Ob Ch 28 With Added Cards From Anna-Marie

Front 1

How much blood loss is considered postpartum hemorrhage?

Back 1

• Defined as > 500 ml after vaginal birth or > 1 L after C/S
• HCT ↓ 10% from admission

Front 2

What is the most common cause of hemorrhage during the first hour after delivery (early or primary postpartum hemorrhage)?

Back 2

Uterine Atony

Front 3

What are the risk factors for pp hemorrhage? (6)

Back 3

• No prenatal care
• Preexisting medical history- DM,HTN etc.
• Cesarean section
• Rupture of membranes(> 24 hours)
• Urinary catheterization

Front 4

Define Uterine atony:

What is the physiology of hemorrhage secondary to atony?

Back 4

• Failure of uterine muscles to contract after delivery

The relaxed muscles allow rapid bleeding from the endometrial arteries at the placental site. Bleeding continues until the uterine muscle fibers contract to stop the flow of blood.

Front 5

What are the signs of uterine atony? (5)

Back 5

Major signs of uterine atony include:

• 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 or clots expelled

Front 6

What is the most important intervention for uterine atony?

Back 6

Massage the fundus.

Front 7

What can happen if nurse tries to expell clots without the fundus being firm?

Back 7

Pushing on an uncontracted uterus could invert the uterus and cause massive hemorrhage.

Front 8

What may be the problem if the uterus does not remain contracted after uterine massage or if the fundus is displaced; higher than expected not midline? what is intervention?

Back 8

Bladder distension
-encourage urination or perform straight cath if unable to urinate on own.

Front 9

What are the pharmacological interventions for atony?

Back 9

Intravenous (IV) infusion of dilute oxytocin (Pitocin) often increases uterine tone and controls bleeding.

Front 10

Methylergonovine (Methergine) may be given intramuscularly, but what is a side effect?

Back 10

Elevates blood pressure and should not be given to a woman who is hypertensive. It should never be given intravenously because of the risk for dangerous hypertension.

Front 11

What is given IV if oxytocin is not working?

Back 11

Hemabate, Prostin are often given intramuscularly or into the uterine muscle - give Tylenol for pain.

Front 12

What can be given rectally?

Back 12

(Dinoprostone) given rectally or misoprostol (Cytotec) may be used to control bleeding.

Front 13

What is an unfortunate side effect of hemabate and cytotek?

Back 13

Diarrhea

Front 14

Early Signs of Postpartum Hemorrhage:(5)

Back 14

• An uncontracted uterus

• Large gush or slow, steady trickle, ooze, or seeping of blood from the vagina

• Saturation of more than one peripad per 15 minutes

• Severe, unrelieved perineal or rectal pain

• Tachycardia

Front 15

Over distension of the uterus causes atony, what causes over distension?

Back 15

• Multiple gestation
• Hydramnios
• Macrosomia

Front 16

What Intrapartum factors can cause atony? (5)

Back 16

• Rapid or prolonged labor
• Pitocin augmentation or induction of labor
• Multiparity (≥5)
• Use of forceps or vacuum extractor
• Cesarean birth or previous uterine surgery

Front 17

What placental factors predispose for atony?

Back 17

Retained placental fragments (later)
Placenta previa, or abruptio placentae

Front 18

What are two other predisposing factors?

Back 18

General anesthesia
Coagulation disorders.

Front 19

When assessing fundus for 'boggines' what do you note? What is normal?

Back 19

• Height (at umbilicus)
• Tone (tight ball size of grapefruit)
• Position of fundus
• Lochia (dark red and moderate amount)
• Bladder (non distended)

Front 20

What is the therapeutic management of atony? (4)

Back 20

• Perform fundal massage (If the uterus is not firmly contracted, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus.)
• Assess for clots (Clots that may have accumulated in the uterine cavity are expressed by applying firm but gentle pressure on the fundus in the direction of the vagina. It is critical that the uterus is firmly contracted before attempting to express clots.)
• Assess bladder status (Nurses should assist the mother to urinate or should catheterize her to correct uterine atony caused by bladder distention and to monitor urine output if bleeding continues.)
• Administer uterine stimulants as ordered

Front 21

When is a laceration suspected? What is nursing intervention?

Back 21

Bright red bleeding with firm uterus.
Contact provider to evaluate and repair.

Front 22

What is the most common site of laceration?

Back 22

Cervix

Front 23

How can you tell if hematoma is getting bigger?

