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NU314 OB > Postpartum Woman at RISK > Flashcards

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

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2
Q

What is the leading cause of maternal death for both developed and developing countries?

A

Postpartum hemorrhage

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3
Q

Postpartum hemorrhage is defined as a blood loss of how much?

A

500 mL after vaginal birth

1000 mL after cesarean

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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
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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

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6
Q

What is the most common cause of postpartum hemorrhage?

A

Uterine Atony

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7
Q

When will a Primary PP Hemorrhage occur?

A

within 24 hours of birth

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8
Q

When will a Delayed PP Hemorrhage occur?

A

24 hours-12 weeks after birth

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9
Q

Uterine Atony

A

Failure of the uterus to contract and retract after birth

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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
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11
Q

What are the 4 T’s to remember the causes of PP Hemorrhage?

A

Tone
Tissue
Trauma
Thrombin

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12
Q

Tone

A

Uterine atony

Distended bladder

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13
Q

Altered uterine muscle tone is usually the result of what?

A

Over distention of the uterus

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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
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15
Q

Tissue

A

Retained placental fragments/clots

Uterine subinvolution

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16
Q

Uterine contractions and retraction leads to what?

A

Detachment and expulsion of the placenta after birth

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17
Q

Failure to complete placental separation and expulsion leads to?

A

Retained fragments/clots which occupy space and prevent uterus from contracting fully

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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

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19
Q

Trauma

A

lacerations
hematoma
inversion
rupture

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20
Q

Thrombin

A

coagulapathy

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21
Q

Mild Symptoms of Shock

A

Loss of 20% blood volume

  • diaphoresis
  • increased capillary refill
  • cool extremities
  • maternal anxiety
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22
Q

Moderate Symptoms of Shock

A

20-40% blood loss

  • tachycardia
  • postural hypotension
  • oliguria
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23
Q

Severe Symptoms of Shock

A

> 40% blood loss

  • Hypotension
  • Agitation or confusion
  • Hemodynamic instability
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24
Q

Uterine Subinvolution

A

the incomplete involution of the uterus or failure to return to its normal size and condition after birth

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25
Q

When does subinvolution typically happen?

A

When the myometrial fibers of the uterus do not contract effectively and cause relaxation

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26
Q

Causes of Subinvolution

A 
Retained placental fragments
Distended Bladder
Excessive maternal activity prohibiting recovery
Uterine Myoma 
Infection
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27
Q

Complications from Uterine Subinvolution

A

Hemorrhage
Pelvic peritonitis
Salpingitis
Abscess formation

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28
Q

What will you see clinically with Uterine Subinvolution?

A
  • PP fundal height higher than expected
  • Boggy uterus
  • Lochia fails to change from red to serosa to alba in a few weeks
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29
Q

When is uterine subinvolution typically identified?

A

at 4-6 week PP visit with bimanual exam or ultrasound

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30
Q

Treatment for uterine subinvolution is directed towards what?

A

Stimulating the uterus to expel fragments w/ a uterine stimulant, and antibiotics given to prevent infection

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31
Q

When can trauma to the genital tract occur?

A

Spontaneously or through manipulations used during birth

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32
Q

Lacerations and Hematomas can cause what?

A

significant blood loss

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33
Q

How can hematomas present?

A

They may present as pain or as a change in vital signs disproportionate to the amount of blood loss

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34
Q

What are the most common causes of hematomas?

A

Episiotomy
Nulliparity
Using instruments to assist birth

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35
Q

When does Uterine Inversion occur?

A

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

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36
Q

Treatment for Uterine Inversion

A

Uterine relaxants and immediate replacement manually by the healthcare provider

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37
Q

Who is uterine ruptures more common for?

A

Women with previous cesarean incisions or those who’ve had previous surgeries

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38
Q

Previous surgeries that may cause uterine rupture are?

A 
Myomectomy 
Peroration of uterus during D&C
Biopsy of Uterus 
Intrauterine system placement 
VBAC patients
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39
Q

Signs and Symptoms of Uterine Rupture

A

Pain
FHR abnormalities
Vaginal bleeding

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40
Q

Cervical lacerations should always be suspected when?

