Maternity Exam 2

Postpartum Hemorrhage

Leading cause of maternal mortality & morbidity. Is life-threatening.

• Blood loss over 500cc after vaginal birth

• Blood loss over 1,000cc after C-section

• OR blood loss with signs of hypovolemia within 24 hours after birth (all types)

SIGNS

• Unresponsive to fundal massage or medication (indicates uterine atony)

• 10% decrease in HCT between admission & postpartum

• The “4 T’s”

Early v. Delayed Postpartum Hemorrhage

Early: Occurs within the First 24 hours

Late: 24 hours to 6 weeks PP

4 T’s of Postpartum Hemorrhage (causes for PPH)

Tone: Uterine Atony → Vessels in uterus aren’t contracted, allowing bleeding

Trauma: Tearing/Trauma to Genital Track

Thrombin: Coagulation Disorders

Tissue: Retained Placenta → Placenta or part of placenta stuck in uterus. Causes uterus to not contract (subinvolution)

Client delivered 4 hours ago. Assessment data: BP 102/58, P96, R 22, T 98.2, Fundus firm at the umbilicus, lochia heavy rubra. Your first action should be:

A. Massage the uterus

B. Administer an oxytocic as ordered

C. Notify the provider

D. Assist the client to the bathroom

C. Notify the provider

• Heavy rubra lochia indicates a tear causing PPH. Is not a uterine problem. Nursing interventions are exhausted, so provider must fix the tear.

• Not B, because oxytocin is only used to make fundus firm, and the uterus is already firm

Uterine Atony

Uterus fails to contract despite being empty. Most common cause for PPH

Risk Factors

• Overdistention: If pt has multiples, uterus can be over-distended and will not contract

• Traumatic birth: Overstimulation of uterus

• MgSO4: Magnesium Sulfate, used to soothe uterus to treat pre-eclampsia. Stops uterine contractions, increasing risk for hemorrhage

• Precipitous Labor: Very fast birth

• Augmented labor w/Oxytocin: “Pitocin”, used to contract uterus during pregnancy. If too much is used, receptors will become sensitized and Pitocin will not work during postpartum to help with uterine contractions.

• Chorioamnionitis (infection): Will have maternal fever & tachycardia, fetal tachycardia, fundal tenderness, & foul-smelling discharge

• Retained placental fragments: Cause uterus to become flaccid because it is not fully empty

• High Parity: High number of pregnancies (G5+) or short-spaced pregnancies (2 babies in less than a year)

• Hx or uterine atony

Treatment of Uterine Atony

• Firm Fundal Massage

• Manual expression of clots → Clots can get trapped in uterus, can be manually removed

• Elimination of bladder distention → Make sure bladder is empty before fundal massage (if fundus is midline, then bladder is NOT distended)

• IV infusion of oxytocin & Lactated Ringer’s or Normal Saline Solution (or IM if no IV access)

  • Can give alternatives

• Bimanual compression and exploration for fragments (provider only)

  • Uses sterile technique with antibiotics after expulsion

Oxytocin Alternatives

• Methergine (IM): Can use in pts w/HTN or elevated BP

• Hemabate (IM): Contraindicates in pts w/asthma. Can cause bronchospasm

• Prostaglandin E2 (Cytotec/Misoprostol) (Rectal or PO)

• Tranexamic Acid (TXA)

• Crystalloid solution & blood products

• Oxygen (non-rebreather 10L) & Urinary Catheter (minimum of 30cc/hr), Labs

Bimanual Compression/Exploration for Atonic Uterus

Compressing of uterine front and back walls, held until uterus contracts. Provider uses hand to manually sweep clots out of uterus

Which symptom do you expect to observe in a postpartum client with a vaginal hematoma?

