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NURS 4500: Final Material > Class 8: Postpartum Hemorrhage > Flashcards

Class 8: Postpartum Hemorrhage Flashcards

1
Q

what estimated blood loss (EBL) from a vaginal delivery indicates PPH

A
  • EBL >500 mL
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2
Q

what EBL from a c-section indicates PPH

A
  • EBL >1000mL
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3
Q

PPH is classified with respect to?

A
  • respect to time of birth
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4
Q

what is considered early/primary/acute bleeding?

A
  • within 24 h of delivery = most dangerous time for potential PPH
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5
Q

what is considered late/secondary PPH?

A
  • between 24h and 6 weeks postpartum
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6
Q

due to the timing of late/secondary PPH, what is important?

A
  • education since the pt will be at home
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7
Q

late/secondary PPH is usually due to

A
  • subinvolution
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8
Q

what is considered PPH

A
  • ANY blood loss that has the potential to cause hemodynamic instability
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9
Q

what is the leading cause of death globally

A
  • PPH
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10
Q

PPH is an…

A
  • obstetrical emergency
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11
Q

how preventable is PPH?

A
  • highly preventable
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12
Q

describe the identification of PPH

A
  • can go unrecognizable for awhile d/t compensatory mechanisms–> until there are serious symptoms
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13
Q

addressing PPH is facilitated by…

A
  • an interprofessional team approach
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14
Q

what are the 4 main causes of PPH?

A
  • Tone
  • Tissue
  • Trauma
  • Thrombin
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15
Q

what is included under the Tone cause of PPH

A
  • uterine atony
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16
Q

what is included under the Tissue cause of PPH (4)

A
  • retained placental fragments
  • placenta accrete/increta/percreta
  • placental abruption
  • placenta previa
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17
Q

what is included under the trauma cause of PPH (7)

A
  • uterine inversion
  • uterine rupture
  • lacerations of birth canal
  • hematoma
  • episiotomy
  • trauma during labor & birth (forceps & vacuum assisted birth)
  • manual removal of retained placenta
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18
Q

what increases the risk of uterine rupture

A
  • c-section
  • VBAC
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19
Q

what is included under the thrombin cause of PPH

A
  • coagulopathies
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20
Q

what can be done to prevent PPH (7)

A
  • be prepared –> know risk factors and communicate them to the team
  • active mngmt of 3rd stage of labor
  • uterine massage (correct process)
  • uterotonics as ordered
  • careful inspection of placenta (ensure no pieces missing)
  • prevent a full bladder
  • close observation of birther
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21
Q

what is included in active mngmt of 3rd stage of labor to help prevent PPH (4)

A
  • admin oxytocin w birth of anterior shoulder
  • gentle cord traction (do not be too aggressive)
  • consider delayed cord clamping (to allow newborn to get as much blood as possible)
  • fundal massage after delivery
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22
Q

birth of the placenta that lasts ____ increases the risk of placenta

A

> 30 min

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23
Q

fundal massage is done until? why is it important to only do it until then?

A
  • fundus firm, no more than that
  • to prevent uterus from becoming too tired
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24
Q

what is uterine atony

A
  • defined as hypotonia or relaxation of the uterus
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25
Q

what is the leading cause of early PPH

A
  • uterine atony
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26
Q

what are risk factors for uterine atony (9)

A
  • uterus overstretched or overdistended
  • high parity (>=4)
  • over tired uterus
  • birth trauma
  • mg sulfate admin during labor or PP
  • halogenated anaesthetic
  • chorioamnionitis
  • subinvolution
  • history of PPH
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27
Q

how can an “overstretched” or overdistended uterus increase the risk of PPH

A
  • causes muscle layer not to be as effective
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28
Q

how can mg sulphate admin increase risk of PPH

A
  • relaxes muscle layer
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29
Q

what can cause an overstretched or overdistended uterus? (4)

A
  • fetal macrosomia
  • multiple gestation
  • polyhydramnios
  • distention w clots
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30
Q

what can cause an overtired uterus? (2)

A
  • prolonged labor
  • includes induction/augmentation w oxytocin
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31
Q

what can cause birth trauma? (2)

A
  • vacuum
  • forceps-assisted delivery
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32
Q

what is included in mngmt of uterine atony (9)

A
  • astute assessments –> estimation of blood loss
  • frequent VS
  • uterine/fundal massage
  • empty the bladder
  • large bore IV access
  • admin of uterotonic meds
  • bloodwork
  • admin of blood components as ordered
  • may require more extensive procedures
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33
Q

what is the first line mngmt for PPH r/t uterine atony

A
  • uterine/fundal massage
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34
Q

what are esp important to assess r/t VS? why?

