Post-partum complications

Postpartum hemorrhages/medications, uterine atony, retained placenta, nurs. assessment of newborn (newborn reflexes, VS, SGA.LGA/AGA, normal GI/GU), Normal newborns needs & care

What is postpartum hemorrhage?

It is excessive bleeding after birth

• identified at 500 mL + after vaginal birth

• Idenitfied at 1000 mL + after c-section

what are complications that can occur following PPH? (postpartum hemorrhage)

think- what might happen with excessive blood loss

Risk factors for PPH?

• uterine atony/hx of uterine atony

• overdistended uterus (uterus stretches beyond its normal capacity)

• prolonged labor/ oxytocin induced labor - makes sensors less sensitive to oxytocin = reducing the uterus ability to contract effectively after placenta is delivered

• high parity (5+ pregnancies reaching at least 20 wks gestation)

• ruptured uterus (direct trauma tearing of the uterine muscles & Blood vessels)

• complications during pregnancy ( placenta previa, abruptio placenta)

• precipitous delivery (rapid delivery, 3 hrs or less, rapid/intense contractions prevent uterus from having enough time to contract and “clamp down” after delivery= leading to uterine atony!)

• administration of mag sulfate therapy during labor (induces uterine atony, as muscle relaxant- tocolytic to suppress contractions), vasodilates which can increase volume of blood loss)

• retained placental fragments (prevents uterus from contracting effectively- uterine atony)

Physical assessment findings with PPH?

• uterine atony (boggy/hypotonic)

• blood clots larger than quarter (sign of significant heavy bleeding, blood is pooling & clotting in uterus/vagina before expelled)

• perineal pad saturation in 15 in or less

• constant oozing, trickling, frank flow of bright red blood from vagina

• tachycardia & hypotension

• pallor skin/muscous membranes, cool/clammy w/ loss of turgor

• Lochia change/increase

what are important nurs. care w/ PPH?

• Firmly massage the uterine fundus

• monitor VS

• assess source of bleeding

• assess bladder for distension (insert indwelling urinary catheter to assess kidney function & obtain an accurate measurement of urinary output)

• maintain/initiate IV fluids to replace fluid volume loss

• provide O2 & monitor O2 saturation

• elevate clients legs to promote circulation to organs (20 - 30 degres)

what does Oxytocin (pitocin) do?

classification: uterine stimulant

• promotes uterine contraction for delivery and to stop bleeding

what to assess?

uterine tone & vaginal bleeding

what is an adverse effect with the use of oxytocin?

• Water intoxication ! (hypoatremia)

It chemical structure is similar to vasopressin (ADH)= retain water!

high does or rapid administration w/ large volumes of electrolyte free fluid during labor can lead to headache, nausea, convulsions, or coma

monitor input/output, limit fluids, & stop oxytocin if intoxication is suspected !

Don’t infuse to long (36 hrs +)

MEMORY: oxy-don’t-pee = oxytocin makes you not pee (retain water!)

how to identify someone has water intoxication from oxytocin infusion?

Associated with high does of oxytocin or prolonged infusion!

• low sodium levels

• severe headchaes, n/v, confusion, lethargy, muscle cramps/twitching, rapid weight gain due to fluid retention

• reduced urine output (oliguria), weight gain

• cardiovascular changes (high BP, low BP- as also vasodilator, rapid heart rate)

What does medication methylergonovine (methergine) do?

• uterine stimulant

controls PPH ! (not to induce labor!!), as causes STRONG uterine contractions!

assess uterine contractions, tone, and bleeding

DO NOT administer to clients w/ HTN/pre-eclampsia/toxemia (high BP)

Adverse reactions- HTN, Nausea, vomitting, & headache

why is methylgonovine (methergine) contraindicated in pts w/ HTN?

• this medication causes uterine muscles to contract, which can also induce significant vasoconstriction, leading to dangerous increase in BP, seizures, stroke

What makes different from other medications that are uterine stimulants?

• causes uterine contractions AND STRONG vasoconstriction (directly tightens Blood vessels)

What does medication misoprostol (cytotec) do?

is a uterine stimulant

• control PPH

• assess uterine tone & vaginal bleeding

What does medication carboprost (hemabate) do?

is a uterine stimulant

• controls PPH

• assess uterine tone & vaginal bleeding

Monitor adverse reactions: fever, HTN, chills, headache, N/V, and diarrhea

What is hemabate contraindicated in?

