Exam 3 Full

A little bleeding postpartum is normal. True or false?

True

• Leading cause of maternal mortality and morbidity

• Defined as cumulative blood loss > 1000 mL or blood loss accompanied by S&S of hypovolemia within 24 hours after birth

PPH

PPH in vag delivery vs hemorrhage in C-section

• > 500 mL blood loss in vag delivery = hemorrhage; may or may not see S&S of hemorrhage (increased pulse/decreased BP); normal-abnormal and is caution sign for hemorrhage → monitor closely

• > 1000 mL in C-section = hemorrhage → will see S&S of hemorrhage → this when you do all the interventions for PPH

PPH (primary) that occurs in first 24 hrs after birth

• Uterine atony → most common cause

• Trauma = 2nd most common cause

  • Hematomas, lacerations

Early PPH

PPH (secondary) that occurs after 24 hrs or up to 12 weeks after birth

• Most common cause =

  • Subinvolution (uterus can’t go back down if there are still placental fragments remaining)

  • Retained placental fragments and infection

  • Increased r/o infection

Late PPH

Complications of PPH

• Hypovolemic shock → excessive blood loss, hypovolemia (tachycardia, low BP, decreased LOC)

• infection

Therapeutic management of hypovolemic shock

• Key is early recognition

• First is IV fluid bolus + start second IV to give blood (may give blood sooner than everyone else since pregnant women good at compensating before big crash)

  • Draw labs (CBC + H&H)

  • Give RBCs immediately if Hgb < 7

• Meds for uterine atony (pitocin, cytotec, etc) and bleeding (TXA) → both promote less blood loss/clotting

• Prophylactic broad-spectrum abx

• Packed RBCs is last resort (may need to give plasma and plts as well to prevent DIC)

1 g of blood =

1 mL of blood

Bleeding from atony vs bleeding from trauma

• Atony = pitocin, TXA (can be used for both trauma/atony), cytotec, hemabate, methergine

• Trauma = fix underlying cause → call HCP

Postpartum patient is SOB, coughing, or chest tightness =

Suspect PE → postpartum patients are hypercoagulable

Clinical manifestations of superficial venous thrombosis

• Swelling and redness of the extremity (unilateral swelling)

• Tenderness and warmth of the extremity

• Client may or may not have pain

Management of superficial venous thrombosis

• Analgesics

• Rest + TED hose and SCDs

• Elastic support

• Elevation of lower extremities

• Anticoagulants if ordered

• Hx of DVT = increased r/o clotting; doctor will put them on prophylactic DVT therapy during next pregnancy

S&S of DVT

• Pain, swelling, erythema, heat, tenderness over affected area, decreased peripheral pulses

  • Pain on ambulation, chills, malaise, stiffness in affected leg

  • Most common in left leg

• May be absent in affected clients

• Caused by inflammatory process and vein obstruction

Diagnosis of DVT

• Doppler US

• MRI

Who is at risk for DVT?

• Hx of thrombosis

• Thrombophilia

Prevention of DVTs

• Ambulation, leg exercises, SCDs + TED hose

• Anticoagulants (heparin) if ordered

Serious complication of DVT. Has clinical manifestations of:

• Dyspnea, chest pain, tachycardia, tachypnea

• Hemoptysis (bloody sputum/coughing blood)

• Pulmonary crackles, cough

• Abd pain

• Low-grade fever

• Decreased O2 sat

PE

Therapeutic management of PE

• Dissolve clot with anticoagulants (heparin therapy)

• O2

• Analgesics

• Bed rest with HOB elevated

• Draw ABGs

• Bacterial infection after childbirth (includes endometritis, UTIs, etc.)

• Defined as temperature of 38 C (100.4 F) or higher after first 24 hrs and occurring on at least 2 of the first 10 days following childbirth/postpartum

  • Low grade fever at day 3-10 (temp of 99.4 F) is normal

• Effect of normal A&P on infection

Puerperal infection

Risk factors for endometritis

Caused by organisms of vagina and cervix

• Ruptured membranes (ROM for 24 hrs or longer = increased r/o Triple I/chorioamnionitis; infants for patients with ROM for 12-18 hrs are also at increased r/o neonatal infection)

• Prolonged labor

• GBS+

• Trauma

• Multiple vaginal/cervical exams

Clinical manifestations of endometritis

• Flu-like symptoms (vague abd pain, slightly more bleeding/cramping)

• Temp ≥ 100.4 F

• Chills

• Malaise

• Purulent, foul-smelling lochia

• Flu-like symptoms (vague abd pain, slightly more bleeding/cramping)

• Temp ≥ 100.4 F

• Chills

• Malaise

• Purulent, foul-smelling lochia

These are manifestations of what condition?

