High Risk Pp Complication

1. Hemorrhage

2. Coagulopathies

• ITP(Idiopathicthrombocytopenic purpura)
• DIC (Disseminated intravascular coagulation)
• Venousthrombosis (deep/superficial)
• Pulmonary embolism

• Endometritis
• wound infections
• UTI, mastitis

=50% thought to be avoidable

=60% of maternal deaths happened PP

Causes:

• Gestational hypertension
• pulmonary embolus
• amniotic fluid embolus
• cardiac disease
  

1. Cardiovasculardiseases, 15.1%. -highest
2. Non-cardiovasculardiseases, 14.1%.
3. Infectionor sepsis, 14.0%.
4. Hemorrhage,11.3%.
   

• Delayed childbearing- moreof a risk fx being older
• Obesity
• Rising surgical birth rate- Csection surgery greater risk
• Cardiomyopathy d/t childbearing-parents prev had heart problems and now having ownchild (this is a risk fx)
• Multiparity- giving birth to more than one child
• Immigration Death certificate changes(identifying more often deaths due to childbearing)
• Artificial reproductivetechnologies
  

•Uterine Atony:Causes 70 - 80%

Risk factors:

•Over-distended uterus

(LrgeGestationalAge, multiples, polyhydramnios)

•History of over-stretching (multiparity)

•Muscle fatigue

(pitocin; prolonged labor; MgSO4)-- utilized induction medication pit or on prolonged MgSO4)

Intrpartum

• Lossof more than 500mL of blood after vaginal birth
• Lossof more than 1000mL after C/S
  

Postpartum

• Dropof more than 10% in Hctbetween pre-labor andpostpartum (fairly ignored)
• Saturated pad in 15-30 minutes;

• Should act on an assessment of“heavy”

• Early: in the first 24h after birth
• Late: 24 h after birth and less than 6 weeks postpartum
  

• Tone[Uterine Atony 75 –90 %]
• Trauma[Surgical or assisted vaginal delivery]
• Tissue[Retained Placenta]
• Thrombosis[Congenital & acquired abnormal clotting]
  

Obstacles to involution

• full bladder
• Accumulationof clots/placental fragments in uterus
  

2/3 of women who hemorrhage don't not have risk fx

• 1st step: palpate

• EBL(est. blood loss), identifysource (palpate,visualization), Call for help
  

If extreme (about or > 1000 cc):

• Trendelenberg orflat supine position
  
• Uterinemassage

-Maintain while other interventionsare being initiated

-Careful not to overdo: oncefirm, STOP

• IV ifnone or 2nd line using widebore (14-16gauge) catheter
• O2(non-rebreather mask@ 10-15 L/min)
• Labs: CBC, coagulation studies, Type & cross –have units of RBCs and other bloodproducts available
  

1.Oxytocin(Pitocin)

-Increase IV rate, increase concentration inIV, or IM

2. Methylergonovine (Ergometrine/Methergine)

- x 1 IM ordirectly into myometrium

-neverIV

-Contraindication: HTN

3.Carboprost (Hemabate)

-up to x 2 IM, 15” apart

-Some providers prefer to skip methergine&go directly to carboprost

-Contraindication: Asthma

4.Misoprostol(Cytotec)

-oral, sublingual,rectal

-Typically drug of last resort in U.S.

-Contraindication: Asthma

• Oxygen, also a drug per standards, can be given at any point, based on amount of blood loss, VS, and assessments
  
• ***if one drug doesn’t work right away(1-5 min), move to a new category typically; should know in 30 minutes if moreinvasive therapy is needed (surgery)***

• Post-acute: HCT, VS, safety (lifting newborn,ambulation)
• Frequentcareful assessment: High risk of future bleeding; verylikely to bleed again
• Document
  

-a small set of evidence-based interventions for a definedpatient population and care setting

-promote team work

• Uterotonic druginjected right after birth and aftercheckingfor a possible second baby
  

• Itcan be used only once, no danger of re-use.
  

• require nursing care and monitoring
• catheter can be placed & perineum is accessible (easily check for lacerations)
• Surgicalprocedures can be completed prior to complete removal
• SLOW,careful, well-monitored removal

Contraindications:

• heart failure
• stenotic heart valves
• pulmonary edema
• bleeding above the diaphragm
• presence of a viable fetus.
  

