chapter 22
baby blues
Emotional lability Irritability Insomnia Typically resolves within 2 weeks (by postpartum day 10) Usually self-limiting
postpartum infectinos
Fever >38°C or 100.4°F after first 24 hours Organisms usually those of normal vaginal flora (aerobic and anaerobic) Metritis: infection of endometrium, decidua, and adjacent myometrium Wound infections Urinary tract infections Mastitis: inflammation of the breast
mastitis
Flu-like symptoms, including malaise, fever, and chills Tender, hot, red, painful area on one breast Inflammation of breast area Breast tenderness Cracking of skin around nipple or areola Breast distention with milk
PPH Therapeutic Management
Focus on underlying cause Uterine massage Removal of retained placental fragments Antibiotics for infection Repair of lacerations
improve PPH outcmoes
Having a hemorrhage cart with supplies and instruction cards on every OB unit Having immediate access to medications used to treat a massive hemorrhage Establishing a response team within the hospital that can be called Developing emergency-release transfusion protocols in the blood bank Educating all staff on protocols and holding unit-based drills frequently
paostpartum infections: assessment
Identify Risk factors Physiological signs and symptoms
Management of PPI
Infection prevention -Aseptic technique; handwashing; perineal hygiene -Screening of visitors -Administration of antibiotics; wound care -Client teaching Therapeutic management -Broad-spectrum antibiotics for metritis -Wound care for wound infections -Fluids and antibiotics for UTIs -Breast emptying and antibiotics for mastitis
metritis s/sx
Lower abdominal tenderness or pain on one or both sides Temperature elevation (>38º C) Foul-smelling lochia Anorexia Nausea Fatigue and lethargy Leukocytosis and elevated sedimentation rate
PP depression
Major depressive episode associated with childbirth Symptoms lasting beyond 6 weeks and worsening
uterine (fundal) massage
Massaging the Fundus Purpose: To Promote Uterine Contraction : 1. After explaining the procedure to the woman, place one gloved hand on the area above the symphysis pubis (this helps to support the lower uterine segment). 2. Place the other gloved hand (usually the dominant hand) on the fundus. 3. With the hand on the fundus, gently massage the fundus in a circular manner. Be careful not to over massage the fundus, which could lead to muscle fatigue and uterine relaxation. 4. Assess for uterine firmness (uterine tissue responds quickly to touch). 5. If firm, apply gentle yet firm pressure in a downward motion toward the vagina to express any clots that may have accumulated. 6. Do not attempt to express clots until the fundus is firm because the application of firm pressure on an uncontracted uterus could cause uterine inversion, leading to massive hemorrhage. 7. Assist the woman with perineal care and applying a new perineal pad. 8. Remove gloves and wash hands.
PPH: assessment and management
Nursing assessment Early Identification of Risk Factors Vigilant assessment of uterine tone; vaginal bleeding Nursing management Fundal massage; pad count Administration of uterotonic medications Fluid administration Monitoring for signs and symptoms of shock (frequent VS - Q15 - 30 min)
affective disorders assessment and mgmt
Nursing assessment Risk factors Signs and symptoms Nursing management Assistance with coping and adjustment Education Referrals for support
contraindications of administrating each of the mediactions used to control PPH
Pitocin—never give undiluted as a bolus injection intravenously Cytotec—allergy, active cardiovascular disease, pulmonary or hepatic disease Prostin E2—active cardiac, pulmonary, renal, or hepatic disease Methergine—if the woman is hypertensive, do not administer. Hemabate—contraindicated with asthma due to risk of bronchial spasm
thromboembolic nsg mgmt
Prevention Adequate circulation: NSAIDs, bed rest, antiembolism stockings, anticoagulant therapy (heparin); emergency measures for pulmonary embolism Education
classifications of PPH