A. Bleeding

B. Pain

C. Redness

D. Warmth

B. Pain

• Only symptom of hematoma (like a bruise)

• Will have intense pain

Trauma to Genital Tract

Laceration to the cervix, vagina, & perineum

CAUSES

• Precipitous birth→ any birth that occurs in less than 15mins at start of contractions or less than 3hrs at start of contractions

• Congenital abnormalities

• Contracted pelvis

• Infant size (large baby)

• Operative Births (forceps or vacuum assistance)

• Abnormal fetal presentation/position

• Previous scars from infection, injury, or operations

• Vulvar, perineal, and vaginal varicosities (enlarged veins)

Treatment of Trauma to Genital Tract

• Identifying site of bleeding (call provider to identify)

  • Venous

  • Arterial → Will have bright red discharge

  • Placenta → Will have spurts of discharge; uterus will go back and forth between boggy & firm

• Control bleeding

• Analgesia (pain relievers)

• Ice

• Diet

• Stool softeners

Uterine Inversion

Life-threatening complication where uterus flips inside out

• NO PULLING ON CORD unless separation is certain

RISK FACTORS

• Fundal pressure or improper fundal massage → Never apply fundal pressure if fundus is firm o

• Short cord → Can pull the placenta out before its ready, pulling on uterus

• Cord traction→ Pulling cord by force. Placenta is ready when cord is lengthening outside the vagina & will have spurts of blood

• Uterine Atony

• Fibroids

• Multiples

• Hx of placenta accreta/increta → Part of placenta grows inside uterus, instead on being attach to it.

• Hx of Past inversion

SIGNS & SYMPTOMS

• Hemorrhage (94% of cases)

• Shock

• Pain

TYPES

• Partial or complete

TREATMENT

• Lactated Ringer’s & blood products → treat shock; must have IV access

• Fundal repositioning after placenta separation

  • Give MgSO4 & analgesia to relax uterus (discontinue after repositioning)

    • MgSO4 relaxes uterine muscle, uterus must be completely relaxed to put back in place

• Oxytocic medications & bimanual compression

• Antibiotic therapy

Coagulopathies Affecting Postpartum

• Idopathic Thronbocytopenia Purpra (ITP)

• von Willebrand Disease (vWD)

• Disseminated Intravascular Coagulation (DIC)

A client is being monitored after a significant postpartum hemorrhage. Which of the following do you need to report to the provider?

A. Urine output of 200cc for last 8 hours

B. Weight decrease of 2 lbs since delivery

C. Drop in Hematocrit of 2% since admission

D. Pulse rate of 68 beats per minute

A. Urine output of 200cc for last 8 hours

• 25cc/hr is too low (should be at least 30cc/hr)

• Not C bc hematocrit is only concerning if its >10% drop

Idiopathic Thrombocytopenia Purpura (ITP)

An autoimmune disorder where antiplatelet antibodies decrease lifespan of platelets

• Can causes severe hemorrhage in C-section or in lacerations

• Increased risk of uterine bleeding or vaginal hematomas

DIAGNOSTICS

• Thrombocytopenia (decreased platelets)

• Capillary Fragility (multiple bruises & petechiae/purpura, bloody gums)

• Increased bleeding time (PT & PTT → takes longer for platelets to clot)

TREATMENTS

• Control platelet stability with platelet transfusion

• Glucocorticoids → Steroids help maintain vessel walls & decrease bleeding

• Splenectomy → Done during pregancy. Removes spleen to raise platelet count by 75%

• Danazol postpartum: Male sex hormone that may raise platelet count. Only give postpartum as causes tetragenic effects during pregnancy

von Willebrand Disease (vWD)

Genentic deficiency in von Willebrand factor, blood clotting proteins.

• Most common clotting disorder in US (type of hemophilia)

SYMPTOMS

• Nose bleeds

• Bruising

• Prolonged bleeding after procedures

• Factor VIII Deficiency

TREATMENT

• Desmopression & Factor VIII supplementation

Disseminated Intravascular Coagulation (DIC)

Overactivation of clotting & anti-clotting processes. An exaggeration of widespread clotting cascade

• Will have initial hypercoagulability is followed by HYPOcoagulability & hemorrhage. Once all platelets are used up, there will be a decrease in fibrinogen & increase in PT & PTT

• Pt must still have 2 IVs even when bleeding

CAUSES

• Disease or Injury

• Snake bites

• Severe trauma

• Extensive surgery

• Acute hypotension

SYMPTOMS

• Widespread internal and external bleeding

  • Gums, nose, petechiae around pressure sites and trauma sites

LAB VALUES

• Low platelets

• Low fibrinogen

• Prolonged PT & PTT

• Abnormal RBC morphology → RBCs trying to produced quickly, leading to immature, non-functional RBCs

