PP Complications

1. PP hemorrhage

2. PP preeclampsia

3. PP infection

4. PP thromboembolic conditions

5. PP affective DO

What are the PP complications?

• Vaginal: ≤ 500 mL

• C-section: ≤ 1000mL

What is the normal blood loss after delivery?

• Vaginal: > 500mL

• C-section: > 1000mL

What is the blood loss for PP hemorrhage?

Within 24 hours after birth

What does EARLY PP hemorrhage mean?

24 hrs to 12 weeks after birth

What does LATE PP hemorrhage mean?

• Hypotension

• Tachycardia

What are the s/s hypovolemic shock?

• Tone

• Tissue

• Trauma

• Thrombin

• Traction

What are the risk factors for PPH?

• UTERNE ATONY

• Boggy fundus

• Deviated fundus

What does bleeding related to TONE mean?

• Overdistension of uterus (macrosomia, twins and triplets, polyhydramnios)

• Multiparity

• Chorioamnionitis (inflammation)

• Use of anesthesia/magnesium sulfate (MGSO4)

• Distended bladder (deviation)

• Prolonged (tired), rapid (can’t keep up), or forceful labor

What are the CAUSES of bleeding related to TONE?

Tissue prevents the uterus from contracting to clamp down on blood vessels

• Boggy uterus (uterine atony) (tissue issue not muscle)

• SUBINVOLUTION (fundal height above expected location, U, U+1)

• Profuse hemorrhage

• Abnormal lochia progression

What does bleeding related to TISSUE mean?

• RETAINED PLACENTAL FRAGMENTS

• Clots in the uterus (blood pooling in uterus)

• Uterine leiomyomas (fibroids)

What are the CAUSES of bleeding related to TISSUE?

• RETAINED PLACENTAL FRAGMENTS (create LATE HEMORRHAGE)

• Distended bladder

• Infection or uterine myoma

What are the causes of SUBINVOLUTION?

SUBINVOLUTION

What is the most common cause of LATE hemorrhage?

• Boggy uterus

• Abnormal lochia progression

• PP fundal height higher than expected

What are the s/s uterine SUBINVOLUTION?

Continuous trickling of bright red blood with a contracted uterus

What does bleeding related to TRAUMA mean?

• Damage to the genital tract, including hematomas

• Lacerations (vaginal, perineal, periurethral, cervical, etc.) or hematomas

• Pushing too soon, precipitous delivery (cause lacerations)

• Abnormal fetal presentation or use of forceps or vacuum extractor

What are the CAUSES of bleeding related to TRAUMA?

Laceration

Trickling bright red blood with contraction, immediately call provider

• COAGULOPATHIES (DO that interfere with CLOT formation)

• Decreased platelet and fibrinogen levels

• Increased PT, PTT

• Prolonged bleeding time

• history

What does bleeding related to THROMBIN mean?

• Determine risk during pregnancy

• Family and personal hx

How to LESSEN the risk of bleeding related to thrombin?

• Excessive force on umbilical cord during third stage of labor

• Pulling on cord to hasten third stage, resulting in cord detachment from placenta (RETAINED PLACENTA)

• Can result in UTERINE INVERSION (prolapse of uterus) bc it’s not ready to come out

What does bleeding related to TRACTION mean?

• INFECTION (antibiotics)

• Uterine atony (uterotonics)

What does uterine involution create a risk for?

• CALL FOR HELP (emergency)

• Fundal assessment

• Hemorrhage cart (all supplies for a hemorrhage)

• Monitor VS (q5min)

• Maintain IV access and prepare for second IV

• Administer uterotonic meds (oxytocin)

• Assess/quantify blood loss

• Notify provider

• Prepare for possible manual exploration or surgery

• Assess s/s HYPOVOLEMIC SHOCK

• Pad counts (what percent of blood does it have?, q1hr)

• PREVENTION

What is the nursing intervention for PPH?

• Massage if boggy

• Empty bladder if deviated

• Straight cath if hemorrhage

What is the fundal intervention to prevent PPH?

• Fluids, meds

• Blood transfusion

Why prepare a second IV in PPH?

