post partum lecture april 18(1)

7/23/2019 Post Partum Lecture April 18(1)

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High Risk Postpartum

Brenda Hanson-Smith, Ph.D,RNC

Jennifer Malana, MSN, RN


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Did ou !no"#

Postpartum Hemorrhage

$eading %ause of mor&idit' andmortalit' in the (nited States

Diagnosis su&)e%ti*e-di+%ult tomeasure

(nderestimated &'

Most "omen gi*ing &irth arehealth' and %ompensate for&lood loss


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PPH De/ning Criteria

Postpartum hemorrhage de/ned as0

1 ml &lood loss for *aginal &irth

1 2 ml &lood loss for C-Se%tion

3r 2 %hange in hemato%rit&et"een admission la&s andpostpartum la&s


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4arl' or Primar' PPH

4arl', 5%ute or Primar' PostpartumHemorrhage

3%%urs /rst 67 hours after &irth

Can o%%ur from time of separation ofpla%enta to e8pulsion

Common %auses

(terine 5ton', 9n%omplete pla%entalseparation, 48%essi*e tra%tion ofum&ili%al %ord, o*er manipulation offundus


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$ate or Se%ondar' PPH

$ate or Se%ondar' PostpartumHemorrhage

3%%urs 67 hours after &irth, &ut: ; "eeks postpartum

Common %auses0 Su&in*olutionof the (terus, endometritis,Retained pla%ental fragments


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Chara%ter of Blood


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Pregnan%' Related ?a%ts

Maternal &lood *olume in%reasesappro8imatel' @from 7 to ; $Aduring pregnan%'

9n%rease in &lood *olume ser*es toful/ll perfusion demands of the lo"-resistan%e uteropla%ental unit pro*ides reser*e for &lood loss thato%%urs "ith deli*er'


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(terine Ph'siolog'

4stimated &lood


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(terine Ph'siolog' @%ontA

M'ometrial retra%tion uni=ue to uterinemus%le.

Maintains shortened length follo"ing

ea%h %ontra%tion. Blood *essels %ompressed and kinked

&' interla%ing latti%e "ork of uterinemus%le.

Normall', &lood


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Ehe $ong $ist of Causes FPredisposing ?a%tors of PPH

(terine 5ton'

$a%eration of &irth %anal

Retained pla%ental fragments

Ruptured uterus 9n*ersion of (terus

5dherent pla%ental fragments pla%enta a%%reta, in%reta, pre%eta

Coagulation disorders

Manual remo*al of retained pla%enta

Magnesium sulfate during la&or or postpartum

(terine su&in*olution


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(terine 5ton'

$eading %ause earl' of PPH-%ompli%ates onein 6 &irths

(suall' o%%urs immediatel' follo"ingdeli*er' of &a&' and up to four hours

?ailure of the uterine m'ometrial /&ers to%ontra%t and retra%t

Can lead to se*ere hemorrhage andh'po*olemi% sho%k

5sso%iated "ith high parit', h'dramnios,ma%rosomi% fetus, rapid for%eful la&or, andmultiple gestation


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(terine 5ton' @%ontA

Ereatment Based on %ause

?undal Massage

Monitor &lood


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Cer*i%al, Gaginal or Perineal$a%erations

Se%ond most %ommon %ause of PPHPerineal la%erations.

Bleeding usuall' slo" tri%kle andor

%ontinuous or frank &leeding ?a%tors in


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$a%erations @%ontA

Ereatment0

5ssessment to identif' sour%e of&leeding

Suture la%eration

Monitor &lood


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Retained Pla%enta

Results from0 Partial separation of normal pla%enta

4ntrapment of partiall' separatedpla%enta

Miss management of Irdstage la&or

5&normal adheren%e of pla%enta

Ereatment0

Monitor &leeding Manual or surgi%al remo*al of pla%enta

?luid repla%ement

5nti&ioti% Eherap'


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5dherent RetainedPla%enta

5&normal adheren%e of pla%enta

Cause-'gote implantation in defe%ti*e

endometrium

Bleeding &e%omes profuse "hen deli*er' of

pla%enta is attempted (na&le to remo*e pla%enta

Pla%ental adheren%e-re%ognied in degrees

Pla%enta a%reta-light penetration of

m'ometrrium &' tropho&loast Pla%enta in%reta-deep penetration of

m'omentrium

Pla%enta per%eta-perfora%tion of uterus &'pla%enta


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9n*ersion of (terus

3%%urren%e 2 in 6 to 6 patients

Ma' reo%%ur "ith pre*ious in*ersion

Classi/ed as partial or %omplete

Ma' &e asso%iated "ith hemorrhage of 6$

Contri&uting fa%tors

?undal implantation

(terine 5ton'

