Postpartum Hemorrhage

Question 1

An early hemorrhage occurs when blood loss is greater than ____ in the first 24 hours after vaginal delivery or c section.

Answer 1

1000 mL (but 500-1000mL would be considered hemorrhage)

Question 2

Normal blood loss after delivery is ___

Answer 2

300-500mL

Question 3

Late hemorrhage occurs after ___

Answer 3

The first 24 hours

Question 4

If you are unsure of how much blood loss there is what could you do to measure?

Answer 4

Weigh pad minus the weight of clean pad.

Question 5

Main causes of early hemorrhage:

Answer 5

Uterine Atony
Lacerations
Retained placenta fragments
Inversion of the uterus (rare out of hospital)
Placenta Accreta (rare)
Hematomas (usually don’t know they’re there, symptoms of hemorrhaging but no blood)

Question 6

Uterine Atony

Answer 6

The myometrium fails to contract in the uterus fills with blood because of the lack of pressure on the open blood vessels of the placental site.

Question 7

Causes of Uterine Atony

Answer 7

Prolonged labor
Intrapartum stimulation with pitocin
Trauma due to obstetrical procedures
Over distention of the uterus
Excessive use of analgesia/anesthesia
Grandmultiparity

Question 8

Most common cause of hemorrhage is _____. Heed a successful management is ____!

Answer 8

Uterine Atony
Prevention & education

Question 9

Uterine Atony signs and symptoms:

Answer 9

Hey boggy uterus that does not respond to massage.
Abnormal clots.
Excessive or bright red bleeding. (Past first hour, pool of blood after just changing pad, pee flow) (Does she have high or low iron? Some women with higher iron can handle bleeding a bit more)
Unusual pelvic discomfort or back ache. (From blood pooling, after birthing placenta)

Question 10

Management of Uterine Atony

Answer 10

-Document Vaginal Bleeding (30-60 secs of rubbing blood should not be oozing out)
-Fundal massage or bimanual compression
-Assess Vital Signs (shock)
- Medication- Pitocin, (Rarely Used: Methergine {can’t give to a woman who has problems with blood pressure issues, Hemabate {you wouldn’t give to a person who has asthma or respiratory issues}, more risks..)
Physician consult: D &C, (rare) Hysterectomy, replace blood and fluids (how far away is hospital, preplan for emergencies, how will you handle it?)

Question 11

Postpartum Hemorrhage lacerations
Predisposing factors
Signs & symptoms

Answer 11

1. Spontaneous or precipitous delivery
2. size, presentation, and position of baby
3. contracted pelvis
4. Vulvar, cervical, perineal, urethral area and vaginal varices

Signs/symptoms
1. Bright red bleeding where there is steady trickle of blood and uterus remains firm.
2. Hypovolemia

Question 12

Postpartum Hemorrhage lacerations treatment and nursing care

Answer 12

1 meticulous inspection of the entire lower birth canal
2 suture any bleeders
3 vaginal pack nurse may remove and assess bleeding after removal
4 blood replacement

Question 13

You are signed to Miss B who delivered vaginally. As you do your postpartum assessment, you noticed that she has a large amount of lochia rubra (bright red bleeding) what would be the first measure to determine if it is related to a uterine atony or a laceration?

Answer 13

Ask how are you feeling? When’s the last time you went to the bathroom? How long has this been going on for?

Put your hand on her tummy and feel if the uterus is nice and firm, is it off to the side, is there a clots coming out, is it up.

Sometimes peeing can fix the problem. If uterus is soft that indicates uterine atony.

Question 14

Retained placental fragments. When does this occur? Signs? Treatment?

Answer 14

This occurs when there is incomplete separation of the placenta and fragments of the placental tissue retained.
(The midwife has to aggressively feel around on the inside to get it all out)
Boggie, and relaxed uterus
Dark red bleeding

D&C
Administration of oxytocin
Administration of prophylactic antibiotics

Question 15

Hematomas: (rare)
Treatment?

