NURS 420 Exam 3 Study Guide Part 3 Ch. 22

4 CATEGORIES OF POSTPARTUM COMPLICATIONS

- Hemorrhage

- Infection (endometritis, wound infection, UTI, mastitis, pneumonia)

- Thromboembolic events (DVT, PE)

- Postpartum psychological disorders (baby blues, PPD, postpartum psychosis)

Most Common Cause of Postpartum Hemorrhage

Uterine atony — the uterus fails to contract adequately after delivery.

Accounts for ~70–80% of all PPH.

Does not happen for just one reason — multiple triggers exist.

Risk Factors for Uterine Atony

* Prior PPH

* Chorioamnionitis

* Fibroids

* Labor induction or augmentation

* Therapeutic use of magnesium sulfate

* Uterine overdistention (macrosomia, multiple gestation, polyhydramnios)

* Uterine inversion

* Previous blood transfusion for PPH

Other Causes of Postpartum Hemorrhage

- Genital tract lacerations (2nd Most common Cause)

- Hematoma of vulva, vagina, or peritoneal tissue

- Episiotomy

- Retained placental fragments

- Uterine inversion

- Coagulopathies (can be pre-existing (e.g., von Willebrand) or acquired during intrapartum period).

Primary Postpartum Hemorrhage

Occurs within the first 24 hours of birth. Most commonly caused by uterine atony.

Secondary Postpartum Hemorrhage

Occurs 24 hours to 12 weeks after birth. Most commonly caused by retained placental fragments and subinvolution.

Volume of Blood Loss = Hemorrhage

Blood loss thresholds:

* >500 mL following vaginal birth = hemorrhage

* >1,000 mL following cesarean section = hemorrhage

- ACOG states 1,000 mL blood loss in the first 24 hours (regardless of route)

Challenges in quantifying blood loss:

* Pooling of blood in the uterus

* Pooling of blood on the floor

* Large hematomas of the labia, vulva, or vagina

Quantitative Blood Loss

STANDARD OF CARE.

- Not EBL (estimated blood loss).

- QBL = actually measuring and weighing the volume of blood coming out.

- EBL = old school: provider looks at the pad and says "400 mL" — not evidence-based.

- Standard for vaginal birth: graduated drape at bottom of bed measures fluid during birth. Subtract amniotic fluid volume → what remains = QBL from blood.

- If initial QBL is under 500 mL after vaginal birth and stable → probably won't go to trouble of weighing everything.

- Once hemorrhage territory is reached → START WEIGHING EVERYTHING.

PATHOPHYSIOLOGY OF PPH: "4 Ts"

- Tone: Uterine atony

- Tissue: Retained placenta, clots

- Trauma: Injury to any structure in the reproductive tract

- Thrombin: Coagulopathy, preexisting or acquired

- (5th T: Traction): how much they pull on the umbilical cord to try and deliver → not okay; can cause cord detachment or uterine inversion.

Common Causes of Subinvolution

-Retained placental fragments -Overdistended uterus (polyhydramnios, multiple gestation, macrosomia)

-Distended bladder

-Uterine leiomyoma (fibroid) Tumor

-Infection

Possible Complications of Subinvolution

* Hemorrhage

* Pelvic peritonitis

* Salpingitis (inflammation/infection of fallopian tubes)

* Abscess formation

Risk Factors for PPH

•Grand multiparity

•Overdistended uterus (multiples, polyhydramnios, macrosomia)

•Prolonged or precipitous labor

•Oxytocin (Pitocin) use during labor

•Operative delivery (forceps, vacuum)

•Chorioamnionitis

•Previous PPH (history of PPH)

•Placenta previa / placenta accreta spectrum

•Anticoagulant therapy

•Obesity, advanced maternal age, anemia

•Salpingitis = inflammation of the salpinges (fallopian tubes).

Assessing Tone: Thorough History

Take a thorough history. Ask about:

* Overdistention?

* Mag sulfate on board?

* Precipitous delivery?

* History of hemorrhage?

* Distended bladder? (Last void / time of catheter discontinuation?)

* Retained tissue fragments? Retained clots?