A
  • HR and RR
  • will increase before BP due to compensatory mechanisms
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35
Q

why is it imp to have an empty bladder r/t PPH and uterine atony?

A
  • a full bladder pushes an uncontracted uterus into an even more contracted state
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36
Q

what may be done to empty the bladder

A
  • an indwelling urinary cath may be inserted
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37
Q

what is included in bloodwork for mngmt of uterine atony (4)

A
  • CBC (hgb, plts)
  • blood type & antibody screen
  • coagulation studies
  • other
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38
Q

what are more extensive procedures for uterine atony?

A
  • bimanual compression
  • surgical procedures
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39
Q

what is bimanual compression of the uterus

A
  • involves physician using 2 hands to compress uterus
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40
Q

what is imp with the interventions for uterine atony

A
  • ongoing monitoring of effectiveness of each intervention
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41
Q

what could happen if uterine massage is done too aggressively

A

can cause:
- overtired uterus
- invert/prolapses uterus

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42
Q

what are examples of uterotonic drugs (4)

A
  • oxytocin
    -misoprostol
  • carboprost
  • ergometrine (ergonovine)
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43
Q

what is the 1st line uterotonic drug

A
  • oxytocin
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44
Q

what is the onset and duration of oxytocin? what implication does this have?

A
  • rapid onset
  • short duration
  • keep close eye on IV bag so doesn’t run out
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45
Q

misoprostol can be given via what routes?

A
  • oral
  • rectal
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46
Q

describe the effectiveness of misoprostol

A
  • debate about effectiveness
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47
Q

what side effect can misoprostol have

A
  • can increase temperature
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48
Q

what side effect can carboprost have? what implication does this have?

A
  • causes signif diarrhea
  • also give an anti-diarrheal
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49
Q

what is a contraindication to carboprost

A
  • asthma –> can cause bronchospasm
50
Q

what side effect can ergometrine have? what implication does this have?

A
  • can increase BP
  • do not give if HTN
51
Q

describe the difference in oxytocin dosing during L&D vs PP

A
  • dosing difference bc not worried abt gas exchange to fetus
52
Q

what is retained placenta

A
  • part or all of the placenta remains in the uterus which prevents the uterus from contracting fully
53
Q

succenturiate lobe

A

A specific lobe on the maternal side of the placenta which is more likely to be retained

54
Q

what may be signs of retained placenta? (5)

A
  • prolonged lochia
  • pain
  • fever
  • foul odor
  • signs occur later
55
Q

what is placenta accreta/increta/perceta

A
  • abnormal adherence
56
Q

what is included in mngmt for retained placenta (5)

A
  • frequent VS
  • astute assess
  • could require manual removal of placenta by obstetrical care provider
  • lab studies as ordered
  • admin of blood components as ordered
57
Q

what is included in nursing care for manual removal of placenta (4)

A
  • requires effective pain control
  • IV access w large bore IV
  • frequent VS
  • ensure correct sponge and needle counts
58
Q

what may be required in the case of acreta/increta/percreta

A
  • hysterectomy
59
Q

where is the placenta located w placenta previa?

A
  • placenta covers opening of cervix
60
Q

how might placenta previa affect PPH?