Endometritis

Therapeutic management of endometritis

IV abx

Patient can breastfeed through any purpureal infection. True or false?

True

Complication of endometritis

• Spreading infection outside the uterus →

  • Peritonitis

  • Paralytic ileus

  • Abd distention

  • Sepsis & SIRS (multiple organ damage)

Most common sites of wound infections

• C-sections

• Episiotomies

• Lacerations

Clinical manifestations of infection at wound site

• Edema, warmth, redness/erythema, tenderness, pain

• Seropurulent drainage, fever, malaise

• Necrosis

Therapeutic management of wound infection

• Wound culture

• Analgesics

• Warm compress, sitz bath

• Surgical debridement

UTIs risk factors

• Bladder and/or urethra trauma from descending fetus

• Catheter insertion (CAUTI)

• Hypotonic bladder and/or urethra after birth (inability to void properly/retention)

• Female anatomy/short urethra

• Vaginal/rectal contamination

• Incomplete bladder emptying

• Frequent vag exams

Clinical manifestations UTIs

Frequency, urgency, dysuria, burning, suprapubic pain

Therapeutic management of UTIs

Abx + prevent pyelonephritis

• Breast infection, occurs most often after 2-4 weeks after birth.

• Usually affects one breast; unilateral

• Often caused by Staph aureus, MRSA, and streptococci

Mastitis

Clinical manifestations of this disease include:

• Flulike sx

• Red, hot streaky breasts that are incredibly tender; very high fever

• Localized lump or wedge-shaped area of pain, redness, heat, inflammation, enlarged axillary lymph nodes

• Patient feels like they are dying

• Make them breastfeed through it to empty the breast of milk; baby is fine drinking that milk

Mastitis

Therapeutic management for mastitis

• Abx therapy for 7-10 days

• Surgical drainage if abscess

• Supportive measures

  • Moist heat or ice packs

  • Bed rest

  • Fluids

  • Analgesics

• Breastfeed through it (baby’s fine with any type of milk)

Are abx safe for baby?

Yes, abx are safe; baby can also breastfeed even if mom has an infection

• Least common of puerperal infections.

• Thrombi/hematoma develops in vaginal or pelvic area and becomes inflamed; infection can spread to pelvic venous system and develop into thrombophlebitis.

• Manifestations are:

  • Groin, abd, flank pain

  • Fever

  • Tachycardia

  • GI distress, abd bloating

  • decreased bowel sounds

Septic pelvic thrombophlebitis

Therapeutic management of septic pelvic thrombophlebitis

• Readmission

• Anticoagulation therapy

• IV abx

• Supportive care similar DVT

Calculating QBL

Subtract dry weight from blood-soaked (wet) weight; 1 mL of blood = 1 g (e.g. dry weight of an item = 40g, and same item saturated with blood = 140g, the net blood loss = 100 mL)

Involution of the uterus

• Stage where uterus “shrinks” after delivery

• Contraction of muscle

  • Controls bleeding from site of placental attachment

  • Decreases size of uterus

• Catabolism

  • Reduction in cell size

  • Byproducts are excreted in urine

• Regeneration of uterine epithelium

  • First layer: decidua, basal layer, then endometrial layer

Contraction of uterine muscle during involution =

• Controls bleeding from site of placental attachment

• Decreases size of uterus

Catabolism of uterus during involution =

• Reduction in cell size

• Byproducts are excreted in urine

Descent of uterine fundus

• Assess fundal height (fundal height should be at umbilical cord)

• Subinvolution can cause PPH (uterus does not contract/shrink which causes hemorrhage)

• Document fundal height in relation to umbilicus

Progress of fundal height after delivery

• Postpartum day 1: at the umbilicus

• Days 2, 3, 4 → fundus gradually goes back down into the pelvis (descends by about 1 cm/day)

• If uterus/fundus is displaced to the right/left → bladder is distended/full → can cause uterus to not clamp down/descend properly and result in PPH

Postpartum after pains

Contractions/cramping of the uterus as it descends back down into pelvis

• more acute for multips

• More severe with overdistension

• More severe during breastfeeding caused by release of oxytocin

After pains are more severe for multips or primips?