Initial & Ongoing Nursing Interventions for PPH: Assessment

•Fundal massage (if uterus is boggy)

•Pad count and weighing pads (1 g = ~1 mL blood)

•Urine output monitoring (Foley catheter)

•Continuous vital signs monitoring

•IV access × 2 large-bore (16–18 gauge); IV fluid resuscitation

•Blood transfusion if needed (type and crossmatch)

•Oxygen administration as needed

Postpartum Hemorrhage: TherapeuticManagement Pt. 1

1. Consider underlying cause/risk factors

2. Quantify blood loss: graduated drape, weights, pad count

3. Initial steps focus on improving tone:

-Fundal massage

-Administration of uterotonics/anti-hemorrhage medication

-IV fluid administration

4. Evacuate uterus:

-Removal of clots/tissue fragments/retained placenta

5. Tamponade measures: bimanual compression, uterine packing, balloon devices

6. Administer antibiotics PRN

7. Repair lacerations

8. Treat hematomas

9. Monitor for DIC/Shock

Postpartum Hemorrhage: TherapeuticManagement Pt. 2

Perinatal nurses are often the first to observe significant postpartum bleeding; prompt response is pivotal.

Multidisciplinary team support is critical.

- Initial management: immediate fundal massage, uterotonic medications, IV fluid resuscitation.

- If methods fail: bimanual compression, internal uterine packing, balloon tamponade.

1. Do not abandon uterine massage!

2. Call provider/additional support/emergency team

3. Delegate tasks

4. Weigh everything that is blood soaked

5. Administer meds as ordered/ Avoid antiplatelet medications (NSAIDs, ASA, Antihistamines)

6. Pain Management

7. May need 2nd IV site for transfusion

8. Monitor V/S every 15-30 min (B/P, HR, R, Temp)

9. Monitor Capillary refill, urine output, & LOC

10. Foley catheter insertion to keep bladder empty

11. Assist provider w/ procedures

12. Order blood products/activate massive transfusion protocol PRN

Nursing Management: Medication Administration Order

1. •Fundal Massage always your first intervention

2. •IV Pitocin (Never give as an IV push)

3. •Methergine 0.2mg IM (HTN contraindication

4. •Hemabate 0.25mg IM (Asthma contraindication)

5. •Misoprostol 800mcg orally or rectally

6. •Tranexamic Acid 1gm IV

Oxytocin (Pitocin)

First-line uterotonic; given to ALL postpartum patients routinely (standard of care for hemorrhage prevention).

- Usually already given; re-dose or increase if hemorrhage.

- Can be given IM if no IV access

-Dose: 10-40 units IV/IM

-Contraindications: None for ATONY

Methylergonovine (Methergine)

-Second-line uterotonic.

-Dose: 0.2 mg IM

-Contraindication: HYPERTENSION, Why CI with HTN: causes peripheral vasoconstriction → shunts blood to core → if blood pressure already elevated → risk of STROKE.

- Give ONE DOSE ONLY. If it doesn't work → move on.

Carboprost (Hemabate)

-3rd-line Prostaglandin (PGF2α)

-Dose: 250 mcg IM q15-90 min (max 8 doses)

-Contraindication: ASTHMA. hy CI with asthma: PGF2alpha acts on beta-2 adrenergic receptors → causes BRONCHOSPASM.

- Use if Methergine didn't work or is contraindicated.

Misoprostol (Cytotec)

-4th-line Prostaglandin

Also a prostaglandin analog, but a DIFFERENT type → does NOT aggravate asthma like Hemabate.

-Dose: 600-1000 mcg SL/PR/buccal

-Contraindication: AFE in asthma patients (alternative to Hemabate).

-Route: oral / buccal = preferred per current evidence. Rectal = option. Use rectal route if: patient is intubated, nauseous/vomiting, or already numb (epidural still in).

Tranexamic Acid (TXA)

-5th-line medication. NOT a uterotonic — it is an ANTI-HEMORRHAGE (Antifibrinolytic) medication.

-Dose: 1 g IV within 3 hrs of PPH onset

-Contraindication: Active thromboembolic disease

-Risk: excessive clotting → thromboembolic events (especially concerning because postpartum patients are already hypercoagulable).

-Can be given at any point in the stepwise order; in clinical practice often given earlier (around the time of misoprostol or even sooner).

