Postpartum complications Chapter 28
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less than normal muscle tone
A clot usually a thrombus forced into a smaller vessels by the blood circulation.
Localized collection of blood
Decreased volume of circulating fluid
Blood clot within a vessel
Mental state in which a persons ability to recognize reallity is impaired
What is the time diffrence between early and late postpartum hemorrhage? What quantity of blood loss constitiutes postpartum hemorrhage?
Early postpartum hemorrhage occurs within 24 hours of birth
late hemorrhage occurs after this time.
More that 500ml of blood after vaginal birth or more thta 1000ml of blood after ceasaren birth constituites postpartum hemorhage.
What is the most common cause of early postpartum hemorrhage? DEscribe the pathophysiology of this cause of hemorrhage?
uterine atony occurs when teh figure eight muscle fibers of the uterus do not contract firmly to compress bleeding endomertial vessels at the placental site.
How will the nurse recognize uterine atony?
the uterus is difficlut to locate and when found it is soft rather than firm and higher than expected level near the umbilicus. It may become firm with massage but fails to remain firm. Lochia is excessive, more than one satruated pad per hour
What is the correct nursing action if uterine atony is discovered.
Support the lower uterus with one hand while gently but firmly massaging the fundus until it contracts
Push on the fundus after the uterus is firm to express clots that have accumulated in the uterine cavity and could interfere with continued uterine contraction. Check for a distended bladder often indicated when teh uterus is displaced to one side (usually the right) Have her urinate or catheterized her if necessary. Durgs such as oxytocin or methylergonovine may be needed to maintain uterine contractio. Maintain IV access.
What signs typically distinguish postpartum hemorrhage caused by uterine atony from that caused by lacerations of the birth canal.
Excess usually brighter red, bleeding in the presence of a firmly contracted uterus that is in the expected location suggests a laceration
How do signs and symptoms of a hematoma differ from those of uterine atony or a bleeding laceration.
Pain is the greatest distictin because confined bleeding exerts pressure on sensory nerves. Th uterus is firm excluding uterine atony as the cause. Lochia is normal because the bleeding is concealed, excluding a bleeding laceration. A rising pulse and resp rate and falling blood pressue are signs of hypovolemia that may occur with any type of hemorrhage
Describe the body's reaction to hypovolemia and the clinical signs the nurse might detect: COMPENSATORY
Stimulation of baroreceptors and release of catecholamines result in vasoconstriction of peripheral blood vessels and rising heart rate and blood pressure. Gradual tachycardia is typically the earliest sigh hypovolemia. Respirations increase as teh woman attempts to increase her intake of oxygen. The skin is pale and cool and capilary refill is prolonged.
Describe the body's reaction to hypovolemia and the clinical signs the nurse might detect: FAILURE OF COMPENSATORY MECHANISMS
Inadequte perfusion results in buildup of lactic acid and metabolic acidocis, resulting in vasodilation which accelerates blood loss. The skin becomes cold and clammy. Urine output fall or even stops as circulation to the kidneys is reduced. When blood volume is inadequte to perfuse the brain and heart, death results
What discharge teaching related to late postpartum hemorrhage is essential
Women should be told the normal sequence amount and duration of lochia. They should be taught assessment and expected descent of the fundus. Guidelines should be provided for reporting deviations from normal
Why are pregnant and postpartum women prone to develop venous thrombosis?
They have higher levels of clotting factors (fibrinogen, factors III, VIII and X) and suppresion of factors that prevent clot formation (plasminogen activator and antithrombin III). In addition, venous stasis occurs and possibly blood vessels injuries
What are the signs and symptoms of pulmonary embolism?
Signs and symptoms vary according to the degree of pulmonary blood flow obstruction but include sudden sharp chest pain tachycardia, dyspnea, tachypenea, pulmonary rales, cough hemoptysis decreased partial pressure of oxygen (arterial blood gases) and atelectasis and pleural effusion seen on X-ray studies
Define plueral infection
A temp of 38 (100.4) or higher after the first 24 hours occuring on at least 2 days during the first 10 days following birth.
at anatomic features of the womans reproductive tract make infection there potentially serious?
All the parts of the female reproductive tract are connected to each other and to the peritoneal cavity. The area is richly supplied with blood vessels and lymphatic providing a well nourished dark warm environment that favors bacteria growth.
What changes of uncomplicated childbirth further increase a womans risk for reproductive tract infection? WHat are her protective factors?
Amniotic fluid blood and lochia make thenormally acidic vagina more alkaline fostering growth of organisms. The necrotic endometrial lining with lochia promotes growth of anarobic organisms. Small areas of trauma allow microorganisnms to enter the tissues. However granulocytes in the endometrium and lochia help prevent infection. Aseptic technique and careful handwashing help prevent transfer of organisms to the mother.