Answer 15

Pain- deep, severe, unrelieved, feelings of pressure
Rectal pain and tachycardia
Many times bleeding is concealed. (Vs changed from internal bleeding)

Treatment: expected management or may have to be incised and drained

Question 16

Inversion of the uterus:
Predisposing factors:

Answer 16

The uterus inverts or turns inside out after a delivery.
Complete inversion a large red rounded Mass protrudes from the vagina.
Incomplete inversion uterus cannot be seen, but felt.

Predisposing factors:
traction applied on the cord before the placenta has separated
**Don’t pull on the cord unless it’s listen to has separated.
Any correct traction and pressure applied to the fundus especially when the uterus is flaccid.
**Don’t use the fundus to push the placenta out.

Question 17

What does the Midwife have to do when a inversion of the uterus occurs?

Answer 17

You have to use your fist in manually invert the uterus back inside the way it’s supposed to go and it is very painful.

Question 18

What’s treatment and continued care for an inverted uterus?

Answer 18

Replace the uterus manually replace and pack uterus.
Call 911 immediately.
Combat shock which is usually out of proportion to the blood loss.
Blood and fluid replacement.
Give oxytocin.
Initiate broad spectrum antibiotics.
May need to insert a nasogastric tube to minimize paralytic ileus.
Humidify The collaborating physician what has occurred.
Care must be taken when massaging.

Question 19

Placenta Accreta:

Answer 19

Our part of the decidua basalis is absent and the placenta grown directly into the uterine muscle. (Usually high risk) (Not for for it of hospital Birth, usually seen on ultrasound)

Question 20

Signs of Placenta Accreta

Answer 20

During the third stage of labor, the placenta does not want to separate. Attempts to remove the placenta in the unusual manner or unsuccessful, and lacerations or perforation of the uterus may occur.

Question 21

Treatment of Placenta Accreta

Answer 21

If it is only small portions that are attached, then these may be removed manually.
If a large portion is attached a hysterectomy is necessary. (Not have kids anymore)

Question 22

Postpartum infections:

Answer 22

Infection of the genital tract that is her within 28 days after abortion or delivery
Mastitis is also considered a postpartum infection of the breast tissue.
Bacterial causes:
Streptococcus groups A and B clostridium, e coli

Question 23

Endometriosis predisposing factors:

Answer 23

Trauma
Hemorrhage, anemia, and hematomas
Prolonged labor
UTI
Excessive vaginal exams
P r o m
Depression
Diabetes
Weekend immune system: sleep deprivation, stress, poor nutritional intake, and limited water intake

Question 24

Critical things to remember: signs and symptoms of postpartum uterine infection (endometritis)

Answer 24

Temperature increase of 100.4 or higher on any two consecutive days of the first 10 days postpartum, not including the first 24 hours.
Foul smelling lochia, discharge.
Malaise. Anorexia, tachycardia, chills
Pelvic pain
Elevated WBC

Question 25

Endometritis treatment

Answer 25

The minister bronze spectrum antibiotics
Provide with warm sitz baths
Promote drainage have pt lie in high Fowler’s position
Horse fluids and hydrate with IVs 3,000 to 4,000 CC’s a day
Keep uterus contracted, give a methergine
Provide analgesics for alleviation of pain
Nasogastric suction is peritonitis develops

Question 26

Other possible postpartum infections and signs and symptoms

Answer 26

Pelvic cellulitis
Peritonitis

Signs and symptoms
Spiking a fever of 102 to 104 ° F
Elevated WBC
Chills
extreme lethargy
nausea and vomiting
abdominal rigidity and rebound tenderness

Question 27

Preventative measures for many infections

Answer 27

Prompt treatment of anemia
Well balanced diet
Avoidance of intercourse late in pregnancy
Strict asepsis during labor and delivery
Teaching of postpartum hygiene measures
Keep pad snug
change pads frequently
wipe front to back
use Perry bottle after each elimination

Question 28

Signs of the localized infection/ treatment

Answer 28

Red and common edematous test, firm, tender edges of skin
I just separate and purulent material drains from the wound.

