Nursing mgmt of postpartum woman at risk

Question 1

postpartum follow up visit

Answer 1

-done within 3 weeks, no longer 6 weeks
-ongoing care no later than 12 weeks

Question 2

postpartum hemorrhage (pph)

Answer 2

-life threatening
-leading cause of maternal death
-blood loss > 1000 ml w/ signs of hypovolemia within 24 hrs after birth, regardless of method of delivery
-Can lead to organ failure, shock, edema, thrombosis, ARD, sepsis, anemia
-blood loss within 24 hrs = primary (immediate or early) pph
-blood loss 24 hrs - 12 weeks after birth = delayed (late) pph

Question 3

uterine atony

Answer 3

-most common cause of pph
-failure of uterus to contract after birth
-mild shock: 20% blood loss, diaphoresis w/ cool extremities
-moderate shock: 20-40% blood loss, tachy w/ hypotension
-severe shock: > 40% blood loss, hypotension w/ confusion

Question 4

causes of pph: tone

Answer 4

-uterine atony –> hypovolemic shock
-distended bladder displaced uterus from midline to either side, impeding ability for uterus to contract

Question 5

causes of pph: tissue

Answer 5

-retained placental fragments, membranes, or clots left inside uterus
-small gush fo blood w/ lengthening of umbilical cord and slight rise of uterus in pelvis
-d/t failure of complete placental separation and expulsion
-clots that occupy space prevent uterine contractions
-placenta accreta: rare condition in which chorionic villi adhere to myometrium, causing placenta to adhere abnormally to uterus and not separate and deliver spontaneously

Question 6

causes of pph: uterine subinvolution

Answer 6

-failure of uterus to return to its normal size and condition after birth
-myometrial fibers don’t contract
-fundal height is higher than expected w/ boggy uterus
-lochia fails to change colors from red to serosa to alba within 4-6 weeks w/ bimanual vaginal exam or ultrasound

Question 7

causes of pph: trauma

Answer 7

hematomas
-present as pain or change in VS disproportionate to amt of blood loss
-seen w/ episiotomy, instrumental birth, or nulliparity
-prevented w/ gentle birth or repair of lacerations

Uterine inversion
-happens when top of uterus collapses into inner cavity d/t excessive fundal pressure or pulling of umbilical cord when placenta is still firmly attached to fundus after birth
-requires uterine relaxants and manual replacement

Uterine rupture
-seen w/ pain, fhr abnormalities, and vaginal bleeding
-more common w/ repeat c-section, IUD, or myomectomy

Cervical lacerations
-common during forceps delivery or mothers who can’t resist bearing down before cervix is fully dilated
-vaginal side w

Question 8

causes of pph: thrombin

Answer 8

-inherited and acquired bleeding disorders and lack of coagulating factors
-thrombosis helps prevent pph
-coagulopathies should be suspected when pph persists w/o an identifiable cause
-ttp: autoimmune disorder of increased platelet destruction, most common in young women, tx w/ glucocorticosteroids and caplacizumab
-von willebrand disease: congenital bleeding disorder that is autosomal dominant trait, bleeding gums and nose, blood in urine and stool
-dic: life threatening where there is widespread clot formation in small vessels, causing depletion of platelets, causes petechiae, proteinuria, tachy, acute renal failure; give blood components and coag factors

Question 9

causes of pph: traction

Answer 9

-pulling of umbilical cord after birth to extract placenta before it is completely separated from uterine wall
-cord detachment from placenta –> manual removal of placenta
-associated w/ maternal shock and DIC

Question 10

factors placing woman at risk for pph

Answer 10

tone
-overdistention of uterus: polyhydramnios, multifetal gestation, macrosomia
-uterine muscle exhaustion: rapid labor, prolonged labor, oxytocin use
-uterine infection: maternal fever, PROM

tissue
-products of conception: incomplete placenta at birth
-retained blood clots: atonic uterus

trauma
-lacerations anywhere: precipitate birth or operative birth
-laceration extensions: malposition of fetus, previous uterine surgery
-uterine inversion: forceful pulling when placenta isn’t separated yet; traction on cord when uterus isn’t contracted

thrombin
-preexisting conditions: hereditary inheritance, hemophilia, von willebrand disease, hx of previous pph, acquired in pregnancy, idiopathic thrombocytopenia purpura, bruising, htn, dic
-traction on umbilical cord: strong traction placed on umbilical cord prior to its separation from uterine wall may lead to hemorrhage

