[Exam 3 OB Study Guide 2/2] STUDY GUIDE CONTENT

Nursing Simulation Scenario: Postpartum Hemorrhage

https://www.youtube.com/watch?v=MxKiGP17C24&t

Nursing Simulation Scenario: Postpartum Hemorrhage

AWHONN Postpartum Hemorrhage (PPH) Project

https://www.youtube.com/watch?v=jjy2Uevf7MM&t

AWHONN Postpartum Hemorrhage (PPH) Project

JADA® System hands-on demo video

https://www.youtube.com/watch?v=2PBDcMK-YRI

JADA® System hands-on demo video

Cook Medical - Bakri Balloon Postpartum

https://www.youtube.com/watch?v=wAnMPMwXbcg

Cook Medical - Bakri Balloon Postpartum

AMC Int'l News - Pelvic Arterial Embolization (PAE) is effective for postpartum hemorrhaging

https://www.youtube.com/watch?v=A3C8cMaNEU8

Asan Medical Center

Quantification of Blood Loss

https://www.youtube.com/watch?v=F_ac-aCbEn0

Quantification of Blood Loss

A nurse is planning care for a client who is postpartum and has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care?

a

​​​​​​​​​​​​​Apply cold compresses to the affected extremity.

b

​​​​​​​​​​​​Massage the affected extremity.

c

​​​​​​​​​​​Allow the client to ambulate.

d

​​​​​​​​​​​​Measure leg circumferences.

​​​​​​​d Measure leg circumferences.

---

Additionally, the nurse should encourage the client to rest with the affected extremity elevated.

Also, do not massage the affected extremity. This action can result in dislodgement of the clot.

Key Nursing Tips (PPH)

• Frequent Monitoring: Check uterine tone, lochia, and vital signs every 15 minutes.

• Rapid Intervention: Start fundal massage and administer uterine stimulants promptly if hemorrhage is suspected.

• Patient Support and Education: Provide emotional support and teach patients to recognize and report warning signs.

Key Nursing Tips (Subinvolution of the Uterus)

• Fundal Checks: Monitor height, firmness, and position of the uterus.

• Lochia Assessment: Observe for quantity, color, consistency, and odor.

• Antibiotic Therapy: Administer as ordered if infection is suspected.

• Patient Education: Instruct on warning signs of infection (fever, foul-smelling discharge) and when to seek medical attention.

• Frequent Monitoring: Check fundus and lochia every 15 minutes initially, then every hour.

• Patient Education:

  • Encourage breastfeeding and early ambulation.

  • Instruct on warning signs of infection (fever, foul-smelling discharge) and when to seek medical help.

• Safety Precaution:

  • Always check blood pressure before administering Methylergonovine.

Key Nursing Tips (Inversion of the Uterus)

Do NOT remove the placenta if still attached—this can worsen the inversion and bleeding.

Initiate IV Fluids and Oxygen to stabilize blood pressure and oxygenation.

Prepare for Surgery: Anticipate surgical intervention if manual replacement is unsuccessful.

Key Nursing Tips (Lacerations and Hematomas)

Frequent Monitoring:

• Check perineal area for swelling, discoloration, and pain.

• Assess for pain unrelieved by standard analgesics (may indicate hematoma).

Vital Sign Monitoring:

• Look for signs of hypovolemic shock (tachycardia, hypotension).

Pain Management:

• Ice packs for lacerations in the first 24 hours.

• Sitz baths for pain relief and healing.

Patient Education:

• Hygiene Measures to prevent infection.

• Warning Signs to Report:

  • Increased pain, foul-smelling discharge, or heavy bleeding.

A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following antepartum complications should the nurse understand is a risk factor for this condition?

a

Preeclampsia

b

Thrombophlebitis

c

Placenta previa

d

Hyperemesis gravidarum

a Preeclampsia

A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as an early indicator of hypovolemia caused by hemorrhage?

a

Increasing pulse and decreasing blood pressure

b

Dizziness and increasing respiratory rate

c

Cool, clammy skin, and pale mucous membranes

d

Altered mental status and level of consciousness

a Increasing pulse and decreasing blood pressure

---

Altered mental status and changes in level of consciousness are late manifestations of decreased blood volume, which leads to hypoxia and low oxygen saturation.