-Route: Rectal/IV route if patient can't take oral.

Know each medication's CONTRAINDICATION

- Methergine → CI: Hypertension

- Hemabate → CI: Asthma - Misoprostol → Safe in asthma (different prostaglandin type)

- TXA → Risk = thromboembolic events; NOT a uterotonic ***

[NCLEX PEARL] Methergine = contraindicated in HTN. Hemabate = contraindicated in asthma. Remember: 'M for Methergine, M for Moms with high BP — NO!' and 'H for Hemabate, H for Huffing (asthma) — NO!'

VS Changes in Hypovolemic Shock

•Tachycardia: EARLY compensatory sign — the body increases HR to maintain cardiac output

•Hypotension: LATE sign — indicates decompensation (body can no longer compensate)

•Narrowed pulse pressure: Early sign (systolic falls, diastolic may rise)

•Tachypnea: Rapid, shallow breathing to compensate for decreased O2 delivery

•Decrease in Urine Output

These signs do not manifest themselves until the patient has an 1,800 – 2,100 ml blood loss

[NCLEX PEARL] Tachycardia is the FIRST vital sign change in hemorrhage. Hypotension is a LATE sign — by the time BP drops, significant blood loss has occurred. Do not wait for hypotension to intervene.

[NCLEX PEARL] Outward symptoms generally appear after loss of ~750–1,000 mL (Class II). A healthy pregnant person can lose up to 15% of blood volume with minimal symptoms due to the expanded blood volume of pregnancy.

Kidney Function In Hypovolemic Shock

•Oliguria (<30 mL/hr): Early sign of decreased renal perfusion

•Anuria: Severe shock — no urine output

•Rising BUN/creatinine: Indicates renal compromise

At what volume blood loss will you see outward s/sx?

1,800 - 2,100 ml blood loss

Outward S/SX When Blood Loss Is: Up to 750 mL (≤15%)

Minimal symptoms; may be asymptomatic; slight anxiety

Outward S/SX When Blood Loss Is: 750-1,500 mL (15-30%)

Tachycardia, anxiety, decreased pulse pressure, slight tachypnea

Outward S/SX When Blood Loss Is: 1,500-2,000 mL (30-40%)

Hypotension, tachycardia, altered mental status, tachypnea, oliguria

Outward S/SX When Blood Loss Is: >2,000 mL (>40%)

Life-threatening; profound hypotension, severe tachycardia, minimal UO, obtundation

DIC (DISSEMINATED INTRAVASCULAR COAGULATION) Pathophysiology

•Paradox: Simultaneous widespread clotting AND bleeding

•Triggers: Amniotic fluid embolism, placental abruption, severe PPH, sepsis, preeclampsia/HELLP, retained dead fetus, massive transfusion

•Mechanism: Massive activation of the clotting cascade → widespread microthrombi form in small vessels → clotting factors and platelets are consumed/depleted → the body can no longer clot → uncontrolled bleeding

•End-organ damage: Microthrombi occlude small vessels → ischemia and damage to kidneys, liver, brain, lungs

Nursing Assessment for DIC

Bleeding signs:

Oozing from IV sites

gums

venipuncture sites

petechiae

purpura

ecchymosis

hematuria

hematemesis

uncontrolled vaginal bleeding

Lab Values in DIC

•Elevated: PT, PTT, INR (clotting times prolonged); D-dimer (elevated — fibrin degradation); FDPs (fibrin degradation products — elevated)

•Decreased: Fibrinogen (<100 mg/dL — depleted); Platelets (thrombocytopenia — consumed)

•Monitor VS for signs of shock

•Strict I&O — monitor urine output

[NCLEX PEARL] DIC labs: think 'everything that should be low is high, and everything that should be high is low.' Clotting times are prolonged (high PT/PTT/INR), but fibrinogen and platelets are depleted (low).

Thrombophlebitis

Inflammation of a vein wall (blood vessel lining) associated with thrombus formation. Can be superficial or deep.

Thrombosis

Formation of a blood clot (thrombus) within a blood vessel.

Thromboembolism

Detachment and travel of a thrombus (becomes an embolus), potentially causing pulmonary embolism (PE).

