childbearing - postpartum complications (4)

how much blood loss in postpartum hemorrhage

> 500 cc following vaginal

> 1000 following c-section

early postpartum hemorrhage

within first 24 hours after birth

late PP hemorrhage

24 hours to 12 weeks PP

4 Ts of postpartum hemorrhage

tone, trauma, thrombin, tissue

uterine atony

tone of uterus not contracting → blood vessels dilating → blood can flow out of it

trauma to genital track

delivery with lacerations

associated with rapid deliveries, weird fetal presentations

retained placenta

If whole placenta doesn’t come off uterus wall, then uterus will not consider itself empty and not fully contract/involute

risk factors for uterine atony

• overdistention (e.g. twins)

• traumatic birth

• MgSO4 (smooth muscle relaxant)

• precipitous labor (contractions go very fast = uterus tired after)

• labor augmentation - oxytocin

• infection (chrioamnioitis)

• retained placental fragments (uterus doesn’t contract because it’s not empty)

• high parity (G6+)

• Hx of uterine atony

treatment for uterine atony 

fundal massage!

manual expression of clots

elimination of bladder distention

infusion of oxytocin

what is the minimum amount of urine postpartum in an hour?

30 cc minimum in an hour

what can trauma to the genital tract cause?

active bleeding

hematoma formation

risk factors for trauma to genital tract

precipitous birth (delivery within 15 mins)

congenital abnormalities

contracted pelvis

infant size

abnormal presentation/position

previous scars from infection, injury (tissue can be more easily torn because it doesn’t stretch as well)

previous outpouching/varicosities

treatment of trauma to genital tract 

• identify site of bleeding (notify provider)

• control bleeding

• analgesia

• ice

• diet (fluids to prevent straining)

• stool softener 

venous trauma will have ___ (color) bleeding

dark red

arterial trauma will have ___ (color) bleeding

deep bright red

uterine inversion

uterus turns itself inside out 

(rare but life threatening!)

risk factors for uterine inversion

• fundal pressure

• short cord (genetics)

• cord traction

• uterine atony

• fibroids

• multiple deliveries

• Hx placenta accreta/increta (placenta attached to uterine muscle)

  • Hx past inversion

signs/symptoms of uterine inversion

• hemorrhage - can’t feel uterus

• shock

• pain

treatment of uterine inversion

• LR and blood products for shock

• fundus repositioned after placenta separated

• MgSO4 and analgesia to relax uterus (so provider can go in and put it back to where it’s supposed to be)

• oxytocin medications and bimanual compression (hold hand in there until uterus firms up)

• antibiotic therapy 

idiopathy thrombocytopenia purpura (ITP)

• autoimmune disorder

• decreased lifespan of platelets

  • increased risk of uterine bleeding and vaginal hematomas

ITP diagnostics

• thrombocytopenia (decreased platelets)

• capillary fragility (bruises, petechiae)

• increased bleeding time (PT and PTT)

treatment of ITP

prevent bleeding during delivery

• platelet transfusion (short-term help)

• glucocorticoids

• splenectomy (for really severe cases)

• IV immunoglobulin

  • Danazol (steroid)

von Willebrand Disease

type of hemophilia - deficiency in blood clotting protein

symptoms of vWD

nose bleeds, bruising, prolonged bleeding, factor VIII deficiency

treatment of vWD

desmopressin and possible Factor VIII

disseminated intravascular coagulation  (DIC)

over-activation of clotting and anti-clotting processes

S/S of DIC

widespread internal and external bleeding

lab values in DIC

low platelets

low fibrinogen

prolonged PT and PTT 

abnormal RBC morphology (immature, not produced quickly)

treatment of DIC

removal of underlying cause (e.g. inversion)

volume replacement and blood component therapy

optimization of O2 and perfusion

retained placenta

uterus feels it’s not completely empty → less involution → hemorrhage

adherent retained placenta 

Placenta doesn’t come off uterus, but providers know about it before deliver (via ultrasound or based on blood loss)

