Postpartum Hemorrhage Flashcards
1
Q
refers to excessive blood loss during or after the third stage of labor.
A
postpartum hemorrhage
2
Q
normal blood loss is _ for vaginal delivery and _ for CS.
A
500 mL
1000 mL
3
Q
leading cause of maternal mortality.
A
postpartum hemorrhage
4
Q
most dangerous time at which hemorrhage is likely to occur is during the _ postpartum.
A
first hour
5
Q
2 classifications of PPH
A
• early or primary
• late or secondary
6
Q
class of PPH that occurs in the 1st 24 hours after delivery.
A
early or primary PPH
7
Q
class of PPH that occurs from the 1st 24 hours to 6 weeks postpartum.
A
late or secondary PPH
8
Q
4 causes of PPH: 4 T’s
A
• tone
• tissue
• trauma
• thrombosis
9
Q
cause of PPH: refers to failure of the uterine myometrial muscle fiber to contract and retract.
A
tone
10
Q
cause of PPH: presence of retained placental tissues prevents uterine contractions resulting to failure to seal off bleeding vessels.
A
tissue
11
Q
cause of PPH: _ of postpartum hemorrhage is due to _ anywhere in the genital tract.
A
20%
trauma
12
Q
cause of PPH: clot formation on placental site stops oozing of blood from uterine blood vessels.
A
thrombosis
13
Q
cause of PPH: disorders of the coagulation system and platelets, whether preexistent or acquired, can result in bleeding or aggravate bleeding.
A
thrombosis
14
Q
causes to lose tone in the uterus: over distention due to (3) MHM
A
• macrosomia
• hydramnios
• multiple pregnancy
15
Q
causes to lose tone in the uterus: fatigue due to (3) PPO
A
• prolonged labor
• precipitate labor
• oxytocic drugs
16
Q
causes to lose tone in the uterus: drugs including (3) AMN
A
• anesthesia agents
• MgSO4 (magnesium sulfate)
• nifedipine
17
Q
causes to lose tone in the uterus: infections like (3) CES
A
• chorioamnionitis
• endomyometritis
• septicemia
18
Q
causes to lose tone in the uterus (7): OFIDSUD old fat iguanas dance so unusually different
A
• overdistention
• fatigue
• infection
• drugs
• (uterine) structural abnormality
• unusual placental site
• distention with blood
19
Q
tissue causes PPH due to (3): PPA
A
• presence of a succenturiate or accessory lobe
• preterm gestation especially in less than 24 weeks gestation
• abnormal adhesion such as accrete, increta and percreta
20
Q
trauma causes PPH due to (4): LECH
A
• lacerations
• episiotomy
• cesarean section
• hematoma
21
Q
cause of PPH: thrombosis includes preexistent coagulation disorder such as (1)
A
thrombocytopenic purpura
22
Q
cause of PPH: thrombosis includes acquired disorders such as (2) HD
A
• HELLP (hemolysis, elevated liver enzymes, low platelet count)
• DIC (disseminated intravascular coagulation)
23
Q
cause of PPH: thrombosis includes dilutional coagulopathy, in which clotting factors are reduced with aggressive transfusion of (2) CP
A
crystalloids
packed red blood cells
24
Q
types of disorders included in thrombosis (3): PAD
A
preexistent coagulation disorder
acquired disorders
dilutional coagulopathy
25
assessment of blood loss and hemorrhage: determine consistency, size and position.
palpate fundus
26
assessment of blood loss and hemorrhage: for continuous oozing of blood and hematoma formation.
inspect vaginal and perineal area
27
assessment of blood loss and hemorrhage: weigh perineal pads, check blood pool under the hips.
monitor blood loss per vagina
28
assessment of blood loss and hemorrhage: tachycardia & hypotension are the most significant signs in hemorrhage.
monitor VS (PR & BP)
29
assessment of blood loss and hemorrhage: ↓ urine output signifies ↓ blood supply to vital organs.