TREATMENT

• Removal of underlying cause → Address uterine atony or hemorrhage

• Volume replacement & blood component therapy → For every cc of blood loss, must be replaced with 3cc of crystalloids or LR

• Optimize O2 & perfusion status

NURSING ASSESSMENT

• Vital Signs → RED FLAGS: decreased BP & increased HR

• 2 IV lines

• Observe signs of bleeding

• Observe adverse blood reactions

• Monitor urinary OP → Insert cath, maintain 30cc/hr

• O2 administration

• Maintain quiet/non-stress environment (pt will be admitted to ICU)

A client who is diagnosed with DIC is to receive a blood transfusion. All actions are critical for the nurse to perform except..?

A. Look up patient’s blood type in the chart

B. Check the patients arm bracelet

C. Check the blood type on the infusion bag

D. Obtain an infusion bag of dextrose and water

E. Document the time the infusion begins

D. Obtain an infusion bag of dextrose and water

• Blood products can only be mixed with Normal Saline Solution

Retained Placenta

2 Types

• Non-Adherent Retained Placenta

• Adherent Retained Placenta

RISK FACTORS

• Pt w/scars on uterus → scars cause placenta to have less fluffy tissue to implant onto.

TREATMENTS

Non-Adherent

• Manual separation & removal

• IV analgesia

• Still at risk for PPH & infection

Adherent

• Attempts to remove may not be successful → May result in lacerations of uterus

• Blood replacement

• Possible hysterectomy (removal of uterus)

Non-adherent Retained Placenta

Partial separation from uterus. Part of placenta is still in uterus.

• Caused by mismanagement during the 3rd stage of labor or abnormal adherence

Adherent Retained Placenta

Placenta grows into uterus.

TYPES

• Placenta Accreta

• Placenta Increta

• Placenta Perceta

A G5P3105 is undergoing repeat C/S. The physician declares the patient has a placenta accreta. Which of the following is consistent with this diagnosis

A. Blood pressure 160/110

B. Blood loss of 2000 cc

C. Jaundice skin color

D. Shortened Prothrombin time

B. Blood loss of 2000 cc

• Adherence placenta due to blood loss

Sub-Involution

Delayed return of enlarged uterus to normal size & function

• @ 6 weeks uterus should be back to normal. If not, then there is subinvolution

RISK FACTORS

• Retained Placental Fragments

• Pelvic Infection

SIGNS & SYMPTOMS

• Prolonged, irregular, or excessive vaginal bleeding

• Enlarged uterus by exam

• Boggy Uterus

TREATMENTS

• Methergine 0.2mg q4h for 2-3 days

• Antibiotic therapy

• Dilation & curettage → removes retained placental parts w/ instruments

Review of PPH Assessment

1. Check for uterine atony/bogginess

• Massage if atonic

• Empty bladder if displaced

• Possible bimanual uterine compression/exploration by MD

2. Assess vaginal canal & cervix for lacerations

3. Assess bleeding from non-genital areas

• Check venous puncture sites

• Lab studies → INR, PTT, platelet count, & fibrinogen

4. Restore Blood Volume

• 3cc crystalloid for every 1cc of blood lost

• 10L oxygen by non-rebreather mask

• Anticipate meds and potential surgical intervention

Nursing Discharge Instructions After PPH

Same as normal postpartum, but emphasize potential for fatigue/exhaustion related ot low blood volume

• Increase iron & protein intake

• Increase fluid intake

• Limit physical activties/need for support system

Call MD if…

• Soaking pad after 1 hr or less

• Clots larger than a plum

• Fever/chills

• Dizziness/fainting

Postpartum Infections

Any infection of the genital tract in the first 28 days after birth or abortion.

