Postpartum Woman at RISK Flashcards
1
Q
What is a potentially life threatening problem that may occur after a vaginal or cesarean birth?
A
Postpartum Hemorrhage
2
Q
What is the leading cause of maternal death for both developed and developing countries?
A
Postpartum hemorrhage
3
Q
Postpartum hemorrhage is defined as a blood loss of how much?
A
500 mL after vaginal birth
1000 mL after cesarean
4
Q
Morbidity with postpartum hemorrhage can be severe and may include what?
A
Shock from blood loss Organ failure Edema Thrombosis Acute respiratory distress Anemia ICU admissions and prolonged hospitalizations
5
Q
What is a major obstetric hemorrhage defined as?
A
More than 1500-2000 mL that requires more than 5 units of transfused blood
6
Q
What is the most common cause of postpartum hemorrhage?
A
Uterine Atony
7
Q
When will a Primary PP Hemorrhage occur?
A
within 24 hours of birth
8
Q
When will a Delayed PP Hemorrhage occur?
A
24 hours-12 weeks after birth
9
Q
Uterine Atony
A
Failure of the uterus to contract and retract after birth
10
Q
What are other PP problems that may occur and cause postpartum hemorrhage?
A
Obstetric lacerations Uterine inversion/rupture Episiotomy Retained fragments Macrosomia Coagulation disorders Failure to progress to second stage Placenta accrete Induction w/ oxytocin Surgical birth Hematomas
11
Q
What are the 4 T’s to remember the causes of PP Hemorrhage?
A
Tone
Tissue
Trauma
Thrombin
12
Q
Tone
A
Uterine atony
Distended bladder
13
Q
Altered uterine muscle tone is usually the result of what?
A
Over distention of the uterus
14
Q
Over-distention of the uterus can be caused by?
A
Multiple gestation Fetal macrosomia Hydramnios Fetal abnormality Placenta previa Precipitous birth Retained fragments Prolonged or rapid labor Bacterial toxins
15
Q
Tissue
A
Retained placental fragments/clots
Uterine subinvolution
16
Q
Uterine contractions and retraction leads to what?
A
Detachment and expulsion of the placenta after birth
17
Q
Failure to complete placental separation and expulsion leads to?
A
Retained fragments/clots which occupy space and prevent uterus from contracting fully
18
Q
What must happen after the placenta comes out?
A
Inspect for tears of fragments left inside because it could indicate accessary lobe or placenta accreta
19
Q
Trauma
A
lacerations
hematoma
inversion
rupture
20
Q
Thrombin
A
coagulapathy
21
Q
Mild Symptoms of Shock
A
Loss of 20% blood volume
- diaphoresis
- increased capillary refill
- cool extremities
- maternal anxiety
22
Q
Moderate Symptoms of Shock
A
20-40% blood loss
- tachycardia
- postural hypotension
- oliguria
23
Q
Severe Symptoms of Shock
A
> 40% blood loss
- Hypotension
- Agitation or confusion
- Hemodynamic instability
24
Q
Uterine Subinvolution
A
the incomplete involution of the uterus or failure to return to its normal size and condition after birth
25
When does subinvolution typically happen?
When the myometrial fibers of the uterus do not contract effectively and cause relaxation
26
Causes of Subinvolution
```
Retained placental fragments
Distended Bladder
Excessive maternal activity prohibiting recovery
Uterine Myoma
Infection
```
27
Complications from Uterine Subinvolution
Hemorrhage
Pelvic peritonitis
Salpingitis
Abscess formation
28
What will you see clinically with Uterine Subinvolution?
- PP fundal height higher than expected
- Boggy uterus
- Lochia fails to change from red to serosa to alba in a few weeks
29
When is uterine subinvolution typically identified?
at 4-6 week PP visit with bimanual exam or ultrasound
30
Treatment for uterine subinvolution is directed towards what?
Stimulating the uterus to expel fragments w/ a uterine stimulant, and antibiotics given to prevent infection
31
When can trauma to the genital tract occur?
Spontaneously or through manipulations used during birth
32
Lacerations and Hematomas can cause what?
significant blood loss
33
How can hematomas present?
They may present as pain or as a change in vital signs disproportionate to the amount of blood loss
34
What are the most common causes of hematomas?
Episiotomy
Nulliparity
Using instruments to assist birth
35
When does Uterine Inversion occur?
when the top of the uterus collapses into the inner cavity due to excessive fundal pressure or pulling on the umbilical cord when the placenta is still firmly attached
36
Treatment for Uterine Inversion
Uterine relaxants and immediate replacement manually by the healthcare provider
37
Who is uterine ruptures more common for?
