Postpartum & neonate complications Flashcards
what is the definition of postpartum hemorrhage in general vs. actual definition
- general: >500mL for vaginal deliveries, >1,000mL for c-section with a 10% drop in H&H
- definition: >1,000mL with s/s of hypovolemia within 24hrs
what is the primary source of blood loss in PPH
the placental site
what are the 4 main causes of PPH in descending order of frequency
- Tone: uterine atony
- Tissue: retained uterine fragments
- Trauma: lacerations
- Thrombin disorders
what are some pre-existing risk factors for PPH
- high parity: 5+ births
- previous PPH
- previous uterine sx
- coagulation defects
what are some pregnancy-related risk factors for PPH
- uterine overdistension: macrosomia, multiple gestation, polyhydramnios
- chorioamnionitis
- placental abnormalities: precenta previa/accreta, abriptio placentae, hydatidiform mole
what is the main difference between primary and secondary PPH
Primary (early)
- occurs within 24 hrs of birth
Secondary (late)
- occurs 24hrs to 6 wks post delivery
what are the causes of primary PPH
- uterine atony
- lacerations
- hematomas
what are the causes of secondary PPH
- hematomas
- subinvolution
- retained placental tissue
what are the indications of primary PPH
aka S/S
- 10% decrease in H&H after birth
- saturation of peripad within 15 mins
- boggy fundus after massage
- late signs: tachycardia & hypotension
how do you measure blood loss from peripads
weigh them 1g = 1mL
what are the causes of uterine atony
- overdistended uterus: multiparity, macrosomia
- birth >5 times
- prolonged or dysfunctional labor
what are S/S of uterine atony
- soft boggy uterus
- saturation of peripad in 15mins
- blood clots
- pale, clammy skin
- anxiety & confusion
- tachycardia & hypotension
what are the medications used for uterine atony
- oxytocin
- methergine
- misoprostol
- carboprost
- TXA (antifibrinolytic)
when is bimanual compression performed
when uterotonics fail to stop the bleeding
what are the treatments/managements for uterine atony
- meds
- bimanual compression
- IV NS/LR
- platelets, FFP, cryo
- uterine packing with gauze or uterine tamponade
- sx: dilation and curettage, hysterectomy
what is dilation and curettage (D&C)
surgical procedure where:
cervix is dilated and a curette is used to scrape or suction tissue from the uterus
what are common causes of hematomas
- episiotomies
- operative vaginal deliveries: forceps, vacuum-assisted birth
S/S of hematomas
- severe pain not managed by pain meds
- heaviness or fullness in the vagina
- rectal pressure
- swelling, discoloration, tenderness
- tachycardia & hypotension
how can a hematoma contribute to PPH
if large, a hematoma can displace the uterus -> uterine atony and increased blood loss
how are large hematomas managed
surgical excision - open vessel ligated and blood is evacuated
nursing actions for hematoma
- apply ice to the perineum for the first 24hrs
- monitor pain and VS
- monitor H&H
what are causes of subinvolution of the uterus
- fibroids: interefere w/ UCs
- endometritis
- retained placental tissue
S/S of subinvolution of the uterus
- soft and larger than normal uterus
- lochia returns to rubra stage
- back pain
what diagnostic test is used to assess subinvolution of the uterus
US to check for retained tissue and subinvolution
what is the treatment for retained placental tissue
D&C
what is the treatment for fibroids causing subinvolution
methergine to promote UC
what patient education should be given for subinvolution
- change peripads frequently
- handwashing
- good nutrition and fluids
- rest
what are 2 major complications of retained placental fragment
- endometritis
- subinvolution
S/S of retained placenta
- profuse, sudden bleeding/increase in lochia
- subinvolution
- fever and uterine tenderness d/t endometritis
- abd pain
- s/s of bleed
what is DIC: disseminated intravascular coagulation
hyperstimulated coagulation pathways leading to:
- clots breaking down faster than they are formed
- depletion of clotting factors
- leading to hemorrhage
what is the most frequent cause of DIC
placental abruption
treatment for DIC
- blood, platelet, FFP transfusions
- cryo
- O2
- IVF
- transfer to ICU
why is pregnancy a high-risk period for VTE: venous thromboembolic dx
hypercoagulable state
- increased venous stasis
- increased blood volume
- compression of the inferior vena cava and pelvic veins
S/S of DVT
- dependent edema
- sudden unilateral leg pain
- erythema
- fever
- positive Homan’s sign: pain with dorsiflexion of the foot
S/S of PE
- SOB, dyspnea, tachypnea
- tachycardia
- pleuritic chest pain
- fever
diagnostics for DVT
- US
- magnetic resonance venography
diagnostics for PE
- CXR
- CT
- EKG
treatment for DVT
- heparin IV then oral warfarin
- compression stockings
- warm compress
