OB: chapter 23: postpartum complications

*postpartum hemorrhage* - vaginal blood loss? - c-section blood loss?

- 500 mL - 1000 mL

what are low molecular weight heparins?

- Enoxaparin (Lovenox) - Dalteparin (Fragmin) - tinzaparin

what are oral factor XA inhibitors?

- Rivaroxaban (Xarelto) - Apixaban (Eliquis) - Edoxaban (Savaysa) - dabigatran

*coagulopathy uterine inversion* treatment - care?

- administer O2 by nonrebreather - place indwelling catheter to facilitate urine output monitoring - low urine = hypovolemia

how do you diagnosis coagulopathy?

- by laboratory assessment and may be congenital or acquired and include immune thrombocytopenic purpura, VWD, and disseminated intravascular coagulation (DIC).

factors that place you at risk for VTE?

- dilated veins leading to slower blood flow and pooling - endothelial injury related to surgical intervention or placental detachment - the increase of coagulation factors in pregnancy to decrease the risk of hemorrhage.

what are symptoms of postpartum infection?

- fever persists after 24hrs - fever begins 2-10 days after birth - elevated WBCS

*hematoma* - risks?

- first birth - preeclampsia - prolonged first and/or second stage of labor - vulvar varicosities - multifetal pregnancy - fetal macrosomia - maternal obesity - clotting disorders

what are risks for coagulopathy?

- hypertensive disorder - intrauterine fetal demise - fetal demise - sepsis - congenital clotting deficiency

*risk factors for PPH* - coagulopathy?

- hypertensive disorder - fetal demise - sepsis - IUGR

what are symptoms of hypovolemic shock?

- hypotension - tachycardia - pallor - decreased capillary refill - cool, pale, clammy skin - oliguria - tachypnea

*risk factors for PPH* - trauma?

- lacerations - LGA

care for DVT and PE?

- legs elevated - apply warm and cold compress (decrease inflammation) - NSAIDS - compression (edema) - ambulate

*coagulopathy: uterine inversion* - risk factors?

- macrosomia - a short umbilical cord - first birth - uterine tumors - retained placenta - placenta accreta, and a rapid delivery

what are uterotonics?

- oxytocin - tranexamic acid - misoprostol - dinoprostone

*coagulopathies* - symptoms of ICP?

- petechiae - thrombocytopenia - hemorrhage - epistaxis - purpura

associated risks with uterine atony?

- polyhydramnios - multiple gestation -macrosomia

what is the treatment for perineal wounds?

- removal of sutures and opening wound

*risk factors for PPH* - uterine atony?

- retained placenta - LGA - induction of labor - infection - high parity ' - failure to progress to 2nd stage of labor

what is PPH caused by?

- uterine atony - blood coagulopathies - trauma

delayed or secondary PPH may occur?

24 hours to 12 weeks after delivery.

*coagulopathy: uterine inversion* - Protrusion of the fundus through the cervical os?

2nd degree (complete)

when is mastitis most common?

3 months of breastfeeding

what is fluid resuscitation?

3:1 ratio - 3 mL of fluids introduced IV for every 1 mL of estimated blood loss.

*coagulopathy: uterine inversion* - Prolapse of the fundus through the uterus to the introitus

3rd degree (uterine prolapse)

*coagulopathy: uterine inversion* - Complete prolapse of both the uterus and vagina (total uterine and vaginal)

4th degree

*VTE* how long does anticoagulatn therapy continue for?

6 months

A family member of a postpartum patient comes out of the patient's room to tell the nurse that the patient is pale, sweaty, and "isn't acting right." What should the nurse do first? A. Notify the patient's primary health care provider. B. Evaluate the patient's uterus and lochia. C. Obtain a set of vital signs. D. Reassure the family member that the patient is doing well.

B - rationale: may experience blood loss

what are risk factors for endometritis?

Cesarean birth Retained placental fragments Prolonged rupture of membranes Chorioamnionitis Internal fetal/uterine pressure monitoring Multiple vaginal exams Prolonged labor Hemorrhage

*diagnostic tests for VTE* - usually elevated even in the absence of a clot.

