distention
What causes overdistension of the uterus?
- multifetal gestation
- fetal macrosomia
- polyhydramnios
- fetal abnormality (hydrocephalus)
- retained blood
Prolonged rapid labor as it relates to Tone
Poor myometrial contraction can result from fatigue
-especially if artificially stimulates with Pitocin
Can be cause by medications that inhibit contractions: anesthetics, nitrates, non-steroidal, anti-inflammatory drugs (magnesium sulfate, beta-agonists, & nifedipine)
Why would the placenta be retained?
Placental Previa- Placental implantation at the lower uterine segment (doesn’t contract as well as upper uterus)
Gestation earlier than 24 weeks
Placenta accreta- when part of the placenta remains attached (placental adherence)
When with placental previa
Should be informed of the risk of severe postpartum hemorrhage, including the possible need for transfusion/ hysterectomy
What do you do if the woman keeps bleeding but uterine atony is not the cause?
Etiology may be from trauma (baby itself or use of forceps) or cloTTing issues
What is cervical laceration most commonly associated with?
Forcep delivery
The use of forceps or vacuum should never be attempted without the cervix being fully dilated.
Also happens when woman cannot resist “bearing down” before she’s at full dilation
Do C/S deliveries result in twice as much blood?
Yes
Are episiotomies common in L&D?
No
They > blood loss and the risk of anal sphincter tears
Should be avoided urgent delivery is necessary
How do hematomas present?
As a change in vital signs disproportionate to blood loss.
Patients with persistent volume loss or enlargening hemotoma may end up back in the OR and require incision and vacuation of the clot
Uterine rupture is most common
In women who have a history of significant uterine scarring
Women who have problems cloTTing probably
Have preexisting diseases such as hemophilia or Von Willebrand’s Disease
Could be cloTTing abnormalities caused by pregnancy though such as
HELLP, placenta abruption, DIC, or sepsis
CloTTing abnormalities brought on by pregnancy:
-HELLP: a serious complication of High blood pressure during pregnancy
Hemolysis, Elevated Liver Enzymes, Low
Platelet Count
-Placenta abruption- A serious pregnancy complication in which the placenta detaches from the womb (uterus).
- DIC
- Sepsis
DIC
Disseminated intravascular coagulation in pregnancy. The DIC syndrome is the most common cause of an abnormal hemorrhage tendency during pregnancy and the puerperium and reflects systemic activation of the coagulation cascade by circulating thromboplastic material, with secondary activation of the fibrinolytic system.
Risk factors for PPH
1) overdistension 2) previous PPH
3) anesthesia (MgSO4)
4) uterine relaxants (nifidipine, terbutaline). 15) retained placenta
5) trauma 6)Grand multiparty (5+ pregnancies )
7) history of anemia or hemorrhage
8) infection (esp. endometriosis)
9) uterine inversion or rupture
10) placenta previa or accreta
11) abnormal labor pattern (hyper/hypotonic)
12) prolonged or fast labor. 13) obesity
14) oxytocin admin. during labor
Placental Previa vs placental accreta
Placenta Previa- cervix entirely of partially blocked by placenta
Placenta accureta- placenta so low it can be palpated by the examiners finger
Signs of impending hemmorage
Bleeding (>2pads/30-60min)
Light headedness, nausea, visual disturbances
Anxiety, pale/ashen color, clammy skin
Hematoma-painful. Contain 3-500 mL blood
> BP + R, BP same or lower
MAP/Pulse ~ 60 to perfuse adequately
AVG 80-100
Sequelae
a condition which is the consequence of a previous disease or injury.
“the long-term sequelae of infection”
Sequelae of hypovolemia would be PPH probably. It’s the secondary result
What might you see in a woman who is hemorrhaging
Pad soaked in 15 min of <
Blood pressure will elevated just before it drops
Vital sign changes are a late sign of hemorrhage. they would have lost a sig. amount of blood already
Notice pain!! Pain+ urge to poo= PPH
If blood is > prob need to go back to OR
What’s he best intervention for all postpartum women
Intervention
Assess risk (assess placenta)
Have IV site ready, administer Pit @3rd stage of labor
Ensure bladder is empty. Massage fundus if PPH but don’t overmassage before (tire out)
Avoid balloon tamponade & hysterectomy
Frequent VS
Know medications to administer
Cytotec/ Misoprostol/Sidotech
Used to induce labor in miscarriage
It causes uteral contractions and for the cervix to soften
Methergine
Uterotonic and analgesic
It can treat severe bleeding from the uterus after childbirth
Hemabate
For abortion
Stops postpartum bleeding
The volume of a blood clot represents how much blood?