Gigorous fundal massage

48%essi*e tra%tion applied on um&ili%al%ord

$eiom'omas

5&normall' adherent pla%enta


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9n*ersion of (terus@%ontA

Ereatment

Based on reason

9G


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Su&in*olution

$ate PPH o%%urs as a result of su&in*olutionCauses

Retained Pla%ental ?ragments

Pel*i% infe%tion

Signs and S'mptoms Prolonged lo%hial dis%harge

9rregular or e8%essi*e &leeding

Hemorrhage

Ereatment

Based on reason for su&in*olution Most %ommon drug 3ral Methergine

@meth'lergono*ine maleateA .6mg = 7 hours for 67 to7 hours @see Ea&le I-2A

5nti&ioti% Eherap'


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Nursing Care

Management 5ssess for Signs and S'mptoms of PPH Re*ie" patient histor' for predisposition

?undal %he%k 5ssess for /rmness of fundus and de*iation

Eurn patient to side to assess &leeding

Bleeding assessment Color, amount, odor

?re=uent *ital signs Not relia&le &ut %an identif' trend

9n%reasing ta%h'%ardia, ta%h'pnea

Bod' rids itself of e8%ess a%ids &' in%reasingrespirator' rate


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Nursing Care Management@%ontA

5ssessment for &ladder distention

Distended &ladder %an displa%e uterus

Skin

Karmth and dr'ness

Che%k nail &eds %olor and %apillar' re/ll

9n hemorrhage skin is sa%ri/%ed to maintain&lood


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Nursing Care Management@%ontA

Nursing 4du%ation

9nform patient a&out %ondition andtreatment plan

Patient edu%ation regarding PPH"hen dis%harged

Normal in*olution

48%essi*e *aginal &leeding Resumption of &right red &leeding

?e*er 1 2.7 L


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Hemorrhagi%@H'po*olemi%ASho%k PPH %an de*elop into Hemorraghi% sho%k

3rgan s'stems shut

Ph'siologi% %ompensator' me%hanisms

are a%ti*ated Prolonged Sho%k - redu%tion of %ellular

o8'genation results "ith &uild of la%ti%a%id and a%idosis

5%idosis %auses arteriolar *asodilationF *enule *aso%onstri%tion

Creates %ir%ular


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Hemorrhagi% Sho%k@%ontA

Medi%al Management

Restore Cir%ulating Blood *olume

Rapid infusion of 9G %r'stalloid

solution

Rate Iml infused for e*er' 2 ml -estimated &lood loss

Pa%ked Red Blood Cells Possi&le fresh-froen plasma

Ereat %ause of hemorrhage


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Hemorrhagi% Sho%k@%ontA

Nursing 9nter*entions

Continued assessment

Pulse, Blood Pressure, Respirator' rate

Patient %olor

Monitor and pro*ide o8'gen

2-26 $min prefera&l' nonre&reathingfa%e mask

$e*el of Cons%iousness

Seeing stars, feeling di' Restlessness or orthopnei%

Confusion

Rea%ts to stimuli slo"l'


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Hemorrhage Sho%k @%ontA

Continuous 4! monitoring H'potensi*e or ta%h'%ardi%

?ole' Catheter

5ssess hourl' output

Minimum I mlhr ?luid or Blood Repla%ement

$arge &ore 9G %atheter

Possi&l' esta&lish t"o 9G lines

?luid resus%itation

Careful o&ser*ation for


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BloodPressure(systo

lic)

BloodVolume

Loss

Symptoms andSigns

Degree ofShock

Normal 500-1000 ml(10-15%)

PalpitationsTachycardia,Dizziness

Compensate

Sliht !all

("0-100mm#$)

1000-1500 ml

(15-5%)

&ea'ness,

tachycardia,Seatin

ild

oderate !all(*0-"0mm#$)

1500-000 ml(5-+5%)

estlessness,Pallor,oliria

oderate

ar'ed !all

(50-*0mm#$)

000-+000 m.

(+5-50%)

Collapse,

air hner,anria

Se/ere

H'po*olemi% Sho%k rid


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Coagulaopathies

9diopathi% Ehrom&o%'topenia

5utoimmune disorder

5ntiplatelet anti&odies

*on Kille&rand diseaseE'pe of hemophilia-most %ommon

hereditar' &leeding disorder

Disseminated 9ntra*as%ular Coagulation

Pathologi% form of %lotting Diuse F %onsumes large amount of

%lotting fa%tors


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Coagulopathies @%ontA

Disseminated 9ntra*as%ular Coagulation

Clotting pro&lem that uses large amounts of%lotting fa%tors

48ternal F 9nternal &leeding %an o%%ur Small *as%ular o%%lusions %an o%%ur

Cause

5&ruptio Pla%enta, 5mnioti%


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Ehrom&oem&oli% Disease

?ormation of &lood %lot or %lots inside of &lood*essel

9n%iden%e 2 in -O "omen

Risk fa%tors 9n%reasing maternal age

9n%reasing parit'

Pre*ious throm&oem&olism

Congesti*e %ardia% failure 3&esit'

3perati*e deli*er'


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Clini%al Manifestations ofEhrom&oem&oli% Disease

