Maternal Health Exam 3

contractions of the uterine myometrium

blood vessels that supply the placental site pass through the myometrium, an interlacing network of smooth muscle fibers, compress the blood vessels at the placental site, decreasing the amount of blood loss

assessment of mastitis

breast tenderness or warmth to the touch, malaise, breast swelling and hardness, pain or burning sensation continuously or while breastfeeding, skin redness

medical management of endometritis

broad spectrum IV antibiotics, CBC, endometrial cultures, blood cultures, urinalysis to rule out UTI

nursing actions of tissue

call provider to assess, D&C may be needed, monitor for signs of shock, administer oxygen if indicated

nursing interventions of trauma

call provider to evaluate, locate, repair laceration or assess hematoma, monitor vital signs and lochia, weigh pads and chux to monitor blood loss, anticipate possible excision and ligation if >3 cm, consider indwelling catheter, continue to assess vitals, blood loss, and fluid maintenance, pain management, ice to area

stage 4 hemorrhage

cardiovascular collapse, massive hemorrhage, profound hypovolemic shock, or amniotic fluid embolism

readiness for hemorrhage

cart with supplies, checklist, instruction cards for intrauterine balloon and compressions stitches, immediate access to medications, establish a response team, establish massive and emergency release transfusion, unit education on protocols

risk factors for endometritis

cesarean birth, prolonged rupture of membranes, prolonged labor, internal fetal and uterine monitoring, meconium-stained fluid, multiple cervical exams during labor, obesity

stage 3 hemorrhage medications

continue stage 1 medications, intitatie massive transfusion protocol

Stage 2 hemorrhage medications

continue stage 1, obtain 2 units RBCs, thaw 2 units FFP

Stage 3 hemorrhage

continued bleeding >1500 mL OR >2 units RBCs given OR patient at risk for occult bleeding/coagulopathy OR any patient with abnormal vital signs/labs/oliguria

Stage 2 hemorrhage

continued bleeding up to 1500 mL OR >2 uterotonics with normal vital signs and lab values

assessment of DVT

dependent edema lower extremities, abrupt unilateral leg pain, erythema in one leg, low-grade fever, positive Homan's sign

stage 1 hemorrhage action

determine etiology, consider 4 Ts, prepare operating room if indicated

thrombin disorders

disseminated intravascular coagulation preeclampsia, stillbirth

assessment of anaphylactoid syndrome

dyspnea, seizures, hypotension, cyanosis, cardiopulmonary arrest, uterine atony that causes massive hemorrhage and leads to DIC, cardiac and respiratory arrest

nursing actions of thrombin disorders

early recognition is key to survival, confirm accurate blood loss estimates, monitor lab values, vitals, I&Os, manage systemic manifestations such as volume replacement, platelets, IV oxygen by face mask

assessment of endometritis

elevated temperature, midline lower abdominal pain/discomfort, uterine tenderness, tachycardia, subinvolution, malaise, headache, chills, heavy and foul smelling lochia

stage 1 hemorrhage initial steps

ensure 16-18G IV access, increase IV fluids, insert indwelling catheter, fundal massage

risk factors for UTI

epidural anesthesia, overdistended bladder or incomplete emptying of bladder which increases bacterial growth, urinary catheter during labor, operative vaginal delivery, intrapartal vaginal exams

assessment of wound infection

erythema, heat, swelling, tenderness, purulent drainage, low-grade fever, increased pain at incision or laceration site

risk factors for mastitis

history with previous infant, cracked/sore nipples, using only one position for breastfeeding, wearing a tight-fitting bra, poor nutrition, ample milk supply and reduction in number of feedings

medical management for postpartum psychosis

hospitalization to the psychiatric unit, psychiatric evaluation, antidepressant and antipsychotic drug treatment, psychotherapy, electroconvulsive therapy

readiness for psychological complications

identify mental health screening tools to be used in every setting, establish a response protocol and screening tools based on local resources, educate clinicians and office staff on use of screening tools, identify a leader for the project

