What is a potentially life threatening problem that may occur after a vaginal or cesarean birth?
Postpartum Hemorrhage
What is the leading cause of maternal death for both developed and developing countries?
Postpartum hemorrhage
Postpartum hemorrhage is defined as a blood loss of how much?
500 mL after vaginal birth
1000 mL after cesarean
Morbidity with postpartum hemorrhage can be severe and may include what?
Shock from blood loss Organ failure Edema Thrombosis Acute respiratory distress Anemia ICU admissions and prolonged hospitalizations
What is a major obstetric hemorrhage defined as?
More than 1500-2000 mL that requires more than 5 units of transfused blood
What is the most common cause of postpartum hemorrhage?
Uterine Atony
When will a Primary PP Hemorrhage occur?
within 24 hours of birth
When will a Delayed PP Hemorrhage occur?
24 hours-12 weeks after birth
Uterine Atony
Failure of the uterus to contract and retract after birth
What are other PP problems that may occur and cause postpartum hemorrhage?
Obstetric lacerations Uterine inversion/rupture Episiotomy Retained fragments Macrosomia Coagulation disorders Failure to progress to second stage Placenta accrete Induction w/ oxytocin Surgical birth Hematomas
What are the 4 T’s to remember the causes of PP Hemorrhage?
Tone
Tissue
Trauma
Thrombin
Tone
Uterine atony
Distended bladder
Altered uterine muscle tone is usually the result of what?
Over distention of the uterus
Over-distention of the uterus can be caused by?
Multiple gestation Fetal macrosomia Hydramnios Fetal abnormality Placenta previa Precipitous birth Retained fragments Prolonged or rapid labor Bacterial toxins
Tissue
Retained placental fragments/clots
Uterine subinvolution
Uterine contractions and retraction leads to what?
Detachment and expulsion of the placenta after birth
Failure to complete placental separation and expulsion leads to?
Retained fragments/clots which occupy space and prevent uterus from contracting fully
What must happen after the placenta comes out?
Inspect for tears of fragments left inside because it could indicate accessary lobe or placenta accreta
Trauma
lacerations
hematoma
inversion
rupture
Thrombin
coagulapathy
Mild Symptoms of Shock
Loss of 20% blood volume
- diaphoresis
- increased capillary refill
- cool extremities
- maternal anxiety
Moderate Symptoms of Shock
20-40% blood loss
- tachycardia
- postural hypotension
- oliguria
Severe Symptoms of Shock
> 40% blood loss
- Hypotension
- Agitation or confusion
- Hemodynamic instability
Uterine Subinvolution
the incomplete involution of the uterus or failure to return to its normal size and condition after birth
When does subinvolution typically happen?
When the myometrial fibers of the uterus do not contract effectively and cause relaxation
Causes of Subinvolution
Retained placental fragments Distended Bladder Excessive maternal activity prohibiting recovery Uterine Myoma Infection
Complications from Uterine Subinvolution
Hemorrhage
Pelvic peritonitis
Salpingitis
Abscess formation
What will you see clinically with Uterine Subinvolution?
- PP fundal height higher than expected
- Boggy uterus
- Lochia fails to change from red to serosa to alba in a few weeks
When is uterine subinvolution typically identified?
at 4-6 week PP visit with bimanual exam or ultrasound
Treatment for uterine subinvolution is directed towards what?
Stimulating the uterus to expel fragments w/ a uterine stimulant, and antibiotics given to prevent infection
When can trauma to the genital tract occur?
Spontaneously or through manipulations used during birth
Lacerations and Hematomas can cause what?
significant blood loss
How can hematomas present?
They may present as pain or as a change in vital signs disproportionate to the amount of blood loss
What are the most common causes of hematomas?
Episiotomy
Nulliparity
Using instruments to assist birth
When does Uterine Inversion occur?
when the top of the uterus collapses into the inner cavity due to excessive fundal pressure or pulling on the umbilical cord when the placenta is still firmly attached
Treatment for Uterine Inversion
Uterine relaxants and immediate replacement manually by the healthcare provider
Who is uterine ruptures more common for?