monitor urine output
30
assessment of blood loss and hemorrhage: assess tissue perfusion and oxygen saturation via pulse oximetry.
monitor tissue perfusion
31
assessment of blood loss and hemorrhage: altered LOC that occurs with shock is due to ↓ blood supply to brain.
assess level of consciousness
32
assessment of blood loss and hemorrhage: CBC (Hgb and Hct)
lab work
33
assessment of blood loss and hemorrhage: to detect causes of hemorrhage (retained placental fragments and occult hematoma).
ultrasound
34
assessment of blood loss and hemorrhage: done when embolization of bleeding vessels is to be performed.
angiography
35
what is to be determined when you palpate fundus to assess for PPH (3)
• consistency
• size
• position
36
most significant signs of PPH (2)
• tachycardia
• hypotension
37
decreased _ signifies decreased blood supply to vital organs.
urine output
38
altered _ is due to the decreased blood supply to the brain.
level of consciousness with shock
39
for PPH, what laboratories are required (3)
• CBC
• hct
• hgb
40
ultrasound is used to detect (2) during PPH
retained placental tissue
occult hematoma
41
to improve venous return, what position should you put your pt with PPH upon admission?
trendelenburg
42
upon diagnosis of PPH, what should you do for the pt in terms of their temperature?
keep warm by providing blanket
43
upon diagnosis of PPH, what should you administer?
oxygen
44
upon diagnosis of PPH, what two IV lines should the pt be ordered?
(1) fluid and drugs
(1) possible blood transfusion
45
upon diagnosis of PPH, what should be done if the estimated blood loss exceeds 2,000 mL?
blood transfusion
46
priority management in women with PPH (6): CRFSSP can rapid first steps save patients
• call for help
• rapid assessment of the woman’s condition
• find the cause of bleeding
• stop the bleeding
• stabilize/resuscitate the woman
• prevent further bleeding
47
management for PPH, prevents bleeding by tamponade effect.
uterine packing
48
during uterine packing for PPH, _ and _ is administered. this is removed after 24-36 hours.
prophylactic antibiotics
oxytocin
49
during uterine packing for PPH, what should you monitor (2) CP
• concealed hemorrhage (BP & PR)
• possible infection (fever, foul vaginal discharge)
50
refers to the failure of the uterus to contract continuously after delivery.
uterine atony
51
most common cause of PPH
uterine atony
52
risk factors of uterine atony (11): COUGH IMPROM
• complication of labor
• oxytocin use during labor
• uterine relaxing agents
• gestational overdistention
• high parity and advanced maternal age
• infection
• (over) massage of the uterus
• presence of fibroid tumors
• retained placental fragments
• other medical conditions
• moment too long (prolonged 3rd stage of labor)
53
risk factor of uterine atony: overdistention due to (4) HMMF
• hydramnios
• multiple pregnancy
• macrosomia
• fibroids
54
risk factor of uterine atony: complication of labor (3) PPO
• precipitate labor
• prolonged labor
• operative delivery
55
risk factor of uterine atony: uterine relaxing agents that includes (4) ATAM
• anesthesia
• terbutaline
• analgesia
• MgSO4 magnesium sulfate
56
risk factor of uterine atony: infection including (2)
• chorioamnionitis
• amnionitis
57
risk factor of uterine atony: medical conditions such as (2) AC
• anemia
• coagulopathy
58
normal clotting is 5 minutes, so if it fails to clot within _, there is a clotting defect or coagulopathy.
7 minutes
59
management for uterine atony: to stimulate uterine contractions and to express clots that have accumulated in the uterus or vagina.
massage uterine fundus
60
causes very strong uterine contractions, too painful for patient and can cause uterine fatigue (losing ability to contract).
forceful massage
61
management for uterine atony: a full bladder interferes with effective uterine contractions.
empty bladder
62
_ is the most common cause of displaced fundus (to the side).
distended bladder
63
management for uterine atony: make the newly delivered woman void every _. if unsuccessful, catheterize with doctor’s order.