Obstruction of a blood vessel by a blood clot carried by the circulation from the original site.

Most Common Types of Thromboembolism

1. Superficial Thrombophlebitis: involves superficial veins. Usually confined to the saphenous veins in the lower leg. S/Sx: warmth, tenderness, redness, palpable cord along the affected vein.

2. Deep Vein Thrombosis (DVT): Most commonly in lower extremities. May originate in any part of the lower extremity or pelvis; may cause pulmonary embolism (PE). Higher risk of embolization to lungs.

3. Pulmonary Embolism (PE): Life-threatening. A DVT clot detaches and travels to the pulmonary vasculature.

Why pregnant/PP persons are at greater risk for Thromboembolic Conditions: Virchow's Triad

•1. Venous stasis: Reduced venous flow from gravid uterus compression, prolonged bed rest, decreased mobility postpartum, C-section recovery

•2. Hypercoagulability: Pregnancy naturally increases clotting factors (fibrinogen, factors II, VII, VIII, X); these remain elevated postpartum and return to normal slowly over 6–8 weeks

•3. Vascular injury: Trauma to pelvic vessels during vaginal or cesarean delivery

Higher-Risk Patients for Thromboembolic Conditions

•C-section delivery

•Obesity

•Prior history of DVT/PE

•Thrombophilia (Factor V Leiden, antiphospholipid syndrome, protein C/S deficiency)

•Prolonged immobility / bed rest

•Varicose veins

•Smoking

•Older maternal age (>35)

•Preeclampsia

Nursing Assessment DVT

•Unilateral leg pain, swelling, redness, warmth

•Difference in leg circumference

•Homans' sign (calf pain with dorsiflexion) — NOT reliable; do not depend on this alone

•Calf swelling and tenderness.

•Low-grade fever

•Positive findings on Doppler ultrasound (definitive diagnosis)

Nursing Assessment PE

•Sudden onset chest pain

•Dyspnea, tachypnea

•Tachycardia

•Hypoxia / decreased O2 saturation

•Anxiety, apprehension, sense of doom

•Hemoptysis (coughing up blood)

•May progress to cardiovascular collapse

DVT Management

•Anticoagulation therapy ( Lovenox (LMWH) — enoxaparin; or unfractionated heparin → warfarin)

•Elevate affected extremity

•Warm compresses to affected area

•SCDs (sequential compression devices) for prevention

•Early ambulation (prevention and treatment)

•NSAIDS: For Pain with SVT Superficial Venous Thrombosis

•Do NOT massage the affected leg — risk of dislodging clot

PE Management — HIGH PRIORITY

•Administer oxygen immediately

•Position: HOB elevated to 30° (semi-Fowler's)

•Establish IV access

•Notify provider STAT

•Anticoagulation therapy

•Continuous vital signs and O2 sat monitoring

•Prepare for possible CT angiography for diagnosis

Thromboembolism Pharmacologic Therapy

•Heparin (unfractionated): Used in hospital setting. IV continuous infusion. Monitored with aPTT. Reversible with protamine sulfate.

•LMWH (enoxaparin/Lovenox): Preferred outpatient anticoagulant. SubQ injection. Routine aPTT monitoring NOT required. Reversible with protamine sulfate. Safe in breastfeeding.

•Warfarin (Coumadin): Oral anticoagulant for long-term therapy. Monitor INR (goal 2.0–3.0). Safe in breastfeeding. CROSSES PLACENTA — do NOT use during pregnancy (teratogenic).

•CAUTION: Avoid aspirin and NSAIDs in combination with anticoagulants (increased bleeding risk).

[NCLEX PEARL] Warfarin is safe in breastfeeding but crosses the placenta (contraindicated in pregnancy). Heparin and LMWH do NOT cross the placenta and are safe in pregnancy.

POSTPARTUM INFECTIONS Common Sources

•1. Endometritis (most common postpartum infection)

•2. Wound infection (C-section incision, perineal laceration/episiotomy)

•3. Urinary tract infection (UTI)

•4. Mastitis

•5. Pneumonia (especially post-operative)

Endometritis

•Definition: Infection of the uterine endometrium

•S/Sx: Fever >100.4°F, uterine tenderness, malodorous lochia, chills, tachycardia, increased WBC

•More common after C-section

•Treatment: Broad-spectrum IV antibiotics — clindamycin + gentamicin (first-line combination). Transition to oral antibiotics after resolution of fever for 24–48 hours.

