post partum risks Flashcards
primary vs. delayed hemorrhage
-primary: within first 4-8 hrs
-delayed: later than 8 hrs
prompt intervention for hemorrhage
palpate and massage the fundus
hemorrhage risk factors
-tone: overdistention, oxytocin, anesthesia, mg sulfate, retention
-tissue: subinvolution
-trauma: lacerations, hematomas
-thrombin: ITP, von willebrand, DIC
-traction: inversion
uterine atony
-inability of uterus to contract adequately after birth
causes of uterine atony
-retention, overdistenion of uterus, prolonged or forceful rapid labor, bacterial toxins, anesthesia, meds (mg, oxytocin)
uterine atony findings
-large & boggy uterus, lateral
-irregular or excessive bleeding
-tachycardia, hypotension
-later signs: pale, cool clammy skin, loss of skin turgor
mgmt of uterine atony
-ensure empty bladder
-assess fundus & massage
-monitor lochia
-monitor for clots
-frequent vitals
-maintain IVF
- 2-3L/min, can be with nasal cannula
-amin methergine, misoprostol
-encourage breastfeeding
subinvolution
failure of uterus to return to its pre-pregnant state
subinvolution risks
-pelvic infection
-endometritis
-retained placenta
subinvolution findings
-prolonged/irregular vaginal bleeding
-uterus higher than normal
-boggy uterus
subinvolution tx
-D&C
-oxytocin
-methylergonovine
-abx
inversion
uterus turns partially or all the way inside out
inversion risks
-retain placenta
-fundal pressure
-excessive traction on cord
inversion findings
-pain in lower abdomen
-large red rounded mass/smooth mass in the dilated cervic
-dizzy, pallor, low bp
inversion tx
-replace uterus
-terbutaline (tocolytic)
-abx
retained placenta
placenta delivered in >30 min after birth
retained placenta risks
-excessive traction on cord
-partial separation of placenta
-entrapment by uterine wing
retained placenta findings
-excessive bleeding
-atony
-return of lochia progression
-malodorous discharge
-elevated temp
retained placenta tx
-manual removal
-D&C
-oxytocin
-terbutaline
lacerations & hematomas risks
-operative
-precipitous birth
-CPD/macro
-previous scarring
-prolonged pressure on fetus head
lacerations & hematomas findings
-lacerations: vaginal bleeding, firm uterus, continuous slow trickle of bright red blood
-hematoma: bulging bluish mass, red-purple discolor, difficulty voiding, possible pain
lacerations & hematomas tx
-repair of laceration & hematoma
-ice packs
-pain meds
ITP- idiopathic thrombocytopenia purpura
-autoimmune, low number of circulating platelets, due to antibodies
-low platelets, low fibrinogen
-increased bleeding times
-prothrombin, PTT, d-dimer
ITP tx
-glucocorticoids
-caplacizumab
-platelet infusion
-splenectomy if needed
-avoid NSAIDS, ASA, antihistamines
von willebrand disease
-congenital bleeding disorder with prolonged bleeding time
-deficiency of von willebrand factor, impairment of platelet adhesion
-bleeding gums, easy bruising, menorrhagia, blood in urine in stool, hematomas
-increases in pregnancy
DIC- disseminated intravascular coagulation
-clotting/anticlotting occurs simultaneously, organ damage
-most important is to identify initiating cause
-tx focuses on perfusion through fluid therapy, heparin, blood & blood products, oxygen
-may use vasoactive meds, abc, uterotonic meds
thrombin diseases assessments
-identify risk factors
-palpate uterus, massage if boggy
-assess quantitative amount of bleeding
-assess for 5Ts
mgmt for bleedings disorders
-massage uterus, express clots
-uterotonic drugs- know CI & SE
-maintian primary IV infusion, 2nd infusion if needed
-foley catheter
-provide 02 via nasal cannula 2-3L/min, monitor o2 status
-elevate legs 20-30 degrees
-monitor vs, LOC, lochia
-be prepared for use of uterine tamponade or bimanual compression
oxytocin
-stimulate uterine contraction
-assess fundus, monitor bleeding every 15 minutes, monitor uterine tone, monitor urine tention
misoprostol
-stimulates the uterus to contract/reduce bleeding