A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching?

Select all that apply.

a

Prolonged labor

b

Obesity

c

Inversion of the uterus

d

Oligohydramnios

e

Retained placental fragments

a Prolonged labor

c Inversion of the uterus

e Retained placental fragments

A nurse is reviewing risk factors for the following disorders.

Drag each risk factor on the left to the correct category on the right.

Deep Vein Thrombosis

Inversion of uterus

Postpartum Hemorrhage

---

Cesarean birth

Immobility

Short umbilical cord

Obesity

High Parity

Lacerations and hematomas

Deep Vein Thrombosis

• Cesarean birth

• Immobility

• Obesity

Inversion of uterus

• Short umbilical cord

Postpartum Hemorrhage

• High Parity

• Lacerations and hematomas

A nurse is reviewing discharge teaching with a client who has a urinary tract infection. Which of the following statements by the client indicates understanding of the teaching?

(Select all that apply.)

a

“I will perform perineal care and apply a perineal pad in a back-to-front direction.”

b

“I will drink grape juice to make my urine more acidic.”

c

“I will drink large amounts of fluids to flush the bacteria from my urinary tract.”

d

“I will go back to breastfeeding after I have finished taking the antibiotic.”

e

“I will take Tylenol for any discomfort.”

c “I will drink large amounts of fluids to flush the bacteria from my urinary tract.”

e “I will take Tylenol for any discomfort.”

---

Breastfeeding does not have to be delayed until the course of antibiotics is completed

Grape juice does not make urine acidic.

A nurse on the postpartum unit is caring for four clients. Which of the following clients should the nurse recognize as the greatest risk for development of a postpartum infection?

a

A client who experienced a precipitous labor less than 3 hr in duration

b

A client who had premature rupture of membranes and prolonged labor

c

A client who delivered a large for gestational age infant

d

A client who had a boggy uterus that was not well-contracted

b A client who had premature rupture of membranes and prolonged labor
Premature rupture of membranes with prolonged labor poses the greatest risk for developing a postpartum infection because the birth canal was open, allowing pathogens to enter. Therefore, the nurse should recognize this client as the greatest risk for the development of a postpartum infection.

A nurse is discussing risks factors for urinary tract infections and endometritis for clients with a newly licensed nurse. Which of the following conditions should the nurse include in the teaching? ​​​​​​​

(Sort the following options into risk factors based on the following conditions).

Urinary Tract Infection

Endometritis

---

History of UTIs

Premature rupture of membranes

Prolonged labor

Intrauterine infection

Epidural

Urinary Tract Infection

• History of UTIs

• Epidural

Endometritis

• Prolonged labor

• Premature rupture of membranes

• Intrauterine infection

You are caring for a postpartum patient who calls you to her room telling you she has soaked her peri pad. She changed her pad 20 minutes ago and now it is completely soaked thru and leaking onto her CHUX pad underneath. She complains of feeling light headed and dizzy. What is you greatest concern at this time?

Post partum hemorrhage

Full bladder

A hematoma

Mastitis

What will be your first assessment/action for the above patient?

Increase the Oxytocin that is running in her left arm at 125cc/hr.

Assess the fundus for uterine atony and massage if boggy.

Draw blood for an Hemoglobin and Hematocrit.

Assess the color of the lochia.

Post partum hemorrhage

Assess the fundus for uterine atony and massage if boggy.

The nurse assesses a 2 hour postpartum patient. The fundus is firm at the level of the umbilicus. The nurse observes a steady trickle of bright red blood. What action should the nurse take?

Assess the respirations of the patient

Place pressure on the perineum with sterile gauze

Call the provider and report a possible laceration with bleeding

Call the provider and report uterine atony with s/s of post partum hemorrhage

Call the provider and report a possible laceration with bleeding

Which of the following patients would be at risk for uterine atony? (Select all that apply)

A client who delivered a 9lb 10oz baby girl.

A client who delivered full term twins.

A client who is Rh negative

A client who had a 4th degree laceration.