A

the uterus is contracted and bright red blood continues to come out of the vagina

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41
Q

Thrombosis helps to prevent what immediately after birth?

A

Postpartum hemorrhage

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42
Q

How does thrombosis help to prevent PPH?

A

by providing hemostasis

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43
Q

Women with a history of what are at increased risk for PPH?

A

menorrhagia

44
Q

What should raise the index for suspicion for PPH?

A

diagnosis of a coagulation disorder

45
Q

Types of Coagulation Disorders

A

Idiopathic Thrombocytopenia Purpura (ITP)
Von Willebrand Disease (vWD)
Disseminated Intravascular Coagulation (DIC)

46
Q

ITP

A

an autoimmune disorder of increased platelet destruction caused by antibodies which can increase a woman’s risk of PPH

47
Q

ITP is most common in who?

A

Young women
Maternal/fetal complications
Caucasian

48
Q

Treatment for ITP

A

Immune Globulin and Glucocorticoids

49
Q

Von Willebrand Disease

A

bleeding disorder that is inherited as an autosomal dominant trait

50
Q

What is the cause of Von Willebrand Disease?

A

Prolonged bleeding time
A deficiency of von Willebrand factor
Impairment of placental adhesion

51
Q

S&S of von Willebrand Disease

A 
Bleeding gums 
Easy bruising 
Menorrhagia
Blood in urine and stools
Nosebleeds
Hematoma
Prolonged bleeding from wounds
52
Q

What happens to the von Willebrand factor level during pregnancy?

A

Increases which allows most labor/births to proceed normally

53
Q

DIC

A

life-threatening, acquired coagulopathy in which the clotting system is abnormally activated

54
Q

With the clotting system abnormally activated in DIC it results in what?

A

widespread clot formation in the small vessels throughout the body which leads to depletion of platelets and coagulation factors

55
Q

DIC is always what type of diagnosis?

A

Secondary diagnosis

56
Q

DIC occurs as a result of?

A 
Abruptio placentae 
Amniotic fluid embolism
Intrauterine fetal death w/ prolonged retention of fetus
Acute fatty liver pregnancy 
Severe preeclampsia
57
Q

HELLP Syndrome w/ DIC

A 
Hemolysis
Elevated liver enzymes
Low platelet count
Septicemia 
PPH
58
Q

Signs of DIC

A 
petechia
ecchymoses 
bleeding gums
fever
hypotension
acidosis
hematoma
tachycardia 
proteinuria
uncontrolled bleeding during birth 
acute renal failure
59
Q

What is the most therapeutic thing to do for DIC?

A

treat initiating disorder/infection

60
Q

Treatment goals for DIC

A

Maintain tissue perfusion w/ fluids, oxygen, heparin, and blood products

61
Q

When excessive bleeding is encountered w/ PPH initial management steps are aimed at improving uterine tone w/?

A

Immediate uterine massage
IV fluid resuscitation
Administration of uterotonic medications

62
Q

If all other measures for PPH fail additional resources that must be utilized are?

A 
Bimanual compression
Internal uterine packing
Balloon tamponade techniques
Blood transfusion
Lab tests
63
Q

What labs should be drawn immediately for PPH?

A

CBC
Type and cross match
Coagulation studies

64
Q

When would transfusion of blood products begin for PPH?

A

once there is an estimate of 1500 mL of blood loss

65
Q

What is the priority intervention for uterine atony?

A

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
Q

First line of PPH Intervention

A

Manual massage and pharmacological therapies

67
Q

Second line of PPH interventions

A

intrauterine balloon
tamponade
uterine compression sutures

68
Q

Third line of PPH interventions

A

radiologic embolization
pelvic devascularization
hysterectomy

69
Q

What is the last resort life saving measure for PPH?

A

Peripartum hysterectomy

70
Q

What has a higher mortality rate than non-obstetric hysterectomy?

