nursing management of the postpartum patient at risk

what is primary postpartum hemorrhage?

within first 24 hours after delivery

what is secondary postpartum hemorrhage?

between 24 hrs-12 weeks postpartum

what are the challenges in quantifying blood loss?

pooling of blood in the uterus, pooling of blood on the floor, large hematomas of the labia/vulva/vagina

what are the causes of postpartum hemorrhage?

uterine atony, genital tract lacerations, hematomas, episiotomy, retained placental fragments, uterine inversion, coagulopathies

what are the 4 T’s of PPH?

tone: uterine atony

tissue: retain placenta, clots

trauma: injury to any structure in reproductive tract

thrombin: coagulopathy, preexisting or acquired

traction: pull too hard on cord during birth; leading to cord detachment or uterine inversion

what is subinvolution?

incomplete involution of uterus after birth; uncorrected may lead to hemorrhage

what are some causes of subinvolution?

retained placental fragments; overdistended uterus; distended bladder; uterine leiomyoma (fibroid); infection

what are some possible complications of subinvolution?

hemorrhage, pelvic peritonitis, infection of fallopian tubes, abscess formation

how to assess uterine tone?

take thorough hx, overdistension?, mag sulfate?, precipituous delivery?, hx of hemorrhage?, distended bladder?, last void/time of catheter d/c?, retained tissue fragments?, retained clots?

what is the therapeutic management of postpartum hemorrhage?

consider underlying cause/risk factors, quantify blood loss, fundal massage, administration of uterotonics/anti-hemorrhage medication, IV fluid administration, removal of clots/tissue/fragments/retained placenta; tamponade measures, administer abx PRN, repair lacerations, treat hematomas, monitor for DIC/shock

what are some nursing interventions for postpartum hemorrhage?

do not abandon uterine massage, call provider/additional supoprt/emergency team, delegate tasks, weigh everything that is blood soaked, administer meds as ordered/avoid antiplatelet medications, pain management; may need 2nd IV site for transfusion; monitor cap refill, urine output and LOC; foley catheter insertion to keep bladder empty; assist provider w/procedures; order blood products/active massive transufsion protocol PRN

what is the order of medication administration during postpartum?

fundal massage → IV pitocin drip → methergine 0.2mg (HTN contradiction) → hemabate 0.25mg IM (asthma contradiction) → misoprostol 800mg PO or rectal → tranexamic acid/TXA 1g IV

what are the signs of hypovolemic shock?

decreased BP, increased HR, decrease in urine output; these don’t manifest until pt ahs 1800-2000mL blood loss

what is DIC?

disseminating intravascular coagulation; activation of the clotting cascade, fibrin clot formation, fibrinogen and platelet depletion; thromboplastin release or vascular damage are precipitating events

what are symptoms of DIC?

spontaneous bleeding from gums, nosebleeds, petechiae, bruising with injections, oozing from venipuncture sites, tachycardia, diaphoresis, hematuria

what are the labs associated with DIC?

low platelets, low fibrinogen, prolonged PT, PTT

what is the nursing care for DIC?

correction of underlying cause, volume replacement, blood/blood product replacement (fibrinogen), observe for bleeding and complication of blood products, foley, before birth position Mom on side lying and administer O2 and EFM

T/F postpartum hemorrhage is most commonly due to uterine atony.

true; uterine atony is the most common cause of PPH

thrombophlebitis

inflammation of blood vessel lining

thrombosis

blood clot within a blood vessel

thromboembolism

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

superficial thrombosis

type of thromboemboli; usually confined to the saphenous veins in lower leg

deep vein thrombosis

type of thromboemboli; may originate in any part of LE or pelvis; can lead to pulmonary embolism

what is the pathophysiology of thromboembolic conditions?

venous stasis; endothelial damage; hypercoagulation of pregnancy/activation of coagulation system

what are the predisposing factors of DVT?

venous stasis, hypercoagulation, c/s, operative vaginal births, hx of venous thrombosis, obesity, ama, genetic factors

signs and symptoms of pulmonary embolism

dyspnea, tachypnea, tachycardia, apprehension, cough, decreased O2 sat, cough, hemoptysis, elevated temp

what are the signs and symptoms of venous thrombosis/phlebitis?

pain, tenderness, warmth, redness, streaking

what is the treatment of DVT?

IV anticoagulants, bed rest, analgesia (not aspirin)

what is the treatment of SVT?

superficial vein thrombosis; NSAIDs, rest and elevation of extremity, heat, stocking

what is the nursing assessment and management of thromboembolic conditions?

oxygen delivery, apply compression stocking, apply SCDs, administer Lovenox, increase fluid intake, IV heparin, NSAIDs for pain with SVT; monitor for calf pain, LE edema, sudden onset of SOB with decreased O2 sats, chest pain; educate, ERAC

which drug would the nurse expect to administer to a postpartum patient with deep vein thrombosis?

heparin; given to reduce the risk of clot formation

what are the signs and symptoms of postpartum infections?

fever > 38C or 100.4F after first 24 hrs, organisms usually those of normal vaginal flora, foul smelling vaginal discharge, uterine tenderness, subinvolution, malaise/headache/chills

what are risk factors of postpartum infections?

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

what is the nursing management to avoid postpartum infections?

good hand hygiene, limit vaginal exams in labor, perineal hygiene, aseptic/sterile technique for specific procedures, remove IVs/catheters ASAP

what is the patient education for postpartum infections?

hand hygiene, peri bottle use, frequency of pad changes, discharge education on identifying/for infection

what is mastitis?

inflammation of the breast; flu-like symptoms of redness, tenderness in the affected breast; swollen axillary glands; caused by staphylococcus aureus

nursing care for mastitis

maintain nipple skin integrity, assess infant position at breast, comfort measures, continue breastfeeding or pumping of breast milk, abx

describe baby blues.

emotional lability is the most prominent sx, onset day 2-3 PP, usually resolves by 2 weeks PP, does not affect ability to function/parent normally, self-limiting/formal treatment not necessary, feel better over time,

signs of postpartum depression

causes multifactorial; dramatic hormonal shift, hx of depression, volatile emotions, fatigue, stressful life events, unresolved feelings, change in body image, inadequate support/relationship problems, hx of trauma, loss of freedom/change in identity

signs of postpartum psychosis

depression + delusion beliefs, hallucinations, disordered thinking, hypomania, intrusive thoughts of harming self, infant

T/F postpartum psychosis is the most severe form of postpartum affective disorder

true