Ma)or %ause

*enous stasis F h'per%oagulation

Ehree %onditions

Super/%ial *enous throm&osis Deep *enous throm&osis

Pulmonar' em&olism

Chara%teried &' pain F tenderness

Deep *ein more %ommon in pregnan%' Ph'si%al e8am

"armth, redness F enlarged hardened *ein


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Ehrom&olem&oli% Disease@%ontA Medi%al management

Super/%ial

analgesia,nonsteroidal

antiin


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Postpartum 9nfe%tions

De/nition-fe*er 1 I L or more on 6 su%%essi*eda's of the /rst 2 da's postpartum @Cunninghamet al., 62A

Ma)or %ause of mor&idit' F mortalit' throughout

"orld-; in (S 9ntrapartal fa%tors %ontri&ute to infe%tions

PR3M, prolonged la&or, maternal fe*er @Garner,2A


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E'pes of 9nfe%tions

3*erall postpartum infe%tion rate 2-

Motalit' .; maternal deaths per2, li*er &irth

E'pes of infe%tions 4ndometritis

Mastitis

(rinar' Era%t 9nfe%tions Sepsis


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4ndometritis

Most %ommon sour%e of postpartuminfe%tion

Chara%teried &' lo"er a&domen pain

Eemperature 1 I.IL ?oul-smelling lo%hia

Risk in%reases after %esarean

deli*er' @2-6A


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Mastitis

?e*er F %hills

Eender engorgement &reasts

?re=uentl' o%%urs in /rst time mothers

Most %ommon organism-staph'lo%o%%us aureus

9nfantQs mother or throat

Ereatment


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(rinar' Era%t 9nfe%tion

?e*er, Chills

?re=uen%' on urinations

Most %ommon &a%teria-normal &o"el


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Septi% Sho%k

Signs F s'mptomsEa%h'pneas 1 6 &reathsmin

Ea%h'%ardia 1 &eatsmin

H'potensionQ

H'pothermia : I L degrees C

H'perthermia 1 I L degrees C

4*iden%e of inade=uate organ perfusion

3liguria

Blood %ultures

(sual %ause ram-negati*e organisms

4arl' sho%k- re%epti*e to 9G


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Case Stud'

C.R. is a 7 'ears old ra*id O Para ; "hodeli*ered a l& 22o &o', after 67 hours of la&orindu%tion. She stated to the nurse that she felt ofgush of &lood and seems to &e upset and fearful.

Her *ital signs are sta&le. C. R.Qs lo%hia is &rightred and hea*' and her fundus is de*iated to theright.


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Case Stud' @%ontiA

2. Khi%h of the follo"ing assessments is the mostimportant for the nurse to perform#

5. Continue to %he%k her *ital signs e*er' 2minutes.

B. Charting the amount of &lood


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Case Stud' @%ontA

C.R. is %onsidered to at high risk for uterine aton'&e%ause of the follo"ing reasons#

5. She is a grand multipara

B. Her &a&' "eighed l&s 22os

C. Ehe length of her la&or D. D. 5ll of the a&o*e


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Case Stud' @%ontiA

.R. has saturated I pads in one hour "ith &rightred &lood. Her *ital signs %ontinue to &e sta&le.Khi%h %ondition is her earl' postpartum &leedingattri&uted to#

5. Su&in*olution related to pla%ental fragments B. Ruptured Hematoma

C. (terine 5ton'

D. $a%eration of the Cer*i8


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Case Stud' @%ontA

Khi%h is the /rst nursing a%tion 'ou shouldperform follo"ing 'our /ndings#

5. Chart 'our /nding

B. Run through the halls asking for help

C. 3pen the 9G to in%rease the le*el of 38'to%in D. Massage the ?undus

4. Che%k her &ladder for distention

?. Eurn the patient to the side


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Case Stud' @%ontA

Khi%h is the main %ause of earl' postpartumhemorrhage#

5. D9C

B. Retained Pla%ental ?ragment

C. Hematomas and $a%erations D. (terine 5ton'

4. Su&in*olution


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Case Stud' @%ontiA

Khi%h is the main %ause of late postpartumhemorrhage#

5. D9C

B. (terine 5ton'

C. Retained pla%ental fragments D. 3*erdistended &ladder

4. Hematomas and $a%erations

?. Su&in*olution


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Case Stud' @%ontA

Khi%h of the follo"ing nursing a%tions help tosta&ilie the motherQs %ondition and relate touterine aton'#

5. Massage the fundus

B. 5ssess the &ladder and if ne%essar'insert a fole' %atheter

C. 9n%rease the 9G infusion of o8'to%in

D. Report /nding to pro*ider

4. 5ll of the a&o*e


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Eake Home

4*aluate patients for predisposition toPPH

Clear %ommuni%ation "ith Pro*iders

5ssess for signs and s'mptoms of PPH De*elop Nursing Care plan &ased on

%ause of PPH

4du%ate patients regarding PPH andtreatment plan

post partum lecture april 18(1)

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