High risk postpartum

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High risk postpartum
2015-04-25 19:20:56

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  1. post partum hemorrhage
    • leading cause of death (first thing to assess is the fundus should be firm and midline)
    • cause: 5 T's
    • - Tone: uterus firm or midline
    • - Tissue: retained placenta if anything left in uterus
    • - Trauma: precipitous labor, big baby forceps etc, tear to the cervix, laceration of the vagina, peritineal (even if uterus is firm mostly likely tear someone needs repair)
    • - Thrombin- decre platelets, some kind of bleeding, DIC, cause thrombocepenia
    • - Traction: pulling of cord- can leave some of of the tissue behind
    • Atony results in subinvolution- uterus not contracting
    • - a failure to return to normal sixe and condition after birth in the normal time period
    • greatest risk is in the 1st 24 hrs but could happen well up to 6 weeks...
  2. PP hemorrhage (signs of shock)
    • Leads to hypovolemic results as a decrease in blood volume
    • symptoms:
    • - can bleed in short time, less than 15 mins bc she is very vascular
    • - restlessness, apprehension, anxiety (lack of O2)
    • - pale
    • - frank external bleeding, or hidden internal bleeding
    • - hypotension (blood loss)
    • - cold clammy skin
    • - tachycardia (weak and thready
    • - rapid breathing- tachyapnea, trying to make up for the fact not enought hgb running around
    • - cool mottled extremities- bloods shunts to organ
    • - low urine output: not enough blood/fluid volume
    • no temp
  3. uternine atony
    • most common cause of post partum hemorrhage
    • risk facts:
    • - overdistended uterus poly hydraminos, macrosomic baby
    • - displaced uterus- full bladder
    • - prolong or rapid labor- uterus gets tired prolonged fast it gets confused
    • - forceful labor stimulating by oxytocin- the uterus gets tired like a marathon
    • - use of mg sulfate- decre muscle stimulation. so your uterus is a muscle decr musclar trans
    • - anesthesia esp general
    • - maternal infection: chorioamnionitis (prolonged rupture of membranes), endomyometritis (inflammation of endometrium), septicemia
  4. Uterine Atony Tissue
    • retained placental fragments
    • - partial separation of normal placenta
    • - inability to expel paratial or completely separated placenta by constricting ring of placenta
    • - excessive traction on umbilical cord prior to spontaneous separation of placenta
    • - causing retained placenta or uterine inversion (turning the uterus inside out)
    • - placenta accreta (chrionic villi and placenta interwine) or placenta with additional lobes
    • - placental previa, placental abruption- leave pieces behind
    • - may need operative procedure to removed retained placenta (D/C dilation and cuterage)
  5. Assessment of Uterine Atony
    • Risk factors: think in the back of mind
    • Assess fundus: have pt empty bladder if needed
    • Massage: the boggy uterus to stimulate contraction. helps to express blood clots accumulating int he lower uterine segment once fundus is firm
    • caution: do not over massage the fundus which could lead to muscle fatigue and uterine relaxation. must support the uterus at the symphis pubis area
  6. Nursing care of Uterine Atony
    • Assess VS, O2 and LOC
    • maintain a primary IV infusion for volume expansion
    • may need a second line if necessary for blood administration
    • assess pain level
    • may need to provide oxygen at 2-3L via nasal cannula
    • draw blood for type and cross match
    • prepare to transfuse the patient crossmatched blood
  7. Medications used for PPH
    • Oxtocin (Pitocin)- never give undilated IV infection as a bolus
    • Cytotec (misoprostol)- allergy, active CHD pulmonary or hepatic disease dont give for any of these (while bleeding in rectum)
    • Dinoprostone (prostin E2)-
    • Prostalgins
    • Hemobate
    • methylergovine maleate (methergine)- never give if someone has HTN will give HTN
  8. Labs
    • CBC
    • - RBC 4-5.5 preg 3.75-5
    • - Hgb : 12-16  prego 11.5-14
    • - Hct 37-47 prego 32-42
    • - Plt 150,00-350,000 mm3 higher after childbirth 3-5
  9. Trauma
    • vaginal, cervical, uterine injury rupture, perineal hematoma
    • Can cause significant blood loss
    • At risk for:
    • - prolonged or rapid labor
    • - forceful labor stimulated by oxytocin and/or prostaglandins
    • - extrauterine or intrauterine manipulation of the fetus
    • - pushing prior to 10cm dilated (cervical laceration)