Question 11

risks for pph and interventions for each

Answer 11

1) uterine atony: massage and oxytocics
2) retained placental tissue: evacuation and oxytocics
3) lacerations or hematoma: surgical repair
4) thrombin: blood products
6) uterine inversion caused by too much cord traction: gentle replacement of uterus and oxytocics

Question 12

nursing assessment

Answer 12

-hematoma require surgery
-most hematoma arise from bleeding lacerations r/t operative deliveries
-uterus would be firm w/ bright red bleeding
-localized bluish bulging area just under skin surface in perineal area
-severe pain around area and difficulty voiding
-incision in bulge area and pressure dressing
-findings that suggest coagulopathy: skin for gingival bleeding or petechiae or ecchymoses, venipuncture sites for oozing or prolonged bleeding; urine output decreases, vs show increased hr and decreased loc

Question 13

nursing mgmt steps

Answer 13

-1st line: massage and meds
-2nd line: intrauterine balloon tamponade or uterine compression sutures
-3rd line: radiologic embolization, pelvic devascularization, hysterectomy (life threatening circumstance)

Question 14

nursing mgmt: fundal massage

Answer 14

steps
1) one hand on area above symphysis pubis (supports lower uterine segment)
2) other hand (dominant one) on fundus
3) massage fundus in circular manner, don’t over massage (exhaustion)
4) assess for uterine firmness (uterine tissue responds quickly to touch)
5) if firm, apply pressure in downward motion toward vagina to express any clots
6) don’t attempt to express clots until fundus is firm (risk for uterine inversion, uterus flips inside out)
7) assist w/ perineal care

Question 15

nursing mgmt: uterotonic drug

Answer 15

-oxytocin (pitocin): 1st line
-misoprostol (cytotec): not fda approved, can be used for acute pph
-dinoprostone (prostin e2)
-methylergonovine maleate (methergine)
-prostaglandin (pgf2a, carboprost, hemabate)

Question 16

nursing mgmt: uterotonic drug contraindications

Answer 16

-pitocin: never give undiluted as bolus injection intravenously
-cytotec: allergy, active cardiovascular disease, pulmonary or hepatic disease
-prostin e2: active cardiac, pulmonary, renal, hepatic disease
-methergine: htn
-hemabate: asthma, risk of bronchial spasm

Question 17

nursing mgmt: primary iv

Answer 17

-prepare to start 2nd infusion for blood transfusion
-draw blood for type and crossmatch
-assess for visible vaginal bleeding and count or weigh vaginal pads (1 peripad per hr = saturation)

Question 18

nursing mgmt: vs

Answer 18

-q15-30m
-assess loc
-foley catheter to avoid displacement of uterus
-fundus above umbilicus and deviated laterally indicates full bladder

Question 19

nursing mgmt: removal of retained placental fragments

Answer 19

-manually separated by hcp
-lacerations are sutured
-prepare to transfer woman to or if tamponade fails
-blood bank notification
-signs of hypovolemic shock

Question 20

nursing mgmt: hemorrhagic shock

Answer 20

-control source of bleeding, fluid resuscitation, correction of imbalance btwn o2 delivery and consumption, treating dic
-woman going into hypovolemic shock is highly anxious and may lose consciousness
-for woman w/ idiopathic thrombocytopenic purpura, expect to administer glucocorticosteroids, iv ig, anti-rhod, platelet transfusions
-prepare for splenectomy if bleeding tissues don’t respond to medical tx

Question 21

nursing mgmt: emergency measures if dic occurs

Answer 21

-icu unit transfer
-replace fluids, administer blood component therapy, give o2
-observe for signs of ecchymosis, or bleeding from cavities
-avoid giving injections and drawing blood