Multips

Nursing management of after pains

• Analgesic/NSAID (ibuprofen > Tylenol)

  • Anti-inflammatory meds such as ibuprofen better than Tylenol for after pains; Tylenol better if mom has tears/trauma from birth

• Medicate before breastfeeding

• Reduced pain leads to enhanced comfort and relaxation to facilitate letdown of milk

Changes in color of lochia (discharge postpartum)

• Lochia rubra → days 1-3

• Lochia serosa → days 3-10

• Lochia alba → after day 10

Reddish discharge that appears postpartum days 1-3

Lochia rubra

Dark red/brown discharge (color of old blood) that appears postpartum days 3-10

Lochia serosa

White discharge that appears after postpartum day 10

Lochia alba

Bleeding less than a 2.5 cm (1-inch) stain on the peripad

Scant bleeding

Bleeding less than 10-cm (4-inch) stain on peripad

Light bleeding

Bleeding less than 15-cm (6-inch) stain on peripad (mom soaks pad every few hours)

Moderate bleeding

Saturated peripad in 1 hr (pad gets saturated every hour)

Heavy bleeding

Saturated peripad in 15 mins → hemorrhage

Excessive bleeding

Rubbing the fundus in the first two hours of postpartum promotes

Contractions of uterus/involution → less bleeding

Amount of clots in lochia (normal vs abnormal)

• Normal = small clots (if mom sits in bathroom or bed too long)

• Abnormal = Excessive amounts of clots

Bright red bleeding even though fundus is firm =

Sign of cervical tear

Changes to cervix postpartum

• Cervix is dilated, edematous, and bruised

• Small tears or lacerations may be present (big cervical tear = bright red bleeding)

• Rapid healing takes places (lots of blood flow)

Changes to vagina postpartum

• Greatly stretched; wall appear edematous

• May have multiple small lacerations

• Few vaginal rugae are present

  • Rugae begin to reappear by 3-4 weeks

  • Vaginal epithelium restored by 6-10 weeks

• Vaginal wall regains thickness

• Dyspareunia (pain with sex)

Changes to perineum postpartum

• Pelvic floors muscles are stretched and thin → kegel exercises

• May be edematous and bruised

• Laceration/episiotomy may be present

• Discomfort

• Nursing considerations

  • Relief of perineal discomfort → ice in first 24-48 hrs for decreased swelling, NSAIDs/tylenol for comfort, narcotics if excessive pain

  • Kegel exercises

  • Teaching self-care measures (wipe front to back, pat to dry, let sutures dissolve on their own)

What can cause discomfort during postpartum

• Episiotomy/laceration/tear

• Hemorrhoids from straining

• Perineal trauma

• Self-care

  • Apply ice first 24-48 hrs

  • Warm sitz bath

  • Perineal care (front-to-back)

  • Topical anesthetics (witch-hazel, benzocaine spray), and cooling astringents

  • Analgesics

Resumption of ovulation and menstruation

• First few cycles for lactating and nonlactating women are often anovulatory (do not have period but still ovulating)

• Ovulation may resume before first postpartum follow-up visit to provider

• Contraceptive measures important → recommend try not to get pregnant again in first 6 weeks

• Nonlactating women usually resume menstruation in 6-10 weeks

• Breastfeeding delays ovulation and return of menstruation; menses usually returns between 10 weeks and 6 months (but they are still ovulating)

Lactation in postpartum women

• Estrogen and progesterone prepare breasts for lactation during pregnancy

• After expulsion of placenta, estrogen and progesterone levels decline rapidly

• Prolactin initiates milk production in 2-3 days after childbirth

• Oxytocin is required for milk-ejection or “let-down” reflex

Recommendations for women who don’t want to breastfeed

• Wear a tight-fitted bra

• Minimal breast stimulation

• Prolactin-reducing products are not safe or EBP

Important postpartum considerations

• Pain control

• Preventing PPH and monitoring lochia/bleeding

• Preventing infection

• Promote bonding between infant and mom

Changes in CV system postpartum

• Increased flow of blood back to heart

• Decreased pressure from the pregnant uterus on the vessels

• Mobilization of excess extracellular fluid into the vascular compartment (there is swelling 5-6 days after delivery)

• CO returns to prepregnancy levels in most women by 6-12 weeks after delivery

How can mom get rid of excess plasma volume (due to excess fluid in vascular compartment postpartum)?

