Postpartum Hemorrhage (PPH) Unit 3 PDF

UNIT 3: - **[Postpartum Hemorrhage: Cumulative blood loss \>500 mL vaginal delivery and \>1000 mL for C/S ]** - [Early PPH] - [Within 24 hours of birth ] - [Secondary PPH] - [24 hrs. to 6weeks. ] - Clinical manifestations: - Uterus boggy and possi...

UNIT 3: - **[Postpartum Hemorrhage: Cumulative blood loss \>500 mL vaginal delivery and \>1000 mL for C/S ]** - [Early PPH] - [Within 24 hours of birth ] - [Secondary PPH] - [24 hrs. to 6weeks. ] - Clinical manifestations: - Uterus boggy and possibly deviated to right; bladder is full. \-\-- so not clamping down! - Heavy vaginal bleeding w/clots - Signs of hypovolemic shock; (hypotension, tachycardia) - PPH causes and interventions: - **Tone: Uterine atony (no tone to constrict itself down)** - **Intervention: Restore contractibility via fundal massage and/or oxytocic medication** - **Trauma: Lacerations** - **Intervention: Repair trauma. Provider will repair any perineal trauma via suturing.** - **Tissue: Retained products of conception (like the placenta)** - **Remove tissue via a surgical procedure completed by the provider, such as D&C** - Thrombin: Coagulation - Decrease blood loss via fundal massage and/or oxytoic medication - **[PPH Tx: If they have it: MASSAGE THE FUNDUS -- CONTRACTING THE UTERUS TO PUSH DOWN THE VESSELS]** - Bimanual exam: Provider does. Putting pressure on the fundus. Also inside the vagina. - Medications: - Oxytocin -- contracts uterine muscle - Misoprostol -- contracts the uterus - Methylergonovine -- contracts the uterus - Tranexamic acid -- inhibits clotting factors from breaking down. So more in blood to prevent the bleeding. Increases clotting factors. - Blood products---depending how much they lost. Depends on sx's - Fluids - Vital signs: Monitor, seeing if pt stabilizes - Apply oxygen: Low hgB. 10L on mask. Keep o2 \>95% - Surgical interventions - Balloon tamponade: Balloon filled with fluid that goes in uterus. - JADA: Suctioning blood out of uterus allowing it to clamp down. Seen more often---new practice. - Retained placenta and subinvolution of uterus - Retained placenta - Placenta does not deliver within 30 min - More than 300 mL blood loss before the placenta delivers. - May have to do manual removal of placenta - D&C it - Subinvolution of uterus: Lack of contracting down. Going down 1cm per day - Leading cause of secondary PPH - Enlarged, boggy uterus with vaginal bleeding - Lacerations: - Risks: - Macrosomia (large baby), malpresentation, shoulder dystocia, nullipara, fetal position, induction of labor and use of forceps or vacuum extractor. - Treatment: - Dermoplast: Numbing spray to use when going to bathroom - Pain management: - Stool softeners - Warm water/sitz bath - Hematomas: Hard lump - Clinical manifestations: - Localized, intense pain - Unilateral swelling---One labia bigger than the other - Urinary retention - Bleeding - Nursing interventions: - Expectant: Pain medications and ice packs when its small - Surgical: Vascular embolization or transcatheter arterial embolization. Cut off bleeding supply - Postpartum Shock - Leading cause: PPH - Clinical manifestations: - Tachycardia - Hypotension - Dizziness - Pallor - Blurry vision - Confusion if serious enough - Deep vein thrombosis: From c/s, increased clotting factors, bedrest - Clinical manifestations: - Pitting edema---unilaterally - Calf tenderness - Red, warm skin - Patient education: - Avoid sitting for long periods of time - Do not wear tight clothing such as leggings - Elevate legs while lying down - Avoid high-fat and high-sugar foods; increase inflammation. - Perform calf muscle exercises several times a day - Nursing interventions: - Ambulate -- first 6 hours - Sequential compression pumps - Prophylactic esp for c/s patients: Lovenox - Low molecular weight heparins: Lovenox - Postpartum infections: - Endometritis: - Infection of the endometrium/uterus causing fever, uterine tenderness, foul smelling lochia, increased lochia. - Mastitis: - Infection of the breast, Check for cracks in nipples---bacteria can grow - **[Fever, Abnormal appearance of milk, Unilateral Swelling, Sensation of burning, Salty flavor of milk, Tenderness, Redness of breast.]