Ch.22: Management of Postpartum Women at Risk
Hypovolemic Shock
Report weak & rapid pulse
Engorged Breast
Bottle feeding education: ice to decrease blood flow (vasoconstrict)
Postpartum Hemorrhage
Defined by: 500 mL blood loss vaginal birth & 1,000mL cesarean birth, s/s of hypovolemia
Early PPH: Blood loss 24 hours of birth, cumulative blood loss of 1,000mL or greater
Delayed or late: blood loss 24 hrs-12 weeks after birth, subinvolution, retained fragments
Risk factors: overdistention, multiparity (twins), precipitate, prolonged labor, forceps, vacuum, history of PPH,
prolonged bedrest, smoking
Prevention: uterotonic meds, gentle cord traction to deliver placenta, uterine massage
Causes and Nursing Intervention
o Uterine atony- Massage & oxytocics
failure of the uterus to contract & retract after birth
S/s: soft fundus, boggy uterus that deviates midline, excessive lochia & clots, heavy lochia,
difficulty locating fundus
Assess uterine tone by palpating fundus for firmness & location
Management: contract uterus, provide fluids
Fundal massage- check firmness
o Assess Fundus for consistency, shape, and location
Uterus should be firm, midline, & decrease 1 cm each postpartum day
o Retained placental fragments: evacuation & oxytocics
o Laceration or hematoma: surgical repair
Laceration: constant trickle of blood, firm & midline fundus, bright red bleeding, bluish bulging
area
o Thrombin coagulation disorders: blood products
o Uterine inversion: gentle replacement of the uterus
oxytocin to cause contraction & decrease blood loss
Patho & Risk Factors: five T’s
o Tone: uterine atony, distended bladder (overdistended uterus)
Uterine muscle exhaustion, uterine infection
o Tissue: retained placenta and clots
Products of conception, retained blood clots
o Trauma: vaginal, cervical, or uterine injury
Lacerations, uterine inversion’
o Thrombin: coagulopathy (pre-existing or acquired)/lack of coagulation
Preexisting conditions
o Traction: too much pulling on umbilical cord
s/s: noncontracting uterus, saturation of 1 pad per 15 min, severe pain, tachycardia, lochia rubra lasting 7-10
days, hypotension
Assess: uterine tone, vaginal bleeding, v/s, coagulation testing
o Assess fundus if perineal pad has become saturated in 15 min
Therapeutic Management
o Focus on underlying cause
, o Uterine massage if uterine atony is noted, assess for firmness & clots
o Remove retained placental fragments, antibiotics for infection, or repair lacerations
Nursing Interventions
o Palpate Fundus as soon as there’s heavy lochia flow w/ large clots
o Before ambulating assess BP, HR, & dizziness
o Immediate fundal massage, place hand over symphysis pubis to anchor fetus & prevent possible uterine
inversion
o Pad counts & weight, assess visible vaginal bleeding, v/s q 15-30 min
o Foley catheter is placed to avoid displacement of the uterus
o IV fluids, For blood transfusions: type & cross match
o Educate to avoid aspirin, antihistamines, NSAIDs
o Once stable: assist to sit up slowly & dangle legs
Administer uterotonic meds to control pph (drug guide 22.1)
o Oxytocin (Pitocin): stimulates contraction to control bleeding
Assess fundus, v/s q15 min, uterine tone, pad count
Never give undiluted as bolus injection IV
o Misoprostol (Cytotec): stimulates contraction to reduce bleeding though rectum, no IV
Not FDA approved, but effective for acute pph
o Dinoprostone (Prostin E2): vaginal or rectal suppository
Monitor BP for hypotension, v/v, diarrhea, temperature elevation
o Methylergonovine maleate (Methergine): stimulates uterus d/t atony or subinvolution
Elevates BP, assess that BP is not high & has no history of HTN
Assess baseline bleeding, uterine tone, v/s (BP) q 15
s/e: hypertension, seizures, uterine cramping, n/v, palpitations
Report any chest pain promptly. Hypertension is contraindicated.