A

Peripartum hysterectomy

71
Q

Pitocin/Oxytocin

A
  • Do NOT administer as an IV bolus
  • First line therapy
  • If IV access is unavailable may use 10 units IM
72
Q

Uterine Contraction Meds

A

Oxytocin/Pitocin
Methylergonovine maleate or Ergonovine maleate
Carboprost tromethamine
Misoprostol/Cytotec

73
Q

Methylergonovine maleate or Ergonovine maleate

A

Avoid in patients w/ hypertensive disease, including preeclampsia

74
Q

Carboprost tromethamine

A

Concurrent of antiemetics and antidiarrheals recommended to treat side effects

75
Q

Misoprostol/Cytotec Contraindications

A

Allergy
Active cardiovascular, pulmonary, or hepatic disease
May cause tachycardia

76
Q

Massaging the Fundus

A

Place one hand on symphysis pubis
Place other hand on fundus
Massage in circular manner
Assess for uterine firmness–should happen quickly

77
Q

If fundus is firm what should you do next during the massage?

A

Apply gentle but firm pressure in a downward motion towards the vagina to express clots that may have accumulated

78
Q

What could happen if you attempt to express clots before the fundus is firm?

A

Could cause uterine inversion which leads to PPH

79
Q

Prostin E12 Contraindications

A

Active cardiac, pulmonary, renal, or hepatic disease

80
Q

Methergine Contraindications

A

Do not administer if patient is hypertensive

81
Q

Hemabate Contraindications

A

patients w/ asthma because it can cause bronchospasm

82
Q

PPH Patient

A
  • 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
Q

What to do for Uterine Atony

A

Massage and Oxytocin

84
Q

What to do for Retained Placental Tissue

A

evacuation and oxytocin

85
Q

What to do for lacerations/hematoma?

A

surgical repair

86
Q

What to do for bleeding disorders (Thrombin)?

A

blood products

87
Q

What causes uterine inversion and what to do for it?

A

Too much cord traction

Gentle replacement of uterus and oxytocin

88
Q

5 Causes of PPH

A 
Uterine Atony 
Retained Placental Tissue
Lacerations/Hematoma
Bleeding Disorders (Thrombin)
Uterine Inversion
89
Q

What are the 3 most common Venous Thromboembolic conditions?

A

Superficial thromboembolic disorder
DVT
PE

90
Q

When is the women’s risk higher for venous thromboembolic conditions?

A

3 weeks after delivery

91
Q

Causes of Thrombus Formation

A

Venous stasis
Injury to innermost layer of blood vessel
Hypercoagulation

92
Q

Nursing Interventions to Prevent DVT/PE

A 
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
Q

Risk factors for PP Infection

A 
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
Q

Common Infections during PP

A

Mastitis
Surgical site infections
Metritis

95
Q

Mastitis

A

Inflammation of mammary gland
Breasts are red, tender, and hot to touch
Abscess can develop if not treated in timely manner

96
Q

When does mastitis typically occur?

A

2 days-3 weeks PP

97
Q

Risk factors for Mastitis

A

Stasis of milk
Nipple trauma
Pain

98
Q

What is the most common organism causing mastitis and where does it come from?

A

S. aureus

-comes from the infants mouth or throat

99
Q

Where is the most common site for mastitis?

A

Upper/outer quadrant of breast

100
Q

Metritis

A

Infection of the uterus

101
Q

What to do for Metritis?

A

Broad spectrum antibiotics
Monitor/maintain hydration and electrolyte balance
Provide analgesia

102
Q

When will the fever decrease in most women with Metritis?

A

within 48-72 hours of initiating antibiotics

103
Q

Surgical Site Infection Treatment

A

Early recognition
Aseptic technique and sterile gloves for wound care
Frequent dressing and perineal pad change
Hydration
Ambulation
IV antibiotic
Analgesia

104
Q

UTI Treatment

A

Early catheter removal
Hydration
Cranberry juice
Antibiotics

105
Q

Postpartum Blues Symptoms

A 
anxiety 
irritability 
mood swings
tearfulness
increased sensitivity 
feelings of being overwhelmed 
difficulty thinking
fatigue
106
Q

S&S of PP Depression

A 
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
Q

Postpartum Psychosis

A 
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

NU314 OB (21 decks)

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