NURS 370 Exam 1 - High-Risk Postpartum Care

maternal death

birthing person dies during pregnancy or up to 42 days after giving birth from health problems r/t pregnancy

pregnancy-related death

birthing person dies during pregnancy or within 42 days after giving birth from all deaths irrespective of cause

maternal morbidity

much more prevalent than maternal mortality

maternal mortality in black women

2x higher than white women

early postpartum hemorrhage

occurs within 24 hours of birth... cumulative blood loss of equal to or >1000mL or blood loss accompanied by s + s of hypovolemia

what blood loss requires additional surveillance

500-999mL or decreased hematrocrit of less than 10%

primary pph

within 24 hours, many caused by uterine atony

secondary pph

after 24 hours up to 6 weeks, usually caused by uterine infection, placental fragments, or delayed placental expulsion, subinvolusion

why do mothers have increased blood volume

maternal tissue, placenta, and third stage of labor

mothers don't quickly show symptoms of blood loss...

10-30% blood is lost before shock symptoms with a presence of tachycardia and hypotension

how to treat blood loss

give blood

4 t's

tone: uterine atony

tissue: retained products

trauma: lacerations, incisions, hematoma

thrombin: coagulopathies (DIC)

hypovolemic shock

shock resulting from blood or fluid loss

shock index (S1)

HR divided by systolic BP. anything >0.9 indicates a need for blood

signs of hypovolemic shock

tachycardia, hypotension, increased respiratory rate, decreased O2sat, cold and clammy skin

maternal assessment

after birth: assess every 15 mins for first hour, 30 minutes for 2 hours, and then every four-eight hours or as needed. assess blood pressure, heart rate, respiratory rate, o2 sat

once stable, how long should you assess vaginal versus c section

4 hours for 24 hours c section, 8 hours for vaginal

when to check vitals when active bleeding

every 5-15 minutes

always document

in a timely fashion to prevent delays in treatment

intrapartum maternal risk factors

•intrauterine fetal demise

•Induction

•Prolonged 1st or 2nd stage

•Precipitous birth (dangerous, difficult)

•Chorioamnionitis (intraamniotic infection)

•amniotic fluid embolism

•Failure to progress to 2nd stage

past medical maternal risk factors

history of pph, obesity, multiparity (usually past 4 or 5)

past surgical maternal risk factors

c section, previous uterine surgery

pregnancy complications maternal risk factors

•Hypertensive disorders

•Fibroids

•Uterine Overdistention

- Polyhydramnios

- Multiple Gestation

- Macrosomia

polyhydraminos

too much amniotic fluid

birth complications maternal risk factors

•Uterine atony

•Perineal or vaginal hematoma

•Lacerations

•Retained products

•Uterine inversion

•Instrumental birth

- Forceps

- Vacuum

placental abnormalities maternal risk factors

placental abruption, adherent placenta

placenta accreta

Improper implantation of placenta into the myometrium with little or no intervening decidua

placenta increta

deep penetration of myometrium

placenta percreta

perforation of uterus by placenta

placenta previa

implantation of the placenta over the cervical opening or in the lower region of the uterus

bleeding maternal risk factors

bleeding disorder, thrombocytopenia

Disseminated Intravascular Coagulation (DIC)

coagulation pathways are hyperstimulated and the body breaks down clots faster than they can be created. complication of anaphylactoid syndrome of pregnancy. can be asymptomatic, bleeding, massive bleeding, or cause organ failure

Anaphylactoid syndrome of pregnancy

Rare complication of pregnancy characterized by the sudden, acute onset of hypoxia, hypotension, or cardiac arrest and coagulopathy that can occur either during labor or during birth or immediately after birth; also known as amniotic fluid embolism

warning signs of pph

uncontrolled vaginal bleeding, swelling around vagina or perineum, change in vitals, symptoms of chock, decreased hematocrit

pph early recognition

evaluate risk factors and signs antepartum, intrapartum, and postpartum

stage 0 pph

usually blood loss is

stage 1 pph

>500mL for vaginal and 1000mL for c sec. consider etiologies and ensure fundal massage and an empty bladder. request a type and cross. monitor QBL and vitals. administer IM uterotonics and IV fluids, notify the provider

stage 2 pph

1000-1500mL blood loss. use uterotonics and potenial uterine tamponade balloon. might need blood transfusion. frequent QBL and vitals, fundal massage. start a 2nd IV and insert foley. notify provider.

