week 5 Flashcards
1
Q
postpartum hemorrhage
A
- defined as a loss of more than 500mL after vaginal, 1000mL after cesarean
- cause of maternal morbidity and mortality
- life-threatening with little warning
- often unrecognized until profound symptoms
- biggest contributor: uterine atony
2
Q
PPH: etiology and risk factors
A
uterine atony - marked hypotonia of uterus - most common cause of PPH - risks: high parity, macrosomia, multifetal gestation, prolonged labor, some medications lacerations of genital tract - trickle of blood hematomas - assessment! - particular with instrument assisted vaginal delivery - perineal or rectal "pressure" unrelieved by medication retained placents inversion of uterus subinvolution of uterus
3
Q
PPH: assessment
A
- early recognition is critical
- assess bleeding and contractility of uterus
- bleeding: saturated pad in one hour; “pooling” of blood under butt; clots (large)
- uterus: boggy, enlarged and boggy (may be full of blood)
- assess kidney status: should have excess urine output
4
Q
PPH: interventions
A
- fundal massage (for boggy uterus)
- re-assess
- medications if necessary
- surgical intervention if necessary
5
Q
PPH: medications
A
oxytocin/pitocin - uterine contractions methylergonovine/methergine (oral) - uterine contractions - may cause hypertension (do NOT give if 140-90 or greater) - may use PO for stabilization q4-6h
6
Q
PPH: surgical interventions
A
- if medication management is unsuccessful: D&C
- IV fluids
- blood transfusion
- management of “hemorrhagic shock” patient
7
Q
hemorrhagic (hypovolemic) shock
A
assessment
- signs may not occur until very late
- excess blood volume of pregnancy protects mother and masks symptoms
- 30-40% total volume lost before symptoms
- assess respirations, pulse, skin, and urine output
medical management
- fluid or blood replacement therapy
- aggressive use of blood transfusion
8
Q
thromboembolic disease
A
results from blood clot caused by inflammation or partial obstruction of vessel
- incidence: SVT more common, venous stasis, hyper-coagulation
- clinical manifestations: pain, tenderness, warmth, redness (palpable vein if SVT; unilateral swelling if DvT)
9
Q
thromboembolic disease: medical management
A
- venous ultrasound
- analgesia, rest, elevation
- anticoagulant therapy for DVT (lovenox vs. heparin)
- bedrest
- observe for s/s PE
10
Q
postpartum infections
A
- puerperal sepsis: any infection of genital canal within 28 days after abortion or birth
- most common infecting agents are numerous streptococcal and anaerobic organisms
- endometritis (infection of lining of uterus)
- wound infections
- urinary tract infections (red flag is inadequate amount of urine)
- mastitis
11
Q
Endometritis/Metritis
A
infection of lining of uterus greater risk - after c-section - ruptured membranes in labor >24hr - pre-existing vaginal infection (B strep) - fever >38C; foul smelling lochia - treat with AB
12
Q
wound infection
A
- surgical wound
- redness induration drainage
- REEDA
- redness above/below incision
- fever
- AB
13
Q
Mastitis
A
- breast infection (soft tissue infection, NOT milk infection)
- unilateral
- after milk production (usually 2-4 wks pp)
- inflammatory edema and engorgement of breast
- red, warm, painful area on one breast
- AB therapy
- continue to breastfeed/pump
14
Q
postpartum depression with psychotic features
A
- postpartum psychosis: syndrome characterized by depression, delusions, and thoughts of harming either infant or self
- psychiatric emergency: may require psychiatric hospitalization
- antipsychotics and mood stabilizers such as lithium are treatments of choice.
15
Q
metabolic disorders: diabetes mellitus
A
- despite advances in care, the woman whose pregnancy is complicated by diabetes may still have poor outcomes
- pregnancy complicated by diabetes considered high risk: most important determinant of fetal well being is Glycemic Control
- diabetes can be successfully managed with a multidisciplinary approach
16
Q
diabetes: pathogenesis
A
- group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both
- may be caused by either or both: impaired insulin secretion, inadequate insulin action in target tissues
17
Q
metabolic changes associated with pregnancy: diabetes
A
- altered carbohydrate metabolism
- increased resistance to insulin due to Human Placental Lactogen
- changes in diet (first trimester)
- changes in “demand”- increased fetal growth 2nd and 3rd trimester
18
Q
pre-gestational DM: maternal risks and complications
A
- ketoacidosis
- hypoglycemia
- more common in first trimester due to hormonal influence and better uptake of glucose
- second and third trimester: insulin resistance due to hormonal changes resulting in greater insulin requirements (HPL, cortisol, insulinase)
- after delivery: decrease in HPL= decreased insulin resistance
- more of a problem in type I than type II. greater change in insulin requirement.
19
Q
pre-gestational diabetes: fetal/neonatal risk
A
sudden and unexplained stillbirth (1%)
congenital anomalies
- CNS
- cardiac defects
- skeletal defects
- excess glucose interferes with surfactant production and can result in respiratory compromise at birth
- hyperglycemia increased risk of LGA/macrosomia and birth trauma
fetal macrosomia and birth trauma
risk of hypoglycemia after birth: baby’s pancrease adapts to excess glucose. hypo when born due to cut off food source.
20
Q
nursing care management: diabetes care and implementation
A
Antepartum
- diet and exercise
- medication therapy
- insulin therapy
- monitoring blood glucose levels
- fetal surveillance
- complications required hospitalization
- determination of birth date and mode of birth: management of glucose during labor
21
Q
diabetes management during pregnancy
A
insulin
- adjustment of regimen/dose
- short acting + long acting
- most type 1 require 2-4 injections per day (pump ok)
Oral agents
- glyburide approved for pregnancy
- not for initiation. only for continuation.