Women with previous cesarean incisions or those who’ve had previous surgeries
Previous surgeries that may cause uterine rupture are?
Myomectomy Peroration of uterus during D&C Biopsy of Uterus Intrauterine system placement VBAC patients
Signs and Symptoms of Uterine Rupture
Pain
FHR abnormalities
Vaginal bleeding
Cervical lacerations should always be suspected when?
the uterus is contracted and bright red blood continues to come out of the vagina
Thrombosis helps to prevent what immediately after birth?
Postpartum hemorrhage
How does thrombosis help to prevent PPH?
by providing hemostasis
Women with a history of what are at increased risk for PPH?
menorrhagia
What should raise the index for suspicion for PPH?
diagnosis of a coagulation disorder
Types of Coagulation Disorders
Idiopathic Thrombocytopenia Purpura (ITP)
Von Willebrand Disease (vWD)
Disseminated Intravascular Coagulation (DIC)
ITP
an autoimmune disorder of increased platelet destruction caused by antibodies which can increase a woman’s risk of PPH
ITP is most common in who?
Young women
Maternal/fetal complications
Caucasian
Treatment for ITP
Immune Globulin and Glucocorticoids
Von Willebrand Disease
bleeding disorder that is inherited as an autosomal dominant trait
What is the cause of Von Willebrand Disease?
Prolonged bleeding time
A deficiency of von Willebrand factor
Impairment of placental adhesion
S&S of von Willebrand Disease
Bleeding gums Easy bruising Menorrhagia Blood in urine and stools Nosebleeds Hematoma Prolonged bleeding from wounds
What happens to the von Willebrand factor level during pregnancy?
Increases which allows most labor/births to proceed normally
DIC
life-threatening, acquired coagulopathy in which the clotting system is abnormally activated
With the clotting system abnormally activated in DIC it results in what?
widespread clot formation in the small vessels throughout the body which leads to depletion of platelets and coagulation factors
DIC is always what type of diagnosis?
Secondary diagnosis
DIC occurs as a result of?
Abruptio placentae Amniotic fluid embolism Intrauterine fetal death w/ prolonged retention of fetus Acute fatty liver pregnancy Severe preeclampsia
HELLP Syndrome w/ DIC
Hemolysis Elevated liver enzymes Low platelet count Septicemia PPH
Signs of DIC
petechia ecchymoses bleeding gums fever hypotension acidosis hematoma tachycardia proteinuria uncontrolled bleeding during birth acute renal failure
What is the most therapeutic thing to do for DIC?
treat initiating disorder/infection
Treatment goals for DIC
Maintain tissue perfusion w/ fluids, oxygen, heparin, and blood products
When excessive bleeding is encountered w/ PPH initial management steps are aimed at improving uterine tone w/?
Immediate uterine massage
IV fluid resuscitation
Administration of uterotonic medications
If all other measures for PPH fail additional resources that must be utilized are?
Bimanual compression Internal uterine packing Balloon tamponade techniques Blood transfusion Lab tests
What labs should be drawn immediately for PPH?
CBC
Type and cross match
Coagulation studies
When would transfusion of blood products begin for PPH?
once there is an estimate of 1500 mL of blood loss
What is the priority intervention for uterine atony?
Before initiating fundal massage the nurse must first place a hand over the symphysis pubis to anchor the uterus and prevent possible uterine inversion
First line of PPH Intervention
Manual massage and pharmacological therapies
Second line of PPH interventions
intrauterine balloon
tamponade
uterine compression sutures
Third line of PPH interventions
radiologic embolization
pelvic devascularization
hysterectomy
What is the last resort life saving measure for PPH?
Peripartum hysterectomy
What has a higher mortality rate than non-obstetric hysterectomy?
