53 terms

Abcaudill Postpartum Hemorrhage

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when is the appearance of early postpartum hemorrhage most common
w/in the first postpartum
what is the primary and secondary main causes for early postpartum hemorrhage
1: Primary Uterine Atony
2: Lacerations
What are some predisposing factors for a pt to be at risk for postpartum hemorrhage
1- large infant
2 - multiple infant
3 - labor induction or augmentation
4 - use of labor assistive devices
how serious is trauma to the birth canal in risks for postpartum hemorrhage
- second main cause of postpartum hemorrhage
- Lacerations are a big culprit here
How can you distinguish source of postpartum hemorrhage from cervical or uterine
- if the fundus is midline and the at the right area without a distended bladder, the bleeding "most" likely may be from the cervical region and not from the uterus
What are the most common sites where lacerations can occur
- perinuem
- vagina
- cervix is the most common
what color will the lochia be for a postpartum hemorrhage that is casued by a laceration
- Lochia is usually bright red
When does laceration postpartum hemorrhage usually occur, and what are some common causes for it to happen
- usually occur during the second stage of labor
- Often caused when the fetus comes down quickly or when assistive devices are used
- suspect laceration when bleeding is happening but the fundus is firm and in place
When does a hematoma occur. what are teh common areas
- occurs with bleeding into loose connective tissue
- common areas are the vagina, vulvar, and retroperitoneal areas
What would the pt feel if they are suffering from postpartum hematoma
- produces deep and sever pain which goes unreliieved
S/S of hemorrhage as postpartum hemorrhage
- tachycardia followed by decreased BP with no indication of bleeding
- Placenta accreta: abnormal adherence of the placenta to the uterine wall
-uterine inversion
what is placental accreta
placental accreta: abnormal adherence of the placenta to the uterine wall
- if placental fragments are w/in the uterus, full contraction is not possible
why is it so dangerous are still w/in the uterus
- full contraction is not possible
when does late postpartum hemorrhage
- typically occurs 6 days to 6 weeks post partum
waht is subinvolution
delayed return of the uterus to its not pregnant size and consistancy
what are some ways to limit the risk of retained placential fragments
- do not force the placenta out
- careful inspection of the placenta
What education would you give a pt concerning post partum hemorrhage
- location of fundus and type of lochia to suspect in "normal" cases
- notify if bleeding persists or becomes abnormally heavy
How would you control excess bleeding for a pt suffereing form late postpartum hemorrhage
- oxytocin, methylergonovine, prostglandins
- use oxytocin first, if bleeding subsides, no other pharm needed
Why would you use antibiotics in treating postpartum hemorrhage
- excessive bleeding can be caused by infxn
- foul smelling lochia, fever
Predisposing factors for late postpartum hemorrhage
- attempts to deliver the placenta before it separates from the uterine wall
- manual removal of placenta
- previous csec births
- uterine leiomyomas
what is uterine leiomyomas
- A benign tumor derived from smooth muscle, occurring most often in the uterus
- number one factor of risk for placental fragments
Why is the nursing assessment vital to caring for the postpartum woman?