A client who delivered her first baby vaginally.

A client who delivered a 9lb 10oz baby girl.

A client who delivered full term twins.

---

A 4th-degree laceration involves a severe tear extending to the rectum, but it does not directly cause uterine atony.

First-time vaginal deliveries (primiparas) are not at high risk unless there were other complications like prolonged labor or uterine overdistension.

The day nurse is assigned to care for a patient delivered by emergency C/Section three days ago. She is a G2T2P0A0L2. Her history includes ROM for 36 hours prior to delivery, and a positive GBS with no antibiotics given. Her 0800 vital signs are 101.6 F, 99, 16, 120/74. The chart records a midnight temperature of 97.9 F and 0400 temperature of 101.6 F. What symptoms might the nurse expect to find? (Select all that apply)

Decreased platelet count

Tachycardia

Incision clean and intact, no REEDA

Uterus at U/+2, that is painful to palpation

Foul smelling lochia.

Your assessment of the above patient indicates pain 7/10 on palpation of the uterus and foul smelling lochia. What is your recommendation when you call the doctor to provide an ISBARR on this patient?

She should be taught to breast feed more frequently.

She should be given antibiotics for possible mastitis.

She should be given antibiotics for possible endometritis.

She needs to stay in the hospital for an additional 24 hours to be observed for possible infection.

Tachycardia

• Infection causes systemic response, leading to increased heart rate.

Uterus at U/+2, that is painful to palpation

• A boggy, tender uterus above expected level suggests infection and subinvolution.

• The uterus should normally descend 1 cm/day postpartum.

Foul-smelling lochia

She should be given antibiotics for possible endometritis.

---

Platelet levels are not typically affected by endometritis unless there is disseminated intravascular coagulation (DIC), which is rare in this scenario.

The Cesarean incision is not necessarily affected by endometritis.

If wound infection were present, you would expect REEDA (Redness, Edema, Ecchymosis, Drainage, Approximation).

A client who came to the clinic complaining of shooting pains and itching in both her nipples has been given a prescription for herself and her baby. She asks if it is still okay to breast feed. The best response from the nurse would be which of the following?

"Absolutely, in fact you should breast feed more frequently to prevent ducts from becoming clogged."

"You can unless it is too painful for you."

"You cannot breast feed and it is best to allow your nipples to rest while healing."

"You cannot breast feed until both you and the baby are no longer infected. You need to pump at the same intervals you would breast feed but dump the milk and give the baby formula until you can breast feed again."

"You cannot breast feed until both you and the baby are no longer infected. You need to pump at the same intervals you would breast feed but dump the milk and give the baby formula until you can breast feed again."

A husband calls the post partum clinic. He tells the nurse that his wife is refusing to feed their 3 day old daughter because she is convinced the baby has a demon inside. The wife became angry when he suggested he feed the baby formula and told him she didn't want the demon to grow. What is the best response at this time?

"It is not uncommon for women to have postpartum blues after having a baby, if this continues more than two weeks be sure to contact the doctor."

"Your description of your wife's behavior indicates she might be experiencing psychosis. She needs to be seen immediately. Do not leave her alone with the baby."

"Tell your wife the baby does not have a demon inside her. Leave her alone with the baby and go buy formula."

"Make an appointment with your medical provider so she can be seen in the next 48 hours."

"Your description of your wife's behavior indicates she might be experiencing psychosis. She needs to be seen immediately. Do not leave her alone with the baby."

A risk factor for DIC

Placental abruption

A cause of postpartum hemorrhage

Atony

Medication given for PPH, can cause maternal fever, diarrhea in breastfeeding infants

Cytotec / Misoprostol

A type of infection

s/s: Vaginal discharge – scant or profuse, foul. Starts 2nd to 5th pp day, Uterine tenderness Flu-like symptoms with chills and fever spikes, Anorexia

Endometritis

This type of massage is the first intervention for PPH

Fundus

A vital sign change that is considered a late sign in a postpartum hemorrhage

Hypotension

Cause of PPH, where fundus is firm but continues to have constant bright red bleeding

Laceration

S/S of this type of infection include Rapid onset of fever > 101, flu-like s/s like muscle pain, fatigue, chills, Warm, red, painful area on breasts. Usually occurs 2-8 weeks pp

Mastitis

Medication given for PPH, contraindicated in hypertensive patients

Methergine

Greatest cause of uterine atony

Overdistension

Medication given for PPH, contraindicated in Asthma patients

Hemabate (Carboprost)

Infection caused by yeast

S/S shooting nipple pain, itching, burning, Redness, Won't have flu s/s.