A
  • implants lower = muscle layer not there to contract/less effective
61
Q

what is inversion of the uterus

A
  • uterus turns inside out after birth
62
Q

what is the risk of uterus inversion

A
  • potentially life-threatening
63
Q

what are 3 types of inversion of the uterus

A
  • incomplete
  • complete
  • prolapsed
64
Q

what is incomplete uterus inversion

A
  • cannot see but felt
  • feel smooth mass that can be palpated thru slightly dilated cervix
65
Q

what is complete uterus inversion

A
  • lining of fundus protrudes thru cervical os
66
Q

what is prolapsed uterus inversion

A
  • thrus introitus
  • see large, red, round mass
67
Q

what are causes of inversion of the uterus (8)

A
  • fundal implantation of the placenta
  • vigorous fundal pressure
  • excessive traction applied to the cord
  • fetal macrosomia
  • tocolysis
  • prolonged labor
  • uterine atony
  • abnormally adherent placental tissue
68
Q

what is included in mngmt of inversion of the uterus? (4)

A
  • emergency situation, call for help!
  • large bore IV
  • fluid resus as ordered
  • uterus must be replaced into pelvic cavity by HCP
69
Q

what should be avoided in mngmt of inversion of uterus

A
  • aggressive fundal massage
70
Q

what meds may be given in mngmt of inversion of uterus (2)? what impact do these have?

A
  • tocolytics
  • halogenated anesthetics
  • may be given to relax the uterus before attempting to replace
71
Q

what is given after the uterus is replaced into the pelvic cavity in mngmt for inversion of uterus

A
  • oxytocin
72
Q

lacerations should be suspected when…

A
  • bleeding continues despite a well-contracted (firm) uterus
73
Q

lacerations to the ___ are most common

A
  • perineum
74
Q

__ and __ degree extensions to episiotomies possible

A
  • 3rd and 4th
75
Q

bleeding from lacerations are often described as…

A
  • a slow trickle or oozing
  • a constant flow
76
Q

lacerations occur more often w (4)

A
  • difficult or precipitous births
  • fetal size
  • abnormal presentation and position
  • operative assisted vaginal birth
77
Q

what is included in nursing mngmt for lacerations (5)

A
  • IV as needed
  • pain mngmt
  • ensure correct sponge & needle count
  • provide explanation and education
  • lab studies as needed
78
Q

if packing is inserted during mngmt of lacerations, what is required? (3)

A
  • clearly document time inserted
  • how much used
  • where
79
Q

define: hematoma

A
  • collection of blood in the connective tissue
80
Q

hematomas can be… which are most common

A
  • vulvar (most common)
  • vaginal
  • retroperitoneal
81
Q

what can cause vaginal hematoma?

A
  • forceps assisted birth
82
Q

what can cause retroperitoneal hematoma

A
  • c-section
83
Q

what can retroperitoneal hematoma feel like

A
  • pressure, like about to give birth again
84
Q

hematomas may require… (2)

A
  • surgical evacuation
  • lab test as ordered
85
Q

describe the uterus, bleeding, and characteristics of bleeding with uterine atony

A
  • uterus: boggy
  • bleeding: intermittent
  • characteristics: clots and dark blood
86
Q

describe the uterus, bleeding, and characteristics of bleeding with trauma

A
  • uterus: firm
  • bleeding: continuous
  • characteristics: bright red blood (arterial)
87
Q

when should we suspect coagulopathies as the cause of PPH?

A
  • if bleeding continues and no identifable source
88
Q

what are 3 diff types of coagulopathies

A
  • idiopathic thrombocytopenia purpura (ITP)
  • von willebrand disease
  • DIC
89
Q

what is ITP

A
  • autoimmune disorder in which antiplt antibodies decrease the lifespan on the plts
90
Q

what impact does ITP have on bleeding time

A
  • increases it
91
Q

medical mngmt of ITP focuses on..

A
  • control of plt stability
92
Q

Idiopathic thrombocytopenia purpura may require what meds?

A
  • corticosteroids
  • IV IgG
93
Q

what is von willebrand disease

A
  • factor VIII deficiency and plt dysfunction which leads to prolonged bleeding time
94
Q

von willebrand disease is a type of?? the most common ____?