Back 23

Changes in vital signs

Front 24

What can be done for hematoma or laceration pain?

Back 24

ICE

Front 25

What is the most common cause of late pp hemorrhage?

Back 25

subinvolution

Front 26

What is subinvolution?

Back 26

Delayed return of the uterus to its nonpregnant size and consistency

Front 27

What is the most common cause of subinvolution?

Back 27

placental fragments

Front 28

What is the tx of placental fragments?

Back 28

Oral methylergonovine (Methergine) provides sustained contraction of the uterus.
Oxytocin and prostalandins are commonly used.
If drugs don't work than dilation and curettage.

Front 29

What is a less common cause of subinvolution?

Back 29

Infection

Front 30

What is treatment and signs of infection?

Back 30

Broad-spectrum antibiotics may be given if postpartum infection is suspected because of uterine tenderness, foul-smelling lochia, or fever.

Front 31

Hemorrhage interventions: (6)

Back 31

1. Vital signs
2. Massage fundus, if bleeding is not controlled, call doctor.
3. Labs for crossmatch
4. IV, large bore in case of transfusion.
5. Bed rest with legs elevated, modified trendelenberg.
6. Get assisstance so one nurse can massage while the other performs and records assessments and calls doc.

Front 32

How long are moms at risk for thromboembolic disease?

Back 32

6 weeks.

Front 33

What kinds of thromboembolic diseases are encountered in pregnancy and postpartum?

Back 33

superficial venous thrombophlebitis (SVT)-confined to lower leg
deep vein thrombosis (DVT) pulmonary embolism (PE)

Front 34

What is the etiology of Thromoembolic disease?

Back 34

A thrombus is a collection of blood factors, primarily platelets and fibrin, on a vessel wall. Once started, the thrombus can enlarge with successive layering of platelets, fibrin, and blood cells as the blood flows past the clot. Thrombus formation is often associated with an inflammatory process in the vessel wall, which is called thrombophlebitis.

Front 35

What are the 3 major causes of Thrombo...?

Back 35

Virchow's Triad: venous stasis
hypercoagulable blood
Injury of the blood vessel.

Front 36

What are s/s of DVT?

Back 36

Leg swelling (>2cm larger than other leg)
erythema
heat
ternderness
Homans sign

Front 37

What are risk factors for Thrombo...? (11)

Back 37

Long birth
• Cesarean Birth
• Inactivity
• Obesity
• Previous DVT hx
• Trauma to extremity
(ie stirrups)
• DM
• Advanced Maternal Age +35
• Hx coagulation disorders
• Varicose veins
• Smoking

Front 38

DVT meds:

Back 38

pregnant: Lovenox but changed at 36 weeks to unfractionated heparin (UH) because of shorter half life. Can't have any within 18 to 24 hours of epidural.

After birth: Heprin is resumed 3-6 hrs after vaginal and 6-8 after C/S if not breastfeeding.
Coumadin has teratogenic effects during pregnancy but safe for breast feeding.

Front 39

DVT Prevention after birth:

Back 39

Ambulation or leg exercises within 8 hours
No pillows under knees
Stockings and SCD's
NSAIDS-decrease clotting factor and dilutes body.

Front 40

Treatment if have DVT:

Back 40

Bed rest, effected leg elevated, no blankets or sheets on top.
Can ambulate when symptoms are gone.
Moist heat for pain and circulation.

Front 41

How can mom improve circulation?

Back 41

Regular activity
Avoid prolonged standing or sitting in one position.
When sitting, elevate legs, do not cross.
12 or more 8 oz glasses of fluids a day.

Front 42

What is puerperal infection?

Back 42

Puerperal infection is defined as a fever of 38° C (100.4° F) or higher occurring on at least 2 of the first 10 days after the first 24 hours following childbirth. Although a slight elevation of temperature may occur during the first 24 hours because of dehydration or the exertion of labor, any mother with fever should be assessed for other signs of infection.

Front 43

What may a puerperal infection affect?

Back 43

• May affect any area of reproductive tract
• Endometrial lining favorable for anaerobic bacteria

Front 44

Puerperal infections cause death in what?

Back 44

Third World Contries

Front 45

Most common puerperal infection?

Back 45

Endometritis

Front 46

Who is at the most risk for getting endometritis?

Back 46

Cesarean Sections, esp. Emergency C/S after prolonged labor and ruptured membranes.

Front 47

What s/s is the nurse most likely to notice?

Back 47

Purulent foul-smelling lochia

Front 48

What are the s/s?