What is the significance of a destended board-like abdomen in a woman who has endometrities? Are other assesments needed? What action should the nurse take?
These signs suggest a paralytic ileus caused by spread of infection into peritoneal cavity. The nurse should assess bowel sounds and report all findings to the physician
List signs of wound infection?
edema warmth redness pain separation of edges seropurulent drainage
What liquids can help acidify urine? Why is this helpful in preventing or treating urinary tract infection?
Apricot, plum, prune and cranberry juices help adidify urine which makes the urine less friendly to microorganisms
Why is it important that the breastfeeding mother with mastits empthy her breasts completly
Stasis of milk promotes growth of infection microorganisms, possibly leading to abcess
How does septic pelvic thrombophlebitis differ from thromophlebitis
Septic thrombophlebitis also involves infection and usually affect the the ovarian uterine or hypogastric veins. It requires antibiotic and anticoagulant treatment
What is the key difference beteen postpartum "blues" and postpartum depression.
Postpartum depression symptoms include persistent loss of feelings in surroundings and loss of loving or pleasurable feelings : persistent fatigue complaints of ill health and difficulty concentrating persistent loss of interest in food and persistent sleep disturbances. It is the persitence of these behaviors and feelings that mark the difference
THe nurse notes that a woman has excess lochia 2 hours after vaginal birth of an 8-pound baby. The priorty nursing action is to?
Assess firmness of her uterus
Choose signs and symptoms that suggest concealed postpartum hemorrhage
Rectal pain accompanied by a rising pulse
One hour after a woman gives birth vaginally the nurse notes that her fundus is firm 2 fingerbreadths above the umbilicus and deviated to the right. Lochia rubra is moderate. Her perineum is slightly edematous, with no bruising; an ice pack is in place. The priority nursing action is to?
Have the woman empty her bladder in the bathroom
What drug should be readily available when a woman is receiving heparin therapy?
The nurse's initial response to a suspected pulmonary embolism should be to?
Raise the head of the bed and administer oxygen
A woman has an 8-pound 9 ounce baby after an 18 hour labor that required a low forceps delivery. Her membranes were ruptured for 15 hours. Based on these facts patient teaching should emphasize
Report foul smelling lochia
postpartum teaching related to urinary health should emphasize
Cleansing the perineum in a front to back direction
THe best position for a woman who has postpartum endometrities is
A breastfeeding woman develops mastitis. SHe tells the nurse that she will just feed her baby formula instead of breastfeeding. The best nursing response is that?
Empthying the breast is important to prevent an abcess
A woman who has a postpartum biopolar psychosis is most likely to demonstrate
Hyperactivity and poor judgment alternating with tearfulness and guilt
Postpartum hemorrhage can sometimes be prevented by careful examination of factors that presdispose to excessive bleeding.
Overstretching of the muscle fibers during pregnancy and repeated stretching during past pregnancies predispose to uterine atony and excessive uterine bleeding.
Inital managment of uterine atony focuses on measures to contract the uterus and provide fluid replacement
Soft tissue trauma (lacerations, hematomas) can cause rapid loss of blood even when the uterus is firmly contracted. Management involves repairng the trauma before excessive blood loss occurs
Compensatory mechanisms maintain the blood pressure so that the vital organs receive adequate oxygen. When these mechanisms fail hypovolemic shock follows.
The process of uterine involution may may be delayed (subinvolution) when placental fragments are retained or when the uterus is infected
Subinvolution of the uterus develops after the mother goes home. The nurse teaches teh family the process of normal involution and the signs and symptoms that should be reported to the health care provider.
Venous stasis that occurs druing pregnancy increased levels of coagulation factors and decreased levels of thrombolytic factros taht persist into the postpartum period increase the risk thrombus formation during the puerperium
Treatment for deep venous thrombosis includes anticoagulants analgesics and bed rest with the affected leg elevated
Nurses who administer anticouagulant therapy assess the mother to determine whether her laboratory tests are within the recommended therapeutic range so that overmedication with anticoagulants does not result in unexpected bleeding
Pulmonary embolism occurs when a clot is dislodged from the vein or amniotic fluid debris is carried by the blood to a pulmonary vessel which may be completely or partially occluded
The risk of infection is increased with childbearing because there is open access to bacteria from the vagina through the fallopian tubes and into the peritoneal cavity. Increased blood supply to the pelvis and the alkalinization of the vagina by the amniotic fluid further increase the risk for infection
Any break in the skin or mucous membranes during childbirth provides a portal of entry for pathogenic organisms and increase the risk of puerperal infection. Nurses must assess women with an incision or laceration for signs of localized wound infections
Urinary stasis and trauma to the urinary tract increases the risk of puerperal infection. Nurses must initiate measures to prevent urinary stasis
Nurses must provide information about the importance of completly emptying the breasts at each feeding and about measures to avoid mipple trauma to prevent mastitis
Mood disorders include postpartum blues, postpartum depression and postpartum psychosis.