Women with previous cesarean incisions or those who've had previous surgeries
38
Previous surgeries that may cause uterine rupture are?
```
Myomectomy
Peroration of uterus during D&C
Biopsy of Uterus
Intrauterine system placement
VBAC patients
```
39
Signs and Symptoms of Uterine Rupture
Pain
FHR abnormalities
Vaginal bleeding
40
Cervical lacerations should always be suspected when?
the uterus is contracted and bright red blood continues to come out of the vagina
41
Thrombosis helps to prevent what immediately after birth?
Postpartum hemorrhage
42
How does thrombosis help to prevent PPH?
by providing hemostasis
43
Women with a history of what are at increased risk for PPH?
menorrhagia
44
What should raise the index for suspicion for PPH?
diagnosis of a coagulation disorder
45
Types of Coagulation Disorders
Idiopathic Thrombocytopenia Purpura (ITP)
Von Willebrand Disease (vWD)
Disseminated Intravascular Coagulation (DIC)
46
ITP
an autoimmune disorder of increased platelet destruction caused by antibodies which can increase a woman's risk of PPH
47
ITP is most common in who?
Young women
Maternal/fetal complications
Caucasian
48
Treatment for ITP
Immune Globulin and Glucocorticoids
49
Von Willebrand Disease
bleeding disorder that is inherited as an autosomal dominant trait
50
What is the cause of Von Willebrand Disease?
Prolonged bleeding time
A deficiency of von Willebrand factor
Impairment of placental adhesion
51
S&S of von Willebrand Disease
```
Bleeding gums
Easy bruising
Menorrhagia
Blood in urine and stools
Nosebleeds
Hematoma
Prolonged bleeding from wounds
```
52
What happens to the von Willebrand factor level during pregnancy?
Increases which allows most labor/births to proceed normally
53
DIC
life-threatening, acquired coagulopathy in which the clotting system is abnormally activated
54
With the clotting system abnormally activated in DIC it results in what?
widespread clot formation in the small vessels throughout the body which leads to depletion of platelets and coagulation factors
55
DIC is always what type of diagnosis?
Secondary diagnosis
56
DIC occurs as a result of?
```
Abruptio placentae
Amniotic fluid embolism
Intrauterine fetal death w/ prolonged retention of fetus
Acute fatty liver pregnancy
Severe preeclampsia
```
57
HELLP Syndrome w/ DIC
```
Hemolysis
Elevated liver enzymes
Low platelet count
Septicemia
PPH
```
58
Signs of DIC
```
petechia
ecchymoses
bleeding gums
fever
hypotension
acidosis
hematoma
tachycardia
proteinuria
uncontrolled bleeding during birth
acute renal failure
```
59
What is the most therapeutic thing to do for DIC?
treat initiating disorder/infection
60
Treatment goals for DIC
Maintain tissue perfusion w/ fluids, oxygen, heparin, and blood products
61
When excessive bleeding is encountered w/ PPH initial management steps are aimed at improving uterine tone w/?
Immediate uterine massage
IV fluid resuscitation
Administration of uterotonic medications
62
If all other measures for PPH fail additional resources that must be utilized are?
```
Bimanual compression
Internal uterine packing
Balloon tamponade techniques
Blood transfusion
Lab tests
```
63
What labs should be drawn immediately for PPH?
CBC
Type and cross match
Coagulation studies
64
When would transfusion of blood products begin for PPH?
once there is an estimate of 1500 mL of blood loss
65
What is the priority intervention for uterine atony?
Before initiating fundal massage the nurse must first place a hand over the symphysis pubis to anchor the uterus and prevent possible uterine inversion
66
First line of PPH Intervention
Manual massage and pharmacological therapies
67
Second line of PPH interventions
intrauterine balloon
tamponade
uterine compression sutures
68
Third line of PPH interventions
radiologic embolization
pelvic devascularization
hysterectomy
69
What is the last resort life saving measure for PPH?
Peripartum hysterectomy
70
What has a higher mortality rate than non-obstetric hysterectomy?