** - Sepsis - Wound infections: C-section or laceration from perineal area - Warmth and pain at incision site, purulent drainage, fever \-- RITA - Nursing interventions: - Endometritis: - Frequent uterine and lochia assessment, antibiotics, pain management - Mastitis: - Breastfeeding education, proper latch techniques, frequent breast assessment, cool compresses, antibiotics and pain medications. - **[They can still breastfeed---Does not harm baby---It is recommended. Do not want milk stasis. Pump after to empty the breast! ]** - Wound infections: - Wound assessment\--RITA, administration of abx therapy and pain management - Education regarding peri-care\-\--peri bottle filled w/ warm water---spray off after using the bathroom. - Biologic Adaptations: - Thermoregulation: - Risk for hypothermia due to evaporation (covered in amniotic fluid---get cold) conduction, convection, and radiation - Dry-off with warm blanket to prevent evaporation. Put a hat on their head to avoid losing heat. - Skin to skin! - Respiratory - 30-60 breaths/min --NORMAL - Come out crying! - Cardiovascular: - 110-160 bpm - 3 shunts close. (Ductus arteriosus and ductus venousus, and foramen ovale) - Hepatic - Immature liver because in utero was not working-liver processes bilirubin (byproduct of broken down RBC=jaundice; yellow skin and eyes (hyperbilirubinemia) - Immune - Mother provides with antibodies: Breastfeeding - Integumentary: - Acrocyanosis: - In newborn is normal, bluish tinge of hands and feet. Prominent when baby is cold. - Vernix: Light covering of whitish stuff. Good moisturizer for baby - Lanugo-Fine hair on newborns, helps keeping them warm in utero. May or may not come off. - Skeletal - Sutures of the skull---Not fused. Allows to deliver and allows for growth. Fontanelle: soft spots; anterior and posterior. - Assessment of newborn - APGAR -- above 7; done at 1 minute and again 5 minutes. Maybe 10 if not responding. - Appearance - Skin color: - 0: pale, bluish-gray skin - 1: Pink body with blue hands and/or feet - 2: Entire body is pink - Heart rate: - 0: No pulse - 1: Under 100/min - Greater than 100/min - Grimace: - 0: No response - 1: Grimaces - 2: Grimaces and coughs; cries; or sneezes - Muscle tone: - 0: Limp or weak movements - 1: Some movements of arms and legs - 2: Active movements - Respirations: - 0: No respirations - 1: slow or irregular breathing, weak cry - 2: Normal breathing rate and effort; strong cry. - Pulse - Grimace - Activity - Respirations - Weight, length, vitals, head circumfence - Reflexes - Sucking - Rooting - Tonic neck -- - Grasping -- "holding hands" it's a reflex; common up until 6 mo - Moro reflex -- starfish/startle reflex - Babinski -- stroke the foot and toes will fan out. If not + CNS problems possibly - Head - Caput: - Fluid underneath the skin d/t pressure during delivery. Squishy area on the head. Cross suture lines. - Cephalohematoma: Don't cross the suture lines. 'little eggs' bleeding underneath. Monitor closely to make sure they don't expand. - Molding - Natural 'football head' 'cone-shaped head' ; after 24 hours head goes back to rounder appearance - Mouth - Cleft palate by sticking fingers in mouth to see if they have it - Lingual frenulum: Can't stick their tongue out fully. Can prevent good latching. - Back - Sacral dimple: Dimple on the lower back - Sacral hair tuft: Little patch of hair - Integumentary - Birthmarks - Slate grey nevus: Mongolian spot: Can look like a bruise. Note on chart. - Millia: Little whiteheads. Immature oil glands and will go away on their own. - Jaundice - GU and GI - 24 hours for first void and BM - Obtaining blood samples - Blood glucose -- esp if mom had GD - Newborn screening: - 24-48 hrs old. Not before 24 hours because they need protein intake. 5 areas. - Screens for metabolic, hematologic, endocrine and other inheritable disorders. To treat them early on! - Other labs : - CBC: for anemia, WBC. Can be from umbilical cord. Typically, a capillary heel stick, stay on the outer edge use middle part only if needed. Use a heel warmer to dilate blood vessels. - Neonatal hearing screen - Identify early on - Different types - Congenital heart disease screening: Identify early on to prevent heart failure - Started prenatal with ultrasound but often missed. - Most common malformation - Check oxygen in right hand and a foot. To see if similar to make sure blood is flowing properly. - Nursing interventions - Safe sleep - Back is best! - Swaddled - No pillows and/or