ch 14 pp complications

most common & preventable causes of severe maternal morbidity & mortality

hemorrhage, infection, perinatal, mood and anxiety disorders, hypertensive disorders, VTE

expected qBLs for cs and vag

vag: 500 mL

cs: 1000 mL

significance of different baby daddies

different can change thr isk of complications because different genes

• same bby daddy = same outcomes

to know in order to decrease mortality

be aware of mom’s PMHx to prevent

what to ask mom before she delivers (in relation to pph)

does she have a clotting disorder/blood problem prior to delivery

blood thinners, dvt, platelets, decreased plotting factors, thrombocytopenia

be a step ahead

postpartum hemorrhage qualities

• cumulative blood loss of 1000 mL or more

• blood loss accompanied by sx of hypovolemia (within 24 hours following the birth process, even during intrapartum loss)

top cause of PPH

uterine atony

pph tx: two pronged approach

• resuscitation and management of obstetric hemorrhage and potential hypovolemic shock

• identification and management of the underlying cause of pph

s/sx of maternal hypovolemia

tachycardia, hypotension, tachypnea, low o2 saturation, oliguria, pallor, dizziness, or altered mental status

• oliguria late sign!

• pt will compensate sx, takes time

• HTN for mom is based on baseline

primary causes of pph

• uterine atony

• lacerations

• hematomas — pain does not go away even if medicated

uterine atony wyd

• uterus is tired and does not want to contract

• always give pitosin, hemabate, cytotec, methergine, TSA (for clot factors)

• #1 cause for PPH

secondary causes of pph

• hematomas

• subinvolution — turns inside out

• retained placental issue

precipitating factors for hemorrhage (4 T’s)

• tone — uterine atony, at umbilicus and tough, ensure bladder empty

• tissue — r/t retained placenta

• trauma — lac/hematoma

• thrombin disorders

risk factors for PPH

• if there’s clotting factors hx

• big baby

• new baby dad

• infection

PPH RN responsibilities

• assess uterus

• know how to get/give blood

• know why she’s bleeding — get labs, help

• give O2, fluids, volume expanders

• rapid response and code

• qbl if pph

what to know about TSAs

• not a uterotonic

• fundus is firm but still bleeding — use this med

uterotonics

pitosin, methergine, cytotec, hemabate

what to know and do for pph

• what causes, what meds

as an RN:

• give o2, call dr, monitor, don’t leave pt, get help

• weigh all blood loss

coagulation disorders

• DIC (disseminated intravascular coagulation) — code btw

  • bleeding and clotting at the same time

  • once pt reaches a certain blood loss

• anaphylactoid syndrome (anaphylactic) — amniotic fluid clot to brain and heart

  • happens after delivery, mom in danger more than baby

• VTE — ambulate asap to prevent

tx of choice for primary postpartum hemorrhage

oxytocin (pitosin)

endometritis sx

fever, tachy, inf sx — pain, chills, fatigue

infection of endometrium

• RBCs will be high asf

endometritis risk factors

smokers!!

• cs, prolonged rupture (open wound), prevent # of vag exams if alr ruptured), internal monitoring, diabetes

most common cause of postpartum fever

endometritis

endometritis management

• tx with broad spectrum IV antibiotics and rest

• blood cultures

• can turn into chorioamnionitis or bladder infection if not tx

endometritis RN actions

• limit vag exams when alr ruptured

• know wbcs

• take temp hourly

• tell dr, know when uterus has been ruptured

• assess SX OF SEPTIC SHOCK — tachy, oliguria

• ambulate, encourage fluids

• change peri pad frequently to avoid infxn

UTI risk factors

• anything non-human put inside

• pregnant, after epi/spinal, foley, vacuum, forceps

mastitis

infection in mom’s breast tissue

safe to bf with mastitis, but can pump and dump

mastitis sx and tx

• crackles, bleeding, inflamed, pain, fever

• tx with abx

mastitis RN actions

• prevent cracked n*pples — lanolin cream

• warm compress, abx, prevent engorgement

• ensure full latch during bf

• no tight clothing

wound infections risk factors

cs, lac, pesiotomy

• obesity!!

• heavy lifting

acute onset of severe hypertension postpartum sx

1. chronic hypertention

2. pregnancy induced htn (pih)

3. chronic htn with superimposed PIH

4. HELLP syndrome

bp for when you need to tx

160/110

• you only need to take criteria for one number, if one is critical, it is still critical

• take again in 15 min, if both high let dr know

if mom has hbp before 20 wks or b4 pregnancy

pt is chronic hypertensive

• these pts are alr on meds

• know hbp meds (labetalol, procardia)

• pt should be dx before pregnancy or up until 20 wks

• chronic htn will keep pts hypertensive

PIH

pregnancy induced HTN

• dx AFTER 20 wks

• dx via 2 different bp 1 min apart (still high)

• do a protein dip for urine to check

PIH vs CHTN

p: lab issues (& high bp)

c: just have hbp (chronically)

how soon do you use first line agents for pregnancy complis

ASAP within 30-60 mins of confirmed hypertension to reduce maternal stroke, seizure, or death

• complications more likely the older you get (> 35)

HELLP

H: high blood pressure → hemolysis: rbcs clot tg

EL: elevated liver enzymes (ALT, AST)

LP: low platelets → high risk for pph

med to prevent maternal sezire

mag sulfate via iv

• decreases stimulation on CNS

cure for PIH and HELLP

delivery!!

• stay on mag sulfate for 24 hrs bc bp high still

• but priority is that labs get better after birth

pregestational diabetes

diabetes caused by pregnancy and can stop when born

• insulin needs decrease post birth — you need more insulin in pregnancy

  • returns to normal glucose tolerance postpartum

• women monitored for mastitis, endometritis, and wound infections

• aware of hemoglobin and A1C (usually under 5.8 for preg pt)

• follow up after birth!

gestational diabetes babies vs nondiabetic babies

baby is used to producing more insulin than nondiabetic babies

• baby gets blood sugar if mom is diabetic

• tends to have a lower blood sugar after birth

• normal bs for baby: 40-45 — if under, needs tx

• babies are high risk for diabetes!

maternal obesity postpartum to know

• higher risk for morbidity and mortality for mother and baby

• pp 6 wks after delivery, pt edu is sx for pph, ppd, infection

acute hypertension is treated with which meds

• iv labetalol and hydralazine

• nifedipine (procardia)

• frequent monitoring of vital signs

POST BIRTH

post: call 911

birth: call dr

POST

• pain in chest

• obstructed breathing or shortness of breath

• seizures

• thoughts of hurting yourself or someone else

call 911!

BIRTH

• Bleeding, soaking through one pad/hr, or blood clots, the size of an egg or bigger

• Incision that is not healing

• Red or swollen leg that is painful or warm to touch

• Temperature of 100.4F

• Headache that does not get better even with meds or vision changes

call dr!

postpartum psychological complications

• childbirth most powerful triggers for psychiatric illness

• 15% of women experience major mood disorders that affect care for themselves/their baby

• postpartum depression and post partum psychosis

postpartum depression

severe depression that occurs within the first 6-12 mo pp

• requires psychiatric intervention

• parent is unable to safely care for self/baby

• it leads to decreased responsiveness to the infant

postpartum blues

within the first 2 weeks

• short term

• no need for medical intervention

• similar feelings to ppd but can still take care of themselves/baby

postpartum psychosis

• rare, onset is rapid and early as 2-3 days after childbirth

• sx: delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior

paternal postnatal depression

• depression — not common, but happens

• during first 6 mo following childbirth