3 types of adherent retained placenta

placenta accreta, increta, percreta

placenta accreta

attached to uterine muscle

placenta increta 

penetrated into muscle 

placenta percreta

penetrates through muscle, into uterine serosa or adjacent organ (e.g. bladder)

treatment of non-adherent placenta

• Manual separation and removal (provider’s hand gets placenta off uterine wall)

• IV analgesia

• Still at risk for PPH and infection

treatment of adherent retained placenta 

• Attempts to remove may not be successful - don’t detach from wall

• May result in lacerations of the uterus

• Blood replacement

• Possible hysterectomy - taking out uterus (may be last baby)

subinvolution

• Delayed return of enlarged uterus to normal size and function

  • Want uterus to go down - Decrease 1 cm for every day postpartum 

risk factors for subinvolution

retained placenta fragments

pelvic infection

S/S of subinvolution

• Prolonged, irregular, or excessive vaginal bleeding

• Enlarged uterus by exam 

• Boggy uterus

treatment of subinvolution

• Treatment depends on cause

• Methergine 0.2 mg Q 4 hours for 2-3 days 

• Antibiotic therapy (if infection)

• D&C (dilation & curettage) for retained placenta

  • Provider needs to dilate cervix and scrape placenta off uterus

what should you do if uterine is boggy?

massage the fundus

what should you do if the uterus is not midline/centered?

empty the bladder

ratio of blood products to restore blood volume 

3cc crystalloid for every 1 cc EBL 

what medications and potential surgical interventions can you anticipate to restore blood volume (+ what do they do)

methergine (prevent bleeding after birth), Pitocin (produce uterine contraction to control PP bleeding), hemovac (removes blood from surgical site)

clinical definition of postpartum infection

fever > 38C (100.4F) after the first 24 hours occurring on at least 2 of the first 10 days after birth

why does prolonged ROM increase risk for PP infection?

water broken > 18-24 hours = no more amniotic sac

endometritis

infection of uterine cavity or muscle

signs of endometritis

• tachycardia

• jagged temp elevation

• chills uterine tenderness

• prolonged afterbirth pains (cramps)

• subinvolution

• abdominal distention

• odorous lochia

pharmacological therapy for endometritis

antibiotics IV until afebrile and pain free for 24-48 hours

cystitis

infection of bladder

when does cystitis usually occur?

2-3 days post delivery

mastitis 

infection of the breast tissue

how does mastitis typically occur?

from organisms on maternal skin or infant

caused by poor latch/breastfeeding

clogged ducts = not completely emptying

when does mastitis typically occur?

2 days-2 weeks postpartum

how to treat mastitis

antibiotics

continue to pump/feed/express Q2-4H (prevent clogged ducts)

I&D (incision & drain) if abscess present

thrombosis 

Formation of blood clots inside blood vessel caused by inflammation or partial obstruction of vessel (pelvis or legs)

signs of superficial venous thrombosis

pain, redness, warmth, enlarged/hardened vein over area

signs of DVT

• unilateral leg pain

• calf tenderness

• diminished cap refill and pedal pulses

signs of pulmonary embolism

SOB, crackles 

medical management for superficial venous thrombosis

• analgesia (NSAIDs)

• rest and elevation

• heat

medical management for DVT

• anticoagulants, analgesia

• heparin IV 3-5 days

• oral anticoagulants 3 months

• avoid oral contraceptives (increased risk of DVT)

• Coumadin = teratogen (avoid pregnancy)

thromboembolic disease nursing interventions

NO homan’s sign (checking leg for DVT)

pneumoboots only used prophylactically 

when does postpartum psychosis typically occur?

usually 2-3 weeks PP, almost always be week 8 PP

what is the drug of choice to treat PP psychosis?

lithium

T/F: PP psychosis requires immediate hospitalization 

true

how long are the baby blues normal for

½ days-2 weeks

medications to treat postpartum depression

SSRIs (sertraline, fluoxetine)

pitocin

everyone gets Pitocin (oxytocin) after birth! (IM, IV)

methergine

give if Pitocin fails (0.2 mg IM)

contraindicated in patients with hypertension (140/90)

hemabate

give if Pitocin fails (0.25 mg IM)

contraindicated in patients with asthma (cause bronchospasm)

cytotec

given if all other medications fail

rectal suppository or PO (800-1000 mcg)