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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...
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Labs infection
- RBC sedimentation increase
- WBC increase
- WBC differential
- urine for analysis (UTI, pyelonephritis)
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Depression
- PP blues- every gets it goes away, tired
- PP depression-
- look at slides
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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
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