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Chapter 33 Flashcards

Postpartum Complications (143 cards)

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1
Q

POSTPARTUM HEMORRHAGE
-What is this?

A

Blood loss GREATER than
-500 mL for vaginal delivery
-1000 mL for c-section delivery
with a 10% drop in HGB and/or HCT

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2
Q

POSTPARTUM HEMORRHAGE
-What should you know before delivery?

A

Woman’s baselines

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3
Q

POSTPARTUM HEMORRHAGE
-Hospitals have what?

A

EBL (estimated blood loss) or QBL ( quantitative blood loss)

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4
Q

POSTPARTUM HEMORRHAGE
-What are the primary causes of PPH? (3)

A
  1. Uterine atony
  2. Retained placental fragments
  3. Lower genital track lacerations
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5
Q

POSTPARTUM HEMORRHAGE
-What is a major complication of PPH?
-What is this due to?

A

-Shock
-HYPOvolemia

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6
Q

POSTPARTUM HEMORRHAGE
-What are the risk factors (why does the uterus get tired)? (9)

A
  1. Fetal macrosomia –> baby is big!
  2. Polyhydramnios –> uterus is stretched
  3. High parity –> multiple births causes weak uterus
  4. Prior PPH
  5. Precipitous OR prolonged (during 1st & 2nd stages) labor and/birth
  6. Chorioamnionitis
  7. Maternal obesity
  8. Coagulation defects
  9. Augmented/induced labor
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7
Q

POSTPARTUM HEMORRHAGE
-The use of what can also be a risk?

A

Vacuum extraction/forceps

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8
Q

POSTPARTUM HEMORRHAGE
-Why is this dangerous?

A

Because nearly 1/3 of the blood volume may be lost BEFORE there is a change in VS

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9
Q

POSTPARTUM HEMORRHAGE
-You need to carefully monitor what?

A
  1. VS (HR for tachy)
  2. LOC changes
  3. Vaginal bleeding
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10
Q

POSTPARTUM HEMORRHAGE
-You need to watch for pad saturation within _____ minutes

A

15

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11
Q

POSTPARTUM HEMORRHAGE
-What are the 4 T’s?

A
  1. Tone –> boggy uterus
  2. Tissue –> retained placental parts
  3. Trauma –> tears/lacerations
  4. Thrombin Disorder –> clotting problems
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12
Q

POSTPARTUM HEMORRHAGE
-In terms of uterine assessment, what are you doing?

A

Assessing fundus & lochia EVERY HOUR for the first 4 hours then PRN

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13
Q

POSTPARTUM HEMORRHAGE
-Assess what signs?

A

Orthostatic vital signs

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14
Q

POSTPARTUM HEMORRHAGE
-You need to increase ____
-You need to decrease ____
-You need to prevent what?

A

-oral/IV fluids
-hypovolemia
-over distended bladder –> have them pee!

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15
Q

POSTPARTUM HEMORRHAGE
-Assist with what?
-R_____ is important
-Diet should include what kinds of foods?
-Check what levels?

A

-ambulation
-Rest!!
-Those that are high in iron
-H&H –> report abnormal results

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16
Q

What do we follow?

A

ACOG safety bundle

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17
Q

UTERINE ATONY
-What is this?
-This is the major cause of ____

A

-Decrease uterus tone –> relaxed/boggy uterus
-PPH

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18
Q

UTERINE ATONY
-A relaxed uterus PP increases the risk of what?

A

Bleeding

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19
Q

UTERINE ATONY
-Normally what happens after birth once placenta is expelled?

A

There is a massive hole where the placenta was SO –> uterine contractions constrict the uterine vessels at placental site to close vessels & DECREASE blood loss

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20
Q

UTERINE ATONY
-As the nurse, what do you usually see with uterine atony? (7)

A
  1. Boggy fundus!!
  2. Saturating pad in 15 minutes or less
  3. Blood clots
  4. TACHYCARDIA –> turns to bradycardia in late stages
  5. HYPOTENSION
  6. Clammy, pale skin
  7. Anxiety/confusion
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21
Q

UTERINE ATONY
-How can bleeding be?

A

Either slow & steady OR sudden & massive

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22
Q

UTERINE ATONY: Interventions
-What is the first thing you want to do?
-How do you do this?

A

-FUNDAL MASSAGE
-bimanually compress the uterus

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23
Q

UTERINE ATONY: Interventions
-What 4 medications can be given?

A
  1. Oxytocin (pitocin)
  2. Methylergonovine (methergine)
  3. Carboprost (Hemabate)
  4. Misoprostol (Cytotec)
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24
Q

UTERINE ATONY: Interventions
-How is oxytocin given - route & dose?