TX: antifungal medicine – may have to pump and discard milk

Nipple infection

More than how many pads an hour is considered excessive bleeding

One

First medication to be administered for PPH

Pitocin

Diagnosis when patient has a break from reality

Psychosis

When the uterus is not contracting down to return to its normal size after delivery

Subinvolution

A vital sign change that occurs first in a postpartum hemorrhage

Tachycardia

The purpose of the Bakri balloon provides this type of intervention to decrease PPH

Tamponade (mechanical)

What must the baby be assessed for if the mother has a nipple infection?

Thrush

Postpartum depression is considered after how many weeks postpartum if a patient is still experiencing depression, tearful, feelings of being overwhelmed, sadness?

Two weeks

Ibuprofen (Motrin)

Contraindication

• Preeclampsia and HELLP syndrome (increased bleeding risk).

• Pregnancy (risk of pulmonary HTN in baby)

Safe postpartum

Docusate (Colace)

Commonly given postpartum for constipation.

Bisacodyl (Dulcolax)

Contraindicated if the patient has a 4th-degree perineal tear (alters suture integrity).

Oxytocin (Pitocin)

Used for:

• Uterine atony

• Postpartum hemorrhage

• Labor induction

Monitor: Can cause water intoxication and must be adjusted based on fetal tolerance.

Misoprostol (Cytotec)

Used for:

• Postpartum hemorrhage

• Cervical ripening

Routes:

• Oral or vaginal (for cervical ripening).

• Rectal (for postpartum hemorrhage to prevent loss through vaginal bleeding).

Side Effects: Fever, severe diarrhea in nursing infants.

Methylergonovine (Methergine)

Used for: Uterine atony and hemorrhage.

Contraindications

• Smokers

• Hypertension

Carboprost Tromethamine (Hemabate)

Last resort medication for hemorrhage.

Side Effects: Severe abdominal cramping, nausea, vomiting, diarrhea.

• NOT fever

Caution

• Asthma (causes bronchospasms)

Tranexamic Acid (Lysteda)

Used for postpartum hemorrhage.

Contraindications

• Bood clot history

• Color blindness.

Depo-Provera (Medroxyprogesterone)

Postpartum birth control

• SLIGHT & REVERSIBLE decrease milk supply in SOME

Avoid w/

• Estrogen-containing birth control while breastfeeding.

  • Reduces milk supply dramatically

Progestin

Mimics the effects of progesterone, a hormone that plays a crucial role in the menstrual cycle, pregnancy, and birth control. Its main functions include:

• Thickening cervical mucus → Makes it harder for sperm to reach the egg.

• Thinning the uterine lining → Makes it less suitable for a fertilized egg to implant.

• Suppressing ovulation (in some cases) → Prevents the release of an egg.

How Does Progesterone Work in Birth Control?

Synthetic progesterone (progestin) actually tricks the body into thinking it’s already pregnant:

1. Stopping ovulation 🚫 → No egg = No fertilization.

2. Thickening cervical mucus 🛑 → Blocks sperm from reaching the egg.

3. Thinning the uterine lining 🏠❌ → If an egg does get fertilized, it can’t implant properly.

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Progesterone’s Natural Role in Pregnancy 🤰

Progesterone is a natural hormone produced by the ovaries and later by the placenta during pregnancy. It helps by:

✔ Thickening the uterine lining 🏠 → Makes it ready for a fertilized egg to implant.
✔ Preventing uterine contractions ⛔ → Keeps the uterus calm so it doesn’t push out the embryo.
✔ Suppressing ovulation during pregnancy 🚫 → Stops the release of more eggs while a baby is developing.