• Hydrate/force fluids to keep kidney functioning

• Body rids itself of excess plasma volume via

  • Diuresis

  • Diaphoresis (NORMAL)

Hematologic changes postpartum

• WBC count increased (sightly increased = NORMAL)

• Hgb and Hct difficult to interpret

  • Plasma dilute caused by remobilization of excess body fluid

  • Returns to normal within 4-6 weeks

  • Important to monitor labs for blood loss

• Coagulation

  • Elevations in clotting factors cause continued r/o thrombus formation → hypercoagulability

  • Hemostasis returns in 4-6 weeks

  • Decrease risk with early ambulation

  • If C-section → post-op considerations (deep-breathing, coughing, incentive spirometer)

Coagulation in postpartum

• Elevations in clotting factors cause continued r/o thrombus formation → hypercoagulability

• Hemostasis returns in 4-6 weeks

• Decrease risk with early ambulation

• If C-section → post-op considerations (deep-breathing, coughing, incentive spirometer)

GI changes postpartum

• Digestion

  • Begins to be active (hunger & thirst)

• Constipation is a common problem (can be caused by narcotics) → stool softeners often prescribed

Urinary system postpartum

• Kidney returns to normal function within 4 weeks past birth

• Physical changes

  • Acetone in urine

  • Proteinuria

  • Lost muscle tone in bladder

  • Traumatized meatus → pain on urination = squirt water on it while voiding

  • Diminished sensitivity to fluid pressure (lots of moms have epidurals)

  • Diuresis

  • Overdistended bladder

    • Urinary distension (uterus pushing up distends the bladder)

    • Hemorrhage (uterine atony)

• KEGEL EXERCISES + STRAIGHT CATH

MSK changes postpartum

• Muscle fatigue

• Relaxin levels subside; pelvic ligaments and joints return to prepregnancy positions

• Hip or joint pain

• Body mechanics and posture

• Maintaining tone and strength of abd wall with exercises is important

• Diastasis recti = do yoga; may need surgery (patient may still look pregnant)

Longitudinal muscles of the abd separate. Return to normal position by 6 weeks postpartum. Some people may need surgery since they still look pregnant and abd wall doesn’t go back to normal.

• Yoga can help

Diastasis recti

Integumentary changes postpartum

• Skin changes gradually disappear:

  • Melasma (mask of pregnancy)

  • Linea negra

  • Spider nevi

  • Palmar erythema

• Striae gravidarum (stretch marks)

  • Fades to silvery lines but do not disappear

Neuro changes postpartum

• Anesthesia or analgesia may cause temporary changes

• Prevention of injury is priority

• Frontal and bilateral HAs common

• Severe HAs are not common; may be related to postdural puncture from regional anesthesia (mom will have severe HA sitting up but subsides when they lie down; AKA spinal HA)

Endocrine system changes postpartum

• After expulsion of placenta, estrogen, progesterone, and human placental lactogen decline rapidly → these help prepare breasts, but decline so that milk production can be initiated

• High prolactin levels trigger body to make milk for breastfeeding

Weight loss in postpartum

• Approximately 10-13 lb lost in childbirth

• Loss of blood and diuresis

• Educate mom about diet and exercise (same amount of calories as they were pregnant; extra 300 calories/day if breastfeeding)

• Goal is to conserve energy and promote mom’s health

What to assess postpartum

• VS

• Skin color

• Lactation and firmness of fundus/fundal height

• Amount and color of lochia

• Perineum for:

  • Edema

  • Episiotomy

  • Lacerations

  • Hematoma

• Pain (PQRST)

• IV patency, meds, and fluid orders

• Urine output, characteristics, and presence/patency of catheter

• Status of abd incision and dressing

• Level of feeling and ability to move if regional anestheisa/epidrual

Chart review for postpartum assessment

• GPs

• Time & type of delivery

• Blood type/STI hx

• Presence and degree of episiotomy or lacerations

• Anesthesia/meds administered

• Medications

• Significant med/surg hx

• Food and drug allergies

• Chosen method of infant feeding

• Condition of baby

Risk factors for PPH and infection

• Multip

• Hx of PPH

• Overdistention of uterus

• Precipitous labor

• Multiple births

• Prolonged labor

• Retained placenta

• Placenta previa or placental abruption

• Coagulopathy; low plts

Risk factors for PPH or infection (trauma, infection, meds)

• Trauma

  • Lacerations

  • Hematoma

• Infection

  • Chorioamnionitis

  • Sepsis

• Meds

  • Tocolytics (arrests preterm-labor)

  • Mag sulfate

  • General anesthesia

Operative procedures that cause risk for PPH and infections

• C-section

• Vacuum extraction

• Forceps delivery

Risk factors for infection postpartum

• Operative procedures

  • C-section, vacuum, forceps

• Multiple cervical exams

• Prolonged labor

• Prolonged ROM

• DM

• Catheterization

• Manual extraction of placenta or retained fragments

• Bacterial colonization of lower GU

Rhogam immunoglobulin IM shot is indicated for

• Rh- clients with Rh+ newborns (give to Rh- mothers if Rh+ baby)

• Given within 72 hrs after birth to prevent maternal antibodies affecting subsequent pregnancies

When is Rhogam IM shot indicated?

