Postpartum Complications Flashcards
Postpartum Hemorrhage (PPH)
Complications that do occur during the postpartum period can be life-threatening
PPH is a major cause of maternal death and morbidity worldwide
- Assessed by EBL or QBL (preferred)
- Use QBL for a perinatal woman with a hemorrhage
- We weigh the amount of blood and the clots
Postpartum Hemorrhage
Remains a major cause of maternal morbidity and mortality worldwide
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* From 24 hours after birth up to 6 weeks postpartum
* Subinvolution of the uterus
* Retained placental fragments
- 1. Uterus can’t contract effectively; 2. and is keeping flow of blood from mother to what was baby, open
- Assess the placenta to make sure no pieces remaining
- Provider does a manual exploration (give a broad-spectrum antibiotic after)
- We could also suspect that a PPH is happening because of an infection
> Think infection as the cause? Because of uterine tenderness, foul-smelling lochia associated or if mother has a fever
- May need to go to the OR; perform a D&C
Late Postpartum Hemorrhage
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Occurs within the first 24 hours > delivery (within 1st hour of birth)
Cumulative blood loss of 1000 mL or greater
Early Postpartum Hemorrhage
PPH: Uterine Atony [relaxed uterus]
Manifestations
* Fundus is difficult to locate
* “Boggy fundus” - soft, blends in with abdominal tissues
* Fundus firms with massage (but doesn’t stay firm)
* Excessive lochia and clots
Management
* Measures to contract the uterus
* Provide fluid replacement
> Help offset any blood and volume loss that’s occurring
Uterine Atony - Risk Factors
- Overdistention of uterus in pregnancy
- Polyhydramnios
- Multifetal pregnancies
- LGA fetuses
- Multiparity
- Obesity
- Prolonged labor
- Precipitous labor
- If induced or augmented with Oxytocin
- If there’s placental fragment retention
PPH: Trauma
Soft tissue trauma (2nd most common cause of early PPH) [trauma to the birth canal]
* May cause postpartum hemorrhage
* Lacerations of the birth canal
* Hematomas - can be vaginal, vulvar, or retroperitoneal
Management
* Repairing the trauma before extensive blood loss occurs [surgical repair = with a hematoma → evacuation (suctioning clot out of the tissues)]
* Visualization of lacerations
- See vaginal, cervical, perineal lacerations
- We can’t visualize a vaginal or retroperitoneal hematoma (vulvar we can)
- Woman experiences deep, severe, unrelieved pain and often reports a sensation of pressure (there is a pooling of blood growing in tissues where it doesn’t belong)
- Signs of hypovolemia but the fundus is firm because blood loss is occurring elsewhere
- Hematomas often go undetected
PPH: Predisposing Factors
Overdistension of the uterus / multiparity / precipitate labor or delivery / prolonged labor
Operative vaginal delivery [one that puts at highest risk of hematoma] / Cesarean birth / manual removal of placenta / uterine inversion
Placenta previa, accreta, or low implantation / medications (tocolytics, mag sulfate) / general anesthesia / chorioamnionitis
Clotting disorders / previous PPH or uterine surgery / DIC / uterine leiomyomas (fibroids) [are typically at the fundus and impair the uterus’ ability to contract appropriately]
Hypovolemic Shock
Women can tolerate blood loss near that of blood that was added during pregnancy
Manifestations
Therapeutic Management
Nursing Considerations
* Response plan in place
* Review events after
* Locate source of bleeding to stop the loss of blood
* Be prepared on the unit = PPH cart
* Identify those with risk factors
* Provide prophylactic rx’s and checks (maybe checking the fundus a little more than we normally would)
Can typically tolerate 1500-2000 mL blood loss
Normal vaginal blood loss is 500 mL or less and Cesarean is 1000 mL or less
* This blood loss deprives the vital organs of O2 which leads mother into ___, eventually circulating volume is inefficient to perfuse cardiac and brain tissue which leads to anoxia which results in maternal death
metabolic acidosis
Signs & Symptoms
* Tachycardia
* Hypotension
* Increased respiratory rate
* Pale, cool, clammy skin
* Changes in mental status (anxiety → confusion → lethargy)
* Urine output decreases
Interventions for Hemorrhage
Preventing Hemorrhage
Collaboration with the Provider
* Uterine massage (to express any clots in the uterus; we cannot push unless the uterus is contracted because it increases the risk of uterine inversion, increasing the risk of hemorrhage and chance of hypovolemic shock)
* Check bladder for distention and empty if full
* Laboratory studies
* Administer fluids and medications
___ is given prophylactically in all births to prevent PPH (* refer to page 384)
___ as a 2nd choice rx
* Can’t give this to patients who have a hypertensive disorder, if pre-eclamptic, gestational htn, chronic htn, or BP readings hypertensive
Oxytocin
Methergine
Misoprostol can be given bucally or rectally
Carboprost Tromethamine - “Hemabate” - can give directly into the uterine muscle
> See this in C-sections
* Don’t give to asthmatic patients [as can cause acute bronchoconstriction] and give as a last choice because a side effect is excessive diarrhea
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A slower than expected return of the uterus to its nonpregnant size and consistency
* Happens from a full bladder, retained placental fragments, or pelvic infection
Uterine subinvolution
Therapeutic Management
Can give ___ orally (will provide long, sustained contractions of the uterus)
If an infection is the cause, it’ll respond to antibiotic therapy
Methergine
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Is an infection of muscle in the lower lining of the uterus
More common post C-section
Fever, chills, malaise, anorexia, abdominal pain, cramping, uterine tenderness, purulent foul-smelling lochia, tachycardia, also may be subinvolution of the uterus occurring
Endometritis
Endometritis
* Treatments with IV antibiotics like cephalosporins, clindamycin, gentamycin, or ampicillin
* Give prophylactic antibiotics before skin incision occurs
* If spreads outside the uterus, could affect the ovaries and fallopian tubes and can lead to sterility
* Can affect the abdomen as a whole → peritonitis
* Use Fowler’s position to promote drainage of lochia
Specific for the postpartum woman = ___ - an infection of the breast
* Common in first 12 weeks after childbirth but can happen anytime during breastfeeding
Common causative agent - S. aureus
Enters through an injured area of the breast
Flu-like symptoms; systemic
Axillary lymph node enlargement
If untreated, can progress to a breast abscess
Prescribe antibiotic therapy and continue to breastfeed or at least pump
mastitis