Question 22

nursing mtm: preventing pph

Answer 22

-avoid episiotomy unless emergency birth is necessary
-active mgmt of 3rd stage of labor
-correct anemia
-assess for lower genital tract lacerations
-blood transfusions
-hemorrhage cart
-immediate access to meds
-response team
-emergency-release transfusion protocols in blood bank

Question 23

venous thromboembolic conditions

Answer 23

-thrombosis: blood clot within blood vessel
-thrombophlebitis: inflammation of blood vessel
-thromboembolism: obstruction of blood vessel by blood clot carried by circulation
-superficial venous thrombosis: saphenous venous system and is confined to lower legs
-dvt: deep veins from foot to calf, thighs, or pelvis
-pe: thrombi that migrates into the lungs

Question 24

patho of thromboembolism

Answer 24

-results from venous stasis, injury to innermost layer of blood vessel, and hypercoagulation
-if clot is large enough to block pulmonary vessels = sudden death
-dx of pe should be considered in pts w/ dyspnea or hypoxia

Question 25

nursing assessment of thromboembolism

Answer 25

-risk factors: oral contraceptives before pregnancy, smoking, employment that requires long standing, hx of thrombosis, current varicosities, severe anemia, varicose veins, age > 34 yrs, prolonged bed rest, dm, obesity, c-section, progesterone-induced distensibility of veins of lower legs
-suspect superficial venous thrombosis in woman w/ varicose veins who reports tenderness and discomfort over site of thrombosis, most commonly in calf (area is reddened and warm, increased pain when walking)
-dvt most common in lower left leg, calf swelling, difference in leg circumference, warmth, pain, pedal edema
-signs of pe: sudden onset of sob, severe chest pain, apprehensive, diaphoretic
-dx of pe: prepare for lung scan

Question 26

nursing mgmt: preventing thrombotic conditions

Answer 26

-leg exercises and walking
-dorsi/plantar flexion feet w/ prolonged sitting
-compression devices until woman can walk
-elevate legs above heart level
-smoking cessation
-deep-breathing exercises
-aspirin or anticoags (enoxaparin or lovenox, rivaroxaban or xarelto, apixaban or eliquis, dabigatran etexilate or pradaxa)
-avoiding pillows under knees, not crossing legs for long periods, not leaving legs up in stirrups for long periods
-padding stirrups
-increase fluid intake
-avoid oral contraceptives

Question 27

nursing mgmt: adequate circulation

Answer 27

-NSAIDs for analgesia
-Rest and elevation of affected leg
-Warm compresses to area
-Stockings at all times
-anticoag therapy: heparin w/ vitamin K antagonists for few days then oral meds
-monitor aptt (35-45 sec)
-for pe: o2 via mask or cannula, give heparin and tpa, bed rest, pain relief

Question 28

nursing mgmt: thromboembolism education

Answer 28

-signs of bleeding: nosebleeds, bleeding from oral cavity, black tarry stools, brown coffee grounds vomitus, red to brown speckled mucus from cough, oozing at incision site, pink red or brown urine, black and blue marked bruises, increased lochia discharge
-reduce bleeding: brush teeth gently w/ soft toothbrush, electric razor for shaving, avoid aggressive activities, don’t use otc aspirin, avoid alc
-if you accidentally cut yourself, apply firm pressure for 5-10 min (do the same after any injections)
-wear id band that indicates you take anticoags
-eliminate risk factors for dvt: smoking cessation, no oral contraceptives, active lifestyle, healthy diet and weight)
-avoid prolonged standing or sitting in motionless, leg-dependent position
-avoid constrictive clothing
-know danger signs: chest pain, dyspnea, tachypnea

Question 29

postpartum infections

Answer 29

-enter thru genital tract and ascend internally
-increased risk d/t decreased vaginal acidity (normal physiologic change)
-s/s: elevated temp, malaise, pain, chills, increased hr, abdominal pain, malodorous lochia
-staph a, e coli, kleb, gardnerella v, gonococci, coliform, group a or b strep, chlamydia

Question 30

postpartum infections: endometritis

Answer 30

-involves endometrium of uterus
-can extend to parametritis (ovaries and fallopian tubes)
-uterine cavity is sterile until rupture of amniotic sac
-increased risk after c-section
-extension of chorioamnionitis: infection of placenta, amniotic fluid, or membranes
-anog recommends abx 1 hr before c-section
-s/s: lower abdominal pain, smelly lochia, anorexia
-tx: abx, restore fluids