• Fundal assessment (what height)

• Blood loss

• VS

• Interventions

What should you notify the provider with during PPH?

• OXYTOCIN

• MISOPROSTAL (cytotec)

• METHYLERGONOVINE (methergine)

• CARBOPROST (hemabate)

• TRANEXAMIC ACID (TXA) (antifibrinolytic)

What are the MEDS for PPH?

IV infusion or IM

• Never give UNDILUTED IV, NO IV PUSH

How to give oxytocin in PPH?

Bucally or per rectum

How to give misoprostol in PPH?

CONTRACTIONS:

• ACTIVE CARDIOVASCULAR, PULMONARY, OR HEPATIC DISEASE

• Use cautiously in women with ASTHMA

Adverse:

• FEVER

• DIARRHEA

What are the contradictions and adverse reactions for misoprostal?

IM (PO after acute bleeding stops)

How to give methylergonovine?

HTN (gestational, chronic, preeclampsia)

When is methylergonovine contradicted?

IM

How to give carboprost?

CONTRADICTION:

• ASTHMA or ACTIVE CARDIOVASCULAR, PULMONARY, RENAL, OR HEPATIC DISEASE

Adverse:

• FEVER

• DIARRHEA

What are the contradictions and adverse reactions for carboprost?

IV infusion

How to give TXA?

• Renal impairment

• Active thromboembolic disease

• Intracranial bleeding

What should you use TXA cautiously with?

• Intrauterine balloon tamponade (pressure inside uterus)

• Vacuum-induced hemorrhage control device (suck uterus walls in)

What are the hemorrhage control devices?

Actual measurement of blood lost during and after birth, rather than estimating; takes blood lost at delivery + blood lost during hemorrhage

Is measured by:

• Machines that can calculate the blood loss in blood-socked materials

• Dry weight substracted by wet weight

• Blood collected in containers

What is quantitative blood loss?

1. Recognition

2. Readiness

3. Response

4. Reporting

What are the steps to PPH prevention?

Recognize hemorrhage risk factors early by assessing:

• Risk factors on admission to L&D

• Risk factors during/after delivery

• If risk present: second IV, CBC, and type and screen or cross for blood

• Review protocol for hemorrhage

What does RECOGNITION mean in PPH prevention?

• Hemorrhage protocol

• Mass transfusion protocol

• Hemorrhage cart

• Who to call, how to get the blood

What does READINESS mean in PPH prevention?

• Get help and assign roles

• Second IV (16-18 gauge)

• STAT labs: CBC, coagulation studies, fibrinogen

• Announce VS and cumulative blood loss

• Transfusion, if necessary

What does RESPONSE mean in PPH prevention?

• Post hemorrhage huddle and debrief

• Incident/event report

• Conduct multidisciplinary review for all events

• Monitor outcomes of all hemorrhages to increase response an positive outcomes

What does REPORTING mean in PPH prevention?

Boggy

• If midline: massage fundus

• If not hemorrhaging and deviated: have pt. void

• Deviated, hemorrhage, or unable to void: straight cath

May need PPH med

What is the intervention for TONE?

Clots or retained placenta (boggy)

• If midline: massage fundus

• Retained placenta: manual evacuation/exploration (provider), possible D&C, AB

May need PPH med

What is the intervention for TISSUE?

Tricking

• Provider repair lacerations

What is the intervention for TRAUMA?

Uterine inversion

• Gentle replacfement of uterus (provider)

• Possible manual evacuation/exploration (provider)

• AB

• PPH med

What is the intervention for TRACTION?

FUNDUS

• Can be multiple causes and multiple interventions

  • Monitor blood loss and VS

  • May need blood transfusion, fluids, etc.

What should you ALWAYS check after PPH interventions?

Hemorrhage control device

What is the intervention if there’s still a hemorrhage after MEDS and INTERVENTIONS?

May need uterine artery EMBOLIZATION or HYSTERECTOMY

What is the intervention if there’s still a hemorrhage after hemorrhage control device and all other techniques don’t work?

• Superficial venous thrombosis

• Deep venous thrombosis (DVT)

• Pulmonary embolism (PE)

What are the thromboembolic conditions?

