Postpartum Complications

Question 1

1st degree laceration

Answer 1

Tear limited to fourchette, superficial skin, or vaginal mucosa

Question 2

2nd degree laceration

Answer 2

Extends to perineal muscles and fascia

Spares anal sphincter

Question 3

3rd degree laceration

Answer 3

Tear includes anal sphincter

Question 4

4th degree laceration

Answer 4

Tear extends into rectal mucosa

Question 5

Laceration risk factors

Answer 5

Operative vaginal birth - forceps, vacuum

Cephalopelvic disproportion

Macrosomia

Abnormal presentation/position

Prolonged pressure on vaginal mucosa from fetal head

Prior scarring of birth canal from infection, injury, operation

Question 6

Laceration complication

Answer 6

Infection

Hemorrhage

Pain

Elimination disturbances/incontinence

Question 7

What might be a clue that a laceration is present?

Answer 7

Vaginal bleeding even though uterus is firm and contracted

Question 8

Postpartum hemorrhage

Answer 8

OB emergency following vaginal or C/S delivery

Early - hemorrhage in first 24 hrs

Late - hemorrhage after 24 hrs up to 12 weeks

Question 9

PP hemorrhage diagnosis

Answer 9

Cumulative blood loss >1000 mL

OR

Blood loss w/ signs/sx of hypovolemia w/in 24 hrs after birth

Question 10

Causes of early PP hemorrhage

Answer 10

Atony
Hematoma
Retained tissue
Lacerations
Coagulation defects
Distended bladder

Question 11

PP hemorrhage risk factors

Answer 11

Grand multiparity (5+ births)
Overdistention of uterus - LGA, macrosomia, twins, polyhydramnios
Rapid, prolonged labor
Retained placenta
Placenta previa
Abruptio placentae
Drugs - tocolytics, Mg sulfate, general anesthesia, prolonged oxytocin use
Operative procedures - C/S, vacuum, forceps
Uterine fibroids
Hx of PP hemorrhage
Coagulation defects
Hx of hemorrhage

Question 12

Management of Immediate PP hemorrhage

Answer 12

Uterine massage
Removal of retained tissue/clots
Meds
Monitor for signs of hypovolemic shock

Question 13

Meds for subinvolution/PP hemorrhage

Answer 13

Pitocin 10-20 units IM or IV
Misoprostol (Cytotec) 800 mcg rectal
Methergine 0.2 mg IM - avoid in HTN
Hemabate 250 mcg IM - caution w/ asthma; potential significant diarrhea

Question 14

Hematomas

Answer 14

Collection of clotted blood within tissues appearing as bulging, bluish mass in pelvic region, vagina, or broad ligament

Question 15

Hematoma causes

Answer 15

Bleeding lacerations

Injury to blood vessel in absence of lac/incision

Question 16

Hematoma expected findings

Answer 16

Pain, pressure, difficulty voiding

Question 17

Hematoma risk factors

Answer 17

Nulliparous
Macrosomia/LGA
Preeclampsia
Prolonged second stage of labor
Multifetal
Vulvar varicosities
Clotting disorders

Question 18

Hematoma treatment

Answer 18

Conservative measures
Surgery
Arterial embolization

Question 19

3 common thromboembolisms in PP

Answer 19

Superficial venous thrombophlebitis

DVT

PE

Question 20

Common DVT sx

Answer 20

Pain in leg or groin

Swelling of leg, erythema, heat, tenderness

Question 21

DVT Diagnosis

Answer 21

Venous US, Doppler flow analysis, MRI

Question 22

DVT prevention

Answer 22

Prophylactic heparin if high risk
Early ambulation
Avoid pillows under knees
SCD, stockings

Question 23

DVT Risk factors

Answer 23

Pregnancy
C/S
Operative vaginal birth
PE, varicosities
Immobility
Obesity
Smoking
Multiparity
Age >35
Hx of VTE

Question 24

PE sx

Answer 24

Dyspnea, chest pain, tachycardia, tachypnea, hemoptysis, low pulse ox

Question 25

PE nursing interventions

Answer 25

``` Frequent RR & VS assessment Auscultate breath sounds Call for help Admin O2 at 8-20 L/min via tight face mask Raise head of bed Narcotic analgesics for pain IV access ```

Question 26

Thrombophlebitis nursing interventions

Answer 26

