chp 22

PPH pathophysiology: 4Ts

Tone: uterine atony, distended bladder Tissue: retained placenta n clots Trauma: laceration n hematoma (vaginal, cervical, uterine) Thrombin: coagulation

PPH physical assessment

blots bigger than a quarter Perineal pad soak <15 min tachycardia n hypotension

Institute emergency measures if DIC develops

emergency measures to control bleeding and shock -prepare transfer to ICU -replace fluid volume -admin blood component therapy -optimize o2 n tissue perfusion maintain cardiac output -monitor coagulation status inc PTT

Prostaglandin, carboprost

last effort to stimulate uterus to prevent hemorrhage due to uterine atony (IM) repeated 15-90 up to 8 times

Uterus massage technique

one hand above symphysis pubis while the other massages fundus

Misoprostol (Cytotec)

stimulate the uterus to contract, acts like prostaglandins (rectum)

Causes PPH

uterine atony (most common) lacerations hematomas (vulva, vagina, sub-peritoneal) episiotomy retained placental fragments uterine inversion coagulation disorders placenta prievia/ abruptio

post partum blues define

85% first few days - 10 days mood swings, tearfulness, insomnia, lack of appetite, and feeling of letdown (no intervention)

PPH blood loss

>500 ml vaginal >1000 ml cesarean

mild shock due to blood loss symptoms

diaphoresis inc. capillary refill cool extremities maternal anxiety

DVT diagnosis

doppler ultrasound computed tomography magnetic resonance imaging

Common postpartum disorders

hemorrhage infection thromboembolic disease postpartum affective disorder

DVT risk factors

pregnancy c-section (2x risk) operative vaginal birth pulmonary embolism immobility obesity smokin multiparity >35 yrs old history of thromboembolism

postpartum depression define

10-15% within 12 months feelings of sadness and intense mood swings (needs intervention)

Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication? -At 8 hours post-delivery she has voided a total of 100 mL in four small voidings. -She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart. -She says she is extremely thirsty. -Her perineum is obviously edematous on inspection.

-At 8 hours post-delivery she has voided a total of 100 mL in four small voiding.

postpartum nurse is caring for a client 8hrs after an uncomplicated c-section. Which interventions can reduce the risk of thrombus formation?

-administer analgesics 30 min prior to ambulation -instruct client to perform hourly leg exercise -maintain sequential compression devices on lower extremities -request a prescription for daily aspirin until the client is discharged

development of mastitis

-incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis -engorgement -clogged milk ducts -cracked or bleeding nipples -nipple piercing -use of plastic-backed breast pads.

A client presents to the clinic with her 3-week-old infant reporting general flu-like symptoms and a painful right breast. Assessment reveals temperature 101°8F (38.8°C) and the right breast nipple with a movable mass that is red and warm. Which instruction should the nurse prioritize for this client? -Complete the full course of antibiotic prescribed, even if you begins to feel better. -Use NSAIDs, warm showers, and warm compresses to relieve discomfort. -Breastfeed or otherwise empty your breasts at least every 3 hours. -Increase your fluid intake to ensure that you will continue to produce adequate milk.

Complete the full course of antibiotic prescribed, even if you begins to feel better. Explanation: Mastitis is an infection of the breast tissue with common reports of general flu-like symptoms that occur suddenly, along with tenderness, pain, and heaviness in the breast. Inspection reveals erythema and edema in an area localized to one breast, commonly in a pie-shaped wedge. The area is warm and moves or compresses on palpation. Nursing care focuses on supporting continued breastfeeding, preventing milk stasis and administering antibiotics for a full 10 to 14 days. The woman should empty her breasts every 1.5 to 2 hours to help prevent milk stasis and the spread of the mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing her fluid intake will keep the mother well-hydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care for this client at this time.

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for?

Consistency, shape, and location

The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis? Complete blood count Vital signs Pad count Urine volume excreted

Pad count Explanation: The way to monitor for bleeding every hour is to assess pads and percentage of the pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour.

The nurse inspects the client's perineum and finds it is red, swollen, and tender. The nurse explains to the client that she needs to be monitored for blood loss, especially because of bleeding into the tissue of the perineum because of the third degree laceration sustained while giving birth. What parameters will the nurse assess to detect signs of additional blood loss? Select all that apply. -Urine output -Blood pressure -Pulse rate -Uterine fundus -Amount of lochia

Urine output Blood pressure Pulse rate Assessment findings consistent with blood loss are increased pulse rate, decreased blood pressure, and decreased urine output. Bleeding into the perineal tissue may not be visible, therefore monitoring these parameters is important. Because bleeding is related to the laceration, uterine involution is not impacted and the assessment of the fundus is not going to provide useful data. Similarly, the amount of lochia will not provide useful data about bleeding into the perineal tissue.

severe shock due to blood loss symptoms

hypotension agitation/confusion hemodynamic instability

Oxytocin (Pitocin)

stimulate uterus contraction to control bleeding from placental site (IV/ IM)

Methylergonovine maleate

stimulate uterus to prevent hemorrhage due to uterine atony (IM) causes hypertension, check bp repeated every 5 min for 2-4hrs

moderate shock due to blood symptoms

tachycardia postural hypotension oliguria

postpartum psychosis define

2-3 wks higher risk bipolar disorder confusion, disorientation, hallucinations, delusions, obsessive behaviors and paranoia

PPH Therapeutic Management

-firmly massage uterus monitor vitals -assess for source of bleeding -assess for bladder distension (catheter to measure output) -maintain IV fluid -provide o2 10-12L/min -nonrebreather mask elevate leg 20-30 degree

postpartum infection risk factors

-prolonged premature membrane rupture (>18-24hrs) -c-section -urinary catheter -regional anesthesia (dec. need to void) -preexisting disease -retained placenta -trauma to genital tract -gestational diabetes