Stage 1 hemorrhage medications

increase oxytocin 10-40 units per 500-1000 mL solution, Methylergonovine 0.2 mg IM, Hemabate, Carboprost 250 mcg IM (repeat Q15min, up to 8x) Misoprostol 800-1,000 mcg type and crossmatch 2 units RBC

endometritis

infection of the endometrium, myometrium, and/or parametrial tissue that usually starts at the placental site and spreads to encompass the entire endometrium

mastitis

inflammation/infection of the breast tissue that is common among lactating woman, usually in just 1 breast

response for psychological complications

initiate a stage-based response protocol to positive screenings, activate an emergency referral protocol for women with suicidal or homicidal ideation or psychosis, provide appropriate and timely support for women as well as family members

pre-gestational diabetes

insulin requirements decrease in the immediate postpartum period higher risk for infection breastfeeding highly encouraged for Type 2 diabetes to improve pregnancy weight decrease

medical management of paternal l postnatal depression

interpersonal psychotherapy, antidepressant medications

assessment of paternal postnatal depression

irritable, overwhelmed, frustrated, indecisive, avoidance of social situations, cynical, increased alcohol consumption, drug use, domestic violence

signs and symptoms of trauma

laceration -firm uterus with continued bleeding, steady trickle of unclotted bright red blood hematoma - firm uterus, sudden onset of painful perineal pressure, bulging area under the skin, difficulty voiding or sitting

assessment of UTI

low grade fever, burning on urination, suprapubic pain, urgency to void, small frequent voidings less than 150 mL per voiding

trauma

lower genital tract laceration hematoma

classification of postpartum depression

major depressive disorder when the woman has a depressed mood or a loss of interest or pleasure in daily activities for at least 2 weeks in addition to 4 of the following symptoms significant weight loss or gain (more than 5% change), insomnia or hypersomnia, changes in psychomotor activity, decreased energy or fatigue, feelings of worthlessness or guilt, decreased ability to concentrate or inability to make decisions

risk factors for paternal postnatal depression

maternal postpartum depression is primary risk factor, depressive symptoms during partner's pregnancy, unplanned and/or unexpected pregnancy, baby with health or feeding problems, lack of social support, excessive stress about becoming a father, preexisting mental health disorder, stressful life event

medical management of postpartum depression

mild - interpersonal psychotherapy moderate - interpersonal psychotherapy, antidepressants severe - intensive psychiatric care, crisis interventions, interpersonal psychotherapy, antidepressants, electroconvulsive therapy

Stage 3 hemorrhage initial steps

mobilize additional help, move to operative room, announce clinical status, outline and communicate plan

Stage 2 hemorrhage initial steps

mobilize additional help, place second IV (16-18G), draw STAT labs, prepare OR

postpartum depression

mood disorder characterized by severe depression that occurs w/in the first 6-12 months postpartum and affects 11.5% of women

response to hemorrhage

unit-standard, stage-based, obstetric hemorrhage emergency management plan with checklists, support program for patients, families, and staff for all significant hemorrhages

medical management of UTI

urinalysis, CBC, urine culture and sensitivity, antibiotics started before culture

tone

uterine atony -large baby, high parity, rapid labor, fever, fibroids

signs and symptoms of tissue

uterus may not respond to interventions, uterus may remain larger than normal, strings of tissue may be seen in the blood

signs and symptoms of paternal postnatal depression

withdrawal from social interactions, cynical in his interactions and experience irritable moods, demonstrate avoidance behaviors such as spending more time away from the family, man's affect may appear to be anxious or mad vs sad

risk factors for postpartum psychosis

woman with known bipolar disorder, personal or family history of bipolar disorder or affective disorder

recognition and prevention for hemorrhage

assessment for risk prenatal, on admission and at other appropriate times, measurement of cumulative blood loss, active management of the third stage of labor

Venous Thromboembolic Disease (VTE)

blood clot that starts in a vein, DVT or PE, blood clot in thigh more likely to break off and travel to the lungs one of the leading causes of maternal mortality and morbidity

tissue

retained placental fragments or abnormal placenta

nursing actions for postpartum depression

review prenatal record for risk, monitor mother infant interactions, anticipatory guidance, be supportive and encouraging, provide support group information

complications of postpartum infection

scarring, infertility, sepsis, septic shock, death

indications of primary hemorrhage

10% decrease in the hemoglobin and/or hematocrit post-birth, saturation of the peripad within 15 minutes, fundus that remains boggy after fundal massage tachycardia and decreased BP (late signs)

nursing actions for tone

assist the uterus contract via massage or medications, monitor vaginal bleeding, weigh pads and chux, maintain fluid balance, monitor vital signs and labs, administer oxygen 10-12 L via face mask, keep pt warm

nursing actions for venous thromboembolic disease

begin ambulation after symptoms dissipate, administer elastic stockings, manage pain, teach women how to administer heparin subcutaneously to abdomen, instruct woman to report side effects

signs and symptoms of tone

bleeding may be slow and steady or profuse, large, boggy uterus, clots

risk factors for disseminated intravascular coagulation (DIC)

abruptio placenta, HELLP syndrome, anaphylactoid syndrome of pregnancy, hemorrhage