A
  • type of hemophilia
  • most common hereditary bleeding disorder
95
Q

individuals w von willebrand disease are at an increased risk for PPH up to ___ weeks PP

A
  • up to 4 weeks PP
96
Q

what med is included in mngmt of von willebrand disease

A

DDAVP

97
Q

describe use of DDAVP for von willebrand disease

A
  • given 30 min prior to delivery = promotes release of von willebrand & factor 8
98
Q

what is SIC

A
  • imbalance between the body’s clotting and fibrinolytic systems
  • acquired disorder of blood clotting in which the fibrinogen lvl falls to below effective limits
99
Q

describe clotting in a health pt

A
  • plts seal over a point of bleeding to prevent further blood loss
  • fibrin strengthens this “plug”
100
Q

describe clotting in a pt w DIC

A
  • at one point in their body, there is increased coagulation ( at the site of the initial insult/bleed)
  • in the remainder of the body, a bleeding deficit exists = no plts or fibrin left
101
Q

what are signs of DIC (6)

A
  • spontaneous bleeding from gums, nose, IV, IM, or subcut site
  • peteachiae around where BP was placed
  • tachycardia
  • hypotension
  • diaphoresis
  • bloodwork changes
102
Q

what labwork changes are seen w DIC (3)

A
  • decreased plts
  • decreased fibrinogen
  • decreased prothrombin
103
Q

what are risk factors for DIC (7)

A
  • acute APH
  • acute PPH
  • placental abruption
  • amniotic fluid embolism
  • fetal demise that remains in utero for extended periods
  • severe preeclampsia
  • sepsis
104
Q

mngmt of DIC requires… (2)

A
  • correction of the underlying cause
  • must be distinguished from other clotting disorders before therapy initiated
105
Q

what is included in mngmt of DIC (7)

A
  • assessment
  • fluid replacement as ordered
  • blood component replacement as ordered
  • optimize oxygenation & perfusion
  • lab studies as ordered
  • consider foley
  • provide explanation & emotional support
106
Q

what should foley w urometer placement be considered w DIC

A
  • DIC can cause renal failure
107
Q

what should urine output be w DIC?

A
  • at least 30mL/hr
108
Q

what is tranexamic acid

A
  • an antifibrinolytic drug that is given concomitantly w other drugs and procedures for control of bleeding with bleeding disorders
109
Q

what is included in assessment for PPH (5)

A

circulatory status:
- palpation of pulses
- inspection
- auscultation
- observation
- measurement

110
Q

what is included in inspection of PPH (7)

A
  • skin color
  • temp
  • turgor
  • LOC
  • cap refill
  • mucos membranes
  • any oozing sites
  • petechiae/ecchymosis
111
Q

what is included in auscultation of PPH (2)

A
  • heart sounds/murmurs
  • breath sounds
112
Q

what is included in observation for PPH (4)

A
  • anxiety
  • apprehension
  • restlessness
  • disorientation
113
Q

what is included in measurement for PPH

A
  • pulse oximetry
  • BP, HR
  • urinary output
114
Q

what is essential w PPH

A
  • early recognition and intervention
115
Q

how can we be prepared for PPH

A
  • be aware of risk factors
116
Q

what is imp to do w PPH

A
  • call for help
117
Q

what is hemorrhagic shock

A
  • perfusion of organs severely compromised d/t bleeding
118
Q

what are signs of hemorrhagic shock (7)

A
  • rapid & shallow resps
  • rapid, irregular, weak pulse
  • decreased BP (late sign)
  • pale, cool, clammy skin
  • decreased urine output
  • increased anxiety & disorientation
  • lethargy
119
Q

the classic signs of shock may not appear until the PP woman has lost ____% of their blood volume

A
  • 30-40%
120
Q

what is included in mngmt for hemorrhagic shock (5)

A
  • large bore IV, maybe 2
  • fluid resus
  • blood component admin
  • lab studies as ordered
  • urinary output –> indwelling cath
121
Q

what should be monitored closely w hemorrhagic shock (3)

A
  • VS
  • breath sounds
  • LOC
122
Q

a massive transfusion is an…

A
  • an emergency situation where there is an expected transfusion of 4 or more RBC within 1 hr and on-going, substantial need is expected

NURS 4500: Final Material (16 decks)

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