ch 25 CORNELL NOTES

Risk factors for postpartum hemorrhage:

The 4 T’s (tone, trauma, tissue, thrombin) 

• Uterine atony - relaxation of uterus; more likely in Asian, Hispanic, and Blacks 

• Trauma (lacerations, hematomas, uterine inversion, uterine rupture) 

  • Lacerations common; any time uterus feels firm but still bleeding, suspect laceration; Tx: sutured, episiotomy, high fluid diet, stool softener,  

• Retained placental fragments 

• Development of disseminated intravascular coagulation (DIC) 

How to detect retained placental fragments:

• Portion retained keeps uterus from contracting fully -> uterine bleeding 

• Dx: Sonogram 

Uterine atony

Management

• Drain bladder; perform fundal massage to encourage cxns

• Administer oxytocin IV/bolus

• Bimanual compression (1 hand in vag, other pushes fundus from abd wall outside)

• manual exploration (if nothing else work

• Blood transfusion; embolization, vessel ligation, compression suturing, or hysterectomy for severe cases

Drugs

• Still relaxed? Call provider for interventions 

• 1st: Bolus or a dilute IV infusion of oxytocin (Pitocin) 

• 2nd: Hemabate or Methergine given IM 

• Methergine can increase BP so use cautiously in pts w/ HTN; assess BP prior to admin + 15mins after 

• Also: Misoprostol rectally, TXA within 3hrs of birth 

Methods to combat

Elevate lower extremities

Empty bladder every 4 hours or insert urinary catheter

Administer oxygen (10-12 L/min) via face mask

Position supine. Monitor vital signs frequently for trends.

Know how to identify signs of a retained placenta:

• Immediate bleeding; uterus unable to contract fully

• Delayed hemorrhage at home

• lochia changing from serosa/alba back to rubra

Nursing management of a vulvar hematoma:

• Report presence, size, and degree of discomfort; establish baseline 

• Administer analgesic, apply ice pack,  

• Usually absorbed over next 3-4 days 

• May need incision and ligation under anesthesia 

Know how to identify keys signs of a puerperal infection:

ALWAYSS POTENTIALLY SERIOUS (potential to spread to peritoneum or go systemic).

• temp over 100.4°F (38°C) for two consecutive 24-hour periods

• Fever on 3rd or 4th postpartum day

• Perineal pain, heat, pressure

• inflamed suture line

• purulent drainage

Mastitis

Prevention

Prevent nipples from cracking 

• Correct positioning 

• Help baby release grasp before removing them from breast 

• Wash hands between handling perineal pads + touching breasts 

• Exposing nipples to air for at least part of every day 

• Vit E ointment daily (soften) 

• Encourage beginning breastfeeding on unaffected nipple 

Management

• ABx

• Continue BF if possible (empty breasts helps to prevent growth) 

• Cold/ice compress for pain, warm wet compress for inflammation + edema 

Differential postpartum blues with postpartum depression:

Postpartum blues - immediate (1-10 days post) feelings of sadness after childbirth (hormonal shifts) 

Postpartum depression - postpartum blues extending beyond immediate period (as long as 1yr) 

Risk factors for postpartum depression:

• Poor family support 

• Disappointment from some aspect of newborn or both