- most patients require change to insulin
- adjust dosing according to the demands of pregnancy
22
Q
pre-existing risk for gestational diabetes
A
- family hx of type 2 DM
- older than 30
- hx of macrosomic infant or unexplained stillbirth
- HTN
Education: finger sticks, insulin administration, how to incorporate exercise into lifestyle.
23
Q
DM: fetal assessment
A
- all types of DM require additional fetal surveillance
- growth
- non-stress test
- biophysical profile
possible respiratory distress
good control = better outcomes
24
Q
DM: intrapartum management
A
- probable induction of labor 38-40 weeks
- may require IV insulin drop with D5LR maintenance IV
- earlier delivery based on fetal status
- c-section based on fetal status or labor progress (don’t necessarily have to have a c-section)
25
DM: postpartum management
```
Type 1:
- continue FS monitoring and adjustment of insulin
- blood glucose/insulin requirements re-adjust 7-10 days
Type 2:
- monitor FS and regimen
Gestational:
- no need for FS assessment
- no need for further insulin
```
26
fetal assessment for hypoglycemia
- s/s: jittery, lethargy, changes in respiratory effort
- heelstick glucose: >40mg/dL
- sign of hyop or low heel stick: FEED
- highest risk usually 2-3 hours after delivery, sooner if traumatic or difficult birth, cold stress, physiologic stress.
- skin to skin contact and BF decreases risk.
27
miscarriage (spontaneous abortion)
- pregnancy loss prior to 20 weeks or less than 500 grams
- 10-12% pregnancies
- largely due to chromosomal abnormalities
- > 90% occur before 8 weeks
- can be associated with medical conditions, infections, exposure to toxins, genetics
28
miscarriage: clinical manifestations and management
cramping and bleeding
management:
- assessment of amount and character of bleeding
- complete: "contents" including fetal tissue is expelled completely
- incomplete: some "contents" remain in uterus. risk for continued bleeding and incomplete empyting, requires medical intervention, misoprostol, dilation and curettage.
29
miscarriage: surgical procedure and medical/nursing care
```
surgical:
- D&C requires OR,consent, postop care, management of postsurgical bleeding, pain management
medical/nursing care
- medication administration by MD
- management of symptoms (pain, diarrhea, nausea)
- assess for bleeding (both procedures)
- RhoGAM if indicated
- discharge teaching
- emotional support
```
30
Ectopic pregnancy: incidence and etiology
```
fertilized ovum implanted outside uterine cavity
95% occur in fallopian tube
other sites include:
- ovary
- abdominal cavity
- cervix
(not viable)
```
31
ectopic pregnancy: clinical manifestations
- missed period
- adnexal fullness
- dark red or brown vaginal bleeding
- verify pregnancy status for women in ER!
- risk of rupture: abdominal pain, blue around umbilicus, risk for hemorrhage
32
ectopic pregnancy: collaborative management
```
conservative management
- Methotrexate: chemo. stops new cells from replicating.
surgical management
- Salpingostomy
- OR/Postop
follow up on Rh status.
```
33
ectopic pregnancy: nursing care
- hemodynamic status
- Rh status
- admin of RhoGAM
- Follow up: blood work
34
late pregnancy bleeding: placenta previa
placenta implanted in lower uterine segment near or over internal cervical os
classification based on degree internal cervical os is covered by placenta
- complete placenta previa
- partial placenta previa
- marginal pp (skirting the edge)
35
placenta previa: risks and potential outcomes
risks
- previous pp, previous c-section, D&C/suction, multiple gestation, African American, Asian, smoker
potential outcomes
- maternal morbidity and mortality
- complications
- fetal risks include malpresentation and congenital anomalies
- preterm birth
36
placenta previa: clinical manifestations
- PAINLESS vaginal bleeding
- occurs after 20 weeks
- bleeding may increase with uterine activity
- you've established that she's not having a miscarriage
37
placenta previa: diagnosis and medication management
```
diagnosis
- transabdominal ultrasound
management:
- expectant management: observation and bed rest
- cesarean birth
- hospital and home care
```
38
placenta previa: nursing care
```
promote rest (including pelvic rest if discharged- no sex)
observe bleeding: amount, character (red to brown? brown to red?), increase/decrease (pad count)
vital sign assessment: may not see change until 40% blood loss
urine output
delivery: anticipate c-section (possible antepartum steroid to promote fetal lung development). if cramping and contracting may need emergency c-section.
```
39
placenta previa: delivery and postpartum care
risk for intraoperative blood loss
- careful monitoring and prompt management
risk for Postpartum hemorrhage
- inability or uterus to effectively contract at site of placental implantation
careful observation of PP bleeding
careful monitoring of VS and urine output
methergine as indicated to keep bleeding under control.
40
late pregnancy bleeding: placental abruption
premature separation of placenta
- primary risk factors: HTN, cocaine use, trauma, prior history of abruption
- risk of maternal and fetal morbidity and mortality
- classification systems: 1 (mild), 2 (moderate), 3 (severe)
41
placental abruption: clinical manifestations
- increasing uterine tone (doesn't relax in between contractions)
- increasing uterine pain
- vaginal bleeding (hard to tell from bloody show)
- changes in fetal heart rate patterns
- bloody amniotic fluid
- maternal shock systems (later sign)
- restless: different from patient in pain
42
placental abruption: management
- delivery as indicated
- preparation for neonatal resuscitation
- prep for maternal blood transfusion
- maternal assessment and management post delivery: v/s and urine output signs of shock, labwork: H&H; coagulophathies (DIC)
