Week 7 guided notes

What are the 4 Ts of postpartum hemorrhage (PPH)?

Tone (uterine atony), Trauma (lacerations), Tissue (retained placenta), Thrombin (coagulopathy/DIC).

Postpartum Hemorrhage: Tone (Uterine Atony)

Characterized by a soft or boggy uterus.

Postpartum Hemorrhage: Trauma

Characterized by heavy bright-red bleeding despite a firm uterus.

Postpartum Hemorrhage: Tissue

Caused by retained placental fragments; placenta appears incomplete upon inspection.

Postpartum Hemorrhage: Thrombin

Caused by DIC or clotting disorders; presents with oozing from IV sites or gums.

Why is fundal massage ineffective for heavy bleeding with a firm fundus?

Fundal massage only treats uterine atony (soft fundus), not lacerations or hematomas.

What should be assessed if postpartum bleeding is heavy but the fundus is firm?

Inspect the cervix, vagina, perineum, and episiotomy site for lacerations or hematomas.

Virchow's Triad in Postpartum: Venous Stasis

Caused by immobility or reduced movement during and after delivery.

Virchow's Triad in Postpartum: Vessel Injury

Caused by surgical trauma from Cesarean birth or birth canal lacerations.

Virchow's Triad in Postpartum: Hypercoagulability

Caused by natural increase in clotting factors during pregnancy and postpartum.

What is the weight-to-volume conversion for Quantitative Blood Loss (QBL)?

1 gram increase in weight = 1 mL of blood loss.

Why is quantitative blood loss (QBL) preferred over visual estimation?

Visual estimation is inaccurate; QBL provides an objective, standardized measurement.

Why is hypotension a late sign of postpartum hemorrhage?

Compensatory mechanisms maintain blood pressure until severe blood loss occurs.

What are 4 early signs of postpartum hemorrhage before hypotension occurs?

Tachycardia, altered mental status/restlessness, cool/clammy skin, and delayed capillary refill.

Oxytocin (Pitocin) in PPH

First-line uterotonic promoting uterine contraction. Monitor fluid balance and uterine tone.

Methylergonovine (Methergine): Contraindication

Strictly contraindicated in hypertension/preeclampsia due to severe vasoconstriction.

Methylergonovine (Methergine): Key Assessment

Check blood pressure before administration; hold if elevated.

Carboprost (Hemabate): Contraindication

Contraindicated in patients with asthma due to risk of severe bronchospasm.

Misoprostol (Cytotec) in PPH

Prostaglandin promoting uterine contraction; monitor baseline uterine tone and chills/fever.

Tranexamic Acid (TXA) in PPH

Antifibrinolytic stopping clot breakdown; give within 3 hours of bleeding onset.

Priority interventions for uterine atony with bladder displacement

1. Massage fundus

2. Empty bladder/catheterize

3. Administer uterotonics

4. Quantify QBL & notify provider

Lab findings expected in Disseminated Intravascular Coagulation (DIC)

Decreased platelets and decreased fibrinogen.

Management during manual replacement of an inverted uterus

Hold uterotonics temporarily and administer uterine-relaxing medications.

Subinvolution of the uterus

Recurrent postpartum bleeding and a uterus larger than expected weeks after birth.

Distinguishing finding of Endometritis

Foul-smelling/malodorous lochia and uterine tenderness.

Distinguishing finding of Mastitis

Localized pain, redness, and warmth in one breast.

Distinguishing finding of Postpartum Wound Infection

Purulent drainage or incision line separation.

Distinguishing finding of Postpartum UTI vs Pyelonephritis

UTI presents with dysuria; Pyelonephritis adds flank/CVA tenderness, high fever, and chills.

How does prolonged rupture of membranes increase postpartum infection risk?

Loss of amniotic sac barrier allows vaginal flora to ascend into sterile uterine cavity.

How do repeated vaginal exams increase infection risk during labor?

Physically pushes vaginal bacteria upward through the dilated cervix into the uterus.

REEDA Acronym for Perineal Assessment

R: Redness

E: Edema

E: Ecchymosis

D: Drainage

A: Approximation

Postpartum Blues: Timing & Features

Onset days 1-3, resolves within 1-2 weeks; mild sadness/crying, self-care intact.

Postpartum Depression: Timing & Features

Onset weeks to months, lasts >2 weeks; persistent sadness, guilt, impairs daily functioning.

Postpartum Psychosis: Features & Urgency

Sudden onset (days to 2 weeks); hallucinations/delusions; psychiatric emergency requiring immediate safety intervention.

Breastfeeding guidance for a patient with mastitis

Breastfeeding may generally continue as tolerated to promote continuous breast emptying.