Birth trauma:

-tears/lacerations & hematomas

-Useof instruments/procedures (forceps/suction; episiotomy)

-Tears,hematoma (vagina,labia,cervix)

• Superficial
• Deep

• Cesarean birth
• obesity
• maternal age
• history ofvaricosities/thrombosis

• redness
• warmth
• unilateral enlarged vein
• calf tenderness
• swelling

• Activity
  
• Elevation
• Compression
• Heparin/enoxaparin
• **Donot give ASA/NSAIDS**
  

=most often a blood clot

• Rare,highmaternal mortality PP

• Anxiety
• Chest pressure
• Dyspnea, tachypnea, cough, hemoptysis; low O2 saturation
• Tachycardia
• Temp

Treatment:

• Oxygen if indicated
• bedrest
• analgesia
• IV heparin/enoxaparin therapy, then PO warfarin.
• **NoASA or other NSAIDs containing products.
  

• rare, 13% of maternal deaths(U.S.)
• 70% occur during labor
• also occur in amniocenteses, D&E, vaginal & c/s births

Dx ofexclusion (could be lots of other problems): *

• sudden onset of CV collapseduring pregnancy or 1st 48hours PP
• sustained tachycardia for 4 hours
• absence of other illness thatwould explain the signs and symptoms.

Diagnostic: scans (CT), D-dimer, coagulation studies,CBC

Treatment:

• Central line IV
• O2 with intubation
• vascular support (vasopressors)
• bloodproducts especially cryoprecipitate
• prepare for probable resuscitation
  

**can happen up to 2 days PP

**not due to mechanical obstruction--> instead type of anaphylaxis

**most women exposed to amniotic fluids and are fine

• Proteins that control clotting becomeoveractive> Used Up
• Clotting consumes lrg amount ofclotting factors= internal and external bleeding or both

• Preeclampsia [PIH]/HELLP syndrome
• Retained dead fetus[fetal demise]
• Sepsis
• Hxof hemorrhage

-Monitornewborn status if DIC began prenatal or intrapartum(CBC)

• D-dimer: small protein fragment present in the blood after a blood clot is brokenup.

-negative d-dimer test rules outthrombosis (no clot)

-positivecan indicate thrombosis, but does not rule out other causes

• often used in thedx of DIC.
  
• Chest X-ray (if serious, getportable)
• Computed tomography
• pulmonaryangiogram uses radioactive dye; may require “pump and dump” if breastfeeding
  

=rare

Symptoms:

• 4 T's (tone, trauma, tissue, thrombin)
• Breathing
• Bleeding (gums, IV sites, wounds, many sites)
• Bruising (may start small)
  

Tests

• Platelets
• PTT
• PT
• D-Dimer(fibrin split products)

• Removethe Trigger
• Treatunderlying cause support
• Replacing> Platelets – Plasma – PRBC – Fibrinogen
  

=Autoimmunedisorder in which antibodies decrease the lifespan of platelets. Capillariesare fragile & increase bleeding.

S/S:

• bleeding gums
• bleeding from open sites (lochia, IV site, injectionsites)

• Supportive,safety
• IV
• Platelets
• Glucocorticoids(Stop Inflammation)
  

=infection

S/S:

• Uterustender on palpation
• Pelvicpain
• Foullochia
• Excessivebleeding
• Chills,fever

• Placental fragments: poor involution,clots with tissue
  

at Surgical incision site:

• C/S
• Episiotomy
• Sx: fouldischarge, REEDA

• antibiotics
• hydration
• pain relief/comfort
• help
• maintain lactation
  

–COMMON MEDICAL COMPLICATION OFpregnancy

PREDISPOSINGfactors:

• hygiene
• nutrition
• anemia
• DIABETES–Occurs in 2-4 % of PP women; oftenunder-diagnosed

• dysuria
• frequency
• urgency
• lowgrade temp
• CVA tenderness
• urinary retention
• hematuria
• pyuria

Risks:

• urinary catheterization
• frequent pelvic exams
• epiduralh/o UTI
• genital tract injury
  

Prevention:

• c/s get the catheter out as soon as ambulatory
• straight catheterization, rather than indwelling catheter on vaginal births.
  

(2-3 weeks pp):

• 10% of new mothers

• poor bf pattern
• delayed emptying
• depressed immune status

• “flu-like symptoms”: pay attention
• may not be visible localized redness on breast
• may be afebrile

• ensure regular emptying
• extreme attention to engorgement problems.

• antibiotics
• continue bf in most cases

• Warm the breast if engorged
• initially pump to promote let down reflex then put baby on.
• NOT ALL MOTHERS NEED TO PUMP.