Peripartum hysterectomy
71
Pitocin/Oxytocin
- Do NOT administer as an IV bolus
- First line therapy
- If IV access is unavailable may use 10 units IM
72
Uterine Contraction Meds
Oxytocin/Pitocin
Methylergonovine maleate or Ergonovine maleate
Carboprost tromethamine
Misoprostol/Cytotec
73
Methylergonovine maleate or Ergonovine maleate
Avoid in patients w/ hypertensive disease, including preeclampsia
74
Carboprost tromethamine
Concurrent of antiemetics and antidiarrheals recommended to treat side effects
75
Misoprostol/Cytotec Contraindications
Allergy
Active cardiovascular, pulmonary, or hepatic disease
May cause tachycardia
76
Massaging the Fundus
Place one hand on symphysis pubis
Place other hand on fundus
Massage in circular manner
Assess for uterine firmness--should happen quickly
77
If fundus is firm what should you do next during the massage?
Apply gentle but firm pressure in a downward motion towards the vagina to express clots that may have accumulated
78
What could happen if you attempt to express clots before the fundus is firm?
Could cause uterine inversion which leads to PPH
79
Prostin E12 Contraindications
Active cardiac, pulmonary, renal, or hepatic disease
80
Methergine Contraindications
Do not administer if patient is hypertensive
81
Hemabate Contraindications
patients w/ asthma because it can cause bronchospasm
82
PPH Patient
- Maintain patent IV infusion and prepare to start another IV if transfusions are needed
- Check vitals q 15-30 mins
- Monitor CBC
- Assess LOC
- Foley catheter to keep bladder empty and prevent uterine displacement
83
What to do for Uterine Atony
Massage and Oxytocin
84
What to do for Retained Placental Tissue
evacuation and oxytocin
85
What to do for lacerations/hematoma?
surgical repair
86
What to do for bleeding disorders (Thrombin)?
blood products
87
What causes uterine inversion and what to do for it?
Too much cord traction
| Gentle replacement of uterus and oxytocin
88
5 Causes of PPH
```
Uterine Atony
Retained Placental Tissue
Lacerations/Hematoma
Bleeding Disorders (Thrombin)
Uterine Inversion
```
89
What are the 3 most common Venous Thromboembolic conditions?
Superficial thromboembolic disorder
DVT
PE
90
When is the women's risk higher for venous thromboembolic conditions?
3 weeks after delivery
91
Causes of Thrombus Formation
Venous stasis
Injury to innermost layer of blood vessel
Hypercoagulation
92
Nursing Interventions to Prevent DVT/PE
```
Early ambulation
Compression Devices/Stockings
Elevating patient's legs
Smoking cessation
Increased fluid intake
Avoid sitting/standing for too long
Avoid oral contraceptives in higher risk patients
```
93
Risk factors for PP Infection
```
Surgical/Instrumental birth
Prolonged ruptured membranes/labor
Inadequate hand hygiene
Internal fetal monitoring
Obesity/Gestational Diabetes/Anemia
Extremes of patient's age
Untreated infection prior to birth
Low socioeconomic status
Retained placental fragments
Uterine manipulation
```
94
Common Infections during PP
Mastitis
Surgical site infections
Metritis
95
Mastitis
Inflammation of mammary gland
Breasts are red, tender, and hot to touch
Abscess can develop if not treated in timely manner
96
When does mastitis typically occur?
2 days-3 weeks PP
97
Risk factors for Mastitis
Stasis of milk
Nipple trauma
Pain
98
What is the most common organism causing mastitis and where does it come from?
S. aureus
| -comes from the infants mouth or throat
99
Where is the most common site for mastitis?
Upper/outer quadrant of breast
100
Metritis
Infection of the uterus
101
What to do for Metritis?
Broad spectrum antibiotics
Monitor/maintain hydration and electrolyte balance
Provide analgesia
102
When will the fever decrease in most women with Metritis?
within 48-72 hours of initiating antibiotics
103
Surgical Site Infection Treatment
Early recognition
Aseptic technique and sterile gloves for wound care
Frequent dressing and perineal pad change
Hydration
Ambulation
IV antibiotic
Analgesia
104
UTI Treatment
Early catheter removal
Hydration
Cranberry juice
Antibiotics
105
Postpartum Blues Symptoms
```
anxiety
irritability
mood swings
tearfulness
increased sensitivity
feelings of being overwhelmed
difficulty thinking
fatigue
```
106
S&S of PP Depression
```
Restless
Worthless/hopeless
Guilty
Sad/Overwhelmed
Low energy
Loss of memory/libido/enjoyment
Lack of interest in baby or family
Worry about hurting baby
Apetite disturbances
```
107
Postpartum Psychosis
```
Mood lability
delusional beliefs
hallucinations
disorganized thinking
tearful and confused
feelings of worthlessness and guilt
depersonalization
manifestations of mania
thoughts of hurting self or infant
```
