POST PARTUM chapter 32 &37 PDF

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MARIA BROWN...

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Care of the Woman with Postpartum Hemorrhage Complications Following Birth- usually the third stage of birth

Early (primary) postpartum hemorrhage 

First 24 hours after childbirth

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More common

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Focus mainly on this one

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Causes: uterine atrophy

Late (secondary) postpartum hemorrhage 

24 hours to 6-12 weeks after birth

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can last a long time

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usually due to uterine sub-embolusion r/t placental retained

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Causes: retained placenta

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Uterus stays pretty high up and doesn’t stay in the pelvis

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Continues to have red lochial discharge

Blood loss greater than 500 mL (vaginal) or 1000 mL (cesarean)

Blood loss: 

2 gram drop in HCT= 500 ml

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1 gram drop Hemoglobin = 500 ml

Early (Primary) Postpartum Hemorrhage

Lacerations of the genital tract (vaginal wall and cervix) Factors that predispose 

Nulliparity (1st time moms)

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Epidural anesthesia- people feel like it dimished pushing effort = assisted birth = laceration

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Forceps- or vacuum-assisted birth

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Suspect laceration if uterus is firm and midline but women is still experiencing bleeding

Retained placental fragments 

Most common cause of late PPH

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Inspect placenta for intactness

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Doesn’t detach completely from the uterus – the vessels still remain and they bleed out

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Risk for if: HCP trying to rush, pulling and tugging

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After deliver: look at maternal (dirty Duncan side) to make sure there no missing pieces

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Can do D& C or suction procedure to get rest of placenta out

Early (Primary) Postpartum Hemorrhage

Vulvar, vaginal, pelvic hematomas o Risks factors 

Big baby

o Small 

Ice packs (constrict vessels) , analgesia

o Larger 

Evacuated with incision and drainage

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Risk for infection

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Women can show s/s of shock= surgery to get it evacuated

o Uterine inversion 

Associated with weakness of musculature, relaxation secondary to anesthesia or drugs, or vigorous manual removal of placenta

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Causes: really big baby in the birth canal, size of baby putting excess pressure on birth tissues

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Inspect perineum: make sure u don’t see bright shiny area

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no excessive lochial bleeding because bleeding is coming from laceration

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might notices: real restless, or agitated = get ice

Uterine Inversion 

Uterus turns inside out

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Causes: weakness of muscles, certain anesthetic (general ), manual removal of placenta

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Life threatening

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Try to very quickly invert and re-insert the uterus if not may have to do hysterectomy

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They’ll notice it if they are trying to deliver the placenta and they will feel the FUNDUS TURN INWARD AND NOT FEEL IT AS WELL, or they can see it in vaginal wall

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May say administer: Brethene or Tuburtiline to relax really quick then when it is in need to contract (Ptosin) it where it will stay in

Nursing Care Management: Postpartum Hemorrhage 

#1 cause: Boggy Uterus

o Fundal massage continuous 

Normal : Every 15 min for 1st hours, then every 30 2nd hour, Want it to be firm and midline @ level of umbilicus or a little below, With no excessive bleeding

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Do a continuous fundal massage to hopefully be stimulated and contracted, you might need help

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Maintain IV access o May need a 2nd large bore IV because possibility of rapid fluid placement o If she doesn’t have an IV get her another one (18-20 gauge)

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Vital signs o Taken every 2-5 min depends of facility o Get an O2 stat, because you dimished perfusion of O2 to organs (give 10 ml by facemask)

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Weigh perineal pads o Will determine how much blood loss o 1 gram HGH = 500 mL of blood o 2 gram HCT= 500 ml of blood

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Catheterize if indicated o Want to make sure the fluid you are putting in is coming out o Watch for pulmonary edema and HF o Full bladder: can encourage uterus to be boggy= bad

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Fluid volume replacement o 3 mL of IV fluid for every 1 mL of blood loss o anywhere from lactated ringers, normal saline= isotonic= stays in vessels

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Central venous pressure monitoring (CVP) o Anyone who is having fluid replacement needs this

o Goes in through right atria and hook up to hemo dynamic monitoring o Tells you if you have to much or to little fluid o Important because this person is at risk for FVE o Normal (o-7 mm of mercury) o Greater than 7= ASSESS LUNG SOUNDS = back down on fluids 

