week 9: postpartum complications Flashcards
what is the difference between mood changes (postpartum blues) and mood disorders
Baby Blues
- within 3-5 days postpartum
- common and temporary emotional state that many women experience in first few days to wks after childbirth.
- mood swings, fatigue, anxiety, weepiness, impaired concentration, diff sleeping or eating
- typically resolves in 2 weeks
- due to hormonal changes
Postpartum Mood Disorders
- affect daily functioning
- more severe, long lasting
- typically emerges within 4-6 wks after childbirth
- persistent sadness, severe mood swings, loss of interest, fatigue, changes in appetite or sleep patterns, feelings of worthlessness or guilt, difficulty bonding
potential risk factors for perinatal mood disorders
- relocation
- problems w infertility, and anxiety
- spontaneous abortion
- change in birth plan
- NICU admission can be stressful
- low milk supply
give examples of cognitive domain
- what is diff btwn postpartum depression, baby blues
- resources for lactation support and possible referrals
- teaching about baby cues
give examples of affective domain
- support groups
- mom baby class
- talking about importance of emotional expression
- birth story share circle
give examples of behavioural domain
- establishing a routine
- responding to cues
- time management
what is the edinburg postnatal depression screen
10 statements about individual reflex about each statement in the last week, they choose the responsiveness that looks like what they felt the past week. individuals should be screening themselves.
perinatal depression + treatment options
- characterized by low mood and lack of interest in activities, can be mild to severe
- intense, pervasive sadness and labile mood swings that last longer than 2 wks
treatment options:
- psychotherapy, CBT, psychodynamic therapy
- antidepressants, anti anxiety meds, and electroconvulsive therapy
health teaching practices for baby blues and postpartum depression
- what are somes signs of baby blues? when should the symptoms go away?
- what are symptoms of postpartum depression and when can they begin?
- what are some ways to support wellbeing in the postpartum period?
- what are warning signs that clients and families should be aware of that require urgent immediate care?
risk factors + s/s for perinatal mood disorders in partners
risk factors:
- previous history
- partner w mood disorder
- work or financial stress
- poor social and relationship
- difference w parenting expectations vs reality
s/s:
- fatigue, frustration, anger, irritability
postpartum psychosis
- most severe
- rare 0.1% of postpartum patients
- onset tends to show within 2 weeks postpartum, small number develop symptoms later
- rapid onset of unusual behaviour, hallucinations, paranoia, disorientation, high levels of impulsivity, increase risk for suicide
postpartum psychosis care
- inpatient psychiatric care, antipsychotics, mood stabilizers, benzodiazepines, electroshock therapy
what is a PPH defined as for v birth and c section
loss of > 500mL of blood after v birth
loss of >1000 mL after c section
- any blood loss that has the potential to cause hemodynamic instability
- blood loss is difficult to estimate and is frequently underestimated
- amount of blood loss required to cause hemodynamic instability depends on pre-existing condition of the client
described early, acute, primary PPH
occurs within 24 hrs of birth
describe late or secondary PPH
occurs 24 hrs but less than 6 wks after birth
PPH prevention
active management in 3rd stage of labour
- oxytocin after delivery of anterior shoulder
- gentle cord traction (no pulling)
- immediate fundal assessment after birth
if 3rd stage of labour takes longer than 30 min, risk of PPH increase 6-fold
4 T’s of PPH
tone - uterine activity
trauma - retained placenta
tissue - lacerations
thrombin - coagulation
describe tone for PPH + risk factors
Most common cause of PPH
Lack of uterine tone*
- Soft, spongy, boggy - slow and steady loss of blood
- Higher amount of blood loss than wed expect
Myometrium: smooth muscle
Contractions -> placental arteries - allows blood vessels to constrict
If too much amniotic fluid, carrying multiples: uterus has been overdistended so takes more work to contract
Why someone who had oxytocin during labour is at more risk for PPH: could be hyperstim of uterus, oversaturation of synthetic oxytocin so body becomes desensitized to it
Mag sulfate: prevention of eclampsia, and preterm labour for neuroprotection, tocolytics (diff tocolytics - mag sulfate to relax the uterus) smooth muscle relaxant make sit more difficult to uterus to relax post birth
Inflammation makes it harder for muscle to contract in chorioamnionitis
uterine atony
- marked hypotonia of uterus
- leading cause of early PPH (around 70%)
risk factors
- overdistended uterus (macrosomia, multiples, polyhydramnios)
- high parity
- prolonged labour, oxytocin induced labour
- MgSO4 administration
- chorioamnionitis
describe trauma for PPH + risk factors
- lacerations of birth canal
- uterine rupture
- uterine inversion
- hematomas
risk factors
- operative birth
- precipitous birth
note: hemorrhage related to lacerations should be suspected if bleeding continues despite a firm, contracted uterus
rupture of uterus, uterine inversion (flips inside and out and prolapses)
Placenta is embedded in uterus, and cord pulls too hard, uterine flips (medical emergency)
Firm fundus - trauma not tone
describe tissue for PPH + risk factors
- retained placental fragments
- placenta previa, placenta accreta, increta, percreta
- higher risk of infection
- manual removal by OB provider
- D&C may be required
