Postpartum Hemorrhage and Complications Flashcards
(36 cards)
1
Q
What is Postpartum Hemorrhage
A
- Major cause of mortality with childbearing
- Vaginal birth: 500cc
- Cesarean section: 1000cc
- Can be Early (within 24hours) greatest danger
- Late (24 hours to 6 weeks after birth)
2
Q
Conditions that distend the uterus beyond average capacity
A
- Multiple gestation (twins, triplets, etc.)
- Polyhydramnios (excess amniotic fluid)
- A large baby (>9 lbs)
- Uterine fibroids (tumors in the uterine wall)
3
Q
Conditions that could have caused cervical or uterine lacerations
A
- Operative Birth
- Rapid Birth
4
Q
Conditions with varied placental site or attachment
A
- Placenta previa (placenta partially or completely covers the cervix)
- Placenta accreta (placenta abnormally attaches to the uterine wall)
- Premature separation of the placenta (placenta detaches from the uterine wall before delivery)
5
Q
Conditions that leave the uterus unable to contract readily
A
- Retained placental fragments
- Deep anesthesia or analgesia
- Labor initiated or assisted with an oxytocin agent
- Hight Parity
- Maternal Age over 35
- Previous uterine surgery
- prolonged and difficult labor
- History of PPH
- Prolonged use of Magnesium sulfate or other tocolytic therapy
6
Q
Conditions that lead to inadequate blood coagulation
A
- Fetal Death
- Disseminated intravascular coagulation (DIC)
7
Q
Causes of postpartum
hemorrhage
A
- Tone
- Trauma
- Tissue
- Thrombin Thrombosis
8
Q
Tone: UTERINE ATONY
A
- Absent or inadequate uterine contraction
- Most frequent cause of postpartum hemorrhage
- s/s: soft, boggy uterus
9
Q
Management:
Atony
A
- Fundal massage.. READ PAGE 661
- Empty the bladder
- Remain with patient and continue assessing her status
- If contractions not maintained, contact the physician
- Oxytocin
- Carboprost
- Methergine
- Misoprostol
10
Q
Management:
Resistant Atony
A
- Bimanual compression
- Manual exploration
- Balloon catheter
- Embolization
- Ligation of uterine arteries
- hysterectomy
11
Q
Management: Hemorrhage
A
- Elevate legs
- Administer oxygen by face mask
- Monitor vital signs
- Blood transfusion
12
Q
Trauma: Lacerations
A
- May occur in the cervix, vagina, perineum
- Associated factors:
❖ Difficult or precipitate labor
❖ Primigravida
❖ Birth of large infant (>9lbs)
❖ Use of a lithotomy position
❖ Use of instruments (vacuum, forceps extraction)
13
Q
Types of Lacerations
A
- CERVICAL
- VAGINAL
- Perineal lacerations
14
Q
Cervical Laceration
A
- Usually arterial (bright red)
- Difficult to visualize
- Occurs immediately after
detachment of placenta - Management:Suturing
15
Q
Vaginal Laceration
A
- Easier to visualize
- More difficult to repair
- Management:
- Suturing
- Balloon tamponade
- Vaginal packing
- Indwelling foley
catheter
16
Q
Perineal Laceration
A
- More apt with lithotomy position
- 4 categories: ASSESS THE EXTENT AND DEPTH
17
Q
4 Categories of Perineal Laceration
A
- First-degree laceration: Involves the vaginal mucous membrane and the skin of the perineum up to the fourchette (the point where the labia meet).
- Second-degree laceration: Extends to the vagina, perineal skin, fascia, levator ani muscle (a muscle group in the pelvic floor), and perineal body.
- Third-degree laceration: Includes the entire perineum and extends to the external anal sphincter of the rectum.
- Fourth-degree laceration: Involves the entire perineum, the rectal sphincter, and some of the mucous membrane of the rectum. This is the most severe type of laceration.