. postpartum
- to assess pts risks for hemorrhage
- a. manage uterine atony if appliable
what is uterine atony
- lack of muscle tone that results in failure of the uterine muscle fibers to contract firmly around blood vessels when the placenta separates
why is uterine atony a problem
- relaxed muscles allow rapid bleeding from the endometrial arteries at the placental site
- bleeding will continue to bleed until the uterine muscles contract
- major cause of early postpartum hemorrohage
S&S of uterine atony
- utuerine fundus that is difficult to locate
- soft, "boggy" feel when the fundus is located
- uterus that becomes firm when massaged, but then goes back to boggy when massage is stopped
- a fundus that is located above the expected lvl
- excessive locia, esp if it is bright red
- excessive clots expelled
- Darker red lochia rubria
If lochia is a darker red, what is this a S&S of
- urine atony
what is the first intervention that you should do when postpartum hemorrhage occurs
- fundal massage
How is postpartum hemorrhage treated
- fundal massage
- assess for bladder distention (foley prn)
- Bimanual compression
- laparotomy
- hyserectomy
- Lactacted Ringers and/or whole blood
- uteirne packing and ballooning
what is a laparotomy
- "tubal ligation"
- may be needed in extreme cases when source of bleeding is needed to be discovered
what is bimanuel compression
- one hand inserted into vagina and the othe compresses the uturus thru the abdominal wall
what is the problem of a distended bladder
- full bladder lifts uterus not allowing the uterus to go back to its original spot
3 main drugs used for treating postpartum hemorrhage
- Oxytocin
- Methylergonovine (Methegine)
- Hemabate, Prostin/15M (Carboprost Tromethamine)
How does Carbooprost Tromethamine work
- stimulates contraction of the uterus
How does Hemabate work
- stimulates contraction of the uterus
How does Methylergonovine (Methegine) work
- stimulates sustained contraction of the uterus and causes arterial vasoconstriction
- also raises BP
Contraindications for using Methylergovonive (Methegine)
- never use during pregnancy or to induce pregnancy
- HTN ( Methegine can increase BP)
- Hepatic or LIver disease
- Thrombophlebitis
- Coronary & Peripheral Artery Disease
- Hypocalcemia
Why use Oxytocin/Pitocin in treating postpartum hemorrhage
- rapid IV infusion often increases uterine tone and controls bleeding
Indications on Methylgeronovine (Methegine)
- used for the prevention and treatment of postpartum or postabortion hemorrhage casued by uterine atony
S/E of Methegine
- N/V
- Uterine cramping and GI cramping
- HTN, chest pain
- dizziness
Nrsg Considerations for Methegine
- Check Ca lvls
- Assess BP
- Avoid smoking due to nicotine constricting blood vessels
- never give via IV
Indications on using Carboprost Tromethamine
- used for the treatment of post part humorrhage caused by uterine atony. Also used for abortion
- give if oxytocin ineffective
How is methegine metabolized
- liver and enzyme in lungs
Contraindications of Carboprost Tromethamine
- hypersensitivity to prostglandins
- acute pelvic inflammatory disease
- cardiac, pulmonary, renal, or hepatic disease
Other than the contraindications for using Carboprost Tromethamine, what are the other cautions to be aware of?
H/O
- asthma
- anema
- jaundice
- DM
- Epilepsy
- previous uterine surgery
what is a tetanic contraction
- . a condition of continuous contraction in a voluntary muscle caused by a steady stream of efferent nerve impulses. Also called tetanic convulsion
Common S/E of carboprost tromethamine
- tetanic contraction
- may cause uterine hypertonus if use w/ oxytocin
- N/V
- freq diarrhea
- fever, chills, facial flushing
- headache
- tachycardia
- pulmonary edema
- HTN or hypotension
what may happen if you use carboprost tromethamine AFTER pt has already been on oxytocin
- may cause uterine hypertonus if use w/ oxytocin
Nrsg Considerations for using carboprost tromethamine
- IM injection
- monitor VS
- admin anitemetics and antidiarrheals as ordered and prn
What are some factors that may cause the uterus to have difficulty contracting
overdistention
- over extended bladder
- multiparity
- a large infant
- hydraaminos
- csec
- oxytocin, prostglandins, tocolytics, mgso4
why would multiparity be a risk factor for postpartum hemorrhage
- production of several offspring in one gestation can cause extra use and extra trauma on birth canal and can overextend the uterus and make it "tired"
what is a hydraaminos
- presence of an excessive amount of amniotic fluid
- can lead to prolonged labor
why would a pt who took oxytocin put a pt at risk for postpartum hemorrhage
labors that were given this drug and or induced labors increase their chances of uterine atony and postpart hemorrhage
Intrapartum Factors that may lead to postpartum hemorrhage
barely effective contractions
a. too vigorous contractions
muscle may be too tired after to contract after a vigour contraction labor