``` Bed rest Elevate extremity above level of heart Frequent position changes Intermittent/continuous moist heat NO massage of affected area Measure leg circumferences Thigh-high antiembolism stockings Administer analgesics Administer anticoagulants for DVT ```

Question 27

Patient education on anticoagulants

Answer 27

``` Avoid aspirin, ibuprofen Use electric razor for shaving Avoid alcohol (warfarin) Brush teeth gently Avoid rubbing/massaging legs Avoid periods of prolonged sitting/crossing legs ```

Question 28

Two week PP visit

Answer 28

C/S patients - check steri-strips All other birthing persons w/ access Mental Health Assessment

Question 29

6 week PP visit

Answer 29

H&P Assessments - Brain/Blues, Breast/Bottle, Bottom, Bleeding, Bladder, Bowel, Baby, Birth Control Labs - diabetes screen, Hgb

Question 30

6 week PP visit - physical exam

Answer 30

``` Physical survey Palpate thyroid Breast exam Abdomen - resolution of diastasis? Perineum Bimanual exam - pelvic floor muscles, cervix closure, complete involution Speculum exam if needed, f/u Pap? Possible rectal exam ```

Question 31

Postpartum Infections

Answer 31

Endometritis, Mastitis, Wound infections, UTI

Question 32

Endometritis

Answer 32

Infection of uterus, most common, usually beginning on day 3-4 PP beginning at placental attachment site and spreading

Question 33

Wound infection sites

Answer 33

C/S, episiotomies, lacs, trauma wounds

Question 34

Mastitis

Answer 34

Infection of breast, usually unilateral; can progress to abscess if untreated

Question 35

Endometritis risk factors

Answer 35

``` Prolonged labor Prolonged ROM Multiple cervical exams Internal fetal or uterine monitoring Large amount of meconium in amniotic fluid Manual placenta removal Low SES Maternal DM, severe anemia PTB BV Operative vaginal delivery Postterm pregnancy HIV infection GBS colonization ```

Question 36

Endometritis signs/sx

Answer 36

Appear 'sick' - fever, chills, malaise, abdominal pain/tenderness/cramping, uterine tenderness, purulent, malodorous lochia, fatigue, loss of appetite

Question 37

Endometritis treatment

Answer 37

IV broad-spectrum abx initially - penicillins, cephalosporins, clindamycin, gentamicin Comfort measures

Question 38

Mastitis signs/sx

Answer 38

Preceded by engorgement, stasis of milk 'Flu-like' - fever, chills, achiness, headache, localized lump, wedge-shaped area of pain, redness, heat, inflammation, enlarged axillary LNs, tender, palpable hard region

Question 39

Mastitis complication

Answer 39

Abscess

Question 40

Mastitis risk factors

Answer 40

``` Milk stasis Nipple trauma Poor breastfeeding technique Decrease in feeding frequency Contamination of breasts due to poor hygiene ```

Question 41

Mastitis treatment

Answer 41

PO abx Heat/cold application Analgesics Continue feeding on both sides! (milk is not infected)

Question 42

UTI PP risk factors

Answer 42

``` Postpartal hypotonic bladder or urethra Epidural anesthesia Urinary bladder catheterization Frequent pelvic exams Genital tract injuries Hx of UTIs C/S birth ```

Question 43

UTI complication

Answer 43

Pyelonephritis w/ permanent kidney damage --> renal failure

Question 44

UTI signs/sx

Answer 44

``` Urgency, frequency, dysuria, pelvic discomfort Fever, chills, malaise VS changes Urinary retention Pain in suprapubic region CVA tenderness ```

Question 45

UTI diagnosis

Answer 45

Urinalysis - WBC, RBC, protein, bacteria

Question 46

UTI treatment

Answer 46

``` PO abx Maintain hydration Proper perineal care Frequent urination Acetaminophen for pain ```

Question 47

Wound infection signs/sx

Answer 47

Fever, redness, swelling around incision, drainage/bleeding, abdominal pain, pain at incision site, not approximated/dehiscence

Question 48

Wound infection management

Answer 48

Office visit - potential I&D, culture Abx prescribed Analgesics for pain Warm compresses, sitz baths

Question 49

Painful intercourse management

Answer 49

Vaginal dryness (low E2), lac, episiotomy Use lubricant, E2 therapy If persists past 3 months, refer to gynecology or PT