A

-IV
-20-40 U at 10mL/min (200 mU/min)

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25
**UTERINE ATONY**: *Interventions* -What is the route of Methylergonovine? -Dose? -CAUTION??
-IM (can repeat) OR IV in one dose -0.2 mg IM -IV dose can raise BP
26
**UTERINE ATONY**: *Interventions* -What is the route of Carboprost? -Dose? -When do you give this? -Can you repeat? -NOTE?
-IM -250 mcg -When PPH has NOT responded to oxytocin or methergine -Yes, q15minutes, MAX 8 doses -**DO NOT GIVE IF MOM HAS ASTHMA**
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**UTERINE ATONY**: *Interventions* -What is the misoprostol dose?
800-1000 mcg pr (per rectum)
28
**UTERINE ATONY**: *Interventions* -What are the non-surgical interventions?
1. Uterine packing with gauze 2. Uterine tamponade
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**UTERINE ATONY**: *Interventions* -Describe what a uterine tamponade is
a 24F foley catheter with a 30 mL balloon bag that is inserted into the uterus via the vagina
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**UTERINE ATONY**: *Interventions* -Basically, how does a uterine tamponade work?
Basically, the balloon is placed inside & opened to put pressure on placental site vessels & stop bleeding
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**UTERINE ATONY**: *Interventions* -What do you fill the catheter balloon with in a uterine tamponade?
60-80 mL of saline
32
**UTERINE ATONY**: *Interventions* -What is the surgical intervention if nothing else is working?
Emergency hysterectomy
33
**MASSIVE TRANSFUSION PROTOCOL** -When is this protocol instituted?
When a patient is **actively hemorrhaging** & requires IMMEDIATE replacement of blood products
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**MASSIVE TRANSFUSION PROTOCOL** -What labs should be done? (5)
1. Blood type & crossmatch 2. HGB/HCT 3. CBC 4. Fibrinogen 5. PT/PTT
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**MASSIVE TRANSFUSION PROTOCOL** -What do labs let you know?
How much blood you should be replacing --> replacement volume depends on labs!!
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**MASSIVE TRANSFUSION PROTOCOL** -What are you administering?
RBCS, FFP, 1 pack of platelets
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**MASSIVE TRANSFUSION PROTOCOL** -What ratio of RBCs to FFP (Fresh frozen plasma) should be administered?
6 units:4 units
38
**MASSIVE TRANSFUSION PROTOCOL** -What does management depend on?
Patient symptomology & lab results
39
**MASSIVE TRANSFUSION PROTOCOL** -You should keep MTP going until when?
Adequate response is reached
40
**LACERATIONS** -These are the 2nd most common cause of what?
PPH
41
**LACERATIONS** -What are the common laceration sites?
1. Cervix 2. Vagina 3. Labia 4. Perineum
42
**LACERATIONS** -Sometimes this may present as _____. Why?
PPH --> because we don't know where the bleeding is coming from
43
**LACERATIONS** -What can cause lacerations? (3)
1. Fetal macrosomia --> baby is big!! 2. Forceps/vacuum extraction 3. Precipitous labor and/or birth
44
**LACERATIONS** -How does bleeding present?
Steady stream WITHOUT clots
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**LACERATIONS** -How does the mom present? (5)
1. Tachycardia 2. HYPERtension 3. Episiotomy 4. Forceps 5. Prolonged 2nd stage of labor
46
**HEMATOMAS** -When do these occur?
When blood collects within the connective tissues of the vagina or perineal areas
47
**HEMATOMAS** -What are hematomas related to?
Vessel that ruptures & continues bleeding
48
**HEMATOMAS** -What may the woman complain about?
Pain in the vagina/perineal
49
**HEMATOMAS** -What will the woman complain of if the hematoma is located in the *vagina*?
1. Heaviness/fullness in the vagina and/OR 2. Rectal pressure
50
**HEMATOMAS** -If the hematoma is located in the *perineal area*, how will the tissue present?
With swelling, discoloration, tenderness
51
**HEMATOMAS** -Hematoma with a blood accumulation of 200-500 mL can become large enough to do what?
Displacethe uterus & cause uterine atony
52
**HEMATOMAS** -Is it easy to estimate the blood loss? -Why?
-NO -Bc blood is RETAINED within the tissues --> PPH may not be diagnosed until the woman is hypovolemic & in shock
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**HEMATOMAS** -What symptoms should you be watching out for?
Tachycardia & hypotension