Uterine Tamponade Balloon

stage 3 pph

>1500mL blood loss. monitor vitals and QBL. massive transfusion protocol. invasive surgical procedures likely. administer TXA Tranexamic Acid and notify provider

first line uterotonics

oxytocin

second line uterotonics

misoprostol, methylergonovine, carboprost

misoprostol (Cytotec)

prostaglandin medication for uterine tone

methylergonovine (Methergine)

Acts directly on the uterine muscle to stimulate forceful contractions. (WARNING IN HIGH BLOOD PRESSURE AND PREECLAMPSIA) (DIARRHEA SE)

carboprost (Hemabate)

oxytocic; Given to IM to produce sustained uterine contractions to control postpartum hemorrhage. Contraindicated in a patient who has asthma. Adhere to dosing and monitor closely when given with oxytocin (HEEEEM *sounds likehard breathing ASHTMA!!!!)

Tranexamic Acid (TXA)

Anti-fibrinolytic

Inhibits plasminogen activation

non-pharm management of pph

fundal massage, blood products, removal of retained products, bimanual uterine compression, balloon tamponade, surgical management

risk for hematoma

genital track lacerations, episiotomies, operative vaginal births, prolonged second stage of labor, precipitous birth, nulliparity... internal hematomas may be missed until signs of shock

symptoms of hematoma

depends on rate size.. pain, pressure, change in vitals

treatment of hematoma

surgical evacuation if >5cm, antibiotics. if not expanding, observation and ice packs, analgesia

mastitis

unilateral breast pain, streaks, redness, sore nipples, flu-like symptoms. treated with 10-14 days of oral antibiotics

metritis/endometritis

fever, tender uterus, lochia foul odor, flu like symptoms. can be related to septic pelvic thrombophlebitis or deep organ infections caused by infected hematoma or pelvic abcess. most of these are treated with 24 hours of IV antibiotics or more, but septic pelvic thrombophlebitis has 40% mortality

cystitis

freqency, urgency, dysuria, foul odor. treated with 7-14 days of oral antibiotics.

wound infections

c section incision, laceration, episiotomy... REEDA. keep under belly dry to help prevent with c section infection

risk factors for infection

•Poor intrapartum hygiene

•Primiparity

•Prolonged rupture of membranes

•Prolonged labor

•Multiple vaginal exams (more than 5)

•C/section

•Low socioeconomic status

management of infection and nursing actions

antibiotics, fluids, rest, antipyretics, pain management, assessments, patient teaching

call OB or provider if

fever 100.4 or greater, flu like symptoms or any infection related symptoms

DVT

swelling in leg, heavy aching or pain in one leg, warm skin, red skin. greatest risk up to 2 weeks postpartum and can even be in groin area. avoid crossing legs. move frequently.

PE

SOB, tachypnea, chest pain, lightheadedness or dizziness, rapid or irregular HR, clammy or cyanotic, recent pain or swelling or warmth in a leg, greatest risk up to 2 weeks postpartum

DVT management and actions

early ambulation (as soon as 2-6 hours postbirth), compression stockings, coagulation therapy with heparin, warfarin, lovenox, doppler USN. call 911 for PE symptoms

perinatal mental health

mental illness that complicate pregnancy or occur within one year postpartum: depression, anxiety, bipolar, PTSD, OCD, psychosis, postpartum rage... these disorders are as much as 1 in 5 prevalence.