Blood volume replacement o More common: packed RBC’s= contain HGH o If women has dec platelets and clotting factors= frozen plasma cells

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Lab work o CBC: platelet, HCT, HGH= let you know if she needs more o PT, PTT, Fibrinogen, D-Dimer (fibrogen split products)= clotting lab work o RUN RISK OF DIC= person has bleed so much that they have used up all there clotting factors and they bleed out

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Hysterectomy o If women keeps bleeding and starts developing signs of shock this is recommended

PPH

Figure 37–1B Manual removal

of

placenta. The fingers are alternately abducted, adducted, advanced until the placenta is completely detached. Both procedures are performed only by the medical clinician. 

Can go in and hopefully remove some of the fragments

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C-section: can do manual removal of placenta

and

Figure 37–1A Manual compression of the uterus and massage with the abdominal hand usually will effectively control hemorrhage from uterine atony. 

Inside compressing anterior and externally compressing the posterior part

Bakri Balloon Tamponade  Medications to Manage Postpartum Hemorrhage (Table 37-1) 

Oxytocin (Pitocin) IV o 10-40 units o Administered very rapidly

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Methylergonovine (Methergine)

      

0.2 mg IM

Not showing signs of shock and hasn’t had Dec. LOC the HCT can take her to surgery and insert a balloon T. Foley catheter with a large balloon at the end (filled with NS) Left in place 6-8 hours Packing the vessels And as it regains its tone it will constrict They will release some fluid over a couple of hour Goal: to keep uterus clamped on the balloon Another option besides Hysterectomy

o Next step o Uterine hyper-stimulants- causes massive vasoconstriction o Cant be administered to any women with HTN (can cause stroke) pre-Eclampsia o IM vastus lateralis 

Carboprost (Hemabate) 250 mcg IM

o Beta-mimetic o Smooth muscle constriction o IM Vastus lateralis o Avoid in: asthma and heart disease 

Misoprostol (Cytotec) 1000 mcg per rectum o Cervical ripening pill (PO or vaginal) o Usually 25 mcg in normal cases o Release prostaglandins – and contracts uterus o Rectum= absorbs quickly

Care of the Woman with a Reproductive Tract Infection or a Wound Infection Puerperal infection = Postpartum infection 

Postpartum endometritis o Is an infection inside the uterus where the placenta was attached (bacteria invaded) (placenta site= perfect medium for bacteria growth) o Strep is more common

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Mastitis o Infection of one or more milk ducts o Staph is more common

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Postpartum wound infection

o Women who’s had C-section or episiotomy 

Urinary tract infection o Pain upon urination o Antibiotics

Table 37–3 Common Causative Organisms in Metritis

Care of the Woman with Endometritis or Wound Infection Risk Factors 

C/section or operative vaginal birth (trauma)

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Prolonged labor or ROM (biggest)

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+GBS

Signs and Symptoms 

Assessment (report abdominal pain, bright red foul smelling lochia, low grade fever chills)

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REEDA scale (redness, edema, ecchymosis, drainage, approximation)

Clinical Management

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Start antibiotics (broad spectrum= ampicillin, gentamicin) allergic to penicillin = clindamycin

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Cultures can be done- but antibiotics are given first

Care of the Woman with a Urinary Tract Infection 

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Risk Factors o Cathertization o After delivery: catheter has been removed but retained urine and urinary stasis o Encourage voiding- warm water, running water, get it shower, sitz bath Signs and Symptoms o Pain upon urination

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Nursing Care Management

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Bladder assessment Voiding techniques Catheterization if necessary Encourage frequent bladder emptying, always wash hands, perineal care, wipe from front to back, apply pad from front to back Clinical Therapy o o o o

o Antibiotic therapy Care of the Woman with Postpartum Mastitis 

Mastitis o Infection of interlobular connective tissue in breast primarily in lactating women o Initiates inflammatory process, milk gets obstructed and gets infected o usually unilaterally o has harden redden area on breast, tender, low grade fever chills

