post partum risks

Question 1

primary vs. delayed hemorrhage

Answer 1

-primary: within first 4-8 hrs
-delayed: later than 8 hrs

Question 2

prompt intervention for hemorrhage

Answer 2

palpate and massage the fundus

Question 3

hemorrhage risk factors

Answer 3

-tone: overdistention, oxytocin, anesthesia, mg sulfate, retention
-tissue: subinvolution
-trauma: lacerations, hematomas
-thrombin: ITP, von willebrand, DIC
-traction: inversion

Question 4

uterine atony

Answer 4

-inability of uterus to contract adequately after birth

Question 5

causes of uterine atony

Answer 5

-retention, overdistenion of uterus, prolonged or forceful rapid labor, bacterial toxins, anesthesia, meds (mg, oxytocin)

Question 6

uterine atony findings

Answer 6

-large & boggy uterus, lateral
-irregular or excessive bleeding
-tachycardia, hypotension
-later signs: pale, cool clammy skin, loss of skin turgor

Question 7

mgmt of uterine atony

Answer 7

-ensure empty bladder
-assess fundus & massage
-monitor lochia
-monitor for clots
-frequent vitals
-maintain IVF
- 2-3L/min, can be with nasal cannula
-amin methergine, misoprostol
-encourage breastfeeding

Question 8

subinvolution

Answer 8

failure of uterus to return to its pre-pregnant state

Question 9

subinvolution risks

Answer 9

-pelvic infection
-endometritis
-retained placenta

Question 10

subinvolution findings

Answer 10

-prolonged/irregular vaginal bleeding
-uterus higher than normal
-boggy uterus

Question 11

subinvolution tx

Answer 11

-D&C
-oxytocin
-methylergonovine
-abx

Question 12

inversion

Answer 12

uterus turns partially or all the way inside out

Question 13

inversion risks

Answer 13

-retain placenta
-fundal pressure
-excessive traction on cord

Question 14

inversion findings

Answer 14

-pain in lower abdomen
-large red rounded mass/smooth mass in the dilated cervic
-dizzy, pallor, low bp

Question 15

inversion tx

Answer 15

-replace uterus
-terbutaline (tocolytic)
-abx

Question 16

retained placenta

Answer 16

placenta delivered in >30 min after birth

Question 17

retained placenta risks

Answer 17

-excessive traction on cord
-partial separation of placenta
-entrapment by uterine wing

Question 18

retained placenta findings

Answer 18

-excessive bleeding
-atony
-return of lochia progression
-malodorous discharge
-elevated temp

Question 19

retained placenta tx

Answer 19

-manual removal
-D&C
-oxytocin
-terbutaline

Question 20

lacerations & hematomas risks

Answer 20

-operative
-precipitous birth
-CPD/macro
-previous scarring
-prolonged pressure on fetus head

Question 21

lacerations & hematomas findings

Answer 21

-lacerations: vaginal bleeding, firm uterus, continuous slow trickle of bright red blood
-hematoma: bulging bluish mass, red-purple discolor, difficulty voiding, possible pain

Question 22

lacerations & hematomas tx

Answer 22

-repair of laceration & hematoma
-ice packs
-pain meds

Question 23

ITP- idiopathic thrombocytopenia purpura

Answer 23

-autoimmune, low number of circulating platelets, due to antibodies
-low platelets, low fibrinogen
-increased bleeding times
-prothrombin, PTT, d-dimer

Question 24

ITP tx

Answer 24

-glucocorticoids
-caplacizumab
-platelet infusion
-splenectomy if needed
-avoid NSAIDS, ASA, antihistamines

Question 25

von willebrand disease

Answer 25

-congenital bleeding disorder with prolonged bleeding time -deficiency of von willebrand factor, impairment of platelet adhesion -bleeding gums, easy bruising, menorrhagia, blood in urine in stool, hematomas -increases in pregnancy

Question 26

DIC- disseminated intravascular coagulation

Answer 26

-clotting/anticlotting occurs simultaneously, organ damage -most important is to identify initiating cause -tx focuses on perfusion through fluid therapy, heparin, blood & blood products, oxygen -may use vasoactive meds, abc, uterotonic meds

Question 27

thrombin diseases assessments

Answer 27

-identify risk factors -palpate uterus, massage if boggy -assess quantitative amount of bleeding -assess for 5Ts

Question 28

mgmt for bleedings disorders

Answer 28

-massage uterus, express clots -uterotonic drugs- know CI & SE -maintian primary IV infusion, 2nd infusion if needed -foley catheter -provide 02 via nasal cannula 2-3L/min, monitor o2 status -elevate legs 20-30 degrees -monitor vs, LOC, lochia -be prepared for use of uterine tamponade or bimanual compression

Question 29

oxytocin

Answer 29

-stimulate uterine contraction -assess fundus, monitor bleeding every 15 minutes, monitor uterine tone, monitor urine tention