So in a natural pregnancy, progesterone is essential to maintain the pregnancy and prevent early miscarriage.

RhoGAM

First dose at 28 weeks (protects for 12 weeks).

Second dose within 72 hours postpartum (prevents erythroblastosis fetalis).

Also given after

• Ectopic pregnancy, miscarriage, trauma, or bleeding events.

Hepatitis B Vaccine

Requires parental consent

Newborn Medications

Hepatitis B Vaccine

• Given in the right leg.

• Requires parental consent.

Vitamin K (Phytonadione)

• Prevents hemorrhagic disease in the newborn.

• Given in the left leg within 1 hour of birth.

Erythromycin Ophthalmic Ointment

• Prevents ophthalmia neonatorum (blindness from gonorrhea or chlamydia).

• Given within 1 hour of birth.

Postpartum Hemorrhage (PPH)

Vaginal delivery: Blood loss ≥500 mL.

C-section: Blood loss ≥1000 mL.

A hematocrit drop of 10 points  (e.g., from 35% to 25%)

• Always compare pre-birth vs. post-birth hematocrit.

Blood Loss Measurement

Visual estimation is subjective!

Best method: Weigh pads/sponges.

• 1 gram = 1 mL blood loss.

Instruct patient to report:

• Large clots.

• Bleeding greater than one pad per hour.

Normal pad use:

• No more than 1 pad per hour.

Postpartum Hemorrhage (PPH) S/S

Excessive bright red bleeding (constant oozing)

Boggy fundus (uterine atony).

Large clots (>golf ball size).

• Pads saturated within 15 mins to 1 hr

Tachycardia (early sign)

Hypotension and dizziness (late signs)

Fundal height rising unexpectedly (indicates internal bleeding).

Decreased H/H

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Massage the fundus FIRST

Elevate legs (20-30 degrees) (not Trendelenburg).

Initiate pad count.

Administer "Please Make Hemorrhage Cease Today" medications.

• Oxytocin (Pitocin) – First-line treatment.

• Methylergonovine (Methergine) – Avoid in hypertension.

• Carboprost tromethamine (Hemabate) – Causes GI upset, nausea, vomiting, diarrhea.

• Misoprostol (Cytotec) – Given rectally, may cause maternal fever/diarrhea, HTN safe

• Tranexamic Acid (TXA) – IV medication, contraindicated in history of blood clots or colorblindness.

Monitor vital signs and urine output (shock signs).

Weigh blood loss (1g = 1mL of blood).

Mechanical interventions:

• Bimanual compression

• Bakri Balloon (uterine tamponade)

• Dilation & Curettage (D&C).

• Surgical repair or hysterectomy (last resort)

Tone (Uterine Atony - 4 Ts) Interventions

Massage the fundus FIRST

Administer "Please Make Hemorrhage Cease Today" medications.

• Oxytocin (Pitocin) – First-line treatment.

• Methylergonovine (Methergine) – Avoid in hypertension.

• Carboprost tromethamine (Hemabate) – Causes GI upset, nausea, vomiting, diarrhea.

• Misoprostol (Cytotec) – Given rectally, may cause maternal fever/diarrhea, HTN safe

• Tranexamic Acid (TXA) – IV medication, contraindicated in history of blood clots or colorblindness.

Monitor vital signs and urine output (shock signs).

Weigh blood loss (1g = 1mL of blood).

Mechanical interventions:

• Bakri Balloon (uterine tamponade)

• Dilation & Curettage (D&C).

• Surgical repair

• Hysterectomy (last resort)

Tissue (Retained Placenta - 4 Ts) Interventions

Manual removal or D&C

Oxytocics post-removal

Trauma (Lacerations or Hematomas - 4 Ts) Interventions

Initial Interventions:

• Ice packs → First hour postpartum and off and on for 24 hours to reduce swelling.

• Frequent assessments → Monitor for increasing size or firmness.

• Analgesia

Advanced Interventions:

• Possible Penrose drain → To evacuate accumulated blood.

• Surgical evacuation if it enlarges or if signs of shock appear.