54
**UTERINE SUBINVOLUTION** -What is this?
When the uterus DOES NOT decrease in size or descend into the pelvis
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**UTERINE SUBINVOLUTION** -By day 1, where should the uterus usually be?
at the umbilicus
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**UTERINE SUBINVOLUTION** -When does subinvolution generally occur?
Late in the PP period
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**UTERINE SUBINVOLUTION** -What are the risk factors (causes)? (3)
1. Fibroids 2. Infection (metritis) 3. Retained placental tissue --> uterus isn't cleaned out so it can't clamp or get smaller
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**UTERINE SUBINVOLUTION** -How does the woman present? (3)
1. SOFT & LARGE uterus 2. Lochia RETURNS to rubra (bright red) stage & heavy 3. Back pain
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**UTERINE SUBINVOLUTION** -What does medical intervention depend on?
The cause
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**UTERINE SUBINVOLUTION**: *Intervention* 1. What is done for retained placental tissue? 2. What is done for Fibroids? 3. What is done for metritis?
1. Dilation & curettage (D&C) 2. Oral methergine is prescribed 3. Antibiotic therapy is initiated
61
**RETAINED PLACENTAL TISSUE** -What is this?
When small portions of the placenta remain attached to the uterus
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**RETAINED PLACENTAL TISSUE** -This is the primary cause of what? -When does it occur?
-Secondary PPH -In the 3rd stage of labor
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**RETAINED PLACENTAL TISSUE** -What does this interfere with? -What can it lead to?
-Involution of the uterus -PPH & uterine metritis
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**RETAINED PLACENTAL TISSUE** -What is the common cause?
MANUAL removal of placenta
65
**RETAINED PLACENTAL TISSUE** -Patient ______ is essential -When do s/s often occur?
-education -AFTER discharge
66
**AMNIOTIC FLUID EMBOLISM** -What kind of complication is this? -When does it occur?
Rare but **FATAL** complication -During pregnancy, labor, OR within the first 24 hours after birth
67
**AMNIOTIC FLUID EMBOLISM** -What is AF composed of?
Fetal debris --> fetal cells, lanugo, vernix
68
**AMNIOTIC FLUID EMBOLISM** -What is this?
When AF enters the maternal vascular system (bloodstream)
69
**AMNIOTIC FLUID EMBOLISM** -What does this initiate once AF enters?
a cascading process that leads to cardiorespiratory collapse & DIC
70
**AMNIOTIC FLUID EMBOLISM** -How does it initially look like?
a PE
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**AMNIOTIC FLUID EMBOLISM** -Where can AF potentially enter through?
1. Cervix after ROM 2. Site of placental separation 3. Site of uterine trauma (EX: lacerations)
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**AMNIOTIC FLUID EMBOLISM** -What is the 1st stage of AFE -What is the end result?
1. AF & fetal cells enter maternal circulation 2. Endogenous mediators are released --> causes vasospasm & pulmonary HYPOtension 3. This will then cause myocardial & pulmonary capillary damage -Heart failure & acute RDS
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**AMNIOTIC FLUID EMBOLISM** -What is the 2nd stage of AFE?
Hemorrhage & DIC
74
**AMNIOTIC FLUID EMBOLISM** -What are the risk factors?
Induction of labor & placental abruption/previa
75
**AMNIOTIC FLUID EMBOLISM** -What does the mother present with? (5)
1. Dyspnea 2. Seizures 3. HYPOtension 4. Cyanosis 5. Cardiac & respiratory arrest
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**THROMBOSIS** -What is this? -When does this occur?
-a blood clot within the vascular system -During pregnancy & for the first 6 weeks PP
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**THROMBOSIS** -Why are women at risk for forming blood clots during pregnancy?
There is an increase in clotting factors I, II, VII, IX, X, & XII AND in fibrinogen
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**THROMBOSIS** -Site for a thrombosis is generally where?
In a vein in the legs --> deep vein thrombosis (DVT)
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**THROMBOSIS** -What is a MAJOR concern with this?
That the clot will detach & become and embolism --> travels to a vital organ, such as the lungs (PE)
80
