Week 7 study guide: Intrapartum and Postpartum
Care- High Risk Neonatal Care
Primary (early) postpartum hemorrhage
Causes: uterine atony, lacerations, or hematomas
Indication: within 1st 24hrs, 10% decrease in H&H, saturation of pad in 15 min, boggy
fundus, tachycardia, decreased BP
Secondary (late) postpartum hemorrhage
Causes: hematomas, subinvolution (not healing properly), retained placental tissue
Indications: after 24hrs
Risk factors: neonatal macrosomia, polyhydramnios, high parity, hx of PP hemorrhage,
operative vag delivery (vacuum), augmented or induced, precipitous, chorio, obesity,
coagulation defects
Readiness (Every Unit)
PPH cart with supplies, checklist, intrauterine balloons and compressions stitches
Immediate access to hemorrhage medications (kit or equivalent)
Establish a response team—who to call when help is needed (blood bank, advanced
gynecologic surgery, other support and tertiary services)
Recognition and Prevention (Every Patient)
Assess of PPH risk
Measurement of QBL
Active management of the third stage of labor
Response (Every Hemorrhage)
Unit-standard, stage-based, obstetric hemorrhage emergency management plan with
checklists
Reporting and Systems Learning (Every Unit)
culture of huddles, post-event debriefs to identify successes and opportunities
Multidisciplinary review of serious hemorrhages for systems issues
Monitor outcomes and process metrics in perinatal quality improvement (QI) committee
Tone (uterine atony) Large baby• High parity• Rapid labor• Fever• Fibroids
Tissue• Retained or abnormal placenta• In addition to the above, uterus may not respond
to interventions• Uterus may remain larger than normal
Trauma• Lacerations• Firm uterus with continued bleeding• Steady trickle of unclotted,
bright red blood
Thrombin disorders• Preeclampsia• Stillbirth
Uterine ATONY
, Definition: decreased tone of the uterine muscle
Risk factors: relaxed uterus=less constricted vessels (macrosomia, poly, tired uterus
from augmentation)
Assessment findings: soft uterus, saturation in 15min, slow and steady bleeding, blood
clots, pale and clammy skin, anxiety, tachycardia, hypotension
Medical management: bimanual compression (fig. 14-1)
Medications: Pitocin, methergine, hemabate-to stimulate UCs (cytotec is not FDA
approved but often used), fluid and blood replacement if needed, uterine packing, uterine
tamponade (Bakri balloon)
Surgical interventions: last-stitch effort is hysterectomy
Nursing actions: assess uterus distention (assist to void), assess firmness and lochia
Risk reduction: be prepared by review hx and risks
Uterine massage: massage uterus, encourage breastfeeding for UCs, have good IV for
pit, admin meds per order (no methergine if high BP) bad hemabate side effects
Lacerations
Definition: second most common reason for PPH (to uterine atony)—common sites are
cervix, vagina, labia and perineum
Risk factors: fetal macrosomia, assisted delivery, precipitous
Assessment findings: firm and midline uterus, heavier and steady bleeding, no clots,
tachycardia, hypotension
Medical management: visual inspection of labia/perineum/vagina/cervix, repair
laceration
Nursing actions: review record regarding risk, monitor VS, monitor blood loss, notify
MD, admin pain med, prepare for cervical exam
Hematomas
Definition: bleeding that occurs in the connective tissue of the vagina/perineum from a
ruptured vessel
Risk factors: Episiotomy, use of forceps, prolonged second stage
Assessment findings: severe pain uncontrolled by nl PP pain management, tachycardia,
hypotension, rectal/vaginal pressure, swelling, discoloration, tenderness, if large
enough=uterine displacement
Medical management: small are evaluated and monitored w/o surgical intervention.