-off label use for acute postpartum hemorrhage
methylergonovine maleate
-stimulates the uterus to prevent and treat postpartum hemorrhage due to atony or subinvolution
-assess baseline bleeding, uterine tone, and vitals every 15min
-monitor for htn, seizures, cramping, n/v , and palpitations
-Contraindications: HTN
carboprost (prostaglandin)
-stimulates uterine contractions/to treat postpartum hemorrhage due to uterine atony when not controlled by other methods
-assess vitals, contractions, bleeding status
-contraindications: asthma active CV disease
tranexamic acid (TXA)
-1gm IV over 10 min, IV push
-antifibrinolytic
-contraindicated: hx of thromboembolic events, hx of coagulopathy
assessing for shock (hemorrhagic)
-monitor vs, mental status, output
-goal: control bleeding, fluid resuscitation (fluids or blood), correct imbalance of 02 delivery & consumption
post partum infections
-endometritis
-surgical sites
-uti
-mastitis
risk factors for pp infections
-18-24 prom/ prolonged labor/c-section
-invasive procedures/birth
-chronic conditions/pre-existing infections
venous thromboembolic conditions
-thrombophlebitis caused by thrombus can become embolus
-superficial and deep vein thrombosis, can lead to pulmonary embolus
-s/s: calf pain, hardened area, redness, warmth, edema
-dx: doppler, ct, mri
prevention of thromboembolus
-SCDs, TED hose
-if BR >8hr, perform ROM
-early ambulation
-avoid prolonged sitting, standing, immobility
-elevate legs, avoid crossing legs
-hydration, d/c smoking
-may have heparin injection before delivery
mgmt of thromboembolus
-encourage rest
-BR & elevate legs
-intermittent warm compress
-dont massage
-leg circumference
-anti-embolism stockings
-analgesics (no NSAIDS or ASA), anticoagulants
thromboembolus treatments
heparin and warfarin
heparin
-prevent clots formation & growth
-IV 3-5 days adjusted by coag. studies
-aPTT 1.5-2.5 times the control of 30-40 seconds
-protamine sulfate on hand
warfarin
-oral tx for clots
-taken for 3mo
-monitor PT 1.5-2.5 times control, 11-12.5 seconds, INR 2-3
-vitamin K on hand
-teratogenic, no OCs
pulmonary embolus
-s/s: apprehension, chest pain, dyspnea, tachycardia, hemoptysis, hypotension, hypoxia
-dx: ventilation/perfusion lung scan, CXR
-semi fowlers, o2 by face mask
-warfarin and heparin
-thrombolytics: altepase, streptokinase
endometritis
-can involve endometrium ( & decuda, myometrium)
-organisms: normal flora- E. coli, klebsiella, G vaginalis
-s/s: pelvic pain, anorexia, fever >100.4 after first 24 hrs, bad lochia, flu like sx
surgical site infections
-c section incision, episiotomy, genital laceration
-redness, swelling, drainage, tenderness, unapproximation, dehiscence, evisceration
-high wbc
UTI
-organisms: e. coli, klebsiella, proteus, enterobacter species
-causes: freq. vaginal exams, catherization, genital trauma
-s/s: freq., urgency, dysuria, lower abdominal pain, costovertebral (pyelo), fever
-dx: ccms
-teaching: hygiene, fluid intake, cranberry/prune juice
mastitis
risk factors: milk stasis, nipple trauma, prev. poor hygiene
-s/s: red, hot, painful, tender area on breast, fever, malaise,
-goals: reverse cause, maintain milk, breastfeed
-admin pain meds, hydrate, abx
PP baby blues
-mild depressive sx, anxiety, irritability, mood swings, tearfulness, increased sensitivity, fatigue
-usually peak at 4-5days and resolve by day 10
-if longer than day 10, seek tx
PP depression
-sx last longer and are more severe and need tx
-may lead to poor bonding, alienation, daily dysfunction, violent thoughts/actions
psychosis
-onset can be abrupt, around 3 months PP, hx of mental illness
-emergency
-s/s: mood lability, delusional beliefs, hallucination, disorganized thinking, anger
-early sx mimic depression, sleep disturbance, fatigue
-dont leave mother alone with infant
-tx: psychotropic drugs, psychotherapy, support groups
-education is key