• Or temperature >100.4F orally after the first 24 hours on 2 separate occasions within the first 10 days postpartum

  • Low-grade fever is common in the first 24 hours postpartum. Is normal & resolves on its own

COMMON INFECTIONS

• Metritis (Most common) → Infection of endometrial lining

• Wound infections (C-section or lacerations)

• Cystitis → Infection of bladder

• Mastitis → Breast Infection, occurs after 1st week

RISK FACTORS

• General: Hx of throbosis, UTI, mastitis, DM, Alcholism, drug abuse, anemia, or malnutrition

• OB Factors: C-section, operative vaginal delivery, Prolonged ROM (18-24hrs), Chorioamnionitis, Prolonged labor, catheterization, Epidural anesthesia (can’t feel urge to void, requiring a Foley), retained fragments, PPH, lacerations, & hematomas

You should suspect puerperal infection when a client exhibits which of the following?

A. Temperature of 100.2

B. White blood cell count of 14,500 cells/mm3

C. Diaphoresis during the night

D. Malodorous lochial discharge

D. Malodorous lochial discharge

• Foul smelling lochia

Endometritis/ Metritis

Infection of Uterine cavity or muscle

• Most Common PP infection

• Elective C-section have lower rates (have more time to prep and minimize infection risk)

SYMPTOMS

• Tachycardia

• Jagged Temp elevation → temps shift quickly. 2 spikes in 24 hours (concerning)

• Uterine tenderness

• Prolonged afterbirth pains

• Subinvolution

• Scant, odorous lochia or heavy, foul-smelling bloody, seropurulent lochia (yellow-green discharge)

• Elevated WBCs after birth

• Increased RBC sedimentation rate (ESR → indicates inflammation)

NURSING INTERVENTIONS

• Get blood cultures before giving antibiotics

• Give broad-spectrum antibiotics → usually IV until afebrile, pain-free for 24-48 hrs, & no fundal tenderness

• Analgesia (NSAIDs are best)

Wound Infections

NURSING ASSESSMENTS

• Vital Signs q4h

• Wound Assessment → MD might need to reopen wound & repack

  • RED FLAGS: Redness, irritation, warmth, tenderness, oozing, foul smell, poor healing, splitting

NURSING INTERVENTIONS

• Open & cleanse wound

• Antibiotic therapy

PATIENT SELF CARE

• Hydration, rest, & good nutrition

• Increase roughage (fiber) in diet

• Clean perineum from front to back

• Report increases in temp, drainage, or pain

Cystitis

Infection of bladder

RISK FACTORS

• Abdominal distention

• Dehydration

• Poor hygiene

• Catherization

• Pelvic exams

• Epidural

• Genital tract injury

• Hx of UTI

• C-section

SIGNS & SYMPTOMS

• Urinary frequency, urgency, & buring

• Suprapubic discomfort

• CVA tenderness if pyelonephritis (assessed by percusing kidneys)

• Fever

• Tachycardia

• N&V

NURSING INTERVENTIONS

• Give antibiotics & analgesics as ordered (NSAIDs & urinary analgesics)

• Increase fluid intake

• encourage frequency voiding

• Routine peri-care (change pad each time they use bathroom)

Mastitis

Infection of breast tissue

• Typically from organism on maternal skin or infants mouth

• Occurs 2 days to 2 weeks PP

• BEST PREVENTION: Proper latch & complete emptying of breast, should keep feeding on effected breast. Best remedy is to empty breast completely

NURSING ASSESSMENT

• Breast pain, swelling, & tenderness

• Temp elevation

• Axillary Adenopathy (swelling in axillary lymphnodes)

• Usually unilateral but can affect both breasts

• Possible purulent drainage

TREATMENT

• Antibiotics

• Continuation of pump/feed/expressing

• Incision & drainage (I & D) if abscess is present

• Analgesics as ordered

A breastfeeding patient is diagnosed with mastitis. Which of the following nursing interventions is appropriate?

A. Advise the woman to apply ice packs to her breasts.

B. Encourage the woman to breastfeed frequently

C. Inform the woman that she should wean immediately

D. Direct the woman to notify her pediatrician as soon as possible

B. Encourage the woman to breastfeed frequently

• Best remedy for mastitis is to completely empty breasts

Thrombosis/ Thromboembolic Disease

Formation of blood clots inside blood vessels caused by inflammation or partial obstruction of vessel

• Seen in pelvis or legs

RISK FACTORS

• Stasis & hypercoagulation (pregnancy is a hypercoagulable state)

• C-section, multiparity, Hx of thrombosis, obesity, tobacco, immobility

COMPLICATIONS

• Superficial Venous Thrombosis (SVT)

• Deep Vein Thrombosis (DVT)

• Pulmonary Embolism (PE)

SIGNS & SYMPTOMS

• Tachycardia

• Edema, warmth, redness, & enlarged, hard veins over thrombis

Superficial Venous Thrombosis (SVT)

Clot in vein that is just below the skin. Superficial, close to skin.