stage 3 hemorrhage action

achieve hemostasis, interventions based on etiology

stage 4 hemorrhage action

ACLS, simultaneous massive transfusion, immediate surgical intervention to ensure hemostasis (hysterectomy)

anaphylactoid syndrome of pregnancy

Amniotic fluid embolism, rare but fatal complication during pregnancy, labor, and birth, or the first 24 hrs postbirth

maternal obesity

BMI > 30 risk for complications regarding the method of birth, increased incidence of infection and wound complication

stage 1 hemorrhage

Blood loss >500 mL vaginal or blood loss >1000 mL cesarean with normal vital signs and lab values

signs and symptoms of thrombin disorder

DIC, oozing from IV sites, nosebleeds, petechiae, bleeding gums, hypotension, signs of shock, abnormal clotting factors

first line medications for hypertension

IV labetalol - increased risk of neonatal bradycardia, avoid in woman with asthma hydralazine - increased risk of maternal hypotension oral nifedipine - increased risk of maternal tachycardia, possibly causing overshooting of hypertension

nursing interventions for diabetes

assess knowledge, risk perception, identify barriers to health prompting barriers and social support, individualized interventions, information about resources such as exercise and diet advice, links as needed to dieticians, breastfeeding, schedule follow-up appointment 2-6 weeks post-discharge

nursing actions for wound infection

assess perineum or surgical incision for REEDA, inform physician of abnormal assessment, assess vital signs, obtain lab specimens, review lab reports, administer antibiotics, pain management, proper hand-hygiene, education on diet, fluids, rest

gestational diabetes

Most return to pre-pregnancy state after delivery, however 1/3 of patients will continue to have impaired glucose metabolism at postpartum screening, and 15-50% will develop T2DM screening recommended 6-12 week postpartum check

hemorrhage

PPH is a blood loss greater than 500 mL for vaginal deliveries and greater than 1,000 mL for cesarean deliveries with a 10% drop in hemoglobin and/or hematocrit

assessment of PE

SOB, tachypnea, tachycardia, dyspnea, pleural chest pain, fever, anxiety

reporting and systems learning for hemorrhage

establish a culture of huddles for high-risk patients and post-event debriefs to identify successes and opportunities, multidisciplinary review of serious hemorrhage for systems issues, monitor outcomes and process metrics in perinatal quality improvement committee

reporting for psychological complications

establish a non judgemental culture of safety through multidisciplinary health rounds, perform a multidisciplinary review of adverse mental health outcomes, establish local stands for recognition and response to measure compliance, understand individual performance, and track outcomes

hypercoagulability

factor VIII complex increases during pregnancy, factor V increases following placental separation, platelet activity increases during pregnancy, fibrin formation increases during pregnancy

when to notify physician

fever, foul-smelling lochia, large blood clots or bleeding that saturates a pad in 1 hour, discharge, erythema or severe pain from incision, hot, red, painful areas on breasts or legs, bleeding and/or severe pain in nipples or breasts, chest pain or dyspnea w/o exertion, frequent/painful urination, signs of depression

maternal hypertension

goal is to normal BP but achieve a ranch of 140-150/90-100 mmHg to prevent repeated, prolonged exposure to severe systolic hypertension monitor BP every 5-15minutes

risk factors for postpartum infections

history of cesarean delivery, premature rupture of membranes, frequent cervical examinations, internal fetal monitoring, preexisting pelvic infection, diabetes, nutritional status, obesity

risk factors for postpartum depression

history of depression before pregnancy, depression or anxiety during pregnancy, inadequate social support, poor quality relationship with partner, life and child care stresses, complications of pregnancy or childbirth, single, low socioeconomic status

risk factors for PPH

neonatal macrosomia, placenta previa/accreta, multiple gestation, previous cesarean or uterine surgery, polyhydramnios, high parity, prior PPH, operative vaginal delivery, augmented or induced labor, ineffective uterine contractions during labor, precipitous labor, chorioamnionitis, maternal obesity, congenital or acquired coagulation defects

medical management of anaphylactoid syndrome

no supportive intervention to improve maternal prognosis, focus is on maintaining cardiac and respiratory function, stopping hemorrhage, and correcting blood loss, complete CBC, ABG, chest x-ray, transfer to critical care, heart-lung bypass, blood loss replacement

nursing actions of anaphylactoid syndrome

notify physician immediately of assessment data to initiate early interventions, administer oxygen, establish 2 IV sites with large-bore catheters, obtain lab specimens, administer blood replacement, provide emotional support, call code and initiate CPR, transfer to ICU