Question 31

postpartum infections: surgical site infections

Answer 31

-c section incisions
-episiotomy
-genital tract lacerations
-wound infections identified after discharge
-s/s: serosanguineous or purulent drainage, discomfort at site, separation of wound edges
-tx: opening of wound for drainage, abx, analgesics, ambulation, hydration, pad changes

Question 32

postpartum infections: utis

Answer 32

-bacteria caused by bowel flora (e coli, kleb, proteus, enterobacter)
-vaginal exam, catheter, genital trauma increase risk
-s/s: flank pain, hematuria, urine positive for nitrates, cloudy urine w/ odor
-dx: clean catch specimen
-tx: abx, acidifying urine by taking large doses of vitamin c or cranberry juice, hydration

Question 33

postpartum infections: mastitis

Answer 33

-inflammation of mammary gland
-d/t infrequent or inconsistent breastfeeding, nipple trauma, rapid weaning, oversupply of milk
-causative organism is s aureus (comes from infant’s mouth)
-upper outer quadrant most common site
-breasts are red, tender, to to touch
-focus on reversing milk stasis, maintaining milk supply, continuing breastfeeding
-s/s: flu-like signs, tender hot and red area, cracking of skin around nipple, breast engorgement
-tx: frequent milk emptying, abx, ice/warm packs, abx

Question 34

postpartum infections: nursing assessment

Answer 34

-s/s: elevated temp, chills, foul-smelling vaginal discharge, headache, malaise, restlessness, anxiety, tachy
-BUBBLE-EE
-REEDA: redness (warmth), edema (infection/hematoma), ecchymosis (vaginal trauma), discharge (expected lochia pattern), approximation of skin edges (aligned w/o gaps)
-risk: prom, c-section, catheter, regional anesthesia that decreases urge to void, manual removal of placenta, insertion of fetal scalp electrode, trauma to genital tract, prolonged labor, vaginal exam, poor nutrition, gestational diabetes

Question 35

postpartum infections: prevention

Answer 35

-asepsis
-adequate lighting to assess episiotomy
-extreme caution when handling sharp equipment
-screen all visitors for active infection
-encourage rest, hydration, healthy eating
-inspect wounds frequently
-monitor frequency of vaginal exams and length of labor

Question 36

postpartum infections: pt education

Answer 36

-take full course of abx
-remove pad using front-to-back motion, fold pad in half so that the inner sides of padd that were touching your body are against each other, wrap in bag before discarding
-apply new pad using front-to-back motion
-angle peribottle so spray of water flows front to back

Question 37

postpartum affective disorders

Answer 37

-d/t sudden drop in estrogen and progesterone immediately after birth
-also influenced by genetic and environment

Question 38

postpartum affective disorders: postpartum blues

Answer 38

-most common
-rapid cycling mood symptoms during 1st week (emotional lability)
-mild depressive and anxious, irritable symptoms
-emotional lability is most prominent symptom
-self limiting, no formal tx other than reassurance and validation of woman’s experiences

Question 39

postpartum affective disorders: postpartum depression

Answer 39

-changes in mood don’t go away on own
-longer than 6 m if left untreated
-symptoms more intense: crying, memory loss, withdrawal/isolation, lack of interest in baby, suicidal thoughts
-d/t fatigue from labor, lack of social support, relationship issues, stress from home/work/personal changes, loss of freedom
-tx: antidepressants, antianxiety meds, adequate sleep, psychotherapy, marital counseling
-up to half of partners of mothers who have ppd experience depressive symptoms
-affected fathers are more angry and anxious than sad (peak at 3 and 6 m)
-dx: EPDS, PDSS (both are self-report)

Question 40

postpartum affective disorders: postpartum psychosis

Answer 40

-s/s: delusions, hallucinations, disorganized thinking, depersonalization, bizarre behavior
-high risk of suicide or infanticide/abuse
-3 m after
-tx: hospitalized w/ psychotropic drugs, psychotherapy, support group