2 hours
64
management for uterine atony: drugs to stimulate uterine contractions (2).
• 1st choice for postpartum uterine atony: oxytocin
• methylergonovine maleate
65
management for uterine atony:
• place left hand on the fundus and make it go down as far as possible behind the uterus.
• place right hand flat on the abdomen between the umbilicus and the symphysis pubis.
• press hands toward each other to l compress uterus, thereby sealing blood vessels at the placental site.
external bimanual compression
66
management for uterine atony: to stimulate and sustain uterine contractions in an atonic uterus.
internal bimanual compression and massage
67
management for uterine atony:
• 1 hand massages posterior aspect of uterus through abdomen, other hand massages the anterior fornix through vagina. Continue compression until bleeding is controlled and uterus contracts.
• uterus is raised from pelvis, compressed between hands to expel clots & decrease bleeding
• physician may administer analgesia / anesthesia to reduce discomfort associated with this, may insert uterine packing to control bleeding.
internal bimanual compression and massage
68
management for uterine atony:
• 1 hand applies pressure above umbilicus slightly to the left, other 1 palpates femoral pulse
• apply pressure on abdominal aorta until femoral pulse is no longer felt.
• maintain compression until bleeding is controlled.
manual compression of the aorta
69
management for uterine atony if there is bleeding but uterus is firm.
inspect for presence of lacerations & developing hematoma
70
management for uterine atony: last resort if bleeding cannot be controlled.
hysterectomy
71
results from over stretching / too rapid stretching of tissues, especially if poorly extensile & rigid.
lacerations
72
can occur anywhere in the cervix, vagina and perineum.
lacerations
73
irregular tearing caused by blunt object.
lacerations
74
risk factors/causes of laceration (7): POPLIMA
• primiparas
• operative delivery (forceps, vacuum extraction)
• precipitate delivery
• large baby (macrosomia, > 9lbs)
• in lithotomy position
• multiple pregnancy
• abnormal fetal presentation and position
75
degree of laceration: limited to vaginal mucosa and skin of the introitus.
first degree
76
degree of laceration: extends to the fascia and muscles of the perineal body.
second degree
77
degree of laceration: trauma involves the anal spincter.
third degree
78
degree of laceration: extends to the rectal lumen, through the rectal mucosa.
fourth degree
79
management for lacerations (4): PVRP
• perineal repair/suturing
• vaginal packing
• relieve discomforts
• promote perineal healing
80
management for lacerations: vaginal packing may be applied to help stop bleeding and maintain placement of suture for _ degree laceration to maintain pressure on suture line.
3rd and 4th degree laceration
81
management for lacerations: to relieve discomfort, administer _ and apply _ compress during the 1st 24 hours postpartum.
analgesic
ice compress
82
management for lacerations: to promote perineal healing, what should be done (3) SHP
• sitz bath
• heat application
• perilight (after 24 hours)
83
collection of blood under the skin due to injury to blood vessels during instrumental delivery or during repair of episiotomy by needle prick.
hematomas
84
two types of hematomas
• genital hematoma
• retroperineal hematoma
85
three types of genital hematoma
• vulvar hematoma
• vaginal hematoma
• vulvovaginal hematoma
86
risk factors of hematoma (7+3): POPLIMA and VIP
• primiparas
• operative delivery (forceps, vacuum extraction)
• precipitate delivery
• large baby (macrosomia, > 9lbs)
• in lithotomy position
• multiple pregnancy
• abnormal fetal presentation and position
• vulvar varicosities
• inadequate suturing of episiotomy or lacerations
• rolonged 2nd stage
87
lower genital tract hematoma signs and symptoms (6): PLS DVP plus discomfort, very painful
• (intense) pain
• localized tenderness
• swelling
• discoloration over the swollen area
• vaginal pressure leading to difficulty voiding
• posterior pressure (rectal pressure if posterior vagina)
88
_ may be palpated as enlarging masses next to the uterus.
broad ligament hematomas
89
small hematomas less than _ usually do not need treatment.
