Lacerations of genital tract, episiotomy, retained placental fragments, uterine inversion, coagulation disorders, LGA newborn, failure to progress during 2nd stage, placenta accreta, induction with pitocin, surgical birth, and hematomas
Petechiae, ecchymoses, bleeding gums, fever, hypotension, acidosis, hematomas, tachycardia, proteinuria, uncontrolled bleeding during birth, and acute renal failure
b. Acute distress.
The immediate reaction to news of a perinatal loss or infant death encompasses a period of acute distress. Disbelief and denial can occur. However, parents also feel very sad and depressed. Intense outbursts of emotion and crying are normal. However, lack of affect, euphoria, and calmness may occur and may reflect numbness, denial, or personal ways of coping with stress. Anticipatory grief applies to the grief related to a potential loss of an infant. The parent grieves in preparation of the infant's possible death, although he or she clings to the hope that the child will survive. Intense grief occurs in the first few months after the death of the infant. This phase encompasses many different emotions, including loneliness, emptiness, yearning, guilt, anger, and fear. Reorganization occurs after a long and intense search for meaning. Parents are better able to function at work and home, experience a return of self-esteem and confidence, can cope with new challenges, and have placed the loss in perspective.
Causes- the Four T's of PPH
• Tone
• Trauma
• Tissue
• Thrombin
• Neonatal macrosomia. Birth weight greater than 4000 grams
• Polyhydramnios
• Operative vaginal delivery. Use of forceps or vacuum extractor
• Augmented or induced labor
• Ineffective uterine contractions during labor; a prolonged first or second stage of labor
• A precipitous labor and/or
birth
• General anesthesia
• Review prenatal labs for anemia, any hemorrhage complications with previous deliveries (if a multip)
• History of fibroids
• Maternal obesity
• PPH occurs in 10% of all deliveries
• Defined as a blood loss greater than 500 mL (vaginal delivery)
• Anemia ( a Hgb less than 10 prior to delivery)
...
• Abnormal placenta implantation:
placenta
accreta chorionic villi is directly attached to the myometrium of the uterus
placenta increta placenta invades the myometrium
placenta percreta placenta penetrates through the myometrium
placenta previa
marginal or complete
Uterine inversion
A prolapse of the fundus of the uterus to or through the cervix so that the
uterus is turned inside out
Rare, but life threatening
Not preventable
Associated with:
Fundal implantation
Abnormal adherence of the placenta
Protracted labor
Weakness of the uterine wall
Uterine relaxation 2ndry to anesthesia or Magnesium Sulphate
Early post-partum hemorrhage (PPH) occurs within the first 24 hours after childbirth
• Most common cause uterine atony - decreased uterine tone. A contracted uterus post-delivery results in constriction of blood vessels at the placental site. When the uterus relaxes there is increased blood loss
Late post-partum hemorrhage (PPH) occurs after 24 hours after birth
• Most common cause is retained placental tissue
Risk factors - manual removal of the placenta
• Subinvolution of the uterus - the uterus does not descend into the
pelvis
Risk factors:
Uterine fibroids
Endometritis
-retained placental tissue
Non uterine related PPH causes
• Lacerations are the second most common cause of early PPH
Common sites of lacerations can be the cervix, vagina, labia and/or the perineal floor
Risk factors for lacerations include:
Fetal macrosomia
Operative delivery (use of forceps or vaccum)
precipitous delivery
•
Hematomas occur when blood collects within connective tissue of the vagina and perineal areas related to a vessel that ruptures and continues to bleed
Risk factors for hematomas are:
Episiotomy (major risk factor)
Use of forceps
Prolonged second stage of labor
Signs and symptoms of Hematomas
Severe pain
Pressure
Visualize purple area of blood accumulation (not always in an area that can be readily visualized
Management:
Surgical excision and drainage causes
immediate relief of pain
Coagulopathies
Normal state of pregnancy is a "Hypercoaguable" state
If preeclampsia progresses to HELLP syndrome increases risk of PPH
H = hemolysis
EL = elevated liver enzymes
LP = low platelets
.
Medical Management of Uterine Atony (Most common cause of PPH):
Depends on the cause of PPH
Dilation and curettage (D&C) - for retained placental tissue
Methergine PO for PPH caused by uterine fibroids
Antibiotic if endometritis
IV fluids to replace blood loss (3:1 ratio) Three 3mL of fluid is to replace each mL of estimated blood loss (EBL)
EBL is evaluated by weighing saturated pads and linen (one gram = to one mL)
Administration of uterotonic medications ...
Lab evaluation of:
Hgb and Hct trends
clotting factors (platelets, fibrinogen, PTT
(partial thromboplastin time) , PT (prothrombin time)
Nursing Interventions:
• fundal massage is the first action to initiate when uterus is "boggy"
• if no response to uterine massage notify OB or certified nurse midwife (CNM)
• Oxytocin is the first medical therapy to be initiated
• Monitor vaginal bleeding (saturation of peripad within 15 minutes is indication of abnormal bleeding)
• Review prenatal record and labor and delivery record for any increased risk
factors
• Monitor vital signs. First vital sign is ↑ in heart rate (know patient's baseline vitals) , later sign is ↓ BP (patient is already going into shock when this presents)
• Monitor for urinary retention (if bladder is full the uterus cannot contract well)
• Provide emotional support and information to patient and her family
• Ensure adequate IV line is established (at least an 18 or 20 g) a second IV site may be required
• Prepare patient for a possible D&C, if
progression and decompensation a hysterectomy may be needed
Uterotonic Drugs for Post-Partum Hemorrhage
pitocin
methergine
hemabate
cytotec
misiprostol
pitocin
(Oxytocin 10 units/mL)
10-40 units per 100mL, rate is titrated to uterine tone
IV infusion
Rarely but can be given IM
frequency: continuous
Usually none (side effects) N&V
Hyponatremia with prolonged administration,
↑ BP and ↑ HR with high doses especially if given IVP boluses
contraindicated: Presence of hypersensitivity to the drug
store at :Room temperature
Methergine
Methylergonivine
0.2 mg/mL
IM
(never IV)
frequency: Every 2-4 hours
If no response after 1st dose, it is unlikely an additional
dose will be of any benefit
side effects-Severe hypertension, especially with rapid administration or in patients with existing hypertension or PIH
contraindications: Hypertension, PIH, heart disease, hypersensitivity to med, use with caution if ephedrine has been used (compounded effect)
HTN event can cause a CVA
store:Refrigerated
Protect from light
Hemabate
15-methyl PG F2a
250 mcg/mL
IM or intramyometrial
Not
IV
frequency: Every 15-90 minutes
Do not exceed 8 doses over 24 hours
If no response after 3 doses an additional dose at this point is unlikely to be of any benefit
side effects: Bronchospasms
N&V, diarrhea, fever, (transient), headache, chills shivering, HTN
Use with caution with women who have liver disease
Hypersensitivity to this medication
Refrigerate
Cytotec
Misoprostol
100 or 200 mcg tablets
800-1000mcg
Per rectum
PR
one time
side effects:N&V, diarrhea, shivering, fever (transient)
contraindicated:
Rare
Only if there is a known allergy to prostaglandins
store at room temp
bakri balloon
uterus isnt contracting due to fibroids
prepare for bakri balloon
blood loss calc.
if dry item ways 40 g,
and then when it is wet it weighs 140 g when saturated,
wet weight minus dry weight = 100 g = 100ml blood loss