hemorrhage, previa, pre-e, gestation diabetes

PP hemorrhage

blood loss of 1,000mL of more following vaginal birth or C-section

can be within the first 24 hours or late (up to 6 weeks after birth)

4 main reasons:

• uterine atony - relaxation of uterus

  • most common cause

• trauma (laceration, hematoma)

• retained placental fragments

• disseminated intravascular coagulation (DIC)

management of uterine atony

drain the bladder and do fundal massage

if oxytocin is not effective at maintaining fundal tone, what do you do?

give Hemabate and Methergine IM

Misoprostol (Cytotec)

administered rectally to decrease PP hemorrhage

Methergine adverse effects

increases BP so use it cautiously in patients with gestational HTN

assess their BP before administration and 15 minutes after

do not give it to someone with preeclampsia

non pharmaceutical interventions for uterine atony

• elevate lower extremities

• assist them to bathroom every 4 hours

  • or give them a bedpan

• administer oxygen (10-12L/min) if in respiratory distress

• position them supine (flat) to allow adequate blood flow to brain and kidneys

• obtain VS frequently

  • watch out for decreasing BP and increasing HR

bimanual compression

when fundal massage and uterotonics do not stop bleeding

this can be done after a sonogram identifies retained placental fragments

dilation and curettage (D&C)

removal of retained placental fragments to stop bleeding

patient is under anesthesia

signs of gestational hypertension

• sudden weight gain

• swelling of the face

• visual disturbances

• severe HA

• decreased urine output

• RUQ pain

• BP above 140/90

  • or 30mmHg+ systolic and/or 15mmHg+ diastolic

• does not have proteinuria or edema; BP returns to normal after birth

preeclampsia without severe features vs. with severe features

develops an elevated blood pressure (140/90 or 30/15+ baseline), have 1-2+ proteinuria, increased weight gain, and mild edema in upper extremities or face

vs.

BP is 160/110, 3-4+ proteinuria, oliguria with elevated Cr, blurred vision, HA, pulmonary or cardiac involvement, epigastric pain, thrombocytopenia, hepatic dysfunction

management of gestational HTN

labetalol, nifedipine, or hydralazine

signs of hypovolemic shock due to significant blood loss

• increased pulse rate

• decreased blood pressure (less resistance due to decreased volume)

• increased respiratory rate

• cold, clammy skin (vasoconstriction to maintain volume in central body core)

• decreased urine output

• dizziness or decreased LOC

• decreased central venous pressure

emergency interventions for bleeding in pregnancy

1. notify HCP

2. place patient flat on bed and start LR

3. administer oxygen

4. monitor uterine contractions and fetal HR

5. omit vaginal examination **

6. NPO → may need surgery

7. assess vitals q 15 minutes, I&Os

8. weigh perineal pads (save any tissue passed)

9. assist with ultrasound*

   1. sees if placenta is the source

signs of magnesium toxicity

• Hyporeflexia

• absent DTRs

• respiratory depression

  • less than 12 → notify

• hypotension

• bradycardia

priority actions when patient is experiencing magnesium toxicity

1. Stop magnesium infusion 

2. Administer calcium gluconate 

3. Activate rapid response

risk factors for placenta previa

• Previous placenta previa

• Previous cesarean section(s)

• Multiple pregnancies

• Smoking

• Cocaine use

• Prior dilation and curettage

• Assisted reproductive technology

how is placenta previa diagnosed?

ultrasound

placenta previa

when the placenta is implanted abnormally in the lower part of the uterus; can grow up or down

it is the most common cause of painless bleeding in the THIRD trimester of pregnancy

place patient on bed rest immediately in side-lying position

needs a C-section

do not allow vaginal exams to minimize trauma

teach to:

• not lift heavy

• not have sex

• may increase risk of PP hemorrhage

signs of a placental abruption

• heavy vaginal bleeding

• Abdominal pain (sharp, stabbing)

  • usually high in fundus

• Hypertonic uterine contractions

• Uterine tenderness

• abnormal fetal heart tracing

needs a large-gauge IV for fluid replacement and oxygen

patient is at risk for: hemorrhage, DIC, shock, and death

fetus is at risk for: preterm delivery, fetal growth restriction, low birth weight, and hypoxemia and asphyxia

management of placenta previa

 1. Immediate assessment and monitoring:

• continuous fetal and uterine monitoring

  • Ask if baby is moving

• Diagnose with ultrasound

• Reassess vitals frequently, watching for signs of shock (ex. hypotension, tachycardia)

• Assess COCA of bleeding and weigh pads

• Avoid a vaginal exam

• pain assessment and where 

• Any recent use of alcohol or drugs

2. Notify the healthcare provider immediately

3. Prepare for possible cesarean section:

• Establish large bore IV access 

• Ask about previous C-sections and if there were any complications

• Allergies

• Get consent for C-section and blood transfusion are signed.

4. Administer oxygen to improve fetal oxygenation

5. Positioning:

• Place patient in the left lateral position

6. Provide emotional support

manifestations of gestational diabetes

• Polyuria (frequent urination)

• Polydipsia (excessive thirst)

• Fatigue

• Nausea

• Blurred vision

• Sugar in urine (found during routine testing)

• Recurrent infections (e.g., yeast or urinary tract infections)

• Large fundal height or macrosomia on ultrasound (clues that baby is growing large)

risk factors for gestational diabetes

• History in previous pregnancies

• T2DM

• Obesity

• PCOS

• sedentary lifestyle

1hr glucose challenge test

done at 24-28 weeks gestation to assess for gestational diabetes

if they fail → 3hr ______

diet for pregnant women with diabetes

• reduced saturated fats and cholesterol

• increased fiber

• carbohydrates with low glycemic index

• should consume 3 small – moderate meals and 4 snacks/day

• monitor sugar 4 times a day

assess:

• 24 hour diet recall

• Economic ability to purchase healthy food

• Access to supermarkets

• Physical activity patterns