Retained products: risk of hemorrhage, but more long term risk is infection
Is there abnormal implementation of placenta
Placenta acreta: (goes deeper into uterus layers, invades, and less likely to fully detach)
Body thinks placenta is there, consistently perfuses blood there = bleeding
Recommended c section due to risk of not getting rid of placenta
Dilatino and evacuation if pt is no longer
Misprostolol if they suspect it’s a blood clot and no parts of birth
describe thrombin for PPH + risk factors
- idiopathic thrombocytopenic purpura (ITP)
- von willebrand’s disease
- disseminated intravascular coagulation (DIC)
When pt is continuing to bleed, bc they have coagulation issues
History of bleeding - may not be known
Issues with ITP, can also be an autoimmune disorder
Hard time having sufficient platelets
Followed by hemotology during pregnancy, and some medications that help with coagulation (transfusinos of platelets can be helpful too)
DIC - imbalance in platelet coagulation, start to bleed somewhere, they send clotting factors there, but then there is a rapid internal hemmorhage that turns into widespread internal bleeding, s/s oozing of blood, BASICALLY BLEEDING EVERYTHING THIS IS SCARY ASF
Low platelets and fibrogen
Risk factors: preeclampsia (HELLP syndrome)
signs of hemorrhagic shock
- tachypnea and shallow respirations
- tachycardia, weak and irreg HR
- hypotension (late sign)
- cool, pale, clammy skin
- urinary output decreasing
- LOC become less alert and lethargic
- anxious
can occur rapidly BUT classic signs of shock may not appear until the postpartum client has lost 30- 40% of their blood volume
To consider: bc we know blood volume in preg increases by 40-50%, to manage blood loss during birth. Now hypotensive, tachycardic, you know they have lost 20% of their blood volume, so hypotension is a late sign of PPH
describe oxytocin
med for PPH
contracts uterus, decreases bleeding
no contraindication for PPH
monitor bleeding and tone
management of PPH
- early recognition is critical
- 1st is evaluation of contractility of uterus
if boggy, firm massage of fundus
expression of clots in the uterus
fundus firm and bleeding continues, assess for the source of bleeding (trauma, thrombin) and treated - elim bladder distention
- admin of meds
- rapid admin of IV fluids
- blood transfusion
- o2 admin
describe misoprostol
contracts uterus
contraindicated if have allergy to prostaglandins
monitor bleeding and tone
describe carboprost thromethamine (hemabate)
contracts uterus
avoid w severe asthma or hypertension
monitor bleeding and tone
describe methylergonovine; ergonovine
contracts uterus
contraindicated in HTN, PET, cardiac disease
check BP before giving, do not give if greater than 140/90
describe tranexamic acid
blood clotting and to stop prolonged bleeding
contraindicated if hx of blood clots or taking any anticoagulants
given in PPH for someone w a bleeding disorder
management of PPH
- bimanual compression by OB
- manual exploratin of uterus for retained placenta
- uterine tamponade (packing or balloon)
- ligation of arteries
- uterine compression suturing
- hysterectomy
postpartum infections
puerperal infection: anu infection of genital canal within 28 days after abortion or birth
- most common infecting agents are numerous streptococcal and anaerobic organisms
- endometritis
- wound infection
- UTI
- mastitis
intrapartum risk factors for infection
- episiotomy or lacerations
- c-section
- prolonged ROM
- chorioamnionitis
- prolonged labour
- frequent bladder catheterization
- internal FHR monitor or IUPC
- multiple vag exams after ROM
- epidural
- retained placental fragments
- PPH
clinical manifestations of puerperal infection
- fever
- foul smelling lochia
- lethargic
- abdo pain
- subinvolution of uterus
venous thromboembolic (VTE) disorders
- blood clot(s) inside a blood vessel due to venous stasis and hypercoagulation
- preg clients have 4-5x increased risk of VTE
- occurs during preg or postpartum (up to 3 wks)
- superficial venous thrombosis
- DVT
- PE (more common in postpartum vs antenatal period)
VTE risk factors
- c-section double the risk for VTE
- operative vaginal delivery
- history of VTE, PE, or varicosities
- obesity
- maternal age greater than 35 yrs
- multiparity
- smoking
clinical manifestations of venous thrombosis
- pain and tenderness in lower extremities
- warmth, redness, enlargement, and hardened vein over the site of thrombosis
clinical manifestations of PE
- dyspnea and tachypnea
- tachycardia
- chest pain
- cough and hemoptysis
- elevated temp
POST BIRTH acronym health teaching
P - pain in chest
O - obstructed breathing or SOB
S - seizures
T - thoughts of hurting yourself or baby
B - bleeding (heavy, large clots)
I - incision that is not healing
R - red or swollen leg, painful or warm to touch
T - temp of 38 or higher
H - headaches
definition of structural disorders following childbirth and risk factors
structural disorders of the uterus and vagina related to pelvic relaxation and urinary incontinence
risk factors:
- fetopelvic disproportion
- prolonged labour
- precipitous labour
- precipitous birth
describe uterine displacement
- posterior displacement
- retroversion (tilted posteriorly and cervix rotates anteriorly)
- retroflexion and anteflexion
uterine prolapse
- pelvic stress and strain
- degrees range from mild to complete
- s/s related to pelvic relaxation most often appear during perimenopausal period
- treatment: estrogen therapy, pessaries, surgery
cystocele
protrusion of bladder downward into vagina when support structures in vesicovaginal septum are injured
rectocele
is herniation of anterior rectal wall thru relaxed or ruptured vaginal fascia and rectovaginal septum