stuffed animals! - Shaken baby syndrome: Colic babies. Set them down and let them cry for 5 minutes. Babies neck is not strong. Shaking neck causes edema and can lead to cerebral palsy. - Medications - Hep B, only vaccine they get at birth! - Vitamin K, helps with clotting. If they refuse this and want circumcision, provider typically refuse it! - Erythromycin ointment- given prophylactically to prevent an infection that causes blindness. - Preventing newborn abductions - ID bands -- matching with baby and parents - Must check bands before letting infant go with parents - Locked units - Nutrition - Breastmilk - Recommended to exclusively breastfeed from birth to 6 mo or longer - Fed is best! - Formula. Patient education about different types. - Parent and NB bonding - Skin to skin - ABO & Rh Incompatibles - Risk: Mom Rh - And newborn Rh + - Different blood type from mother. Mom creates antibodies and tries to fight off positive blood cells. - Clinical manifestations: - Anemia - Jaundice -- immature liver - Lethargy - Pallor - Tachycardia or bradycardia - Seizures - Apnea - Kernicterus: bilirubin enters the blood brain barrier, causing serious swelling. - Diagnostics: - Direct Coombs test: Fetus positive antibodies if present baby is at an increased risk of jaundice. - CBC - Transcutaneous bilirubin test - Serum bilirubin - Hyperbilirubinemia - ***Bilirubin \> 12 mg/dL in newborns \< 24 hrs: CONCERNING*** - Risks: - ABO or Rh incompatibility, excessive bruising, birth trauma, cephalhematoma, inadequate feeding intake, infection, breakdown of RBCs too fast. - Clinical manifestations: color changes first noticed in face and neck, lethargy, poor feeding, high-pitched cry, seizures, and decreased output - Diagnostic - CBC: RBCs to check for breakdown - Transcutaneous bilirubin test: Don't need to be poked! It's a probe that averages out the number. - Serum bilirubin: Blood draw - Hyperbilirubinemia - Nursing interventions: - Monitor bilirubin, output: bilirubin is excreted in stool, lethargy - Phototherapy management: Newborns need to wear eye shields because retinas are immature. - Encourage oral intake: Feeding q 3 hrs. Wake them up to eat. - Transition to parenthood - Bonding - Signs of appropriate bonding: feeding, bathing, affectionate actions - Risks for delayed bonding: traumatic birth, young patients - Maternal role attainment - Stage 1: taking in: occurs in the first 48 hours after birth as the mother focuses on the birthing experience. Concerned about self - Stage 2: Taking hold: lasts several weeks as the mother learns more about newborn care. Mom asking questions/first bath. - Stage 3: Letting go: can take months as the mother integrates their various roles. Taking on new role of becoming a family. - Co-parents - Encourage involvement - Siblings - Ease transition by allowing to participate in activities - May see regression in younger children as the attention is divided. - Baby blues: - Temporary emotional lability experienced the first two weeks after birth - Postpartum depression: - Intense feelings that develop after birth and can include anxiety, sadness, irritability, loss of appetite, insomnia, and difficulty bonding with the baby. - Risk factors: - Depression/anxiety before or during pregnancy - Significant stressors during the first few weeks PP - Birth trauma - Having a premature newborn - Infant illness or admission to the NICU - Lack of social support - Difficulties w/ breastfeeding - Newborn Care: - Bathing: - Wait 24 hours for first bath - No lotion for the first 2 weeks - Only needed up top 3x weekly - Sponge bath until umbilical cord comes off - Cleanest to dirtiest - Umbilical cord: - Roll diapers below until falls off - 1-2 weeks - Notify provider if foul-smelling discharge, redness, crying when touched or still on at 3 weeks. - Car seat safety: - Rear facing until 2 years old: Can be longer if they want! - Straps should be snug and clip armpit level. - No extra fabric under straps. No snowsuits or jackets on. - When to call a NB's PCP - Temp greater than 100.4 F rectal - Yellowing of the skin or eyes - Sleeping more than usual or difficult to wake up. - Lack of movement - Seizure activity - Refusing multiple feedings in a row - Difficulty breathing - Vomiting or diarrhea, especially if blood is present. - Health assessments across the lifespan: - Yearly