Week 7: Monday, High Risk Newborn Flashcards
Postpartum period
- The first 6 weeks after delivery
- Also called puerperium, 4th trimester (which doesn’t work cause tri means three)
Postpartum hemorrhage definition
- 500 + mL blood loss after vaginal delivery or
- 1000 + mL blood loss after c-section or
- > 1000 mL loss within 24 hours after delivery
- FYI: Most likely to occur in first 24 hours after delivery but can also occur up to 6 weeks postpartum
- 54 - 93% of maternal deaths due to obstetric hemorrhage may be preventable
Signs of potential complications (case study)
- Vitals: 100.4 Temp, after 1st 24 hours. tachy, brady. Hypo or HTN.
- Uterus: Not in midline, Boggy, above umbilicus
Signs of potential complications CONT.
- Lochia: heavy, bright red (NOT LOCHIA THEN), foul odor
- Perineum: Pain, edema, not intact, bad odor (infection)
- Legs: pain, redness/warmth, edema
Complications: breasts
- Redness
- warmth
- pain
- cracked/bleeding/flat/inverted nipples
- Engorgement
Complications: Elimination
- Insufficient voiding
- Urgency/dysuria
- Constipation
- Diarrhea
- Gas pain
- Epigastric gas pain
Complications: Appetite
- N/V
- Loss of appetite
Complications: Neuro
- Headache
- Blurred vision
- Altered consciousness
- inability to rest/sleep
Indications of excessive bleeding that require immediate assessment, intervention, and notification of provider
- A peripad is saturated in 15 min or less, consecutively. Can be caused by uterine atony.
- Constant “trickle” of un- clotted blood. Can be a laceration.
- Pooling of blood under the buttocks. Most likely uterine atony (70% of PPH)
Precipitating factors for Hemorrhage - The 4 T’s
- Tone
- Trauma
- Tissue
- Thrombin disorders
Tone (70% of the time). What causes issues with tone? (6 pts)
- Large baby (or multiples)
- High parity
- Rapid labor
- Fever
- Oxytocin induction
- Fibroids
Symptoms of uterine atony (5 pts)
- Bleeding may be slow and steady, or profuse
- Large, boggy uterus
- Clots!
- Weigh pads, chux for quantitative blood loss.
- 1 G = 1 mL
Nursing actions related to postpartum hemorrhage (6 pts)
- Assess lochia (amount, color, clots or not)
- Fundal massage
- Pad saturation (time it takes)
- Saturated within 15 min is heavy bleeding
- Vital sign indicators of shock
- Administer uterotonic(s)
Medical intervention for PPH (FYI)
- Bakri balloon inserted into uterus to keep it from “leaking”
- Also B-lynch sutures to essentially suture the uterus to prevent it from bleeding
Fundal massage “review” (3 pts)
- Fundus should feel firm like a grapefruit
- Use two hands
- Immediately after delivery, observe the perineum during fundal check to check for clots, gush of blood, etc
Involution of the uterus (4 pts)
- The height of the uterine fundus decreases approx. 1 cm per day until it is no longer palpable at 1- days’ postpartum
- At delivery: 1/U
- Day 1: U/1
- Day 3: U/3
Meds to control bleeding may be given ____ (1 pt)
PO, IV, IM, or directly into uterine muscle
Oxytocin admin details (2 pts)
- 30 units in 500 mL lactated ringers
- Or 10 - 20 mg IM
Uterotonic detail (this med starts with an “M”)
- Misoprostil 800 mcg per rectum
- Some providers order it p.o.