risk factors for wound infections

obesity, diabetes, malnutrition, long labor, prolonged operative time during c-section, premature rupture of membranes, pre existing infection, immunodeficiency, corticosteroid therapy, poor suturing techniques

medical management of wound infections

obtain a culture specimen from wound or laceration no purulent drainage - administer oral antibiotics, apply warm compress purulent drainage - open and drain wound, IV antibiotic therapy

recognition for psychological complications

obtain individual and family mental health history, past/current medications, conduct validated mental health screening during appropriately timed patient encounters during and after pregnancy, provide appropriately timed perinatal depression and anxiety awareness education to woman her family/support system

secondary hemorrhage

occurs 24 hrs to 12 weeks (Jenn) post delivery and is caused by hematomas, subinvolution, or retained placental tissue

paternal postnatal depression

occurs in 1-8% of new fathers during the first 6 months following childbirth, testosterone levels lower and is linked with depression often goes undiagnosed and untreated

primary hemorrhage

occurs within the first 24 hrs after childbirth and is caused by uterine atony, lacerations, or hematomas

medical management of DIC

optimizing hemodynamic function and improving overall tissue oxygenation lab tests, identification of primary cause, IV therapy, blood replacement, platelet transfusion, FFP, cryoprecipitate, oxygen therapy

medical management of mastitis

oral antibiotic therapy 10-14 days, culture of expressed milk from affected breast if infection does not resolve

assessment for postpartum psychosis

paranoia, grandiose or bizarre delusions, mood swings, extreme agitation, depressed or elated moods, distraught feelings about ability to enjoy infant, confused thinking, strange beliefs, disorganized behavior

associated risks of postpartum psychological disorders

poor adherence to medical care, exacerbation of current medical conditions, loss of interpersonal and financial resources, smoking, substance abuse, suicide, infanticide

nursing actions of postpartum psychosis

screen patients for condition, review prenatal record for risk factors, educate woman who are at risk of the early signs, early detection and treatment can prevent major episode

nursing actions for maternal obesity

precisely assess uterus, measure and record height and weight to determine BMI, reinforce information on maternal complications, provide referrals to dietitian, support breastfeeding, encourage woman to sleep sitting position, make appropriate environmental changes to accommodate larger patients

risk factors for venous thromboembolic disease

pregnancy, venous stasis, hypercoagulability, diabetes, compression of lower body, heart disease, hypertension, renal disease, sickle-cell anemia, smoking, infections

assessment of DIC

prolonged, uncontrolled uterine bleeding, bleeding from the IV site, incision site, gums and bladder, purpuric areas at pressure sites, abnormal clotting study results, increased anxiety, signs of shock (pale, clammy skin, tachycardia, tachypnea, hypotension)

nursing actions for paternal postnatal depression

provide information on PPND to the man and his partner, stress the importance of seeking professional help if he is experiencing symptoms

postpartum psychosis

rare, patient develops frank psychosis, cognitive impairment, grossly disorganized behavior that represents a complete change from previous functioning

nursing actions for DIC

reduce risk, obtain IV with large-bore catheter, administer oxygen, obtain lab specimens, start blood transfusion as ordered, emotional support, facilitate transfer to ICU

nursing actions of UTI

reduction - assist woman to bathroom w/in a few hrs of birth, catheterize woman if unable to void 2-3 hrs post birth, remind woman to void every 3-4 hrs, measure I&O, drink minimum 3000 mL/day obtain lab specimens, administer antibiotics, push oral hydration

nursing actions for mastitis

reduction - complete emptying of breasts, regular breastfeeding/pumping, proper hand-hygiene, importance of healthy diet, larger bra size, massaging breasts during breastfeeding administer antibiotics and analgesics, apply warm compress to affected area, instruct woman to continue breastfeeding or pumping

nursing actions for endometritis

reduction - educate woman regarding hand-washing, proper peri care, change peripad every 3-4 hrs, encourage early ambulation, encourage intake of fluids, high protein and vitamin C diet monitor WBC, administer antibiotics, provide pain management, provide emotional support

assessment of postpartum depression

sleep and appetite disturbances, fatigue, despondency, uncontrolled crying, anxiety, fear, panic, inability to concentrate, feelings of guilt, inadequacy, worthlessness inability to care for self or baby, decreased affectionate contact with infant, decreased responsiveness to infant, thoughts of harming infant, thoughts of suicide

yellow triggers

temperature 35-36 systolic BP 150-160 or 90-100 diastolic BP 90-100 HR 100-120 or 40-50 RR 21-30

red triggers

temperature <35 or >38 systolic BP <90 or >160 diastolic BP >100 HR <40 or >120 RR <10 or >30 Oxygen sat <95