**THROMBOSIS** -What are the risk factors for a DVT?
1. C-section (risk id 5x greater) 2. Metritis 3. Decreased mobility (venous stasis, obesity)
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**THROMBOSIS** -What is generally effective in preventing DVTs?
SCDs
82
**THROMBOSIS** -What are the s/s of a DVT?
1. Heat 2. Tenderness 3. Redness 4. Leg pain while walking 5. Unilateral leg swelling
83
**THROMBOSIS** -How is a DVT diagnosed?
with a doppler
84
**THROMBOSIS** -What is the medical treatment?
Blood thinners --> heparin, warfarin, lovenox (Coumadin)
85
**THROMBOSIS** -What is needed for Coumadin? -What is the normal therapeutic range?
-INRs -2-3
86
**ENDOMETRITIS** -What is the most common PP infection?
Metritis
87
**ENDOMETRITIS** -What can metritis affect? -Where does the infection usually begin at?
-The endometrium, myometrium, &/or parametrial tissue -the placental site & then spreads to the ENTIRE endometrium
88
**ENDOMETRITIS** -Which delivery method experiences metritis the most?
C-section --> PRIMARY RISK FACTOR!!!!
89
**ENDOMETRITIS** -Aside from c-section, what are 6 other risk factors?
1. PROM 2. Prolonged labor 3. Internal monitoring (uterine or fetal) 4. Meconium stained fluid 5. Multiple cervical exams 6. Obesity
90
**ENDOMETRITIS** -What is the most alerting sign?
FEVER --> temperature above 100.4F (38C)
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**ENDOMETRITIS** -What is the fever accompanied with/without? (7)
1. Chills 2. Lower abdominal pain 3. Uterine tenderness 4. Subinvolution 5. TACHYCARDIA 6. Malaise 7. HEAVY FOUL smelling lochia
92
**ENDOMETRITIS** -What is a later sign?
1. Anerobic organisms are present 2. Lochia is scant/odorless 3. (beta-hemolytic) streptococcus is present
93
**ENDOMETRITIS** -What is this diagnosed with? (5)
1. CBC for leukocytes 2. WBC > 20,000 3. Endometrial cultures 4. UA/UC 5. Blood cultures
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**ENDOMETRITIS** -What is the treatment?
Antibiotics --> should get a culture beforehand
95
**POSTPARTUM INFECTIONS** -What are the 4 common sites?
1. Uterus 2. Bladder 3. Breast 4. Incision site
96
**POSTPARTUM INFECTIONS** -Risk factors? (6)
1. C-section 2. Prolonged ROM/labor 3. Internal fetal/uterine monitoring 4. Meconium 5. Multiple SVE 6. Obesity
97
**CYSTITIS** -What is this? -When is it common?
-Infection of the bladder -In the PP period
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**CYSTITIS** -Is it easily treated? -What if it is left untreated?
-Yes, with antibiotics -It can become pyelonephritis
99
**CYSTITIS** -What are the typical causes? (5)
1. Epidural anesthesia 2. Over-distended bladder OR incomplete emptying of bladder 3. Foley insertion 4. Operative deliveries, including vacuum extraction & forceps 5. SVEs pre/during labor
100
**CYSTITIS** -Why is epidural anesthesia a risk factor?
Because it decreases the urge to void & increases risk of distended bladder
101
**CYSTITIS** -What can operative deliveries/forceps/vacuum extraction cause?
Edema to peri-urethral opening
102
**CYSTITIS** -Why do SVEs cause cystitis?
They may contaminate the urethra with bacteria
103
**CYSTITIS** -What are the maternal s/s? (6)
1. 100.4 fever or greater 2. Burning on urination 3. Flank pain 4. Supra-pubic pain 5. Urgency 6. Voiding less than 150 mL/void
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**CYSTITIS** -How is this diagnosed?
UA/UC, CBC
105
**CYSTITIS** -How is it managed before culture results?
IV/oral antibiotics
106
**VENOUS THROMBOEMBOLISM (VTE)** -What is this? -What are patients usually given?
-Blood clot that starts in vein -SCDs
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**VENOUS THROMBOEMBOLISM (VTE)** -What is a PE?
Blood clot that forms in vein & travels to the lungs
108
**VENOUS THROMBOEMBOLISM (VTE)** -What are the risk factors? (7)
1. Obesity 2. H/o blood clotting disorder 3. HYPERtension 4. Smoking 5. Diabetes 6. Heart disease 7. Renal disease
109
**VENOUS THROMBOEMBOLISM (VTE)** -What are the s/s? (4)
1. Dependent edema 2. Unilateral leg pain 3. Low grade fever 4. Positive Homan's sign
110
**PE** -What would you see? (6)
1. SOB 2. Tachypnea 3. Tachycardia 4. Chest pain 5. Fever 6. Anxiety
111
**HYPERTENSION** -What is postpartum preeclampsia?
High BP & excess protein in urine soon after childbirth
112
**HYPERTENSION** -When does PPP develop?
Up to 6 weeks OR LATER after childbirth