• Indicated for

  • Rh-negative

  • Unsensitized (negative indirect Coombs' test - meaning they haven't already developed antibodies)

  • Carrying or delivered an Rh-positive baby (within 72 hrs)

  • After amniocentesis or other procedures where maternal/fetal blood mixing can occur

  • After miscarriage before 13 weeks

When is Rhogam IM shot contraindicated?

• If the mother is already sensitized (positive indirect Coombs' test), Rho(D) immune globulin is not given because antibodies have already formed - it's too late for prevention.

• If the baby is Rh-negative, Rh antibody formation does not occur and Rho(D) immune globulin is not necessary.

Immunizations postpartum

• Rubella → clients should not become pregnant for 30 days after receiving vaccine (rubella is live-virus vaccine)

• Flu & pertussis vaccines

  • Effectiveness fades over time

  • Full protection requires entire series

  • Booster recommended for adults

  • Usually administered with diphtheria and tetanus vaccines

  • These vaccines can give additional immunity to baby via breastmilk/placenta

• Varicella vaccine can cause infection and serious complications in pregnant patients

  • Given after delivery/before discharge if patient not immune

  • Do not get pregnant for 30 days/1 month after receiving (live vaccine)

Postpartum focused assessment frequency

• q15 min for 1st hr after delivery

• q30 min for 2nd hr

• q4h for first 24 hrs

• q8-12h thereafter (after 24 hrs)

Fundal postpartum assessment

• Fundus should be firm and near level of umbilicus

• Recheck after voiding

• Clots interfere w/ uterine contraction

• Support uterus when expelling clots to prevent inversion

• Drugs may be necessary to maintain contraction

Drugs for PPH

• Pitocin → first line med for uterine atony (promotes contraction)

• Methergine → promotes contraction/reduces bleeding if pitocin not enough; C/I in HTN

• Cytotec → promotes contraction/reduces bleeding if pitocin not enough (prostaglandin)

• Hemabate → effective for persistent bleeding (prostaglandin); C/I with asthma

• Tranexamic acid (TXA) → opposite of tPA; antifibrinolytic for active bleeding

• Prophylactic broad-spectrum abx to prevent infection

Lochia assessment

• Amount

  • Constant trickle, dribble, or oozing indicates excessive bleeding and requires immediate attention

• Color

• Odor

  • Normal is fleshy, earthy, or musty

  • Foul odor = infection

Lochia odor =

• Normal is fleshy, earthy, or musty

• Foul odor = infection

Constant trickle, dribble, or oozing lochia indicates

Excessive bleeding → requires immediate attention

REEDA (assessment of perineum)

R – Redness

E – Edema

E – Ecchymosis (dark purple-blue bruise/discoloration)

D – Discharge

A – Approximation

Breast postpartum assessment

• Breasts should be soft and nontender on days 1 and 2

• Examine whether or not mother is breastfeeding

• Observe size, symmetry, and shape

• Assess for flat or retracted nipples

• Assess for signs of nipple trauma if breastfeeding

• Palpate for firmness or tenderness

Norma-abnormals for breasts

• Normal to get some clogged milk ducts resulting in lumps and bumps

• Normal to get engorged/swollen at days 3 or 4

Postpartum assessment of lower extremities

• Assess for S&S of thrombophlebitis and DVTs

  • Palpate pedal pulses

  • Assess for edema

  • Assess for DTRs

Implications for sitz baths

• Cool water for first 24 hrs postpartum

• Warm after 24 hrs

Promoting bladder elimination postpartum

• Medicate woman for pain to help her relax

• Run water in the sink or shower, place mom’s hands in warm water and pour water over the vulva

• Provide hot tea or fluids of choice

• Hot tea

• Asking the mother to blow bubbles through a straw (sound of water helps mom void)

• Encourage to urinate in warm shower or sitz bath (helps bladder relax)