Hemabate ( carboprost) is contraindicated in asthma b/c it acts as a potent bronchoconstrictor

Causes smooth muscle contraction throughout the. body, including the bronchial tubes, which can severely worsen asthma.

What is uterine atony?

• happens when the uterus fails to contract (tighten) after childbirth, causing severe PPH !

• boggy/soft uterus = failing to compress Blood vessels where the placenta detached.

Risk factors of uterine atony?

• retained placental fragments

• prolonged or precipitous labor

• oxytocin induction or augmentation of labor

• over distension of uterine muscles

• mag sulfate administration as a tocolytic (suppress contraction)

• trauma during labor & birth from forceps or vacuum assisted birth

physical assessment findings for uterine atony?

• increased vaginal bleeding

• uterus larger than normal

• boggy w/ possible lateral displacement on palpating

• prolonged lochial discharge

• irregular/excessive bleeding

• tachycardia/hypotension

• pallor of skin and mucous membranes, cool, clammy w/ loss of turgor

Nurs care w/ uterine atony?

• ENSURE URINE IS EMPTY!

• monitor- fundal height, consistency, & location , lochia for quantity/color/consistency, VS

• Perform fundal massage if indicated!

  • if uterus becomes firm, continue assessing hemodynamic status

  • if uterine atony persist, anticipate surgical interventions (like hysterectomy)

• maintain/initiate IV fluids

• provide O2 (2-3 L/imn) nasal cannula if needed

why do you need to make sure urine is empty for uterin atony & PPH?

critical for managing b/c a full bladder physically displaces the uterus, preventing it from contracting effectively to compress bleeding vessels.

• keeps boggy and causes severe postpartum bleeding!

what is retained placenta?

It is the placenta or placental fragments that remain in the uterus and prevent the uterus from contracting .

can lead to uterine atony or sub involution (uterus fails to return to its normal size, remaining enlarged!)

what is subinvolution?

postpartum condition where the uterus fails to return to its normal size, remaining enlarged, soft, or boggy!

• causes prolonged bleeding due to retained fragments, infection, or uterine fibroids (non cancerous (benign) tumors that grow in or on the muscular wall of the uterus, can sometimes cause infertility/miscarriage/complication during labor)

risk factors of retained placenta?

• partial separation of normal placenta

• entrapment of a partially or completely separated placenta by a constricting ring of the uterus

• excessive traction (tension) on the umbilical cord prior to complete seperation of placenta

• placental tissue that is abnormally adherent to the uterine wall

• preterm births between 20-24 weeks

nurs care with retained placenta ?

• monitor uterus (fundal height, consistency, & position)

• monitor lochia (color, amount, consistency, odor)

• monitor VS

• maintain/initiate IV fluids

• provide O2 as directed (2-3 L/min)

• anticipated surgical intervention (D&C, hysterectomy) if PP bleeding is present and continues

Nurs. assessment of newborn (delivery, admission, discharge)

• Delivery: assess need for resuscitation measures! (stable? newborn can stay with parents)

• upon admission to nursery /mother-baby unit estimate gestational age & thew newborns adaptation to life outside the uterus

• prior to discharge: complete physical exam to detect problems or readiness for routine care at home including nutritional status/ability to breast or bottle feed

Normal reflexes and what they are?

• rooting: corner of mouth stroked → baby turns and opens their mouths to feed

• sucking: touching roof of the mouth causes the baby to suck. This develops fully around 36 weeks gestation

• palmar grasping: touching palm → close their fingers tightly

• Moro: (startle reflex) sudden, loud noise or feeling of falling causes the baby to extend their arms/legs, throw their head back, and often cry

• Tonic neck: when the head turns, the corresponding arm straightness while the opposite arm bends

• Stepping: when held upright with feet touching solid surface, the baby makes a stepping motion

what is SGA, AGA, LGA?

• classification defining baby’s birth weight relative to their gestational age (wks in womb)

  • Can indicate clues about potential problems

• SGA: small for gestational age, weighs lower than 90% of other infants at same GA. May be constitutionally small (genetically) or have experienced fetal growth restrictions (placental issues, maternal HTN, infections, genetic factors)

• AGA: appropriate for gestational age, falls between 10th & 90th percentile for their GA! considered normal growth in the womb (low risk of complications)

• LGA: Large for gestational age, higher then 90% of other infants at the same GA. often linked to faster growth, sometimes known as macrosomia. (causes- maternal diabetes, maternal obesity, excessive weight gain during pregnancy)

normal newborn VS ?