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Breast/nipple trauma

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Bacteria invade breast tissue

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Milk stasis, duct obstruction

Figure 37–2

Clinical Therapy- mastitis 

Clinical diagnosis in most cases

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Bed rest for 24 hours

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Increased fluid intake

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Supportive bra

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Assessment of breastfeeding technique o Really good latch on- prevent sore or cracked nipples o Needs to take all the nipple and areola if possible o Breast shields to protect breast tissue

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Frequent breastfeeding

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Manual expression of breast milk o Wipe breast milk on the nipples

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Local application of warm, moist heat o Or ice packs- during breast feeding

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Analgesics- ibuprofen, Tylenol

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Antibiotics

Care of the Woman with Postpartum Thromboembolic Disease 

Venous thrombosis

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INCREASE IN CLOTTING FACTORS o Three major causes 

Hypercoagulability of blood

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Venous stasis

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Injury to epithelium of blood vessel (during pushing)

o Superficial vein disease o Deep vein thrombosis o Pulmonary embolus

Superficial Vein Disease 

Often involves saphenous veins

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Localized area with decreased blood flow

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Symptoms o Tenderness, heat, redness @ one area o Low-grade or no fever o Palpable cord along a portion of vein (*hardened*)

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Treatment o Local heat and analgesic agents o Elevation o Bed rest

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Risk for DVT and PE is very low

Deep Vein Thrombosis 

Women with history of thrombosis o Obstetric complications o Clot in portion of leg= blocks blood flow

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Clinical manifestations include: o Edema o Low-grade fever o Limb color changes o Unilateral leg pain, calf tenderness o Positive Homan’s sign o Abdominal pain or inguinal pain

o Changes in limb size and limb color

Clinical Therapy 

Can do Doppler studies to determine if clot present

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If DVT= bed rest

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Immediate IV o Heparin using infusion pump o Dissolves the clot o Subcutaneous heparin for prophylaxis o Oral warfarin (Coumadin) 

International normalized ratio (INR) 2.0 to 3.0

o Strict bed rest o Elevation of leg

Pulmonary Embolism 

Signs and symptoms o Sudden severe chest pain o SOB, dyspnea, tachypnea, tachycardia o Worst: cardiac arrest

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Nursing management: o SIT THEM STRAIGHT UP o O2 my face mask

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Clinical emergency o Most fatalities within 30–60 minutes

o Elevate head of bed o Oxygen by face mask at 8 to 10 L o CPR- no pulse and not breathing o Narcotics for pain- helps sedate the pt. and that can dec. O2 demand

Care of the Woman with a Postpartum Psychiatric Disorder 

Adjustment reaction with depressed mood o Postpartum bleus (1st few days after deliver up to a few weeks) (normal)= drop in hormones and fatigue o Concern: getting worst which PPD

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Postpartum depression (PPD) o Continue few weeks to a few years after deliver o Astjustment reaction can develop into this

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Postpartum psychosis o The women condition has progressed the women is hallucinating, hearing voices

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Posttraumatic stress disorder (PTSD) o Maybe related to a condition of the 1st deliver (911 C-section) o Rape victim- put with a nurse that is very calm and quiet

Nursing Care of the Woman with a Psychiatric Disorder Early Management 

Observe for objective signs o Baby bleus: has diff sleeping, no appetite, cant care for baby= assess further for PPD

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Listen for statements o This baby would be better off without me

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Anxiety prominent feature

o Can’t ever sit still, over anxious about simple things (type of diaper) 

Fatigue o Appear or report it o + Correlating with mom developing PPD which could lead to PP Psychosis o Prescribe: restorative sleep- go somewhere and sleep

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Assessment of suicide risk o Having a plan, access to weapons o Put on suicide precautions o Really-really down to really up-beat and happy

Nursing Plan and Implementation 

Offer support and information

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Social support

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Screening o Notice women who are at risk for PPD and psychosis o Check lists

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Follow Up o Treatment: tricyclic antidepressants

Care of the Newborn with Respiratory Distress Syndrome (RDS), Ch. 32 Respiratory Distress Syndrome 