Postpartum depression is a disabling affective disorder that affects the entire family. Nurses help the woman acknowledge her feelings and assis her in identifiying measures that will help her cope with the condition
Anxiety disorders include panic disorder postpartum obsessive compulsive disorder and posttraumatic stress disorder.
Hemorrhage in the first 24 hours after childbirth is called?
Hemorrhage after the first 24 hours and up to 6-12 weeks after birth is called?
When does early postpartum hemorrhage commonly occur and what causes it?
within the first hour after delivery, and caused by uterine atony
What is atony?
lack of muscle tone that results in failure of the uterine muscle fibers to contract firmly around the blood vessels when the placenta separates
What is placenta accreta?
abnormal adherence of the placenta to the uterine wall
what can cause overdistention of the uterus
signs of uterine atony
A uterine fundus that is difficult to locate
A soft or boggy feel when the fundus is located
A uterus that becomes firm as it is massaged but loses its tone when massage is stopped
A fundus that is located above the expected level
Excessive lochia especially if it is bright red
excessive clots expelled.
Common predisposing factors of postpartum Hemorrhage?
Overdistention of the uterus
Multipara (five or more)
precipitate labor or delivery
Use of forceps or vacuum extractor
Manual removal of the planceta
Placenta previa Placenta accreta or low implantation
Durgs, (oxytocin, prostaglandins., tocolytics or magnesium sulfate)
Previous postpartum hemorrhage or uterine surgery
Uterine leiomyomas (fibroids)
how does the uterus feel for the first 24 hours after childbirth?
a firmly contracted ball roughly the size of a large grapefruit.
If the uterus is not firmly contracted the first intevention?
to massage the fundus until it is firm and express clots that may have accumulated in the uterus.
What can happen to a uterus that is not contracted when it is pushed on?
could invert the uterus and cause massive hemorrhage and rapid shock
If the uterus does not stay contracted after massage or if the fundus is displaced the problem may be?
A distended bladder, a full bladder lifts the uterus moving it up and to the side preventing effective contraction of the uterine muscles.
What do you do if massage and drugs are ineffective in stopping uterine bleeding?
Bimanual compression- one hand is inserted in the vagina and the other compresses the uterus through the abdominal wall.
What is the last resort to save a woman life with uncontrolled postpartum hemorrhage?
What is the second most common cause of postpartum hemorrhage?
Trauma to the birth canal.
Most common causes of late postpartum hemorrhage?
fragments of placenta that remain attached to the myometrium when the placenta is delivered.
Predisposing factors of late post part hemorrhage
attempts to deliver the placenta before it separates from the uterine wall.
manual removal of the placenta
What is hypovolemic shock?
Acute peripheral circulatory failure resulting from loss of circulatin blood volume.
Early signs of blood loss?
hypotension (may not appear until 20%-25% of the womans blood volume has been lost
what is early sign of hypovolimic shock?
even gradual increses in pulse rate
decrease in B/P and narrowing of pulse pressure.
resp rate increases
pale cool skin
as hemorrhage worsens the skin becomes more pallor, cold and clammy
what happens to urine during hypovolimic shock?
URine output decreases and eventully stops.
What gauge IV needle do you use for shock?
with hypovolimic shock how much urine do you want to come out?
at least 30ml/hour
Signs of postpartum Hemorrhage?
a uterus that does not contract or does not remain contracted
Large gush or slow steady trickle ooze or dribble of blood from the vagina
Saturation of one peripad per 15 min
Severe unrelieved perineal or rectal pain
If the fundus is firm but bleeding is excessive the cause may be?
Lacerations of the cervix or birth canal
signs of subinvolution?
prolonged discharge of lochia
irregular or excessive uterine bleeding
sometimes profuse hemorrhage
feelings of pelvic heaviness
- persitent malaise
When does thrombophlebitis occur?
When vessel wall develops an inflammatory response to a thrombus
the most common thromboembolic disorders ecounterd during pregnancy?
What is the major cause of maternal mortality?
Three major causes or thrombosis are?
injury to the endothelial surface (the innermost layer) of the blood vessel
What causes venous stasis in pregnancy?
compression of the large vessels of the legs and pelvis by the enlarging uterus.
Foods with Vitamin K
cabbage lettuce spinach and lentils
What drugs are use in pulmonary embolism
- thrombolytic drugs
tissue type plamingen activator for life threating pulmonary emboli
What is an embolectomy
surgical removal of the embolus
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