Question 30

misoprostol

Answer 30

-stimulates the uterus to contract/reduce bleeding -off label use for acute postpartum hemorrhage

Question 31

methylergonovine maleate

Answer 31

-stimulates the uterus to prevent and treat postpartum hemorrhage due to atony or subinvolution -assess baseline bleeding, uterine tone, and vitals every 15min -monitor for htn, seizures, cramping, n/v , and palpitations -Contraindications: HTN

Question 32

carboprost (prostaglandin)

Answer 32

-stimulates uterine contractions/to treat postpartum hemorrhage due to uterine atony when not controlled by other methods -assess vitals, contractions, bleeding status -contraindications: asthma active CV disease

Question 33

tranexamic acid (TXA)

Answer 33

-1gm IV over 10 min, IV push -antifibrinolytic -contraindicated: hx of thromboembolic events, hx of coagulopathy

Question 34

assessing for shock (hemorrhagic)

Answer 34

-monitor vs, mental status, output -goal: control bleeding, fluid resuscitation (fluids or blood), correct imbalance of 02 delivery & consumption

Question 35

post partum infections

Answer 35

-endometritis -surgical sites -uti -mastitis

Question 36

risk factors for pp infections

Answer 36

-18-24 prom/ prolonged labor/c-section -invasive procedures/birth -chronic conditions/pre-existing infections

Question 37

venous thromboembolic conditions

Answer 37

-thrombophlebitis caused by thrombus can become embolus -superficial and deep vein thrombosis, can lead to pulmonary embolus -s/s: calf pain, hardened area, redness, warmth, edema -dx: doppler, ct, mri

Question 38

prevention of thromboembolus

Answer 38

-SCDs, TED hose -if BR >8hr, perform ROM -early ambulation -avoid prolonged sitting, standing, immobility -elevate legs, avoid crossing legs -hydration, d/c smoking -may have heparin injection before delivery

Question 39

mgmt of thromboembolus

Answer 39

-encourage rest -BR & elevate legs -intermittent warm compress -dont massage -leg circumference -anti-embolism stockings -analgesics (no NSAIDS or ASA), anticoagulants

Question 40

thromboembolus treatments

Answer 40

heparin and warfarin

Question 41

heparin

Answer 41

-prevent clots formation & growth -IV 3-5 days adjusted by coag. studies -aPTT 1.5-2.5 times the control of 30-40 seconds -protamine sulfate on hand

Question 42

warfarin

Answer 42

-oral tx for clots -taken for 3mo -monitor PT 1.5-2.5 times control, 11-12.5 seconds, INR 2-3 -vitamin K on hand -teratogenic, no OCs

Question 43

pulmonary embolus

Answer 43

-s/s: apprehension, chest pain, dyspnea, tachycardia, hemoptysis, hypotension, hypoxia -dx: ventilation/perfusion lung scan, CXR -semi fowlers, o2 by face mask -warfarin and heparin -thrombolytics: altepase, streptokinase

Question 44

endometritis

Answer 44

-can involve endometrium ( & decuda, myometrium) -organisms: normal flora- E. coli, klebsiella, G vaginalis -s/s: pelvic pain, anorexia, fever >100.4 after first 24 hrs, bad lochia, flu like sx

Question 45

surgical site infections

Answer 45

-c section incision, episiotomy, genital laceration -redness, swelling, drainage, tenderness, unapproximation, dehiscence, evisceration -high wbc

Question 46

UTI

Answer 46

-organisms: e. coli, klebsiella, proteus, enterobacter species -causes: freq. vaginal exams, catherization, genital trauma -s/s: freq., urgency, dysuria, lower abdominal pain, costovertebral (pyelo), fever -dx: ccms -teaching: hygiene, fluid intake, cranberry/prune juice

Question 47

mastitis

Answer 47

risk factors: milk stasis, nipple trauma, prev. poor hygiene -s/s: red, hot, painful, tender area on breast, fever, malaise, -goals: reverse cause, maintain milk, breastfeed -admin pain meds, hydrate, abx

Question 48

PP baby blues

Answer 48

-mild depressive sx, anxiety, irritability, mood swings, tearfulness, increased sensitivity, fatigue -usually peak at 4-5days and resolve by day 10 -if longer than day 10, seek tx

Question 49

PP depression

Answer 49

-sx last longer and are more severe and need tx -may lead to poor bonding, alienation, daily dysfunction, violent thoughts/actions

Question 50

psychosis

Answer 50

-onset can be abrupt, around 3 months PP, hx of mental illness -emergency -s/s: mood lability, delusional beliefs, hallucination, disorganized thinking, anger -early sx mimic depression, sleep disturbance, fatigue -dont leave mother alone with infant -tx: psychotropic drugs, psychotherapy, support groups -education is key