• Most common in PP

• Usually harmless, very superficial

SYMPTOMS

• Calf pain

• Tenderness

• Swelling

NURSING INTERVENTIONS

• Analgesics (NSAIDS)

• Rest & Elevation

• Heat

• Use compression socks prophylactically

Deep vein Thrombosis (DVT)

Extends from foot to iliofemoral region

NURSING INTERVENTION

• Measure thigh circumference in affected leg

• Assess cap refill & pedal pulse (affected leg will be diminished)

• Anticoagulation therapy (heparin IV for 3-5 days)

• Strict bedrest

• Elevation of leg

• Analgesia

• Compression sock ONLY WHEN symptoms go away and used prophylactically

  • Compression socks can cause even more clotting if DVT is still present

• Assess for symptoms of PE (will see wet cough)

SYMPTOMS

• Reduced peripheral pulses on affected side

• Will have unilateral swelling, pain, & redness

• DO NOT perform Homan’s Sign → Shape flexion of pt calf to access pain (can dislodge DVT)

DIAGNOSTICS

• Real-time & color Doppler ultrasound

Pulmonary Embolism (PE)

Complication of DVT where clot dislodges and is carries to pulmonary artery, occludes the vessel, and obstructs blood flow to lungs

• IS AN EMERGENCY

A postpartum woman is diagnosed with deep vein thrombosis. For which additional complication is this client at high risk?

A. Hemorrhage

B. Stroke

C. Endometritis

D. Hematoma

B. Stroke

• thrombus can dislodge and become an embolus, which will travel to occlude a vessel. Causing a stroke or PE

Baby Blues

Short term mood swings, sadness, or fatigue that occurs 1-2 days after delivery through 2 weeks PP (should be gone after 2 weeks)

• IS NORMAL - affects 85% of PP women

NURSING INTERVENTIONS

• Encourage communication of needs & fears

• Praise mom on feeding, assessing infant needs, etc

• Encourage rest when baby sleeps

• Continue to monitor mother & infant bonding

• Educate on what signs are not normal and who to contact if postpartum depression occurs

Postpartum Depression

Can occur at anytime in the first year PP

• Greatest risk: during 1st month post delivery

SYMPTOMS

• Insomnia (can’t sleep even when given the chance)

• Crying & prolonged sadness

• Obsessive thoughts/not being able to care for baby

• Decline in personal hygiene

• Suicidal ideation or harming baby/self

NURSING INTERVENTIONS

• Edinburgh Postnatal Depression Screen: Test that assesses severity of PPD.

  • If 10 or greater, set up w/help

  • If pt is having suicidal ideation, set up help regardless of score

• Early assessment & education

• Home visitation

• Stress rest

• Give contacts for mental health care

• Give information on meds & complementary treatments (yoga, massage, etc)

Postpartum Psychosis

Can occur at any time within the year of birth

Nursing Assessment

• Signs of agitation/confusion

• Irrational statements or behaviors

• Delusions (false sensory perception) or hallucinations

• Insomnia & hyperactivity

NURSING INTERVENTIONS

• Education & assessment of family → Never leave baby alone with woman

• Provide emergency contact info

• Home visitation if available

• If mother is having delusions, should be brought to ER asap

A postpartum woman is diagnosed with postpartum psychosis. Which of the following is essential to be included in family teaching?

A. The woman should never be left alone with her infant

B. Symptoms rarely last more than a week

C. Clinical response to medications is usually poor.

D. The woman must have her vitals assessed every two days

A. The woman should never be left alone with her infant

The Fiver P’s

Factors that affect birth

• Passageway

• Passenger

• Power

• Position

• Psyche

Passageway

The birth canal

• Includes bony pelvis & soft tissue

Passenger

Include the baby and the placenta. The fetal movement through the birth canal.