D-dimer

*diagnostic tests for VTE* - is superior for assessing iliac vein DVT

Magnetic resonance venography

an infection of the fascia that progresses rapidly and destroys skin and cutaneous tissue, may develop but is very rare. With this type of infection, drainage is thin and copious, and the subcutaneous tissue bleeds easily

Necrotizing fasciitis

what may a coagulopathy lead to?

PPH and, in turn, PPH results in a loss of clotting factors, thus limiting the body's ability to stop the bleeding.

is a blood clot or multiple clots that form within a vein.

VTE

when are C-section wounds diagnosed?

after d/c, from 4-7 days postpartum

*hematoma treatment care* - what do you give for small vulvar hematomas?

analgesics, as ordered, and ice packs, as these hematomas are quite painful

*hematoma treatment* - A patient who is not hemodynamically and requires two large-bore IVs for fluids and blood products, as well as immediate surgery.

arterial bleed

*coagulopathy uterine inversion* treatment - This is typically a task for the obstetric provider and is very uncomfortable for the patient. - insert a gloved fist into the vagina, pushing against the anterior wall of the vagina. With the other hand, the provider kneads the posterior wall of the uterus. The provider may also reach inside the uterus to manually remove clots or placental or membrane fragments.

bimanual compression

*coagulopathy* symptomatic VWD include?

bleeding from the skin, easy bruising, and extended mucosal bleeding.

a disorder in which the blood's ability to clot is impaired

coagulopathies

what do you treat ITP?

corticosteroids and IV immune globin

what factors contribute to mastitis?

delayed breast emptying, poor drainage of one or more ducts, inconsistent pressure on breasts (like poorly fitting bra), oversupply of milk, or nipple trauma.

*uterotonics* - 20mg vaginally or rectally q2hr o Side effects: N, V, D, headache, fever, chills o Caution: with asthma, hypotension, or HTN

dinoprostone

symptoms of PE?

dyspnea, cough, sweating, and pleuritic chest pain

*coagulopathy uterine inversion* treatment - Bladder distention can contribute to uterine atony, and should be ____________ either voluntarily or with catheter.

empty bladder

an infection of the lining of the uterus. caused by a mix of bacteria originating in genital tract.

endometritis

what are hematomas associated with?

episiotomies and lacerations occurring with operative deliveries, also can happen with closed trauma

*coagulopathy uterine invserion* treatment - boggy uterus requires?

firm massage of fundus

*coagulopathy: uterine inversion* - Prolapse of the fundus into the uterine cavity. Blood loss generally less severe

first degree (incomplete)

may present as shortness of breath, pulmonary edema (crackles on auscultation), edema of the extremities or face, or ascites.

fluid overload

is a collection of blood in the body outside of a blood vessel.

hematoma

*hypovolemic shock* - measures oxygenation, flow, and pressure within the cardiovascular system

hemodynamic monitoring

a dangerous, life-threatening condition in which organs become dangerously under-perfused (loss of blood volume) and under-oxygenated, leading to compromised function and even death.

hypovolemic shock

*coagulopathies* - an acquired disorder in which autoantibodies act against platelet antigens. lasts 12 months

immune thrombocytopenic purpura (ITP)

Pregnancy-associated DVT is almost always in the?

left lower extremity

what med poses a risk with uterine atony?

mag sulfate

*uterine atony* - treatment?

massage uterus and administer uterontonics

Inflammation of the breast tissue often associated with infection.

mastitis

*uterotonics* - 800-1000 mg rectally - Side effects: N, V, D, headache, fever, chills

misoprostol

*coagulopathy uterine inversion* - interventions?

o Call for help o Stop any infusion of uterotonic drug such as oxytocin because uterus must be relaxed o Place 2 16 or 18g IV catheters and infuse fluid to adequately support BP o Bradycardia resulting from parasympathetic stimulation may be corrected by 0.5 mg IV atropine given according to orders. o Get CBC and coagulation studies and administer blood products as ordered per protocol

interventions for PPH?

o Call for help. o Fundal massage of a boggy uterus. o Assess for lacerations or hematoma if the fundus is firm. o Bladder catheterization for inability to void. o Establishing intravenous access. o Oxytocin administered as a first-line uterotonic medication.

what are symptoms of endometritis?

o Fever o Uterine tenderness o Flu-like symptoms o Tachycardia

what are symptoms of c-section wounds?

o Induration o Redness o Warmth o Pain at the incision site o Wound edges may separate o Purulent discharge and fever may be noted

what are risk factors for perineal wounds?

o Operative vaginal delivery o Prolonged second stage of labor o Third- or fourth-degree laceration o Meconium-stained fluid

*hypovolemic shock* - aldosterone tells kidneys to hold urine which causes?

oliguria

how do you treat C-section wounds?

opening and draining the wound. Wounds are left open but kept moist and covered.