Primary (immediate or early) -PPH Blood loss that occurs within 24 hrs of birth Delayed (late) PPH -PPH blood loss occurs 24 hrs to 12 weeks after birth
risk factors
Prolonged (>18-24 hours) premature rupture of membranes (removes the barrier of amniotic fluid so bacteria can ascend) Cesarean birth (allows bacterial entry due to break in protective skin barrier) Urinary catheterization (could allow entry of bacteria into bladder due to break in aseptic technique) Regional anesthesia that decreases perception of need to void (causes urinary stasis and increases risk of urinary tract infection) Staff attending to woman are ill (promotes droplet infection from personnel) Compromised health status, such as anemia, obesity, smoking, drug abuse (reduces the body's immune system and decreases ability to fight infection) Preexisting colonization of lower genital tract with bacterial vaginosis, Chlamydia trachomatis, group B streptococci, S. aureus, and E. coli (allows microbes to ascend) Retained placental fragments (provides medium for bacterial growth) Manual removal of a retained placenta (causes trauma to the lining of the uterus and thus opens up sites for bacterial invasion) Insertion of fetal scalp electrode or intrauterine pressure catheters for internal fetal monitoring during labor (provides entry into uterine cavity) Instrument-assisted childbirth, such as forceps or vacuum extraction (increases risk of trauma to genital tract, which provides bacteria access to grow) Trauma to the genital tract, such as episiotomy or lacerations (provides a portal of entry for bacteria) Prolonged labor with frequent vaginal examinations to check progress (allows time for bacteria to multiply and increases potential exposure to microorganisms or trauma) Poor nutritional status (reduces body's ability to repair tissue) Gestational diabetes (decreases body's healing ability and provides higher glucose levels on skin and in urine, which encourages bacterial growth) Break in aseptic technique during surgery or birthing process (allows entry of bacteria)
psychosis
Surfaces within 3 weeks of giving birth Sleep disturbances Fatigue Depression Hypomania
5 ts of PPH
Tone: uterine atony, distended bladder -displace uterus causes bogginess. assess bladder Tissue: retained placenta and clots subinvolution refers to incomplete involution of the uterus or failure to return to its normal size and condition after birth. cause relaxation. Causes of subinvolution include retained placental fragments, distended bladder, excessive maternal activity prohibiting proper recovery, uterine myoma, and infection. All of these conditions contribute to delayed postpartum bleeding. The clinical picture includes a postpartum fundal height that is higher than expected, with a boggy uterus; the lochia fails to change colors from red to serosa to alba within a few weeks. This condition is usually identified at the woman's postpartum examination 4 to 6 weeks after birth with a bimanual vaginal examination or ultrasound. Treatment is directed toward stimulating the uterus to expel fragments with a uterine stimulant, and antibiotics are given to prevent infection. Trauma: vaginal, cervical, or uterine injury Thrombin: coagulopathy (pre-existing or acquired) Idiopathic thrombocytopenic purpura (immune disorder blood doesn't clot normally) von Wildebrand disease (congenital bleeding disorder; inherited as an autosomal dominate trait) Disseminated intravascular coagulation (DIC) (life threatening) traction: cause uterine inversion. any traction on the cord and placenta can cause prolaspe
UTI
Urgency Frequency Dysuria Flank pain Low-grade fever Urinary retention Hematuria Urine positive for nitrates Cloudy urine with strong odor
Misoprostol (Cytotec)
action: Stimulates the uterus to contract/ to reduce bleeding; a prostaglandin analog 800 mcg per rectum, one dose (range, 400-1,000 mcg) nsg interventions: Contraindications: never give undiluted as a bolus injection IV. As above. Not FDA approved for this indication, but a very effective drug therapy for acute postpartum hemorrhage. Contraindications: allergy, active CVD, pulmonary or hepatic disease; use with caution in women with asthma.
