AWHONN PPH Packet

what can maternal blood loss also be from (7)

ruptured ectopic pregnancy, uterine rupture, laceration, abruptio placenta, placenta accreta, retained products of conception, uterine atony

what does the reading have to say about deaths being due to PPH

they are preventable

prevention of adverse outcomes is dependent on

recognition of risk factors, identify bleeding, initiate management

how much does maternal plasma volume expand by

42%

how much does RBC volume increase by

24%, increase overall blood volume but also produce physiologic anemia

women with hypertensive disorders have____, making them greater risk for ________

diminished maternal plasma volume expansion, hemorrhage

average blood loss for spontaneous vaginal delivery

500 mL

average blood loss for c-section

1000 mL

avg blood loss for elective cesarean hysterectomy

1500 mL

PPH defined as a what percent drop in H&H

10% drop

primary PPH

occurs in first 24 hrs after birth

secondary PPH

after 24 hours to 6 weeks

massive transfusion

replacement of patient’s total blood volume within 24 hrs

most common etiology of PPH

uterine atony

other common etiologies of PPH

retained placenta and lower genital tract ulcerations

antepartum etiologies of obstetric hemorrhage

uterine rupture, placental abruption, placenta previa, vasa previa

intrapartum etiologies of obstetric hemorrhage

uterine rupture, placental abruption

postpartum etiologies of PPH 

uterine atony, retained placenta, lower/upper genital tract lacerations, placenta accreta, increta, percreta, uterine inversion, inherited coagulopathy

what are some associated risks for PPH

prolonged labor, uterine overdistention (large baby, mulitple, polyhydramnios), infection

preparation for women with protracted labor with a large baby and suspected intrapartum chorioamnionitis

IV access, type and cross match PRBC and fresh frozen plasma, uteronic agents

prep for woman with suspected abnormal placentation

CVC, blood pressure assessment, blood samples, available for volume infusion, prep for blood components

examples of uterine and maternal risk factors of PPH

previous c-section, prolonged labor, precipitous labor, exposure to oxytocin, macrosomia, polyhydromnios, chorioamnionitis, episiotomy, operative delivery (forceps, vacuum), grand multi,, obestiy, multi gestation

placenta risk factors for PPH

plcental abruption, placenta previa, accreta, percreta, increta, abnormally adherent placenta, HTN

coagulation deficits- acquired, risk factors of PPH

hemoglobin less than 9, or HCT less than 27, thrombocytopenia, anticoagulation therapy, liver disease, prolonged aPTT, sepsis/septic shock, severe pre e, amniotic fluid embolus

amniotic fluid embolus

amniotic fluid or other debris enter mother’s bloodstream, leads to immune reaction, cardio/resp collapse

congenital coagulation deficiti risk factors of PPH

von Willebrand disease, antibodies to factor VII, factor X, XI, XIII deficiencies

how much blood does a lap sponge full saturate with

100 mL

interventions for PPH start with

least invasive measures like medications

initial management of uterine atony

bimanual uterine massage and medical therapy for uterine contractility

normal uterine tone can be augmented by

draining the bladder

pharmacologic therapy for uterine atony consits of

oxytocin, ergot alkaloids, prostaglandins

what is first line of therapy for uterine atony

oxytocin

ergot alkaloids should be avoided in women with

HTN

prostaglandins should be avoided in women with

reactive airway diseases, asthma

misoprostol (cytotec) use, route

PUD and PPH, rectally or orally

oxytocin (pitocin) infusion rates

20-50 mL/min

oxytocin (pitocin) IM injection dose

10-20 units

adverse effects of oxytocin (pitocin)

hypotension, myocardial ischemia, chest pain, water intoxication

avoid mixing oxytocin in what

dextrose containing solutions or with water containing IV solutions

mix oxytocin with what

normal saline, ringer’s lactate, other isotonic solutions

uterotonic agents of PPH (5)

oxytocin, methylergonovine, carboprost, dinoprostone, misoprostol

methylergonovine IM injection

0.2 mg

methylergonovine is contraindicated with what

HTN, heart disease, pre e

methylergonovine ADEs

HTN, seizure, N/V, MI, cerebral ischemia

carboprost (hemabate) should not exceed how many mg per IM injection

2 milligram

how should hemabate be stored

refrigerated

dinoprostone insertion via

vaginal rectal suppository

dinoprostone use

treat PPH from uterine atony

misoprostol given via

rectally

misoprostol contraindications

allergy to prostaglandins

obstetric patients may not show s/s of hemorrhage until how much blood is lost

1/3 of blood volume

vitals with postpartum bleeding

pulse increase, BP decrease, pulse pressure decrease

what occurs (GU) during blood loss

urine output declines as hypovolemia worsens

what else can be used to stop bleeding

intrauterine balloon tamponade, condoms, catheters, tubes

uterine artery balloon placement is usually used in patients with 

high chance of massive PPH, such as placenta percreta

surgical interventions for PPH if non-surgical management doesn’t work

laceration repair, curetage, hypogastric or uterine artery ligation, compression suture

average blood loss from hysterectomy

3,500 mL

shock definition

inadequate oxygen delivery and tissue perfusion secondary to decreased intravascular volume

shock can progress to

cellular hypoxia, acidosis, organ system damage, death

etiology of hypovolemic shock

inadequate circulating volume from blood volume loss (hemorrhage, burn)

cardiogenic shock

inadequate cardiac output from decreased contractility (MI, arrhythmias)

obstructive shock

extra-cardiac obstruction to blood flow (PE, pneumothorax, cardiac tamponade)

distributive shock

inadequate circulating volume from decreased vascular tone

examples of distributive shock

sepsis, anaphylaxis, neurogenic, acute adrenal insufficiency, inflammatory