MATERNITY EXAM 3: PP Woman at Risk 1
PP Conditions that put Women at Risk:
● Postpartum hemorrhage
● Thromboembolic conditions
● Postpartum infections
Postpartum Hemorrhage
● Potentially life threatening complication
● Leading cause of worldwide
● Defined as blood loss of:
○ > 500 ml (vaginal birth) 10%
○ > 1000 ml (C section) 25%
●
Causes→ 4 T’s
●
○ Uterine atony: failure of the uterus to contract after birth (most common cause of pp hemorrhage)
■ CAUSES
●
● Overdistention of uterus caused by: multifetal gestation, macrosomia, placental
fragments
● Prolonged or rapid labor
● Uterine infections
● Anesthesia, MgSO4, Pitocin given before delivery of placenta
○ Magnesium: dangerous drug, high dose can stop heart (only give to severely
hypotensive pts)
●
○ Retained placenta
○ complete detachment & expulsion permits continued contraction & optimal occlusion of blood vessels
○ Thorough inspection of placenta necessary
●
○ Damage to genital tract: ○ Hematomas: (damage to larger blood
■ Cervical and vaginal wall vessel→ blood seeps outside into tissue)
lacerations ■
■ “Trickling” of ■
■ Spontaneous or via manipulation ■
● :
○ Hypercoagulation: normal* and protective; YOU WANT BLOOD TO BE CLOTTING
○ Coagulopathies:
■ bleeding disorders characterized by prolonged excessive bleeding
■ suspected if postpartum bleeding persists
■ Often masked by routine use of
■ Assess lab values for: ↓ platelets & fibrinogen, ↑ prothrombin time, and prolonged bleeding
time
○ Examples:
■ Idiopathic thrombocytopenic purpura (ITP): disorder of increased platelet destruction r/t
autoantibodies, will see bleeding from IV sites, bruising
■ von Willebrand disease (vWD): congenital disorder of bleeding time, doesn’t show up until
significant bleeding event, treated with (desmopressin) give IV if dx is 100%
● von Willebrand factor (WWF) is an essential clotting protein
● Missing or lacking WWF in vWD
, MATERNITY EXAM 3: PP Woman at Risk 2
■ Disseminated intravascular coagulation (DIC): clotting system abnormally activated causing
widespread clots throughout the body, increased systemic clotting depletes factors needed to
stop excessive bleeding; caused by severe injury or infection
Nursing Assessment for Bleeding:
● Assess amount of bleeding:
○ Heavy and slow, steady loss
○ Weigh peri pads to measure blood loss (ml = g)
■ 1,000 mL of blood weighs 1,000g
● Assess tone and location of fundus q 15 min for 1-2 hrs then q 1 hr for 4 hours
● Assess VS especially BP and pulse, UO, LOC
○ UO helps assess kidney function
○ < 30mL in 1 hr → kidneys starting to shut down r/t lack of perfusion
○ Foley catheter with urine meter for exact measurement in mL
● Look for hematoma
Risk Factors for PP Hemorrhage:
● Prolonged labor ● Preeclampsia ● Grand multiparity
● Precipitous birth ● Maternal hypotension ● Hydramnios (too much
● History of PP hemorrhage ● Lacerations amniotic fluid)
● Multiple gestations ● Operative birth ● Coagulation abnormalities
● Uterine infection ● Augmented labor
● Manual extraction of (stimulation of uterus to
placenta promote cxs)
During Hemorrhage:
● Monitor VS q 5 min until stable
○ Note trend in VS (pulse and RR increases, BP decreases, temp shouldn’t change)
● Administer oxygen at L via mask
● Palpate fundus and massage prn
● Insert foley catheter
● Initiate pad count**
● Assess emotional and mental status
● Administer uterotonic drugs:
Parameters Class I Hemorrhage Class II Hemorrhage Class III Hemorrhage Class IV Hemorrhage
Estimated 15% 15-30% 30-40% > 40%
Blood Loss
Pulse < 100 > 100 > 120 > 140
BP Normal or increased Decreased Decreased Decreased
RR Normal 20-30 30-40 > 40
Urine output > 30 ml/hr 20-30 ml/hr 5-15 ml/hr Negligible
Thromboembolic Conditions: Thromboembolism
● Obstruction of a blood vessel by a blood clot