o Prostaglandin (PGF2α), Carboprost (Hemabate): last line method, IM injection
Assess v/s, contractions, comfort level, bleeding
s/e: fever, chills, headache, n/v/d, flushing, bronchospasm
Monitor for s/s of shock w/ excessive blood loss
o Assess BP, pulse, cap refill, mental status, urinary output
o Mild, 20% blood loss: diaphoresis, increased capillary refill, cool extremities, maternal anxiety
o Moderate 20-40%: tachycardia, postural hypotension, oliguria
o Severe 40%: hypotension, agitation/confusion, hemodynamic instability
Emergency measures if DIC occurs
o s/s: petechiae, ecchymosis, bleeding gums, fever, hypotension, bleeding from cesarean incision site or IV
site, hematuria, blood in stool, decreased urinary output, pallor
o Can occur w/ septicemia, abruptio placenta, severe preeclampsia
o Goal: maintain perfusion through fluids, oxygen, heparin, blood products
o Treat the underlying cause & DIC will go away
o Replace fluids, administer blood, optimize oxygenation
Subinvolution- incomplete involution of uterus after birth
Causes: Retained placental fragments, distended bladder, uterine myoma, infection
Complications: fatigue, hemorrhage, pelvic peritonitis, salpingitis, abscess formation
s/s: 4-6 weeks uterus is enlarged, soft, lochia discharge
Hypovolemic Shock
Report weak & rapid pulse
Engorged Breast
Bottle feeding education: ice to decrease blood flow (vasoconstrict)
Postpartum Hemorrhage
Defined by: 500 mL blood loss vaginal birth & 1,000mL cesarean birth, s/s of hypovolemia
Early PPH: Blood loss 24 hours of birth, cumulative blood loss of 1,000mL or greater
Delayed or late: blood loss 24 hrs-12 weeks after birth, subinvolution, retained fragments
Risk factors: overdistention, multiparity (twins), precipitate, prolonged labor, forceps, vacuum, history of PPH,
prolonged bedrest, smoking
Prevention: uterotonic meds, gentle cord traction to deliver placenta, uterine massage
Causes and Nursing Intervention
o Uterine atony- Massage & oxytocics
failure of the uterus to contract & retract after birth
S/s: soft fundus, boggy uterus that deviates midline, excessive lochia & clots, heavy lochia,
difficulty locating fundus
Assess uterine tone by palpating fundus for firmness & location
Management: contract uterus, provide fluids
Fundal massage- check firmness
o Assess Fundus for consistency, shape, and location
Uterus should be firm, midline, & decrease 1 cm each postpartum day
o Retained placental fragments: evacuation & oxytocics
o Laceration or hematoma: surgical repair
Laceration: constant trickle of blood, firm & midline fundus, bright red bleeding, bluish bulging
area
o Thrombin coagulation disorders: blood products
o Uterine inversion: gentle replacement of the uterus
oxytocin to cause contraction & decrease blood loss
Patho & Risk Factors: five T’s
o Tone: uterine atony, distended bladder (overdistended uterus)
Uterine muscle exhaustion, uterine infection
o Tissue: retained placenta and clots
Products of conception, retained blood clots
o Trauma: vaginal, cervical, or uterine injury
Lacerations, uterine inversion’
o Thrombin: coagulopathy (pre-existing or acquired)/lack of coagulation
Preexisting conditions
o Traction: too much pulling on umbilical cord
s/s: noncontracting uterus, saturation of 1 pad per 15 min, severe pain, tachycardia, lochia rubra lasting 7-10
days, hypotension
Assess: uterine tone, vaginal bleeding, v/s, coagulation testing
o Assess fundus if perineal pad has become saturated in 15 min
Therapeutic Management
o Focus on underlying cause
, o Uterine massage if uterine atony is noted, assess for firmness & clots
o Remove retained placental fragments, antibiotics for infection, or repair lacerations
Nursing Interventions
o Palpate Fundus as soon as there’s heavy lochia flow w/ large clots
o Before ambulating assess BP, HR, & dizziness
o Immediate fundal massage, place hand over symphysis pubis to anchor fetus & prevent possible uterine
inversion
o Pad counts & weight, assess visible vaginal bleeding, v/s q 15-30 min
o Foley catheter is placed to avoid displacement of the uterus
o IV fluids, For blood transfusions: type & cross match
o Educate to avoid aspirin, antihistamines, NSAIDs
o Once stable: assist to sit up slowly & dangle legs
Administer uterotonic meds to control pph (drug guide 22.1)
o Oxytocin (Pitocin): stimulates contraction to control bleeding
Assess fundus, v/s q15 min, uterine tone, pad count
Never give undiluted as bolus injection IV
o Misoprostol (Cytotec): stimulates contraction to reduce bleeding though rectum, no IV
Not FDA approved, but effective for acute pph
o Dinoprostone (Prostin E2): vaginal or rectal suppository
Monitor BP for hypotension, v/v, diarrhea, temperature elevation
o Methylergonovine maleate (Methergine): stimulates uterus d/t atony or subinvolution
Elevates BP, assess that BP is not high & has no history of HTN
Assess baseline bleeding, uterine tone, v/s (BP) q 15
s/e: hypertension, seizures, uterine cramping, n/v, palpitations
Report any chest pain promptly. Hypertension is contraindicated.
o Prostaglandin (PGF2α), Carboprost (Hemabate): last line method, IM injection
Assess v/s, contractions, comfort level, bleeding
s/e: fever, chills, headache, n/v/d, flushing, bronchospasm
Monitor for s/s of shock w/ excessive blood loss
o Assess BP, pulse, cap refill, mental status, urinary output
o Mild, 20% blood loss: diaphoresis, increased capillary refill, cool extremities, maternal anxiety
o Moderate 20-40%: tachycardia, postural hypotension, oliguria
o Severe 40%: hypotension, agitation/confusion, hemodynamic instability
Emergency measures if DIC occurs
o s/s: petechiae, ecchymosis, bleeding gums, fever, hypotension, bleeding from cesarean incision site or IV
site, hematuria, blood in stool, decreased urinary output, pallor
o Can occur w/ septicemia, abruptio placenta, severe preeclampsia
o Goal: maintain perfusion through fluids, oxygen, heparin, blood products
o Treat the underlying cause & DIC will go away
o Replace fluids, administer blood, optimize oxygenation
Subinvolution- incomplete involution of uterus after birth
Causes: Retained placental fragments, distended bladder, uterine myoma, infection
Complications: fatigue, hemorrhage, pelvic peritonitis, salpingitis, abscess formation
s/s: 4-6 weeks uterus is enlarged, soft, lochia discharge