- elevate the leg
- bedrest & ambulate once s/s subside
treatment for PE
- transfer to ICU
- tPA
- catheter or surgical embolectomy
what is the heparin goal for DVT & PE
1.5 - 2.5
risk factors for postpartum infection
- c-section: primary factor
- PROM, prolonged labor
- frequent vaginal examinations
- diabetes, poor nutrition, smoking
S/S of endometritis
- fever >100.4F (38C)
- uterine tenderness
- subinvolution
- lochia dark & smelly
treatment for endometritis
broad-spectrum oral or IV abx
nurse teachings for endometritis
- change peripad q3-4 hrs
- early ambulation promotes uterine drainage
- adequate hydration
- high protein and vit C diet
risk factors for UTI
- epidural: decreased feeling to void
- incomplete or overdistended bladder
- operative vaginal deliveries -> trauma
- catheters, c-section, vaginal exams
S/S of UTI
- fever
- burning during urination
- suprapubic pain
- urgency to void
- small frequent voiding of < 150 mL
risk reduction teachings for UTI
- reminder to void q3-4 hrs
- cathe if can’t void in 2-3hrs
- change peripads q3-4 hrs
- hydration 2L/day
- encourage high acidity foods (i.e. cranberry juice)
cause of mastitis
bacteria from the infant’s mouth enters through cracked or sore nipples
can a mother continue to breastfeed if she has mastitis
yes, breastfeeding helps clear the infection and will not harm the baby
risk for mastitis
- cracked or sore nipples
- oversupply of milk
- infrequent or missed feedings
- tight bra
S/S of mastitis
- breast tenderness
- warmth
- swelling and hardness
- pain or burning
- fever
how is mastitis treated
oral abx for 10-14 days
how can mastitis be prevented or managed
- empty breasts regularly
- cold or warm compresses
- hand wash before feeding
- massage breast while feeding
- larger bra
what is the diagnostic criteria for postpartum depression
depressed mood or loss of interest for at least 2 wks plus 4+ of the following:
- >5% weight loss/gain
- insomnia or hypersomnia
- decreased energy or fatigue
- feelings of worthlessness or guilt
- decreased ability to concentrate, indecisiveness
- loss of interest in normal activities
- psychomotor agitation
difference between postpartum blues vs. depression
postpartum blues
- symptoms dissapear without intervention
- occurs within the first 2 wks
- able to care for self and baby
postpartum depression
- requires psychiatric intervention
- occurs during the first 12 M
- unable to care for self and baby
treatment for postpartum depression
- interpersonal psychotherapy
- antidepressants
- admission for psychiatric care
what is postpartum psychosis
severe psychiatric emergency characterized by delusions, hallucinations, and disorganized behavior
which women are at the highest risk for postpartum psychosis
women with preexisting bipolar disorder
what is transient tachypnea of the newborn (TTN)
condition that will resolve by itself; delay in clearance of fetal lung fluids after birth
risk factors for TTN
- c-section or rapid vaginal delivery
- chorioamnionitis
- PTB
- maternal asthma or smoking
- macrosomnia of GDM moms
treatment for TTN
- O2
- positive pressure ventilation
- IVF
- tube feeding
POST-BIRTH acronym for warning signs for postpartum complications
Call 911 if
- P: pain in chest
- O: obstructed breathing
- S: seizures
- T: thoughts of hurting self or baby
Call provider if
- B: bleeding in excess or large blood clots
- I: incision not healing
- R: red or swollen leg that’s painful or warm
- T: temp >100.4F
- H: headache w/ meds or vision change
risk factors for jaundice
- PTB
- significant bruising during birth
- incompatibility between mom and baby’s blood
- breast-feeding poorly
- sepsis
- enzyme deficiency
treatment for infant jaundice
- increase frequency of feeds to 10-12/day
- phototherapy
common complications for premature neonates
- intraventricular hemorrhage
- TTN
- resp distress
- necrotizing enterocolitis: portion of bowel dies
- sepsis
- bronchopulmonary dysplasia: damage to lungs d/t MV & O2
management for premature neonate
- Resp support
- blood transfusion
- IVF
- parenteral nutrition
- EPO
- exogenous surfactant therapy
- sodium acetate for metabolic acidosis
what is defined as a postmature neonate
lasting >= 42 wks gestation
risk factors for postmature neonates
- hx of post-term
- first pregnancy
- grand multiparous women 5+ births
why can postmature neonate lead to LGA or SGA
placenta no longer adequately support, and the fetus has to use its subq fat and glycogen stores
s/s of postmature neonate
- dry peeling skin
- creases cover soles
- meconium stained
- limited vernix and lanugo
- hair and nails long
complications of postmature neonates
- meconium aspiration
- fetal hypoxia -> seizures
- hypoglycemia
- hypothermia
- polycythemia HCT >65% (compensatory response from altered O2 transport)