HR: 110-160

RR: 30-60

BP: 50/30 - 70/45

axillary temp: 36.5-37.2 (97.7-99)

normal newborn measurements?

weight: 2500 - 4000 g (5 Ibs 8 oz -8 Ibs 13 oz)

Length- 48-52 cm(18-22)

head circumference: 32-37 cm (12.6 -14.6 inches)

chest circumference: about 2 cm smaller than head circumference

normal newborn GI patterns?

term baby ready to digest fats, carbs, and proteins at birth

• suck & swallow is natural reflex !

SHOULD pass meconium (first stool) 24-48 hrs after delivery (if not → notify hcp)

• meconium: tarry, sticky, black, or dark green & odor less during the first few days during first few days or life

  • after GI system develops normal flora, the infant stool will have odor!

• meconium → transitional → then day 5:

  • breast fed: seedy/yellow mustard gold/soft to liquid, more frequent stools

  • bottle/formula fed: pale/yellow, formed firmer

Normal GU in newborns?

• should urinate in FIRST 24 hrs!

  • characteristics: sterile, odor less, straw colored, cloudy appearance,

    • typically voids 2-6 times initially a day, increase 5-25 times per 24 hrs!

Newborn needs & care?

• provide comprehensive care!

• have personnel & equipment available at birth to handle any anticipated problems !

• support/teach family how to care for newborn

prior to birth review what?

• prior to birth review prenatal & labor records (identify risk for baby

when should there be immediate skin to skin?

If baby is term, crying, breathing, & has good muscle tone!

what happens in baby’s transition to extaruterine life?

• healthy newborn adapts quickly

  • pattern of blood flow changes quickly! (multiple shortcuts close immediately)

  • PROVIDE: warmth, open airway, dry & stimulate first then be ready to support breathing/circulation if not adequate!

prevent heat loss & promote thermoregulation?

prevent heat loss through 4 ways:

• convection: heat lost to air moving around baby(drafts) (keep baby AWAY from drafts! use incubators or warm rooms)

• radiation: cold objects nearby, even if not touching (keep baby away from cold surfaces, use radiant warmers)

• evaporaton: heat is lost when moisture on skin evaporates (dry baby immediately, remove wet blankets, put on hat)

• conduction: direct contact when touching something cold! (warm blankets, pre-warmed surfaces, dry skin)

Memory: C- contact (touch), C- currents (air), R- radiation (nearby cold tings), E- evaporation (wet skin)

Newborn: has trouble maintaining core body temp. even healthy!

• limited subcu fat, thinner skin, larger body surface compared to mass

Newborns do use thermogenesis to maintain body heat: increased metabolic rate, muscular activity, use of brown fat stored during 3rd trimester of gestation

how might eye of newborn be affected in birth?

can be exposed to gonorrhea or chlamydia during birth which can lead to blindness!

treatment for eye infection in newborn?

• ophthalmic ointment:

  • erythromycin or tetracycline effective against both!

• Prophylactic treatment legally required in the U.S.

• administer along the lower conjunctival surface of each eye!

• Delay administration of eye ointment for up to one hour to promote better eye opening

Signs of neonatal distress?

• RR: >60

• grunting

• nasal flaring

• retractions

• cyanosis

• pallor

• jaundice

• lethargy

• jitteriness

• problems voiding/stooling

• hypo/hyper thermia

how long after birth best time to initiate breast feeding? and signs baby is ready?

• Best time- FIRST hour of birth (baby alert & responsive)

• readiness signs: licking of lips, hand in/near mouth, cry that quiets w/ rooting or sucking behaviours, active bowel sounds (RECOGNIZE SUBTLE CUES!)

what is vitamin K and why is it important for newborns?

Vitamin K is a fat soluble nutrient essential for blood clotting and stopping bleeding!!!

• it helps the body create proteins (clotting factors) necessary for blood to clot properly

Newborns are born with low levels of vitamin K (no bacteria in colon that are necessary for synthesising fat soluble vitamin K)

→ at risk for vitamin K deficiency bleeding (VKDB)

Give IM injection of vitamin K (in vastus lateralis)

bonding/attachment

• facilitate bonding (skin to skin, talk to baby face to face)

• teach parents

nurs care after transition period

• continue to monitor cardiopulmonary function

• maintain thermal environment

• monitor hydration & nutrition (weigh baby/ track voids/stool)

signs of illness in newborn

temp. > 38 (100.4)

temp. <36.6 (97.8)

>1 episodes of vomitting

refusal of 2 feedings in a row

lethargy/difficulty waking up

cyanosis

absence of breathign (apnea) > 20 secs