ob ch 25 Flashcards
What are the four main causes of postpartum hemorrhage?
Uterine atony, trauma (lacerations, hematomas, uterine inversion, or rupture), retained placental fragments, and disseminated intravascular coagulation (DIC).
What are the “Four Ts” of postpartum hemorrhage?
Tone (uterine atony), Trauma (lacerations, hematomas, uterine rupture/inversion), Tissue (retained placenta), Thrombin (coagulation disorders).
What conditions can cause excessive uterine distension?
Multiple gestation, polyhydramnios, large baby (>9 lb), uterine myomas (fibroid tumors).
What factors increase the risk of cervical or uterine lacerations?
Operative birth, rapid birth.
What conditions affect placental site or attachment?
Placenta previa, placenta accreta, premature placental separation, retained placental fragments.
What factors can prevent the uterus from contracting effectively postpartum?
Deep anesthesia/analgesia, oxytocin-induced/assisted labor, high parity, age >35, previous uterine surgery, prolonged/difficult labor, chorioamnionitis/endometritis, anemia, prior PPH, prolonged magnesium sulfate/tocolytic therapy.
What conditions contribute to poor blood coagulation postpartum?
Fetal death, disseminated intravascular coagulation (DIC).
How can retained placental fragments cause postpartum hemorrhage?
The uterus cannot fully contract with a retained fragment, leading to excessive bleeding.
How can retained placental fragments be detected?
If a large fragment is retained, immediate postpartum bleeding occurs, and the uterus will not be fully contracted on examination.
What is the first step in managing uterine atony?
Drain the bladder and perform fundal massage to encourage uterine contraction.
What should be assessed after fundal massage?
Stay with the patient and ensure the uterus remains contracted for the next 4 hours.
What is the first-line medication for uterine atony if fundal massage is not effective?
Oxytocin (Pitocin) via IV bolus or dilute infusion.
What medications can be used if oxytocin is ineffective?
Carboprost tromethamine (Hemabate), methylergonovine maleate (Methergine) (both IM), or misoprostol (Cytotec) (rectally).
What additional medication can be used to reduce postpartum hemorrhage?
Tranexamic acid (TXA), best used within 3 hours of birth to reduce mortality.
Why must Methergine be used cautiously?
It can increase blood pressure and should not be given to patients with gestational hypertension or preeclampsia of gestational DM
When should blood pressure be assessed in a patient receiving Methergine?
Before administration and about 15 minutes after to monitor for dangerous hypertension.
Why should the patient’s lower extremities be elevated in uterine atony?
To improve circulation to essential organs.
How often should the patient be assisted to the bathroom or offered a bedpan?
At least every 4 hours to ensure bladder emptying and prevent uterine atony.
Why might a urinary catheter be prescribed for a patient with uterine atony?
To prevent bladder distension, which predisposes the patient to uterine atony.
What oxygen therapy is recommended for a patient with respiratory distress due to uterine atony?
Administer oxygen via face mask at 10-12 L/min.
What position should the patient be placed in if experiencing low blood volume?
Supine (flat) to allow adequate blood flow to the brain and kidneys.
What vital sign trends indicate worsening uterine atony?
Decreasing blood pressure with a continuously rising pulse rate.
What diagnostic test may be performed if fundal massage and uterotonics fail?
A sonogram to check for retained placental fragments.
What is bimanual compression?
A procedure where the provider inserts one hand into the vagina while using the other hand to push against the uterus through the abdominal wall to stop bleeding.
When is blood transfusion necessary for postpartum hemorrhage?
When significant blood loss occurs and replacement is needed.
What surgical procedures may be used as a last resort for severe postpartum hemorrhage?
Uterine artery ligation, compression suturing, or hysterectomy.
How can a retained placenta cause postpartum hemorrhage?
Retained placental fragments prevent full uterine contraction, leading to continuous bleeding.
How can a retained placenta be identified?
Persistent postpartum bleeding and a uterus that is not fully contracted on examination.
What is a vulvar hematoma?
A collection of blood beneath the vulvar epidermis due to blood vessel injury during birth, often after rapid, spontaneous births.
How should a vulvar hematoma be documented?
Describe the size specifically (e.g., “5 cm” or “size of a quarter”) rather than “large” or “small” for accurate baseline assessment.
What interventions help manage a vulvar hematoma?
Report to the provider, administer analgesics, apply an ice pack with a towel, and monitor for changes.
When might a vulvar hematoma require surgical intervention?
If it is large or continues to grow, the patient may need an incision and vessel ligation under anesthesia.
What is a puerperal infection?
An infection of the reproductive tract after birth, which can spread to the peritoneum (peritonitis) or bloodstream (septicemia).
What factors increase the risk of puerperal infection?
Tissue trauma, edema, membrane rupture, virulent organisms, slow uterine involution, and reproductive tract lacerations.
What is mastitis, and when does it typically occur?
Breast infection, occurring as early as day 7 postpartum or weeks/months later due to milk stasis.
How can mastitis be prevented?
Proper baby positioning, correct latch, handwashing before handling breasts, airing nipples, using vitamin E ointment, and starting feeds on the unaffected nipple.
What is the therapeutic management of mastitis?
Antibiotics (dicloxacillin or cephalosporins), continued breastfeeding or milk expression, cold compresses for pain, and warm compresses for inflammation.
Should breastfeeding continue during mastitis?
Yes, if possible, to prevent milk stasis and bacterial growth, but manual expression can be used if feeding is too painful.
What is the difference between postpartum blues and postpartum depression?
Blues: Short-term (1-10 days), due to hormonal shifts. Depression: Lasts longer (up to 1 year), often linked to disappointment or poor support.
What are risk factors for postpartum depression?
Disappointment in childbirth experience, lack of family support, or prolonged feelings of sadness beyond the typical postpartum blues.