Peripartum hysterectomy
Pitocin/Oxytocin
- Do NOT administer as an IV bolus
- First line therapy
- If IV access is unavailable may use 10 units IM
Uterine Contraction Meds
Oxytocin/Pitocin
Methylergonovine maleate or Ergonovine maleate
Carboprost tromethamine
Misoprostol/Cytotec
Methylergonovine maleate or Ergonovine maleate
Avoid in patients w/ hypertensive disease, including preeclampsia
Carboprost tromethamine
Concurrent of antiemetics and antidiarrheals recommended to treat side effects
Misoprostol/Cytotec Contraindications
Allergy
Active cardiovascular, pulmonary, or hepatic disease
May cause tachycardia
Massaging the Fundus
Place one hand on symphysis pubis
Place other hand on fundus
Massage in circular manner
Assess for uterine firmness–should happen quickly
If fundus is firm what should you do next during the massage?
Apply gentle but firm pressure in a downward motion towards the vagina to express clots that may have accumulated
What could happen if you attempt to express clots before the fundus is firm?
Could cause uterine inversion which leads to PPH
Prostin E12 Contraindications
Active cardiac, pulmonary, renal, or hepatic disease
Methergine Contraindications
Do not administer if patient is hypertensive
Hemabate Contraindications
patients w/ asthma because it can cause bronchospasm
PPH Patient
- Maintain patent IV infusion and prepare to start another IV if transfusions are needed
- Check vitals q 15-30 mins
- Monitor CBC
- Assess LOC
- Foley catheter to keep bladder empty and prevent uterine displacement
What to do for Uterine Atony
Massage and Oxytocin
What to do for Retained Placental Tissue
evacuation and oxytocin
What to do for lacerations/hematoma?
surgical repair
What to do for bleeding disorders (Thrombin)?
blood products
What causes uterine inversion and what to do for it?
Too much cord traction
Gentle replacement of uterus and oxytocin
5 Causes of PPH
Uterine Atony Retained Placental Tissue Lacerations/Hematoma Bleeding Disorders (Thrombin) Uterine Inversion
What are the 3 most common Venous Thromboembolic conditions?
Superficial thromboembolic disorder
DVT
PE
When is the women’s risk higher for venous thromboembolic conditions?
3 weeks after delivery
Causes of Thrombus Formation
Venous stasis
Injury to innermost layer of blood vessel
Hypercoagulation
Nursing Interventions to Prevent DVT/PE
Early ambulation Compression Devices/Stockings Elevating patient's legs Smoking cessation Increased fluid intake Avoid sitting/standing for too long Avoid oral contraceptives in higher risk patients
Risk factors for PP Infection
Surgical/Instrumental birth Prolonged ruptured membranes/labor Inadequate hand hygiene Internal fetal monitoring Obesity/Gestational Diabetes/Anemia Extremes of patient's age Untreated infection prior to birth Low socioeconomic status Retained placental fragments Uterine manipulation
Common Infections during PP
Mastitis
Surgical site infections
Metritis
Mastitis
Inflammation of mammary gland
Breasts are red, tender, and hot to touch
Abscess can develop if not treated in timely manner
When does mastitis typically occur?
2 days-3 weeks PP
Risk factors for Mastitis
Stasis of milk
Nipple trauma
Pain
What is the most common organism causing mastitis and where does it come from?
S. aureus
-comes from the infants mouth or throat
Where is the most common site for mastitis?
Upper/outer quadrant of breast
Metritis
Infection of the uterus
What to do for Metritis?
Broad spectrum antibiotics
Monitor/maintain hydration and electrolyte balance
Provide analgesia
When will the fever decrease in most women with Metritis?
within 48-72 hours of initiating antibiotics
Surgical Site Infection Treatment
Early recognition
Aseptic technique and sterile gloves for wound care
Frequent dressing and perineal pad change
Hydration
Ambulation
IV antibiotic
Analgesia
UTI Treatment
Early catheter removal
Hydration
Cranberry juice
Antibiotics
Postpartum Blues Symptoms
anxiety irritability mood swings tearfulness increased sensitivity feelings of being overwhelmed difficulty thinking fatigue
S&S of PP Depression
Restless Worthless/hopeless Guilty Sad/Overwhelmed Low energy Loss of memory/libido/enjoyment Lack of interest in baby or family Worry about hurting baby Apetite disturbances
Postpartum Psychosis
Mood lability delusional beliefs hallucinations disorganized thinking tearful and confused feelings of worthlessness and guilt depersonalization manifestations of mania thoughts of hurting self or infant
