Module 3 @Risk PP Family

Question 1

What percentage of maternal deaths are preventable?

Answer 1

1/2

Question 2

What race is the most susceptible to maternal death

Answer 2

African American women

Question 3

What are the top 4 causes of maternal mortality? What’s the top?

Answer 3

1) sepsis
2) cardiac disease
3) hemorrhage
4) venous thromboembolism

Question 4

Many women in this US almost die due to pregnancy related complications. What’s the top pregnancy complication?

Answer 4

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

Question 5

Define postpartum hemmorage

Answer 5

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

Question 6

Early postpartum hemmorage

Answer 6

First 24 hours after delivery

• blood loss often underestimated
• usual cause is uterine atony (uterus fails to contract)

Question 7

Late or delayed postpartum hemorrhage

Answer 7

24 hours to 6 weeks postpartum

Usual case is retained placental tissue

Question 8

Doctors usually underestimate the amount of blood loss. Why don’t we use hemoglobin and hematocrit levels

Answer 8

Change is dependent on the timing of the test and amount of fluid resuscitation given.

Question 9

Do different women have different blood loss capacities?

Answer 9

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.

Question 10

Potential causes of postpartum hemorrhage:

Answer 10

4 Ts:

1) Tone
2) Tissue
3) Trauma
4) cloTTing

Question 11

Describe Tone

Answer 11

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

Question 12

What causes uterine atony?

Answer 12

Overdistension of the uterus
Prolonged rapid labor
Placental abnormalities
bladder distention

Question 13

What causes overdistension of the uterus?

Answer 13

• multifetal gestation
• fetal macrosomia
• polyhydramnios
• fetal abnormality (hydrocephalus)
• retained blood

Question 14

Prolonged rapid labor as it relates to Tone

Answer 14

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)

Question 15

Why would the placenta be retained?

Answer 15

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)

Question 16

When with placental previa

Answer 16

Should be informed of the risk of severe postpartum hemorrhage, including the possible need for transfusion/ hysterectomy

Question 17

What do you do if the woman keeps bleeding but uterine atony is not the cause?

Answer 17

Etiology may be from trauma (baby itself or use of forceps) or cloTTing issues

Question 18

What is cervical laceration most commonly associated with?

Answer 18

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

Question 19

Do C/S deliveries result in twice as much blood?

Answer 19

Yes

Question 20

Are episiotomies common in L&D?

Answer 20

No
They > blood loss and the risk of anal sphincter tears

Should be avoided urgent delivery is necessary

Question 21

How do hematomas present?

Answer 21

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

Question 22

Uterine rupture is most common

Answer 22

In women who have a history of significant uterine scarring

Question 23

Women who have problems cloTTing probably

Answer 23

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

Question 24

CloTTing abnormalities brought on by pregnancy:

Answer 24

-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

Question 25

DIC

Answer 25

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.

Question 26

Risk factors for PPH

Answer 26

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

Question 27

Placental Previa vs placental accreta

Answer 27

Placenta Previa- cervix entirely of partially blocked by placenta Placenta accureta- placenta so low it can be palpated by the examiners finger

Question 28

Signs of impending hemmorage

Answer 28

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

Question 29

Sequelae

Answer 29

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

Question 30

What might you see in a woman who is hemorrhaging

Answer 30

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

Question 31

What’s he best intervention for all postpartum women

Answer 31

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

Question 32

Cytotec/ Misoprostol/Sidotech

Answer 32

Used to induce labor in miscarriage It causes uteral contractions and for the cervix to soften

Question 33

Methergine

Answer 33

Uterotonic and analgesic | It can treat severe bleeding from the uterus after childbirth

Question 34

Hemabate

Answer 34

For abortion | Stops postpartum bleeding

Question 35

The volume of a blood clot represents how much blood?

Answer 35

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

Question 36

Puerperal sepsis

Answer 36

Any infection of the genital canal within 28 days after birth or abortion

Question 37

Common pathogens after birth

Answer 37

Group B strep | E.Coli

Question 38

Temperature that characterizes postpartum infection

Answer 38

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

Question 39

Common infections after birth

Answer 39

``` 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

Question 40

Preconception risk factors

Answer 40

``` History of previous DVT, UTI, mastitis, pneumonia Diabetes Alcoholism Drug abuse Immunosuppression Anemia Malnutrition ```

Question 41

Intrapartum risk factor for infection

Answer 41

``` 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 ```

Question 42

Endometriosis

Answer 42

``` 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 ```

Question 43

Treatment for endometriosis

Answer 43

Administer broad spectrum antibiotic Provide analgesia Provide emotional support

Question 44

Interventions for postpartum endometriosis

Answer 44

Monitoring Administering antibiotics If risk of hemorrhage is noted, order medications to treat subinvolution Encourage semi-Fowler’s position (90)

Question 45

Risk factors for developing mastitis

Answer 45

Engorgment Cracked nipples Blocked ducts Pegged ducts Mild engorgement means that milk is not coming due to edema and milk stasis

Question 46

What’s he best preventative measure for engorgment

Answer 46

A good latch and baby drinking | Education

Question 47

Interventions for engorgment

Answer 47

Warmth/ warm showers Use of ice or cabbage leaves after breastfeeding Anti-inflammatory meds and breast massage Cracked nipples give bacteria an “in”

Question 48

Lanolin

Answer 48

Treats sore nipples

Question 49

What bacteria causes mastasis?

Answer 49

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

Question 50

What factors put the mom at risk for postpartum mastasis

Answer 50

Underwire bra Missed feedings Improper breast hygiene Poor infant suck NOT breast pumping

Question 51

Best prevention for UTI

Answer 51

``` Wipe front to back Use peri bottles Sitz bath > fluid intake Wash their hands ```

Question 52

Symptoms of UTI

Answer 52

``` Burning and pain while urinating Lower abdominal pain Low grade fever Flank pain Protuenuria, hematuria, bacteriuria, nitrates, and WBC ```

Question 53

Treatment for a UTI

Answer 53

``` assess vitals Q4 Encourage fluid intake monied I&O Administer antibiotics as ordered Administer antipyretics, antipasmodics, and antiemetic Encourage rest ```

Question 54

3 thromboembolic conditions concerned with the postpartum period

Answer 54

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

Question 55

Why has incidence of thrombosis declined in the past 20 years?

Answer 55

Early ambulation after childbirth Major causes of thrombosis are venostasis & hypercoagulation (to prevent hemorrhage PP women have high fibrinogen)

Question 56

Risk factors for thrombosis

Answer 56

``` > 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 ```

Question 57

What are the nurses psychological responsibilities for her patient family?

Answer 57

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

Question 58

Postpartum depression

Answer 58

10-20% of all postpartum patients Symptoms generally noted within the 1st 3 months but can occur up to a year after delivery

Question 59

Treatment for PP depression

Answer 59

``` Primary prevention Psychotherapy Medication Electroconvulsive therapy Combination therapy ```

Question 60

Postpartum Psychosis

Answer 60

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+