When do they appear?

Back 48

• Fever, chills
• Malaise, lethargy
• Abdominal pain w/ tenderness
• Foul lochia
tachycardia and subinvolution

Within the first 24 to 48 hours.

Front 49

Therapeutic Management:

Back 49

CBC, WBC > 25000
IV antibiotics- broad spectrum (cephalosporins, clindamycin gentamycin) Metronidazole
May give prophylactic for C/S

Front 50

Nursing Mangement:

Back 50

Assess V/S, they may be increased.
High Fowler's
Assess perineum for lacerations.
Assess abdomen for peritoneal infiltration.
Comfort, pain meds, ICE

Front 51

What are predisposing factors for endometritis?

Back 51

C/S most common
Prolonged labor
Ruptured Membranes > 24 hrs.
OB trauma-forceps, episiotomies
Preexisting infections
Diabetes, Compromised health status(HIV, Drug addicts)
Catherizations

Front 52

If breast infection is suspected, what do you assess for?

Back 52

• Cracking & plugged milk ducts
Signs of mastitis:
• Fever
• Redness
• Pain
Note: signs of abcess!

Front 53

What are the mastitis risk factors?

Back 53

• Cracked nipples
• Poor hygiene
• Engorgement
• Supplemental feedings
• Change in routine or infant feeding patterns
• Abrupt weaning
• Lack of proper breast support

Front 54

What is nursing management of mastitis for breastfeeding mom?

Back 54

EMPTY BREAST
Bra support
heat to relieve pain and express milk.
Keep breastfeeding, but wash nipples before and after feeding. Change breast pads when wet.
Lanolin cream for nipples, but wash off, causes diarrhea in infant.

Front 55

Nursing management for bottle feeding?

Back 55

Ice packs every 4 hours with good support bra to dry milk up.

Front 56

Postpartum depression

Back 56

Baby blues is self limiting, not lasting more than 10-14 days.
PP depression is overwhelming feelings of sadness or inability to care for infant.

Front 57

What is the main cause of postpartum blues?

Back 57

Fatigue! Teach moms importance of rest, and if lasts longer than 10-14 days to see doctor.

Front 58

Treatment for Depression

Back 58

Zoloft -ok for breastfeeding
Counseling

Front 59

Who are more prone to have pp depression?

Back 59

Moms of infants with defects.

Front 60

What contributes to depression?

Back 60

• Changing hormone levels
• Psychological adjustments
• Unsupportive environment
• Insecurity
• Fatigue
• Discomfort
• Overstimulation

Front 61

Postpartum Psyhcosis

Back 61

Extreme depression-becomes despondant. Need support in home.

Front 62

Who is more at risk for psychosis?

Back 62

Hx of depression
OCD
Panic disorders
Drugs during pregnacy

Front 63

atony

Back 63

Absence or lack of usual muscle tone.

Front 64

dilation and curettage (D&C)

Back 64

Stretching of the cervical os to permit suctioning or scraping of the walls of the uterus. The procedure is performed to obtain samples of uterine lining tissue for laboratory examination, during the postpartum period to remove retained placental fragments, and in abortion.

Front 65

embolus

Back 65

A mass that may be composed of a thrombus (blood clot) or amniotic fluid released into the bloodstream to cause obstruction of pulmonary vessels.

Front 66

hematoma

Back 66

Localized collection of blood in a space or tissue.

Front 67

hydramnios

Back 67

Excess volume of amniotic fluid (more than 2000 mL at term). Also called polyhydramnios.

Front 68

hypovolemia

Back 68

Abnormally decreased volume of circulating fluid in the body.

Front 69

hypovolemic shock

Back 69

Acute peripheral circulatory failure caused by loss of circulating blood volume.

Front 70

mastitis

Back 70

Infection of the breast.

Front 71

metritis

Back 71

Infection of the decidua, myometrium, and parametrial tissues of the uterus.

Front 72

placenta accreta

Back 72

Placenta that is abnormally adherent to the uterine wall. If the condition is more advanced, it is called placenta increta (the placenta extends into the uterine muscle) or placenta percreta (the placenta extends through the uterine muscle).

Front 73

psychosis

Back 73

Mental state in which a person's ability to recognize reality, communicate, and relate to others is impaired.

Front 74

subinvolution

Back 74

Slower than expected return of the uterus to its nonpregnancy size after childbirth.

Front 75

thrombus

Back 75

Collection of blood factors, primarily platelets and fibrin, that may cause vascular obstruction.