causes of PPH
Uterine atony - most common -loose vessels lose more blood -failure of the uterus to contract and retract after birth Lacerations of the genital tract Episiotomy Retained placental fragments -source of leakage, obstruction of vessels. may come out as a clot. may have to d/c to remove tissue Uterine inversion -immediate emergency -uterus on outside of body. from forceful delivery. When postpartum assessment, fundal message second hand at Suprapubic area so uterus does not fall out. If it comes out, may require sx or take fist to push it back up immediate. r/o infection, trauma, reoccurrence. Coagulation disorders LGA -Large for gestational age Failure to progress during 2nd stage of labor Placenta accreta -Line, ditch In the uterine wall the placenta adheres to. Problems with separation Induction and augmentation of labor with oxytocin -Could over stimulate uterus Hematomas -Vulva -Vagina -Subperitoneal areas (bladder, cervix, and last part of rectum)
wound infection s/sx
Weeping serosanguineous or purulent drainage Separation of or unapproximated wound edges Edema Erythema Tenderness Discomfort at the site Maternal fever Elevated white blood cell count
stats of PPH
accounting for about 35% of all maternal deaths. Every year about 14 million women globally suffer from PPH or approximately one in twenty births A hemorrhage occurs in 5% of all births and is responsible for a major part of maternal mortality. The majority of these deaths occur within 4 hours of childbirth, which indicates that they are a consequence of the third stage of labor management
Oxytocin [Pitocin] first-line therapy
action: Stimulates the uterus to contract/to contract the uterus to control bleeding from the placental site 20-40 units in a liter IV Or 10 units IM nursing interventions: Assess fundus for evidence of contraction and compare amount of bleeding every 15 min or according to orders. Monitor vital signs every 15 min. Monitor uterine tone to prevent hyperstimulation. Reassure client about the need for uterine contraction and administer analgesics for comfort. Offer explanation to client and family about what is happening and the purpose of the medication. Provide nonpharmacologic comfort measures to assist with pain management. Set up the IV infusion to be piggybacked into a primary IV line. This ensures that the medication can be discontinued readily if hyperstimulation or adverse effects occur while maintaining the IV site and primary infusion.
methlergonovine maleate [mathergine]
action: Stimulates the uterus/ to prevent and treat postpartum hemorrhage due to atony or subinvolution. 0.2 mg IM injection. May be repeated in 5 min. Thereafter every 2-4 hr nsg interventions: Assess baseline bleeding, uterine tone, and vital signs every 15 min or according to protocol. Offer explanation to client and family about what is happening and the purpose of the medication. Monitor for possible adverse effects, such as hypertension, seizures, uterine cramping, nausea, vomiting, and palpitations. Report any complaints of chest pain promptly. Contraindications: Hypertension
dinoprostone [prostin e2]
actions: 20 mg vaginal or rectal suppository. May be repeated every two hours. nsg intervention: Monitor blood pressure frequently since hypotension is a frequent side effect along with vomiting and diarrhea, nausea, temperature elevation.
prostaglandin (PGF2), carboprost, [hemabate]
actions: Stimulates uterine contractions/to treat postpartum hemorrhage due to uterine atony when not controlled by other methods. 0.25 mg IM injection. May be repeated every 15-90 min up to 8 doses. Stimulates uterine contractions to reduce bleeding when not controlled by the first-line therapy of oxytocin. nsg interventions: Assess vital signs, uterine contractions, client's comfort level, and bleeding status as per protocol. Offer explanation to client and family about what is happening and the purpose of the medication. Monitor for possible adverse effects, such as fever, chills, headache, nausea, vomiting, diarrhea, flushing, and bronchospasm. Contraindications: asthma or active cardiovascular disease Same as above Contraindications: active cardiac, pulmonary, renal, or hepatic disease
blood loss from PPH
blood loss greater than 500 mL after vaginal birth or more than 1,000 mL after a cesarean birth. However, this definition is arbitrary, because estimates of blood loss at birth are subjective and generally inaccurate. Moreover, average blood loss from birth frequently exceeds 500 or 1,000 mL, and symptoms of hemorrhage or shock from blood loss may be hidden by normal plasma volume increases that occur during pregnancy
morbidity of PPH
can be severe, with sequelae including organ failure, shock, edema, thrombosis, acute respiratory distress, sepsis, anemia, intensive care admissions, and prolonged hospitalization
major obstetric hemorrhage
defined as a blood loss of more than 1,500 mL to 2,500 mL or bleeding that requires more than 5 units of transfused blood
REEDA
frequently used for assessing a woman's perineum status. It is derived from five components that have been identified to be associated with the healing process of the perineum. These include: 1. Redness—area may also feel warm to touch. 2. Edema—may indicate infection or a hematoma. 3. Ecchymosis—may indicate vaginal trauma. 4. Discharge—should follow the expected lochia pattern. 5. Approximation of skin edges—should be well aligned without gaps. Each category is assessed and a number assigned (0 to 3 points) for a total REEDA score ranging from 0 to 15. The higher scores indicate increased tissue trauma Monitor the woman's vital signs, especially her temperature. Changes may also signal an infection.
postpartum hemorrhage
potentially life-threatening complication of both vaginal and cesarean births. It is the leading cause of maternal mortality in the United States. It is also most preventable cause of maternal death any amt of bleeding that places the mother in hemodynamic jeopardy consistutes a PPH blood loss subjective