18
Q
Perineal lacerations:
Management
A
- Suturing
- Extra precaution to avoid loosened suture or infection
- High oral fluid intake
- Stool softener
- Avoid enema or rectal suppository
19
Q
Other traumatic causes of hemorrhage/ bleeding
A
- Uterine inversion
- Perineal hematoma:
20
Q
Perineal Hematoma
A
Usually due to precipitate labor
In women with perineal varicosities
S/S: severe pain in the perineal area or feeling of pressure between legs
Area of purplish discoloration with obvious swelling,
tender
Treatment: analgesic, ice pack, incision and ligation
21
Q
Tissue: Retained Placental Fragments
A
- Retained fragments prevent uterus from contracting
- Especially in succenturiate placenta, Placenta accrete
- If small, bleeding may not be detected until postpartum
day 6 to 10
22
Q
Retained placental fragments: Diagnostic Tests
A
- Inspection of delivered placenta
- Ultrasound
- Human chorionic gonadotropin (hCG) determination
23
Q
Retained placental fragments:
Management
A
- Manual Removal of retained placenta
- Dilatation and curettage (D&C)
- Balloon occlusion and embolization
- Methotrexate
24
Q
Thrombin/Thrombosis: Bleeding Diathesis
A
- Due to the presence of a comorbidity
- Thrombocytopenia
- Functional abnormalities of platelets
- Familial clotting disorder
25
Thrombocytopenia
A. HELLP syndrome
B. Abruptio placenta
C. DIC (from missed early miscarriage or FDIU)
D. Sepsis
26
Normal Platelet Value
150,000 to 400,000
27
Others causes of PPH
1. Uterine Subinvolution
2. UTERINE INVERSION
28
Uterine Subinvolution
* Incomplete return of the uterus to
its prepregnant size and shape
* Enlarged and soft and 4 and 6 week postpartal visit
* Lochia is still present
* Can be from:
Retained placental
fragments
Mild endometritis
Uterine myoma
29
Consequences of Uterine Subinvolution
Anemia
Infection
Impaired bonding
30
Uterine subinvolution:
management
* Methylergonovine
* Antibiotics if necessary
31
UTERINE INVERSION
- Uterus turns inside out
- occurs in the first 24 hours after birth
- rare complication
32
Degrees of Uterine Inversion
- 1st Degree: The fundus (top part) of the uterus is inverted, but the cervix remains within the vagina.
- 2nd Degree: The entire uterus is inverted, but it remains within the vagina.
- 3rd Degree: The inverted uterus protrudes partially from the vagina.
- 4th Degree: The entire inverted uterus is completely outside the vagina.
33
PPH Pharmacological Management
* Oxytocin: first line medication to promote uterine contractions (short acting 1hour, atony could recur)
* Methergine: an ergot alkaloid that causes sustained uterine contraction (may be repeated every 2 to 4 hours up to five doses, WOF: HYPERTENSION)
* Carboprost : a prostaglandin to induce contractions, helps with hemostasis at placental site (repeated every 15 to 90 mins up to 8 doses)
* Misoprostol: used when other uterotonics are unavailable, (repeat dose at least after 2 hours)
* Tranexamic Acid: anti fibrinolytics, inhibits blood clot breakdown (recommended by WHO to use within 3 hours of birth for client with PPH
34
NURSING DIAGNOSSIS
* FLUID VOLUME DEFICIT RELATED TO BLOOD LOSS
* ACUTE PAIN RELATED TO A COLLECTION OF BLOOD IN TRAUMATIZED TISSUE SECONDARY TO BIRTH TRAUMA
* INFECTION RISK RELATED TO MICROORGANISM INVASION OF SURGICAL SITE OR MIGRATION OF MICROORGANISIM FROM VAGINA TO UTERUS
35
NURSING INTERVENTIONS for PPH
* WILL DEPEND ON THE CAUSES OF BLEEDING
* Fundal massage
* CLOSE MONITORING
OF V/S and BLEEDING
* Treat the cause
* BLOOD TRANSFUSION
* Increase fluid via IV infusion
* Provide oxygen therapy via facemask (10 to 12 L/min)
* Supine with leg elevation to improve circulation
36
NURSING OUTCOME EVALUATION
* LOCHIA IS FREE OF FOUL ODOR
* FUNDUS REMAIN FIRM AND MIDLINE WITH PROGRESSIVE
DESCENT
* MAINTAINS VITAL SIGNS AND OXYGEN SATURATION
WITHIN DEFINED NORMAL LIMITS
* MAINTAINS NORMAL URINE OUTPUT >30ML/HR
* CONTROLLED AND MANAGED BLEEDING
* PREVENT COMPLICATIONS
