NCM109 MIDTERMS

• Postpartum Hemorrhage (PPH)


  Severe bleeding after giving birth
• PPH


  • A serious and dangerous condition
  • Occurs within 24 hours of childbirth, can happen up to 12 weeks postpartum
  • Total blood loss is greater than 32 fl oz or 500mL after delivery
• Types of PPH


  • Early PPH or Primary PPH
  • Late PPH or Secondary PPH
• Early PPH or Primary PPH

  Occurs in the first 24 hours, 70% due to uterine atony
• Late PPH or Secondary PPH


  Occurs from 24 hours to 12 weeks, caused by retained placental tissue or infection
• Assessment for hemorrhage and shock

  • Persistent significant bleeding: Perineal pad is soaked within 15 minutes
  • Restlessness, increased pulse rate, decreased blood pressure, cool and clammy skin, ashen or grayish color
  • Complaints of weakness, lightheadedness and dyspnea
• Causes of PPH


  • Uterine Atony
  • Laceration of the cervix or vagina
  • Hematoma development in the cervix, perineum, or labia
  • Retained placental fragments
• Uterine Atony


  Poorly contracted uterus that does not adequately compress large open vessels at the placental site
• Assessment of Uterine Atony


  • Soft and boggy uterus on palpation of fundus
  • Excessive vaginal bleeding with blood clots

  
• Intervention for Uterine Atony

  • Massaging uterus until firm
  • Empty woman's bladder (voiding or catheter)
  • Notify HCP if not resolved for oxytocin administration
• Degrees of Laceration


  • 1st Degree: Fourchette, Vaginal mucus membrane, Perineal skin
  • 2nd Degree: Fourchette - Perineal skin, Muscles of perineal body
  • 3rd Degree: Fourchette - Muscles of perineal body, Anal Sphincter
  • 4th Degree: Fourchette - Anal sphincter, Mucous membrane of rectum
• Assessment of Laceration


  • Bright red vaginal bleeding with firm fundus
• Intervention for Laceration


  • Vaginal packing
  • 3rd and 4th degree lacerations should not be given an enema or rectal suppository, constipation should be avoided, temperature should not be taken rectally
• Hematoma Development


  Localized collection of blood in the tissues: occurs internally, involves vaginal sulcus or other organs, most common is Vulvar Hematoma
• Factors for Hematoma Development

  • Forceps delivery
  • Inadequate suturing or episiotomy > injury to blood vessel
  • Vulvar varicosities
  • Precipitate labor
• Assessment of Hematoma


  • Abnormal, severe pain
  • Pressure in the perineal area
  • Sensitive, bulging mass in the perineal area with discolored skin
  • Inability to void
  • Decreased hemoglobin and hematocrit levels
  • Changes in vital signs> SHOCK
• Intervention for Hematoma


  • Monitor abnormal pain or perineal pressure
  • Watch for signs of hypovolemic shock
  • Ice compress on hematoma site
  • Analgesics & blood products as prescribed
  • Antibiotics as prescribed, infection is common after hematoma formation
  • Prepare for incision and evacuation of hematoma if necessary
• Retained Placental Fragments


  When the placenta doesn't completely come out of the uterus after the baby is born
• Factors for Retained Placental Fragments

  • Partial separation of a normal placenta
  • Manual removal of placenta
  • Entrapment of placenta in the uterus
  • Abnormal adherent placenta (accreta)
• Assessment of Retained Placental Fragments

  • Boggy uterus
  • Excessive vaginal bleeding with blood clots
  • Late signs of shock (air hunger, anxiety, apprehension)
• Intervention for Retained Placental Fragments

  • Dilatation and curettage (D and C) to remove adherent placenta
  • Hysterectomy if manual removal of the placenta and other techniques are successful and will result in grace complications such as severe hemorrhage, DIC and perforation of the uterus
• Subinvolution


  Incomplete involution or failure of the uterus to return to its normal size and condition
• Assessment of Subinvolution


  • Uterine pain or palpation
  • Uterus larger thane expected
  • More than normal vaginal bleeding

  
• Intervention for Subinvolution


  • Assess vital signs
  • Assess uterus and fondus
  • Monitor for urine pain and vaginal bleeding
  • Elevate legs to promote venous return
  • Encourage frequent voiding
  • Monitor Hgb and Hct
  • Administer methylergonovine maleate, this provides sustained contraction of the uterus

  
• Puerperal Infection


  Also known as "childbed fever", infection of the genital tract after delivery
• Infecting Organisms


  • Anaerobic streptococci
  • Escherichia coli
  • Chlamydia trachomatis
  • Staphylococci
• Predisposing Factors; PUERPERAL INFECTION


  • PROM
  • Prolonged labor
  • Postpartum hemorrhage
  • Retained placental fragments
  • Intrauterine manipulation: manual exploration of the uterus
  • Excessive vaginal examination (IE) during labor
  • Malnutrition
  • Instrumental deliveries
  • Presence of infection elsewhere in the body or in the genital tract during labor, delivery and puerperium
  • Sexual intercourse near labor or after membranes had ruptured

  
• Assessment of Puerperal Infection

  • Fever (elevation of 100.4 F or above for 2 consecutive dates or more after the first 25 hours postpartum
  • Foul smelling lochia or vaginal discharge
  • Rapid pulse, chills
  • Abdominal pain or tenderness
  • Uterus is boggy
  • Body malaise
  • Lack of appetite perineal discomfort
  • Nausea and vomiting
• Prevention of Puerperal Infection

  • Good prenatal nutrition
  • Prevention of anemia and hemorrhage good maternal hygiene
  • Strict adherence to to aseptic technique by hospital personnel
  • Well- balanced diet to promote healing
  • Antibiotics as prescribed
• Types of Puerperal Infections

  • Infection of the Perineum, Vulva, and Cervix
  • Endometritis
  • Urinary Tract Infections
  • Mastitis
• Signs and Symptoms of Perineal, Vulvar, and Cervical Infection

  • Pain and sensation of heat or feeling of pressure on the affected area
  • Presence of pus
  • Fever
  • Redness, swelling
  • Dysuria
• Prevention of Perineal, Vulvar, and Cervical Infection

  • Observe good perineal hygiene
  • Change perineal pad frequently to avoid contamination and reinfection
  • Wash hand before and after changing perineal pads
• Postpartum Hemorrhage (PPH)


  Severe bleeding after giving birth
• PPH


  • A serious and dangerous condition
  • Occurs within 24 hours of childbirth, can happen up to 12 weeks postpartum
  • Total blood loss is greater than 32 fl oz or 500mL after delivery
• Types of PPH


  • Early PPH or Primary PPH
  • Late PPH or Secondary PPH
• Early PPH or Primary PPH

  Occurs in the first 24 hours, 70% due to uterine atony
• Late PPH or Secondary PPH


  Occurs from 24 hours to 12 weeks, caused by retained placental tissue or infection
• Assessment for hemorrhage and shock

  • Persistent significant bleeding: Perineal pad is soaked within 15 minutes
  • Restlessness, increased pulse rate, decreased blood pressure, cool and clammy skin, ashen or grayish color
  • Complaints of weakness, lightheadedness and dyspnea
• Causes of PPH


  • Uterine Atony
  • Laceration of the cervix or vagina
  • Hematoma development in the cervix, perineum, or labia
  • Retained placental fragments
• Uterine Atony


  Poorly contracted uterus that does not adequately compress large open vessels at the placental site