• Sitz baths → After 24 hours to promote comfort and healing.

Trauma (Lacerations - 4 Ts) Interventions

Immediate Interventions:

• Identify source of bleeding → Check perineum, vagina, and cervix.

• Notify healthcare provider → For evaluation and repair.

Repair and Treatment:

• Suturing by provider.

• Ice packs for 24 hours to reduce swelling.

• Sitz baths after 24 hours for comfort.

• Analgesics and stool softeners

Thrombin (Coagulopathy - 4 Ts) Interventions

Blood and component therapy (platelets, FFP, cryoprecipitate)

Treat underlying cause​

Hematoma (Localized mass of blood in tissues) S/S & Management

Pain/pressure (fullness) - Main sign

• NOT bleeding

Bluish discoloration.

Shiny, hard, swollen, or bulging mass.

Rectal pain or pressure.

Unrelenting pain.

Difficulty voiding.

---

Notify provider → Surgical repair if needed.

Assess for hemodynamic instability.

All Infections S/S & Management

Temp > 101°F (first 24 hrs)

Temp > 100.4°F (after 24 hrs)

Tachycardia

Chills

---

Antibiotics

Fluids

Good Hygiene

Handwashing

Front-to-Back Wiping

Sitz Baths

Estimating Blood Loss (EBL)

Subjective and often underestimated.

Best method = Weigh pads/sponges (1 gm = 1 ml blood loss).

Patient Education:

• Report large or multiple clots.

Report bleeding > 1 pad/hr.

Endometritis (Uterine Infection) S/S & Management

Fever > 38°C (100.4°F) within the first 24 hours postpartum.
Uterine tenderness → Pain on fundal checks.
Foul-smelling vaginal discharge

• REPORT TO PROVIDER

Flu-like symptoms → Chills, fever spikes, anorexia.

Tachycardia
Temperature spikes – Fluctuate from high to normal and back to high.

---

Good handwashing and hygiene practices.

Wiping front to back to prevent bacterial spread.

Changing perineal pads frequently.

Vitamin C and protein intake → To boost immune system and wound healing.

Antibiotics: Clindamycin

Sitz baths and peri bottles for comfort and hygiene.

Incision/Wound Infection (Episiotomy/C-Section/Lacerations) S/S & Management

Redness, warmth, edema, and pain at the site.

Purulent drainage with foul odor.

Temperature > 38°C (100.4°F)

• 2 or more days.

Poor wound approximation – Gapping at the incision line.

---

Antibiotics → Based on culture and sensitivity.
Analgesics for pain management.
Possible drainage or packing if abscess is present.
Frequent dressing changes with sterile technique.
Education on hygiene and signs of infection.

Mastitis (Bacterial: Milk stasis, clogged ducts, cracked nipples) S/S & Management

Rapid onset of fever (> 38.3°C or 101°F).
Flu-like symptoms → Muscle pain, fatigue, chills.
Unilateral breast pain, redness, warmth, and swelling.

Hard, tender mass in the affected breast.

Usually occurs 2-8 weeks postpartum.

---

Continue breastfeeding or pumping → To maintain milk flow.

Antibiotics: Dicloxacillin or Cephalexin.

Warm compresses and analgesics for pain relief.

Education on proper latch technique.

Breast hygiene and frequent pad changes to prevent bacterial growth.

Nipple Yeast Infection (Candidiasis) S/S & Management

Red, peeling skin, baby has oral thrush.

---

Antifungal medication

Mother must pump and discard milk.

Urinary Tract Infection (UTI) S/S & Management

Frequency, urgency, burning on urination.

Cloudy & foul odor

Suprapubic pain or flank pain (if infection ascends to kidneys).

Proteinuria, bacteriuria, WBCs, and nitrates in urine.

Fever and chills if pyelonephritis develops.

---

Diagnosis: Urinalysis

• Elevated WBC

• Positive Nitrites/NO2 (indicates kidney infection)

  • Formed when bacteria reduce urinary nitrates (NO3)

Antibiotics (e.g., -floxacin), hydration, cranberry juice (Vitamin C)

No spicy or sugary foods

Empty bladder every 2 hours

Postpartum Blues

Common (affects ~80% of mothers).