● Superficial or deep (both can cause pulmonary embolism)
● Leading cause of in the US
Nursing Management:
, MATERNITY EXAM 3: PP Woman at Risk 3
● Identify those at increased risk (smoking, history of birth control pills, varicosities)
● Prevent venous pooling
○ Elevate legs with pillows
○ Stirrups maximizes leg drainage (legs above heart level)
○ Avoid crossing legs
● Prevent : encourage ambulation, TEDs, compression devices (especially after C section)
● Meds to decrease hypercoagulability (if pt really at risk):
● Coagulation studies & elevation
Postpartum Infection
● Affects of all births
● Defined as fever > 100.4 after 24 hrs postpartum occurring for at least 2 of the first 10 days after birth
● Normal physiologic changes of childbirth increase risk of infection (amniotic fluid, blood, lochia all )
Common PP Infections:
● Teach mom to report any temp >
● Metritis
○ Inflammation of uterus
○ Caused by bacterial infection of uterine wall
● Wound infection: cesarean incisions, perineal lacerations/incisions
● UTIs
● Mastitis: milk stasis & (can be caused by improper latch)
Postpartum Period
Postpartum Period:
● Begins after the delivery of the placenta and lasts 6 weeks
● Marked by physiologic and psychological changes
○ Attempt to return to pre-pregnant state
○ Adjustment within family, change in family structure and roles
Uterine Involution: Pregnant→ Non-Pregnant State
*Remember to support uterus at the bottom, place head of bed
flat, and check for increased bleeding as you massage
Factors
Factors that facilitate Uterine Involution:
that inhibit Uterine Involution:
Complete expulsion of placenta Incomplete expulsion of placenta
Complication free labor and birth process Uterine atony
Breastfeeding Prolonged labor and difficult birth
Early ambulation Uterine infection
Full bladder or overdistention of uterine muscles
Anesthesia
Close birth spacing
PP Conditions that put Women at Risk:
● Postpartum hemorrhage
● Thromboembolic conditions
● Postpartum infections
Postpartum Hemorrhage
● Potentially life threatening complication
● Leading cause of worldwide
● Defined as blood loss of:
○ > 500 ml (vaginal birth) 10%
○ > 1000 ml (C section) 25%
●
Causes→ 4 T’s
●
○ Uterine atony: failure of the uterus to contract after birth (most common cause of pp hemorrhage)
■ CAUSES
●
● Overdistention of uterus caused by: multifetal gestation, macrosomia, placental
fragments
● Prolonged or rapid labor
● Uterine infections
● Anesthesia, MgSO4, Pitocin given before delivery of placenta
○ Magnesium: dangerous drug, high dose can stop heart (only give to severely
hypotensive pts)
●
○ Retained placenta
○ complete detachment & expulsion permits continued contraction & optimal occlusion of blood vessels
○ Thorough inspection of placenta necessary
●
○ Damage to genital tract: ○ Hematomas: (damage to larger blood
■ Cervical and vaginal wall vessel→ blood seeps outside into tissue)
lacerations ■
■ “Trickling” of ■
■ Spontaneous or via manipulation ■
● :
○ Hypercoagulation: normal* and protective; YOU WANT BLOOD TO BE CLOTTING
○ Coagulopathies:
■ bleeding disorders characterized by prolonged excessive bleeding
■ suspected if postpartum bleeding persists
■ Often masked by routine use of
■ Assess lab values for: ↓ platelets & fibrinogen, ↑ prothrombin time, and prolonged bleeding
time
○ Examples:
■ Idiopathic thrombocytopenic purpura (ITP): disorder of increased platelet destruction r/t
autoantibodies, will see bleeding from IV sites, bruising
■ von Willebrand disease (vWD): congenital disorder of bleeding time, doesn’t show up until
significant bleeding event, treated with (desmopressin) give IV if dx is 100%
● von Willebrand factor (WWF) is an essential clotting protein
● Missing or lacking WWF in vWD