Uterotonic details (This med starts with a type of street drug)
- Methergine 0.2 mg
- IM ONLY – NEVER IV
- Contraindicated for pts with HTN
Uterotonic details (starts with an “H”)
- Hemabate
- 250 mcg (1 vial) IM
- Often violent G.I. S/E
- Contraindicated with hx of asthma
3 details concerning meds during PPH (3 pts)
- 2nd IV line necessary with pph
- May need surgical management with hyst possible
- Serious risk of DIC accompanies severe pph
Trauma (the 4 t’s)
- Laceration: perineal, cervical, or vaginal wall
4 degrees of lacerations (4 pts)
- 1st degree: vaginal mucosa torn
- 2nd degree: perineal muscles torn
- 3rd degree: Anal sphincter torn
- 4th degree: Rectum torn
PPH lacerations Definitions (3 pts)
- A tear anywhere in the genital tract
- Can be the result of operative delivery, rapid labor, or normal labor
- Perineal lacerations are classified by degrees with the 4th being the worst (p. 407 in text gives more details)
PPH lacerations, S&S and Interventions (5 pts)
- Signs and symptoms: Firm uterus with continued bleeding
- Steady trickle of unclotted bright red blood
- Interventions: Monitor VS’s and lochia, measure QBL
- Maintain fluid balance
- Call provider to evaluate, locate and repair laceration
PPH: Hematoma (2 pts)
- Definition: Collection of blood in the pelvic tissue due to trauma to a vessel (without laceration)
- Location may be vulvar, vaginal, cervical or retroperitoneal
PPH: Hematoma S&S (4 pts)
- Firm uterus
- Sudden onset of painful perineum (pressure)
- Bulging area just under the skin
- Extreme difficulty voiding or sitting
Hematoma Interventions (6 pts)
- Assess for visible hematoma
- Call provider to assess
- May need to be excised and ligated
- May insert bladder catheter
- Continue to assess VS, EBL, fluid maintenance
- Pain management, ice to area
Tissue (4 T’s) 10% of the time (1 pt)
Retained or abnormal placenta
Retained placental fragments (6 pts)
- Most late PPH is caused by retained placental fragments
- S&S: Uterus is atonic and remains larger than normal
- Strings of tissue in the blood
- Interventions: Call provider to assess – D&C may be needed
- Monitor for signs of shock
- Administer oxygen if indicated
Thrombin disorders (1% of the 4 T’s)
- Pre-eclampsia
- Stillbirth
Disseminated intravascular coagulation (DIC) (3 PTS)
- Not a separate cause of PPH, but a result of rapid and excessive blood loss
- DIC is a disturbance in normal coagluation
- Pregnant and PP women are at greater physiologic risk to develop DIC
Predisposing conditions for DIC (1 pt)
Severe pre-eclampsia, HELLP syndrome, missed or incomplete abortion, abruptio placentae, severe trauma or infection
Signs of potential psychosocial complications (4 pts)
- Unwilling to hold baby
- Refuses to care for baby
- Markedly depressed
- Lacks support system
Postpartum depressive disorders (3 pts)
- Postpartum blues
- Postpartum depression
- Postpartum psychosis
Postpartum blues (4 pts)
- Occur in about 50% or more of women within the 1st few weeks after delivery
- Onset often around 3 days postpartum, resolves on its own within 2 weeks
- Low mood and mild depressive symptoms, transient and self-limited
- Sadness, crying, irritability, anxiety, exhaustion, feeling overwhelmed, difficulty sleeping
Postpartum depression (3 pts)
- Similar to postpartum blues, but more intense
- Usually develops within the first few weeks after giving birth, but may occur after a year
- Psychotherapy and antidepressants can be helpful
Postpartum depression S&S (8 pts)
- Crying too much
- Difficulty bonding with the baby
- Withdrawing from family and friends
- Less interest and pleasure in activities once enjoyed
- Intense irritability and anger
- Fear that shes not a good mother
- Thoughts of harming one’s self or the baby, thoughts of suicide or death
- Untreated, may last for many months
Postpartum psychosis (4 pts)
- a rare condition that usually develops within the first week after delivery
- The symptoms are severe
- May lead to life-threatening thoughts or behaviors and requires immediate treatment
- Generally requires hospitalization and therapy
Postpartum psychosis S&S (7 pts)
- Feeling confused and lost
- having obsessive thoughts about your baby
- hallucinating and having delusions
- Having sleep problems
- Mania
- Feeling paranoid
- Making attempts to harm yourself or your baby
ABO incompatibility (3 pts)
- During pregnancy, some of the mother’s antibodies are transported across the placenta and enter fetal circulation
- This is necessary because by the time of birth, newborns have only a primitive immune system, and the continuing presence of maternal antibodies helps ensure that they survive while their immune system matures
- A downside to this protection is that by targeting fetal RBCs, maternal antibodies can also cause hemolytic disease of the fetus and newborn (HDFN)
Two main signs that a newborn has an ABO incompatibility
- Jaundice
- Anemia (generally mild)
FYI: ABO incompatibility and HDFN (5 pts)
- A congenital, inherent mismatch between maternal and fetal blood types, causing immune-mediated red blood cell (RBC) disorder
- Occurs in 15 to 25% of pregnancies
- Maternal antibodies attack fetal or newborn RBCs
- Effects on fetus : Mild anemia or hyrops fetalis
- Effects on newborn: Hyperbilirubinemia and Kernicterus
Bookmark at slide 57