Small versus large hematomas—large are surgically excised and blood evaluated, the
open vessel is identified and ligated
Risk reduction: review chart for risk, apply ice to perineum to reduce risk
Comfort measures: assess degree of pain, assess heaviness or fullness in vagina/rectum,
monitor for hypotension or tachycardia, admin pain med, review labs for H&H, notify
MD
Subinvolution
Definition: uterus not decreasing in size and not descending into pelvis. Before this
diagnosis-lochia and uterus shown nl involution signs
Risk factors: fibroids, metritis (inflammation of the uterus), retained placenta
Assessment findings: soft and larger than it should be for the PP day
Medical management: US to ID intrauterine tissue and placental site healing,
management depends on reason
Medications: Methergine PO for fibroids, ABX for metritis
Surgical intervention: D&C for retained placental tissue
, Nursing actions: review records for risk
Patient education: PPH from subinvolution usually occurs after discharge (teach nl
amount of bleeding and look of bleeding), educate risk of infection reduction
Retained Placental Tissue
Definition: portion of placenta remains attached to uterus after placental delivery
Risk factors: manual removal of placenta
Assessment findings: profuse bleeding occurring after week1 PP, subinvolution, elevated
temp and tender uterus if metritis is present, pale skin, tachycardia, hypotension
Medical management: D&C, ABX to tx or prevent metritis or infection
Nursing actions: PPH from retained placental fragments usually occurs after D&C
Patient education: call provider if sudden increase in lochia, bright red bleeding,
elevated temp or uterine tenderness
Disseminated Intravascular Coagulation (DIC)
Pathophysiology: coagulation pathways are hyperstimulated, body breaks down blood
clots faster than it can form them=depleting the body of clotting factors=hemorrhage and
death
Risk factors: Abruptio placenta, HELLP syndrome, amniotic fluid embolism
Assessment findings: prolonged and uncontrolled bleeding, bleeding from
IV/incision/gums/bladder, pupuric (bleeding spots under skin) from BP cuff, abnl clotting
labs, increased anxiety, s/s of shock (pale and clammy skin, tachycardia, tachypnea,
hypotension)
Medical management: improve hemodynamic function and improve tissue oxygenation
while IDing and eliminating the cause, obtain labs, IV therapy, blood replacement,
platelet transfusion, fresh frozen plasma, O2 therapy
Nursing actions: reduce risk (review prentals for risk, assess those w/ risks, assess S/S,
VS), Obtain IV for fluids and replacements, admin O2, obtain labs, review labs, admin
blood products, educate pt
Amniotic Fluid embolism (Anaphylactoid Syndrome of Pregnancy)
Anaphylactictoid Syndrome (Amniotic fluid embolism): embolism forms when the
amniotic fluid that contains fetal cells, lanugo, and vernix enters the maternal vascular
system and results in cardio-respiratory collapse. The cause is not fully understood
(possibly through cervix after rupture, site of placental separation, site of uterine trauma
(lacerations or C/S)) See table 14-1 on pg 363. Pts usually die within 1 hr of symptoms
Risk factors: induction, placental abruption, placental previa
Assessment findings: dyspnea, seizures, hypotension, cyanosis, cardiopulmonary arrest,
Uterine atony=DIC, cardio and pulm arrest
Medical:no data that supports interventions to improve prognosis (maintain
cardiopulmonary function, stop hemorrhage, correcting blood loss, labs,
blood/PLT/Plasma transfusion, chest x-ray, transfer to ICU, heart-lung bypass if available
Nursing actions: monitor for signs, notify MD immediately, admin O2, Establish 2 IVs,
obtain labs, admin blood, provide support, call CODE when needed
SLIDE = Amniotic fluid may gain access to uterine veins following a tear in the
placental membranes and embolize to the lungs, producing acute dyspnea with cyanosis
Care- High Risk Neonatal Care
Primary (early) postpartum hemorrhage
Causes: uterine atony, lacerations, or hematomas
Indication: within 1st 24hrs, 10% decrease in H&H, saturation of pad in 15 min, boggy
fundus, tachycardia, decreased BP
Secondary (late) postpartum hemorrhage
Causes: hematomas, subinvolution (not healing properly), retained placental tissue
Indications: after 24hrs
Risk factors: neonatal macrosomia, polyhydramnios, high parity, hx of PP hemorrhage,
operative vag delivery (vacuum), augmented or induced, precipitous, chorio, obesity,
coagulation defects
Readiness (Every Unit)
PPH cart with supplies, checklist, intrauterine balloons and compressions stitches
Immediate access to hemorrhage medications (kit or equivalent)
Establish a response team—who to call when help is needed (blood bank, advanced
gynecologic surgery, other support and tertiary services)
Recognition and Prevention (Every Patient)
Assess of PPH risk
Measurement of QBL
Active management of the third stage of labor
Response (Every Hemorrhage)
Unit-standard, stage-based, obstetric hemorrhage emergency management plan with
checklists
Reporting and Systems Learning (Every Unit)
culture of huddles, post-event debriefs to identify successes and opportunities
Multidisciplinary review of serious hemorrhages for systems issues
Monitor outcomes and process metrics in perinatal quality improvement (QI) committee
Tone (uterine atony) Large baby• High parity• Rapid labor• Fever• Fibroids
Tissue• Retained or abnormal placenta• In addition to the above, uterus may not respond
to interventions• Uterus may remain larger than normal
Trauma• Lacerations• Firm uterus with continued bleeding• Steady trickle of unclotted,
bright red blood
Thrombin disorders• Preeclampsia• Stillbirth
Uterine ATONY
, Definition: decreased tone of the uterine muscle
Risk factors: relaxed uterus=less constricted vessels (macrosomia, poly, tired uterus
from augmentation)
Assessment findings: soft uterus, saturation in 15min, slow and steady bleeding, blood
clots, pale and clammy skin, anxiety, tachycardia, hypotension
Medical management: bimanual compression (fig. 14-1)
Medications: Pitocin, methergine, hemabate-to stimulate UCs (cytotec is not FDA
approved but often used), fluid and blood replacement if needed, uterine packing, uterine
tamponade (Bakri balloon)
Surgical interventions: last-stitch effort is hysterectomy
Nursing actions: assess uterus distention (assist to void), assess firmness and lochia
Risk reduction: be prepared by review hx and risks
Uterine massage: massage uterus, encourage breastfeeding for UCs, have good IV for
pit, admin meds per order (no methergine if high BP) bad hemabate side effects
Lacerations
Definition: second most common reason for PPH (to uterine atony)—common sites are
cervix, vagina, labia and perineum
Risk factors: fetal macrosomia, assisted delivery, precipitous
Assessment findings: firm and midline uterus, heavier and steady bleeding, no clots,
tachycardia, hypotension
Medical management: visual inspection of labia/perineum/vagina/cervix, repair
laceration
Nursing actions: review record regarding risk, monitor VS, monitor blood loss, notify
MD, admin pain med, prepare for cervical exam
Hematomas
Definition: bleeding that occurs in the connective tissue of the vagina/perineum from a
ruptured vessel
Risk factors: Episiotomy, use of forceps, prolonged second stage
Assessment findings: severe pain uncontrolled by nl PP pain management, tachycardia,
hypotension, rectal/vaginal pressure, swelling, discoloration, tenderness, if large
enough=uterine displacement
Medical management: small are evaluated and monitored w/o surgical intervention.