Types

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Causes o Doesn’t have adequate surfactant o Prematurity

o MAS o Transient tachypnea of newborn TTN (MC- C-section, not getting good chest squeeze and recoil and they don’t have all that fluid and they retain that fluid and show s/s of RDS) Complications 

PPHN (persistent pulmonary HTN) o Blood is not going to the lungs and being O2 like it needs to o Endomethasine

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Pneumothorax o ^^ Risk when using O2 therapy o Very little bursts of air can cause you to blow a lung out o Deteriorated very quickly: dec. RR, no lung sounds (everything shifted to other side) SEVERE RDS

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CLD (chronic lung disease or bronchopulmonary dysplasia) o Baby has been on a ventilator, and there is a risk that the settings aren’t perfect and baby develops scar tissue and can develop stiff or fibrous lungs

Clinical Therapy 

Preterm birth prevention o MAG sulfate, Betamethasone, Brethene

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Surfactant therapy o Makes alveoli better, prevents them from bursting

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Ventilator therapy o HR staying low O2 low, blue= need ventilator therapy

Hypoxia

Respiratory Acidosis

Metabolic Acidosis

When babies are born: breathing and crying= o2

Surfactant required maintaining alveolar stability. Decreased surfactant 

leads to increased surface tension, making reinflation of the alveoli very difficult; this causes increased energy expenditure to maintain respiration (each breath becomes harder than the last).

Decreased respiration 

leads to hypoxia and acidosis due to lack of adequate gas exchange: decreased PO2, increased PCO2, decreased pH (aka hypoxia)

Hypoxia 

leads to increased PVR and a possible return to fetal circulation (PPHN); this also leads to decreased CO and perfusion to vital organs.

Respiratory acidosis 

(increased PCO2 and decreased pH) is caused by alveolar hypoventilation.

Metabolic acidosis 

(decreased pH and decreased bicarbonate) occurs because the poor 

 perfusion to the cells and lack of O2 to the cells causes anaerobic metabolism to begin.

X-ray Findings: show classic ground glass or white out appearance.

Nursing Care of the Newborn with RDS S/S of RDS



Central cyanosis, grunting, nasal flaring, retractions, head bob or chin tuck

Other assessment findings 

mottling or pale skin from poor perfusion, apnea > 20 seconds with possible decrease in HR, labored breathing (chin tug, head bob), decreased breath sounds, substernal retractions, continuous murmur, flaccid posture.

Oxygen therapy 

Mild: O2 by nasal cannula, or they oxi-hood

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Warm and humidified O2 (prevent fluid loss)

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depends on the severity of the RDS (cord gas, O2 sat monitoring, worsening condition); done to prevent hypoventilation and hypoxia; mild RDS may only need humidified O2 delivered by NC or oxyhood; moderate RDS may require CPAP; severe RDS requires ventilator; O2 always warmed and humidified; infant on ventilator may require sedation with fentanyl or morphine; caffeine citrate to help treat apnea; with adequate ventilation and perfusion will see pink skin, increased CO, adequate chest expansion, and increased urinary output.

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NTE prevents cold stress.

Administration of surfactant Maintenance of: 

Temperature o Warmer or incubator

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Nutrition o Mild: (not have diff sucking, swallowing or breathing) continue with breast o If they are RDS: TPN

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Fluid balance o IV therapy

Care of the Newborn with Hyperbilirubinemia (Jaundice),Ch. 32 

Types of Jaundice o Physiologic

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Happens 24 hours AFTER 2-3 days after deliver result of baby being prone to get jaundice

o Pathologic 

Bad usually caused by RH incompatibility

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appears within 24 hours of birth; caused by a pathologic condition (hemolytic disease of the newborn.

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Untreated jaundice can lead to kernicterus; permanent but preventable brain damage.

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Newborns susceptible to jaundice: o immature liver, increased RBC destruction, poor or delayed feeding, delayed cord clamping, trauma at birth, environmental cooling

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Clinical Therapy o Phototherapy 

UV light therapy, converts the bilirubin to an excretable form

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Being fed more quickly (watch for wet and dirty diapers)

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Can have bili-blanket placed underneath them (just in a diaper)

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