, MATERNITY EXAM 3: PP Woman at Risk 2
■ Disseminated intravascular coagulation (DIC): clotting system abnormally activated causing
widespread clots throughout the body, increased systemic clotting depletes factors needed to
stop excessive bleeding; caused by severe injury or infection
Nursing Assessment for Bleeding:
● Assess amount of bleeding:
○ Heavy and slow, steady loss
○ Weigh peri pads to measure blood loss (ml = g)
■ 1,000 mL of blood weighs 1,000g
● Assess tone and location of fundus q 15 min for 1-2 hrs then q 1 hr for 4 hours
● Assess VS especially BP and pulse, UO, LOC
○ UO helps assess kidney function
○ < 30mL in 1 hr → kidneys starting to shut down r/t lack of perfusion
○ Foley catheter with urine meter for exact measurement in mL
● Look for hematoma
Risk Factors for PP Hemorrhage:
● Prolonged labor ● Preeclampsia ● Grand multiparity
● Precipitous birth ● Maternal hypotension ● Hydramnios (too much
● History of PP hemorrhage ● Lacerations amniotic fluid)
● Multiple gestations ● Operative birth ● Coagulation abnormalities
● Uterine infection ● Augmented labor
● Manual extraction of (stimulation of uterus to
placenta promote cxs)
During Hemorrhage:
● Monitor VS q 5 min until stable
○ Note trend in VS (pulse and RR increases, BP decreases, temp shouldn’t change)
● Administer oxygen at L via mask
● Palpate fundus and massage prn
● Insert foley catheter
● Initiate pad count**
● Assess emotional and mental status
● Administer uterotonic drugs:
Parameters Class I Hemorrhage Class II Hemorrhage Class III Hemorrhage Class IV Hemorrhage
Estimated 15% 15-30% 30-40% > 40%
Blood Loss
Pulse < 100 > 100 > 120 > 140
BP Normal or increased Decreased Decreased Decreased
RR Normal 20-30 30-40 > 40
Urine output > 30 ml/hr 20-30 ml/hr 5-15 ml/hr Negligible
Thromboembolic Conditions: Thromboembolism
● Obstruction of a blood vessel by a blood clot
● Superficial or deep (both can cause pulmonary embolism)
● Leading cause of in the US
Nursing Management:
, MATERNITY EXAM 3: PP Woman at Risk 3
● Identify those at increased risk (smoking, history of birth control pills, varicosities)
● Prevent venous pooling
○ Elevate legs with pillows
○ Stirrups maximizes leg drainage (legs above heart level)
○ Avoid crossing legs
● Prevent : encourage ambulation, TEDs, compression devices (especially after C section)
● Meds to decrease hypercoagulability (if pt really at risk):
● Coagulation studies & elevation
Postpartum Infection
● Affects of all births
● Defined as fever > 100.4 after 24 hrs postpartum occurring for at least 2 of the first 10 days after birth
● Normal physiologic changes of childbirth increase risk of infection (amniotic fluid, blood, lochia all )
Common PP Infections:
● Teach mom to report any temp >
● Metritis
○ Inflammation of uterus
○ Caused by bacterial infection of uterine wall
● Wound infection: cesarean incisions, perineal lacerations/incisions
● UTIs
● Mastitis: milk stasis & (can be caused by improper latch)
Postpartum Period
Postpartum Period:
● Begins after the delivery of the placenta and lasts 6 weeks
● Marked by physiologic and psychological changes
○ Attempt to return to pre-pregnant state
○ Adjustment within family, change in family structure and roles
Uterine Involution: Pregnant→ Non-Pregnant State
*Remember to support uterus at the bottom, place head of bed
flat, and check for increased bleeding as you massage
Factors
Factors that facilitate Uterine Involution:
that inhibit Uterine Involution:
Complete expulsion of placenta Incomplete expulsion of placenta
Complication free labor and birth process Uterine atony
Breastfeeding Prolonged labor and difficult birth
Early ambulation Uterine infection
Full bladder or overdistention of uterine muscles
Anesthesia
Close birth spacing
