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