MCN MOD 6.1

• Postpartum Hemorrhage

  • Uterine Atony
  • Lacerations
  • Retained Placental Fragments
  • Disseminated Intravascular Coagulation
• Puerperal Infections

  • Endometritis
  • Infections of the Perineum
  • Peritonitis
  • Urinary Tract Infection
• Thromboembolic Disorders

  • Thrombophlebitis
  • Femoral Thrombophlebitis
  • Pelvic Thrombophlebitis
  • Pulmonary Embolus
  • Amniotic Fluid Embolism
• Psychiatric Disorders

  • Postpartum Blues
  • Postpartum Depression
  • Postpartum Psychosis
• A postpartum client receiving heparin asks whether she can continue to breastfeed. The best advice for the nurse to give is that she can continue to breastfeed but must assess the baby daily for ecchymotic spots
• Factors that predispose women to infection in the postpartum period

  • Placental fragments retained in the uterus
  • Placement of internal fetal heart monitoring
  • Rupture of membranes less than 24 hours before birth
  • Instrument births
  • Pre-existing anemia
• Late postpartum hemorrhage

  Bleeding that occurs after the first 24 hours until 6 weeks puerperium
• The symptoms of fever of 101°F, abdominal pain, and a "bad smell" to the lochia are associated with endometritis
• When uterine rupture occurs, the highest priority intervention is to limit hypovolemic shock
• When membranes were ruptured for 28 hours before delivery, the most important action is to monitor the mother's temperature every 2 hours
• Nurse's initial action when a postpartum woman is bleeding heavily

  1. Assess and massage the fundus if soft

  2. Take vital signs

  3. Place the client in sharp Trendelenburg position

  4. Notify the physician immediately
• The first action when a postpartum woman is having difficulty breathing and the area around her mouth is blue is to raise the head of the bed
• The delivery factor most likely contributing to a postpartum hemorrhage is that the woman received Pitocin after delivery of the placenta
• Postpartum depression


  Maladaptation to the stress and conflicts of the postpartum period, a disorder that often occurs during the first month after delivery and lasts for weeks to months
• The postpartum period is 6-8 weeks after childbirth, also known as the puerperium
• Postpartum hemorrhage is one of the primary causes of maternal mortality associated with childbearing
• Postpartum hemorrhage


  Blood loss of 500 mL or more following a vaginal birth within a 24-hour period, or 1000 mL with cesarean births
• Postpartum hemorrhage occurs in as many as 5-8% of postpartum women
• The greatest danger of postpartum hemorrhage is in the first 24 hours due to the unprotected uterine area after placental detachment
• Classifications of postpartum hemorrhage

  • Early (within first 24 hours, more dangerous)
  • Late (24 hours to 6 weeks after birth, usually not severe)
• Causes of postpartum hemorrhage

  • Uterine atony
  • Lacerations
  • Retained placental fragments
  • Uterine inversion/rupture
  • Abnormal placentation
  • Coagulation disorders
  • Trauma
  • Disseminated intravascular coagulation
• The 4 Ts of postpartum hemorrhage

  • Tone (failure of uterine contraction)
  • Tissue (retained placental tissues)
  • Trauma (lacerations and hematoma)
  • Thrombosis (clot formation and fibrin deposition)
• Conditions that increase risk of postpartum hemorrhage

  • Conditions that distend the uterus
  • Conditions that could cause cervical/uterine lacerations
  • Conditions with varied placental site/attachment
  • Conditions that leave the uterus unable to contract readily
  • Conditions that lead to inadequate blood coagulation
• Signs and symptoms of postpartum hemorrhage

  • Excessive bright red blood
  • Boggy fundus unresponsive to massage
  • Abnormal clots
  • High temperature
  • Pelvic discomfort/backache
  • Persistent bleeding despite contracted uterus
  • Signs of hypovolemic shock
• Uterine atony


  Failure of the uterus to contract
• Risk factors for uterine atony

  • Chorioamnionitis
  • Prolonged labor
  • Prolonged use of oxytocin
  • General anesthesia
  • Asian/Hispanic ethnicity
  • Conditions causing increased uterine distention
• Active Management of the Third Stage of Labor (AMTSL)

  1. Do not wait for signs of placental separation

  2. Uterine/fundal massage

  3. Nipple stimulation

  4. Immediate cord clamping and cutting

  5. Controlled cord traction with counter-traction
• Uterotonics (oxytocin)

  Uterotonic and pharmacologic agents typically the first step for uterine atony
• Oxytocin is a hormone naturally produced by the posterior pituitary that works rapidly to cause uterine contraction with no contraindications and minimal side effects
• Oxytocin does not cause an increase in blood pressure compared to methergine
• Adverse reactions to oxytocin include nausea, vomiting, cardiac arrhythmias, uterine hypertonicity, uterine rupture, and severe water intoxication
• Uterotonic


  Pharmacologic agents that cause uterine contraction
• Uterotonic administration

  1. Identify uterine atony

  2. Administer uterotonic

  3. Monitor blood pressure

  
• Oxytocin

  Hormone naturally produced by the posterior pituitary that causes uterine contraction
• Oxytocin


  • Rapid action but short duration
  • Does not cause increase in blood pressure compared to methergine
• Oxytocin adverse reactions


  • Nausea and vomiting
  • Cardiac arrhythmias
  • Uterine hypertonicity
  • Uterine rupture
  • Severe water intoxication
  • Fetal bradycardia
• Oxytocin is given routinely at delivery, but additional uterotonic medications may be given with bimanual massage in response to hemorrhage
• Carboprost tromethamine (Hemabate)


  Synthetic prostaglandin analogue used to treat postpartum uterine hemorrhage due to atony
• Carboprost tromethamine side effects


  • Nausea and vomiting
  • Diarrhea
  • Headache
  • Flushing
  • Bradycardia
  • Bronchospasm
  • Wheezing
  • Cough
  • Chills
  • Fever
• Methylergonovine maleate (Methergine)


  Semi-synthetic ergot alkaloid that works rapidly for sustained uterine contraction