Onset: 2-3 days postpartum

• Resolves within 2 weeks.

Symptoms: Mood swings, crying, anxiety.

Postpartum Depression

Onset: 4 weeks up to 1 year postpartum

• Symptoms last beyond 2 weeks.

Signs: Withdrawal, lack of interest in baby, severe fatigue.

May require medication (SSRIs) and therapy.

Lesser Known Risk Factor

• Rapid decrease in progesterone and estrogen levels

Postpartum Psychosis

Onset: Within 2-3 weeks postpartum.

Severe condition requiring hospitalization.

Symptoms: Hallucinations, paranoia, disconnection from reality.

High risk for harm to self or baby (requires 24/7 supervision).

• CPS referral if no other family member is available for infant care.

DIC (Disseminated Intravascular Coagulation)

Clotting disorder where clotting and bleeding occur simultaneously.

• Causes:
  ✔ Abruption, amniotic fluid embolism, hemorrhage, missed abortions, molar pregnancy.
  ✔ Severe preeclampsia, eclampsia, HELLP syndrome.

Labs:

• ↓ Platelets, ↓ Fibrinogen.

• ↑ PT and PTT, ↑ Fibrin split products, ↑ D-Dimer

DIC (Disseminated Intravascular Coagulation) S/S & Management

Oozing from IV sites, gums, nose, and other puncture sites.

Hematuria, hemoptysis, and gastrointestinal bleeding.
Petechiae, ecchymosis, and purpura.
Hypotension, tachycardia, decreased urine output.
Organ ischemia and failure (renal, hepatic).

---

Early recognition and rapid intervention

• Draw coagulation tests, fibrinogen, platelet count

• Medical emergency.

Replace blood products, volume expanders & O2

• Packed RBCs, Fresh Frozen Plasma (FFP), Platelets.

Administer Cryoprecipitate

• Replaces fibrinogen.

Oxygen therapy and fluid resuscitation.

Treat underlying cause

• e.g., delivery in cases of abruption or preeclampsia.

Strict intake and output monitoring

• Foley catheter to assess renal perfusion.

Assess for signs of organ failure and prevent injury from bleeding.

Idiopathic Thrombocytopenia (ITP)

Autoimmune platelet destruction.

Occurs during pregnancy or postpartum.

Idiopathic Thrombocytopenia (ITP) S/S & Management

Petechiae, ecchymosis, and purpura.
Excessive bleeding from gums, nose, and injection sites.
Menorrhagia (heavy menstrual bleeding)
Low Platelet Count → Severe thrombocytopenia.

---

Corticosteroids → Prednisone or Dexamethasone to suppress the immune response.

IV Immunoglobulin (IVIG) → Raises platelet count.

Platelet transfusion → Only in life-threatening bleeding.

Splenectomy → If medical management fails.

No epidural or spinal anesthesia → High risk of hematoma.

Vitamin C and D supplementation → To support immune and platelet function.

Frequent monitoring of platelet counts and avoidance of NSAIDs or aspirin.

Causes of PPH

Uterine Atony

• Failure to contract properly.

• Excessive uterine massage.

Retained Placenta

Overdistended Uterus

• Twins, polyhydramnios.

• Distended bladder (displaces uterus).

High Parity (multiple previous pregnancies).

Prolonged or Precipitous Labor

• Oxytocin-induced or augmented labor.

Pregnancy Complications

• Placenta previa, placental abruption.

Tocolytics (labor-stopping meds)

Operative Procedures (C-section, forceps, vacuum).

Unrepaired lacerations.

Bleeding disorders:

• DIC (Disseminated Intravascular Coagulation).

• Idiopathic Thrombocytopenia (ITP).

Medications:

• Magnesium sulfate (MgSO4).

• Regular tocolytic use.

Uterine Inversion (turning inside out).

Legal Requirements for Adoption

Parental rights must be terminated before adoption is finalized.

Birth mother must consent to adoption after delivery

• No coercion allowed.

Adoptive parents undergo home studies, background checks, and interviews.

Requirements must be met if adoptive parents are from another state.