Endometritis S/SX

-Lower abdominal tenderness or pain on one or both sides

-Temperature elevation (>100.4°F / >38°C)

-Foul-smelling lochia

-Anorexia

-Nausea

-Fatigue and lethargy

-Leukocytosis and elevated sedimentation rate

Wound Infection (C-section / Laceration / Episiotomy)

•S/Sx: Redness, warmth, edema, purulent drainage, increasing pain at site, fever, wound dehiscence

•Management: Wound culture, antibiotics targeted to organism, wound care, irrigation, possible incision and drainage

Wound Infection S/SX

-Weeping serosanguineous or purulent drainage

-Separation of or unapproximated wound edges

-Edema

-Erythema

-Tenderness

-Discomfort at the site

-Fever

-Elevated white blood cell count

Pneumonia (Post-Operative)

•Causes: Immobility, splinting from pain (not deep-breathing due to incisional pain), decreased respiratory effort after general anesthesia

•Prevention: Incentive spirometry (10 breaths q1–2h while awake), early ambulation, deep breathing/coughing exercises, adequate pain control to allow deep breathing

UTI S/SX

-Urgency

-Frequency

-Dysuria

-Flank pain

-Low-grade fever

-Urinary retention

-Hematuria

-Urine positive for nitrates

-Cloudy urine with strong odor

UTI Risk Factors in PP Patients

•Urinary stasis — decreased bladder tone from progesterone and trauma

•Catheterization during labor (introduces bacteria)

•Perineal contamination (proximity of urethra to vagina/rectum)

•Decreased sensation from regional anesthesia → overdistension → stasis

•Trauma to urinary structures during delivery

Mastitis

•Definition: Infection of breast tissue, usually unilateral.

•S/Sx: Localized redness, warmth, swelling, tender lump; flu-like symptoms (fever, myalgia, fatigue, chills)

•Organism: Staphylococcus aureus — most common causative agent

Mastitis S/SX

Unilateral breast redness/warmth/pain, flu-like symptoms (fever, myalgia, fatigue)

Pneumonia S/SX

Cough, fever, dyspnea, decreased breath sounds, chest pain with breathing

Organisms Causing Infection

Ascending vaginal flora.

Bacteria that are already colonized in the vagina, not from an outside source.

Postpartum Infections: Risk Factors

Surgical delivery

Genital tract trauma

Prolonged rupture of membranes

Multiple cervical assessments during labor

Intrapartum chorioamnionitis

Colonization of lower genital tract w/ specific organisms

General anesthesia

Diabetes

Indwelling urinary catheter

Retained tissue

Nipple trauma

Mastitis Lactation Interventions

•CONTINUE breastfeeding/pumping from affected breast — this prevents milk stasis and does not harm the infant

•Frequent feeding (every 2–3 hours)

•Ensure proper latch technique

•Antibiotics: dicloxacillin or cephalexin (safe in breastfeeding)

•Warm compresses before feeding (promotes milk flow)

•Cold compresses after feeding (reduces swelling)

•Supportive bra

•Rest, fluids, analgesics (ibuprofen/acetaminophen)

Mastitis Prevention (Prophylactic Measures)

•Proper latch technique (assess at every feeding)

•Frequent and complete emptying of the breast

•Hand hygiene before breastfeeding and breast care

•Avoid nipple trauma (break suction before removing baby)

•Treat cracked nipples promptly (lanolin, breast milk applied to nipples)

•Avoid restrictive clothing or bras

[NCLEX PEARL] Do NOT stop breastfeeding with mastitis. Continuing to breastfeed from the affected breast helps clear the infection by emptying the breast.

Fever Diagnostic Threshold

Temperature ≥100.4°F (38°C) on any 2 of the first 10 days postpartum (excluding first 24 hours — some low-grade fever immediately PP is normal due to dehydration and exertion).