physicals - Pelvic exams - Look for cervical and ovarian cancer and STI's - Pap test---detects cervical cancer - 21-29yo q 3 years - 30-65 yo q 5 years if combined with HPV screening - Care of transgender men. - Make sure they are addressed with preventative care. - Make them feel comfortable and coming back for these appts. - Family planning and contraception - Prior to choosing: - Obtain px exam, OB/med history, sexual activity and lifestyle - Discuss effectiveness, side effects, client preferences and barriers - Support patients in making decision that is best for them - Methods include: natural family planning (fertility awareness), barrier, hormonal, intrauterine and surgical procedures. - Natural family planning/fertility awareness - Basal Body Temp - Temp rises slightly during ovulation - Temp should be taken upon waking before getting out of bed. Use accurate thermometer - Standard days method - Similar to calendar with beads. - Calendar rhythm method - Estimates time of ovulation - Cervical mucus ovulation: - Ovulation: cervical mucus can stretch between fingers (spinnbarkeit---egg white appearance) - Fertile period when mucus is thin, slippery; lasts 3-4 days - Coitus interruptus: pull out method - Lactation amenorrhea method - Needs to be exclusively BF; only up to 6 mo. - Barrier Methods: physical barrier for sperm to uterus. Use water-soluble lubes only. - Condoms---Penile or vaginal - Spermicide - Chemical barrier that destroys sperm before they can enter the cervix. Insert 15 minutes before and lasts about an hour. - Diaphragm - Should be properly fit by provider and replaced every 2 years. Get resized if gained weight, after abdominal or pelvic surgery and after pregnancy - Leave in at least 6 hr but not longer than 24 hrs. Can be inserted with spermicide. - Cervical cap - Comes in 3 sizes and needs to be replaced 2 years, or after GYN surgery, birth or major weight fluctuations. - Leave in at least 6 hr but no longer than 24 hrs - Contraceptive sponge - Acts as a physical and chemical barrier. - Leave in at least 6 hrs but no longer than 30 hrs - Leaving these in for too long can lead to TSS! - Hormonal methods: - Combined oral contraceptives---contain estrogen and progestin (progestin only---tricking body into thinking its preggers=minipill) - Action: suppress ovulation, thicken cervical mucus, altering uterine lining to prevent implantation if fertilization were to occur. - Possible therapeutic effects: - Prevents pregnancy, regulates menstrual cycle, decreases acne, and prevents and treats PMS - Patient education: - Consistency: Missing dose - Take dose ASAP - IF 2 MISSED: look for directions for specific and use alternative contraception - Report any chest pain, SOB, leg pain, headache, vision changes, or hypertension - Side effects: - Headache, nausea, breast tenderness, and breakthrough bleeding - Decrease the effectiveness when taken with meds that affect liver enzymes - Anticonvulsants - Antifungals - Some abx - Contraindicated with - Thromboembolic disorders - Stroke - Heart disease - CAD - Gallbladder - Cirrhosis or liver tumor - Headache with focal finding - Uncontrolled hypertension - DM with vascular involvement - Breast or estrogen related cancers - Pregnancy, lactating or less than 6 weeks postpartum - Smoking \> 35 years - Progestin-only pills (minipill) - Action: same as COC; decrease chance of fertilization and implantation - Therapeutic use: prevents pregnancy, regulates menstrual cycle, treats endometriosis - Patient education: - Needs to be consistent (same time every day) since they don't have any estrogen. - Might need another form of BC for first month as the body is getting used to it! - Safe while BF - Side effects: - Breakthrough, irregular vaginal bleeding, headache, nausea, and breast tenderness. - Contraindications: - Very similar to COC - Hormonal methods: - Transdermal contraceptive patch: - Continuous hormones transmitted through patch - Apply patch weekly on same day, take 1 week off - Contraindicated in BMI \>30 - Injectable progestins: Medroxyprogesterone - IM or SQ injection given every 11-13 weeks - Very effective - Side effects: - Decreased bone mineral density, weight gain, increased depression, amenorrhea, headache, and irregular vaginal spotting or bleeding; delayed fertility up to as long as 18 mo - Typically short term (\