what is the leading comorbidity in childbearing individuals

perinatal mood disorder

what is the first leading cause of perinatal death

suicide

most perinatal suicides occur between

9-12 months postpartum in which

maternal risk factors for mental health disorder

family history, history of premenstrual dysphoric disorder, limited support, complications regarding birth or pregnancy or breastfeeding, surviver of IPV, admission of newborn to NICU, stillbirth or neonatal loss, stressful life, adolescent or single parent

when are mental health risk factors (Depression screen) assessed

many organizations try to assess at prenatal visit and at 32 weeks, upon admission and at 6 week check (Edinburgh Perinatal Depression Scale)

baby blues

•Affects 4 out of 5 new parents

•Waves of sadness

•Occurs 2-3 days after birth

•Can last up to 2-weeks; resolve on there own

•Caused by a sudden decrease in hormones after birth

•Can be exacerbated by lack of sleep or emotional issues

postpartum depression

•Affects 1 in 8 new parents

•Feelings of sadness, anxiety, or rage

•Can affect care for self or baby

•Can interfere with maternal/newborn bonding

•Occurs within 1- 3 weeks after birth; needs treatment to resolve

•Classified as a medical condition

treatment for mental health disorders postpartum

cognitive behavioral therapy, SSRI's like Zoloft

mental health conditions

What is the number 1 cause of pregnancy-related deaths? (23%)

Cardiovascular conditions

What is the leading cause of pregnancy related deaths for black birthing people?

Cardiovascular changes

1. Blood loss

2. Auto-transfusion

3. Mobilization of fluid

and increased stroke volume and cardiac output by 80% in the first hour postpartum

10%

Hematocrit below ?% can be supportive data for PPH?

tone, trauma, tissue, thrombin

What are the 4 Ts?

DIC

widespread activation of clotting mechanisms exhausts the body's blood-clotting factors, causing simultaneous abnormal blood clotting and uncontrollable bleeding

Hypovolemic shock

S+S:

Tachycardia

Hypotension

INC rr

DEC O2 sat

cold, clammy skin

IUFD

medical term for a stillbirth or the death of a fetus in the womb at or after the 20th week of pregnancy

(fetus passed in utero)

Precipitous birth

extremely fast birth where the baby is delivered within three hours of regular contractions starting (can cause physical trauma)

chorioamnionitis

a bacterial infection of the membranes and amniotic fluid surrounding a fetus during pregnancy

AFE

amniotic fluid (the fluid surrounding the baby) or fetal cells enter the mother’s bloodstream. This triggers a severe, allergic-like immune reaction that can cause heart and lung collapse and dangerous bleeding issues

Fibroid

non-cancerous muscle growth that develops in or on the wall of the uterus during or before the childbearing years (if removed could lead to uterine rupture)

Uterine atony

muscle walls of the uterus fail to contract effectively after childbirth, leading to severe bleeding

Maternal warning signs

Uncontrolled heavy vaginal bleeding

swelling/ pain around vag*na/ perineum

Change in vital signs

symptoms of shock

decrease in hematocrit

tamponade ballloon

inserted into the uterus and filled with sterile fluid to compress bleeding blood vessels after childbirth when medications fail (first used in stage 2 PPH)

TXA

intravenous medication used to treat heavy bleeding after childbirth by preventing blood clots from breaking down

First line uterotonic

Oxytocin (Pitocin)

Second line uterotonics

Misoprostol (Cytotec)

Methylergonovine (methergine)

Carboprost (Hemabate)

Hematoma

Collection of blood that pools in the pelvis, vagina, or vulva due to damaged blood vessels and usually happens in traumatic birth

Infection

fever 100.4 or greater

flu like symptoms

abdominal pain or tenderness

foul smelling lochia

pain, urgency, frequency, or hesitation upon voiding

Breasts have red streaks, intense pain

DVT

symptoms:

swelling in legs

Heavy ache in affected area

Warm skin around the clot

red skin in the affected area

Can affect lower leg, thigh, or groin area

At greatest risk up to 2 weeks pp

PE

symptoms:

SOB

tachypnea

Chest pain

lightheaded and dizzy

clammy or cyanotic skin

pain, swelling, warmth, redness

greatest risk 2 weeks PP

DVT management

Early ambulation

compression stockings/ SCDs

Coagulation therapy (anticoagulants)

Dopper USN (identify vessel blockages)

Greater risk during first 2 weeks PP

1/5

Fraction of birthing people that experience a serious mood or anxiety disorder during the perinatal period

1-2/1000

Fraction that experience psychosis in the postpartum period

1/10

fraction of people that report trauma related to their childbirth experience

What is the leading cause of pregnancy-related death>

9-12

How many months post-partum do most perinatal suicides occur?