• Venous stasis

• Hypercoagulation

• Injury to blood vessel

• other…

What are the causes of thromboembolic conditions?

• Focus on prevention

• Promote adequate circulation

• Therapeutic management; dependent upon condition

• Education: s/s DVT and PE

What are the nursing interventions for thromboembolic conditions?

• Active and passive ROM

• SCD’s (C-sec)

• Early ambulation

• IS and deep breathing

• Increase fluids

• enoxaparin (Lovenox) if ordered

How do you promote adequate circulation for thromboemoblic conditions?

Dependent upon condition

• Analgesics

• Rest

• Warm packs

• Elevate extremity

• Anticoagulant therapy

• Oxygen

What are the therapeutic tx for thromboembolic conditions?

• Endometritis

• Mastitis

• Surgical site infection

• UTI

What are the PP infections?

• Hx of previous infection

• C-section

• Trauma

• PROM

• Prolonged labor

• Hemorrhage, retained placental fragments

• Hx diabetes

• Excessive number vaginal exams

• Catheterization

What are the RISK FACTORS for PP infection?

• An infection of GENITAL tract up to 42 DAYS PP

• FEVER 100.4 or higher

What is PP infection?

Endometritis

Infection of endometrium after delivery

ANTIBIOTICS

• Clindamycin

• Ampicillin

• Gentamicin

What is the tx for endometritis?

• FEVER 100.4 OR GREATER

• Chills, malaise

• Tachycardia

• Pain, backache

• Foul-smelling lochia

• Subinvolution

What are the s/s ENDOMETRITIS?

Mastitis

Infection of breast caused by STAPH AUREUS, usually in first 12 WEEKS after birth but can develop any time

• UNILATERAL

• Often preceded by ENGORGEMENT and STASIS

• Flu-like symptoms (chills, fever, malaise)

• Red/warm/very painful in one spot

What are the s/s MASTITIS?

• Continue REGULAR breastfeeding to empty breast (or pump)

• Warm compresses to breast

• ANTIBIOTICS

• Acetaminophen

What is the tx for mastitis?

Milk stasis; bacteria can grow in breast (can also be from infant’s mouth) and feels like a clogged duct

• Milk is safe for baby still

What is the RISK FACTOR for mastitis?

Yes, safe for breastfeeding

Can a woman still breast feed if taking antibiotics?

Early removal of catheter (CAUTI)

How to prevent UTI?

• Urinary catheterization

• Manipulation

• Trama

What are the RISK FACTORS for UTI?

• Dysuria

• Frequency

• Urgency

• Low grade fever

• Hematuria

What are the s/s UTI?

• AB

• Good hygiene

What is the tx for UTI?

• REEDA/COCA

• AB

• Possible I&D

• Good hygiene

• Aseptic wound management

• Ambulation

• Hydration

What is the tx for WOUND INFECTION (surgical inscision, episiotiomy, lacerations)?

• Administer appropriate AB and analgesics

• Provide emotional support

• Promote f/e balance

• Assess perineum, wounds, VS frequently (REEDA/COCA)

• Prevention by aseptic technique and hand hygiene

What are the nursing interventions for PP infections?

Preeclampsia

New onset HTN accompanied by proteinuria and/or maternal organ dysfunction targeting the cardiovascular, hepatic, renal, and CNS

• Maternal age

• Chronic HTN

• Non-hispanic, black

• Diabetes

• Increased BMI

• Family or personal hx

Can happen anytime even if no complications PP

What are the RISK FACTORS for preeclampsia?

CONTINUE MGSO4 24 HOURS AFTER

What happens if PP preeclampsia is diagnosed prior to delivery?

• BP >140/90

• Headache

• Vision changes

• Epigastric pain

• Proteinuria

• N/V

• Swelling of face, hands, extremities

• Decreased UOP

• SOB

• Risk for eclampsia (seizure)

What are the s/s preeclampsia?

Antihypertensives

• Labetalol

• Hydralazine

• Nifedipine

• Furosemide

What meds should be given for preeclampsia?

• CBC

• CMP

• PROTIEN/CR RATIO (≥ 0.3 mg/dL)

What labs are drawn for preeclampsia and PP preeclampsia?