*coagulopathy uterine inversion* treatment - what first medication is given?

oxytocin

*uterotonics* - 10-40 U IV in 500 mL - 1L NS at rate sufficient to control atony, 10 U IM o Side effects: N, V, water intoxication

oxytocin

symptoms of superficial vein thrombosis?

pain, tenderness, and redness along the length of the vein

flat, red lesions that do not blanch

petechiae

is bleeding of more than 1,000 mL despite uterine massage and first-line uterotonics (such as oxytocin).

postpartum hemorrhage

can be related to perineal wounds, cesarean wounds, endometritis, mastitis, and urinary tract infections.

postpartum infections

*coagulopathies* - is characterized by autoimmune platelet destruction that is not associated with any other condition.

primary ITP

occur as a result of a birth and are an accumulation of blood in the vulva, vagina, or, rarely, the retroperitoneal space. This space is behind the peritoneum.

puerperal hematoma

an area of discoloration on the skin caused by a coalescence of petechiae.

purpura

*hematoma treatment care* - typically do require surgery or embolization of the bleeding vessels, although conservative management may be preferred in some circumstances.

retroperitoneal hematoma

*coagulopathies* - is characterized by autoimmune platelet destruction that is associated with another condition, such as systemic lupus erythematosus or hepatitis C.

secondary ITP

*uterine atony* - atony R/T infection or retained placenta or fetal membranes

secondary PPH

*endometritis* - can infection may cause uterus to become?

soft and sub-involution

failure of uterus to shrink as a whole

sub- involution

*coagulopathy* - An inversion that occurs from 24 hours to 4 weeks after delivery is termed ___________ and an inversion that happens 1 month or more after delivery is referred to a ____________

subacute, chronic

what are symptoms of DVT?

swelling, pain, localized redness and tenderness

*hypovolemic shock* - your body is losing alot og blood, so your body trys to work harder causing?

tachypnea and tachycardia

what are assessment findings of perineal wounds?

tenderness, redness, and swelling, as well as purulent discharge

*uterotonics* - 1g infused over 10-20 min o Side effects: N, V, D, hypotension o WITHHOLD: disseminated intravascular coagulation (DIC

tranexamic acid

*diagnostic tests for VTE* - is an often-used diagnostic test and is highly sensitive for detecting DVT in proximal veins, although less useful for a DVT in the iliac vein.

ultrasound imaging

failure of the uterus muscle to sufficiently contract, thus allowing blood to seep from the site of placental implantation.

uterine atony

*coagulopathies* - Unusual cause of PPH - a condition in which the uterine fundus prolapses into the endometrial cavity, turning the uterus inside out. - It can result in hemorrhage and shock.

uterine inversion

*coagulopathy uterine inversion* treatment - uterus is packed or a balloon is inserted to try to occlude the blood vessels from which the bleeding is occurring by compressing the inside of the organ.

utrine tamponade

*coagulopathy uterine inversion* - symptoms?

vaginal bleeding, shock, fundus not palpable

may exist independently or as an extension of a vulvar hematoma. may be acutely painful but may also present as a patient report of a sensation of rectal pressure. An examination typically reveals a vaginal mass.

vaginal hematoma

*hematoma treatment* - likely to be hemodynamically stable and receive a single large-bore IV line for fluids. Such patients are more likely to be managed conservatively.

venous bleed

how do you diagnosis PE?

ventilation/perfusion (V/Q) scan and computer tomographic pulmonary angiography.

*coagulopathy* - common inherited bleeding disorder. - is a deficiency in the amount of von Willebrand factor (VWF) or in its action. - role in binding platelets to endothelial components and in fibrin clot formation.

von williebrand disease

usually develops rapidly and is extremely painful. Upon examination, a purplish mass can be identified that is tense with compartmentalized bleeding.

vulvar hematoma

when do symptoms for hematomas develop?

within 24hrs after delivery

early PPH occurs?

within 24hrs of birth