    • - forceps deliveries
    • - fetal malpresentation (ie vertex with hand included) double presentation
    • - shoulder dystocia
    • - macrosomia
    • may need operative procedure to stop bleed
  10. Trauma what happens?
    • Vaginal and cervical lacerations
    • perineal hematoma
    • - collection of blood in the subcutaneous layer of tissue of the perineum
    • - if you don't stop bleed it could grow and be painful
    • - reassess if ice or pain doesn't work
    • cause
    • trauma to a blood vessel during birth or laceration/episotomy repair
    • some dissolve on its own and the other OR to cut it and sometimes left open to drain
  11. trauma Assessment
    • Assessment: review of risk factors
    • - severe pain, perineal pressure, purplish color and swelling of vulva.perineum or rectum (perineal hematoma)
    • may become anxious
    • assess lochia
    • continous slow trickle of bright red blood from vagina. laceration or episotomy even though uterus is firm and contracted (cerival/vaginal laceration)
    • assess pain
    • assess vital signs 9may exhibit signs of bleeding anemia, hypovolemia
  12. Perineal Hematomas nursing care
    • ice packs to treat hematoma's
    • frequent inspection and evaluation of area
    • administer prescribed pain medication
    • assist with repair procedure it needed
    • encourage sitz bath and frequent perineal hygiene
  13. Thrombin
    • Thrombosis- thrombophlebitis- thromboembolism
    • Thrombophlebitis of the lower extremities may be superficial or deep. most commonly found in the femoral, saphenous or popliteal vein
    • Risk factors
    • pregancy
    • immobility
    • obesity
    • smoke
    • c-section
    • multiparity
    • over 35
    • hx
    • DM bc of poor vascular circulation
    • stirups not for long
  14. DIC
    • a life threathen acquired wide spread clotting formation
    • abruption
    • all clotting factors platelets will run to the site
    • all small blood clots formed in blood vessels
    • some of these can cut of blood supple to brain and kidney
    • no excessive clotting factor
    • you might to see her ooze
    • high risk of bleeding from a minor injury or no injury
    • u would could anticoagulants
    • knock clotting cascade back into normalacy
    • maintain treatment prefusion
    • HOP like sickle, heparin and blood
  15. Traction- uterine inversion
    • turning inside out of the uterus. may be partial or complete. emergency situation
    • assessment:
    • pain in the lower abdomen
    • vaginal bleeding
    • complete inversion: large, red, rounded mass that protrudes outside the uterus
    • partial inversion: palpation of a small mass thru the dilated cervix
    • dizziness
    • hypotension
    • pallor
    • three above hypovolemia
    • therapeutic treatment
    • manual replacement of uterus into unterine cavity
    • use tocolytics, analgesia anesthesia- to relax uterus
  16. Postpartum infection
    • Puerperal infections
    • Defined: fever of 100.4F or higher (not including first 24 hours after childbirth) lasting for more than 2 days of the first 10 days of birth. tachycardia
    • Cause: decrease vaginal acidity, increase alkaline environment
    • increase risk: tissue edema and tissue trauma
  17. Mastitis
    • Area of inflammation on the breast that may be red, swollen, warm and tender to touch
    • often painful
    • Nursing Intervention:
    • - hand hygiene
    • - cleaniness of the breast and frequent changes breast pads
    • - let nipples air dry after feeding
    • - teach proper infant position and latching techniques. include teaching proper technique for releasing latch
    • - instruct to completely empty breast with each feedings
    • frequent for breast feeding mom if they don't empty
  18. mastitis education
    • encourage her to use ice or warm packs to affected breast for comfort
    • educate to breast feed frequently (at least 2-4 hr) especially on affected side
    • goal is to keep breast empty
    • if breast feeding is painful may pump
    • begin feeding on unaffected breast first to initiate the let down reflex in the affected breast that is distended or tender
    • encourage rest, analgesic and fluid hydration 3000ml/day
    • take all medications as prescribed
    • well fitted bra
    • report redness or fever
  19. Labs infection
    • RBC sedimentation increase
    • WBC increase
    • WBC differential
    • urine for analysis (UTI, pyelonephritis)
  20. Depression
    • PP blues- every gets it goes away, tired
    • PP depression-
    • look at slides
  21. postpartal pregnancy induced HTN
    • Symptoms:
    • Proteinuria, edema, htn
    • cause:
    • may be retained placental material
    • Treatment
    • - bedrest quiet atmosphere, frequent monitoring of vital signs and urine output, mg sulfate and antihypertensive
    • Seizures
    • occur 6-24hr after birth