PP Complications

Question 1

What is a hematoma

Answer 1

Localized collection of blood in loose connective tissue beneath the skin of the vagina or c/s incision

Question 2

What are some causes of PP hematoma

Answer 2

• occurs from trauma
• assisted deliveries (vacuum, forceps)
• sometimes from a c/s hematoma

Question 3

What are some signs/symptoms of PP hematoma

Answer 3

1) Pain/pressure - due to pressure of built up blood
2) Difficulty voiding - urine flow can be obstructed due to
3) Bulging or skin discoloration
4) Decreased hemoglobin and hematocrit counts
5) S/S of hypovolemic shock/hypovolemia

Question 4

What are some signs and symptoms of hypovolemic shock/hypovolemia

Answer 4

a. Hypotension
b. Low H/H
c. Tachycardia
d. Febrile (fever)
e. Pallor (pale)

Question 5

What can you do to manage a PP hematoma

Answer 5

• maintain hydration
• blood transfusions
• monitor I&O and vitals
• insert foley catheter for urinary obstruction
• surgical drain may need to be inserted
• cold packs can be used to reduce swelling
• pain meds

Question 6

What is a PP hemorrhage (PPH)

Answer 6

severe bleeding of the vagina or perineum (blood loss that causes hemodynamic instability)
Ex. saturating a pad in 15 min.
major cause of maternal mortality

Question 7

What are some risk factors for PPH?

Answer 7

1) history of PPH (previous hemorrhage)
2) overstretched utereus due to:
- multiples (ex. twins)
- large fetus
- iii. Polyhydraminos (too much fluid in uterus)
3) tired uterus (tired to contract) due to:
- multipara
- prolonged labour
- precipitous labor (super fast delivery = uterus can’t contract properly)
4) Placental abruption – (when placenta detaches from the uterus before it should, filling the uterus w blood)
5) Placenta previa – when placenta is in the wrong spot (over the cervix where the baby comes out)
6) Preeclampsia – high BP during pregnancy
7) Assisted delivery – vacuum or forceps that cause tissue damage

Question 8

What are the main causes of PPH? (4 Ts)

Answer 8

1) Tone - boggy vs. firm
- a boggy uterus impairs blood coagulation and is the #1 cause of PPH
2) Trauma - injury to the birth canal during delivery (ex. laceration or episiotomy)
3) Tissue - Retention of tissue from the placenta or fetus stuck in the uterus
4) cloTting - problems blood clotting (coagulopathies)
- most dangerous being Disseminated intravascular coagulation (DIC)
Also -> subinvolution

Question 9

What is DIC

Answer 9

Disseminated intravascular coagulation is when there is a clotting failure in blood causing excessive clots to be passed.

Question 10

What are the signs of PPH

Answer 10

Earl signs: first 24 hrs PP
Late signs: after the first 24 hrs up to 2 weeks PP when they are home (edu pt)

• Bleeding: 500mL vaginal or 1000mL c/s
• Saturating a pad withing 15 min, puddles of blood in the bed
• boggy uterus or off-center
• signs of shock
  (Restlessness and tachycardia are early signs
  Hypotension is a late sign)

Question 11

What are some ways a nurse can manage a PPH

Answer 11

Fundal massage/assessment
- Every 15 minutes for first hour PP
- Every 30 minutes – 2 times
- Every hour – 4 times 
- Assessment of location and bleeding.
Estimate blood loss
- check pad for bleeding and make sure to turn patient and look under them to quantify all of bleeding
Blood labwork for Hb and hematocrit should be done once stable and 6 hours after to see effects
Oxytocin  and blood transfusions may be given
Urinary bladder status
Circulatory support: IV fluids, O2
Surgical interventions may be done 
     Dilation and curettage (D&C)  to remove tissue from inside your uterus
     Hysterectomy (last resort)
     Intrauterine balloon tamponade
     Uterine artery embolization

Question 12

What are some ways a nurse can manage mastitis

Answer 12

1. Continue feeding to promote lactation despite mastitis – it is safe
   - Either manually express or utilize a breast pump at least q4hr
2. Use a warm compress to help with pain and duct dialation
3. Administer pain meds (ibuprofen) and antibiotics if indicated
4. Support breasts with bra without underwire, which can irritate the already inflamed breast and potentially clog ducts

Question 13

What is subinvolution? What is the biggest reason for subinvolution?

Answer 13

A medical condition in which after childbirth, the uterus does not return to its normal size.

Question 14

What are some common causes of subinvolution?

Answer 14

Infection (most common)
Overdistended uterus
Retained placenta

Question 15

Signs of subinvolution

Answer 15

• Heavy bleeding
• Pain upon palpation (infection)
• Fundal height not decreasing as expected
• Uterus larger than expected

Question 16

What are some ways to help manage/treat subinvolution?

Answer 16

1. Treat the cause
   - remove retained fragments of placenta
   - treat infection (antibiotics)
   - fundal massage to get uterus to contract
   - oxytocin

Question 17

What is Thrombophlebitis

Answer 17

Inflammation of the blood vessel caused by a clot, putting the client at increased risk

Question 18

Why are PP patients at an increased risk for thrombophlebitis

Answer 18

due to the increase of clotting factors that naturally occurs during pregnancy

Question 19

What are some signs/symptoms of thrombophlebitis

Answer 19

• Diminished pulses (petal, femoral, etc)
• Unequal swelling/edema bilaterally
• Pain/tenderness
• Skin discoloration

Question 20

What events can be caused by an embolus

Answer 20

Embolus (a dislodged clot) can cause:
Pulmonary Embolism
Stroke
Myocardial Infarction

Question 21

What are some interventions to prevent thrombophlebitis

Answer 21

• encourage ambulation asap (ambulate every hour to PREVENT formation)
• avoid massaging the area
• avoid restrictive clothing, crossing legs, and prolonged sitting or standing (including in car/plane rides)