Treat with antibiotics and wound care

Question 29

Postpartum Cystitis (bladder infection) prevention, treatment, causes:

Answer 29

To prevent you will monitor patients you’re a urination diligently.
Don’t allow to go longer than three or four hours before intervening.

Treatment could be antibiotics with ampicillin or urinary tract and antispasmodics

Caused from stretching or trauma to the base of the bladder, results in edema of the trigone that is great enough to obstruct the urethra and to cause acute retention or from anesthesia.

Question 30

Mastitis

Answer 30

Marked and gorgement, paint, chills, fever, tachycardia, hardness and redness (redness comes about 6hrs before sickness), and enlarged and tender lymph nodes.

Put nose of baby pointing at the red spot while nursing.

Question 31

Mastitis can turn into what that could need surgery?

Answer 31

Abscess

Question 32

There’s 2 different kinds of mastitis. Name them and the differences:

Answer 32

Mammary Cellulitis- information of the connective tissue between the lobes in the breast.

Mammary Adenitis- infection in the ducts and lines of the breasts

Treatment and assessment is the same. You’d have to do testing to find which specific one it is.

Question 33

Causes of mastitis:

Answer 33

Improper breaking of suction, first nursing experience, poor positioning of infant, strong sucking infant, cracked nipples equals entry for bacteria and then there’s also a supplemental feedings the lazy theater abrupt-winning interval between nursing too long which leads to engorgement, stasis of milk and plug ducts.

Question 34

If mastitis is left untreated what does this lead to?

Answer 34

Breast Abscess (requires surgery)

Question 35

Treatment of mastitis

Answer 35

Rest
Appropriate antibiotics usually cephalosisporins.
Hot and or cold packs.
Don’t stop breastfeeding because if the milk contains bacteria, it also contains the antibiotic.
Sudden cessation of lactation will cause severe engorgement which will only complicate the situation. Breastfeeding stimulates circulation and moves the bacteria containing milk out of the breast.
(Pump)

Question 36

Thromboembolic disease predisposing factors and signs and symptoms:

Answer 36

Predisposing factors are slowing of blood in the legs and trauma to the veins.
Signs and symptoms are sudden onset of pain tenderness of the calf redness and an increase in skin temperature positive Homan’s sign
(Medical Emergency)

Its a clot in the leg jand it can move and go into your lungs which is a deadly situation.

Question 37

Thromboembolic disease treatment and complication:

Answer 37

Treatment is heparin– it does not cross into breast milk
Antidote is protamine sulfate
You need to teach patient to report any unusual bleeding or pet shay, bleeding gums hematuaria, epistaxiz etc.

(Care need to be given by a doctor)

Question 38

Postpartum psychiatric disorders

Answer 38

Mental health problems can complicate the postpartum period.

There are days when each new mother may feel inadequate, but the mother who has a constant feeling of inadequacy needs professional counseling.

Psychological and physiological stressors relating to pregnancy may bring on an emotional crisis.

If she has low vitamin D this could lead to depression.

Question 39

Mood disorders that can occur:

Answer 39

Anxiety
Depression
Baby blues
Postpartum depression
Bipolar disorder

Less common
Postpartum psychosis

(Mild negative thoughts are normal but if Mom doesn’t want to get out of bed or do anything then there may be an issue)

Question 40

Baby blues

Answer 40

50 to 80% of moms are affected self-limiting up to 10 days

the cause seems to be related to changes in progesterone, estrogen and prolactin levels
symptoms are tearful yet happy and overwhelmed treatment is self-care support system and breastfeeding support.

Question 41

Postpartum depression risk factors and clinical therap

Answer 41

Risk factors are primiparity
history of postpartum depression lack of social and relational support.

Clinical therapies:
counseling and support groups medication and child care assistance.