5 cm
90
prevention of hematoma (2) PI
• proper suturing of laceration and episiotomy
• ice pack 1 hour after delivery, then intermittently for 8-12 hours
91
if patient persistently complains of perineal pain, do not assume that it is due to _.
episiotomy
92
management for uterine atony: a surgical procedure involving an incision (cut) into the abdominal cavity, also known as an abdominal exploration.
laparotomy
93
management for hematoma: large hematomas are potentially dangerous because they may rupture and cause severe bleeding and infection.
incision, evacuation, and ligation of bleeding vessels
94
management for hematoma: to prevent or treat infection because hematomas are good medium of bacterial growth.
broad spectrum antibiotics
95
management for hematoma: to combat hypovolemia if severe bleeding occurs.
blood transfusion
96
most common cause of late postpartum hemorrhage.
retained placental fragments
97
3 types of abnormal adherent placenta
• placenta accreta
• placenta increta
• placenta percreta
98
abnormally adherent placenta: the placenta adheres to the myometrium without invasion into the muscle.
acreta
99
abnormally adherent placenta: the placenta adheres into the myometrium.
increta
100
abnormally adherent placenta: the placenta invades the full thickness of the uterine wall and possibly other pelvic structures, most frequently the bladder.
percreta
101
abnormal placental adhesion is most likely in (4): PPPH
• previous peripartum curettage
• previous cesarean
• placenta previa
• high parity
102
risk factors of retained placental fragments (4): PAME
• partial separation of normal placenta
• abnormal adherent placenta
• manual removal of placenta
• entrapment of placenta in the uterus
103
complications of retained placental fragments (2): II
• infection
• interfere with breastfeeding
104
why does retained placental fragments interfere with breastfeeding?
retained placental tissue may produce estrogen that inhibit prolactin secretion
105
signs and symptoms of retained placental fragments (3): PHP
• passage of large clots
• heavy bleeding
• presence of tears or missing cotyledons on inspection of placenta
106
confirmation for retained placental fragments is done through (2)
• manual uterine exploration
• ultrasound
107
to remove adherent placenta, what is done?
dilatation and curretage
108
if D&C fails to remove adherent placenta, what is done?
hysterectomy
109
occurs when there is a delay in the return of the uterus to its pre-pregnant size, shape and function.
subinvolution of the uterus
110
risk factors of subinvolution of uterus (3): RIU
• retained placental fragments
• infection
• uterine tumors
111
signs and symptoms of subinvolution of uterus (3): EPB
• enlarged and boggy uterus
• prolonged lochial discharge (foul odor if caused by infection)
• backache
112
initial management for subinvolution of uterus to stimulate contraction
medication for 2 weeks
113
management if bleeding in subinvolution of the uterus persists after 2 weeks
dilatation and curretage
114
management for subinvolution of uterus, treat the cause (3): RAE
• removal of uterine tumor
• antibiotics for infection
• evacuation of retained placental fragments by D & C
115
causes of early PPH (3): ULCI
• uterine atony due to retained membranes and placenta
• laceration of birth canal
• coagulopathy or clotting failure
• inversion of the uterus
116
causes of late PPH (3): RIS
• retained placental fragments
• shedding of dead tissue after obstructed or ruptured uterus
• infection
117
management for uterine atony:
external bimanual compression
left hand on the _ and make it go down as far as possible behind the _.
right hand on the _ between the _ and _.
left hand on the **fundus** and make it go down as far as possible behind the **uterus**.
right hand on the **abdomen** between the **umbilicus** and **symphysis pubis**.
118
management for uterine atony:
internal bimanual compression or massage
one hand massages the _ through the _, the other massages the _ through the _.
one hand massages the **posterior uterus** through the **abdomen**, the other massages the **anterior fornix** through the **vagina**.
119
management for uterine atony:
manual compression of the aorta
one hand applies pressure above the _, the other palpates the _.
one hand applies pressure above the **umbilicus slightly to the left**, the other palpates the **femoral pulse**.
