Postpartum Complications Flashcards
How is Postpartum Hemorrhage (PPH) classified?
- Immediate – occurs within 24 hours of delivery
- Late – occurs anywhere between 24 hours after delivery until 6 weeks postpartum
Different stages of PPH?
- Stage 1: blood loss >1000ml with normal vital signs and lab values
- Stage 2: Continued bleeding with EBL up to 1500ml or already received >2 uterotonics and normal vital signs
- Stage 3: Continued bleeding with EBL > 1500ml or >2 RBC given or possible occult bleeding/coagulopathy, or abnormal VS
- Stage 4: Cardiovascular collapse
Postpartum Hemorrhage (PPH) medium risk factors during admission?
- prior cesarean, uterine surgery, or multiple laparotomies
- multiple gestation
- > 4 prior births
- prior PPH
- large myomas
- EFW > 4000 g
- obesity (BMI > 40)
- hematocrit < 30 %
Postpartum Hemorrhage (PPH) high risk factors during admission?
- placenta previa / low lying
- suspected accreta / percreta
- platelet count < 70,000
- active bleeding
- known coagulopathy
- 2 or more medium risk factors
PPH medium risk factors during intrapartum?
- chorioamnionitis
- prolonged oxytocin > 24 hours
- prolonged 2nd stage
- magnesium sulfate
PPH high risk factors during intrapartum?
- new active bleeding
- 2 or more medium risk factors
PPH nursing interventions?
- Call for assistance
- Frequent uterine assessment (fundal location, firmness) and vital signs
- Fundal massage
- Empty bladder
- Notify the provider
- IV access, preferably 18g
- Administer uterotonics
- Oxytocin
- Methergine: PO or IM, NEVER IV push
- Misoprostol
- Hemabate
- TXA: tranexamic acid preserves the fibrin/clotting network
- Accurately assess and record blood loss via QBL
- Prepare for blood product administration
What to consider for Postpartum Infection?
- Consider dehydration
- Breast engorgement
- Urinary tract infection
- Endometritis – infection of the endometrium
- Prolonged ROM
- Internal fetal monitoring
- GBS Status
- Operative vaginal delivery
- Postoperative wound/laceration infection
- Redness
- drainage from incision
- tenderness
Postpartum Infection S/S?
- Fever
- Headache
- Chills
- Increased pulse rate
- Uterine tenderness
- Costovertebral angle tenderness
- Lower abdominal/pelvic pain
- Foul-smelling lochia
- Painful urination
- Wound drainage, redness
Postpartum Infection nursing interventions?
- Watch vital signs closely
- Tachycardia can be early sign of worsening infection
- Chills/fever
- Anticipate possible need for blood cultures
- IV antibiotics administered per orders
- Watch infant for signs of infection
- Promote bonding and breastfeeding as appropriate
DVT / VTE risk factors?
- Cesarean delivery
- Varicose veins
- Co-morbidities: Diabetes, IBD, cardiac disease, hypertension, lupus
- Preterm delivery
- Stillbirth
- AMA (age > 35)
- Multiple birth
- BMI at least 25
- Clotting disorder
- Smoking
- Infection
DVT / VTE signs?
- Unilateral leg pain and edema
- May be warm and tender
- Homan’s sign– no longer checked
DVT / VTE nursing interventions?
- Prevention is key!
- Mechanical compression devices (SCDs) for pts on prolonged bedrest or s/p C/S
- Early ambulation (within 12 hours of C/S)
- Assessment: extremities
- Pulses, edema, pain/tenderness, diameter
- Bedrest (don’t want to dislodge clot)
- Elevate affected extremity
- Anti-thombolytic stockings
- Anticoagulants
Preeclampsia risk factors?
- 16-20% chance she will have either gestational HTN or preeclampsia in future pregnancy.
- Greater risk of recurrence with earlier gestational onset.
- History of preeclampsia or gestational HTN is a major risk factor for future development of cardiovascular disease.
Preeclampsia symptoms?
- SBP > 140 or DBP > 90
- Proteinuria > 300 mg/24 hr
- Headache not relieved by Tylenol
- Visual disturbances
- Epigastric or RUQ pain
- Seizure activity
Preeclampsia nursing interventions?
- Administer magnesium sulfate
- Patients on Mag need frequent assessment of:
- VS, DTR, I&O, LOC
- Toxicity: absent reflexes, respiratory rate <12, altered LOC
- Calcium gluconate is the antidote
- Administer antihypertensives
Cardiomyopathy risk factors?
- Maternal: AMA, HTN, diabetes, obesity, primipara, family history, environmental risk factors, substance abuse
- Fetal factors: multiple gestation, assisted reproduction
- Pregnancy conditions: preeclampsia/eclampsia, anemia, thyroid dysfunction, poorly controlled asthma or autoimmune condition
- Delivery related: prolonged tocolysis
Cardiomyopathy symptoms?
- chest discomfort
- cold extremities
- fatigue
- nocturnal cough
- nocturnal dyspnea
- orthopnea
- palpitations
- peripheral edema
- sinus tachycardia
Cardiomyopathy treatment?
- Aggressive diuresis
- ACE inhibitors-after delivery only
- Anti-coagulation therapy
- Beta blockers
- Heart transplantation
- Mechanical assistive devices
List some PPH medications.
1st-line:
- Oxytocin (Pitocin)
- Methylergonovine (Methergine)
- Misoprostol (Cytotec)
- Carboprost (Hemabate)
2nd-line:
- Tranexamic Acid (TXA)
How do the 1st-line PPH medications work?
stimulates uterine contractions
Hemabate contraindications?
Use with caution in patients with HTN or asthma
Methergine contraindications?
- HTN
- Preeclampsia
TXA indication?
- 2nd-line medication (given after 1st-line medications and interventions not effective)
- Reduces bleeding by inhibiting breakdown of fibrin blood clots
TXA contraindications?
- History of coagulopathy
- Active intravascular clotting (HELLP syndrome)
List some Preeclampsia medications.
- Magnesium Sulfate
- Antihypertensives
- Nifedipine
- Labetalol
- Hydralazine
Magnesium sulfate indication?
prevents seizures that may occur with preeclampsia
Antihypertensives indication?
sustained SBP ≥ 160 or DBP ≥ 110
Factors contributing to maternal morbidity and mortality?
Direct causes:
- Severe bleeding (mostly bleeding after childbirth);
- Infections (usually after childbirth)
- High blood pressure during pregnancy (pre-eclampsia and eclampsia)
- Complications from delivery
- Complications of unsafe abortion
Indirect causes: infectious and non-communicable diseases
What role do nurses play in reducing maternal morbidity and mortality?
- Safety bundles with evidence-based guidelines
- Hemorrhage
- Sepsis
- CV disease
- VTE
- HTN disorders
- Implicit bias training
- Mock codes/simulations
- Quantifying blood loss
- Communication
- Get involved!