The actual blood amount is 2x the volume of the clot
Symptoms of hypovolemia may not develop until a large volume of blood has already been lost
Puerperal sepsis
Any infection of the genital canal within 28 days after birth or abortion
Common pathogens after birth
Group B strep
E.Coli
Temperature that characterizes postpartum infection
Temp >100.4 on at least 2 of the first 10 days after birth, exclusive of first 24 hours
OR
Temp >101 within first 24 hours
Common infections after birth
Endometriosis Wound infections UTI Mastitis Respiratory Infection
Prevention is the best intervention:
Hand hygiene, maternal perineal hygiene,
Antibiotic administration, wound management
Breast care
More common after c/s
Preconception risk factors
History of previous DVT, UTI, mastitis, pneumonia Diabetes Alcoholism Drug abuse Immunosuppression Anemia Malnutrition
Intrapartum risk factor for infection
Prolonged labor Poor aseptic technique Birth trauma. C/s Prolonged rupture of membranes (water breaks) Chorioamnionitis. Catheterization Internal fetal/uteral ministering Multiple vaginal exams after rupture of membranes Epidural anesthesia PPH Manual removal of placental fragments Episiotomy or lacerations Hematomas
Endometriosis
Most cause of PP infection Usually starts at placental site Can involve entire endometrium & spread to Fallopian tubes + ovaries Lower abdominal tenderness, chills Foul smelling Lochia Tachycardia Subinvolution Reason why we give c/s mom antibiotics prophactically prior to surgery
Treatment for endometriosis
Administer broad spectrum antibiotic
Provide analgesia
Provide emotional support
Interventions for postpartum endometriosis
Monitoring
Administering antibiotics
If risk of hemorrhage is noted, order medications to treat subinvolution
Encourage semi-Fowler’s position (90)
Risk factors for developing mastitis
Engorgment
Cracked nipples
Blocked ducts
Pegged ducts
Mild engorgement means that milk is not coming due to edema and milk stasis
What’s he best preventative measure for engorgment
A good latch and baby drinking
Education
Interventions for engorgment
Warmth/ warm showers
Use of ice or cabbage leaves after breastfeeding
Anti-inflammatory meds and breast massage
Cracked nipples give bacteria an “in”
Lanolin
Treats sore nipples
What bacteria causes mastasis?
S. aureus
Engorgment and stasis of milk preceded mastasis
Typically happens in the lactating breast at the 2nd or 2rd week after pregnancy
Treatment: antibiotics, analgesics, & antipyretic
What factors put the mom at risk for postpartum mastasis
Underwire bra
Missed feedings
Improper breast hygiene
Poor infant suck
NOT breast pumping
Best prevention for UTI
Wipe front to back Use peri bottles Sitz bath > fluid intake Wash their hands
Symptoms of UTI
Burning and pain while urinating Lower abdominal pain Low grade fever Flank pain Protuenuria, hematuria, bacteriuria, nitrates, and WBC
Treatment for a UTI
assess vitals Q4 Encourage fluid intake monied I&O Administer antibiotics as ordered Administer antipyretics, antipasmodics, and antiemetic Encourage rest
3 thromboembolic conditions concerned with the postpartum period
1) Superficial venous thrombosis
- involves superficial venous thrombosis
2) Deep vein thrombosis
Involves veins in the calves, thigh, or pelvis
3) pulmonary embolism
Complication of DVT
Occurs when part of a blood clot dislodges and is carried to pulmonary artery where it occludes the vessel & obstructs blood flow to lungs
Why has incidence of thrombosis declined in the past 20 years?
Early ambulation after childbirth
Major causes of thrombosis are venostasis & hypercoagulation (to prevent hemorrhage PP women have high fibrinogen)
Risk factors for thrombosis
> fibrinogen levels during pregnancy (normal) History of thromboembolic disease or varicosities > parity Obesity. Smoking Advanced maternal age Immobility C/s Tissue trauma Blood type other than O Dehydration
What are the nurses psychological responsibilities for her patient family?
Assess and screen for women who are at risk for either devoting or are currently suffering from a mood disorder
We’re focusing less on baby blues and more on PP depression and PP psychosis
Postpartum depression
10-20% of all postpartum patients
Symptoms generally noted within the 1st 3 months but can occur up to a year after delivery
Treatment for PP depression
Primary prevention Psychotherapy Medication Electroconvulsive therapy Combination therapy
Postpartum Psychosis
Days to weeks after delivery
EMERGENCY
Hallucinations, delusions, agitations, inability to sleep, bizarre or irrational behavior
History of bipolar disorder or history of postpartum psychosis
Risk of suicude or homicide is high.
Antipsychotics & mood stabilizers like Li+