Infection Preventive Measures

•Hand hygiene — patient and all staff (most important single intervention)

•Sterile technique during catheterization and procedures

•Early ambulation — reduces DVT and pneumonia risk

•Adequate perineal care (peri-bottle, front-to-back wiping)

•Wound care education (C-section incision, perineal site)

•Promote proper breastfeeding technique (prevent mastitis)

•Bladder emptying and hydration

•Incentive spirometry for post-operative patients

Infection Treatment

•Antibiotics — specific to source and organism

•Wound debridement/irrigation if needed

•Antipyretics (acetaminophen, ibuprofen)

•IV fluids if severely ill or dehydrated

•Pain management

•Lactation support — do not stop breastfeeding unless absolutely necessary

Infection Patient Education

•Signs of infection to report: fever, foul odor from lochia or wound, increased pain/swelling, wound opening/drainage

•Wound care technique (keep clean, dry; follow provider instructions)

•Proper perineal hygiene (front to back, peri-bottle)

•Breastfeeding technique to prevent mastitis

•Handwashing before breast care and newborn care

•Finish full antibiotic course even if feeling better

•Follow-up appointment importance — do not miss postpartum visit

REEDA

•R = Redness — Erythema at or beyond wound edges

•E = Edema — Swelling of perineal tissue

•E = Ecchymosis — Bruising / discoloration

•D = Discharge/Drainage — Amount and type of wound drainage (serous, serosanguineous, purulent)

•A = Approximation — How well the wound edges are coming together / closing

•Each criterion scored 0–3; total score 0–15; higher score = more trauma / complication.

[EXAM TIP] A REEDA score of 0 = no abnormality. Report scores >3 or any single criterion scoring 2-3 to provider.

Baby Blues

-Onset: 1-5 days PP

-Duration: ≤2 weeks (self-resolving)

-Prevalence: 50-80%

-Primary Trigger: Rapid hormonal drop (estrogen and progesterone)

-Safety Concern? NO

Primary trigger for baby blues: Precipitous drop in estrogen and progesterone after delivery of the placenta.

[NCLEX PEARL] Baby blues affects up to 80% of new parents and resolves on its own. If symptoms last >2 weeks, screen for PPD using the Edinburgh Postnatal Depression Scale (EPDS). A score ≥10 warrants further evaluation.

Baby Blues Symptoms

Tearfulness, mood swings, anxiety, fatigue, irritability, difficulty concentrating

Baby Blues Treatment

Reassurance, support, self-care; resolves spontaneously

Postpartum Depression (PPD)

-Onset: Within first year (peak 2-4 weeks PP)

-Duration: Weeks to months if untreated

-Prevalence: 10-20%

-Primary Trigger: Multifactorial: hormonal, psychosocial, prior MH history, lack of support

-Safety Concern? Yes — monitor for suicidal ideation; screen with Edinburgh PPD Scale

Postpartum Depression (PPD) Symptoms

Persistent sadness, hopelessness, inability to care for self/baby, anhedonia, sleep/appetite changes, guilt, possible suicidal ideation

Postpartum Depression (PPD) Treatment

Therapy (CBT), antidepressants (SSRIs — sertraline preferred, safe in BF), social support

Postpartum Psychosis

-Onset: Within 2 weeks PP (often 24-72 hours)

-Duration: Weeks to months if untreated

-Prevalence: 0.1-0.2% (rare)

-Primary Trigger: Unknown; likely hormonal + genetic predisposition (esp. bipolar history)

-Safety Concern? YES — risk of infanticide and suicide; do NOT leave alone with baby

[NCLEX PEARL] Postpartum psychosis is rare but life-threatening. Patients with a history of bipolar disorder are at highest risk. Onset is rapid (often 24–72 hours PP). This is a psychiatric emergency requiring immediate hospitalization.

[EXAM TIP] NCLEX priority: If a postpartum patient reports hearing voices telling her to harm her baby → FIRST ensure safety of both mother and infant → notify provider STAT → do NOT leave patient alone with baby.

Postpartum Psychosis Symptoms

Hallucinations, delusions, disorganized thinking, extreme agitation, confusion, bizarre behavior, paranoia

Postpartum Psychosis Treatment

PSYCHIATRIC EMERGENCY — hospitalization, antipsychotics, mood stabilizers, possible ECT