Small versus large hematomas—large are surgically excised and blood evaluated, the
open vessel is identified and ligated
Risk reduction: review chart for risk, apply ice to perineum to reduce risk
Comfort measures: assess degree of pain, assess heaviness or fullness in vagina/rectum,
monitor for hypotension or tachycardia, admin pain med, review labs for H&H, notify
MD
Subinvolution
Definition: uterus not decreasing in size and not descending into pelvis. Before this
diagnosis-lochia and uterus shown nl involution signs
Risk factors: fibroids, metritis (inflammation of the uterus), retained placenta
Assessment findings: soft and larger than it should be for the PP day
Medical management: US to ID intrauterine tissue and placental site healing,
management depends on reason
Medications: Methergine PO for fibroids, ABX for metritis
Surgical intervention: D&C for retained placental tissue
, Nursing actions: review records for risk
Patient education: PPH from subinvolution usually occurs after discharge (teach nl
amount of bleeding and look of bleeding), educate risk of infection reduction
Retained Placental Tissue
Definition: portion of placenta remains attached to uterus after placental delivery
Risk factors: manual removal of placenta
Assessment findings: profuse bleeding occurring after week1 PP, subinvolution, elevated
temp and tender uterus if metritis is present, pale skin, tachycardia, hypotension
Medical management: D&C, ABX to tx or prevent metritis or infection
Nursing actions: PPH from retained placental fragments usually occurs after D&C
Patient education: call provider if sudden increase in lochia, bright red bleeding,
elevated temp or uterine tenderness
Disseminated Intravascular Coagulation (DIC)
Pathophysiology: coagulation pathways are hyperstimulated, body breaks down blood
clots faster than it can form them=depleting the body of clotting factors=hemorrhage and
death
Risk factors: Abruptio placenta, HELLP syndrome, amniotic fluid embolism
Assessment findings: prolonged and uncontrolled bleeding, bleeding from
IV/incision/gums/bladder, pupuric (bleeding spots under skin) from BP cuff, abnl clotting
labs, increased anxiety, s/s of shock (pale and clammy skin, tachycardia, tachypnea,
hypotension)
Medical management: improve hemodynamic function and improve tissue oxygenation
while IDing and eliminating the cause, obtain labs, IV therapy, blood replacement,
platelet transfusion, fresh frozen plasma, O2 therapy
Nursing actions: reduce risk (review prentals for risk, assess those w/ risks, assess S/S,
VS), Obtain IV for fluids and replacements, admin O2, obtain labs, review labs, admin
blood products, educate pt
Amniotic Fluid embolism (Anaphylactoid Syndrome of Pregnancy)
Anaphylactictoid Syndrome (Amniotic fluid embolism): embolism forms when the
amniotic fluid that contains fetal cells, lanugo, and vernix enters the maternal vascular
system and results in cardio-respiratory collapse. The cause is not fully understood
(possibly through cervix after rupture, site of placental separation, site of uterine trauma
(lacerations or C/S)) See table 14-1 on pg 363. Pts usually die within 1 hr of symptoms
Risk factors: induction, placental abruption, placental previa
Assessment findings: dyspnea, seizures, hypotension, cyanosis, cardiopulmonary arrest,
Uterine atony=DIC, cardio and pulm arrest
Medical:no data that supports interventions to improve prognosis (maintain
cardiopulmonary function, stop hemorrhage, correcting blood loss, labs,
blood/PLT/Plasma transfusion, chest x-ray, transfer to ICU, heart-lung bypass if available
Nursing actions: monitor for signs, notify MD immediately, admin O2, Establish 2 IVs,
obtain labs, admin blood, provide support, call CODE when needed
SLIDE = Amniotic fluid may gain access to uterine veins following a tear in the
placental membranes and embolize to the lungs, producing acute dyspnea with cyanosis