• ICPC (Interstate Compact on the Placement of Children)

Safe Surrender Law: Within how many days can parents legally surrender a newborn? Within how many days can they reclaim custody?

Parents can legally surrender a newborn within 3 days of birth.

No questions asked.

14 days to reclaim custody if desired.

• Requires ID Bracelet

If the birth mother changes her mind and adoptive parents are out of state, what happens?

The baby becomes a border baby → Social services arrange temporary foster care.

Traditional Surrogacy

Surrogate's egg and sperm from intended father or donor

• Surrogate is genetically related to the child.

Gestational Surrogacy

Embryo created using the intended parents' or donors' egg and sperm

• Surrogate not genetically related to the child.

Agency Adoption

Can be public or private

Licensed in the state

Can facilitate international adoptions

Independent Adoption

Private only

Usually requires a lawyer.

Faster but less regulation/certainty

Foster Care to Adoption (Child is first placed in foster care with intent to adopt.)

Occurs if reunification with birth parents is not possible.
Often involves children with special needs or older children

Closed vs Open Adoption

No contact between birth parents and adoptive family.

Records are sealed

• The child may seek information upon reaching adulthood.

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Birth parents receive updates and may have visits.

Surrogacy

The gestational carrier is not listed on the birth certificate (only biological parents).

• Requires specific legal documentation to transfer parental rights.

Should be screened before discharge

Postpartum mood disorders

• Edinburgh Postnatal Depression Scale (EPDS)

  • 10 or higher may indicate possible depression. 

Leading cause of maternal death (and its most common cause/treatments)

PPH
Uterine atony is the most common cause of PPH; massage and medications are first-line treatments.

Primary vs Late PPH

Occurs within 24 hours of delivery.
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Occurs 24 hours to 12 weeks postpartum.

Causes of Postpartum Hemorrhage (4 Ts)

Tone (Uterine Atony) – Most common cause.

• Failure of the uterus to contract after childbirth.

• Risk Factors: Overdistension of uterus (macrosomia, twins, polyhydramnios), multiparity, prolonged labor, rapid labor, oxytocin use, anesthesia.

Tissue (Retained Placenta)

• Placental fragments prevent uterine contraction.

• Risk Factors: Placenta accreta, previa, previous uterine surgery.

Trauma (Lacerations, Hematomas)

• Injuries to genital tract.

• Risk Factors: Operative vaginal delivery (forceps, vacuum), episiotomy, macrosomia, precipitous delivery.

Thrombin (Coagulopathy)

• Blood clotting disorders.

• Risk Factors: HELLP syndrome, DIC, anticoagulant therapy, sepsis.

A nurse is caring for a post-partum client who delivered her third infant 2 days ago. The nurse recognizes that which of the following findings are suggestive of\post-partum depression? (Select all that apply).

Fatigue

Insomnia

Euphoria

Flat affect

Crying

Fatigue

Insomnia

Flat affect

Crying

A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following antepartum complications should the nurse understand is a risk factor for this client?

Preeclampsia

Thrombophlebitis

Placenta Previa

Hyperemesis gravidarium

Preeclampsia

Placenta Previa

Laceration

 Tearing of the soft tissues adjacent to the birth canal, including the cervix, vagina, and perineum.

Can occur as an extension of an episiotomy.

Types:
✔ First Degree: Superficial involving skin and vaginal mucosa.
✔ Second Degree: Involves muscles of the perineal body.
✔ Third Degree: Extends through the anal sphincter.
✔ Fourth Degree: Extends through the rectal mucosa.

Laceration S/S & Management

Bright red bleeding with firm uterus → Continuous trickle of blood.
Pain and swelling in the perineal area.
Visible laceration or tear.
Signs of hypovolemia if bleeding is significant.

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Immediate Interventions:

• Identify source of bleeding → Check perineum, vagina, and cervix.

• Notify healthcare provider → For evaluation and repair.

Repair and Treatment:

• Suturing

• Ice packs for 24 hours to reduce swelling.

• Sitz baths after 24 hours for comfort.

• Analgesics and stool softeners for pain relief and comfort.