113
**DIC** -What is this?
When the body breaks down blood clots quicker than the body can form them
114
**DIC** -What does this lead to?
Depleted clotting factors --> hemorrhage & death
115
**DIC** -What are the risk factors? (3)
1. Placental abruption 2. HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) 3. AFE
116
**DIC** -Usually you will see what kind of bleeding?
PROLONGED uterine bleeding, bleeding from IV or incision site, gums, bladder
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**DIC** -What are the signs of shock that you should look out for? (4)
1. Tachycardia 2. Tachypnea 3. HYPOtension 4. Pale/clammy skin
118
**DIC** -_____ factors are abnormal
Clotting (PT/PTT)
119
**DIC** -How do you manage this? (4)
1. IV therapy 2. Blood/platelet transfusion 3. FFP 4. Oxygen
120
**DIABETES** -What is the PP screening?
2 hr glucose test
121
**DIABETES** -These women are at risk for ____ & need to be monitored for what?
-infections -mastitis, endometritis, woun infections
122
**MASTITIS** -What is this? -Who is it common among?
-Inflammation/infection of the breast -lactating women
123
**MASTITIS** -When does it occur? -It is usually confined to...?
-Within the first 2 weeks PP --> after milk flow is established -one breast
124
**MASTITIS** -What are the risk factors? (3)
1. H/o mastitis 2. Cracked/sore/red nipples 3. Use of antifungal nipple cream (for NB thrush)
125
**MASTITIS** -What are the s/s? (7)
1. Hard, tender, palpable mass 2. Redness 3. Pain 4. Fever 5. Malaise 6. Tachycardia 7. Prurulent drainage
126
**MASTITIS** -How is this diagnosed?
Culture expressed milk from the affected breast
127
**MASTITIS** -What can you do to treat this?
1. Antibiotic treatment 2. Warm compress 3. Continue breastfeeding OR empty out the breast
128
**PP DEPRESSION** -What is this?
Severe depression that occurs within first 6-12 months PP
129
**PP DEPRESSION** -How is the woman?
Depressed --> loses interest/pleasure in family/daily activities for at least 2 weeks
130
**PP DEPRESSION** -Who is a risk? (5)
Women with... 1. H/o depression before or during pregnancy 2. Poor social support 3. Poor relationship with partner 4. Life/child stressors 5. Pregnancy or childbirth complications
131
**PP DEPRESSION** -Read through S/S
1. Sleep/appetite disturbance 2. Fatigue greater than expected for caring for a NB 3. Despondency, uncontrolled crying, anxiety/fear/panic 4. Inability to concentrate or take care of personal ADLs or care for baby (often seen as decreased affectionate contact with NB—thoughts of harming the NB) 5. Feelings of guilt/inadequacy/worthlessness, suicidal ideations
132
**PP DEPRESSION** -How do you treat mild PPD?
Interpersonal psychotherapy
133
**PP DEPRESSION** -How do you treat moderate PPD?
Interpersonal psychotherapy & antidepressants
134
**PP DEPRESSION** -How do you treat severe PPD?
1. Intense psychiatric care 2. Crisis intervention 3. Interpersonal psychotherapy 4. Antidepressants 5. Electroconvulsive therapy (ECT)
135
**PP DEPRESSION** -What is the state law?
ALL mothers are screening for PPD using Edinburgh depression scale in the hospital, 6 weeks follow up, & pediatrician office
136
**PP PSYCHOSIS** -What is this?
A variant of bipolar disorder --> SERIOUS PP mood disorder
137
**PP PSYCHOSIS** -What do these women require? -Why?
IMMEDIATE hospitalization & evaluation --> they are at risk for harming themselves & their NB
138
**PP PSYCHOSIS** -Read through S/S
1. Paranoia 2. Grandiose/bizarre delusions generally associated with the NB 3. Mood swings 4. Extreme agitation 5. Depressed or elevated moods 6. Distraught feelings about their ability to enjoy/love/care for the NB 7. Strange beliefs that she or her NB must be harmed or die 8. Disorganized appearance/behavior
139
**PP PSYCHOSIS** -What is the treatment?
1. Hospitalization is psych unit 2. Antidepressants & antipsychotics 3. Psychotherapy 4. ECT
140
**PATERNAL POSTNATAL DEPRESSION** -When does this develop?
within 6 months after NB is born
141
**PATERNAL POSTNATAL DEPRESSION** -What happens to testosterone & estrogen levels?
During first few months testosterone decrease & estrogen increases --> LOW testosterone is related to depression in men
142
**PATERNAL POSTNATAL DEPRESSION** -What is the primary risk factor?
Maternal PPD
143
**PATERNAL POSTNATAL DEPRESSION** -Read through rest
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