BP ≥160/110 TWICE within 15 MINS of each other

What is HTN crisis in PP preeclampsia?

• Labetalol

• Hydralazine

• Nifedipine PO if no IV access

What is the tx for HTN crisis in PP preeclampsia?

• MGSO4 infusion for 24 HOURS

  • LOADING DOSE 4-6G followed by 1-2G/HR CONTINUOUS INFUSION

• Start PO ANTIHTN MEDS

• Assess and reassess EVERY HOUR

• Seizure precautions

• Monitor for Mg toxicity

• D/C edu and follow-up

What is the tx for PP preeclampsia?

Infuse for 24 hours

• Loading dose 4-6G followed by 1-2 G/HR continuous infusion

How much MGSO4 should be given for PP preeclampsia?

• RESPIRATORY DEPRESSION (lower than 12)

• LOSS OF DTRs (lower than 2+)

• N/V

• Headache

• Decreased UOP

• Hypotension

What are s/s Mg toxicity?

5-8 mg/dL

What should the normal Mg levels be?

Calcium gluconate

What is the reversal agent for Mg toxicity?

• Turn to side lying and stay with her

• Administer O2

• Raised bed rails with padding

• Document time and duration of seizure

• Contiue MGSO4

What are the seizure precautions?

Assessment EVERY HOUR

• VS

• Strict I/O

• DTR (3+, increased)

• Symptoms (HTN crisis, Mg toxicity, seizure)

• LOC

• Breath sounds

What are the assessments for PP preeclampsia?

1. PP blues

2. PP depression

3. PP psychosis

BPD

What are the PP affective DO?

Postpartum blues

“Baby blues”

• Very common (50-75% PP women)

• Estrogen and progesterone decline rapidly

Mild depressive sx

• Insomnia

• Irritability

• Tearfulness

• Mood instability, anxiety

• Fatigue

EMOTIONAL LABILITY and usually self-limiting

What are the s/s PP blues?

On PP DAY 3 and USUALLY RESOLVES BY DAY 10

When does PP blues start?

If persistant sx for 2 WEEKS OR MORE, contact physician

How long until PP blues becomes PP depression?

2 WEEKS OR MORE depressed mood or loss of interest in all activities accompanied by 4 of the following:

• Changes in appetite or weight, sleep, and psychomotor activity

• Decreased energy

• Feelings of worthlessness or guilt

• Difficulty thinking, concentrating, or making decisions

• Recurrent thoughts of death or plans or attempts of suicide

What are the s/s PP depression?

• CALL PROVIDER

• ANTIDEPRESSANTS

  • zuranolone

• Psychotherapy

• Marital counseling

• Screening tools: Edinburgh Postnatal Depression Scale

What is the tx for PP depression?

PP psychosis

Impaired ability to recognize reality, communicate, and relate to others

• EMERGENCY psychiatric condition

• Occurs in 1-2 out of 1000 births

• May occur anytime in the FIRST YEAR of PP

• Onset can be abrupt and unexpected

1st year of PP

• DELUSIONAL BELIEFS

• DISORGANIZED THINKING

• HALLUCINATIONS

• DISORIENTATION

• RAPIDLY SHIFTING MOODS

• Escalates to thoughts of suicide or infanticide

What are the s/s PP psychosis?

• IMMEDIATE HOSPITALIZATION

• Psychotropic meds

• Psychotherapy/group therapy

What is the tx for PP psychosis?

• Poor coping skills

• First pregnancy

• Low self esteem

• Numerous life stressors

• Hx of abuse

• Previous psychological problems

• Substance abuse

• Limited social support network

What are the RISK FACTORS for PP affective DO?

• Activity level

• Sleeping habits

• Fatigue

• Anxious behaviors

• Poor personal hygiene

• More than expected weight loss

• Not responding to infant cues

What are the assessments/OBSERVATIONS for PP affective DO?

• Panic DO

• PP OCD

• PTSD

What are the PP anxiety DO?

• Tachycardia

• Palpitations

• SOB

• CP

• Fear of going crazy

What are the s/s PP panic DO?