• Movement depends on head size, presentation, lie, attitude, & position

Placenta Previa

Placenta comes out before baby, needs immediate C-section

Fetal Head Size

Ability to devliery depends on baby’s head size. The larger the head, the more dilated the cervix needs to be

Sutures

Membrane filled gaps between cranial bones

• Include sagital, lambdoidal, coronal, & frontal suture

Fontanel

Where sutures intersect

• Most important: anterior & posterior fontanels

• Palpation after ROM reveals fetal presentation, position, & attitude

• The more pushing during labor, the more molding of the infant’s head, due to pressure

Fetal Presentation

Types

• Cephalic → Head first

• Breech → Sacrum first

• Shoulder → scapula first (transverse lie)

  • Never deliver transverse lies because of increased risk of umbilical cord prolapse (baby's head should come out first)

Molding

Overlap/sliding of bones to change the shape of the head

Fetal Lie

Relationship of the baby’s spine to the mother’s spine

• Longitudinal/Vertical: Mother and baby’s spine are align. Cephalic or breech presentation

• Transverse/Horizontal: Mother and baby’s spines are not aligned. Can be at any angle. (shoulder is the presenting part)

Biparietal Diameter (BPD)

Largest diameter of baby’s head

• Important indicator of fetal size

Fetal Position

Relationship of the presenting part to the 4 quadrants of the mother’s pelvis. Noted by 3 letter abbreviation

• First letter: location of presenting part in right or left side of mom’s pelvis (is posterior fontanel facing the right or left)

• Middle letter: the specific presenting part of fetus (occiput or sacrum)

• Third letter: location of presenting part in relation to anterior, posterior or transverse portion of maternal pelvis ( is back facing anterior or posterior)

EX: ROA → Right, occiput, anterior

What is the best position for a fetus to be in before delivery

LOA & ROA

• Occiput anteriors are easier to deliver than Occiput posterior

• If mother has lower back pain, indicates fetus is OP

Fetal Station

Relationship of the presenting part to maternal ischial spines (smallest part of pelvis)

• Measured in centimeters above or below the ischial spines

Negative Station

Station -3 to -1. The fetus is higher up

0 Station

The “Point of Engagement”. When the baby’s head descends into the ischial spine

• The infant should be at least in this station before active labor

Positive Station

+1 to +3, the more positive the number, lower the fetus’s head is to the pelvic bone

• The lower the better

• Pt will have the urge to push at station +3 (should not encourage pushing UNTIL urge is felt

Engagement

Term used to indicated that the largest part of presenting part has passed through the maternal pelvic brim.

• Largest part of baby or placenta has passed the pelvic brim

• Usually corresponds to station 0

• If fetus is still high (has - station) even after hours of dilation/active labor, then should consider C-section

What part tells us where we are in labor?

The cervix. Dilation is more important than effacement or station. If not at least 10cm dilated, cannot start pushing.

Effacement

Ability of cervix to get thinner and shorter

• Measure in percentage

• Cervix needs to thin out for baby to be delivered

Cephalopelvic Dysproportion (CPD)

When pelvic bone is too small for infant to pass. Will have negative station after hours of labor. Will need C-section

Bony Pelvis

Separated by the brim/inlet into two parts

• False pelvis → Upper iliac crest & pelvic rim (width of hips)

• True pelvis → Pelvic inlet (width of pelvic opening)

Soft Tissues

Corpus (Uterine Body)

• Upper uterine segment → contracts during labor

• Physiologic retraction ring → tells us that upper is more muscular & lower thins out

• Lower uterine segment → Thins out (cervix)

Fetal Attitude

Posting of the fetal joints and the relationship of the fetal parts to one another

• Flexion or extension

• Chin must be tucked in (flexion) so that head circumference decreases, making it easier to deliver head

Power

Power is needed to expel the fetus & placenta

Primary Power: Involuntary contraction that start at beginning of labor

• Measured by frequency, duration, & intensity

Secondary Power: Voluntary bearing down efforts by woman

• Pushing only after 10 cm dilated